Medical record; a journal of medicine and surgery

'^''-logical
*■' MedicaJ
Serials

dical

-eiKii^

MEDICAL RECORD

A Weekly Journal of Medicine and Surgery

EDITED BY
THOMAS L. STEDMAN, A.M., M.D.

"Volume 71.

JANUARY 5, 1907— JUNE 29, 1907

/

NEW YORK
WILLIAM WOOD AND COMPANY

1907

//

/

COPYRIGHT, 1907,
By WILLIAM WOOD «t COMPANY

LIST OF CONTRIBUTORS TO VOL. LXXI.

Baginsky, Adolph, Berlin.
Bailey, Pearce, New York.
Ballenger, Edgar G., Atlanta,

Ga.
Baller.\y, G. H., Paterson, N. J.
Bangs, L. Bolton, New York.
Barringer, Benjamin S., New

York.
Barringer, Theodore B., New

York.
Beard, John, Edinburgh.
Beck, Carl, New York.
Belfield, William T., Chicago.
Bell, Robert, London, England.
Bennett, A. B., Washington,

D. C.
Berg, A. A., New York.
Birch more, Woodbridge H.,

Brooklyn, N. Y.
Bishop, William H., New York.
Bleyer, J. Mount, New York.
Blumgart, Leonard, New York.
Booth, J. Arthur, New York.
Boston, L. Napoleon, Philadel-
phia.
Brewer, Isaac W., Fort Huachu-

ca, Ariz.
Brooks, Harlow, New York.
Brothers, Abram, New York.
Brown, Robert C, Milwaukee,

Wis.
Brown. Wallace E.. North

Adams. Mass.
Brownson, J. J., Dubuque, la.
Bryant, Joseph D., New York.
Bryant, W. Sohier, New York.
Bull, Charles S., New York.
Butler. George F., Chicago.
Burt. Stephen Smith, New

York.

Carter, Willi.\m AA'esley, New

York.
Chapman, H. \\'., White Hall,

111.
Clapp, Herbert C, Boston.
Clark, L. Pierce, New York.
Clea\-es, Margaret A., New

York.
Cleghorx, Charles D., New

York.
Clouting, Ch.xrles A., London,

England.
CoE, Henry C, New York.
CoLEY, William B., New York.
Collins, Joseph, New York.

Cottam, Gilbert G., Rock Rap-
ids, la.

Coyle, John G., New York.

Crothers, T. D., Hartford,
Conn.

Crutch er, Howard, Mexico,
Mo.

Curtis, G. Lenox, New York.

Dana, Charles L., New York.
Denslow, L. M., New York.
Dickey, Wm. A., Toledo, O.
Dickinson, G. K., Jersey City,

N. J.
Dillon, Charles J., New York.
Ditman, Norman E., New York.
Dock, George, Ann Arbor, Mich.
Douglas, Richard, Nashville,

Tenn.

Edgar, J, Clifton, New York.
Einhorn, Max, New York.
Erdmann, John F., New York.
EsHNER, .\l;gustus a., Philadel-
pliia.

Fanoni, Antonio, New York.

Feild, Edward D., Norfolk, \'a.

Ferrer, Jose M., New York.

Field, C. Everett, Richmond.
L. I.

Fischer, Louis, New York.

Fisher, Jessie Weston, Middle-
town, Conn.

Foster, Nellis B.. New York.

French, James L., San Diego,
Cal.

Fridenberg, Percy, New York.

Friedman, G. A., New York.

Frischbier, Charles P., BrooK-
Ivn, N. Y.

Funk, W. A., East Orange, N. J.

Fi'RNiss, Henry D., New York.

FuRNiss, John P., Selma, Ala.

G.\tks, Manley F., U. S. Navy.
Gii!B, W. Travis, New York.
Gilbert, J. L., Kendallville, Ind.
Gnichtel, a. L.. New York.
Gorgas, W. C, U. S. Army.
GnuLD, George M., Philadelphia.
Gordon, Alfred, Philadelphia.
Graef. Charles, New York.
Griffith, Frederic. New York.
Gross, M., New York.

Hald, p. Tetens, Copenhagen,
Denmark.

Hall, James K., Morgantown,
N. C. .

Hartzell, M. B., Philadelphia.

Haynes, Irving S., New York.

Heineman, H. Newton, Bad
Nauheim, Germany.

Heiser, \'ictor G., Manila.

Heubner, O., BerHn, Germany.

Hollis, Austin W., New York.

Hudson, Makuen G., Philadel-
phia.

Hunter, J. D., Arequipa, Peru.

Isaacs, A. E., New York.

Jackson, Chevalier, Pittsburg,
Pa.

Jacooi, a.. New York.

Jacobson, Arthur C, Brooklyn,
N Y

James, Prosser, London, Eng-
land.

Janet, Pierre, Paris, France.

Kakels, M. S., New York.
Kelsey, Charles B., New York.
KiEFFER, Major Charles F.,

U. S. A.
King, Herbert M., Liberty, N. Y.
KosMAK, George W., New York.

Ladinski, Louis J., New York.
Lederer, Ernst, Vienna.
Leuf, a. H. p., Philadelphia.
Lewis, Bransford, St. Louis,

Mo.
Link, Goethe, Indianapolis, Ind.
Lloyd, Samuel, New York.
LooMis, Henry P., New York.
Luys, Georges, Paris, France.

McCampbell, Eugene F., Colum-
bus, ( ).

McCaskev, G. \\'., Fort Wavne,
Ind.

McCouRT, P. J., New York.

McCuli.ougii, John ^^■., Alliston,
Ont.

McGrath, John J., New York.

McKee, E. S., Cincinnati.

MacKee, George M., New York.

MacMurrough, F. K.. Jersey
City, N. J.

McWiLLiAMS, Clarence A., New
York.

IV

CONTRIBUTORS TO VOL. LXXI.

Maker, Steppiex J., New Haven,
Conn.

Marple, Wilbur B., New York.

Martin, A. J., New York.

Mason, Albert, Exeter, N. H.

Meier, Nathan, Berlin, Ger-
many.

Meyer, William, West Hoboken,
N.J.

Miller, F. E., New York.

Mills, H. Brooker, Philadelphia.

Morris, Robert T., New York.

Morton. William James, New
York.

Moschcowitz, Alexis V., New
York.

Neustaedter, M., New York.
Newcomb, James E., New York.
Norstrom, Gustav, New York.

O'CoNNER, p. T., Waterbury,

Conn.
O'Crowley, C. R., Newark, N. J.
Oppenheimer, .'^eymour. New

York.

Palier, E., New York.

Parker, Delos L., Detroit, Mich.

Peabody, George L., New York.

Peet, Edward W., New York.

Peterson, Frederick, New York.

Petit, Raymond, Paris, France.

Phillimore, R.\ymund, Mon-
treal.

PiFFARD, Henry C, New York.

Pooley, Thomas R., New York.

Porter, \\'illiam Henry, New
York.

Prager, Paul, Vienna, Austria.

Reid, John J., New York.
Richardson, Hubert, Baltimore,

Md.
Robinson, Beverley, New York.
Robinson, William J., New

York.
Rockwell, A. D., New York.
Ronginsky, a. J., New York.
Rose, A., New York.
Russell. Colin K., Montreal,

Canada.
Rl'therford. J. G.. Ottawa, Ont.

Sandler, Da\td, Constantinople.
Saxe, De Santos, New York.
ScH.-\DLE, Jacob E., St. Paul,

Minn.
Scott, R. J. E.. New York.
Scripture, E. W., New York.
Sheffield. Herman P... New

York.

Sheldon, John G., Kansas Citv,

Mo.
Shiels, George F., New York.
Smith, Emmet L., Chicap^o, 111.
Smith, E. Franklin, New York.
Smith, Stephen, New York.
Spingarn, Alexander, Brooklyn,

N. Y.
Starr, M. Allen, New York.
Stedman, Thomas L., New York.
Stern, Arthur, Elizabeth, N. J.
Stern, Heinrich, New York.
Stone, William S., New York.
Strauch, August, Chicago, 111.
Straus, S., New York.
Study, Joseph M., Cambridge

City, Ind.

Talbot, Eugene S., Chicago.
Talmey, B. S., New York.
Talmey, Max, New York.
Thayer, A. E., Galveston, Tex.
Thtenhaus, C. O., Milwaukee,

Wis.
Thompson, W. Gilman, New

York.
Townsend, Terry M., New York.
Trenwith, W. D., New York.
Turck, Fenton B., Chicago.

\'ale, Frank P., Washington.

D. C.
A'alextixe. Ferd. C. New York.
Van Baggen, N. J. Poock, The

Hague, Holland.
\'an Fleet, Frank, New York.
Vixeeerg. Hir.-\m N., New York.
Vinton. M.\ria M., East Orange,

N. J.
Vogel, Karl M., New \ork.

Walker, Emma E., New York.

Walter, F. J., Kramer, Ind.

Ward, Nathan G., Philadelphia.

Weber, Leonard, New York.

Whitford, William, Chicago,
111.

Wiener, Joseph, New York.

Williams, John Roy. Greens-
boro, N. C.

^^'ILLIAMS, W. Roger, Bristol,
Eng.

^^'ILS0N, Omar M.. Ottawa, Ont.

Wise, Fred, New York.

Woldert, Albert, Tyler, Tex.

Wood, Francis C, New York.

Wood. Percy R.. Marshalltown,
la.

Wood, \\'illiam C, Gloversville,
N. Y.

^^■oRSTER, W. p.. New York.

Wright, Harold W., Astoria,
L. I.

Zinsser, Hans, New York.

Societies of xvhich Reports Have
Been Published.

American Climatological As-
sociation.

American Gynecological So-
ciety.

.A.MERICAN Medical Association.

American Pediatric Society.

American Surgical Associa-
tion.

Association of American Phy-
sicians.

Chicago Medical Society.

Chicago Pediatric Society'.

Chicago Surgical Society.

College of Physicians of Phil-
adelphia.

Congress of American Physi-
cians and Surgeons.

Medical Association of the

Greater City of New York.
Medical Jurisprudence Society

OF Phil.'\delphl\.
Medical Society of the County

of Kings.
Medical Society of the County

OF New York.
AIedical Society of the State

OF New York.

N.\tional Associ.\tion FOR the
Study and Prevention of
Tuberculosis.

New York Ac.-\demy of ^Iedi-

CINE.

New York Psychiatrical So-
ciety.

Philadelphia County Medical
Society.

Philadelphia Neurological
Society.

Philadelphia P.\thological So-
ciety.

Philippine Isi_\nds Medical
Assocl^tion.

Practitioners' Society of New
York.

St. Louis Medical Society of
Missouri.

Southern Surgical .\nd Gyne-
cological ASSOCI.ATION.

Williamsburg Medical Society.

Medical Record

Vol. 7 J, No. J.
Whole No. J 887.

A Weekly Journal of Medicine and Surgery

New York, January 5, 1907,

$5.00 Per Annum.
Single Copies, lOc.

(©ngtual Artirbs.

SUGGESTIONS OF A PLAN OF ORGANIZ-
ING A HOSPITAL SYSTEM FOR THE
CITY OF NEW YORK.*

By STEPHEN SMITH. .\I.D,,

.\EW YORK.

For the following reasons the present seems espe-
■cially opportune for the discussion of the question,
What shall be the hospital system of New York
during the twentieth century ?

I. There is a growing disposition on the part of
the medical profession to prefer and seek the ad-
vantages of hospital care and treatment for their
patients. 2. Wealthy citizens are contributing more
freely to the establishment and support of hospitals
than at any previous period. 3. The municipal
authorities are contemplating the expenditure of
enormous sums of public money on hospitals, viz.,
$12,000,000, on a monster hospital at Bellevue;
$7,000,000 on extension of the Blackwell's Island
hospitals ; $7,000,000 on hospitals for the Borough
of Brooklyn ; $2,000,000 on a tuberculosis hospital
on Staten Island; $1,000,000 for a public hospital
•on the west side, and, finally, an incredible number
•of hospitals is being projected by private indi-
viduals.

Hitherto, New^ York has had no hospital system,
and, as a consequence, these institutions, both public
and private, have been located, constructed, and
managed with slight regard to the necessities of
the sick poor, or to healthfulness and economy.
The first governmental restraint over the establish-
inent of private hospitals was by an act of the
Legislature, 1894 and 1893, requiring the approval
of the certificate of incorporation of a proposed
hospital by the State Board of Charities. Before
approving a certificate the Board establishes, affirm-
atively, the following facts: i. The desirability of
such hospital at the time and place stated in the cer-
tificate. 2. The character, as to responsibility of the
proposed incorporators. 3. The financial resources
of the proposed incorporation. This law has proved
■of great importance by preventing the establish-
ment, in undesirable localities, of hospitals, man-
aged by irresponsible persons, and without adequate
financial support. The location, construction, and
management of the public hospitals are under the
control of three independent departments of the
municipal government, viz., the Charities, Health,
and Bellevue and Allied Hospitals. The private
hospitals are under no other governmental supervis-
ion than that exercised by the State Board of Chari-
ties, as stated above, in approving their certificates
of incorporation.

A system of hospital development adapted to the
-wants of the people of the City of New York, dur-

*A paper prepared for the Discussion of the '"Hospital
■Question" before the New York Countv Medical .\ssocia-
tion.

ing the twentieth century, must be based on a judi-
cious consideration of the following questions :

(i) What Will be the Future Demand for Hos-
pital Care for the Sick? — The experience of the
last half of the nineteenth century teaches an im-
pressive lesson as to the future demands of the sick
for hospital care and treatment. During the first
half of that century, there was but one hospital in
the old city of New York, excluding the Almshouse,
although the population increased from 60,515 to
515,547. During the last half of the century the
hospitals increased to upwards of 70, with an in-
crease of the population to 1,850,093. A similar
ratio of increase of hospitals to population occurred
in the Borough of Brooklyn. At the present time
the elTorts of public authorities and private cor-
porations, and citizens to increase hospital accom-
modations is unprecedented.

The increasing popularity of hospitals is due to
the great advance of scientific medicine and sur-
gery in determining more accurately the nature of
diseased processes, and the conditions essential to
their successful treatment. New methods of analy-
sis and instruments of precision are more and more
enabling the students of pathology to discover the
ultimate elements of disease. The result has been
the identification of large numbers of individual
diseases hitherto grouped under one name, and con-
sequently treated in gross. These discoveries have
enormously enlarged the field of operative surgery,
and multiplied remedial measures that must be ap-
plied with the greatest exactness.

As these revelations of the modern requirements
of practice are in an early stage of developinent, we
can but conclude that hospitals will become more
and more the resort of the sick during the present
century. Already the conditions of success in sur-
gical practice demand so much apparatus, and such
precision in its use. that skilled and judicious sur-
geons insist upon the removal of their patients to
the hospital. Not less important is the hospital for
the treatment of a largely increasing number of dis-
eases that fall to the care of the physician, and to the
specialist. So impressed are practitioners with the
necessity of hospital care of their patients that
tnany are creating their own private hospitals.

^^'e are justified in concluding that there is to be
a constantly increasing demand for hospital accom-
modations for the sick of New York. It is, perhaps,
not unwarranted to predict from the experience of
the past that the time is not distant when acute dis-
eases will not be treated in the homes of the people,
but in hospitals.

(2) What Shall be the Organized Municipal
Authority Having Jurisdiction of the Hospital
System Suggested? There should be created a
"Department of Hospitals." The chief officer should
be a "Commissioner of Hospitals,'' who should be
a physician of not less than ten years' experience
in hospital practice, and of assured executive abil-
ity. The "Department of Hospitals" should be
tmder the control of a Board consisting of the Com-

MEDICAL RECORD.

[Jan. 5, 1907

missioner of Hospitals, the Commissioner of Chari-
ties, and the Commissioner of Health.

This plan of organizing- a department is similar
to that of the Department of Health, the Board of
which consists of the Commissioner of Health, the
Commissioner of Police, and the Health Officer of
the Port. The object sought to be accomplished is
the union, in the government of the Department of
Hospitals, of the allied departments which have an
interest in its operations. The Department of Hos-
pitals should exercise complete control of all the
public hospitals now or hereafter created, viz., the
Belkvue and Allied Hospitals, the hospitals under
the control of the Department of Charities, and the
Contagious Diseases Hospitals under the control of
the Department of Health. The assignment of
ambulance districts to hospitals should be trans-
ferred from the Police Department to the Depart-
ment of Hospitals.

(3) What Should be the Relation of the De-
partment of Hospitals to Private Hospitals? —
The Department should have the duty of approval
or disapproval of the certificate of incorporation of
all private hospitals, now imposed by statute upon
the State Board of Charities, and such approval
should be based on the facts required by that Board,
viz. : I. The desirability of such hospital at the time
and place proposed in the certificate. 2. The re-
sponsible character of the proposed incorporators.
3. The adequate financial resources of the promoters.
The Department should utilize the private hospitals
in the care and treatment of dependent patients,
Vi'hen satisfactory arrangements can be made with
the managers. There are many private hospitals so
located, constructed, and equipped that they would
form an important part of the hospital system sug-
gested if they were subsidized by the payment of
an adequate sum for the care of the patients re-
ceived by them. \'ast sums of money expended in
the construction, equipment, and management of
new hospitals could be saved if the public authori-
ties would pay private hospitals a liberal per capita
allowance for the treatment of charity patients. The
Department should have visitatorial powers of all
private hospitals, and such supervisory jurisdiction
as will harmonize their management with the sys-
tem of hospital administration created by the
Department.

(4) What Should be the Relation of the Public
Hospitals to the Medical Profession? — Every per-
son who is legally qualified to practise medicine in
the State of New York should be allowed to send
his patients to the public hospitals of the city, to
attend his patients exclusively while in the hos-
pital, and to invite any legally qualified practitioner
to cooperate with him in the treatment of his
patients, whether as a consultant or operator. This
plan of organizing the hospital service has been pur-
sued for many years by hospitals in this State with
the happiest results.

The exclusion of the medical profession from a
participation in the benefits of a public hospital is
not only a wrong to that profession, but works a
serious injury to the sick. Under present hospital
regulations, the medical staff exercises all the
powers of the most exacting monopoly though the
method of appointment secures only ordinary prac-
titioners. Physicians, not members of the attending
staff, whatever may be their abilities or rank, have
no rights in the hospital. On sending their patients
to a hospital they lose all control of the care and
treatment, which are assumed by the physicians
who have been so fortunate as to be appointed to
the medical staff of the hospital. The result is thai
the outside physician loses his patient, and, what is

perhaps of more importance, the patient loses his
physician. Hence, large numbers of medical prac-
titioners, perhaps more competent to treat their
patients than the members of a hospital staft', refuse
to send their patients to a hospital, though the dis-
ease is of a kind to require hospital advantages for
successful treatment. This old-time custom of ex-
cluding the profession from the benefits of hospitals
has come down to us from the hospitals of London,
and ought to be abolished in this progressive age.

(5) What Should be the Relations of the Public
Hospitals to the Medical Schools? — Practical in-
struction in hospitals is becoming more and more
recognized by the Medical Colleges as an essential
part of a complete medical education. It is good
public policy to encourage the promoters of medical
education to utilize the hospitals under municipal
control for the purpose of clinical instruction by
giving them access to the patients under proper
rules. The popular prejudice against the admission
of medical students to the wards of hospitals for the
purpose of bedside instruction was formerh- intense.
It was regarded as an outrage upon the patients to
expose their diseases to the observation of a class
of students. In practice, however, it was found that
the patients in a ward who were selected for study
were very proud of the distinction, while those who
were passed by were ofifended at their apparent
neglect. The facts established by experience show
that the benefits of clinical instruction are reciprocal
as between the hospital and the school. The hos-
pital which has the most perfectly organized system
of clinical instruction has the most thorough and
exhaustive investigation of the diseases of the pa-
tients, and, as a consequence, the highest grade of
treatment, and this necessarily results in the most
efficient administration of the entire hospital. On
the other hand, the value of clinical instruction to
the school is inestimable. The time is not distant,
we trust, when the hospitals of the city will, as in
the European capitals, be the centers of medical
instruction, rather than merelv accessories.

(6) What Should be the Relation of Public
Hospitals to the People? — The public hospitals,
built and supported by public funds, should furnish
adequate facilities to all classes and conditions of
the people, who, by accident or disease, require the
advantages of hospital care and treatment. To
meet these requirements the hospital should be so
constructed as to furnish apartments adapted to
every rank and grade of society, from the charity
patient to the millionaire. The rate of pay should
be scaled on the basis of the accommodations sup-
plied, whether in a general ward, a room with one
or more occupants, or an entirely private apartment,
or apartments. Moreover, the patient who pays for
hospital accommodations should have the privilege
of selecting as his medical attendant any legally
qualified practitioner, unconnected with the hospital
staff, and all the resources of the hospital should be
given to the ser\-ice of such practitioner.

(7) What Should be the Classification of the
Public Hospitals Adapted to the Necessities of
the People? — The first class of hospitals which
the sick and injured require is that which meets
emergencies, viz., "The Emergency Hospital" : the
second class should provide for the sick during con-
valescence, viz.. "'The Convalescent Hospital"; the
third class should be equipped for the treatment of
special forms of disease, viz., "The Special Hos-
pital" : the fourth class should be devoted to diseases
which require isolation, viz.. "The Contagious Dis-
eases Hospital."

(8) The Emergency Hospital. — The first hos-
pital in the proposed system is the Emergency Hos-

Jan. 5, lyo-

MEDICAL RECORD.

pital, where the sick and injured receive first treat-
ment. The capacity for these hospitals must vary
witli conditions, but in general it would be compara-
tively limited, as the term of residence of those
requiring its special care and treatment must neces-
sarily be brief. As much will depend upon the char-
acter of the population of the locality it may be
estimated that their capacity will be for 300 patients
as a minimum, and 600 patients as a maximum.
The location of these hospitals must be in the vicin-
ity of the people they are intended to serve. To
determine this fact the city should be divided into
Hospital Districts, the division being based on the
laboring or tenement-house population, and regis-
tered sickness.

The construction of an Emergency Hospital in
New York City admits of a variety of plans and
details. The principle governing the construction
of hospitals since the Civil War is to the effect that
the danger to the health of the people, in domicil,
increases in proportion to the increase of the per-
sons occupying a given ground space. Therefore,
the wards were spread out over a large area and
were one, or at most, two stories in height. This
sanitary maxim is true where people live in loosely
constructed structures, or in many-storied buildings
in which one story ventilates freely into another.
In the country where land is cheap and construction
work is not of the highest order, the best style of
hospital architecture is the cottage form, with wards
one or two stories in height. But in a city where
land is expensive, and construction is under close
governmental supervision, the conditions are so
completely changed as to warrant an entire re-
versal of the ancient sanitary maxim. The modern
"apartment hoter' has demonstrated the fact that
construction may be so perefct that, in the multipli-
cation of stories in a city structure, the healthfulness
of apartments increases in proportion to their dis-
tance from the level of the street. The lofty apart-
ment houses are rapidly supplanting the old style
residences, on account of both health and the many
additional conveniences and economies in living.
In like manner the many-story hospital is destined
to supplant, in cities, the two or three-story struc-
tures. The lower two or three stories will be de-
voted to the administrative duties, while the higher
stories, exposed to the sunlight and free air of the
country, will be devoted to the sick.

The plan here suggested of building a series of
Emergency Hospitals, ten, fifteen, or more stories in
height, on very limited areas of ground, in "Hos-
pital Districts" carefully defined according to the
needs of the people, greatly simplifies the problem
we are attempting to solve. In the first place it will
not be necessary to select expensive plots of ground,
but any available place within a given distance
could be taken. Xe.xt would be the diminished cost
nf building owing to the compactness of the struc-
ture; it is estimated that such buildings could be
erected for hospital purposes at a cost per bed not
to exceed $1,000. Again, the administration of
such a hospital would be far less cumbersome and
expensive than the old-time Cottage Hospital.
Finally, the healthfulness of the hospital of many
stories would be far greater than the hospital whose
wards are constantly exposed to the foul air, heat,
and noise of the streets.

The Attending Staff should consist of two grades,
viz., the Senior and the Junior. The term of service
in each grade should be five years, or a total of ten
years in both grades. The Senior grade should be
filled by promotion from the Junior grade, and no
person should be eligible to the Junior grade who
is over fiftv vears of asre, nor who holds a similar

position in another hospital. The Senior .Attending
Staff should have supreme control of the division
of the service assigned to each, and the Junior
Attending Staff' should act as assistants and substi-
tutes to the Seniors.

Tlie Resident Staff should consist of two grades
of graduates, viz., the Senior and the Junior. The
term of service should be six months in each grade,
or one year in both grades. The members of the
staff" should be residents through both terms. In
apportioning the service an average of fifty patients
should constitute a division to which an individual
member of the Senior Attending Staff and his as-
sistant, and a Senior and Junior member of the
Resident Staff, is assigned. The service should be
continuous.

The Consulting Staff should consist of two
classes, viz., (a) General Consultants, and (b) Spe-
cial Consultants. The General Consultants should
be physicians and surgeons who have served the
full term of ten years in the hospital, and the Special
Consultants should be eminent practitioners in
branches of medicine and surgery, classed as spe-
cialties. When the Consultants of either class are
called in consultation on patients, in public hos-
pitals, they should be paid a reasonable professional
fee.

The Medical Board should consist of the Senior
Attending Staff, and any member of the Junior
.Attending Staff' acting as a substitute. The Med-
ical Board should be responsible to the Department
of Hospitals for the nomination of all subordinate
officers and for a close, daily supervision of the
order, discipline, efficiency, and economy of every
branch of the service.

The Executiz'c Officer should, preferably, be a
physician of assured executive efficiency. The Ex-
ecutive Officer and subordinate officials should be
recommended by the Medical Board to the Depart-
ment for appointment, and no such official should
be appointed without such recommendation.

The special features of the above plan of organ-
izing the Medical Service of an Emergency Hos-
pital, which require comment, are as follows :

I. The division of the Attending Staff into two
grades, Senior and Junior, is important, viz.: (a)
The diseases of the patients being acute, the mem-
bers of the staff should visit daily, which requires
that there should be two attendants to meet emer-
gencies, (b) The training of the Junior member,
during his five years' service, fits him to take the
place of the Senior, on retirement, and thus a high
degree of qualification is maintained in the medical
service, (c) A fixed term of service of ten years,
five years in each grade, is ample in an Emergency
Hospital, to secure all the benefits of experience
that a hospital can confer : if the term is limited the
attendant is far more likely to attend strictly to his
duties in order to gain all the advantages possible
during his term ; within ten years a competent phy-
sician will secure a private practice which will
absorb all his interests and energies : finally, the
limited term admits of the admission of a far larger
number of capable and deserving young physicians
to the advantages of hospital practice. This scheme
would result in a reform of the present obsolete
practice of appointing men for life to hospital staffs,
many of whom, far advanced in years, hold similar
positions in other hospitals, and would give scores
of competent graduates opportunities for hospital
experience. fd) Hospital consultations are too
much neglected. Every medical staff of a hospital
should have the counsel and advice of men of large
experience when emergencies occur in practice, and
hence the necessitv of the two grades of Consult-

MEDICAL RECORD.

[Jan. 5, 1907

ants. The General Consultants are men who have
already served in the hospital for a full term of
years, and are able to appreciate the conditions
which are present, and which require a judgment
based on experience for their proper determination.
The Special Consultants are necessary to meet sat-
isfactorily the emergencies which arise on the ad-
mission of special forms of disease. The profes-
sional fee is the just due of the Consultant of either
class, (e) The term of one-year service for the
Resident Stafif, in two grades of six months each,
would secure greater devotion to duty and admit a
larger number of recent graduates to the advantages
of the hospital, (f) The continuous service and an
average of fifty patients to each division secures
that continuity of treatment of, and interest in, in-
dividual patients, so essential to their recovery, (g)
The ]\Iedical Board should be composed of officers
having the largest experience in the affairs of the
hospital, and immediately responsible for every de-
tail in its management.

(9) Convalescent Hospitals. — The questions
which arise in the discussion of the establishment of
Convalescent Hospitals are much more readily de-
termined. The most important are, (a) Location ;
(b) Construction; (c) Administration.

(a) The location of a Convalescent Hospital
should be in the open country, on an elevated site,
easily accessible to the city. The location should be
on a water front navigable from the city, for two
reasons, viz.: i. For facility of transportation of
both passengers and supplies, and, 2. For the cura-
tive effect of the recreation afforded to the sick
by excursions on the water. The site should con-
tain ample grounds for the cultivation of farm sup-
plies, as vegetables, milk, fruits, stock. There is
a great variety of available sites for Convalescent
Hospitals along the shores of the Bay, the Sound,
and Hudson River, within suitable distance of the
city.

(b) The Construction should be a colony, with
cottages of the family type, and sufficient in number
to allow of minute classification. These structures
should be very simple and inexpensive, but sub-
stantial and durable. It has been experimentally
determined in Germany that convalescents who do
suitable work out-of-doors, on farms, recover much
more rapidly than do those confined in city hos-
pitals.

(c) The administration of the Convalescent
Hospital should be under the direction of a med-
ical officer of large experience in the practical du-
ties of hospital management, with a resident medical
staff of recent graduates, having a limited tenure of
service. The Training School for Nurses of the
Department should be located in this hospital, and,
by properly arranged scheme of assignment, should
furnish nurses to all of the other hospitals. The
members of the attending staffs of the various hos-
pitals should have the right to the continuous care
of the patients whom they send to the Convalescent
Hospital.

(10) Special Hospitals. — There is a growing
need of well-equipped and managed special hospitals
in this city in which instruments of precision are
necessary to successful treatment. The provisions
made in existing hospitals and dispensaries for the
treatment of the special diseases of the poor, as of
the eye. ear, nose, and other organs, are inadequate
and preventive of that high grade of success. The
importance of these special institutions is seen in
the crowds which throng the few better-conducted
hospitals and dispensaries, numbering often five and
six hundred during the two or three hours of at-

tendance. The proper treatment of the diseases of
sensitive organs, as the eye and ear, requiring the
expert use of delicate instruments, under these con-
ditions of rush and confusion, is impossible. The
only possible relief to those seeking treatment of
special diseases is a large increase in the number of
thoroughly equipped hospitals and dispensaries de-
voted to these specialties.

(11) Contagious Diseases Hospitals. — These
hospitals were formerly under the control and man-
agement of the Department of Charities. Owing
to their inefficiency, the Department of Health, in
1872-3, began to create hospitals for contagious dis-
eases on an entirely new basis of location, construc-
tion, and management. The value of these new hos-
pitals was at once demonstrated. The protection
which they have afforded the tenement-house classes
from the brood of domestic pestilences which for-
merly decimated the homes of the poor cannot be
estimated. The remarkable improvement in the
efficiency of these hospitals when removed from a
department devoted to the custodial care of the poor
to a department having expert knowledge of con-
tagious diseases, strikingly illustrates the defects of
our hydra-headed system of hospitals.

(12) Organization of Hospital System. — The
practical application of the foregoing suggestions to
e.xisting conditions could be much more readily
effected if the previous development and growth of
our hospitals had been along definite and well-
devised lines, and under a competent municipal au-
thority. But even in their present chaotic state as
regards location, construction, and division of author-
ity in management, a serious effort should be made
to so organize them into a system that during the
present century they will develop symmetrically, and
thus be better adapted to fulfill their mission to the
sick efficiently and economically. To that end the
following suggestions as to the method of organiz-
ing the hospital system, above outlined, are submit-
ted:

1. The "Department of Hospitals" should be pro-
vided for by an amendment of the charter of the
city.

2. When organized the Department should create
"Hospital Districts," the division of territory being
based on the population of the laboring or tenement-
house classes and the sickness-rate.

3. The following public hopitals should become
"Emergency Hospitals," with properly assigned
districts, viz., Gouverneur, Bellevue, Harlem, Ford-
ham. In furtherance of this plan, the proposed New
Bellevue Hospital, to accommodate 2,000 or 3,000
patients and to be built at a cost of upwards of
$12,000,000, should be discarded, and an Emergency
Hospital should be constn.icted there on the plans
above given, to accommodate 600 patients. The
remaining grounds should be sold, the income of
which would construct the proposed Bellevue Emer-
gency Hospital and provide a Convalescent Hos-
pital. This plan would save to the city, not only
the $12,000,000 for the greater Bellevue, but, as
seen in paragraph (5), also the S7.000.000 for the
extension of hospital accommodations on Black-
well's Island.

4. In providing Emergency Hospitals for dis-
tricts where none now exist, the Department of
Hospitals should endeavor, first, to arrange with
any private, well-equipped hospital in that vicinity,,
by suitable payment for the care of public patients,,
to become the "Emergency Hospital" of that dis-
trict. There are a large number of private hospitals-
which would gladly accept that position and thor-
oughly perform its duties, if they could be com-

Jan. 5, 1907]

MEDICAL RECORD.

pensated adequately, thus saving to the city the
enormous cost of erecting, equipping, and managing
its own hospitals..

5. One or more "Convalescent Hospitals" should
be at once created on ample farm lands located on
the water front within easy access of the city. When
such a hospital is ready for occupation the inmates
of the hospitals on Blackwell's Island should be re-
moved as they convalesce to the "Convalescent Hos-
pital," and these Island hospitals should be con-
verted into infirmaries for the incurables and other
classes in that Department of Charities. By this
change the $7,000,000 required for the additions to
these buildings for hospital purposes would be saved
to the city, and the accommodations of the Depart-
ment of Charities would be greatly improved.

6. The "Special" and "Contagious Diseases"
Hospitals would take their proper places in the sys-
tem of hospitals organized by the proposed Depart-
ment of Hospitals, and their location, organization,
and management would be in accordance witli the
latest teachings of science and experience.

300 Central Park West. Z

REPORT OF TWO CASES OF DEMEX^TIA

PARALYTICA, ONE ASSOCIATED WITH

A LARGE HEMORRHAGIC LESION,

THE OTHER WITH ATROPHY

OF THE OPTIC TRACT.

By JESSIE WESTON FISHER, .M.D.,

MIDDLETOWN. CONN.
PROM THE LABORATORY OF THE CONN. HOSPITAL FOR THE INSANE.

Though medical literature abounds in discussions
of dementia paralytica in all its phases, few cases
are recorded associated with gross focal lesions of
the brain.*

Case I. — A. C, a well-developed male probably
forty-eight or fifty years old, was arrested by the
police for disorderly conduct and intoxication about
two weeks prior to his admission to the Connecticut
Hospital for the Insane, but subsequently it was
ascertained that he was insane. No information
was obtained in regard to his family or personal
history, or the psychosis up to the time of his arrest.
Upon admission to the hospital, and during resi-
dence there, he presented symptoms of the ex-
pansive form of dementia paralytica, accompanied
by considerable deterioration. His memory was
markedly impaired. His train of thought was de-
sultory and he talked incoherently, never reaching
a goal idea, and presenting many rapidly changing
delusions of grandeur. His emotional state was one
of elation in accord with his expansive delusions.
He sat around the ward happy and contented, sing-
ing softly to himself, absolutely oblivious of his
environment, or of his personal needs.

Physically, there were marked ataxia, Romberg's
symptom, tremor of tongue, eyelids and facial
muscles, exaggerated patellar reflexes, faulty articu-
lation, and equally contracted pupils, which re-
sponded sluggishly to light and accommodation. At
the end of a year he was more markedly deteriorated
mentally, the patellar and deep reflexes were appar-
ently abolished, the pupils were equallv contracted
but irresponsive to light or accommodation, and he
was unable to stand alone. He laughed and sang
happily the greater part of the night, but was gen-
erally quiet and stupid during the day. He de-

*The two cases here reported were on the service of
Dr. A. B. Coleburn, to whom we are indebted for valuable
notes. I wish also to express my grateful appreciation to
Dr. A. R. Diefendorf for report of autopsy and suggestions.

mented rapidly in the next few months, and ground
his teeth together hours at a time until they were
worn down to the gums, causing much laceration
and swelling. From this time on he would lie in
bed, softly crooning to himself, unmindful of his
personal needs or of his environment.

Fig. I. — Case I. a. Indicates the anterior tip ol the lesion in the
left side.

About one year before his death there was ob-
served a progressive paresis of the muscles of the
right forearm, accompanied by increasing contrac-
tures. This gradually extended to the upper arm,
to the left arm, and both legs, so that at the time of
death, three and a half years after adinission to the
hospital, the arms were strongly adducted with
flexed forearms, while the legs were firmly flexed
upon thighs, and thighs upon the abdomen.

.\n autopsy was performed some fifteen hours
after death. The brain weighed 1,115 grams, and
presented general cerebral atrophy, chronic lepto-

^^r^^ A

.«^^^^^^^^H

^^B

K/ ^ ^

^^^H^ 1 ^. '

/^^k

I^K^sv ~ al^^L.

^Ijf

Fig. 2. — Case I. a. Note the marked dilatation of the left ventricles
and the reduction of the caudate nucleus.

meningitis, and edema of pia. The left hemisphere
of the cerebrum was slightlx' reduced in bulk, with
a corresponding reduction of the right cerebellum.
The frontal lobes were adherent. The cord pre-
sented calcareous placques in the pia. Frontal sec-
tion of cerebrum revealed marked dilatation of the
anterior horn and body of the left lateral ventricle.
The posterior horn of the left, the entire right, and
the third ventricles were moderately distended, and
the ependyma of all presented marked granulations.

MEDICAl. RECORD.

[Jan. 5, 1907

The corona radiata of the left hemisphere presented
an area of hemorrhagic degeneration measuring in
frontal section anteriorly 4 cm. by i cm., and
about 6 cm. by ^ cm. at the broadest portion. It
began just anterior to the tip of the anterior horn
of left ventricle, extending posteriorly to the dor-

FiG. 3. — Case I a. Shows the lesion almost encircling the lateral
ventricle, which is markedly dilated. Also note dilatation of right
and third ventricles.

sal extremity of the caudate nucleus. It was
located above, below and external to the ventricle,
forming almost a half circle around it. The cau-
date nucleus was much reduced in size, especially
in the middle third, where it was so attenuated as
to be scarcely recognizable. The lesion was grayish
in color, and very spong)'. Microscopically, it was
composed of vacuoles surrounded by a compact
mass of fine fibrils, with an increase of neuroglia
cells. It lay in apposition to a similar, though much
smaller lesion, involving the cortex, as well as some
subcortical tissue of the external portion of the gyrus
rectus. The structures involved in the larger lesion
were the left caudate nucleus, the corona, lying
adjacent to the external wall of the anterior horn
and body of the lateral ventricle, as well as the
anterior limb of the internal capsule.

Microscopical examination of the cerebral cortex
showed the characteristic vascular changes of de-
mentia paralytica. The right and left paracentral
regions were studied, but tlie most marked changes
were observed in the right and left first frontal con-
volutions. The corte.x was everywhere atrophied,
many cells having fallen out, while the others were
crowded irregularly together. Neuroglia cells were
generally shrunken and deeply stained, but not in-
creased in number. The blood-vessels were increased
in number, showing periarteritis, with infiltration of
the adventitia by small, round cells, plasma cells, and
mast cells. Stabchenzellen (red cells) were numer-
ous in the vicinity of vessels. The contour of the
small nerve cells was irregular, very few processes
being traceable. The chromatic substance presented
a fine network of partially-stained fibers. The nu-
cleus was not always centrally placed, and was often
distorted and deeply stained with nucleolus fre-
quently seen at the periphery. There was marked
central chromatolysis of the Betz cells, with staining
of the achromatic substance, accompanied by a
pigmentary deposit at base of cell and vacuolation
of nucleus.

The spinal cord presented arteriosclerosis, with
marked degeneration of fibers of the right-crossed
pyramidal tract, with moderate degree of degenera-

tion in the left direct pyramidal tract, and in the
column of Goll on both sides.

Case II. — J. \V. This patient, was a well-devel-
oped, temperate Irish laborer. Syphilis was denied,
and family and personal history were negative up to
his thirty-eighth year, when he suddenly lost the
sight of both eyes, about which occurrence nothing
more definite could be learned. There was no men-
tal change noted for seven years after the loss of
vision. At this time he had a "shock," which was
said to have affected his hands and speech. He was
mute for about an hour, after which his speech was
stuttering in character. His insanity came on grad-
ually following this "shock," and was characterized
by insomnia, defective memory, irritability, talka-
tiveness, excitability, and violence.

He was admitted to the Connecticut Hospital for
the Insane, September 26, 1902, nearly eight months
after the so-called "shock," and over seven years
after the loss of vision. At the time of admission he
was totally blind, except for the distinction between
light and darkness. No hallucinations were elicited,
but he was completely disoriented. His memory was
seriously impaired, his thought was apparently very
limited, and his replies were irrelevant and incoher-
ent. No delusions were elicited during his residence
in the hospital. Emotionally, he showed slight oscil-
lations with predominance of depression, but voli-
tionally he manifested no marked change.

Physically, he presented almost complete blind-
ness, shuffling gait, Romberg's symptom, stuttering,
explosive, and indistinct speech, tremor of eyelids,
tongue, and fingers, active superficial reflexes, a
moderate Babinski sign, and active patellar reflexes.
He continued in much the same condition for a cou-
ple of months, when he became very restless, and
frequently groaned as if in pain, but when ques-
tioned denied any uncomfortable sensations. His
intellect was markedly deteriorated, and he showed
considerable physical impairment, with incoordina-
tion, especially of the leg muscles.

Five months later the patient gave evidence of
extreme pain by groaning, moaning, and moving
restlessly from side to side. The next morning he
was found in a semicomatose condition, with hands,

Wfr ' %'~''' ^^I^^I^B

1 1

Fig. 4. — Case I. a. Note the reduction in size of the lesions and the
reappearance of the caudate nucleus.

arms, and legs twitching continually, and eves turned
to the left side. The muscular twitching subsided
during the day, but he never regained consciousness,
dying at 6 p.m. February 27, 1903, about one year
after the so-called shock.

The autopsy was performed five hours after

Jan. 5. 1007

MEDICAL RECORD.

death. Aorta and coronaries were sclerotic. About
3 cm. above the aortic valve there was adherent to
the atheromatous vessel w-all, a globular thrombus
2.5 cm. in diameter, which nearly occluded the
lumen of the vessel. The thrombus was composed
of a mixed clot, elsewhere the aorta, while atheroma-
tous, was free of clots, but the mesenteric artery
about 3 cm. from its origin contained a thrombus
about 3 cm. long, firmly adherent to the vessel wall,
with beginning necrosis of intestine.

The dura was free, but the frontal lobes were
adherent. The pia was everywhere thickened, more
especially over the motor, frontal, and temporal re-
gions. The same areas showed shrinkage of the
convolutions. The vessels at the base were sclerotic,
but there was no external evidences of cerebral
hemorrhage or embolism. The brain weighed 1.437
grams. The floor of the fourth ventricle was
slightly granular. Frontal section was made one
month after autopsy, when slight dilatation, with
marked granulation of ventricles, was found. There
was atrophy of both optic nerves and tracts, and
the lateral geniculate bodies of each side were about
one half normal size. These were brownish green

Fig. s. — (,ase I. a. Showing only the extreme posterior tip of the
lesion. The dilatation of the posterior horns of the lateral ventricle
IS nearly identical.

in color, and the white laminae were completely
absent. The superior corporaquadrigemina were
somewhat reduced in size, and the superior colliculi
were entirely absent.

Microscopically the right paracentral lobule
(stained by Nissl's original method), showed the
pia thickened and infiltrated with small, round cells.
Immediately beneath the pia a few corpora amvlacea
w-ere seen. The vessels were increased in number,
their walls being much thickened, and the adventitia
infiltrated with small round and plasma cells with
much pigmentation. Stiibchenzellen (rod cells)
were numerous in vicinity of vessels. The neuroglia
cells were not increased in number, but their nuclei
were shrunken. The neuroglia fibers were increased
in the first layer. The regular arrangement of nerve
cells was lost, and they were crowded together, the
intercellular substance being much reduced. The
small nerve cells were normal in shape, but some-
what irregular in contour from retraction between
the processes, which were traceable but a short dis-
tance. The cytoplasm was composed of a fine, irreg-
ular reticulum of slightly stained fibers with many
vacuoles. The nucleus was shrunken, deeply
stained, and often triangular. The nucleolus was
frequently seen at the periphery of the nucleus and
was very deeply stained. The Betz cells were

shrunken, the contour irregular from retraction, and
the processes were not traceable. The chromatic
substance exhibited no granules, except near the
apical process. The achromatic substance was
stained, giving a homogeneous appearance to the
cell. The nucleus was shrunken, elongated, deeply
stained, and the membrane thickened. The nuclear
cap was very prominent and the nucleolus deeply
stained.

Frontal section, as well as the left paracentral
lobule, showed an increase in the number of neu-
roglia cells, the presence of many satellite cells, and
the "rassen" formation of Nissl ; otherwise the sec-
tions closely resembled those of the right hemi-
sphere. In the cord there was a degeneration of a
large number of fibers in the crossed pyramidal tract
of the right side, the cervical and lumbar regions
suffering the miost.

In the first case there were no unusual symptoms
until about one year previous to death, when con-
tractures of the right side were noted, beginning
with the hand, but gradually involving the arms and
legs of both sides. The absence in this case of any
history of shock, or any symptoms pointing towards
a focal lesion, leave us in the dark as to the primary
affection. Whether the hemorrhage antedated the
mental symptoms, or appeared during the psychosis
and was masked by it, is impossible to say.

In the second case, however, the sudden blindness,
"shock,'' and dementia rather inasked the symptoms
of general paresis, so that there was some doubt as
to the diagnosis before autopsy.

The duration of the disease does not seem to have
been afifected by the focal lesion, nor did it color the
picture to any great extent in the first case.

THE INTESTINAL BACTERIA; HOW THEY
ACQUIRE TOXICITY, AND HOW TO
DETERMINE THIS EXPERIMEN-
TALLY FOR CLINICAL
PURPOSES.

By E. PALIER, M.D.,

NEW YORK.

In Spite of the fact that a great deal has been writ-
ten on the common intestinal bacteria, we are prac-
tically not much the wiser. We know that ordinarily
the intestines contain numerous microbes, which
may become harmful to the system, but the ques-
tion is whether the same microbes of the intestines
which are ordinarily harmless may become injuri-
ous, and if so under what conditions ; or whether
they cannot, and the harmful microbes are new-
comers and are derived from other sources.

This most important question has not been
answered clearly and definitely, but vaguely and
guessingly. We often hear such exnlanations as
lowered resistance or vitality, which are simply
empty phrases, as we are not told in what the low
resistance consists, how it is brought about, or how
to prevent it. Such phrases make matters still more
obscure, and those who do not wish to deceive them-
selves or their fellow men by using words without
meaning, had better not use them at all. In this
paper the writer will attempt to answer this ques-
tion clearly from experimental facts.

First, however, it is necessary to know what bac-
teria are usually found in the intestines of man. An
exhaustive treatise on this subject is given by Prof.
Mannaberg.' It would be improfitable to discuss
here at length a subject that has been already so ably
discussed,

A great many microhic species are said by inves-

8

MEDICAL RECORD.

[Jan. 5, 1907

tigators to have been isolated from the intestines,
t. e., the feces, as the bacteria are usually studied
from the feces, and it is assumed that naturally they
represent those of the intestines. This is so if proper
precaution is taken to prevent the contamination of
the feces by the bacteria from the container, the air,
etc. In all probability .some of the discrepancies in
the findins^s of some authors are due to such con-
taminations.

The following- bacilli are said by investigators to
have been found in the intestines, /. c, feces of man :
(a) Bacillus coli or some of its congeners, like the
B. lactis (rroi;ciu's: (b) B. siibtilis; (c) B. mesen-
tericus z-iilgaris; (a) B. butyricus. and (c) some
other species. All investigators agree that the coli
bacilli are constantly found in the intestines of
man, even in those of young infants, and they have
been found even in the meconium of newly born
infants. It is a polymorphous organism, and accord-
ing to Mannaberg the same microbe has been redis-
covered under different names, with which I fully
agree. I shall revert to it soon again. The other
bacilli mentioned above are admitted not to be con-
stant hosts of the intestines, but are found now and
then, .\naerobes are, of course, found now and
then : but the statement made by some that they are
constant hosts of the large intestines is not true.

As to cocci, investigators agree that in one form
or another they are also constantlx found m the
feces.

I have made a number of examinations of the bac-
teria of the feces, and in some cases the gastric
contents of the same individuals were also exam-
ined chemically and bacteriologically. Tn cases
where the gastric juice was normal, or in hvperchlor-
hvdria. the only microbes I found in the feces in
cultures were the coli bacilli and cocci, and in some
cases of hyperchlorhydria an organism resembling
the Oidhtm lactis. but which took the Gram stain,
and fungi w-ere also found, but none of the other
bacilli mentioned before claimed to have been found
bv other authors. Several examinations of the feces
of the same individuals at intervals gave nearly the
same results. Tlie authors, who claim to have made
investigations of the intestinal bacteria, fail to state
whether or not they examined the stomach contents
of the same individuals.*

I have treated elsewhere of the bacteria which are
likely to be found in the various conditions of the
stomach, and it would be unprofitable to dwell on
this subject here. Some investigators seetu, how-
ever, either to he unaware of these findings or to
neglect them entirely. I wish, therefore, to repeat
here briefly and emphatically, that in a normal human
stomach after a light meal, the only bacteria that
can be found is yeast, and in hyperchlorhydria, espe-
ciallv when accompanied with alimentary stasis,
there may be found in addition a small bacillus
named by the writer, the bacillus chlorhydrici, and
also sarcinre, and sometimes fungi." But no other
bacilli are fonnd as a rule in such conditions of the
stomach. t In achlorhydria. where the gastric juice
exerts little or no germicidal powers, other microbes
can be found in the stomach, and the bacterial flora
in the intestines are also apt to be richer, and in some
cases they are.

It must be stated emphatically that many microbic

* Some authors describe microbes which they did not
isolate in cultures, but which they claim to have seen in
smear preparations. This is. of course, ridiculous, as one
can never identify microbes except in cultures.

■^ .An investigator recently claimed that ulcer of the stom-
ach is caused by the coli bacilli. Tf that investigator had
examined conscientiously the human stomach he would not
have made such an absurb claim, as in ulcus ventriculi
there is usually hyperchlorhydria.

species are never found at the same time in one nat-
ural medium. The writer has carefully examined
the sputum, the gastric juice, and the feces, and he
states positively that very seldom are more than
four species of microorganisms found at one time
in any of those natural media, and most frequently
there are only two or three. It stands to reason that
many species cannot grow together in the same
medium, as the slowly growing ones are necessarily
destroyed by the fast-growing. This is a well-
known biologic law. and we see it all over in nature.

The coli bacilli and the cocci which are found in
the intestines of individuals whose stomachs are nor-
mal, or in a state of hyperchlorhydria are probably
old inhabitants, having found their way perhaps
soon after birth, before the gastric secretion was
fully established. For, though repeated examina-
tions of the stomach contents did not show any such
microbes, yet they were found in the feces of the
same individuals. In the feces of a suckling infant
ten weeks old. e.xamined by the author at that age,
and a month later, each time only coli bacilli and the
same cocci were found. There were no other bac-
teria at the second and third examinations ; evidently
the stomach of the infant does not allow the passage
of new bacteria. This may happen, however, under
certain conditions, when the stomach is overtaxed
or otherwise greatly disturbed. But it would appear
that such an occurrence is the exception rather than
the rule.

But as for the feces, admitting even that besides
coli bacilli and cocci there may be found now and
then some of the microbes referred to above, such as
B. siibtilitis, B. meseiitericus z'ulf^aris, etc.. as they
are nonpathogenic, their presence is practically of
no importance. We thus have to deal with only
two microorganisms which are constantly found in
the feces, and which may become pathogenic, and
these we shall consider here.

We shall first take up the coli bacilli. The mor-
phology and cultural peculiarities of this microbe
have been sufficiently described in standard works,
so they need not be treated here. But as to the viru-
lence the status of the colon bacillus has not been
clearly established. We know that it is sometimes
virulent and sometimes it is not. Thus, according to
Lesage and Macaigne,^ the microbe in question is
nonvirulent when taken from healthy intestines,
but when the intestines are affected, when there is
diarrhea it is found to be virulent. The question to
be decided is whether the nonvirulent colon bacillus
may become virulent, and if so under what condi-
tions; or whether the virulent and the nonvirulent
coli bacilli are two difterent microbes, derived from
different sources. Furthermore, it has not been
proven to us whether the virulent coli bacilli
found in diarrhea, as stated bv Lesage and Ma-
caigne. are the cause of the diarrhea or the effect of
it. This question will be answered from the follow-
ing facts :

In studying the feces of mice and rats the writer
has always found in them cocci and coli-bacilli, or
someof their congeners. The same microbes were also
found in the intestines and in the stomach of these
animals. It has been said in the stomach, which is
not the case w-ith normal stomachs of human beings.
The stomachs of mice and rats contain hardly any
hvdrochloric acid, as was shown repeatedly by ap-
l)iying the usual tests for HCl : therefore, the above-
mentioned microbes can be found in it. whereas
they cannot thrive in a stomach containing a nor-
mal amount of HCl.

Now, by injecting into mice intraperitoneally
fresh agar cultures of coli bacilli and cocci obtained
from the feces of mice fed on bread and water, there

Jan. 5. 1907]

MEDICAL RECORD.

was no effect at all. Some time ago, however, the
writer isolated coli bacilli from a dead mouse, and,
by injecting into mice intraperitoneally small doses
of such an old agar culture, the mice thus injected
invariably died within twelve hours. A fresh cul-
ture was then made from the three-months-old one,
and the fresh one, when it was only two days old,
was injected into mice, and, to the writer's surprise,
the new culture did not act as did the old one. Of
five mice injected, three died in about eighteen
hours, on one there was no effect at all, and one died
in four weeks.

It is interesting to say a few words concerning the
last animal. There is, as a rule, an inflammatory
state of the peritoneum and intestines of animals
dying from the injection of virulent coli bacilli. The
last-mentioned mouse was unwell all the four wrecks,
as w'as evidenced from its apathy and its apparent
weakness in the hind legs. After its death its ab-
domen was greatly distended, and on dissection the
intestines and stomach were greatly distended with
gas, and were very thin, appearing like big soap
bubbles ; but there was also an inflammation of the
peritoneum, the intestines, and the stomach, and the
bubbles were greenish, and in spots reddish. The
same condition may occur in human beings in
chronic aft'ections due to the coli bacilli.

Coli bacilli are, as a rule, found in the blood of
dead mice, and also in other animals, some hours
after their death, no matter what the cause of death
may be. Frequently there are also found in the
blood of dead mice cocci . which have been dealt with
by the writer elsewhere.^ Now, the coli bacilli from
dead mice have always shown a great virulence.
They evidently enter into the blood of the dead ani-
mals from the alimentary canal, and not from the
air, because frequently they are the only bacilli pres-
ent, no other bacilli usually found in the air being
present, except, of course, when decomposition has
already fully set in.

The same microbe, then, which is nonvirulent
when obtained in cultures from the feces of a healthy
animal fed on bread and water only, is virulent when
obtained from the blood of the same animal when
dead.

It is frequently stated that during life certain
antibodies serve to mitigate or to diminish the
virulence of bacteria. How far this is correct in
general it would be out of place to discuss here.
But it certainly cannot explain why the coli bac-
illi obtained in cultures from feces of mice fed
on bread are nonvirulent, as the feces are just as
much dead matter as the dead body of the mouse,
and the former can no more form antibodies than
the latter. The explanation we shall see immedi-
ately. It has been referred above to the feces of a
healthy suckling infant studied by the writer. The
feces, as has been said, contained coli bacilli and
cocci. The former differed slightly morphologically
from those found in dead mice, in that they were
bigger ; otherwise they were alike. The cocci were
diplococci, and some of them fomied short chains of
from four to eight individuals, resemblingshort strep-
tococci. Now, on injecting intraperitoneally into
mice two days old agar cultures containing both the
coli bacilli and the cocci, obtained from the feces of
the infant in question, no effect was produced. The
same was repeated at an interval of a month with
fresh cultures, from fresh feces, with the same re-
sults. The idea suggested itself to me that the non-
virulence of the coli bacilli obtained from the feces of
mice and from that of a suckling infant was due to
the fact that such feces are deficient as a nutritive
medium, and that the coli bacilli, in order to attain
virulence, must have a medium of dead flesh.

To test the matter, the following exneriment wa;-
made : A piece of butcher's meat was boiled for
about half an hour ; then it was put into a test tube,
and to this was added normal gastric juice, and left
for a few hours. This was done to destroy the bac-
teria of the meat and to imitate what takes place in
the stomach. Before the meat was fully digested
the gastric juice was poured off and sterile water
added. Then were added a few loopfuls of a fresh
culture from the feces of the infant, which culture
contained coli Dacilli and cocci, and were nonviru-
lent. .\t the end of tliree days an agar culture was
made from the test tube containing the meat and
sterile water, to which bacteria from the infant's
feces had been added. This new agar culture con-
tained again coli bacilli and cocci, and these were
injected into mice, and it caused their death in six-
teen hours. The same mice which had not been
aft'ected when injected with a culture obtained from
the feces of the infant ( which we shall call culture i )
died when injected with a culture obtained from the
test tube of meat, and the latter culture was an
offspring of the culture i. Evidently a nutritive me-
dium of flesh enables the coli bacilli to acquire viru-
lence.

Furthermore, when culture i was two weeks old
it was tested again, and this time it was found to
have an eft'ect on a mouse, causing its death in
twenty hours. Indeed, gelose is practicallv also dead
flesh, but evidently it takes some time for the viru-
lence of the coli bacilli to develop in this medium,
but it is accomplished much quicker in the bodv of
a dead animal.

From the above facts and from others, which will
be referred to soon, the writer considers it justifiable
to draw the following conclusions : That a flesh
medium enhances the virulence of the coli bacilli,
and that in agar, older cultures are, on the whole,
more virulent than fresh ones. This latter statement
is not in accord with what w-e know about soine other
m.icrobes, particularly diplococci and streptococci,
which behave differently, nor is it in accord with the
statements found in some books, that fresh two-
days-old cultures are more active ; but such were the
findings of the writer, and so he records them.

I have also studied the feces of adults, and will
briefly describe three cases.

C.-vsF. I. was that of a man of 56, who suff'ered
from, gastrointestinal trouble. He had vomiting and
diarrhea a few months previous to his coming under
the writer's observation, but he improved under
treatment. When the w'riter saw him he had no
more vomiting, but he had from three to five evacu-
ations from the bowels daily. The patient was ema-
ciated, had little appetite, and what troubled him
most was flatulence. Gaseous distention of the in-
testines appeared in circumscribed places, simulating
a phantom tumor, but there was no real tumor. An
examination of the stomach and its contents showed
seme atony accompanied with hyperchlorhydria and
hypersecretion. A bacteriological examination
showed yeast and the bacillus chlorhydrici and also
some sarcina; and fungi, but no other bacteria. The
feces were semisolid, very offensive in odor, and
contained numerous gas bubbles. The feces rose in
the container like fermenting dough. Microscopical
examination of the feces showed nothing of special
importance. Bacteriological examination yielded in
cultures coli bacilli and cocci. A six-weeks-old agar
culture of this feces injected into a mouse caused its
death in twelve hours. Then the coli bacilli were
isolated from the cocci and a two-days-old agar cul-
ture of the former injected into a mouse caused it?
death in twenty hours. This was evidently a case of
enteritis due to the colon bacillus. What is impor-

10

MEDICAL RECORD.

[Jan. 5, 1907

tant to note in this case is that the stomach contents
did not contain any coh bacilH nor cocci, though they
were examined several times very carefully.

Case II. was that of a man of 40 suffering from
chronic duodenal catarrh, with flatulence, and a
tendency to diarrhea. There is occasional hyperacid-
ity of the stomach, but the motility of this organ is
good. Cultures from the feces yielded coli bacilli,
cocci, an organism resembling the oidium lactis, but
which was Gram positive, and also fungi. An in-
jection of the same into a mouse caused its death in
twenty hours, and in the blood of the mouse were
found only coli bacilli.

Case III. was that of a woman 35 years old, ap-
parently in good health, with rather costive bowels.
This woman had typhoid fever at the age of 16
years, from which she fully recovered, and has been
apparently in good health since. She is a heavy meat
eater. The feces have a very disagreeable odor. An
agar culture therefrom yielded coli bacilli and cocci,
which caused the death of a mouse in twenty-four
hours.

Cases I. and II. are also meat eaters. Now, from
what has been said above, it appears that under a
meat diet the coli bacilli of the intestines are most
likely to become virulent. This is especially the case
when some of the ingested meat happens to pass
through the stomach and duodenum indigested so
that it affords a good nutritive medium to the coli
bacilli. Once the coli bacilli become virulent, they
will, in their turn, cause injury to the intestines, and
so the pathological process will go on. Under a milk
or a vegetable diet some injury may also occur to
the intestines from the ingestion of too much food
or too irritating food, and the nonvirulent coli bacilli
mav thus settle at the injured part, thrive there as
on dead flesh, and thus continue the pathological
process.

I was able to produce sloughing experimentally in
this way. The tails of mice were squeezed with for-
ceps and allowed to drag in their own feces in the
jar. The tails began to slough away, and the bac-
teria found on the sloughing tails were those of the
feces, /. e., the coli bacilli and cocci. If a clean bed
is given to an animal the sloughing discontinues and
the tail heals. Thus the injured tail afifords a nidus
and also nourishment for the coli bacilli of the feces,
and endow^s them with some virulence, as they are
not virulent when injected into the very same ani-
mals intraperitoneally. But healthy tails of mice,
allowed to drag in their own feces, are not affected.
Thus, in diseases of the intestinal canal due to the
coli bacilli, these bacilli need not necessarily be new
intruders, but the old. umocent bacilli may under in-
discretion in diet become virulent and pathogenic.
Indeed, it has been said that meat eaters are more
subject to appendicitis than vegetarians. I quote the
following: "Freedom from Appendicitis. — Dr.
Nicholas Senn has made an interesting observation
while visiting the hospitals in towns on the east coast
of Africa. The physicians in those institutions in-
formed him that they had never seen a case of ap-
pendicitis among the blacks The relax-
ing effect of climate, laziness, and a fruit and vege-
table diet would seem to oft'er the best explanation
of this immunity."'^ How far climate and laziness
can have any efTect on the intestinal bacilli the writer
cannot sav, but the effect of diet was shown above.

According to some investigators quoted by
l\ot\ma^e\ ' (Erkraiiktingen dcs Darins mid des
Peritoneum, p. 682) most of the cases of appen-
dicitis are due to the coli bacilli. The same can be
said of the affections of the biliary ducts. If we
examine the feces of animals living on a vegetable
diet, like those of mice fed on bread only, and of

cows and horses, and of healthy nursing infants, it
will be noticed that there is hardly the offensive odor
of the feces of the carnivora like cats and dogs, and
of adults partaking of meat, though coli bacilli are
found in the feces of all those mentioned. It is be-
cause indol, skatol and phenol are not formed in the
healthy intestines on a milk diet and a vegetable diet,
to any appreciable extent, as they are on a meat diet.
The poisonous products of the coli bacilli are evi-
dently less on a diet of the former than on the latter.

The above is said, not with the view of condemn-
ing a meat diet entirely, but to show that as far as
the coli bacilli are concerned, their virulence is apt to
be enhanced by such a diet. How other pathogenic
bacteria are affected by it is a question yet to be
answered.

Virulent coli bacilli also contain an extra cellular
toxin, which they secrete into the medium in which
they develop, and hence there may be an autointoxi-
cation derived from the intestinal canal.

I shall now say a few words concerning the cocci.
A great many varieties of these are said to have been
isolated from the feces. As the writer found them,
they were usually like those in the feces of the
suckling infant mentioned above. They appear
usually in the form of diplococci, or form short
chains. Sometimes they appear as staphylococci, and
in this form they are usually found in the feces of
mice. Pageand" doubts whether they can cause dis-
ease at all, as he found them in the feces of healthy
suckling infants, and they were not virulent to mice.
That is exactly my experience. Furthermore,
whereas the coli bacilli, as was stated before, ac-
quired virulence by passing through meat, the cocci
did not. By injecting such cocci alone into a sus-
ceptible animal, like a mouse, the animal is not
affected. If we inject such nonvirulent cocci,
together with virulent coli bacilli, the animal dies,
but neither in smear preparation nor in cultures from
the blood of the dead animal can cocci be found. In
such cases only coli bacilli are found. If, however,
w-e inject both virulent diplococci and coli bacilli,
both of these microbes can be recovered in cultures
from the blood of the dead animal. When such
microorganisms are injected into a mouse intraperi-
toneally, the animal usually dies in eight hours, and
frequently the cocci cannot be seen in smear prep-
arations, but they can be recovered in cultures from
the blood of the dead animal.

The cocci obtained from the feces of the other
cases seem also to be devoid of virulence.

Thus there seems to be a difference between the
cocci obtained from the human sputum and those
obtained from the feces. In the former they are,
as a rule, somevidiat virulent, which vindence can
be enhanced by their passage through a susceptible
animal like the mouse ; but in the latter they seem
to have lost their virulence entirely, and it cannot
be restored. As to the coli bacilli the case seems to
be reversed ; they are more frequently found in a
virulent fomi in the feces than in the sputum.

Though it is generally admitted that the coli ba-
cilli are in most cases responsible for appendicitis, yet
in some cases cocci, mostly diplococci and strepto-
cocci, are found alone in this affection. In such
cases the trend of opinion is that the virulent cocci
gain entrance through the blood and not from the
intestines, and the writer is also inclined to this
belief. Furthermore, the affection in question some-
times occurs endemically. Thus Galubow" reported
an epidemic of appendicitis in Moscow in the spring
of 1896; Louenburg. in the spring of 1899 •" ^ '^^^'
tain section of Berlin, and similar reports are made
bv others. It is noteworthy, however, that these re-
ported epidemics occurred in the spring and winter

Jan. 5, 1907]

MEDICAL RECORD.

ir

months, when pneumonia is most prevalent, and not
in months when gastrointestinal diseases are preva-
lent. The writer has elsewhere brought proofs to
show that mice which are very susceptible to the
pneumonia bacilli are responsible for this affection.
Mice, in fact, are very susceptible to all kinds of
cocci, and also to B. coli, which latter are enhanced
in virulence on passing through the mice. The
writer has furthermore proven that these animals
are more abundant in houses at certain seasons, and
that by their decomposing bodies after their death,
or through their feces when they are sick, they are
apt to spread very virulent germs. Are not mice
the cause also of the local outbreaks of appendicitis,
and in fact of most, if not of all, virulent cocci in-
fection? This question is of sufficient importance
to be taken up by investigators and to be decided
one way or another.

I shall now say a few words concerning the
method of testing the virulence of the intestinal bac-
teria : Obtain some feces, for obvious reasons bet-
ter at the end of defecation, in a sterile container.
Then make two cultures, one in glucosed agar by
stab and one on agar slant by smear, and put them
into the incubator at 38° C. for forty-eight hours.
In hot summer weather the room temperature is
sufficient. Make smear preparations of the cultures
and stain by Gram and a counter stain like eosine.
By examining the cultures and the smear prepara-
tions therefrom, one can usually see what bacteria
there are. As the writer has said, in most instances
there will be found Gram positive cocci and coli
bacilli, the latter, of course. Gram negative. There
is no necessity to make cultures on plates, and to
isolate the bacteria, as this is a rather tedious process,
and not easily applicable to clinical purposes. The
easiest and simplest methods are the best. Then
take an ordinary loopful of a platinum wire needle,
the size of a small drop, that is, about a twenty-fifth
of a c.c, either from the stab culture, if the growth is
sufficient, or from the slant culture, or from both,
and dissolve in 2 c.c. of sterile water, and inject the
whole of it intraperitoneally into a mouse. If the
animal happens to be small, half of it should be in-
jected.

If the animal does not die, the bacteria are non-
virulent. If the cultures contain both virulent cocci
and coli bacilli, the animal dies in about eight hours.
Virulent coli bacilli alone will kill in from twelve to
twenty-four hours, depending on the degree of viru-
lence. If one wishes to go a little further, the mouse
should be dissected and smear preparations from the
blood of the heart and cultures therefrom should be
made. The dissection should be made immediately
after the death of the animal. If the smear prepara-
tions and the cultures contain only coli bacilli thev
are the only virulent microbes. If the injected cul-
tures contain also virulent cocci, in addition to the
coli bacilli, they can be recovered in the cultures from
the blood of the dead mouse, but are hard to be de-
tected in smear preparations, as the animal dies too
quickly after the injection. If one suspects virulent
cocci or anthrax bacilli, for instance, the injection is
better made subcutaneously, not intraperitoneally, in
which case death is not so sudden, and the bacteria
develop better in the animal. Of course one can use
two mice, one for intraperitoneal, and the other for
subcutaneous injection. As was said before, the
presence of cocci in the dead animal shows them to
be virulent, as nonvirulent ones are destroved in the
body of the animal and cannot be recovered.

By remembering what was said before, we can
conclude that the presence in the feces of virulent
cocci, particularly diplo- and streptococci, as shown
by the fact that they can be recovered from the dead

animal, denotes a localized point of suppuration
somewhere in connection with the intestinal canal,
for in simple enteritis the cocci are, as a rule, non-
virulent, and the process is due to the colon bacillus,
or some of its congeners.

This method is so easy and so simple of application
that there is no reason why it should not be used
very often, whenever there is reason for its use. In
affections which are said to be due to autointoxica-
tion from the intestinal canal, such as giddiness, neu-
ralgic pains, melancholia, etc., the toxicity of the
intestinal bacteria should be tested. As has been said
before, the ingestion of meat on the whole enhances
the virulence of the coli bacilli, and they may be
virulent in constipation as well as in diarrhea. In
fact, in chronic catarrhal conditions of the intestines
the two conditions are ant to alternate, and in con-
stipation the danger of the toxins being absorbed
into the system, as well as of localized affections,
such as diseases of the biliary ducts and of the ap-
pendix, are greater and more frequent than in diar-
rhea.

The quantitative analx'sis of bacteria is a tedious
and uncertain proceeding, and of little value. It is
their virulence that is of importance. The writer
has tried the injection of feces instead of cultures
therefrom, but the results are apt to be misleading.

The same method should be applied to testing milk
and other substances.

REFERENCES.

1. Mannaberg: Die Bakterien des Darms, Nothnagel's
Erkraiikungen des Darms iind des Peritoneum, pp. 18-44.

2. Vide: The Bacteria of the Stomach, Medical Rec-
ord, November 19, 1904. .\lso. The Bacillus Chlorydrici,
American Medicine. February 24, 1906, by the author.

3. Lesage et Macaigne : Archives de Medecine Experi-
mentale, IV, 1892. p. 350.

4. On Diplococci and Pneumococci, etc.. Medical News,
November 18, 1905 ; also illustrated article in Medical
Council. October, igo6.

5. Editorial in New York State Journal of Medicine,
October. 1906, p. 40S.

6. Quoted by Mannaberg in Nothnagel's Erkrankungen
des Darms, etc., loc. cit.

7. Galubow: .Berliner k-liniselie IVochenschrift, 1897,
No. I.

321 East Thirteenth Street.

AN ORIGINAL INVESTIGATION OF AN

EPIDEMIC OF GRIPPE. FOLLOWED BY

A LARGE NUMBER OF CASES OF

PNEUMONIA;*

WITH SPECI.\L REFERENCE TO THE INFECTIOUS N.\-

TURE AND PERIOD OF INCUBATION OF THESE

TWO DISEASES.

By ALBERT WOLDERT. M.D.,

TYLER, TEXAS.

I DESIRE herewith to record eight cases of croupous
pneumonia — pneumonia with consolidation (4 per
cent, of the entire population), and upwards of lOO
cases of grippe (or 50 per cent, of the entire popula-
tion), and occurring during a period of six weeks,
from February 14 to March 28, 1905, in a small
rural district, Messer (Smith County), Te.xas.

As for the infectious nature and period of incuba-
tion of these two diseases, I believe that a report of
these cases will be of special interest for the reason
that the locality in which they occurred is one in
which the inhabitants at this period of the year do
not intimately coine in contact with those living in
cities, and who by such residence might have become
exposed to more numerous sources of infection.
Dwellers in the larger cities mingle with each other

* .\n address read before the Smith County Medical
Society, held in Tyler, Tex., November 13, 1906.

12

MEDICAL RECORD.

[Jan. 5, 1907

to such an extent in public schools, parks, street cars,
carriages, hotels, hospitals, and apartment houses,
that the special focus, person, medium, or thing by
tvhich the infectious agent is spread renders the
determination of the period of incubation of an in-
fectious disease exceedingly difficult.

Of the 200 inhabitants of the above-named com-
munity the eight cases here reported were all those
of croupous pneumonia occurring within the six
weeks above noted. As far as can be learned there
was only one case of pneumonia which was reported
in this community during the corresponding period
of the previous year. It might be of interest to say
that during the corresponding period of the follow-
ing year (1906), there were only a few cases of
grippe (less than 10 per cent, of the population),
which occurred in this same connnunity, while not
one case of pneumonia occurred. While about one-
third of the population are colored, all of the eight
cases occurred in the white race.

The community of Messer is situated in East
Texas, and in a well timbered and well watered dis-
trict. The country is quite rolling in character, the
iiills being upwards of 200 feet in height, with grad-
ual slope in all directions. The soil for the most part
is composed of very red and gray sandy loam, with
clay subsoil lying as a rule within eighteen inches of
the surface. The climate, according to Cline, is be-
twen "low damp warm and low damp cold." Extend-
ing from north to south lies a small valley, and
traversing it in the same direction is the International
and Great Northern Railway. The area of the Mes-
ser communitv is about two miles square, and within
this area upwards of 200 people reside. The dis-
tance between the houses of the inhabitants ranges
from 100 yards to half a mile. Agricultural and
truck farming are the principal pursuits.

During the period from February 14 to March 28
the inhabitants had just begun to plow their lands,
and were preparing the soil for planting corn, cot-
ton, and vegetables. During this time the weather
conditions had been unusuallv variable, marked by
more or less sudden or sharp changes in the temper-
ature, with an abundance of ice upon the ground
and trees, and the soil was kept saturated with
moisture.

The dwelling houses for the most part are con-
,=tructed of pine lumber, one inch in thickness, while
others are composed of logs, the interspaces being
sealed with clay or pine boards. Many wide cracks
exist in the floors and sides of the houses. \\'ood is
the only fuel used ; it is burned in large open fire-
places. These houses are ill suited to protect one
against the icy touch of winter, and against sudden
changes in the temperature.

One interesting fact should be recorded here, to
wit. that during the previous fall, and throughout
the winter, grippe had been more or less prevalent in
this community. About March 7, 1905, grippe began
to rage and within a month thereafter probablv 50
per cent, of the population had suffered from this
disease. By April 3. 1905, it had almost subsided,
and by ]\Iav 3. both grippe and pneumonia had to-
tally disappeared. Therefore, in considering the in-
fectious nature of croupous pneumonia as it seemed
to have fKcurred in this community in the vear 1905.
it will be necessarv to observe the relationship which
seemed to exist between it and the grippe. The
writer is aware that inflammation of the lungs may
be induced bv other pathogenic microorganisms than
the diplococcus of pneumonia, such as the bacillus of
bubonic plague and tubercle bacillus, and is also
fully aware of the susceptibility to what is now
called '"croupous pneumonia" during an attack of

grippe. The relationship which seemed to exist
between these diseases will be considered subse-
quently in this article, first bv the study of the indi-
vidual cases of pneumonia, and later in the epidemic
of grippe.

In presenting this report I desire to say that I
hope that certain inferences, which now seem ten-
able, may be left open to me for proper revision and
correction, should such prove to be erroneous by
more complete researches on this subject. I believe,
however, that a rejjort of the cases will furnish ad-
ditional evidence of the infectious nature of the two
diseases — croupous pneumonia and grippe.

Cases numbered i to 8 under the head of "pneu-
monia" correspond to the same families numbered
I to 8 under the head of "la grippe." ,

Case I. — The first case of croupous pneumonia
which occurred in the Messer community developed
on February 21, 1905, in the person of W. R., a
boy nineteen years of age, who had during this
season been exposed to grippe, but not to croupous
pneumonia. On February 14 he had been out hunt-
ing when the ground was covered with snow and
ice. On the following day he had a cold and two
days later had a severe cough. On February 17
he had some fever, and two days later developed a
pain in the chest. He was examined on February
21, and lobar pneimionia was found. He was ill of
pneumonia for six weeks. The lower lobe of the
right lung was consolidated. There had been no
other cases of pneumonia in his family and no sub-
sequent cases of pneumonia developed after his
recovery. No other member of the family developed
grippe after his recovery from pneumonia. This
patient had grippe in Februarv. 1904, and measles in
.April following. No member of his father's or
mother's familv had ever previously suffered from
pneumonia.

C.\SE II. — The patient, Mrs. T. B. S., was a
woman, aged thirty-five years. She had not been in
the same room with a pneumonia patient for eleven
months. She was taken ill with grippe. February
27, but did not go to bed. Croupous pneumonia
developed March 6. the onset being ushered in with
a severe chill and high fever. When first seen by
the physician attending her on March 7 she was ex-
pectorating large quantities of blood. The tem-
perature ranged about 104° F. She was in the sixth
month of gestation, miscarried on March 9, and died
March it. The entire left lung and lower lobe of
the right lung were consolidated.

The patient had never previously had pneumonia.
Her brother, many years before, had suffered
from pneumonia, but had recovered. Her father
had at one time had pneumonia.

On the evening of March 7 or morning of 8 her
sister and her sister's child (aged eight years"), then
seemingly in perfect health, moved over to the pa-
tient's home to nurse her. On the third dav after
going to the patient's house this sister and child,
together with the patient's husband and daughter
(the latter. Case TIT.), fell ill of the errippe almost
on the same dav. The svmptoms in these cases
were cough, pains, throush the chest, fever, laryn-
gitis, and otitis media. The husband was sick one
week, and the others remained ill for two or three
weeks.

C.-\SE III. — This patient. M. A. S.. aged nine
years, was a daughter of the patient just mentioned
(Case II.)- She had been in the room with her
mother, who developed pneumonia on March 6.
.About March 9 she developed grippe, and on March
II or 12 croupous pneiunonia came on. the upper
lobe of each lung being consolidated. The patient

Jan. 5, iyo7_

MEDICAL RECORD.

13

had fully recovered on April 11. Her grandfather
on the mother's side had years before sulfered with
pneumonia, but had recovered. Her grandfather
on the father's side died with pneumonia in i88,v

Case IV. — The patient, Mrs. J. B., was a woman
aged 25 years. She had not been exposed to any
case of pneumonia. About March 5 she developed
grippe, but did not go to bed. Pneumonia developed
with a chill at i a. m., on the night of March 12.
When first seen she was expectorating large quanti-
ties of blood (temperature 104°), and the upper lobe
of each lung was consolidated. She had a miscar-
riage (sixth month of gestation), on Alarcli 15. and
died March 20. This patient resided about 200
yards distant from the home of her father's family
in which grippe was prevailing, nearlv every mem-
ber of the family suffering with it. She had made
many visits to this house during the time the inmates
suffered with the grippe. She had never before
suft'ered with pneumonia, and no member of the
family had ever had the disease.

Case V. — The patient, R. B., was a boy, aged two
years and two months, living with his mother ( Case
IV.), and had been exposed to both pneumonia and
grippe. About Alarch i he became ill with grippe
(cold and cough), and on March 24, though he had
not entirely recovered from the grippe, was removed
out of the neighborhood a distance of some ten
miles. Pneumonia developed March 28 and the
child was seen by a physician only once, that being
April 4 ; he found the lower lobes of each lung con-
solidated. Patient was complaining of pain in the
diest, was breathing fiftv or sixty times per minute,
and had a temperature of 103° or 104°. Death oc-
curred April 3. The child's mother died of pneu-
monia on March 20. One aunt, one uncle, and one
cousin had suffered with pneumonia during this
epidemic of grippe (see Cases \T. and \^II., and also
the case appended). The child had never previously
had pneumonia.

Case VI. — Patient, C. B., was a woman, aged
twenty-four who had nursed her sister (Case IV.)
suffering with pneumonia. About March 8
the patient developed grippe (cough, cold, body
pains, and perhaps fever), but did not go
to bed. On IMarch 18 she had a chill about
2 A. M.. followed by croupous pneumonia, which
ran a typical course. The upper lobe of the
left lung was consolidated. Recovery occurred at
the end of two or three weeks. The patient's father
and mother had never had pneumonia. One sister,
one brotlier, and two nephews had pneumonia dur-
ing this epidemic of grippe. The patient had not
previously suffered with pneumonia.

Case \TI. — The patient, B. F., was a girl, eight
years of age. About March 12 she began to have
pains in the back and chest, cough, and fever. The
tongue was dry, and parched. The bowels were con-
stipated and the abdomen slightly tympanitic. .V
physician was called, and on ^larch 18 examined
lungs, but found nothing abnormal. On March 10
the lungs were again examined, and it was found
that the left lung and lower lolie of the right lung
were consolidated. The patient died on March 22.
One of the patient's uncles on tlie father's side, and
one of her uncles on the mother's side had suffererl
with pneumonia. The patient bad never previously
had this disease.

Case VIII. — The patient, E. P.. was a man. aged
about thirty rears, who lived some twelve miles
from the home of his sisters (Cases TV. and VI. ).
Qn March 22. while he was helping nurse his sister
who had pneumonia, he developed grippe, but he did
not go to bed. After the Iwrial of his sister (Anarch

2u).he returned lK)ine, some twelve miles away. On
March 28 he became wet by rain and during the
night following he had a chill, followed by all the
typical symptoms of ijneumonia. The lower lobe
of the left lung was consolidated. The patient fully
recovered at the end of two or three weeks. This
|)atient's two sisters (Cases IV. and VI.), and his
nephew (Case V.J, all had pneumonia during this
epidemic of grippe. The patient had never pre-
viously suft'ered with pneumonia.

Case IX. — While the following appended case of
pneumonia did not occur in the neighborhood of
Messer, it may have some bearing upon the ques-
tion of susceptibility of certain families in their
relation to pneumonia. The patient was the son
of the patient in Case VIII., the nephew of Cases
No. I\'. and VI., and a cousin of Case V. Or in
other words, of this series of nine cases of pneu-
monia, four occurred in one family. This patient's,
aunt and cousin had died of pneumonia during this
epidemic of grippe. The patient was a boy, a,ged
three years, who lived with his father, twelve miles
distant from Messer. The child had not been away
from home, and had not been exposed to any case
of croupous pneumonia. For a few days previous
to March 29 he had suffered from a cough and
cold. The patient lived in the same room with his
father, who developed pneumonia on March 28. The
patient developed croupous pneumonia on the fol-
lowing da\-, or one dav later than the father. The
lower lobe of the right lung was consolidated, and
recovery occurred at the end of two or three weeks.

Did aiiv of tlicsc cases of cronl'oiis pucunionia
contract the disease front any of those afflicted : and
if so. zi'hat zcas tlie period of incnbation?

In considering these eight cases of croupous pneu-
monia above presented, it is found that nut of this
number there were four who had been exposed to
other cases of croupous pneumonia, namely: Cases
III., v., ^T., and VIII. and in whom there was
some possibility of infection from forms of pneumo-
cocci of sufficient virulence to bring on an attack of
croupous pneumonia.

A summary of these four cases so exposed may
be made as follows: Case III., !M. A. S., was in a
child nine years of age. Her mother had developed
pneumonia ]\Iarch 5, and six davs later pneumonia
developed in the case of the child. Case V., R. B..
was in a child two vears of age. The mother had
developed pneumonia on March 12, and sixteen
flays later pneumonia developed in this case. Case
VI., C. B., was a young lady, twenty-four years
of age, who had nursed her sister, who developed
jmeumonia iNIarch 12, and six days later she fell ill
of this disease. Case ATI!., E. B., occurred in a
man, thirty years of age, and apparently in perfect
health. On March 17 he went a distance of some
twelve miles to nurse his sister, suffering with pneu-
monia, and himself developed pneumonia eleven
days after his arrival.

In this scries of four cases in persons zvho had
been exposed to other cases of croupous pneumonia,
the shortest possible period of incubation could have
hen si.v days, and the loui^est possible sixteen days,
or a zeneral averaoe of ten days.

In this connection it might be interesting to reit-
erate that in the following year (190^1). though 10
per cent, of the population in this locality had grippe,
not one case of pneumonia occurred.

The question of heredity, or those cases in which
tlie parents or grandparents had previously suffered
with pneumonia :

Case II. — Father several years previously had
^uttered with pneumonia.

14

MEDICAL RECORD.

[Jan. 5, 1907

Case III. — Grandfather on mother's side years
before had suffered with pneumonia.

Case VII. — One uncle on father's side had pneu-
monia ten or fifteen years previously ; and one uncle
on mother's side had pneumonia six years pre-
viously.

Therefore, of this series of eight cases of pneu-
monia, heredity might have exerted some influence
in 37 per cent, of the cases. Xo one in this series of
eight cases ever previously had pneumonia.

The question of susceptibility of certain families
towards this disease has already been noted, but it
may be well to reiterate that of these eight cases
(and one appended case), there were four which
occurred in one family, though the patients lived in
different houses.

The Part of Lung Involved. — C'vse I. — Lower
lobe of right lung (recovered). Case II. — Entire
left and lower lobe of right lung (died). Case III. —
Copper lobe of each lung (recovered). Case IV. —
Upper lobe of each lung (died). Case V. — Lower
lobe of each lung (died). Case VI. — Upper lobe
of left lung (recovered). Case VIl. — Left and
lower lobe of right lung (died). Case VIII — Lower
lobe of left lung (recovered).

Age of Patients. — Case I., aged nineteen years;
Case II., aged thirty-five years ; Case III, aged nine
years; Case I\'., aged twenty-five years; Case V.,
aged two years; Case \T., aged twenty-four years;
Case \'II., aged eight years ; Case \'in., aged' about
thirty years.

The fatal cases occurred in patients aged respec-
tively thirty-five years, twenty-five years, two years_,
and eight years.

Alortality. — Of the eight cases here reported there
were four deaths or a mortality of 50 per cent. This
high mortalitv was doubtless due to the fact that
those physicians who had charge of the fatal cases
did not have the opportunity of seeing the patients
as a rule in the early stages and could pay only in-
frequent visits to them, sometimes not oftener than
once in every two days, and in one instance only
one visit was made. In two of the fatal cases mis-
carriage occurred about the sixth month of gesta-
tion. In this series the writer of this paper treated
only three cases (Cases VI.. and \TII, and the ap-
pended case), and all the patients recovered.

After studying this series of cases of pneumonia
it was found impossible to determine the possible
source of infection in the first patient, since she had
not been exposed to anv other case of pneumonia.
The disease evidently came on as a complication or
sequela of grippe. \\"hether she harbored in the
sputum the virulent diplococcus of pneumonia before
the attack came on was not determined.

Pneumonia and Grippe. — From an investigation
of the histories afforded by these eight patients, who
suffered with pneumonia, it is believed to be prob-
able that everv one of them suffered from grippe
for a few days previous to the onset of pneumonia.
This assumption is based purely on the symptoms
and clinical signs presented, since the microscope
and cultural methods were not resorted to in any
instance. In the absence of complete bacteriological
examinations the writer is fuUv conscious of the
errors which might occur from making such an
assumption as this. He is also fullv conscious of
the errors which might occur in dift'erentiating cor-
rectly between a "severe cold." and grippe, and also
the prodromal symptoms of pneumonia bv the clini-
cal signs and symptoms presented in anv given case.

The symptoms and clinical signs exhibited bv the
cases of grippe in this epidemic were as follows :
Cough, pains through the chest, fever, laryngitis,

otitis, bronchitis, constipation, and a considerable
degree of prostration, lasting in some instances two
or three weeks. In all the cases of pneumonia the
grippe was the first to appear. In some instances
the grippe persisted in the family while the pneu-
monia was in progress, and in certain families the
.grippe continued after the pneumonia had disap-
peared. In one family (Case \ II.), there was only
one case of grippe, and this was later followed by
pneumonia, though tliere were several other mem-
bers of the family, aged respectiveh', five, eleven,
thirty-one and thirty-seven years.

The climatic conditions (snow and ice, with rain
and changeable weather), was perhaps the principal
cause in rendering the soil of man more fertile for
the cultivation of the bacillus of grippe, followed in
certain instances by the possible development of the
virulent pneumococcus and consequent production
of croupous pneumonia.

Grippe in the Douglas Community in Previous
Years. — At different periods during the past few
years, grippe has prevailed to a certain extent in this
community. Quite a number of cases existed here
during the month of February, 1904, while, as has
been previously stated, a few cases persisted
throughout the following winter and were prolonged
into February, IQ05.

Grippe in the Family of Case I. (see Pneumonia,
Case I.), \V. R. — About January i, 1905, the young-
est child in the family, a.ged eleven years, had grippe
which lasted one week ; the second case in this fam-
ily was the next older, aged fourteen years, who
developed grippe about January 1 5 ; the third case
was in the mother, aged forty-two years, who de-
veloped grippe about February i ; and the fourth
case was the patient, aged nineteen years (see Case
I., Pneumonia), who developed grippe February 15
(after having been out hunting in the snow), and
who developed pneumonia on February 21.

Possible Source of Infection. — In this family pa-
tients I. and II. slept together in the same bed and
one developed .grippe fifteen davs after the first
one became affected. Patient III. was the mother
who slept in a different room. Patient IV. (who
had both grippe and pneumonia), until the pneu-
monia developed, slept in an adjoining room with
his brother, aged twenty-one years, but this brother
never had the grippe.

The only members of the family who did not have
grippe were the father, aged sixty years, and the
son. aged twenty-one vears. There were three cases
of grippe in the familv during February, 1904. They
all occurred at the same time and the patients were
aged respectively eleven, seventeen, and nineteen
years. Two of these cases slept in the same bed.
The possible source of infection in the first case per-
haps could not be traced.

Grippe in the Family of Case II. (see Pneumonia
Case II)., Mrs. T. B. S. — -The first case to develop
grippe in this family was the mother (see Pneu-
monia Case II.), aged thirty-five years. She devel-
oped .grippe February 27, but did not go to bed.
Croupous pneumonia developed March 6. On
March 9 her husband and her son (the latter fifteen
years of age) and daughter (aged nine years — see
Pneumonia Case III.), and another daughter, aged
four years, all fell ill of grippe about the same day.

Possible Source of Infection. — The husband and
three children developed grippe ten days after it
occurred in the case of the mother. In this family
there was only one member who escaped the grippe.
.After this patient with pneumonia recovered no
other cases of grippe developed. The source of
origin of grippe in the case of mother is unknown.

Jan. 5, 1907J

MEDICAL RECORD.

Grippe in the FamiK' of Case III. (see Pneumonia
Case III.), M- A. S. — Was a daughter of Case II.
(see Pneumonia) aged nine years. She and her
father, and two sisters and a brother all developed
grippe about nine or ten days after the mother first
became ill of grippe. This patient had been in the
same room with her mother (see Pneumonia Case
II.) and on March 11 or 12 this patient developed
croupous pneumonia. Her mother developed pneu-
monia five or six days previously.

Possible Source of Infection. — This patient be-
came ill of grippe ten days after it had developed in
the person of the mother. The ijossible source of
origin of the disease in the case of the mother was
not investigated. In this connection it might be
well to state that the sister of Case II. and aunt of
Case III. (see Pneumonia) about ten days after
Case II. developed grippe, went over to nurse Cases

11. and III. This sister who went to nurse the sick
ones (the mother ill of pneumonia and child with
grippe) took with her a little daughter, aged eight
years, both of whom were in perfect health. Within
three days after the two latter persons entered the
house occupied by the sick, both of them developed
grippe, March 9.

Grippe in the Family of Case I\". (see Pneumonia
Case IV.), Mrs. J. B. — In this family there were
five members, namelv : the father, about thirty years
of age, the mother, twenty-five years of age (see
Pneumonia Case IV.), one girl aged six years,
another girl aged four \'ears, and a little boy, aged
two years and two months (see Pneumonia Case
\'.). They resided about 200 yards distant from
the home of Case \T. (see Pneumonia). The young-
est child, aged two vears and two months, developed
grippe March i and was at the time sleeping with
its mother. The mother, although in good health,
continued" to sleep with the sick child until March

12. Six days after grippe developed in the child
the mother became affected with erippe (March 5)
but did not go to bed, and on March 12 the motlier
developed croupous pneumonia. When the mother
developed pneumonia (March 12) the child was
taken out of its mother's bed and afterwards slept
by itself in a cradle adjoining the bed. The mother
died of pneumonia March 20. On March 24 this
child was taken through the country a distance of
some ten miles. It developed pneumonia March 28
and died April 5. The father during February and
March was sleeping with the two children, aged four
and six years respectively, and continued to sleep
with them until the mother developed pneumonia
on March 12. About March i the little girl, aged
four years (and who was sleeping with its father)
developed grippe and had a mild attack. This sick
child for a few- days continued to sleep with its
father, and the other sister, aged six vears. but it
was later taken over to the home of its grandparents,
some 300 yards distant. The other sister, six years
of age, was then allowed to sleep bv herself, but~'on
March 10 developed grippe. The father, though at
the time sleeping with the sick child suft'ering with
grippe, and waiting upon both his wife and children,
never developed grippe.

Possible Source of Infection. — Careful inriuiry
fails to reveal the possible source of infection in the
first case, since no one suffering with grippe for
convalescent) had visited this familv, and these pa-
tients had not gone to any place where grippe was
prevailing. In the other cases occurring in this
familv the possible source of infection might more
easilv be traced.

Grippe in the Familv of Case V. (see Pneumonia
Case v.), J. B.— A boy, two years and two months

of age. This case is the youngest one in the fainily
referred to under the head of Case IV. (see Grippe)
who developed grippe March i, and has been dul^
considered above.

Grippe in the Family of Case \'l. (see Pneumonia
Case \ I.), Miss C. B. — Of this family there were
seven members living at home, namely : the mother
and father and children, wdiose ages were as fol-
lows : the father, aged sixty years ; the mother, aged
forty-seven years; a daughter, aged twenty-four
years, a son, aged twenty-one years ; a daughter,
aged seventeen years ; another daughter, aged twelve
years, and a son, aged eight years. They resided
about 300 yards distant from the home of Case IV.
(see Pneumonia and Grippe). The youngest boy,
eight years of age, slept with his mother and father
during February and iVIarch. The daughter, aged
twelve years, slept alone, while the other two daugh-
ters, aged seventeen and twenty-four years, slept to-
gether until March 12. The first person to develop
grippe in this family was the boy, aged twenty-one
years, who became ill on Februarv 28 : the second
person who became ill of grippe was the father,
which occurred on March 3 ; the third patient was
the mother, who became ill on March 6 ; the fourllt
case was the girl, aged twenty-four years, who be-
came ill ^larch 8, and who at the time was sleeping
with her sister, aged seventeen years. While having
the grippe she continued to sleep with her sister, but
the latter person never developed grippe. The fifth
patient was the boy, eight years of age, and who be-
came ill March 13. This boy had been sleeping
with his father and mother, both of whom had suf-
fered with grippe a few da)s before he became
affected. The only members of this familv who
never developed grippe were the daughters, aged
twelve and seventeen vears. The only member of
the famil}' who had grippe last year was Case Vl.
(see Pneumonia). After the pneumonia had sub-
sided, ]March 27, no other member of the family
developed grippe.

Possible Source of Infection. — In the first patient
the possible source of infection cannot be traced,
while in the other instances such sources of infection
might perhaps be more easilv done.

Grippe in the Familv of Case \TI. (see Pneu-
monia Case VII.), B. F. — The only case of grippe
which occurred in the familv during this epidemic
was the patient, a girl, aged eight years, who de-
veloped grippe March 12 and pneumonia March 19.
There were four other members of the family, aged,
respectively, thirty-seven, thirty-one, eleven, and
five years. No member of the family had suffered
from grippe or pneumonia during the previous vear.
Five years previously three members of the family
had grippe lasting two weeks. No case of pneu-
monia had occurred in the house for eight years.

Possible Source of Infection. — There had been
no illness of any kind in this household since the
previous June. Three weeks before the patient be-
came ill she had spent the night at the house of a
relative in which grippe was prevailing. For many
months no one had visited her home who had pre-
viouslv been ill. The patient had been attending
a school in the neighborhood in which the pupils
were suffering from cough, and some perhaps were
convalescing from grippe.

Grippe in the Familv of Case \TII. (see Pneu-
monia Case \'TII.). — E. B.. was a man, thirt\- years
of age. He was a brother of Cases IV. and VI. (see
Pneumonia) and lived about twelve miles distant
from them. On heine apprised of the illness of his
two sisters, he. nn March 17. went to aid in nursing
them. He stated that when he left home he was feel-

i6

MEDICAL RECORD.

[Jan. 5, 1907

ing perfectly well, and there had been no illness in
his family. He helped to nurse his sisters and on
March 22, or five days from the time he began nurs-
ing them (one of whom had developed pneumonia
on March 12, and the other one of whom developed
pneumonia the day after his arrival), he fell ill of
grippe. Un IMarch 2^ he returned to his home and
lay in bed two days, during which time he com-
plained of having had fever, pains, and cough. He
afterwards got up and went to work. On March
28 he became wet by rain, and during the night
developed croupous pneumonia. His son, aged three
years (see appended case of Pneumonia) sleeping in
the same room with him, began to have a cough a
few days previous to ?ilarch 29, and on that day
de\eIoped croupous pneumonia.

Possible Source of Infection. — Infection might
have occurred while patient was nursing his sisters,
live days before he fell ill of grippe. Whether his
child (appended case) had grippe previous to the
development of pneumonia is not known, but the
circumstance at least looks suspicious.

The Possible Period of Incubation in These Cases
of (jrippc. — Of this series of cases of grippe the
shortest possible period of incubation could have
been three days; and the lonii^est fifteen days or a
general ai-erage of seieu days.

In this epidemic of grippe age did not seem to
e.xert any influence in regard to the susceptibility
of the patient. In some instances the first one
affected was very young, in another the first affected
was middle-aged, and in still another instance the
first one aff'ected was quite old. Sex exerted no
influence.

In reviewing this series of cases of grippe it might
be impossible to determine the source of infection
in the first case of grippe occurring in the Messer
community, since the disease had been more or less
prevalent throughout the winter. The prodromal
symptoms of croupous pneumonia must of course
be considered in analyzing these cases of pneumonia
and grippe.

Conclusions from the Stud\ of this Series of
Cases of Croupous Pneumonia. — \\'hile it is granted
that croupous pneumonia may arise or develop in
persons who have not been recently exposed to any
other case of pneumonia ( such as in those who may
carry in their sputum the virulent diplococcus of
pneumonia), which event misrht j)erhaps occur after
getting wet by rain, and while it is granted that the
evidence furnished in this investigation is based
purely upon clinical grounds not supported either
by microscopic findings or cultural methods, and
wliile the writer is fullv conscious that the absence
of such data renders these observations less con-
clusive than they otherwise would be, it is believed
that from a careful study of this series of cases of
pneumonia the following cnnclusions seem tenable:
I. — Infection of the human svsteni by the bacillus
of grippe so lessens tlie natural immunity, or pre-
pares the soil of man, that subsciucnt infection by
the virulent diplococcus of pneumonia and con.se-
quent production of croupous pneumonia may more
readily occur.

2. — The possible average period of incubation of
croupous pneumonia bv air transmission is about
ten davs.

3. — The influence of hcreditx renders certain fam-
ilies more susceptible to croupous pneumonia.

4. — The rise and fall of a large scries of cases of
croupous pneumonia occurring within a limited time
and locality, may be dependent to a large degree
upon the coexistence of grippe.

^.— Prearnancv occurring during an attack of

croupous pneumonia renders the prognosis more
grave.

Conclusions from the i>tud\ of this Series of
Cases of Grippe.

I. — While grippe appears to be an infectious dis-
ease, not all of tliose who come in direct contact
fsuch as sleeping in the same bed) contract the dis-
ease.

2. — The possible average period of incubation of
grippe by air transmission is about seven days.

3.— One suffering with grippe should be warned
against the tendency to develop pneumonia.

4. — An infant suffering with grippe should not be
permitted to sleep with a healthy mother, and when
the mother is affected she should not be permitted to
sleep with a healthv infant.

5. — The weather conditions, such as excessive
rains with snow and marked variations in the tem-
perature exert the greatest influence in the spread
of grippe and consequent production of pneumonia.

6. — Age and sex exert no protective influence
against grippe.

7. — Proper care should be exercised to destroy all
sputa and fomites which may aid in the spread of
grippe.

Mv sincere thanks are herewith tendered to Drs.
B. T. Bryant and C. H. Willingham, of White-
house ; Mrs. Sam Messer, of Messer, and Dr. J.
Z. Ferrell, of Tyler, dl of whom so kindly assisted
me in compiling the data regarding these cases.

THROAT DISEASES CAUSED BY THE
MISUSE OF THE VOICE.

Bv .\'. J. POOCK VAN BAGGEX.

THE H.\GVE. HOLL.^ND.

E\"ERV specialist for throat diseases knows that
ver\- many of the sufferers from those aff'ection.s
are to be found among those whose profession
demands constant use of the voice, as orators,
clergymen, professional speakers, and singers.
The clergymen's sore throat disease is known to
c\ery throat specialist. It is obvious that the
misuse of the voice is in most of those cases the
cause of the affliction.

The patient, after speaking or singing, will
c<:)mplain of a dry and hot feeling in the pharynx
and the larynx, of irritation, and a frequent
cough. It is only w'ith the utmost exertion that
the patient delivers his speech or song, and when
the work is done he is hoarse or his voice gives
out entirely. Gradualh' the evil increases, and
finally the patient, singer, or orator consults his
doctor in the hope of finding relief for his suff'er-
ings.

Examining those patients, we shall find the fol-
lowing characteristic symptoms: Catarrh of tlie
I'harynx and of the larynx, with congested and
swollen mucosa. The pillars of the fauces are
swollen and often highly developed. There is
always paresis of the vocal cords which are red
or vellow- in color and which do not close well.
The paresis of the vocal cords is mostly united
with paresis of the m. cricothyroid anterior, the m.
thvroid aryt. int.. and the m. crico. aryt. laterales.
In some serious cases a swelling of the aryepiglottic
ligament is observed. Organic defects are not the
cause in this case. They may be. .It is known well
enough that enlarged tonsils, adenoids, nasal poly-
pus, or malformations of the tongue may be the cause
of exertion in speaking, hoarseness, and loss of the
\oice. This is not the case here ; the fault is
purely functional. This is clearly proved by the

Jan,

1907 J

MEDICAL RECORD.

17

fact that as soon as the ])atient gives entire rest
to his organ the affliction decreases and some-
times even disappears altogetlier, to reappear,
however, as soon as the voice is used again in
the wrong way.

Observing those patients while speaking or
singing, we shall see that they do not use their
breathing, articulation, and vocal muscles nor-
mally. There is no harmonious cooperation be-
tween those three groups of muscles; the faulty
breathing and articulation fail to support the
vocal muscles sufficiently, and are therefore an ob-
stacle to the undisturbed vibration of the vocal
cords.

As the breath is the chief element in the pro-
duction of voice and speech, the patient has to
learn in the first place the right way of breathing
and how he may make the best use of the breath
in phonation. Usually the breathing is clavicular
in those cases, but even when the breathing is
diaphragmatic the patient does not know how to
control his breath and how to direct it. He lets
it go as it will. Instead of striking the hard
palate, the sound or vibrating air strikes the soft
palate, whereby the tone is smothered as in a
room hung with heav}- curtains, and in order to
make himself understood the orator or singer has
to e.xert his voice to the utmost, while, if the
breath is directed against the hard palate the
voice is clear and carries to a long distance with
out an)- particular effort. The combined dia-
phragmatic and costal breathing is recognized
as the best way of breathing. We get not only
the largest amount of air and the best control of
it in this way, but this is also the only way of
breathing by which wc are able to direct the
breath consciously.

In regard to the articulation, we shall see the
back of the tongue rising as a thick and heavy
wall between the opening of the mouth and the
pharynx. The consonants are not formed in the
anterior part of the mouth with the tip or the
middle of the tongue leaning against the hard
palate, as is the right way, but the articulation is
done way back in the mouth. K, g, and r are
formed between the back of the tongue and the
soft palate, or the pharynx.

The thickness of the voice tells us also that
the action of the soft palate is insufficient ; while
the dullness of the voice betrays to us a lack of
resonance caused by the swelling of the mucous
membrane which lines the resonance cavities.
However, those two defects just mentioned have
to be considered as a result, but not as a cause of
the disease.

As to the use of the vocal cords, we observe
mostly an unnatural contraction of the muscles
of the larynx. When pronouncing the vowel we
hear constantiv the shock or spasm of the glottis
which means that the vocal cords are pressed tightly
together by the pronunciation of each vowel. It is
clear that this imnecessary efifort is fatal to the
already overstrained cords, and is not one of the
least causes of the congestion of the larynx.

All speakers who misuse their organ must be
specialh' warned not to take singing lessons to
improve their speaking. The speaking has to be
faultless before any good results in singing can
be obtained.

It is superfluous to say that no exercises are to
be undertaken before the patient has gone
through a judicious medical treatment united
with rest to the organ.

10 a Pla.^ts.

Pregnancy and Abortions in Women Employed in
Tobacco Manufactories. — J. Livon has investigated this
Siibject. He refers to tlie opinions ol' various autlioritiis
who have been interested in the effect of tobacco on the
pregnant woman. The opinions of these men vary. Among
others, Brochard and Decaisne are convinced that women
who work in tobacco manufactories are more subject to
abortion than other women. Other observers, for e.Kample
Ribemont and Lepage, do not believe in the harmful influ-
ence of tobacco on the progress of pregnancy or on the
newborn. All observers are in accord concerning the con-
siderable mortality of the newborn whose mothers work
with tobacco. The larger number of deaths occur from
the second to the fourth month. This is the period in
which the mother resumes her work and gives the child,
according to Vinay, nicotinized milk. A mother e.xposed in
her work to the vapors of nicotine ought not to nurse her
child. Her milk has a very pronounced odor of tobacco,
although the presence of the poison has not yet been de-
termined chemically. — Revue l-iangaise de Medecine et de
CItirurgie.

Alteration of the Functions of Nutrition in the Nurs-
ing Infant. — G. Mya discusses the alterations in nutri-
tion produced in the nursling by the use of cow's milk
as a substitute for mother's milk. In some infants it
agrees perfectly, especially when its use is not begun
in the first months of life. In others, and when begun
soon after birth, it produces affections of the digestive
system, nervous •.ystem. skin, circulatory apparatus, and
finally death from marasmus. The author believes that
no single factor is the cause of these changes. The
excess of casein, e.xcess of fat, which being saponified
uses up the alkalies of the body, the antagonism be-
tween the human and the cow's ,-illmniinnids, thf
changes due to sterilization of the milk, making it less
digestible, may all contribute to the bad effects, .An-
other factor is the rapidity with which the milk is
taken, permittin.sf tlu- child to he ia^il\ overfeil Indi-
vidual idiosyncrasy is an added f.ictor m the causation 01
the evil effects of the milk. The liver lias as one of
its functions the reductiou of alimentary and other sub-
stances, so as to render them innoxious in the circula-
tion, and in the baby this power is slight. The weak-
ness of the infant makes him succumb more easily
than the adult to infections or general diseases. As
to the treatment of such conditions, medicines should
be little given. The indications are to change the diet
so as to render it easily assimilable by the baby. Get
him a wet nurse if possible. If not modify the milk,
so as to render it easy of digestion. — Rknsta Critiea di
Clinica Pediatriia.

Resistance of the Spores of Bacillus Anthracis. —

Santi Sirena has shown that spores of anthrax, when
dried in the hot sun in free air. live for nineteen days,
hi the thermostat in dry air they li\e 406 days. When
dried l>y chemicals they live a longer time. Creolin
up to 60 per cent, strength does not destroy them, but
when used pure, they die in twenty-four hours. The
bacilli are killed in fresh blood after ten minutes by
10 per cent, creolin, and after twenty minutes in the
spleen of a diseased animal. In sterilized garden earth
they lived fifteen years. In damp earth they lived four
years. In earth saturated with moisture they lived
thirteen years. In sea water they lived eight years.
In sterilized water they lived more than eight years.
In pregnant animals they passed from the mother to
the fetus by way of the maternal and fetal placental
vessels. They were found in the chorion, and in the
placenta in great numbers. There were alterations of
the muscular and epithelial layers of the uterus, con-
sisting of hyperemia, dilatation of the vessels, and ex-
travasation of blood. There were extravasations in
the serotina also, — Aichh'io f'' '■" Scien:e Mediche.

i8

MEDICAL RECORD.

[Jan. 5, 1907

Medical Record.

A Weekly "Journal of Medicine and Surgery.

THOMAS L. STEDMAN. A M., M.D., Editor.

PUBLISHERS
WM. WOOD &. CO.. 51 FIFTH AVENUE.

New York, January 5, 1907.

MUNICIPAL CAR£ OF THETUBERCULOUS.

The active campaign which is being waged in this
city against the spread of tuberculosis may be said
to have had its actual beginning in 1894, when the
reporting of cases of pulmonary tuberculosis in pub-
lic institutions was made compulsory. This was
supplemented in 1897 by an amendment to the San-
itary Code, in which the condition was included
among infectious, communicable, and reportable
diseases. The scope of this w^ork has been grad-
ually broadened, and it was early recognized that
the establishment of a municipal clinic or dispensary
would be of great assistance in the attainment of
several most desirable objects. These were the
early recognition and diagnosis of pulmonary tuber-
culosis, the intelligent supervision of patients under
treatment, the continued observation of the indigent,
the removal of suitable patients to a hospital, and
the care of those suffering from laryngeal tubercu-
losis, which is among the most distressing and pain-
ful of complications. The first report of this clinic,
which was opened in March, 1904, shows that the
results attained have been most satisfacton.', and
one of the important features of the work is that
alrhost fifty per cent, more patients were seen in the
second than during the first year in which the clinic
was open. This shows conclusively the value of the
institution in bringing new cases to light, and many
cases hitherto concealed were sent to hospitals, ben-
efiting in this way both patient and family. .Sana-
torium treatment was also made available for a large
number of incipient cases, and many other patients
were assisted by the furnishing of an extra diet.

Although much has thus far been done with the
means at hand in bringing tuberculosis under con-
trol, the authorities point out three essentials which
must be carried out to complete this process. First
and foremost comes the education of the people as
to the nature of the disease and the procedures to
be adopted to avoid its contraction ; second, the
early recognition of the disease and the removal to
more favorable conditions of all sufferers, and third,
the location and disinfection of all infected houses
and premises occupied by the tuberculous subjects.
It is only a public clinic, undertaken and supjxirted
by mimicipal agency, which can hope to enforce the
suggestion of bringing patients suffering from
tuberculosis under direct control, particularlv those
of the indigent class. It constitutes a form of pa-
ternalism in government which should be encour-
aged, however, rather than combated, as is unfor-
tunately done in certain quarters. In addition to
the help which it affords the needy, an institution of

this kind should also serve as an object lesson to
the profession in showing what can be done m the
treatment of the disease with the means at hand.
Too many practitioners still cling to medication as
the essential in treatment, and neglect the many di-
etetic and physical measures which have been shown
to effect the largest percentage of cures. The thor-
oughly scientific and ethical character of this public
institution is well shown by the leaders in the move-
ment, and the i'uit';d and cordial support of the
profession in this city should be extended to it in
the effort to eradicate, if such a thing were possible,
or at least to limit the spread of this destroyer of
man."

THE EFFECT OF SALIVA ON BACTERIA.

It is a well-known clinical fact that operative or
traumatic wounds in the oral cavity have a tendency
to heal kindly in all but exceptional cases. In ex-
planation of this phenomenon it has been assumed
that the saliva possesses bactericidal properties
which serve to protect the individual against infec-
tion, although no one has come forward with any
satisfactory experimental proof to sustain the claim.
An attempt to solve the question has recently been
made by Clairmont of v. Eiselberg's clinic in Vienna,
who investigated the bactericidal properties of the
saliva in animals and the human subject. His
results, which are published in the Wiener klinische
Wochcnschrift, November 22, 1906, form an inter-
esting contribution to the subject and show that
the salivary secretions can be depended upon to
furnish a certain degree of protection to the
organism.

When wounds of the oral cavity heal by primary
union, this fact, according to Clairmont, may be
ascribed primarily to two conditions, viz., an unsuit-
able local environment and the mechanical cleansing
action of the salivary flow. No specific bactericidal
action of the saliva could be detected in tests made
with the pathogenic germs of typhoid fever or
tetanus, or with staphylococci, streptococci, or the
colon bacillus, nevertheless a small number of organ-
isms will find here such unsuitable conditions pres-
ent for extended grow-th that they are soon de-
stroyed. In this respect the saliva may perhaps be
compared with physiological salt solution. Ani-
mals seem to have these properties much more mark-
edly developed than human beings. .'Kside from in-
dividual variations, differences in the secretions of
the submaxillary and of the parotid glands could be
determined in the case of most of the species exam-
ined. The former produces saliva which seems to
have but little or no effect at all on bacterial growth,
while that from the parotid of both man and animals
has a well-marked inhibitory action on the same, so
that a considerable number of bacteria may be de-
stroyed. It was found that the most intense effect
was present in goats and other ruminants, and that
the pyogenic organisms suffered to the greatest
extent. In culture experiments, however, the addi-
tion of a favorable medium to the saliva seems to
offset whatever inhibitory action may have been
manifested by the salivary secretions. If the latter,
in either man or animals, are artificially stimulated
the resultant fluid will after a time be found to be
perfectly sterile or to contain only a very small

Jan. 5, 1907]

MEDICAL RECORD.

19

number of organisms, which soon perish. Another
curious fact which was noted in the course of these
experiments was that the excised suppurating- paro-
tid gland showed a remarkable resistance to decom-
position.

The observations made by Clairmont afford us
some ground for believing that the conditions pres-
ent in the oral cavity constitute an important element
in the protection of the organism against infection
from without. If this is so it is possible that the
protective action may be increased by stimulating
the salivary flow and washing away various culture
media which would otherwise favor bacterial
growth. This is probably of more importance than
any bactericidal action which the saliva may exert.

UTERINE RELAXATION.

An atonic condition of the uterus has been observed
under various circumstances, but most commonly
perhaps during the puerperal state. Kossmann some
years ago directed attention to the fact that it may
also occur in nonpuerperal women during or after
the operation of dilatation and curettage, and since
then various explanations have been advanced to
account for the phenomenon. The most probable
of these is concerned with a local congestion of the
uterus due to the operative invasion which also re-
suits in a relaxation of the uterine blood-vessels.
The accompanying increase in the blood pressure is
then believed to result in a straightening of the tor-
tuous vessels which carry the relaxed muscle along
in this process. The whole uterus swells and
straightens out like an erectile organ while the
cavity is distended. If the tone relaxation of the
vessels and that of the muscle remain entirely coor-
dinated the phenomenon will end as it began — si-
multaneously ; the congestion disappears and the
muscle contracts. Should there be, however, an
incoordination, which is readily possible when the
irritation is artificial instead of physiological, the
congestion may disappear before the muscle regains
its tone, the expansion remains and the condition
becomes one of complete atony.

This condition of uterine atony in the nonpuer-
peral state as the result of dilatation and curettage
probably occurs quite frequently, but is not recog-
nized or the operator assumes that perforation has
taken place. The subject is discussed in a recent
paper by Maier in Surgery, Gynecology, and Obstet-
rics for December, 1906. In reporting several cases
the writer draws attention to the practical interest
and value of a definite knowledge of this fact. Dila-
tation and curettage are probably among the mosi
frequently performed gynecological operations. For
this reason it is well to bear in mind the acute
changes which may take place in the uterus at this
time and not to be too hasty in assuming that |)er-
foration of the organ has taken jilare when the
condition is merely one of atony. Unless this fact
is borne in mind, an abdominal operation may often
be undertaken in cases in which, after dilatation,
the curette suddenly slips into the uterus to an
apparently abnormal degree.

Another possibility, to which the writer does iint
call attention, however, which may result from this
atonic condition of the uterus, is the entrance of
irrigating fluid through the Fallopian tubes into

the abdominal cavity. The fact has occasionally
been referred to, and in isolated instances in which
a laparotomy has followed curettage, the fluid has
actually been demonstrated free in the peritoneal
cavity. This phenomenon may be explained in the
same way, and a knowledge of the possibility of
the accident should lead to the exercise of great
care in douching the uterine cavity ; and to the use
of absolutely sterile and nonirritating solutions for
the purpose, so that if they do gain entrance into
the abdominal cavity a niinimmn of harm will re-
sult.

A New Suture M..\-ieri.\l.

The disadvantages inherent to most of the suture
materials in common use are too well known to re-
quire rehearsal, but several new methods of prepar-
ing silk for this purpose, founded on what appear
to be rather important considerations, described by
W'ederhake in the Milnchcner medizinische Wo-
clienschrift, December 4 and 11, upC, seem of more
than usual interest, .\fter a lengthy disquisition on
the physical properties which render silk, catgut,
and silver wire undesirable as routine materials for
buried sutures, the author tlescribes several new
forms of suture material which he says possess de-
cided theoretical and ])ractical advantages. The first
of these is the so-called silver silk, which is intended
for use as a ligature material in small sizes only, and
not for buried sutures. Its advantage is that it pos-
sesses powerful and lasting antise|)tic properties. It
is prepared by rendering" the silk fat-free by extrac-
tion with ether and absolute alcohol, sterilizing by
boiling in 1-1,000 aqueous solution of bichloride of
mercury, immersion in a 10 per cent, peroxide of
hydrogen solution, and treatment for several hours
with an alkaline silver solution, by means of which
it becomes impregnated through and through with
metallic silver. This silver solution is made by add-
ing potassium hydrate solution to a i per cent,
solution of silver nitrate and dissolving the result-
ing precipitate in ammonia. As a last step the ma-
terial is again sterilized by boiling in bichloride
solution. The author is of the opinion that a mate-
rial intended for use in buried sutures should not be
permeable by fluids, and in order to effect this he
impregnates silver silk prejjared as above with
caoutchouc. The silver silk is dried, is soaked in
chloroform, and is then immersed for from two to
twelve hours, according to its size, in a 16 per cent,
solution containing 8 grams of caoutchouc in 50 c.c.
of chloroform. This material also can be sterilized
by boiling in bichloride solution. Silk prepared in
this wav is not onlv impermeable to fluids, and
therefore not likely to become infected in the
wound, but is stronger than the corresponding size
of ordinary silk and than the silver wire ordinarih'
used for suturing. The third of the author's inno-
\ations is an absorbable silk. This is prepared in
a manner similar to that used in making parchment
|iaper. According to its size the thread is treated for
from twentv seconds to diur niiinites with concen-
trated sulphuric acid, is washed with water, is dehy-
drated in alcohol, and is then subjected to a harden-
ing process by means of tannin and ahsohite alcohol.
This silk is said to be as strong as untreated silk
and is rendered flexible hv treatment witli glycerin.
It can be sterilized hv boiling in bichlnride solution,
and when buried in the tissues it is coiui)letely ab-
sorbed at the expiration of from four to six weeks.
It would require too much space to rcjiroduce the
author's theoretical discussions concerning these

20

MEDICAL RECORD.

[Jan. 5, 1907

outure materials, but while it may be that others
will not be as successful in their practical applica-
tions as he has been, they at any rate represent a
promising attempt to solve what has been one of
the greatest difficulties in operative work.

Primary Carcinoma of the Appendix.

Although in this country the consensus of opinion
among surgeons is in favor of inspecting the appen-
dix in all laparotomies in which this is possible and
of removing it when any abnormalities are present,
this doctrine has not yet apparently gained accept-
ance in Germany. At least Landau makes a strong
plea to this effect in a recent number of the Berliner
klinischc IVochenschrift (December 10, 1906), tak-
ing as his text the occurrence of primary carcinoma
of the appendix. So far he says sixty-four cases
of malignant disease of the appendix have been re-
ported, and he considers that the lesion will be ob-
served much more frequently in future now that
more and more attention is being directed to it. In
Landau's own case the laparotomy was made for
the purpose of enucleating a uterine fibroid and of
removing a tube and ovary. The appendix was
found stiff and sharply bent on itself with a some-
what enlarged extremity, and was therefore re-
moved. It was not until microscopical sections had
been made that the condition was recognized as one
of tvpical carcinoma simplex. Landau, therefore,
urges upon his colleagues the rule to inspect the
appendix whenever possible, and states that in order
to do this he has come to resort more and more to
laparotomy instead of vaginal operation. If the
organ appears to be healthy both on inspection and
on palpation he does not interfere with it ; but if
there are any evidences of disease, or if the history
points even remotely toward appendicular involve-
ment, it should be removed without hesitation.

.Suboccipital Tuberculosis.

A SURGICAL operation of unusual difficulty is de-
scriljed by Payr in the Deutsche medi^inische JVo-
chenschrift, December 13, 1906. It consisted in the
removal of considerable portions of the atlas and
adjoining structures owing to tuberculous disease.
The patient was a woman of thirty-five years, who,
eighteen months before the operation, manifested
the first evidences of the lesion, consisting in en-
largement of the cer^'ical glands and pain behind
the ears and in the nape of the neck. Later on,
stiffness, dysphagia, and a retropharyngeal abscess
developed, and at the time of operation, in addition
to a profusely discharging cervical sinus, there was
a communication of the abscess cavity with the
pharynx. For the details of the operative proce-
dure by means of which the diseased areas were
extirpated, and which, of course, presented many
technical difficulties, the original must be consulted.
The postoperative course was luicomplicated, the
extensive wound healed without sinus formation,
and now, about a vear later, the patient is still free
from anv evidence of impending relapse and is able
to do all her own housework. While, as the author
points out. the conditions under which an operation
of this sort can be carried out with hope of a radical
cure are no doubt but rarelv encountered, the fact
that even occasionally a patient can be freed from
a lesion that must otherwise lead to a miserable
death is a sufficient incentive to stimulate the daring
of surgeons.

The Geographical Distribution of Gastric
L'lcer.

It is a well-known and long recognized fact that
certain diseases of the stomach are more prevalent in
certain localities than in others, that their symptoms
likewise assume varying degrees of importance, and
that complications which are prevalent in one place
are scarcely ever found in the other. In a recent
book Riitimeyer has subjected these facts to a criti-
cal analysis, using for the purpose not only his own
series of over two hundred cases, but also a large
number of extracts from the literature on the sub-
ject. This investigation shows conclusively that the
frequency of gastric ulcer varies within wide limits
in different countries, and that even in a relatively
restricted geographical section differences may ex-
ist in its constituent parts. The clinical symptoms
also vary considerably in men and women, hyper-
acidity and hemorrhages being more common in the
fonner than in the latter, in addition to a number
of other distinctions. Hyperacidity also varies as it
seems with the locality ; in Zurich, for example,
about 20 per cent, of the cases of gastric ulcer are
attended by this symptom, whereas in Geneva, not
so very far off, nearly 100 per cent, of the cases
are thus characterized. These facts are of general
interest, and if they can be further developed can
perhaps also be made of practical interest in the
treatment of this condition, for if climatic influences
exert themselves on the progress of the lesion in the
manner indicated a knowledge of this favorable ef-
fect is of considerable value.

Memorial to Dr. Christian Fenger. — Original
research work in all branches of medicine is to be
fostered by an organization in memory of Dr.
Christian Fenger. The Fenger Memorial Associa-
tion for Medical Research was incorporated at
Springfield, 111., recently, the incorporators being
Drs. Frank Billings, Ludwig Hektoen, and Karl
Doepfner. The plan is to raise a fund of from
85,000 to $10,000 to be used in encouraging medical
students to take up original research work in bac-
teriology, surgery, and other branches of medicine.

Dr. Charles S. Benedict, upon his retirement,
on December 31, from the Health Department after
twenty years' service in the division of contagious
diseases was presented with a silver service by
thirty of the men in this department who have
served a good part of the time with him. Dr.
Darlington presented the gift.

The Weber-Parkes Prize and Medals. — Mr.
Edward Liveing. the Registrar of the Royal College
of Physicians, London, announces that the next
award of these prizes w-ill be made in 1909, and that
the adjudicators have selected as the subject of the
essay for that occasion : "The value of bacterial
products in protecting against or in curing tubercu-
lous diseases, with special reference to pulmonary
tuberculosis in man." All essays, totjether with any
preparations made in illustration of them, must be
transmitted to the Registrar of the College during
the last week of May. 1909. in accordance with the
regulations relating thereto, copies of which will be
forwarded from the college on application. The
award will be made at some time previous to October
18 in that year, on which day the prize and medals
will be presented to the winners.

Death Rate at Panama. — The report for No-
vember of Colonel Gorgas to the Isthmian Canal

Jan.

i<;o;

MEDICAL RECORD.

21

Commission shows that during this month there
were sixty-six deaths among the employees of the
commission in Panama. This is as against 113
deaths in July, the decrease being largely dtie to the
lessened mortality from pneumonia, .\mong the
5,000 American employees there were only three
aeaths. Among the whole population in Panama,
employees and others, there were 241 deaths, as
against 422 in July.

Brain Surgery and Moral Qualities. — Accord-
ing to the newspapers a fifteen-year-old Cleveland
boy who was operated on some time ago by trephin-
ing in order to correct moral deficiencies supposed
to be the consequences of a depression of the skull
due to an accident received in early childhood, has
lapsed into his former evil ways. For a time the
operation appeared to have been successful in re-
storing his moral control, but then as the result of
the fall of a hammer from a height his head was
again injured, and now he is a bad boy again.

To Control Immigration. — A commission to
investigate the existing legislation relative to immi-
gration has been appointed by Secretary of Com-
merce and Labor Straus. The law whicli regulates
steerage accommodations on steamships coming to
this country was passed in 1882, and since that time
the changed conditions of ship building, etc., have
made many alterations desirable in order to conform
to the requirements of the times.

A Remedy for Mountain Sickness. — In a re-
cent communication ti;> the Kci'iie Scicn/Hique, Pro-
fessor Agazzotti announces that he has been able to
prove that the sole cause of mountain sickness is
the rarefaction of the air, and that by administering
a mixture of oxygen, carbon dioxide, and nitrogen
the svmptoms can be entirely prevented.

Bubonic Plague. — Owing to the presence on
board of a Lascar seaman suffering from what he
officials suspect may be bubonic plague the steamer
Kybfels, which arrived last week in Philadelphia
from Calcutta, is being detained at quarantine. In
the week ending November 3, the day the Kybfels
cleared, there were seven deaths from the plague in
Calcutta and eighty-three cases and fifty-six deaths
in Bengal. The Kybfels got a clean bill of health
at Calcutta, but a suspicious death occurred on the
voyage.

"Brooklyn Medical Journal" — In its December
issue this journal contains the announcement that
with the close of the year 1906 its publication will
cease. During the twenty years of its existence the
journal has been prominent in reflecting the iriedical
activity of the Borough of Brooklyn, and has been
the official organ of the Medical Society of the
County of Kings. Its editors have been Drs. Wil-
liam C. Braislin, James P. W'arbasse. John A. Lee.
and Clarence R. Hyde.

The Craig Colony. — Dr. \Vm. T. Shanahan has
been promoted to the position of First Assistant
Physician and Dr. Kirby Collier has been promoted
to the position of Second Assistant Phvsician in this
institution, b<>th promotions to date from January
I, IQ07.

Death of an Oldest Inhabitant. — On Decem-
ber 28 patient No. 7 of the Middletown. N. 'S'., State
Hospital died after having been an inmate of the
institution for thirty-two years. He was the oldest
patient of the hospital, having been the seventh to be
admitted after the institution was opened.

The Chicago Home for the Friendless, ]:>y the
will of Otto Young, will receive $20,000, and the
Chicago Home for Incurables $4cx>,ooo.

Donation to Cancer Fund. — < hi the occasion
.if their golden wedding -\Ir. and -Mrs. Henry Louis
r.ischoffesheim of London distributed $500,000 to
\arious charities, and of this sum the Imperial Can-
cer Research Fund received $200,000.

The Scranton Typhoid Epidemic. — From
thirtv to forty new caNCS of typhoid fever daily have
been reported from Scranton, and on December 29
the total for the month was 751 cases, and for the
epidemic 791. The hospitals are all overcrowded,
and even their emergency accommodations are taxed
to the utmost. The epidemic is believed to have
originated from water from the Elmhurst dam.

Tuberculosis Exhibition. — The Committee on
the Prevention of Tuberculosis of the Charity L)r-
ganization Societv will hold a tuberculosis exhibi-
tion at the Twenty-third street branch of the Young
Men".s Christian Association, 215 West Twenty-
third Street, beginning Wednesday, January 2, and
lasting until January 16. Numerous public lectures,
illustrated with stercopticon views, are to be given by
various speakers. The exhibition will be open all
dav, and adnii^si.jn w ill be free.

Washington Heights Hospital. — The entire
medical board of this institution has resigned, but
four of its members have been reinstated by the
Board of Directors. These are Drs. Nathan, Fris-
ner. Sable, and Clarence E. Sichel. Early in Janu-
ary the hospital will be removed to if)5th street, near
Broadway.

Beth Israel Hospital. — At the seventeenth an-
nual meeting of this organization it was announced
that $76,500 had been contributed toward the erec-
tion of the new hospital building. According to the
report there were during the year 1,353 ^''^s patients
treated out of a total of 2,377. JMore than i.ooo ap-
i:>licant5 had to be refused because of lack of facili-
ties. There were 72.712 consultations and 81,841
]Trescriptions given. The actual hospital expenses
were $83,492 and the total expenses Si 14.000. This
included $30,000 fijr imiiro\ements.

Western Reserve University of Cleveland. —
President Charles F. Thwing, of this L'niversitv.
announces that a chair of experimental medicine has
been established in the medical school, and that Pro-
fessor George N. Stewart of the University of Chi-
cago, has been appointed to the professorship. The
funds for this purpose and for the endowment of a
laboratory have been provided by two gifts of $100,-
cioo each, made b\- Mr. H. M. Hanna and Col.
rtliver H. Payne.

American Association for the Advancement of
Science. — At the closing session of this associa-
tir>ii, held in New York, December 31, the following
'ifficers were elected for the coming year: Preside:/!.
E. L. Nichols, professor of physics at Cornell Uni-
versity : General Secretary. F. \\'. McNair, president
of the ?ilichigan School of Mines: Secretary of the
L'oiiiicH. Prof. William Harper Davis, of Lehigh
University. Besides these ten vice-presidents were
elected. A banquet was given the retiring president.
Prof. W. H. Welsh, at the I'niversity Club by the
members of the executive council.

Comanche County (Okla.) Medical Society. —
This society has elected the following officers for
the ensuing year: President. Dr. .\. N. Campbell:
Vice-President. Dr. M. A. Jones: .Secretary and
Treasurer. Dr. J. L. Lewis.

Dickinson and Iron Counties (Mich.) Medical
Society. — ( )fficers for this .society have been
elected as follows: President, Dr. F. Larson. Crys-
tal Falls: Vice-President. Dr. Libby, Iron River:

MEDICAL RECORD.

[Jan. 5, 1907

Secretary and Treasurer, Dr. H. Sethnev, Crystal
Falls. i

Jefferson County (Tex.) Medical Society. — At
the annual nieetinsj of this society, held at Beaumont
on December 18. the following officers were elected :
President, Dr. H. A. Barr; Vice-President, Dr. A.
A. Bailey ; Secretary and Treasurer, Dr. R. R. Sul-
livan.

Farmington (N. H.) Medical Society. — The
physicians of this town and vicinity have organized
under the name of the Farmington Medical Society
and have elected the following officers : President,
Dr. G. W. Ellison; Vice-President, Dr. R. J. P.
Goodwin ; Sccretarx. Dr. P. H. Greeley ; Treasurer,
Dr. H. P. Wheatley!

Neosho (Kan.) County Medical Society.— Offi-
cers for this society for the following year have been
elected as follows : President, Dr. j. C. Lardner ;
J'icc-President. Dr. M. A. Duncan ; Secretary, Dr.
\\'. K. Mathis: Treasurer, Dr. A. M. Davis.

Kent County (Mich.) Medical Society. — At its
recent annual meeting, held at Grand Rapids, the
following officers were elected by this society :
President. Dr. S. L. Rozema ; Vice-President, Dr.
William Fuller : Secretary, Dr. H. Alden Williams ;
Treasurer. Dr. F. C. Warnshuis.

Kankakee (111.) Physicians' Club. — At a regu-
lar meeting of this club the following officers were
elected: President. Dr. G. H. Lee: Vice-President.
Dr. T. E. Caron ; Secretary-Treasurer. Dr. C. K.
Smith.

Obituary Notes. — Dr. Walter Jvdson of New
Haven died on December 25, at the age of eighty-
seven years. He had been visiting a patient, but
slipped on the pavement and fell, and shortly after-
ward died of cerebral hemorrhage. He was born in
r.ristol, Conn., and was graduated from Yale in the
class of 1864. He received his medical degree from
the College of Physicians and Surgeons in this city.

Dr. Timothy H. Bishop of Xew Haven, died of
pneumonia on December 26, at the age of seventy
years. He was graduated from Yale in i860, and
iiad practised in New Haven for many years. He
was a member of numerous historical and geneolog-
ical societies.

Dr. Frank E. Beckwith of New Haven died of
apoplexv on December 27, at the age of fifty-nine
years. Dr. Beckwith was born in Norwich, Conn.,
and was graduated from the College of Physicians
and Surgeons in 187 1. He practised in this city
until 1880, and was then appointed to the chair of
obstetrics at the Yale Medical School. In 1885 he
relinquished this position and devoted himself exclu-
sively to private practice.

Dr. Francis E. Doughty of this city died of
pneumonia on December 28, at the age of fifty-nine
vears. He was born in Albany and w'as graduated
from the College of Physicians and Surgeons in the
class of 1869. He was consulting surgeon to the
Hahnemann. Flower, and Laura Franklin Hospitals.

Dr. L. W. Babcock of W'adena, Minn., died on
December 25. at the age of sixty-six years. He was
Speaker of the Minnesota House in 1903.

Dr. William Stfan'ard of this city died on De-
cember 24 in the Brooklyn Hospital. He was born
in England and received his medical education in the
Bellevue Hospital Medical School. He was actively
interested in medical missionary work.

Dr. Johx C. Saxders of Cleveland, O., died at
the age of eighty-two years, on December 23. as the
result of injuries due to a fall on an icy pavement.
Li 1882 and 1883 he served as president of the

American Institute of Homeopathy and had prac-
tised for fifty years in Cleveland.

Dr. J. W. Mount of Kansas City died on Decem-
ber 18 at the age of sixty-eight years. He had prac-
tised in Kansas City during the past twenty years.

Dr. William H. Hipp of Chicago died on De-
cember 19 of pneumonia. He was born at Berrien
Springs, Mich., in 1864, and was graduated from the
Bennet Medical College in 1885. He had been sur-
geon at the Cook County and Chicago Hospitals,
and was a member of the State Board of Health.

Dr. John MacDonald of Chatham, N. B., died
on December 18 after a lingering illness. He was
born at Mount Stewart, P. E. I., fifty-six years ago,
and was a graduate of St. Dunstan's College, Char-
lottetown, and the Jefferson Medical College of Phil-
adelphia. He had practised in Chatham for about
twenty-five years.

Dr. A. J. DoOLEY of Marion, Ind., died on Decem-
ber 18, at the age of thirty-four years. He was a
graduate of the Rush Medical College in the class of
1897, and had practised in Marion ever since.

Dr. William H. Huger of Charleston, S. C, died
on December 17 at the age of eighty-one years. He
was graduated from the South Carolina College in
1846 and a few years later from the Medical College
of South Carolina. He completed his medical edu-
cation in Paris and then returned to Charleston,
where he had practised ever since. Two years ago
he completed a half century of ser\'ice to the Charles-
ton Orphan House and was presented with a silver
bowl in commemoration of this event.

Dr. Clark Le.\vitt of Danville, 111., died on De-
cember 19 after a long illness. Dr. Leavitt was
born in 1833 and received his medical education at
the L'niversity of Ann Arbor, from which he was
graduated in 1861. .A.fter practising in Newport,
Ind.. for sixteen years, he removed to Danville,
where he had practised ever since.

THE FIFTH HARVEY SOCIETY LECTURE.

The fifth lecture in the present series given by the
Han-ey Society was delivered at the Academy of
Medicine on Saturday evening, December 15. The
speaker, Dr. S. J. Meltzer of this city, chose for
his topic "The Factors of Safety in .Animal Struc-
ture and Animal Economy."' He began by defining
what was meant by factor of safety, and illustrated
the use of the term in the construction of buildings,
bridges, and machinery. All of these, as was well
known, w-ere constructed of more than sufficient
strength to bear even the extraordinary strains to
which they might be subjected. Such construction,
however, was not economical.

To what extent was the animal body provided
with factors of safety? The speaker said that al-
though there were quite a number of facts bearing
on this point, no one, so far as he was aware, had
ever approached the subject from just that point of
view. Just this, however, was really an advantage,
for then one might feel sure that the facts w-ere
without prejudice. W'e all knew that nature, above
all. was economical : factors of safetv, as already
pointed out, were not economical. Was the animal
body constructed to work with the greatest econ-
omv. or were factors of safety provided ?

Safety provided for by excess of structure was
well exemplified in the bilateral organs. If one of
the kidneys were excluded the loss was compen-
sated by the other. The increased work was taken
up immediately without any noticeable impairment.
It was possible to remove as much as two-thirds of

Jan. 5, 1907]

MEDICAL RECORD.

23

each kidiiev without ill effect. The normal secre-
tion of the kidney, it was pointed out, was not near-
ly the maximal capacity ; the margin was at least
twofold. The lungs were organs of supply and
elimination. In spite of their important work, life
was possible with the major portion of the lung tis-
sue consolidated or destroyed. In pneumonia and
empyema death was due not so much to mechanical
interference with respiration as to toxemia. Halle
had completely removed the right lung of rabbits
— more than half of the respiratory organs — with-
out deleterious eft'ects and without altering the res-
piratory quotient. In the lungs, then, there was a
large factor of safety in the amount of lung tissue
provided. This was not realh* excessive when w-e
considered the importance of this function. The
speaker next cited the tissues of the generative
organs as another example of quantity in excess
of that apparently required. Small pieces of the
organs left after surgical removal were capable of
functionating normally. It had even been recorded
that pregnancy had occurred after supposed double
ovariectomy. These cases had been explained by
assuming that a tiny piece of ovarian tissue had
been left behind. In operations on the young, if
fragments of the organs were left behind after re-
moval, the sexual character was normally devel-
oped. This had been well shown by experimental
work on cocks.

In the thyroid gland the removal of four-fifths or
five-sixths was not followed by the symptoms pro-
duced by complete removal of the organ, symptoms
of cretinism, etc. In other words, one-fifth or one-
sixth of this gland, or a single small accessory thy-
roid, sufficed to carry on the functions of the larger
structure. Complete removal of the adrenal glands
was followed by death in from thirty-six to forty-
eight hours. If, however, only a tenth of a large
gland or a small accessory one were left the func-
tions were normally maintained. Here the margin
of excess capacity was at least ten times the normal
requirement.

Going on next to the nervous system the lecturer
pointed out that the brain did not follow the rules
just indicated. This structure should be regarded
rather as a number of isolated functionating organs
than as a single bilateral organ. It was not really
bilateral ; the right motor area, for example, con-
trolled the muscles of the left side. However, this
division did not hold for the centers of muscles of
respiration, of deglutition, etc. Thus if only one of
the vagi were cut the normal respiratory rhythm was
maintained. If both were severed the inhibition of
the rate of the heart beat was abolished, while the
respiratory muscles were paralyzed. One vagus,
therefore, was sufficient so far as functional capac-
ity was concerned, yet two vagi were provided.

The same provision for safety was found in the
unsymmetrical organs. Complete removal of the
pancreas resulted in glykemia and glycosuria. If
but a tenth of the organ were left behind, however,
the animal would be completely protected. Re-
moval of half of the Kver did not interfere w-ith its
many important functions : in fact, as much as
three-fourths could be removed without special ill
effects. The stomach could be completely excised,
or as much as 70 to 80 per cent, of the small intes-
tine removed without necessarilv interfering with
normal health. It had recently been suggested that
functionally the colon was almost useless to man.

A similar abundant provision was found in the
products of tissue activity. Thus in the digestive
enzymes we had pepsin, trypsin, and Cohnheim's
erepsin for the digestion of proteids, ptyalin and

amylopsin for carbohydrates, steapsin and gastric
lipase for fats. The last mentioned enzymes were
also present in the liver and bile. The amount of
the enzymes secreted was also far above that really
required, and it was known that most of them could
be excluded, individually, from the digestive tract
without noticeable ett'ect on nutrition.

It was interesting, the speaker said, to see how
well nature safeguarded the reproductive functions.
For the sexual functions of a woman about 500 ova
were all that could possibly be used. At birth the
ovary of a female child contained perhaps a hun-
dred thousand ova, and even at the time of puberty
there were still some thirty to forty thousand. Sim-
ilarly, in the male, there is an enormous production
of spermatozoa. It had been calculated that an
average ejaculation contained several million sper-
matozoa. Only b}- providing this enormous excess
was nature certain to overcome the many obstacles
in the passage of the spermatozoon to the ovum,
and so provide for a continuation of the species.

It was strange, at first sight, to see how scantily
in this respect certain vital functions were provided
for. This was particularly exemplified in the me-
dulla, where slight mechanical injury caused serious
damage. On the other hand few of the organs were
so well protected mechanically from external vio-
lence, and few possessed such an abundant vascular
supply.

Factors of safety were also provided in the circu-
lation. There was, for example, more blood in the
bodv than was actually required. One-half of it
could be withdrawn without serious consequences,
and the loss was rapidly and easily replaced. The
relation of the volume of the blood to that of the
vessels, and the fact that the blood can easily be
thrown into the splanchnic areas, the skin, or the
working muscles, were also factors of safety. So
also was the existence of collateral vessels which
might be called upon in an emergency. The heart
possessed a superabimdance of force and volume.

The speaker then called attention to another
method of furnishing a margin of safety, namely,
by providing multiple and parallel mechanisms.
The principle was well exemplified in the several
vasomotor centers, £?.,q-. the main one in the well-
guarded medulla, and subordinate and compensat-
ing centers in the dorsal cord, in the sympathetic
ganglia, and even in the vascular wall itself. Cen-
tral as well as local mechanisms were also provided
for the heart, the intestines, and the uterus. In the
pancreatic secretion and in the formation of milk
we had examples of chemical-stimulating mechan-
isms supplemented by nerve control. Pancreatic
and gastric proteolysis, and water elimination by
the sweat glands, kidneys, and mucosa were exam-
ples of coexisting mechanisms. The distribution of
work among several groups of tissues so that some
act as reserve forces was also a factor of safety.
Self-repair, regeneration, hypertrophy were factors
of safety peculiar to living forms, and these proc-
esses tended not only to replace or cotnpensate in-
jured and used tissue material, but to maintain and
restore margins for safety beyond present or nor-
mal requirements.

Did principles of economy or those of super-
abundance pre\'ail in nutrition ? There was a re-
serve of oxygen, and gh'cogen and fat were saved
for unforeseen emergencies. A storing up of proteid
food did not occur except in convalescence, in the
spawning of fish, etc. Dr. Mcltzer believed that a
diet containing more ayailablc proteid than that
advocated by Chittenden was desirable, for this
would be in accord with the existing principles of

24

MEDICAL RECORD.

[Jan. 5, 190;

maintaining a large niargin of safety in the animal
body. Chittenden's a priori assumption that the
smallest amount of proteid on which the animal
body could reg'ularly maintain itself would be the
nx>st desirable, was, Dr. Meltzer said, quite un-
warranted and seemingly opposed to the principles
above enunciated.

OlflrrfHpmtltrnrr.

THE SCIENTIFIC CRITERIUX OF A .AIALIGX.-\XT
TUMOR.

To THE Editor of the MEmc.xL Record:

Sir: — In view of the publication by Dr. Clarence C. Rice
(Medical Record, November 24, 1906) of a case of laryn-
geal cancer, treated by injections of pancreatic ferments,
the time seems opportune for a few words upon the matter
looked at from the standpoint of the scientific investigator.
Dr. Rice in his paper only states that it was "supposed
to be carcinomatous," and I am given to understand that
this point and the fact that no pathological examination
was ever made before treatment (rightly in my scientific
opinion) have been seized upon by the critics. What do
they suppose it might have been? No number of injec-
tions of pancreatic ferments would ever have the slightest
effects in diminishing the size of a benign neoplasm, for
such a thing is composed of normal or somatic tissues,
not of "imitation tissues," like a malignant tumor. The
true nature of a malignant tumor is a question to be
determined by scientific methods, and at this juncture it is
fitting that the scientific investigator should place himself
in front of the physician, annotnicing his determination to
defend the latter 'against all attacks. Well, the scientific
investigator steps confidently into the arena, the sword of
science is now held ready to strike ; it has no scabbard to
throw away, its point is sharp, its edge keen. The hand
i^rasping it and holding it aloft knows how to use it!

During the past few weeks (November, 1906) the pages
of a medical journal in Great Britain contained several
letters upon that neoplasm of the mouse, commonly known
as "The Jensen Mouse-Tumor." The controversy, orig-
inally started by Mr. W. Roger Williams, F.R.C.S., raged
at first around two points: ( i> its nature and whether it
was or was not a true cancer, and (2) the justification of
applying to it the name of its finder, and thus of naming
it "The Jensen Mouse-Tumor." In the sequel, apparently,
the first point was lost sight of, and the original writer and
Mr. Henry Morris, President of the Royal College of Sur-
geons, narrowed the discussion to the second and more
trivial point as to whether Morau's or Jensen's name should
be applied to it. Looked at from the strictly scientific point
of view, it should not be called by either name. Like the
chameleon, "the creature's neither th' one nor t'other!" In
anatomy, at all events, that system of nomenclature has
been abolished.

But the original question, raised by Mr. W. Roger Will-
iams, touches much graver issues. He denies that this
tumor is a cancer at all ! If this conclusion be right, it
is not very flattering to the scientific acumen of any orie
of all the investigators of cancer, who have used or still
employ this neoplasm in their work. Tn the Cciitralblatt
fiir allgcmcinc Pathologic (Vol. 17, p. 870) the pathologist,
F. Henke. now of Konigsberg, states the results of his
critical e.xaminations of this and other now well-known
mouse-tumors. The paper was read before the German
Pathological Societv at its tiieeting in Stuttgart on Septem-
ber 18, 1906. Obviously, Mr. W. R. Williams was not
present, for Henke's verdict met with no contradictions !
Briefly, his conclusion was that the Jensen mouse-tumor,
like the others examined, was a true cancer, and analogous
to a human carcinoma.

We have here the diametrically opposed views of two
experienced pathologists. My concern is not with the con-
clusion arrived at by Henke, but with that advanced by
Mr. W. Roger Williatns. One might, indeed, surmise that
there was no pathological criterion for a cancer. What
is the criterion for the statement that this mouse-tumor
is not a cancer? Scientific reasons are not contained in the
original report of his lecture in London or in his letters
to the medical papers. The criterion for his jud.gment is
simply his authority. The Jensen mouse-tumor is not a
cancer, because— he savs it is not! -•\s he stated in The
Lancet of 1904 (December 3, p. 161.3) re.garding other
aspects of the problems of cancer, he is satisfied, he has
convinced himself, he has stated his convicition, that the
Jensen neoplasm is not a cancer. "Damit Punktum!'' as the
Germans sav.

Is this or is it not a scientific que.stion? Are or are
not the pa.gcs of the chief medical newspapers in Great

Britain open (unpaid) to the pens of all scientific men?
I am w ell aware that they are not open freely to mine !
.Matters have reached a clima.x, when scientific questions
are disposed of in this arbitrary fashion. It is the kind of
"argument" which authority always employs. "I know
far more about the thing than you do!" But — it is not
"science." One is reminded of some of the things — wonder-
ful things they were — contained in a leader in The Lancet
of February 4, 1905, and written by one who did not
understand the difference between a scientific fact and
a conjecture. "In short, Dr. Beard passes from one con-
jecture to another. He begins by views on embryology,
which on his own showing are not generally accepted by
embryologists. He goes on to express opinions on the
histology and the pathology of cancer which are not
in ;;ccordance with known truths and launches into the
realm of therapeutics with assertions about the action of
ferments which would inevitably cause the rejection of a
candidate in physiolog)-." The lack of commas in these
passages is quite characteristic of the writings, up to date,
of him who wrote these highly complimentary things.
Since that time he has himself adopted, without acknoTJi'l-
cdgmcnt, two of the "opinions," i.e. conclusions, expressed
by me, that of the "mimicry" of the tumors, and that of the
identity of cancer and sarcoma. As to the rejection of
a candidate in physiology, perhaps he is not aware that
in the year of my birth, 1858. it was held by physicians
and physiologists that the sweetbread, or pancreas gland,
had no digestive functions, and both Corvisart and Kiihne,
who were the first to describe the functions we now
assign to it, also ran this serious danger of rejection, but
as they had no intentions of being examined in physiology,
they did not mind running the risk. It is nothing less than
a gross insult to the intelligence of a scientific man of
nearly twenty-five years' standing to say such things re-
.garding his work. He is not a paid official researcher. As
if, too, the "generally accepted'' in science were of necessity
true ! From 1870 to 1900 a somatic origin of germ-cells,
based on the researches of Waldeyer, was "generally ac-
cepted." but in 1902 Waldeyer, like the great man of
science that he is, withdrew his researches, and thus took
away all the basis of this general acceptance. The view
is now without any basis in observation, but it is still
''generally accepted" because it fits in w-ith other human
superstitions.

The writer is not a pathologist, and probably he would
never have felt deeply concerned about the sayings of
pathologists had they not invaded the realm of biology
and embryology. The proceedings of the Stuttgart meet-
ing are full of both biology and embryology — of a sort —
biology and embryology, which only exist in the human
pathological imagination. However, this writing is not
intended to be a treatise on either science, based in actual
observation. To come to the point at issue. What is the
pathological criterion of a cancer? Now, in asking this
que<ition I have no desire to raise a storm about anaplasy,
nietaplasy. and all the other words, not things, ending in
■'plasy." Therefore, the question may be put in another
form: What is the scientific criterion of a cancer?

There is now a pretty general agreement that a growth
made up of normal tissues and containing hair, skin, teeth,
and Ix>nes is a more or less reduced individual, an em-
bryoma, a twin identical with the individual harboring it.
Can any similar conclusion be reached regarding a cancer?
Is it germinal in nature, as some have insisted? Where
is the criterion" If it be .germinal in nature, it should form
eggs or sperms, or both, but it never does so. Unless
it be due to a parasitic organism, as it is neither somatic
nor germinal, it can only be one other thing. For of the
life-cycle there only remains trophoblast. Cancer is on
irresponsible trophoblast. If this be true, where and what
is the criterion? The criterion is, that if it be trophoblast
it cannot live in the presence of the secretion of the pan-
creas .gland, especially in that of the ferment or enzjTne,
trypsin. The chemical test (exact science) of cancer is its
liehavior, when living, toward injections of extracts of real,
not imaginary, pancreatic ferments.

.■\s these words are written one seems to hear certain
surgeons and official researchers remark, "We have tried
trypsin, and it has no action upon cancer. It is useless."
Softly! Wait a little! .\s an Italian physician said: "I
have given any number of injections of trypsin in a case of
cancer of the tongue, and the thing calmly pursued its
■parabola.' its course." The reply made to this gentleman in
choice (?) Italian was: "Yes. and nearly all the time you
were acting in opposition to my scientific advice, while a
similar cancer of the tongue further south in your own
country was gradually healing." I will not invoke the
microscopical e^'idences. but will instead refer to the nu-
merous human patients, who have been, or are being,
treated with h>-podernial injections of pancreatic ferments,
which are .guaranteed to he what is printed of them on
the labels of the boxes. From many of these cases I have

Tan.

1907]

MEDICAL RECORD.

noted, and some physician? have agreed, that it is an easy
thing to kill every cell of an ordinary nnoperated cancer,
even 3 matter of a few weeks, but not at all easy to remove
the dead tumor. In the presence of sufficient trypsin, and
this is not a large amount, no cell of an ordinary nnoperated
cancer can live. Where is the proof? Recently I was
informed of two cures in New York, one a cancer of
the larynx, the other a cancer of the tongue. The former
has been reported, and possibly by this time the latter also.
"None in Great Britain?" Not yet, for most of them are
like the one which ran its parabola in Italy, and for the
same reason, because the wrong stuff was employed. "Two
only, then." Tzco human lives saved! Add to these some
others who will be saved, as v^'ell as a certain lady in South
Italy. She had suffered from the torments of "inoperable"
cancer of the tongue since January, 1903. She is the mother
of a large family of children, all living and healthy. Early
ni March, 1903. the lady was examined, cancer of the tongue
diagnosed, operation at first advised, but afterwards de-
clined, by Dr. Guiseppe Caccioppoli, Professor of Operative
Medicine and of Clinical Surgery in the Regius University
of Naples, Surgeon to the Hospitals for Incurables and
Loreto, and she was also examined and the like diagnosis
given by Dr. Cavaliere De Giacomo Annibale, Professor
of Operative Surgery in the Regius University of Naples.
The pancreatic treatment (injectio trypsini and injectio
amylopsini, Fairchild) was undertaken under the scientific
directions given by me from time to time, by Gennaro
Cavaliere Guarracino, Physician and Surgeon to the Pro-
vincial Hospitals for the Insane of Naples, and to the
Hospital of St. Eligio, and by Professor Michele Manzo,
Surgeon to the Pilgrims' Hospital. In the opinion of these
two latter the last of the cancer is gone, but she has lost
most of her tongue, which the two eminent surgeons hesi-
tated to try to remove. By the end of September the last
remains of the cancer came away. The chief physician
wrote confirming this, and added: "This is a wonderful
result, and I declare that it seems to me the most consider-
able fact which our science has ever obtained." Long ago
he promised me his full notes with a view to their publica-
tion in English. That is the scientific criterion of a cancer
— the chemical test!

Certain British surgeons and others have obtained only
negative results. Why have they not reported them? The
reasons for their failures would then have been apparent.
Some of them tell patients that they have tried trypsin and
found it "useless in cases of cancer." How do they know
that they were using trypsin? Have they ever tested, as a
chemist must do his reagents, the injection as to its ferment
powers? Are they sure they were not using something
little, if any. better than glycerin and water? ,\s well
might a brewer assert. 'T have tried yeast, and it w'on't
act upon the wort of my intended brew of ale. It is quite
useless for brewing beer." I and others have tested all
the injections advertised, and I have seen the results of
assays. The finds are astounding. My published scientific
work lays down that the injection should be "the secretion
of that important digestive gland, the pancreas." that is to
say, be prepared from the fresh gland direct, that this injec-
tion should contain all the ferments, that, generally speak-
ing, it should be .given for not a very great number of
weeks, and be followed by injections of amylopsin. the
diastatic ferment of pancreas gland, to remove all the bad
symptoms of "eclampsia" — a thing it has done a.gain and
again, and never failed.

Two persons claimed to have discovered that "the pro-
teolytic ferment of the pancreas, and not the diastatic"
converted glycogen or animal starch, and acting logically
on this ''discovery." they put out, the one selling and the
other using, an injection of trypsin so pure that it had no
.iction upon glycogen or animal starch! When in 1005 I
wrote of the secretion of the pancreas gland, do those
who have failed imagine that I really meant the dispensing
in a chemist's back shop of somebody's trypsin in powder,
just as though it were so much blue pill? There is only
one set of preparations now on the market which satisfies
the above requirements. Before they put out their injec-
tions-the makers of this preparation, and they alone of all
the makers, asked my opinion of their procedure. .MI their
products are stable and aseptic. There are in my house, as I
write, ampoules of injection, which, if taken out of the
thrice-sealed bo.x, would be found to be — so much glycerin
and water !

Those surgeons who have described the treatment as
"useless" have actually never employed it. They are really
in the same logical "scientific" position as one of their
colleagues in Cliicago. Dr. Nicholas Senn, who frankly
condemns it as "a failure." while admitting that he has
never tried it! (Chicago Tribune, .'\ugust 5. 1906.) He
mi.ght just as well declare that yeast will not ferment the
wort of beer, and state at the same time that he has never
made an experiment with yeast to test its supposed powers

in this direction ! Surely this is not a sample of science,
"made in Chicago!"

The criterion of a cancer, the exact chemical test, is not,
let me insist, its behavior toward a glycerin and water
solution of ferments in powder, but toward an extract of
fresh pancreas gland, scientifically prepared. Unless
"boiled" or otherwise spoiled, such an injection can never
be described as "useless."

All this is not merely a criterion, but it is the criterion,
and no other is possible. Therefore, one does not need to
ask the surgeon named in the opening passages of this
writing to produce a criterion, for he has none, any more
than Dr. Nicholas Senn has. except in each case his "author-
ity." Science, sad to say, does not recognize this as valid.
By the chemical test the mouse-tumor, known as Jensen's,
is a malignant neoplasm, a cancer, for it is killed and its
albumin pulled down by the ferment, trypsin. That is
a fact of comparative physiological chemistry, an exact
sciewe! It is not open to the contradictions of any sur-
geons living, least of all to those of Mr. W. Roger Williams
and Dr. Nicholas Senn.

In the same way the "supposed cancer" treated by Dr.
Rice according to the scientific method of treatmeiit re-
vealed by my work, is now proved to have been a true
malignant neoplasm, for the chemical test has demonstrated
its nature. It is no argument to the contrary to assert
that other cases failed to yield. Chemical experiments do
not always succeed at the first attempt. I have known
the two great men of science, who taught me chemistry,
Sir Henry Roscoe and the late Professor C. F. W. Kruken-
berg, to fail often, but in the end they alzvays succeeded.
In cases of failure, some of the conditions needed for the
success of the experiment may be absent.

Em.vBURGH. John BE.aiRD, D.Sc.

OUR LONDON LETTER.

(From Our Special Correspondent.)

BRADSH.IlW lecture — EOSINOPHILE PLEURITIS — INFECTIVE
TUMORS OF DOGS — CH0RE.\ — NOMENCL.\TURE OF DISE.\SES —
ELECTION TO GENER.VL MEDIC.'^L COUNCIL — LE.-\GUE OF MERCY
— .ACTION AG.AI.VST SURGEONS — OBITUARY.

London, December i.;. 1906.
The "Bradshaw Lecture" was delivered on Wednesday
at the Royal College of Surgeons by Mr. Edmund Owen,
V.P., who took for his subject "Cancer: Its Treatment by
Modern Methods." He laid down emphatically that in the
present state of our knowledge the only way of dealing with
it is by prompt and thorough removal. As soon as a sur-
geon has made up his mind that a growth is malignant
and could be removed, no time should be lost. No surgeon,
from a desire to lessen mental distress or allay the dread
of his patient, should be led to consent to any dallying
with any problematical treatment. Surgery could not go
in advance of facts, and at present she could not promise
cure, whether by cutting operation, by A'-ray, by Finsen's
light, or by any drug. Treatment was not the same thing
as cure. The most effectual treatment of cancer, however
small, was the knife. It was owing to the freedom
and thoroughness of operations that great ad-
vances had recently been made. Our fore-
fathers would have been astonished at the
thoroughness of modern methods of operating. To them
the presence of enlarged glands was almost a bar to inter-
ference. But men and women have now no greater powers
of resistance than fifty or a hundred years ago. The
triumphs of modern surgery, to put it figuratively, might
be ascribed to Lister having shown the virtue that lay in
soap and water and the nailbrush. In the world of therapeu-
tics there were dark tracts and continents which could
only be discovered by men of imagination and energy.
When the happy discovery should be nvade it would not
be by columns of figures and percentage calculations, which
like pancakes must be served quickly or be spoiled. Per-
centages might be of value worked out by an actuary in
a life office, but were hardly the same when compiled by a
surgeon to set forth the result of his treatment, for two
patients with a disease called by the same name were not
of the same clinical value, nor were twenty nor two
hundred. The sootier surgeons discarded the activarial
method of settin.g forth progress in connection with cancer,
the better. Speaking of the excellent work of the Imperial
Cancer Fund, the lecturer referred to the patient, hopeful
work of the Director, Dr. Bashford. and his staff. He
regretted that their researches were running the risk of
being hampered by the limited space in which they worked
and the inadequate skilled assistance the fund could afford.
It was likely that experimentation on mice would he
mentioned at a meeting of the Vivisection Commis-
sion, and some misinformed and therefore apprehensive
witness, or some little Englander of the scientific world
might be asking himself what profit can come from sucli

26

MEDICAL RECORD.

[Jan. 5, 1907

experimentation, claiming that mice are of more value tlian
many human beings who are or may be the subjects of
cancer, and demanding that further experimentation — the
only means by which a cure is likely to be discovered —
shall forthwith cease. .'Vs to the precise value of the work
it was too early to speak ; but seeing into whose care the
direction of the laboratories had been placed the result
might be awaited in full assurance that no cruelty would
be allowed to dishonor the research.

Regretting that it was not possible to call attention to
any metliod of treatment which could honestly and confi-
dently promise a cure, as surgery at present knew of none,
Mr. Owen added that nevertheless the surgeon would do
a great deal for his patient; might be able even to set him
free from his disease. But the word "cure," if ever used,
should at present be uttered only in a whisper as it were ;
though perhaps later it might be proclaimed from the
housetops. Disheartening as it was to be obliged to confess
that at present no certain cure had been discovered, and
that, so far as known, the searchers w'ere not obviously
on the track of one, yet the public might be assured that
if ever a cure should be found those who are strenuously
working at the subject would be in immediate possession
of it. If the exact position of affairs could be placed
before the public it might induce more people to give
financial support to the National Fund for the promotion
of cancer research and might also prevent some who fear
they are attacked from falling into the hands of so-called
"cancer-curers."

At tlie Pathological Society, on the 4th inst., Drs. Perkins
and Dudgeon contributed an account of a case of eosino-
phile pleurisy. .A girl of twenty-two attacked with bron-
chitis and acute pleurisy in a few days developed acute
pericarditis, and, twenty-two days after admission to hos-
pital, endocarditis. By aspiration nine ounces of yellow
fluid were removed from the pleural sac. Cytological
examination showed 34.6 per cent, of coarsely granular
polymorphonuclear eosinophiles in a count of 500 cells,
10 per cent, polyneutrophiles. 23 per cent, small lymphocytes,
32.4 per cent, epithelial cells. Examination of the blood
at the same time gave leucopenia, slight anemia, eosino-
philia. and increase of mononuclear cells. Staphylococcus
aureus, and albus were cultivated from the sputum. A
blood examination six weeks later showed absence of eosin-
ophiles, a normal number of leucocytes, and a normal dif-
ferential count. .A.utopsy showed pleural adhesions on
both sides, adhesions, pericarditis, and vegetations on the
mitral and aortic valves. No sign of tuberculosis in any
part of the body. No positive information was obtained as
to the source of infection, and the authors suggested it
might possibly have been influenzal.

Dr. Seligm'ann exhibited a number of infective venereal
tumors of dogs from British New Guinea. It could not
be said the dogs were of pure native breed, as there had
been too much crossing with those introduced, but the
natives said the disease was known before white men came
there. The tumors were considered as most probably
identical with those described by Bellingham Smith and
Washbouriie. The position, microscopic appearances, and
transmission were the same. An important point was that
in one instance metastasis had occurred to the testicles,
both of which were completely replaced by new growth
which, however, had not penetrated the tunica albuginea.
Mr. Shattock considered this last point particularly inter-
esting, the testicles showing real metastasis and not ex-
tension by continuity with the prepuce. The tumors pre-
sented perfect histological pictures of large, round-celled
sarcoma with no signs of inflammation. That they were
contagious did not prove them not malignant. Contagious-
ness and infectivity were only relative terms. The tumors
should be classed with sarcomata, and it might be that
the investigation of such ambiguous forms or connecting
links w-ould eventually lead to a knowledge of the patho-
genesis of cancer.

At the Therapeutical Society Dr. Cecil Wall read a paper
on the value of certain drugs in chorea. The effects of
different methods of treatment were compared, the criterion
adopted being the number of weeks before the choreic
movements ceased. Under arsenic it appeared that the
duration was the same as under no treatment. I'nder
sodium salicylate the result was very little better. Under
acetosalicylic acid the duration was nuich less. In half the
cures the movements ceased in less than a month ; in g2
per cent, in less than two months. Under arsenic the move-
ments continued for over two months in 62 per cent, of
the cases. Dr. Duncan.son said that in the North of
England they obtained excellent results with arsenic, and
he'suagcstcci that probably in the south there was some
difference in the disease or else in the temperament of
the children.

Dr. A. F. Hertz then read an elaborate paper on the
importance of a salt-free diet in the treatment of edema
and serous effusions.

The third revision of the fourth edition of "The Nomen-
clature of Diseases" is being issued this week. The work
may be considered official, as its primary use is for the
purposes of the registration of diseases, and to this end
the elaborate index is of the greatest value. It is to be
feared indeed that many practitioners confine their atten-
tion to this, consulting the work only as the necessity of
certifying a death may recur. But the book is full of
information in a condensed form and represents no small
amount of the most recent advances in our views. The
preparation of the first edition dates back to 1859, the
second to 1880, the third to i8g2. This fourth was begun
in 1902. At the meeting of the Royal College of Physi-
cians, Sir William Church presiding, in July of that year,
it was determined to begin the decennial revision, to be
issued in 1906, and here it is before the year has expired.
-■Ml along it has been the production of a committee ap-
pointed by the college, representing not only its own
fellows but the public services, the universities, and most
medical authorities. There is also a very strong "sub-
committee on classification" and twenty-three other sub-
committees (worthy of two persons) for the revision of
the classification of local diseases. The Latin, French,
and German translations have engaged three separate schol-
ars. Mr. Shattock, the Latin reviser, has adopted a plan
deserving of the highest commendation, selecting as far as
possible Latin equivalents which would be readily under-
stood should the language again become an international
medium of communication. Moreover, he has not followed
the absurd plan of Latinizing proper names, but treats them
as indeclinable — though when a Latinized name has been
established he sometimes admits it as a synonym. A memo-
randum by the classification committee reminds us that the
large, heterogeneous section, headed "General Diseases"
in the third edition, has been broken up into the following
groups: (l) Infective diseases, (2) intoxications, (3)
general diseases not included in the two preceding groups,
and (4) certain morbid conditions incident to various
parts. These embrace conditions which do not necessarily
alTect the whole organism, but which it is desirable for
registration purposes to return under a general rather than
a local heading. They are Malformations, New Growths,
Cysts, Effects of Injuries, of Parasites, of Poisons, and of
Foreign Bodies.

An action against two surgeons at Cardiff for negligence
was tried last year at the local assizes, and the jury could
not agree. A second trial was wanted and held last week
in the high court, and the jury, after three or four times
reporting that they could not agree, at last gave a verdict
10 the plaintiff with £100 damages instead of i2,ooo asked
for. The case was one of a bicycle accident causing a dis-
location of the humerus, complicated with extensive bruis-
ing and swelling, concealing at first a fracture of the
surgical neck of the humerus. This was found with Roent-
gen rays, but the danger of gangrene prevented active
manipulation, and a pad in the axilla, and bandaging the
arm to the side, was considered at the consultation the best
course. The patient recovered with some stiffness of
the shoulder, for which with a patient's gratitude he
sought a solatium of £2,000, and Messrs. Rose, Pepper, and
Baike gave evidence for him, though they were opposed
by Sir F. Treves, Sir W. Bennett, and ^lessrs. Bowlby,
MouUin, Lane, Page, Owen, and Waterhouse. An appeal
is expected, so not much may be said. I hear that the costs
of this trial are expected to be £6,000 or £8,000 — a scandal
to the law which permits it. and lawyers who profit by it. If
doctors are to be subjected to these dangers in obscure
cases they will have to demand an indemnity before pro-
ceeding to treat the sufferer.

-As I anticipated, the British Medical Association has
carried its three nominees at the election of representatives
to the General Medical Council. I have nothing to say
against the three gentlemen chosen except that they repre-
sent— instead of the electorate — the British Medical Asso-
ciation, which is always striving to get everything under its
control. But the profession is to blame, for, like the grum-
bling ratepayer, it is too apathetic to vote. The elections
have regularly declined in interest so far as votes show.
The highest number polled this year is below that of unsuc-
cessful candidates ten years ago. .Another rather discredit-
able circumstance is the inability of so many electors to fill
up the voting paper, notwithstanding most explicit directions
which accompanied it. Out of the 12.82S voting papers
sent in. 911 were returned through the dead-letter office. 615
voters had not signed the identification envelope, and 467
had not fastened it. 193 had not put the voting paper in
the envelope, 165 sent in too late, and 35 had not properly
marked their paper with the cross onh'.

The League of Mercy is making great progress. The
annual meeting of the presidents of districts was held on
Wednesday, when it was stated that probably a sum of
£17,000 would this year be handed to the King's Hospital

Jan. 5, 1907]

MEDICAL RECORD.

27

Fund. This will bring up the total obtained by the league
in its eight years of existence to £80.000.

Dr. \V. T. Greene died on Monday. A highly-cultured
man with a fine literary taste, he was also a naturalist of
•wide attainments and a special bent toward ornithology.
His great work on the "Gray Parrot" is probably known
to you. Smaller books on birds of various kinds fell from
his ready pen, and he also wrote some stories and verses
for magazines which displayed delicate and refined taste.
He practised for many years in a southern suburb and
later in a western quarter of London. Possessed of an
attractive personality and courteous manner, his patients
had the greatest confidence in his skill, and well they
might, for in some branches he was more than up to date
and had forestalled certain advances. He was partly
-educated in France, where he took the degree of Bachelor
in Letters, .\fterward he entered Trinity College, Dublin,
and took the .\.^L and M.D.

Mr. R. S. Fowler, F.R.C.S.. of Bath, where for many
years he had enjoyed the confidence of a wide clientele
resorting to that famous spa, died on the Qth inst., aged
seventv-six.

Lieut.^Col. C. R. Bartlett. R..A..M.C., died on the 5th
inst., aged forty-seven, at Sierra Leone, where he was
senior medical officer. He saw service in the .\shanti
Expedition of 1895-6, and two years later on the North-
western Frontier, India.

OUR LETTER FROM THE PHILIPPLXES.

(From Our Special Correspondent.)

THE CH0LER.\ EriDEMIC OF I905. ITS ORIGIN, .\ND THE MEANS
T.\KEN TO SUPPRESS IT — LEPERS IN P.\N-\Y — PERSON.'\L.

M.\.N-iL.\, November 10. iqo6.
The regular monthly meeting of the Manila Medical Soci-
-ety was held November 5, 1906, at 8.30 p. m. at the St.
Paul's Hospital. Dr. McDiU demonstrated a number of
cases, among others a case of carcinoma of the uterus, and
stated that his experience of the past year confirmed the
earlier reports that carcinoma was not very prevalent in the
Philippines. This experience is in conformity with the
generally-accepted statement that carcinoma does not occur
with the same frequency in tropical climates as it does in
temperate ones.

The first paper of the evening was read by Dr. Victor
G. Heiser, Director of Health for the Philippine Islands,
entitled "The Outbreak of Cholera in the Philippines of
1905, and the Methods LTsed in Combating It. with Sta-
tistics to January i, 1906," He stated that in the pandemic
which ended March 8, 1904, there were 166,252 cases, with
109,461 deaths reported, but, that reliable observers were
of the opinion that at least one additional case occurred
for each one that found its way into ofticial records. From
March, 1904, until .\ugust. 1905, there were no cases known
to have occurred, but suspicious cases, which clinically
resembled Asiatic cholera, were encountered from time to
time. .^11 those that came under notice were carefully
autopsied and bacteriologically examined by such competent
observers as Dr. Richard P. Strong, of the Bureau of
Science (Bureau of Government Laboratories), with nega-
tive results. The first recognized case of the present out-
break occurred in the person of a prisoner in Bilibid
Prison. The next case occurred outside the prison in the
person of an American woman residing in the Walled
City; the next case was that of an American residing in the
Santa Cruz district, a distance of over a mile from the
first case, the two persons having nothing particularly in
common. At the same time suspicious cases were occurring
at Fort William McKinley, which is located about seven
miles up the Pasig River from Manila, with symptoms
which were attributed to vino poisoning, but later definitely
diagnosed as cholera.

Cases then occurred in Manila as follows : .August 2.3,
2; August 24, I ; August 25, 3; .-August 26, 8; .August 27, 10,
and thereafter an average of about ten cases per day until
about the middle of September.

The characteristic tendency of the outbreak continued
during the early weeks of the scourge, i.i\ no connection
could be traced between cases ; no two cases occurred in
any one house, nor did any two cases occur in any one group
of houses, neither did more than one case occur at a time in
any one section of the city. It was pointed out that during
the first two weeks of this outbreak there had actually
been more cases than during the same period of the out-
break of 1902, which went to show that the disease was
virulent in character, and that perhaps the principal reason
that it did not reach the proportions of the epidemic of ig02
was probably due to the measures employed in suppressing
it. .After the presence of the disease in Manila was recog-
nized it was learned that it had made its appearance about
a week earlier in a small town called Jalajala, in Laguna

Province. A review was then given of the foreign ports
which had direct steamship communication with Manila.
From the evidence it appeared that the disease was prob-
ably not introduced from without, but was rather a recru-
descence.

Numerous tables were exhibited, showing the number
of cases by age, race, nationality, occupation, etc. The
table by race was the most interesting, and is given in full :

No. of No. of Mor- Ratio of Date of

Race. cases, deaths, tality. I case to. last case.

1905

.Americans II 6 54.0 399. Oct. 10

Filipinos 220 200 90.9 862.6 Dec. 31

Chinese 4 4 loo.o 5,.107.5 Oct. 8

Foreigners 20 16 80.0 227. Nov. 8

From the above table it will be seen that in proportion to
their number more foreigners contracted cholera than any
other group ; that the .Americans ranked next, but had the
lowest death rate, and that the smallest number occurred
among the Chinese. The mortality of 100 per cent, among
the Chinese may be attributed to the very few cases that
occurred among them, and that those who recovered prob-
ably escaped detection by the health authorities. This
immunity among the Chinese is particularly noteworthy,
because it is, in all probability, due to their firmly-established
habit of drinking tea instead of water, and not eating raw
vegetables.

That no further cases occurred among .Americans after
October 10 was probably due to the fact that as soon as
they believed the disease to be actually present they
observed the prophylactic measures against cholera more
strictly.

In mapping out the campaign for combating the disease
the work was divided into four parts: (i) The isolation
of the sick in the cholera hospital, and rigid disinfection of
their houses and effects; (2) protection of the city water
supply, including the closing of wells located in the City of
Manila; (3) the prohibition of the sale of foodstuffs likely
to become contaminated, and the proper protection, by fly-
screens, of the remainder; (4) the education of the public
in the precautions to be observed in order to avoid the
disease.

Particular stress w^as laid upon the fourth part of the
w'ork : the education of the public, and the success in con-
trolling the outbreak was no doubt due to the cooperation
which was given. In order to place something practical
before the public sixteen simple rules for combating cholera
were printed in the newspapers, and then issued in the form
of a handbill in English, Spanish. Tagalog, Ilocano,
Visayan, and other native dialects. The Bureau of Edu-
cation sent these circulars to every teacher in the Islands,
with instructions that the rules should be taught to the
pupils until they could recite them, and then the pupils were
requested to repeat them to their parents. The .Archbishop
of Manila sent the circulars to all priests, with instructions
that they explain their contents to their parishioners, and
the churches of other denominations did likewise. In
addition, large, flaring posters with the rules printed in
the different languages were displayed in the postoiBces,
municipal buildings, and other places throughout the
Islands. Later a more advanced cholera circular was pre-
pared for the use of teachers, and the information contained
in them enabled many of the .American teachers to cope
successfully with cholera when it made its appearance in
the towns in which they were working.

By the above means many thousands of Filipinos soon
learned that they could easily avoid contracting the disease,
which was an entirely different attitude from that dis-
played in the epidemic of 1902, when only f.atalistic indiffer-
ence was shown, and the only measures taken by the
natives themselves consisted in nightly religious proces-
sions. This time, with the exception of a few instances,
in the districts in which dense ignorance prevails, the
religious processions were scarcely ever encountered.

The following conclusions were given: (l) From the
evidence obtainable at this time it is impossible to state
whether the cholera was reintroduced into the Philippines
or whether it remained here in some latent form during
the year and a half in which no cases were detected; (2)
while there is no evidence to show that the disease spreads
by other means than that of enteric fever, yet the rapidity
w^ith which it makes its appearance in many widely sepa-
rated places puts it in an entirely different class so far as
combating it successfully is concerned; (3) that maritime
quarantine can practically insure the prevention of its
spread by sea; (4) that it is practically impossible to make
land quarantine effective, hence it is useless to engender
the opposition with which it is usually met. and the time
and monev required by quarantine will yield much better
results bv' the education of the public in the manner in
which the disease spreads; (s) that education of the public
is a much more effective measure in the suppression of

2S

MEDICAL RECORD.

[Jan. 5, 1907

cholera tlian mctliods tliat depend upon force for their
application; (6) in order to make a serious outbreak of
cholera in the Philippines impossible it will be necessary
to replace the present insanitary water supplies with arte-
sian wells, or other sources by which infection from surface
drainase cannot be effected, or to correct it by lilters or
other means where it occurs.

The collection of the lepers from the Island of Panay
was successfully accomplished, and over three hundred
were landed at the Leper Colony at Culion November I.
The officials in charge of collecting the lepers report that
many persons who have heretofore been carried in the
official reports as lepers were, upon microscopical examina-
tion, found not to be afflicted with the disease. If this
same proportion should hold in the remaining islands of
the Philippines the total number of lepers will be much
less than has heretofore been thought to have been the case.
Many physicians, with considerable experience in the Isl-
ands, have always maintained that there were at least ten
thousand, but later observation seems to indicate that there
are under four thousand. If such should actually prove to
be the case it should not be so many years before the leper
problem in the Philippine Islands is entirely solved.

Owing to the improved cholera conditions in Manila and
vicinity, the outgoing quarantine detention which has here-
tofore been imposed upon outgoing vessels bound for
Philippine ports was removed November 10.

Major Mearns, United States Army, who has been Chief
Surgeon of the Department of Mindanao, and who was
previously reported as being relieved from duty in the
Philippines and proceeding to the United States by the
next transport, has decided to remain some time longer in
the Islands, and last week went to one of the least explored
of the Philippine Islands, viz.. the Island of Mindora, for the
purpose of pursuing his studies as a naturalist. Mr. Horace
Fletcher, the advocate of the so-called "Fletcherism." has
accompanied Major Mearns on the trip.

-Vrtc ]'oyk Mcdiial Journal, December 22. 1906.

Paralysis of the Peroneal Nerve Following Child-
birth.— .\fter some obbervations on the various para-
lyses following childbirth, J. H. Lloyd gives the history
of one case of paralysis of the peroneal or external pop-
liteal nerve. His patient was a woman of twenty-three
years, primipara and delivered by forceps. Labor was
slow and the pelvic measurements were rather small
throughout. The patient did well till the ninth day,
when she complained of numbness and tingling in the
left leg. It was found that there was paralysis limited
to the muscles supplied by the peroneal nerv-e and of
the skin supplied by the same nerve. There was also some
pain about the hip and a subjective sense of numbness
which the patient said involved the whole limb. The
otiice of the muscles involved being to extend the fool
and toes, the result of paralysis was to produce a very
characteristic foot drop. The author finds the true ex-
planation of involvement of this particular nerve in the
anatomical relations of the lumbar and sacral plexuses.
The sacral plexus receives from the lumbar a large
ner\e trunk called the lumbosacral cord which, pass-
ing from above downward into the true pelvis runs over
the brim of the pelvis at a point where it may be readily
compiressed. The great sciatic nerve generally divides
into its two terminal trunks just above the back of the
knee joint, but it may divide anywhere between the sa-
cral plexus and the lower third of the thigh. In case
of a high division the portion of the main nerve going
to form the peroneal nerve is really the lumbosacral
cord. In fact the former is a continuation of the latter.
Hence pressure from the child's head might easily affect
the lumbosacral portion and the manifestations of such
pressure would be noted in the regions supplied by the
perr.neal nerve.

Rhinitis in Children Including Recurrent Coryza, due
to Intestinal Autointoxication. — .\iter some remarks on
the circumstances under which rhinitis occurs in chil-
dren. L. Fischer describes what he calls intestinal rhi-
nitis, a form caused by the results of indigestion. It oc-
curs frequently in dyspeptic children with residual and
intestinal stagnation. The vasomotor nerves supply-
ing the mucosa of the nose when affected by intestinal
toxins produce vasomotor disturbances, one of which
is recurring coryza. Climatic conditions are naturally
a minor factor in such cases. When this form occurs
in children the urine invariably contains indican. The
peculiar gastric and intestinal disturbance arises from
o\ creating meat. It should be prohibited in every form
as soon a< any evidences of the rhinitis appear. Saline

cathartics should be given, sodium phosphate being ad-
ministered in sufficient quantities to produce liquid
stools and the administration kept up until the urine
contains indican. Water should be taken freely and
fruit may be given in abundance. -Milk, buttermilk,
cereals and butter should be prescribed. The author
regards it as irrational to use the familiar oil sprays
and powders. The proper plan is to seek out the
csuse of the rhinitis and remove it. We must remem-
ber that rhinitis may usher in meningitis, various erup-
tive fox ers. diphtheria, influenza, and specific disease.

Is the Supposed Efficacy of Quinine in Malarial
Fever More Apparent Than Real? — A. C. Jacobson
says that we know that Plasmodia are driven out of the
blood stream and kept out as long as sufficient quinine
is administered and absorbed. Their disappearance does
not mean that they have been destroyed since upon the
withdrawal of the quinine they reenter the blood seek-
ing refuge and sustenance, when hard pressed, within
the erythrocytes. Hence quinine is at best only a pal-
liative. It is not curative and is in no sense of the
word a specific against malaria. It frequently happens
with patients whose paroxysms have been relieved by
quinine, but who have the Plasmodia still remaining in
their blood that on the withdrawal of the quinine they
again have the paroxysms. Large doses of the remedy
may even induce chill and fever. The leucocytes be-
come paralyzed. Kidney damage may result from
quinine and it is the author's opinion that the renal
damage following artificially induced paroxysms of
malaria is of a higher grade than that of the usual
kind. Hemolysis must be favored by quinine because
of the full sway of the plasm.odia in the presence of leu-
cccytic paralysis. This increased hemolysis when coin-
cident with the renal irritation constitutes with the
latter the determining factor of hemoglobinuria. The
author also declares that the withholding of quinine
during acute malarial attacks will expedite ultimate
cure. In chronic malarial cachexia the uselessness of the
remedy is generally recognized.

The Scope of the Federal Food and Drugs Act. — H.
W. Wiley calls attention to the fact that under the new-
law there are two standards for drugs entering into in-
terstate commerce. First, that of the U. S. Pharmaco-
poeia and second, those placed on the drugs themselves.
Drugs used for technical purposes are not included in
this category. In case of alcoholic beverages when used
as such, it is not necessary to state on the label the
quantity of alcohol they contain, but if used as tonicj,
etc.. the label must bear the percentage statement. A
legal point comes up here concerning which the author
givs no positive opinion. .\ physician orders wine or
malt extract. The patient may buy it at a saloon where
it is a beverage or at a druggist's 'where it is called a
remedy. In either case, however, the package should
theoretically contain a label stating its alcoholic per-
centage. The most striking feature of the act is that re-
lating to the practical exemption from supervision as to
the standards, of the so-called proprietary remedies.
Amendments to the act are needed which shall impose
equally rigid inspection upon such proprietery remedies.
A large majority of all these preparations are made by
firms whose names do not appear on the labels and who
would doubtless be ashamed to have them there. As is
well known, most of this class of remedies which are of
any real therapeutic value are merely old-time prescrip-
tions done up under new names or compounds of some
of the newer laboratory products.

Journal of the Aincrieaii Medical Associatioit. December
29, 1906.

Closing Aseptic Abdominal Wounds. — H. O. Marcy
emphasizes the importance of accurate readjustment of
the severed structures with aseptic buried sutures, and
gives details of his methods in abdominal wounds. He
considers the reduction of scar tissues to a minimum a
very important factor, rejects drainage as a rule, and rn
dressing the wound, instead of employing dressings for
absorption of exudates he uses one for their retention
in the form of collodion, in which has been incorporated
enough iodoform to make it light-yellowish urine color.
He prefers the contractile collodion, as it contracts more
firmly and holds the skin better in place. This come.s
off in about ten days, and he usually uses a second and
third application to complete the process.

Diphtheria Bacilli in Meningitis. — J. Morrell and H.
E. \\'olf report a case of meningitis in a child in whoffi
the diphtheria bacillus, identified morphologically anil
culturall}- as well as bj' inoculation experiments on
guinea-pigs, in which it produced typical symptomj,
was obtained from the cerebrospinal fluid. The
bacillus was found both by antemortem spinal pane-

Jan.

1 907 J

MEDICAL RECORD.

turf and after dcatli. Tlie authors remark that tliey
have found but one case in the literature, that of Wil-
sor and Head, in which this organism was positively
identified from the central nervous system, and think
that the circumstances of this case indicate that it oc-
curs more commonly in that location than has been sus-
pected, and that, with careful examination, it will be
found more frcc|ucntly.

Cerebral Palsies of Children. — W. J. Butler discusses
the etiology of the spastic cerebral paralyses in children,
and reports three cases. He comes to the conclusion
that the causes are essentially the same as those that
give rise to hemiplegia in later life, and can be stated
briefly as follows: First, vascular lesions, viz.: (a)
hemorrhage from venous or arterial rupture, the result
of trauma occurring spontaneously in intense conges-
tions, as in convulsions, or the spasms of whooping
cough; (b) embolism from cardiac or arterial thrombi
or endocarditis; (c) endarteritis and thrombosis. Sec-
ond, inflammatory changes, to-wit: acute encephalitis
and meningoencephalitis. Third, rarely, a tumor. In
children we lack the miliary aneurysms and arterio-
sclerosis of later life, but the intense congestions to
which they are subject in convulsive diseases are
enough to compensate. While the frequency of acute
inflammatory processes as a cause may be in dispute,
the fact that they may be occasionally causes seems
established beyond a doubt.

The Blood in Infantile Bowel Troubles.— J. C. Cook
reports the results of examinations of the blood in ,16
cases of bowel and other affections of infants, in which
the white and red cell counts, differential counts of the
white cells, and hemoglobin tests were made. The cases
all presented, more or less, the clinical aspect of anemia,
and included, besides the intestinal and gastric disor-
ders which constituted the majority, cases of acute in-
fections, chronic disorders, like scurvy, rickets, etc., and
also syphilis, cretinism, and cerebral paralysis. From
the results it would appear that the value of the blood
count in the diagnosis of infantile anemia is compara-
tively slight. In those cases, however, which present
the clinical aspects of anemia and show a higher f)r even
normal blood count, there is a concentration of the
blood, indicating a lack of sufficient fluid ingestion or a
depletion from vomiting or diarrhea, and probably a
high concentration of toxic substances. An examina-
tion of the special congenital diseases in the series, as
compared with those of so-called enteritis, would sug-
gest that the increase in the number of white cells is
probably due to the specific character of absorbed
toxins. If there is more than one variety of microor-
ganism in the intestinal and other lesions, the number
of white cells and the differential count will not be
characteristic of either. We must look to the hemoglo-
bin test for more definite information as regards the
condition of the blood in these cases. Taken in con-
junction with the red cell crnint it can be seen that the
color index gives the more exact indication of the clin-
ical condition.

Reduplication of Heart Sounds. — From a study of 162
cases, m which were con-idered all the various condi-
tions that might affect the phenomenon, past and pres-
ent morbid states, general conditions, relations to exer-
cise, habits, etc.. H. C. P. Pillsbury summarizes his re-
sults, in substance, as follows: Reduplication of heart
sounds is a not uncommon symptom. The cause may
be either the asynchronous contraction of the ventri-
cles or the auricular sound. Normal persons with thin
chest walls usually show reduplication. Those with
thick chest walls should not. In persons who should
not show reduplication it is a valuable sign. Reduplica-
tion of the first sound means that the heart is not
working properly. This may be due to nervous inter-
ference, as in persons with bad habits, or it may mean
that the heart is hampered by external causes, by pres-
sure or by traction; or it may signify that the heart
muscle is inefticient, either from systemic conditions or
from inherent defects. Reduplication of both first and
second sounds is usually only a more advanced degree
of the same condition. Reduplication of the second
sound alone means an alteration in the relative blood
pressure of the systemic and pulmonary circulations.

Uveal Sarcoma. — Brown Pusey emphasizes the im-
portance of making microscopic sections of the eyeball
as soon as possible after its enucleation for uveal sar-
coma. He reports a case in which, while the diagnosis
of choroidal sarcoma was clear, the enucleated eyeball
shewed no macroscopic indication of external extension
of the growth. Nevertheless a year and a half later a
pigmented tumor was removed by exenteration of the
orbit. If the sections of the eyeball had been promptly
made and examined microscopically at the time of the

first operation the later operation might have been
a\oided.

7 /it- LuHccl, Dccoiihcf 8 and 15, 1006.

Epileptic Idiocy Associated with Tuberose Sclerosis
of the Brain. — The patient of .Mr. G. Uobsun was a boy
of ten years, who died from pneumonia. 1 he mother wa?
of a nervous temperament, and the father had a weak chest.
The whole family circle was neurotic, and some had died
from pulmonary tuberculosis. Convulsions came on one
year after birth. Autopsy showed the corte.x cerebri cov-
ered with large white granular looking and e.xceedingly
hard areas, occupying more especially the fronto-parietal
and temporosphenoidol lobes of both hemispheres. These
sclerosed areas protruded slightly above the general sur-
face of the brain, and a few showed central umbilication.
On section these areas showed considerable cortical hyper-
trophy; they were white in color, and the normal striations
were almost absent. The cortex was badly defined, and
tended to pass gradually into the underlying medulla. The
transition from normal to sclerosed corte,K was sharp.
The vessels of the medulla, more especially in the occipital
regions, were surrounded by collars of gelatinous-looking
material. The lateral ventricles were not dilated. The
choroid plexuses were healthy. Under the ependymal
lining, which was smooth and glistening, hard, white,
nodular growths were seen (varying in size from that of
a pin's head to that of a small hazel nut) projecting into
the ventricular cavity. These growths occurred in the
groove between the caudate nucleus and the optic thalamus,
and appeared to run along the course of, and to be in-
timately connected with, the vein of the corpus striatum.
Two \ ery tiny growtlis appeared on the wall of the third
ventricle; the fourth ventricle was healthy. No patholog-
ical change was noticed in the cerebellum, pons, or medulla.
Red hepatization of both lungs was present. No change
of any interest was found in the other organs of the body.
The microscope revealed the sclerotic areas as a firm,
dense network of fibers quite devoid of cells. The sub-
ependymal tumors were covered by a single layer of
columnar-shaped epithelial cells. Beneath this healthy
ependyma was a firm, dense network of fibers, containing
numerous cells. The blood-vessels in this layer were
fairly numerous, and were contained in dilated perivascular
canals. The main growth beneath this layer was composed
of coarse connective tissue, the blood-vessels of wdiich had
thick, diseased coats, the lumen being in some instances
iK-arly obliterated. In the medulla the vessels were con-
tained in round, wide spaces. Surrounding the vessel wall
and occupying this space were found cells having long,
delicate intertwining branches. The appearance suggested
myxomatous degeneration of the ailventiti.il coat.

Coincident Acute Appendicitis and Twisted Ovarian
Pedicle. — J. Cahill and W. H. Bennett report the case
of a girl of seventeen years suddenly seized with the usual
symptoms of inflammation in the right iliac fossa. Sur-
gical intervention was recommended but refused, and the
patient went along for a week, the evidences of inflamma-
tory deposit gradually becoming more and more evident.
Abdominal incision was finally made on the seventh day
from the initial symptoms. The appendix, which lay
posteriorly, intimately matted to the bowel, and surround-
ing parts by firm adhesions was removed and showed a
tight constriction at a quarter of an inch from its junction
with the cecum and another towards its distal end. Be-
tween these points it was greatly distended with pus, and
its wall showed all the conditions of very chronic disease.
The extreme distal end was little more than a fibrous cord.
No suppuration had occurred outside the appendix itself,
but the intestinal coils around were greatly injected and
matted by recent adhesions. Upon making the usual fur-
ther examination of the abdominal cavity a dark firm rnass
was found occupying the upper part of the pelvis and inti-
mately adherent to the rectum, the uterus, and the bladder.
.\fter a considerable extension of the abdominal incision
this mass was with very great difficulty separated from the
parts with which it was matted and was brought up to the
wound. It proved to be an ovarian cyst of about the size
of a cocoanut. with a very thick jiedicie wdiich had become
twisted upon itself for about three-quarters of a complete
turn. Its walls were thin and blackish and its contents
mainly decomposing blood. The pedicle was ligatured in
the usual way and the cyst was removed. The operation
which was necessarily prolonged, was well borne and the
subsequent progress was steady and uneventful.

The Influence of an Excessive Meat Diet on the
Osseous System. — The investigations made by D. C.
Watson on a large numlier of meat-fed rats show that the
bones of animals fed on an excessive me.at_ diet present an
appearance of delayed and imperfect ossification with in-
creased vascularitv and an increase in the number of red
blood corpuscles. .Associated with this there is ina number
of cases the presence in the bony ribs of nodules of cartilage.

30

MEDICAL RECORD.

[Jan. 5, 1907

developed from the periosteum, witli direct transformation
of these cartilage cells into bone. It is noteworthy that,
while the naked eye appearances of the skeleton may closely
simulate those present in advanced cases of rickets in the
human subject, the microscopic appearances in the epi-
physeal lines of the long bones are quite distinct from those
present in that disease. The author is able to add the his-
tory of the case of a child fed on raw meat juice for six
weeks. Under this diet the child, originally anemic, be-
came very pronouncedly so and steadily deteriorated. There
was marked physical and mental letliargy, fretfulness on
movement and a few purpuric and petechial spots. The
general appearance recalled to the author the clinical pic-
ture he had frequently noted in young rats, and he formed
tiie opinion that the state of profound anemia and physical
and mental lethargy was dependent on an exhaustion of
the functions of the bone marrow, thyroid gland, and other
structures, consequent on the excessive meat consumption
by the mother. The child died in a few days. At the post-
mortem examination no trace of tuberculosis was found,
nor other recognized cause of marked anemia in children.
A partial post-mortem examination only was allowed and
was conducted by the consultant who had charge of the
case, and who kindly gave the author pieces of tissue for
histological examination. The long bones were unduly soft
in consistence and it is declared that the histological ap-
pearances of the radius of this child were identical in their
essential features with those present in the ribs of the rats.

Appendicitis as a Cause of Intussusception. — L. Rawes
gives the history of a boy three years of age admitted
to hospital with an abnormal swelling and colicky pain.
For three months previous he had had attacks of abdomi-
nal pain, for six weeks frequent vomiting, and occasionally
some slireds of blood in the stools. Under anesthesia
a renifarm tumor about three inches long was dis-
covered just above and chiefly to the left of the umbili-
cus. On the second day following, abdominal incision re-
vealed the case to be one of intussusception. It was
easily reduced with the exception of the last portion
(about one and one-half inches), which was edematous
and consisted of the appendix deeply imbedded in a fold
in the wall of the cecum firmly bound down by ad-
hesions, and this, it would appear, had formed the
apex or head of the intussusceptum. On ''freeing" the
appendix it was found to be in a chronic inflammatory
condition and to have perforated about one inch from
its base. Appendicectomy was performed and the ab-
dominal incision was closed. The boy made an uninter-
rupted recovery.

Cancer of the Male Breast. — The patient of G. E.
Peachell was a man of fifty-eight years, admitted to
hospital for melancholia, with auditory and visual hal-
lucinations. In the left breast, below and internal to
the nipple, there was a small, irregular soft lump, non-
adherent to the skin or underlying tissues. Squeezing
of the breast caused the exudation from the nipple of
a little blood-stained fluid, but there was no glandular
enlargement. The growth increased in size and was
finally removed. It proved to be a typical scirrhus
carcinoma invading the pectoral muscle. The man died
eight months later from fatty heart and syncope, but
autopsy revealed no secondary deposits.

Sprue Treated by Strawberries. — On the strength of
the successful result from this plan of treatment in a
case previously reported. M. F. Squire details his experi-
ence with a man of twenty-nine years with vomiting,
diarrhea, and emaciation. At first the case was con-
sidered one of colitis and treatment was carried out
with this end in view. Later it was realized that the
condition was due to sprue. Under a milk diet his
condition rapidly improved, but he was a gluttonous
eater and was rebellious against dietetic restrictions.
The addition of bread and butter and an egg brought
about a relapse. Under various diets and on various
drugs he gradually deteriorated. Then the strawberry
season came around and he was allowed one pound of
berries (gradually increased to three pounds) daily.
This was in addition to his regular diet of milk, beeftea,
bread and margarine, milk pudding, and an egg. From
this time he permanently improved, and by the time the
berry season was over he was able to resume ordinary
diet and made an uninterrupted recovery. Concerning
the action of the berries, the author advances no
theories along chemical lines. He says simply that
they seemed to supply something to the alimentary
canal which enabled it to digest and assimilate the nour-
ishment supplied in the diet.

Some Observations on Paralyses of the Brachial
Plexus. — .X careful consideration is given this subject
by \V. B. Warrington and R. Jones, who find the com-
mon causes of these palsies to be (excluding invasion
of the nerve roots by disease of the meninges and ver-

tebrae and pressure by new growths and aneurysms)
(I) indirect violence (Erb's or Klumpke's palsy in
adults, or Duchenne's if at birth) and (2) rare cases
due to neuritis. They have been able to trace the
records of thirty cases with eleven complete recoveries,
the percentage of recoveries in traumatic cases being
somewhat less. They discuss the nature of the lesions
and their pathology, and they pass on to consider the
syinptoms of loss of function in nervous tissue inde-
pent of cause, and finally the symptoms of complete
loss of function. Under the latter heading are men-
tioned: Alteration in sensation, extent of the muscular
paralysis, and the electrical reaction of the muscles
involved. Under the headmg of clinical guides to the
seat of the lesion, they state as follows: (i) Pupillary
paralysis results from an intravertebral lesion; (2)
paralysis of the rhomboid, serratus magnus, or levator
anguli scapulK indicates a lesion internal to the extra-
vetebral portion, situated in either the intra or inter-
vertebral portion; (3) paralysis of the supra and infra-
spinati muscles indicates a lesion before the formation
of the plexus proper. The white rami for the sympa-
thetic, stimulation of which causes dilatation of the
pupil and enlargement of the palpebral fissure, are de-
rived from the first, second, and third dorsal anterior
roots, and especially from the second. Hence, though
damage to the first root causes characteristic oculo-
pupillary signs, they may not be permanent; the use
of cocaine may give some information as to the extent
of damage, for if the pupil fails to dilate when a solu-
tion of this drug is instilled into the eye it is probable
that the lesion has affected the second as well as the
first root. As to prognosis unmodified by surgical
treatment, they conclude (l) that the condition is a seri-
ous one, only from thirty to forty per cent, terminating
in useful recovery. That birth palsy of any severity
less commonly results in good recovery than the cor-
responding condition in adults. That the cases due to
a local neuritis are a good deal more favorable than
when injury is the cause. (2) The pathological experi-
ence shows that the lesion is in general a severe one
caused by laceration, tearing, or tension of nerve tissue,
simple pressure being less common. (3) That a com-
plete block of conduction with a corresponding graver
prognosis may be diagnosed from (a) a consideration of
the extent and kind of anesthesia (Head and Sherren) ;
(b) a study of the electrical reactions, especially with
the constant current; but that the presence of the full
reaction of degeneration is compatible with complete
recovery: and (c) attention to the extent and distribu-
tion of the muscular palsy. The order of gravity of
prognosis is lesions of the spinal cord, roots, plexus
proper, peripheral nerves. (4) That if spontaneous re-
covery happens, some signs of it are visible within
seven months in adult palsj-. but that in birth palsy
signs of recovery may be delayed for a longer period,
but are complete within a year. In birth palsies partial
recovery is frequent, leaving the residual paralysis to
he treated surgically. The authors hold that if the
paralysis has lasted several weeks, there is little chance
of complete recovery unless the elongated muscles are re-
la.xed.

British Medical Journal, December 8 and 15. iqo6.

Errors of Vision as a Factor in Motor Car Accidents.

— C. Clements reports a series of cases of examination of
the eyes in those who have experienced motor car col-
lisions. He notes that both eye and nerve strain if at all
excessive, as is so often the case with motorists, are always
liable to emphasize an error of vision or a deficiency of
muscular tone. This tendency is much increased by ap-
proaching dusk. Clements utters a word of warning about
motor goggles. Goggles with bow'ed glasses should never
be used under any circumstances, and for this reason —
though theoretically they are similar to plain glass, prac-
tically they are really myopic glasses of varying strength.
Hence they may just turn the scale in favor of spasm of
accommodation. Flat, glazed goggles should be worn, and,
if required, they can be replaced by the requisite correct-
ing lenses, care being taken that the existing goggles are
properly centered. No smoked goggles should be worn
after sundown, as they are liable to create a false dusk and
so increase the existing danger.

Present Views on Diseases of the Joints. — H. Marsh

declares that infection of some kind is the one great factor
in joint disease. He makes the following classification :
1st. those following wounds or occasionally operations, or
occurring in the progress of acute infective osteomyelitis or
pyemia ; 2d. those met with in the specific fevers, rheuma-
tisin, scarlatina, typhoid, influenza, or in dysentery; and 3d,
those caused by some such organism as the streptococcus,
staphylococcus, or gonococcus, which may produce, how-

Jan. 5, 1907]

MEDICAL RECORD.

31

ever, various types of symptoms. While the gonococcus
generally causes an acute infection, it may set up an in-
flammation of a low grade of intensity. It seems to be
growing on an exhausted soil and dwindling by extinction.
It is doubtless present in small numbers and associated
with other organisms which enfeeble its effects. Under
these conditions the joint effusion is not necessarily great,
but there is a slowly increasing swelling of the synovial
membrane and a perisynovial tissue. Pain is a minor
factor. Stiffness is usually marked and there is the mus-
cular wasting characteristic of chronic arthritis from any
cause. In fact the symptoms strongly suggest tuberculosis.
The author says that under the influence of environment
the gonococcus has been deprived of so much of its viru-
lence and is in such small quantity that the degree of irri-
tation it produces is practically identical with that to which
the B. tuberculosis gives rise. Several cases of the type
above referred to are detailed. The sources of infection
may be various. Even a bad tooth or a mere surface
abrasion may lead to joint involvement. The primary step
and treatment of such cases is to discover and shut off the
source of infection. The particular steps to be followed
in handling the joints in any given case will depend on the
exact bacterial factor in action. Thus in some instances we
should open and drain the joints early. In other cases the
joints should be kept at rest and the patient live an open-
air life. Douches should be employed twice daily as hot as
can be borne without blistering. Small blisters are often
useful. If the joint is cool and painless but stiff, manipu-
lation should be the first step. Sometitnes permanent ad-
hesions may form leading to ankylosis. Force may be em-
ployed to rupture a fibrous union if the limb has become
fixed in such a position that the heel cannot be brought
down.

Sprains and Their Consequences. — W. Bennett di-
vides sprains nito three classes: 1st. those involvin.g the
soft parts only ; 2d, those associated with fracture, and
3d, those with gross nerve injury. He notes that deferred
or remote swelling in deep sprain may show itself a long
way from the seat of the original injury in consequence
of its being caused by the blood tracking along the fascial
planes in the lines of least resistance. In all cases of
sprain the first thing to determine is whether fracture co-
exists, and this can be done by radiography. We should
next eliminate the existence of gross nerve lesion. If
numbness is found and if it persists for more than twelve
hours a gross lesion of the nerve branch is pretty certain.
In sprains without swelling, the first indication is relief of
pain. We should rest the part and e.xercise pretty firm
compression. This having been effected, massage cannot
commence too soon. If extravasation of blood is present,
we should first stop the bleeding. Rest is the best remedy.
Ice applications are practically useless, and in persons with
renal lesions may easily cause sloughing. Hot fomenta-
tions, however, are often of value. The increase of the
immediate swelling having ceased, should the part involved
be a joint, firm pressure by means of a porous bandage,
firmly and evenly applied for twenty-four hours, followed
by massage, gives the best and quickest results. The use of
impermeable rubber bandages is unadvisable. For the pre-
vention of adhesions and muscle waste, voluntary move-
ments, massage, and passive movements rank in the order
mentioned. Slight voluntary movements cannot be com-
menced too soon; splints, therefore, should in a general way
not be used. The patient should, in fact, from the
earliest moment amuse himself by seeing how far the part,
if a joint, can be bent without permanent increase of dis-
comfort. Massage should not, except in special circum-
stances, be delayed for more than twenty-four hours or at
the most thirty-six hours after the cessation of increase in
the local swelling. Passive movements should follow
freely as soon as all heat has left the damaged part. In
regard to remote consequences of sprains, the author makes
the following tabulation. Preventable consequences are
persistent pain, stiffness, muscular wasting, general joint
relaxation, and deformities. Unavoidable in certain cases
are osteoarthritis, local paresis, and myositis ossificans.

Cancer: Its Treatment by Modern Methods. — In the
Bradshaw lecture E. Owen speaks particularly of can-
cer of the breast, lip, and tongue, and takes up the
treatment by starvation and injections. He gives cer-
tain statistical results, discusses the conditions of the
"Imperial Cancer Research Fund." and shows results
obtained by the labors of the committee of the fund
as thus far accumulated. He declares that the Doyen
method of injection has proven a flat failure and that
the Bncillus ncoforinans of the French surgeon pro-
duces in animal experimentation only inflammatory and
not cancerous deposits. As yet we know of no sure
"cure" for cancer, and he regrets the publicity afforded
from time to time in newspapers and periodicals to
very misleading notices in favor of the numerous so-
called cures. He notes that in the course of inocula-

tion experiments upon mice every now and then
a mouse which has been infected with cancer gradually
triumphs over the disease, and at last gets entirely free
from it. The same thing sometimes occurs in the hu-
man subject — an undoubtedly malignant deposit steadily
growing smaller, and eventually fading away. Unfor-
tunately, this takes place so rarely in the human subject
that it is impracticable to hope for it. But it may liap-
/'t'li; and in cases in which the disease is regarded as
inoperable, the surgeon does not lose sight of this pos-
sibility. The question arises as to what there was in
those mice, or in that happy individual, which enabled the
natural forces to vanquish the disease. And as soon as we
are able to imitate that process in the laboratories, the
cure of cancer will be within our reach. Is it due to some
extraordinary property in the colorless blood corpuscles
which has. somehow or other, been awakened into activity,
so that the cancer cells— which, in the absence of proof
of the existence of specific cancer germs, must still be
deemed the essence of the disease — are routed and de-
stroved? In this dirction experimenters are already at
work, some with drugs administered by the mouth; others
with injections of sterile cultures of potent germs ; others
w^ith animal or vegetable juices, chemical solutions, or
emanations of some radium or electricity. The author
refers to the work of Bashford and Murray, who made
the discovery that by injecting a few drops of blood from
a normal mouse into the circulation of a healthy mouse
on which they are about to graft a cancer, they can effec-
tually prevent that graft taking root._ though blood of a
rat or of a guinea pig similarly injected has no such
protecting influence on the mouse. If these results be con-
firmed by other workers, the next thing will be to find
out ic'/jy this happens. And if it he conceded that the mere
injection of a few drops of healthy blood can prevent the
mouse becoming a prey to cancerous infection, the thought
comes home that, after all, it may be only some small
thing which is needed to check the progress of a cancer
by which a human being is infected — it needs but an in-
finitesimal amount of vaccine lymph to render a whole
countrv proof against the ravages of smallpox. The time
is surely ripe for the advent of a Jenner in the world of
cancer !

BcrHiicr klinisi-hc Wochcnschrift, December 3. 1906.

The Transference of Tumors in Dogs by the Sexual
Act. — Sticker expresses the opinion that the reason why
it has been found impossible to secure the transference of
tumors from one animal to another by the contact that takes
place when they are kept together in captivity is because
anv injury which might become the site of an inoculation is
usiiallv also the seat of an infection whereby the vitality of
the transplanted cells is destroyed. He was able, however,
to produce tumors in a number of dogs that he had inocu-
lated with tumor juice squeezed from a sarcoma of the
vagina of a bitch. He also reports the occurrence of sar-
coma of the penis in two dogs out of seven that were al-
lowed to copulate with a bitch having sarcoma of th=
vagina. In each of these instances the period of incubation
was about three and a half months, and the growth appeared
at a spot on the penis corresponding to the position of the
vaginal ulceration. The author suggests that the proof that
is thus afforded of the possibility of inoculation in this
way should be taken into account in passing judgment on
the case of cancer a deux occurring in husband and wife
which have heretofore usually been considered as being the
result of coincidence.

A New Cardiac Remedy. — Lewin and Stadelmann
jointly contribute a favorable report on a substitute for
digitalis in heart disease. The former author has carried
out the chemical and pharmacological investigations and the
latter has tested it clinically. The remedy in question is
obtained from an East African tree, the Acokanthera, be-
longing to the family of the Apoeymccce, and occurring
from Lake Xyassa, northward into Abyssinia and Somali
land. Two varieties arc recognized, Acokanthera schimpen
and Acokanthera deftcrsii. From the wood of these trees
several toxic principles may be obtained, of which the most
active is a crystalline glucoside, oubain. This is highly
toxic and in many respects, which are detailed by die au-
thors, appears to' resemble digitoxin. Stadelmann's clini-
cal observations were made on twenty-nine cases of heart
lesions, and the remedy was usually given in the form of
an infusion made from the wood in the strength of about
one per cent, and given in tablespoonful doses. The thera-
peutic effect is analyzed in detail, but appears to be closely
allied to that of digitalis. The remedy has the advaritages,
however, that the wood appears to keep its virtues indefi-
nitely, in contrast to the well-known instability of digi-
talis' leaves, and oubain can be injected hypodermically
without causing pain or irritation. While the authors feel
very sanguine as to the future of this drug, they consider

Z2

MEDICAL RECORD.

1907

that imicli more experience with it must be gained by care-
ful tests in hospitals and clinics before its use can be
permitted in general practice.

Miinchcnrr mediciiiische VVochenschrift, December 4 and
II, 1906.

Packing the Nose in Ozena. — Sondermann states that
;]ie ordinary means available for use by patients with ozena
in order to remove the crusts, are inadequate and impracti-
cal. The commonly used method of irrigation is troublesome
and is therefore often omitted by the patient, and in addition
it involves danger of infection of the Eustachian tube and
middle car. He proposes the following plan which he says he
has found very successful. The patient is provided with a
small bag of very delicate rubber tissue, which is affi.xed
to a detachable tube and rubber bulb. The bag is intro-
duced into the nasal passage in the collapsed condition, and
is then inflated by means of the bulb. It applies itself
closely to all the irregularities of the wall of the nasal spape
and even reaches into the nasopharyngeal space. The air is
prevented from escaping by the use of a pinch cock, and
the bulb is detached; at the expiration of five or ten min-
utes, the air is allowed to escape and the tampon can easily
be removed, carrying with it the crust. The apparatus is
kept in water and by the time it is to be used again the ad-
hering crusts will have separated from it. The author ad-
vises the use of this method twice a day during the first
week and later once a day.

The Treatment of External Anthrax. — Lengfellner
says that excision is being used less and less frequently in
the treatment of external infections with the anthrax bacil-
lus, and that the conservative method is gaining constantly
increasing favor. The essentials of this method consist in
leaving the pustule absolutely undisturbed, in thoroughly
cleansing its surroundings, in applying a nonirritating oint-
ment in order to prevent rubbing of the dressing, and in sus-
pending the injured member, and keeping it absolutely at
rest. The underlying principle is not to interfere with the
tissues in their struggle against the germs or to do anything
that may cause the entry of these into the blood stream.
The author reports fifteen cases of anthrax, in which the
diagnosis was made miscroscopically and bacteriologically,
and which were treated by this method in von Bergmann's
clinic with 100 per cent, of recoveries. In about a third of
the cases the pustle was situated on the arm. in another
third it was on the face, including one case in which the
upper eyelid was infected, in one-fifth it was on the neck,
and in one-fifth on the hand. The author states that one
case is reported in the literature in which a severe infection
was cured by the use of a serum, and he is of the opinion
that this method oflfers great possibilities for the future, and
should receive more attention than has hitherto been ac-
corded to it.

An Autopsy on a Typhoid Bacilli Carrier. — Levy and
Kayser believe that they have been able to offer the first
positive proof that the gall-bladder can be the nidus of pro-
liferation for the typhoid bacilli in cases of chronic typhoid
carriers. The patient on wdiom the observations in question
were made at autopsy was a woman of forty-eight years,
who for thirteen years had been a patient in an institution
for the insane. In 190,3 she went through with an ordinary
typhoid infection without complications, and .apparently re-
covered from this completely. Early in October, 1905. on
■.he occasion of a typhoid epidemic in the institution, it
was discovered that the stools of this patient contained
;yphoid bacilli, and in the course of the follow'ing year
tile authors were able to verify this discovery on ten differ-
ent occasions. On October 11 the patient died of a septic
nifection, and at the autopsy it was found that the right
lung was the seat of a hypostatic pneumonia. Cultures
made from the interior of the spleen, the interior of
the liver, the wall of the gall-bladder, the bile, and the
interior of a gallstone whose exterior had been sterilized
by heat, all revealed the presence of typhoid bacilli in these
situations. In the authors' opinion this case, particularly
the discovery of the bacilli in the interior of the gallstone,
affords proof of the view that the gall-bladder is the seat
of chronic typhoid infections, and also of the fact that
such persons may suffer from an autoinfection, for they
regard the patient's death as being the result of a typhoid
sepsis as evidenced by the presence of bacilli in the spleen.

A Convenience in Examining Sediments. — Sachs-
Mukc calls attention to the length of time that is often
necessary in examining sediments microscopically, such,
for example, as those obtained from supposably tuberculous
sputum by means of inoscopy or some other similar process.
He then describes a procedure intended to render such e.x-
aminations less tedious. This consists in spreading out
about .5 c.c. of the sediment on the surface of the slide and
allowing it to dry. .\ similar amount of sediment is added
and the procedure is repeated, and the process is continued
until the necessary quantity of sediment has been tr.ans-

ferre'l to the slide. The preparation may then be stained
in the usual way. .As the sputum by previous treatment has
been rendered free from coarser particles, mucus, etc., the
film of sediment adhering to the slide is perfectly well
suited to microscopical examination, and in this way a
considerable bulk of sediment can be thoroughly searched
through in much less lime than if a large number of sepa-
rate preparations were made.

Deutsche niedizinische Wochensehrifl, December 6 and 13,
1906.

Agglutinins and Specific Immune Bodies in Gono-
coccus Serum. — Vannod describes the manner in which
he was able to obtain a specific agglutinating serum from
rabbits that had been treated with an extract of gonococcus
cultures. For this jjurpose the bacteria were treated with
potassium hydrate and a precipitate was obtained by the
addition of acetic acid. This precipitate when dried formed
a powder soluble in sodium solution, and it was this
material that was used to inject into the rabbits. In this
way a serum was obtained which was strongly agglutinat-
ing, both macroscopically and microscopically, for gono-
cocci. but not for staphylococci, streptococci, or typhoid
bacilli. Meningococci, on the other hand, were agglutinated
by the serum, and meningococcus serum was found to ag-
glutinate gonococci. The author also describes the steps
by which he was enabled to prove the existence in the
gonococcus serum of specific amboceptors, but that the
serum did not contain amboceptors specific for meningo-
cocci, and that therefore the demonstration of the specific
amboceptors, rather than agglutinative power, affords the
best differential diagnostic method.

The Catgut Suture in Fracture of the Patella. — Riedel

does not believe in the use 01 silver wire ,i,s a suture mate-
rial in cases of fracture of the patella, and describes a
procedure which he considers preferable to the open opera-
tion. .\n incision one cm. in length is made two cm. above
the upper fragment of the bone, and through this a suitably
curved handled needle is pushed behind the patella and
is brought to the surface through the ligamentum patella
just below the lower fragment. The point of the needle
is cut down upon before it is pushed through the skin
in order that the four cat.gut threads, which are now
threaded into its eye, may be more readily drawn through
the little incision, behind the patella, and out through the
upper wound. The needle is then reinserted in the upper
incision, is passed down in front of the bone, and emerges
at its former point of exit below the patella. It is a.gain
threaded with the same strands of catgut, which are
brought out at the upper opening and tied to their other
ends. In this way the patella is surrounded by the catgut
ligatures, and the two fragments are held firmly in appo-
sition. The knot is a buried one, and each of the two
small incisions is closed with a single stitch of catgut. The
author recommends this procedure very warmly for recent
cases, though he gives warning of the aseptic inflammation
which the presence of the catgut may occasion. He cites
eight cases of fresh fractures treated in this way with
excellent functional results. For old cases of ununited frac-
ture Riedel also recommends suture with catgut, but as in
these instances it is necessary to freshen the surfaces of
the fragments and to remove any synovial fringes, etc.,
that may have dropped between them, he employs two
lateral longitudinal incisions on either side of the patella
in order to secure access to the joint. This is done because
he is very much opposed to long incisions in front of
the patella or below it on account of the interference
with kneeling that scars in these situations are likely to
occasion.

• Analgesia of the Ulnar Nerve from Pressure and Its
Value as a Symptom in Tabes. — Jean Heitz declares
that analgesia of the ulnar nerve from pressure is not a
special symptom in tabes. This symptom is noted with
very great frequency in tabes and is found after the aboli-
tion of the reflexes and .Argyll's symptom. It is more fre-
quent than anesthesia of the skin of the inner region of
the arm. Biernacki's symptom appears very early. It is
a useful indication in those cases in which the associa-
tion of two or three symptoms makes clear the diagnosis
in incipient tabes. This holds good in patients showing
aortic lesions, and old syphilitic lesions, in whom the nerv-
ours system and the aorta are affected at the same time.
In patients of this kind determination of ulnar analgesia,
especially if it is bilateral, offers one symptom more for
the clinching of the diagnosis. — Jountal de CHnique Mcdi-
cdle cl Chinirgiealc.

Tan.

1Q07,

MEDICAL RECURD.

33

Maak ^Atvxtms.

Rational Organotherapy with Reference to Urosemi-

OLOGY. By Prof. Dr. A. von Poehl, Prof. Prince J.

VON Tarchanoff, Dr. .\lf. von Poehl, Dr. P. Wachs.

Translated by Dr. Carl Schulin, Billings, Mont. Vol.

I. Philadelphia: Blakiston's Son & Co.. 1906.
In 1878 Schrciner isolated in crystalline form spermin, an
organic base found in semen, styling it spermin. The crys-
tals of spermin phosphate had been discovered by Boett-
cher as far back as 1865. In 1890 von Poehl first prepared
the base in the pure state in large amounts and published
certain important investigations upon its physiological ac-
tion. Since then he has been unremitting in his labors in
this field of organotherapy. The first volume of this work
is devoted to a general outline of organotherapy from the
viewpoint of von Poehl and his followers, describing the
chemistry of spermin. the physiological action, and the
clinical value of this preparation.

Prof, von Poehl supports his brief with a mass of ex-
perimental data and quotes a full bibliography of the sub-
ject. His work is an amplified and codified collection of
the mass of research which has been done in his own par-
ticular branch of organotherapy, and he is supported in
this by a group of workers whose names appear on the
title page, including Prince Tarchanoff, who was the first
to study the physiological action of spermin. Poehl and his
pupils regard spermin as a catalysant (catalysator is the
word they use), which assists in o.xidation and promotes
metabolism. He maintains that spermm is one of the nor-
mal division products of the leucocytes and takes a great
share in oxidation, and supports this claim by an elaborate
meshwork of scientific data, including chiefly observations
on the urine — the osmotic coefficient of this fluid, and other
means of studying urinary metabolism.

The book will be accepted with a certain reserve by
those who have followed the trend of Professor Poehl's
work. It will be remembered that doubts have been ex-
pressed as to whether his preparation is actually spermin
hydrochloride (CjHhNdHCI), and his methods have been
severely criticised. The controversy is an old one now,
however, and receives due consideration in this volume.
The translation is, on the whole, good, although many un-
English words have been coined, not always with felicity,
to reproduce the original expressions. Such silliness as
the reneafed mention nf Dr. G. v. Hirscli as ''the Czar'<
physician" -hould be discouraged in a scientific work.

A Textbook of Obstetrics. By Barton Cooke Hirst,
M.D., Professor of Obstetrics in the University of Penn-
sylvania ; Gynecologist to the Howard, the Orthopedic,
and the Philadelphia Hospitals, etc. Fifth Edition. Re-
vised and Enlaraed. Philadelphia and London : W. P..
Saunders Conip;iny, IQ06.
Hirst's Obstetrics is so well and favorably known to the
medical public that it is hardly necessary to add anything
to this announcement of the appearance of a new edition.
In this the author has made a careful revision wherever
necessary, "paying particular attention to the recent ad-
vances in o\ir information regarding puerperal infection
and gestational toxemia, but incorporating in the text only
the facts that seem at present clearly established." A com-
parison with the previous edition, published about three
years ago, shows few changes of importance, yet such as
have been made are of a character to increase the value
of the work as a teaching guide to the student and to the
practitioner whose lines are laid in the field of obstetrical
practice. The illustrations are sood, 767 in number. 40 of
which are colored. A sacrifice has been made to them in
printing the book on glazed paper, the reflection of which
makes the reading of the text a trying task to the eyes.
Most of the pictures would have been as clear if paper with
a dill! finish had been used, and those which called for a
special surface might ha-ie been printed as in^et plate*.
The reader would have been therebv spared much irrita-
tion, and we venture to say the book would have found a
much wider circle of readers. Publishers in these days
.apparently attach an undue iniridrtnnre to the work of the
illustrator Pictures are utiefu], and often necessary, but
the text is. after all. the thing, and the reading of this
text should be made as easy as possible instead of. as in
so many books, a vexation of eyes and spirit.

Abpominal Operations. By B. G. .\. Movxihan. M.S.
(London), E.R.C.S. Leeds. Second Edition. Thor. ■uglily
Revised. Philadelphia and London: \V. B. Saiimlcrs
Company, 1906.
The first edition of this really superb work appeared only a
liltle over a year ago. yet so rapid is proore** in ihi; nuist
important surgical field that the author has found it neces-
sary to make a large number of additions to the text and

illustrations. In this work Mr. Moynihan treats of those
diseases and the operations for their relief which concern
the abdominal organs common to the two sexes, and all
strictly gynecological subjects are oitiittcd. He also ex-
cludes, rather arbitrarily, consideration of those organs,
such as the bladder and the kidney, which are partly
extraperitoneal, and of hernia. The title might he rather
"Intraperitoneal Operations," which would more accurately
define the scope of the work. The author has very definite
views and does not hesitate to advance them, rejecting, to
the point of absolute silence, any consideration of methods
or technique which do not meet with his approval. This
renders the book of special service to the practising surgeon,
but lessens its value as a guide to the recent graduate who
cannot afford to pin his faith upon the teachings of any
one man, however great an authority he may be. The
illustrations are numerous and handsome, but it is a pity
that the publishers should have sacrificed the text to them
by printing the book on highly glazed paper. The reading
of the book, especially by artificial light, is for this reason
most trying to the eyes. If half-tone pictures cannot be
printed on paper with a dull finish, then the illustration
.should be drawn and not photographed; the text is the
thing, after all, in a book of this sort, and simple diagrams
will suffice to illustrate it. The book will perhaps be less
"showy," but it will be more useful and more read.

Essays on Pastoral Medicine. By .-Xustin O'Malley,
M.D.. and J. J. Walsh, M.D. .\ow York and Bombay:
Longmans, Green & Co., 1906.
These essays are addressed to the priesthood of the Roman
Catholic Church, but their importance will tie appreciated
by clergA'men of other denominations. The subjects pre-
sent that part of medicine which concerns a pastor and his
flock and those divisions of ethics and moral theology which
concern a physician in his practice. Pastoral Medicine sets
forth facts and principles whereby the physician himself or
his pastor may direct the operator's conscience whenever
medicine takes on a moral quality: and it also explains to
the pastor, who must often minister to a mind diseased
certain medical truths which will soften hard judgments,
and other facts which may be indifferent morally, but
which assist him in the proper conduct of his work. There
is. therefore, an urgent necessity that competent men
should fix that shifting and debatable point of ethics and
moral theology which includes pastoral medicine. The
following are among the many topics treated in these
essays : Ectopic gestation : pelvic tumors in pregnancy ;
abortion, miscarriage, and premature labor: cesarean sec-
tion and craniotomy; maternal impressions ; social medicine;
hypnotism, suggestion, and crime; the priest in infectious
diseases; infectious diseases in schools: school hygiene;
mental diseases and spiritual direction; menstrual diseases;
epilepsy and responsibility; venereal diseases and marriage,
and social diseases. These scholarly essays by Drs. O'Mal-
ley and Walsh are pathfinders and most admirable, .ind
should be read and pondered over by the physician, surgeon,
■gynecologist, priest, minister, editor, lawyer, patient, teacher,
and parent. The volume really fills a long-telt want in
medicine and sociologv'.

Die Tuberculose. Von Prof. Dr. G. Cornet. Berlin und
Reichenhall. Zweile. vollstiindig unigearbeilete und im
Umfang verdoppelte .Xuflage. Slit i.i lllustrationen. T
Karte. und 5 Tafein in Farbeudruck. W'ien : .\lfred
Holder, 1007.
-Some idea of the scope and thorougliuess of this work may
be gained from the author's statement that during the
seven years that have elapsed since the appearance of the
first edition aliout i.^.ooo articles on tuberculosis have been
published, and that most of these have been consulted by
him in the original. In consequence of this enormous
amount of material to be incorporated, in its present edition
the book has been almost doubled in size and now com-
prises over 1,400 pages. In its original form the work was
recognized as one of the most comprehensive on this sub-
ject, and it now undoubtediv stands preeminent among
treatises on tuberculosis. It would be a work of super-
erogation to try to summarize the table of contents, which
covers twelve pages, or, indeed, to particularize at all in
regard to the subjects discussed, for there is no question
connected with the disease as encountered by the internist
that is not covered, and the author's_ authority both as a
clinician and as an investigator is so firmly established that
no discrimination is possilile between his achievements in
either direction. Within the jireseiit limits of space it is
useless to attempt to ilo more than to call the attention of
medical readers to the fact that the work has been revised,
.ind to assure those not alreadv familiar with the first edition
ihat this book undoubtedly represents the most comprehen-
sive single treatise on tulicrculosis as a whole that has yet
been published. Its \alue as a work of reference may be
inferred from the fact that it contains a classified and m-
ilexed bibliographv of o..;oo ;irlicles liy aliout 8.000 authors.

34

MEDICAL RECORD.

[Jan. 5, 1907

NEW YORK ACADEMY OF MEDICINE.

SECTION ON DERM.\TOLOGV.

Stated Meeting, Held October 30, 1906.
Dr. a. R. Robinson in the Chair.

Three Cases for Diagnosis. — Dr. Chas. Mallory Wil-
liams presented three children, the oldest twelve years
of age, of a family of four, several of whom had shown
typical lesions of syphilis of the skin and of the
bones. For several years they had all shown a similar
eruption, occurring principally on the forehead near the
nose, and consisting of deeply-scratched papules ; some-
times arranged in segments of circles, sometimes scattered
irregularly. They had been treated for several years,
taking mercury, iodine, and tonics internally, and using
protective and antiseptic ointments and pastes locally ; often
with temporary improvement, but with no permanent
benefit. Prolonged observation left a strong impression
that the scratching was the cause of the eruption, but its
persistence in the same region in all of the children was
very curious.

Dr. PoLLiTZER said that without going into the question
he was quite willing to concede that these three patients
were syphilitics; but he was confident that the papular
lesions on the face and hands had nothing to do with
syphilis. As to the nature of the process it would be pre-
sumptuous for any one to venture on a diagnosis after a
single and rather inadequate examination when the excel-
lent dermatologists who had long had the cases under
observation confessed themselves at fault. He would like,
however, to venture the suggestion that this family disease
characterized by the occurrence of intensely pruritic
papules, possibly vesicles, resulting in loss of tissue and
scarring, located on the exposed parts of the face and
hands, might bear some relation to that group of diseases
described under the inept term of summer prurigo.

Dr. Whiteholse saw undoubted stigmata of syphilis
in all the children exhibited, but was not familiar enough
with their histories to state the exact course of the dis-
ease in each case. The obstinate skin lesions which they
now manifested upon the head and face, however, he did
not regard as syphilitic in any respect. It was a second-
ary local septic dermatitis such as might occur, and con-
tinue unaffected to any appreciable degree by treatment,
in subjects e.xhibiting such a lowered state of nutrition,
whether due to syphilis or to some other dyscrasia.
General constitutional and hygienic measures looking to
improvement in their general tone would, in his opinion,
be the only successful means of removing the eruption.

Neurotic Eczema. — Dr. Williams reported the case
of a man 25 years of age, a laborer, whose family and
the previous personal history were negative. The patient
denied having had syphilis or gonorrhea. He did not use
coffee or alcohol, but smoked about three ounces of tobacco
a week, and took about three cups of tea daily. His diet
was rather low, being chiefly bread, milk, and tea, with
very little meat. He began to masturbate at 18 years of
age, performing the act two or three times a day, often till
the blood came. .About a year later he noticed an eruption
like the present, which he said appeared first on the back of
the right thigh. The self-abuse was continued till two or
three years ago, since which time he had had sexual inter-
course about once in two weeks. Partial erections were
now easily provoked, and mental excitement often caused
emissions, even without erection. Nocturnal emissions
were common, and seemed to occur regardless of sexual
intercourse. Since its first appearance, six years ago, the
eruption had never been absent more than a week or two
at a time. An outbreak was provoked by any nervous or

physical strain — a normal coitus, a nocturnal emission, a
day's work in the field — and was sufficiently distressing to
incapacitate him, so that he hardly did a full month's
work in a whole year. The region most affected was
usually the face. He said an attack always began with
great swelling and redness, so that .sometimes he could
hardly see. Soon vesicles appeared which ruptured and
exuded, the serum drying to a yellow crust, and the
process then gradually declined. He was a man of 167
pounds in weight, of stocky build, and nervous, restless
manner; tongue moist and coated, appetite good, bowels
regular; pulse 66, regular, good force; the urine amounted
to 36 ounces in twenty-four hours, sp. gr. 1.018, acid, total
urea 12.4 g., trace of albumin, few hyaline and granular
casts, no spermatozoa. The scalp was clean. The skin
on the middle of the face and forehead, extending oa
each side about as far as the external canthus, was red
and swollen. The border was irregular, with outlying
spots of disease, but still fairly sharp. The affected area
was set was small papules and vesicles, many of the latter
having ruptured, their secretion drying to a yellow crust.
There were many scratch marks. Besides the crusts there
were many fine, small scales. The swelling was firm, as
from a subacute inflammation, not soft and edematous.
The skin of the scrotum was dull red, thickened, harsh,
and scaling slightly. On the forearms and thighs were a
few scattered red papules, the appearance here being that
of a mild dermatitis. The chief interest in this case lay
in the coincidence of the appearance of the dermatosis with
the development of sexual neurasthenia, and in the close
causal relationship between the expenditure of nervous
force and the outbreak of an acute attack. The diathesis,
the faulty metabolism, the personal idiosyncrasy, or what-
ever it was that determined this particular cutaneous
reaction, was at present beyond our know-ledge and control;.
the exciting cause, on the contrary, w-as found in the
neurotic condition of the patient, and this furnished a.
good mark for therapeutic attack.

Case of Argyria. — Dr. Daisy M. Orleman Robinson"
reported the case of a woman, 54 years of age, a house-
worker, brunette, tall, and quite stout. No history of a
cutaneous disease at any time in the family. Patient had
suffered from constipation since childhood. She was
treated by a physician for a catarrhal condition of her
throat four and a half years ago, once every two weeks, for
a period of two months, a solution of nitrate of silver ia
the form of a spray having been applied. She then con-
tinued this treatment herself daily until she came under
the speaker's observation, .^n ounce of the solution lasted
one month, hence she used about five grains of nitrate of
silver every month. She first noticed a discoloration of
the skin two years ago, after having used about one hun-
dred and thirty grains of the salt, but could not state
where it first appeared. The discoloration at present was
general over the entire body, but most marked upon the
parts exposed to the light, and was of a bluish-gray shade.
That on the lower extremities was lighter in color and
might not be recognized if examined independently of
the rest of the body. The mucous membrane of the
mouth had a decided bluish tinge. The discoloration
on the gums was less marked. The vaginal mucous mem-
brane, arms, and rectum were similarly discolored. Blood
examination showed little or no change in erythrocytes.
There was no leucocytosis, the differential count was:
eosinophiles I per cent., transitional 1.6 per cent., lympho-
cytes 30.8 per cent, polynuclear 66.6 per cent. The urine
had a specific gravity of 1.020, slight trace of albumin, a
few hyaline casts, blood, vaginal epithelium, bacteria, and
mucus. The case was shown on account of the com-
parative infrequency of the disease at the present time,
and especially because it had been caused by the topical
application of tlie silver salt to the throat. A portion of
the skin from the upper part of the shoulder had been

Jan. 5, 1907]

MEDICAL RECORD.

35

removed for microscopical study, and a report would be
given at another meeting.

Multiple Tumors. — Dr. Lapovvski presented a man, 20
years of age, with negative personal and family history.
The present disease started eight years ago, when a cherry-
sized tumor was noticed in the region of the right a.xilla.
Since that time tumors had appeared on various parts of
the body, the last coming several days ago on the abdomen.
They were now scattered over the whole body, on the fore-
head, upper and lower extremities, and trunk. Some were
round, from the size of a small pea to that of a bean;
others were oblong, from one-half to two inches long. The
tumors were under the skin, and both the skin and the
tumors were movable. The color of the skin was normal.
The tumors were painless, slightly hard, and appeared
without any prodromal manifestations. The color of an
excised tumor on section was white, of the color of lard;
the mass was compact and hard. The glands w'ere not
perceptible, the visible mucous membranes were normal,
and the general condition of the patient was good. Micro-
scopical e.xamination would determine whether the tumors
were fibromata or neurofibromata.

Dr. PoLLiTZER said he thought the case was one of
Recklinghausen's disease — multiple neurofibromata of the
skin. The patient's trunk was covered with countless
yellow-brown pigmented areas, forming the second symp-
tom in the syndrome of Recklinghausen's disease. The
little tumor which he had seen seemed to him to be a
neuroma or fibroma, and after an inspection of the case
clinically he would say it was probably neurotibroma. He
would be pleased to examine the specimen and report on
its histopathology at an early meeting.

Tuberculide. — Dr. Lapowski presented a man, 41 years
old, of Polish birth, a tailor. Ten years ago he had a pimple
of some kind on his penis, which disappeared in a few
days. He did not remember any secondary symptoms on
either skin or mucous membranes. The present eruption
began about fourteen years ago on the face, coming and
going, and spreading gradually downward, and had re-
mained practically unchanged for the past eight or ten
years, liach lesion began as a pimple witli a white center,
from which water or matter could be expressed. If not
scratclied the papules dried and scabbed, the scab later
falling, leaving a depressed opening. There was no itching.
The eruption was scattered over both lumbar regions and
on the flexor surfaces of the upper and the lower limbs, in
rings and half rings, which on healing left pea-sized scars,
without any pigmentary border on the abdomen, while on
the lower extremities there were pigmentary spots. Some
had dry blood scabs, on removal of which punched-out
bleeding ulcers appeared, not deep or dry enough for a tu-
berculide. While the man was under observation two
months ago. a pea-sized patch developed on the right
palm ; the epidermis was raised at the edges, the base was
slightly scaly. Last month he had an urticarial and im-
petiginous eruption, which gradually disappeared, leaving
the original lesions but little changed. The patient took
mixed treatment for a month, and then mercurial inunc-
tions for two weeks, leading to marked improvement in
some of his lesions, while the others were quite unafifected.
Dr. Lapowski presented also, in connection with this case,
the woman shown as a case of tuberculide at the preceding
meeting.

Dr. Dillingham did not regard either case as one of
tuberculide. The woman he considered as being a case of
chronic urticaria ; the man had an entirely different disease,
and although at first it would suggest syphilis, closer exam-
ination showed that the lesions were acute and not charac-
teristic of that disease. It appeared to be a general infection
and as there was atrophy it was possible there might be
a syphilitic element in it. The speaker would wish to
study the case more carefully before making a diagnosis.

Dr. PoLLiTZER was glad to find himself in accord with

the views expressed by most of the speakers as to the
nature of these two cases. One of the earliest cases of
the disease, now regarded as a type of the tuberculide, to
be published with full histological details was the speaker's
case of hidradenitis. The evolution and course of that
case were perfectly clear in his mind and they were nothing
like the case of the woman shown by Dr. Lapowski. The
characteristic features of the speaker's case were the origin
of the nodules in the deeper layers of the skin, their slow
evolution, the breaking down of the epidermis with dis-
charge of pus and necrotic shreds, and the resulting small,
depressed cicatrices, the whole without any subjective
symptoms. This description agreed perfectly with Barthel-
emy's account of his acnitis published almost simultane-
ously and Dubreuilh's subsequent publications. In this case
there was nothing of the course of the so-called tuberculide
acneiforme. Here the lesions appeared abruptly on tho
surface, there was intense pruritus, a papule was formed
(as in prurigo), the patient scratched violently, tearing
off the epidermis with the nails, a crust resulted, and
finally a slight scar. Dr. Pollitzer would call this case one
of chronic papular urticaria. As to the tuberculides in
general, he desired to place himself on record as not
accepting that group of dermatoses as presented by our
French colleagues. They were grouping together a number
of different diseases virtually on the sole basis of a sup-
posed common etiology which, in the speaker's opinion,
did not exist. As to the case of the man, the patient
admitted having had a chancre some years ago, and had
to-day general adenopathy. He was without doubt syphi-
litic, and his skin lesions were part of his syphilis.

Dr. Whitehouse regarded the skin affections in these
two subjects entirely distinct one from the other, and he
considered neither of them examples of so-called tubercu-
lides. The evolution of the lesion in this affection, which
he preferred to call necrotic granuloma, was uniform and
characteristic in every case that he had seen. It was a
deep-seated papule or nodule, developing slowly with slight
inflammatory symptoms, the summit of which, after some
days, sank in and went on slowly to complete necrosis;
upon healing a variola-like scar remained. The man just
shown had syphilis, as seen in a circinate patch upon the
ankle now about healed and a group of indolent, dull-red
papules on the calf of the leg. The eruption on the trunk
and limbs elsewhere he considered an independent affection,
a folliculitis. He had seen this condition go on for years
as the result of an intestinal toxemia. Dr. Whitehouse
considered the woman's case to be one of chronic urticaria.
The evanescent character of the eruption, including an
edematous plaque upon the wrist, the intense itching, pig-
mentation, and even scars, were all consistent with the
diagnosis of chronic urticaria. Pigmentation was not un-
common in this disease nor were scars as the result of
local infection due to scratching.

Dr. Lapowski, closing the discussion, agreed that there
was a decided element of urticaria.

A Case of Psoriasis of the Scalp and Hands Only. —
Dr. A. R. Robinson presented this patient, a man, aged 60,
cigarmaker, married, five children, seven sisters, and two
brothers. No history of any cutaneous disease in the family.
Had always been healthy. He was accustomed to eat
moderately of a mixed diet, to drink much tea and coffee,
and for thirty years had drank two quarts of beer daily.
Eruptions first appeared seven years ago, first on the scalp
as a small pea-sized lesion ; others formed, and by exten-
sion and coalescence the entire scalp was affected. Six
months after the first appearance on the scalp the lesions
appeared on the palm of the left hand, and six weeks later
upon the palm of the right hand, and gradually extended to
the wrists. The disease had existed continuously since
that time, though milder in winter than in summer. The
eruption appeared upon the palms as small lesions some-
times increasing in size and uniting to form a patch. Five

36

MEDICAL RECORD.

[Jan. 5, 1907

years ago small scborrhea-like lesions appeared upon the
right side of the nose and upper lip and had remained
ever since. \o eruption had appeared at any time upon
other parts of the body. On the scalp were well-defined
areas of psoriasis. Where the hair was absent as on top of
the scalp no lesions were present. The case was shown on
account of the age at which the psoriasis first appeared and
on account of the close similarity of the lesion upon the
palms to that of a papulo-squamous syphilide — a resem-
blance the speaker had noticed before in these cases of
atypical psoriasis. A few months ago he exhibited before
the New York Dermatological Society an atypical case of
psoriasis with very similar lesions upon the palms. In that
case the disease was limited to the hands and tongue. This
case was at>pical on account of the age when the eruption
first appeared and the limitation to the scalp and hand^.

Case of Atypical Psoriasis of Elbow and One Palm. —
Dr. Dillingham presented a case which he said was inter-
esting in that the eruption did not appear until the patient
was 45 years of age, and for four years it was confined
to the elbows; the case also illustrated that it was often
impossible from the palm alone to make a diagnosis be-
tween psoriasis, eczema, and syphilis. Jacob S., 49 years
of age; no- history of venereal disease. Had no eruption
until four years ago, when a small lesion appeared on
his left elbow, gradually increasing in size, and followed
by otliers, all commencing as small lesions spreading at
the periphery. After several months lesions appeared on
the right elbow. The eruption had never disappeared,
and at no time had there been any serious exudation. A
certain amount of itching had been present. A month ago
lesions appeared on the left palm without any history of
irritation from occupation or otherwise. There had been
no eruption on the rest of the body. A diagnosis of
psoriasis was made on the character and history of the
lesions, the location, manner of spreading, and absence of
exudation. Squamous syphilis could be excluded by the
location, absence of lesions on the rest of the body, slow
growth, and character of the lesions, thickening instead of
infiltration in the corium, and absence of atrophy. Eczema
could be excluded by the location, character of scales,
sharply limited margin, manner of spreading, and absence
of serous exudation and of vesicles and papules at the
margin. The speaker said he realized that the margin and
manner of spreading would not exclude dermatitis sebor-
rhoeica, but the reddish color and the elevated and almost
tubercular character of some of the lesions would. The
age of the patient and the limitation of the disease, although
unusual, were not against the diagnosis of psoriasis. Wilson
had reported a case of psoriasis appearing for the first time
in a patient 85 years of age, and Crocker one at 81 years.
In Nielssen's cases 2 per cent, appeared after 50 years of
age. In regard to the limitation, Crocker had reported a
case in which, although there were two or three attacks,
the eruption was present on the palms only, and another
case in which it was confined to the left hand for several
years and never affected any other part of the body except
the right hand earlier. Cavafy had reported a case in
which the eruption was limited to the right forearm and
hand for twenty years, beginnin.g on the palm. .A. number
of cases had been seen in which the disease was limited
to the scalp. When the eruption made its appearance late
in life it was more apt to be atypical in character and
location.

Two Cases of Syphilis and One Case of Psoriasis of
the Palms. — Dr. Williams reported the following cases:
Case I. — The patient, a clerk, 30 years of age, applied
for treatment February 21, igo6. He had a healed chancre
on the penis, a well-marked papular eniption all over the
body, and mucous patches in the mouth. The symptoms all
disappeared under treatment, which was continued until
.August. He returned to the dispensary October 3, 1906,
with rounded and oval ham-colored spots in both palms,

one of them being partially denuded of epithelium in tlie
middle, another just beginning to scale in the middle, others
showing only the color and a very slight infiltration.

Case II. — The patient, a cook, 49 years old, denied having
had a chancre. He had two living children, 23 and 21 years
old, respectively, and one child, born nineteen years ago,
had died. His wife had had no miscarriages. He now
had a characteristic tubercular syphilide on both elbows,
and syphilitic lesions on the palms, soles, and nails. Some
of the lesions on the palms were small, round, very
slightly infiltrated, and hardly distinguishable from similar
spots on the palms of the accompanying case of psoriasis.

Case III. — The patient, 55 years old, married thirty-eight
years ago, and a widow for twenty-eight years, had had
eight children and no miscarriages. Seven of the children
died in epidemics. She denied positively having had any
eruption until five months ago, when t>-pical psoriatic lesions
appeared on the hands and forearms. Some of the lesions
on the palms were very suggestive of syphilis, showing the
characteristic "collarette," but they were bright red in color
instead of dull.

In presenting these cases of eruptions on the palms Dr.
Williams called attention particularly to the difficulty in
distinguishing certain cases of palmar syphilis from pso-
riasis on the one hand and eczema on the other. The
diagnosis was usually readily made from concomitant
lesions elsewhere on the body, or from the history of such
lesions, hut to decide from, an inspection of the palm alone
was a different matter. Elliot's sign (the induration or
infiltration of the border of a syphilitic eruption), the
absence of such infiltration in the other diseases, and
Fournier's sign (the sharp limitation of each sjlihilitic
patch as contrasted with the numerous small islands of
disease lying near the edge of a larger patch of eczema),
were the most useful, but these might fail, and it had been
said repeatedly that some cases of syphilis might copy
exactly the picture of psoriasis, and others that of eczema.
It was in the hope of eliciting further aids in diagnosis
that these cases were shown.

SECTION O.V DERMATOLOGY.

Staled Meeting. Held December 4. 1906.
Iht. A. R. RoBixsox IN- THE Chair.

Rhinoscleroma; Marked Improvement Under Radio-
therapy.— Dr. W. S. GoTTHEiL presented a woman thirty
years of age sent to him by Dr. J. Frankel, July 17, 1905.
The growth was said to have begun on the septum five
years before, and had been progressing ever since. The
central portion of the upper jaw and the septum and alae
of the nose were the seat of a deep and fairly sharply
limited infiltration of cartilaginous hardness and absolutely
insensitive. The growth evidently involved the bone and
cartilage as well as the skin, causing marked protrusion
of the upper lip and tilting up the projection of the nose.
Both nasal passages were almost entirely occluded, per-
mitting the passage of only the finest probe. The hard and
soft palate and the faucial isthmus and posterior pharynx
were deformed, thickened, and cartilaginous, and were the
seat of chronic ulcerative and cicatricial processes. The
general health was fair, though there was some interfer-
ence with nutrition on account of the interference with
deglutition. The larynx was free. The chief subjective
complaint being occasioned by the nasal stenosis, attempts'
were first made at careful dilatation. The most cautious
efforts, however, were followed by very profuse and ob-
stinate hemorrhages, one of which was so severe that the
patient had to remain several hours at the office with the
anterior nares and posterior pharynx tightly plugged be-
fore it was safe to send her home. Recourse was then
taken to the ^-ra}-, and during the past eighteen months
the patient had had about fifty sessions at rather irregular

fan.

I uoj

MEDICAL RECORD.

intervals. There was a moderate reaction at various times,
during which the patient's subjective dilScuIties had always
been increased ; but she aUvays improved when the
inflammation subsided. Dr. Gottheil was using the Cornell
tube of small size in the mouth and nares. The result had
been a marked diminution m size, to the e.xtent of about
one-half, in the tumor mass of the upper jaw and nose.
The external deformity had been very greatly improved.
The pharyngeal ulceration had also gotten better, and swal-
lowing was easier. The nasal stenosis had not yet been
affected; but the intranasal treatment had been begun only
a short time ago.

Dr. Gottheil, replying to questions, said that he had
found radium of no value in these cases. He said he
used Cornell .r-ray tubes, made so small and of such shape
that they could be put in the mouth and in the nostril, in
contact with the diseased tissue, and he believed that by
preventing the passage of the rays through thV atmosphere
he avoided their irritant effect. He said also that he was a
great sceptic as to the value of the .v-rays, and used them
here because he did not know what else to do, the patient
bled so alarmingly at the slightest touch.

Syphiloderma Frambcesiodes. — Dr. W. S. Gottheil
presented this patient, a colored woman, twenty-three years
of age, potator, smoker, dissipated. She had been admitted
to City Hospital October 15, 1906. There was no venereal
history. She had been operated on for cervical adenitis in
childhood, and a laparotomy was performed at Johns Hop-
kins for reasons unknown five years ago, and for the sinus
left therefrom an operation was performed one year ago
at the Metropolitan of this city. The present skin lesions
developed four years ago, and while they had improved at
times, she had never been well. .Subjective symptoms had
been limited to itching, with occasional attacks of soreness.
She had been in the City Hospital for her skin affection on
three previous occasions for various periods as follows;
February 15, 1904, Service of Dr. Bronson, diagnosis,
chronic eczema ; also had gonorrheal ophthalmia. March
29, 1904, Service of Dr. Fordyce : diagnosis, eczema sicca.
April 13, 1905, Service of Dr. Greene : diagnosis, chronic
eczema. There is a note on this last record of tertiary
syphilis being suspected ; but no antihietic treatment was
instituted. She showed the following conditions on ad-
mission: Nostrils. left of half of upper and lower lips,
and adjacent cheek were covered with impetiginous crusts,
under which \va= an eroded and fissured skin; lesion ap-
parently eczematous. Mucosk normal. The entire pubic
and adjacent regions were covered by a large triangular
lesion, the upper base of which started on each side one
and a half inches from the iliac crests and extended in-
wards and upwards toward the umbilicus. The apex of the
affected triangle extended downwards along the sides of
the labia on to the perineum and thighs, and then upwards
to the very extremity of the intergluteal folds ; there was
also on each side posteriorly a transverse extension of the
affected area in each fold between buttock and thigh. The
lesion itself formed a continuous moderately hard infil-
trated and indurated mass covering the above-described
area. Its margins were sharp, elevated, and slightly cir-
cinate in places. Its surface was irregular, oozing, and
partly covered with crust of exudation and macerated
epithelium. Where the folds of the skin were in apposition
in the fairly stout patient the surface of the affected area,
while slightly hypertrophic, was moist, oozing, and ecze-
matous. The diagnosis at first was eczema marginatum,
though the essentially hyperplastic and tuberculous charac-
ter of the lesions was not usual in this affection. Thorough
cleansing and a dusting powder were ordered. Examina-
tion of the scales and detritus failed to reveal any hypho-
mycetic fimgi. By October 29 the surfaces were cleansed
and the eczematous symptoms had subsided. It then be-
came evident that the lesion was essentially f ramboesiform ;
distinct tubercles were visible at the margins, and there

were circular depressed areas of scar tissue in various
places, especially at the posterior apex of the affected re-
gion over the sacrum. Microscopic sections showed no
fungi, but a small-celled inflammatory infiltration round
the basal capillary vessels and evidences of chronic vas-
cular inflammation. The diagnosis was changed to tertiary
syphilis, and the patient put on appropriate treatment. By
November 26 the patient had had three ten-minim doses
of the ten per cent, mercury salicylate intramuscular ni-
jections, and was up to 160 grains of potassium iodide
daily, with no local treatment. The improvement was very
marked, the surfaces absolutely dry; the tuberous in-
filtration rapidly disappearing. When shown to the sec-
tion, only the remains of the eruption were visible.

Dr. BuLKLEY said that there must have been something
more than syphilis in this case to account for the duration
and the unusual appearance of the lesions, and called at-
tention to their resemblance to those of blastomycosis.

Dr. Lapowski endorsed the suggestion of blastomycosis,
and called attention to the fact that, as this disease im-
proved under the use of potassium iodide, the improvement
in this case under nii.xed treatment was no proof of its
syphilitic nature.

Dr. Gottheil admitted the presence of an impetiginous
element in the eruption, but did not accept the suggestion
of blastomycosis.

A Case of Multiple Chancre. — Dr. Lapowski presented
a man thirty years old who had had coitus eight weeks
ago. and who at that time had an abrasion on the abdomen
a little below the umbilicus. The patient showed when
presented three lesions, each about the size of a twenty-five
cent piece : one of thirty-five days' duration, at the site of
the former abrasion on the abdomen, one of twenty-eight
days' duration on the upper surface of the root of the
penis, and a third of twenty days' duration on the anterior
surface of the pendulous portion of the penis. All the
lesions were hard to the touch, especially the one at the
root of the penis and that on the abdomen. The lesion on
the abdomen was round and sharply defined, the surround-
ing skin normal. The edges were sloping, the surface
smooth, shiny red, and on pressure a serous fluid oozed
out. The center was crateriform, with a yellowish-gray
adherent membrane. The lesion on the root of the penis
had the same characteristics, but it was harder to the
touch, and the central part showed scar tissue. The lesion
on the pendulous portion was not so hard, and had a
narrow border with dry, bloody crusts. The central
portion was covered with a detachable membrane, under-
neath which the surface was red and shiny. On the scrotum
was a longitudinal abrasion of one day's standing. On the
trunk a macular eruption was developing, which was not
visible five hours before. In both inguinal regions were
packets of hard, enlarged, painful glands. The mucous
membranes were normal. Dr. Lapowski promised to re-
port at the next meeting in regard to the presence or
absence of spirochetes.

Case for Diag^nosis. — Dr. A. R. Robinson presented
a man, aged forty-nine years, a piano-maker by occupa-
tion. He had always enjoyed good health except when
at the age of seventeen years he was ill for eleven months
with "nervous gastric fever." On March 16, 1906. he was
admitted to the German Hospital on account of an "eczema"
and muscular rheumatism. For the cutaneous eruption
chrysarobin was employed. About the beginning of March
he noticed a few pimples in the inguinal region on the
left side. They all disappeared except one, which con-
tinued to increase in size, and on account of which the
speaker presented him before the section for diagnosis.
The patient stated that at one time the growth became re-
duced in size to that of a bean. It was situated somewhat
to the right of the middle of and above Poupart's ligament.
The condition had not changed since he came under Dr.
Robinson's observation six weeks ago. The lesion was

38

MEDICAL RECORD.

[Jan. 5, 1907

about one inch in diameter, sharply limited, elevated about
one-quarter of an inch above the general surface, reddish
in color, and with an erosive surface covered with a clear
mucoserous exudation. There were no signs of ulceration
or abscess formation. The lesion was quite firm and re-
sistant on pressure. The clinical characters were very sim-
ilar to some forms of hard chancre. The exudation showed
only leucocytes and staphylococci and liquid exudate. A
small portion was excised for microscopical examination.
The diagnosis seemed to lie between a lesion from staphy-
loccoci or mycosis fungoides. The latter was regarded as
not probable, on account of the history of the case. Dr.
Robinson promised that the case would be carefully studied
and reported upon later.

Dr. Wise said that he had seen this man at the New
York Skin and Cancer Hospital about nine months ago.
At that time he had a dry, scaly eruption on the scalp,
while most of the rest of the body was covered with a
moist eczematous eruption, which was believed to be the
premycotic stage of mycosis fungoides. There was no
tumor in the groin at th-it time. He saw the patient a
week or two later at the German Hospital, where the first
diagnosis was severe seborrheic dermatitis, which was later
changed to mycosis fungoides.

Dr. BuLKLEY said he believed the case to be one of a
very early stage of mycosis fungoides, with beginning
ulceration. He thought that other tumors would develop
before long.

Lupus Erythematosus Disseminatus.— Dr. L. DfNMN
BvLKLEY presented two cases of this disease. The first
patient was a woman twenty-five years of age. Her father
was living, sixty-eight years of age, but suffering from a
chronic cough and progressive loss of strength, following an
nttack of pneumonia eight years before. The rest of the
family were well. The patient was married in September,
igo3, and her only child was born in April, 1905, and died
three months later of summer complaint. Her husband
had been in the King's Park Insane Asylum since April,
1905, and was said to have a red, scaly eruption on his
scalp. The patient had scarlatina and measles in childhood,
but no other illness until the spring of 1904. when she had
an attack of diarrhea with bloody stools, lasting about a
week. The blood was bright red, but not clotted. There
was a good deal of colicky pain and some tenesmus, but no
continuous rectal pain, and no hemorrhoids. She had
been subject to diarrhea ever since, especially after catching
cold, but the later attacks had never lasted so long, and
there had been no bleeding. Piles were first noticed
about the time of the birth of her child, in April, 1905, soon
cifter which she went to the King's County Hospital on ac-
count of severe steady pain in the lower part of the ab-
domen and in the pelvis. This was relieved, but returned
again in a week or two, and was again relieved by in-
ternal medication without local treatment, and had not
been felt since. In February, 1905, when seven months
pregnant, she first noticed a swelling and redness of the
upper lip. There were no papules at that time, not even a
scale, and no constitutional symptoms, and after a few
weeks the lesion disappeared. In February, 1906, she began
to suffer from loss of appetite, languor, weakness, and
headaches worse at night. Her hair began to fall, and she
had chills, often quite severe, and usually occurring at
night. After being sick a month she went to a physician,
who she says gave her mercury, and after a week's treat-
ment with him the present eruption developed, coming
first on the lip, as it had done the year before, affecting the
eyebrows about two weeks later, and spreading thence to
the nose and cheeks, and then involving the fingers. There
was still only redness and swelling; neither pimples nor
scaling. Her general condition grew worse as the erup-
tion developed, and in April she entered the King's
County Hospital, having then a temperature of 104°. She
said nothing was done for her there, but she improved, and

was discharged after a month's stay, and remained in fair
condition all summer, though not quite so strong as usual,
and with a slight redness of the affected portions of the
face and hands. Early in the fall, both constitutional and
local symptoms increased again, and then for the first time
scaling was noticed, and red pimples with white centers
appeared, which on healing left deep pits. When she first
came to the Skin and Cancer Hospital on November 14,
1906, she had typical lesions of lupus erythematosus on the
eyebrows, cheeks, nose, and lip; and on the fingers red,
shiny infiltrated masses, one-eighth to one-half inch across,
thinning out toward the periphery, and sometimes beginning
to scale in the middle, and occupying the skin itself, rather
than forming papules or tubercles. Both the palmar and
the dorsal surfaces of the fingers were affected. On the
rest of the body the skin was clear. The hair was very thin
and the scalp was scaly, with a few small ill-defined atrophic
areas, but w'ithout typical lesions of lupus erythematosus.
The inguinal, a.xillary, and cervical glands were enlarged,
and the right epitrochlear gland was palpable. The breath-
ing over the upper part of the chest behind was slightly
roughened and the expiration prolonged, and a few sub-
crepitant rales were heard just above and internal to the
right scapular spine. The abdomen was normal and not
tender. While in the hospital the patient had no elevation
of temperature. Although the symptoms and physical
signs were not definite enough to make a positive diagnosis
of latent tuberculosis, they might bear that interpretation.
The treatment was a six per cent, lotion of resorcin up to
November 24, after which date lotio alba of double strength
was used. Internally she took one grain of iodoform
three times a day up to November 28, when this was re-
placed by two drops of nitric acid in glycerine and water
three times a day. The improvement had been considerable,
the congestion in particular being greatly diminished. The
second patient was a married woman thirty-eight years of
age. Two of her sisters had died of tuberculosis, her
mother and three brothers were living and well, her hus-
band had died as the result of a fall. She had had occa-
sional rheumatic pains in the joints for several years, but
could tell of no other sickness until the spring of 1904,
when she was in bed for two months with weakness, chilli-
ness, feverishness, and eruption of vesicles around the
lower part of one side of the chest, accompanied by a
burning pain. The scars left by this eruption, which seems
to have been herpes zoster, could still be seen. She said
that in the early part of the attack she suffered for a week
from diarrhea, with bloody stools and colicky pains. She
had been losing flesh and strength ever since. About
three months after the onset of the above illness she
first noticed a red pimple on the right cheek, and within two
months the disease spread to the other cheek, and then over
the whole head, causing very great loss of hair. After
that there was very little change, either in local or general
condition, until May or June of 1906, when she was sick
in bed with prostration, headaches, anorexia, vomiting, and
feelings of chilliness and feverishness, and of great heat
in the face. The eruption on the face grew worse at that
time, and scabs appeared. Later the eruption appeared
on the backs of the hands, spreading thence to the fore-
arms and arms. When she came to the hospital in July,
1006, she presented a curious mixture of le-sions, including
a large number of superficial pustular bullae, while the
lesions on the arms and scalp were characteristic. She left
the hospital much improved, but two or three weeks later,
becoming overheated, she relapsed into the same condition
as before, and returned. She had no elevation of tempera-
ture while in the hospital. Under treatment with nitric
acid internally and soothing preparations externally, she
had made marked improvement; still the spread of the
disease over the back and chest occurred only a month
ago. When she was presented before the section, the hair
was very thin over the entire scalp, which was thin and

Jan. 5, 1907]

MEDICAL RECORD.

39

atrophic, but which showed few distinct scars. Above and
behind each ear was a poorly-defined bald spot about two
inches in diameter. The skin of the entire face was
atrophic, reddened, scaly, with considerable rather dense
scar tissue on each cheek, where also there were bloody
crusts. Throughout the scar tissue on the face were many
fine telangiectases. The atrophy was so marked that the
mouth could not be opened wide. This condition extended
into the chest and down the back to tlie lumbar region.
On these parts the process seemed to be very superficial,
and resembled a seborrheic dermatitis, but there was a
considerable development of scar tissue in the older parts,
the border was erythematous, and beyond the border were
characteristic discoid patches. Over the posterior and ex-
ternal surface of the right arm, and the posterior surface
of the right forearm, extending around the radial border to
the anterior surface and reaching nearly to the ulnar border
of the anterior surface in the middle third, and extending
down on to the back of the hand, the skin was red, rough,
slightly scaly, crinkly, and hot, and showed the develop-
ment of scar tissue in places. The redness was more
marked toward the border, which was raised, erythematous,
limited internally by a line of scales attached by their outer
margins, and passing externally into normal skin. There
were numerous outlying islets of diseased skin. The left
arm, forearm, and hand were similarly but less extensively
affected. The right palm showed several erythematous
spots, about a quarter to a half an inch in diameter, in
the middle of which was a small depression left by the de-
struction of the superficial epidermis, the color being darker
about these depressions. Similar spots of erythema with
a darker center but without destruction of epithelium oc-
curred on the left palm. Similar spots occurred on both
the palmar and dorsal surfaces of the fingers. The lungs
were normal. The cervical glands were enlarged. She
had a slight cough, raising a little mucus in the morning,
but so slight that she disregarded it.

Dr. PoLLiTZER said he had never seen so extensive a case
of erythematous lupus as that in the older woman, and
that while the disease appeared fairly often on the backs
of the fingers, he believed the lesions on the palms to be
unique.

Dr. GoTTHEiL agreed with Dr. Pollitzer. He had never
seen erythematous lupus upon the palms, and could not re-
call ever having seen a report of such a case. He felt
very hopeless about the treatment. In the great majority
of cases that are cured the lesions must be replaced by
scar tissue, and he therefore applied trichloracetic acid or
some similar caustic at once, in order to cause destruction
of the diseased tissue.

Dr. DiLLiNGH.\M said that in certain superficial forms,
like that on the older woman's back, the diagnosis from
eczema might be very difficult.

Dr. Williams said that the dense scar tissue on the
older woman's cheeks and a few of the small nodules were
very suggestive of lupus vulgaris, while some of the papules
on the younger woman were suggestive of acnitis, and
called attention to the relation of these facts to the theory
of the tuberculous origin of lupus erythematous.

Dr. BuLKLEY, closing the discussion, said that he believed
that the great loss of hair in both cases was due, in part
at least, to a coincident seborrheic dermatitis, which he
believed accounted also for part of the eruption on the
older woman's back. Both patients were being treated with
nitric acid internally, and both showed marked improve-
ment, though the treatment was purely empirical.

Tuberculosis of the Tongue. — Dr. L.\powski pre-
sented this patient, who had been shown before the Sec-
tion on October 2. Since that time he had given him in-
jections of calomel and of salicylate of mercury, and the
improvement in the tongue had been very great indeed.

Dr. Lapowski also reported that the woman shown at
the same meeting as a case of tuberculide had received two

injections of tuberculin, but that she had shown no reaction
to it. The man shown at the meeting of October 30 as a
case of tuberculide had received injections of calomel and
of salicylate of mercury, and he had improved, but after
the injections a few new papules had appeared.

Dr. Pollitzer reported that he had examined sections
from the case of multiple tumors in the skin shown by Dr.
Lapowski at the preceding meeting, and that they were
typical of neurofibroma.

Chicago Medic.\l Society.

At a meeting held November 28, 1906, Dr. Arthur R.
Elliott read a paper entitled "Clinical Observations on
Blood Pressure in Arteriosclerosis and Bright's Disease,
with Suggestions Regarding the Therapeutic Control of
Persistent High Blood Pressure," in which he stated that
after making due allowance for physiological variations the
normal limits of the blood pressure range was from 105
mm. to 140 mm. of mercury. He reported observations
on thirty cases of typical advanced arteriosclerosis. The
average age of the patients was sixty-one years, and the
average maximum systolic blood pressure 148 mm. In
fourteen cases (47 per cent.) the blood pressure fell with-
in the normal range. In sixteen cases (43 per cent.) it
was persistently above normal, and in six of these latter
there was positive hypertension (over 170 mm.), each
case displaying evidence of aortic atheroma. The points
brought out by his observation in arteriosclerosis were
the frequency with which it is not attended by elevation
of blood pressure, and the necessity for using the sphygmo-
manometer in all cases to determine this point, owing to
the impossibility of detecting high blood pressure in sclerotic
vessels by the unaided finger. The writer called attention
to the frequency of chronic nephritis in arteriosclerosis,
and the necessity for carefully excluding this factor in
high-tension cases. He referred to the researches of Hasen-
feld and Hirsch as to the relative involvement of the ab-
dominal arteries and aorta in cases with and without ten-
sion, and concluded his consideration of arteriosclerosis
with the statement that in any given case of arterio-
sclerosis the degree of involvement of the superficial ves-
sels is no criterion of the severity of the vascular disease,
and that in cases marked with high tension, where chronic
nephritis can be proved not to exist, arteriosclerosis of
the splanchnic area or of the aorta above the diaphragm
is to be suspected. Dr. Elliott also reported blood pressure
observations in 60 cases of chronic Bright's disease, as
follows: Males, 34; females, 26; average age, 51 years;
average weight, 160 pounds ; average maximum systolic
blood pressure, 190 mm. ; maximum recorded in series,
285 mm.; minimum in any case, 1 10 mm. The essayist re-
viewed the investigation somewhat in detail, showing that
no constant ratio existed between the height of the blood
pressure and the amount of albuminuria, the- highest aver-
age systolic pressure being observed in cases without albu-
min in the urine. No definite relationship exists between
the amount of urine and the height of the blood pressure,
a pressure of 283 mm. coinciding with 1,000 c.c. of urine,
and, on the other hand, low pressure being observed with
a copious polyuria. Attention was directed to the diagnostic
value of high pressure reading in nephritis. A pressure
of 200 mm. or over should awaken suspicion of nephritis,
and necessitate the elimination of this factor beyond doubt
before any other diagnosis is accepted. The essayist then
proceeded to discuss the management of high pressure
cases. He reviewed the pathogenesis of hypertension, point-
ing out the secondary nature of this symptom and its de-
pendence on systemic toxemia. Reference was made to the
greater degree of comfort enjoyed by the nephritic with
high tension than by the patient with Bright's disease
who had low tension. Inasmuch as the cardiovascular
sequence was a reaction against toxemia, he regarded it as

40

MEDICAL RECORD.

[Jan. 5, 1907

a compensatory, and, from the physiological viewpoint, to
some extent a conservative process. Owing to the liabiHty
of hypertension to cause serious and often fatal develop-
ments, such as apoplexy, cardiac failure, etc., it often re-
quires regulation. The basis of all true procedure in this
direction lies in reducing toxemia by regulation of the
patient's diet, fluid intake, hygiene, etc., and the main de-
pendence is to be placed on these measures. Increasing
tendency is apparent to administer vasodilators for the re-
duction of excessive blood pressure. This the essayist
takes exception to, and advises the utmost caution in pro-
cedure along this line. Reduction by drugs is occasionally
rendered imperative by serious symptoms, such as angina
pectoris, apoplexy prodromes, etc., and imder such con-
ditions nitrites, etc., may be freely administered for their
temporary etTects. As a routine procedure for the regula-
tion of hypertension, vasodilators are seldom justifiable,
and when employed should be very cautiously and slowly
introduced, watching meanwhile the pulse rate and sub-
jective comfort of the patient as indications of good effect,
rather than the degree of reduction in the blood pressure
record. The best results are evidenced by a reduction and
steadying of the pulse and an increase in the bodily comfort
of the patient. A marked fall in blood pressure, which is
more than temporary, following the institution of vaso-
dilator medication, is apt to have an unfavorable signifi-
cance, as it implies a weak heart. The essayist strongly
urges greater care and discrimination in the use of medici-
nal vasodilators in high-tension cases.

While the Medical Record is pleased to receive all new
publications zvhich niay be sent to it. and an acknowledg-
ment li'ill be promptly made of their receipt under this
heading, it must be ivith the distinct understanding that its
necessities are such that it cannot be considered under
obligation to notice or review any publication received by it
which in the judgment of its editor icill not be of interest
to its readers.

Manuel d' Histologie P.\thologiql'e. 8vo. 1171 pages,
illustrated, paper. Felix .A.lcon, Editeur. Paris.

The Treatment of Diseases of the Digestive System.
By Robert Saundbv, M.D., M.Sc. LL.D.. F.R.C.P. i2mo,
133 pages. J. B. Lippincott Company. Philadelphia.

Klinik fCr Psvchische VXD Nervose Krankheite.v.
Herausgegehex von Robert Sommer. I Band. 4 Heft.
Verlag von Carl Alarhold. Halle a. s.

Thirty-seventh Annual Report of the State Board
OF Health of Massachusetts. 8vo. 626 pages, muslin.
Wright & Potter Printing Co., Boston.

International Clinics. Edited by A. O. J. Kelly,
A.m., M.D. Volume III.. Sixteenth Series, 1906. 8vo,
302 pages, illustrated, muslin. J. B. Lippincott Co., Phila-
delphia.

Lectures of the Chautauqua School of Nursing.
4to, illustrated, muslin. Published by the School.

An Introduction to Physiology. By William Towns-
end Porter, M.D. i2mo, 587 pages, illustrated, muslin.
J. B. Lippincott Co.. Philadelphia.

Pedi.atrics (Vol. VII. of the Practical Medicine
Series). Edited by Isaac A. Abt, M.D. i2mo, 267 pages,
illustrated, muslin. The Year Book Publishers, Chicago.
Price. $1.25.

The Medical Record Visiting List or Physicians'
Diary' for 1907. New revised edition. l6mo, flexible
leather. William Wood & Co., New York.

The Integrative Action of the Nervous System. By
Charles S. Sherrington, D.Sc, M.D., etc. 8vo, 411 pages,
illustrated, muslin. Charles Scribner's Sons, New York.

Surgery, Its Principles and Practice. By various au-
thors, edited by William Williams Keen, IM.D., LL.D.
Volume I. 8vo, 983 pages, illustrated, muslin. W. B.
Saunders Company, Philadelphia. Price, $7.00.

The Diseases of Children, Medical and Surgical. By
Henry Ashry. B.A.. M.B. Oxon.. F.R.C.S. Eng.. and G.
A. Wright, B.A., M.B. Oxon, F.R.C.S. Eng. Fifth edi-
tion, thoroughly revised. 8vo, 920 pages, illustrated, mus-
lin. Longmans, Green & Co.. New York.

Operationen .\m Ohr ; die Operationen bei Mittel-
ohreiterungen und ihren Intrakraniellen Komplika-
tionen. Fiir .^erzte und Studierende. von Dr. B. Heine.
Verlag Von S. Karger, Berlin. 4to, 197 pages, paper.

OiliFraiifuttr l^tnta.

Conjunctivitis. —

U Sol. adrenahn. chlor. I-IOOO 5ss

Sod. biborat gr. v

Sol. acid boracici 3 per cent 31

.•\q. camph 5ii

M. S. Eye lotion.

Pruritus Vulvae. —

IJ /\cid. borici gr. iii

-Vcid. carbolici gr. iii

Morph. hydrochlor gr. i

Lanolin oz. ii

M. Ft. Ung. S. Apply locally.

— Buffalo Medical Journal.

Migraine. —

Caffeina; 0.25

Sodii salicyl 0.5

Cocaina; hydrochlor 0.02

.Aquse 30.0

Syr. simplicis lO.o

M. S. Take at a dose.

^Bjorkmann.

Pharyngitis in Scarlatina. — D. R. Lucy recommends:

IJ Tr. f erri chlor 5ii

Pot. chlorat 5i

Glycerini.

Aquae aa q.s. ad. ^iv

M. S. A teaspoonful every two hours.

— Denver Medical Times.

Gastric Hyperacidity. — Salisbury uses the following:

5 Sodii sulph 50.0

Sodii bicarbonat 20.O

Sodii chloridi lO.O

M. S. One to two teaspoonfuls in a glass of hot water
before breakfast.

— Therapeutic Record.

Periostitis. — Van Buren and Keys recommend:

]J Potass, iodid 5ij

.Animon. iodid 5j

Tr. cinchonse comp 5iij

M. S. A teaspoonful well diluted with water after
eating.

— Medical Rcviezv of Reviews.

Tonsillitis. —

Pot. bicarb 3iv

Spt. menth. pip.

Spt. camphorae aa 5ss

.Aq. ferv s\v

S. L^se hot; gargle every hour.

. — JViscousin Medical Journal.

Colitis in Pneumonia. — For this complication Musser
uses :

5 Beta naphthol 1.50

Bismuth, subnitrat 3.0

M. Ft. capsule No. X. S. One capsule every four
hours.

Or the following:

B Acid carbol i.o

Bismuthi subgal 8.0

Mucilag. acacije.

Glycerini.

Aq. menth. pip aa q.s. ad. 60.0

M. S. One teaspoonful every three hours.

Furunculosis. — Le Gendre gives internally the follow-
ing:

1j Beta naphthol.

Bismuthi salicylat.

Mag. carb aa gr. v

M. S. Give at a dose every four hours.

— Union Mcdicale.

Bronchitis in Children. —

R Tr. opii camph 5i

Syr. ipecac iTIxxxii

Syr. tolutan Sii

M. S. Teaspoonful every three hours.

— KOPLIK.

Indigestion. —

R Tr. capsici tJExvi

Tr. nucis vomicae 3ii

Tr. gent, comp ad 5ii

M. S. -^ teaspoonful in water three times a day.

— Da Costa.

Menorrhagia. —

R Ext. hydrastis fl.

Ext. hamamelidis fl aa Siiss

Ext. viburni fl 5iss

M. S. Twenty drops in water three times a day.

— Le Progres Medical.

Jan. 5, 1907]

MEDICAL RECORD.

41

#tat^ Mf iitral iCimising loariia.

STATE BOARD EXAMINATION QUESTIONS.

K.ANSAS State Board of Medical Registration and

Examination.

October 9, 1906.

anatomy and histology.

1. Locate the brachial plexus and its branches, naming
the latter.

2. Describe the medulla oblongata.

3. Locate and describe a femoral hernia and name its
coverings, beginning with the surface.

4. Describe the intestinal tract and name its divisions.

5. Locate and describe the omentum, giving the histol-
ogy of the same.

6. Describe the vulvuls conniventes.

7. Locate and describe the i)ancreas, giving its histolog>'.

8. Give the histology of the arteries. Does it differ
from the histology of the veins? If so, how?

9. Describe the sympathetic nerve, naming its divisions,
and number of ganglia in each.

10. How many bones are there in the human skeleton?

chemistry and toxicology.

1. What is galvanism?

2. How can it be demonstrated that hydrogen is lighter
than air?

3. What is analysis and what is synthesis?

4. What is the effect of inhaling air rich with ozone on
the respiratory organs?

5. In what manner does arsenic prove poisonous?

6. How does CO act as a poison?

7. What is the action of KOH on the tissues?

8. What is the atitidote for acute poisoning by HgCIj?

9. What is the reaction of blood during gout?

10. What is Trommer's test for sugar in urine?

obstetrics.

1. Write a page on deformities of the pelvis.

2. What would you do in a case of postpartum hemor-
rhage?

3. How would you treat a case of hour-glass contrac-
tion ?

4. Write a page on puerperal eclampsia.

5. How would you treat a case of pel\ic cellulitis?

6. Into how many stages is labor divided?

7. How would you treat a case of face presentation?

8. How would you treat a case of adherent membranes?

9. Write a page on the use of the forceps.

10. How would you treat fibroid tumors of the uterus?

pathology.

1. Define gangrene.

2. What is a sarcomatous tumor? Give its pathology.

3. Define chronic gastritis and give its pathology.

4. Give symptoms, etiology, pathology, diagnosis and
prognosis of herpes zoster.

5. Give symptoms, etiology, and prognosis of erysipelas.

6. Give etiology, symptoms, diagnosis, and prognosis of
neuritis (multiple).

7. Define lithemia.

8. Define purpura ha?morrhagica.

9. Give differential diagnosis of septicemia and pyemia.

10. Describe the pathology of rachitis.

BACTERIOLOGY.

1. How do bacteria multiply?

2. What is essential to the life of bacteria?

3. Name and describe the malarial parasites.

4. \\'hat disease does the bite of an infected Stcgomyia
fasciata produce?

5. Name five culture media.

6. Name and describe the pus-producing germs.

•It is proposed In this department to publish from time to
time the examination papers of the various State Boards.
In order that a candidate may become familiar with the
character of the examination and so In some measure free
himself in advance from the ner\'ousness and dread which
the unknown inspires. In furtherance of the same object
answers to some of the questions will be published in order
to show the candidate what the examiners expect of him.
Not all the questions of all the papers will be so treated,
for the answers to many, especially In the anatomical papers,
are obvious or can be found in the Index of any text-
book on the subject: the answers to other questions, especially
in the surgical papers, must sometimes be omitted because of
the space they would demand. The candidate for a medical
license will not find in these answers a short and easy road to
success in the examination, for he is not likely to meet the
same questions In the papers placed before him by the
examiners. The object of publishing the questions and
answers is only, as noted above, to acquaint the candidate
with the general character of these examinations and to
Inipire him with confidence in the result of his trial.

7. Describe Widal's test for typhoid fever.

8. \\'hat are leucocytes, and what occurs when they
come in contact with pathogenic bacteria?

9. What are ptomaines and toxins?

10. What are sterilization, antiseptics, disinfectants, and
germicides ?

PHYSIOLOGY.

1. What are the functions of the spinal cord?

2. What is the origin of urea and of uric acid?

3. (a) Describe the vasomotor nervous system and
explain its functions, (b) Where is the vasomotor center
located?

4. (al Give the function of the suprarenal glands, (b)
What is result of their extirpation?

5. What kind of membrane lines the mastoid cells, and
why ?

6. Explain the portal circulation.

7. (a) What are the functions of bile? (b) Give its con-
stituents.

8. Describe the pleurje, giving kind of tissue and func-
tions.

9. (a) Give functions of the cerebellum, (b) What is
the result of its extirpation?

10. Give the functions of the medulla oblongata, (a)
Name the "centers" located in the bulb.

SURGERY.

1. ^^■hat class of patients take ether better than chloro-
form, and why? What class take chloroform better, and
why ?

2. What are the signals of danger in general anesthesia?

3. How would you treat a suppurating cavity of the
thora.x?

4. What is the proper surgical treatment of a chronic
varicose ulcer of the leg? Give details.

5. What is osteoplasty, and in what part of the body is
it most frequently called for? Give an example.

6. Give the cause and treatment of painful cicatrix, ad-
herent cicatrix, contracted cicatrix, and exuberant cicatrix.

7. What kinds of tumors are most safely removed ?
What kinds are the least safely removed ?

8. How would you treat an ingrowing toenail? Give
full details.

9. What is the best surgical treatment for hemorrhoids?
Give details.

10. A\"hat bone in the body is frequently fractured and
is the most difficult of all bones to reunite by bony union?
How should it be treated when fractured? Give details.

OPHTHALMOLOGY, OTOLOGY, RHINOLOGY, AND MEDICAL JURIS-
PRUDENCE.

1. Name some causes of ozena.

2. Discuss the pathological characteristics of nasopharyn-
geal adenoids.

3. Define strabismus. What causes it?

4. Describe the crystalline lens and give its relations.

5. The vast majority of all the diseases of the ear have
tlieir origin in inflammations of what particular membrane?

6. Prescribe for chronic case of otitis media purulenta.

7. Nasal polypi — give diagnosis and surgical treatment.

8. What do you understood by medical jurisprudence?

9. What constitutes a dying statement, and what condi-
tions are necessary to make it admissible as evidence in a
court of justice?

10. Give diagnostic symptoms between diphtheria and
follicular tonsillitis.

THEORY AND PRACTICE,

1. Write a page on epidemics.

2. Write a page on the treatment of typhoid fever.

3. Give diagnosis and treatment of scarlet fever.

4. Give treatment of erysipelas.

.". Give diagnosis and treatment of rickets.

6. Give diagnosis and treatment of acute laryngitis.

7. Write a page on pneumonia.

8. Describe the different murmurs of the heart and tell
what they indicate.

0. Give treatment for acute peritonitis.
10. Write a page on Bright's disease.

M.\TERIA MEDICA.

1. In what disease is opitnn used principally?

2. Name the excifomotors.

3. What are the preparations and doses of conium?

4. Is ether ever used as a cardiac stimulant?

5. How should poisoning by digitalis be treated?

6. What are the medicinal uses of ipecac?

7. What substances are incompatible with belladonna?

8. ^^'hat are the effects, uses, and doses of calcium
chloride ?

0. What are the preparations and doses of gold salts?
10. Name the mineral tonics.

42

MEDICAL RECORD.

[Jan. 5, 1907

ANSWERS TO STATE BOARD EXAMIN.\TION
QUESTIONS.

Kansas State Board of Medical Recistr.\tion' and
Examination.

October g, 1906.

CHEMISTRY AND TOXICOLOGY.

1. By the term Galvanism is meant current electricity
derived from chemical action, in opposition to that pro-
duced by heat or induction. The term is no longer used
scientifically ; but is laxly employed to denote the constant
current as distinguished from the induced current (which
is sometimes called Faradism or Faradization).

2. Soap-bubbles or a toy balloon, if filled with hydrogen
gas, will rise rapidly in the air.

3. Analysis is the splitting up of a compound into its
elements or into simpler compounds. Synthesis is the build-
ing up of a compound from elements or from simpler
compounds.

4. It causes severe coryza and hemoptysis.

5. By the ingestion of flypaper, or the water in which it
has been placed, poisoning by elementary arsenic may be
caused. By the inhalation of hydrogen made from zinc and
sulphuric acid containing arsenic, poisoning by Arsin may
be produced. Arsenic trioxidc can cause poisoning by being
absorbed from the mouth, stomach, rectum, vagina, or
urethra ; or by absorption from the skin in the use of
parasiticides or cancer cures containing arsenic ; also by
inhalation of dust from wallpapers containing arsenic; from
clothes dyed with arsenic; and by the ingestion of rat
poisons, etc.

6. By uniting with the hemoglobin of the blood and
forming a more stable compound than o.xyhemoglobin. In
this way the power of the red corpuscles to carry oxygen
from the air to the tissues is destroyed ; and asphyxia is
thus produced.

7. It acts as a caustic on living tissues ; and disintegrates
all tissues, whether dead or alive.

8. White of egg, in not too large a quantity, and fol-
lowed by an emetic.

9. Alkaline ; but the degree of alkalinity may be lowered,
and uric acid crystals may be found in the blood.

10. Place in a test tube some urine free from albumin ;
add a few drops of a solution of cupric sulphate, and then
some liquor potassae (about half as much as the urine) ;
shake and boil. A yellow or red precipitate is formed in the
presence of sugar.

OBSTETRICS.

3. First, give a hypodermic of morphine and atropine,
or a dose of chloral or an anesthetic, and then, with one
hand in the vagina, gently introduce the index and middle
fingers into the uterus and throii^th the constricting band.
After a time the resistance of the constriction will be
thus overcome. By pressing the uterus downward, the
fingers and the border of the placenta are brought in con-
tact. Effort is then made to bring part of the placental
mass through the constriction : the placenta being removed
as in case of adherent placenta.

5. The vagina should be made as aseptic as possible,
by means of vaginal douches of bichloride of mercury
1 :2,ooo. The vaginal vault and the cervix uteri can then
be painted with tincture of iodine; sometimes the insertion
of a vaginal suppository containing about thirty grains of
iodoform is of benefit. In case suppuration occurs, the
abscess should be opened: if it bursts into the rectum or
vagina, measures must be instituted for drainage and dis-
infection. Very frequently an abdominal operation is neces-
sary. .A.ntipyretics should be given for the fever ; and for
the pain cold compresses or ice bags should be applied to
the perineum and lower part of the abdomen.

7. If the chin is presenting anteriorly, expectant treat-
ment may suffice ; but care must be taken to observe that
the chin does not rotate backwards. Spontaneous version
may occur, and the presentation become a vertex one. Fail-
ing this, or as a means of favoring this, postural treatment,
such as Walcher's position, has been recommended. If, in
spite of this, engagement has not occurred, cephalic version
is indicated, care being taken not to rupture the membranes.
If this is not successful, podalic version should be tried.
If, after all these manipulations, the child is still alive and
the head is engaged, symphyseotomy is indicated ; if the
child is dead, craniotomy should be performed.

PATHOLOGY.

1. Gangrene is the complete and permanent loss of
vitality in a considerable area of tissue.

2. A sarcomatous tumor is one arising from connective
tissue, with excessive cell formation and very little intercel-
lular substance. The cells are either embryonic or imper-
fectly developed connective tissue cells. Sarcomata are

always mesoblastic in origin; their blood supply is abun-
dant, and it is through this channel that they are dis-
seminated ; of their lymphatics and nerve supply nothing is
known. In gross appearance sarcomata are of a more or
less homogeneous nature, the color depending upon the
quantity of blood present; occasionally a milky fluid can be
expressed, but there is never anything corresponding to the
"cancer-juice" of carcinomata. Sarcomata may undergo
various secondary changes, such as fatty degeneration,
hemorrhages, and mucoid softening. Sarcomata are malig-
nant, hence they have a tendency to spread to distant organs
(metastasis), are heterologous, have no definite limiting
capsule, tend to infiltrate the surrounding tissues, tend to
recur after removal, and cause cachexia and death. They
have been classified in a variety of ways: (i) according
to the cells, as round cell sarcoma, spindle cell sarcoma,
giant cell sarcoma, mixed cell sarcoma ; (2) according to
the stroma, as fibrosarcoma, myxosarcoma, chondrosarcoma,
osteosarcoma; and (3) according to secondary changes,
as melanosarcoma, liposarcoma, chloroma.

7. Lithemia is a condition due to imperfect metabolism,
and is characterized by an accumulation of uric acid or
urates in the blood. It dififers from gout in the absence of
joint involvement.

8. Purpura Hemorrhagica is a disease of unknown or-
igin, and is characterized by hemorrhages into the skin and
mucous and serous membranes, and usually runs a rapid
and fatal course.

9. Septicemia begins with a rigor, followed by a rise of
temperature up to about 104° F., which remains constant.
The pulse is weak and progressively rapid ; there is an-
orexia and constipation, which is followed by diarrhea;
the urine contains albumin ; the temperature may become
subnormal. There are no repeated rigors and no secon-
dary (metastatic) abscesses. Pyemia begins with a rigor,
which may last for half an hour, and is repeated every
one or two days. The temperature rises as in septicemia,
but rapidly falls, and at the same time the patient suffers
a profuse perspiration. The pulse is weak and rapid; there
is anorexia: and there may be delirium, with jaundice and
signs of abscesses in the lungs, joints, etc. In pyemia
there are repeated rigors and secondary abscesses.

BACTERIOLOGY.

1. Bacteria multiply by fission and by sporulation.

2. Most bacteria require (i) proper temperature, gen-
erally at or near that of the body; (2) oxygen is generally
needed, those that cannot live without it being called
aerobic, and those that can grow without it, anaerobic ;
nutriment of a proper kind, containing both organic and
inorganic material ; a slight degree of moisture ; a medium
of slightly alkaline reaction : and rest. Individual bacteria
may require modifications of the above essentials.

4. Yellow fever.

5. Gelatin, agar, potato, bouillon, and blood-serum.

6. The pus-producing bacteria are : staphi;lococcus pyo-
genes aureus, staphylococcus pyogenes albus, staphylococ-
cus pyogenes citreus, staphylococcus cereus aureus, staphy-
lococcus cereus albus, staphylococcus cereus flavus ; strep-
tococcus pyogenes ; micrococcus tetragenus, micrococcus
pyogenes tenuis : gonococcus ; pneumococcus ; bacillus pyo-
cyaneus, bacillus typhosus, and bacillus tuberculosis.

8. Leucocytes are white blood corpuscles. When they
come in contact with pathogenic bacteria, if the conditions
are favorable, they devour and destroy the bacteria (phago-
cytosis) ; sometimes, however, the bacteria manage to de-
stroy the leucocytes.

9. Ptomaines are the putrefactive products of dead ani-
mal tissues or fluids.

Toxins are the products of pathogenic bacteria or of pto-
maines or leucomaines, and are actively poisonous.

10. Sterilization is the process of freeing a substance
from the live bacteria that may be on it or in it.

AntiseHfics are agents which prevent or restrain putre-
faction.

Disinfectants are agents which restrain infectious diseases
by destroying or removing their specific poisons.

Germicides are agents whch destroy bacteria and their
germs.

PHYSIOLOGY.

1. The functions of the spinal cord are: (i) the conduc-
tion of nerve impulses; (2) reflex action ; (3) coordination;
it also contains special centers which preside over definite
functions.

2. Urea is derived from the nitrogenous food ingested;
it is manufactured by the cells of the liver.

Uric acid: "In man uric acid has a twofold origin; one
portion, coming from the breaking down of the nuclein-
containing tissues or cell elements of the man's own body,
and hence is of endogenous origin, while the other portion
— usually the larger — is of exogenous origin, coming from
the transformation of free and combined purin compounds
present in the food." (Chittenden.)

Jan.

1907 J

MEDICAL RECORD.

43

3. The vasomotor nervous system consists of (1) a
vasomotor center in the bulb, (2) of some subsidiary
centers in the spinal cord, and (3) of vasomotor nerves,
which are of two kinds: (a) those causing constriction of
the vessels, and so-called vasoconstrictor nerves; and (6)
those causing dilatation of the vessels, and so-called vaso-
dilator nerves. These nerves supply the muscle tissue in
the walls of the blood-vessels and regulate their caliber,
thus influencing the giiantity of blood supplied to a part ;
at the same time they regulate the quality of blood supplied
to a part: they also regulate the nutrition of a part, also
secretion and heat production. They are concerned, too, in
the control of the heart-beat. The centijr is in the medulla,
in the fioor of the fourth ventricle, near the calamus scrip-
torius.

4. The function of the suprarenal glands is unknown ;
it is supposed that they are able to destroy or remove
some toxic substance produced elsewhere in the body. Re-
moval of these glands is rapidly followed by death.

5. The mastoid cells are lined by epithelium, continuou';
with that of the tympanic cavity.

7. The functions of the bile are: (l) to assist in the
emulsification and saponification of fats: (2) to aid in
the absorption of fats ; (3) to stimulate the cells of the
intestine to increased secretory activity, and so promote
peristalsis, and at the same time tend to keep the feces
moist: (4) to eliminate waste products of metabolism, such
as lecithin and cholesterin ; (5) it has a slight action in
converting starch into sugar ; (6) it neutralizes the acid
chyme from the stomach, and thus inhibits peptic digestion ;
(7) it has a very feeble antiseptic action.

The constituents of the bile may be shown in the follow-
ing table, which presents the averages of three analyses
given by Hammarsten ; the results are given in parts per
thousand :

Water 97i.3So

Solids 28.620

Mucin and pigments 4Qio

Bile salts 12.197

Taurocholate 2.431

Glycocholate 9.766

Fatty acids from soaps 1.200

Cholesterin 1.243

Lecithin and fats 0.070

Soluble salts 7.360

Insoluble salts 0.317

9. The functions of the cerebellum are: (i) coordina-
tion, (2) equilibrium. Removal of the cerebellum causes
loss of these functions.

10. The functions of the medulla are: (i) Conduction
of nerve impulses and impressions, (2) as an independent
reflex center.

The "centers" located in the bulb are: (i) center for
mastication, (2) for secretion of saliva. (3) for sucking,
(4) for deglutition, (s) for vomiting, (6) for voice, (7)
center for expression (8) cardiac centers, (9) respiratory
centers, (10) vasomotor centers.

SURGERY.

2. The danger signals are: (l) lividity or extreme
pallor of the face, (2) feeble, irregular, or intermittent
pulse , (3) slow and shallow respiration, (4) dilatation of
the pupils during deep narcosis.

5. By osteoplasty is meant the transplantation of bone
Cwith periosteum). It is most frequently performed on
the skull.

6. Painful cicatrix is caused by the pressure of a con-
tracting cicatrix upon the cut end of a nerve or by the
inclusion of a nerve in the scar of an amputation stump.
In the former case the painful part should be excised; in
the latter the stump must be opened and the end of the
affected nerve removed.

Adherent cicatrix is caused by simultaneous injury (such
as burns or scalds) to contiguous and approximated parts,
such as the fingers, or the pinna and the side of the head.
A plastic operation is indicated.

Contracted cicatrix is most apt to occur in the flexure
of a joint: a serious burn of the hand may cause flexion-
contracture of the fingers. The treatment is to divide the
cicatrix, dissect out the scar, and follow with skin-grafting.

Exuberant cicatrix consists of a hyperplasia of scar tissue,
it is most often found in tuberculous patients, and is of
unknown etiology. E.xcision is useless, as it is very apt to
recur. Sometimes it disappears spontaneously.

10. The patella. It is best treated by open operation and
wiring.

OPHTHALMOLOGY, OTOLOGY, SHINOLOGY, .«iND 1IEDIC.\L JURIS-
PRUDENCE.

I. (l) Atrophic nasal catarrh, due to syphilis, glanders,
caries, or necrosis of the nasal bones; (2) ulcers of a

syphilitic, lupoid, or tuberculous origin; (3) foreign bodies
and new growths in the nose or nasopharynx.

2. Adenoids consist of lymphoid tissue, which is com-
posed of masses of round cells held together by connective
tissue. Mucous glands may be found in the deeper parts
of the lymphoid tissue : and the whole is covered with cil-
iated columnar epithelium.

3. Strabismus, or squint, is a condition in which the
lines of sight of the two eyes are not directed towards the
same object of vision.

The causes are: d) disturbances of equilibrium of
the ocular muscles ; (2) errors of refraction ; (3) opacities
in the cornea or lens; (4) intraocular disease.

5. The membrana tympani.

6. 5. Acidi borici gr. xxx

Zinci sulphatis gr.xvj

Glycerin 5ij

AquK destillatce Jij. M.

Sig. A few drops to be instilled into the ear several
times a day.

8. Medical jurisprudence is the application of the knowl-
edge of any of the branches of medicine to the problems
and requirements of the law.

9. Any statement made by a dying person who believes
that he cannot recover and that he is, at that very time, in
actual danger of death. The statement need not be sworn
to ; it should be voluntary and sincere : and it is admissible
as evidence in a court if the individual dies.

ID. In diphtheria the onset is more gradual ; the temper-
ature rises to about 101° to 103° F. ; the tonsils are not much
enlarged; there is an exudate of a thick grayish mem-
brane which is very adherent, is removed only with diffi-
culty, and leaves a bleeding surface; this membrane soon
re-forms and may be found on the fauces and pharynx as
well as on the tonsils; in the exudate the Klebs-Ldfiler
bacilli may be found.

In follicular tonsillitis the onset is more suddeii ; the tem-
perature may be a little higher than that of diphtheria; there
is no membrane, but the tonsils are red and swollen, and in
the crypts are seen white cheesy spots or plugs, which
consist of broken-down epithelium, and are easily brushed
away ; Klebs-LofHer are not found.

THEORY AND PR.\CTICE.

8. (i) A systolic murmur, soft and blowing, heard best
at the ape-N, and transmitted to the left axilla and toward
the angle of the left scapula, indicates mitral regurgitation.
(2) A presystolic murmur, harsh and rough, heard best
very near the apex, and not transmitted, denotes mitral
stenosis, (j) A diastolic murmur, soft, heard best in the
second right intercostal space, and transmitted down the
sternum or toward the apex, denotes aortic regurgitation.
(4) A systolic murmur, harsh, heard best in the second
right intercostal space, and transmitted into the carotids,
denotes aortic stenosis. (5) A systolic murmur, heard best
over the lower end of the sternum, denotes tricuspid regur-
gitation. (6) A presystolic murmur, heard best over the
ensiform cartilage, and not transmitted, denotes tricuspid
stenosis. (7) A diastolic nuirmur, heard best in the second
left intercostal space, denotes pulmonary regurgitation. (8)
A systolic murmur, heard best in the second left inter-
costal space, and not transmitted to the large vessels of the
neck, denotes pulmonary stenosis. (9) A murmur, usually
systolic, soft, and blowing, heard best over the pulmonic
area, associated with evidences of chlorosis or anemia, and
affected by the position of the patient, is a hemic or func-
tional murmur, and denotes as a rule an impoverished con-
dition of the blood.

MATERIA MEDICA.

1. In diabetes ; particularly diabetes mejlitus.

2. Xux vomica and ignatia (and their alkaloids strych-
nine and brucine). thebaine, ammonia, ether, chloroform,
opium, ergot, alcohol in small doses.

3. Coqium, three grains; fluid extract of conium. three
minims.

4. Yes: on account of the rapidity of its action, ether
is a very valuable cardiac stimulant.

5. The patient must be kept in the recumbent position;
the stomach should be washed out with infusion of tea ;
give stimulants and keep the patient warm : tannic acid
may be given, as the chemical antidote; and tincture of
aconite, as the physiological antidote.

6. Ipecac is used externally as an antiseptic, in cases of
anthrax. Internally as a stomachic, an expectorant, an
emetic, a diaphoretic, and a cholagogue. It is given in cases
of dyspepsia, dysentery, bronchitis, asthma, croup, and in
the vomiting of pregnancy.

7. The caustic alkalies are incompatible with belladonna.

8. It is an irritant: applied externally it hastens the
coagulation of the blood and makes a firmer clot. It is used

44

MEDICAL RECORD.

[Jan. 5, 1907

in cases of gastric catarrh and fermentative dyspepsia, in
hematemesis and hemoptysis, in glandular swellings of
tuberculous patients. It has also been employed in the treat-
ment of pneumonia and phthisis. The dose is seven and a
half grains.

9. Auri et sodii chloridum is the only official gold salt ;
dose, one-tenth of a grain.

10. Iron, manganese, arsenic, bismuth, and phosphorits.

MfJttral 3It*ma.

BULLETIN OF APPROACHING EXAMIX.-\TIONS.t

STATE.

Indiana..

NAME AN'D ADDRESS OF PLACE AN'D DATE OP

SECRETARY. N'EXT EXAMIN'ATIOX.

Alabama* W. H. Sandere. Montgomeo'- • Montgomer>' .Feb. 1-6

Arizona* . .AncU Martin. Phoeni-x Phoenix January 7

Arkansas* F. T. Murphy, Brinkley Brinkley January S

California Chas. L. Tisdale, .Alameda. . . .San Francisco.. \pril 16

Colorado S. D. Van Meter, 1723 Tre-

mont Street, Denver Denver .April 2

Connecticut*.. .Chas. A. Tuttle. New Haven. .New Haven. . ..March 12

Delaware J. H. Wilson, Dover Dover June 18

Dis. of Corbia. .\V. C.Woodward. Washington. Washington.. .January 10

Florida* J. D. Fernandez, Jacksonville. Jacksonville.. ..May 15

Georgia E. R. Anthony. Griffin ."Atlanta Apri] —

Idaho J. L. Conant, Jr.. Genesee Boise Aph] 2

Illinois J. A. Egan, Springneld Chicago January 16

. W. T. Gott, 120 State House,

Iniiianapolis Indianapolis. . May. ... 28

Io%va J. F. Kennedy, Des Moines... . Des Moines.. . .March 19

Kansas T. E. Raines, Concordia Topeka Feb. 12

Kentucky*.. ..J. N. .McCormack, Bowling

Green Louisville .April 23

Louisiana F. A. La Rue. 211 Camp St.,

New Orleans New Orleans.. . May 9

Maine Wm J. Maybur>', Saco Portland March 5

Maryland J. McP. Scott, Hagerstown.. . .Baltimore June —

Massachusetts*. E. B. Harvey. State House,

Boston Boston March 12

Michigan B. D. Hanson, 205 "ttTiitney

Building, Detroit Ann Arbor. . . .June 1 1

Minnesota O. E. Linier. 24 South Fourth

Street, Minneapolis St. Paul January 7

Mississippi J. F. Hunter. Jackson Jackson May 14

Missouri J. A. B. .\dcock, Warrensburg.Kansas City.. .

MonUna* Wm. C. Riddell. Helena Helena .April —

Nebraska Geo. H. Brash. Beatrice Lincoln

Nevada S. L. Lee. Carson City Carson City . . . February 4

N. Hamp're*. .. Henry C. Morrison, State Li-
brary-, Concord Concord January —

New Jersey J. W. Bennett, Long Branch. .Trenton June 18 .

New Mexico B. D. Black, Las Vegas Santa Fe June 3

( New York, ^
.C.F.Wheelock Univ.of State J Albany.

of New York, .Albany. . . . } Syracuse.

( Buffalo. )

N.Carolina*... .G. T. Sikes, Grissom Morehead City. May —

N. Dakota H. M. \\Tieeler, Grand Forks. .Grand Forks.. ..April 2

Ohio Geo. H. Matson, Columbus... .Columbus June 11

Oklahoma* .... J. W. Baker, Enid Guthrie Jlarch —

Oregon* B. E. .Miller, Portland Portland .April —

Pennsylvania.. N. C. Schaeffer, Harrisburg f Philadelphia 1 June —

1 Pittsburg, J

Rhode Island.. .G. T Swarts, ProWdence Providence.. . .April 4

S. Carolina W. M. Lester, Columbia Columbia June —

S. Dakota H E. .Mc.\utt, .Aberdeen Sioux Falls. . . January- g

f Memphis, ]

Tennessee* T. J. Happel, Trenton { Nashville, i May —

[ Knoxville, J

Texas T. T. Jackson, San .Antonio. . ..Austin .April 30

Utah* R. W. Fisher, Salt Lake City. .Salt Lake City. January 7

Vermont W. Scott Nay. Underbill Montpelier. .. .January- 8

Virginia R. S. .Martin, Stuart Lynchburg... .June iS

"Washington*.. .C, W. Sharpies, Seattle Spokane July 2

W. Virginia*. . H. .A. Barbee, Point Pleasant.. Wheeling -April 9

Wisconsin J. V. Stevens, Jefferson Milwaukee .... January 8

"Wyoming S. B. Miller. Laramie Cheyenne

*No reciprocity recognized by these States.

tApplicants should in every case write to the secretary for latest
details regarding the examination in any particular State.

NewJY'ork .

■ January 29

Pennsylvania. — .\s a result of the recent examinations
held by the Pennsylvania State Board of Medical Ex-
aminers licenses to practise medicine were granted to
91 of 122 applicants.

Illinois. — On January 16, 17. and 18. 1907, the Illinois
State Board of Health will hold an examination for
license to practise medicine at the Great Northern
Hotel, Chicago. The applicant must present a diploma
from a medical college in good standing. Application
must be made to the Secretary, Dr. James A. Egan,
Springfield, 111., and a card of admission to the examina-
tion secured. Students who are to graduate in 1907
■will be required to present documentary evidence of
preliminary education.

Virginia. — The Medical Examining Board of this
State will reciprocate with boards of other States, but
requires that every applicant claiming such recognition
shall in person present with his petition a diploma
from a reputable medical college, together with an at-
tested certificate from a State Medical Examining
Board having equal requirements with the \'irginia
Board, and willing and authorized to give similar recog-
nition to those who hold Virginia certificates. -Appli-
cants complying with the above conditions and paying
the usual fee. will be granted a certificate. The ]MedicaI
Examining Board of Virginia declines to recognize the
diploma of any college which does not conform to
the requirements of the Association of Medical Col-
leges.

Influence of Diet in the Treatment of Eczema. — A.

Ravogli says that next to the kidneys the skin must be
considered as an organ of elimination. Indeed it has more
eliminating power for some products than the kidneys them-
selves. The occurrence of eruptions after the ingestion
of certain foods is not accidental. The skin is active in
eliminating substances which are detrimental to the general
economy. The presence of toxic elements in the skin im-
pairs its nutrition. Relapsing forms of acute eczema of
the face which have been considered as nervous eczema
often result from the ingestion of questionable foods. In-
dividuals subject to eczema should subsist upon good,
wholesome home cooking. The food should be fresh and
not of a questionable nature. When products of fermen-
tation develop in the stomach or in the intestines it must
be admitted that there is a diseased condition of the func-
tional activity of these organs. There is usually a catarrhal
condition of the mucosa of the stomach or a nervous con-
dition which brings about dyspepsia. The same conditions
are present in the intestines. The diet in such cases must
protect the parts as much as possible and eliminate non-
irritating qualities. Food which leaves the smallest possible
residue should be eaten. The writer believes that a coarse
diet is better than a light diet. He advises the use of
graham and rye bread together with honey, fruit juices,
stewed plums, leguminous plants, boiled and baked potatoes;
plenty of fresh milk, cream, and butter are also advised.
Meats, beef, veal, fresh pork, boiled ham, chicken with plenty
of vegetables are to be given without fear, as well as fresh
white fish, trout, and so forth. Dark meats, venison, corned
beef, mackerel, lobster, eel, and strong cheese are forbidden.
Candies and sugar must not be taken. Certain obsti-
nate cases of eczema of the face are due to the use of
whiskey and chewing tobacco. Fresh country air and natu-
ral mineral spring waters are very helpful in the treat-
ment of these cases. The influence of diet on the treatment
of eczema in gouty people is almost incredible. The writer
believes that obstinate infantile eczema instead of being
due to the cutting of the teeth is rather due to the erroneous
feeding of the child. In most of these little patients there is
present a condition of enterocolitis. — The Dietetic and Hy-
gienic Gazette.

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the Surgeon-General, Public Health and Marine-
Hospital Service, during the week ended December

28, 1906.

SMALLPOX^U-NITED STATES

CASES. DEATHS.

District of Columbia, Washington. .Dec. 9-1S i i

Georgia, -Augusta Dec. 11-17 i

Illinois, Galesburg Dec. 9-15 7

Indiana. Indianapolis Dec. 10-16 3

Minnesota. 14 Counties Nov. 12-Dec. 10... 56

Missouri. St. Joseph Dec. 9-15 3

.Mew York. New York Dec. 9-13 5

North Carolina. Greensborough. . . . Dec. 9-15 7

Oregon, Umatilla County Nov. 1-30 i

Virginia, Norfolk Dec. 17 2 In Cranev-

Island Hospital

Richmond Dec. 11-17 Present

Washington. Spokane Dec. 9-15 3

Wisconsin, La Crosse Dec. 9-15 i

.Appleton Dec. 9- IS 2

Milwaukee Dec. 9-IS 29

SMALLPOX — FOREIG.V.

.Africa, Cape Town Nov. iS-24

Brazil. Bahia Nov. 18-24

China, Chefoo Nov. 4-10

France, Marseille Nov. 1-30

Paris Nov. 2s-Dec. i.

Gibraltar Dec. 3-9

Greece, -Athens Nov. iS-24

Malta, Valetta Nov. 18-24

Russia, Odessa Nov. 2S-Dec. i.

St. Petersburg Nov. 18-24

On S. S.
Raleigk

CHOLERA — FOREIGN'.

India, Bombay Nov. 14-27.

Calcutta No v. 3-10. .

Rangoon Nov. 11-17.

17

66

6

YELLOW FEVER — FOREIGX.

Cuba, Cardenas Dec. 22.. . .

Habana Dec. 22-27.

Mexico, Veracruz Dec. 2-S. ,

1 On Ger-
man S. S. Kron-
prinsessin Cecil
from Veracruz.

PL.VGCE — FOREIGN".

Brazil, Bahia Nov. 11-24..

India, Bombay- Dec. 14-20..

Japan, Osaka Nov. 14-20..

Matsuyama Nov. 14-20..

Russia, Trans'oailkal Province Nov. 4-10.. .

1

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 71, No. 2,
Whole No. J888.

New York, January 12, 1907.

$5.00 Per Annum.
Single Copies, lOc.

©rtjjtnal Artirka.

STUDY OF A CASE OF YELLOW FEVER.

By a. E. THAYER, M.D..

GALVESTON, TEXAS.
PROFESSOR OP PATHOLOGY, UN'IVEKSITY OF TEXAS, MEDICAL DEPAUlMEN'i .

On December 26, 1905, a patient was admitted into
the John Sealy Hospital at Galveston, with the fol-
lowing history :

P. F., Irish, thirty years old, single, worker in
silver. Family and previous history not important.
On Friday, November 24, he left New York City
for Jacksonville, Fla., arriving there on November
30, leaving again after eight days for Havana by
way of Tampa and Key West. In Havana he spent
twelve days, leaving on December 20 for Galveston,
and arriving there at noon on Sunday, December 24.
He had been very seasick after leaving Havana, and
on the evening of December 24 felt chilly on going
to bed, but slept well. Ow rising the next morning,
and attempting to dress, he was dizzy and fell, strik-
ing the back of his head against an iron bed. He
went back to bed and slept half the day, had a glass
of milk for breakfast, but vomited it at 3 p.m. What
he vomited on board the boat had been greenish;
this was of a redder color. After 3 p.m. on Mon-
day everything he took was vomited.

Admitted to the hospital on December 26, the pa-
tient was slightly jaundiced over the general surface
and the sclerotica wee muddy and more deeply
jaundiced. He remembered having had slight
frontal headache on the 23d. He vomited dark fluid
when admitted, and, during the two days of his stay
in hospital, twenty-one vomiting seizures were re-
corded on the bedside notes. The material ejected
was always the same, in small or large amounts, thin
and dark reddish-brown, semitransparent fluid, with
finely divided, pulpy, granular material settling
toward the bottom.

He was catheterized three times during the two
days, the amounts obtained being two ounces, two
drams, and three drams. Expressing this in cubic
centimeters, and assuming that he should have
passed 1,500 c.c. in twenty-four hours, the amount
actually secreted during forty-eight hours was 65 c.c.
instead of an assumed normal of 3,000 c.c. But,
according to his own account, the patient passed no
urine from his chill on the evening of December 24
up to the time of his death, four days later, except
what was drawn by catheter during his stay in hos-
pital. He, therefore, secreted but 65 c.c. in ninety-
six hours, instead of 6,000 c.c.

His temperature had reached 103.4° F. at one
o'clock on the 26th, from that point falling steadily
to normal at 3 a. m. on the 28th, and remaining sub-
normal afterward. The pulse reached its highest on
the 27th at 3 K. M., namely, 92, and thereafter re-
mained about 74-80 till he died. Respiration varied
between 20 and 14.

Soon after admission it was noticed that the

movement of his tongue was impeded in some way,
and upon examination there was found a small
extravasation of blood beneath the right side of the
tongue, involving the floor of the mouth also. This
steadily extended until the entire right side of the
tongue and adjacent tissues were involved, the dark
bluish red hematoma raising the tongue and pushing
it toward the left side. His speech became pro-
gressively laborious and indistinct. Up to a short
time before his death his mind was perfectly clear,
and he complained of nothing but pain in the rigKt
side of his chest, and faintness and dizziness. An
hour before death he was slightly delirious.

The examinations made in the case were as fol-
lows: I. Diazoreaction, negative. 2. Blood for
malaria, negative. 3. Blood for cells, etc. Reds
(first examination), 4,920,000; (second examina-
tion), 5,904,000. Whites (first examination), 8,800;
(second examination), 4,950. Hemoglobin, 100 per
cent. Malarial organisms, none. Small lympho-
cytes, 31.7 per cent. Large mononuclears, 1.5 per
cent. Transitional, 1.3 per cent. Polynuclears, 65.5
per cent. Eosinophiles, none counted. Basophiles,
none counted. Neutrophile myelocytes, 2 counted.
4. Widal reaction, negative. 5. Vomitus for Teich-
mann crystals positive (twice). 6. Urine: Specific
gravity not determined, dark, amber, acid. Albu-
min, marked reaction by nitric acid. Many granular
and some epithelial casts, much granular detritus,
many red cells.

The patient died at 8 p.m. on Thursday, December
28, at the end of the fourth day of his disease, if the
chilly sensations of the previous Sunday evening
mark the commencement of the disease. The post-
mortem examination was held at 9 p.m. of the same
day, one hour after death. The protocol is as fol-
lows :

General Inspection. — Body well nourished, warm,
very slight degree of rigor mortis in muscles of
lower jaw. Moderate degree of hypostatic conges-
tion in the integuments of the back, with a few
small punctate hemorrhages into the upper layers of
the skin. General surface slightly yellow, sclerotics
more deeply tinged with yellow. Superficial nodes
of axilla and inguinal regions a little enlarged. The
hard palate is covered by a thin red film of coagu-
lated blood. The right side of the tongue, for a dis-
tance of 6 cm. from the tip, is the seat of an extrav-
asation which reaches to the middle line and partly
involves the sublingual tissues.

Preliminary Internal Inspection. — The tissues of
the thorax wall are edematous. The liver in the
median line is 10-12 cm. below the xiphoid cartilage;
the lower edge of the right lobe is at the right iliac
crest in the midaxillary line. The gall-bladder is
distended and projects 4 cm. beyond the free edge of
the liver. The coils of small intestine are moderately
distended with gas, the colon, except at the cecum,
is partly collapsed. The omentum is well supplied
with fat, and its veins are distended with semifluid
blood. In the mesentery, at the ileocecal junction.

46

MEDICAL RECORD.

[Jan. 12, 1907

there are two small ecchymoses. The mesenteric
nodes are congested and swollen. No adhesions or
fluid in the abdomen. Diaphragm, fifth rib in mid-
clavicular line on each side.

Thorax. — Triangularis sterni unusually well de-
veloped and of a uniform dark-red color, like all the
other muscles of the thorax. The lungs meet along
their anterior margins to a point opposite the fourth
ribs. No adhesions or fluid in either pleural cavity.
Pericardial fluid, 20 c.c, clear yellow serum. Heart :
The blood of the inferior cava is fluid and its plasma
is tinged reddish with dissolved hemoglobin. The
endothelium of the heart and great vessels is yel-
lower than normal. In the ascending portion of the
aortic arch there is a slight imbibition of blood pig-
ment; there are also a few small spots of atheroma
in the first part of the arch ; coronary arteries nor-
mal. The cavity of the right ventricle is a little
dilated, the valves are all normal and competent, the
muscular tissue is opaque, but there is no fatty
change visible. Lungs : The posterior aspect of
both upper and lower lobes is intensely congested
and spotted with many small hemorrhages, as is also
the pleura between the lobes. Pleura everywhere
transparent and shiny. On section the entire lung
on each side contains countless small hemorrhages,
and much frothy blood-stained fluid flows from the
surface of the incision. Bronchi intensely congested
and contain a small amount of blood-stained froth.
\'essels empty and apparently normal. Esophagus
distended with bloody fluid, and presents a linear
ecchymosis 5 cm. long in the upper third.

Abdominal Organs. — Spleen slightly larger than
normal, capsule opaque and wrinkled, both fibrous
tissue and lymphoid follicles more prominent than
normal. Adrenals apparently normal. Kidneys :
Normal in size, capsule adherent in places, surface
dark and congested, stellate veins prominent, two
small cysts in upper pole of left kidney, none in
right. Markings not well preserved, cortex broad
and opaque, lobules broad and yellow, especially in
the lower zone of the cortex just above the pyra-
mids, and here and there groups of straight tubes
show broad and yellow on the congested back-
ground. Stomach : Contains 500 c.c. thin dark fluid,
mucosa uniformly softened, with small punctate
hemorrhages in it which are most numerous in the
cardiac end. Common bile duct pervious. Intes-
tines : The mucosa throughout both small and large
intestines is edematous and covered with an excess
of whitish mucus. The tips of the valvulje conni-
ventes are congested, and in places there are many
punctate hemorrhages in the submucosa, especially
toward the lower end of the ileum. The Peyer"s
patches are dark and prominent, and the solitary fol-
licles are edematous. The contents of the small
intestine are thick white mucus, which is tinged with
bile in the duodenum and upper jejunum ; in the
colon there is a thin white fluid resembling milk
(enema). Pancreas: Congested and its duct dis-
tended with secretion. Liver : Slightly larger than
normal, especiallv the right lobe. Generally of a
marked yellow color, which is most distinct in the
peripheries of the acini. Urinary bladder entirely
empty, ecchymoses under mucosa near the internal
meatus : prostate edematous : seminal vesicles dis-
tended with semen. Abdominal and thoracic aorta
filled with fluid blood. Trachea and inner aspect of
larynx and posterior surface of epiglottis, intensely
congested, with minute hemorrhages into the super-
ficial tissues, and an excess of mucus on the surface.
On section of the tongue the extravasation is found
to extend beneath rather than into it, and is confined
entirely to the right half.

Head. — Superior longitudinal sinus empty. Slight

excess of serum in the meshes of the pia, both sur-
faces of the dura slightly yellow, internal carotids
a little atheromatous. Brain generally congested,
slightly edeiuatous, and tinged with yellow.

Clinical diagnosis, yellow fever ; pathological diag-
nosis, yellow fever.

Microscopic. — Portions of various tissues were
embedded in paraffin and stained with the following :
hemalein, eosin ; hematein, picrofuchsin ; eosin, poly-
chrome blue : eosin, Gram-W'eigert ; Nikiforoff' s.
The findings by these various staining methods are
grouped together.

1. Brain. Portion of cortex in the Rolandic area
of the left side. The tissue shows marked conges-
tion and edema, the perivascular lymph sheaths are
wide, there are no hemorrhages, the ganglion cells
are cloudy and vacuolated.

2. Tongue. Muscle fibers swollen and stain un-
evenly with eosin. Striation in places fairly well
preserved ; on transverse section Cohnheim's areas
are too distinct. The vessel walls and their invest-
ing endothclia are swollen. There is very free hem-
orrhage, the unaltered red cells separating bundle
from bundle and filling the areolar spaces. In places
there is marked cross fragmentation of the fibers.
In other places neither striae nor longitudinal mark-
ings can be made out, the sarcoplasm is broken into
fine granules, imperfectly filling the sheath, and
there are red cells within the perimysium.

3. Stomach. Tissue generally hyperemic with
some hemorrhage. Almost no desquamation of epi-
thelia, very few goblet cells, nuclei well defined. In
the glandules the cytoplasm of the cells is much
swollen, filling the lumina, the oxyntic cells suffer
with the others, but no more than they. Pushing
between the cells normally present are many large
ameboid lymphocytes. Fev^f small lymphocytes, no
pus cells. In the lumina of some of the glandules
the cytoplasm is breaking down by vacuolation and
granular changes. The endothelia in vessels and
lymph channels are swollen and tend to desquamate.
All coats are edematous.

4. Small intestine. The tips of the villi are de-
nuded of their epithelia in groups. Remaining epi-
tlielia are swollen and granular, and in many cases
the cytoplasm is fused, cell with cell. There are
very few beaker cells. Lymph channels are crowded
with red cells, and their endothelia are large, swollen,
and desquamating. All muscle fibers are edematous
and stain badly, both in the muscle coats and the
muscularis mucosse, and their nuclei are coarsely
granular. Scattered through the intestinal coats are
a few eosinophile and a few polynuclear leucocjrtes,
with a larger number of lymphocytes, chiefly large.
Edema of all coats.

5. Pancreas. There are hemorrhages between
the lobules. The ducts are distended with coagu-
lated material, their epithelia are swollen, prolifer-
ating, and desquamating ; the entire wall of the duct
is edematous. The nuclei of the gland cells show
marked karyolysis, the chromatin in many places
being scantv and granular, and in others swept
entirely out of the cell as fine dust. The same con-
dition is noted in the epithelia of the main ducts. In
the islands the cytoplasm of the cells is fragmented
and fused, swollen and cloudy, and the nuclei contain
but little chromatin. In the vessels, both arteries
and veins, the wall is edematous, the lumen is full
of blood, and the capillaries show frequent rhexis.

6. Liver. The hepatic epithelia show marked
general fatty degeneration. There are but few free
nuclei remaining, for the nuclei appear to suffer as
early and as much as the cytoplasm. Here and there
verv large nuclei can be found, almost empty of
chromatin, with a verv distinct eccentric nucleolus.

Jan. 12, 1907]

MEDICAL RECORD.

47

and the latter is acidophile. Other nuclei show
karyorhexis, but this is limited to a few cells. Be-
tween the liver cells are occasional ameboid lympho-
cytes. The capillaries are very hyperemic, especially
those of the portal system. The smaller bile ducts
are everywhere occluded by swollen and desqua-
mated epithelia, in places forming a tightly-packed
granular mass, so that the structure is not recogniz-
able as a duct. Many of the liver cells contain gran-
ules of precipitated bile pigment. Much of this lies
within the partly empty cell membrane, amid gran-
ules of broken-down cytoplasm, but there is also a
high proportion of such pigment, in the aggregate a
great deal, which lies free in the capillaries leading
to the central vein ; the bile pigment thus has a direct
access to the systemic circulation. The large ducts
are somewhat similarly affected, but there are many
with a lumen. Kupfer's stellate cells are swollen
and dividing. The large increase in pigment in the
liver points to active erythrolysis in some part of the
portal territory, and to the alimentary tract as the
place of entry for the disease. The ability of the
liver to destroy or hold back the toxins would soon
be exceeded, and they and the bile would enter the
general circulation together.

7. Abdominal node (mesenteric). Apparently a
rapid proliferation of small lymphocytes, the germi-
nal areas being remarkably distinct and tightly
packed. The small blood-vessels are partly occluded
by swelling of the endothelia. In the main lymph
channels the endothelia are swollen, and tend to
desquamate, but are not fused. But very few poly-
nudears are noted. Whole tissue is edematous. In
the adjacent fat tissue there is edema with capillary
hemorrhages, and the nuclei of the fat cells are vacu-
olated.

8. Heart. The muscle fibers are swollen and ir-
regular in outline, in places vacuolated, the nuclei
very much swollen, and with indented edges. Much
fragmentation in places. The usual pigment at the
poles of the nuclei is absent, and triangular clear
spaces are found instead, in which an occasional
granule of hemofuscin remains. The tissue is gen-
erally hyperemic and edematous, and there are a few
minute hemorrhages. The walls of the vessels are
swollen. No cellular exudate observed.

9. Lung. The hyperemia in the arterioles and
capillaries is extreme, many of the smaller vessels
being full to bursting, with frequent hemorrhage
both by rhe.xis and diapedesis. Many of the septa
between alveoli are packed with red cells and many
alveoli are full. In form the red cells are normal,
except that the central pale area is a little larger
than normal, the rim is slightly swollen, and the disk-
is more cupped, but there is no crenation, anomaly of
form or size, or destructive process observed in the
extravasated red cells. The epithelia in the alveoli
are swollen and opaque, but their nuclei stain well.
Many of the respiratory bronchioles contain red
cells. There is remarkably little pigment in the
fibrous tissue of the lung.

10. Adrenal. The cells of the glomerular zone
and of the outer fascicular zone show swollen
nuclei, the cytoplasm washed out, and the cell empty
except for a few delicate strands. The cells of the
lower fascicular and reticular zones are pigmented
by a fine reddish-yellow amorphous intracellular
dust. In many of these cells the nucleus is merel\'
an outline, free from chromatin. The capillaries all
through the organ are hyperemic, with a few minute
hemorrhages.

11. Kidney. All the epithelia throughout the
organ are swollen, in many places completely closing
the tubules ; this is especially distinct in the convo-
luted tubules. Manv of the tubules are filled with

homogeneous acidophile casts. In some of Henle's
loops the entire epithelial investment is partly sep-
arated from the wall, but generally there is but little
desquamation. The glomeruli are swollen, very
h\ peremic, and compressed somewhat by amorphous
pale material between the layers of their capsules.
This is in part derived from the cytoplasm of the
epithelia, which are scanty and degenerated, some
cells appearing as round opaque globules lying free
in the amorphous material ; part of it is probably
proteid derived from the blood, and unable to escape
through the occluded tubules. In view of the degree
of active hyperemia present, there are remarkably
few hemorrhages in the organ.

12. Spleen. The lymphoid follicles are large,
their vessels are partly closed by swelling of their
endothelia, and their walls are wide, and in places
structureless, from edema. In the larger arteries
the nuclei of the muscle cells are much swollen and
distorted. The vascular spaces of the pulp are
crowded with red cells, which appear of normal
outline, .\mong the white cells present are many
eosinophiles.

13. Prostate. The organ is hyperemic and
edematous. Epithelia are swollen, granular, and
opaque, their nuclei vesicular, and chromatin scanty.
Gland and duct lumina are more or less filled with
detritus and some desquamated epithelia.

By Nikiforoff's meth(i(l some of the prostatic
epithelia show a tendency to take the indulin
strongly. In the adrenal some of the cells pick out
the aurantia, and the nuclei are acidophile ; other
cells refuse both aurantia and eosin. In the pan-
creas an occasional cell is acidophile, the islands do
not stain, the capillaries of the islands show espe-
cially wide and empty ; in the ducts there are some
acidophile and degenerated epithelia, and nuclear
lysis is very distinct. In the intestine nothing stains
except the red cells, so that the villi look like sacs
stuffed with red cells.

With Gram-Weigert stain no fibrin is found in
any of the organs, even where the fluid exudate is
most copious and the effects of the edema most
clear.

Summing up the microscopic features of the case,
we recognize :

First, an intense and general edema, involving all
the tissues examined, and in general it has acted
destructively on both cells and nuclei, tending to
dissolve out chromatin from all nuclei. This is
more' important than appears at fir.st sight, since
the patient ingested no fluids which could be re-
tained.

Second, there is a severe effect upon the walls of
vessels, especially of small arteries and capillaries.
This includes swelling of endothelia, desquamation
of endothelia, such imbibition of fluid by the media
and other coats that they may become structureless
and none of the elements present will stain, and,
lastlv, increased permeability (of capillaries espe-
cially) with rhexis.

Third, there is a pronounced and destructive
effect upon epithelia, which is twofold in nature,
partly the result of imbibition of fluid, an.I partly
the result of a diffusible toxin. There is nothing
catarrhal about it, no tendency to produce profuse
mucinous discharges, no great desquamation of
dead cells in masses, no large collections ot leu-
cocytes, either polynuclear or other forms. Fur-
thermore, there is no fibrin in the exudate in any of
the organs examined. The destructive effect upon
epithelia is widespread, but most distinct where the
cells are most highly specialized, as in liver, kidney,
and adrenal, but of the same character everywhere.

Fourth, there is no cellular exudate anywhere.

48

MEDICAL RECORD.

[Jan. 12, 1907

Fifth, there is no hemolysis. The red cells, both
in the vessels and extravasated into the tissue, are
apparently normal, except for some swelling, and
this is probably a post-mortem change, for even in
the hour between death and the autopsy there was
time for slight staining of the endothelium of the
ascending arch by dissolved hemoglobin, and swell-

FlG. I . — SnaaU round and ameboid forms from the mucous surface of the
ileum; one presents two \'acuoles; one hes in an empty red cell with a
finely granular border; the accompanying bacilli also stain.

ing of the red cells is the first step of the process
which leads to this efifect.

Of course, all this applies to this single case,
dying on the fourth day of the disease, and is not
supposed to apply to any other case.

Microorganisms. — By the Gram-Weigert method,
preceded by eosin, a number of large boat-shaped
bacilli were found in the pancreas and among the
epithelia of the small intestine. This was an acci-
dental find and was not followed up, as it was felt
that ordinary bacterial stains of all kinds had been
tried so thoroughly that it was unnecessarj^ to repeat
them.

The following staining method was adopted after
numerous unproductive efforts :

Material is hardened either in 5 per cent, formalin
solution, made with normal salt solution, for 24
hours, or in saturated bichloride solution in normal
salt for the same time ; it is then transferred to 95
per cent, alcohol. Imbedding in paraffin is as fol-
lows :

Out of 95 per cent., to absolute, alcohol 4-6 hours ;
anilin oil, 3 hours to overnight, excess removed by
filter paper ; xylol, 3-4 hours ; soft paraffin, 3-4
hours ; hard paraffin, 3-4 hours. The last three steps
are sometimes best carried out at 37° C. Sections
were cut 5-7« , flattened in warm water, and fastened
to the slide in the drying oven at 38° C. overnight.
The slide is then freed from paraffin by flooding
with xylol, dipped in 95 per cent, alcohol, and before
the section is quite dry a few drops of the stain are
added. This consists of
Solution of ammoniated oxide of copper. ... 10 c.c.

Glycerin 10 c.c.

Saturated alcoholic gentian 30 c.c.

The stain acts for 15-20 minutes, and is decolor-
ized by flooding with yi per cent. HCl in alcohol,
ceasing before all the color is extracted. The sec-
tion should have a delicate bluish tinge. Usually
one minute is enough. To the acid alcohol a trace
of eo-'n or basic fuchsin may be added as a con-
trast sta'n. The section is dried with blotting paper
cleared wi h xylol and mounted in balsam.

Results. — Wherever the capillaries contain red
cells, some of these present within their bodies
deeply stained blue or purple bodies. The balance
of the cell is not stained by the gentian, or only
faintly so; with a contrast stain, of course. It will
have no bluish tinge. Some of the blue staining
bodies are free. Such e.xtracellular forms were
observed on the surface of the ileum, among des-
quamated epithelia, and extravasated red cells, and
in the glandular spaces of the prostate they were
very numerous, but they occur in all the tissues
examined, lying either in capillaries, lymphatics, or
tissue spaces. Others were found in endothelia, or,
rarely, in epithelia, as in the kidney.

In size these bodies vary from a round point in
the body of a red cell, of less than one-fifth the
diameter of the cell, that is, about i-2//, up to a body
which occupies all the cell except a narrow margin
(Fig. 2, Nos. 2 and 4). Between these extremes of
size are various ameboid and horseshoe forms.
Where red cells lie in small capillaries as elongated
oval or triangular objects, the stained body fre-
quently occupies one end. In some red cells the
ameba shows distinict pseudopods (Fig 2, No. 2),
and in the intestinal wall, the prostate, kidney, and
elsewhere, such ameboid forms have been found
free. In an endothelial cell, desquamated from a
lymphatic in the submucosa of the ileum, a small
elliptical body was found, lying in a space in the
cell protoplasm, which it did not entireh' fill, the
unstained cell nucleus lying at the side. A similar
observation was made on a large lymphoc>'te, which
presented no nucleus (Fig. 2, No. 5).

Where hemorrhages occur, as in the alveoli of
the lungs and upon the mucosa of the ileum, in-
fected red cells are often found, with the propor-
tions between cell and ameba varying according to
the development of the latter, and among these are
unstained, uninfected red cells. Occasional!}' red
cells have been found with more than one dark-blue

Fig. 2. — Intracellular forms, i. Small round body at one end of a
compressed red cell in a narrow capillary. 2. Red cell with large
vacuoled ameboid body. 3. Small round body in the cytoplasm of
an endothehal cell, its nucleus laterally displaced. Taken from a
lymphatic of the submucosa of the ileum. 4. Horseshoe form in a red
cell. 5. Oval body lying in the cytoplasm of a large lymphocyte, its
nucleus not seen.

body inclosed, recalling multiple infection with Plas-
modium malarias and pyrosoma bovis.

Occasionally a capillary is so filled with red cells,
which carry these blue bodies, that with a low power
the vessel stands out as a solid cord among the un-
stained elements.

The distribution of the amebae varies in diflferent
tissues and different parts of the same organ. In

Jan. 12, 1907]

MEDICAL RECORD.

49

the kidney they are found in the small vessels prox-
imal to the glomeruli, distinctly but scantily in the
glomerular loops, and still fewer on the distal side.
In the convoluted tubules only a few epithelia were
seen, which contained the small blue bodies, and
here and there one lies free in the lumen of the
tube. A few casts in the deeper portion of the cor-
tex were slightly tinged with blue, as if material
from amebae were contained in them. In the liver
numerous examples may be seen in one field, and
but few in another. Here and there the swollen,
unstained nuclei of the hepatic epithelia appear to
contain small blue bodies, and these probably are
not chromatin particles, for the stain docs not per-
sist in nuclei. In the lung the amebse seem to be
less numerous than elsewhere ; in the spleen they
showed particularly v/ell after the bichloride method
of hardening; in the mucosa and submucosa of the
ileum and stomach very clear pictures were ob-
tained, both of free and of intracellular forms.

Interpretation. — This method of staining does not
stain either the cytoplasm, the nucleus, or the nu-
cleolus of the cells in the body, with the exception
that in the bichloride series some of the red cells
were faintly tinged in a diffuse manner if decolori-
zation had been incomplete. It does not stain either
the red or the white cells in blood films. It does not
stain the ameba coli, in the few cases thus far tried.
The method does stain the pus cocci, but not very
well ; the tubercle bacillus stains well, even in tis-
sues where it is difficult to find it by carbol-fuchsin,
and the malarial organism in blood smears is very
distinctly stained. Hence the blue bodies found can
not be due to a reaction with normal hemoglobin,
or they would occur in blood smears; nor are they
due to reaction with hemoglobin altered in the
course of yellow fever, for among the red cells
which bear them are others which do not stain ; in
red cells which are almost filled by these bod-
ies there is often an unstained margin about the
parasite ; in some red cells the ameboid margin,
with pseudopods, has been distinctly seen, while the
balance of the cell is unstained ; the same is true
where the parasite occupies one end of a com-
pressed red cell, and other forms occur where the
ameba is of a horseshoe shape, with rounded ends,
within the body of the red cell. When the ameba
is free it often has small pseudopods (Fig. i).
There is a regular gradation in shape and si;!e
between the small round dot in a red cell, of cne-
fifth the cell's diameter or less, up to a body which
entirely occupies the cell's capacity. The ^^mall and
middle-sized forms are often provided with one or
n'ore vacuoles, seldom more than two. With the
method described the blue ameboid objects are the
only elements stained in sections of various organs.
Taking all these facts together, the blue ameboid
bodies can not be regarded as artefacts nor as ele-
ments of the tissues.

The internal structure of the ameba is difficult
to make out, and this is one point in which the
method needs improvement. The staining is usuallv
dense and uniform, except for the presence of
vacuoles, but no nucleus is visible, and no pigment.
In some of the forms observed after bichloride
hardening there were a few of the amebre which
presented a reddish tinge on one side ; this may
perhaps prove to be nuclear.

From this single case it can not be claimed, far
less proved, that the ameboid bodies observed are
causal in the disease known as yellow fever, though
provisionally the name Amceba febris flavce may be
suggested. Before such a claim can be made the
following conditions should be fulfilled :

I. The same bodies must be found in the organs

of other cases of yellow fever, and early autopsy is
probably important.

2. They should be found in the blood of yellow
fever patients, in all probability within the first three
days of the disease, for transmission by the ste-
gomyia occurs only during that period.

3. They must be found, under some guise, in the
tissues of mosquitos known to be infected.

4. More than one observer, in different parts of
the world, should find and identify them.

5. They should he cultivated, but here, as in the
case of the malarial parasite, the condition is not
urgent for the mere establishment of a causal rela-
tion.

All these conditions imply access to fresh cases of
the disease and to infected mosquitos, which is not
the good fortune of the writer.

In conclusion, it is my pleasant duty to express
my thanks to Prof. Marvin L. Graves, in whose
service the case occurred, for permission to report
it; and also to Prof. E. C. Schneider, of the Colo-
rado Springs College, who placed at my disposal
the resources of his laboratory, and thus enabled
me to complete the case during my vacation.

PRACTICAL POINTS IN THE OPERATION
OF COLOSTOMY.

Bv CHARLES B. KELSEY, .M.D.,

NEW YORK.

To one as thoroughly convinced as the writer of
the great benefits of this operation in many cases,
it seems strange that the natural objections to it
held by the profession at large, and especially
that part of it devoting itself to medicine rather
than surgery, should not, ere this, have been more
completely overcome. That the operation has
been abused admits of no more question than
that the family physician often prevents his pa-
tient from receiving the benefits which would cer-
tainly follow its performance.

In trying to point out concisely the real indica-
tions for this most valuable addition to the sur-
geon's weapons for combating disease, a certain
allowance must be made for personal feeling on
the part of surgeons and for honest differences of
opinion. Some will advise it much more fre-
quently than others, according to their own ex-
perience of its advantages. There is hardly room,
however, for any such radical difference of opin-
ion, as was shown by an enthusiastic young oper-
ator who had taken a short course in diseases of
the rectum under me some years ago, and then
started practice in the West, who wrote to me
after a few months that he had already done the
operation twenty times, but his county society
was making him trouble, and he wished to know
how many times I had done it during the same
period. My answer was in one word, "once," and
I was then running a large clinic.

In most cases there should be no uncertainty.
Take, for instance, cancer of the rectum which is
inoperable. No palliative measure has ever been
devised approaching colostomy in its benefits,
where it is done, as it always should be, early.
The average duration of life in this disease is
supposed to be two years, though such an esti-
mate may be open to question from the impossi-
bility of fixing, with any accuracy, the time of
its onset. But, accepting this from St. Mark's
Hospital as being correct, I have had manycases
where the opera"tion was done after the disease
had existed fullv as long as this, in which the

so

MEDICAL RECORD.

[Jan.

1907

patient has lived in comparative comfort from
two to five years after.

In fact, I will venture the statement that in
cancer of the rectum the average duration of life
is much longer after colostomy than after extir-
pation, though of course there is never a cure.
So plainly has this been demonstrated in my own
practice for years back that some of my associates
have made up their minds that if they ever found
themselves afflicted with this dread disease they
would take a simple colostomy, and let it go at
that.

Of course, there have been the usual number
of unsatisfactor}- cases and fatalities — cases done
"after there were symptoms of obstruction," as
so often advised by the medical attendant, and
cases in which there was alread}' undiscovered
nietastasis, and in which the operation on this
account has not been worth the while. But, set-
ting these aside, I cannot state too forcibly the
simple fact that in my cancer cases, in which
extirpation was impossible, the relief given by
this treatment has earned me the heartfelt grati-
tude of many patients who have found them-
selves slipping quietly and painlessly down to the
grave from gradual exhaustion. And, with this
experience behind me, my lack of sympathy with
other palliative measures may easily be under-
stood.

Colostomy in cancer relieves the constant bear-
ing-down pain ; prevents abrasion of the surface
and consequent hemorrhage ; prevents the forma-
tion of abscesses and fistula in the vicinity of the
disease, and slows the growth by avoiding the
irritation due to natural defecation. Its danger,
v.'hen done early, is almost nil, but this danger
increases directh' in proportion as the disease ad-
vances, until where chronic obstruction has ac-
tually been established, it reaches 33 per cent.
Why, then, delay till obstruction sets in? Sim-
ply from an exaggerated idea of the discomforts
attendant upon this means of relief — an idea
which any e.xtended experience will certainly
o\ercome.

Congenital malformations of the rectum and
anus constitute another of the strongest indica-
tions. Not all of them, by any means, but some
of them.

Think of a man born with an imperforate anus,
and living for forty odd years with a bath sponge
tied against the fistula, resulting from the punc-
ture by a trocar! During all that time the entire
colon had been a reservoir for solid feces, and
when I did a colostomy it was hypertrophied
from cecum to anus to three-eighths of an inch
in thickness. He died from acute dilatation of
the stomach, due to unloading the colon, which
filled the entire abdomen.

In all this class of cases colostomy is the last
resort after every eft'ort has been made to estab-
lish an outlet at the natural site, but it sometimes
is manifestly the only way of prolonging life.

Cases of extensive ulceration are more fre-
quently an indication for an artificial anus than
are the benign fibrous strictures. And destruc-
tive ulcerative processes which can be made to
cicatrize by no other treatment will often heal
quickly after the flow of feces has been diverted.
In the benign strictures I do not use this method
of relief as often now as formerly, having learned
by experience how long and in what compara-
tive comfort patients may bear this condition.
The chronic hypertrophic proctitis, which is the
cause of the lessened caliber, seems in manv cases

to be self-limiting. There is little or no cicatricial
contraction to be o\ercome which might in time
cause complete obstruction ; but a thickening and
infiltration of the wall of the gut and surrounding
tissue, which once having taken place remains
comparatively stationary and does not advance.
The formation of abscesses and extensive fistulae
in the neighborhood of the stricture is more to be
feared, and is a stronger indication for colostomy
than the mere narrowing of the canal, which can
generally be quite satisfactorily managed by other
methods.

Rectovesical fistula in either sex, unless very
small, usually calls for prompt relief by this
means, and so do some of the more extensive fis-
tula; where there is no communication between
neighboring organs. For fistula is not always
curable by cutting, nor is attack upon the exten-
sive tracts always justifiable, even when the dis-
ease is destroying the vital powers. Many of
them have to be borne, and those which cannot
be are often best cured by an artificial anus — in
fact, can only be cured in this way.

In acute intestinal obstruction from any cause
(vohulus, intussusception, enteroliths, bands,
apertures) the conditions found in each case upon
opening the abdomen will decide for or against
establishing a temporary or p>ermanent artificial
anus.

There is, I think, a growing feeling that in all
cases in which any sort of artificial anus is neces-
sary the colon in some part is the most conve-
nient place for it ; and, as a more or less artificial
anus (generally more) is a necessary result of
nearly all cases of extirpation of the rectum, if
this idea finally prevails the operation of excision
will be one of the most frequent of all the indica-
tions for colostomy. With me this idea has
always had great weight, simply because, as a
rule, the patients upon whom I have done colos-
tomy for any cause, have been cleaner, more com-
fortable, and have had better control of the pas-
sages than those upon whom, after extirpation,
I have made the gut to end as near the natural
anus as the operation allowed. This is a matter
upon which one can speak only in a general way,
and there are exceptions, but anything like sphinc-
teric power after any variety of excision is very
rare. These patients usualh' have a good deal of
difficulty in keeping themselves clean, whereas
one with a properly formed opening in the groin
will have no difficulty whatever. Even if there
be no real sphincteric power, the bowels may be
educated to move once a day, and very often no
receptacle need be worn, the opening being cov-
ered merely with a pad of lint held in place by a
light abdominal bandage.

Of the surgical advantages of always doing a
preliminary colostomy before extirpation I will
not speak. There is much to be said in its favor,
but we are now considering the question from
the patient's standpoint of personal cleanliness
and comfort, and I am often surprised to find
that those with whom I have taken the greatest
care to make a temporary opening which could
be easily closed, decline the second operation as
not being worth while. Xor is this only with men.
but it applies equally to women, and not neces-
sarily in the lower walks of life,

A question now suh jitdice is whether mucous
colitis is an indication for colostomy or appen-
dostomy, and in what class of cases. It has not
won its way as yet with conservative advisors,
and mv own feeling is that its advantages will

Jan. 12, 1907]

MEDICAL RECORD.

51

have to be proven beyond a peradventure before
it ever will. Too many family physicians are con-
vinced of the nervous causation of the symptoms
which make the condition to have them recom-
mend any kind of local treatment very enthusi-
astically, and especially this operation. The
question must be left to time, and will be settled
rather in the hospital ward than in private prac-
tice.

Technique. — The operator should have a prety
clear idea beforehand whether the opening is to
be permanent or only temporary. If the former,
certain steps may be taken to insure absolute
efficiency and the greatest amount of control with
the certainty that nothing can pass below the
opening — the chief essentials. If the opening is
to be only temporary, more regard must be paid
to the future closure, and efficiency must be some-
what sacrificed in order that the gut be as little
injured as possible in the primary operation. In
this, as in other things, the personal equation will
modify the author's choice of method. With
myself, most colostomies are intended to be per-
manent, and even in those which I have intended
to be temporary I have not always been able to
get the patient's consent to a second operation,
for the reason given above. A few times I have
been called upon also to close what I had sup-
posed would be a permanent condition on account
of the cure of the disease, and here the operation
has been much more extensive than the colos-
tom)' ; so that the technique is not in its final
stages the same for the temporary and perma-
nent operations, and the distinction is practically
important, and can usually be made beforehand
without making a large incision into the abdomen
for exploration by the whole hand, and utilizing
this for the artificial anus — a method with mani-
fest objections. The del)alable cases are the ex-
tirpations. If the operator believes a sacral or
ischiorectal artificial anus has sufficient advan-
tages over an inguinal to make it worth while to
close the inguinal, which has been formed merely
as a source of additional safety during the opera-
tion of excision, he will make many more tem-
porary than permanent openings. Otherwise the
temporary openings will be confined to the cases
of benign ulceration, extensive fistulre. and some
of the cases of acute obstruction. In my own
practice I do not find "provisional colostomy" at
all necessary to the success of an extirpation, and
if I did I should not think of closing it after mak-
ing it ; so it results that most of my own cases are
permanent.

There is no necessity for going over all the de-
tails of the operation found in the te.xt-books, but
a few points may be dwelt upon with advantage.
Nearly all of the many modifications which have
been made since the operation became thoroughly
established have been in the line of elaboration
rather than simplicity. The Mayde-Reclus
method of substituting a glass rod for a suspen-
sory suture under the gut, and the omission of
any suturing to the abdominal wall is about the
only exception. So that now the operator who
has had little experience and no fixed ideas on the
subject is fairly flooded with methods from which
to choose. There are spurs of all sorts, stitches
of all sorts, openings in the inguinal region, over
Poupart's ligament, and down the thtgh. The
bowel is incised lengthwise, and transversely, or
both ways. A recent text-book describes thirteen
different recognized procedures, with the names
of their sponsors; so that the state of mind of the

operator may be thoroughly appreciated who
wanted my advice the other day, not as to the
advisability of the operation, and not as to its
permanency, but as to the value of these elabora-
tions, and how best to operate.

Regarding the Mayde-Reclus method, which is
a modification of my own, its simplicity is not
devoid of danger peculiar to itself, and it should
not be trusted except in cases of very small in-
cision tightly plugged by the loop of gut drawn
through it. More than once a hernia of small
intestine has escaped between the incision and
the loop, and in one case of my own this accident
ended fatally. There is no occasion for any such
risk. The glass rod simplifies the operation, and,
if left in situ two or three weeks, makes a good
spur; but two or three sutures in addition will
make all safe, and should not be omitted.

My own method has changed but little, in spite
of the changes by others, and the same is the case
at St. Mark's. The incision was for a time un-
necessarily large. It is now half the length and
"gridironed," as in appendicitis. In other words,
muscles are separated as far as possible, and fibers
cut as little as possible, and an opening one inch
long will usually allow the insertion of the inde.x
finger, the hooking up of the sigmoid, and pulling
it out of the abdomen. If, as I hold, as useful and
cleanly an opening can be made in this way as by
any more elaborate effort at sphincteric power by
carrying the loop to a distance from this opening
through other muscles or under the skin, and clos-
ing this opening for another more or less removed
from it, these modifications, which constitute most
of the supposed improvements, will not hold their
own. I have never adopted them.

It is unfortunate to so far improve upon an
operation as to spoil it ; but not long ago I had
a very serious time in resecting one of these long
intermuscular and subcutaneous outlets, which
nas a mere fistulous tract, and giving the patient
a real anus to overcome chronic obstruction.

In the temporary operation, pass the sutures
througli the edges of the abdominal incision, the
parietal peritoneum, and the wall of the gut. In
the permanent operation do not include the pari-
etal peritoneum in the suture.

The reason is obvious. If the parietal peri-
tc neum be left out a firmer union between gut and
abdominal wall is secured than when the two peri-
toneal layers are united. In the latter case, the
gut, though not as well adapted for permanency,
is more movable, is more completely shut off
from the general peritoneal cavity, and can often
bt- closed by an operation which shall not extend
into the cavity.

In temporary colostomy make a free longitudi-
nal incision in the gut, but cut away none of the
intestinal wall. In permanent colostomy trim the
gut freely down to the edges of the abdominal
incision. In both keep the opening into the gut
between the spur and the upper angle of the
wound, and do nut cut into the bowel below the
level of the spur. In this way feces are forced
to the surface by the spur and by the partially-
contracted lower segment of the gut beyond the
level of the spur, and the longitudinal section,
with no sacrifice of tissue, is much more easily
closed by subsequent operation.

Were it not for one thing, the lower segment
could, with advantage, be invaginated and
dropped in everv permanent operation ; but it is
often of advantage to wash through it from above
downwards, and when the upper end is thus

52

MEDICAL RECORD.

[Jan. 12, 1907

closed I have known a collection of mucus and
discharge to accumulate in the cul-de-sac to a
tumor the size of the fist, and cause great pain
and very acute symptoms before being relieved.

In cases of severe or long-continued chronic
obstruction, operate on the right side instead of
the left, and make the opening temporary, with
the idea subsequently of enlarging it and allowing
it to remain, or preferably closing it and substi-
tuting an opening on the left, if conditions admit.

The reason for this is that in such cases the
greatest accumulation is often in the cecum ; that
the sigmoid is likely to be so distended with solid
feces as to make a proper colostomy opening
impossible until it has emptied itself; and that
an opening in the sigmoid, even though large and
free, may fail entirely to give relief to the dis-
tended large bowel before fatal results are caused.
This has happened in my own practice from
failures to exactly appreciate the conditions ex-
isting. The patient, with cancer of the rectum,
was an exceedingly large man, though emaciated,

still weighing at least two hundred and fifty
pounds, and the abdomen, although verj- large,
was not at all distended, nor were there signs
of obstruction. In fact, he was having solid pas-
sages by the aid of laxatives every other day,
but the feces consisted only of two or three large
scybalse. An opening was made as high in the
sigmoid as possible, and the gut was found only
moderately full of hard fecal matter. Thinking
we might have trouble, the opening was made
much larger than usual and the stitches placed
very strongly and with care, and an excellent
spur was formed, but within forty-eight hours the
whole sigmoid and rectum, both above and below
the opening, were flooded and packed with solid
masses, and the artificial anus gave no relief what-
ever. Several times these were removed with for-
ceps and the finger, but without any relief, and
in the end the pressure of this avalanche was too
great, the adhesions between the bowel and the
abdominal wall gave way, and fatal extravasation
into the peritoneum occurred. A second tem-
porar}' opening into the cecum should have been
made, and might have saved the patient.

In making an opening into the sigmoid make
it as high up as possible to avoid prolapse, and in
the cecum make it as far from the valve as possi-
ble, to prevent the end of the small gut being
pressed directly into the opening in defecation,
thus allowing the direct evacuation of fluid feces.
This is always the objection to cecostomy, and,
although in time the evacuations may become
formed, it is a serious one. Another is that the
whole large bowel is cut off from the economy,
and, though patients seem to bear this remark-
ably well, it is more than probable that it has in
nature some function besides a mere reservoir,
and that patients are better with than without it.
Any of the operations for an artificial anus may
as w^ell be completed at the time as to wait two
or three days before opening the gut. All that is
necessary is to guard against feces soiling the
peritoneum, and a few sutures carefully placed
will eliminate any danger of this kiad. ' The
opening of the bowel is not painful, however,
even when postponed for adhesions to form ; but,
until it is opened, there is generally complete
obstruction at the site of the spur both for gas
and solid matter, and the condition of the patient
must be carefully watched. Often in forty-eight
hours all the symptoms of acute obstruction may

be distinctly marked, and the gut must be opened
without further delay.

I have known a man to die of obstruction in a
hospital ward after a colostomy while the operator
was waiting for the adhesions to become firm
enough for the gut to be incised.

Sigmoid colostomy may be impossible for three
reasons. The gut at this point may have no mes-
entery ; it may be so implicated in cancerous dis-
ease as to be either unrecognizable or absolutely
fixed and immovable, or it may be overdistended
with feces so that only a lateral incision without
a spur is possible. In all these cases the abdomi-
nal incision should be closed. In the last a tem-
porary opening should be made in the cecum with
the expectation of making a permanent colostomy
after the bowel has been evacuated. In the other
two conditions a permanent anus should be made
in the transverse colon, as near the splenic flexure
as possible. Here we secure solid passages and
cut off no more large bowel from the economy
than necessary.

A temporary anus made as here described may
generally, and a permanent one may frequently,
be closed by a plastic operation without opening
the peritoneal cavity. As the first step toward
this the spur should either be destroyed or pressed
back. Destruction may be by excision or by
sloughing from the grasp of any form of pressure
forceps. As there is always some danger from
the enterotome, Banks' method by elastic pres-
sure upon the spur should first be attempted. This
consists in introducing as large a piece of thick
rubber tubing into the proximal and distal endi
of the gut as these will admit, and fastening it
in this position for several days. This is accom-
plished by passing a piece of aluminum wire
through the side of the tube (not the caliber),
bending the ends over the edges of the abdominal
incision, and holding them with adhesive plaster.
The rubber will cause pain, but can generally be
borne, and after three or four days the spur will
be found considerably reduced and the contracted
distal orifice considerably dilated.

When this has been accomplished, the edges
of the gut, with the cicatricial tissues, are dis-
sected free from the parietes down to the sub-
peritoneal fat on all sides, and the parietal peri-
toneum, with its fat, is stripped from the abdomi-
nal wall to a sufficient extent in every direction
to allow free mobility of the gut, and partial or
complete withdrawal of the part to be sutured
from the wound.

This dissection should not be begun in the cica-
tricial tissue at the sides, where the parts are mat-
ted together, and there is more or less ectropion,
because the peritoneal cavity may be opened
before the operator knows just where he is; but
a clean incision in normal tissue should be made
from the upper angle of the anus upward for at
least an inch, and from the lower angle downward
for another inch, and w^hen subperitoneal fat and
peritoneum have been recognized at these two
points, blunt dissection with the finger and a
few- strokes of the knife will loosen the sides of
the opening, and permit the drawing out of the
portion of bowel to be sutured. The opening in
the bowel is then closed carefully with Lembert
sutures passed through the cicatricial edges. No
sacrifice of tissue should be made to secure clean
approximation of peritoneal surfaces, for this is
not necessary-. The suturing must be adapted to
the nature of the opening which has been made.

i

Jan. 12, 1907]

MEDICAL RECORD.

53

and may be transverse or vertical. Where much
bowel has been sacrificed in the original opera-
tion, it must be transverse ; hence the advantage
of a longitudinal incision without sacrifice of the
wall.

Where too much bowel has been resected to
allow of this plastic procedure, the problem is
simply one of end-to-end intestinal anastomosis.
I have a favorite Murphy button which has done
its work successfully four times in these cases,
and the recent experiments of Cannon and Mur-
phy would indicate that end-to-end anastomosis
is always preferable to lateral, in that the cir-
cular fibers are not cut longitudinally, and peri-
stalsis is not, therefore, rendered impossible.

As to plugs to close the artificial anus, and re-
ceptacles worn to collect escaping feces, the
former I never use, and the latter are by no means
always necessary. Often a simple pad of cotton
and a body bandage answer better than any more
elaborate contrivance, and the bowels can usually
be trained to act but once a day, and this with
solid movements. Should an}' contrivance be de-
sired, however, an excellent and very simple truss
can be made to meet the indications for support.

The one shown in the cut was made for me by Ford
& Co., some years ago, and seems to have given sat-
isfaction to both surgeons and patient.s. It is a sim-
ple truss with a fork at the end. Between the two
prongs of this fork slips a flat, hard rubber ring
about an inch thick and two inches in diameter, and
onto this ring the soft rubber pocket is held by its
own elasticity. The contrivance is light, firm, and
cleanly. Most of those pictured in the textbooks
are unnecessarily cumbersome.

44 East Twenty-ninth Street.

A GENERAL CONSIDERATION OF DEMEN-
TIA PRECOX.

By EUGENE F. McCAMPBELL.

COLUMBUS, OHIO.

FORMERLY ASSISTANT IN PATHOLOGY. COLUMBUS STATE HOSPITAL FOR

I.N'SANB; late pathologist to MINNEQUA HOSPITAL, PUEBLO,

COLORADO; INSTRUCTOR IN BACTERIOLOGY, OHIO STATE

UNIVERSITY, COLUMBUS, OHIO.

Of the many forms of insanity which are found
among those who populate the hospitals for the
insane throughout the country, without a doubt one
of the most prominent, and one which attracts our
attention as much as any other, is dementia precox.
This psychosis is also known by a variety of other
names, such as primary dementia, adolescent insan-
ity, juvenile insanity, stupiditas, etc., and, as these

names signify, the disease is one which has its out-
set in early life and it usually ends, after running a
chronic progressive course, in a state of mental
apathy and deterioration. The state of profound
dementia is usually preceded by a preliminary state
of depression varying in length, but nearly always
terminating in complete lethargy and indifference.
About fifteen to twenty-five per cent, of all ad-
missions to hospitals, according to Kraepelin, are
patients sulTering from this form of mental disease.
It has only been in the last few years that the dis-
ease, as such, has been recognized. Formerly these
cases were classed among the imbeciles and idiots,
or, to use the general term, "dements."

It is only necessary to investigate the histories of
many of the so-called imbeciles and idiots who have
been residents of the hospitals for years to find that
in early youth many of them were children of ordi-
nary mental capacity, and that some had even been
exceptionally intelligent. We find oftentimes in
these cases that some time about the age of pubes-
cence, and on up to their thirtieth year, these men
and women suffered some attack of mental disorder
which has left them, after many years, in this state
of progressed dementia.

The term dementia prrecox is one of some fifteen
years' standing, being first used by Pick' in 1891.
At this time he applied the term to a class of cases
which we now call hebephrenia or hebephrenia
gravis. Its usage has since been broadened, and it
is now made to include a large variety of cases.

In our opinion, by far the best classification that
can be used in separating the various cases which
are placed under the head dementia prsecox, is that
of the German psychiatrist, Kraepelin. The disease
may be said to include, according to Kraepelin, (i)
Hebephrenia, a term first applied by Kahlbaum and
Heckter to a class of cases which sometimes show
maniacal .symptoms, but rapidly terminate in a state
similar to melancholia; (2) Katatonia, first used by
Kahlbaum in 1874 to designate a class of cases hav-
ing a stuporous condition with negativism, automa-
tism, stereotypy, echolalia, echopra.xia, etc.: (3)
Paranoid dementia, being applied to certain forms
of paranoia which terminate with decided mental
impairment and degeneration.

Psychical Syiiiptojitatology. — Considered as a
whole, dementia praecox is not difficult to diagnosti-
cate, especially in its early stages, although a train
of symptoms which is most varied is often pre-
sented. To diagnose the various forms of the psy-
chosis is perhaps more difficult, and it may not be
amiss to consider the symptomatology of these vari-
ous types of dementia praeco.x.

Hebephrenic Form. — The development of this
form of the psychosis is usually very gradual. The
first manifestations of the disease are frequently the
display of a violent temper without cause, irritabil-
ity and restlessness in some cases, while in others
the first change noted is the difficulty in the concen-
tration of thought, and with this comes a loss of
interest in everything, and lack of energy. In the
restless and active type of hebephrenia the patients
are often found assuming peculiar attitudes. They
walk about the wards picking up pieces of paper,
rags, etc. They grin foolishly, and frequently burst
out into loud laughter without cause. Others of
the more depressed type sit for hours at a time on
a seat, the head cast down, and facial e.xpression
apathetic. Some patients seem immobile, and will
not change their position except when forced to do
so. Frequentlv they refuse to eat, and remain in a
state of absolute mutism. It is not a defect in speech
that prevents these patients from talking ; it is sim-

54

MEDICAL RECORD.

[Jan. 12, 1907

ply because they have nothing to say. It is some-
times difficult to differentiate between hebephrenia
and katatonia in some cases of this kind. Not in-
frequently, seized with sudden impulses, some of
these patients will suddenly start up from the posi-
tion they have held for some time, grasp some ob-
ject, and throw it. Often these impulses take the
form of suicidal and homicidal tendencies, and the
patients make frequent attempts on their own lives
and those of others. For the most part the orienta-
tion of the patients is unimpaired. Usually they
comprehend clearly where they are, reckon time
correctly, and do not fail in the recognition of their
acquaintances. Along with the orientation we can
say that the perception of internal impressions and
consciousness are not seriously impaired. They
understand thoroughly all that happens to them and
everything that goes on about them, even when they
appear the most stupid. Some patients also seem
to retain all their mental faculties in periods of great
excitement and activity. After the onset of the dis-
ease, in the majority of cases, there is a rapid de-
cline into the depressed state, in which it may be said
the symptoms become more prominent and pro-
nounced. In this state orientation frequently suf-
fers and is decidedly impaired by delusions. Brown-
rigg- says that the difficulty is not in the inability
of the patient to perceive or reflect rightly, but it is
because the morbid and false perceptions are more
persistent and insistent than the true perceptions.
The patients undoubtedly acquire these delusions as
a result of various hallucinations which present
themselves. These hallucinations are of many kinds
and descriptions. They often diminish gradually as
the disease progresses, and reappear again in the
last stages. In some cases, however, they are per-
sistent throughout the entire disease. The halluci-
nations are most frequently those of hearing, and
following these, and occurring less frequently, are
hallucinations of sight and feeling. Very often the
hallucinations are of a disagreeable character, and
the patients are apt to become depressed and sus-
picious as a result of them. The delusions which
accompany the hallucinations of this kind are, of
course, of the same type. The patients imagine
that they have committed most atrocious crimes,
that they are unworthy and unfit to live, etc. In
this state they frequently manifest suicidal tenden-
cies. Kraepelin speaks of the augmentation of these
various delusions by fabrications. The patients
chim to be persons of distinction and control, and
that they are antagonized on this account. In nearly
all cases the judgment is greatly impaired. Great
difficulties are encountered when these individuals
are called upon for some decision. There is most
always difficulty in comprehension, and a distorted
conception of the exact surroundings. The train of
thought is also disturbed. The expressions of the
patients seem to be disconnected, and this condition
progresses with the disease leading up in some cases
to a complete incoherency and confusion of speech.
In many cases the train of thought gives evidences
of stereotypy, the patients using certain rhythmic,
meaningless, and peculiar expressions continually in
their speech.

Memory is progressively deteriorated. .At the
onset of the disease patients usually can give their
past history very accurately, and the knowledge
gained in school seems to be held very tenaciously.
The disease does not progress far without marked
deterioration being noticed. There is especially loss
of memory for recent events in the excited or stu-
porous condition. The attention is usually greatly
impaired in all stages of the disease. With difficult\

the patient's mind is held on any subject for even
a very short period. Every interest in the subject
rapidly disappears, and there is a relapse into the
former state. In the most advanced stages it is
impossible to arouse any active attention. The
patients do not attempt to learn or comprehend any-
thing in this state, notwithstanding the fact that
the perceptive powers are not always markedly im-
paired. The disposition of the patients, and with this
the emotional life, suffer quite serious changes. At
the onset of the disease we frequently see a sad,
anxious, and careworn expression upon the patients,
indicative of a depressed mood. Paroxysmal laugh-
ter and crying alternately is not infrequent. Later
the patients usually become apathetic, and utterly
devoid of all emotions. They lose all affection for
relatives and friends, and experience no change of
feelings within themselves, no matter how great the
stimulus may be. Xot infrequently we find a mor-
bid expression of the religious or sexual life, usually
leading to excesses along these lines. In cases where
these morbid feelings occur they are usually found
in the early stage of the psychosis, and generally
disappear as the disease progresses.

In this class of cases we usually note a marked
change in the power of will or volition, and in the
latter stages it most always entirely disappears.
With a change in the will power we, of course,
expect a corresponding change in conduct and ac-
tion. There is usually a decline in all ambition and
desire to be active. The patients are usually idle,
neglect their personal appearance and obligations
to others. They are in general hypersuggestible,
although frequently excitable and untractable. In
the excited periods the hebephrenic is liable to per-
form all sorts of impulsive acts. There is frequently
an inability to express the sudden impulses on ac-
count of other impulses which are stronger, devel-
oping and overpowering the weaker ones. In this
way the symptom of negativism develops, which is
more characteristic of katatonia, and will be con-
sidered fully under that form of dementia prjecox.

Katatonic Form.— This form of the disease is
characterized, according to Kraepelin, by a peculiar
condition of stupor with negativism, automatism,
and muscular tension ; excitement with stereotypy,
verbigerations, echolalia, leading in most cases with
or without remissions to a condition of mental de-
terioration. The onset of this form is not unlike
that of the depressed type of hebephrenia. The pa-
tients are usually noticed to be quiet and seclusive
for some time before the direct onset of the psycho-
sis. The same difficulties of thought are prominent
symptoms, as is the anorexia, cephalgia, and general
nervousness found in hebephrenia. It may be said
that the clouding of consciousness is more marked
and the perception of internal impressions is more
impaired earlier in the disease than in hebephrenia.
Consequently, the patients become disorientated
sooner than in the hebephrenic type.

The judgment is of course much impaired, as is
the train of thought. There is a decided amount
of incoherency and disconnection in the speech of
this class of patients. It is with difficulty that the
attention can be held for any length of time. ^lem-
ory suffers about the same changes as in hebephre-
nia. In the latter stages of the disease there usually
comes a complete cessation of the psychic function,
and consequently there is a complete inhibition of
all thought. Early in this form of the disease hallu-
cinations appear with their customary delusions.
Kraepelin thinks that the delusions are usually of a
religious nature, but the experience in the majority
of ^American hospitals does not substantiate this

Jan. 12, 1907]

MEDICAL RECORD.

55

assumption. While a great many of tiie delusions
are religious in character, it cannot be said that they
are in predominance, for many others of widely dif-
ferent character are equally prominent. We find
the emotions in decided harmony with the halluci-
nations and delusions.

During the period of depression which follows
or occurs at the onset of this form of the psychosis
there develops a series of conditions which are most
characteristic. The first of which we will speak is
katatonic stupor, and the symptom most prominent
in this stupor is negativism. As we said in consid-
ering hebephrenia, negativism results in the inabil-
ity to express certain voluntary impulses on account
of their being overpowered by stronger impulses,
which are inhibitory in character. This strange
condition is easily demonstrated in certain patients ;
they begin to act readily, but these voluntary im-
pulses are not strong enough to resist others which
arise, and the patient does exactly the opposite of
the thing desired or asked. Some of the impulses
are those which are most natural and to which the
patient is most accustomed. They shut their eyes
when told to open them, and conversely ; they re-
fuse food when it is offered to them ; they object to
changing their position, etc. Their actions appear
to the casual observer as pure stubbornness. All
active attention is inhibited by negativism, as is seen
by the patients, developing the attentive attitude
when the negativism is gradually disappearing.

External impulses do not often affect the symp-
tom, negativism. It is certain internal impulses in-
terrupting the natural impulses which move the
patients to arouse suddenly from their stupor
and commit some act. As is oftentimes the case,
these internal impulses are persistent, and they fre-
quently repeat themselves, causing in these patients
what is known as stereotypy, a condition in which
the movements and attitudes of the patients are
always performed in the same manner, and, as it
were, become stereotyped. Stereotypy with im-
pulsive action characterize katatonic e.xcitement,
which usually follows the stuporous condition.
Along with the stereotypy in these cases can be
mentioned the mannerisms of speech and facial ex-
pression and the verbigerations most common in
this form of the disease. The every attitude of the
patients, their gait, writing, speech, etc., portray
the action of the internal impulses which are con-
tinually interrupting the natural impulses.

In the condition of katatonic excitement, owing
to the serious impairment of the volitionary im-
pulses and the inability of the natural impulses to
inhibit correctly, there develops a condition known
as automatism. In this condition, as the name
implies, the actions of the patients are automatic,
and this, together with the stereotypy, presents a
very interesting combination of symptoms.

A large majority of these cases also exhibit echo-
lalia and echopraxia at some period during the con-
dition of katatonic excitement. The patients act
readily on the suggestions of others, and perform
the routine duties of the ward in a willing manner.
There seems to be a heightened susceptibility of the
will in these cases, and especially in those where the
mind has become very much deteriorated.

Paranoid Form. — This type of dementia prsecox
is made to include two types of cases, one in which
the hallucinations and delusions are incoherent, and
the other in which there is a decided coherencv.
These delusions usually persist for vears, notwith-
standing the fact that they are attended with grad-
ual mental deterioration. Kraepelin distinguishes
the delusions and hallucinations of the paranoid

form from the hebephrenic and katatonic forms, in
that in the last named forms the delusions and hal-
lucinations disappear as the deterioration progresses,
while in the paranoid form such is not the case. He
makes the distinction between the paranoid form
and true paranoia in that in the former form the
onset is usually more acute, and accompanied by
otiier symptoms of dementia ])rc'ecox, and the men-
tal deterioration is more rapid than in paranoia.

In the first class of cases the patient usually has
two kinds of delusions, those of persecution and
those of grandeur. They are decidedly incoherent
and changeable. They are attended by a slight
degree of motor excitement and deterioration of
mind. The hallucinations which accompany, and
the delusions, are usually of hearing. Patients
imagine, when they hear the sound of voices, that
the conversation is relative to themselves, and they
frequently become fearful, agitated, and quite emo-
tional. In the early stages of the disease there is
no clouding of consciousness or disorientation.
During the later stages there is gradual impairment
I if these qualities. The capacity for mental work is
considerably lessened, although some patients are
able to perform certain mechanical tasks under the
supervision of others. In general the patients are
exalted, irritable, and loquacious. The train of
thought based upon the morbid delusions is, of
course, incoherent, although questions relative to
the delusions may be answered coherently and rele-
vantly. Alemory for past events is nearly always
good, while that for recent events is somewhat im-
paired. The powers of attention and volition suffer
gradual impairment as the mental deterioration
advances.

In the second class of cases we find the same
delusions of grandeur and persecution, but they are
in most respects quite coherent. The delusions are
often expansive, taking the form of those found in
dementia paralytica. In this class, as in the first,
the hallucinations are of hearing, and are intimately
connected with the delusions. The persecutory and
expansive delusions are more gracUial in their de-
velopment than those of the previous class.

The consciousness and train of thought remain
unimpaired in the majority of cases. There is some
slight disturbance of the emotional life, the patients
usually in the first stages being depressed, and later
quite cheerful and ecstatic. Kraepelin speaks of the
ideas of spirit possession being prominent charac-
teristics in some cases.

Physical Syiiif^toiiialnlo'^y. — The physical -symp-
toms of the three t\iies of dementia pr;ocox will be
considered together briefly. The most prominent
symptom of this psychosis is found in the general
disorder of nutrition. There is usually some dis-
turbance of the vase^motor system which may cause
blushing, cyanosis, bromidrosis, and hyperidrosis in
some cases, and all degrees of dermatographia.
The cardiac action is usually imi-iaired, producing
irregular, accelerated, or retarded moveiTients. The
Ijatients frequently lose in weight and suffer with
anorexia, intense headache, and insomnia. There
is an amenorrhea in certain cases, together with a
complete cessation of sexual desire. In a large per-
centage of cases in the latter stages of the disease
there'is a partial return to the normal, the patients
increasing in flesh ; the heart action improves : the
appetite returns, and sonietimes becomes excessive.
This condition, however, is usually quite tran-
>-ient. and many of the bodv functions fluctuate as
the disease progresses. Kahlbaum and Jensen de-
scribe convulsions of the epileptiform and fainting
t\pes occurring: in dementia prrecox, also cramps

MEDICAL RECORD.

[Jan. 12, 1907

and tetanic contracture of certain groups of mus-
cles ; apoplectiform convulsions with combined pa-
ralysis, etc. Kraepelin thinks these attacks occur in
about eighteen per cent, of all cases. He also speaks
of hysterical convulsions and paralysis, aphonia,
hiccough, and certain choreiform movements, which
he designates as "athetoid ataxia."

The pupils are usually dilated, but react readily.
The deep and superficial reflexes are exaggerated,
and there is an increased excitability of nerves and
muscles. A state of increased muscular tension
sometimes exists in katatonic stupor. This condi-
tion is frequently attendant to negativism of the
body functions such as the retention of urine and
feces, and some authors regard this as a partial
cause of the increased tension. There occurs in this
stage of increased tension frequentlv a uniform
position of the body or the parts, which in some
patients is very difficult to change. They often
remain in this characteristic position for long
periods, only changing it when compelled to do so.
When there is less muscular tension there often
exists a condition known as "cerea flexibilitas," in
which the patient can be changed into any position,
whether uncomfortable or not, and will remain in
this position indefinitely.

In a good many cases of dementia prascox there
is an increase in salivary excretion. In one kata-
tonic patient, to my knowledge, 200 c.c. have been
collected in three hours. Kraepelin reports a case
in which 375 c.c. were collected in six hours.

The temperature is in most cases subnormal, but
in some cases of excitement it has been known to
rise to 102 degrees.

Prognosis. — Dementia pr.-cco.x runs a very pro-
gressive course, and usually ends, witli few excep-
tions, in mental deterioration and apathy. The
course in the hebephrenic form is frequently inter-
rupted by great improvement in the patient's condi-
tion and partial return to the normal state. The
degeneration, however, usually progresseJs more
rapidly when a remission occurs. The disease runs
a course lasting in most cases for years. The pro-
found states of dementia are sometimes reached in
from eighteen to twenty-four months after the onset
of the disease, but in most cases the length of time
is much longer. In hebephrenia there are often
short periods of increased excitability, incoherence
of thought, clouding of consciousness, irritability.
aggressiveness, etc., lasting for an hour or more,
and then subsiding. In katatonia there is usually
the period of depression, followed by the period of
excitement leading on to mental deterioration.
Sometimes the period of excitemnet does not occur,
and the patient passes from the stupor into the
demented state. The katatonic usually succumbs
as a result of some intercurrent disease, and not
from the psychosis direct.

In the paranoid forms the course is progressive,
and is characterized by the absence of remissions.
As the disease progresses the mental deterioration
becomes more marked, and the patients gradually
become disorientated and incoherent in thought,
leaving them completely incapacitated for mental
work.

In giving statistics, we quote in the main from
Kraepelin. In hebephrenia, seventv-five per cent, of
the cases reach a state of profound dementia :
seventeen per cent, of cases reach a state of deteri-
oration not so far advanced, and eight per cent, of
cases are cured. In katatonia. eighty-six per cent,
of cases end in mental deterioration of different
stages, and about fourteen per cent, seem to re-

cover. In the paranoid form, the outcome, accord-
ing to Kraepelin, is always deterioration.

It can be said that dementia prsecox never termi-
nates fatally. Those afflicted with this psychosis
usually die as a result of some other disease.

Etiology. — The etiology of dementia priecox has
not as yet been definitely estabHshed in every par-
ticular, but a few facts can be said to have been
accepted. Kraepelin says that more than sixty per
cent, of the cases appear before the twenty-fifth
year. When we consider the various forms we find
a still w'der variation. In the hebephrenic form
almost seventy-five per cent, of cases appear before
the twenty-fifth year. In katatonia we find a still
smaller number, only sixty-eight per cent., and in
the paranoid form only forty per cent, appear before
the twenty -fifth year. The hebephrenic form is
most prevalent (Kraepelin, si.xty-four per cent.)
among males, and in the paranoid and katatonic
forms the females are said to predominate.

The most causative factor of this disease of early
life seems to be a defective and deficient heredity.
We find in nearly all patients of this class a consti-
tution which is distinctly neuro*^ic, and this condi-
tion to be due undoubtedly to a similar constitution
in the patients' ancestry. We have an unstable
nervous system of this kind subjected to severe
strains and stresses either of mental or physical
nature, and we have a psychosis produced due to
the exhaustion of the nervous system. This con-
dition in the majority of cases is typical of demen-
tia prjecox. These strains and stresses in a large
number of cases come on at pubescence when the
sexual functions are becoming prominent and most
frequentlv result in excessive sexual indulgence.
At this period, and the vears following, the body
is more susceptible to both mental and physical
overwork, and we frequently find this peculiar
psychosis developing as a result.

Certain febrile diseases, such as scarlet fever and
typhoid fever, are sometimes etiological factors.
Peterson' gives frequent child-bearing as sometimes
a cause. Frequently we find the psychosis develop-
ing after the birth of the first child. A case of this
kind is reported under the metabolism work on de-
mentia pr?ecox done by the author.*

Brain trauma and hemorrhages may be said to
be the cause of a small percentage of cases, also the
excessive use of alcohol and drugs, which aftect the
metabolism of the nerve cells directly.

Pat/iology. — In regard to the pathology^ of de-
mentia prseco.x there is still some doubt. Some
authors regard it as a purely functional psychosis,
while others give it a definite pathological basis.
That there is a lesion in the brain cortex seems quite
probable, judging from the clinical course of the
disease. The fact that a small percentage of cases
are cured is indicative of a bram lesion, which is
sometimes capable of being repaired. Kraepelin, in
his Clinical Psychiatry, reports the findings of
Alzheimer in a case of acute delirium., vvhich he
classed with katatonia. He found the nucleus
swollen and its membrane wrinkled, the cell body
shrunken, the neuroglia fibers increased and at-
tached to the cell in a peculiar manner. He reports
also a displacement of the neuroglia cells, very large
< nes being found in the deeper, instead of the super-
ficial layers of the cortex. ,

The theory of autointoxication has been given
seme consideration. This is due to the intimate con-
nection of some cases of the osychosis with pu-
bescence, pregnancy, pueperium. disturbance of the
menstrual function etc.

That there is a marked change in the nutritive

Jan. 12, 1907]

MEDICAL RECORD.

57

processes are to be regarded as primary conditions
causing a neurotropiiosthenia which produces this
psychosis, or whether they are to be re;.^arded as
secondary to the mental disturbance, is a question to
be proven. What the changes in the nutrition are
has not been thoroughly investigated, and the causes
of these changes and the results of them still remain
an unsettled problem.

REFERENCES.

1. Pick : Prager medizinische Wochenschrift. 1891.

2. Brownrigg: American Journal of Insanity, 1900, p.
455.

3. Church and Peterson: Nervous and Mental Diseases.

4. McCampbell: Metabolism in Dementia Prascox. Col-
umbus Medical Journal, November and December, 1904.

PES PLANUS FROM THE VIEWPOINT OF
NEUROLOGY.*

By CH.\RLES p. FRISCHBIER. M.D..

BROOKLYN. NEW YORK.

The relatively large number of cases coming to the
clinic of Prof' Collins at the New York Post-Grad-
uate Hospital for the relief of pains in various parts
of the bodv, in whom after careful examination flat-
foot or weak foot is found as the sole attributable
source of such pain, has led me to believe that the
discussion of this subject might be profitable.

Although the pain of flatfoot is usually of the feet
and legs, it may be of any part of the body, for I
have seen improvements of flatfoot in most instances
followed by a cessation, or at least amelioration of
aches and pains in remote parts. From an analysis
of 125 cases, I feel justified in regarding congenital
or acquired weak and flatfoot a source of irritation
capable of causing widely-scattered pains and dis-
comfort to the degree of depression and exhaustion
in particularly susceptible subjects. In all cases and
all degrees of flatfoot we naturally e.xpect to find
local pain or tenderness about the foot, ankle, or
leg, and these sensory disturbances frequently are
not commensurate with the development of deform-
ity, so that in the beginning destruction of the joint,
long before any noticeable change of outline, the
pains are apt to be most severe and continuous.
Quite frequently also the pains appear localized at
first about the knee or hip joints, and later travel
downward to concentrate themselves about the
member at fault. In 56 cases pains extended to the
thighs : in 47 there was great pain in buttocks and
lumbar region ; in 39 the pain was first felt in hips,
thighs (anteriorly ) , and inguinal region ; in 34 cases
there was backache up to the shoulder blades; in 21
extreme general irritation, followed by depression ;
in 17 there was pain in back, also right or left arm ;
in 4 cases there were restlessness, insomnia, pains
worse at night in opposition to the general rule that
resting the feet relieves pain.

The dysesthesias were variously described as
pressure constriction, numbness, dull ache, or pains
of shooting, stabbing, pulling, or throbbing char-
acter. The extreinely ingenious method of taking
an impression of the feet upon specially prepared
paper by means of the ferrocyanide of iron reaction
having failed so often to reveal deformity, simply
because of the insidious joint change residing only
in the upper parts, we must relv upon the follow-
ing:

I. Other causes being excluded, increase of pain
on active and passive manipulation of the joint, on
standing particularly, on walking, jumping: tender-
ness on pressure over some or all the bony promi-

*Read before the Brooklyn Neurological Society, October
25, IQ06.

nences. as the scaphoid, metatarsal heads, os calcis,
etc., and impaired mobility of the ankle joint some-
what impeding adduction, limiting extension, and
causing a feeling of constriction or weakness of the
joint, point to weakfoot, beginning flatfoot.

2. More advanced cases present greater promi-
nence of the internal malleolus and astragalus, with
corresponding depression or gradual ettacement
of the fibular landmarks. Weakness is more pro-
nounced at the inner side of the foot and ankle;
there are strain and ache of these parts and the
calves. Coldness, numbness, hyperidrosis, all ag-
gravated by atmospheric changes, are noticed. Dis-
comfort and tire after short walks necessitate fre-
quent rests, during which the joint components par-
tially reposit themselves in the normal order, shortly
after again to be jarred and jounced, and stretched
apart, so as to cause renewed and increased torture.
The patients become more or less awkward in their
gait, watch their footing more in order to avoid
rough or uneven places (cobblestone pavements,
ruts, obstacles), feel less secure on their feet, use
their heels more than their toes, and wear away the
inner side of the .sole of the shoe.

3. \Mien tlie deformity has become eyideiit the
gait and station may change to an actual wobbling,
limping, or staggering, and slight efforts of the
pedal extremity may require such an excess e.x-
penditure of energy and force as to tempt the patient
to remain inactive, or at least to save locomotion.
As above mentioned, the pains usually are not so
severe in this stage, being replaced by a transient
dull ache.

Let us recall that the arch of the foot is formed
in a longitudinal direction by the oscalcis, and the
posterior part of the astragalus as its shorter, pos-
terior limb, while the rest of the tarsus and the
five metatarsals may he regarded as constituting
its longer anterior portion. The junction of these,
the calcaneocuboid and the astragaloscaphoid ar-
ticulations, is made more stable and useful by a
number of ligaments, the calcaneonavicular liga-
ment particularly being considered one of the strong-
est and most resilient in the body. The summit of
the arch is the articular surface of the astragalus,
which supports the tibia and fibula. Transversely
from within outward a half arch is formed by the
gradual downward slope of the central portion of
the foot till its outer border rests upon the ground.
The fundament or base of these arcs is composed of
the tubercles of the oscalcis posteriorly and the meta-
tarsal heads anteriorly.

The action of the foot is that of a lever nf the
second order. In normal walking the weight of the
body is lifted by the calf muscles, the power, acting
upon the metatarsal heads as the fulcrum. To use
this power properly and economically the relation of
the foot to the leg should be that of a plane passing
through the center of the knee and ankle joints to
the center of the foot anteriorly, i.e., the second toe.
Thus the forefoot, in lifting over the fulcrum, is
slightly adducted, so thcit a degree of intoeing and
parallel action of the feet is natural and normal, and
is seen in all primitive people and those who walk
barefooted. Outward rotation (abduction) of the
feet, as taught civilized people, and practised to an
extreme in armies, is unnatural, not hygienic, and
should be condenmed. In weightbearing. while
standing, the feet are normally abducted, and the
internal malleolus seems to slide downward, because
of slight inward displacement of the astragalus.
This latter, the passive weightbearing. not walking,
attitude is assumed by the weak or flatfoot, and may
be called a fairly constant, early s\niptoni.

S8

iMEDICAL RECORD.

[Jan. 12, 1907

\\ hen ihe arch is originally low, or of eongeni-
tally weak, bony development, as is apt to be the
case in the rachitic, tuberculous, or so-called scrof-
ulous type of subjects, considerable deformity may
exist without pain or disability, due to early accom-
modation of the readily-yielding components. In
the beginning coUanse of the arch, the astragalus
and scaphoid are lowered and rotated inward ; this
is followed by a settling of the internal border of the
oscalcis and a depression of its anterior extremity.
This may progress to such a degree of dislocation as
finally to cause the entire inner sole to rest upon
the ground, producing a callosity.

The anterior and post-tibial nerves, directly sup-
plying sensation and motion to the ankle joint and
tarsus, will be the first, we may assume, to respond
to the irritation caused by the gradual continuous
change. In many, in fact at least 45 per cent, of
these cases, there is not only no localization of pain-
ful sensations in the lower parts, but even a high
degree of radiation, as above described, so that one
may infer a spreading or referring of pain by way
of the branches of the sacral and lumbar plexuses,
which would perhaps account for symptoms felt in
the regions of these cord-levels. Pains in the upper
parts (jf the back, trunk, and arms may possibly be
interpreted as due to strain in favoring the impaired
liml) by postural measures, thus further disturbing
the equilibrium eventually. It must also be borne
in mind that a great number of these patients are
neurotics, or otherwise physically below par, so that
even mild stimulation is reacted to e.xcessivelv and
extensively.

The ages of the individuals examined varied be-
tween 16 and 64 years : the majority were in the
second and third decade. The duration of the trou-
ble, counting from the time of beginning pains in
the feet or legs, was from one month to ten years,
83 per cent, of the cases being of the acute or sub-
acute form. The occupations represented here
agree well with those common! v cited as favoring the
development of weak or flatfoot, i.e. ( i) those requir-
ing much standing, particularly when limited to a
confined space (waiters, salesmen) ; (2) conditions re-
sulting in a weakening of structure from compara-
tive nonuse, those of sedentary habits especially,
with limbs in cramped positions, as tailors, squatting
on tables: (3) those calling for an excess of work
with consequent weakening, as in agents, canvassers,
and letter-carriers. To this latter class may be added
the large number of sewing-machine (foot-power)
operators, largely represented at this clinic by the
lower East Side Hebrews, some of whom were at
work before their fourteenth vear, turning the wheel
eight or ten hours daily.

Treatment. — Foremost is rest in the horizontal
position, to relie\e the feet and legs of all strain ;
passive and active manipulation of the parts, elec-
tricity, baths, and massage aid in eliminating in-
flammation. Fixation of the feet for a certain period
of time in a position of flexion, inversion, and adduc-
tion by means of strapping, bandaging, or in bad
cases plaster casts, is beneficial. In extreme cases
surgical measures may be necessarv to secure resto-
ration of function. Unfortunately, the majoritv of
our patients cannot afford this more thorough, but
slow, rest treatment, being compelled to earn their
daily bread ; they ask relief to enable them to con-
tinue their avocation.

Here the much vaunted arch supporters and
braces made of metal, leather, or hard rubber were
found on actual trial not to sustain the reputation
they undeservedly bear, unless properly fitted by the
orthopedist.

The wage-earner is best served bv shoes con-

structed on scientific jjrinciples — broad, substantial,
roomy, with stitT counters and built-up soles and
heels. Exercises carefully adapted to individual
needs, such as balancing on tiptoe, moderate danc-
ing, alternately raising the body on the toes or heels,
and inverting the feet are of great value.

122S Putnam .-Vvenue.

THE HYOSCINE SLEEP IX OBSTETRIC
PRACTICE.

Bv WOODBRIDGE H.AiL BIRCHMORE, .M.D.,

BROOKLYN, NEW YORK.

SixcE the rediscovery of the conditions under which
the deep sleep, resembling death in its soundness,
of which the tradition had come down through the
ages, could be produced, men in various parts of the
world have made use of it to obtain insensibility to
pain. -A. few have made use of it in the practice of
the obstetric art, and some have furnished to me
notes more or less complete of their experiences.
From their notes I have gathered certain facts which
I ha\e used to form the material for this thesis,
which may be considered, I believe, as a statement
of the conditions in fact and in practice, on which
that great improvement in the obstetric art for which
we have long been looking, may reasonably be
grounded.

The actual results which have been attained may
be summarily stated in very few words; the patient
slept, labor came on, and progressed in accord with
usual conditions, normally in relation to the details.
The labor was not prolonged, far otherwise, and in
no case was it needful to use an anesthetic, although
the forceps was used thrice. The only case in which
the mother showed any signs of awakening was not
one demanding interference. Xo results influencing
the infant unfavorably were observed, although most
anxiously looked for. Such is a summary of the
results, but that this summary may be duly appre-
ciated it is well to consider the whole proposition,
theorem, and demonstration in detail. The hyoscine
was administered hypodermically in doses of i-ioo
grain, in combination with morphine, 1-4 grain, and
cactin 1-67 grain. This amount was given in solu-
tion in I c.c. of water, and repeated as required.
Much stress is laid upon the absolute purity of the
ingredients for reasons which are obvious, but it is
of special moment when so small a dose as that of
the hyoscine is used that the nearest possible to abso-
lute jHirity should be attained.

As a rule, the remedv was given hypodermically,
but in one instance the first dose was given per os,
and, except for a delay in taking effect, no change
from the normal was seen. The first dose was given
as soon as the first stage of labor was certainly
begun, and was in most cases sufficient to hold the
patient un.til the so-called expulsive pains were dis-
tinctly pronounced. The instant the patient began
to show the least evidence of perception, the second
dose was given. In the cases requiring the aid of
the forceps a third dose was given in two instances,
but not in the third case, and probably the second
forceps case did not really need the third injection.

The effect upon the patient does not show the
variation which might in some sense have been
expected, so far as the depth of the sleep and the
length of it is concerned, nor did the doses have
the cumulative effect which might have been ex-
pected. On the question of the length of the nap
one group of cases suggests six hours as the normal
duration, while another group gives eight hours
from the time the second dose was given. But in
the case in which there was an eight-hours' sleej),

Jan. 12, 1907]

MEDICAL RECORD.

59

the time between the two doses was less than in those
in which the sleep was for six hours. The exact
relation between the doses and the length of the nap
is still very indeterminate.

In one instance onlv was any effect upon the un-
born child alleged. In this case the os uteri was
dilating, but slowly ; and, as the woman complained
of the exceeding severity of the "cutting and tearing-
pains,'' the physician gave the hyoscine by the mouth
rather sooner than the apparently best practice,
when the intention is to give the second dose as soon
as true labor begins. The mother had repeatedl\'
declared that "this child kicks something awful,"
and continued to complain for at least four hours
after the dose was given, at which time she was
becoming drowsy. She was soon fully under the
influence of the drug, the unsatisfactory pains of the
first stage continuing until she was fully asleep ;
after this they rapidly improved. The woman slept
onlv five hours, and when she awoke the os uteri
was still undilated. The pains continued after she
awakened in about the same force as during
her sleep, but she suffered much less than
before her nap. She now noted that the
child had ceased to kick, and it was some
hours before "the boy recommenced his exer-
cise, which he did gradually, and continued to cause
discomfort as long as he was able." The words are
his mother's, who, in describing the sensation, said :
"If he is such a kicker all his life he will make lots
of trouble." The os uteri was not fully dilated until
well on in the evening, and the mother having re-
ceived a second injection at the beginning of real
labor slept until after the birth of her child, becom-
ing somewhat restless at the end, but not regaining
consciousness until after the baby had been cared
for and all provisions made for the comfort of the
mother. In one other case there was strong evi-
dence that the baby was put to sleep, but in neither
case is it proper to regard the fact as actually
proven. All direct evidence of long-continued inter-
ference with the actions of the child after birth is
wanting, and in only one instance was any effect
positivel}- affirmed by the physician attending.

Apart from the influence upon the direct progress
of the labor, the eft'ect upon the mother was most
noteworthy, first as quite hindering the mental dis-
turbance which pain and suft'ering in all cases pro-
duce. The effect was fully covered by a remark
made by one who used it: "Objectively, as evi-
denced by the mother's condition, it appeared a pre-
posterous proposition to say that she had given birth
to a child." The mother shows no si.gns of exhaus-
tion, and although the resistance (passive) of the
tissues must be quite the same, it can be clearly seen
that no spasmodic resistance, by inhibition due to
pain, in any way interferes. This absence of the in-
hibitory (active) resistance is perhaps the most re-
markable effect produced. One woman whose labors
had been notably tedious was delivered of her fourth
and largest baby in less than two-thirds the time of
the shortest of her previous experiences, and in one-
third the time of her longest. She had always been
notably restless and hard to manage, but in this case
she simply slept through the whole series of phe-
nomena : she did not awaken until she had been re-
moved into a clean bed and provided with all things
needful. At the birth of the head, although soundly
sleeping, she made certain spasmodic actions and
changes of position which caused some surprise to
the nurse and attending physician. Although the
attending physician described them as carefully as
possible, the intention of his words is not clear
enough to my mind to justify any attempt to repeat
the account, Init the conviction is forced upon me, as

it were, that the physician's two statements, ''Her
actions showed that certain combined movements
should occur which are inhibited in the large ma-
jority of cases," and "It was as if I had seen the
natural action of a woman for the first time," really
contained an important truth.

If an attempt is made to describe the phenomena
from the time when the patient falls asleep in the
first stage of labor to the end of the slumber, it must
be admitted that the remarkable character of the
phenomena is too plain to be missed. If Byron Rob-
inson's theories are accepted in full, and we regard
the action of the muscles usually controlled by the
cerebrospinal system, we cannot but wonder at and
question how the coordination is maintained. In
two cases the woman rolled onto the left side, par-
tially flexed the left leg upon the thigh, and the thigh
upon the pelvis, so that the child was, or rather
would have been, supported and guided onto its back
bv the act of extrusion. The right lower extremity
extended to the extreme, the toes pressed against the
foot of the bed, gave a "fixed point" for the muscu-
lar leverage.

In the majority of cases the heels were brought
uj) close against the buttocks, and in these cases the
muscles were made tense, lifting the buttocks com-
pletely oft' the mattress at the instant of the birth of
the head, yet there was no sign of awakening. The
steadv, slowly increasing, and tremendous force
exerted by the abdominal muscles during the expul-
sive pains, attracted the attention of all observers.
One who has seen great numbers of labors said that
he never saw anything like it before, and added, in
an extended opinion, that the great advantage over
chloroform is easily seen in that, with the hyoscine
sleep, refle.xes are greatly augmented, not sup-
pressed.

All who have made use of hyoscine a few times
appear to regard this restoration of the truly natural
conditions as being of almost as much importance as
the unconsciousness from sleep. "If we use hyo-
scine the mother cannot do mischief by her own
excited and voluntary or semivoUmtary actions," is
a remark made by every user.

It appears probable at first sight that there must
be greatlv increas-jd danger of perineal rupture, and
I so suggested to some whom I was able to question.
All of Uiem said that proof of this jjroposition was
wanting, and one man said: "I am quite sure that
you are wrong in this opinion, for the rupture of the
perineum, when not due to the haste of the accou-
cheur, is due to the excitement of the mother. From
what I have seen I am inclined to re.gard the dilata-
tion of the perineum much as I regard the dilatation
of the os uteri. It is gradual, and the obstruction,
although usually needless now. must have been of
importance once. The waking mother makes con-
vulsive efforts to overcome the resistance of the
perineum, and when she feels the obstruction has a
titanic, if not a tetanic spasm, to force the head by,
and then the shoulder catches. But in the hyoscine
sleep the first perineal jiains are not convulsive, and,
instead of two or three ineffectual attempts ending in
an almost convulsion, the sleeping woman has a
dozen small pains gradually stretching the sphincter,
and, beside this, the head is not held so firmly
against the sphincter, or rather against the fold of
submucus tendon, that this cannot roll ; and after
once or twice trying the whole apparatus — tendon,
muscles, and mucous membrane — slips out of the
wav, and the last expulsive pain comes on. For my
part, I regard this use of hyoscine as important be-
cause it has restored the conditions of natural labor;
I know my expression is bad, but somehow hyoscine
gives the management of labor back to the reflex

6o

MEDICAL RECORD.

[Jan. 12, 1907

ganglia from which the brain had, in women, taken
it away."

Naturally, the obiection is made that in some ways
this theory proves too much ; that in the apes the
difference in position made the perineum a less im-
portant organ, but this objection is countered by
saying that we really know but little of labor in the
highest apes, and nothing of what it may have been
in other — the simio — human race. "Anyway, in the
hyoscine sleep the 'perineal pains' are more orderly,"
insisted this physician.

In the cases referred to in which the use of the
forceps w^as judged to be needful, the cases in no
way differed from others of their kind in which a
more transient insensibility is obtained bv the em-
ployment of familiar anesthetics, but owing to the
activity of the natural forces of parturition the de-
livery in fact rather suggested the use of the for-
ceps in the conscious woman's behalf than in that
of the unconscious one. No special details or un-
usual reasons for the use are recorded. Certainly
the use had no connection with the insensibility of
the patient. One or two suggestive facts were men-
tioned in this connection, as if the accoucheurs had
in their minds a strong suspicion, amounting almost
to a convinced opinion, that the conditions of the use
of the forceps would be found to differ, and perhaps
to differ profoundly, from the cause, which is by
many believed to be the cause most frequently de-
manding the use, namely the threatened exhaustion
of the mother. This because all who have made use
of this narcotic, without any exception, insist that
exhaustion, even to a small degree, is hardly to be
perceived. The absence of excitement, the regular-
ity, and above all the maturity of the expulsive
efforts, the fact that none of the vitality of the
mother is expended in useless and exhausting, be-
cause ineffectual and disorderly efforts, promises to
lessen greatly surgical interference, the special in-
terference demanded by the mother's exhausted
state.

Speculations and Conclusions. — Such data as are
given here must be regarded only as so many facts,
observed by competent and experienced men indeed,
but considered simply as facts they are quite barren
of usefulness, for it is only when we consider them
as the data to be examined by logical processes that
they, becoming living and productive, are the foun-
dation on which we can erect a useful theoretical
structure.

In the first place, the importance of the livoscine
sleep in obstetric practice is amply demonstrated,
and experience shows that it can give us all the aid
in quieting the patient that any narcotic can give,
and in addition it gives us a practical anesthesia of
prolonged duration, and gives this anesthesia with-
out risk to either mother or child. Further than
this, we have the most abundant proof that this
practically anesthetic sleep is quite without danger
because the respiratory system is in no way inter-
fered with, nor is the heart's action restrained. It is
also clear that the reflex actions which find their
point of departure peripherally and return to the
periphery again from spinal and sympathetic system
ganglia, specifically from the "pelvic brain" of Byron
Robinson, are not restrained, but rather thev are
augmented by the action of this drug. Clearly, then,
it is a drug sedative to the cerebrospinal a.xis, but
not to the ganglia connected with the reflexes of
common life.

This fact alone is of no trifling importance, but
the import grows when we note that in shutting the
door, so to say, to the influence of all the inhibitory
actions, it leaves quite unopposed the influence of
the sympathetic system, and the physician using it

need have no fear of any accidents to disturb the
normal evolution of a birth.

It is, then, for the accoucheur the ideal anesthetic,
one which so far as we yet know he can use to obtain
the desired effect without fear of an overdose. So
far as I have been able to learn no one has yet had
any experience with an excessive dose. Until this
excessive dose shall have been given our informa-
tion remains in a sense defective, but we certainly
know that all we need to give can be given without
risk or danger.

Finally, and perhaps of all the most important,
this use of hyoscine has stripped motherhood of its
horrors. The dread of pain has been the great dread
of the coming birth ; until this discovery the "pains
of maternity" remained a horrid and incontestible
truth, but these have vanished and the exhausting
ordeal of motherhood is gone, to be seen no more.

163 Fulton Street.

WORKING FORMULA TO FACILIT.^TE

THE PERCENTAGE MODIFICATION

OF MILK.

By CHARLES J. DILLO.V, M.D..

NEW YORK.

CLINICAL ASSISTANT. DEPART.MENT OF PEDIATRICS. BBLLBVUB ASD
UNIVERSITY MEDICAL SCHOOL.

The percentage modification of cow's milk now so
generally used for the feeding of infants has brought
with it a plague of petty mathematics, from which
the practitioner is wont to shelter in the kindly and
accommodating "round number," and accuracy is
sacrificed to convenience.

Accuracy is a very desirable quality in milk modi-
fication, and the following contracted formulas, while
simple, will certainly be found serviceable in this re-
spect. They are simple enough to be remembered,
but perhaps a better plan would be to have thera
on a card for easy reference. They are designed for
the rapid and accurate determination, for a definite
quantity of a given modification, (I.) of the per-
centage cream necessary for dilution, (II.) of the
quantity of the cream required, and finally (III.)
of the quantity of gravity, or 16 per cent, cream re-
quired, which w'hen diluted with whole milk will
give a percentage cream as determined by I., and
to the quantity determined by II.

Rule 1. — The fat percentage (f) of the modifica-
tion multiplied by 4 and divided by the proteid per-
centage (p) of the modification will give the fat
percentage of the cream required for dilution, or,

f X 4
graphically : = fat percentage of cream re-
quired.

Rule II. — The total quantity in ounces (n) of the
modification multiplied by the proteid percentage
(p) and divided by 4, will give the ounces of cream

, f ■•, ■ n X P ,

required for dilution : ^ = ounces of cream

required.

Rule III. — To determine the quantity of 16 per
cent, cream required to make, with a proper quan-
tity of milk, a desired quantitv (N) of cream of a

stated fat percentage (F) : ' — ^ ^ :^ ounces of

16 per cent, cream required.

To make an application of these rules we will
suppose that we require 48 ounces of a 4-7-2 modi-
fication.

fX4 , • , .

— = percentage cream required, m

Bv Rule I.

this case

4X4 16

^ 8 per cent, cream.

Jan. 12, 1907]

MEDICAL RECORD.

61

By Rule II.

n X p

: nuantity of 8 per cent.

. ^, . 48X2 96

cream, in this case — = — = 24 ounces.

.44
Having ascertained by the two previous equations
the quantity and fat percentage of the cream re-
quired, 24 ounces of S per cent, cream, we have still
to derive that cream from the gravitv cream, and, bv
Rule III.,

N(F-
12

•4) = ,

cream re-

: quantity of 16 per cent.

■ , • , • 24 (8 — 4) 96 „

quired, in this case = — :^ 8 ounces, 16

^ 12 12 '

per cent, cream. Here we have quickly and accu-
rately determined that, to make 48 ounces of a 4-7-2
modification, we require 24 ounces of 8 per cent,
cream, or its equivalent, 8 ounces of 16 per cent,
cream, and 16 ounces of whole milk.

Of course one can see at a glance the percentage
cream and quantities necessary for a 4-7-2 modifica-
tion, but in many cases they are not so obvious, and
in these the formulae will be found particularly ad-
vantageous.

Contracted for easy reference, the formulas would
be as follows :

= fat percentage of cream required to

I.

make a modification with fat at f per cent.

-T n X P

II. = quantity m ounces of cream re-
quired to make n ounces of modification.

In Rule I. and II. p is the proteid percentage of
the modification.

,^T N (F— 4) . , ^

III. ■ = quantity of 16 per cent, cream

required to make N quantity of cream with a fat

percentage of F.

Since Rule III. is based on a general formula for

the reduction of a cream of a certain fat percentage

to one of a lower fat percentage, those who use a 12

per cent, cream for their modifications may modify

Rule III. for 12 per cent, cream as follows :

N (F— 4)

— ^^-^--J^ = quantitv of 12 per cent, cream re-
o

quired to make N ounces of cream of a fat percent-
age of F.

! 306 West Ninety-fipth Street.

Poison Ivy. — A. Hadden has observed that, if the
skin is moist from perspiration, the poison of rhus is more
apt to take effect than when the skin is dry. The poison
is more active during the summer months and the last two
months of spring and the first two months of autumn. It
does not seem to be active during the other months of
the year. The nature of this poison has not yet been clearly
defined. On the leaf and stem of this vine there is a fine,
hairy formation on both the upper and lower sides. To
this is attributed the chief agency of communication of
the poison. Both flies and mosquitos are doubtless the
carriers of these small, hairy particles as well as of the
sap to many sensitive skins. It is doubtless these insects
instead of the innocent breezes which carry this poison. The
writer advises those with skins sensitive to the poison to
wear veils and gloves when in the vicinity of the vine.
He has had the greatest success in the treatment of the
poison by means of Labarraque solution, a solution of
chlorinated soda. In the first stage it mav be used in full
strength, but should be washed off at once with cold water.
This is followed by an application of a weak solution
of the same in the proportion of a tablespoonful of the
solution to a pint of water, by means of a fold of cotton

or linen fabric kept constantly applied for several hours.
The application of Labarraque has never failed in the
writer's hands. — Medical Rcricw of Rcz'ii'zcs.

Sahli's Desmoid Reaction in Gastric Diagnosis.—
Thomas R. Boggs describes Sahli's desmoid reaction. In
order to carry out this test a pill of methylene blue or
iodoform, or both together, is placed in a rubber sack.
This sack is made by twisting the pill in the center of
a square piece of thin rubber dam. The twisted neck is
tied with three turns of number 00 raw catgut previously
soaked until soft in cold water. The knots are made on
the same side of the bag. This test causes the patient no
distress, and, as it is given at the principal meal, it is
subjected to the activities of the gastric functions when
they are at the height of their stimulation. The desmoid
pill is relatively heavy and so remains in the stomach for
the maximum length of time. It thus fully tests the
activity of the gastric juice. It often gives a positive result
when, with the test breakfast, an absence of free hydro-
chloric acid is indicated. .A.s Sahli pointed out, this is a
matter of considerable diagnostic importance in distinguish-
ing cases with true achylia, car?inoma, or pernicious anemia
from less serious disorders in which the Ewald breakfast
is insufficient to cause an excess of hydrochloric acid. The
writer has examined thirty-four cases in which there was
impairment of the gastric function, in addition to twelve
normal persons. The latter were all positive. In the car-
cinoma cases, all but one gave a negative test. This
patient was an ignorant negro in whose case the test was
unsatisfactory and unfortunately could not be repeated. All
of the seven cases of pernicious anemia gave negative tests
.\ case of secondary anemia of long duration gave a positive
test. Various other interesting negative tests were ob-
served. In each case with two exceptions the result of t'lc
test was compared with the findings of the Ewald breakf '-t
or Fischer's meal, or both. The results of these ex' r;
ments. which are given in a tabulated form, seem.; to
bear out Sahli's contention that the desmo'd pill d'-'i-^ <\\->w
the ability of the stomach under the best conditioi.- Ih--
writer believes that its principal value is as a test fi . 're ■
HCl. As he says, it cannot replace the test meal, but is
a useful adjunct to this essential measure. In the stools of
the negative cases the pills which were found showed no
evidence of digestion, yet in most cases the intestinal diges-
tion of foods, including meats, was good. The writer de-
clares that this fact speaks strongly for the specificity of
tlie test for gastric digestion. — Bulletin of the Johns Hop-
kins Hospital.

Venous Compression as a Diagnostic Method in the
Case of a Latent Roseola. — Rene Hornad cites the case
of a patient in Jaboulay's service. This patient had en-
tered the hospital with an anal fistula. The man had had
a chancre. A distinct roseola was noted on the front of
the abdomen of this patient. Stasis of the blood current
brought about by venous compression rendered the roseola
far more evident. .A.n elastic rubber band is a simple
means for causing this compression, although a cloth band-
age will be of equal service. When this is put around
the arm, for example, the color soon becomes violet in
hue and the spots of the eruption, which may be latent,
become apparent, red, copper-colored, and, Hvid. The writer
has been able by this means, in some cases, to detect a
roseola when it could not be seen even with a blue glass.
Venous compression might be applied for the early diag-
nosis of eruptions other than specific. — Lyon Medical

The Rapidity of Absorption of Odors by Milk.— F.

Bordas and Toutplain have determined, in their researches
which they have made with the aid of formic aldehyde,
that this is absorbed most rapidly by milk which has been
freshly drawn. This absorption of aldehyde by milk is so
rapid that it has been suggested to use the impregnated
milk for revealing traces of formic aldehyde in the air.—
La Presse Mcdicale.

62

MEDICAL RECORD.

[Jan. 12, 1907

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A M., M.D., Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, January 12, 1907.

THE LOXGEVITY OF COLLEGE ATHLETES.

A v.\LU..\DLE contribution to the literature of this
subject has recently been made by Dr. W. G. Ander-
son, the head of the Yale gymnasium. He notes the
general impression that the star athletes from Amer-
ican colleges do not live as long as do their less
athletic fellows. ".A good many people claim," he
says, "that the highly-developed athlete has more
muscle and more lung power than he can use when
he graduates and takes up his long apprenticeship
in some sedentary occupation. If he is not careful
the very jiower of lung and heart which made him
a force in the long four-mile pull, if he be a crew
man. becomes a danger to him, because there is no
call in his every-day life for the abnormal develop-
ment he acquired in college. If he does not keep
up some prettv vigorous exercise outside of ofifice
hi "s the lu:.g tissue developed in his college life
falls into 'Ii^use and may be the indirect cause of
con-;ini->tion, cr the heart, forced to do overwork
in th: strain of the competition in the big sports, and
ovcicleveloped, may retaliate in after life by refusing
to do its work in some great stress, like pneumonia,
for instance."

The athletic records of Yale show that between
the years 1855 and 1905 the number of men who
gained positions on either the crew, baseball, foot-
ball, or track teams was 807. Of this number 58
have died. Of these 58, 18 were crew men (natu-
rally as this is the oldest sport), 16 were football
men, 13 track, and 11 baseball men. If an estimate
be made on the basis of the average of years in the
life of the sport it is found that the greatest mor-
tality has occurred among the football men. Crew
men were second, track men third, and baseball men
fourth with an extremely low average. Compared
with the select mortality tables of the Actuarial Soci-
ety made up from mortality averages all over the
country, the athletes show a remarkable longevity.

As contrasted with these figures are those col-
lected b\- Dr. Anderson as to the mortality of the
general graduates, who have not won team positions,
though many of them have doubtless done more or
less systematic athletic work. During the fifty years
above stated 10,922 men have been graduated from
the academic and scientific departments. Of this num-
ber 1,406 have died; that is 12.9 per cent., as
against 7.2 per cent, of the athletes. Consumption
carried off 12 of the 58 deceased athletes, but this
percentage is not greater than would be expected
among nonathletes from a similar cause, as is proven
by reference to the records of the large insurance
companies. "Deaths from heart disease in the list

of 58 men were 4 at the ages of thirty-five, fifty-
seven, sixty-eight, and 'eventy. The average is
ver\- low. Pneumonia carried of? 6, typhoid fever 5,
and tyi)hoid pneumonia 2. Those who wish to push
their argument that high athletics are bad for the
lungs and heart might find some ground for that
argument in the fact that 24 of the 58 deaths were
caused by lung trouble of various kinds, and heart
failure. The table of deaths further shows that 9
of the 58 athletes met violent deaths, of which 2
were suicides. One died of dissipation, which was
not traceable to participation in athletics."

Dr. Anderson's paper is all the more valuable
because it is temperate in tone. He is not seeking
to prove or disprove any particular theory, but is
content to let the facts and figures speak for them-
selves. He declares that the "inevitable conclusion
from the figures gathered is that the Yale man
who came to high honors in the major sports of
the last half century has more than the ordinary
man"s share of long life." But he freely admits that
"whether this is due to his high development as an
athlete or to the original strength of the man himself
is still unproven, and seems likely to remain so
unless some more perfect means of comparison can
be found."

FETAL MALFORMATIONS.

Among the aspects of the obstetric art to which
little attention is paid by the general practitioner is
the subject of fetal deformities. This may possibly
be due to the vagueness of the etiology of the subject
and the comparative rarity of such malformations of
the major grades, for many physicians never meet
with an instance of this kind even during years of
practice. The condition has provoked much dis-
cussion, but no satisfactory explanation has yet been
advanced. Heredity may perhaps play some part in
the production of deformities of a minor degree such
as hypospadias, harelip, etc., but monstrosities in
the generallv accepted sense can hardly ever be of
direct hereditary origin as the subjects of these
rarely arrive at a stage wdiere procreation is possible.
The so-called maternal impression theory is ordinar-
ily assumed by the laity to afford a sufficient explan-
ation of such anomalies, and some physicians also
give credence to a belief which has been repeatedly
shown to be, in most cases at least, without founda-
tion, for the shock or other disturbance experienced
bv the mother is usually felt at a period when the
fetus has already reached a stage of perfect anatomi-
cal development when it seems impossible that
further changes can take place.

In a recent article by Cooke in the American
Journal of Obstetrics for December, 1906, the writer
points out that some relation exists between the
production of fetal deformities and the quantity and
quality of the liquor amnii and even claims that the
diagnosis of these changes has a prognostic value.
He has observed that this anomaly is frequently
accompanied by maldevelopment in the infant and
cites seven cases of oligohydramnios or polyhy-
dramnios in which the fetus was malfomied — and
in five out of the series the condition was foretold
before birth. Even the type of malformation can,
according to Cooke, be foretold in a general w-ay,
for while deformities of the trunk seem to occur in

Jan. 12, 1907]

MEDICAL RECORD.

03

cases of polyhydramnios, loss or shortening of the
extremities is more usual when oligohydramnios is
present.

The amniotic bands which are believed to cause the
latter class of deformities are not always present,
and it is more probable that the malformations are
due to destructive atrophy of the parts brought
about by direct pressure of the uterine wall unre-
lieved by the interposition of the normal amount of
amniotic fluid. In connection with this theory there
are still a number of points unaccounted for, but the
prognostic feature of the writer's statement is in-
teresting. So long as nothing can be done to correct
the condition, however, it may be just as well for
the medical attendant to guard the knowledge so
acquired very closely, for it will without doubt prove
unwelcome to the prospective parents and their kin,
and — well, "sufficient unto the day is the evil
thereof."'

The Urine in Psori.xsis.

The attempt to determine by analysis of tlie urine
the faults of metabolism which are believed by many
to be the ultimate cause of various eruptions, has
been made so often, and with such uniform ill-suc-
cess, that an investigation which promises even an
explanation of the failures is most welcome. In their
report on the urine of psoriatics, Brocq and Ayrignac
{Aiiiialcs (Ic Dermatologie et de Syphiligra/^hic.
Mav, iQC'i) lay particular stress upon two precau-
tions which are often neglected, and the neglect of
which would vitiate any experiment. In the first
place, they give an exact definition of psoriasis, lim-
iting it, for the purpose of this investigation, to casc.>-
showing characteristic clinical symptoms and exclud-
ing all those about which dispute is possible. There
are so many cases of doubtful diagnosis, cases show-
ing every jwssible gradation from frank psoriasis on
the one hand to typical dermatitis sel;>orrh(eica on the
other, that this restriction of the investigation to an
easily recognized group is the only wav to avoid the
chance of including cases which later study may
prove to be not psoriasis at all. The same pre-
caution should be observed in dealing with eczema
and other dermatoses also. In the secinul place, thry
show that there is no one normal urine for all
healthy individuals, but that each form of diet in a
healthy subject has a corresponding urine, and that
the variation caused by diet in a healthy subject is
greater than the difference between the urine of a
liealthy person on a fixed diet and that of a psoriatic
•on the same diet. It is absolutely necessary, there-
fore, to know e.xactly what diet a patient is taking,
and what kind of urine would be secreted bv a
health)- jierson living on the same diet, if we are to
discover the changes caused by disease. Of course
this is an old story, but if we may judge from the
broad conclusions sometimes drawn from experi-
ments in wdiich this factor is neglected, the lesson
it teaches is still needed. The iiuportance of these
precautions is, indeed, the most instructive part of
the article, for the results of repeated and careful
analyses were so often contradictory that the authors
have been forced to conclude that the study of the
diflferent urological coefficients does not by any
means establish a urinary formula characteristic of
psoriasis. It seems to be unquestionable that all
patients subject to psoriasis sufifer from some kind of
nutritive disorder, but the character of the disorder
varies in different cases.

Fever of Pregn.\ncy.

PiiYsici.-\NS are by no means at one in regard to
this peculiar affection. It has been described by
various investigators, among whom are Tarnier and
Ahlfeld. In general, it is classified as acute and
subacute or chronic. Edgar believes these to be
entirely separate conditions. He says that the acute
fever of pregnancy bears a likeness to such condi-
tions as acute miliary tuberculosis, typhoid fever,
and septicemia. The chronic type, however, seems
to be a neurosis with participation of the heat center.
From a clinical point of view it often resembles a
confirmed phthisis. Among those who are opposed
to the use of this term "fever of pregnancy" is Klein-
wiichter. He does not believe that this condition is
an indication for the termination of pregnancy. In
the Revue Mcdicale de la Suisse Rouiande. of No-
vember 20, igo6, Rene Koenig reports work that has
1)een done on this subject in Jentzer's gynecological
and obstetrical clinic of Tieneva. From the experi-
ence gained from the study of this affection in that
clinic, the importance, in face of an abnormal rise of
temperature in pregnancy, of never losing sight of
the possibility of the existence of appendicitis or of
pyelonephritis is emphasized. Pyelonephritis is al-
ways easy to diagnose when one thinks of it. In the
liresence of symptoms of ]ieritonism when an affec-
tion of the urinary passages can be excluded surgical
intervention should not be too long delayed. It is bet-
terto practise an unnecessary laparotomy than towaiL
for symptoms which clinch the diagnosis of general-
ized peritonitis. As to appendicitis occurring during
pregnancy, Atunde published the first well-estab-
lished case in the Mkuical Riccord of December i,
1894. In 1898 Fraenkel reported thirteen cases and
Pinard forty. In 1S99 Koenig succeeded in collect-
ing nearly one hundred. Since these reports many
observations have been made on this condition.
Appendicitis is a complication fairly rare in the
puerperium. As to appendicitis in pregnancy the
pessimistic statistics which exist hardly represent
conditions as they really are. for many slight ca^es
are ne\-er reported, and indeed many are not even
noterl. The diagnosis of appendicitis in pregnancv
is not often easy, and in some cases it presents in-
surmountable difficulties, ^'arious opinions are held
concerning the treatment for this condition, Prophv-
laxis plays an important role.

The TRE.\TiMENT OF G0NORRIIE.\L EPIDIDYMITIS.

In preantiseptic tiines French surgeons sometimes
treated cases of this affection by incision with the
idea of relieving tension. The frequent occurrence
of infection, suppuration, and even necrosis brought
the method into discredit, however, and for years
the treatment of this complication of specific ure-
thritis has been a verv conber\ativc one. .\ return
in principle to the methods of the French surgeons
is suggested by Schindler {Deutsche niediciuiselie
Woclienschrift, December 20, 1006), who seeks to
relie\'e the tension due to the swelling of the eiii-
did\iuis bv puncture, and if possible, aspiration.
The punctures are made at the point where the ten-
derness is greatest, and if no secretion can lie aspi-
rated, are repeated several times in different direc-
tions. Strange to say, the author has not found
that the procedure is at all painful, and he directs
that it should be carried out without any attempt
at local anesthesia, as the latter serves only to
increase the discomfort of the patient. The eft'ect
of the puncture is seen in the prompt relief of
pain, in the subsidence of the fever, and in the rapid

64

MEDICAL RECORD.

[Jan. 12, 1907

resolution of the induration. The author made use
of this method in t\vent_v-three cases of gonorrheal
epididymitis, performing forty-four punctures on
these patients, and found that, as compared with
the conservative method of treatment by rest in bed
and local applications, the duration of the detention
from work was reduced by about one-half. He
also tested in a series of cases a form of Bier's
treatment by hyperemia, but although the results
obtained were encouraging he does not consider
that the method is as satisfactory as the treatment
by puncture. He has not yet tried the combination
of the two, though it is not impossible that by this
means still better results might be obtained, for,
unfortunately, even the punctures do not cause com-
plete absorption of the exudate and restoration of
the epididymis to its normal condition to take place.
Even though this suggestion of Schindler's should
prove as successful in other hands as in his own,
the most important consideration in connection with
gonorrheal epididymitis will still consist in prophy-
laxis, first on the part of the physician, who by
judicious treatment must prevent the infection from
penetrating to the posterior urethra, and second on
the part of the patient, who must be educated to
seek proper medical advice at the earliest indication
of infection, and thus render the task of the physi-
cian less difficult. The second requirement is, how-
ever, one which the circumstances in the case unfor-
tunatelv render verv difficult of fulfilment.

E.xpi.0R.\T0RY Puncture of the Brain.

The exploring needle has long been regarded as one
of the most useful aids to the diagnostician and there
are now but few recesses of the body that have not
been subjected to this mode of inquiry. Kocher,
some years ago, suggested exploratory puncture of
the brain through fine drill holes made in the cal-
varium. and subsequently the method was developed
and a careful technique described by Neisser and
Pollack. These authors perforated the skull by
means of drills of small diameter operated by an
electric motor. Although they reported favor-
able results in a considerable number of cases,
the method has not seemed to find ready acceptance,
and it is therefore interesting to note that it has
gained another supporter in Ascoli (Berliner klin-
ische Wochenschrift, December 17, 1906), who
gives the histories of six cases in which more or
less important diagnostic information was obtained
by this means. The method followed w-as in most
particulars that of Neisser and Pollack, though the
drills were actuated simply by means of an ordinary
dental engine. Ascoli speaks of the technique as
not being especially difficult, and states that the
procedure can be carried out under cocaine anes-
thesia without causing undue discomfort. In none
of his cases does it appear that any undesirable
results followed the twelve punctures made, though,
of course, this is by no means a guarantee of the
harmlessness of the procedure, and numerous un-
pleasant possibilities at once suggest themselves.
Still it must be borne in mind that patients for
whom such a method would come in question are
likel\- to be already in a precarious state, and explor-
atory puncture is probably a less serious procedure
than the exploratory trephining that is oftentimes
recommended. Brain surgery has progressed so
greatly of recent years that a method which, like
the one advocated by .A.scoli in the article referred
to, has some prospect of utility deserves at least to
be tested and have its actual value definitely deter-
mined.

Mimicry of Malign.^nt Dise.\se of the Bowel.

Disappearance of tumors supposed to be malignant
is common enough, and sometimes operation dis-
closes a very different state of affairs from that
assumed to exist. At a recent meeting of the Lon-
don Clinical Society (British Medical Journal, De-
cember 22) Air, Moynihan reported six cases in
which he had operated within the last few years
in which a diagnosis of malignant disease of the
intestine had been made at the time of operation or
before, yet subsequent examination of the specimens
or the after-history of the patients showed the in-
correctness of the diagnosis. For instance, a woman
of twenty-nine years had intestinal obstruction due
to a growth blocking the rectum. Left inguinal
colotomv was performed, and six weeks later the
whole of the rectum and sigmoid flexure below the
colotoniy opening were removed by the abdomino-
perineal route. Examination of the specimen, which
was shown, revealed no evidence of malignant dis-
ease. The rectal walls were thickened and stenosed.
TJie mucous surface showed heaped-up, irregular
masses of soft growth, here and .there ulcerated
to a degree which resulted in festoons of mucous
membrane being left, attached at each end, free in
the middle. There was no evidence of tubercle or
syphilis. . The other histories are similar. Mr.
Moynihan observed that mimicry of malignant dis-
ease in the cecum and ascending colon by a hyper-
plastic process was w-ell known. Inflammatory
tumors presenting all the clinical appearances of
cancer may exist in all parts of the large intestine.
Some of these may be due to the presence of false
diverticula. Such cases are analogous to those
tumors of the stomach which disappear after gastro-
enterostomv.

The Effect of the Tropical Sun on P.\tho-
genic Bacteria.

The well-known resistance to infection exhibited by
the natives of tropical Africa has led to the conclu-
sion that the natural protective powers of these
individuals are developed to an unusual degree.
According to the reports of surgeons who have
practised in these regions injuries of all sorts, even
when brought under observation with the most
unaseptic sort of first-aid dressings, heal without
suppurative complications, and primary union is
often obtained in the most unpromising wounds. It
is rather unlikel}-. however, that the benign course
observed in such cases is altogether to be put to the
credit of the black man's fortunate idiosyncrasy and
it' is probable that to some extent at least the pre-
vailing paucity of pathogenic bacteria may have
something to do with the absence of the proneness to
infection that exists in civilized regions. An inter-
esting communication by Martin (Mihichener medi-
cinischc Wochenschrift, December 18, 1906). bears
witness to this opinion, for his experiments appear
to indicate that the climatic conditions in the tropics
are more actively hostile to bacterial life than is
usually supposed. This observer occupies an official
position in a German colony in tropical Africa,
where the average temperature during the eight
warm months is jy° F. at six in the morning, 144°
in the noonday sun, and "jy" again at night. These
extreme fluctuations in temperature were considered
by the author as likely to be particularly unfavorable
to bacterial life, and he tested the matter by exposing
in various ways pure and mixed cultures of various
pathogenic organisms to the influence of the sun
and air. He also tested the bacterial contents of
the air both indoors and out, and of the soil. .\1!

Jan. 12, 1907]

MEDICAL RECORD.

of these experiments lead him to the conclusion
that in tropical regions there is a well-marked
scarcity of pathogenic bacteria. This is probably
in great measure due to the sun's heat, though un-
doubtedly considerable importance also attaches to
the bactericidal effect of the light rays. It was
found that a number of nonpathogenic organisms
were not susceptible to these influences, however.
A series of tests of sand taken from the shore
leads to the interesting conclusion that the mechani-
cal action of the surf appears to render sterile the
sand on beaches exposed to the action of the waves.

Neuronophagia.

DtJRiXG recent years the study of the nervous sys-
tem has absorbed the attention of various brilliant
investigators. Many problems are yet in the realms
of obscurity, and any new and careful work is wel-
comed, not only by the neurologist, but also by the
general practitioner. The recent reports by Laignel-
Lavastine and Roger Voisin of the laboratory in-
vestigations which have been carried on in connec-
tion with the Laennec Medical Clinic (L. Landouzy),
and that of Jules Voisin at the Salpetriere are of
the greatest interest. It is known, as these workers
state, that when the central nervous system in
animals killed in full health is examined there
are seen among the various nerve cells only certain
slightlv colored nuclei which correspond to neu-
roglia without any tendency to agglomeration, either
perivascular or pericellular. On the contrary, when
one examines the central nervous system of an ani-
mal which has succumbed to any affection whatso-
ever, the following condition can be seen : all about
the nerve cell there are small rounded nuclei, vari-
able in appearance and in color, some of which are
in relation with the protoplasm of the cell, and some
of which even encroach upon the nerve tissue. Here
the cellular protoplasm has disappeared. This dis-
appearance resembles the figures of phagocytosis.
Many authorities have supposed that the pericellular
nuclei attack and digest the cell, and Marinesco has
named these small, round elements neurcphages or
neuronophages. and the phenomenon itself neu-
ronophagia. The writers conclude that these forms
spoken of do exist. The neuronophages are never
united in all parts in the cellular protoplasm. They
are diverse in nature (neuroglia nuclei, lympocytes,
polynuclears, connective tissue cells, endothelial cells,
plasma cells), and in origin (ectodermic and meso-
dermic). From their appearance one cannot al-
ways infer their nature : it is necessary to make a
complete examination of the anatomo-pathological
concomitants. Their role depends upon their origin.
The elements of ectodermic origin play the role
alone of substitution. Among the elements of meso-
dermic origin Laignel-Lavastine and Voisin have
not determined anv neuronophage, properly speak-
ing, in the sense of MetchnikofT ; but the lympocytes,
if they are not cytophages, may produce cytolysis.
It is then in this cytolitic role alone that these cells
called neuronophages are found. Neuronophagia,
therefore, considered as a special case of phago-
cytosis, properly speaking does not exist.

erative apparatus or other organs of the mother.
The theories of the first group may again be divided
into two classes, according to whether the etiological
factor is assumed to reside in the fetus itself or in
the fetal adnexa. The theories of the second group
are based on changes in the uterus or its appendages.
Those of the third are distinguished by the fact that
the nervous system, the urinary apparatus, or the
digestive tract is regarded as the source of the diffi-
culty. Stella, who has recently studied this sub-
ject'(Ga:;r<?«a degli OspedaU, No. 126, 1906), con-
siders that the symptoms of the hyperemesis of preg-
nancy can be directly attributed to the fact that
during this time there is a restriction in the internal
secretion produced by the ovaries. If such were the
case it is possible that the abnormality might be
corrected by the administration of ovarian extract.
The writer resorted to this in a number of cases,
which although insufificient in number to warrant
drawing definite conclusions, demonstrate so far
as thev go the possibility of truth in the theory. In
no case at any rate was the effect of these prepara-
tions entirely negative. In submitting the proposi-
tion to further trial, it is also suggested that the
ovarian extract be given with a prophylactic intent
in cases in which certain gastrointestinal disturb-
ances indicate the possibility of further trouble. As
the treatment is entirely harmless, Stella holds that
it should be tried in every instance before abortion is
resorted to.

A New Theory of the Pathogenesis of Hyper-
emesis Gravidarum.

The numerous theories which have been advanced
to account for the production of this condition may
with advantage be classed in three groups, depend-
ing on whether the cause resides in the uterine con-
tents or in secondarv changes in the maternal ccen-

Pneumonia Paralyses.
The paralytic affections which have been observed
in adults during the course of a pneumonia or in
convalescence are subject to considerable variation
in their clinical manifestations. This, according to
Daireaux, depends on the age of the patient. Those
of very advanced years are subject to hemiplegias
which always end fatally. In younger individuals,
although the svmptoms may be very severe, they
are more apt tn be recovered from. Daireaux
had occasion to observe a case in which the hemi-
plegia following pneumonia was of this transitory
type, and a few other instances have been reported
in the literature. The general paralyses are char-
acterized by a polyneuritis or, in exceptional cases,
as in one reported in the Archives gencrales dc
Medecine, No. 36, 1906, by poliomyelitis. The
damage to the nervous system in these cases can
most likelv be accounted for by the direct action of
the toxins of the disease on the nervous system.
Observations of this character are in thorough ac-
cord with the modern idea that pneumonia is a
general, rather than a local disease, in which, as in
most infectious diseases, the peripheral nerves as
well as the spinal cells may be damaged. The com-
paratively short-lived character of the pneumo-
coccus, as well as the short period during which the
toxins are being developed, mav serve to account for
the transitory character of the paralyses in younger
patients. Those which occur in more advanced
years, however, during or after a pneumonia, must
be attributed to disease of the cerebral vessels,
which constitutes a complication rather than the
result of an infection.

The New York Neurological Society. — .\t the

annual meeting of this society, held on January 8.
1907. the following officers were elected : President,
Dr. Charles L. Dana ; Vice-Presidents. Drs. B. Sachs
and L. Pierce Clark ; Corresponding Secretary, Dr.
Hallock: Recording Secretary. Dr. E. G. Zabriskie;
Treasurer, Dr. Graeme M. Ilammond.

66

MEDICAL RECORD.

[Jan. 12, 1907

3^fui0 of thr HJrrk-

Lectures on Insanity. — The Psychiatrical So-
cietv of New York has arranged for a series of four
lectures on the problems of insanity, to be held
rnder the auspices of the Academy of Medicine, on
Saturdays, January 19, February 2, February 16,
and March 2, 1907, at 8:30 p. m. The purpose of
these lectures is to put within the reach of the med-
ical profession and also of the non-professional
leaders of sociological interests a program of work
and facts for orientation, with a view to the
organization of a movement toward prophylaxis and
the development of sound interest in this eminently
important topic. The first lecture will be given by
Dr. Adolf Meyer, on modern psychiatry, its possi-
bilities and opportunities ; the second lecture, by Dr.
August Hoch, on the manageable causes of insanity,
exclusive of heredity ; the third lecture by Dr. C. L.
Dana, on the data of heredity and their application
in psychiatry ; and the fourth lecture by Dr. Allen
]\IcLane Hamilton, on the development of the legal
regulations concerning the insane. Physicians and
others interested in a movement toward prophylaxis
and the best management of mental disorders are
cordially invited.

Typhoid Fever in Scranton. — Impro\ement is
reported in the typhoid situation at Scranton as the
number of new cases is diminishing, although it is
admitted that the entire water supply is contami-
nated and the disease is also appearing in the sur-
rounding localities. The number of cases so far
reported is over one thousand, and over fifty deaths
have occurred. In Pittsburg also the water supply
is infected, and the situation is serious owing to the
overcrowding of the hospitals.

In Memoriam of Dr. Mary Putnam Jacobi.
— At the memorial meeting in honor of the late Dr.
Mar\- Putnam Jacobi held on January 4 at the
Academy of Medicine, the Women's !\Iedical Asso-
ciation agreed to raise a fund of $25,000 to estab-
lish the ^larv Putnam Jacobi Fellowship, the income
from which is to be used to defray the expenses of
some woman medical student in whatever country
she chooses to study. It was announced that about
S2.000 had already been pledged. Eulogies were
pronounced by Dr. \MlIiam Osier, Richard Watson
Gilder, Dr. Elizabeth M. Cushier, Afrs. Florence
Kelley, Felix Adler, and Dr. Charles L. Dana.

New Training School for Bellevue. — Plans have
been filed for the new si.x-story fireproof training
school for women nurses for I3elleyue and Allied
Hospitals, to be erected at a cost of $575,000, in
Twentv-sixth street, east of First avenue. It is to
have a frontage of one hundred and fifty-one feet
and a depth of one hundred and ninety-four and
one-half feet. The main floor will contain the as-
sembly hall and a dining hall, and the second floor
will have a laboratory. The other floors will be
fitted with sleeping chambers, and there will be a
roof garden with a pergola ornamented with terra
cotta columns. The building is to cost $575,000.

Antivivisection Petition. — .\ monster petition
was presented last month to tlie British House of
Commons in behalf of the National Canine Defence
League. It was announced that this document con-
sisted of nine miles of parchment, weighing a
quarter of a ton, and was subscribed to by 400,000
signatories. The petitioners set forth that they were
opposed to the vivisection of dogs, and prayed the
House to pass a Dogs' Protection Bill, which should
prevent those animals from being made the subject
of experiment.

Changes Recommended for the Cook County
(111.) Hospital. — In his inaugural message, Ed-
ward J. Brundage, President of the Board of Com-
missioners of Cook Count}', recommends among
other things that in every abnormal case admitted
to the Cook County Hospital, Chicago, the patient
should receive the attention of an expert pathologist,
and in order that the service may be brought up to
the required standard of efficiency, he advocates
reorganizing the present pathological department.
He believes an effective reorganization may be ac-
complished by employing an e.xpert pathologist,
requiring him to live in the hospital and give it all
his time, and providing the department with the best
modern ecpiipment. In further development of the
scientific side of the service at the hospital, he recom-
mends that a permanent .r-ray department be
created.

American National Red Cross. — The annual re-
port of the National Red Cross shows that during
the year the organization collected $3,358,974 used
for relief given to the sufferers from the Vesuvius
eruption, the San Francisco disaster, the Japanese
famine, the earthquake in Chili, and the Mobile
storm. The report shows that there are branch
organizations in twenty-nine States, with a total
reported member.ship of about 18,000. Before the
end of the present year it is expected that branches
will be organized in all States and Territories, in-
cluding Hawaii and Porto Rico.

The Cartwright Prize of the Association of the

Alumni of the College of Physicians and Surgeons
of Columbia University is to be awarded at the
coming commencement. Its value is S500, and it is
given for the best essay containing the results of
original work in medical research. Information
regarding the conditions of the competition may be
obtained from Dr. H. E. Hale, 752 West End ave-
nue, Xew York, who is the secretary of the associa-
tion.

Deaths from Snake Bite in India. — The num-
ber of persons killed in India in 1905 by wild beasts
was 2.054, as against 2,157 i" t'l^ previous year.
The number of deaths reported from snake bite,
21,797, is also a little smaller than that of 1904.

Ambulance Service Stopped. — Owing to alleged
delay in answering ambulance calls the Board of
Police Surgeons last week discontinued the ambu-
lance service of the Washington Heights Hospital.
Until the matter has been settled the district from
West Eighty-sixth street to Spuvten Duyvil Creek
will be assigned to the J. Hood Wright Hospital.

The City's Vital Statistics. — The number of
births in the city of Greater Xew York last year was
111,772, an increase of 8,000 over 1905. The num-
ber of marriages was 48,355, an increase of 5,700.
The deaths reported had increased by 2,492, the
total being 76,206. There was an increase of deaths
from diphtheria, cancer, heart disease, nephritis,
old age, suicide, homicide, and violent deaths due
to accidents, while there was a decrease in deaths
from typhoid fever, malaria, whooping cough, cere-
brospinal meningitis, influenza, bronchitis, and gas-
trointestinal disorders in children under five years
of age.

Statistics of the Coroners' Office. — During the
past year there were 5.890 death? reported to the
Coroners' office during the year, and of this number
there were 3.160 deaths of a violent character. The
total number of deaths in which the injuries
received were chargeable to some other person was
549. The total number of cases tried by the Board

Jan. 12, 1907]

MEDICAL RECORD.

67

of Coroners and presented to juries during the _\ear
was 936; the number of inquests held at wliich
testimony of witnesses was taken and reduced to
writing and verdict rendered in accordance there-
with was 1,224; the total number of inquests held
w'here a verdict was rendered upon the sworn testi-
mony of the Coroners' physicians, was 3.730; the
total number of autopsies performed by the four
physicians attached to the oiifice was 1,112. There
were 68 deaths due to caisson disease and accidents
in connection with the tunnel work going on under
various parts of the city and the North and Kast
rivers.

Immigration Statistics. — The records of the Im-
migration Department issued last week show that
in the past twelve months there has been an in-
■crease of nearlv 400,000 in the number of persons
landing at this port over the preceding year. There
were 119,231 first, 134.386 second, and 944,917
third class passengers reaching this port, making a
total of 1,198,434 that entered the country in 19(76.
Of this number 142,603 were citizens of the United
States, and 1,055.831 were aliens.

Tobacco Smoking in Austria. — Recently pub-
lished statistics furnished by the Austrian Govern-
ment tobacco monopoly indicate an enormous in-
crease in cigarette smoking in that country. Nearly
four billion cigarettes were smoked in Austria in
1906, as well as some 1,200,000,000 cigars. Thirty
vears ago 2.3 cigarettes was the annual average con-
sumption per capita for the whole population. Last
year the average was 145.5 P^'' c^pha. In the same
period the consumption of cigars decreased from
49.7 to 44.3 per capita. Last year 31.000,000 fewer
•cigars were smoked than in 1904, while cigarettes
showed an increase of 167,000,000. During the
year the amount spent for smoking tobacco was
$50,000,000, which was $200,000 more than in 1905.
The receipts of the tobacco monopoly exceeded the
■expenses by more than .$30.000, txx).

A New Hospital on the East Side. — What is to
he known as the Mount Merijah Hospital is to be
founded in the lower east side by the Federation of
•Galician and Bucovinean Jews in America. Two
four-story dwelling houses at 138 and 140 East
Second street have been secin-ed and will be altered
for hospital and dispensary purposes. About thirty
beds are to be maintained, and the hospital will be
free to persons of all races and creeds.

Midwife Convicted as a Nuisance. — The Dis-
trict Attorney's office has found it so difficult to
secure convictions of abortionists on the charge of
performing illegal operations that in future the
experiment will be made of trying such offenders
luider the charge of being common nuisances. A
midwife was convicted last week under the pro-
visions of the code pertaining to common nuisances
and sentenced to a year's imprisonment in the peni-
tentiary and $500 fine. One witness who had been
€mployed in the house of the prisoner testified that
in three months over fifty women had been operated
on in the house, and one had died.

Rabies. — Seven persons have been bitten re-
cently by rabid dogs in the neighborhood of City
Island, where there are at present a number of dogs
?t large that are supposed to have been infected.
The Health Department and the Society for the
Prevention of Cruelty to .A.nimals are making efforts
to trace these animals and imprison them. A some-
what similar state of affairs is also in existence in
the neighborhood of Mount Vernon and Port Ches-
ter, where several people have been attacked by

rabid dogs. Three per.'^ons are under treatment who
are belie\ed to have been infected by a mad cow.

American Physiotherapeutic Association. — .\n
invitation is extended to [jhysicians interested in
the study and legitimate practice of the physical
(drugless) therapeutic methods, notably electro-
therapy, phototherapy, mechanotherapy, hydro-
therapy, suggestion, and dietetics, to join the Ameri-
can Physiotherajjeutic Association. The officers of
the association are : President, Dr. H. H. Roberts,
Lexington, Ky. ; Secretary, Dr. Otto Juettner, 8
West Ninth street, Cincinnati, Ohio ; Treasurer,
Dr. George H. Grant, Richmond, Ind. ; Executive
Council, Drs. W. F. Klein. Lebanon, Pa. ; James
Hanks, Brashear, Mo. ; J. W. Unger, West Point,
Miss. ; Charles S. Northen. Talladega, Ala. ; R. W.
Gibbes, Columbia, S. C. ; S. J. Crumbine, Topeka,
Kan., and A. L. Blesh, Guthrie. Okla.

Congress on Climatotherapy and Urban Hy-
giene.— The third congress on these subjects w-ill
be held on the French Riviera from April i to 10,
1907. The sessions will be held at Cannes, r\[onaco,
Mentone, and Ajaccio ; but all the towns and stations
on the Mediterranean Littoral are included in the
program — Cannes, Nice, Monte Carlo, Mentone,
Hyeres, Antibes, Grasse, St. Raphael, Juan les Pins,
Beaulieu, Cap IMartin. Thorenc, etc. The congress
will last about one week on the French coast, and
will finish in Corsica. The general secretary is Dr.
\'erdalle. i Boulevard d'.Msace, Cannes. The con-
gress will be held under the presidency of Dr. Cal-
mette. director of the Pasteur Institute, Lille.

Perry County (Miss.) Medical Society. — This
society has elected the fdllowing officers for the
ensuing year: President, Dr. I. H. C. Cook; J 'ice-
President, Dr. W. R. Thomas ; Secretary and Treas-
urer, Dr. S. Lewis Knight.

The Riley and Pottawatomie (Kan.) County
Medical Society. — The following officers have
been elected for this organization: President. Dr.
T. R. Cave, Manhattan; rice-President, Dr. George
II. Letsinger. Riley; Secretary. Dr. J. C. Montgom-
ery, Manhattan ; Treasurer. Dr. C. A. Roberts,
Randolph.

Dr. W. W. Keen has resigned from the chair of
the principles of surgery in Jeft'erson Medical Col-
lege and has been elected emeritus professor. He
will spend the coming year in Europe.

Police Surgeons Appointed. — Dr. Henry G.
\\'ebster and Dr. Thomas A. McGoldrick of Brook-
lyn last week received appointments as police sur-
geons.

Dr. Henry Leffmann has resigned from the
Philadelphia Board of Health fur the assigned rea-
son that there is UDthing nf an administrative char-
acter for that body to dn. The remaining meniliers
are Dr. A. C. Abbott .md Ih'. Leonard Pear<;on.

The American Hospital for Diseases of the
Stomach was formally opened at Philadelphia on
January 3. Dr. Lewis Brinton is chief physician,
Dr. John B. Deaver chief surgeon, and Dr. John B.
-Shober gynecologist. Dr. Ludwig Loeb is associate
surgeon. Dr. L. Napoleon Boston director of the re-
search laboratory. Dr. I. R. Stravvbridge assistant
physician, Dr. Francis B. Jacobs pediatrist, Dr.
James C. Wilson consulting ph\'sician. and Dr.
James Thorington consulting ophthalmologist.

Sanatorium for Insane Hospital. — The Illinois
Western Hospital for the Insane at \Vatertown, 111.,
contemplates erection of a modern sanatorium at a
cost of $100,000. This is an improvement or addi-

68

MEDICAL RECORD.

[Jan. 12, 1907

tion which the superintendent and trustees will ask
of the new Legislature.

Obituary Notes. — Dr. Edward Oliver Belt of
Washington, D. C, was one of the victims of the
wreck on the Baltimore and Ohio Railroad at Terra
Cotta on December 29. Dr. Belt was graduated
from the Maryland School of Medicine in Baltimore
in 1886 and was well known as a specialist in dis-
eases of the eye.

Dr. Richard M. Coghan of Providence, R. I.,
died on January 3 at the age of twenty-eight years
of scarlet fever contracted from a patient. Dr.
Coghan was graduated from Brown University in
1901, and received his medical degree from the
Jefferson Medical College in 1905.

Dr. Joseph A. Aldrich, who was formerly a
surgeon in the United States Army, died in this
city on January 4 at the age of eighty-nine years.
He was stationed at New Ulm, Minn., during the
Indian wars and distinguished himself for braver}'
at that time.

Dr. Joseph W. Glvxn of Flatbush died on De-
cember 30 in his thirty-seventh year. He was grad-
uated in 1894 from the Long Island College
Hospital.

Dr. Olive F. McCune of Brooklyn died on
January 4 in Binghamton, N. Y., at the age of
seventy-eight years. She was born in Delhi, N. Y.,
and had practised in Brooklyn for about thirty-five
years. Her husband, who was also a physician, died
some years ago.

Dr. Hexrv W. Dudley of Abington, Mass., died
on December 29 of heart disease at the age of
seventy-five years. His death was very sudden and
he had been making calls up to noon of the day on
which he died. Dr. Dudley was born in Gilmanton,
N. H., and was graduated from Harvard Medical
School in 1864. He was president of the Plymouth
District Aledical Society in 1878 and had held nu-
merous other official and teaching positions. For
sixteen years he had been medical examiner of the
second Plymouth district, and he had practised in
Abington for over forty years.

Dr. Charles Culpepper of Portsmouth, Va.,
died suddenly on December 28, at the age of forty-
three years, after several years of broken health.
He received his medical education in the University
of \^irginia and had practised in Portsmouth for
many years.

Dr. S. Cyrus K. Bartlett of Minneapolis, Minn.,
died on December 27 at the age of seventy-seven
years. Dr. Bartlett was born in Boxford, Mass.,
and after receiving his medical education at Harvard
IVIedical School he practised in Boston for six years.
In 1868 he was appointed superintendent of the
insane asylum at St. Peter, Minn., and after twenty-
five years of service resigned and went to Minne-
apolis. For the past twelve years he had been the
professor of mental diseases at Hamline University.

Dr. Jacob G. Wolf of Morristown, Ind., died on
December 27 at the age of eighty-three years. In
1849 he was graduated from the Ohio Medical
College, and two years later he settled in Morris-
town.

Dr. Jeaxnette C. Welch of Grand Rapids,
Mich., died of pneumonia on December 31. She
was born in Canaan, N. H., in 1867, and was a
graduate of Wellesley College and the College of
Physicians and Surgeons of Chicago. She also held
the degree of Doctor of Philosophy from the Uni-
versity of Chicago.

Dr. J, W. Standley of Alexis, 111., died suddenly
on December 23. He was born in Putnam County,
Indiana, in 1848. He was graduated from Rush

Medical College with the class of 1872, and prac-
tised in Greencastle, >.Io., until 1880, when he went
to Alexis.

Dr. William H. Dixgee died at Philadelphia
on December 30 at the age of thirty-two years. He
was graduated from the medical department of the
University of Pennsylvania in the class of 1896.
He was connected with the eye, ear, and throat
dispensaries of the Samaritan, Episcopal, and St.
Mary's Hospitals.

(larttBpanhtmt.

TREATMEXT OF ACUTE SEPTIC PERFORATIVE

PERITONITIS.
To THE Editor of the Medic.\l Record:

Sir: — The letter of J. J. Brownson, M.D., in your issue
of December 15, 1906, anent the subject of treatment of
acute septic perforative peritonitis, contains statements that
should not be allowed to pass unchallenged, for the wide
publicity given them by your journal might result in the
acceptance here and there of misjudged conclusions and
consequent deprivation to many of the chances of possible
assistance through operative interference.

The conclusions expressed by Dr. Brownson regarding
hopelessness and contraindication of operation in cases of
general peritonitis are those that were generally accepted
some si-x or eight years ago, but surgeons who have
been awake these few years have noted quite some progress,
and think differently, and have proven differently to-day.
The assertion of Drs. Marshall and Quick is up-to-date:
"We operate in every case when the radial pulse can be
felt. Early, intermediary, and late operations, as defined
by hours, days, are terms that should be relegated to the
attic, etc. We have awakened from that condition which
makes a god of pulse and temperature." The definiteness-
of this statement is only accentuated by Dr. Brownson's
criticism, "Or, in other words, they care nothing for the
condition of the patient or the period of the disease. All
they want is the diagnosis and a pulse at the wrist when
they cut away." This is exactly the case, especially in
regard to peritonitis, for, according to Dr. Brownson's
own statement, these cases are hopeless, "forlorn tasks
with which a surgeon should not risk his reputation," if
rot operated on. Then what is to be lost by operation?
The surgeon's reputation? Dr. Brownson certainly does
not mean to balance that against a chance of saving the
patient's life. Yet the fact is that to-day a fair proportion^
of these patients are saved by operating on them.

It is unfortunate that we have not a better classificatioiv
of "general peritonitis" than has been and is yet in vogue.
The doctor is justified in referring to "what is meant by
certain writers when they report cases of 'general suppu-
rative peritonitis' termmating in recovery." But the doc-
tor's description of the cases he refers to is not at all any
more definite, in fact, less so. He says "produced by the
bursting of an abscess pouring its septic contents directly
into the abdominal cavity," and that no such case "will
be found with a temperature of 102° and a pulse of 120.
Rather will they have a temperature of 105° or 106° and
a pulse of 140 or 160." The bursting of an abscess, pour-
ing its septic contents into the abdominal cavity is the
cause of the spreading peritonitis in almost all cases of
diffuse septic peritonitis, both those where the infection is
limited more or less to the region of the original lesion,
and those of general peritonitis, which result from the
further spread of the local diffuse infection, taking a
longer or shorter period to develop, according to the charac-
ter of the infection, the personal resistance of the patient,
etc.

Perforation and peritoneal infection with a temperature
of 105° or 106° and pulse of 140 or 160 is a rare combina-
tion, and does not represent the conditions in the really
bad cases. These, have the bad pulse, but a moderate tem-
perature. The high temperature shows effort on the part
of the system to overcome the invasion of the infection,,
and in so far is a favorable symptom. The bad pulse in-
dicates want of resistance or exhaustion, and is generally
accompanied by a moderating temperature as the power of
resistance wanes. The outlook with a poor pulse and high
temperature is better than with a poor pulse and low tem-
perature, which are the results of want of active resistance
on the part of the economy, or of the cumulative and in-
creasing toxic effects of the infection which has been
developing and spreading for some days. Here the prog-
nosis is poor but not hopeless. This is the class of cases
described by Dr. Baldwin as those he does not expect to

Jan. 12, 1907:

MEDICAL RECORD.

69

save, and, although they do not answer the description of
the cases referred to by Dr. Brownson, are quoted by him
in support of his contention. Dr. Baldwin bases his
opinion on failure in two such cases, hardly sufficient to
judge by. especially w'hen others report recoveries, some
more, some less, in larger series of cases.

Dr. Brownson's conclusions regarding time of operation
in appendicitis cases in general, referred to briefly in this
letter, are expressed more in detail in his article in the
JIedical Record of October 6, 1906. He designates three
periods when operation should be done, and an "inter-
mediary period when there is fever and distention of the
abdomen" when it ought not to be done. This period as
the doctor defines it is very indefinite, but it evidently
refers to some time between the beginning of the attack
and the development of abscess. Postponement of opera-
tion till after this period can only contribute towards in-
creasing the proportion of cases complicated with general
peritonitis. When no abscess develops there is no in-
termediary period, and no operation until the interval.
Waiting for this interval, though, would permit of the
possibility of something happening as the result of an
unrecognized abscess, such, for instance, as might form
in the appendi.x or around it, and fortunately discharge
into the cecum without even having been recognized, and
yet end in recovery. Where is the "intermediary period"
when, with no abscess forination, a concretion ulcerates
through the appendi.x wall and permits discharge of in-
testinal contents into the peritoneum? Where is it when
a distended gangrenous appendix suddenly bursts and dis-
charges its bacteria-laden, not necessarily purulent, con-
tents into the peritoneum? Where is it when infection
of the general peritoneum is found coincident with almost
the first signs of appendicitis? In a good proportion uf
■cases, before the belly is opened, it is impossible to say
in which any of these conditions is present or absent, or
will or will not occur. Waiting for the "intermediary
period" to pass before operating gives the opportunity for
any accident to happen, and permits the development of the
usual proportion, in nnoperated cases, of a spreading
peritonitis, which if said "period" is permitted to last long
enough, becomes general septic peritonitis "with a tempera-
ture of 105° or 106° and pulse of 140 or 160." On the
other hand, to operate when the diagnosis is made is to
forestall the possibility of these accidents, and to operate
in the "intermediary period" is no worse than at any other
time; in fact, preferable to waiting till abscess has formed,
with its concomitant inflammatory infiltration and ex-
tensive and brittle adhesions.

Nothing is as conclusive in an argument as facts, and
I can cite a few such that will go to prove what I claim.
Referring to my report of 147 appendectomies (Medical
Record, March 24, 1906), it is noted there that of 142
of these, 23 were operated on within two days of the be-
ginning of the attack. 50 in three to four days, 41 in
five to seven days, 18 within two weeks, and 10 in one to
three months. In referring to my notes I find that
among the 50 who were operated upon on the third and
fourth days of the attack, presumably the "intermediary
period," there were two deaths, one primarily of general
peritonitis, to which the intermediary period would not
apply, and in the other there was a large pelvic abscess
with a gangrenous appendix, and the case was very septic.
Neither of these patients could have been in the inter-
mediary period. In fact, the causes of all the deaths in the
series, as given under "mortality" at the end of the article,
could, by their very nature, have no relation to the "period"
in which the operation was done. In a subsequent series
of over 50 appendectomies, where the time of operation
was "as soon as possible" after coming under observation,
there were two deaths, one in a case of a general peri-
tonitis ; the other patient was sick for a couple of weeks
with a large retrocecal abscess and gangrenous appendix,
in addition to an old and advanced pulmonary tuberculosis,
and died of post-operative hynostatic pneumonia. .As in
the previous series, neither of these deaths could be attrib-
uted to operation in the "intermediary period." and as there
are none in these 200 cases that could by any stretch of
the imagination be ascribed to this cause, the intermediary
period or any other period becomes a negligible quantity.

As to recovery from general peritonitis, and relative
temperature and pulse ranges and their significance in
this condition, I would again refer to the same article and,
in addition, copy the following from my notes on these
cases, the observations given being those of the patient's
condition on admission to the hospital. Among the re-
coveries from general peritonitis, those with the highest
temperatures were the following: temp. 1052-10^. pulse
112; temp. I04!4°, pulse 112: temp. 104°, pulse 140; temp.
1036-10°, pulse 124. .Among the deaths the highest tem-
perature was 1026-10°, pulse 100; others were temp. 102°,
pulse 142; temp. 102°, pulse 130; temp. 101°, pulse 130;

and the lowest temperature was 96^^°, with pulse of 130.
Among the fifty odd additional appendectomies mentioned
above were fourteen cases of diffuse and general peritonitis.
Their temperature and pulse ranges were within the limits
given in the previous series, and on the average they were
of the same nature. The results were better, due. I be-
lieve, to added experience in method of handling, especially
in the mode of dramage and limitation of unnecessary
manipulations, though different from Dr. Murphy's cases,
in that the appendix was invariably removed. Of the
fourteen there were thirteen recoveries. I shall have more
to say on this subject in an article to appear in the near
future. -A. E. Isaacs, M.D.

240 East Broabwav, New York.

TRYPSIN FOR THE CURE OF CANCER.

To the Editor of the IMeuical Record;

Sir ; — In the Medical Record of December 8, 1906,
there appeared an article under this title by William J.
Morton, M.D., which article has been very extensively
quoted in the lay press and has called forth considerable
discussion. Into this discussion medical men have entered,
contending that such articles should not be copied or pub-
lished in the lay press. The lay press has answered
that it was simply printing "facts," and publicity
in the use of "facts" in the cure of disease was a public
benefaction. Now, I do not wish to discuss the use of
trypsin in the treatment of cancer, which I am using along
with many other medical men, but I wish to say some-
thing about "facts" in so far as Dr. Morton's article
referred to me and case No. i came under my observa-
tion.

Dr. IMorton says that case i was "referred by Dr.
Edw. W. Peet." ' I beg to correct this statement, for I
did not refer the case to him and did all I could to
keep the case from him. I was the family physician of the
patient and she got her early knowledge of_ Dr. Morton
through the reports of him in his connection with the
treatment of the late President Harper of Chicago Uni-
versity. .After repeatedly calling my attention to these
notices the patient w^ent to Dr. Morton and brought back
such accounts of results in the use of A'-ray that I was
constrained to see him also. I did so and the results he
reported did not tally with the results I had obtained
with .r-ray. I continued to attend the patient at her
home and made very careful and frequent notes of the
progress of the case while she was under treatment. My
notes do not at all agree with the report made by Dr.
Morton in his article. He says: "The patient received 32
;r-ray treatments, e.xtending over a period of seven weeks.
The gland had reduced one-third in size, the tumor was
freer, and absolutely every sign of Imyphatic infection had
disappeared." The tumor did increase and decrease in
size depending on whether her menses were present or
remote. .At all times during these seven weeks I was
able to triake out enlarged axillary glands and detect
lymphatic infection by palpation. How any one could
make such an optimistic statement about this case is
beyond my comprehension. .According to my observation
the tumor and axillary involvement slowly but continu-
ously progressed. And this coincides with the histories
of most of my cases treated with .v-ray. I did the first
operation referred to by Dr. Morton and assisted at the
second, and feel it a duty to put on record my observations
of the "facts" in this case.

Edward W. Peet, M.D.

348 Central Park West.

OUR LONDON LETTER.

(From Our Special Correspondent.)

THE RECESS — H0SPIT.\L SUNDAY FUND — KOCH ON SLEEPING
SICKNESS — HEP.VTIC INADEQUACY AND GOUT — MIMICRY OF
MALIGNANT DISEASE — RUPTURE OF THE DIAPHR.^GM.

London. December 21, 1006.
The Xmas recess has arrived and is a welcome rest to
those wdio have been working strenuously in the schools,
whether as teachers or students. Many assiduous attend-
ants at the societies are also pleased for the interruption of
the work. I may add that the sclieme of amalgamation is
making haste slowlv.

Yesterday, the constituents of the Hospital Sunday Fund
held their annual meeting at the .Mansion House, the Lord
Mavor presiding. The total collections for the year
amounted to £63.000. The sums collected in the places of
worship reached £44,647 less than the previous year by
£4.307.

The Bishop of London, in moving the adoption of the

70

MEDICAL RECORD.

[Jan. 12, 1907

report, thought the fund ought to rise to fico.ooo, and the
Chief Rabbi, who seconded, tho.ight sonic of the falling off
was due to week-ends out of town, and he hoped those
absent on the Hospital Sunday would forward their dona-
tions. The report was adopted and Hospital Sunday for
1907 fixed for June Q.

Koch's report on sleeping sickness has been presented to
the German government, and telegraphic summaries appear
in our newspapers this morning. No doubt you will gel the
same by cable, so I will only allude to one or two points.
He says the disease is not indigenous in German South
Africa, and that the cases occurring there come from
British territory — a statement that requires corroboration,
seeing that the Glossina, as he admits, is prevalent in the
German colony. He pronounces atoxyl to be a specific.
He speaks of 900 cases, all serious, under treatment, and
expresses the opinion that the majority of them will be
cured in from two to three months. It will be necessary
to watcli for relapses before absolute certainty is obtained.
One remembers tuberculin, and can await the verdict of the
medical societies, where no doubt criticism will be forth-
coming.

There was an interesting discussion at the Medical
Society on the loth inst., introduced by Sir L. Brunton in
a paper on hepatic inadequacy in reference to gout and
other diseases. He said people might be healthy whose
muscles were unequal to heavy work, as others whose
brains did not fit them for some positions. So lungs,
stomachs, kidneys, etc., might be inadequate. The liver, he
said, might be inadequate as regards carbohydrates, hence
glycosuria: but its deficient power with regard to proteins
and purins was not so fully recognized unless what passes
ES torpid liver be so considered. He referred to the ex-
periments of Stokvis, which suggested that the liver is con-
cerned in the conversion of uric acid into urea. This
work he had confirmed in conjunction with Dr. Bokenham,
as also continental physiologists had done. He thought
probably an enzyme capable cf decomposing uric acid was
present in the cellular juice of the liver during active diges-
tion, and not at other times. This enzyme might be set free
by some secretion. Hepatic inadequacy as to carbohydrates
needs a meat dietary, but as to purins a purin-free diet. To
put every one on a purin-free diet was as absurd as to put
healthy people on a diabetic's diet. The best diet for man
was, as Professor Chittenden said, "a mixed diet, and not
too much of it." The paper, then, was a new appearance
of the old idea of torpid liver.

Sir D, Duckworth said he had learned to recognize vari-
ous phases of gout in the system, and not to look to uric
acid as the cause of all its symptoms. It was a relief to
hear nothing about microbes, and that gout could be re-
lieved by old-fashioned remedies with exercise. Dr.
Fortescue Fox said we must distinguish between acquired
gout, which was a diet disease to be treated by diet, and
hereditary gout, which was not relieved by dieting. Dr.
Ewart said the essence of gout was functional, but it passed
into a structural disease. The offspring of gouty parents
should be treated with a view of preventing structural
changes.

Dr. Luff threw down the gauntlet against the "fetich of
uric acid." which, he said, was in no sense a poison, but a
comparatively harmless by-product. The liver could con-
vert uric acid into urea to a certain amount, but that
amount had no part in the patholo,gy of gout, which was
an autointoxication, and might be due to the bacteria of
the intestines becoming altered so as to give o({ the toxin
of gout. The liver could destroy that toxin, but if its
function fell below par the undestroyed toxin would pro-
duce gout.

At the Clinical Society, on the 14th inst., Mr. Moynihan
read a paper on "Mimicry of Malignant Disease of the
Large Intestine." He related six of these puzzling cases
upon which he had operated. In all, a diagnosis of malig-
nant disease had been decided on before or at the time of
operation, and yet this was incorrect. In one there was a
growth blocking the rectum ; in another a tumor of the
sigmoid flexure; in two others inflammatory tumor due to
pericolitis ; in another a tumor with a number of divertic-
ula, one of which had perforated, but no evidence of
malignancy ; in the other an inflammatory tumor of the
splenic flexure, which disappeared after a short-circuiting
operation. Mr. Moynihan remarked that mimicry of ma-
lignant disease about the cecum and ascending colon by a
hyperplastic tuberculous process was pretty well known.
He had operated on two such cases in the belief that they
were cancerous, but it was not so generally recognized that
inflammatory tumors with all the clinical appearances of
cancer attacked all parts of the large intestine. Many of
them, he thought, might be due to false diverticula.

The president, Mr. Clutton, recognizing the importance
of the paper, compared the cases with those of gastric
tumors supposed to be cancer, but which disappeared after
gastroenterostomy. He was very skeptical about the syphi-
litic nature of rectal cases so commonlv assumed. Dr.

Brook related a case operated on for acute obstruction
when a fixed tumor of the cecum was found. Short-circuit-
ing was done, and eighteen months afterwards the man
was well, and no sign of the tumor was detected. Mr.
Spencer had operated on a similar case, and seven years
later at the post mortem the intestine was found normal.
He sug,gcsted that many cases that recovered after ex-
ploratory operations were of this nature. Mr. Moynihan,
in reply, thought syphilitic cases could often be distin-
guished, though in one of those related there had been a
mistake. In literature he had found forty cases of diver-
ticula. In museums he had seen forty specimens described
wrongly as syphilitic.

Two oases of ruptured diaphragm, with accompanying
severe injuries caused by squeezing between railway buf-
fers, were then read. The first was by Mr. J. Berry, and
his patient, a railway man of nineteen, was admitted soon
after his injury in a state of profound collapse. The
physical signs pointed to rupture of lung, and blood and
air in the pleura. It was also thought that the diaphragm
had been ruptured. For three days he continued collapsed,
the heart being pushed more and more to the right, and
signs of strangulation set in. In this desperate state it was
thought best to open the abdomen and attempt to reduce
the strangulation. On doing so a large rent in the left
posterior part of the diaphragm was found, through which
most of the stomach, colon, and omentum, upper end of
left kidney, and half the spleen (which was cut in two)
had passed into the thorax. The herniated viscera were
with difficulty drawn back into the abdomen and the opera-
tion completed by closing the rent, partly with sutures and
partly by fixing the liver. The patient died almost imme-
diately.

The other case was read by Mr. J. P. Roughton. The
abdomen was opened the day after the injury, and the
stomach, which had passed high into the thorax, was
withdrawn, blood coming from the chest into the abdomen.
The patient died the ne.xt day. At the post mortem the
diaphragm was seen to have been torn away from its
attachment between the ensiform cartilage and ninth rib;
there was a rent in the spleen, probably the source of the
blood mentioned above. The delay in this case of serious
symptoms made it a more favorable one for an attempt
to deal with it. The great interest of the cases was com-
mented on by the president and others, and the authors
congratulated on their eftorts, which seem to show how
perhaps surgery may yet accomplish something in these
terrible cases.

OUR PARIS LETTER.
(From Our Special Correspondent.)

THE APPOIXTMENT OF PROF. .\LB.\RR.\X — THE TRE.\TMEN'T OF
CANCER — IN'VEsTIGATIOXS OX TUBERCULOSIS IN SCHOOL CHIL-
DREN'— THE SURCIC.\L TRE-\TMEXT OF HEM.\TURI.\ — .\BD0M-
IX.VL HYSTERECTOMY FOR C.\XCER OF THE CERVIX — R.\DI-
OTHERAPY IX THE TRE.AT.MEXT OF CARCIXOM.\ — THE REMOV.VL
OF TATTOO MARKS — A WORK OX DIETETICS.

Paris, December 15, igo6.
The chair of Diseases of the Urinary Organs having
become vacant in the University of Paris in consequence of
the retirement of Prof. Guyon, who has reached the age
limit, Dr. Albarran has been appointed as his successor.
The very considerable and important advances made by
Prof, .\lbarran in all branches of this specialty, as well
as his favorable reputation in other countries made it seem
quite natural that he should receive the appointment. His
first lecture was held on November 14. before a large audi-
ence assembled to welcome the new head of the well known
Ecole de Necker.

Several of the recent sessions of the Academic de Mede-
cine have been devoted largely to the question of the treat-
ment of cancer. Prof. Poirier is firmly convinced of the cur-
ability of cancer by the resort to early and extensive surgi-
cal intervention. \\'hile it is true that the nature of car-
cinoma is still entirely unknown it is certain that the disease
is at first local and remains so for a longer or shorter
period of time, and during this time is curable by wide-
spread excision. According to M. Poirier, no serum has
ever cured a single malignant growth. As for radiotherapy,
which to be sure has a specific action in regard to certain
superficial cancers, no cure of a deep cancer can be credited
to it. The speaker also insisted on its especially deplorable
eflrects in cancer of the tongue, .^t first pain is relieved
and the glandular enlargements are reduced in size, but
the process continues in the deeper parts and the condition
has already become inoperable when the patient finally aban-
dons radiotherapy in order to consult the surgeon. The
speaker concluded by saying that it was greatly to be re-
gretted that there was not in France an institute for cancer
research like those of Germany and England.

Prof Berger also affirmed that surgical operation is still

Jan. 12, 1907]

MEDICAL RECORD.

the only remedy by which cancer may be cured. Medication
and serum therapy were both ineffectual, and radiotherapy
was of value only in the very superficial forms, but even
operation gave results only under very restricted conditions
and its benefits were sometimes uncertain. Like the pre-
ceding speaker, Prof. Berger proposed the organization of
a scientific committee for cancer research which should
centralize and direct investigations in this field. Prof.
Cornil also spoke in favor of this idea and said that the
cancer institute should possess a laboratory for histological
studies and another for experimental work.

Prof. Grancher submitted to the Academic the result
of his investigations on adenopulmonary tuberculosis car-
ried out in the schools of Paris. He said that during the
past three years he had made systematic examinations on
more than 4,000 school children. He considered that adeno-
pulmonary tuberculosis in children was curable, but only
under certain favorable conditions. It was necessary to
begin the treatment in the very earliest stages of the dis-
ease. He had been able to detect it in its first beginnings
in from 15 to 16 per cent, of the Parisian school children.
It h.ad been found that the treatment tried in the schools
of giving the children an extra meal of meat extract and
cod liver oil was not sufficient. It failed to do more than
to keep the condition from progressing in the majority,
while it did not prevent some from becoming growing
worse. It was therefore necessary to assist the parents
of the child and this might be done in two ways. Children
sultering from slight degrees of tuberculosis and not
throwing off bacilli might be placed in country families
who would be informed that the child was sick and would
be paid a sufficient amount to secure adequate care and
proper feeding for it. Under these conditions the child
should be under the care of a physician who would be able
to determine when the tuberculosis became infectious and
the patient should be removed. The other method was
considered preferable by iNI. Grancher and consisted in
placing the children in a school sanatorium in the country
under medical supervision.

At the recent meeting of the Societe de Chirurgie M.
Pousson of Bordeaux discussed the surgical treatment of
renal hematuria. The author advocated the conservative
operations, comprising nephrotomy, the nephrolysis of
Rovsing, and the decapsulation of Edebohls. In his opinion
simple incision of the kidney had a very beneficial effect.
Unfortunately the patients who have been subjected to
simple decapsulation have not been under observation a
sufficiently long time to determine the value of this pro-
cedure.

j\l. Jean Louis Faure reported the result of his experi-
ence in the treatment of cancer of the cervix by abdonunal
hysterectomy. He had performed this operation forty
times; eighteen of the patients had been kept under obser-
vation, and of these ten had suft'ered recurrences, whereas
several others appeared to have been permanently cured.
The author employed the technique of Wertheim. Out
of twelve patients who had survived the operation nine had
remained without recurrences for a period of time varying"
between fourteen months and four and a half years. The
operation was long, difficult, and fatiguin.g, but the results
appeared to recompense the surgeon largely for the pains
he took. Faure believed that by operating early and care-
fully still better results could be obtained, and that perhaps
cancer of the cervix would come to be in the same clasa
with cancer of the breast.

The treatment of cancer by radiotherapy was considered
by the Societe Medicale des Hopitaux and iM. Beclere
offered the following conclusions: In dealing with a sub-
cutaneous new growth, and especially a new growth of the
breast, of which the nature was still uncertain, the physician
could not do better than to obtain the advice of a competent
surgeon, but in all cases where operation was either volun-
tarily deferred by the surgeon or refused by the patient it
was the duty of the physician to resort to radiotherapy
rather than to lose precious time by the use of so-called
resolving ointments or other equally ineffectual measures.
.An interesting procedure for obliterating tattoo marks
was described by M. Variot. The patient was a man of
twenty-five years who had two tattoo marks on his left fore-
arm, one anteriorly representing a naked female and the
other on the posterior surface. On account of the
indecency of the pictures the man, who was a laborer, was
unable to find employment, and accordingly he was very
anxious to he relieved of his adornments. Variot resorted
to the method of cauterization by means of tannin and
silver nitrate. For this purpose a bundle of needles was
used to pierce the skin, to the same depth as was done in
performing the tattooing, and in this way the solution of
tannin or silver nitrate was enabled to penetrate to the
layer where the pigment particles had been deposited. Two
months after the termination of the treatment one saw only
a slightly pigmented scar, brownish in color, and not very
conspicuous. The skin of the region was soft and moved

readily over the aponeurosis, .•\nother procedure was sug-
gested by M. Danlos, who recommended the repeated
application of blistering agents, but he said that the ideal
method was electrolysis, by means of which it was possible
to destroy the tattoo marks very rapidly without leaving
any visible scar.

An interesting book entitled "Les Aliments Usuels," by
Dr. A. Martinet, has recently appeared. It is intended to
place within reach of the general public modern ideas on
the subject of rational dietetics. The first part is
devoted to the study of the fundamental foodstuffs and to
a description of the methods employed for their chemical
and physiological investigations. The author then describes
the separate foods in detail and discusses their value in
health and in disease.

OUR BERLIN LETTER.

(From Our Special Correspondent.)

XEW BERLIN HOSPIT.-\LS — THE HEART IN GOITER — THE MODE
OF ACTION OF GASTROENTEROSTOMY — A BARE BLOOD DISEASE —
EXPERIMENTAL KYPHOSIS — • ELECTRIC OPHTHALMIA — THE
MEDICAL TREATMENT OF PROSTITUTES.

Berlin. December iS, igoo.

During the past few weeks most of the Berlin physicians
have been inspecting the various new hospitals. The
Rudolph Virchow Hospital especially is proving a great
center of attraction for visitors, and with its beautifuUy-
laid-out grounds shows to its best advantage in these
delightful autumn days. Only 300 of the 2,000 beds are
now occupied, but one can already gain an adequate im-
pression of this enormous institution which is especially
mteresting to visit since the directors themselves conduct
sightseers through the buildings. Recently the new hos-
pital of the suburb Paukow has been opened, which, though
small, is planned so that it can be enlarged to a capacity of
400 beds and possesses all the facilities of a modern hos-
pital. It is expected that the much larger Schoenberg
Hospital will be ready for occupancy this year, and it seems
as if in the near future it would no longer be possible to
speak of a scarcity of hospital accommodations in Berlin.

In the first session of the Vcrcin fiir innere Medizin
Kraus read a paper on the condition of the heart in goiter.
He stated that the relations of the thyroid gland to heart
action could be toxic or mechanical. Three chief varieties
of etiological factors could be distinguished. First, those
present in exophthalmic goiter, second in struma, and third
in artificial hyperthyroidism. In these eases tachycardia
might be present, with a heart beat of from 80 to 120 while
at rest, and 140 after exercise. The tonus of the vessels
was diminished, but the blood pressure was often somewhat
elevated. Staring eyes, wide pupils, exophthalmos, sweat-
ing, tremor, and dcrmatographia were usually present. A
partial strumectomy was generally effective in giving relief
and iodine was a valuable remedial agent. The term
"Formes frustes" of exophthalmic goiter applied by Char-
cot to this condition of the heart was a bad one, and
kocher's expression "equivalent of exophthalmic goiter"
was better. The fact that in some cases the condition re-
mained a local equivalent, while in others real exophthal-
mic goiter developed, depended on individual conditions, as
had been shown by the experimental feeding of thyroid
extract to animals.

Katzenstein addressed the same society on the eft'ect of
gastroenterostomy on gastric ulcer and gastric carcinoma.
He believed that the beneficial effect of the operation was
due largely to the improvement brought about in the motor
function. In order to investigate the causes of this action
he performed gastrostomy on seven dogs that had been
subjected to the operation of gastroenterostomy. The
speaker stated that the action of pepsin was inhibited in
an alkaline medium, but that trypsin, even after having
been subjected for twenty-four hours to the action of
hydrochloric acid and then being rendered alkaline, did
not lose its potencx'. That was why, after gastroenteros-
tomv, in which the bile and pancreatic juice entered the
stomach, the food could still be thorou.ghly digested. On
introducing food into the stomachs of dogs that had been
subjected to gastroenterostomy the speaker stated that a
diminution in acidity could be detected one and a half
hours liter, and if meat and fat were given, after even half
an hour. He made artificial ulcers in the stomach and
intestines and dabbed them with hydrochloric acid. The
gastric ulcers in these dogs were cured through the alka-
iinization of the gastric juice, but those of the intestine
went on to perforation. The prolongation of life that often
occurred in carcinoma after gastroenterostomy was ex-
plained by the speaker on the assumption that the car-
cinoma was digested bv the trypsin.

.At a meeting of the Medizinische Gesellschaft, held on

72

MEDICAL RECORD.

[Jan. 12, 1907

October 24, Senator read a paper on a rare disease, o£ which
only a few cases have been observed, and which is called
polycythemia rubra megalosplenica. The disease, he said,
was characterized by a dark coloration of the skin, erythro-
cytosis, and splenic enlargement. In the two cases observed
the red blood-cells were increased to si.x to ten millions per
cmm. In its other characteristics the blood was normal,
though the blood pressure was raised somewhat. The
causes of the erythrocytosis were either a diminution in
the destruction of the red cells or a stimulation of the
hematopoietic organs. In favor of the latter view was
the fact that in three cases of the disease hyperplasia of
the bone marrow was reported. It was possible that the
spleen produced stimulating substances which gave rise to
the polycythemia.

K new subject for experimental research was suggested
by a paper on experimental kyphosis recently read by
Munk at a meeting of the Physiologische Gesellschaft.
This investigator was able by various operative procedures
to produce spinal curvatures of various types in monkeys
and described the method of causation of secondary palsies
of the extremities and the lesions of the spinal cord
produced by these measures.

Czellitzer read an interesting paper on electrical injuries
before the Medizinische Gesellschaft. This paper should
prove of interest in all countries where electricity is largely
used for industrial purposes. Thirty-two employees in a
foundry where w-elding was done by means of a powerful
electric current which gave out an intensely brilliant light
were afifected with electric ophthalmia, so called, although
they simply passed by the source of light at a distance of
fifteen or twenty feet. The patients awoke during the
night suffering from pain in the eyes, the lids became
swollen, the eyes could not be opened, and photophobia,
epiphora, and swelling of the conjunctiva were present.
The condition was relieved after several days of treatment
by boric acid compresses. The speaker pointed out that
in this case the workmen simply passed by the source of
light without looking at it, and yet they were affected. He
assumed that the disease was caused by the ultraviolet
rays and not by the red light rays.

The Berlin police officials have been planning for a reform
which will do away with an abuse of long standing. It is
the duty of the police department to supervise the treatment
of all prostitutes who become diseased. Many of these
women avoid treatment because they are obliged to go to a
special hospital and are kept under observation for a long
period of time. On this account the danger of spreading
venereal disease is great, and, besides, sojourn in this special
hospital and association with old offenders serves to com-
plete the demoralization of those for whom otherwise
there might still be hope of reform. The police depart-
ment has secured the services of specialists in venereal dis-
eases who will treat such women gratuitousl}-. Under these
coiiditions the patients will not be required to remain under
police observation. The physician's certificate will be suffi-
cient to relieve the w-omen from the necessity of being
under sur\-eillance and of entering the special hospital.

PrngrPBH of iHrMral 0rtrurp.

New York Medical Journal, December 29, 1906.

Errors in the Treatment of Cutaneous Cancer. — A. R.

Robinson refers to the many plans of treatment which
have had their run and are now forgotten. He has
seen no noticeable benefit from the use of thyroid ex-
tract in visceral cancer. Toxins, sera, etc., are use-
less. He describes the methods he follows in cancer in
the various bodily areas, holding that that method of
treatment is best which removes with the greatest
certainty all of the pathological tissue, even if the re-
sulting deformity is greater than that caused by some
other less effective method: and that of two methods
oiTering equally good results as regards a cure, there
should be employed that one which would cause the
least deformity, when deformity from a cosmetic stand-
point must be considered. The comparative effects of
the various caustics are fully described. The author
says concerning the x-ray that it is a decided addi-
tion to our armamentarium against cancer, but its vir-
tues have been overexploited by some writers, perhaps
for reasons best known to themselves. It is a grave
error to maintain that with the J'-ray alone all cases
of cancer of the skin can be cured. This is not
even true of cancers seen in a very early stage. It
is also an error to hold that in all such cases where it
could effect a cure it is the best sgent to be employed.
He believes its exclusive use should be limited to a
very few cases out of all those that come under ob-
servation, such as those of rodent ulcer and some cases

of superficial prickle-celled epitheliomata. In closing,
the author calls attention to the following principles:
All cases of multiple cutaneous cancer and all aged
persons with cutaneous cancer require internal treat-
ment in the form of diet and drugs in addition to local
measures. A diet of milk and green vegetables and the
avoidance of meats in general and of meats of such
organs as liver and kidneys in particular, and the
avoidance of alcohols, is advisable in all cases of cancer,
whether external or internal. Thyroid extract should
be given in as large doses as can be borne in all cases
where there is a senile condition of the skin and in
most superficial epitheliomata. A knowledge of the
kind of cancer present, the pathological anatomy, and
the manner of extension of the disease in general and
of the special variety of the case to be treated is
necessary to a correct' choice of method of treatment.
When possible all cases should be under observation
at least one year after commencing treatment of any
kind, in order to treat promptly any recurrence of the
disease. Early diagnosis and correct treatment place
cutaneous cancers among that class of diseases, which
do not deserve the name of incurable diseases, as almost
without exception they can be treated successfully if
the method employed is the correct one.

The Physiology of Language and Its Relation to the
Treatment of Stammering. — G. H. Mackuen defines
stammering as a more or less constant inability to
speak freely owing to an incoordinate and spasmodic
action of the respiratory phonatory or articulatory
muscles. It is a very common affection. One per
cent, of school children stammer. The author describes
the methods followed in the analysis of the funda-
mental sounds of letters as used in speech, and shows
how it is necessary to construct an alphabet of sounds
which shall bear the same relation to speech that
the English alphabet of letters bears to writing. He
presents a tabulated "physiological alphabet" thus con-
structed. The use of such an alphabet in the treat-
ment of stammering serves as a mental, as well as a
physical, discipline. Just as a child learns to read
one short word or syllable at a time, so the stammerer
should be taught to phonate or articulate one short
word or syllable at a time. This process is known as
syllabication. Attention is also called to the physio-
logical division of words into syllables for the purpose
of syllabication. They should be divided, not accord-
ing to their etv'mology, as you find them in the dic-
tionaries, but according to their physiological enuncia-
tion. For instance, we say phy-si-o-lo-gi-cal, not phys-
i-o-!og-ic-al, and e-ty-mo-lo-gi-cal, not et-ym-ol-o-gic-
al. This is the natural or easy way to pronounce
words, and we take advantage of the fact not only
by calling the attention of the stammerer to it, but
by practising him in the art of doing it. We also
teach him syllabication by having him read the ele.-
ments of language as they appear in sentences. This is
called phonetic reading.

Eyestrain as a Cause of Headache. — Linn Emerson
sa\-s that eyestrain is the cause of insomnia, vertigo,
nausea, neuralgia, migraine, and failure of general
health, and has but scant patience with those who be-
lieve otherwise. He believes that more than half the
cases of so-called bilious or sick headache are due to
eyestrain, and that many cases of the above nam.ed
nature are referable to the same cause. He also finds
that another class of cases frequently failing to receive
proper treatment are the early presbyopes. The indi-
vidual with normal eyes and health goes to the age
of forty-five before glasses are required for near work.
But if there is moderate impairment of health or latent
hyperopia present, the patient begins to have head-
aches at forty, or even sooner, and for various reasons
the eye condition is overlooked. One of the principal
reasons why the eye condition is often overlooked is
because the mind of the layman associates the use of
glasses for near work with oncoming senility, and as
a \voman is only as old as she looks and a man as old
as he feels, the imputation that the oatient is getting
old is sharply resented. That the power of accommo-
dation fails rapidly after the age of twenty-five is
unknown to the patient, and to sav that they are
presbyopic or old-sighted is an unpardonable breach of
courtesy. There is such a condition as premature presby-
opia, and in many instances we are obliged to give
glasses for near work to patients even in the twenties,
.^mong women all the head sv-mptoms occurring be-
tween the ages of forty and fifty are generally at-
tributed to the menopause. Many of these cases would
be markedly relieved of their troublesome head symp-
toms by the use of proper glasses for near work.

Jan. 12, 1907]

MEDICAL RECORD.

73

Divers' Paralysis with Scarlet Fever.— R. Ellis re-
ports the case of a civil engineer working in com-
pressed air who had a sudden attack of acute myelitis.
There was complete I'jss of sensation and motion from
the nipple line down, with partial paralysis of the
diaphragm and entire loss of temperature sensation.
There was partial paralysis of arms and neck, so that
his hands, arms, and head were not under control.
There was complete paralysis of the bowels and blad-
der. His mental condition was normal. Two days
afterward an expert in spinal diseases gave a bad prognosis
and ordered no treatment. His temperature ranged
from 99° to 102°. pulse about 90. On the fourth
day scattered red points appeared about both elbows.
On the fifth day there was quite intense hyperemia
of the skin of the entire body looking like scarlet fever
rash. The throat was not sore, but slightly red; the
tongue was coated with red edges. There never was
nephritis, but cystitis developed early. There was coin-
plete desquamation. There were severe rheumatic
pains in left shoulder and elbow nad left knee joints.
There were no other •complications. Three experts
made a positive diagnosis of scarlet fever and as a
result the patient, with four attendants, was isolated
for SIX weeks in the hospital garret. No other case
of rash developed among 250 patients who were ex-
posed. The author says that further study is called
for to determine whether the rash attending some cases
of myelitis is really scarlet fever or an acute exfoliating
dermatitis.

Journal of the American Medical Association, January
5, 1907-

Lupus Vulgaris. — Two cases of lupus of the ear, illus-
trating the serious nature of the disorder, are reported
by .■*!. Ravogli. In both, the tubercle bacillus was
found in the extensive ulcerations destroying the ex-
ternal car, and in one the disease had deeply involved
the underlying bony and other tissues. He remarks
that connective tissues, bones, and fascia do not have
the resisting power to the tubercle bacillus that is
possessed by the skin, and when the germ gets away
from the latter it is no longer under control, and in
a short time the' disease is reproduced in a nodular
or disseminated form which represents miliary tu-
berculosis of the intestinal organs. Lupus therefore is
always a serious disease, and prognosis should be
guarded in any case. In these cases treatment was
discouraging; the Finsen method failed, though it was
at first apparently helpful in one case. The best re-
sults, so far, were obtained by applications of pure
lysol, which forms a hard whitish eschar, followed
by healthy cicatricial tissue. The article is illustrated,

Cancer-Infected Cages for Rats and Mice. — H. R.
Gajlord and G. H. A. Clowes give the history of the
endemic occurretice of sarcoma in rats in an infected
cage in the New York State Cancer Laboratory. Three
years previously the cage had been used for the keep-
ing of rats inoculated with sarcoma. They also give
an account of another infected cage in which, in the
course of three years, over sixty cases of carcinomatous
tumors have occurred in white mice. The frequent
changes of location of the cage and of its occupants
in at least one instance without interrupting the occur-
ence of tumors seem to leave no doubt that the in-
fection is in the cage. The authors consider it the
most striking example of cage infection that has yet
been recorded. These observations, they remark, indi-
cate that both sarcoma in rats and carcinoma of the
breast in mice (all the cases in the mice seemed to
occur in females), must be looked on as contagious,
and. taken in conjunction with other like observations
on record, should, they think, lead us to give more
consideration to the possibility of the contagion or
local infection of malignant growths in the human
species.

Migrainic Psychoses. — Alfred Gordon reports twelve
cases of migraine associated with mental symptoms,
observed within the last four years, and all presenting
sitiiilar types of derangement, namely, confusion, deliri-
um, usually with hallucinations, and stupor. The hal-
lucinations were usually visual, though gustatory and
auditory hallucinations were also observed. The confu-
sional stage predominated in all, and was frequently ac-
companied with illusions of identity, incoherence and
disturbance of orientation. Some of the cases suggested
psychic epilepsy or procursive epilepsy. In the ma-
jority of cases the mental symptoms occurred during
the attacks, and in ?ome they continued twenty-four
hours after the subsidence of the migraine. In some
cases, however, they occurred either before or after

and they lasted in some cases for tvvtnty-four hours
after the subsidence. He does not think that he can
explain these conditions as epileptic or hysterical,
though in some cases they suggested it. The special
point is their association with an autotoxic condition,
which is the basis of migraine.

Atrophic Rhinitis. — G. L. Richards reviews some of
the more recent literature and theories of this disease.
He finds little support in the facts for die theories that
have been advanced of its etiology; that it is secondary
to accessory sinus disease, that it is dependent on spe-
cial conformation of the parts, that it is due to ex-
cessive dryness of the atmosphere, or that it follows
the purulent rhinitis of childhood. It has not been
proven in any case that the bacilli that have been found
in the lesions or atrophic rhinitis are responsible for
anything more than the odor of the disease, aiid Rich-
ards is inclined to think the view of Cozzolini, that
it begins primarily in the bone, as an atrophy of the
medullary blood-vessels, becoming later a periostitis or
a rarifying ostitis, and the microorganisms play only
a secondary part, as the most reasonable of all which
have been advanced. The etiology is as yet an unde-
termined one and a subject for further study. There
seems to be a predisposition, sometimes apparently
hereditary, but just what constitutes this predisposition
is undetermined. The various measures proposed for
the treatment are reviewed and the result is rather
discouraging. When all is said and done, the local
therapeutics, he says, seems to reduce itself to a thor-
ough cleansing of the nasal mucous membrane, and
the use of any application which produces a mild stimu-
lation is probably as effective as anything. The severer
remedies do not seem to have anv advantage over the
milder ones. He hopes that a specific may yet be found
and that the future will give a successful treatment.
Notwithstanding his pessimism as to perfect cure, he
always tells patients that they can be improved, which
is true, and that with careful self-care they can keep
the nose free from crusts and have a reasonable degree
of comfort with it. In a few cases in which he has
been able to control the treatment for a sufficient
length of time in voung persons, it seems to him that
ho has brought about a cure.

Digitalis Heart Block.— .\. W. Hewlett gives the his-
tory of a case in which the use of digitalin was followed
by slow and irregular pulse, the irregularity consisting
in a dropping of the beats accompanied with precordial
distress. Auscultation showed that the dropping was
not due to the occurrence of extra systoles, but that
during the intermission there was either absolute si-
lence or at most only a faint and indefinite soft sound
over the base of the heart. Simultaneous tracings
from the veins of the neck and the apical region showed
two forms of irregularity, the first due to a blocking
of the cardiac contraction wave passing from the auri-
cles to the ventricles, while in the second form the beat
was also dropped out, but there was no auricular pul-
sation in the pause of the ventricular rhythm. He
discusses the mechanism and causes of these phenom-
ena and assumes the probability of a block occurring
above the auricles as well as at the auricular ventricu-
lar scplum.

The Lancet. December 22, 1906.

Heart Massage as a Means of Restoration in Cases
of Apparent Sudden Death. — An analysis of 40 cases
is made by T. A. Green. From the tables presented
we learn that there are records of 9 successful cases
and of 8 partially successful cases; that is, cases in
which life wa:s prolonged for periods ranging from two
to twenty-four hours. Epitomized histories of the
40 cases are given. The author makes the following
statements: (i) It has been possible in human beings
to restore the heart beat by massage when ordinary
measures of resuscitation have failed, even when the
massage has not been commenced until the heart had
been stopped for fortv-five minutes, but a definite and
complete cure has never yet been effected when this
interval has been longer than from seven to eight min-
utes. (2) In many of the cases the adoption of mas-
sage for a period of from thirty seconds to five
minutes has been sufficient to restore the heart beat,
but it has sometimes been necessary to go on with it
for fifteen minutes, or even longer. (3) Artificial res-
piration and its adjuncts must also continuously be
applied, and sometimes it is necessary to persevere
with it long after pulsation is restored in order to
reestablish the respirations. For cases, therefore, of
sudden heart and respiratory failure, he lays down
the following order of procedure: (l) Immediate

74

MEDICAL RECORD.

[Jan. 12, 1907

lowering of the head and the commencement of arti-
ficial respiration and tongue traction, taking care that
a free access of air to the lungs is possible and there-
fore implying tracheotomy if necessary. (2) If the
abdomen is open, pressure on the abdominal aorta to
confine the circulation to the upper part of the body.
If it is not open the intravenous injection of adrenalin
solution and the application of Crile's rubber suit or,
failing this, tight bandaging of the limbs and abdomen.
(3) The subcutaneous or intravenous injection of nor-
mal saline solution, partly to raise the blood pressure
and partly to dilute any poisons which may be in the
blood and tissues. (4) If the above methods have not
been successful after being applied for from eight to
ten minutes heart massage by the subdiaphragmatic
method. This route should always be adopted, unless
the chest is already opened or to be operated upon, as
being the easiest way of access, the one fraught with
least danger to the patient, and the one which has given
the greatest percentages of success. The time is fixed
at from eight to ten minutes because eight minutes is
the limit of the interval at which up to the present time
a complete success has been obtained in man. and if
it is exceeded the danger of the production of fibrillary
twitchings, inability to restore consciousness, and the
development of spasms in the voluntary muscles with
consequent failure of the manipulations have to be
taken into consideration. The unavoidable extension
of this limit should, however, be no bar to the adoption
of the method, as very hopeful results have been ob-
tained, even when forty-five minutes have elapsed from
the onset of the syncope before it has been tried. (5)
After normal pulsation has returned to the heart, arti-
ficial respiration must be continued until spontaneous
breathing has been restored or until circumstances
make it improbable that such restoration will be ob-
tained.

An Operation for the Cure of Prolapsus Ani and In-
ternal Hemorrhoids. — .\fter some general observations
D. Xewman describes the operation, the object of which
is to cauterize the mucous membrane of the rectum
into six narrow strips from above downwards, each
strip being four inches long by a quarter of an inch
to one-sixth of an inch broad. This is done through
a fenestrated speculum six inches long, four inches in
circumference, and one and a ciuarter inches in diam-
eter, with six windows four inches long and one-sixth
of an inch broad. When the speculum is inserted fully
the lowermost limits of these windows is half an inch
above the anus, so that the mucocutaneous line is
protected from the cautery. A aeneral anesthetic hav-
ing been administered, the patient is placed in the
lithotomy position with the knees well raised and the
hemorrhoids or prolapsed rectum is fully reduced.
Then, having explored the passage with the finger, the
fenestrated speculum containing the obturator is in-
troduced to its full length: the obturator which pre-
vents the mucous membrane from protruding into the
lumen of the speculum during the introduction is then
withdrawn. When light is reflected by a forehead
mirror into the speculum the congested mucous mem-
brane is seen protruding through the six openings in
the speculum, the disc is then passed into the speculum
to close the upper end of it. in order to prevent the
mucous membrane at the end of the speculum from
being accidentally scorched by the cauterv. .^11 the
mucous membrane which protrudes through the open-
ing of the speculum is freelv cauterized with an iron
cauterv at a dull-red heat. and. if necessary, the specu-
lum is cooled bv allowing a stream of water to play
upon its interior for a few seconds between each appli-
cation of the cauterv. When the operation is com-
pleted six narrow strips of cauterized mucous mem-
brane are seen, the surface of which is almost level
with the metal of the speculum. The disc is now with-
drawn: a half-grain morphine suppository is introduced
and the speculum is firmly packed with gauze covered
with vaseline, and against the outer end of the cauze
the obturator is held, and over it the speculum is
withdrawn. The gauze tampon is retained within the
rectum, its free end alone showing at the anus. The
after-treatment is — small doses of opium bv the mouth
and verv limited diet for a week, so as to give the
lower bowel complete rest during that time. The ex-
ternal parts are kept well cleansed, the tampon is
retained till it causes uneasiness, and on the seventh
dav a laxative is given. The instruments above referred
to are fisrured in the original article.

The Influence of Calcium Chloride on the Agglutina-
tion of Vibrios. — The results of further observations bv
M. Cren'^iropouls and C. B. S. .\mos are presented in
tabular form. Their methods are described and their

conclusions are given in the following language, their
work being confined to vibrios obtained from choleraic
and dysenteric stools at various Egyptian localities,
notably El Tor: (i) Chloride of calcium greatly favors
the agglutination of the vibrios usually considered to
be those of true cholera. (2) On certain other vibrios
which, though agglutinated by the so-called cholera
serum yet without all the so-called specific characteris-
tics of cholera vibrios, the effect of the calcium salt
agglutination was very slight. These latter vibrios,
while agglutinated by the serum, were hemolytic and
did not fix the immune body of cholera serum.

British Medical Journal, December 22, 1906.

The Exanthem of Scarlet Fever and Some of Its
Counterfeits; Clinical Significance of Skin Hemorrhages
in Diphtheria. — These topics reCL-ivc an interesting con-
sideration by J. MacCombie. who discusses the scar-
latiniform rashes seen at times in measles, variola,
varicella, in enteric fever, scalds, etc., and in diphtheria
following antitoxin injections. "He points out the fac-
tors of differential diagnosis, noting, with special refer-
ence to German measles, the absence of the purely
erythematous rash of scarlatina and observing that
the spots are to be found on the face as well as on
the trunk and extremities. On the trunk the indi-
vidual macules are larger than the fine punctations of
scarlatina in the same location. On the forearms and
legs the scarlatinal rash is frequently papular, and
the individual spots may be as large as the head of a
good-sized pin, but this characteristic does not obtain
of the rash as a whole. Skin hemorrhages in diphtheria
signify a pretty general toxemia. The author has noted a
little over 200 cases in a total of 6,755 diphtheria patients.
Xone were seen in cases brought under treatment on the
first day of the disease. The patients have practically
all been under twelve years of age. and the hemor-
rhages have been rather more common below than
above the seventh year. They are more marked on
areas subject to pressure, but are by no means limited
to such areas. They are more common in severe
faucial diphtheria with which nasal involvement is as-
sociated. In pure larvngeal diphtheria they are rarer.
The areas most frequently involved are the trunk and
extremities, but they may develop on the face, ears, and
neck. .-\s a rule the number of spots does not exceed
six. There may be in addition scattered red petechial
spots. If only one or two hemorrhagic areas are pres-
ent, the patient may recover: but if there is a greater
number, the case is nearlv alwavs fatal. For this rea-
son they afford a most valuable aid to prognosis which
it is wise not to overlook. In some of the cases per-
sistent epista.xis precedes or accompanies the appear-
ance of these skin signs. Incidentallv the occurrence
of persistent epista.xis about the fourth or fifth day of
faucial diphtheria leads one to anticipate the very prob-
able occurrence of skin hemorrhages within a short
time thereafter. Hematemesis is someiimes present,
due in manv cases to hemorrhage from the mucous
membrane of the stomach. Persistent vomiting and
signs of cardiac failure are to be noted in most cases
showing skin hemorrhages, the patient dying of tox-
emia and cardiac failure. The duration of life after
the date of onset of the skin hemorrhages is usually
four or five days, sometimes less, while some cases
live for a week or a fortnight. In preantitoxin days
Patients hardly ever survived more than two days after
the skin hemorrhages appeared. Cases which recover
are those in which vomitinar and cardiac failure are
absent, or are little in evidence.

Berliner kliiiische Woehensehriff. December I", 1906.

The Successful Removal of a Tumor of the Occipital
Lobe of the Brain. — Oppenheim and Krause describe
this case in which a tumor of unusual size was removed
from the occipital lobe of the brain. The patient was
a man of thirtv-five vears. who. after suffering for some
weeks from headache, developed right-sided hemianop-
sia, optic neuritis of the right eye. vertigo, vomiting,
bilateral choked disc most pronouncecd on the right
side, and partial alexia and agraphia. K little later
right-sided hemihyperesthesia. hemiataxia. and hemi-
paresis developed. Iodine and mercury as well as
other internal remedies proved without effect, and as
it was believed that from the clinical signs the tumor
could be located in the occipital region of the left
side, operation was decided upon and performed in two
stages three and a half months after the onset of the
headache. At the first stage a large quadrilateral bone
flap was made over the occipital lobe, exposing the
lateral and longitudinal sinuses. Si.xteen days later

Jan. 12, 1907

MEDICAL RECORD.

75

the wound was reopened and the dura incised. The
tumor could be immediately seen occupying the lower
median angle of the opening made, and it was easily
removed by blunt dissection. It measured 32.X5SX58
mm., and was egg-shaped. On microscopical examina-
tion it was found to be a ppindle-celled sarcoma. The
operation lasted only one-half hour and there was
little loss of blood, but during several days the patient
was in a very precarious condition owing to high tem-
perature and rapid and feeble heart action. He ulti-
mately recovered completely, however, and has been
able to go about his business as well as ever, the only
symptoms persisting being a moderate contraction of
the right visual field, while otherwise he is entirely
free from difficulties.

A Gigantic Renal Calculus. — Johnsen says that the
largest kidney stone removed by operation heretofore
reported is one described by Sheild in the Lancet,
October 15, 1904. This stone, which weighed 570 g.,
had a length of 13 cm., and its largest lateral circum-
ference measured 26 cm. A calculus recently removed
by Pelz surpasses this specimen in size, though not in
weight, as it measured 14.1 cm. in length, and its largest
longitudinal circumference was 33.5 cm., and the largest
lateral circumference 28.5 cm. Its surface was extremely
irregular and, owing to the very dense fibrous tissue
growth its presence in the kidnev had evoked, the
removal of the stone, together with what remained
of renal substance, could be eflfected only with the
greatest difficulty. The patient made a good recovery.

Milnchcncr tncdicinische IVochenschrift, December 18, 1906.

Immunity in Mice Against Carcinoma. — Schone de-
scribes e.xperiments made in Ehrlich's laboratory to
determine whe.ther by injecting emulsions of various
organs it is possible to render mice refractory to inocu-
lation with Jensen's mouse tumor. Experiments with
mouse liver, mouse testicle, and chick embryos seemed
to confer a slight degree of immunitv. though this was
not very marked, but on using mouse embryos a very
pronounced grade of immunity could be obtained. A
moderate degree of immunity was also secured by
injections of human carcinoma of the breast. Schone
considers that these experiments as well as Bashford's
similar results with the injection of mouse blood are
sufficient to overthrow Doyen's belief that carcinoma
immunity is bacterial and that the Micrococcus ncofor-
nians is concerned in the process.

Three Cases of Neuralgia of the Tongue. — Hoefl-
mayer says that neuralgia of the tongue is extremely
rare, and yet in the last year he has seen three cases of
the affection. All of the patients were men, moderately
neurasthenic and suffering from chronic constipation.
In none of the cases were cither the glossopharyngeal
or hypoglossal nerves affected. The pain involved only
the domain of the lingual nerve, and the anterior third
of the tongue which is supplied by the chorda tympani
was not included in the painful area. In each case
cure was effected by relieving the tendency to constipa-
tion, and the author ascribes the condition to the ab-
sorption of toxins from the intestines.

Deutsche mcdizinisclic ]]'ochcnschrift, December 20, 1906.
Diagnostic Difficulties in Regard to Incarcerated
Femoral Hernia. — Haberern calls attention to the many
different conditions, such as hydrocele, testicular swell-
ings, enlarged glands, abscesses, etc., that may simu-
late hernias, and that have led to wrong diagnoses,
but speaks particularly of varicosities of the saphenous
vein in connection with femoral hernia. He himself
was led into error in dealing with the case of a woman
of forty-nine years who presented what appeared in
all ways to be the typical picture of an incarcerated
femoral hernia accompanied by the usual symptoms of
sudden onset of painful swelling, nausea, vomiting, and
constipation. Some years previously, on consulting a
prominent gynecologist, she had been assured that she
was suffering from hernia and a radical operation
was proposed. This was refused bv the patient and
since that date she had worn a truss constantly. On
cutting down upon the tumor, suddenly a tremen-
dous gush of blood was poured out, and the true nature
of the condition became evident. The saphenous vein
was tied off together with the plexus of inflamed
varicosities and the wound heqled by primary union.
At present, three vears after the operation, there is
no trace of either varicosities or hernia. The author
states that while it is usually easy to distinguish vari-
cosities from a reducible hernia, it may be a matter of
the greatest difficultv to differentiate between vari-
cosities and an incarcerated hernia, and he reports
his case as an illustration of this fact.

French and Italian Journals.

Appendectomy Phlebitis o£ the Lower Left Ex-
tremity.— Broca refers to a case reported by Diculafait,
This patient, a man twenty-two years old, was operated
upon after a third crisis of appendicitis. The operation was
simple and easy, and healing was rapid without suppuration.
Nevertheless, on the fifteenth day a small oozing of bloody
fluid was noticed at the cicatrix, and the existence of a
phlebitis of the left leg was discovered. Different inter-
pretations of such a condition are given. Dieulafait thinks
that perhaps it is due to the relative mobility of the left
leg during the period of dressings and rest. Broca has
observed several such complications following kelotomy
practised on the right. He knows of no explanation for
such an occurrence. — Le Bulletin Medical, October 20, 1906.

Electricity in the Treatment of Skin Diseases.—

Augustino di Luzenberger says that electricity is beuehcial
to various forms of skin diseases, and m various forms or
application, .\mong these are galvanism, electric cataphor-
esis, static electricity, and the .r-rays. Cataphoresis is useful
in the destruction of keloids, acne rosacea, erectile and
cavernous angiomata by causing coagulation in them. The
direct galvanic current produces dilatation of the vessels,
and dissipates edema. The chief power of cataphoresis is a
biological rather than a chemical one. There is cellular and
trophic stimulation. Static electricity given in form of
baths has a stimulating and tonic effect, and increases the
activity of metabolism, assimilation, and elimination. It is
useful' in pruritus, urticaria, impetigo, and furuncles. It is
used for varicose ulcers and for alopecia. The resonator of
Oudin has a sedative effect on pruritus, stops the develop-
ment of infective agents, produces transitory analgesia,
causes vasoconstriction, and modifies inflammatory proc-
esses. It is useful in eczema, prurigo, lupus, acne, impetigo,
etc. The value of the .v-rays in lupus is well known. —
Annali di Elettricita Medico e Terafia Fisica. September,
1906.

Abdominal Pregnancy with Fetal Retention Dating
Back Twenty-one Years. — Begouin observed this pa-
tient, a woman who at nineteen years of age had given
birth to a child. At the age of twenty-four years she had
a miscarriage of two months and a half, and at the age of
thirty-three she had become pregnant again, .^t the third
month of pregnancy she showed the grave symptoms of
hematocele, which were repeated at the fourth month;
nevertheless, the pregnancy continued. At the ninth month
false labor occurred, with death of the fetus. The fetus
remained twenty-one years in the abdominal cavity, caus-
ing only slight disturbance. Then extreme pain developed,
with loss of sleep and appetite, which rendered life intoler-
able. Laparotomy was performed, and the fetus, which was
very adherent to "the maternal tissues, was removed. Three
months after the operation the patient died from intestinal
occlusion. The fetus was in an excellent state of preserva-
tion, showing no calcareous incrustation. .\n abdominal
fetus ought to be extracted at the end of some months, or
in the course of the first year, when the maternal adhe-
sions are comparatively soft. — La Tribune Medicate, Oc-
tober 13, 1906.

The Heart in Basedow's Disease. — Guido Dernini

gives the histories of fourteen cases of exophthalmic goiter
observed by him, in which he made a special study of the
condition of the heart. He sums up his observations for
us thus: !. The heart in Basedow's disease is particularly
sensitive to fatigue, soon using up its reserve force. 2.
There is slight increase in the diameters, especially the
transverse, but they are transitory. 3. The amount of
fatigue of the heart is in relation to the general asthenia
of the patient. 4. The return to its original size is almost
complete; in advanced cases of the disease the return may
be slow and incomplete. 5. The murmurs heard in the dis-
ease are very variable, and change rapidly in a short period.
The condition of the blood has no influence in the produc-
tion of such murmurs.— L(7 Riforma Medica. October 27,
igo6.

Calculous Anuria and Ureteral Catheterism.— Imbert

has recently had under his care two patients suffering with
calculous anuria who were cured by ureteral catheterism.
In these two cases the sound reached without difficulty up
to the pelvis of the kidney. From this fact the observer
concluded that there is no reason for admitting the exist-
ence of mechanical obliteration of the ureter by a calculus
acting like a simple plug. In one of the patients a siniple
vesical lavage sufficed to reestablish the course of the urine.
It is probable that there existed a do'.ible reflex: the first,
provoked by the contact of the calculus with the ureteral
mucosa, determined the contraction of the subjacent mus-
cular layer; the second, which succeeded the preceding,
was the arrest of the renal secretion which was due not to
the presence oi the stone, but to the tension of the kidney,
—La Presse Medicate. October 17, 1906.

MEDICAL RECORD.

[Jan. 12, 1907

lock Sputpuii..

An Introduction to Physiologv. By U'illiam Townsend
Porter, M.D., Associate Professor of Physiology in the
Harvard Medical School. Philadelphia' and London:
J. B. Lippincott Company, 1906.
This Introduction to Physiology is a guidebook for work
in the physiological laboratory; and as such will probably
be found useful by those in need of help in this line. The
book is divided into three parts: the first dealing with the
general properties of living tissues, the second with the
income of energy, and the third with the outgo of energy.
In the preface the author calls attention to the "concentra-
tion" system as adopted in the Harvard Medical School.
By this method the first half-year in the medical school is
devoted to anatomy and histology, the second half-year to
physiology and biological chemistry, the third to pathology
and bacteriology, the fourth, fifth, and sixth to practical
medicine and surgery ; while the seventh and eighth are
elective, each student choosing for himself the studies best
suited to his needs. The present volume is a collection of
fundamental and accessory experiments in several fields of
physiological knowledge, printed in an abbreviated form for
the temporary use of Harvard medical students and other
interested persons.

Oper.^tionen am Ohr. Die Operationen bei Mittelohreit-
erungen und ihren intrakraniellen Komplikationen. Fiir
Aerzte und Studierende, von Dr. B. Heine, a.o. Professor
an der Universitat und Direktor der Universitats-Ohren-
Poliklinik zu Konigsberg i. Pr. Zweite. neubearbeitcte
Auflage. Mit 29 Abbildungen im Text und 7 Tafeln.
Berlin : Verlag von S. Karger, 1906.
The second edition of this work is well fitted for practi-
tioners and students desiring a knowledge of the operations
relating to the ear. To the student familiar with the Ger-
man language, this treatise is especially beneficial. Going
into the minutest detail, the author has taken pains and
succeeded in covering the field in two hundred pages of
excellent printed^ rnatter. The description of the operations
for acute mastoiditis and for chronic suppuration of the
middle ear are particularly interesting. The book is divided
into two parts : the first treats of the operations of the
tymp.inum and attic, the mastoid operation, and the opening
of the labyrinth : in the second part are included the opera-
tions for extra- and intradural and brain abscesses, sinus
thrombosis, ligation of the jugular, serous, and purulent
meningitis, lumbar puncture, etc. Seven photoengravings,
illustrative of the various operations on the temporal bone,
contain some of the best descriptive pictures of the intri-
cacies and pitfalls of these operations.
The Treatment and Prophylaxis of Syphilis. Bv .Al-
fred FouRNiER, Professor at the Faculty of Medicine,
Member of the .A.cademy of Medicine. Physician to the
St. Louis Hospital. Paris. English Translation of the
Second Edition (Revised and Enlarged), by C. F. Mar-
shall, M.D., F.R.C.S., late .Assistant Surgeon to the Hos-
pital for Diseases of the Skin, Blackfriars, London,
formerly Resident Medical Officer to the London Lock
Hospital. London: Rebman Limited; New York: Reb-
nian Company, 1906.

Dr. I^Iarshall is to be congratulated on his skill in con-
verting Prof. Fournier's brilliant French into clear and
attractive English, and in shortening the text, not by omis-
sion of matter, but by condensation of form. This is made
possible by the fact that the original volume on treatment
was a series of lectures, and therefore somewhat full, while
the volume on prophylaxis was a collection of papers writ-
ten at long intervals and containing many repetitions. By
judicious pruning these two books of 714 and 558 pages
respectively have been brought together into a single work
of about 500 pages. The special paper used makes the
volume very light and pleasant to hold. It is to be regretted
that the publishers are not consistent in their choice of
type for paragraph headings, using generally small capitals,
but occasionally, and for no obvious reason, heavy black-
faced type. The first part gives a very thorough description
of the various methods employed, the greatest stress being
laid on the chronic intermittent treatment with mercury
given by the mouth, because, as Fournier insists, treatment
must be kept up for at least two or three years, because the
drug must not be allowed to lose its effect as a result of
continuous administration, and .because ingestion is efficient
in the great majority of cases and is the only method
which patients will consent to follow for so long a period.
Chapters are devoted to inunctions, injections, and the use
of potassium iodide, the value of all being fully rec9gnized.
The second part treats of the prophylaxis of sj-philis by
State regulation, by protection of nurses, by treatment, and
by instruction, and is remarkable chiefly for the overwhelm-
ing evidence it affords of the havoc wrought by this disease
among those who suffer from it through no fault of their

own, recalling in this section the excellent treatise on
"Syphilis Insontium," by Bulkley, of this city.
DiSEA^is OF THE Stomach. A Textbook for Practitioners
and Students. By Max Einhorn, M.D., Professor of
Clinical Medicine at the New York Post-Graduate Medi-
cal School and Hospital ; Visiting Physician to the Ger-
man Hospital. Fourth Revised Edition. New York:
William Wood & Co., 1906.
Dr. Ei.\ horn's book is already so well and so favorably
known to the profession that its appearance in a new edition
does not demand detailed discussion. Gastric ailments
have always been and will always continue to be among
the commonest disorders that the practitioner encounters,
but their successful management is often a matter of the
greatest difficulty. The present volume was designed to
assist in coping with the problems these cases involve, and
it is extremely practical in conception and execution. The
chief considerations of pathology and etiology are given
due weight, but the greatest merit of the work lies in the
clear and detailed expositions of the methods of diagnosis
and treatment. The author's many contributions to this field
have met with general appreciation, and in his textbook he
presents in concise and readable form the results of his
wide experience in special practice. Among the more im-
portant additions to this edition are profusely illustrated
discussions of the application of the Roentgen rays and
radium for purposes of gastric diagnosis. It is a pleasure
to commend this highly serviceable book to the attention of
all medical readers.

Traite d'Hygiene. Public en Fascicules sous la Direction
de MM. P. Brouardel, Professeur a la Faculte de Mede-
cine de Paris, Membre de ITnstitut; E. Monsy, Medecin
de I'Hopital Saint- Antoine ; III Anthropologie, Hy-
giene Individuelle, Education Physique. Par R.
Anthony', Secretaire de la Societe d'Anthropologie ;
E. DuPRE, Agrege a la Faculte de Medecine, Medecin des
Hopitaux de Paris ; P. Ribierre, .'\ncien Interne des
Hopitaux de Paris ; G. Brouardel, Medecin des Hopitaux
de Paris .'\uditeur au Conseil Superieur d'Hygiene; M.
Boulay, ."^ncien Interne des Hopitaux de Paris ; V.
MoitAX, Ophthalmologiste des Hopitaux de Paris; P. La-
FEUiLLE. Medecin-Major de I'.A.rmee. Avec trente-huit
figures dans le te.xte. Paris : J.-B. Bailliere et Fils, 1906.
The present volume of this excellent series is attractively
arranged in several sections, the first two of which are de-
voted to the consideration of physical and psychical anthro-
polog}-, respectively. The means of studying the human
form from life, including instruments and technique, and
the use of statistics, are first considered. A discussion of
the normal method of growth closes this section. Evolu-
tion and psychical growth are next taken up — phylogenesis
and psychical ontogenesis, education of the intellect, physi-
ological effects of fatigue of the mind, and the methods of
estimating this fatigue in students and their practical appli-
cations follow in order. The remainder and greater part
of the volume is given up to the consideration of Individual
Hygiene in its different aspects. L'nder this subject cloth-
ing, its use, materials, various articles for different parts
of the body and for the different ages, as well as cleanliness
and disinfection of the same are all treated of in consider-
able detail. Following this is a most interesting chapter
on the care of the skin, including the aspect and structure,
the functions and microorganisms of this organ, as well
as the subjects of baths and soap. The hygiene of the ear,
nose, mouth, and throat, in both the infant and adult, is
followed by a section on vision. The last part of the text
treats of physical exercises and physical education. These
subjects like the preceding are discussed in a broad and
interesting manner. This work will prove a most valuable
addition to any library.

Letters fro.m a Surgeon of the Civil \\'ar. Compiled by
Marth.\ Derby Perry, Author of "God's Light as It
Came to Me." Illustrated from Photographs. Boston:
Little, Brown & Co., 1906.
These delightful letters were written by the late Dr. John
G. Perry of Boston, who took part in the Civil War as a
surgeon with the Army of the Potomac. While a student
at Harvard he entered the army as a volunteer assistant to
Dr. Gushing at Fortress Monroe in 1862. In .-^pril, 1862,
he went back to Boston on account of a serious illness,
and afterwards passed his graduating examinations. On
March iS. 1863. he married the compiler of the letters. A
month after his wedding he returned to the army with the
Twentieth Massachusetts, taking part in the military opera-
tions at Fredericksburg, Falmouth, Culpepper, Bristoe Sta-
tion, j\Iountain Run, Stevensburg, The W'ildemess, and at
the hospital near Petersburg. The letters were written to
his sweetheart, later his young bride, during the campaigns
and are alive with human and historic interest on every
page. The book makes good reading for the doctor's
family and for the waiting patient in his reception room.

Jan. 12, 1907]

MEDICAL RECORD.

71

fi'orwtg Erporta.

NEW YORK ACADEMY OF MEDICINE.

Regular Meeting, Held December 20, igo6.

The President, Dr. Charles L. Dan.i^, in the Chair.

This meeting was held under the auspices of the Section
on Surgery.

General Considerations in Reference to Blood Ex-
amination in Surgical Diseases. — Dr. Frederic E. Son-
DERN read this paper. He said that laboratory investiga-
tions, no matter how important, were an aid only to the
clinician ; they did not and were never intended to replace
his clinical diagnostic skill or his prognostic ability based
on clincal e.xperience. Blood examinations in surgical cases
were an aid in determining the general state of health
before and after surgical procedure; they aided in the
diagnosis of conditions inducing lesions subject to surgical
intervention or those complicating surgical diseases or
their convalescence ; they furnished information in the
differential diagnosis between some surgical disorders and
lent aid in determining the degree of depletion due to
hemorrhage ; and finally they presented evidence of decided
value in determining the presence or absence of an inflam-
matory lesion, and, in the former event, they might indicate
the degree of toxic absorption and the resistance otTered
by the animal economy toward this infection. The arbi-
trary rule that no surgical procedure should be undertaken
when the amount of hemoglobin was below 30 per cent.,
while better than no rule was crude in the light of present
knowledge. The evidence in the blood of malaria, typhoid
fever, the different forms of leukemia, Hodgkin's disease,
and the different types of anemia were often of decided
value to the surgeon not only in diagnosis but also in
differential diagnosis. The value of blood work in the
differential diagnosis between Hodgkin's disease and sar-
coma and between secondary anemia and so-called per-
nicious anemia needed no comment. The determination
of the coagulability of the blood was of value to the surgeon
particularly as means had been devised for increasing the
coagulability prior to the operation. The determination of
the opsonic index would lack practical application until
ways and means were found for increasing this index when
desirable. The most important service the blood e.xamina-
tion could render the surgeon was to give information
regarding the presence or absence of an inflammatory
lesion, some idea of its severity, and some indication of
the resistance offered. lodophilia as a guide in this regard
had not rendered signal service in his hands. Since advo-
cating the value of the differential leucocyte count as an
aid in the diagnosis of acute inflammatory lesions and the
added significance it gave to the leucocytosis, his daily
contact with cases in which this diagnostic help was
sought strengthened his belief in this adjunct. In the
application of this procedure it was absolutely necessary
to kegp in mind the fundamental principle on which it was
based : the increase in the relative number of polynuclear
cells was an indication to the severity of the toxic absorp-
tion, and the degree of leucocytosis as evidence of the
body resistance toward this absorption. As in every other
technical procedure, the differential count to be at all
accurate demanded proper technique and faithful execution,
usually expected but by no means invariably obtained from
the hospital interne and even from the pathologist's assist-
ant as he had reason to know from control examinations
which he had been asked to make. This diagnostic pro-
cedure lacked many refinements, and he added a few words
concerning the disappointments and failures sometimes
encountered. Children, and particularly infants, did not
give the uniform results obtained in adults ; in these the
normal polynuclear percentage was a more variable quan-
tity. When a purulent exudate was confined in dense
pyogenic membrane so that no toxic absorption occurred,

or when a purulent exudate was the result of a tuberculous
or typhoid infection alone, there was no leucocytosis and no
polynuclear increase. Suppurative bone lesions, and particu-
larly suppurative processes on the surface of mucous mem-
branes, showed lower counts probably on account of
slower to.xic absorption. Mixed infections, with or follow-
ing tubercle bacilli or typhoid bacilli, did not show the
extreme polynuclear percentages noted in primary staphyl-
ococcus and particularly streptococcus infections. The
exact nature of the infection also had a bearing on the
degree of polynuclear increase, some organisms causing
higher percentages than others, everything else being equal.
In closing he said that it was unfortunate that this diag-
nostic aid, blood cultures in septic conditions, had not
found more favor in private practice.

The Surgical Application of Blood Examinations. —
Dr. John B. Deaver of Philadelphia presented this paper.
He considered what proper estimate might be placed by
the surgeon upon the results of blood examination. These
examinations in acute posthemorrhagic anemias were of
more value after operation in indicating the rapidity with
which the blood returned to normal. In these cases it was
extremely common that the red corpuscles were restored
sooner than the hemoglobin percentage. He said that
diagnostically he had found the number and character of
the red cells and the percentage of hemoglobin so nearly
similar in patients afflicted with chronic suppurative
processes and in others with malignant tumors, as per se
to be often of no value. Given a hemoglobin percentage
below 25, a paucity of small distorted red blood-cells and
a disease-spoiled body, he considered the patient's condi-
tion provocative of the surgeon's most serious and sober
contemplation. To him the white blood-cells had been a
frequent source of perplexity. Clinically, one usually
followed this biological phenomenon by comparing the num-
ber of leucocytes to the condition in which the patient was
found shortly after the count was made, or, later, by com-
paring these various counts to each other and to the course
of the disease, so that in this manner one should have a
reliable indication of the presence of inflammation and
suppuration, and should be able to gauge its course and
severity. Now and then a case occurred in which a bac-
terial invasion did not permit itself to be revealed by any
such method, and so he had been compelled to employ
such terms as "usually" and "should have." If he had
been asked to explain the modus operandi in those negative
cases he said that he might reply in such indefinite phrases
as "lack of resistance," ''personal susceptibility," "impaired
state of health," "idiosyncrasy," and so on, but instead he
would resort to the subterfuge of answering a question by
a question, and ask for example, why, in the Jewish race,
diabetes mellitus was so frequently encountered, and tuber-
culosis so seldom, or why the Japanese were so immune to
scarlatina, and the negroes to malaria? Therefore, with
these reservations, leucocytosis would usually be found in
infections leading to suppuration in any part of the body.
In appendical abscess a leucocytosis was the rule, and,
in looking over his records for the last 100 cases, he
found that the count varied from 6,300 to 47.200, with
an average of 17,760. Those below 10,000 numbered 10;
between 10,000 and 20,000 numbered 61 ; between 20,000
and 30,000 numbered 23 ; above 30,000 numbered 6.
The diagnosis of appendicitis was most frequently con-
fused with pyosalpingitis and with biliary tract dis-
ease and a comparison of the counts was there-
fore of interest. In appendicitis with abscess (extra-
appendical exudate) the high was 47,200; low, 6.300;
average, 17,760 ; above 10.000, go per cent. ; above 15,000,
62 per cent. In pyosalpingitis, high, 42,200; low, 5,300;
average, 13,000 ; above 10,000, 67 per cent. ; above 15,000,
32 per cent. In biliary tract disease, high, 23.300; low,
4,000; average, 9,000; above 10,000, 15 per cent,; above
15,000, 6 per cent. Dr. Deaver believed that iodophilia
was of little value. It was only of value in the detection

78

MEDICAL RECORD.

[Jan. 12, 1907

of suspected deep abscesses when the leucocyte count had
proved normal. In gall-bladder cases associated with
jaundice he had found the time of coagulation had been
delayed. Dr. Deaver believed that the greatest value of
the differential leucocyte count was obtained by the gen-
eral practitioner, if he had the requisite training for the
work and the time ; but he asked how many men were
able in a suspected case to take the blood, go back to the
office, spend twenty minutes on the white cells, stain the
films, and count at least 500 leucocytes. This was prac-
tically impossible.

The Clinical Value of the Differential Blood Count
in Operative Otology. — Dr. James F. McKernon asked
if a differential blood count would help in doubtful cases
to make a more accurate diagnosis. He thought it would,
and this opinion was based upon the differential leucocyte
count in 166 operative cases, 108 of which were adults
and the remaining 58 being children ranging in age from
si.K months to twelve years. In all of these the differential
leucocyte count was taken as an aid in diagnosticating
mastoid disease, and the sequelae resulting from it. Of
the 108 adult cases, a positive diagnosis of mastoid involve-
ment was made in 8^ without recourse to the blood count,
which was made only for confirmatory evidence. Of this
number of cases the lowest polymorphonuclear percentage
was 73.2 per cent., the highest 97.6 per cent. In the 24 re-
maining cases many of the typical symptoms of the disease
were absent, and it was here that the dift'erential leucocyte
count proved of the utmost value. Of these 24 18 did not
present the usual clinical signs of mastoid disease, and it was
only after a differential leucocyte count had been made
that an operation was decided upon. Of these 18 cases the
lowest polymorphonuclear percentage was 73.2 per cent., the
highest 86.4 per cent., and all contained pus in the mastoid.
The remaining si.x cases were complicated with a phlebitis
of the sigmoid sinus, and in these case's the polynuclear
percentage prior to operation was high, the highest being
96.6 per cent, and the lowest 86.8 per cent. Of the 58
cases in children a positive diagnosis of mastoid involve-
ment was made in 47 prior to the differential count. The
lowest polynuclear percentage was 68.6 per cent., the high-
est 82.8 per cent. Of the 11 remaining cases none exhibited
the usual symptoms of the disease, and here again the dif-
ferential leucocyte count proved of value in 8 cases. Of
these 8 cases the lowest polynuclear peri'-ntage was 72.2 per
cent., and the highest 83.4 per cent., and pus was found in
abundance in the mastoid process. In the 3 remaining
cases there was nothing to explain the high temperature,
and marked prostration, except the presence of a discharge
from the ear. The lowest polynuclear percentage was 42.4
per cent, and the highest 56.8 per cent., and from this the
natural deduction would be absence of sepsis, but in rela-
tion to this low polynuclear percentage was a marked de-
crease in the number of white cells usually found. Upon
operation an abundance of pus was found in each of these
three cases. The conclusions he arrived at were that in septic
cases the differential blood count was of practical value
in enabling one to complete a diagnosis ; in cases of sepsis,
when the physical symptoms and signs are distinct and
definite, it was then only confirmatory and gave an added
link to complete the chain of evidence. A fact of impor-
tance brought out in this series of cases was that when
cellular bone structures, like the mastoid, were involved
in a septic inflammation, without involvement of the adja-
cent blood currents, one found that in the majority of the
cases the differential count showed a relatively lower
polynuclear percentage than when a sep'ic process was
present in the soft tissues of the body. ~' ' -.-.'.d be
explained on the theory that an absorptic: :.3 was

less rapid when such a process took place in a bone cavity.
A point mentioned by Dr. Sondern. and corroborated by
a study of the above cases, showed that when there was a
pronounced leucocytosis and a pronounced polynuclear
increase it was indicative of a severe infection with good

systemic resistance, and that a pronounced polynuclear
increase with little or no leucocytosis showed a severe
grade of infection, with but little body resistance, and also
that the increased polynuclear percentage, with stationary
or decreasing leucocytosis, showed an increasing degree of
infection, with decrease of body resistance.

The Value of Differential Leucocyte Counts in Gyne-
cology.— Dr. How.^RD Canning T.-v-ixoR read this paper,
dividing it into the consideration of three sections, as
follows: (i) Ectopic pregnancy. In this the blood count
was that of hemorrhage from any cause. The amount of
leucocytosis depended upon the amount and rapidity of
the hemorrhage, reached its highest point within a few
hours, and diminished rapidly during the following three
or four days, reaching normal only after a number of days
more. With a recent hemorrhage the high total count and
high percentage of polynuclear cells, taken with an absence
of temperature, were signs that rarely would point to any
other condition. (2) New growths. If uncomplicated he
had found no change in the leucocyte count. If the new
growth, for instance, a fibroid tumor, became infected, or
if there had been a recent degenerative change or a hemor-
rhage sufficiently extensive to produce a posthemorrhagic
leucocytosis, one found change in the leucocyte count. With
carcinoma, either of the cervi or fundus of the uterus, any
leucocytosis that might be present was due to the com-
plicating inflammation and not to the growth itself. (3)
Inflammatory diseases. The most marked changes in the
blood count were found in inflammatory diseases of the
appendages. In an acute case both the total count and
the polynuclear cells were increased in proportion to the
severity of the disease, decreasing as the condition im-
proved. If the infection was tubercular there was usually
little or no change in the count. In gonorrheal infections
the changes were less marked than in more severe forms
of infection. He emphasized the fact that blood counts
should be considered with the other symptoms, and to be
of the greatest value there must be repeated counts. The
negative condition of the blood that was found in uncom-
plicated new growths w'as not of the same value as the
positive findings of the hemorrhage following ectopic
pregnancy, or of the inflammatory diseases, yet it was of
value in excluding other conditions that might be present
as complications. In the inflammatory diseases the blood
changes were more marked and more constant. There
was, beyond doubt, a definite relation between the amount
and the virulence of the infection and the blood changes.

Dr. Howard Lilienthal believed that in the matter of
blood examinations there was other than the leucocyte
count, and that something would have to be done to have
more frequent e.xaminations made by the chemist, and
less by the microscope. Blood cultures were of enormous
importance in prognosis in serious peripheral disease. In
acute abdominal cases these examinations w-ere not so im-
p, rtar.L because the bacteria were stopped by the viscera,
the liver, and any secondary invasion of the
gi..;^r<i. , ;.od stream did not come until long after the pri-
mary invasion of the liver. Blood cultures were very
important ' - ' 'axis. In the acute infectious surgical
diseases I -il said he had come to the conclusion

that in determining whether to operate or not the blood
count could be entirely disregarded. In every case that
he waited for the blood findings he said he was sorry; but
he had never been sorry when he went ahead and did not
wait for blood counts. He reported three interesting cases.
The first was a gentleman fift5' years old, sent by a
colleague because of a thick induration of the face, and
which eventually developed into a malignant carbuncle of
the lip. There was considerable swelling and brawny
infiltration. Incision was at once made. No pus was
present. The blood count was practically normal. Another
operation became necessary two days later, when he tied
the facial to prevent invasion of the circulation by sepsis.
A blood culture taken from a vein of the foot gave positive

Jan. 12, 1907]

MEDICAL RECORD.

79

results. No pus was present at any time. The number
of leucocytes was normal, the polynuclears were low, and
prognosis bad. There was no enlargement of the lymph
nodes. Operation was again resorted to, and the patient
died. The second case was a fat woman who was sud-
denly stricken with severe right-sided abdominal pain,
vomiting, and with temperature of 103°. Twenty-four
hours later she was admitted to the hospital with these
symptoms and with an irreducible umbilical hernia. There
was a question as to the existence of a strangulated
hernia with gangrene or appendicitis. The leucocytes
numbered 30.CC0. the polynuclears 90 per cent. A small
incision over the appendix was made and revealed the fact
that she was suffering from a twisted ovarian cyst. The
cyst was removed and the patient did well. He expected
to find a suppurative process, but there was no pus any-
where. The third case was a boy of seven years with
typhoid fever, who had a sudden drop in the temperature,
bi:t no increase in the pulse rate, no prostration nor other
signs except distention, the latter not being present when
the drop in temperature occurred. The blood count
wai normal for typhoid, i.e. leucocytes ",000, polynuclears
67 per cent. He decided to wait three hours in order to
see whether the blood count would go up. At the end of
that time there was more distention and an e.xploratory
incision was then made. A large perforation was found,
peritonitis developed, and the boy died. Waiting for the
leucocytosis lost him two, three, or four hours.

Dr. Nathaniel B. Potter spoke of the difficulty of
estimating the value of the differential count in children.
Again in the City Hospital where they had so many chronic
cases the differential count was very irregular, and they
never had been able to follow any rule. In regard to the
value of the hemoglobin estimation, he said he had found
that even with a low percentage these patients stood opera-
tions fairly well; whereas, if there was a sudden drop in
the hemoglobin percentage and a low count, they would
not stand operations as well. The determination of the
opsonic inde.x was a very complicated problem, and he did
not believe it would be of any practical value until the tech-
nique was simplified. It could be stated, though, that, in a
large percentage of chronic localized staphylococcus infec-
tions, and in some cases of chronic localized tuberculous in-
fections, raising the opsonic inde.x by proper doses of dead
cultures of the corresponding germ would improve the
patients materially, if not cure them. He told of the
observations made by himself and coworkers last summer
in cases of appendicitis. He believed that the future for
infections like chronic acne, or general furunculosis, car-
buncles, sycosis, and in some of the other staphylococcic
infections, was very bright for the use of this method of
treatment. It was too soon to say what the future would
be for tuberculosis. The great trouble at present was the
difficulty encountered in making a uniform emulsion of
the tubercle bacilli which would phagocyte with regularity.
Dr. Trudeau's experiments with tuberculin led one to
believe that if they could determine the tuberculoopsonic
inde.x they might eventually cure more cases which hitherto
had been helpd but little.

Dr. George Slo-\n Dixon thought they all would agree
with what had already been stated, that the examination
of the blood was simply an aid in diagnosis. In diseases
of the ear the leucocyte count was likely to be low because,
the disease being in the bone, did not aft'ect the circula-
tion as though in the soft parts. He showed some charts
which were based on some selected cases. There were
31 cases of purulent chronic otitis media, with or without
complications, and 77 cases of acute purulent otitis, with
or without complications. The blood counts were made
only at or about the time operation was performed. In
the acute cases the leucocytosis rose from 9,000 to i7,S03
without complications ; those that were complicated with
mastoiditis ran a little higher. The polynuclear percentage
in the acute purulent otitis media cases ran from 40 per

cent, to as high as 81 per cent., and much the same curve
was shown in the mastoiditis cases. The most important
feature was that when the patient had a sudden rise in
temperature with a leucocytosis running as high as 25,000
or over, whether a high polynuclear percentage or not,
they were likely to find a pneumonia or meningitis present.
If 20,000, it was noted that a meningitis would develop
within twenty- four hours; if beyond 25,000, probably a
deep pneumonia. In the chronic cases the curve was a
trifle lower, and the same held good for pneumonia and
meningitis. The highest percentage of polynuclears in
meningitis noted was 97 per cent.

Dr. Max Einhorn said that twenty-two years ago he
undertook to study the relation of the lymphocytes to
the blood corpuscles and made differential counts in normal
and diseased individuals. This claim was upheld by the
presentation of some of his writings on the subject at
that time.

Dr. Samuel Lloyd emphasized the necessity of a com-
plete blood count, and that we should not depend upon a par-
tial one. He believed, too, that there was something in the
idea advanced lately regarding lymphocytosis in progressive
septic diseases. One should not depend upon the percent-
age of polynuclears alone, but should take them down the
scale, noting any increase in the other blood elements
which might give an indication as to the progress of the
disease. With regard to the hemoglobin percentage as an
index for operative work, the rule of 30 per cent, he
believed to be too high; he said he had operated success-
fully in cases where the percentage of hemoglobin was 20
per cent. Much was yet to be studied on the coagulability
of the blood, and it was particularly of value in cases of
long-standing jaundice where one anticipated a dangerous
hemorrhage. Dr. Lloyd said he had had one case in which
the coagulability was thirteen minutes. He referred to
Dr. Crile's suggestion that w-here one got a reduced hemo-
globin, or a preoperative anemia, or where other conditions
were present which reduced the hemoglobin too low, direct
transfusion of blood could be done and often with marked

SECTION ON MEDICINE.

Stated Meeting, Held December 18, 1906.

Dr. Warren Coleman, Chairman.

A Case of Aneurysm. — Dr. William B. Noyes reported
this case at the request of Dr. Lewis and Dr. Keller of the
Columbus Hospital. The previous history was practically
negative except that the patient had syphilis fifteen years
ago, and used alcohol in e.xcess. Seven days prior to ad-
mission the patient suffered from cough and expectoration,
the sputa being bloody. Physical examination showed the
patient to be fairly well nourished. The apex beat was
not localized by inspection, the greatest point of intensity
being over the fouith costal cartilage, one inch to the right
of the sternum. Area of impulse extended all over the
chest wall. The first sound was diffused over the anterior
chest of greatest intensity to the right of the sternum.
The second sound was accentuated and the respiratory mur-
mur was absent on the left side. The vocal resonance was
decreased over that side and hyperresonant over the right
chest. Examination of sputa was negative as to tubercle
bacilli. The voice of the patient was noticeably hoarse.
On November 26 a needle was introduced posteriorly and
four ounces of fluid was aspirated ; this had a specific gravity
of i.oio, was alkaline in reaction, reddish in color, and
coagulated, but not spontaneously. It contained large num-
bers of red blood-cells. Two days later laryngoscopical
examination showed that the left vocal cord was paralyzed.
At about this time tracheal tug was obvious. On November
29 a systolic murmur, low pitched with greatest intensity
over the internal half of the clavicle, was noted. There
was no temperature, and the patient was up and about the

8o

MEDICAL RECORD.

[Jan. 12, 1907

ward. He expectorated bloody fluid and sometimes pure
blood. He died suddenly December 12, igo6. At autopsy
the right pleural cavity was found to be free of adhesions,
but the left pleural cavity was obliterated by dense ad-
hesions, laterally and posteriorly. The left lung was com-
pressed and hard to identify, being replaced by a mass
consisting of clots of blood, some recent, red, or black, some
appearing of long duration. The heart was flabby, dilated,
while the tricuspid and mitral valves were normal. The
aorta showed very great atheromatous changes and was con-
stricted above the semilunar valves. At the transverse
arch of aorta and upper part of descending aorta
was an aneurysmal sac the size of a cocoanut, and
which had ruptured into the posterior mediastinum. The
walls were thick, except over the rupture, which was very
thin. The diagnosis was made of aneurysm even before the
tracheal tugging was noted. The aspirating needle was
thrust through the aneurysm. From the syphilitic history
given the probabilities were that this was a syphilitic process
and not due to ordinary atheromatous changes.

Dr. Charles H. Lewis said that the case was of interest
from the presence, as well as the absence, of certain clinical
signs and symptoms. In the first place, the complete flat-
ness over the upper left side, due, as shown at the autopsy,
to the entire absence of lung tissue; then the tracheal tug-
ging was well brought out. These signs, together with the
paralysis of the left vocal cord, and the strong aortic second
sound, were the ones on which a diagnosis of aneurysm was
based. There was no expansile or heaving pulsation over the
flat area, no bruit was heard, and no difference in volume or
time between the right and left pulse was detected, although
carefully and repeatedly looked for. Dr. Lewis said that
he had introduced a small exploring needle about one inch
below the spine of the scapula and withdrew a hypodermic
syringeful of what he then supposed to be serosanguinolent
fluid. He thought this fluid was in the pleural cavity and
secondary to the aneurysm. He directed the house surgeon
to aspirate in the same place, which was done a few days
later, and "the four ounces withdrawn" was reported by
Dr. Noyes. Dr. Lewis had grave doubts as to whether
the fluid came from the aneurysmal sac, which presumably
would contain pure blood. One could, however, perforate
such a sac with a small needle without the slightest harm.
This he had done in other cases and he had withdrawn
blood in order to differentiate aneurysm from solid tumors.
In this case the rupture occurred at some distance from
what was supposed to be the tract of the aspirating needle.
Dr. NoYES said that the left pleural cavity was almost
completely obliterated with adhesions and the right pleural
cavity was practically normal. The left lung was practically
cornified from pressure from the aneurj'sm and from the
clots. The aneurysm had been leaking before the final
rupture if the old clots and the ragged state of the lining
membrane of the aorta were any proof. How long this had
been going on was hard to say. The patient seemed fairly
well until the day he died. Histological examination of
sections of the aorta had not yet been made, but on gross
examination it seemed like a chronic inflammation, with a
ragged, sloughy surface of a rather unusual pale-red color
rather than the typical appearance of atheroma of the aorta.
It seemed to him a chronic aortitis of a distinctly syphilitic
nature.

Pathology and Symptomatology of Chronic Adhesive
Pericarditis. — Dr. AIontgomerv Hunt Sicard read this
paper. He said that among 2,000 autopsies at the Presby-
terian Hospital there were 77 cases of fibrous pericarditis,
or about 3'/2 per cent, of the post-mortem examination; 45
of these 77 were extensive, involving the greater part of the
sac; 32 were slight; there was but one case of mediastino-
pericarditis. In 33 of these TJ there was existing endocar-
ditis : in 5 gross myocardial changes occurred ; in 15 there
was marked sclerosis of the coronary arteries ; in 4 severe
aortic sclerosis : in 4 aneurysm, and in 33 chronic diffuse
nephritis. Of these 77 cases 9 were tuberculous, 4 having
pulm.onary tuberculosis and 5 having general miliary tuber-

culosis. Among the 2,000 autopsies there were 329 cases of
chronic endocarditis, so that chronic pericarditis formed
about 5 per cent, of the cases of chronic valvular disease.
At St. Mary"s Free Hospital for Children, out of 97 au-
topsies there were 5 cases of adherent pericardium ; there
were also among this number 4 cases of pyopericardium
with considerable thickening, but without actual adhesions.
Symptomatically he divided the disease into a number of
fairly well defined classes. (l) Cases that ran a latent
course and were only discovered upon the autopsy table;
(2) those cases in which one, during a routine e,xamination,
discovered a harsh systolic murmur over the pulmonary
area, increased by pressure and by leaning forward, the
pulmonic second sound being accentuated; (3) cases with
circulatory embarrassment, palpitation, irregularity, and
intermission of heart beats, sometimes precordial pain, with
moderate general hypertrophy, and sometimes tenderness
over the base of the heart. No murmur or friction sound
was heard to account for the cardiac change and so only a
tentative diagnosis was made from the absence of direct
signs ; (4) cases with adhesions between the outer surface
of the pericardium and the neighboring structures ; here
there would be considerable enlargement of the heart with
diffuse pulsation of the precordium and systolic retraction
of the apex. The heart was pretty well fixed by adhesions;
paradoxical pulse might be present; (s) severe cases of
mediastinopericarditis resembling the last group except that
the mediastinal inflammation was more widespread, with
consequently more serious changes in the abdominal viscera.
These patients suft'ered from cyanosis and dyspnea, and
constantly recurring ascites. A curious appearance was
the frosted or iced liver, "Zuckergusslcber," a white, fibrous,
thick mass of connective tissue coating the liver and leading
to much irregularity and distortion. The picture in this
last group of cases was enlargement of the liver and
ascites, and it was difficult to differentiate it from cirrhosis
of the liver. The chief factors of distinction were absence
of the causes of cirrhosis, nondilatation of the superficial
veins, absence of the common symptoms of liver obstruction
as hematemesis, jaundice, hemorrhoids, diarrhea, or consti-
pation, signs of chronic pericarditis. In mild cases patients
died of intercurrent disease which had nothing to do with
the pericarditis. In severe cases there was a gradual
cardiac failure due to increasing dilatation. Sudden death
might occur at any time from myocardial degeneration
or coronary sclerosis.

Dr. C. N. B. Camac referred to the Broadbent sign, and
said there were great variations in the signs of adherent
pericarditis, much like the signs of endocarditis, and they
depended upon how much of the pericardium was involved
and also what part of it. As the pericardium was possibly
attached to the deep cervical fascia and below to the lateral
wing of the diaphragm, perhaps to the central tendon, he
said it was a question whether they could get Broadbent's
?ign if the pericarditis involved that portion in contact
with the diaphragm. He said he had in mind three cases,
two of which came to autopsy. Broadbent's sign was pres-
ent, but disappeared. This was a very important sign in
making a differential diagnosis, especially in differentiating
pericarditis from those painful affections at the base of
the heart. Broadbent's sign with the pulse under the ensi-
form he believed to be pathognomonic of adherent pericar-
dium. Another point was the bulging of the precordium ;
this was not necessarily a sign of enlargement of the heart,
or enlarged and adherent heart. He did not know what
statistics gave regarding ascites with adherent pericardium.
In two cases reported by Osier there was a definite peri-
hepatitis and a perisplenitis ; in both cases during life the
diagnosis was simply that of congestion of the liver. Much
confusion existed regarding cardiac murmurs. In both of
the cases mentioned there were no valve lesions at all, and
yet there was a distinct diastolic and systolic murmur. The
interpretation of murmurs in adherent pericarditis was
extremely difficult as it was in endocarditis.
Dr. Theodore C. Janew.^y took exception to Dr. Sicard's

Jan. 12, 1907]

MEDICAL RECORD.

81

statement regarding the murmur over the pulmonary area
which he said was intensified by leaning forward ; it seemed
to Dr. Janeway that this harsh pulmonary murmur was
frequent in perfectly healthy men, and he had observed
many such in West Point students, and among the most
competent athletes in the class. Among these men there
would even be noted a thrill wlien they leaned forward.
In these cases the murmur would disappear on full inspira-
tion.

Dr. Theo. B. Barrikcer said lie had seen four cases "t
supposed adherent pericardium, three of which came to
autopsy. In the first case there was no retraction of the
precordium ; only a rapid heart, congestion of the liver,
some ascites, moderate cyanosis, and edema. The diagnosi-.
was made of myocarditis. At autopsy adhesions of tlK-
pericardium were found. In this case there were no mur-
murs ; the only physical signs were those showing insufii-
ciency of the right ventricle. In the second case there wa^
a systolic retraction of the precordium, Broadbent's sign.
and disappearance of the apex beat. At autopsy the external
layer of the pericardium was found to be adherent to the
pleura and liver. In the third case there was systolic
retraction of the precordium, Broadbent's sign, and a loud
systolic murmur. At autopsy there was found a stenosis
of the pulmonary valve, an hypertrophied right heart, liut
no adherent pericardium. The last case did not come to
autopsy, but the boy, aged fifteen years, had all the classical
signs of adherent pericardium. He thought that those
cases where the internal and external layers of the pericar-
dium grow together were the easiest to diagnose.

Dr. SiCARD said that at Cornell University during eigh-
teen months he had a number of cases from which he drew
his conclusions. Murmurs were present all the time and
were exceedingly harsh and grating. One should bear in
mind the chances of congenital heart lesions ; these would
frequently be found in a routine examination, and would
not cause any trouble during life.

Specimen of Chronic Bacterial Endocarditis, with
Remarks. — Dr. E. Libman believed in calling all endocar-
ditis cases acute, subacute, or chronic, according to the
duration. If bacteria were found in the blood one could
add the name of the infecting organisms. The cases of
chronic and subacute bacterial endocarditis have been called
ulcerative endocarditis, malignant endocarditis, etc., but
such terms had not been found satisfactory. Among the
cases of subacute and chronic endocarditis in which the
heart valves were attacked by bacteria, one of two types
of organisms was usually found, either a streptococcu.-^
which grew poorly or an organism which looked like the
pneumococcus, but which had no capsule and which other-
wise could be differentiated. These organisms had not
been isolated. Dr. Libman reported as an example the
case of a woman twenty-seven years old whom he saw
June II, 1906. She had had rheumatic attacks in the joints
of her lower extremities for six weeks and had been bed-
ridden three times. She never had tonsillitis. One year
before admission to the hospital she had dyspnea and
cardiac palpitation. She had pains in different parts of
the body, but particularly in the joints of the lower extremi-
ties. She coughed and sweat at night. When examined
on admission there were petechial spots on the abdomen
and the dorsum of both hands. There were evidences of
enlargement of the right heart. At the apex there was
heard the snap of a mitral stenosis. A presystolic murmur
could not then be heard. The liver was enlarged, but the
spleen was not palpable. There were thrombosed veins
in the leg and a periphlebitis. During her stay in the
hospital the temperature was exceedingly irregular. Some-
times it was 101°, and again it would be 103° or 104°. On
June 16 pain in the region of the spleen was noted, and
this organ could be felt below the free border of the ribs.
On June 19 pain in the thyroid cartilege was complained of.
Examination of the blood was interesting. There was no
increase in the leucocytes ; these numbered about 8,400,

sometimes as low as 5,600. The polymorphonuclears ran
from 72 per cent, to 80 per cent. The hemoglobin was 80
per cent, and diminished to 45 per cent. There developed
tenderness over the sternimi and over the tibiae.
June 30 she complained of pain in tlie right lumbar
region. The kidney was found to be distinctly en-
larged, tender, and red blood-cells were found in the
urine, probably from an infarct of the kidney. July
iS no changes were found in the retina. August 28 the
right knee joint became swollen, reddened, hot, and tender,
persisted for several days, and then subsided. There were
signs of infarct of the right lower lobe, increasing tempera-
ture, gradual failing, and she died September 20. The
urine contained albumin, casts, and red blood-cells In
each of the five blood-cultures taken an attenuated strep-
tococcus w'as found. There were about twenty to the cubic
centimeter of blood. The organism was not virulent, even
lor mice. At autopsy vegetations of a greenish color were
found on the mitral valve ; they extended into the auricle.
Many infarcts were found in the lungs ; the plugs were not
as ordinarily found, but distinctly yellowish; some were
rather soft, but there was no pus in the thrombi. There
was an open foramen ovale. The infarcts were produced
by transmission of these plugs from the mitral valve,
through the open foramen ovale, and so to the lungs. At
the hospital they had had fourteen or fifteen cases and
all had come to post-mortem except two. In many of these
cases there was a mitral stenosis, but a presystolic mur-
mur could often not be heard, especially when there was
fever. These cases should be carefully watched until the
fever subsided. Petechi.-e were found as a rule practically
in all the cases, and they were very suggestive, especially
when the diagnosis was not clear. Dr. Libman asked
what the temperature was due to. His own impression
was tliat the sharp rise was due to the discharge of emboli
from the heart valve, and their lodgment somewhere. As
a rule the leucocyte count was 13,000 or less. The progres-
sive anemia was curious and not easily explained, but was
probably due to hemolysis. In the case reported the bac-
teria lodged in the arteries of the spleen, causing an in-
farct ; they grew along the vessels and extended to other
vessels. In all these cases of endocarditis extending along
weeks or months these two organisms would be found con-
stantly; if one got one of these organisms from the blood
he could be certain that he was dealing with an acute
infection of the heart valve. With regard to the relation
of these cases to rheumatism he could not claim that rheu-
matism ever had anything to do with them. All one could
say was that there was a tendency to infect a valve that
had previously been damaged by rheumatism.

Dr. Alfred Meyer said that in looking for confirmatory
evidence, if petechia: could not be found in the skin they
might be found in the conjunctiva, and in quite a number
of cases in the mouth. With regard to the treatment of
this disease, he believed in the use of silver salts. In
ulcerative endocarditis or bacterial endocarditis of chronic
type he used an ointment of colloidal silver, apply-
ing half a dram twice a day, and rubbing in for twenty
minutes in order to insure absorption. Whatever had
appeared in the discussion in reference to pericardial ad-
hesions and the bacterial type of infections of the pericar-
dium only confirmed the suspicion that auscultatory evi-
dences were very deceptive and treacherous to deal with.
Li order to show how deceptive auscultatory evidences
were he cited a case seen at Mt. Sinai Hospital, one of
chronic endocarditis, with typical evidences of aortic in-
sufficiency, capillary pulse, diastolic murmur in the vessels
of the neck, and murmur over the pulmonic area, etc. In
a few days the murmur was not audible an>nvhere. Later
it returned.

Dr. Warren Coleman said that he had been using the
silver salts in the treatment of infectious diseases for
some years, but instead of ointment he used it intravenously
in I per cent. solution, and sometimes he gave it per rectum.

82

MEDICAL RECORD.

[Jan. 12, 1907

During the summer he treated a case of infective endocar-
ditis where several blood-cultures failed to give results.
He used silver twice a day per rectum, giving two or three
grains, and the patient got well. He was not willing to
draw any conclusions from this case, however.

Dr. Leonard Webek said he used ointment of silver in 40
per cent, or 50 per cent, strength. In two cases of severe
puerperal septicemia, as acute as he had ever seen, one-half
dram every three hours was rubbed in night and day. One
of these women had a temperature of 106° and over. These
cases recovered. Three years ago he saw a case that be-
came acutely septic, a case of typhoid fever, and llie results
from this ointment were equally satisfactory. In other
cases he had had good success with the ointment. But in
a case of sepsis during the course of an attack of erysipelas
involving the head, neck, ami face it failed to show any
influence whatever.

Dr. E. Libman closed the discussion.

The Prognosis of Cases of Transient Spontaneous
Glycosuria and the Relation Between This Form and
Alimentary Glycosuria. — Dr. Theo. B. B.\rringer, Jr.,
and Dr. Joseph C. Roper presented this communication,
which was read by Dr. Barringer. They gave the following
summary: (l) At the end pi five years 20 per cent, of
a group of twenty cases of spontaneous glycosuria had be-
come diabetic, 15 per cent, had become suspicious cases, and
ID per cent, somewhat suspicious ; 55 per cent, had remained
free from diabetes. (2) F.ight out of eleven cases of spon-
taneous glycosuria, in which sugar recurred, became dia-
betic or probably diabetic. (,3) The alimentary glycosuria
arising from glucose or cane sugar, provided the test was
properly conducted and repeated at intervals, afforded a
valuable aid to prognosis in cases of spontaneous glycosu-
ria. A positive test was of much more value than a nega-
tive test. (4) .Alimentary glycosuria following the inges-
tion of sugar was essentially diabetic in nature. They
found that at the end of five years but 45 per cent, at the
most of their cases had become diabetic. If it was possible,
as they believed, to detect these cases at a relatively early
date it would not seem necessary to maintain a permanently
restricted diet in all cases. If a small quantity of sugar
was found in a patient's urine, and there was no history
of overindulgence in sweets, he should be placed on a
restricted diet and the reaction to the glucose test should
be frequently ascertained during the next six months. If
the reaction were positive the restricted diet should be
continued, even though the spontaneous glycosuria had
not recurred. H the reactions were negative and sugar
did not reappear a restricted diet would seem superfluous.
The conflicting opinions as to the essential nature and
diagnostic worth of alimentary glycosuria might be har-
moni/'ed by more observation of tlie course of cases of
spontaneous glycosuria and by tlic frequent determination
of their reaction to the glucose lest.

Dr. Theodore C. J.\new.\y said that the paper showed
the type of work which was of real value on a subject
about which there was too much speculation. He reported
one patient whom he saw in 1900 who had a transient glyco-
suria with catarrhal jaundice; after lasting two weeks it
cleared up. This was followed by a diminution in sugar
tolerance. .After his jaundice the patient went South, but
took along his test solution. While there he ate syrups,
etc., but without any reduction of the Fehling's solution.
For four years he never had su,gar in his urine. He then
developed a severe attack of pyonephritis with a reappear-
ance of sugar in his urine, and since then he had been
mildly diabetic with a slight tendency to loss of tolerance.
He was never able to take bread, but could take an equiva-
lent of eight ounces of bread. The possibility must be
borne in mind that cases of spontaneous glycosuria might
develop diabetes under certain circumstances, and it was
incumbent upon them to pay attention to transient glyco-
suria and keep such patients under observation for a certain
time. Dr. Janeway also called attention to the necessity

of following children of diabetics and testing their glucose
tolerance.

Dr. Theodore Stewart Hart said that the results ob-
tained were particularly interesting because they were able
to get results on patients under observation fifteen years.
In studying the cases one must divide and classify the cases
of diabetes and glycosuria. Testing with carlxshydrates
was interesting, especially in cases of glycosuria due to, or
coincident with, liver lesions.

Dr. John J. Morrissey said that from the standpoint
of a medical examiner for life insurance it should be borne
in nnnd that glycosuria as a basis for statistical calcula-
tion, and glycosuria as a fundamental principle upon which
to make a diagnosis of diabetes, were different. Glyco-
suria in itself was the red flag of danger; but he would
not say that the majority of cases of glycosuria ter-
minated in diabetes. One could get the slightest trace
of su.gar one or two hours after a hearty meal. Too much
stress should not be placed on statistics.

Dr. J. F1N1.EV Bell said that in igoi he had a case that
was supposed to have transient glycosuria. Examination
of the urine on a number of occasions was made and copper
was reduced each time. Being desirous of having a quanti-
tative analysis made, the fermentative test was applied with
negative results. The urine would reduce Fehling's solu-
tion, but not bismuth. A few years ago he examined a
patient for life insurance. The home office told him the
patient had been examined by another examiner who found
sugar in large quantities. He made further examinations,
two being positive and one negative. He then learned
that the individual had brought the urine in a bottle which
had in it a piece of cork and syrup of figs.

Dr. Theo. B. Barringer, Jr., closed the discussion. He
said that as the cases numbered only twenty only tentative
deductions could be made.

Election of Officers. — C/;aiV)«a»j Dr. Warren Coleman;
Secretarx. Dr. H. .S. Carter.

Chic.\go Medical Society.

At a regular meeting, held December 12, 1906, there was
a symposium on "Exophthalmic Goiter." Dr. Frank
Billings described the chief symptoms of exophthalmic
goiter. He said he had records of sixty-one patients who
had come under his direct personal care; eight were males
and fifty-three females. Of the males two were acute, and
the remainder chronic forms of the disease. One male
had sufltered from goiter for several years preceding the
onset of the symptoms, and w'ith seven the goiter developed
as an incident of Graves' disease. Of the females thirty-
two had no goiter preceding the development of the dis-
ease, while twenty had suffered from goiter for from thret:
to twenty years. Ten of the fifty-three females suffered
from acute Graves' disease, and in all of these acute cases
the goiter was primary, that is, developed as a part of the
disease. Thyroidectin was used in twelve cases. The
powder form of the serum was used in a dose of from
fifteen to forty grains a day in divided doses, w"ith varying
results In no instance had he secured the favorable results
recorded by many other physicians. In two instances the
symptoms were aggravated by the remedy. He had used
the hydrobromate of quinine in eight cases. This drug had
been given in from fifteen to thirty grains in divided doses
in twenty-four hours. It had afforded a more uniform
improvement in the symptoms due to vasomotor disturbances
than any other drug. He had used the serum of thyroi-
dectomizod goats prepared under the direction of Moebius,
in one male. This patient was put upon rest treatment
in the hospital, and in addition to the full doses of the
serum hydrobromate of quinine was given. The improve-
ment was steady and continuous. He had not had experi-
ence with the use of specific serum prepared by Beebe
of New York, and used by Rogers and Thompson
in the treatment of thirtv-nine or more cases. Three

Jan. 12, 1907]

MEDICAL RECORD.

83

cf the patients included in the group were operated on.
and of this number two made satisfactory recoveries and
have remained well, while one died on the operating table.
Dr. Dean D. Lewis discussed the pathology of exophthal-
mic goiter. Dr. R. B. Preble spoke of the cardiac symp-
tons. Dr. L. H.\rrison Mettler suggested three principles
that he believed would be found useful in distinguishing
the presence of any of the said diseases in a patient whj
might at the same time have exophthalmic goiter. Tht-
first principle was to keep close to the narrow definition
of Graves' disease as being represented in one or more
only of the cardinal symptoms — tachycardia, struma, exoph-
thalmos, no matter what the other neurasthenic, hysteroid.
or general nervous manifestations might be. Whether
regarded as a mere syndrome, or as the essential expression
of the disease, the famous triad in part or in whole must
be the basis of diagnosis and nothing else. The second
principle was that we should always endeavor to align
the so-called secondary, nervous symptoms of exophthalmic
goiter with any other corresponding symptoms present
that belong to some other distinct, well-known trouble.
The third principle was that all organic diseases and all
symptoms that represented an organic lesion were com-
plications rather than a mere part of the exophthalmic
goiter. Cardiac valvular lesions, tabes dorsalis, ocular
palsy, nuiltiple neuritis, for example, were complications,
and should not be confused with the symptomatology of
Graves' disease. Dr. Casev A. Wood discussed the ocular
signs and symptoms. Dr. William E. Quine spoke on
the medical treatment of exophthalmic goiter, and under
this head discussed rest, diet, hydrotherapy, electricity, the
Roentgen ray, organotherapy, serum therapy, medicinal
therapy, and saline purgatives. Speaking of scnnn therapy,
the author said that two kinds of serum had been intro
duced — the serum of throidectomizcd animals, and the
serum of animals treated with increasing doses of thyroid
extract. Neither of these products had furnished im
portant results. In medicinal therapy iodine usually proved
hurtful. The same was true of digitalis and strychnine.
Belladonna, given in the dose of ten minims of the tine
ture, three or four times a day, was recommended 1)>
more writers than any other medicine ; but to the author
it seemed inferior to some others. Forchheimer recoin
mended the employment of hydrobromate of quinine, give;:
in the dose of five grains every six hours, sometimes
alone, and sometimes with the addition of one grain of
ergotin to each dose. Salicylate of sodium, in the dose of
ten grains, repeated every six or four hours, usually sub-
dued symptoms for a short time, but its effects were not
lasting. Of saline purgatives, the phosphate and the
glycerophosphate of sodium were of undoubted value. In
his own practice improvement of the patient under their
use had rarely failed to occur. Aside from the saline
purgatives, the medicines he had learned to rely on niostly
wcrc stronhrcn'uis. cdcine, and the bromides. Pulverized
strophanthus in the dose of one grain, codeine one-lhird to
one-half grain, and bromide of sodium in the dose of twent>
grains, each repeated at regular intervals three or four
times in twenty-four hours, often proved very serviceable
It was usual for him to give two of these medicines, hut
not codeine and the bromides at the same time. He esti-
mated that 60 or 70 per cent, of the cases of exophthalmic
goiter terminated in recovery under medical treatment.
Some cases terminated spontaneously in this way, and he
had witnessed three instances in which the occurrence of
pregnancy contributed to the result. Charcot had recorded
a similar observation. When medical treatment had been
well sustained for six months without distinct benefit to
the patient, or if the patient should get worse under thr-
best medical treatment that could be devised, surgical treat-
ment must be considered. Dr. .^rthi-r Dean Bevan re-
viewed the development of the surgery of the thyroid
gland, and reported the results obtained in sevenfcon
cases of exophthalmic goiter in which he operated. Two

of these patients died, one on the table, and the other
shortly after operation. Dr. Carl Beck demonstrated two
rare cases. The first was a case of "Suppurative Throm-
bophlebitis of the Iliac Vein," following a primary infec-
tion of a finger. There was general pyemia, with many
localizations, but one very extensive thrombus of the fem-
oral and iliac veins. Dr. Beck incised the vein at differ-
ent places subperitoneally, but did not reach pus. A few
days later the pus appeared in the dressings. The patient
recovered after many weeks of patient treatment. He
.summed up his remarks with the recommendation not to
be too radical in dealing with primary infections. He
noticed an intermittent edema preceding the permanent
edema as a premonitory pathognomonic symptom of a
deep thrombus. He recommended multiple incisions into
deep thrombi. The second case was one of "Atresia of
the Rectum" with a communicating canal into the bladder.
The child was si.x years old, and cured after many opera-
tions. At first, the first day of life, a left colostomy was
performed ; si.x months later a resection of the coccyx with
fastening of the intestine to the same; some months later
rectoplasty and closure of vesicorectal communication, and
three months ago closure of the colostomy.

Philadelphia Neurological Society.

.\t a stated meeting held December 21 Dr. G. E. Price
demonstrated ".'K Case with Incomplete Brown-Sequard
Paralysis Following a Knife-wound of the Neck." The
Ijatient was an Italian, who received an incised wound
between the spines of the sixth and seventh cervical verte-
Ijrsc, in the sequence of which he developed paralysis on
one side of the body, with sensory changes on the opposite
side. Marked improvement in the symptoms had taken
place with the lapse of time. Dr. Augustus A. Eshner
demonstrated "A Case of Hysteria Presenting Symptoms
of Cerebellar Disease." The patient was a man forty-two
years old, who presented difficulty in walking following
emotional disturbances, with tinnitus and impairment of
hearing and also impaired sensibility, but without motor
weakness or changes in the eye-grounds. Recovery ensued
under treatment with hypnotic suggestion. Dr. Eshner
demonstrated also "A Case Presenting Symptoms of Cere-
bral Tumor, with Recovery." The patient was a huckster
thirty years old. without venereal history, who suffered
from vomiting, headache, vertigo, hemiparesis, with in-
creased reflexes, but without changes in the eyegrounds.
Improvement almost to the point of perfect recovery ensued
under administration of active doses of iodide and mer-
curials. Dr. JosEi'n Sailer presented a communication
entitled "Paralysis Agitans Developing in the Unparalyzed
Side of a Hemiplegic." The patient was a woman who
eight years previously had had an attack of apoplexy fol-
lowed by right hemiplegia. Four years later symptoms of
paralysis agitans began to make their appearance on the
opposite side of the body. Various views were expounded
in possible explanation of the association. Dr. W. W.
Hawke demonstrated "A Case Showing Psychical Passive
.Apperception." The patient was a girl who had been em-
ployed at housework and in a mill, and who came to the
city to do philanthropic work. She stated that she saw
historic persons, whose images and surroundings she could
call up at will. The case presented some of the features
of dementia prscox. but it was decided that it was more
likely one of dementia paranoides. Dr. D.wiD Riesman
demonstrated "A Case of Probable Myasthenia Gravis in a
Roy of Eight Years." The patient presented headache and
causeless laughter, followed by diplopia, staggering gait,
want of equilibration, obscurity of vision, ophthalmoplegia,
unilateral palsy of the extremities, difficulty in swallowing,
mumbling speech, nausea, vomiting, increased kneejerk,
Babinski reflex, and congestion of fhe optic discs. Although
the diagnosis of myasthenia gravis seemed probable at one
time, especially in view of the marked improvement in the

84

MEDICAL RECORD.

[Jan. 12, 1907

symptoms that took place, it was decided, m view of the
persistence of ocular palsy, left hemiplegia, with increased
kneejerk on the afYected side and Babinski phenomenon,
that the condition was more likely superior polioencepha-
litis. Dr. T. H. Weisenburg demonstrated ".\ Case of
Complete Ophthalmoplegia" in a girl about seventeen years
old, in whom the condition had been present for several
years. Dr. Weisenburg e.xhibitcd also a case of tabes
dorsalis with optic atrophy, oculomotor palsy, and some
want of action in the muscles of one side of the face and
loss of taste on tlie anterior two-thirds of the same side of
the tongue.

While the Medical Rf.cokd is flensed to receive all new
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heading, it must be with the distinct understanding that its
necessities are such that it cannot be considered under
obligation to notice or revictv any publication received by it
which in the judgment of its editor <c!lt not be of interest
to its readers.

Trans.'\ctions of the Clinical Society of Loxdon'.
Volume 39, 8vo, 272 pages, illustrated, muslin. Longmans,
Green & Co., London.

Mal.^wes des Oroanes Genitourinaires de l'Homme
ET DE LA Femme. Par R. Le Fur, Ancien Interne des
Hopitau.K de Paris, A. Siredey, Medecin de THopitau
Saint-.^ntoine. 8vo, 458 pages, illustrated, paper. Librai-
rie J. B. Bailliere et Fils, Paris.

Seventeenth .Annual Report State Commission in
Li\'-' V. State of New York. 8vo, 144 pages, muslin.
Er '"inting Company. .A.lbany.

flCHT UBER DIE LEISTI.'NnEN UND FORTSCHRITTE
AUF DEM GeBIETE DER ErKRANKUNGEN DES UrOGENITAL-

APPARATES. Redigiert von Geh. Med.-Rat Prof. Dr. M.
Nitze in Berlin. Dr. S. Jacoby in Berlin, Nach Nitzes
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Leipzig. Verlag Von S. Karger, Berlin, 1906. 4to, 342
pages, paper.

GeSAMMELTE BeITRAGE AUF DEM CiEBIETE DER PhYSIOL-

OGiE, P.\thologie, UND Therapie DER Verdauung. Von
Dr. L Boas und seincn Schulcrn. Vol. I, 8vo. 7S8 pages;
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Genitourinary Diseases and Syphilis. By Charles
S. HiRSCH. M.D. 8vo, 351 pages, illustrated, muslin. P.
Blakiston's Son & Co.. Philadelphia. Price, $1.00.

Die Tuberkulose. Von Prof. Dr. G. Cornet. Svo,
1,248 pages, illustrated, paper. .Mfred Holder, Wien, 1907,

Die Tuberkulose. Von Prof. Dr. G. Cornet. Svo, 548
pages, paper. Alfred Holder, Wien, 1907.

Green's Encyclopedia and Dictionary of Medicine
AND Surgery. Vol. H, 4to, 52S pages, illustrated, unbound.
William Green & Sons, London.

Transactions of the .'\ssociation of .American Physi-
cians. Twenty-first session, held at Washington, D. C,
May 15 and 16, igo6. Vol. XXI. 8vo, 863 pages, illus-
trated, muslin.

Parent.\l Rights and Economic Wrongs. By Virginia
M. Butterfield. i2mo., 92 pages, paper. Stockham Publish-
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B.\by Craft. By .^lice B. Stockham, M.D., i2mo, 47
pages, paper. Stockham Publishing Co., Chicago.

Abdomin.-\l Pain, Its Causes, and Clinical Signifi-
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Dermatologische Vortage fur Praktiker Heft i. Des
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Jessner. Fitnfte .^uflage. Svo, 52 pages, paper. A Stuber's
Verlag (Curt Kabitzsch) Wiirzburg.

Dermatologische Vortr.\ge fur Praktiker Heft 17.
Kosmetische Hautleiden. Von Dr. S. Jessner, Svo, 124
pages, paper. .^ Stuber's Verlag (Curt KabitzschX Wiirz-
burg.

Traitement R.vtionnel du mal de Pott. Par le Dr.
F. C.^lot. Svo, 115 pages, illustrated, paper. Octave Doin,
Editeur. Paris.

Tr.waux de Chirui?gie .^N.■\TOMO-CLINIQUE.. Par Henri
Hartmann. Chirurgie de I'lntestin. Georges Steinheil,
Editeur, Paris, IQ07.

The Diseases of the Nose. Throat, and Ear. By
Charles Prevost Grayson. A. M., M.D. Second Edition,
Revised and Enlarged. Svo, 532 pages, illustrated, muslin.
Lea Bros. & Co., New York.

Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious disease reported to
the Sanitary Bureau, Health Department, New York
City, for the weeks ending December 29, 1906, and January
5, 1907:

Wi-pV

'vVeek o£ Jan. 5
Cases Deaths

Tuberculosis Ptilmonalis.

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal .Meningitis.
Malarial Fever

Totals

■83

342I

30

298

3

i57i

b

225

—

118

12

40:

II

66

180

5S
12

14

9

14

254

1260

29s

Health Reports, — ^The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the Surgeon-General, Public Health and Marine-
Hospital Service, during the week ended January 4,
1907.

SMALLPOX UNITED STATES.

California. San Francisco Dec. 15-22..

Illinois, Danville Dec. 20-27..

Galesburf? Dec. 15—22..

Indiana, Elkhart Dec. 15-22..

Indianapolis Dec. 16-30..

South Bend Dec. 15-29..

Kansas, Topeka Dec. 15-22..

Louisiana, New Orleans Dec. 22-29..

Shrevcport Dec. 22—29..

Michigan. Detroit Dec. 22-29.,

New York, New York Dec. 15-22..

North Carolina. Greensboro Dec. 15—29..

Ohio, Toledo Dec. 15-22..

Wasliinf:;ton. Spokane. . Dec. 15-22..

Wisconsin, Appleton Dec. 22-29..

La Crosse Dec. 15-22..

I Imported

SMALLPOX — FOREIGN".

Brazil. Rio de Janeiro Nov. 18-25..

Canada, New Brunswick — Kent

County Dec. 16-22..

Nova Scotia — Colchester

County Dec. 16-22..

Nova Scotia — Cumberland

County Dec. 16-22..

Chile, Coquimbo Nov. s-i6. . .

Iquique Nov. 22 ,

Ecuador, GuayQuil Nov. 1—30.. ,

France, Paris Dec. S-15. . .

Great Britain. Cardiff Dec. 9-15.. .

Hull Dec. 1-15...

India, Calcutta Nov. 10—24.

Madras Nov. 10—30. .

Persia, Hamadan Oct. 1-3 1. ..

Kerman Oct. 1-3 1. ..

Kermanshah Oct. 1-31. . .

Meshed Oct. 1-3 1 . . .

Shiraz Oct. r-3 1 . . .

Teheran and Vicinity Oct. 1-31. . .

Yezd Oct. 1—31. . .

Russia, Moscow Nov. 17-24.

Odessa Dec. S-15.. •

Spain, Barcelona Dec. 10-20..

YELLOW FEVER.

Brazil, Rio de Janeiro Nov. iS-25.

Cuba, Habana Dec. 31....

Ecuador, Guayaquil Nov. 1-30.

Present

Present

Present

I

Present

36

Imported

3

3

3
Present
Present
Present
Present
Present
Present
Present

CHOLERA.

India. Calcutta Nov. 10-24.

Madras Nov. 10-30.

150
5

Brazil, Bahia Nov. 10-17 4

Rio de Janeiro Nov. iS— 25 11

Sao Paulo Nov. ii-iS

Chile. Antofagasta Nov. 22 2

EgJ'pt, AleNandha Nov. 17 6

Garbieh Nov. 17 2

Guerfia Nov. 22-29 =5

Keneh Nov. 29 11

Menenfish Nov. 30 i

India. General. Nov. 5-17 12,759

Bombay Nov. 13-27

Calcutta Nov. 10-24

Peru, Catacaos Oct. 19 3

Lima Oct. 19 2

Mollendo Oct. 19 i

Tru.iillo Oct. 19 o

9,481

33

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 71, No. 3.
Whole No. <889.

New York, January 19, 1907.

$5.00 Per Annum.
Singfle Copies, lOc.

©rtginal ArttrlfH.

THE DIAGNOSIS AND SURGICAL TREAT-
MENT OF GASTRIC AND DUODENAL
ULCER AND THEIR COMPLICA-
TIONS.*

By a. a. berg. M.D..

NBW YORK.

ADJUNCT SURGEON TO MOUNT SINAI HOSPITAL.

The intent of the writer in this paper is to consider
the diagnosis and surgical treatment of gastric and
duodenal ulceration and their complications.

The description, merits, and technical details of
the various operations that are performed for the re-
lief of these conditions will be ignored as far as is
possible.

It probably seems to many of you, and especially
to those who have had least experience with ulcera-
tion of the stomach and duodenum, that the diag-
nosis of this malady is usually easy to make ; and
so it is in the cases that present all the classical
symptoms, viz., epigastric pain radiating into the
back, heartburn, hyperacidity, hematemesis, melena,
and a typical Head zone. Such cases, however,
are not the majority, and we must not expect that
the recognition of this disease is invariably simple
and readily made.

There are firstly a class of patients who never
present any symptoms of gastric or duodenal ulcer
until some life-threatening complication, e.g. a pro-
fuse hematemesis or a perforation of the ulcer into
the peritoneal cavity arises. As a rule, in such cases
the ulcer is not situated at either of the orifices of the
stomach, nor on the lesser curvature near the pyloric
end, for with ulcers at these sites there are more or
less well pronounced symptoms occasioned by the
passage of the food across the ulcerated area or by
the contraction of the pyloric or cardiac muscles. In
patients of this class the diagnosis of ulcer will not
be made, and should complications arise, we must
always be in doubt as to whether they are dependent
upon a long standing latent ulcer.

In the next place there is a class of patients who
manifest, as the only sign of the gastric or duodenal
ulceration, an atrocious pain in the right hypochon-
driac or epigastric region. There is no heartburn,
no vomiting, no hyperacidity, no Head zone. The
pain is severe, and often enough it incapacitates the
affected individuals from doing their usual work.

If the pain is in the right hypochondriac region, it
may simulate biliary and kidney colic, and subacute
or chronic gall-bladder and appendicular inflamma-
tion. With gallstone disease, however, there is apt
to be a history of preceding attacks of biliary colic,
some of which have been attended with jaundice,
and after some of them stones may have been found
in stools. With kidney colic there is likely to be he-
maturia, often only microscopic in character, crystals

*Read before the Harlem Medical Society, April 3, 1906.

of uric acid, oxalate of lime, etc., may be present in
the urine, and during the attack there are often
marked intestinal and gastric disturbances, such as
nausea, vomiting, and obstinate constipation. With
subacute or chronic cholecystitis and appendicitis
there is usually a history of one or more preceding
attacks of fever, pain, gastric disturbances, and ten-
derness over the appendicular or gall-bladder
region.

A carefully taken anamnesis, the employment of
the -v-ray, cystoscope, and ureteral catheter and a
thorough urinary examination will usually enable us
to differentiate ulcer cases from those of biliary or
tenal lithiasis ; but in a certain number of them the
exact diagnosis can be made only by exploratory
laparotomy. We should not forget, furthermore,
that gastric ulcer is quite frequently combined with
gallstone disease, and that the contraction of peri-
pyloric adhesions which have originated from gall-
bladder, inflammation may occasion a stenosis of the
pylorus that resembles clinically, in every detail, the
pyloric stenosis which follows the cicatrization of a
pyloric ulcer.

Many of the patients of this class become very
neurotic and hysterical on account of the pain, and
the symptoms arising from this disturbance of the
nervous system mav be so prominent as to cause us
to look upon it as the primary trouble and the gas-
tric manifestations as secondary thereto. Thus only
recently the writer was called upon to operate a pa-
tient with perforated ulcer of the stomach, who had
been treated by an eminent specialist for neuras-
thenia and dyspepsia. So commonly is this error
made, and so little do the patients benefit from the
treatment they receive for the neurasthenia, that Dr.
Wm. Mayo has been led to state "that if the pa-
tients with neurasthenia and intense epigastric, or
hypochondriac pain are referred to the surgeon, the
latter will be able to restore them to perfect health
by an operation directed to the cure of their gastric
malady.

With reference to the diagnosis of the complica-
tions of gastric and duodenal ulcers, this will be easy
if there is a previous history of such a condition.
Thus, in a patient who has presented the symptoms
of gastric or duodenal ulcer, a sudden tearing pain
in the epigastrium or right hypochondrium, followed
by rigidity of this part of the abdomen wall, tender-
ness in these regions, and rise of pulse rate, are very
significant of perforation. In the writer's experience
of eight cases of this complication, shock, vomiting,
rise of temperature, and concentric obliteration of
liver and splenic dullness have not been constant
manifestations. In duodenal perforations it is to be
noted that the point of maximum abdominal tender-
ness is frequently in the appendicular region, owing
to the gravitation of the duodenal contents along the
outer side of the ascending colon into the right iliac
fossa. Inasmuch as duodenal ulcers frequently run
a latent course until perforation occurs, this site of
maximum tenderness may lead to an erroneous diag-
nosis of appendicular perforation.

86

MEDICAL RECORD.

[Jan. 19, 1907

In cases of hemorrhage from gastric or duodenal
ulceration a previous history of these conditions en-
ables one readily to determine from whence the
blood comes; but in the absence of such a history
it may be impossible to determine the origin and
causation of the bleeding.

The most difficult of all the complications to diag-
nosticate are those which result from ulcers that
run a latent symptomatic course until their healing
and cicatrization occasions a benign pyloric stenosis,
or until adhesions that form around them occasion
disturbances in the patency and motor function of
the pylorus, stomach, bile passages, etc., or until
they have become adherent to and eroded into neigh-
boring organs, such as the pancreas, gall-bladder,
etc. Only by excluding all other causes for the
condition at hand can we arrive at a correct anatomi-
cal diagnosis. These cases, however, always call for
explanatory laparotomy, and the incision will clear
up any doubtful points.

There is ordinarily no difficulty in differentiating
ulcer of the stomach from cancer thereof, and yet
when the ulcer has very much thickened edges and
occasions a palpable tumor in the epigastric region
the differential diagnosis may be attended with con-
siderable difficulty, for the gastric symptoms in both
conditions have much similarity, and the changes in
the chemical composition of the gastric juice are
very inconstant. The difficulty is all the more en-
hanced by the fact that it is just these ulcers with
thickened edges that undergo cancerous degenera-
tion. The only safe plan of procedure in these cases
is to explore by laparotomy every palpable tumor
of the stomach, and that without too much delay.

These few remarks indicate the difficulties that
sometimes attend the making of a diagnosis of gas-
tric and duodenal ulcer. Let us now look to the
treatment of these conditions, and here we encounter
another stumbling block and a rock upon which the
internists and surgeons seem to split.

Gastric and duodenal ulcers, in their uncompli-
cated and in many of their complicated phases, have
long been considered as belonging to those diseases
that come under the pale of internal and dietetic
treatment, and the recent suggestion of surgeons
and some internists that surgical measures be em-
ployed in some of these cases has been received in
a manner which is indicative of doubt as to the
propriety and efficacy thereof.

First of all let us consider the treatment of the
uncomplicated open gastric and duodenal ulcer.
Leube, than whom no one is more entitled to speak
of the medical treatment of this malady, before the
German Surgical Congress of 1897 reported his
results in uncomplicated gastric ulcer.* He stated
that in 493 cases 74 per cent, were completely cured,
21 per cent, were improved, 2.4 per cent, died, and
about 2.6 per cent, were unimproved. The cases
that he considered as improved were freed of their
pain, but at once relapsed when they stopped treat-
ment, went back to their work, and resumed their
ordinary diet. This is about the result that most
practitioners with whom the writer has spoken and
whose publications he has consulted achieve.

Evidently with the 74 per cent, of cases that can
be and are cured by medical and dietetic means,
the surgeon has nothing to do. But what about the
26 per cent, of cases that cannot be and are not
relieved by these measures? What is to be done
with them ? Are they to be told that they are beyond

*By open uncomplicated gastric or duodenal ulcer is meant
an unhealed ulcer. It does not imply a bleeding nor a rup-
tured ulcer, nor one attended with any complicating con-
dition.

medical aid ; that they are to resign themselves to
their fate, and continue to suffer from their dis-
ease until relieved by a kind Providence, or are they
to be advised to resort to other means of help ?

It is this 26 per cent, of cases that internal meas-
ures do not cure that the surgeon asks you to send
to him for operation. He does not advise you to
employ surgical treatment in all your cases of un-
complicated, open ulcer of the stomach or duode-
num ; on the contrary, he counsels you to exhaust
all the methods of dietetic and local treatment before
you consider operative interference ; but if all these
fail to bring relief and cure, then he urges you not
to temporize further ; not to surrender these patients
to the pains and dangers that are inherent in their
disease ; not to repeat and repeat your medical en-
deavors until the patient's strength is exhausted and
his morale dissipated, but to employ operative meas-
ures, and he promises you to restore a large percent-
age of such patients to perfect health and comfort.
In this statement lies the main indication for the sur-
gical treatment of onen, uncomplicated gastric and
duodenal ulcer. It answers one of the questions put
to the writer, at a previous meeting of this society,
when he presented a case of gastric ulcer that had
resisted all medical therapeusis and was finally cured
by operation, viz., "what the indication was that led
him to employ surgical treatment."

Once you recognize the necessity and the adequacy
of surgical interference in some cases of gastric
and duodenal ulcer, you will at once ask what are
the risks and what are the late results of the opera-
tions performed for this condition. You have a right
to know what percentage of patients die directly or
indirectly from the operation ; for if the mortality
from surgical interference is higher than that from,
the disease itself, then we are not justified in advis-
ing its emplo}Tnent. The death rate from gastric
ulcer is usually put down as about 13 per cent., 6-7
per cent, from perforation and 5-6 per cent, from
hemorrhage. In Leube's series of cases the death
rate while the patients were under his care was only
2.5 per cent., but this does not take into considera-
tion the ultimate outcome of the 21 per cent, of cases
that were not cured by the medical treatment which
he instituted. The 13 per cent, of deaths evidently
do not occur in those 74 per cent, of cases that
are cured by internal and dietetic means, but is con-
fined to the other 26 per cent. In other words, one-
half of the patients that are not cured by the non-
operative measures succumb sooner or later to their
disease. Now, inasmuch as the surgeon asks you
to call upon him only in those cases which have not
yielded to the internal and dietetic treatment, his
results must be better than 50 per cent, mortality if
he is to expect the patient and general practitioner
to listen to his plea for the employment of operative
measures. It is hardly necessary for me to say that
no modern surgeon has anything like such a mor-
tality. The Mayos, in a very large number of cases,
report an operative mortality of about 2 per cent. ;
the writer, in the last three years, has had 10 cases,
all of which recovered, and other operators have
about the same results. All cases considered, the op-
erative mortality is about 2 per cent, to 5 per cent.
Thus we see that if the patient is not cured of his
ulcer by medical means he stands one chance out of
two of dying from the disease, if nothing further is
done, and one chance in 20 of succumbing to an
operation that is undertaken for his possible cure.
This brings us to the consideration of the second
portion of this query, viz., what are the final results
as to cure of this malady by operation. Von Eisels-
berg of Vienna has very carefully traced all the

Jan. 19, 1907]

MEDICAL RECORD.

87

cases operated upon by him during the past ten
years.

Of the 40 cases that recovered from operation 38
were discharged from the hospital free of all symp-
toms; 14 remained well and had no further gastric
disturbances; 13 were unimproved; 4 could not be
traced ; 9 died since their discharge, 6 of them with
gastric symptoms. It is to be noted that in this
series of cases operations, such as pyloroplasty, py-
loric divulsion, etc., were performed for the cure of
the ulcer that are to-day no longer done, their in-
adequacy for effecting a cure having been estab-
lished ; and, further, that of the 13 cases reported as
not improved, some could have been cured by sec-
ondary operation.

Of the writer's 10 cases, done in the last three
years, 7 have remained entirely well, i developed
pernicious anemia two years after operation, i had
to be reoperated several months after for recurrent
symptoms that did not yield to internal measures
and which seemed to be rapidly sapping the patient's
strength and vitality, and from last reports she was
well, and a third had slight recurrent symptoms one
year after operation that readily subsided under die-
tetic and local treatment. If you consider that these
reports concern only those cases that have not been
cured by internal treatment, i.e. the 26 per cent.
of cases that Leube reports as not amenable to cure
by medical means, you must confess that much good
is accomplished by operation in these cases. Can
there remain, tlien, any doubt as to the advisability
of treating surgically those cases of gastric ulcer
that are not cured by dietetic and local treatment,
and can there be any further excuse for waiting in
these cases until the patient's strength is exhausted
and operative measures thereby rendered far more
dangerous and serious?

The writer has thus far only considered the treat-
ment of the uncomplicated cases of open gastric and
duodenal ulcer : let us now look to the treatment of
the complications of this malady.

The most frequent and important of these is steno-
sis of the pylorus, due either to the contraction of
the cicatrices of healed pyloric ulcers or to the con-
traction of peripyloric adhesions that result from the
peripyloritis that frequently attends this condition.
Only recently it has been stated here that the pyloric
stenosis arising from these causes can be, and is,
best treated by dietary regulations and gastric lavage.
The writer readily concedes that the moderate
grades of stenosis, viz., those in which the narrowed
condition of the pylorus is fully compensated for by
hypertrophy of the muscular coat of the stomach and
which are not attended with material stagnation of
gastric contents, nor with a considerable grade of
gastric dilatation, can be and are successfully treated
by these therapeutic measures. But unfortunately
all the cases do not belong in this category. In many
of the severer ones the pyloric orifice is almost com-
pletely closed, the stomach wall is atonic, the cavity
of the viscus is dilated, and there is more or less
complete stagnation of food within it ; nutrition is
markedly interfered with because the chyme cannot
enter into the intestine for elaboration and absorp-
tion, both of which functions, as you know, are very
slightly performed in the stomach. If such patients
are put on a liquid diet and daily gastric lavage their
condition is made more comfortable ; their gastric
distress, vomiting, and autointoxication from the
absorption of stagnant material in the stomach is
greatlv relieved : but not even the most ardent ad-
vocates of this method of treatment believe that the
cicatrices or perigastric adhesions can be absorbed
or removed in this way. .-Xnd while we are relieving

the distress, and vomiting and autointoxication, what
is happening to the nutrition of the patient? Gas-
tric lavage and liquid diet, which latter is for the
most part removed again by the lavage, are not par-
ticularly nourishing, nor are they calculated to pro-
mote that sense of well being and comfort that are
essential for mental and physical work.

These unfortunate individuals, and they are truly
unfortunate and most miserable, lose flesh and
strength under this daily regimen of fluids and gas-
tric lavage, become neurotic, and at last cast aside
the advice of their physicians and seek the surgeon
who promises them relief, no matter what the dan-
ger thereof may be. But what are these awful dan-
gers that prompt this fear of surgical measures of
cure, and that permit us to let these patients sink
into a deplorable, neurotic, miserable, poorly nour-
ished condition. The mortality attending operation,
done at an early period when the patient's strengtli
and vitality are good, is in competent hands about 2-5
per cent. Surely this is not commensurate with the
pain, distress, loss of flesh, and strength, general
discomfort, and inability to do work that is the lot
of those who are treated with liquid diet and gastric
lavage, nor is it equal to the mortality that ultimately
attends this condition if not relieved by surgical
means. With operation the patient must face a defi-
nite risk of 2-5 per cent., but if he survives there-
from he has a rosy outlook for complete restoration
to health and enjoyment of life. Of 34 patients of
von Eiselsberg, 32 recovered and 2 died ; 20 were
permanently cured ; 3 were not cured, though one of
these remained well for two and one-half years ; 2
died some time after the operation, and in one of
them there were no gastric symptoms before death,
and 9 could not be traced. Without operation the
individual has to expect a slow undermining of his
health, a gradual loss of flesh and strength, in-
creasing disability, neuresthenia, and, eventually,
exhaustion. Can there under these conditions, be
any doubt which course you, as practitioners, will
advise your patients to follow, or which plan of
treatment your patient will select ! The surgeon's
aid to these patients is a God-send, which only they
can appreciate and recognize.

Perforation and hemorrhage are the two most
serious complications of gastric and duodenal ulcer-
ation, the statistics of Leube showing that about 12
per cent, of the fatal cases are due to these causes.
At the present time there is no one who will ques-
tion the advisability of immediate operation in the
cases of acute, sudden perforation, for we have
learned that spontaneous cure from adhesion of
neighboring parts to the floor of the perforated
ulcer rarely, if ever, occurs. On the other hand,
the cases in which the ulcer slowly and gradually
eats through the walls of the viscus and in
which the floor of the ulcer becomes adherent
to neighboring organs before actual perforation
occurs, thereby preventing extravasation of gas-
tric contents into the free peritoneal cavity,
are not urgent ones for operation unless a local
abscess at the site of the perforation or slough-
ing, or necrosis of the adherent organ, calls for im-
mediate surgical interference. Such patients as these
latter, however, are the very ones that need opera-
tion for the cure of the ulcer, and they should be
referred to the surgeon as soon as the local evidences
of inflammation have subsided.

Clear cut as is the indication for immediate opera-
tion in the cases of acute perforation, so doubtful
and uncertain is it in the case of hemorrhage. The
writer knows of several eminent practitioners who
have had a large experience with gastric ulcers and

MEDICAL RECORD.

[Jan. 19, 1907

have never met with a fatal case of hemorrhage
therefrom, though they admit that in several in-
stances it seemed as if the affected patient would
die. Probably many of you have had the same ex-
perience, and in consequence thereof feel disinclined
to advise surgical interference in these cases. And
yet fatal cases do occur, as many as 6 per cent, of
the deaths in this malady being due to this cause.
The writer has seen several cases of ulcer bleed to
death without surgical aid. We must admit then
the possibility of a fatal issue from this cause, and
we must concern ourselves with the question, firstly,
is anything to be done to avert it? and secondly,
when is it best to do it?

The writer has heretofore been guided in making
a decision for operation in the face of bleeding from
gastric or duodenal ulcer that was not to be con-
trolled by medical means by the rules that were
formulated by Mikulicz and Leube, viz., that op-
eration is indicated (i) in the presence of acute,
profuse, uncontrollable, bleeding, which places the
life of the patient in grave jeopardy; (2) in the
presence of frequently repeated bleedings, even if
they are not profuse, that undermine the patient's
strength, and lead to a chronic anemia.

The writer has never had occasion to interfere
surgically for frequently repeated small hemorrhages
from gastric ulcer, but in the past few years he has
had 6 cases of gastric or duodenal ulcers that were
suddenly complicated with several times repeated
profuse hemorrhages. In four of these cases gastro-
enterostomy was done, and in two the e.xpectant
plan of treatment was pursued. In two the opera-
tion was done as a dernier resort, in enfeebled
and exsanguniated patients, after internal treatment
had failed to check the bleeding ; both patients died
shortly after the operation. In two the operation
was done while the patients were still in compara-
tively good condition. These two recovered. Of
the two oatients who were treated expectantly one
recovered and one died ; the former of these two
had commenced to convalesce from a diffuse peri-
tonitis to which a perforated duodenal ulcer had
given rise, and our minds were at ease as to the
ultimate outcome, when suddenly there were, in
rapid succession, three enormous bloody (tarry)
evacuations from the rectum. His pulse rate jumped
from 92 to 148, became thin and compressible ;
his respirations were sighing; his color extremely
pallid, and his heart sounds feeble. The hemoglobin
of his blood was 19 per cent. The experience I had
gained from the two other cases in which, in the
face of such a desperate general condition, a gastro-
enterostomy had been established under cocaine
anesthesia, led me to refrain from and advise
against operation in this patient. This decision
proved to be a wise one, for, under medical treat-
ment, the bleeding did not recur, and the patient
made an uninterrupted convalesence. The fatal case
that was treated expectantly was a woman, several
months pregnant, who had suffered from the symp-
toms of gastric ulcer prior to her marriage. There
had been but little nausea and vomiting during the
pregnancy. Several days prior to the time I first
saw her with Dr. Libman. she commenced to vomit
blood. This was repeated several times, and the
family physician with whom Dr. Libman had seen
the patient requested him to take her into the hospi-
tal. On her admission she vomited about 16 ounces
of fresh blood. Her hemoglobin was about 40 per
cent., her pulse rate about 120. and not of good
qualitv. In spite of absolute rest to the stomach and
the careful use of internal remedies, the hematemesis
recurred, and surgical interference was advised, but

rejected by the family. Thinking that perhaps the
pregnancy excited the vomiting and hematamesis,
Dr. Vineberg was asked to see the patient ; his advice
to terminate the pregnancy was followed, but in
spite of this and all other means the bleeding con-
tinued and caused the death of the patient.

Of the operated cases only in one was an attempt
made to locate the bleeding vessel and directly con-
trol it.

When the stomach was opened the bleeding had
ceased ; the ulcer was readily located ; it was on the
posterior wall immediately over the celiac axis,
Its base was cauterized with the Pacquelin, and then
an anterior gastroenterostomy was established. In
this patient the search for the ulcer somewhat pro-
longed the operation, which was done under cocaine
anesthesia. In the other three cases no attempt
was made to find the bleeding vessel ; the writer con-
tented himself with rapidly establishing a posterior
gastroenterostomy. In none of the four cases that
were operated upon was there any evidence of fur-
ther bleeding.

The method in which a gastroenterostomy checks
the bleeding is not quite clear, but probably by put-
ting the stomach at rest it permits the bleeding ves-
sels to contract and retract within their sheath, and
the clot which forms over them is not constantly
displaced by the peristaltic movements of the viscus.
We must not think, however, that gastroenteros-
tomy succeeds in stopping the bleeding in all cases.
There have been reported in the last few years about
6 cases of fatal bleeding from gastric ulcer for which
a gastroenterostomy had been done several days
prior to the onset of the bleeding. In these cases
the ulcer was probablv surrounded by much inflam-
matory thickening, which prevented the eroded ves-
sel from contracting and retracting. In cases of
ulcer of this kind, complicated by bleeding, it is bet-
ter to excise the ulcer-bearing area than trust to
gastroenterostomy to check the bleeding.

The good effect on checking the bleeding from
the stomach, from causes other than ulcer, that is
to be obtained by putting the stomach at rest by
gastroenterostomy was seen in a case of the young
girl with repeated and profuse hematemesis from
cirrhosis of the liver. After the gastroenterostomy
there was no further bleeding.

The number of cases with sudden, profuse bleed-
ing from gastric and duodenal ulcers that the
writer has had is still much too small to permit of
his forming any decided rules for future guidance
in these cases. A review of the cases, how^ever, may
afiford a hint that may help in the successful man-
agement of patients whose lives have suddenly been
placed in the gravest jeopardy by the occurrence
of this complication. Of our six cases four were
in most desperate condition as a result of the bleed-
ing ; one declined operation ; one had had repeated
hemorrhages (hematemesis and melena) for six
days, and just before operation had a pulse of 156,
soft and threadv in character, and a hemoglobin per-
centage of 30 : one had had repeated hemorrhages
for 12 days: her hemoglobin was less than 25 per
cent., her pulse was 140 to the minute, soft and
scarcely perceptible, and her sensorium was clouded.
In both of these cases the attending physicians had
called upon the surgeons to stop the bleeding, only
after all internal measures had failed to accomplish
this, and as a dernier resort gastroenterostomy was
done. Neither patient reacted from the laparotomy ;
death occurred in one case fourteen hours after the
operation, and in the other about ten hours after.
These two experiences would seem to show the
futilitv of operating when the patients are in such

Jan. 19, 1907]

MEDICAL RECORD.

89

desperate condition. They are scarcely able to with-
stand the operative shock and rapidly succumb to it.
and that whether a general anesthesia has been
administered or not. When the patients are in such
condition, it seems to the writer that it is better to
continue with internal measures than to do any op-
eration, no matter how simple it is nor how rapidly
executed it may be. This view would seem to be
borne out by our fourth case, in which the hemor-
rhage occurred on the tenth day after a successful
operation for the closure of a perforated duodenal
ulcer, and for which no operation was done.

The good effect of gastroenterostomy in instantly
checking bleeding in two of the writer's cases shows
what can be accomplished in these cases when the
operation is done at a time when the patient is in
fair condition. The hemoglobin in these cases was
about 40-45 per cent., the pulse, though rapid, iio-
120, was good in quality.

If the writer summed up the impression made
upon him by the observation of our own cases he
would say that operation is not advisable when the
patient's general condition is bad, the hemoglobin
very low, 19-20 per cent., and the pulse not very
rapid. In such a condition the operative shock, no
matter how slight it may be, whether or not it is
combined with the added depressing and hemolytic
influence of a general anesthetic, is sufficient to
cause the death of the patient. It is far better, in
such cases, to trust to internal remedies and com-
plete rest, induced by morphine, to check the bleed-
ing. When, however, the patient's general condi-
tion is still good, and the hemoglobin count is about
35-40 per cent., he would strongly advise immediate
operation, either e.xcision of the ulcer, if it has in-
durated edges, or gastroenterostomy. This will
have a double effect ; it will check the bleeding and
so remove the immediate threatening complication
to life, and it will further favor the removal or
healing of the ulcer.

Acute dilatation of the stomach, secondary to
pyloric stenosis from cicatrized pyloric ulcer, or con-
traction of peripyloric adhesions, is one of the
rarer complications. The cases are still too few to
permit us to state whether it is more advisable in
these cases to resort to immediate gastroenteros-
tomy, and thus drain the stomach, or to accomplish
the latter by repeated gastric lavage. From the
experience gained in two cases of acute dilatation of
the stomach due to other causes, and treated by re-
peated gastric lavage, the writer thinks that this
mode of procedure is the more advisable, at least in
the acute stage. Of course, eventually a gastro-
enterostomy or pylorectomy would have to be done.
The writer hopes that in these brief remarks he
has put before you the present status of the surgical
treatment of gastric ulcer and its complications.
The subject is a new one, bordering on the line of
medicine and surgery, and only by the concerted ef-
forts of the internist and surgeon can the full de-
velopment thereof be achieved and the best results
accomplished.

923 Madison Avenue-

"RHEUMATISM" AND ITS TRE./VTMENT.

By F. J. WALTER, M.D.,

KRAMEK, IND.

We have made a poor diagnosis when we pronounce
a case of rheumatism. The term directs us to no
pathological condition, though, like some other
terms in our vocabulary, it serves to satisfy the pa-
tient, while confusing the mind of the physician.
Why should we not be more definite and apply the

exact meaning to the condition as : arthritis, synovi-
tis, neuritis, and autointoxication with nuiscular
pain? This covers most of so-called "rheumatism.""
"Autointoxication with muscular pain" is most con-
fusing, but in reality is due to the absorption of tlie
products of indigestion, from our habits of living,
no doubt. Note how nearly 99 per cent, are consti-
pated or have abundant evidence in the urine of
some absorption of toxic products. Here we may
have the lithemic condition (if one will call it such),
acute conditions coming at once to our notice from
the lowered resistance after cold or exposure.

In arthritis we have an infection made to flourish
by the above condition. Fertile soil we say. While
we do not know the definite infection -in arthritis or
polyarthritis in every case, often it is a mixed infec-
tion and never can be clearly isolated. The gonor-
rheal and tuberculous joints give us a definite pic-
ture. We put them off by themselves as under-
stood ; this is not right, for the other forms of ar-
thritis have many more characteristics than are
shown on a superficial survey. The majority of
patients with arthritis have a history of some mfec-
tion, and many old persons give us the historv of
grip, which is an infectious catarrhal fever. Then
we have tonsillitis, pneumonia, typhoid fever, and
this class of infections. Some avenue of entrance
can usually be discovered, if only the cavity of a
tooth. We know we can have pneumonia of a joint
and not have it in the lungs. In other words, the
pneumococcus may go to a joint and escape the
lungs entirely. ^Ve call this "acute rheumatic
fever" or "acute articular rheumatism," while in
reality these terms apply to acute polyarthritis,
though all cases of polyarthritis are not produced
by the diplococcus of pneumonia. Also we have our
tvphoid, gonorrheal, tuberculous, pneumonic, and
postgrippal forms of arthritis. Arthritis deformans
is an infection (progressive in those of low resist-
ance) and we do not know just what germ causes
it ; perhaps not always the same bacterium ; but with
it we have a trophic disturbance of the spinal cen-
ters, bilateral. There is every evidence of nutri-
tional change in the muscles, joints, and nerves.
These cases are years coming on ; at times with
long historv of indigestion and urine loaded with
urates, uric acid, and oxalates, and other evidence
of incomplete digestion, such as flatulent dyspepsia,
anemia, and weakness. Now, we must associate in
our minds infection, inflammation, and poor nutri-
tion with feeble powers of absorption and what is
absorbed of poor quality ; then we have an intelli-
gent idea of arthritis deformans. We may have
tabetic and hysterical joints. Is it not better to dis-
tinguish between all forms of arthritis and classify
them than siniplv to diagnose "articular rheuma-
tism" ?

Of neuritis we have several forms: traumatic, in-
fectious, toxic, inflammatory (without a definite in-
fection known), infiltrations, reflex, and from pres-
sure. Of the toxic forms of neuritis we have those
of lead, arsenic, alcohol, and autointoxication, all
affecting the nerve trunk, sheath, or the periphery ;
the sciatic nerve, or any other, mav be the one
chosen vv'itli a varictv of sharp, lancinatmc ov burn-
ing pains. What is the use of ailding "rhcuniatic"
to the already better diagnosis of sciatic neuritis,
peripheral neuritis, or neuritis of the anterior crural
nerve? To be sure, we have muscle contraction
from muscle irritation. Look out for neuritis in the
diagnosis of intercostal neuralgia, and other local
persistent neuralgic conditions, and look out for
tabes dorsalis in the diagnosis of neuritis of the
legs.

go

MEDICAL RECORD.

[Jan. 19, 1907

In the muscles we have nerves. It may be a neu-
«ritis of some finer twigs causing the myalgia. Now,
nvhat shall we do with "muscular rheumatism"?
In the muscles we have a large surface for circula-
tion and absorption, and we have the absorption
of the toxic products above alluded to — the products
of indigestion ; also sprains and trauma. It is just
here that it is most difficult to apply the proper di-
agnosis, as we are so prone to say "muscular rheu-
matism," yet we can fathom the cause and apply
a term meaning more than the term "rheumatism."
Some say "give the salicylates, and if they relieve
it is 'rheumatic' " I believe that the salicylates act
only on the pain as an anodyne. Many cases are
apparently cured because the salicylates and salol
are such good intestinal antiseptics and antacids.
We can apply our electrical tests here and find some
cases of neuritis. In these cases of autointoxication
the system is highly acid. I find nearly every case
turning litmus red in the mouth. The dentist will
notice it in the tartar of the teeth before the definite
pains come on. How this o-oes to prove saturation
and absorption of the products of fermentation ! In
local conditions of the feet don't forget "flatfoot."
With a stock of foot arches on hand, of every size,
one can cure many cases of so-called "rheumatism"
of the feet. From the practical experience of 3,500
•cases a year I am learning that uric acid, as well
as leukomains, purin bodies, oxalates, urates, cystin,
phosophates, indican and decreased urea are symp-
toms of this condition and somewhat of a barometer
of the case ; uric acid is not the cause. With poor
elimination these things accumulate and are influ-
enced by diet. These products certainly are found
most often in those of sluggish habits and sedentary
lives. These products of decomposition of the food
circulate in the blood and are irritants to cell life
and intoxicate more or less the brain centers as well
as act as irritants to the endothelium of the kidneys,
producing "Bright's disease" and bladder irritation.
As a guide to our treatment and diagnosis, it is well
to keep in mind the amount of toxemia, the resist-
ance of our patient, the presence or absence of in-
fection, the degree of inflammation, the nutrition,
the vitality, the social conditions, the character of
the food, the amount of exercise the patient can and
should take, and, what is verv important, glandular
action and elimination.

Proper food, intestinal antiseptics, tonics, ant-
acids, and active elimination by every means of es-
cape are very necessary. The skin is a larger organ
than the liver, and elimination by its wonderful ex-
cretory glands is not to be overlooked. This is why
hot baths and mud packs do so much for this class
of cases. These people are, or have been, large
■eaters, fond of the good things of life, and have
"the best in the land" on their tables, but they have
been unable to take care of it : what is more, they
do not know in time that they are not digesting and
eliminating properly. They will remark that a se-
lected diet is excluding just what thev like, and yet
this does not mean that we have to starve them. It
is not easy to find what will produce the least evi-
dence of autointoxication, though by patience and
individualizing we can in some little time produce
gratifying results in most obstinate cases. In gout
one will find the patients "overloaders," and it is but
another phase of this same condition with a lowered
resistance and an acute infection developing that
produces the acute attack.

Treatment. — Physicians differ greatly in dietetic
matters. Many patients will be found on a starva-
tion diet when thev most need nourishing food.
""Diet" does not mean starvation, but it does mean

the selection of good food to suit the individual.
With anything like an agreement by physicians as
to the cause of these so-called "rheumatic" condi-
tions, the chances for a common ground will be bet-
ter. To individualize the diet we must exclude
foods which in a given case cause fermentation,
pain, distress, anorexia, gastric or intestinal disten-
tion, acidity, constipation, or myalgia as nearly as is
possible ; for example the starches and sweets fer-
ment in those of sluggish motor power or having
nervous dyspepsia and cause flatulency. Tomatoes
and strawberries are frequently followed by a seri-
ous aggravation of the myalgia and the urine will
be found loaded with oxalates. Pork and veal are
both a great tax on all the parts concerned in diges-
tion and take hours to be assimilated, and unless
the motor power is extra fine they should not be
given ; but few can omit meat for a long time and
not show the need of some strengthening food.
Most persons can take mutton, chicken, and small
amounts of bacon or beef. Some persons cannot
take fried food at all. The nitrogen of meat is not
so bad ; it is the products of incomplete digestion of
the food (purin bodies, xanthin bases, or leuko-
mains) that are so toxic. Many cases of sluggish
bowels are greatly helped by the cannon-ball mas-
sage of the abdomen and the use of dates, figs, or
prunes daily. Acid conditions of the contents of
the intestines sometimes keep up the constipation
which exists in over half of these cases. Acids will
increase the acidity as well as the fermentation.
Lemons are the least objectionable, and with some
improve the condition by being converted into an
alkali.

Diet alone will not do everything, but every
means in therapeutics must be used to bring about
normal physiolog}- in every disease process. It
seems to me that we cannot too strongly urge pa-
tients to use every means and impress the use of co-
operation and combined methods and let the patient
not feel that diet, baths, massage, electricity, climate,
or one or two means can bring about a cure. Great
patience, combined with persistent methods and a
clear insight into the cause, by physician and pa-
tient, are necessary to bring about the disappearance
of symptom after symptom. Too much stress can-
not be given our social conditions as a factor in the
etiology ; our methods in the preparation of foods ;
highly seasoned foods ; food that needs but little
mastication ; the enormous appetites of so-called
"rheumatics" ; in general, how our farmers, during
the winter (their season of inactivity), keep their
tables loaded most bountifully, and how, in spite of
indigestion, people are inclined to "overload" in
eating.

Combined with diet we use baths of various kinds,
drugs, exercise or rest, electricity and light, climate,
massage, vibration, topical irritants or anodynes,
proper clothing, operative measures, water drinking,
proper surroundings, heat and cold, besides all the
attention wc can give to die nervous svstem, going
back of all this to every avenue of Dossible infection.
I am satisfied that some infection may come through
the glandular tissue (similar to tonsil tissue) of the
appendix vermiformis. through the mucous mem-
branes of the head and throat, through the tonsils,
teeth, ulcerations, any suppurating focus, and after
any infectious disease. Before taking this syste-
matically I wish to say that at "watering resorts"
one sees a large class of patients who are "last re-
sorters" ; people who have tried ever^'thing ever
suggested or thought of at home, and usually none
of them long enough to do any good, and often the
very wrong thing. If we poor doctors had the

Jan. 19, 1907^

MEDICAL RECORD.

91

chance of our prescriiHions beiniJ" renewed even as
often as the six bottles of patent medicine for five
dollars, our well-regulated prescriptions would have
a chance to assist a great deal more than they do.
It is seldom that we hear of a chronic case taking
more than an eight-ounce prescription. That tried,
many times they feel in their own minds they have
been to the end of the resources of their doctor. It
is a good plan to follow^ in taking a case from an-
other physician, to try some form of relief other
than the salicylates, if he has been unsuccessful, and
you would be successful, for the chances are that he
has given the salicylates. I try to keep my patients
busy with a lot of things and never discourage the
tise of any harmless method or topical application.
It is not "having faith" in a physician that is neces-
sary to bring about good results, as we so often
hear ; it is the cooperation that faith brings which
produces the results.

Baths do their part by elimination, equalizing the
circulation, relaxation or stimulation as desired, and
at resorts in placing the patient where he will make
a business of getting well. The best results come
from long baths at an even temperature. Too hot
baths cause a marked aggravation by distributing
through an excited circulation these xanthin and
other to.xins ; extra hot baths cause fainting and
general aggravation, at times driving the patient to
bed. All this can be avoided by more, longer, and
cooler baths. Patients w'ill w'ant the temperature
warmer than is best for them, in the hope of hasten-
ing matters. A fever of 102° is a contraindication
for a very hot bath, and many times it is best to
omit the warm bath for a day when the fever is
high, depending upon other measures for a few
hours. Shifting pains and increased swelling under
bath treatment are looked upon with favor. Local-
ized, persistent inflammation is more stuliborn and
slower. Anv compen.sated heart can staml baths if
due consideration is used. The head should be ele-
vated and the bath cooled down somewhat quickly
and of short duration. Baths are indicated in all
cases of autointoxication unless there is too much
prostration or high blood pressure with arterio-
sclerosis. In such doubtful cases it has been my
habit to satisfy myself as to the amount of pressure
to use Stanton's blood-pressure indicator. Exclud-
ing these cases and the dilated hearts, the baths can-
not be other than a sheet anchor in the treatment
of the so-called "rheimiatic" conditions. \ly great-
est experience has been with the mud baths, concern-
ing which, to quote a noted author, "a great feature
Avhich commends itself is the evenness of the tem-
perature and absence of chill." With a water and
mud bath side by side the patient who is sufifering a
great deal of pain will totalh^ ignore the water bath
and express great gratification and satisfaction of
relief from the mud. It is most important that the
use of the baths should be associated with the drink-
ing of quantities of pure alkaline water; during the
haths three or four glasses of hot water should be
taken slowh-. This promotes perspiration and neu-
tralizes acidity of all the secretions. Too much
water must not be taken just before the meal time
or for two hours after : then never more than two
glasses (slowlv) at a time, avoiding all danger of
dilatation of the stomach. From eight to twenty
glasses can in this w^ay bo taken in a dav. It is best
not to drink large quantities before retiring, as it
excites the kidneys tmduly and does not give them
or the patient the nightlv rest. Fifteen or twenty
glasses a day for anv length of time is too much of
a tax on the endothelium of the kidneys, unless as-
sisted by baths. When the da\-s are warm and dry

greater quantities can lie eliminated through the
lungs and skin b\ evaporaliun. Less should be
drunk on damp clays, less shoidd be taken in cases
of organic heart disease, high blood pressure, and
sijlanchnoptosis. Large quantities increase the pro-
duction of fat. and many fat people are aw'are of
this and do not drink water enough for gooil health.
Alost persons do not drink water enough, and the
need of doing so simple a thing is hard to impress
upon them. In cities it is practicable to prescribe
distilled water, with certain salts and drugs added
at times, to be mentioned later. Most persons do
not know that a healthy and active condition of the
skin will increase their resistance to many infectious
diseases. This wonderful organ expels what is left
behind bv incomplete action of the kidneys, liver,
bowels, and lymphatics. Too much diuretic action
by any water will cause constipation. Niter cannot
be given for any great length of time without carry-
ing off enough fluid by the kidnevs to react on the
bowels and cause dr\ ness of the contents and a con-
stipation similar to that which is associated with
diabetic conditions. A diuretic and a cathartic never
act well at the same time ; one should never give
them the same day and expect full action of the
diuretic. Large quantities of any jmre water will
act as a diuretic, and this is especially true of an
alkaline water, so you nnist watch the constipation
so apt to follow. This constipation, however, does
not seem to follow in all cases.

Exercise is a great and important problem in
stout, so-called ■"rheinuatics" with sore, intlamed
joints — especiallv heavy persons with arthritis of
the knees or ankles. We cannot conscieritiously
advise these persons to walk and irritate an already
inflamed surface, nor can we advise active massage
in such cases. Inflammation demands rest. There-
fore 1 say to such individuals: "Be out in the air all
you can, drive wdien the w-eather iiermits, bathe all
you can, watch \our diet, take such remedies as are
prescribed for you, and as soon as the evidence of
inflammation is gone, and the soreness and swelling
disappear, begin to walk and exercise, tlie:i take
x'our massage under the direction of a competent
I)h_\sician." Muscular stiffness and pain that is not
a neuritis demand exercise, bending, kneading, per-
cussion, and friction, but inflammation ne\er calls
for such methods. The best way to limit an infec-
tion is to |nit it up in a splint, and this applies to
arthritis. Exercise in autointoxication to assist
glandular inactivity is most important : it would be
advised in arthritis and neuritis if it were not for
the local conditions. When a patient comes to you
with swelling and every evidence of inflammation,
put him on crutches or in a wheel chair. Tins will
be seriouslv objected to, though in a few i;.i}s the
results will be evident, and the i);iticnt will thank
you for one of the first positive indications of a cure.
Systematic exercise mav come later, the i.:se of
dumbbells, clubs, w'alks, and massage will lie indi-
cated as soon as this stage is passed. Then start
your movements up to the point of slight S'lreness
again. In this way vou will prevent adhesions : or
if some have formed, break them up before they
have become organized. Some old and neglected
plastic joints can be broken down and worked every
day : when once you start, never stop until you get
as near perfect motion as your judgment tells you
is possible. It is best to be firm and discourage ex-
ercise or motion in neuritis of the sciatic nerve and
to tell such patients to lie around, go to bed a part
of the time (as it is hard to sitL keep pressure off
the nerve, avoiil walking, or go on crutches when
they do walk. Massage or vibration is not indicated

MEDICAL RECORD.

[Jan. 19, 1907

in sciatica until all acute inflammation, pain, and
soreness are gone. C.'omplications and cramps will
in this way be avoided.

Having spoken of baths, waters, exercise, and
rest, let us speak of the use of electricity. The re-
sults in a few cases cannot be taken into account, for
under no treatment at all disease often makes sud-
den and unmistakable changes for the better. In
general the faradic current, while a stimulant, will
be found to aggravate most of these muscular, ner-
vous, and joint lesions. The immediate results
often are palliative, but improvement is seldom last-
ing. It is difficult to select cases which are curable
bv electricity, as a remedy in tliese complications re-
quires some positive indications, and the action of
electricity is too uncertain. Faradic currents are
certainly disappointing in their results. The gal-
vanic current, however, I consider one of the most
useful means we have to soften and absorb deposits
and infiltrations, paying attention to the action of
each pole. The high-frequency, high-tension, static
current is a good sedative and I have faith in it in
some cases. The white-light or high-power incan-
descent ray has done some wonderful things for me
in the relief of pain, and as an anodyne in some
local inflamed conditions. I can report no good re-
sults by the use of the .i--ray except as a means of
diagnosis. Cataphoresis with cocaine and opium is
a means of relief for acute painful conditions. The
static spark irritates most cases. The breeze is with
the proper pole somewhat of a sedative.

We must recognize massage as one of the best
treatments for the so-called "rheumatic" conditions
that we possess when followed out properly, at the
jjroper time. Massage, or systematic manipulation
of the tissues of the body, is one of the oldest means
employed in the treatment of disease, dating back
as far as 3,000 years B.C., being used in the Orient
at that time. It has been used, associated with more
or less medical treatment, by all nations ; but in the
present age, from some unknown cause, it has been
singled out as a science of its own and is applied to
the treatment of all disease, regardless of the science
of medicine. It lays special stress on the treatment
of this class of troubles, Init can no more stand alone
here than electricitv. Medical men must be broad
enough to clothe their minds with more than one
idea in the practice of this interesting profession.
This is why radical sectarian physicians are distinct-
ly narrow. First the system must be rid of the
toxins and active inflammation before one can think
of manipulation, else we elevate the temperature and
increase the liability to organic heart trouble and
other complications; if massage is employed too
earlv the patient is left in a weakened condition and
the liability to infection is greatly increased. Pain
is always increased by the most scientific masseur
in active inflammation, though it may "numb" the
)irocess for a few hours. In a localized inflamma-
tion of a joint, in the passive stage, where there is
stifl^ness or ankylosis, massage of light, stimulating
character should be used, great care being exercised
not to increase the pain or set up additional inflam-
m.ation, but some hvperemia (to such a degree as to
arrest alliesionsl. One .should have a trusted mas-
seur to be certain of this. In chronic cases where
there is ankylosis or adhesions about the joints,
nerves, and muscles without appreciable soreness,
massage is nearlv always of benefit. It sets up light
inflammation, which promotes absorption and per-
mits motion, doing all those things hoped for with-
out much aggravation. Active motion must be em-
ployed and continued, though the manipulations
should be guided by the soreness produced. Fol-

lowing the above lines of manipulation, the gonor-
rheal joints will be found to be (in the subacute and
chronic stages) the ideal subjects for massage.
.After the long relaxing bath will be the most favor-
able time for treatment. This .should be followed
]))■ rest in bed for an hour or two. Cannon-ball, ab-
dominal massage will, as mentioned before, be use-
ful for constipation. A tuberculous joint must not
be massaged.

Many cases of this form of autointoxication are
better in a warm, slightly humid climate, because
the skin is kept active and constant elimination is
induced. The dry climates of Montana, North and
South Dakota send us most of the so-called "rheu-
matics," the Gulf States comparatively few ; the
Southwest has less changeableness and is perhaps
the best all-around climate we have in the United
States for infections, and as a place to be out of
doors and induce resistance. Too high an altitude
should not be sought where the nervous system is
in the least involved, as the integral parts of the
nervous system must be complete or convalescence
will be slow. These infections and "acid turns" will
be found everywhere and a study of the social con-
ditions must be kept in mind. Even the Southwest
would not do if the particular section were subject
to too much dust, because of continuous throat irri-
tation and infection from the head or throat. Cali-
fornia is said to have every climate of the three
zones ; a few desirable places can be found, but the
cold nights and the dampness in certain seasons
near the coast make it favorable for infections, and
the "barometer acid" patient is likely to have con-
siderable myalgia. The West Indies or Florida,
down at least 300 miles south of Jacksonville, are
among the best places to be found anywhere during
the winter for old persons and patients with heart
lesions, particularly those with bronchial affections
and subjects inclined to pneumonia. The coast from
New Orleans to Savannah is given as the region
with the fewest kidnev diseases of any section of
the United States, due largely to the soft water and
the constant excretive action of the skin. This is
always favorable to so-called "rheumatics." In any
climate the surroundings ought to be congenial ;
worry is most depressing and disastrous. The
subjects of nervous cases in particular must be kept
out of doors, and this is not practical in the North,
which is a good reason for sending such persons as
can afford it to the South ; and I think it will be
found (fortunately for them) that the most "ner-
vous exhaustion" is present in the families of the
well to do. The region west of the Cascades in
Washington and Oregon, except in the very rainy
season, is better than the region through Wyoming
and Montana. Wind is the worst enemy of neuritis,
and this includes sciatica. A study of the govern-
ment reports regarding the averages for the year at
all of the most important stations in the United
States shows some interesting figures. If one
studies the chart, which is a complete summary for
the vear 1902 of the velocity and direction of the
wind, the number of clear, cloudy, and partly cloudy
days, the average rainfall in inches, the extremes of
temperature, the number of gales (storms in which
the wind exceeded forty miles an hour), the average
humidity, fog, and the barometric pressure, it will
materially aid in the selection of a proper climate
for anyone. It will take but a glance to note that
Roseberg, Oregon, has the least wind of any point
in the I'nited States (for the year 1902), and the
Pt. Reyes Light off California the most. Chicago
and Buffalo, as well as our own section, are ex-
tremely windy when compared w-ith other points.

Jan. 19, 1907]

MEDICAL RECORD.

93

A country with much wind is apt to have extremes
of heat and cold, as is found along' the Lakes. This
is to be avoided, as it suddenly checks the perspira-
tion. A section with a larg-e number of cloudy days,
much humidity, and a hi,a:h barometer is better than
one of sudden chang-es. The "Land of the Sky" in
North Carolina is delightful throughout the year and
beneficial where altitude does not disagree, except
for a couple of months in the winter, when it is fre-
quently rainy and chilly. These months can advan-
tageously be spent in southern Florida. In the mat-
ter of clothing, wool is much better than linen, silk,
or cotton, to be worn nine months in the year. The
more changeable the climate the more need of wool.
The section sending to us the greatest number of
so-called "rheumatics" for treatment is the North-
west.

I now want to speak of the social conditions more
in detail. Lack of the proper clothing when society
calls for low-neck and short sleeves in manv women,
predisposed to neuritis or myalgia with autointoxica-

of importance can be given this question of our sur-
roundings. The disease of the age is so-called
"rheumatism." One can hardly meet a soul who will
not tell of having myalgia occasionally. This is the
age of overindulgence. It is the age of overfeeding,
overtaxing the nerves, the age of taking chances,
the sacrificing of strength and health for business
and "the dollar." It is with prosperity that w'e ex-
pect these things. The common people have lux-
uries and the rich have more banquets. Here in the
temperate zones we have food from every part of
the world on our tables, perhaps at the same time.
There is lack of exercise of the proper kind at the
proper time, or too much exercise of a wrong kind,
with inattention to the kidneys and the bowels as
well as no thought of eliminative baths. The over-
heating of our houses during the winter with a low-
ered resistance and a-sociatcd prevalent infections
during the spring bring to a climax latent troubles.
For those who leail sedentary lives, two meals a day
for a course of time is of benefit, as inactive habits

Chart of Selected Points of Observation in the U. S. Meteorological Summary for the Year igo2

Location

.^Iti- I Temp. Rain

tude Ex- Fall

tremes

. J-

Atlanta. Ga

Astoria. Ore. . . .
Atlantic City, N
Bisir.ark, N. D..
Buffalo. .\. Y. . ,
Cheyenne, Wyo.

Chicago, 111

Denver, Colo. . .

Duluth, Minn | '

El Paso. Tex 3

Galveston. Tex

Hatteras. N. C

Independence, Cal 3

Indianapolis, Ind j

Jacksonville, Fla . . .

Jupiter, Fla

Key West. Fla

Los Angeles, Cal.. . .

Memphis, Tenn

MinneapoUs, Minn . .
NewY'ork, N. Y....

Phoenix, Ariz

Pt. Reyes Light, Cal

Portland, Ore..
Roseberg, Ore..

,174 ft.

Salt Lake, Utah.. .
San Antonio. Tex..
San Diego. Cal. ...
San Francisco, Cal..
Santa Fe, N. M...,

Seattle, Wash

Spokane, Wash —

Tampa. Fla

Washington, D. C.
Ytima. Ariz

674

767

088

823

201

702

762

54

II

010

822

43

28

22

338

,^97

837

314

108

490

154
31S

4.366

701

87

JS5

7,013

123

1,1)29

34

112

141

98-IS
86-19
94-12
98-29

83-3
94 •=27
9l-=8
igo-= 20
86-= 22
ios-24
91-32
92-24
100—10
93 -=S
101-24
96-38
91-50
94-32
104-2
88 -=20
91-8
116-30
78-36

I
97-13 I
99-19

103-26 !
Bi-36 i
83-38

QI-S
05-13

94^12

95-29

99-5
1 1 6-.^ 1

43-96

86.48

SO. 58

15.9s

32.

16.50

37.58

13.3s

26. 14

10. 15

37.62

40.13

3.83
37.10
55.52
45.79
38.61
13.12
34.58
32.01
47.07

6.88
23.18

50. 15
39.58

II .41
24.79
11.49
19.18

Wind,
Average
Velocity

i '^

45

5"
78

19

23

50

3»

46

■;8

I

•:b

9-3

9.6
15.
10.3
16.

7.9
10. 1
10. 8
11.9
13.8

8.2

10. 2
8.5

7.0
3.5

5.8

10.3

6.9

7.1

5 0

6.5

Prevail-
ing Di-
rection

N. W.

S. W.

N. W.

N.W\
W.

N.W.

X. E.

N. W.

N. W.
W.

S. E.

S. E.

N. W.

S.W.

S.W.

S. E.

N. E.
W.

N. W.

N.W.

N. W.

E.

Once 1 10

Mi. X.W.

N. W.
28 Max.
N.

S. E.
S.E.
N. W.

W.
S.E.

S.E.
S. W.

N. E.

N. W.

W.

Gales

63
17
1 1

44

7

25

167
S

Clear

116
86
126
195
36
130
120
147
91

210
159
161

167
I 27
162
6y
113

152
92

loij calm,
100 clear

169

123

24 5

177

24 3 1

17 calm..

8,;

71

1 1 1

144

Partly
Cloudy

136
97

166
71

133

142

124
124
101
114
162
144
202
150
203
117
■ 3S
1 1 2

5 7
SO

121
87

142
69

107

97
138

87
1 66

1 %2
36

Cloudy

113
182

202
93

100
76

I 27
31
82

103
34

loS
86

38
48

3 5

86

158

140

Rain

132
74

202
98

133
70

134
45
91

109
23

122

127

1 10
89
36
80

122
140

35

Fog

13

10

24

Barom
eter

28.810Y.
29. Dec.
29. Year
28. 1 19 "
29 . 1 5 1 "
23.072 ■■
29.124 ■■
24 . 69 2 "
29. 208 "
26. 140 "
29.924 "
30.024 "
25.943 "
29.987 "
29. 143 '^
29.989 "
29.987 "

29 . 6 I 2 "

20.624 "

156

87

119

187

188

.9

144

161

48

100

75

8

100

79

18

<;i

44

20

Si

80

8

2,;

78

0

144

183

17

207

127

s

88

103

89

121

1 2

18

12

0

29. 6q? "
28.7'27 '•

29 . + "
29.853 ■■

29.456 '
25.593 ■
29.244 *
29.9':8 '

20.871 •

23 . 248 •

20.886'
27.947 '
29.990 ]
29 .905 '
20 . 707 ^

Wind velocity of over 40 miles an hour is a
Vapor Pressure highest at Key West, Fla.

Gale.
690. Lowest at Modena Utah, 112 at 8 A.M.

At Roseberg, Ore., V. P. 227

tion. will bring about an attack. Many of the voca-
tions of men require sudden changes of temperature
when the body is not properly clothed, and account
for the same thing. The kind of food, the way it is
prepared, and eating, whether the previous meal has
been properly digested or not, out of a sense of pro-
priety, or duty, are accountable for fermentation
and constipation. In a short time it looks as if the
race would not need teeth from the lack of use for
them, from having our food almost void of anything
solid. Overindulgence is practised and admitted by
most of us, and no one cares to be the pioneer in
making a radical change of this whole complicated
system. In the early days of the settlement of this
country the prevalent disease was "fever and ague" ;
we heard very little about "rheumatism." The food
was plainer and our forefathers were n>cn who had
to work actively out of doors ; there was very little
to make the organs torpid. No one will deny that
each nationality has its diseases and this brings to
our notice the diseases of to-dav. A great amount

are responsible for much autointoxication. In my
opinion it will lake radical measures to change these
things. \\'e all have patients who will not give us
j.>ositive evidence of autointoxication and this should
lead us to a better diagnosis by obtaining a history of
a different kind. It we were to speak of the differ-
ential diagnosis 've would include every possible
kind c)f arthritis ami neuritis, monoplegias, as we
have in some forms of torticolis, central and peri-
pheral nerve lesions, the characteristic inflammation.-,
of sacroiliac disease, hip-joint disease, and cellulitis,
as well as "crick in the back" and local spasms,
gout, "joint mice," and svphilitic osteoarthritis,
trauma of every sort, and the conditions ordinarily
called "rheumatic" which suggested this paper.

Finally I wish to speak of operative measures and
of .some of the most effectual clrugs and their indica-
tions.

First of the operative measures, let us nientiot7
the Bier treatment because of recent experiments
with it. Cases are being reported with most satis-

94

MEDICAL RECORD.

[Jan. ig, 1907

■factor}- results. The principle i.s that of hyperemia
producing absorption, followed by resolution. This
is brought about by constriction of a rubber bandage
above the effected joint, to be worn all night, or part
■of the day and all night for a period of from ten to
fourteen days. It is not to be used in acute artliritis,
but as a rational treatment for the slow, chronic in-
ilammations. Baths will produce a mild degree of
hyperemia and perhaps some of the good results
from the Bier treatment reported in the journals
have previously been brought about by baths. This
treatment is as yet in the experimental stage and ex-
perience will tell us its worth. All pus joints should
be opened and drained, splints or plaster used, and
the joint placed in a position to be of the most use in
case it should become ankylosed. Exudations and
soft noninflammatory swellings are best treated by
the use of the elastic web compression bandages, first
applying a cotton bandage below to prevent swelling
of the parts. The operative treatment of sciatic neu-
ritis should be limited to the removal of all sources
of reflex and direct irritation, and to the secur-
ing of rest. Have all piles removed, attend to rectal
strictures or any growth in the region of the nerves,
immobilize sacroiliac disease, keep the principle of
"inflammation at rest" in mind. It is not best to
advocate nerve stretching, vibration, or electricity in
the acute stages of neuritis, some few good reports
to the contrary. Salt injections along the nerves are
helpful, and so are hot air and electric-light baths.
It is certainly of the utmost folly to speak of specific
drugs for tliese numerous complications. Other
means of therapeutics must be combined, else we are
jilanning a "hit or miss" campaign of the worst
form. The whole picture must be studied and stress
laid upon prophylaxis. One will find himself at times
treating the nose and throat or sending a patient
who can afford it to a suitable climate as a pro-
phylactic measure. In their order I will enumer-
ate the class of drugs usually used to treat a de-
veloped case, viz., Intestinal antiseptics, eliminants,
(cathartics, diuretics, diaplioretics), hepatic stim-
ulants, antacids, tonics (glandular, nerve, and
muscle), alteratives, anodynes, antiphlogistic ap-
plications, counterirritants, antipyretics, antispas-
modics, spinal sedatives, cardiac stimulants, and
serums. An admirable combination of an ant-
acid, intestinal antiseptic, and anodyne is a 5-grain
capsule of equal parts of aspirin and acetphenetidin
to be given as required. For acute, painful condi-
tions it will be of daily use. In extremely painful
localized inflammations add '4 to j-j .grain of
codeine. Salicin has its advocates, but has no ad-
vantages and some disadvantages. The sulphocar-
bolates of lime, zinc, and socla. with salines for
bowel elimination, have many followers, and consti-
tute good treatment. .Vs laxatives we can use sul-
phur waters, salt water, magnesium, sulphate or cit-
rate. Rochelle salts, almost anv a|)erient water, cas-
cara, or combinations for complications of calcium,
bithium salicylate, and colchicine.

An active saline is magnesium sulpliate i lb., ar-
omatic sulphuric acid i oz., essence of gaultheria 2
drams, water i qt.. mix, filter. Dose: — from one
to two ounces occasionally. Of hepatic stimulants,
calomel or the following: podophyllin I4 grain, lep-
tandrin J4 .grain, iridin ':; grain, extract of nux-
vomica 1-16 grain, pnlv. capsic t-,^ grain, mix. Ant-
acids ; alkaline waters, aspirin, .sodiimi bicarbonate.
Throat and nose prophylaxis .should consist of the
free topical use of peroxide of hydrogen glycerin,
and water, equal parts as a spray and gargle, fol-
lowed by alkaline antiseptic washes and oleaginous
antiseptic sprays. Tonsillitis will sometimes be

aborted by the use of equal parts of oil of sweet al-
monds and liquid guaiacol as a spray ; this should
be repeated. It is an irritant, but the irritation
passes off soon and will produce gratifying results.
Camphor and menthol in a hydrocarbon oil can be
used freely for the same symptoms. Hamamelis,
calendula, and ]jine oil, for the more chronic inflam-
mations, will be found useful. Surgery and the caut-
ery may be required. Of the tonics, those which
build up the nervous, muscular, and glandular tis-
sues shoifld be combined. The hypophosphites,
phosphoric acid (in neuritis and neurasthenia), hy-
drastis, alkaline elixirs, quassia, gentian, syrup of
the iodide of iron, or iodine. Of late formic acid has
been used for muscular fatigue and as a muscle
tonic. Olive and codliver oils are nearly always
indicated. Strychnine should not be given at all in
hyperesthesia of spinal origin. This drug is not well
borne in many nervous conditions. Fowler's solu-
tion in wine with colchicine and intestinal antiseptics
should always be considered. The iodides and mer-
cury lead the list of alteratives, bichloride 1-40 grain
three times a day. Of the anodynes use aspirin, ac-
etphenetidin, codeine, morphine, and local applica-
tions, such as ointment of the following, applied un-
der cotton: oil of gaultheria, menthol crystals, and
the tincture of opium of each ; one dram, liquid
guaiacol one-half dram, lanolin four ounces. A lini-
tnent of the following applied hot under cotton
properly held in place by a bandage, is of temporary
benefit: oil of gaultheria, menthol crystals, tincture
of aconite, tincture of opium, of each, one dram
chloroform and soap liniment, of each two ounces,
and glycerine four drams. Antiphlogistic applica-
tions of hot mud, clay, and glycerin. Serums are as
yet in the experimental stage and the results of such
experiments will depend largely upon the isolation of
specific germs and the methods employed in the man-
ufacture of the serum. We are making some ex-
periments in the use of antigonorrheal and strepto-
lytic serums, but we are not yet prepared to give
our resiflts. It is a great field and promises much.
Plasters of belladonna, rhus toxicodendron, and bry-
onia are palliative. It is seldom necessary to use
irritants ; the best is the tincture of iodine.

Conclusions. — (i) The various infections will ac-
count for every form of so-called "rheumatism" ex-
cept muscular and that is an intoxication. This
intoxication accompanies or precedes most articular
and some nerve infections.

(2) The term "rheumatism" is a misnomer, but
must be retained for a time, until real facts are ap-
preciated by the profession and laity.

I 3) Better diagnosis brings intelligent treatment.

(4) Intelligent treatment means the use of com-
bined methods and a thorough working knowledge
of the case. This should consist of prophylaxis —
better understanding between patient and physician,
with attention in the main to social conditions, die-
tetics, exercise (or rest) as indicated, elimination by
proper baths, fresh air, the right cooperative mental
attitude, and in some cases climate.

(5) .Autointoxication with faulty elimination is
directly responsible for these conditions.

(6) That it is necessarv for physicians to make a
greater study of the toxic effects of leukomains and
to lay more on the findings in the urine of the prod-
ucts of indigestion.

(7) An examination of the urine is important in
every case for these products of metabolism as well
as albumin, casts, and sugar.

(8) Heredity has no effect except as establishing
social conditions followed by the family.

(9) The importance of baths and the precedence

Jan. 19, 1907]

iMEDICAL RECORD.

95

of hot mud-packs over other baths for equalizing the
circulation, stimulation of glandular activity, and
elimination.

( 10) The avoidance of a sedentary life and also
of great mu.scular fatigue, the latter being a cause of
muscle pains in children and working men.

(11) Alkaline waters and drugs hold a large place
as antacids and antiseptics to the intestines, though
they are greatly abused.

(12) Hot baths must not be given in dilated
hearts, high blood pressure, arteriosclerosis, tubercu-
losis, and great emaciation, though they are indi-
cated in autointoxication without such complications.

PROGNOSIS IN THE CONSUMPTIVE.*

By J. MOUNT BLEYER, M.D., LL.D.. F.R.A.M.S.,

NEW YORK.

The word consumption ordinarily suggests an
incurable condition, and one which proceeds slowly
yet steadily to its termination, so that there is with-
out doubt in the public mind a greater dread of it
than of any other chronic disease in the whole
category of illness known to the human family.
This is well based upon the facts of the widely-
spread cases of the disease, the opportunity which
nearly all persons have of tracing its progress from
a certain point, and the multitudes who die from it.
But on reflection it will be seen that all this may be
true, and yet the inference which has been drawn
may be unsound, for it onlv proves that tuberculosis
(consumption) is not commonly cured, and not that
it is incurable. Indeed, admitting as we do the
general truthfulness of the generally received opin-
ions, we feel assured that there are good grounds
for believing both the apparently contradictory .state-
ments, viz., that tuberculosis is commonly fatal, and
yet is commonlv curable.

In past years the nature of tuberculosis was not
known as it is to-day. We think that there are some
reasons for believing that it was not precisely the
same then as now. That belief has an excellent
foundation when we consider the hygienic condi-
tions in the broadest sense of the times, also, for
example, the inflammatory tendency which was com-
mon in the seventeenth, eighteenth, and the earl\-
part of the nineteenth century, and which is rare
now, owing to our modern mode of living ; conse-
quently we shall not be justified in adducing former
experience either in aid of, or in regard to, the pres-
ent opinion. But still the most widely-spread
source of error is the fact that neither a percent-
age of the profession nor a great percentage of
the public has taken cognizance of the disease in
its earliest manifestation, but has admitted its exist-
ence only after much advance has been made, and
then watching the case from that starting point, it
has been seen that the disease is almost universally
fatal. If that starting point were the earliest period
at which we could become acquainted with the dis-
ease, then we would think that the popular belief
could not be gainsaid. Hence, the whole question
turns upon that point, viz., the general recognition,
both by the profession and the public, of the disease
in its earliest manifestations. This is the modern
trend of the medical world of to-day.

In this view it is easy to admit that the present
age is right in believing consumption to be curable
in a high percentap'e of cases, while former ages
were equally right in their confirmed belief in the
contrary: for, until ovu- improved means of earh'

* Read before the American International Congress on
Tuberculosis, November 14. 15. and 16. igo6.

diap'nosis were discovered and widely made known,
and cases of the disease were brought together in
large numbers for careful investigation and study
in the hospital, sanatorium, laboratory, and dead
house, it was quite impossible either for the public
or the majority of medical practitioners to do other-
wise than commence their recognition of the disease
at an advanced period of its progress. Then the
disease seemed involved in mystery as to its nature,
and so hopeless was it in its progress that practically
little attempt was made to control it. But now that
we have means of tracing conditions preexisting to
those which constituted the starting point of former
times, we venture to affirm that but few diseases
are more clear in their nature, or more readily
capable of detection in their vers- early period of
manifestation, than tuberculosis. The modern
trained methods employed in recognizing the early
stages of tuberculosis should be the study of every
practitioner. It is common to speak of the mysteri-
ous character of phthisis, as though we assumed
that there were other conditions of disease which
were more clear, forgetting that we are unac-
quainted with the essential processes by which either
healthy or unhealthy nutrition is carried on, and
with the nature of the various conditions of disease
to which we have given names. In all these in-
stances we are acquainted with certain leading facts,
while the minute changes which they grosslv repre-
sent are hidden from view ;and in like manner, and in
various degrees, we possess certain powers by which
we may violently arrest the processes upon which
the diseased action appears to depend : Init in all,
our duty is chiefl\- confined to aiding the efforts of
nature. Unquestionably if the want of success which
has attended our efforts to arrest the progress of
consumption is greater than has attended our eflforts
to arrest the progress of any other disease, accom-
panied by an equal destruction of the organ with
which it is associated, it is only the great prev-
alence of the malady, and the vast importance of the
organ affected in relation to the animal economy,
which has led to the present belief of the special in-
curability of tuberculosis. It need not lie affirmed
that we are equally powerless to restore the struc-
ture or the function of the liver, or of an\- other
organ on which an equal amount of injury has been
inflicted.

Hence we infer that while the present belief may
be true under certain existing conditions, the oppro-
brium which has specially been cast upon the heal-
ing art in reference to tuberculosis, is at least in
great part most undeserved, and that now, admitting
partly the practical incurability of the disease after it
has made a certain degree of progress, it is our duty
to look at the affection in its earliest aspect, and in
doing so to lay aside opinions founded upon facts
belonging to a later stage, so that with unprejudiced
minds we may ascertain if in that new condition we
have not the materials by which the remedial art
may act more effectually, and a disease which is in
its nature curable.

There is one leading particular in reference to this
question in regard to which the present miiid is less
prejudiced than in former ages. From the da\s of
Hippocrates to those of Laennec the disease was
distinguished by its general symptoms almost ex-
clusively, but Laennec, introduced the new era, and
from that time on the progress of om- knowledge
has been one gram! march forward.

I think I'nat we mav with confidence refer to the
authorities of the entire medical world adduced as
proof of th.e advance which has been made on this
subject within th-'^e last few years, and while they

o6

MEDICAL RECORD.

[Jail. 19, 1907

may differ as to the exact nature of this prctubercu-
lous (or early stage), they all tend to prove that
there is a stage of the disease which exists before
that critical period is reached when evidences are
to be found, both in the lungs and in the general sys-
tem, which leave no doubt as to the exact nature
of it.

Under what Condition May We Hold Out a Good
Prognosis for the Early Stage of the Tuberculousf —
It seems almost superfluous or absurd to speak upon
prognosis here when we profess to treat a curable
disease, but as there are many questions upon which
the wished-for issue depends besides the stage of the
disease, I think it most convenient to discuss the
subject at hand separately.

The conditions in which we may confidently hope
for a successful result are the following, especially
when they are all present at the same time :

1. The disease in the stage preceding any evidence
of a lesion, or when the tuberculous lesion is very
small and isolated at the apex of one lung.

2. The progress of the disease has been slow, so
that there have been slight evidences of failure of
the general system during many months, and with
no evidence of a recently accelerated rate.

3. The original state of the constitution was mod-
erately good.

4. The age of the patient is from about twenty
year> to middle life.

5. The existing state of the health is moderately
good, so that, by careful regulation, a due amount
of nitrogenous food and of exercise may be taken
with comfort.

6. The rates of pulsation and respiration do not
vary materially from those in health.

7. Cheerful willingness to obey the prescribed
directions, and such pecuniary and domestic circum-
stances that the whole arrangement necessary to the
treatment of the case may be carried out.

8. Due freedom from anxiety, and removal from
whatever conditions are unfavorable to the restora-
tion of health.

9. Continuous breathing of fresh air, 'with all
hygienic accompaniments, etc.

Such are the most favorable conditions, and it
must further be observed that they are met with in
a large proportion of cases in the middle and upper
classes of society, but they cannot be universal. As
for the poorer classes, the municipalities and the
States are taking charge of them and placing them
under the best conditions possible to meet these re-
quirements.

The Lungs. — I will now enumerate the several
circumstances which are unfavorable, and the degree
of importance which should be attached to them,
and fir.st the conditions present in the lungs :

1. When the lesion is increased so that it may be
detected below the clavicle. The extent of the lesion
is important, both because of the interference with
the \-ital functions of the lungs, and by reason of its
affording grounds for the occurrence of new compli-
cations : but under these conditions there is ground
for hope if the amount of the lesion does not appear
to be great, so as to interfere much with the circula-
tion of the blood in the parts thus occupied, if the
progress has been slow and uniform, and if all the
other conditions are favorable. We should attach
far greater importance to the limitation of a consol-
idated or infiltrated mass to a moderate space than
to an equal quantity distributed in small masses of
ii'fijtration. and yet not spread over a large area.

2. When the deposit is met with in both apices.
\A'e think that it cannot admit of a doubt that the
progress of the case is greater and the prognosis
more unfavorable when there is a small amount of

infiltration in both lungs, than when only one lung
is implicated in the same, or even in a somewhat
greater degree. This would probably imply that the
causes of the disease exerted a more general
influence, or were more intense, as we should cer-
tainly infer that there was double danger of compli-
cations; yet, when the deposit is very small, and all
other conditions satisfactory, the case is still hopeful.

3. When softening and breaking down of tissue
has already taken place. We have limited the cur-
able conditions to those in which the extent of soft-
ening is small, and yet involving the whole consoli-
dated mass deposited. Such cases have been seen in
which these conditions existed, and every mark of
disease has passed away except a certain degree of
unevenness of the vesicular murmur over the lesion.
We have, however, the conviction that softening in
any degree very seriously complicates the case, and
it is then only under most favorable circumstances
that we can hope for the removal of the softened
matter, whether with or without the production of a
cavity, which may remain open for a period. In
such cases it is impossible to give a favorable prog-
nosis except by watching the progress of the case,
but when it is found that the softening is strictlv lim-
ited, that the evidences of it gradually pass away,
that the vesicular murmur is gradually restored by
the increased degree of expansion of the surround-
ing cells, and that no further deposition takes place,
a favorable issue may be anticipated.

4. When the feebleness of respiration is very
great, so that there is general flattening of the chest
wall. It not unfrequently occurs that the degree of
diminution of respiratory power and action is very
great, without there being any evidences of tubercu-
lous deposit, and in such instances there is marked
prostration of the whole nervous system. This is
much more common in females than in males, but in
both it is particularly found in those who pursue
strictly sedentary or indoor occupations, attended
by much anxiety and poor living, as for example,
seamstresses, tailors, shoemakers, and many such
workers,

5. \Mien the patient cannot fully pursue the sys-
tem of deep respiration, from want either of respi-
ratory power or of appreciation as to the right
method of performing it ; the causes may also reside
in nasal and throat obstructions, etc, I have already
here intimated that many such cases are met with
in which, with all the training which can be given,
the respiratory action is short, quick, and gasping,
when an attempt is made to adopt the plan of deep
respiration. It is difficult to dissociate the two
conditions, but I have no doubt that many persons
who have pursued sedentary occupations sedulously
for years, and who have lost much courage and nerv-
ous power, have also lost the power of easy and deep
respiration — in other words, they have forgotten
how to breathe. Also those belong in this category
who have been born with contracted and deformed
chest walls, or who suffer from acquired nasal de-
formities and many such conditions which interfere
with normal breatliing, etc. In such instances, the
chest falls in respiration below the normal degree,
so that there is a less amount of residual air remain-
ing in the lungs, and hence the diminution in the
vital processes and the difficulty of maintaining a
due degree of expansion of the lungs are propor-
tionally increased. Unless such patients can be
taught to respire slowly and deeply, so as to expand
the air cells, and also to keep them expanded from
time to time, at the end of respiration, we cannot but
believe that their condition is hopeless. All deform-
ities hindering the natural respiratory dynamics
must be remedied wherever such exist.

Jan. 19, 1907]

MEDICAL RFXORD.

97

6. When hemoptysis is persistent where tlicre is
no evidence of progress of the disease or when the
disease progresses very slowly. We often run across
cases in which the disease appears to be kept in abey-
ance for two or three years, and the general health
is improved, but in which there are, from time to
time, attacks of hemoptysis, in those ultimately the
signs of progress appear. The importance of this
sign is no doubt in the indication it furnishes of the
want of freedom of circulation in the lungs as a
whole, which attends deficient expansion, or of a
depraved state of the blood and general organism,
whereby a healthy condition of nutrition is not re-
gained. It occurs without any sign whatever of
softening of the tuberculous infiltration which may
have been deposited.

The General System. — The following are the un-
favorable conditions in the general system which
affect the prognosis :

1. When the powers of the general system are
greatly enfeebled.

2. Whi.'n the capability of reaction is found by
experience to be very small.

3. When the appetite, digestion, or assimilat'on is
very defective, and particuiarlv when certain kinds
of fats, milk, and other kinds of animal food cannot
be sufflcientlv taken, even after careful training.

4. When food, clothing, or proper shelter is de-
ficient in any marked degree.

5. When there is oppressing an.xiety.

6. When such a patient cannot be removed from
injurious conditions, such as foul or heated air,
exposure to cold, and seder tary occupations.

7. When self-abuse or other degenerate practic;
in either sex is or has been largely practised, or
when there are confirmed habits of excessive indul-
gence in alcoholic liquors or tobacco.

8. When the system is highly sensitive, so that
the whole organization is in a state of perp"etual
unrest, or when it is so deficient in nervous sensibil-
ity and activity that it does not rcsi)ond read:iy to
the ordinary stimuli.

9. When the patient is younger or older than the
limits above mentioned.

10. When from any cause the jiatient will n t, or
cannot obtain change of climate, providing the case
is a typical one for that special treatment, and will
not, or cannot steadily pursue the prescribed p'nn
of treatment.

I have not thought it necessary to offer separate
comments under these heads, since the whole forms
a connected series, and any of them is sufficient to
greatly lessen, or perhaps extinguish, hope in the
prognosis of the case.

So much importance must be attached to these
several questions that I advise the most careful con-
sideration of each one of them, and it is often neces-
sary that the case be watched for a time before a
correct judgment can be formed.

As to the importance of age, we mav sav that in
persons aged twelve or fifteen years, or thereabouts,
in whom the evidences of tuberculosis exist, we
usually find the disease less capable of arrest or cure
than in those at a later age. This may be owing to
the fact that the early attack of the disease may be
in some degree evidence of the deep implication of
the system, and probably it may be in part due to
complications which arise in reference to the appear-
ance of the menses, and the various rapid changes
which occur in the organism and the passions at the
period of puberty. But however it may be explained,
we augur less favorablv of a case in which the dis-
ease begins before the age of sixteen than of one in
which it is deferrerl until twentv vears of age, or

later. I'he more unfa\orable prognosis in arlvanced
age is clearly associated with the ijrogressing delect
of the vital powers, the diminution in the e.xpansibil-
itv of the lung, which is always progressive at that
period, and the diminished possibility of adopting
some of the means which are necessary to a cure.

There is one most important relation between the
state of the lungs and the general system which we
niust always consider when forming a prognosis.
A small amount of lung disease, with a very enfee-
bled system, is far more unfavorable than a some-
what larger amount of the former, with a moder-
ately robust state of the latter. While there are
many cases in which the general health appears to
be moderately good when the lung disease is far
advanced, the rule is to find the system injured
while the lung disease is yet very limited, and hence,
after having ascertained that the latter is restricted
wilhin the narrow limits already indicated as hope-
ful, the whole question of prognosis rests upon the
state of the general system.

The Prognosis Based on the General and Numer-
ical Conditions. — Under this heading I purjjose to
introduce a short summarv of facts derivetl from a
very extensive inquiry into the conditions which may
be presumed to have modified the constitution of
phthisical persons when they were still in health.
The primary aspect of this inquiry is that of etiology,
and had it been my purpose to have written sijecially
upon the causation of tuberculosis. I should doubt-
less have referred to the inquiry under that special
head. As it has, however, an important bearing
upon prognosis in reference to the constitution of
the patients. 1 purpose to insert the results in this
place. I do not, however, intend to enter into much
detail, but simply to show the direct relation it bears
to the prognosis of this disease.

The inquirv embraced an experience of over
twenty years. .\ thousand patients make up this
statistical stud\-. Six lumdred and twenty-one were
males and three huuilred and scvcnt\-nine females.
I will first consider the circumstances which refer
to the parents, and then those belnnging to the pa-
tients.

Fifty-tour per cent, had lost father, 46 per cent,
the mother, and 28 per cent, had lost both jjarents.
In 25 per cent, only were both parents living. Their
average at death w^as 50.8 years, with an increased
duration of 4.7 years on the part of the fathers. The
most frequent age at death was 35 to 35 years,
whilst only 11 per cent, dieil under the age of 35,
and some lived to the age of 95. Eighteen i)er cent,
had experienced feeble health before birth of the
patient, and 34 per cent, thrnughout life. In J2.7 per
cent, one or both parents had led unsteaih li\es:
21.7 per cent, of the parents had died of c(iii-.ump-
tion, whilst in 2.8 per cent, the grandparents, in 23.3
per cent, the brothers or sisters, and in 9.1 per cent,
the uncles or aunts had died of the same disease.
They had- suffered from rheumatism in 22 per cent.,
from asthma in 9.4 per cent., from liver disease and
gout in 9 and 7.2 per cent., and from fevers, ague,
insanity, and diabetes in between 4 and 5 per cent.
Presmned scrofulous and syphilitic affections were
extremely few and difficult to compute.

The age of the parents at the birth .if the patients
was, in half of the cases, between 25 and 35 vears,
and onlv in 2 per cent, was it less than 20 vears.
The nuiiiber of children was very large, viz., an
average of 7.5 to a family, and in sotne families there
were "twentv-three children. The patient was the
first child in 20 per cent., and the first, second, or
third child in half of the whole cases: 40 per cent.
of the parents' children had died.

98

MEDICAL RECORD.

[Jan. 19, 1907

Hence, in reference to ciuestions involved in the
idea of hereditary jM-edisposition, it has been proved
that in a large proportion of the cases the parents
died in the middle of life, and had had feeble health.
Their children had died in large proportion, and
tuberculosis occurred in one-fifth of the parents. Hut
in all these matters there was a large proportion in
which there was no evidence of feeble health or
direct tendency to tulierculosis. The parents did not
marry too early or too late, and the patient was the
result neither of immaturity nor of senile exhaus-
tion, so far as age may indicate those conditions, yet
he was connnonly amongst the earliest children born
to the parents. The question of hereditary taint im-
plies either the direct transmission of the disease to
the child, or a state of system in which tuberculosis
is preeminently liable to occur. The results show
that no one condition is dominant.

The average age of the patients at the period of
the inquiry was 28.8 years, and 44 per cent, of the
whole were between 20 and 30 years of age. In
only 13 per cent, were they under the age of 20.
and a few were at the age of 60. Twenty per cent,
had been feeble at birth, but only 22 per cent, had
suffered from feebleness of the general health, and
17 per cent, from generally defective appetite. In
12.6 ner cent, the lungs had always been delicate.
Only 2.5 per cent, had been drv nursed, 25.4 per
cent, had perspired very freely, and 25 per cent,
had never worn flannel next the body. Si.xteen.
65.4, 60, and 41 per cent, respectively, had not had
measles, scarlet fever, smallpo.x, whooping-cough, or
nose and throat affections of various kinds and the
frequency of anv long-continued ill effects from
these diseases was insignificant. Twelve and one-
eighth per cent, had suffered from enlarged glands,
and 4.5 per cent, from aft'ections of the eyes, but
otherwise the evidences of scrofulous diseases ex-
isted in a very small per cent. .Sixteen and one-
seventh per cent, had suft'ered from acute conditions
of the lungs, and 14.8 per cent, from rheumatisin,
whilst typhoid fever and fre(|uently diarrhea had
occurred in 8.0 per cent. Malaria had occurred in
5.6 per cent., and liver disease in 4.3 per cent, of the
patients.

Forty and one-fifth per cent, were married, and
of these 13 per cent, were up to the period of m>'
inquiry childless. Their average age at the birth
of their first child was from 20 to 25 years, and in
only 9 per cent, were they under the age of 20.
The number of children was one and two in 44 per
cent., and one, two, and three in 55 per cent. Thirty-
eight per cent, of the children had died, and in 43
per cent, the general state of the health of the chil-
dren was bad. Abortion had occurred in 46.2 per
cent, of the child-bearing married women, and some
had suffered ciglit abortions.

Eleven and one-sixth per cent. Jiad committed
sexual excesses, 18.2 per cent, had masturbated, and
22 per cent, had suff'ered from involuntary emis-
sions. Sixteen per cent, had had svphilis, and 38.5
per cent, gonorrhea. Twent\-nine and one-sixth per
cent, had led a hard life at some period. 24.5 per
cent, had drank to excess, and 48 per cent, had
smoked tobacco. N'inetcen and one-third per cent,
had kept late hours, and 22.2 per cent, had suffered
much an.xiety. In 70 per cent, there was some com-
plaint as to the injurious influence of their occupa-
tions, and of those causes exposure, long hours,
close, and hot rooius. bending posture, and the in-
halation of dust or futres. were complained of in
32.1. 28.6. 24.4, 20. and 15.8 per cent., in their order.
Xine per cent, had taken mercury largely, and with
iodide of potassium, in one or many wavs of admin-
istration.

Thus a large proportion of the patients had been
born with feeble constitutions, had had feeble and
short-lived children, had suffered from the effects of
injurious occupations, and had been injured by the
anxieties and immoralities of life. They were thus
influenced by original and acquired causes of dis-
ease ; but however important the former might be,
it is impossible not to admit that the latter were
stili more so. They had not suffered from early
marriages, and, considering their average age, they
had been sufficiently prolific, and no inconsiderable
proportion had been sterile.

Hence, again, we cannot but regard tuberculous
patients as a very mi.xed class of persons, and one
which derives its causes of disease from a greater
variety of diverse conditions, many of which are,
however, within their control and preventable. The
proportion of those who had suffered from general
feeble health and insufffcient appetite throughout life
was very small, but as they were the judges it may
be that their standard of health was low.

One striking feature wdiich I must mention wa^
the greater liability of the -female over the male sex
to many of the ills to wdiich I have referred. Thus,
in reference to the parents, more mothers than
fathers had children early, had feeble general health,
and had died early. Of the patients, more females
than males had mothers who died early, had most
relatives who had died of tuberculosis, had parents
with one child onl\', had experienced feeble health
and defective appetite through life, had had delicacy
of the respiratory tract, were married when very
young, had feeble children, had lost most children,
iiad suff'ered from anxiety, had had measles, scarlet
fever, whooping-cough, and other diseases, had not
worn flannels, had had a very defective education,
were of susceptible temperament, had brown eyes,
florid complexions, and fleshy habit, and had suf-
fered from coldness of the extremities, etc. This
is most striking evidence of the liability of females
to conditions tending to constitutional disease.

We may now ask, in conclusion, in what way are
we to regard these inquiries as important in refer-
ence to prognosis? It may be fairly replied that
whatever conditions will so affect the constitution
as to induce a disease will, when the disease exists,
be so many reasons against the cure ; and hence, in
estimating the probability of cure of anv disease, it
is requisite to weigh well the relative importance of
the causes which may have induced it. The first
requisite in forming a prognosis in the early or
curable stage of tuberculosis is to ascertain the
leading conditions to which the disease may have
been due, with a view to ascertaining the degree of
their influence over the constitution and the proba-
bilitv of tlieir removal, and hence, instead of regard-
ing the cases as belonging to one class of persons,
it will be found that they are exceedingh- nuiltiform
and varied. The first place must doubtless be given
to such as originally aft'ected the system, and to the
sex ; so that in those patients whose parents and rela-
tives have exhibited special marks of disease, or of
defective constitution, whether tuberculous or other-
wise, and in females, the prognosis mu.st be less
favorable. So also we must give the first rank to a
defective state of the system of the patient com-
mencing in early life and long continuing, from
whatever cause it might have arisen. The impor-
tance of the acquired causes of disease must be esti-
mated by their intensity and continuance, as well as
bv the natural vigor of the constitution and the
effect which tliey had produced upon it. As a w-hole,
their position must be secondary to that of those
jrst referred to: but those which acted before adult
life, and which then injured the health, and as sex-

Jan. 19, 1907

MEDICAL RECORD.

99

ual excess and masturbation are of prime mipoi--
tance, I am therefore of tlie opinion that in every
case there should be careful inquiry into the cir-
cumstances now referred to. and that the probability
of cure w ill rest as much upon this as upon the more
minute examination of the lungs, etc., and the im-
pression as to the state of the general system of the
patient.

These inquiries of a statistical nature which I
here offer are simply to illustrate how many differ-
ent conditions are at work in the predisjjosing
causes of tuberculosis, and to show that there is not
only one cause at fault in the acquiring of this dis-
ease, but that ther-e are many. This fact I wish to
impress strongly for the sake of the patient who
comes for an honest advice, and to whom one may
frankly tell tlicse facts. Such a consultation will go
far to help relieve his anxiety and gain his conlidence
for future treatment, when he has comprehended
that this disease mav have had its origin from one or
the other of his environments, etc. The family will
also be much relieved bv the knowledge of the analy-
sis of the case which has been so explicitly given to
them, as well as to the patient who seeks treatment
for the disease. .After all, it is the duty of every
physician to give a clear, comjjrehensive stateinent
of this disease to every patient. If such a rule was
carried out, much good in the prevention and cure
of the disease would be the outcome.

836 Lexin'Gton Avenuk.

A AIEDICOLEGAL STUDY OF A MORPHIA-
MANIAC.

Bv T. D CROTHERS, M.D..

HARTFORD, CONN.
SUPERINTENDENT WALNUT LODGE IIOSPITAI .

The main facts of this case are these: Dr. J. B.
Matthews of Greensboro, N. C, was indicted for
the murder of his wife December, 1905, and tried
for the crime February, igo6. He was found
guilty of murder in the second degree and sentenced
to twenty years in prison. He was bailed out pend-
ing an appeal to the higher court, taken to a sana-
torium and treated for his addiction, and later dis-
charged. He evidently relapsed, went to a low
boarding-house, and committed suicide. The facts
of his history and crime are as follows ; He was
born in Durham, N. C, in 1870, of highly respecta-
ble parents. .-\s a child he was delicate, nervous, er-
ratic, and impulsive, and was indulged by his par-
ents freely. During his school days he drank beer
at times, then whiskey, ran awav from home and
remained concealed for a few days, then returned.
From fourteen to twenty \ears of age his life was
very irregular; at one time a railroad brakeman,
then a clerk in a tobacco house, and in a grocery
store, then in a drug .store, then became a student
in pharmacy, finally took up medicine, and graduat-
ed from a medical college in Richmond in 189,^ with
honors.

During his medical studies the death of a young
woman, to whom he was encaged, produced depres-
sion and a suicidal mania. He wrote letters, bidding
good-bye to his parents and friends, giving direc-
tions as to the conduct of his funeral, and the distri-
bution of his personal effects, then took a large dose
of morphine, and later was found in a comatose
state, from which he was resuscitated with great
difficulty.

A year after he married, and later entered upon
the general practice of medicine. So far as it was
known his married life was very happy ; he was very

attentive to liis wife in public, and a little boy, born
two years after marriage, seemed greatly to increase
the enjoyment of each other's society. The first
years of his practice were uneventful, except that at
intervals he drank spirits to excess, and was known
as a drug taker. The last two or three years it
was oliserved that his wife used morphine and was
imder its influence at times.

His conduct became more and more eccentric, and
he changed his place of residence to a neighboring
town, then finally settled in Greensboro. He was
recognized as a physician of fair attainments, who
might have had a lucrative practice and been popular
in the communitv were it not for his eccentric habits
and unreliable business methods, which were evi-
dently due to drug taking. The last year or so he
used cocaine at times, which fact was evident from
his talkative and excited periods, alternated with
stupidity and moroseness. His personal appearance
showed great physical changes. His habits were
careless and his manners abrupt, and his words and
statements were unreliable. Prescriptions given at
this time were so unusual and careless as to suggest
mental disturbance and indifference. .\11 his friends
and associates noted liis addiction to morphine and
other narcotic drugs, and his wide variations of
conduct from profound stupor and indifference to
irritability and impulsiveness, and regarded him as
unsound and more or less irresponsible. On the
night of November t,o. i9(\=;, he was seen walking
to the railroad depot with his wife, in a very happy
state of mind. The\ both seemed to be enjoying
themselves with the familiarity of children.

Next morning, December i, a friend called at his
house and found Mrs. IMalthews unconscious and
breathing badly. The doctor was also in a state of
semistupor, and a neighboring woman was sent for.
•She recognized the gravity of the case and called
in two doctors: thev summoned the coroner, who
was a physician. Extreme morphine poisoning was
recognized, and active measures for restoration were
begun promptly.

Injections of strvchnine and nitroglxcerin were
given, together with the gahanic liatterw and other
means were freeh- used. The doctor exjilained that
his wife had taken a large quantity of strvchnine
tablets the night before with suicidal intent, and
soon after c<)mi)lained of extreme pain and began
to vomit, and for this he had given her a quarter of
a grain of morphine everv half hour from tip. m.
until morning. Hue of the phvsicians ga\-e an un-
favorable prognosis. This seemed to please the
doctor, who sent several telegrams announcing the
death of his wife, and talked of the disposition of
her personal effects in a childish wav. Later he ap-
pealed to the physicians to certify that his wife had
died from heart disease, and thus avoid public scan-
dal. In the course of a couple of hours an improve-
ment took place in the svmptoms. The battery giv-
ing out at this time, an efl'urt was made to get
another one, and the doctor was asked to lend his
horse and carriage for this purpose. This he re-
fused in a verv childish way, claiming that he
needed the horse for another piu^pose. His conduct
was generally suspicious, begging the physicians to
leave the room so that he could be alone with his
wife. Failing in this, he was iletected secretly in-
jecting into the arm of his v ife some solution from
a hypodermic svringe. which was forciblv taken
from him, and he made no complaint or explanation.
He seemeil to be in a confused state and ^vas con-
stantlv smoking cigarettes. In the course of an
hour after this event his wife was seized with con-
vulsions and died. The physicians concluded that

lOO

MEDICAL RECORD.

[Jan. 19, 1907

deatli was due to poisoning, and that the sohitior.
which he had given by the needle was strychnine.
They reasoned tliat the motive for his strange con-
duct and repeated ettorts to be left alone with his
wife was for the purpose of making her case fatal
by secretly administering some drug, and, failing in
this, he boldly attempted to inject a solution under
the cover while on the bed. Later he tried to brilie
one of the physicians by offering payment for hia
services, and to enlist his sympathy by the fact of
membership in the secret societv.

After the death of his wife he talked freely of the
funeral, ate a hearty supper, and went to bed, pro-
foundly indifferent to the circumstances and condi-
tions. When arrested, about midnight, he seemed
to have no clear idea that he had committed a crime,
but regarded the arrest as a very formal matter,
which could be adjusted by his explanations to the
sheriff. When taken to the jail he demanded whis-
key and morphine, and seemed quite irrational and
confused. The coroner, who had forcibly taken the
syringe from the doctor immediately after the act
of injecting the contents in the arm of his wife,
found a large mass of white powder, undissolved in
the barrel of the syringe. This he took to a drug
store, and, by test, decided that it was strychnine.

This fact and circumstances of the death seemed
so clear that the prosecuting attorney did not con-
sider it necessary to have a post-mortem examina-
tion. Hence the body was buried without any ex-
amination, although the undertaker swore that it
did not differ from other bodies, and had no appear-
ance of extreme rigidity. The syringe was kept by
the coroner until a few weeks before the trial, when
it was taken to the Professor of Chemistry at the
State University for analysis. He found the powder
remaining in the syringe to be morphine, and with-
out any possible trace of strychnine. In jail it was
found necessarv to give the prisoner morphine daily,
and spirits occasionally, and during the trial the
amount was greatlv increased. The defence was
insanity. It was claimed that the prisoner was a
morphiamaniac, and by reason of his drug taking
was unable to understand the nature and conse-
quence of his conduct, and that he was in such a
confused mental condition as to be unable to reason
or act rationally, and that the act of injecting se-
cretly into the arm of his wife some substance was
idiotic and unreasonable, and did not have anv in-
fluence in hastening the death of his wife.

It was assumed that his statements of his wife
using a large quantity of strychnine tablets might
be true, and that his efforts to prevent its poisonous
effect by the continuous doses of morphine from 10
or 1 1 o'clock at night until the earlv morning of the
next day would naturally result in poisoning and
coma. Also that during this time, while using mor-
phine himself, his mental condition would be so con-
fused that such a course would be natural and
characteristic of the imbecile conduct of a morphia-
maniac. The experts for the defence swore that
the prisoner was suft'ering from morphiamania and
dementia, with delusions of paretic nature, and that
he was in no wav able to act sanely or with full
consciousness of what he was doing : also that he
was incapable of planning and executing a homicide,
requiring reason and judgment as to the conse-
quences and nature of the act. Tn support of this
contention it was claimed that he was mentally de-
fective by inheritance. His grandmother on his
father's side was insane during her lifetime, and
was said to have killed one of her infant children.
On his mother's side one uncle died insane and an
aunt had some form of convul>in;ir. ::: cr,e cf which

slic was burned to death. Another one drowned
herself, and a third member of the family committed
suicide by jumping into a well. Other members of
the family were nervous and erratic. In his early
life he was impulsive, irritable, and nervous, was
eccentric in conduct and manner. It was evident
that he inherited a defective brain and nervous sys-
tem, with a decided predisposition to some form of
insanity. His early use of spirits and irregular life,
with an attack of suicidal mania, were unmistakable
evidences of this. His continued use of spirits and
drugs, first at intervals and "latterly continuously,
was confirmatory evidence. His drug taking had
become so prominent as to attract attention and cre-
ate doubt among his friends of his mental sound-
ness. All the evidence showed that the relations
with his wife were amicable, and that she had used
morphine with him, and that probably the comatose
condition she was found in on the morning of her
death was a repetition of what had occurred many
times before, in which both had indulged in this
drug up to stupor without any serious results fol-
lowing. There was no evidence of malice or motive
on the part of the prisoner to procure the death of
his wife. His strange conduct and semistuporous
condition showed no degree of sanity, but rather the
foolish weakness of a dement. The morphine found
in the barrel of the syringe had been thrown in reck-
lessly and then water turned on with a view of dis-
solving it, and in this condition he had attempted
to inject it, with a strong probability that none of
the contents was actually forced through the needle.
The convulsions following had no probable connec-
tion with the injection, even had the substance been
strvchnine. With the pulse not distinguishable and
the respiration reduced to five or six per minute, it
was exceedingly doubtful that either strychnine or
morphine could have been absorbed, even if injected
in large quantities, so as to make any impression on
the heart.

The prosecution urged that the convulsions and
death were caused bv the injection of strychnine and
that the prisoner had a motive to put his wife out
of the way. It was also urged that in other matters
he was treacherous, vindictive, and competent to
reason and execute a crime, that his drug taking
was for the purpose of covering up the responsi-
bility of the act, and that, while under the influence
of some narcotic, he appeared conscious during the
efforts to resuscitate his wife, and acted rationally
on most matters. It was agreed that he was not a
combative or irritable man. but nervous and impul-
sive, and when under the influence of drugs was de-
mented and stupid in his talk and acts. His present
appearance was that of pronounced anemia, with a
melancholy, abstract face ; his eyes were staring and
glassy, his voice was jerkv and husky, his conversa-
tion was in monosyllables, and his general appear-
ance was that of great indifference and unconcern
to the surroundings, His face was unsymmetrical,
with a V-shaped palate arch and decayed teeth, and
the skin of the face was pallid and tightly drawn.
He complained of rheumatism, which was literally
neuritis.

The toes and feet were contracted and painful,
and reflexes were absent from both legs. His heart
was regular, but feeble, the- appetite was variable
and his sleep broken, except when under the
influence of morphine. In conversation his voice
would drop down to a whisper as if the thought had
escaped his mind. At times he claimed to be very
faint and would go out into an anteroom, where in-
jections of morphine could be given him, then return
and fall into a drowsv state until the effects were

Jan. 19, 1907,

MEDICAL RECORD.

lOI

worn off. For the last two years his drug taking
had been noted in his depressed sensory and reason-
ing faculties, and the impulsive, stupid conduct
which showed unsoundness and irresponsibility. The
judge charged the jury that the question of the kind
of poison used, its quantity, when and how admin-
istered, should not be considered in their decision,
but only the fact beyond all reasonable doubt, that
death followed from the iioison, administered by the
prisoner, also, that if at the time, by reason of mor-
phine which he himself took, and while under its in-
fluence administered the same or other drugs to his
wife, and by the eft"ect of the drug which he was suf-
fering from he was unconscious of the character and
consequence of his act, he could not be guilty of mur-
der in the first degree. But he could not be excused
because of the temporary insanity voluntarily brought
on himself, and would be guilty of murder in the
second degree. If at the time the prisoner adminis-
tered morphine, or any other poison to his wife he
was under the influence of a similar drug and had
no purpose to kill her, but recklessly and carelessly
administered it. causing her death, there could be no
malice, hence he would not be guilty of murder in
the first degree, but it would be manslaughter; and
no excuse on account of, and by reason of, his men-
tal condition should be considered. He also charged
that no matter how far he was under the influence
of morphine, if he had mind enough to be conscious
of wrong doing, he was responsible. If his moral
perceptions were so blunted as not to be able to dis-
tinguish between right and wrong, such voluntary
incapacity did not excuse his crime. The confusion
of the jury was apparent in the verdict of murder
in the second degree, and the trial was another ex-
ample of the effort to administer justice and main-
tain the majesty of the law and force twelve men to
settle the question of the sanity and responsibility of
an evident imbecile. A restatement of the leading
facts undisputed make this clear.

1. The heredity history in Matthews' case showed
a distinct neurotic taint and predisposition to men-
tal instability, with feeble controlling power. In the
ordinary strains and drains of life he was incompe-
tent to live normally, but would most naturally de-
velop some form of neurotic disease, according to
the environment and conditions of life.

2. His defective heredity was apparent in the sen-
sitive nervous system of early childhood and erratic
conduct, manifest in a suicidal mania at the begin-
ning of manhood. This, with the historv of spirit
and drug taking, \\as the natural course of defective
organism with faulty culture in bad surroundings,
disease would follow with absolute certainty from
such conditions.

3. The fact of graduating with honors and becom-
ing a popular physician, making and losing many
friends by his erratic conduct and increasing eccen-
tricity, was further evidence of a neuropathic and
an unstable, unsound brain,

4. The vear before the alleged crime he was noto-
rious for his periods of stupor, depression, and talk-
ative delusional deliriums. He became careless in
his dress and disregarded many of the proprieties of
life, indicating great physical and mental changes.
His untruthfulness, lack of respect for his word,
absence of pride of character, and petty efforts to
take advantage of others further confirmed the fact
of his defective reason and irresponsibility.

5. His relations with his wife gave no indication
of any variance or disagreement, and at times in
public they exhibited great respect and affection for
each other. He was not considered by his friends

combative or revengeful, but rather the opposite,
hence there could be no motive apparent to dispose
of his wife.

6. The comatose condition of his wife on the
morning of her death could not be called an unusual
event, when both were using morphine. His state-
ment that she tried to commit suicide by taking a
large dose of strychnine and that he had given as
an antidote continuous doses of morphine every half
hour, was a very natural order of events, particu-
larly as he was using it himself. His indifference
to the efforts of the physicians in restoring her and
his apparent impulse of a lunatic, without conscious-
ness of the consequence and results of his act.

7. The further history of the prisoner in jail and
during the trial, in which a degree of nervousness
bordering on delirium came on unless he was given
morphine in sufficient quantities to make him com-
comfortable. His general demented condition, er-
ratic talk, and stupor alternating with apparent san-
ity, but always followed by general unconsciousness
concerning himself and surroundings. After the
trial he was taken to a sanatorium and the morphine
was gradually withdrawn. He was erratic, unrea-
sonable, had delusions, and was with great difficulty
managed. His general health improved and he was
finally discharged, restored, but he soon after re-
lapsed, began to use spirits and cocaine, and became
very violent and delirious when opposed. He was
taken back to the hospital and recovered partially,
then went out and in a course of a few days went to
a low boarding house and shot himself; evidently
he was under the influence of morphine and cocaine
at this time. This termination of the case was nat-
ural and characteristic and confirmed the diagnosis
of insanity and imbecility.

Some of the general conclusions may be stated as
follpW'S :

1. It was an error of the authorities to assume
that death was caused by strychnine, and not verify-
ing it by post-mortem examination and chemical
analysis of the contents of the syringe.

2. It was a still more serious error to assume that
Matthews was sane and responsible for his acts,
especially in that community where his mental con-
dition was a subject of common observation and
talk and his drug taking was acknowledged bcvond
all question.

3. The apparent motive for injecting into his
wife's arm some substance to increase the fatality
of her condition would naturally demand his arrest
and confinement, Init the assumption that this was
the sane act of a responsible man was a reflection
on the intelligence and judgment of the authorities.

4. Matthews should first have been tried by a
commission of lunacy, and his mental condition de-
termined. Then the facts of the possibility of his
brain being normal with full power of restraint
would have appeared. The question of how far a
person could use spirits and morphine and other
drugs for years and be capable of planning any act
requiring judgment and consistency would be an-
swered. How far such a man could be considered
rational and conscious of duty, responsibility, and
oliligation would be apparent. The delusional con-
dition of such a brain and the delirious reasonings
and childish talk and conduct would be natural in
such a condition. This trial and verdict should
mark the close of the medicolegal efforts to deter-
mine the criminality and responsibility of persons
who are notoriously degenerate and incompetent by
reason of the use of spirits and narcotics. There is
certainly something gruesome in the effort to de-

102

MEDICAL RECORD.

[Jan. 19, 1907

termine de,£;rees of sanity in persons wlio are no-
torious spirit and drug takers and whose appearance
and conduct attract attention and are prominent to
all tlieir associates. The law gains nothing by such
farcical efforts to determine crime and the degree
of punishment which it merits, and human justice
gains nothing by attempting to decide how far in-
competent and defective brain culprits are able to
control and judge of the results of their acts. Jn real-
ity the higher consciousness of the community and
its intelligence are hurt by the injustice of attempt-
ing to adjust wrongs in jury trials on the basis of
full responsibility. The attempt to make a jury of
twelve men understand the actual condition of the
mind and motives of a morphiamaniac and deter-
mine how far he could reason and judge of the na-
ture and consequence of his acts is a reversion to
the theory and practice of the Middle .Ages.

PUBLIC COx\TROL OF DISEASE THROUGH

A NATIONAL DEPARTMENT OF

HEALTH.

By HAROLD W. WTHGIIT, M.I).,

ASTORIA, LONG ISLAND.

This subject was recently discussed in a general
way by Prof. J. Pease Norton, Professor of Eco-
nomics at Yale University, in the Journal of the
American Medical Association, September 29, 1906.
I wish to present a few remarks upon this subject
from the more personal point of view of a private
practitioner of medicine.

In the first place I would speak of some of the
disadvantages which result from the present
methods of practice and which affect both physician
and patient. 1 think I am correct in saying that
there is no thoughtful general practitioner living
to-day who, no matter how successful he may be
from the world's standpoint, is satisfied with the
present-day methods by which he is obliged to pur-
sue his vocation.

We start out in the beginning with the highest
ideals ; we intend to practise as scientific medicine
as is possible without regard to pecuniary rewartl.
These ideals have either come to us naturally or
have been instilled in us by our teachers in the medi-
cal school. We have been told that the practice of
medicine is not a trade but a Inimanitarian calling,
and the most noble calling that has ever existed or
will exist. We are taught to feel that the knowledge
of having done good work should be sufficient re-
ward for our labors. All this we feel to be true : it
appeals to our highest nature and we want to act ac-
cordingly.

In our hospital course we give ourselves up en-
tirely to the welfare of our patients, we watch the
course of their malady with untiring diligence, and
we do so purely from a sense of duty which is in
accordance with the unselfish and scientific standard
we set for ourselves when we were in the med-
ical school. When we enter upon general practice
we confidently expect that we shall be able to con-
tinue our work in such a spirit, and so we look for-
ward to our life work with much pleasure and en-
thusiasm. But what happens to the great majority
when they have at last become lavmched upon "the
sea of troubles"? And bv the "great majority" I
mean those who are obliged to live by the practice of
their art and yet want to live up to the ideal stand-
ard they have set for themselves. These soon find
that expenses are heavy, competition severe, and the
readiness or ability of the patient to pay for one's

services limited to an unexpected degree. They find
that they must see a large number of sick people
every day in order to pay expenses and have any-
thing left over. Most patients cannot or will not
pav for more than one visit a day, if that. Conse-
quently the doctor cannot afford to give more than
a verv small portion of the clay's time to each indi-
vidual case, especially if his patients are spread over
much territory. The doctor finds that he cannot
give the same amount of thought and attention to
his patient as he did when a hospital interne ; it is
both a physical and financial impossibility, and so,
perforce, he gets the habit of rushing through his
work in the modern strenuous and superficial man-
ner. When he has a little time to think quietly a
feeling of dissatisfaction, a vague sense of some-
thing wanting will come, .^nd what of the other
party, the patient? Does he or she never feel that
there is something lacking?

.•\s the vears pass the doctor sees men of less skill,
less intelligence, and lower standards than his own
making "a success" ; this adds to his dissatisfaction
with things in general, and his fellow-practitioners
in particular. He may be at odds with his col-
leagues on account of some slight misunderstanding
or indiscretion on his or their part, some little breach
of professional etiquette, which is often contributed
to by a thoughtless patient's lack of fidelity or love
of gossip. Thus, in manv communities, we find lit-
tle or no harmony and cooperation within the pro-
fession ; everyone is working for himself, forgetful
of the purpose of his calling — to save life and pre-
vent disease.

Another source of worriment and disappointment
to man\- is the lack of hospital facilities ; either there
is no hospital in the neighborhood or none to which
the physician feels he can entrust the care of an op-
erative or difficult medical case.

There is another condition which hinders the true
progress of our work, and that is the popular de-
mand for a prescription which will alleviate the
symptoms at once, regardless of their cause. This
condition is due to the fact that in the past physi-
cians have been either too ignorant or too careless
to investigate their cases scientifically, and have
yielded to this demand rather than take the trouble
to instruct their patients in matters of hygiene.

The popular mind being so uneducated has no
respect for such advice unless accompanied by the
inevitable prescription which usually makes the
greater, if not the only impression. So. in order to
"succeed," it happens that we must "bluff." Truly,
a most disgusting state of affairs in the light of our
vouthful ideas ! In order to make a living we must
cater to the public taste like any tradesman.

These are a few of the disadvantages of the
present system. Now, let us suppose the existence
of a radically different order of affairs and see if
these disadvantages would be overcome and bene-
fits, unattainable at present, be obtained.

First, let us presume the existence of a national
bureau of health having subordinate bureaus in
every community of about a thousand inhabitants.
.\t the head of these bureaus are physicians who
have proved their abilitv to deal with public health
problems : men who are wholly devoted to the great-
est good of humanity by the prevention of disease.
Those of the central bureau have the right to select
their subordinates from successful civil service ex-
aminees according to the standing and personal
qualifications of the latter. All physicians are there-
fore licensed onlv bv the central bureau and are
in the emplov of the same. Then let us suppose all
the hospitals under the control of the national de-

Jan. 19, 1907]

MEDICAL RECORD.

103

partment and that one hospital is supplied for each
comniuuity or district, containing a certain num-
ber of people. The hospitals would be the head-
quarters of the subdivisions of the health depart-
ment; they would have a staff of resident visiting
physicians and a stall' of resident and visiting
nurses, all under the authority of the hospital su-
perintendent, who would be a physician also. All
of these officials would be appointed by the civil
service commission of the national bureau.

Every case of illness would then be reported to
the local health bureau by the patient or his rela-
tives ; a health officer would be sent to the home to
investigate the case and treat it there, or at the
hospital, according to circumstances, a nurse being
also provided if necessary. The attending physician
is responsible to someone above him for the conduct
of the case, and he has constantly at his command
the counsel of liis colleagues and the facilities of a
hosjiital. There would be none of the competition
and lack of cooperation that exists among physicians
at present, because all would be working together
for the good of humanity and not for a fee. The
physician in charge of a case would have the right
and feel free to visit his patient at any time and
study the disease in all its aspects ; he would not be
subject to popular prejudices and have to cater
thereto for fear of his patient deserting him.

Under such a system the medical profession
would be invested with such a degree of dignity
and authority that its counsel would not only be
always sought, but its words of advice would also
be considered as words of command, and would
carry enough respect to be obeyed. The local
health bureaus with their hospitals would be centers
of medical education of both the profession and the
laity in matters pertaining to personal and public
hygiene, the prevention of epidemics, and the care
of infants and children.

Under such a system medical inspections of the
entire population could be made at periodic inter-
vals. Thus many ailments could be abated or pre-
vented and wrong liabits of living corrected ; the
spread of venereal disease could be checked. Re-
cause there is strength in consolidation, manv san-
itary measures could be enforced which are now
impracticable ; cities could be made to have pure
water, a proper sewage system, clean streets, smoke-
less and dustless air, and sanitary homes. As Pro-
fessor Norton suggests, the national health depart-
ment and subdepartments could be allied in
cooperation with the departments of education,
labor, conmierce, immigration, agriculture, and food
inspection and the regulation of the drug and pro-
prietary medicine business. Under such a union
what good thing for the public well-being could not
be accomplished?

Finally, bv reason of the fact that everv licensed
physician had an assured living, he would be able
to devote all his time and thought to his proper
work with an interest and energy impossible under
present conditions. No fortunes could be made out
of our fellows' ills, to be sure, but the kind of men
who would enter the profession under a system such
as I have indicated would neither desire nor attempt
to make capital out of their work.

Now as to the practicability of such a system.
Are these ideas, which I know might be much better
expressed, visinnarv and impossible of realization or
wrong in principle ? I grant that thev are visionary
m the sense that they cannot be carried out practi-
cally at once ; but I am looking into the future, and
a great many plans for human welfare which were
once "visionjtry" have been realized, and not all of

them have been found to be wrong in principle or
disastrous in results. It may be argued that such a
system would "savor too much of paternalism, it
would interfere too much with personal liberty, and
would be altogether unAmerican." I do not believe
that anything is unAmerican which brings the
greatest good to the greatest number of peo-
ple. There has been no such outcry against
the present methods of controlling some of
the contagious diseases or against international
t:|uarantine. Are not these interferences with
personal liberty ? But would anyone abolish
them on that account? Do they not "savor of pa-
ternalism" ? Is not the public school system .guilty
in like manner?

But it may be said that such a system would be
impracticable, by reason of the great expenditure
necessary for its support. I do not believe that such
would be the case because such a system could be
supported by a just income tax upon its beneficiaries
among whom would be numbered every inhabitant
of the country. Furthermore, the individual would
not feel the expense involved as much as at present
he feels the average yearly doctor's bills, and I have
already tried to indicate that he would have his ail-
ments much better attended to, as well as other
troubles he knows not of, prevented.

The nucleus for such a system already exists in
the Public Health and Marine ITospital Service and
in our municipal and State health boards. There
are already evidences of the growth of power and
influence for good in these organizations which now
are separate and noncooperative. How much more
good they might accomplish, if united, T have al-
ready attempted to show.

Coi!c!iisio)is. — I. Present methods of practice
hinder us from pursuing our vocation in the spirit
approjiriate to it.

2. A national department of health, conducted in
the way indicated above, would do away with many
of these present hindrances and would give better
treatment of, and protection from, disease.

3. There are no insurmountable obstacles in the
wav of such a system, and there are already indi-
cations of a complete public control of disease in
the future as manifested in the greater influence
being acquired by the Public Health Service at
Washington and hv our municipal health depart-
ments.

Method of Infection of the Amniotic Liquid by the
Passage of Bacteria and Toxins Through the Mem-
branes of the Ovum. — Giiiseppe Ranieri consir'or? t!ie
way in which b,icteria and toxins may gain access to the
amniotic fluid in cases in which the membranes are in-
tact. The amniotic fluid has some bactericidal action on
many s;erms. but ihc addition to it of meconium renders it
more ready t" undergo putrefaction. The author has made
experiments on animals to ascertain the method of entrance
of the germs and gives us his conclusions. The amniotic
sac formed of its three membranes, when all perfect cannot
be penetrated by patho.genic bacteria. The amniotic liquid
can become infected when the sac is still closed, but not all
of the three mendiranes are perfect. The death or macera-
tion of the fetus brings about, after a time, changes in the
membranes, such that it allows the passage of pathogenic
organisms. Putrefaction, and infection of an unruptured
sac may take place with either a living or a dead fetus.
Germs and toxins acting on the membranes produce changes
in them, such that the poisons are absorbed by the
mother, and she experiences fever and intoxication. Toxins
pass through mfire rapidly than bacteria. Emptying of the
uterus puts an end to the dangers of the mother. — Anna'i
di Ostctriria c Cir.i-tro'osui

104

MEDICAL RECORD.

[Jan. 19, 1907

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A.M.. M.D., Editor.

PUBLISHERS
WM. WOOD & CO . 51 FIFTH AVENUE.

New York, January 19, J907.

ADVANCED THERAPEUTICS IN A GOV-
ERNOR'.S MESSAGE.

In a recent annual messaj^e, characterized by the
Chicago papers as of wider scope than ever ad-
dressed to a legislature, Governor Deneen of Illinois
devotes a larger portion to medical matters than is
cu.stomary in such documents. "To elevate the pub-
lic charity service to the level of modern efficiency,"
Governor Deneen makes many wise recommenda-
tions which evidence his broad grasp and intelligent
understanding of the humane interest in the subject.
It is exceedingly heartening to the medical profes-
sion, which has long and persistentlv labored, despite
discouragement and lack of sympathy on the part of
statesmen and politicians, to elevate the public med-
ical service, to note the recommendations of this
progressive Governor of Illinois. "In discussing
the improvement in medical administration and treat-
ment," he writes, "I desire to call attention to the
fact that medical and nursing science has advanced
by leaps and bounds during the past twenty-five
years."

"Drugless treatment, work, recreation, and amuse-
ment, are prescribed by physicians just as drugs are
prescribed" in the psychopathic institute at Kanka-
kee. 111., and its branches in each State hospital,
"where local clinics are conducted to which physi-
cians are invited. These," writes the governor, "will
be used in an effort to learn new things about men-
tal and nervous disorders, and perhaps to discover
new remedies which will benefit the whole human
family." The governor evidently regards hydro-
therapy as one of the latter, inasmuch as he dwells
upon it as follow? : "For hopeful cases the water
treatment, known as hydrotherapy, already has been
installed in some of the institutions, and I hope will
be extended speedily to others. By means of this
treatment manv incipient and acute cases of in-
sanity are cured, and the patients, in.stead of becom-
ing lifelong inmates of hospitals, and placing a
burden upon the State, return to their homes as
productive members of society. The installation
of the bath treatment costs from $3,000 to $40,000
for each institution, according to the number of
acute curable cases admitted. I heartily favor the
extension of the system of treatment to all State
hospitals receiving acute cases."

Tlie conclusions of this humane layman's message
to his Legislature are doubtless based upon reports
of his medical advisers: they verify the published
observations of the late George W. Foster, who
made the first svstcmatic and extensive observations

in the (jovernment (Elizabeth) Hospital at Wash-
ington, and of the late Dr. Dent of Ward's Island
Hospitals and others who have reported striking
results in mental and nervous disorders. If the
latter are obtained at Kankakee by "prescribing
water," as the Governor says, "just as drugs are pre-
scribed," the question obtrudes itself, Why are med-
ical students not instructed in the prescription of
water as in the prescription of drugs? \Miy does
the young physician, as Kussmaul said years ago
in his official report on improvements in medical
education, feel humiliated when in practice he finds
himself displaced by the empiric, because he is less
capable in applying hydrotherapy, than in using his
hypodermic syringe ? In the lectures on therapeutics
and in the leading textbooks on Materia Medica and
Therapeutics, the application of water in disease re-
ceives but scant attention. Indeed it were far better
for suffering hiTmanity if hydrotherapy were en-
tirely omitted, for these works do not discuss water
as they do drugs, and their description of technique
of water application is as faulty as is the rationale,
if compared with special works on this subject. The
clinical results cannot fail to be disappointing, when
based upon faulty teaching, which appears to be
reproduced by successive authors. In one of the
most popular textbooks, one-half of a page, devoted
to the drip sheet, is occupied by an imperfect illustra-
tion, and the remainder contains a faulty descrip-
tion of its technique. In a recent work on Prophy-
laxis and Treatment of Diseases, hydrotherapy is
mentioned in the treatment of two-thirds of the
diseases discussed, but the methods advocated testify
to the otherwise well-informed author's imfamiliarity
with the teachings of the men who have made hydro-
therapy a life study and practice. These works,
written by progressive and otherwise capable teach-
ers, reflect the status of instruction in our schools.
Is it not high time for American medical schools
to follow the example of tlie continental imiversities
and establish chairs, from which the principles of
hydrotherapy may be taught, and clinics in which
its practice may be learned ? It is to be hoped that
the example of Columbia University, which in-
augurated a course of lectures on hydrotherapy last
spring, may be emulated by other progressive med-
ical schools.

THE NAVAL MEDICAL SERVICE.

In the interesting report, recently issued, of the
Surgeon-General of the U. .S. Navv for the fiscal
year ending June ,^0, 1906, considerable space is de-
voted to the consideration of the needs of the Med-
ical Corps. For reasons not far to seek, the naval
medical service has never, at least not for many
years, been popular among young medical men, the
result being that there are always many vacancies in
the Corps which it is impossible to fill. These va-
cancies numbered 44 at the close of the fiscal year in
1906, and this notwithstanding that a medical officer
was sent to the leading medical colleges of the East
in the spring of last year to address the fourth year
students and set before them the advantages of the
naval medical service.

The attractions of the service are many. The
young man, j.'ithout ties, who enters the Navy leads

Jan. 19, 1907]

MEDICAL RECORD.

!"5

a pleasant life with congenial companions ; he has an
■assured social position; opportunity is afforded him
of seeing much of the world, at least of that part of
it bordering the sea ; he has enough to do to keep him
occupied, yet the work is in general not arduous, and
while on shore duty ample opportunity is afforded
him of prosecuting original research ; and finally, his
pay, for the early years at least, is greater than he
could naturally expect to earn in practice, and he is
assured a certain, though moderate, income for life.
The disadvantages are that promotion is slow, much
slower than in the medical services of the Army or
of the Public Health and Alarine-Hospital Service ;
the medical officers of the Navy, unlike his col-
leagues in the other services, is unable to retire on
half pay after thirty years' service; and finally, the
naval medical officer, unlike the ''Admiral of the
Queen's Navie," is obliged to go to sea, and, indeed,
to spend much of his life in sea service. To the man
who is married, or who hopes to marry, this is a very
serious fact. The wife and family cannot go to sea
with him. If he is ordered to some definite station,
such as the Mediterranean or the Philippines, his
family can follow him and take lodgings in some
seaport where his ship is likely to be the greater part
of the time, and he can see them occasionally. But
they may have made the journey at great expense
and have just settled down in the foreign city, when
orders come for the surgeon to return home or go to
some other station at the other end of the world, and
then comes another long separation and another
tedious and expensive journey for the wife and
children. This is the most serious objection to a
naval life whether in the medical corps or the line,
and it is one which is inseparable from the service.
To the young man with no thought of marrying, it
may have little weight, but one who thinks of the
future and who is not sure of immunitv against the
Bacillus inafriinonice will be apt to hesitate before
shutting the door against wedded happiness.

The other disadvantages of the service are not
irremediable, and Admiral Rixey makes several rec-
ommendations in his report looking to an improve-
ment in these respects. At the present promotion, ex-
cept to the lower grade of passed assistant surgeon,
is practically at a stand,still. There will be a yearly
average of only three retirements for age for the next
twenty-two years, or 63 in all, and deaths and vol-
untary resignations will not more than double this
number. Congress has relieved in a measure the
stagnation in the line by providing for voluntary re-
tirement in the grades of captain, commander, and
lieutenant-commander in order to create an average
number of vacancies in the upper grades, and for re-
tirement by selection in these grades in case the vol-
untary retirements are not sufficient to cause the
required number of vacancies. But the bill provid-
ing for promotion in the line did not include the
medical corps. In order to remedy this .\dmiral
Ri.xey recommends an increase in the number of
surgeons, medical inspectors, and medical directors,
thus creating a corresponding number of vacancies
in the lower grades and giving a chance for promo-
tion. He also urges that provision be made for vol-
untary retirement in the medical corps, such as
exists in the Army and Marine Corps and in the line
in the Navy. If this were done, promotion would be

more rapid, and the young man who enters the
medical service of the Navy to-day would not be
kept indefinitely in the grade of passed assistant sur-
geon with no prospect of rising higher until his hair
is thin and gray and his heart made sick by de-
ferred hope.

The suggestions of the Surgeon-General are mod-
est enough, and the necessities of the service demand
that they should receive recognition by Congress.
The disadvantages of the service inseparable from
the necessary sea-duty are great and they can ht
counterbalanced only by making the prizes greater.
Instead of being slow, promotion in the Medical
Corps of the Navy should be more rapid than in the
Army or Marine-Hospital Service, and the pay in
the corresponding ranks should be greater than in
the other services. It is only by offering greater in-
ducements that those contemplating entering one of
the medical services can be attracted to the Navy in
sufficient numbers to keep the service up to the nec-
essary point of efficiency.

TUBERCULOSIS AND :\IILK.

The sensational declaration made by Robert Koch,
at the London Tuberculosis Congress a few years
ago, that there is no danger to man from the flesh or
milk of tuberculous cattle, fortunately never ob-
tained wide credence in English-speaking countries
and indeed was speedily discredited in his own coun-
try. Nevertheless, the weight of his authority and
the extended publicity given to his utterances by the
public press tended to allay in a measure the very
salutary fear of the consumption of milk from dis-
eased cows. The health authorities never relaxed
their efforts to exterminate the disease among dairy
herds, but individuals here and there have raised
their voices against what they termed the useless
sacrifice of valuable cattle, basing their protests on
the injudicious statements of Koch. It is well, there-
fore, that the subject has continued to receive atten-
tion at the hands of experimenters here and abroad,
until overwhelming proof has been accumulated that
Koch was as wrong as wrong can be.

The latest evidence in this direction is contained
in a recently published Bulletin of the Bureau of
Animal Industrv' of the U. S. Department of Agri-
culture. The Bulletin embodies a report of experi-
ments that have been conducted by Dr. E. C.
.Schroeder and W. E. Cotton of the experiment
station of the Bureau of Animal Industry. They
have undertaken experiments for the purpose of
testing the susceptibility of the lung to infection with
tubercle bacilli, and have most conclusively demon-
strated that pulmonary tuberculosis niav be caused,
no matter through what channel the bacilli gain en-
trance to the body. Those experimenters claim, in-
deed, as a result of their experiments, that the lung
is the part most frequently attacked, even when the
infectious material is ingested, and furthermore that
fresh tuberculous material, such as is contained in
the milk of diseased cows, induces the disease more
quickly and more certainly than the dried bacilli,
whether inhaled or ingested in dust-contaminated
food. A tuberculous cow is a greater menace to man
than the human consumptive, for "tuberculous ma-
terial from cattle has the his^hest virulence for all

io6

MEDICAL RECORD.

[Jan. 19, 1907

tested species of the mammalian kingdom, to which
man anatomically and physiologically belongs, and
tuberculous material from man has a lower viru-
lence."

The Bulletin concludes that there is "no more ac-
tive agent than the tuberculous cow for the increase
of tuberculosis among animals and its persistence
among men." This statement is strong, but it seems
to be based u|>on the results of careful experiments,
and if it is not exaggerated its significance can
hardly be overestimated when we consider not oidy
the wide consumption of milk by children and adults,
in health and disease, but also the fact that milk
forms one of the sta])le articles of diet for the
tuberculous.

Defective Death Certificates.

Attention is drawn in the Bulletin of the Xew
York State Department of Health for December,
1906, to the unsatisfactorv returns often made by
physicians regarding the cause of death. In many
cases the physician neglects to supply the informa-
tion called for regarding the occupation, conjugal
conditions, birthplace, and birthplace of the parents
of the decedent. This is a seemingly small matter,
yet it is of importance as regards the accuracy of
the statistics. The most serious defects, however,
are in respect of the cause of death. The signer of
the certificate often contents himself with a general
statement, such as "debility." "inanition," "exhaus-
tion," or "old age," without specifying to what the
debility or the exhaustion was due, or noting the
disease which caused death in the aged — for un-
fortunately death from simple slowing down of the
vital processes unaided by defect in some vital organ
is extremely rare. Other indefinite terms employed
are abscess, convulsions, fever, paralysis, spinal dis-
ease, heart disease, tumor, etc.. no qualification being
given as to the location of the abscess or tumor, the
nature of the fever, the cause of the convulsions, or
the particular disease of the spinal cord or of the
heart which existed. The Bulletin states that there
has been a marked improvement in these respects
in recent years, but there are still many defective
certificates returned. \\'ith a view to obtaining ac-
curacy in the records of the Department notice is
given that all officers designated to receive death
certificates and issue burial permits are instructed
to refuse to accept any certificate which is defective
in the ways above mentioned, which is not written
throughout in black ink. which is mutilated or illeg-
ible, or in which there is any erasure, interlining,
correction, or alteration of anything printed or writ-
ten on the certificate. .A-part from the fact that
a properlv filled certificate is essential if accurate
records are to be kept, it is to the interest of the
physician himself to perform this work properly,
for the records are open at all times to the public,
and are frequentiv consulted, and some of the re-
turns would be looked upon with shame by the
phvsicians issuing them in case they were made pub-
lic, as thev might be under certain circumstances. If
the phvsician whose unpleasant duty it is to fill out
a death certificate always performed his task with
care and conscientiousness, he would have the satis-
faction of knowing that he. had contributed his part
to the perfection of the statistical records, and he
might also be spared the chagrin of having his un-
satisfactorv diagnosis made public, or of having the
certificate returned to liim for correction by the
health officer.

Hem-Viocolpos and Hem.vtometra.

It is not the existence of either one or the other of*
these conditions that is so extremely rare, but their
combination is a very unusual clinical fact. A.
Deletrez, in the Aiuiales de Gynecologic et d'Ob-
stetriqitc for December, 1906, gives a most interest-
ing account of a case of this nature in which he op-
erated in Jul)-, 1906. The patient was a girl eight-
een \ears old, without any hereditary history re-
lating in any way to the anomaly which she pre-
sented. Menstruation had never taken place. For
four years the patient had suffered pain every month
in the hypogastric, iliac, and mammary regions.
The pain had been so severe that the patient had
been obliged to rest in bed for several days every
month during the attack. Within the last three or
four months before operation the abdomen had in-
creased distinctly in volume. The pain was almost
continuous with periodical exacerbations. The gen-
eral condition was very satisfactory, micturition was
normal, and constipation was habitual. .Abdominal
palpation determint-d the existence of a median
tumor, globular, slighth' movable, and extending
up beyond the umbilicus. Examination of the ex-
ternal genitals demonstrated an imperforate vagina,
but with no projection of the hymen. The urinary
meatus was edematous and varicose. Vesical cathe-
terism indicated that the bladder was directed toward
the right. Incision of the hymen did not result in
any discharge, but incision of a membrane ob-
structing the lower third of the vagina was followed
by a discharge of about three liters of a viscous
chocolate-colored liquid. At the same time the ab-
domen decreased in size, and the uterus decreased
progressivelv in volume. The opening was dilated
by the aid of the fingers, and the operator was able
to reach the cervi.x, which was softened and easily
allowed the introduction of the first phalanx of the
first finger. Dilatation was practised for several
days. The first menstruation was established four
weeks after intervention, and since that time this
function has been regular. The involution of the
uterus was complete. Hematocolpos is almost al-
ways congenital. It develops slowly. When hema-
tocolpos extends to the uterus and produces hem-
atometra. the blood may invade the tubes and give
rise to a hematosalpinx, or it may overflow into
the peritoneal cavity and determine phenomena
which are grave, sometimes even resulting in death.

The Technique of Spinal Anesthesia.

W'hile spinal anesthesia does not seem to be alto-
gether justifying the oftentimes extravagant enthusi-
asm with which it was taken up during the earlier
vears of its history, many surgeons believe that it
has a well-defined province of utility. An interesting
observation which if it turns out to be well founded
should serve to reduce to a considerable extent the
dangers, if not the uncertainties, of the method has
been recently published by Hofmann in the Mi'in-
clicncr medisinische W ochenschrift of December 25,
iQOf^. This operator found that by reducing the
amount of anesthetic drug usedi but increasing the
amount of fluid injected, the area of anesthesia ex-
tended much higher than was the case under the
ordinary conditions. According to the anesthetic
used, the solution is made ud in a strength of from
I'i to I per cent., wit hone drop of i-iooo adrenalin
solution to each c.c, and of this solution from S^'^ 7
c.c. is iniected. The escape of cerebrospinal fluid is
prevented as mtich as possible, and no attempt is
made to extend the area of anesthesia bv elevating

Jan. 19, 1907]

MEDICAL RECORD.

107

the pelvis, llofmann states that by observing this
technique the results obtained were more satisfactory
than when smaller amounts of tluid containing larger
doses of the anesthetic were used, though he admits
that occasional failures still occurred. Although
he uses the method not infrequently, he believes that
spinal anesthesia is usually more satisfactory to the
operator than to the patient, particularly if the per-
itoneum is attacked, and in this connection he relates
the experience of a medical man on whom he per-
formed a hernia operation under spinal anesthesia.
The manipulations of the hernial sac and stretching
of the parietal peritoneum occasioned severe pain,
and the patient, who had already on a previous occa-
sion been subjected to anesthesia by inhalation, stated
that he should certainly prefer this method in case
another operation should ever become necessary.

Mir.K .\S .\ HEiIO.ST.\TIC.

Till-: novel suggestion has been made that as milk
contains several constituents which are prescribed
as remedies in hemorrhage, the substance itself be
used for this purpose. Among these ingredients
are iron, phosphoric, citric, and sulphuric acids, the
lime salts, and allnmiin. The calcium salts are an
important element in coagulation of the blood and
the alljunn'iioiils haxe a tendency- tn increase the
fibrinogen. In a recent article in the Therapeutischc
Monatshefte, 1906, No. 10, Solt states how his atten-
tion was attracted to the value of milk in this rela-
tion. A young girl flowed very profusely during
her first menstrual period, and by none of the usual
means was it possible to check the hemorrhage. She
became comatose and vomited constantly. .A nu-
trient enema was given consisting of milk with only
a little salt added and the bleeding ceased. Some
years ago Aronsohn reported good success with
milk enemas in hemoptysis, and animated by this
and his own success the writer continued the use
of the agent in a variety of bleeding cases. In a
male patient who suffered from severe gastric hem-
orrhage as the result of ulcer of the stoinach, the
bleeding was quickly checked b}' the rectal injec-
tion of a liter of milk which was freely salted. In
postpartum uterine hemorrhages Solt also employed
these milk injections with goml results, as well a-
durine the climacteric when every otlicr remedy
had failed. It is recommended that the injections
be given with the patient on the side so that the
fiuid can be easily retained, and its temperature
should be that of the bod\. The effect seems to
be favored if a bulb syringe is used, as the inter-
rupted stream, particularly in uterine hemorrhage,
produces a kind of vibratory pressure on the organ.
Solt's suggestion is certainl\' interesting, and as it
can be readilv applied, no harm can come from fiu'-
ther trials of it.

The Trk.'Vtment of Tuberculosis.

TriE Committee on the Prevention of Tuberculosis
of the Charitv Organization Societ\- points out the
great value of the tuberculosis exhibition as a means
of educating the people in regard to the prophylaxis
and treatment of this disease. Starting with an
exhibition held in New York City by the National
Association for the Study and Prevention of Tuber-
culosis and the local committee, there have been
held in New York City and other places fourteen
tuberculosis exhibitions, which have been visited by
300,000 persons. These exhibitions have been de-
vised to show in a popular way that tuberculosis is
a communicable disease, that it is a curable disease.

and that it is a preventable disease. This is demon-
strated by lectures, by photographs of sanatoria, hos-
pitals, and dispensaries for the treatment and cure
of tuberculosis, by many models of tenement houses,
sleeping shacks, and "lean-tos," by diagrams and
charts showing the prevalence of the disease in the
population at large, and especially in certain sec-
tions and in certain occupations, by pathological
specimens of infected lungs and other organs of the
body. The wdiole subject is presented in such a way
as to carry conviction to the layman, and to lead
to a realization that effort to stamp out the disease
is worth while. An evidence of the popular interest
that has been excited in the subject is the fact that
at the exhibition held in the tenement districts of
New \ork City there was an attendance of 94,000
persons.

Ciiix.a's Attempted Refcirm.

Lv view of their expected losses on the enormous
stocks of opium in bond at Shanghai and Hongkong,
British merchants are seeking indemnity from the
Chinese Government for losses they may sustain
under the operation of the new anti-opiuni law. It is
estimated that the export of opium "from India
amounts to 75,000 chests annually, valued at $38,-
950,000, and this business will be entirelv lost in a
few years if the law is strictly enforced. The
regulations issued on November 21, igofi, as the
result of a decree of the Empercir of China and
the Council of State, contain the following provis-
ions : The cultivation of the poppy and the use of
opium must cease in ten years. No new ground can
be placed under culti\-ation, and the ground under
cultivation now must be reduced one-tenth every
year, under penalty of confiscation. All persons who
use opium must be registered, and so must the
quantity each uses. Only a registered person can
bu\- opium. No one may begin the use of opium
after the issuance of the regulations. Shops that
sell opium are to be closed gradually. All opium
dens are to be closed within six months. The au-
thorities must set the example of discontinuing the
use of the drug. Those who find that they cannot
discontinue within six months will be deprived of
rank and ofifice. Teachers, scholars, soldiers, and
sailors are allowed three months in which to discon-
tinue. We should not regard as unduly sceptical one
who might doubt the practicability of the enforce-
ment of such a Draconic law as this. It has been
the e.xperience of Western nations that legislative
prohibition of the sale of alcoholic beverages may
restrict, but does not wholly prevent their use or
abuse, and it is not likelv that greater success will
attend China's eft"ort to overcome a national vice in
as short a time.

]\Iedic.\l News i.x the D.5,iey Press.

I.\ the Journal of the American Medical Association
of January 5 is a letter with the above heading from
Mr. C. S. N. Hallberg. a member of the Council on
Pharmacy and Chemistry, calling to account two of
the Chicago dailv papers for their cabled extract of a
symposium on influenza, published in the London
Practitioner for January, 1907. He takes special
exception to the statement that Sir William Broad-
bent found quinine of service, and that his normal
prescription was "one drachm of ammoniated qui-
nine and two drachms of liquor ammonise acetatis
everv hour for three hours, and then every four
hours." The newspapers were right, however, for

io8

MEDICAL RECORD.

[Jan. 19. 1907

that is the prescrii)tion e.xactl_v as Sir WiUiam Broad-
bent wrote it, or at least as the Practitioner printed
it, and the writer's wrath was misdirected. Indeed
the newspapers are deserving of praise in this in-
stance for their extreme accuracy, something which
is not usually characteristic of press reports of med-
ical matters, and which, being so rare, is worthy of
the prominence given to it by the Councilor's pre-
mature reprobation. To an Englishman the state-
ment is perfectly intelligible, for of course Sir Wil-
liam meant the ammoniated tincture of quinine of the
British Pharmacopreia, which Mr. Ilallberg declares
to contain "one grain of quinine sulphate to the
fiuidrachm in diluted alcohol with a little ammonia
water." This is not the exact formula, but it is
probably as nearly correct as the newspapers would
have got it.

NfuiH of tl)p Up?k.

The Society for the Prevention of Unnecessary
Noise was organized on ]\Ionday of this week at a
meeting attended by a number of prominent physi-
cians, hospital superintendents, and others interested
in the welfare of the citizens of this town. Mrs. Isaac
L. Rice was unanimously elected president of the
society and ^Ir. John J. Rooney secretary. A consti-
tution was adopted and an appeal to the public,
setting forth the objects of the society and the need
of its existence, was read and approved. Member-
ship in the society is open to all in sympathy with its
object. The annual dues for active members are $2,
and there is no initiation fee. Other classes ef mem-
bership are the founders, who pay $100, patrons $50,
and life members $25.

The Sewage Disposal Problem. — The United
States Geological Survey has just issued, under the
title of "Water Supply and Irrigation Paper No.
185," a valuable contribution to the literature on the
disposal and purification of sewage. The investiga-
tions described in this publication were made at the
Sanitary Research Laboratory and Sewage Experi-
ment Station of the Massachusetts Institute of Tech-
nology, under the direction of Prof. William T.
Sedg\\ ' ' e results of this work, and the prac-

tical cc is that have been drawn, are by no

means applicable merely to large cities, but contain
lessons of practical value to all communities having
to deal with the ever-present sewage disposal prob-
lem. The description of the experiments is pre-
ceded by a historical review of the whole sewage
disposal problem, from its origin up to the present
time. The paper may be obtained by application to
the Director of the Geological .Survev. Washington,
D. C.

Typhoid Fever. — The number of new cases of
typhoid fever in .Scranton and vicinity is diminish-
ing, and in three days recently the total number of
new cases reported was twenty-five, which is a
great improvement. The total number of cases is
given as 1,084, with 168 deaths. Pittsburg is also
suffering severely from the disease, and there has
been a marked increase in the number of cases of
typhoid fever in Philadelphia, the majority occur-
ring in sections not yet supplied with filtered water.
Two hundred and fifty-two cases were reported for
the week ended January 14. There were more than
9,000 cases during the year 1906. with upward of
1,000 deaths.

Food and Drug Inspectors Needed. — The Civil
Service Commission has issued notice of a general
examination on February 5 for the purpose of

obtaining a list of persons qualified for appointment
as inspectors and chemists in the Department of
Agriculture. The examinations are limited to men,
and the salaries range from $2,000 to $3,000 per
annum. These positions are made necessary by
the large inspection service required by the en-
forcement of the Pure Food and Drug Act, which
went into efi'ect on January i.

Leprosy in Russia. — The Russian Government
is said to be making active efforts to resist the
spread of leprosy in the Baltic provinces, where
the disease is very common, especially among the
Lettish population. As one means of repressing the
disease a society for the cure of leprosy has been
formed at Dorpat, and sanatoria have been built.
Doctors have been sent out to travel through the
country to search out persons suffering from the
disease, but they have met with great difficulties,
as the people refuse to submit to examination or to
avail themselves of the facilities offered for treat-
ment. These official investigations, however, have
shown what immense strides the disease has made.
The numlier of lepers in Esthonia alone is reported
as 5,000, distributed in various areas.

A Lacteal Fluid from Beans. — A Japanese, Dr.
Kalayama, is reported to have devised a method for
preparing milk-like fluid from soy beans that can
be condensed and produced at a far less cost than
cow's milk. The bean juice consists of 92.5 per cent.
water, 3.02 protein, 2.16 fat, 0.03 fiber, 1.88 other
nonnitrogenous substances, and 0.41 ash. To the
juice the inventor adds a little sugar and potassium
phosphate, and then condenses the mixture. The
milk thus prepared is of a yellowish color, and is
pleasant to the palate, ta.sting somewhat like cow's
milk, with a slight flavor of soy beans.

The Army Canteen. — A movement intended to
aid in the restoration of tlie army canteen has been
started by a number of Washington, D. C, women.
They have formed a societ)' to be known as the
.\rmy Canteen Club, and have taken steps to form
similar clubs in Chicago, Cincinnati, and several
places in New York State. These ladies hold that
the restoration of the army canteen will be in the
interest of genuine practical temperance, and against
what they designate as "the mistaken theory of tem-
perance."

Influenza in Baltimore. — According to the esti-
mates of the Baltimore Health Department over
100,000 persons have been affected by the prevalent
epidemic of grip in that city.

Scarlet Fever in Boston. — A mild epidemic of
scarlet fever is prevalent in Boston and its environs,
and in one day recently fifty new cases of the disease
were reported to the Board of Health.

The Fenger Memorial Association was incor-
porated in Chicago on December 26. It is the
plan of the association to establish a fund in mem-
ory of the late Dr. Christian Fenger, for the purpose
of encouraging original research in bacteriology,
surgery, and patholog}". Annual cash prizes are
to be awarded. The incorporators are Drs. Frank
Billings, George W. Webster, John B. IVIurphy, Wm.
T. Belfield, Ludwig Hektoen, Carl Doepfner, and
Charles S. Bacon.

An Inquiry into the "Poison Squad" Tests. —
A resolution has been introduced into the House
of Representatives asking the Secretary of Agri-
culture to inform the House by what authority the
food tests by Dr. Wiley, Chief of the Bureau of
Chemistry, and his "poison squad" were held. The
resolution also seeks to ascertain whether or not these

Jan. 19, 1907'

MEDICAL RECORD.

109

tests were responsible for the death of a member of
the group of young men who ate the experimental
food. The physicians who attended the young man
have stated that his death was due to pulmonary tu-
berculosis, but his mother alleges that the disease was
induced by the so-called poisoned food. One of the
statements made by the mother in her charge is
that on one occasion her son let fall one of the
capsules to be added to the food he was to take,
and there was so much boric acid in it that "it took
the paint off the floor!"

Red Cross Aid to China. — Plans are being
made by the Red Cross for the regular shipment to
China of supplies for the relief of famine sufferers.
Three hundred tons of flour have been ordered
through the Commissary-General of the Army, and
will be shipped to Shanghai.

Premature Senility. — An unusual instance of
the untimely inset of senility is reported from Min-
neapolis, Minn. A boy of eleven years who has
just died in the City Hospital is stated to have
had organs corresponding in their condition to those
ordinarily seen at an advanced age. It is alleged
that when the child was six years old his hair began
to turn gray, his eyesight began to fail, and he
walked with the deliberate care of a per.son well
advanced in years. As a very young child he was
exceptionally bright, but his mental faculties had
been failing for the last two years.

Cold Cars. — Health Commissioner Whalen, of
Chicago has forced the street car officials to comply
with the city ordinance requiring that street cars
be heated to a certain temperature.

Flat Car Wheels Removed.— The Health De-
partment has announced that since the investigation
of the flat car wheel nuisance was begun a few weeks
ago, 1,56s such wheels have been removed bv the
New York City Railway Company.

Dr. Wm. H. Taylor, for forty years obstetrician
to the Cincinnati Hospital, has resigned, and been
.succeeded by Dr. W'm. D. Porter.

Gifts to Hospitals. — Ry the will of the late
Adam \\'eber, recently filed in the Surrogate's office,
the Isabella Heimath is to receive $1,000, and the
German Hospital $500. By the will of Louis C.
Vanuexem the sum of $25,000 has been devised to
Jefferson Hospital of Philadelphia. In accordance
with the terms of the will of Miss Harriet Rich-
ards, who died at Philadelphia ten years ago, the
sum of $5,000 has been donated to St. Joseph's
Hospital and to St. Mary's Hospital, for the en-
dowment of free beds. Mr. Bernard M. Baruch has
donated $5,000 for a bed in the J. Hood Wright
Memorial Hospital, to commemorate his father's
long active service to that institution. Dr. Baruch
has resigned as attending physician to the hospital,
and has been placed on the consulting .staff. Mr.
Frederick G. Bourne of New York has presented to
the Nassau, L. I., Hospital a dispensary and labo-
ratory building, which it is estimated will cost about
$10,000. In connection with Mr. Bourne's dona-
tion, a Mr. Bird, who formerly lived at Garden City,
has presented as a memorial to his wife. Mabel
Thorne Bird, $2,000 for an operating room, to be
used in connection with the dispensary. A wing
on each side of the hospital is now in course of
erection, and will be completed March t. This
addition was the gift of Mrs. William K. Vander-
bilt, Jr.

Mt. Sinai Hospital. — .\t the recent meeting of
ihe managers of this hospital Mr. Isaac Wallach
resigned the presidency, after having served three

years as director, seventeen years as vice-president,
and ten years as president of the institution. The sec-
retary's report showed that during the past year
10,543 applicants had been admitted to the hos-
pital. Of these 4,713 were admitted free, 647 were
private patients, 249 were private patients in public
wards, 622 were paid patients in public wards, while
the consultations in the dispensary numbered 158,-
295 for the year. The total disbursement for the
vear for the support of the hospital and dispensary
was $356,722.63, against receipts of $347,859.84.
The deficit of about $9,000 was paid from cash in
hand.

The Sixth International Dermatological Con-
gress will be held in this city September 9 to 14,
1907, at the Academy of Medicine. The meetings
will be open to the public, and any member of the
medical profession in good standing may become
a member of the Congress by registering with the
Secretary-General at the time of the meeting or
previously. The fee for membership is five dollars,
payable to the Secretary-General in New York, or
to the foreign secretaries. Papers may be presented
in writing in the English, French, German, Spanish,
or Italian languages, and may be discussed in the
language most familiar to the speaker. The Con-
gress will be held under the presidency of Dr. James
C. White of Boston, and Dr. John A. Fordyce of
80 West 40th street, New York City, is the Secre-
tary-General. The first Congress of this kind met in
Paris in 1889, and since that time at intervals of
about three years it has been held in Vienna, Lon-
don, Paris, and Berlin.

American International Congress on Tubercu-
losis.— At the session of this organization re-
cently held in this city the following were elected
as officers for 1907: President, Dr. Clifford H.
Trion, New (Orleans, La.; Fice-Prcsideiifs, Dr. Geo.
1\. Tabor. Austin, Te.xas. Dr. Thos. Bassett Keys,
Chicago, 111., Dr. Francis T. B. Fast, Las Vegas,
N. M'., Dr. W. F. Drewry, Petersburg, Va., Dr.
J. W. McDonald. Fairmont, W. Va. ; Secretarx and
Treasurer, Dr. M. M. Smith, .Austin, Texas.

Missoula County (Mont.) Medical Society. —

At the recent meeting of this society officers were
elected as follows : President, Dr. E. W. Spotts-
wood : Vice-President. Dr. E. F. Dorlds ; Secretary-
Treasurer, Dr. H. B. Farnsworth.

New Britain (Conn.) Medical Society. — The

following were elected as officers by this society at a
meeting held on January i : President, Dr. T. G.
Wright ; Vice-President, Dr. S. W. Irving ; Secre-
tary-Treasurer. Dr. Arvid .Anderson.

Muskegon Oceana Counties (Mich.) Medical
Association. — Officers were elected as follows at
the meeting of this society, held at Muskegon on
January 4: President, Dr. John F. Denslow ; Vice-
President, Dr. W. W. L. Griffin of Shelby : Secre-
lary^ Dr. Vernon A. Chapman ; Treasurer. Dr. Jacob
J. Costing.

Millers River (Mass.) Medical Society. — At
the annual meeting of this society, held on January
T, the following officers were elected: President,
Dr. E. F. Mullins of Baldwinville ; Vice-President,
Dr. A. C. Leach of Orange: Secretary-Treasurer,
Dr. George L. Perry of Athol.

Medical . 1-

nua'i ■._i'.v..' i!"i ' ./.ccrs of thi.- ~. -wv ^ , , ,.v_.,, ._., ,^...'.i-
ary i, resulted as follows: President, Dr. E. T.
Camp, Gadsden : Vice-President, Dr. J. P. Stewart,
.'Kttalla : Secrefarv. Dr. .Aker, Gadsden.

no

MEDICAL RECORD.

[Jan. 19, 1907

Obituary Notes. — Dr. Edward Oilman Bryant
of this city died on January 8 at the age of thirty-
nine years. He was born in Boston, and was a
grachiate of Harvard University. After serving for
a time as physician to the port of Boston he came
to this city, and for some years had been connected
with the '\\'illard Parker Hospital.

Dr. Edmund C. Rickerts of Brooklyn died on
January 9 in his fifty-third year. He was gradu-
ated from the College of Physicians and Surgeons
about twenty years ago.

Dr. Simon I. Groot of Washington, D. C, died
en January 8 at the age of eighty-nine years. He
was one of the founders of the Homeopathic Hos-
pital in Washington, and was one of the oldest
practitioners of the city.

Dr. Alfons Muller of this city died on January
9 at the age of forty-five years. A few hours before
his death he made two visits on patients suffering
from pneumonia, although he was himself the vic-
tim of the same disease. He was graduated from
the University of Halle in 1886.

Dr. Philip E. Johnson, recently of this city,
died suddenly in Portland. Ore., on January 8. Dr.
Johnson was graduated from Columbia University
in the class of 1892, and had settled in Portland a
few months ago.

Dr. E. O. Bennett of Detroit, Mich., is dead at
the age of seventy years. He had served as a sur-
geon during the Civil ^^'ar. and for nineteen vears
was superintendent of the County Asylum at Eloise.
He resigned this position in 1900 to become sur-
geon of the Michigan Soldiers' Home at Grand
Rapids, but was forced by failing health to give up
yctive work in 1903.

Dr. H, C. Berger of Milwaukee, ^^"is., died sud-
denly of heart disease on January 2. He was a
native of Milwaukee, and had practised in that city
since 1891, when he was graduated from Rush r\Ied-
ical College, Chicago.

Dr. Julius Cesar Lehardy of Savannah, Ga.,
died on January 7 of nephritis, at the age of seventy-
six years. He was born in Belgium, and after re-
ceiving a classical and scientific education in Brus-
sels and Paris completed his medical studies in the
Jefferson Medical College of Philadelphia, from
which he was graduated in 1S55. He commenced
to practise near Rome. Ga., but soon after accepted
the chair of chemistry in the Oglethorpe Medical
College. S.avannah. Dr. Lehardy served as a vol-
unteer surgeon in the confederate army through the
Civil War, and had occupied numerous official posi-
tions, including the presidency of the Georgia State
^Fedical Societv and the medical directorship of the
Citizens's Sanitary Association of Savannah, an or-
ganization which did much to place the sanitation
of the city on its present footing.

Dr. Gilbert L. Rose of Decatur. :\Iich., died on
Januarv 5. after an illness of five days. He was
born in Lakepnrt Ci^unty, Ind.. in 1853. and received
his • lucation in the Cincinnati College of

yied: Je had practised in Decatur for thirtv-

one years.

Dr, ^^'ILLIAM IT. Myers of Fort Wayne. Ind.,
died on January 3 at the age of eighty vears. He
was a graduate of the JeiTerson Medical College
of Philadelphia, in the class of 1855, and had prac-
tised in northwestern Indiana ever since. He was
said to have been the first to perform cesarean sec-
tion in that part of the State.

Dr. F. A. W^^GGONER of Hamilton, 111., died on
January i in Boulder. Col., at the age of thirty-five
years. He was a graduate of Keokuk !\Iedicai Col-
lege, and had practised for some years in Hamilton.

Dr. W. -Murray Johnston of Los Angeles, Cal.,
died on December 29 at an advanced age. Dr. John-
ston was a native of Maine, and a graduate of the
University of Michigan. He had practised in Kan-
sas and Arizona before removing to Los Angeles
seventeen years ago.

Dr. Herman Stein of Chicago died on Decem-
ber 25, at the age of eighty years. He was born in
Germany, and received his education at the Uni-
versity of Heidelberg. He came to this country to-
gether with Carl Schurz as a political refugee, and
for a time practised medicine in Cincinnati, later on
settling in St. Louis. During the Civil War he was
a major in General Siegcl's regiment. Ten years ago
he retired from active practice, and went to Chicago.

Dr. GusTA\E A. Bach MAN died at Philadelphia
on January 8, at the age of sixty-four years. He
was graduated from Jefferson Medical College in
the class of 1874.

Dr. Benjamin Pitt Johnson, .surgeon of the
Cunarder Coroiiia died at Liverpool on December
30, of pneumonia, at the age of forty-five years.
Dr. Johnson had been in the service of the company
for sixteen years, and had been surgeon of the
Utubria, Etruria. and Coronia. He was a native
of Ludlow, England.

Dr. Daniel S. Adams of Manchester, N. H., died
on January II at the age of sixty years. He was
born in Lockport, N. Y,, and had practised in Man-
chester since 1872. He was at one time president of
the Xew Hampshire Medical Society.

TRYPSIN FOR THE CURE OF CAXCER.

To THE Editor of the Medical Record:

Sir: — Dr. E. W. Peet, in your last issue, under the above
caption, lays stress upon the value of "facts" insofar as
relates to a preceding article of mine, also published by you
under the same title. Regretfully, I feel forced to make
answer to this communication, for I well know that, un-
answered, misapprehensions and trivialities grow to larger
proportions. It seems to me also that a personal attack of
this nature is entirely uncalled for.

As to facts in which I am alleged to have been remiss,
the first is that Dr, Peet referred a certain case to me.
This statement was indeed an inadvertence on my part.
I was misled by the fact that Dr. Peet met the patient twice
at my office during her early visits, and I believed, there-
fore, that she was acting with his approval. Hence, as a
matter of professional courtesy, I mentioned his name.

.As to Dr. Peet's second fact, namely, that he had closely
attended the patient at her home during the seven weeks
she had been under treatmnt by .r-ray given by me ; that
he had made "very careful and frequent notes of the case ;"
that his "notes do not at all agree with the report made
by Dr. Morton in his article," which latter as regards the
results of x-ray reported in Case I. is further termed
"optimistic," beyond comprehension, etc., etc., I submit the
following letter, written to me bv the patient :

"New York, Jan. 15, 1907. Dear Dr. Morton: In refer-
ence to the statement of Dr. E. \V. Peet, published in the
Medical Record of January 12, 1907, where he says, 'I
continued to attend the patient at her home and made very
careful and frequent notes of the progress of the case while
she was under treatment,' and further says 'that at all
times during these seven weeks I was able to make out
enlarged axillary glands and detect lymphatic infection by
palpation,' I think it my duty to say to you that at no time
during the seven weeks referred to was I aware that Dr.
Peet was in attendance upon me at my home or elsewhere,
nor do I know of a single instance during that time when
he examined me. except on two occasions when, at his own
instance, he came to your office when I first was bemg
treated. -As a matter of fact, the late President Harper of
Chicago University introduced me to you and advised me
to take treatment with vou. I left my case with you
unreservedly. In justice to you I make this simple state-
ment. Believe me, most cordially yours. K. H. _ The
patient's full name is signed to the above letter with her
permission to use it, but I have preferred to use her initials
as in Case I. of my report.

Jan. 19, 1907]

MEDICAL RECORD.

Ill

Under tlie above circinnstances, I can hardly see how
Dr. Peet arrived at his third fact, namel\', that my report
of the progress of the case during the seven weeks of
jr-rav treatment was optimistic or otherwise, since accord-
ing to the patient's statement, supplemented I may add by
her mother's, he did not "attend the patient at her home,"
and did not examine her during this time, except at my
office, and in the early stage of treatment. The opportunity
for making these careful notes of the results of the .r ray
treatment would seem to have been wanting. The .r-ray
treatment, by the way, was merely mentioned by me in my
original article as a part of the remote history of the case.
And, as a matter of fact, what bearing has Dr. Feet's
criticism upon "trypsin for the cure of cancer?"

William J. Morton, M.D.

.•\ METHOD OF OPERATION ON THE LIP.

To THE Editor of the ^Ieuic.\l Record :

Sir: — In your issue of November 3, 1906, there is an
article with the above title, by C. F. Buckley, M.D., of
Brooklyn. Although the author does not distinctly claim
this to be a new method, it is rather inferred. I trespass
upon your time and space to say that I have used the
inethod to control hemorrhage as well as to increase the
effect of local anesthesia.

In operating for the removal of an epithelioma of the lip,
at the suggestion of my colleague. Dr. J. Herbert Claiborne,
I applied two artery forceps at a suitable distance from the
proposed lines of incision, to prevent hemorrhage from the
coronary arteries, which it most effectually did. This
patient was under general anesthesia, and the method,
therefore, only had to do with the use of the forceps as a
hemostatic.

Now, as to the application of the clamp before the injec-
tion of cocaine — this I myself did long ago in an operation
for the removal of an epithelioma of the auricle, which
I reported to the New York Medical Society. I, however,
never made any claim for originality in this connection.
The credit for discovering the method belongs to Dr. J.
Leonard Corning (Transactions of the Medical Society of
the State of New York, 1887, p. 94).

Dr. Buckley says the necessity under which he once was,
"of operating entirely alone on a growth involving the
lower lip, was the originator of this idea, which has been
used successfully since that time." My object is to show
that, although the idea was to him original, practically the
same method has been employed before.

Thos. R. Pooley, M.D.

107 M.\DISON .\VE.\UE.

OUR LONDON LETTER.

(From Our Special Correspondent.)

CHRISTMAS AT THE HOSPITALS — SURGICAL TREAT.MENT OF
XOX .MALIGNANT GASTRIC ULCER.ATION — OBITUARY.

London. December 28, igob
Christmas day this year was, so far as weather goes, the
most enjoyable for a long period past. Some hours of sun-
shine, a very slight touch of frost, and very moderate
breeze made getting about a pleasure to healthy people.
The next day London woke up to a complete transforma-
tion ; a mantle of snow four to six inches deep covered the
ground and impeded locomotion. There was, in fact,
hardly any traffic for the first half of the day. The local
authorities had been caught napping, and even such quar-
ters as Westminster and Kensington were unprepared, and
the snow enforced a rest on horses and men, and with it a
delightful silence, as if far from the maddening noise of
traffic.

All the hospitals observe Xmas day. There was extra
fare for those able to partake, amusements and visits of
friends, and all sorts of efforts to cheer suflterers. The
children's wards, like the others, were decorated, but the
Christmas trees and bountiful distribution of toys were
the chief attractions of the little invalids. The supply
was unusually large. In many cases the gifts came from
one or two generous benefactors ; in others there was a
subscription among the supporters of the hospital. The
decoration of the wards has become a rather expensive
feature of the season, and is often done largely at the cost
of students and nurses. In some cases this is becoming
oppressive, and attempts to restrain the ardor of contrib-
utors have been made. This seems especially desirable
considering that the work of decorating is mostly done by
the same persons.

The surgical treatment of gastric ulcer has occupied the
attention of the profession for some time, and it was there-
fore deemed desirable to hold a full dress debate on it at the
Royal Medical and Chirurgica' Society. This was opened

in November, and has extended over three meetings. Emi-
nent physicians and surgeons stated their opinions and
reviewed their experience, and, on the whole, the debate
gives the impression of a syinijosium rather than a discus-
sion. The subject was wide, perhaps too wide, for it was
put as the "operative treatment of noninalignant ulcer of
the stomach and its complications." Each speaker could,
accordingly, deal with the point he felt most interest in,
and there was not much opportunity of coming to close
grips with divergent views. Nevertheless, the expression
of diverse opinions is of no little interest, and a comparison
of them will be made by the general practitioner on whom
so much responsibility rests for early treatment. There is
a general consensus of opinion that perforation calls for
immediate operation. But then the question arises as to
whether the surgeon should stay his hand when he has
closed the opening, or proceed to a further operation. The
danger of a second perforation is diminished by a gastro-
enterostomy which favors the healing of the ulcer and line
of sutures, and diminishes the risk of hematcmesis. Then
arises the question of the patient's condition. Is he able
to bear the additional operation? To this one speaker
seemed to think the worse he might be the greater the
demand for gastroenterostomy, while it offered the only
chance in the presence of some complications, eg-, cicatri-
cial stenosis of the pylorus. .A.s to hemorrhage, there is a
general agreement that operation should not be performed
during an acute attack, which is rarely fatal, not 5 per cent,
dying during the hemorrhage. On the other hand, the
fatality rises to 60 or 70 per cent, for operation during such
attack. This is doubtless because in so many cases the
bleeding comes from erosion of the mucous membrane,
which in itself has not a high mortality, though the risk of
operation is enormous and the chance of benefit slight. The
advance of surgery has so greatly diminished its risks that
we have become accustomed to statistics which would for-
merly have been incredible. Mr. Mayo Robson has achieved
a mortality of 2 per cent, in early cases of gastric ulcer,
and ,3 per cent, is not considered unusual. These figures
contrast well with the death rate of former hospital admis-
sions ; but statistics as to these are very unequal, showing
that the conditions must have been very variable. Dr.
Hawkins stated that of 556 consecnive cases admitted to
St. Thomas' Hospital, the deaths were 13 per cent. Of
these 400 were admitted early, and discharged cured, but
about 25 per cent, of them relapsed. It was among relapsed
cases that nearly all the deaths occurred. The foregoing
figures were submitted at the fi[st adjourned meeting. .A.t
the next adjournment another series was brought forward
by Dr. H. S. French, which may be compared with them,
though the conditions were different. At Guy's Hospital
up to 1905 only 47 gastrojejunostomies for nonraalignant
gastric disease had been performed, and of these 13 were
fatal. Excluding 2 cases in which hematemesis was the
cause, the mortality was still very high — over 23 per cent.
This was partly due to the fact that all had ulcers or their
results, and the health of all was very low at the time of
operation. These statistics. Dr. French admitted, over-
stated the risk of gastrojejunostomy, but he did not agree
that it was slight in cases of cicatricial stenosis of the
pylorus. Of the cases that recovered, 32 per cent, obtained
no lasting relief from the operation. As to the after-his-
tory of patients who had recovered after operations in
(niy's Hospital for perforated ulcers, he found that 30 had
recovered, 18 for periods varying between two and eight
years, 15 without the recurrence of any gastric symptoms.
The other 3 had done badly. In none of these 18 was the
gastrojejunostomy done at the time of suturing the ulcer.
Mr. ^Iayo Robson thought these statistics quite dreadful,
for there was a failure to relieve symptoms of 32 per cent.,
with a mortality of 27 per cent. If we had no other statis-
tics we should all leave the meeting saying that patients
should no longer be submitted to operation.

The difficulty of drawing conclusions from so prolonged
a discussion, ranging over so wide an area, will be under-
stood by every reader, and the general practitioner will
perhaps be inclined to fall back on his previous routine,
modified by whatever he finds to be an advance distinctly
shown. He will say that many cases recover under pro-
longed rest in bed and strict diet, so that grave operations
are not to be risked in most cases, or by other than highly-
skilled surgeons, time being in favor of medical treatment.
Rectal feeding may give absolute rest to the stomach for a
short time, but is" admitted to be an inadequate diet for
long, and even hematemesis need not prevent nutriment
being given bv mouth. Six weeks' absolute rest "u milk
diet, followed bv a like period of comparative rest, and that
bv a further three months careful dieting, was recom-
mended bv Mr. Paterson in his Hunterian lectures. If
then the p'atient were not free from definite symptoms, or
after an apparent cure had a relapse, he considered an oper-
ation was in the best interest of the patients. Out of 143
gastrojejunostomies he found the after-history showed

112

MEDICAL RECORD.

[Jan. 19, 1907

complete relief in 82 per cent. The operation had been so
successful that there was clanger of its becoming a fashion-
able panacea for vague stomach disorders, and so bringing
discredit on a most successful treatment in suitable cases.
This is an important lesson from tlie discussion, .-\nother
was emphasized by Dr. White's warning that when there
seemed great danger of death from hemorrhage it should
not be said something must be done, for operation might
further shoiten t!ie short time t!ie i)aticiu might sur\ive if
left alone.

The death of Dr. William Travers removes a prominent
physician from Kensington, in which lie had practised since
1866. At first he was a general practitioner, but he attained
the position of a consultant among his colleagues of the
district. He was physician to the Chelsea Hospital from
1883 to 1894. His health had been failing for some time,
but his death was unexpected. He was F.R.C.S., 1864, and
M.D. Dub., 1879, and a member of several societies.

Dr. Alfred Sheen, consulting surgeon to the Cardiff
Infirmary, died on the i6th inst., in Iiis sixty-eighth year.
He studied at Madras College and then at Guv's Hospital,
took M. D. Hand.. 1862, and M.R.C.S., 1863, D.'P.H. Camb.,
1888. He wrote "The Workhouse and Its Medical Officer,"
and was widely known as the author of the "Handy Visit-
ing List and Medical Bookkeeping." In 1880 he contributed
to the Lancet "Five Years' Surgical Work in Cardiff In-
firmary." He leaves a wife and eleven children. His eldest
son is a consulting surgeon at Cardiff.

Dr. Jatnes Gray, A.M., M.B., etc., of Dundee was found
dead in his bed on the 7th inst. He was in his usual health
on retiring at night and had visited his patients during the
previous day, on which also he had been reappointed assist-
ant surgeon to the Dundee Infirmary. He was assistant
professor of surgery at the college and only thirty-four
years old.

Deputy Inspector General of Hospitals and Fleets R. W.
Beaumont died on the 21st inst., aged seventy-eight. He
had seen much service and received official recognition of
his valuable work with regard to epidemics and disease.
He also had the medal for duty well done in the Kaffir war,
1850-2. In 1878 he was senior medical officer in the flagship
at the occupation of Cyprus.

OUR LETTFR FROM PERU.

(From Our Special Correspondent.)

THE PL.\GUE — IXrLUEXZ..\ — DYSEXTERV .■\ND ABSCESS OF THE
LIVER — A PaiSONOUS LIZARD.

.'^REQUIPA, Peru, Xoveraber 17. 1006.
Theke has been no case of bubonic plague in our part of
Mollendo for at least six months. Last year it reappeared
in the hot months of December, January, and February.
In Lima, during the whole year, there have been cases, but.
strange to say, th.e disease has never become epidemic.

August and September may be said to be the months
when there is most sickness, especially pneumonia. This
year the unhealthy season has been prolonged into October.
There have been many cases of influenza, some longer
than usual and a few accompanied by pains in one or more
bony prominences of a joint or joints, these pains disappear-
ing slowly.

In one of yc.ir Philippine letters your correspondent says
that t; there find that all cases of abscess of the

liver '.. preceded by dysentery. That is not our

experience, :i;id 1 see that Dr. Adviozola, a prominent physi-
cian of Lima, in a short lecture published in the Cronica
Mcdica of that town, says that he has not found that to be
invariably the case.

There is a small lizard here and on the coast which
is popularly looked upon with great dread. They call it
"salamanqueja" (corruption of salamandra?), length, 12
centimeters. So far as I can see, in a preserved specimen,
the only difference between it and the common lizards is
that the "salamanqueja" has clubbed digits. On the coast
it gets the credit of being able to cause death. Here I
have never seen such a result. True, most venomous ani-
mals are more venomous in hot than in colder regions.
My experience of the effects attributed to the bite is con-
fined to a few cases ; but they were all similar. The patient
feels as if stung by a wasp. He rubs the part a little and
the feeling passes off. I have never seen a case where the
animal was caught in the act ; it has been found (or not
found) later — perhaps next day— in the room. Supposing
the bite to have been received in the middle of the day.
at night the patient feels an itchy and then a painful burn-
ing. There generally are shivering and then fever. I have
even seen urticaria. The constitutional symptoms pass off
in a few days, but the local affection extends, with itchy,
burning, swelling and dusky redness, to about the size of
the palm of an ordinary hand. At last a line of demarca-
tion appears. The whole sphacelates, skin, subcutaneous,
and adipose tissue exposing the muscles. The wound heals
kindlv.

New York Medical Journal, January 5, 1907.

The Treatment of Tuberculous Glands of the Neck
by the X-ray. — Histories of two cases are given by
G. S. L. Feldstein whose conclusions on the general
subject are as follows: (l) Such glands should be
subjected to .r-ray therapy when no softening or casea-
tion has taken place; (2) softening or caseous glands
should be referred to the surgeon, and ought not to
have .r-ray treatment; (3) postoperative .i-ray treatment
is important if there is any doubt of remaining glands
which might be infected; (4) for cosmetic reasons; (5)
the size of the gland or glands does not influence the
successful result of the treatment.

Formaldehyde in the Disinfection of Rooms. — The
paper of .M. J. Roscnau is an affirmation of the validity
of the work done in this direction by- one of the govern-
ment services. Experiments were conducted in a zinc-
lined room. The general conclusion is that considerable
volumes of formaldehyde gas are not sufficient to de-
stroy bacteria unless the proper conditions of moisture
and temperature are present. The author declares that
much of the work upon the germicidal action 01 for-
maldehyde gas is contradictory. We know that the
usual source of error is that the cultures exposed are
sometimes moist and sometimes dry. Moist cultures
may be killed with dry formaldehyde gas. But the dry
gas does not kill dry cultures. In a general way it may
be said that the most serious limitations to the use of
formaldehyde gas as a disinfectant are temperature and
moisture. The gas cannot be depended on in cold or
dry weather. When the temperature is below 60° F.,
and the relative humidity of the atmosphere is below
65 per cent., the gas frequently fails to kill nonspore
bearing organism''.

Albuminuria of Prostatic and Seminal Origin with Re-
ports of Two Cases. — W. G. Young reports two cases.
This form of albuminuria seems to occur in cases of
prostatic congestion, and mild inflammation in both
continent men and men of irregular se.xual life. Hab-
itual sexual excitement without gratification is an im-
portant factor in bringing about the prostatic and vesic-
ular condition responsible for the albuminuria. Con-
stipation is also a factor in causing and keeping up the
condition. The prostates in these cases are found to be
tender, slightly enlarged, soft, and edematous. "^ ' ■ ■-:-
cles are usually tender, often distended, and th r

urethra very sensitive. .A.n interesting feature in :)... ^„i-s
is the fact that the albuminuria is intermittent. It was
noticed in the author's cases that it was sometimes absent
in the morning, but present the same afternoon. The
prostate and vesicles are in a relaxed and atonic con-
dition, and the exercise of the day's goiug about may
act like massage, squeezing out their contents into the
posterior urethra and bladder. The patient passes his
urine in two glasses, but not entirely emptying the blad-
der. The first two specimens m— ' - •' -r. or they may
show a slight cloudiness, not to phosphates

or to pus. The prostate and ve^ .,; .: then palpated

per rectum, and their contents expressed. In these case;
the expressed fluid is often sufficient to appear at the
meatus. The remainder of the urine is then passed, and
is found to be turbid, and often to contain bluish white,
translucent, tapioca-like bodies. This urine will be found
to give a much more marked reaction for albumin than
that passed before massage. The source of the albumin
may be the semen or prostatic fluid altered by a transuda-
tion into it of serum from the blood, possibly both. The
author does not believe that normal prostatic fluid alone
when mixed with the urine would give the reaction for
albumin. The albumin u.sually found in the urine after
massaging the prostate and vesicles is probably due to
the semen expressed during the massage. There is no
question but that semen, even in small quantities, mi.xed
with absolutely normal urine, will give positive reactions
for albumin.

Journal of the American Medical Association, Jantmry
12 1907.

Endothelioma of the Skin. — W. S. Gottheil. says that
It is now the geii ' ' ii of pathologists that to the

class of endothel: ng many of the atypical or

mixed new growth,-. ^,...> .. ^ ..iothelial carcinoma, endothelial
sarcoma, angiosarcoma, etc. Their differentiation from
cancer and sarcoma is important, as these endothelio-
mata are essentially benign, slow in growth, without
tendency to metastasis or to lymphatic gland involve-
ment, and are not prone to recur after removal. Re-
corded cases of endotheliomata of the skin are rare.

Jan. 19, 1907]

MEDICAL RECORD.

113

and their clinical characteristics are not well defined.
As yet a positive diagnosis can be made only with the
aid of the microscope. Most of the cases have appeared
on the scalp as single or multiple, flat or pedunculated
tumors. They are not likely to break down, but are
very liable to undergo degeneration, more especially of
the'Vatty type, and so to show a more or less marked
yellow color; their growth is slow, and they show no
evidence of malignancy.

Trypanosomes. — F. G. Novy describes the trypano-
somes. gives what is known of their life history, and
transmission through insects, etc., and describes the
diseases they produce. He does, not accept Koch's
views of the specific unity of many of the pathogenic
trypanosomes, but recognizes eight pathogenic species
for mammals, including the kala azar organism, the
generic relations of which seem to be somewhat in
doubt. Only two of these are pathogenic for human
species, the Tr. gamhicnsis. which causes the African
sleeping sickness, and the Ti:? {Piroplasma) donovani,
responsible for the kala azar disease of India, but these
are formidable enotigh. The most formidable trypano-
some infection of the domestic animals, the tsetse fly
disease of South Africa, has become a much less serious
matter since the extermination of most of the wild
game of that region that harbored the parasite, the
fly itself being only the passive carrier of germs. It
is probable also, in Novy's opinion, that the same is
true of the Glossiiia j^alpalis, the biting fly that trans-
mits the germ of sleeping sickness which has lately
depopulated whole regions of Eastern Africa. ^ The
treatment of \\\t severer forms of trypanosome disease,
including those affecting man, is very unsatisfactory.
Encouraging results, however, have been obtained with
anilin dyes and arsenic in monkeys aft'ected with
sleeping sickness, though, save in one case reported by
Button and Todd, treatment has been ineffectual so
far in the human species.

Fractures of the Neck and Shaft of the Femur. — F. E.
Peckham describes at length the method of using a
modified Thomas splint for treatment of fractures of
the shaft of the femur according to the method devised
by Ridlon. He makes a special point of frequent meas-
urements under the straps in order to insure the proper
length of the leg throughout the treatment, and also of
properly supporting the lower end of the leg between
the end' of the splint and the ankle by a smooth pad.
He has used this method in a number of cases with
excellent results. In some cases, however, it became
necessarv to take additional measures to render the limb
immovable when constant daily attention could not be
given, and he describes a method adopted by him of
fitting a plaster cast and windlass attachment during
etherization, and illustrates it with cuts. It has, of
course, the disadvantage of rendering the surface ofthe
leg inaccessible in part, and therefore some excoriations
cannot be avoided, whereas with the Thomas-Ridlon
splint every part of the skin can be reached. In fracture
of the upper third of the shaft, shortening is almost un-
avoidable except with children with whom it is also the
rule. He treats these cases also with the plaster frame
and windlass attachment described. He summarizes as
follows: (i) Find out as accurately as may be and with
:f-ray, if possible, exactly what the condition is. Port-
able ;i--ray outfits now permit radiographs at the bed-
side, so that fractured necks and shafts may be accu-
rately studied in this way; (2) reduce the fracture under
ether and apply the Thomas splint in fractures of the
neck and plaster-of- Paris in case of fractured shaft ;
(3) practise eternal vigilance all through the bed treat-
ment to prevent pressure sores or any other trouble
from arising; (4") operate immedi.itcly in all cases of
nonunion.

The Quinine Treatment o£ Pneumonia. — M. A. B.
Smith testifies to the value of quinine in the treatment
of pneumonia, reporting four cases in which it was suc-
cessfully employed. He believes that in the large doses
advocated by Galbraith quinine acts as a specific, as
much so as antitoxin in diphtheria. He found that lar^e
doses of the drug were better borne by pneumonia
patients than small ones, and thinks he might safely
have given still larger ones than those of from thirty to
fifty grains, which he employed. There were more
symptoms of quininism with from six to ten-gram
doses than with the larger ones.

X-ray and Radium Treatment of Deep-Seated Cancer.

— J. Rudis-Jicinsky reports three cases of inoperable
abdominal cancer treated with the .r-ray. and .r-ray and
radium, with apparent benefit. One patient was appar-
ently well three years after first being seen, and in
another the disease seems arrested after a year's treat-

mtnt. The other palieiU, tluMigh temporarily bene-
fited, died from a recurrence and autointoxication over
three years after being first seen. Two other cases are
mentioned in which the growth disappeared under the
treatment, but the patients died lati'r from recurrences.
He thinks the facts show thai in these cases we must
not delay our operative procedures, but, if possible,
should make an exploratory incision to ascertain the
state of things in every inoperable and deep-sealed
case, and then ray the growth as soon as possible to
prevent suflFering and local or general recurrence. In
primary operable malignant tumors it is well perhaps
to ray the field about ten days before operation, and
after operating, ray it again at once to prevent recur-
rence or infiltration into the glandular tissue, especially
in carcinoma and sarcoma. An area three or four
inches larger than that of the original tumor is exposed
by him to a hard tube; in fact, the harder and deeper
the lesion the harder should be the tube.

The Lancet, December 29, 1906.
The Treatment of General Peritonitis.— .\. W. Maya
Robson gives a general review of the attitude taken by
surgeons" relative to the proper treatment of this con-
dition, tracing the question from the time of merely ex-
pectant measures up to its present-day operative status^
He refers to various papers by different men on both
sides of the Atlantic and presents some suggestive statis-
tics. The cases thus collated he divides into four groups,
as follows: Group i. Acute appendicitis without perfora-
tion, 20 cases with immediate operation and a mortality
rate of two and one half per cent., 55 cases with delay in
operation, no mortality. Group 2. Acute appendicitis
perforated or gangrenous without abscess, 21 immediate,
no mortalitv; 34 with delay, no mortality. Group 3. Acute
appendicitis" with peritonitis and abscess, 38 immediate,
mortalitv two and one half per cent., 78 with delay, and
the sanie mortality. Group 4. Acute appendicitis with
diffuse peritonitis, 33, all with delay in operating, and a
mortality of thirty per cent. Concerning the position taken
by Ochsner, he states that if we compare the figures here
given with the results of the extensive operation involving
manipulation of the abdominal contents or evisceration,
we cannot but pronounce in favor of Ochsner's treatment,
as carried out by himself, which is, moreover, undoubtedly
the best treatment in the absence of the possibility of
skilled surgery, if it can be carried out thoroughly in
every detail as advocated and practi.'^ed by its authr.r.
If, however, we compare the results of delay, even in
Ochsner's hands in this class of cases, with those of less
severe operations, the author thinks w-e shall be driven to
the conclusion that where efficient surgical help and nurs-
ing are available immediate operation in spreading or gen-
eral peritonitis due to appendicitis is likely to yield bet-
ter results than can be obtained by delay. Moreover,
Robson notes the difficulty in making a diagnosis a.s to
the cause of the peritonitis. No one counsels delay m a
case of undoubted .gastrointestinal perforation or bowel
strangulation, but in 52 ca^cs, shown at operation to be
due to perforated duodenal ulcer, a correct diagnosis
had been made in only 2. .A.cute pancreatitis may also
simulate perforative appendicitis, and delay in such cases
certainly would be disastrous. A similar observation ap-
plies to perforated gastric ulcer and typhoid perfora-
tions. .-Ks to the latter Robson declares that it is quite
clear that an extensive operation can never be borne and
that a rapid repair of the cause and drainage will yield
the best results. In the after-treatment the administration
per rectum of large quantities of saline fluid with which
liquid peptonoids and some diffusible stimulants are mixed
is most useful, and if needful it may be supplemented
by subcutaneous or intravenous saline infusion. Feeding
by the bowel may be supplemented by the subcutaneous
administration of a five per cent, glucose solution or by
the administration of sterile olive oil subcutaneously
until the stomach is capable of retaining nourishment.
Liquor strychnine in five-minim doses subcutaneously every
four hours' is most useful in combating shock and stren.gth-
ening the heart. After removal or repair of the cause of
the peritonitis one-eighth of a grain of calomel given
every hour or two by the mouth until a grain has been
administered not only helps the passage onwards of flatus,
but by its antiseptic effect tends to prevent decomposition
in the gastrointestinal contents and so to arrest the for-
mation of gas; if necessarv a turpentine enema is given
to assist the expulsion of flatus from the large intestine.
If there is distention of the upper abdomen with inefficient
vomiting, or if vomiting is persisting, gastric lavage is
resorted to and, if needful, repeated from time to^ time, a
method of treatment that often gives groat relief.

Cyanosis, General and Local.— XTnder this heading
T. Oliver discusses onfcrnocnous cyanosis, that of intestinal

"4

MEDICAL RECORD.

[Jan. 19, 1907

origin, that of aniline workers, and finally local cyanosis, or
Raynauas disease. The first variety frequently occurs in
those who regularly take, on their own responsibility,
the various modern headache and other powders con-
taining acctanilid and similar compounds. Some cases
have been found due to intestinal organisms which possess
the power of influencing blood composition. Workers in
aniline colors become markedly cyanosed and pass dark
colored urine. In man the poison may enter by the skin,
by the alimentary canal, or by the respiratory organs, and
the symptoms are always the same — viz., nausea, vertigo,
oppressive sleepiness, muscular pains, and a sense of weak-
ness w-ith tremors and anesthesia. The skin becomes
blue, the cyanosis being often very pronounced. The
buccal mucous membrane, the gums, the conjunctivjc. the
lobes of the ears, the face, the hands, and the feet show
the discoloration best. The cyanosis is not due to venous
stasis, but depends upon a colored substance in the blood,
probably methemoglobin. The men recover if they cease
work for a time. The pathology of Raynaud's diseas.e
is unknown. No special lesion has yet been noted in either
the cardiovascular or nervous systems, central or pe-
ripheral. Yet there must be some nervous causes, since
the attacks come on after emotional states. The causes
of tissue death are: (l) obstructed arterial circulation;
(2) impeded venous flow; (3) obstructed capillary circu-
lation owing to diseased walls of vessels; and (4) death
of the cells by poisons due to microbes. Excepting in
those cases where gangrene has occurred and where the
structural alterations in the blood-vessels and nerves have
been the consequences rather than the cause of gangrene,
no constant changes have been found in the peripheral
nerves and blood-vessels. It would seem as if some pe-
culiar local change occurred in the tissues of the part
affected in Raynaud's disease, whereby either in conse-
quence of the contraction of arteries and veins due to
some central nervous condition influencing the vasomotor
center, or in consequence of altered chemical states of
the blood or pathological changes in the walls of the
minute vessels, that either of these conditions singly
or combined, but accompanied by poisoning of the cells
of the part either through their own toxins or bv poisons
brought to them, is capable of causing death of the tis-
sues and the formation of a gangrenous slough.

Origin and Differentiation of the Red Blood Cells in
Mammals. — .\t a recent meeting of the London Patlioloy-
ical Society Dr. C. E. Walker presented a paper on this
subject, stating that he used the word leucocyte in his
paper to cover all the wandering nucleated cells of the
body. From a certain class of leucocyte foimd in the
bone marrow of mammals he traced a gradual series of
stages of degeneration in the nuclei, and the gradual ap-
pearance of hemoglobin in the cytoplasm to cells with a
relatively large, round, and almost homogeneous nucleus.
During this process the nuclear membrane generally
showed some small breaches through which some of the
nuclear contents exuded into the cytoplasm. After this
Dr. \\'alker described a large breach as occurring in the
nuclear membrane of some of the cells, by which the
nucleus was completely disintegrated. In other cells
the nucleus apparently disintegrated by exudation through
smaller breaches. The centrosomes were retained through-
out in a certain proportion of the red corpuscles which
had got rid of their nuclei in this manner. In the bone
marrow a very large proportion of the red corpuscles con-
tained remnants of the nucleus. A very small proportion
retained these remnants after they had been thrown into
the blood stream. Dr. Walker had observed the bodily
ejectio: uicleus in these hemoglobin-bearing cells,

but o:; st-mortem phenomenon. He based his

interpri. Kitujii of the sequence of the changes which he
described upon comparison with what happened . in der
gcncratint;- cells in the tests of various animals, and upon
the changes which he had observed in the nucleated red
corpuscles of amphibia, reptiles, and birds after removal
from the body of the animal. In all these cases the exact
sequence of events could be followed with the greatest
certainty. He incidentally recorded the presence of two
or more centrosomes, often hypertrophied, in practically all
the red corpuscles of axolotl and other amphibia.

British Medical Joiinia!, December 29. IQ06.

Tenotomy of Inferior Oblique and Consideration of
the Conditions that May Call for the Operation. — .\fter

describing the technique of the operation, wiiich consists
in a division of the tendon of origin through a cutaneous
incision, -\. Duane discusses the conditions which may
call for the operation, namely: (l) Conditions simulating
spasms of the inferior oblique, (a) Complete stationary
paralysis of the superior rectus of one eye. Fixation
with the other eye. Xo true spasm. C2) True secondary

spasm of the inferior oblique. (6) Partial paralysis or
insufficiency of the superior rectum, causing pronounced
secondary deviation of the other eye, due to spasm of its
inferior oblique, (c) Paralysis of a superior oblique or
some other muscle, causing secondary spasm of the inferior
oblique in the same eye. (3) Primary spasm of the in-
ferior oblique. We must be sure before operating (l) that
the condition is permanent and stationary, and (2) that
the symptoms are so marked as to call for interference.

Treatment of Unripe Cataract. — W. M. Killen extols
the utility of the McKeown apparatus for intraocular
irrigation in cases of unripe cataract. The fluid used is
saline solution, 4 gr..to the oz., boiled in a glass flask
before use and rapidly cooled to blood heat. The eve
tolerates this solution w-ell. and very free intraocular ir-
rigation can be kept up w-ith it for a long time wdiere
sticky cortex has to be removed without any serious reac-
tion. The absolutely essential conditions are that the solu-
tion is sterile, at blood heat, and that the vitreous chamber
is not opened. .Vbout a pint should be in the flask for an
operation. Irrigation niay be done in two stages. The
first is injection of fluid under the capsule of the lens im-
mediately after the corneal section and before the usual
capsulotomy. The hollow needle is much like a fine hypo-
dermic needle, and it should be introduced about half way
between the section and the center of the pupil, so as to
.ivoid penetration of the edge of the lens or suspensory
ligament. It must also be kept well in front of the nucleus.
The use of the needle at this stage is a valuable means
of diagnosis of the consistence of the lens. If it penetrates
the capsule easily, without moving the lens, the fluid will
spread usually and help to opacify the unripe cortex, and
irrigation w-ill be useful both now and after delivery of the
nucleus. On the other hand, if it does not penetrate the
capsule or if it commences to push the lens before it. we
have probably to deal with a sclerosed cataract, which
will not require irri.gation. The section of the capsule
is now made, and •'• ' ' ■ ' *' 'lie lens extracted, after
which further irri-- the nozzle, combined

w-ith massage, .serve; .... ...: ^ remove masses of cor-
tex still remaining. In many cases the nozzle irrigation
is quite sullicient. the needle not being used.

Eyesight in Relation to Compensation. — F. Fergus
refers to the attempts whicli have been made to derive
formula by which to assess the damages due for the loss
or partial impairment of one eye. He has gathered
some data about :nen possessed of only one eye who were
not entitled to compensation owing to their loss of vision
from disease, etc. He gives the results obtained in a series
of such cases. .-X great deal depends on what might be
called the patient'* resource. It seems to the author that
it is hopelessly futile to establish a definite relation be-
tween a person's wage-earning capacitj- and his eyesight
Some men with only one eye seem practically helpless,
while others get on without difficulty, .^nother element
equally impossible of evaluation is the injured man's truth-
fulness. 'Fhe only means which we have of measuring a
person's visual acuteness is by letters, or by other objects
of known size. But when a patient is placed in front of
letters which gradually diminish in size we have no means
of testing whether the smallest letters which he reads are
the smallest which he sees. He may only read 6/.36, while
all the time his vision is 6/9. There is obviously a great
temptation placed before frail humanity if the worse the
vision the greater the compensation. Frequently a witness
goes into the box and states on oath that the vision of
the injured man is, say, 6/36. What he really should say
is that at the examination the patient read letters of 6/36,
but as to whether that is his best or not he (the witness)
is entirely ignorant — unless, indeed, when he has during the
examination found something which would account for
such a diminution of the acuteness. Here, therefore, we
have another factor which must falsify any formula which
attempts to express a relation between wage-earning ca-
pacity and the form sense. Lastlv. and most important of
all, there are many kinds of employment in which the form
sense does not seem to play any appreciable part. To this
category may be added, e.g.. all persons who have an ex-
pressivel.v high degree of myopia. A young man had
worked for several years in a coal pit. He thought he
would try to get employment above ground, and accordingly
applied to a railway company, but was rejected on account
Tf his sight. He came to the hospital, and it was found
that he had a myopia of 10 D in one eye and of 15 D in the
other. The acuteness of the better eye was only 1/30
Snellen. >'et this lad had no idea that there was anything
wrong with his eyes.

Berliner kUnische Woehcnschrifl, December 24, 1906.
The Spirochete Question. — Schulze considers that by
means of his experiments on the inoculation of the rabbit's
cornea with syphilitic material he has been able to prove

Jan. 19, 1907]

MEDICAL RECORD.

1 1 =

that syphilis can be transmitted to these animals and also
that he has been able to demonstrate the presence in the
lesions of the Cyiorrhyctcs luis of Sicgel. He is further-
more of the opinion that the structures to be seen in syph-
ilitic material after treatment by the modified Golgi method
of Levaditi are only artefacts composed of some tissue
element, usually nerve terminals. He points out that tlicse
structures are demonstrateil most successfully in tissues,
such as those of syphilitic fetuses, that have undergone
more or less maceration. He has been able to demonstrate
them in the cornea of a nonsyphilitic fetus, although only
in small numbers, and explains their fewness in this case
on the assumption that chemical conditions existing in
syphilitic tissues facilitate the staining by the silver method.
He gives as a strong argument against those who believe
that the silver-stained structures really are spirochetes the
fact that in this case the so-called spirochetes should also
be susceptible of demonstration by the Giemsa method, but
states that this is not so. Against the argument, of those
who contend that the silver-stained structures cannot be
artefacts because they are sometimes seen in the lumen of
blood-vessels he brings forward the possibility that portions
of the macerated wall of the blood-vessel, such as the inter-
cellular cement substance, may become detached and take
the stain.

Blood Pressure Determination in Man. — Bing gives
the theoretical and practical considerations which lead
him to conchide that the blood jiressure determinations
obtained by the ordinary methods in clinical use represent
not the end pressure in the brachial artery, but the lateral
pressure. Comparative observations made on the two arms,
one of which was suljjectcd to either cold or heat, showed
that the results obtained by the sphygmomanometer were
dependent on the condition of contraction of the vessels be-
low the point of measurement so that changes in the lumen
of these vessels produced alterations in pressure without
necessarily being attended by any correspondin.g fluctua-
tions in the aortic pressure.

Miinchencr mcdirjiiische W'oclienschiifl. December 25, 1906.

Perforation of the Duodenum by a Hairpin. — Mcn-
nacher describes a case of fatal peritonitis following per-
foration of the duodeninn caused by a hairpin swallowed
about five months previously. The patient was a .girl of
six years, and for four weeks after the forei.gn body had
been swallowed constipatin.g diet and observation of the
stools was kept up. Although the hairpin did not appear,
as the child suffered from no inconvenience these precau-
tions were gradually relaxed, and durin.g the following
four months the little patient gave no evidence of anything
being wrong. She then suddenly developed acute abdom-
inal symptoms, and the possibility of appendicitis or intes-
tinal perforation was considered. In the next few hours
so remarkable an improvement in the patient's condition
occurred, however, that the operation was postponed.
About twelve hours later the peritoneal symptoms had
returned with full violence, and on openin.g the abdomen
a diffuse suppurative peritonitis was revealed and it was
discovered that the blunt end of the hairpin had pierced
the duodenum at the junction of the descending and
ascending parts, most of the pin still rem.iining inside the
intestine. Death occurred in the night following. The
author calls attention to the length of time that the hairpin
must have remained in the stomach, as he concludes that
the onset of the acute symptoms must have occurred shortly
after its passage into the duodenum, and also to the very
striking period of remission of symptoms, wdiich is a not
unusual feature in cases of perforation of duodenal ulcers.

The Technique of Staining for Spirochetes. — Krauss
describes an improvement iu the methods for staining
spimchetes in syphilitic lesions. The preparations arc
fixed in osniic acid fumes and stained with Giemsa's solu-
tion in the manner indicated by HofTman-Halle. The
chief objection to preparations made in this way consists
in the precipitates of dye that always somewhat obscure
the field. These may be removed, according to Kraus,s,
by immersin.g the preparation for about half a minute in a
30 per cent, aqueous solution of tannin, by means of
which very sharp dififerentiation is produced. The
spirochetes have a bright red color which is in strong
contrast to the colorless or pale-pink back.ground. It is
stated that the tannin solution never decolorizes th;
spirochetes,

Frencit and Italian Journals.

Amputation of the Cervix for Hypertrophic Elonga-
tion at the Fourth Month of Pregnancy: Labor at Term,

— Potocki describes a circular amputation of the cervix
which he performed at the foMrth month of pre.gnancy.
The elongated cervix protruded the width of a finger below
the labia minora and could not be pushed back into the
vagina. The cervix in its entire length was hard; th;

cervical canal was not dilated: the fundus of the uterus
was at the umbilicus, .^fter amputation the intracervical
nmcosa was carefully sutured with catgut to the vaginal
membrane. The section amputated measured seven centi-
meters and showed signs of sclerotic lesions. A natural
and rapid labor occurred at term. The child is now six
years old. In a previous case of the same kind which
Potocki observed the cervix had not been amputated ; it did
not disappear during labor; the membranes broke and the
child died. In this case the fetus had to be extracted
by basiotripsy and the patient recovered after suffermg
niany complications. In the operation of amputation the
danger of abortion arises, but this danger can be greatly
lessened by injections of morphine during the first few
days after "the operation; besides this the danger of abor-
tion froin operations in the genital region during preg-
nancv appears only in a small proportion of cases. — Le
Bulletin Medical. October 24, 1906.

Surgical Treatment of Renal Calculi. — During the pro-
ceedir.g> of the .Association Fran(;aise d'l'rologie, 11. Pous-
son stated that in aseptic renal lithiasis the treatment of
choice is nephrotomy. When treating a suppurative calcii-
Inus kidney the surgeon must take into consideration condi-
tions such as infectious changes destructive of the renal
tissue with perinephritis, with or without suppuration, as
well as the general condition, before deciding to proceed by
nephrotomy or nephrectomy. The present methods of
judging the actual condition of the kidneys have greatly
reduced the uncertainties of nephrectomy. In using this
method fistula and septicemic accidents are avoided and
the convalescent period is shortened when the disease is
not too deep-seated. In discussing the statements of
Pousson, Rafin said that the danger of nephrectomy lay
in the fact tliat renal lithiasis often affects both kidneys.
'1 he diagnosis could be made by radiography. He showed
five calculi which had been diagnosed by radiography,
four being extracted by nephrotomy and one by pyeloHth-
otoniy. In suppurative lithiasis great care is necessary to
prevent infection wdiere catheterization of the ureter of
the healthy kidney is employed, — La Prcsse Medicale,
October r7, looi).

Sudden Death from Acute Pulmonary Edema During
the Course of Phlegmonous Periamygdalitis. — Louis-
-\lbert .\mblard describes a patient under his care who,
after the symptoms of a mild attack of phlegmonous
periamygdalitis had subsided, suddenly died from an acute
.general edema of both lungs. He considers this case an
interesting actual proof of the theories which attribute
extremely acute edema of the lun.gs to troubles of the
nervous system. It seems especially to uphold the theory
of pulmonary vasodilator inflammation, on account of the
irritation of the pneumogastric caused by the compression
of this nerve against the cervical region by an inflamed
lymphatic ganglion. Careful macroscopic and microscopic
examination proved the integrity of the organs usually
involved. There was no nephritis, the heart was he ilthy,
the aorta showed no trace of atheroma, nor were there
any signs of those valvular lesions, such as mitral stenosis
and aortic insufficiency of rheumatic origin, which have,
at times, been considered the cause of acute edema of the
lungs. — Cacctte des Hofitaux ( ;r //.< et Militaires. .'\ugu3t
21, 1906.

Changes in Gastric Chemism Following Gastro-
enterostomy.— Kat/enstein describes the results of e.K-
perimeuts on a number of dogs. Gastric fistulas were
produced in the dogs and the .gastric juice obtained from
the fistula was examined both before and after a gastro-
enterostomy. The results w-ere found to be as follows:
After the formation of a .gastroenteroanastomosis lar.ge
quantities of bile and pancreatic juice enter the stomach;
the flow is at first continuous, but varies later with the
sta.ge of digestion. The presence of these alkaline intes-
tinal juices diminishes the acidity of the gastric juice both
by chemical action and by reducing the secretion. Pepsin
does not act in a neutral medium ; the pancreatic trypsin
acts in a medium which has a temporary acid reaction,
but its action is easily weakened. The diastase and the
emulsifying ferment act in sli.ghtly acid media, but not as
strongly as in media wdiich are neutral or alkaline. Secre-
tions of bile and pancreatic juice can be excited reflexly,
when fats are introduced into the stomach. This Inst fact
offers a method of diminishing the acidity of the gastric
juice after gastrnentcroslomy. — La Prcs.w .lledicale. Octo-
ber 20, 1906.

Diffuse Neurofibromatosis, — Christofiiro Pastine de-
scribe* an interesting case of neurofibromatosis in wdiich
manv nerves, especiallv among the cranial nerves, were
involved. The tumors were in this case all on the left side,
whereas thcv are nsiially ^cattere<l indiscriniinately on both
sides of the bod\-. The patient was sixty-seven years old,
an age more advanced than usual in such cases. He first

ii6

?nIEDical record.

[Jan. 19, 1907

noticed severe neuralgic pains of the left upper arm and
discovered a tumor of small size in the same region. Fol-
lowing this he had symptoms which indicated the involve-
ment of many nerves, lie had vertigo, myasthenia, uncer-
tain gait, severe occipital headache, somnolence, apathy,
and melancholia, while all his mental faculties were intact.
AH these symptoms indicate a tumor of the cerebellum.
The neuralgia extended to the left side of the neck, indi-
cating involvement of the cervical ])le.\us as well as the
brachial. The pulse was absent in the whole left arm,
from pressure of a tumor on the subclavian artery. The
disease involved all three branches of the trigeminus, the
lesion being intracranial. There was a total left facial
paralysis, from a lesion of the trunk of the nerve in its
intracranial portion. The hearing on the left was lost.
There was great difficulty in swallowing and paralysis of
the velum of the palate from lesions of the hypoglossus,
accessorius, vagus, and glossopharyngeu.s. There was
paralysis of the left vocal cord. The chief interest of the
case is due to the large number of nerves involved as indi-
cated by the symptoms, while only the one small tumor of
the arm could be felt. — La Riforma Mcdica, September
22 and 29, 1006.

Struma the Result of the Diplococcus of Fraenkel. —

D. Buttino and !•". Cattanea tell us that it is well known
that various infections may affect the thyroid .gland, espe-
cially wdien the gland is in a pathological condition to
begin with. The thyroid may suppurate in typhoid, puer-
peral fever, pyemia, rheumatism, and malaria. They
record a ca.se in which the infective agent was the dip-
lococcus of Fraenkel. This germ becomes a pus producer
and localizes itself in other regions besides the lungs. But
it is exceedingly rare to find suppuration of the thyroid
from this .germ, only ten ca?es being recorded. The patient
came into the hospital for a mild pneumonic affection,
having a chronic enlargement of the thyroid gland at the
beginning of the disease. No pneumococci were found in
the blood. There occurred suppuration of both lobes of
the thyroid, and in the pus removed the pneumococcus
was found. — Rivista Critica di Clinica Medico, October
6, 1906.

Differential Diagnosis Between Poisoning with Char-
coal Vapors and with Illuminating Gas. — A. Cevidalli
and .\. Chistoni have endeavored to find a means of diag-
nosis between poisoning by charcoal vapor and that pro-
duced by illuminating gas. This is sometimes of great
medicolegal importance in fixing the responsibility for acci-
dental poisonin.g. The symptoms and post-mortem appear-
ances are very nnich the same. Poisoning with illuminat-
ing gas is more dangerous than that with carbon monoxide,
inasmuch as when a gas jet has been left open the flow
goes on constantly as long as the pressure in the pipes
continues, while in the use of charcoal for heating the
flow stops when the fuel is consumed. In poisoning by
charcoal there is a deposit of soot about the nostrils and
in the respiratory tubes. In cases in which illuminating
gas has filtered through the earth the hydrocarbons which
give it its odor are removed, and it becomes odorless, and
thus far more dangerous. The authors experimented on
the action of the two gases with methemoglobin as a
method of diagnosis. Their results are thus given: illu-
minating gas transforms a solution of methemoglobin so
as to produce a clear, red color, and there is a wide band
of absorption in the green of the spectroscope. The blood
of man and the ox methemoglobinized behave in the same
way with illuminating gas. Co pure, or air. passed through
a solution of methemoglobin produces no change in the
solution. — Lo StcriHicntale. Vol. III. Anno LX.

The Cerebellar Syndrome in Malaria. — G. Pecori finds
that dysarthria is a rather common symptom in severe cases
of malaria, especially of the estivoautunnial variety. It
often goes with symptoms of incoordination that are at-
tributable to a localized lesion in the cerebellum. In a
case imder his care there was complete inability to speak,
although cries and moans were continual. It was impossi-
ble for the patient to sit or stand erect ; there was midriasis,
nistagnnvs. difficulty of muscular movements, and in swal-
lowing, and general muscular relaxation, with normal sen-
sibility and normal reflexes: retention of urine and feces
were followed by incontinence, .\fter some time the most
of the symptoms disappeared, but bardyarthria remained
and defect in the pronunciation of the dentals and linguals.
After six years there was still some dysarthria The author
considers that there was a lesion of the cerebellum due to
a polyencephalitis of infective origin. In a ca«e that came
to autopsy, in which there was a similar syndrome, puncti-
form hemorrhages were found in the white substance of
the frontal lobes and the gray sulistanoe of the cerebellum.
— // Polidinico. November. !go6.

Symptomatclcgy of Cancer of the Pylorus. — Leon

\'or.ter< reviews this subject in an interesting paper. The
Stomach is often considered as the organ most frequently

invaded by cancer. It can hardly be denied that the pylorus
is the region where gastric cancer is most often found.
Statistics show that among 100,000 people there are about
fifteen deaths each year from this cause. Pyloric cmcer
is rare before the age of thirty and after the age of
seventy. Following certain dyspeptic disturbances which
are rather vague, pyloric can.cer may be considered to pass
through two stages. The first or initial period is marked
by characteristic dyspeptic symptoms, gastric dilatation with
retention due to pyloric stenosis. The second or terminal
pefiod is that in which the tumor is perceptible and
cachexia develops. A?, has already been indicated, the be-
ginning of this trouble reveals itself by obscure symptoms.
Cancer, when it has its seat in the pylorus, almost invariably
gives rise to pain. In spite of this, however, pain is variable
and may be lacking entirely. Vomiting is frequent in all
forms of gastric cancer. In cases of pyloric cancer vomit-
ing is almost constant. Hemorrhage in these cases is fre-
quent and varies in the different patients in its appear-
ance, in its quantity, and in its frequency. Pyloric cancer
is an affection which has a continuous and progressive
course. In the terminal period metastases are looked for.
Propagation may take place by the blood-vessels or by
the lymphatic route. — Gacettc dcs Hopitaux Civils et Mili-
taires, November 17, 1006.

Three Cases of Gastric Wounds Treated by Lapa-
ratomy. — .-Xuvray presents three new observations
of gastric injury which were treated surgi-
cally. He has now operated on seven pa-
tients with gastric injury, with four recoveries ;.nd
three deaths. He insists upon the necessity of making a
i.'irge opening in the gastrocolic omentum for the explora-
tion of the posterior surface of the stomach in order to
determine if this part has been injured. An opening which
is too narrow renders exploration very difficult, and he has
discovered that a large transverse incision can be made
without compromising the vitality of the intestinal walls.
Even then the opening is often insufficient for prcjper
exploration. In such cases this operator advises exploratory
gastrotomy. This increases the danger to the patient. How-
ever, its advisability depends upon the indications observed.
The writer believes that it is especially useful in injuries
by bullets and when the stomach is empty at the time
of the accident. — Revue de Chinirgie^ November 10, 1906.

Tetanus Neonatorum Treated by Baccelli's Method. —

Lavinio Miserocchi gives us the history of a case of tetanus
neonatorum treated successfully by injections of phenic
acid after the method of Bacelli. The child was six years
old when it was attacked by trismus, which went on rapidly
to opisthotonos and tetanic seizures, with high tempera-
ture. Injections of phenic acid were at once begun, with
antiseptic treatment of the navel, which secreted some pus.
Four or five injections were given daily in sterilized oil.
The seizure diminished and the temperature went down.
.•\fter thirty-four days of treatment the child was cured
without having shown any symptoms of carbolic acid
poisoning. The type of the disease was severe, with very
high temperature, and in general such cases end fatally.
This seems to be a good ease for a test of the treatment,
and its happy ending appears to show that this treatment
will be curative when undertaken early. — Rivista Critica di
Clinica Pcdiatrica, Novetnber. 1906.

Decapsulation and Capsulotomy in Nephritis. — Tom-
maso Costa tells, us that we may regard decapsulation of
the kidneys as of the greatest value in most varieties of
kidney diseases, acute as well as chronic. It is contraindi-
cated in old age, cardiac disease, and albuminuric neuro-
retinitis. which is the precursor of a fatal ending. The
author believes that the benefit is due to a new formation
of the capsidc which allows the tissue of the kidney, before -
bound down by the contracted capsule, to expand. New
blood-vessels are formed in the new capsule. The epithelial
elements are not regenerated, but the better nutrition makes
them change within themselves so as to better perform
their function. '1 he hyperemia and pol\"uria which follow
the operation aid in the absorption of morbid products
within the kidney, and render the urinary tubides permeable.
The author has produced an artificial nephritis in dogs
by the injection of a solution of chlorohydrate of hydroxyl-
amine, which produces a nephritis very similar to that
seen in the hum.an r.ace. Fifteen dogs were treated in
this way: a part were then submitted fo decapsulation or
capsulotomy, while others were ifed. Eight of

those operated on were cured of itis, while those

not operated on died. The author concludes that the decap-
sulation of one or both kidneys w'tll cure an artificially
produced nephritis. Cure is m.ore rapid and progressive in
capsulcctomv than in capsulotomy. .After forty days the
capsule is found reformed and thicker and more vascular
than before. A unilateral operation, by means of the renal
reflex, results in a cure of bilateral nephritis. — Giornah In-
icrnazionale dclle Scien:e Mcdiche. November 15, 1906.

Jan. 19, 1907I

MEDICAL RECORD.

117

Diseases of the Digestive System. Edited by Frank
Billings, M.D., Professor of Medicine, University of
Chicago, and Professor of Medicine and Dean of Faculty,
Rush Medical College. .\n authorized translation from
"Die Deutsche Klinik" tnider the general Editorial Super-
vision of Julius L. S.nlinger, M.D. With Forty-live
Illustrations in the Te.xt. New York and London : D.
Appleton & Co., 1906.
The best method of giving some idea of the scope of this
volume of eight hundred odd pages, which is composed of
a series of articles on various diseases of the digestive
system by German authors, is to enumerate the subjects
discussed, together with the names of the writers to whom
they have been allotted. The list is as follows : Stenosis
of the Esophagus, by Th. Rosenheim; The History and
Clinical Indications of Gastric Lavage, by W. Fleiner ;
Functional Diseases of the Stomach, by H. Leo; The
Dia.2;nostic and Therapeutic Significance of Secretory Dis-
turbances of the Stomach, by H. Strauss; Diagnosis and
Treatment of Gastric Dilatation, by F. Ricgel ; Gastric
Ulcer and Gastric Hemorrhage, by C. A. Ewald ; Gastric
and Intestinal Carcinomata, by J. Boas : Displacement of
the -Abdominal Viscera and of the Heart, by F. Hirschfeld;
Symptomatology of the Diseases of the Pancreas, by L.
Oser; Jaundice and Hepatic Insufficiency, by O. Min-
kowski ; Chronic Inflammation of the Liver, by E. Stadel-
mann ; Neoplasms of the Liver and Biliary Passages, by
Fr. Kraus: Echinococcus of the Liver, by E. Stadelmann ;
Gallstones, by E. Neusser; Acute Diffuse Peritonitis, Ap-
pendicitis, and Perityphlitis, by O. Vierordt and J. Boas ;
Examination of the Feces, by J. Strasburger : Diarrhea. In-
testinal Catarrh, and Intestinal Tuberculosis, by W. Fleiner ;
Constipation and Hemorrhoids, by J. Boas; Mucous Colic
and Membranous Intestinal Catarrh, by G. Hoppe-Seyler ;
Intestinal Constriction and Intestinal Occlusion, by H.
Nothnagel. From the foregoing it is evident that the
volume is composed of essays by some of the most eminent
German-speaking clinicians on a well-selected series of
topics concerning the disorders of the alimentary tract, but
that the work does not — and is not intended to — cover the
entire subject in a systematic way. As is usual in such
compilations, some of the sections are much better than
others, but the general average is high and the articles are
written in a way to prove interesting and directly useful to
the practitioner. The book, therefore, is of a sort to serve
as a highly desirable acquisition to any medical man's ref-
erence library, but it should not be the first treatise on
diseases of the digestive system purchased by the student
or young practitioner.

The Ear and Its Diseases. A Textbook for Students and
Physicians. By .Seth Scott Bishop, B.S., M.D., LL.D.,
Surgeon to the Post-Graduate Hospital and to the Illi-
nois Hospital, etc. Illustrated with Twenty-seven Colored
Lithographs and 200 .Additional Illustrations. Four
Hundred and Forty Pages. Bound in Extra Cloth.
Price, Sj.oo. net. Philadelphia : F. A. Davis Company.
1906.
Probably no textbook on diseases of the ear. nose, and
throat has been used in more .American medical schools
than that of Dr. Bishop, which has passed through several
editions. Objection having been made that the portion
devoted to otology was too abridged, the author has pre-
pared a special treatise on this special subject, not only
elaborating the ideas expressed in the original work but
also introducing nuicli new material. This is especially
noticeable in the opening chapters devoted to anatomy of
the ear, which, says the author, "has heretofore been a field
both dreaded and unconqucred by the average student."
Many of the illustrations in these chapters are from prep-
arations and sections made by the writer, who has drawn
freely on his extensive clinical experience rather than
slavishly following the usual beaten tracks so strongly in
evidence in many textbooks. Two interesting chapters dis-
cuss the ill-effects of various diseases and drugs on the ear,
and reference is also made to the relation of ear diseases to
life insurance risks.

The He.\lth-Care of the Baby. A Handbook for Mothers
and Nurses. By Louis Fischer, M.D., Author of "Infant
Feeding in Health and Disease," "A Textbook nn Dis-
eases of Infancy and Childhood" ; Attending Physician
to the Willard Parker and Riverside Hospitals; Former
Instructor in Diseases of Children at the New York
Post-Graduate Medical School and Hospital, etc., etc.
New York and London : Funk & Wagnalls Company,
1906.

In this condensed manual the writer gives many details
in relation to ventilation, clothing, and bathing which should
be familiar to every mother and nurse. The most impor-
tant part of the book consists in the suggestions and advice

pertaining to infant feeding in health and in conditions of
stomach and bowel disorder. The management of rashes
and fever is considered. Many hints are given as a guide
to the mother during attacks in her children of measles,
skin diseases, croup, and like affections. First-aid sugges-
tions in cases of accidents and poisoning, and bad habits
are discussed. The last chapter treats of external applica-
tions and the medicine chest. The young mother and
nurse will find this little volume very helpful.

Conferences on the Mor.^l Philosophy of Medicine,
prepared by an American Physician. New York : Reb-
man & Co., 1906.
This modest volume treats of many subjects essential to
the well-being and success of every medical man, be he stu-
dent or physician. The following excerpt from the intro-
duction is a peculiar!) illuminating syllabus of the sub-
jects treated of. The author says "that the systematic
teaching of medical morals should constitute the early
part of the student's education is evinced by the frequently
expressed desire of young men to obtain the right kind of
information for guidance in their professional relations and
obligations. The moral philosophy of medicine, compris-
ing as it does the science of the physician's duty in all his
acts and concerns, the thorough knowledge of the laws of
medicine, and of the relations of the student as well as
the graduate with his associates and other members of the
community seems a suitable title for these colloquies which
consist of an exposition of some of the general and special
principles of conduct i.f the aspirant to medical studentship,
of the matriculated student, of the hospital interne, and
of the young practising physician, and include considera-
tions on physicians of the past and present, on medical
teachers, schools, and students, on the early cultivation of
the senses as essential to the proper conduct of the study
and practice of medicine, on the evolution of medical
morals, on the special relations of the physician and patient,
of the physician and collea,gues. and of the profession and
public, besides a discourse on the language of medicine ;
another on young writers and speakers, and a third on the
length of life of physicians."

We commend to young men the chapters on the "As-
pirant to Medical "Studentship." on "Physicians of the
Past." and on "Teachers, Schools, and Students of Medi-
cine," since they contain much necessary information which
will aid a man so materially in his conduct and conceptions
of medical life, and tend to equip him for successful effort.
In like maiiiKT the directions to tlie "Matriculated Stu-
dent," to the "(Graduate as Hospital Interne" are most
impressive. One of the best chapters in the book is upon
"The Young Practising Physician." The chapter on "The.
Evolution of Medical >lorals," which treats of the earliest
principles of conduct and shows how the obligations of
physicians have gradually been formulated and crystallized
into practical demonstration is most valuable and com-
mands close attention. The question of the relation of the
physician and his patient is handled in a masterly manner,
and the duties of each one to the other are brought out
with the greatest clearness and simplicity. These chapters,
together with that on the "Physician, Professimi, and
Public," embody an epitome of character, conduct, and en-
deavor which should be generally studied. The whole
book is a ■iode iiironv. which should he in the hands of all
medical men. In reviewing a work such as this, with its
loftv scnfimenis and aspirations and its pure, practical.
Christian teachings, one would fain wish that its author
had not cluthed himself with anonymity.

PiioToscorv ('Skiascopy or Rf.tinoscopy). By Mark D.
SrFxi-xsnN-. M.D., Ophthalmic Surgeon to the Akron
City Hospital: Oculist to the Children's Home, .Akron,
Ohio. Philadelphia and London: W. B. Saunders Com-
pany, 1906.
This new competitor for favor with those who determine
the refraction of the e>e is written by one who has studied
the subject profoundly and who is familiar with the wants
of those ]iiirsuing this branch of medical pr.actice. The
term "photoscopy," which is employed as the title of the
work, is somewhat unfortunate, since it is not sufficiently
specific to indicate the method to which it is applied. The
volume, which includes 126 pages, is well written, well
printed, and well illustrated. The text is divided into five
chapters. Chapter I. contains suggestions for beginners and
describes the instruinents necessary for the work. Chap-
ter II. deals with the underlying principles of the method,
considers the intensity and kind of light desirable, and
describes the various phenomena observed. Chapter III.
takes up the practical application of the method. Chapter
LV. is devoted to general considerations, cyclople.gics, aids
to accuracv, etc. Chapter V. is historical. .\ bibliography
and index'follow. The work ranks well with others of its
kind.

ii8

MEDICAL RECORD.

[Jan. 19, 1907

00rtFtii Reports,

SOUTHERN- SURGICAL AND GYNECOLOGICAL
ASSOCIATION.

Niiieicoith Aiuuial Meeting, Held at Baltimore, Md.,
December 11, 12, and 13, 1906.

The President, Dr. Georc;e II. Noni.E or .•Xtl.ant.^, G.'^.. in
THE Chair.

Sulphate of Sparteine in Surgical Practice. — Dr. Stuart
McGuiRE of Richmond, Va., said lie believed he had acci-
dentally discovered in this drug a valuable remedy for the
prevention and treatment of postoperative suppression of
urine. In the last five years be had lost more cases from
postoperative suppression of urine than from all other
causes combined, and tliis, despite the almost routine use
of chloroform as an anesthetic. The cases had usually
been those with preexisting nephritis from sepsis or cho-
leniia. Shock had not apparently been a factor, as the con-
dition would not develop for twenty-four or thirty-six
hours. A patient operated on for retention of urine or
for jaundice due to obstruction of the common duct wouhl
do well for one or two days, and just as the patient was
thought to be out of danger there would come the news
that he w-as passing no urine. He would become restless,
then listless, would develop a stupor which would rapidly
deepen into coma, and would die with all the symptoms
characteristic of uremia. In the treatment of this condition
he had tried water by mouth, under the skin, and in the
rectum; hot packs and vapor batlis ; cups and counter-
irritants ; strychnine, digitalis, and nitroglycerin : calomel
and saline purgatives, and in one case stripping the kidney
capsules, with uniformly bad results. Two years ago he
began empirically the use of sulphate of sparteine, and
he now had a record of six cases in which he was sure the
drug was the means of saving the patient's life. Its
therapeutic effect was to increase the blood pressure, make
the pulse slower and stronger, and act as a powerful diu-
retic. Its action was manifest in thirty minutes after
administration and lasted for four or six hours. To get
results sulphate of sparteine must be given hypodermically
in from one to two grains, repeated every three to si.x
hours. Its use should not be delayed luitil suppression of
urine existed, but it should be prescribed as a prophylactic
as well as a curative agent. He did not claim it was a spe-
citic or that it should be employed to the exclusion of
Other measures such as purgatives, transfusions, and hot
pack?. He did beiieve. however, from actual experience,
that it was preferable to the drugs of the digitalis type in
rapidity of action, ease of administration, and efficiency of
results.

Dr. William Perrix Nicolsox of .-Ntlanta. Ga., had used
sulphate of sparteine in a similar way. He preferred it
as a heart tonic to digitalis. Therapeutically, it combined
the virtues of being a pow'erful heart tonic and of dilating
the capillaries. .An important point was to give it in large
doses — say two grains. Usually it was put up by drug
manufacturers in doses of one-tenth of a grain. Its
value depended on large doses. He recalled one case in
which suppression of urine lasted for forty-seven hours,
but the patient finally recovered

The Comparative Advantages and Disadvantages of
Hysterectomy and Removal of the Body of the Uterus.
— Dr. J. Wesley Bovee of Washington, D. C. said it was
found that an important proportion of cases of tumors
thought to be simple fibromata or myomata had in reality
taken on malignant degeneration or were complicated by
a malignant degeneration of the corporeal endometriimi.
Carcinoma of the cervix had been detected within a few-
days after the removal of the body of the uterus, showing
clearly it existed at the tiiue of the supravaginal amputa-
tion. In innumerable instances removal of the cervical
stump had been done at the same sitting, prompted by

discovery of malignancy in the uterine body just removed.
Not a few observers had seen cases in which fibromata
had existed for years, the patients declining operation,
and cancer of the cervix developing subsequently, with a
fatal result. He had seen two such cases. One of them
he saw first in consultation in 1886, and again a few
months before her death in 1902. That cancer of the
cervi.x occurred more frequently with uterine fibroids than
without them had not been proven. The same could not
be said of cancer of the body of the uterus. Admitting
that the presence of fibroids in the uterine body had no
influence with the development of cancer of the cervix,
valuable information from statistical tables on the com-
plications of fibroids is available to demonstrate the re-
markable increase in the frequency of cancer of the body
of the uterus as compared to its e.xistence in the cervi.x as
such complications. The percentage of cases of cancer
located in the body and the cervix was generally estimated
by many competent observers as ID per cent, and 90 per
cent. It was likewise conceded that the ratio was markedly
changed in the presence of uterine fibroids. C. P. Noble
found, in a study of 2,274 cases of uterine fibromata, that
cancer of the body was found in 45, and of the cervix in
16 of them. This changed the percentages to 74 in the body
and 26 in the cervix. The proportion of cases of cancer
of the body of the uterus to those of cancer of the cervix
was thus shown to be increased twenty-six times in the
presence of fibroids. Williams had found but four cases
of cancer of the body of the uterus to 156 involving the
cervix in 160 consecutive cases of uterine cancer coming
under his observation. Winter, in studying 2,331 cases
occurring in Germany, found the proportion was one to
fifteen. Noble suggested the proportion of cases of cancer
of the uterus to those of cervical cancer was about one to
ten. Sutton had in 500 cases of fibroids of the uterus 63
that were more than fifty years of age. In eight of the
63 cancer of the body of the uterus was microscopically
proven, and in two primary cancer of the Fallopian tube
was noted. He had had 23 cases of cancer of the body of
the uterus, in eight of which fibroids were present as a
complication. Piquand had collected 179 cases of cancer
of the body of the uterus complicated by fibroids, and
had had in 1,000 cases of fibroids cancer of the body of
the uterus as a complication in 15 cases. Robb had found
that of 42 cases of cancer of the uterus six of them were
of the corporeal variety, a proportion of one to six. Com-
plete extirpation of the uterus was not an operation, even
by the abdominal route, that necessarily taxed the patient's
vitality to an extent appreciatively greater than did the
removal of the body alone. The vaginal route was a much
easier and more commonly practised operation than the
removal of the body and not the cervix. Objections to
the removal of the cervix with the body because of
weakening of the vaginal roof and shortening the vagina
were practically nullified by suturing the round and broad
ligaments to the vaginal walls, and the fact that in em-
ploying the vaginal route these objections were forgotten.
As against the removal of the cervix, when the body of
the uterus was removed, the abdominal route was the
only one to be considered. The comparative ease of the
amputation was of moment only in critical cases. The
cosmetic effect to young women deserved more considera-
tion. Oftentimes retention of the portio vaginalis was
deemed by them to be of great value. It would seem that
in the young woman without a family history of malignant
disease and in the absence of uterine growths the cervix
should not be removed if the body was to be taken out by
the abdominal route. In very critical cases in which the
body of the uterus was to be removed by that route, even
in the presence of tumors, it would occasionally be ad-
visable not to remove the cervi.x. In practically all other
cases the cervix should not be saved, and this injunction
would seem to be the stronger in old women, particularly
if evidence of uterine growths be present.

Jan. 19, 1907I

MEDICAL RECORD.

119

Dr. Isaac S. Stune of Washington, D. C, had never
regretted having left the cervix. So far as malignant dis-
ease was concerned, it had been his good fortune to save
two patients Ijy subsequent operations, wlio had what was
called subtotal hysterectomy done, with stump remaining,
wliich was subsequently found to be malignant and opera-
tion was done. Both of these patients were still alive.
However, one was a case of sarcoma. He thought a large
number of surgeons were well satisfied with the mortality
of the Baer operation of leaving the stump.

Dr. Henry T. Bvford of Chicago said that no cut-and-
dried rule could be laid down to take out the cervix in
the class of cases under discussion. One would not think
of removing the cervix in a young woman unless there
was demonstrable malignant disease. Even in an old
woman it was a dangerous procedure, and one attended
with great difficulty. The cervix should not be removed
unless there were good reasons for so doing.

Dr. Maurice H. Richardson of Boston recalled but one
instance in which cancer of the cervix developed after
supravaginal amputation for fibroids. While he had not
looked up his records, he should say that cancer of the
cervix was very rare after such operations.

Dr. Herman J. Boldt of New York said that so far as
the occurrence of malignant disease in the cervi.x after
supravaginal hysterectomy was concerned, it must be ad-
mitted that it did occur. He did not believe, however, that
if the cervix was left it was a causal factor in the produc-
tion of malignant disease. So far as the relative risk be-
tween supravaginal amputation and panhysterectomy was
concerned, he did not consider that it cut any figure. One
who was accustomed to doing pelvic surgery could do one
operation as quickly as the other. The main question was.
What was the condition of the vaginal vault subsequently?
In the majority of instances it made no difference whether
there was a good va.^inal vault following supravaginal
amputation, or whether there was a vaginal vault with
more or less cicatricial tissue in it, but it did occasionally
make a difference, for he had seen patients become:
markedly neurasthenic as the result of scar tissue in the
vaginal vault, and be did not consider it desirable to dn a
panhysterectomy when the cervi.x was in a fairly normal
position. When the vaginal portion of the cervix was
diseased, the vagina torn, and the cervix eroded, the
cervi.x ought to be removed ; but otherwise he thought it
was just as well to leave it because it made a better
pelvic floor.

Dr. Robert S. Hii.i. of Montgomery, .Ma., said there were
as potent reasons for leaving the cervix in some cases as
there were in others for removing it. If we considered
the anatomy of the pelvic floor we must conclude that the
removal of the cervix weakened the pelvic diaphragm, and
therefore postoperative vaginal hernia was more likely to
occur. The verdict of the majority of the profession was
that panhysterectomy was an operation of greater magni-
tude than supravaginal amputation of the uterus, when we
considered the increased traumatism to the parts, the
increased liability to injury of the rectum and bladder, and
the increased chance of interfering with the ureters through
cicatricial tisstie. as well as the increased chance of infec-
tion by entering the vagina. He could not agree with the
statement that panhysterectomy as an operation was of no
greater magnitude than was supravaginal amputation of the
uterus. This might be true in the hands of the most expert
hysterectomists. But we must consider what could be done
by the average surgeon, and not by the men of superior
skill in the performance of hysterectomy. When the sub-
ject was considered from this standpoint, then it would
seem to the speaker that supravaginal amputation of the
uterus still had a place in the category of legitimate sur-
gical procedures. .As to the amputation of the body of the
uterus increasing the chances of cancer of the cervix, he
was not aware of any evidence which suppnrted that posi-
tion.

Extrauterine Pregnancy. — Dr. U. L. Shivers of Ma-
rion, .\la.. niinriiil iwn cases of extrauterine pregnancy.

An Improved and Accurate Method of Locating For-
eign Bodies with the X-Ray. — Dr. RoiiEin Carothers of
Cincinnati, U., said the most important step in foreign
body surgery was some definite idea of the location of the
fcn'eign body. The ,v-ray had been of untold value in
developing this step. Stereoscopy as applied to radiog-
raphy, called stereoskiagraphy, was the most improved
method, and would seem to give the most accurate location
of a foreign body. This idea had been worked up by many
radiographers in different parts of the country indepen-
dently of each other. The ordinary .v-ray plate looked flat.
The stereoscope gave a perspective view very much as if
ihe parts (bone and bullet) were before one in nature.
Two separate plates were made of the same part w'ithout
changing in the least the position of the part skiagraphed,
which was placed on the compression diaphragm table,
the compression diaphragm itself being discarded, on a
hollow board or plate-holder, with a metallic bottom, so
that the rays might be partially obstructed, and in this
way one plate could be removed and a second supplied.
The tube was held in the tube-holder, and with the use of
a plumb-bob it was carefully centered through the center
of the part to be skiagraphed onto the center of the plate.
The plates were made with the tube placed one and three-
eighths inches to either side of this central point, so that
they were made from points two and three-quarter inches
separated from each other, corresponding to the dis-
tance between the human eyes. The developed plates
were placed in highly illumined bo.xes facing each other,
and were from them reflected into two small looking-
.glasses which were placed at a right angle to each other
with the apex of the angle placed between the eyes of the
observer in the stereoscope. One now looked into the two
looking-glasses, each eye in a separate glass, saw a separate
plate; then by adjusting the plates and the stereoscope to
get an exact focus, the two plates were made to look as
one. and it would appear that there was one looking-glass
behind which the observer looked, reflecting the object back
onto the retina, producing a perspective view. This niethoa
was of especial value in locating foreign bodies in the spine,
thorax, or abdomen, where it was almost impossible to get
a plate which was not flat liy any other method.

The Surgical Treatment of Thyroid Disease Based
on Three Hundred Personal Observations. — Dr. Chas.
11. Mavo of Rochester. Minn, s.iid the medical profession
of .•\merica was taking a prooressive position in recom-
mending operation as a cure for goiter, including also
exophthalmic goiter. The simple goiters in girls at puberty
were not included in this class. Excepting operations for
malignancy and Graves' disease, the great majority of
operations were those of expediency and not of necessity.
Therefore, a low operative risk was imperative. In un-
complicated cases the mortality following operations was
almost an accidental one. There were no cases of Graves'
disease, with nine deaths, anri but two of these were in the
last sixty-four operations. In two sarcomas and six car-
cinomas there was one operative death, which occurred on
the third day. .Aside from those recorded, there was one
death from pneumonia on the eighth day. Pathologically,
there was a change in the gland which was essential to
Graves' disease or hyperthyroidism. This was in the
greater number, size, and shape of the cells, and in the
lack of normal colloid. Patients were prepared as to lung
complications, and the rhythm and tension of the pulse,
wdiich should be carefully investigated, .is they were the
danger signals. Very rarely was local anesthesia cm-
ployed, the preference being for the open drop method
of giving ether. The patients rccei\ed from 1-120 to ^-^S^^
grain of atropine and one-sixth of a grain of morphine,
twenty to thirty minutes before the administration of the
anesthetic. The position of the patient was head up

(reverse Trendelenburg), with a roll of gauze under the

I20

MEDICAL RECORD.

[Jan. 19, 1907

neck to elevate small tumors. A transverse collar incision
was made through the skin and platysma muscle, the
sternohyoid muscles being separated at the midline. In
exophthalmic goiter and complicated cases the anterior
muscles on one side at least were severed as high as pos-
sible over the thyroid to preserve the nerve supply and
break tlie scar effect. Cysts and encapsulated growths
were enucleated. Other goiters were extirpated, care being
exercised in preserving the parathyroids to prevent tetany
and in protecting the recurrent laryngeal nerve. In this
one was aided by leaving the posterior capsule of the
gland in the extirpation. Sufficient gland substance should
be preserved to prevent myxedema, and, as it depended
upon the character of the gland, no definite rule could be
given as to what constituted the proper amount.

Dr. George W. Crile of Cleveland, O., said that in a
series of 114 operations upon the thyroid gland, his smaller
experience had compared very well with the conclusions
reached by Dr. IMayo, with the exception that he had been
unable thus far to get as low a mortality as was reported
by Dr. Mayo from operations in the presence of hyperthy-
roidism. In the late cases of colloid goiter of long-standing,
if sym.ptoms of Graves' disease appeared, he had found that
operations on this class were comparatively simple and
safe. Young persons with acute Graves' disease, coining
on without previous goiter apparently, appearing with
other symptoms, he had found to be great risks from an
operative standpoint. Of the 114 operations upon the
gland, there were five cases of carcinoma and five of
sarcoma. In one of the cases of carcinoma the author
noticed unmistakable symptoms of Graves's disease. He
had not had a fatality in any case of Graves' disease en-
grafted upon a chronic goiter, but he had had three deaths
in twenty cases of acute Graves' disease following opera-
tions.

Dr. R.AXDOLPH WiNSLOW of Baltimore said he had had
the opportunity of seeing some surgical work on the thy-
roid gland done abroad this summer at the Kocher clinic
and elsewhere, and had been particularly interested in the
anesthetic employed in these cases. Personally, he had
been usin^ scopolamine-morphine anesthesia by injection as
a means of general anesthesia, and the infiltration of the
skin with the Schleich solution for strictly local anes-
thesia, and found that it worked well, and that, as a rule,
the patients did not complain.

Toxemia of Pregnancy. — Dr. W. M. Jord.'\x of Bir-
mingham, Ala., called attention to the nonspecific nature
of the liver lesions in cases of toxemia of pregnancy, and
said that much the same character of changes occurred in
toxemias from other causes. There was a decided ten-
dency for toxemia cases to get worse after the uterus was
emptied, except in the case of eclampsia, which for special
reasons was not considered in the paper. The cause of
this behavior of toxemia cases was attributed to a probable
increase in the preexisting toxemia through the addition of
toxins resulting from the process of involution of the
uterus. For this reason pregnancy should be terminated at
an earlier date than would otherwise seem necessary, as
this probable post-partum increase in the toxemia must be
allowed for. .Attention was called to the probable unfa-
vorable influence of anesthesia, as most of the inhalation
anesthetics were to some extent liver poisons. Speaking of
the treatment, the w-riter expressed himself as being a firm
believer in radicalism. He advised that pregnancy be ter-
minated as soon as it became evident that the symptoms
were of toxemic origin. The reasons given by him were the
impracticability of influencing the antitoxic function of the
liver, and the unreliability of treatment directed against
the toxemia itself.

Dr. D. F. T.-\LLEV of Birmingham, Ala., read a paper in
which he reported eight cases of to.xemia of pregnancy.

Cholecystectomy, when Indicated; Some Operative
Sequelae. — Dr. I. S. Stonk of \\'ashin,i:ton. D. C. said that
cholecystectomy had become popular because cholecystot-

omy, or rather cholecystotomy, had frequently failed to
cure patients with gallstone disease. He preferred the
designation as just stated because the mere finding and
removal of gallstones frequently failed to cure many of the
invalids who had pain, jaundice, or other symptoms of some
mischief about or within the biliary passages. Some op-
erators spoke of dilatation of the common and hepatic ducts
as a result of cholecystectomy, and Robson was convinced
that this dilatation was a compensatory and perhaps a con-
servatory action, although he had found that stones devel-
oped in such dilated duct as they did in the gall-bladder.
Cholecystectomy sometimes failed to prevent a recurrence
of colics and of other symptoms which necessitated opera-
tion. .\n important question, therefore, naturally arose, Un-
der what circumstances should the gall-bladder be removed?
This question could not be answered until the possibility
of definite knowledge of the hepatic and common ducts was
considered, especially their patency and contents, and if they
were the seat of an infection. A careful review of the re-
cent literature convinced the author that however popular
this operation had become, the bad results had not as yet
been reported as generally as would appear desirable. Nearly
all of those who favored cholecystectomy as an operation
of choice agreed to operate when the gall-bladder had, by
reason of trauma, infection, or malignant disease, become
either useless or dangerous. They say, however, that the
operation should add very little to the risk involved in a
cholecystotomy. The Mayos removed two out of every
five gall-bladders they inspected. They performed a chole-
cystectomy under the following conditions: When stones
were lodged in the cystic duct, the removal of which would
leave permanent interference with drainage; when the
disease was confined to the gall-bladder, and when it was
filled with pus or any fluid or bile which had undergone
septic change; when the gall-bladder had become greatly
thickened or had lost its function, or was the seat of in-
flammation without stone in which the liver ducts were not
involved, or in malignant disease. The mortality of chole-
cystectomy had been compared to that of cholecystotomy.
The writer thought, however, that very few would succeed
in obtaining the low rate reported by the Mayos, who had a
record of 1.37 per cent, for cholecystotomy and 1.64 per
cent, in cholecystectomy. The author thought the tvio
operations could not be compared for safety in the hands
of most operators. Cholecystectomy w-ould be performed
by all surgeons for conditions w-hich were a result of severe,
long-standing disease which had caused any complications,
besides the changes in the gall-bladder itself. On the other
hand, cholecystotomy was one of the least dangerous opera-
tions in abdominal surgery when the patient had only gall-
bladder disease, or possibly a stone with healthy bile. There-
fore, the author thought that Robson's figures, 57 operations,
33 of which were for gallstones complicated by various mor-
bid states, with a recovery in 32, and 13 of which were for
iistula, were w-ithout signification, unless compared with
precisely similar cases in the hands of others. The same
might be said of 72 cholecystectomies collected by Klieber,
with a mortality of 16, 7 of which were due to the opera-
tion. The contraindications to cholecystectomy were not
numerous, but were of great importance. All the authors
agreed upon one point, namely, the propriety of leaving the
gall-bladder for drainage purposes in pancreatitis, espe-
cially the chronic interstitial variety. The same opinion
was expressed by most authors regarding the propriety of
leaving a gall-bladder when a cholecystenterostomy might
be needed, as in certain common duct obstructions. The
writer's experience with cholecystectomy had been satis-
factory in some particulars, and he found it especially use-
ful in those cases where the gall-bladder had been out of
use for a long time. In contracted bladder with an open
choledochus, in obstructions of the cystic duct, whether due
to stone or other cause, which have resulted in permanent
alteration of either bladder or duct, he found the very best
indications which would assure perfect cure. In cholelith-

Jan. 19, 1907]

MEDICAL RECORD.

X2I

iasis he had had two unfortunate results, because stones
continued to pass at intervals after the removal of the gall-
bladder. He knew of a third case in the practice of another
surgeon where the same difficulty occurred. Cholecystec-
tomy necessitated a better and clearer knowledge of the
hepatic ducts than we had hitherto possessed, or the opera-
tion would fall into ill favor. The demand at the present
time was for a safe and practical method of insuring pa-
tients against subsequent attacks of pain, jaundice, or any
kind of distress after gallstone operations.

Dr. Robert T. Morris of New York said that in the
past surgeons groped over the abdominal wall in the dark,
and it was only recently that they had touched the button
and turned on the light. He thought that surgeons could
turn on the light on this subject if they included all gall-
stone and cholecystitis cases under one heading, and called
them cholecystitis cases and adhesion cases. Adhesions in
the region of the gall-bladder and bile ducts would produce
the same symptoms as gallstones, whether gallstones
were present or not. He cited a case in point on which
he had operated. Proper selection of cases was everything
in surgery. With increased experience and further ob-
servation, he inclined more and more toward the complete
removal of the gall-bladder, for the reason that there was
a chronic infection going on all the while in many patients.

Dr. W. P. Carr of Washington, D. C, thought surgeons
should consider these cases more as instances of chole-
cystitis and the gallstones as incidental, when it was re-
membered that gallstones did not cause any symptoms until
they produced cholecystitis or obstruction of the common
bile duct. It was really a cholecystitis or an obstruction of
the bile ducts that led to the diagnosis of gallstones. The
gall-bladder should be left unless there were positive indi-
cations for its removal.

Dr. Samuel Lloyd of New York said the possibility of
an occlusion of the duodenal opening in gallstone cases was
not infrequent. He had operated once for congenital clo-
sure of the opening from the ampulla of Vater into the
duodenum. In a number of gallstone cases surgeons found
a very much distended common duct, that is, the duct was
distinctly larger than usual, and one should suspect occlu-
sion at the ampulla of Vater, the stone coming down and
acting as a ball-valve, pushing against the duodenal open-
ing, producing an inflammatory condition, and finally con-
traction. The only hope of possible recovery of patients
with this type of trouble was to do a choledochoduodenos-
tom}'. He spoke of inspissation of the bile throughout the
ducts in some cases.

Dr. Henry O. Marcy of Boston referred to the early
history of surgery of the gall-bladder and gall-ducts, and
said he had written a good deal on this subject. If anyone
would take the time to look up the early literature he
would find that Marion Sims in his time went over the
ground as thoughtfully and carefully as anyone could do
it to-day. Eighteen years ago Dr. Marcy operated on a
woman for the removal of a gallstone in the common duct.
A few weeks ago he operated on the same patient for the
purpose of releasing adhesions which had caused biliary
obstruction. The woman recovered from the operation.

Dr. J. Montgomery Baldy of Philadelphia said that in
many cases a diagnosis of gallstones or of gall-bladder
disease was made, yet at the operation no gallstones or
disease was found. No adhesions, no cancer, and no oc-
clusion were found; yet the patient had undoubted symp-
toms, so far as one could tell, of long-standing gallstone
trouble. On the other hand, in other cases operations had
disclosed disease of a gross character of the gall-bladder;
the patient had been relieved apparently, but after leaving
the hospital there was a return of the symptoms, even
after a secondary operation or cholecystectomy. He re-
called one case of long-standing of that character. He
admitted that this entire field was as yet very largely
unsolved, and so far as his own practice was concerned,
there were still elements of doubt both diagnostically and
pathologically.

Dr. Joseph Price of Philadelphia reported four recent
cases, and said that in two, when he opened the abdomen,
he had to side-step to get out of the way of the
gallstones. The patients were dying, and he was called to
see and operate on them because they were dying. They
were not suitable for the removal of the gall-bladder. He
thought if he had attempted to remove the gall-bladder in
these cases he would have lost the patients on the table.
He made toilets, drained, put in coffer-dams, and the pa-
tients were now well.

Dr. Frank Martin of Baltimore called attention to two
cases of cholecystectomy which he reported in 1895. Since
that time he had not changed his opinion, although he had
not operated on many cases since. He had resorted to
cholecystectomy in fourteen cases out of sixty. In most
of the fourteen cases there was a chronic cholecystitis, with
di.'-organized gall-bladder, and acute gangrenous infection.
Ill two or three of them there was an acute gangrenous
niflammation of the gall-bladder. In these cholecystectomy
was followed by excellent results. He had had no deaths
or serious shock following the operation.

Dr. Howard A. Kelly of Baltimore said that when he
operated for any intraabdominal pathological condition it
was now his practice to examine the gall-bladder, among
other organs, to determine whether it was diseased or
whether gallstones were present or not. He believed in
cholecystectomy where the gall-bladder w-as grossly dis-
eased, although one could not always do an ideal opera-
tion. He recalled two cases in which an ideal operation
could not be done on account of the great density of the
adhesions.

Dr. Charles H. Mayo of Rochester, Minn., said that in
their clinic they occasionally operated, after having made a
thorough examination, and thinking they had a case of
gallstones to deal with, and found no stones. It was rare,
however, for them to diagnose gallstones or disease of the
bile ducts, even though no stones were found, without
finding some abdominal condition which would have made
it necessary to operate. He did not think a patient cared
whether he had gallstones, duodenal ulcer, or ulcer of the
pylorus, if he could be relieved. In other words, the
patient had no special preference, although he might think
it nice to have the gallstones in a bottle to show to his
relatives and friends, proving that he had had that trouble.
Some years ago they operated and found a blue gall-
bladder, which was ordinarily considered a healthy gall-
bladder, but covered with adhesions. They drained such
gall-bladders and tried to relieve the adhesions. Two of
these cases, however, were reoperatcd, one a year after-
ward, the other two years thereafter, for the same condi-
tion, and at that time they found that a duodenal ulcer
was the cause, which had been overlooked at the first
operation.

The Treatment of Hemorrhage by Direct Transfusion
of Similar Blood. — Dr. George W. Crile of Cleveland, O.,
said the basis for the clinical use of transfusion of blood
in the treatment of hemorrhage was as follows : That
normal blood of an individual of one species was physiolog-
ically equivalent to that of any other individual of the
same species, and was therefore interchangeable ; that the
vascular systems of two individuals might by an end-to-
end anastomosis of vessels be united; that such union
might be accomplished so as to approximate intima to
intima ; that the blood that was transformed across this
artificial continuity did not come in contact with any foreign
body or any tissue but the intima; th'it under these condi-
tions blood would not clot and the rate of flow and the
amount transferred were under immediate control. Only
the gravest and apparently hopeless cases had thus far
been transfused. Altogether fourteen clinical cases had
been observed. All were done painlessly under morphine
and cocaine anesthesia. No unfavorable symptoms of im-
portance had been noted. The donors had regained their
lost blood in from five to six days. Every donee had felt
immediate improvement. Striking evidence of this had

122

MEDICAL RFXORD.

[Jan. 19, 1907

been shown in tlie facics, the improved circulation, and
the feeling of well-being and even buoyancy. The technique
was by no means simple, and must be carried out with
absolute precision to prevent clotting. In no instance
was there observed nephritis, hemoglobinuria, agglutina-
tion, hemolysis, or laking of blood. The transfused blood
apparently exercised no unfavorable influence on its new
host, and the latter none upon the new blood. The blood
of individuals of the same species, therefore, seemed to be
physiologically iiUercliangeable. Certain cases of pathologi-
cal hemorrhage had been cured by the addition of fresh
normal coagulable blood. Transfusion in a case of per-
nicious anemia was tried with totally negative results.
Partly on the basis of Wright's work on opsonins and
partly on other grounds, two cases of transfusion after
bleeding in tuberculosis had been done. In every instance
in the research and in the clinic the effect of hemorrhage
had been overcome by the replacement of the lost blood by
means of transfusion. He was not yet ready, however,
to reach conclusions or to make deductions or predictions.
This was but a report of progress.

The Management of Laparotomy Patients and Their
Modified After-Treatment. — Dr. Her.man J. Bolut of
New York, in a paper on tliis subject, said that no par-
ticular preparatory treatment was necessary for patients
upon whom it was intended to do an abdominal operation,
unless the operation involved the opening of the stomach
or the bowels. Stomach lavage was of benefit at the con-
clusion of the operation. Patients should not be kept un-
necessarily under an anesthetic. The application of a
tight bandage around the upper part of the thighs to keep
a blood reservoir in the lower e.xtremities in exsanguinated
and very weak patients, was e-xcellent. The same might
in exceptional cases be done with one of the upper extremi-
ties. These bandages were taken off as soon as the opera-
tion had been completed, and thus more blood was thrown
into the trunk. The administration of strychnine during
and after an operation should be used with more care
than was usually done. The intravenous infusion of a o.g
per cent, saline solution should not be too long delayed
when the condition of the patient made it evident that its
employment might be of benefit. In instances of large
myomata, where the patient had been much exsanguinated
by hemorrhage, it was desirable that the infusion be begun
as soon as the patient was fully under an anesthetic, so
that by the time the operation had been completed about
one thousand to fifteen hundred c.c. might have been
infused. The application of a very simple dressing over
the wound, and the adjustment of a snugly-fitting Scultetus
handage made of oxide of zinc plaster were made. The
administration of a dose of morphine was desirable if there
was restlessness or pain, the medication acting clinically
as a heart stimulant. The author allowed regular diet
and unrestricted mobility within twenty-four hours after
the operation, unless specially contraindicated. Patients
were allowed to get out of bed as soon as possible after
an operation. The author avoided forced catharsis before
the first four or five days after an operation, unless there
was a special indication for it. In cases where resort to
vaginal drainage was had, or where it was evident that
there would be some secretions intraperitoneally after an
operation — as in purulent cases and oozing from torn ad-
hesions— trunk elevation was employed as soon as the
patient was put into bed. For this the employment of a
bed I'fter. which the author exhibited and described, or
the placing of high blocks or chairs under the bead of
the bed, was preferable to back-rests.

The Treatment of Senile Gangrene. — Dr Edw.nro H.
OcHSXER of Chicago called attention to the fact that there
were two distinct types of senile gangrene, the first occur-
ring in cases with only moderately generalized arterio-
sclerosis, but in which there was a distinct mural thrombus.
In this class of cases there was an early formation of a
distinct line of demarcation, and it was best to delay opera-
tion until this line of demarcation had become well estab-

lished, and then to amputate directly through the line of
demarcation. In the second class of cases there was a
marked generalized arteriosclerosis, the whole affected ex-
tremity was markedly involved, there was no tendency to
the formation of a line of demarcation, and an early high
amputation was indicated.

{To be concluded.)

MEDICAL SOCIETY OF THE COUNTY OF KINGS.

Stated Meeting, Held September 18, 1906.

Dr. W. F. C.\mi>I!ei.i. i.x the Ch.mr.

The Water Supply of New York. — Mr. Ch.as. N. Chad-
wick, Commissioner of Water Supply of New York, read
this paper. He referred to the fact that five years before
the same subject. His object now, as then, was to de-
scribe the work that was being done to increase the water
su])ply of New York. Ten years ago the Mer-
chants' .'Vssociation and other civic bodies began the
agitation, which resulted in the appointment of a
committee composed of delegates from the Chamber
of Conmierce, the Manufacturers' Association, and the
Board of Fire Underwriters. In 1900 a board of
eminent engineers was appointed. This selected the Cats-
kill region as the place best adapted to furnish the increased
water supply. The Adirondacks had been considered.
The Housatonic watershed and the Ten Mile Creek had
been rejected on account of interstate complications. The
Hudson River as a source of water supply was rejected
on account of its pollution and the necessity of building a
filter for its water. If the Adirondacks region had been
accepted it would have been necessary to build a reservoir
at great expense in this remote locality. The Catskill
watershed appeared to be the ojie best fitted to furnish the
water most economically. It was, of course, necessary to
divert the water from the Esopus, Rondout, and Schoharie.
For the prosecution of the work the New York Board of
Estimate appropriated $161,000,000. A State commission
had to be appointed to adjust the claims of towns whose
supply of water might be diminished by the utilization of
the Catskill watershed. The enormity of the task that
confronted the engineers was illustrated by the fact that
230 miles of territory had to be surveyed in order to find
the best eighty miles for the aqueduct. In addition to the
complex organization of the various corps of engineers,
there was established a laboratory in which analytical
chemists determined the nature of the various soils, the
tensile strength of cements, the strength of concrete, etc.
The peculiar geology of the Hudson River presented a
difticult problem for solution. It was decided to tunnel
inider the Hudson River at Stony Point. One of the most
difficult problems was that of running an aqueduct under
the Rondout Valley. The plans included the building of a
reservoir in the Catskills, having a length of fifteen miles
and a width of one and a third miles. The enormity of this
undertaking was to be appreciated by considering the fact
that in building the reservoir eleven villages were to be
wiped out, and a portion of the Ulster and Delaware Rail-
way had to be removed. An additional reservoir was to be
built at Kensico, having a fifty days' supply, and at Scars-
dale, a filtration plant. It was estimated that at the cost
of $161,000,000 the completed improvements would yield
a supply of 500,000,000 gallons of water per day. The plans
included an aqueduct to Long Island which would yield
52,000,000 gallons per day. For speedy relief it was
intended to construct first the aqueduct from Stony Point
to Eshoken reservoir, a distance of fifty-eight miles, to
empty into the Croton watershed. This was to be accom-
plished in eight years.

The Underground Water Resources of Long Island.
— Prof. Isaiah Bowman of the Department of Geology,
Yale I'niversity. read this paper. He said that the demand
for water was always a serious one in the life of municipali-
ties. Hydrology was consequently reduced to a science.

Jan. 19, 1907]

MEDICAL RECORD.

123

As a member of the Government Geological Survey, ths
speaker had made an investigation of the underground
water resources of Long Island, which formed part of a
special government report. He had found extensive water
sources on the south side of the island. The deep-ground
water was practically unlimited, the bedrock of Long
Island being a continuation of that of the mainland. There
was a continuous flow of ground water toward the sea.
This flow was carefully measured. Natural underground
reservoirs were furnished by impenetrable beds of clay
overlaid by fairly coarse gravel, so that wells driven to the
■clay would serve to tap these reservoirs. Most of the wells
would yield permanent and abundant supplies of water.
The sand and gravel through which the water had to
travel in order to reach the lower levels furnished an
efficient filter for all organic impurities. Whatever part of
this supply was not available immediately for drinking
purposes could be made so by storage in reservoirs either
exposed to the sun or possibly supplied with cultures of
opposing organisms.

Stated Meeting, Held October 16, 1906.

Dr. W. F. Campbell in the Chair.

Presentation of the Medical Library of the Late Dr.
Willard Parker. — Dr. James Peter Warbasse, Directing
Librarian, made the address of presentation of this library
of 400 volumes, a gift to the Librar>' of the Medical Society
of the County of Kings from Dr. Willard Parker of New
York City.

The Treatment of Certain Chronic Infectious Proc-
esses.— Dr. Lewellys F. Barker, Professor of Medicine,
Johns Hopkins University, read this paper. He alluded to
the fact that the bacteriologists taught a great deal about
the nature of infection and that it was the duty of clinicians
to apply this teaching in diagnosis and treatment. The
process of infection had been made clear; also how the
body entered into competition with lowly organisms in
the struggle for existence. This teaching included the
mechanisms of defense, the ways in which they were over-
come, and the mode of entry of bacteria and protozoa into
the body. It was shown that some bacteria entered the
body by one door only — the cholera vibrio entering only
through the intestinal epithelium ; likewise the typhoid
bacillus. Other parasites entered by various paths, e.g.
the staphylococci and streptococci. The period of incuba-
tion was the time during which the organisms multiplied
until they were numerous enough to have an appreciable
effect on the host. This was produced either by the toxins
or by the bodies of the microorganisms. Sometimes the
invasion was merely local, as in an ordinary boil. Some-
times the bacteria spread by direct continuity, as the ex-
tension of the gonococci from the urethra through the
prostate, bladder, ureter, to the pelvis of the kidney.
Another form of e.xtension was by metastasis, e.g. the
arthritis and endocarditis secondary to tonsillar infection
with streptococci. The rose spots in typhoid were meta-
static infections of the skin, containing typhoid bacilli.
True septicemia was an expression of a general blood ex-
tension of microbic infection, e.g. general streptococcus and
staphylococcus infections, and quartan malaria. It was
remarkable that a certain organism, like the gonococcus,
might have a varying behavior, in one case being confined
to the urethra, in another extending to the prostate, in
another, spreading by metastasis to the heart and joints, or
even giving rise to a true gonooocous septicemia. Differ-
ent bacteria also had different predilections; leprosy had
an affinity for the nerve trunks and multiplied in them: the
cholera vibrios thrived only in tlie intestinal epithelium,
even when injected into the blood» The gonococci. when
inoculated into the blood, chose the susceptible joints.
Other bacteria, like the staphylococci, streptococci, and
pneumococci, had less limited predilections. The bacteria
overcame the mechanisms of defense in various ways by
means of to.xins, endotoxins, Ivsins, agsrressins, antigens.

and the like. The general phenomena of infection were
leucocytosis or leucopenia, fever or subnormal temperature,
hemorrhagic diathesis, splenic tumor, anemia, general dis-
turbances of nutrition in the organs, parenchymatous de-
generation of the kidney, and changes in the nerve-cells.
Rather than symptoms of infection, these were to be re-
garded as biological reactions, taking place in the body
during infection. The biological reaction was frequently
associated with a subsequent more or less complete immu-
nity. One had to differentiate between the acute and
the chronic infections. Typhoid, cholera, plague, pneu-
monia, and influenza ran usually a very acute course;
the patient was either killed or soon recovered. In chronic
infections, like tuberculosis, leprosy, and actinomycosis,
there was little tendency to spontaneous cure. But the
distinction between acute and chronic infections was not
a hard-and-fast one. As regards the varieties of biological
reactions, it was noted that in antitoxic immunity the
body manufactured a substance to neutralize the soluble
bacterial poison, as in diphtheria and tetanus. In the
majority of infections there was instead an antibacterial
immunity, as, in typhoid fever or cliolera, the body elabo-
rated substances which prevented the further growth and
life of these bacteria. The antibacterial substances were
either agglutinins, as evidenced by the Griiber-Durham-
Widal reaction, or the bactericidal substances, which actu-
ally killed the bacteria, or the bacteriolytic substances
which in addition dissolved them. Finally there were
the substances recently discovered by Wright of London,
which neither killed, clumped, or dissolved the bacteria,
but acted upon them in some mysterious way, modifying
them in such a manner as to make them suitable food for
the leucocytes. They sensitized the bacteria for the leu-
cocytes, and acting as substances that catered to the
leucocytes, they were called by Wright "Opsonins." Some
infectious processes yielded a permanent immunity after a
simple attack had run its course, while others apparently
yielded no immunity at all. In diseases like tuberculosis
and leprosy, it was hard to find evidences of immunity.
Such diseases were apt to last the entire lifetime of an
individual. The speaker commended Dr. Rickett's book
on "Infection, Iinmunity, and Serum Therapy" as a valu-
able exposition of these subjects, giving a clear and suc-
cinct account of the newer work. The speaker next dis-
cussed the therapeutic measures employed in combating
chronic infections and the principles underlying the former.
Ever since Hippocrates physicians had been trying to
help nature. Gradually a whole series of measures had
been found. In all times the principal object was to keep
up the strength of the patient, to maintain the natural
resources of defense. Bacteriologists had proven that
with good food, sufficient sleep, and relief from strain, the
mechanical defenses were better, the opsonic index higher,
and the bactericidal power of the blood greater. The first
therapeutic measure discussed was that of the use of
chemical disinfectants. The object was to open up the
infected part of the body and wash it out with antiseptics.
This method' had its uses, but its vogue was getting less
and less. Surgeons were relying more on opening up a part
and washing it out with substances not chemical disin-
fectants. This was a fortunate change, for substances,
powerful enough to kill bacteria, would also succeed in
killing the cells. This was especially true in pyogenic
infection. Some chemical disinfectants also destroyed this
substances in the blood which had the special function of
fighting the bacteria. A minute quantity of lysol in the
blood was capable of doing this. The method of surgical
extirpation of the infective focus was also not without its
dangers. In the presence of a tuberculous joint this was
fully realized, and surgeons succeeded best by leaving it
alone. Eff'orts at excision led to difTusc miliary tubercu-
losis. Moreover, the incision stirred up the infective agent
and interfered with nature's powers of resistance. As the
result of massage of such a joint the opsonins were
diminished in amount Mass.-ge of a tuberculous joint

124

MEDICAL RECORD.

[Jan. 19, 1907

caused inoculation of the patient, which might poison his
body and interfere with its native powers of dealing with
the infection. Simple percussion of the chest or having
twelve students percuss it might likewise cause a diminution
in the amount of opsonins and in the natural resistance.
The next therapeutic method alluded to was that of in-
creasing the flow of blood to a part by means of hot
fomentations, hot ovens, acute hyperemia, counterirritation,
cautery, or sinapisms. The rationale of these procedures
was now understood more than formerly. They increased
the amount of lymph, blood, and phagocytes in the part, and
also the amounts of antito.xic and antibacterial substances.
They increased also those sensitizing substances known as
opsonins which prepared the bacteria for the phagocytes.
In the presence of suppuration poultices were often used.
Why did not the infection cure itself? The reason was
that the lymph, blood, and leucocytes accumulated to so
great an amount that they could not get out. The bacteria
used up the antibacterial substances, and no new ones
could get in. So the rational procedure was to open up
the part, let out the waste, and allow fresh blood and
phagocytes to come in and complete the cure. In localized
chronic infections massage served to increase the flow of
blood, and had the same effect as passive hyperemia. The
Bier method of producing the latter consisted in com-
pression. If the wrist joint was involved the veins of the
forearm were compressed, allowing the arterial blood to
flow to the joint, but preventing the venous blood from
getting out. The joint was thus flooded with blood-
serum, phagocytes, bacteriolysins, bactericidal substances,
and opsonins. In Bier's method there was no easy outflow
of the serum until the obstruction was removed. To en-
hance the value of this method Klapp made an incision
into the aft'ected part, after which passive hyperemia was
produced. This insured the venous engorgement and in-
creased the lymph formation of Bier's method, and at the
same time effected an exit of lymph through the incision,
exposing the part to a continuous flow of fresh serum,
and its contained protective substances. The next ther-
apeutic method discussed was that of serum therapy. Only
two or three sera proved their usefulness; they were the
antitoxins for diphtheria, tetanus, and perhaps that of
snake-poisoning. The antipneumonic, antistreptococcic, and
antityphoid sera, although bactericidal, had practically no
antitoxic value. The products of the living activity of these
germs were practically harmless, these germs owed their
virulence to the endotoxins which were set free when the
bacteria died and were broken down. The streptococci,
staphylococci, gonococci, typhoid, and cholera germs did
not produce soluble toxins in any appreciable quantity, and
the symptoms of infection were to be accounted for only
by the endotoxins set free when the bacteria died. Accord-
ing to Pfeiffer, the organism did not build antibodies to
these endotoxins; there could not be antiendotoxins com-
parable to the antitoxin of diphtheria. Bactericidal sub-
stances might be of value, but if injected into the system
they would kill the bacteria, set free the endotoxins, and
actually make the patient worse. It had not yet been found
possible to produce a serum containing so rich a content in
opsonins as to be available for human inoculation. It was
found possible to increase the opsonins in horse's serum,
but not in sufficient concentration as to make this form of
treatment efficacious. There was as yet no knowledge
about the other possible antibacterial substances that might
help in the production of immunity. Antibacterial sera
were as \-et disappointing. A method of treatment recently
urged by Wright was that of inoculation with the bacteria
themselves. The symptoms of tuberculosis were due to
the endotoxins set free by the death of the bacilli. It was
found that in various forms of tuberculosis, as in tuber-
culous cervical adenitis and in tuberculous arthritis, there
was a lowering of the opsonic power of the blood. Bac-
terial inoculation produced an increase in the opsonic
power. Wright had devised a method of measuring the
opsonic index. In cases of tuberculosis in which the

opsonic inde.\ was high, the body was doing well in the
battle and inoculation was unnecessary. The injection of
minute quantities of dead tubercle bacilli served to increase
the opsonic index in cases in which it was low. It seemed
as if in certain chronic tuberculous infections the body
was not destroying enough tubercle bacilli to cause the
biological reactions which gave rise to the opsonins. By
artificially introducing dead tubercle bacilli, the produc-
tion of opsonins was stimulated so that the body could fight
the living tubercle bacilli to better advantage. This was
the principle underlying the tuberculin treatment of tuber-
culosis, as still practised with apparent success at Saranac
Lake by Trudeau. The bacterial inoculations were found
by Wright to be helpful in the treatment of tuberculous
glands and lupus, and in the cure of tuberculous sinuses
after operation. The speaker described the method of
determining the opsonic index. It consisted in drawing
from the patient's finger a little blood, which was diluted
with sodium citrate and centrifugalized so as to obtain
the white blood corpuscles in a layer. Some of these
were mixed with a suspension of tubercle bacilli and the
patient's serum. A smear taken from this mixture after
it had been kept for half an hour in the thermostat was
stained and the number of bacilli ingested by fifty leucocytes
was counted. On dividing by fiftj' this gave the average
number of bacteria ingested by each leucocyte. The nor-
mal number of bacteria taken up by each leucocyte would
represent the index i.oo. Twice that number would give
an opsonic inde.x of 2.00. The work of Wright was con-
firmed by Hektoen of Chicago, by Simon of Baltimore, and
Potter of Xew York. Among the cures effected by
Wright's method were tuberculous cystitis and furunculosis.
Large doses of bacterial vaccines were harmful in pro-
ducing a marked diminution in opsonic power. The speaker
next alluded to various recurrent metastatic infections
having a chronic course, particularly polyarthritis and
endocarditis. The majority of the so-called acute and sub-
acute rheumatisms, many of the chronic forms and some of
the cases of arthritis deformans were instances of infec-
tious arthritis. The joint infections were due to local
foci situated elsewhere. The persistence of the primary
focus led to recurrent exacerbations in the joints. In a
large percentage of the cases this primary focus was in the
palatine tonsils, even though the latter were atrophic.
Such local focus might be in the pharyngeal tonsil, or in
the gums, as in pyorrhea alveolaris (Rigg's disease). In
women the uterine canal or the Fallopian tubes might be
the seat of the local infection. Gonorrheal rheumatism
was tlie first of the metastatic arthritides to be recognized.
Other local sources of metastatic joint disease were otitis
media, or disease of the accessory sinuses of the nose, or
even bronchitis, pneumonia, or enteritis. The obvious
treatment of these metastatic infections was removal
of the local cause. The common endocarditis in young
people was strongly suggestive of a primary focus of infec-
tion. This view was supported by the analogical rheu-
matic endocarditis. In many cases the endocarditis was
secondary to a tonsillitis. An excision of an hypertrophied
tonsil might be the sole means of preventing a recurrence
of an endocarditis. In very young children there might be
some protective function in the physiological activity of the
tonsils connected with an internal secretion. This might
make one hesitate to remove the tonsils in them. But
in later life this was not to be considered. Even in very
young children the removal of the palatine tonsils would
leave the lingual tonsil to carry on the function of internal-
secretion. Acute tonsillitis was to be regarded as a very
serious infection on account of its metastatic possibilities,
and therefore rest in bed, together with very active
therapeutic measures, were to be enforced in order to com-
bat the disease and overcome it in time to prevent metas-
tases. The responsibility for a great deal of polyarthritis,
endocarditis, and perhaps acute and chronic nephritis rested
upon the shoulders of the general practitioner who failed to-
remove the local exciting cause.

Jan. 19, 1907I

MEDICAL RECORD.

125

STATE BOARD EXAMINATION QUESTIONS.

Medical Examiners State of Florida; Regular Board.

October 17 and 18, 1906.

anatomy.

1. Name the bones and ligaments of the ankle joint.

2 What bones form the shoulder?

3 Facial artery— origin, course, and distribution.

4 Define and describe capillary circulation
S. Mention the salivary glands and their ducts, btate

where these ducts opeji.

6 Give the gross anatomy of the stomach.

7 Into what and how far from the pyloric orifice of t he
stomach does the ductus communis choledochus normally

8. Describe the appendix vermiform. Locate McBur-

ney's point for performing appendectomy.
g What is the pons Varolii, and where situated.'
10. Give origin, course, and distribution of median

nerve.

PHYSIOLOGY.

I Describe the normal pulse; state the factors active
in its maintenance, and give the rate during infancy, youth,
and adult life. . , ,

2. Describe a complete physiological revolution of the

heart. , ....

3. Give the principal characteristics of gastric juice in

man. ...

4. Describe the phenomena of (a) asphy.xia, Cb) syn-
cope, (c) sleep. , . , J ■ .1,

5. What changes are produced in the air and in the
blood by respiration?

6. Define (a) tonic muscular contraction; (b) clonic
muscular contraction. Give an example of each.

7. State the function of the anterior spinal nerve roots.
How is the function proved?

8. Describe the fetal circulation.

9. What is (a) an efferent nerve, (b) an afferent nerve?
Give an example of each.

10. What is the composition of human milk?

SURGERY.

1. Name five forms of bacteria and the surgical disease
produced by each.

2. Describe thrombosis and embolism. Give the cause
of each.

3. What causes gangrene? Name two varieties. Give
treatment.

4. Define suppuration and give the cause. What is an
abscess?

5. Define inflammation and name three varieties. Give
five cardinal symptoms of inflammation.

6. Give etiology, symptoms, and treatment of iritis.

7. Give the diagnosis and treatment of fracture of the
clavicle.

8. What important structures would be divided in an
amputation four inches below the knee joint?

9. Give the symptoms of a dislocation of the wrist
joint. Method of reduction and treatment.

10. Describe the method of sterilizing the field of opera-
tion, the hands of the operator and his assistants, and the
instruments for a major surgical operation.

GYNECOLOGY.

1. What is the normal size and position of the uterus?

2. What do you ascertain from a digital examination
and what constitutes a complete gynecological exami^
nation ?

*It is proposed in this department to publish from time to
time the examination papers of the various State Boards,
in order that a candidate may become familiar with the
character of the examination and so in some measure free
himself in ad\'ance from the nervousness and dread which
tlie unl^iiown inspires. In furtlierance of the same object
answers to some of tlie questions will be i>ublished in order
to show the candidate what the examiners expect of him.
Not all the questions of all the papers will be so treated,
for the answers to m.any, especially in the anatomical papers,
are obvious or can be found in the index of any text-
oook on the subject: the answers to other questions, especially
in the surgical papeis, must sometimes be omitted because of
the space they would demand. The candidate for a medical
license will not find in these answers a short and easy road to
success in the e.vamination. for he is not likely to meet the
same questions in the papers placed before him by the
examiners. The object oi^ publishing the questions and
answers is only, as noted above, to acquaint the candidate
with the general character of these examinations and to
Inspire him with confidence in the result of his trial.

3. Give symptoms and treatment of acute vaginitis.

4. What pathological conditions and symptoms usually
follow laceration of the cervix uteri?

5. Give symptoms and treatment of retroversion of the
uterus. .

6. What is oophoritis, and how could yoii diagnose it.'

7. Give etiology and treatment of salpingitis.

8. Enumerate symptoms of sarcoma of the mammary
gland. . ,

9. What are the nervous manifestations of amenorrhea.'
ID. What is a vesicovaginal fistula, and explain the

operation for same.

THERAPEUTICS.

1. Define what you understand to be the therapeutic
limit of a drug, taking digitalis for an example.

2. Give the medicinal uses of belladonna, and state from
what source it is obtained.

3. Write a prescription for intertrigo in infants.

4. Name the indications for the use of morphia, sul-
phate, atropia and aconite, and give the physiological doses
of each.

5. What remedies would you prescribe to obtain intesti-
nal antisepsis in typhoid fever?

6. Give the physiological action and therapeutic uses
of the officinal digestive ferments.

7. Give the officinal name, composition, and therapeuti-
cal uses of Lugol's solution.

8. Litharge. Officinal name and medicinal uses.

9. Manganese. Division into groups. The officinal salt
most used, and doses of same.

10. Sedatives. Divide into classes, and state upon what
conditions may a sedative become a stimulant.

OBSTETRICS.

1. What are the three stages of normal labor?

2. Signs of pregnancy at end of first three months?

3. Define menstruation.

4. Symptoms of extrauterine pregnancy.

5. Mechanism of labor in R. O. A.

6. Management of breasts after delivery.

7. Treatment of puerperal sepsis.

8. Treatment of pregnancy complicated by nephritis.

9. Treatment of eyes of new-born.

10. Give methods of preventing tears of perineum.

CHEMISTRY.

1. Define the terms matter, solids, liquids, gases, and
water of crystallization.

2. Name the five gaseous elements.

3. Give the chemical formula of nitric acid, and men-
tion its properties.

4. What metals belong to the arsenic group?

5. Give the usual tests for sugar and albumin in the
urine.

6. Describe the method of making tests for the diazo
reaction in suspected urine.

7. Give antidote for arsenic poisoning, and how to pre-
pare same.

8. Give antidotes for caustic potash poisoning.

9. Give tests for salts of sodium and potassium.

10. Name the element found in greatest abundance on
our earth and mention its properties.

ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.

Medical Examiners, State of Florida; Regular Board.

October 17 and 18, 1906.

physiology.

I. The pulse is the impulse conveyed to the column of
blood in the arteries by the contraction of the ventricles and
the propulsion of more blood into the already full arterial
system. The characters of the pulse which are of most im-
portance are its force, frequency, length, rhythm, and ten-
sion. It is maintained by the ventricular systole, the
elasticity of the arterial walls, and the volume of the blood
in the vessels. In infancy the rate is about one hundred and
twenty a minute: in youth about eighty-five, and in adult
life about seventy.

3. It is a thin, colorless, acid fluid, with specific gravity
of about 1.002, and containing from one-half to one per
cent, of solids. The average daily amount has been placed
anywhere between six and twelve pints. It contains
(besides water) hydrochloric acid, pepsin, rcnnin, mucin,
and salts of sodium, potassium, calcium, .-md magnesiuiri.
The pepsin is a proteolytic enzyme which will only act in
an acid medium; the rennin congnlatcs caseinogen.

126

MEDICAL RECORD.

[Jan. 19, 1907

5. The changes produced in the air by respiration are:

Oxygen

Nitrogen

Carbon dioxide.
Other gases. . . .
Watery vapor . .
Temperature. . .

Volume

Bacteri.i

Dust

Inspired Air.

21 per cent.
79 per cent
0.4 per cent
Rare.
Variable.
Variable.
Varies.

Always present
Always present

Expired Air.

16.6 per cent.
79 per cent.
4.4 per cent
Often present.
Saturated.
That of body.
Diminished.
None.
None.

In the blood the changes take place in the capillaries of
the lungs, and are: (i) the giving up of the CO; by the
venous blood, (2) the absorption of oxygen during inspira-
tion, (3) the blood is cooled, and (4) it also loses a small
amoimt of watery vapor.

6. In tonic muscular contraction the muscle remains for
some time in a state of rigid contraction. In clonic con-
traction the muscle alternately contracts and relaxes. Tonic
muscular contraction occurs in tetanus; clonic, in an ordi-
nary convulsion.

9. Efferent nerves carry impulses away from the nerve
centers. Afferent nerves carry impulses to the nerve cen-
ters. The motor nerves are efferent; the sensory nerves
are afferent.

SURGERY.

1. (i) Streptococcus pyogenes, producing abscess; (2)
bacillus tetani, producing tetanus; (3) bacillus anthracis,
producing malignant pustule ; (4) bacillus tuberculosis, pro-
ducing tuberculous disease of bones or joints; (5) strep-
tococcus erysipelatis, producing erysipelas.

2. Cause of thrombosis: (i) changes in the walls of
the blood-vessels, due to the presence' of infection or foreign
bodies ; (2) changes in the blood, whereby its tendency
to coagulate is increased; (3) diminished rate of the blood
flow, due to weak heart action or obstruction. Embolism
is generally due to thrombi, but is also caused by fragments
of vegetations or atheromatous or calcareous masses from
the cardiac valves or the intima of the arteries ; other
causes are parasites, pieces of new growths, pigment
granules, fluid fat, or air.

4. Suppuration is a special form of inflammation, in
which the exudate is unusually prolific in cells, and in which
pus is found. The cause of suppuration is tlie invasion of
the tissues by pus-producing bacteria, when the said tissues
are in a state of lowered vitality or are not capable of
withstanding and disposing of the bacteria and their
products. An abscess is a circumscribed collection of pus
in a newly formed cavity.

8. Skin ; fascia ; bones, tibia, and fibula ; interosseous
membrane; muscles, tibialis anticus, tibialis posticus, ex-
tensor longus digitorum, extensor proprius hallucis, flexor
longus hallucis, flexor longus digitorum, peroneus longus,
peroneus brevis, soleus, gastrocnemius, and the tendon
of the plantaris; arteries, anterior tibial, posterior tibial,
peroneal; veins, the venae comites of the arteries, external
saphenous, internal saphenous ; nerves, anterior tibial, pos-
terior tibial, external saphenous, communicans peronei,
musculocutaneous.

GYNECOLOGY.

1. In the nulliparous adult the uterus is about tliree
inches long, about two inches wide at the upper part and
about one inch thick. The uterus lies between the rectum
behind and the bladder in front; it is below the abdominal
cavity and above the vagina. Its position is one of slight
anteflexion, with its long axis at right angles to the long
axis of the vagina. The anterior surface of its body rests
on the bladder, and the cervix points backward toward the
coccyx. The uterus is not fixed, but moves freely within
certain limits.

2. From a digital examination can be learned the presence
or absence of vaginismus ; the size, position, temperature,
sensitiveness, moisture, and laxity of the vagina; the pres-
ence of foreign bodies, hernia, fissures, or caruncles ; the
position, form, and consistency of the cer\'ix uteri ; lacera-
tions (including position, number, extent, and direction),
erosions, growths, or cysts on the cervix ; prolapse, dis-
placements, and size and position of the uterus.

.\ complete gynecological examination would include (i)
anamnesis, including family history; personal history, with
special reference to menstruation, labors, and miscarriages;
and present illness. (2) Examination of the abdomen (and
breasts), including inspection, palpation, percussion, auscul-
tation, and mensuration. (3) Inspection of the external
genitals. (4) Vaginal examination, digital, bimanual, and

with speculum, (s) Bimanual examination of uterus and
appendages. (6) Sometimes the sound, or curette, may
be required. (7) Chemical and microscopical examination
of the urine. (8) Microscopical examination of discharges
or uterine scrapings. (9) Rectal examination. (10) Cys-
toscopic examination and perhaps ureteral catheterization.
(11) In case of phantom tumor or pseudocyesis, anestheti-
zation would be required.

4. Hemorrhage, sepsis, hypertrophy, and erosion of
cervix, prolapse of uterus, subinvolution, endometritis, can-
cer, and disease of the tubes and ovaries.

8. According to Gross "a tumor of soft, elastic, appa-
rently fluctuating consistence, which attains the volume of
an adult head in a few months, can scarcely be anything
else than a small-celled sarcoma. On the whole, the diag-
nosis is based upon their indolent origin, lobulated outline,
rapid increase, large dimensions for the period of their
existence, freedom from lympathic involvements, and
marked tendency to ulcerate ; upon the not infrequent dis-
coloration of skin, enlargement of the subcutaneous veins,
and possibly elevation of temperature; upon the suffering
which they awaken late in the disease, and upon their
greatest frequency after the thirty-fifth 5'ear."

9. Hysteria, paresis, tinnitus aurium, perspiration, defec-
tive vision, acne, herpes, urticaria, headache, and flashes of
heat

THERAPEUTICS.

3. R. .A.myli

.A.cidi borici aa 5j. Misce.

Signa : Apply as a dusting powder.

5. Guaiacol carbonate, salol, betanaphthol, naphthalin,
thymol, carbolic acid, calomel, and corrosive sublimate.

6. Note that only two — pepsin and pancreatin — are
officinal.

7. Liquor iodi compositus. Iodine, 5 parts; potassium
iodide, 10 parts ; and water up to one hundred parts. It is
used as a counterirritant and as an alterative; on bruises
and sprains, also for pleurisy, synovitis, chronic rheumatism,
intercostal neuralgia. It is also used internally, in doses of
from one to ten minims, well diluted, for the vomiting of
pregnancy, or after anesthetics. It is used, too, as an in-
jection, for goiter, also into the various serous cavities in
cases of chronic inflammations.

8. Plumbi o.xidum. Used in the manufacture of lead
plasters, and of some of the other lead salts, also as the
basis of other plasters. It is further used as a protective
agent against chafing from splints and other appliances, and
to prevent bedsores.

9. Mangani dioxidum praecipitatum, dose four grains;
mangani sulphas, dose four grains ; mangani hypophosphis,
dose three grains ; and potassii permanganas, dose one
grain.

CHEMISTRY.

1. Matter is anything which occupies space. A solid
is a form of matter in which the relative positions of the
molecules are fixed and constant In a liquid the molecules
glide past each other and the substance assumes the form
of its container. In a gas the molecules tend to get away
from each other and to occupy a greater space. In a solid
both volume and form are definite: in a gas both volume
and form are indefinite ; and in a liquid the volume is defi-
nite but the form is indefinite.

2. Hydrogen, ox3'gen, nitrogen, fluorine, and chlorine. ■

3. HNO3. It is a colorless liquid, with a strong acid
taste and reaction. It is a strong oxidizing agent, and
dissolves most metals, with the formation of nitrates.
With hydrochloric acid, it forms aqua regia. which is capa-
ble of dissolving the so-called "noble metals." In damp
air it gives off white fumes. When strongly heated it is
decomposed into H-O, N.O* and oxygen.

4. The answer to this question will depend upon the
textbook used b}- the student (or examiner). Witthaus
puts arsenic in the same group with nitrogen, phosphorus,
and antimony ; Remsen, in the same group with nitrogen,
phosphorus, antimony, and bismuth ; Simon, in the same
group with antimony, tin, gold, platinum, and molybdenum ;
Holland, in the same group with antimony and tin.

6. The reagent is made of two solutions, which should
be kept in separate bottles. One is a saturated solution of
sulphanilic acid in a mixture of 50 c.c. of hydrochloric acid
and 950 c.c. of water. The other is a 0.5 per cent, solution
of sodium nitrite. To make the test: 40 c.c. of the
sulphanilic acid solution are mixed with I c.c. of the
sodium nitrite solution, and the mixture is well shaken.
Equal quantities of the urine and reagent are then shaken
together in a test tube, and upon the surface of this mixture
from I to 2 c.c. of ammonia are floated. A red band formed
at the junction of the liquids implies an affirmative result

7. Freshly prepared ferric hydro.xide, FcjOcHj. The

Jan. 19, 1907]

MEDICAL RECORD.

127

two following solutions should be kept in separate bottles,
and when required should be mixed and administered :
(i) I^. Liquoris ferri tersulphatis. . . 5'j

AquK destillatse 5vj- M.

(2) 5. Magnesias 3iij

Aqu^E destillatae jviij. M.

8. Dilute vinegar, vegetable acids, milk, and neutral oils.

9. Sodium colors the Bunsen flame yellow. With peri-
odic acid (HlOt) in e-xcess, it gives a white precipitate
in not too dilute solution. Potassium colors the Bunsen
flame violet. With periodic acid it gives a white precipi-
tate, sparingly soluble in water, and insoluble in alcohol.

10. O.xygen. A colorless, odorless, tasteless gas, slightly
soluble in water. It has a strong tendency to combine with
other elements, and forms binary compounds with all ele-
ments except fluorine and bromine. Oxygen is necessary
to the processes of life and combustion.

BULLETIN OF APPROACHING EXAMINATIONS.!

STATE.

NAME AND ADDRESS OP PLACE AND DATE OP

SECRETARY. NEXT EXAMINATION.

Alabama* W. H. Sanders. Montgomery .. Montgomery . .Feb. 1-6

Arizona* Ancil Martin. Phoenix Phoenix April i

Arkansas* F. T. Murphy, Brinkley Brinkley April 0

California Chas. L. Tisdale, Alameda. . . .San Francisco . April 16

Colorado S. D. Van Meter, 1713 Tre-

mont Street. Denver Denver April a

Connecticut*.. .Chas. A. Tuttle. New Haven. .New Haven. . March i»

Delaware L H. Wilson. Dover Dover June 18

Dis. of Col'bia. .W.C.Woodward. Washington. Washington-. .April 11

Florida* ID. Fernandez. Jacksonville. Jacksonville . . May is

Georgia E. R. Anthony, Griffin Atlanta April —

Idaho J. L Conant, Jr., Genesee Boise April 1

Illinois J A. Egan. Springfield Chicago

Indiana W. T. Gott. 120 State House.

Indianapolis Indianapolis. . May 28

Iowa iL ^- Kennedy. Des Moines... .Des Moines .. .March iq

Kansas T. E. Raines. Concordia Topeka Feb. u

Kentucky*.. . .J. N. McCormack, Bowling

Green Louisville April 23

Louisiana F. A. La Rue, 211 Camp St.,

New Orleans New Orleans.. . May 9

Maine Wra J. Maybury, Saco Portland March s

Maryland J. McP. Scott, Hagerstown . . . Baltimore June —

Massachusetts*. E. B. Harvey, State House,

Boston Boston March 12

Michigan B. D. Harison, 20s Whitney

Building. Detroit Ann Arbor. . . .June n

Minnesota O. E. Linier, 24 South Fourth

Street, Minneapolis St. Paul April 2

Mississippi J. F. Hunter, Jackson Jackson May 14

Missouri J A. B. Adcock. Warrensburg.Kansas City. . .

Montana* Wm. C. Riddell. Helena Helena April —

Nebraska Geo. H. Brash, Beatrice Lincoln February 13

Nevada S. L Lee, Carson City Carson City . . February 4

N. Hamp' re*. . .Henry C- Morrison, State Li-
brary. Concord Concord January —

New Jerwy J. W. Bennett, Long Branch. .Trenton June 18

New Mexico. . . .6. D. Black, Las Vegas Santa Fe June 3

( New York, )
NewrVork C.F.Wheelock Univ.of State J Albany. (

of New York, Albany. ... J Syracuse. f
( Buffalo. )

N.Carolina*... .G. T Sikes, Grissom Morehead City. May —

N. Dakota H. M. Wheeler, Grand Forks. .Grand Forks... April 2

Ohio Geo. H. Matson, Columbus... .Columbus June 11

Oklahoma* J. W. Baker, Enid Guthrie March 26

Oregon* B. E. Miller, Portland Portland April —

Pennsylvania.. N. C. Schaeffer, Harrisburg / .Philadelphia 1 June —

\ Pittsburg. /

Rhode Island... G. T. Swarts, Providence Pro\'idence. .. .April 4

S.Carolina.. . . . W. M. Lester, Columbia Columbia June —

S.Dakota H E. McNutt, Aberdeen Sioux Falls. ... July 10

(Memphis, I

Nashville, May —
Knoxville, J

Texas T. T. Jackson, San Antonio. . . Austin April i

Utah* R. W. Fisher, Salt Lake City. Salt Lake City.

Vermont W. Scott Nay, Underbill Montpelier. . . .

Virginia R. S. Martin, Stuart Lynchburg... .June 18

Washington*.. .C W. Sharpies, Seattle Spokane July 2

W. Virginia*. . .H. A. Barbee, Point Pleasant .Wheeling April 9

Wisconsin J- ^- Stevens, Jefferson Madison July 9

Wyoming S. B. Miller, Laramie Cheyenne

•No reciprocity recognized by these States.

tApplicants should in every case write to the secretary for latest
details regarding the examination in any particular State.

- January 29

A Case of Frozen Feet Treated by Thermaerother-
apy. — Francis S. Skiflf had under his care a patient
whose toes had been frozen. The toes of both feet were
lifeless and in half of each foot when pricked with a
needle there was little sensation. After treating the feet
for three days with hot bichloride packs, the writer turned
to local, dry, hot air applications. The patient was made
to place his feet in the apparatus at a temperature of
140-150° F., three or four times a day, for from an
hour to an hour and a half each time, during a period
of two weeks. After two treatments the patient felt better.
The feet were finally saved with the exception of a '■art
of the two great toes and the second toe. The after-treat-
ment consisted of antiseptic dressings and irrigations with
lysol or carbolic acid solution. — Archives of Physiological
Therapy.

Intussusception. — In discussing this condition Cole

says that the records of large numbers of cases show that
spontaneous cure occurs in less than 2 per cent
of the cases. The diagnosis is rarely doubtful in
infants. Tumor exists in almost all cases. Search for
it should be made under anesthesia, and by the conjoined
bimanual examination of rectum and abdomen. Sudden
onset, paroxysmal pain, vomiting, bloody discharges, ab-
sence of fecal matter, and the presence of tumor, leave no
doubt for diagnosis even in cases in which the baby is
suffering from enterocolitis. Purgatives aggravate the
symptoms, and are inadmissible. Attempts at reduction
of the invagination by distension of the colon under water
pressure should be used only in cases that are of not
more than six hours' duration. Irrigation should be per-
formed slowly, thoroughly, and with the greatest care,
the baby being anesthetised. The dangers of this treat-
ment are: (o) Shock, (6) loss of time, (c) increase of
the constriction, {d) rupture of the colon. In every case
in which the complete disappearance of the tumor is in
doubt, abdominal section should be at once performed. —
Intercolonial Medical Journal.

Narcosis in Diabetes. — The question of administering
anesthetics to diabetic patients is discussed by Kausch, who
summarizes his opinions as follows: General anesthesia
should be used as seldom as possible in dealing with dia-
betics, and the various methods of local anesthesia should
be resorted to when feasible. Anesthesia for diagnostic
purposes alone is to be avoided, as well as repetition of
the anesthesia. Ether is always to be preferred to chloro-
form. The amount of the anesthetic agent and the dura-
tion of the anesthesia should be reduced as much as pos-
sible, and in order to avoid the production of acetonuria
through long fasting it is advisable to operate early in the
morning. In order to prevent acidosis every diabetic who is
about to be operated on should be given bicarbonate of soda
until the urine becomes alkaline. If coma is threatened
sodium bicarbonate should be administered vigorously by
mouth, by rectum, and intravenously. — Archil' fiir klinische
Medicin.

Sterilization of the Hands. — Apropos of the various
procedures in use for sterilizing the hands Leedham-Green
says that unless the hands are in an exemplary cosmetic
condition good results cannot be obtained by any method.
A roughened or chapped hand does not admit of disinfec-
tion. Even after the most prolonged and energetic wash-
ing of the hands in soap and hot water, it is not possible
materially to diminish the number of microbes on them, and
there is no advantage to be gained by unduly prolonging
this washing process, as the hands never become sterile,
and, owing to the loosening of the epidermis, generally
appear more infected after than before the washing. The
use of turpentine, benzoline, or xylol during or after the
washing with soap and hot water, or of soaps to which anti-
septics had been added, does not appreciably improve the
results. The aqueous solutions of carbolic acid, lysol,
perchloride, or biniodide of mercury are practically pow-
erless to affect the microorganisms situated on the hands,
and the use of these antiseptics after a thorough pre-
liminary washing of the hands utterly fails to render them
sterile. The use of a saturated solution of permanganate
of potash followed by the application of strong oxalic acid
gives wholly inadequate results. Alcohol, owing to its
property of hardening and fixing the superficial cells of
the epidermis and its marked bactericidal action, possesses
a remarkable power of sterilizing the hands, far surpass-
ing that of all other agents. Of all the methods tested,
the best results were obtained by the following modifica-
tion of Fiirbringer's process: (a) The hands are first
scrubbed for five minutes with soap and very hot water
(about 50° C.), the water to be frequently changed. The
use of sterile sea sand as an addition to the nail-brush is
an advantage. (6) The hands are then rubbed with
methylated spirit for three minutes. (c) .Afterwards
scrubbed for a minute or two with 70 per cent, sublimate-
alcohol (l in 1,000). (d) And finally rubbed until dry,
and polished with a sterile cloth. — Birmingham Medical
Review.

A Simple Truss for Children. — An efficient, cheap,
and cleanly truss for u-^e in cases of inguinal hernia in
infants is described by Fiedler. It consists of an ordinary
skein of zephyr wool which is provided at one end with
two tapes. The skein is passed about the child's body,
and the end having the tapes is slipped through the loop
and across the inguinal region between the legs. It is then
secured in this position by tying the tapes around the legs.
A number of such skeins are kept on hand and washed as
often as necessary. The efficiency of the device is increased
by placing a small pad over the hernia.— Zcntralblalt fiir
Chirurgie.

128

MEDICAL RECORD.

[Jan. 19, 1907

Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious diseases reported to
the Sanitary Bureau, Health Department, New York
City, for the week ending January 12, 1907:

Tuberculosis Pulmonalis.

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis.
Malarial Fever

Totals

Cases

Deaths

446

162

291

51

204

6

234

8

3

—

154

—

43

8

60

4

21

9

1456

248

Origin of Urinary Casts. — Alessandro Amato states
that hyaline casts arise from fibrinous fibrillary cylinderi
by the action on them of a special pathological secre-
tion of the cells of the convoluted tubes, which shows
itself in the form of droplets which have a strong affin-
ity with basic coloring matters. He believes that this
is not the explanation of the genesis of all homogeneoui
cylinders. They may also be derived from a pathologi-
cal secretion of the epithelium of the convoluted
tubules, which appears in large drops in the tubes. These
may be slightly granular, and may be found in the as-
cending and descending limb of Henle's tube, and in the
straight tubules. Granular cylinders arise from proto-
plasmic detritus derived from changes in the internal
border of the epithelial lining of the canaliculi, which
gradually empty the cell contents into the lumen of the
tubule, leaving the nucleus and the wall of the cell be-
hind. Epithelial casts represent the desquamation of th«
straight tubes. Waxy casts are derived from the fusion
of droplets of a yellow color found in the lumen of th«
canals, and in the epithelial cells of the convoluted
tubules. They may be interpreted as hemoglobin sepa-
rated from the blood. — Rivista Critica di Clinica Medico.

Favorable Effects of the Use of Extract of the Supra-
renal Capsules in a Case of Addison's Disease. — P.

Spillman and M. Perrin have given careful study to
the treatment of Addison's disease. They refer to the
results of various authorities who have been interested
in this same subject. Adrenalin has been employed
sometimes with success. This success, however, has
been far more rare than in cases in which the total extract
of the suprarenal capsules has been used. Adrenalin is
only one part of the suprarenal capsules, and does not offer
a complete substitute when the destruction of these organs
is excessive. In certain cases even when the entire ex-
tract has been used no result has been obtained. It must
be accepted that the alteration of the suprarenal capsules
is only one part of the disorder; there are lesions of the
solar plexus, and there is also tuberculosis of other organs,
the course of which must be considered a most important
element in the prognosis. The writers then refer to a pa-
tient, a man forty-two years old, whom they have treated
with suprarenal extract by means of injections with ex-
cellent results. It is necessary to repeat the treatment from
time to time. But even with these limitations these inves-
tigators are satisfied with the effect of the drug as employed
in this case. — Revue Fraii(aise de Mcdecine et de Chirur-
gie.

Acidification of the Viscera as a Certain Sign of
Death. — Brissemoret and .■\mbard have made researches
in this subject. In the living animal the liver and the
spleen have an alkaline reaction, but some time after death

these same organs show a progressively increasing acid
reaction. The acidification of the viscera may be a valu-
able sign of death, because the acid reaction occurs rapidly
after death, because it is an absolutely constant phenome-
non, and because it is easy to prove. In order to make
the experiment one makes use of litmus paper and a fine
needle mounted on a syringe. As the liver and spleen
both become very rapidly acid after death, one may punc-
ture either of these organs. A little of the visceral pulp
and a little blood are extracted in the lumen of the needle.
The conclusions of these investigators have been confirmed
by the work of Ascarelli, who has conducted his researches
in relation to both man and the lower animals. Acidifica-
tion is more or less rapid, according to the cause of death,
and it is more rapid after death from hemorrhage (7 to
12 minutes) than after death from asphy.xia (18 to 28
minutes). This condition does not appear at the same
time in the different organs. The spleen is the first to
show evidence of it ; the liver, the lungs, the kidney, and
the heart follow in order. In the muscles the development
of the acid reaction is tardy and is related to rigor mortis.
Nevertheless, in certain cases, muscular fatigue and
strychnine poisoning, the acidity of the muscular tissues
may exist before death. The determination of visceral
acidity constitutes the first certain sign of death, a sign
which is simple and easy to determine in routine practice.
— La Tribune Medicale.

Health Reports.— The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the Surgeon-General, Public Health and Marine-
Hospital Service, during the week ended January 11,
1907:

SMALLPOX UNITED STATES.

California. Los .A.ngeles Dec.

San Francisco Dec.

Georgia, Augusta Dec.

Illinois. Abingdon Nov.

Chicago Dec.

Galesburg Dec.

Moline Sept.

Victoria and Vicinity Jan.

Indiana, South Bend Dec.

Kansas. General Nov.

Louisiana. New Orleans Dec.

New York. New York Dec.

Texas, Houston Dec.

Virginia, Louisa County Nov.

Washington, Spokane Dec.

Wisconsin, Milwaukee Dec.

CASES. DBA IBS.

!2-Jai

?7-No

22—29

8-is

2S-Jan. I..

16

2^-29

'an. s .
ov. 9.

7

2 2- Jan. 5.

30

29-Jan. s.
2 2-Jan. 5.
29-Jan. s .
I i-Jan. s .

22—29

15-Jan. s.

18
s

s
41

6
9
»3

Present.

SMALLPOX — FOREIGN.

Africa, Cape Town Nov.

Brazil, Bahia Nov.

Pemambuco Nov.

Rio de Janeiro Nov.

Chile, Coquimbo Nov.

Iquique Nov.

France, Paris Dec.

Gibraltar Dec.

Great Britain, Manchester Dec.

India. Calcutta Nov.

Madras Dec.

Italy, General Nov.

Russia, Odessa Dec.

St. Petersburg Nov.

Spain, Barcelona Nov.

Cadiz Nov. 1—30 .

Seville Nov. 1—30.

Syria, Beirut Dec. 8-15 .

YELLOW FEVER.

10—24

24-Dec. 8. .

I-J5

I i-Dec. 3 . .

15-30

24-Dec. IS.

1-8

2-9

15-22

23-Dec. I . .

1-7

22-Dec. 13.

S
28

16
2
a
Present

Imported

3
3

23-Dec. I . .

X4

17
6

S

3

33

Present

Cuba, Habana Dec. 26 .

Santa Clara Jan. 8.

CHOLERA.

India, Bombay Nov. 24-Dec.

Rangoon Nov. 24-Dec.

Chile. Antofagasta Nov. 26-Dec. 9. .

Egypt, .Mexandria Dec. 4-18

Garbeih Dec. 11

Guerga Dec. 11

Keneh Dec. 7—20

Henatfith Dec 10-18

India, General Nov. 17-24

Bombay Nov. 28-Dec. 8 . .

Calcutta Nov. 24-Dec. i . .

Rangoon Nov. 24-Dec. i . .

Japan, Kube Nov. 24-Dec. 8..

Mauritius Oct. 4-Nov. 8. .

6,941

4

4

r

I

6

23

1

|7

I

S.300

18

14

i8

Medical Record

A Weekly Jdiirnal of Medicine and Surgery

Vol. 71, No. 4.
Whole No. J890.

New York, January 26, 1907.

$5.00 Per Annum.
Single Copies, lOc.

(irisiual Artuks.

REMINISCENCES OF MEDICAL PRACTI-
TIONERS IN NEW YORK DURING THE
PERIOD OF THE EARLY HIS-
TORY OF THE ACADEMY.*

Bv A. JACOLII, M.D., LL.D..

NF-W VOUK.

The New York Academy of Medicine was founded
in 1847, sixty years ago, by one hundred and eighty-
four physicians. Two of those are still alive ; one,
is Nicholas Lafayette Campbell ; he resigned 1849.
I. C. Hepburn, a graduate of the University of
Pennsylvania, has continued his membership since
April I, 1863, as a nonresident. He lives at 71
Glenwood avenue. East Orange, N. J.

These sixty years correspond with the existence
of modern medicine established on two solid pillars,
viz., sound and repeated clinical observation, and
anatomical, local, histo- and bacteriological, and
biochemical diagnosis. The rapid progress of medi-
cine during this time in the United States is best
explained by the unprejudiced blending of cool
Anglo-Saxon empiricism with the readily adopted
anatomical, pathological, and general laboratory
work. You understand that I speak of that privi-
leged part of the profession which is no longer
where we stood sixty or more years ago, when the
words : paralysis, spinal irritation, dropsy, hydro-
cephalus, lung fever, continued fever, cyanosis,
idiocy, convulsion, were taken or offered as full-
fledged diagnoses, or when the principal etiological
factors were colds, worms, and teeth, and the thera-
peutic refuge calomel.

The study of the discourses before the stated
meetings of the New York Academy of Medicine
and the gatherings of the best men of the profession
will pay you. That is why I want you to look at
least over the two first volumes of our Transactions
and the two first volumes of the Bulletin. They
were published nearly half a century ago. By so
doing you will learn that many of the men who
participated at a mature age in whatever came up
for general consideration were those who will
uphold our American fame for all times. It appears
when they grew older they became more impressed
with their' responsibility to the profession. John
Watson, Alonzo Clark, Fordyce Barker, J. Marion
Sims, Gurdon Buck, James M. Minor, Ernst Krac-
kowizer, John H. Griscom, and many more were

*Read in part at the animal nieeting of the New York
Academy of Medicine, January 3, 1907. Not all of these
sketches could be read in this meeting for want of time.
They are here printed at the suggestion of the Editor.
Many more memories should be revived from time to time,
for the number of great and good and warm-hearted men
who once were fellows of the New York Academy of Med-
icine cannot easily be exhausted. They are still active,
like (he light and warmth of the sun after it has descended
below the horizon. Of the biographical notes many are
taken from old numbers of the Medical Register.

always present, and gave their best. They dis-
cussed diphtheria, tracheotomy, sudden death dur-
ing labor, albuminuria, fracture of the thigh, moral
insanity, epilepsy, hip joint disease, the eternal milk
question, public health, pulmonary tuberculosis,
human monstrosities, cyanosis, alcoholic stimulants,
anesthetics, cerebrospinal meningitis, hematocele,
lunacy legislation. Some of you may find, when pe-
rusing these papers and discussions, that several
things which had to be discovered and rediscovered
by persons ignorant of our medical history, may be
read with ease and profit in those old volumes. I
may also assure you that in those distant times only
very advanced age and sickliness were reasons for
staying away. The interest in the Academy and the
profession exhibited by our old colleagues did not
die out with the termination of presidential and
other offices. To us, the young men of that time,
many of them seemed like gods and detnigods, but
not, like them, invisible. They remained with us.
White hair and bald heads were always seen in our
meetings, and we young men were gladdened by
their presence and the instruction gathered from
their lips.

My memory recalls, however, some proofs that
they were not all angels. Some of them knew it all,
like, in our days, a hospital junior, and could not be
converted, though it is true that the majority were
anxious for any supply of learning or information
near at hand or from afar. I may have to speak
of the ignominious treatment dealt out to Horace
Green, within my hearing, though before my mem-
bership, by the majority of a committee appointed
for the purpose of looking into his local treattuent
of the larynx and trachea. Nor was it possible
to keep the hatred and jealousy of the Civil War
out of this Academy. T. G. Thomas, a Southerner,
was charged with harboring Southern proclivities
within his bosom and giving expression to them.
He was the recording secretary, and the first year of
the war was the last of his secretaryship. I think
I am quite correct — for it is only forty-six years ago
that it happened — when I state that he had only
two votes in his favor, those of two abolitionists of
foreign extraction. It is surely true that there are
no blinder tyrants, nor greater enemies of public
welfare, than the prejudices of race, religion, and
politics.

Of my own time there are but few survivors.
Stephen Smith joined 1855, Thomas Addis Emmet
1856; he writes history, and is happy in such, as
he made himself; Dr. Mark Blumenthal, who at
present enjoys his honeymoon, in 1857; Ellsworth
Eliot in 1858. Him I should be tempted to call ven-
erable if he had not succeeded in remaining young
through the aid of his eternally youthful enthusiasm,
fired by the study of the history of American med-
ical, municipal, and social lore.

Having been permitted to indulge in personal
reminiscences, I thought I could not entertain you
better than bv refreshing your memory through call-

130

MEDICAL RECORD.

[Jan. 26, 1907

ing up names that should be dear to every American
medical man. What warmth and enlightenment
there are in history are best represented by biog-
raphies. The first president under whom I
served was Valentine Mott, the excellent sketch of
whose life has just been read by Dr. Smith. His
name is familiar to everyone. He was president in
1849 and in 1857, when I joined the Academy. The
history of his life may be studied to advantage by
every medical man who is desirous of learning about
and of appreciating the difficulties of medical study
and teaching in bygone times. He died on April
26, 1865, nearly eighty years old. My personal
intercourse with him was not exactly intimate, but
he was prominent among the old and grand men
that took kindly to the young foreigner who, if
nothing else, was willing to learn and anxious to
work. That is why I could not understand the cruel
treatment Horace Green experienced at his hands.
Mott was always active, always interested. Such
vanity as he had I never had reason to feel to any
disagreeable extent. He did not object to speaking
of his surgical triumphs, but was more proud of his
labors in the dissecting room. Once he asked me
on the sidewalk in Fourth avenue : "Have you ever
seen a double cremaster?" I looked puzzled. He
laughed merrily and said : "I think nobody has,"
took me by the collar to his house in Gramercy
Park, and there in a jar, lo and behold, there w;is
"his" double cremaster.

His successor in the presidency was John Putnam
Batchelder, born in New Hampshire, .August 6,
1784. He died in New York, April 7, 1868. After
having practised medicine on a license he took his
degree in Harvard 181 5. The last twenty-five years
of his life he practised in New York, where he was
the president of the Academy of Medicine in 1858.
In 1817 he took the chair of anatomy in Castleton,
Vt., afterwards that of surgical anatomy in Pitts-
field, Mass. Of those early times he would often tell
me of the scarcity of bodies, of the expeditions
undertaken on the worst moonless nights to distant
cemeteries, quite frequently armed, always prepared
for traps and scuffles, and hairbreadth escapes.
Smilingly he would say, with a twinkle in his eyes :
"I was young then, and not at all stiff as you see me
to-day." He became widely known by his opera-
tions on tumors, on stone in the bladder 1818, liga-
ture of the carotid 1825, for sarcoma of the maxilla,
which operation had to be followed by the removal
of the maxilla (the first after Valentine Mott), 1832
removal of the upper jaw. If not the first, he was
one of the first to remove the head of the femur.
He wrote on inflammation, compressed sponge,
cholera, and "thoughts on the connection of life,
mind and matter in respect to education." That
shows the variety of his interests. He never ceased
to work and keep his eyes open. He tried to learn
from his peers and his inferiors. When I was in
Amitv street after T858, I had the good luck to
live in his neighborhood. Very often he would
come in with a specimen in whose histological struc-
ture he was interested. I never met with a man
who was more enthusiastic over Virchow's cellu-
lar pathology, which he studied in Chance's
translation of 1861.

John Hoskins Griscom was born on Augrtist 13,
1809, in New York, and died .\pril 28, 1874. He
studied medicine in Rutgers College and the Uni-
versity of Pennsylvania, took his degree 1832, was
professor of chemistry in the College of Pharmacy
from 1836 to 1838, 1842 city inspector, and as such
the head of the Health Department, and later at-
tending physician to New York Hospital. City in-

spector he was a single year only, for the step-
fathers of the town wanted a pliable and ignorant
political tool. When in the Health Department he
ruled that no burial could take place without a per-
mit, the permit depending on a medical certificate.
If you consider that New York had at that time
nearly half a million of inhabitants — that meant a
very large city — you will estimate the low state of
our civilization only sixty years ago. Griscom's
labors in favor of e.xecuting principles of sanitation
remained inefficient before the legislature passed
the first health laws suggested by him. In the three
years following January. 1848, when he was Com-
missioner of Emigr linn. 700,000 emigrants landed
on our shorev 1 wenty thousand had ship fever,
and Dr. Griscom caught it. Ilis memorial, trxposing
the hardships of emigrants due to the lack of food
and accommodations, overcrowding in steerafr
absence of medical care, cruelty of captains, brutal-
ity of sailors toward men, and still more toward
women, and the indolence of our laws and law-
givers, was a State paper of great value, and cei-
tainly contributed to open the eye^ of the public, if
not the hearts of the legislature. Fifteen years he
was a member of the prison association, and ten
years the chairman of its executive committee.
Many laws ameliorating the fate of the prison in-
mates are due to his initiative. In this Academy hs
was seen very often, never without a contribution,
never without exerting a great influence, both on
account of the value of his words and of his im-
pressive presence, and often passionate bea; ing.
He spoke best when his warm heart was full, and
warm and full it always was. If every generation
had many men of his stamp, with complete irastery
of the subjects he was interested in, a clear under-
standing of what was wanting in our public affairs,
a generous heart which made him offer his labor
unstintedly in the public service, the community
would be better off, and the profession stand as high
in the estimation of the thinking part of the public,
as in that of many of the sages of antiquity and
modern times.

William Currie Roberts, born in London, 1810,
emigrated to New York 1820, graduated at the Col-
lege of Physicians and Surgeons 1832, founded
1835 the first infirmary for the diseases of women
and children (in 361 Broome street), which had
soon to be closed on account of lack of funds,
started a class for women and children, and nervous
diseases in the Northern Dispensary in 1844, was
afterwards physician to the city prison and to the
Park police. In the third year of the Civil War,
1864, he was an enrollment officer. Much money
was made at that time — not by him ; the cowards,
the tradesmen, the sympathizers with the rebellion
paid heavily for being pennitted to stay at home, or
for not furnishing a substitute — not to him ; the
love of country came second to that of the bargain
counter or of the shoddy factory ; graft was the
shibboleth — not to Roberts. He died poor, and the
well-to-do persons called him "a fool." In the pro-
fession he was highly esteemed for his scientific
attainments, his frequent contributions to the dis-
cussions of the Academy, his probity, aye for his
occasional ebullitions of temper always, however,
exhibited in the cause of right and justice.

Dr. John W. Francis was born 1789, when Wash-
ington was inaugurated in the city of New York
as our first President, and died on the 8th of Feb-
ruary, 1861, a few weeks before the attack on Fort
Sumter. Perhaps some of my readers who
were born before yesterday may remember when
and what that was. So his life is of exactly

Jan. 26, 1907]

MEDICAL RECORD.

131

the duration of the first great period of our national
existence. In the history of the nation in its social
and political development, in its incipient literature,
not only medical, he took the warmest interest. He
was a keen-eyed, warm-hearted, plain-spoken, and
generous-minded man, a practitioner of wide re-
pute, and the consultant of the greatest authority,
not only in obstetrics, to which he gave special at-
tention ; and for a number of years a teacher of the
institutes of medicine, or of materia medica, of
medical jurisprudence, and of obstetrics and foren-
sic medicine in the Rutgers Medical College and in
the College of Physicians and Surgeons, of which
he had been the first graduate. You must not smile
at the multiplicity of chairs he filled in a dozen years
and of things he taught. You must not forget that
this took place nearly a hundred years ago, that
the limits of knowledge were narrower than to-day,
that the great men in the profession had spent all
their lives studying classics, history, and medicine,
and its adjuvants, and that there was no specialism
of nowadays. Not a half a hundred years before
Francis it was considered natural that a profound
mind and studious worker could be both a great
medical man and a thorough philologist ; not tliirty
years before Francis, Albrecht von Haller taught
anatomy, physiology, botany, and the practice of
medicine, and was the examiner in surgery, though
he never performed an operation. Nor should we,
in the America of the twentieth century, be too gen-
erous with our ridiculing smiles. Many of us know
that within our own time, within a score of years,
men would teach in our own colleges, willingly or
unwillingly, physiology, materia medica, and sur-
gery, or materia medica, physiology, and obstetrics.
Let us fervently hope that medicine will, for the
future, get the better of politics and money, or social
influences in our schools, and that this future may
arrive soon, while some of us may still enjoy that
felicity.

Dr. Francis' sojourn in Paris, London, and Edin-
burgh brought him into connection with eminent
men, such as Cuvier, Gall, Gregory, Playfair,
Brewster, and many others. His library and ar-
tistic tastes kept him in constant contact with pro-
fessional men of all kinds. That is why very few
men whom I knew in the profession of New York
could at any time compare with him in mental
breadth and vigor. He was very social when you
knew him more intimately, and inclined to be
jocose. I had seen him a few times only, when
one day he stopped me at the corner of Broadway
and Bond street, near where he lived. "They speak
well of you," he said, "and you will get on : only
people want sometimes some outward show. Now,
I am an old man, and you will not mind it when I
say you ought to have another tailor." I replied :
"You see. Dr. Francis, you are an old doctor, and
famous, and you can afford to wear the old-
fashioned clothing of the eighteenth of Brumaire
and of the century of William Penn. but I cannot
afford yet a better tailor." He laughed, took me to
his office, and we had a pleasant half hour, at least
L for he tried to make me believe that I taught him
something of medical doings in Germany, with
which he said he was not so well acquainted as with
the affairs of Great Britain and France. My re-
marks on his clothing appeared rather to please
than to shock him. He was somewhat inclined to
be a little pompous, and the cut of his clotliing was
fashionable when he was a boy. Otherwise his
mental outfit and the breadth of his knowledge, and
manifoldness of interests, and wide general
horizon have often reminded me in after years of
our friend, William H. Draper, who had all the

accomplishments of Francis, perhaps some more,
but without vanity, and with an undisturbed temper
and unruftled, kind-hearted geniality, all of which
outlasted his healtli. Draper was to the end of his
days, with the exception of Ernst Krackowizer*,
who was his equal, the finest specimen of a thor-
oughly cultured medical gentleman of his genera-
tion.

Under Dr. Hosaclc he took part in the edit-
ing of the Aincricaii Medical and Philosophical
Register, and with Beck and Dyckman, of the New
York Medical and Sur:^ical Journal. "On the Use
of Mercury" was published 181 1, "Some Morbid
Anatomy Descriptions" 1814, his edition of "Den-
man's Practice of Midwifery" 1825, "Letter on
Cholera Asphyxia" 1832. The history of New York
was published 1866.

At the age of sixty-five years, there died in 1864
James Stewart. In him I was very much interested,
on account of his exertions in the interest of sick
children. In 1839 he translated Billard's diseases
of children, in 1841 he published a "Practical
Treatise," in 1852 "A Few Remarks About Sick
Children in New York, and the Necessity of a
Hospital for Them, By Philopoedes, an ex-Dispen-
sary Doctor," in 1857 the Academy of Medicine
prize "Essay on Cholera Infantum," and was busy
in collecting a fund to establish Christ's Hospital
for Sick Children. In an obituary he was called
"retiring and thoughtful, yet humorous." The first
was certainly true; the latter he may have been
when I once left his house in Abingdon Square.
It happened this way. I was very anxious to make
his acquaintance, and told him so when I called
upon him without any other introduction than my
assertion that I was interested in diseases of chil-
dren, and desired very much to have him cooperate,
or rather lead in the establishment of a children's
section in the Academy. Indeed he was "retiring;"
my visit was a very brief one; I was chilled all
through. I see myself still sitting down on one of
the stoops in his block pwndering over my misdeeds
and what sin I might have committed. I must have
risen after a while, but 1 am pondering yet.

In regard to my pediatric efforts, I was more
fortunate when I approached a younger man, Mor-
timer G. Porter, who died November 24, 1863, of
typhoid fever, at the age of thirty-seven years. He
aided me in the attempt at establishing a section for
the diseases of children in the New York Academy
of Medicine. Either the time, or we, were not ma-
tured for that achievement. It took twenty-five
more years to consummate what we then planned.
Meanwhile a similar section was established in the
A. M. A. Its first meeting was held at Richmon<l
with the cooperation of Samuel Busey of Washing
ton, whose interest in all subjects connected with
medicine and the welfare of the medical profession
should always he remembered, t cannot sufficiently
extol the interest and labor bestowed on the perfec-
tion of our plans by Dr. T. M. Rotch, at that time
not so famous, hmt quite as active as to-day.

Another young man who died much too soon was
William Rice Donaglie. He was born in New
Haven, Conn., 1830, and died in the Bloomingdale
Asylum after a long illness. I knew him well. A
year after I tried my feeble strength in the spring
course of 1857 of the College of Physicians and
Surgeons, he and T. Gaillard Thomas arranged
private courses in anatomy and obstetrics at 104
Third avenue. They insisted at that, for us, early
time on practical work ; dissection and the applica-

*UnfortiinateIy, to the eternal detriment of the profes-
sion and the commimitv, Kr.Tcknwizer died as early as
1875-

132

MEDICAL RECORD.

[Jan. 26, 1907

tion of the forceps were taught, and their school was
successful. He was a manly, tall, blond, long-haired
man, with a pale, fearless face, and upright and
outspoken, sometimes, as a few thought, too much
so. When he was taken sick, some said '"1 told you
so." But it need not be insanity that makes a manly
man outspoken, fearless, and pounding away when
he is right.

Dr. George Thomson Elliott was bom May 11,
1827, and died on the 28th day of Januan.', 1871.
After graduating in the University Medical Col-
lege in 1849 he spent three years in Edinburgh,
Dublin, London, and Paris, worked in the lying-in-
hospital from 1852 to 1854, and was one of the
founders of the Nursery and Child's Hospital.
With the Infant Hospital on Randall's Island and
the New York Woman's State Hospital he was con-
nected at an early time. He taught anatomy at
Woodstock in 1856. and was one of the founders of
the Bellevue Hospital Medical College in 1861. He
missed a great chance, when the new school was
established, in not daring to insist upon at least a
three years' course and a shorter vacation. I had
for some time been connected with the New York
Medical College in East Thirteenth street, and knew
the shortcomings of our college methods from my
own observation. Perhaps he was too much bent
on pleasing, for he was genial, amiable, and
sociable, to exhibit the courage of a reformer, or
even a revolutionist. In a large general practice,
which was promoted by his social connections, his
genera! achievements, and his knowledge of French
and Spanish, and by extensive obstetrical and gyne-
cological work, he exhausted himself and fell an
early victim to apoplexy. He was die first to be in
possession of the hx'podermic syringe invented in
Paris by Pravaz, 1831, for the purjxjse of in-
jecting chloride of iron into aneurysms, and intro-
duced into Edinburgh, 1858, by Alexander Wood
through a pamphlet entitled: "On a New Method
of Introducing Medicine Into the System More
Especially Applicable to Painful Local Nervous
Affections." In the summer of 1858 Elliott visited
that city, and carried with him to America some
of the valuable instruments. He gave me of his
bounty. I need not say that after they once entered
America thev were soon generally known among
us. You mav wonder whv it took 3'ears before one
of the most useful inventions crossed the ocean.
Still, fifty years ago it was big and vast. Elliott's
"Obstetric Clinic" was published in 1868: it proved
a vast improvement on similar previous works, and
spread his reputation over the States. The book
was preceded and followed by a number of maga-
zine articles. He was always diligeuE, studious, zeal-
ous, and withal gracious. He should be remem-
bered as a m.an of taste, a refined scholar, an ami-
able colleague, and should not be forgotten in this,
our fast-living time. His linguistic advantages, as
I said, were many, hut not quite so varied as he
thought. Once he returned frora Germany and
France, and hailed me with the exclamation : "I
!-iiow German." I requested him to tell me some-
thing in German. He posed and said: "Kellner.
eine Flasche Markobruimer." I laughed, and asked
him to say sometliing else. "Don't ask me too
much,'' he replied. "I had only a few weeks and
a great deal of T>ractical work to do, biit I do Icnow
something else." "What is it?" "Kellner, noch
eine Flasche Markobrunner."

James Livingston Brown was bom April 2, 1831.
He furnishes an example of a typical American
career, cut short by death. He attended the public
school, was a pupil in a private school in Canal

street, and paid his fee by serving as janitor. He
began early to teach Latin, Greek, and the rudi-
ments of music. He had a scholarship in Columbia
College, received his B.A. in 1852, and A.M. in
1868. In his vacations he would peddle thermome-
ters, pens, and what not in New York, Albany, Bos-
ton, and Philadelphia. Add to this indefatigability
and ambition, amiable manners, and great personal
chann and modesty, together with the idealistic
tendency not only to become prominent but also
useful, and you have the picture of what makes
a great doctor and a good citizen. After his gradu-
ation in 1856 in the University Medical College,
Dr. Rrown soon rose in the opinion of the profes-
sion, if not in riches — for it was not his love of
music alone that made him retain his place as
organist in St. Luke's Church fully seventeen years.
He was long connected with Demilt Dispensary,
wth the Health Department as a sanitary inspector,
and with Professor G. T. Thomas as his chief of
clinic. His practical work turned more and more
to be gynecological, and his contributions to litera-
ture belonged mostly to that specialty. Few may
have known that the case of diabetes in a baby of
less than two years, described in the first volume
of the Journal of Obstetrics and Diseases of Women
and Children, 1869, occurred in his own child.
That was one of the accidents occurring in a life full
')f hardships, exertions, and incipient successes only,
which promised so much and was cut off too soon.
David Meredith Reese died March 1,3, 1861, after
having occupied the chair of the Practice of Medi-
cine in the New York Medical College for several
years. Born 1800 in Maryland, he graduated from
the Medical University of Maryland 1819, and be-
■ame a vaccinating physician in Baltimore 1824. He
was profesfjor in Castleton 1841-42, in the Wash-
ington University of Baltimore 1842-45, then in
.Albany, N. Y. Afterwards he became resident phy-
sician of Bellevue. New York, and one of the
foimders of this Academy in 1847. Cordell. in the
medical annals of Maryland, speaks of him as an ex-
tensive writer on yellow fever. In 1844 he pub-
lished an .American edition of Cooper's dictionary
of practical surgery, and edited until his death,
which occurred in New York. May 13, 1861, the
America}'. Medical Gazette. Being his colleague in
the New York Medical College. I knew him well.
He was a queer mixture of Southern humor and
dyspeptic grimness, a hard worker, and open to
scientific suggestions, no matter whence they came.
He was older than most of his colleagues, but the
small hours of the night never frightened him
liomewards from the northwest corner of University
place and Eleventh street. His anxious life com-
panion blamed us for his early death.

Dr. Richard J. O'Sullivan was born in Ireland,
1833, and died "in New York May 16, 1896. He
read a paper on school hygiene before the New
York Academy of Medicine June 19. 1873. He was
sanitary superintendent of the Board of Health, and
for some years sanitary school inspector, until the
office was abolished. One of the results accom-
plished by him was this: that of 40.000 children
vaccinated by him not one was taken with smallpox
during an epidemic of that superfluous, preventable,
nast>- disease of medieval semicivilization, the pet of
anti vaccinationists. That is what he did. and many
more things. In appreciation of his merits, the
Board of Education rewarded him by abolishing
the office of sanitary school inspector. In his paper,
which was discussed by C. R. Agnew. A. Jacobi,
,-md John C. Peters, he claimed equal rights for
physical and mental culture, censured the iniquitous

Jan. 26, 1907]

MEDICAL RECORD.

133

habit of sending children to school prematurely —
he found children of four years in the public classes
— and claimed that "seven years is an early enough
age for a child to be sent to school." That is the
same conclusion I arrived at in my contributions
to Gerhardt's "Handbuch," 1876, and to Buck's
"Hygiene," and which, fortined by further studies,
I am prepared to uphold at the present time. He
insisted upon a proper division of time in schools.
short lessons, and long recesses, mainly for the very
young. Perhaps you are aware of the circumstance
that, within a few months this last year, when the
question of the shortening of the school hours was
discussed by the authorities, it was proposed to
insist upon an uninterrupted in.struction of the
unfortunate young victims through three full hours
in succession. If there is a more direct method of
raising a nation of invalids and idiots, I am not
, acquainted with it. O'Sullivan rejected the drill-
sergeant exercises and demanded spontaneous
sports and amusements during the recesses, ob-
jected to insensate cramming, recommended meas-
ures for the protection of the eyes, and for ventila-
tion of the classrooms and against the dissemina-
tion of contagious diseases. What happened? Dr.
Ellsworth Eliot, president of the County Society ;
Dr. Austin Flint, president of the New York Acad-
emy of Medicine : Dr. John C. Peters of the Journal
Association, and a number of others, memorialized
the Board of Education in behalf of the reappoint-
ment of Dr. O'Sullivan as sanitary school inspector
on April 12, 1873, the Medical Rfxord of Septem-
ber 15, 1873, and the Evening Post took an able
part in the discussion, all to no purpose. Thus the
office created on January i, 1871, was on April 30,
1873, abolished by the Board of Uneducation. Please
to remember that Dr. O'Sullivan worked and wrote
for medical school inspection more than one-third of
a century ago, both as a member of the Academy
and of the medical society of the county, and as a
conscientious citizen of the Commonwealth.

John C. Peters was born on the 6th day of July.
1819, in Long Island, and died on the 21st day of
October, 1893. As a child he lived in Yarick
street, as a boy in Bethlehem, Pa. He studied
medicine in Berlin, Vienna, and Leipzig. In the
minutes of the stated meeting of November 14,
1842, his name appears for the first time in connec-
tion with the Medical Society of the County of New
York. It was resolved that his examination before
the Comitia Minora be sustained, and that he receive
a license entitling him to practise physic and sur-
gery. Of the same society he was president in
1866 and 1867, after Henry B. Sands and before
Freeman T. Bumstead, George T. Elliott, and
myself. The example of a relative who was an in-
fluential homeopathic physician in the city of New
York, prevailed upon the young, inexperienced doc-
tor to join homeopathy. His social connections
with many of the prominent families of the city
who partook of the sectarian infection which had
spread rapidly on account of the persecution from
which the homeopaths had to suffer at the hands of
the regulars — a shortsighted and suicidal policy —
secured for the cultured, witty, and refined new-
comer an extensive and lucrative practice. During
that period of his life he began his literary career.
Between 1853 and 1856 he published books and
pamphlets on apoplexy, headache, diseases of the
eye, on married females, on the brain and nerves.
They were in part original, in part adaptations of
the writings of Riickert, a German homeopathist,
and every one of them homeopathic. Plis paper on
"Materia Medica" written from 1856-1860 bore the

same stamp. For years he was the chief editor of
the North American Journal of Homeopathy, the
author of several works on homeopathic practice,
and the leader, or surely one of the leaders, of what
at that time was called a school. You may be able to
appreciate the surprise both of friends and foes,
when, on August 17, 1861, he published in the
American Medical Times, then the most influential
weekly of the United States, his renunciation of
homeopathy. Many hands were raised against him,
many armed with clubs. One of the most ethical
of our brethren, fed on the dogmatic rule of the
code of ethics of the American Medical Association
which prohibits newspaper advertising, declared he
would not be satisfied until Dr. Peters would pul>
lish his renunciation in the daily papers. But h.e
himself remained anonymous, like other cowards.
That no friend was left to John C. Peters among
his homeopathic colleagues is self-understood. But
such was the character of that staunch and stead-
fast man that neither the suspicion of what was
the regular profession, nor the enmity of his asso-
ciates, nor the loss of a lucrative practice, swerved
him from what to him was the plain duty of a
scholar, a man, and a gentleman. He survived
enmity, however, jealousy, and pecuniary injury,
and enjoyed to his last days the profound respect
of the profession. He was, 1844, one of the found-
ers of, and an earnest worker in the New York
Pathological Society, and for years the editor of
its proceedings, but was forced to resign on ac-
count of his homeopathic connections. He was
one of the founders and presidents of the Medica!
Library and Journal Association, which contributed
so much to the greatness of the library of the New-
York Academy of Medicine by the donation of all
its books and journals. He exhibited a great and
important interest in infectious diseases, mostly in
Asiatic cholera, on which he began to write in 1866.
Almost every year thereafter he added to its liter-
ature up to 1873, and again in 1885. His main
work, of a thousand pages, was published by Con-
gress in 1873. For the Health Board of New Yorlc
he studied and wrote on yellow fever in 1878. As
he was a believer in the filth origin of infectious
fevers, it came natural to him to adopt, when the
lime matured, the bacteric etiology. I knew him
well ; that is why I want you to know him, and to
remember his name and doings. He was learned,
had a general broad, classical, and modern educa-
tion, and extensive reading. To the last hours an
earnest student, a facile and fluent writer, witty
and sarcastic, but mostly of a kind humor, and re-
spectful. His temper would sometimes get the bet-
ter of him, but, as a rule, he controlled it, for he
was just to everybody and loyal to his friends.
Best of all, he was fearless, as is shown by his rene-
gation of what then was called homeopathy, and a
good citizen, ever active in medical aflFairs, and de-
voted to the interests of the profession. One side
of his character and doings is well illustrated by the
following letter, which appeared in the Evening
Post many years ago. It reads as follows :

"To THE Editor of the E\-exing Post :

"Sir: — It is interesting (and not least so to
those who worked in the .^anitary Commission
towards the assuagement of the inevitable horrors
of civil conflict) to hear anything authentic in illus-
tration of what Miss Wormeley calls 'the other side
of the war:' and such reminiscences are still more
worthy of record if they tend to harmonize, for cur-
rent uses, the feelings of those who, though once in
deadly array against each other, ought now, for

134

MEDICAL RECORD.

[Jan. 26, 1907

their mutual good and for the advance of general
civilization, to meet in purely fraternal relations.

"I repeated last night to a sister of Dr. Peters
what I had read an hour or two before in your issue
of yesterday evening about his refusing a fee from
a Union soldier for professional services rendered
during the war, whereupon she told me this: Dr.
Peters was in the habit of attending, without
charge, those soldiers needing medical attendance
who were quartered during the conflict at Camp
Scott, on Staten Island. When Mobile was taken
by the Union forces, the house belonging to one
of Dr. Peters' friends — deserted by all its residents
but one negro — was entered, as lawful prey, accord-
ing to the ethics of warfare in an enemy's country,
by the bluecoats, consisting mainly, in this instance,
of a contingent from Camp Scott, and the faithful
servant was. of course, powerless to stop the looting
they immediately began.

"But among the decorations of the walls was a
portrait of Dr. Peters. This discovery changed the
situation. 'Boys !' cried the leader of the Camp
Scott men, after some explanations from the old
negro, 'here's the doctor's portrait. We can't touch
this house. It belongs to one of his kin. Let's
skip, and try somewhere else.' And undespoiled
it was accordingly left to the old caretaker, his
friends reaping where Dr. Peters had sown.

"A. J. Bloor."

The two last named men died within a dozen
years ago. Very few of you, however, remember
their labors, even their names, for what Sir Thomas
Browne said three hundred years ago is surely true :
"The iniquitv of oblivion blindly scattereth her
poppy, and deals with the memory of men without
distinction to merit of perpetuity." Thus it happens
that otherwise good and true men forget the bene-
factors within their own ranks, that the men, who
by accident or push, arc able to arrogate high
places, are remembered, and the memory of the
modest, consistent, warm-hearted, far-seeing, and
altruistic is buried with their caskets.

I wish I could contribute to changing all that.

THE HOUSE FLY AND ITS CONNECTION
WITH DISEASE DISSEMINATION.

Bv G. K. DICKIN.SON-. M.D.,

JERSEY CITY, N. J-

The channels by which disease germs are carried
is a matter much discussed by the profession and the
laity. This question has been answered by supersti-
tion and plausible ignorance for ages. Agents, at
one time believed noxious, have become practicallv
ignored. It behooves the physician and the sani-
tarian to investigate carefully and scientifically such
means of dissemination as seem potent. The men-
tal attitude of the profession towards flies as an im-
portant agent in the spread of disease has been one
of credulity and indiflFerence. The object of this
paper is to present this question in its several
aspects, quoting only those authorities whose state-
ments are the result of careful observation and ex-
perimental investigation.

'Seven different varieties of flies are found in our
houses. 98 per cent, of which is the common house
fly (I'i'fiisca (iomestico). Born in manure, generally
that of the horse, or in decomposing matter of anv
kind, vegetable as well as animal, they enter our
homes to alight on foods there stored. Their tastes
are indelicate and omnivorous ; they subsist on
sputum, fecal juices, and the slime and dirt that
sticks to exposed surfaces.

House flies are without stings, and are unable to
penetrate the skin. Their proboscides, through
which they feed, are connected with an extremely
active salivary gland, capable of pouring out a large
quantity of saliva, which the fly projects against a
dry surface, swallowing the subsequent solution.
Naturally, solid particles, living organisms, para-
sites, and eggs, small enough, may pass into this
digestive tube. Bacilli of diflferent types and eggs
of the nematodes have been observed in the probo-
scides, stomach, intestinal tract, and defecations.
The time that particles remain in the digestive tract
of the fly is from 12 hours to 23 days. Evidently
the digestive secretions are not active for harm, as
organisms will not only pass through alive, but in-
crease in number while in transit. There must be
some absorption of the toxins of bacilli, for flies die
in large numbers which have had the fortune to
imbibe such bacilli as those of the plague and an-
thrax. Flies are large breeders, lay their eggs by
preference in horse manure, but also in decaying
meat, meat broth, cut melons, dead animals, and
even in cuspidors. On these substances their larvse
subsist until they hatch. From 10 days to 2 weeks
after the time the egg has been laid the fly is fully
hatched. It is estimated that one fly, laying 120
eggs at a time, will have a progeny amounting up
to the sextillions at the end of the season. Busck^*
took a quarter of a pound of horse manure and
found in it 160 larvje and 146 pupse. This would
make about 1,200 house flies to a pound of manure.
In a cubic inch of manure taken two inches below
the surface 200 pupse were found.

Caldwell,*^ noting fly larvfe in countless numbers
in refuse which had been buried 3 days, questioned
as to what became of the flies when the pupae were
hatched deep in the ground, where, after careful
search, but one dead fly was found. He made
experiments to solve this problem, taking earth and
night soil from the trenches, putting it in a glass
box, the top of the box being covered with muslin
carefully fastened down witli gummed paper. The
soil and earth were carefully arranged so as to form
an imitation of a shallow trench. On the fourth
day the first fly made its appearance, and by the
morning of the seventh day the space between the
muslin and the paper was swarming with them.
He analyzed the events as follows : The ova are
deposited in the latrines, and are conveyed in filth-
carts to the trenches ; the larval and pupal stages
take place below the ground, and the developed
fly makes its appearance between the covering of
earth. He never succeeded in hatching flies in wet
earth.

^lost writers claim that flies do not travel far
from the locality in which they are bred, and little
is known as to just what distance they may cover.
Professor Packard, according to Ernst," gives the
rate of speed of the common house fly as 5.35
meters per second, or a mile in 5 or 6 minutes,
which is at the rate of 10 miles an hour. Packa*-d
thinks any of the flies can scent their food for sev-
eral miles, and might fly 20 or 30 miles a day if
aided by winds.

Our present accurate knowledge of the possible
spread of diseases by flies is antedated, like many
of our modern ideas, by the inferential observations
of a.stute observers of past times. As early as 1498,
in a work attributed to Bishop Knud,-* is the state-
ment that the plague may be foretold by frequent
changes in the weather, much fog and rain, andthe
increased number of flies, and in 1577 Mercurialis
noted that flies, after lighting upon the sick, visit
other houses, depositing their contents upon bread
and other articles of food.-'

Jan. 26, 1907]

MEDICAL RECORD.

135

Sydenham' (1666) says: "From my own prac-
tice I know of only two observations by which we
can prognosticate the heahhiness of the autumn
that is to follow ; first, if fevers appear unnaturally
early, the season that follows will be exceedingly
favorable to the development of epidemics. I have
remarked that, if swarms of insects, especially
house flies, were abundant in the summer, the suc-
ceeding autumn was unhealthy. This I observed to
be the case during the whole summer of the afore-
said year (1661), while in the summers of the two
following years, which were ve'ry healthy, the
insects were very few. Still, I must remark that at
the approach of even so severe a disease as the
plague, they were not observed to be very abundant.
With these two exceptions T have observed that all
prognostics are fallacious.'"

In 1853, "J. F."-* referred to the increased num-
ber of flies in cholera times, and in 1873, Nicholas,-'
speaking of the cholera epidemic at Malta in 1849,
states that he was then impressed by the possibility
of flies transferring diseases, as they were present
in great numbers, and had free access to dejections
and food.

Marpmann-' (1864) said that the natives of
Friesland blame the spread of hog erysipelas to
flies, and Francis," in 1893, reported the case of a
woman he saw in 1846 who developed cholera
shortly after swallowing a fly, and who died from
the disease. Joseph-^ believed that domestic flies
may carry bacilli and deposit them on wounds, and
that anthrax may result from infected flies being
crushed on a wounded surface.

The inferential deductions of the better-informed
writers of recent date should be admitted to the
argument. Davaine (1868)-'' stated that the infini-
tesimal quantity of blood which suffices to transmit
anthrax corresponds with the amount of fluid in the
fly's proboscis. He claimed (1870) that the role
flies play in the transmission of anthrax had long
been known. Moore' (1893) .suspected flies as
being carriers of cholera, typhoid fever, tubercu-
losis, anthrax, and leprosy. Battersby' (1895)
attributed an epidemic of typhoid fever to flies which
were abundant, the water supply being beyond sus-
picion. Bachman'" ( 1898) suspected the ability of
flies to carry the eggs of parasites and deposit them
on food. Joly-* ( 1898) argued that if flies can carry
pollen, why not bacterial matter. Veeder'* (1898),
noting a commode from which typhoid excreta had
been recently emptied without cleansing, and placed
next to a pitcher of milk, saw flies gather around
both, endangering, in his opinion, not only that
household, but the whole neighborhood.

Hervioux,-^ observing that in the epidemic of
smallpox in Tamorna-Djedida the disease spread in
the direction of the prevailing winds, placed the
responsibility on flies. Abbott"'* and Rosenau"'
make flies responsible for much of the spread of
typhoid fever, for they breed in and feed upon
infected discharges, and convey the infection to
the food supply, particularly milk. They may alight
on the lips and other portions of the body.

Parke-' notes the possibility of flies distributing
anthrax, plague, cholera, typhoid fever, tubercu-
losis, trachoma, septicemia, erysipelas, recurrent
fever, and leprosy, and adds that they may also
transport the eggs of animal parasites and deposit
them on food. Martin'^ observes that an increase
in the number of flies is followed in about i week
by a corresponding increase in diarrheic diseases.
and in 3 to 4 weeks by an increase in typhoid
fever. Nash'* noted the unusual absence of summer
diarrhea, and at the same time an absence of flies

— the flies and enteric conditions appearing at the
same time later in the summer.

Cobb'* saw a box of dates exposed within 100 feet
of 5 tuberculous patients spitting, and watched
flies going from the sputum to the exposed fruit.
Brauii^" lays the distribution of the oxyuris to flies.

There seems to be no restriction to the diet list of
the fly. Common observation will show that any-
thing organic serves as food. In Egypt they swarm
around the sore eyes of the natives. In the hos-
pitals they congregate around exposed wounds and
dressings ; in the field, on dead animals ; in barns,
on the sores and nares of sick animals, and wherever
dejecta have been thrown or sputum expectorated
there will flies alight and feast. The logical con-
clusion would be that whatever particles existed in
these several localities small enough to be drawn
into the stomach of the fly, passage of such would
occur, and, if bacteria be present, make the host a
receptacle and carrier of the same, to be dissemi-
nated later.

Any marked change in fly life impairs their vital-
ity. In the open they undoubtedly live for a season ;
confined in bell-jars or cages at ordinary tempera-
tures, a goodly number die within a week.-* ^° '°
The health and longevity of flies also seem to be
materially afifected by the bacteria which they may
ingest.

It has been noted that in plague laboratories dead
flies are numerous, giving the suggestion that they
might have succumbed to the effect of contained
plague bacilli.-' This has been proven Ijy Da-
vaine,-* who fed 4 flies on anthrax blood, 3 of
which died.

Nuttal-* experimented with Musca domestica fed
on animals dead from the plague at 14° C. All were
alive at the end of 8 days. Another experiment
found them all dead on the seventh day, whereas of
the controls only 20 per cent, had died. In the third
experiment all were dead on the eighth day, and 6
out of 14 died of the disease. At higher tem-
peratures flies die more rapidly, mostly within 3
days. He states that the fact that infected flies can
live for several days points to the probability of their
playing an important part in the dissemination of
the plague, as they have plenty of access to food
into which they might fall and die, or on which, in
again feeding, they would deposit their excreta
laden with plague bacilli.

Lord'*" fed flies on tuberculous sputum, 10 to a
field. Out of 30 flies, 26 died in 3 days, the- remain-
ing ones becoming inactive. Of the controls, 6 flies
confined and fed on nontuberculous sputum were all
foimd dead in 2 days. Of 6 others fed on water,
sugar, and meat, and similarly confined, 2 died in
2 days ; the remaining 4 were alive at the end of
the week. A writer in the Healthy Home^- found
that confined flies fed on tuberculous sputum died
within 2 to 3 days : controls, fed on clean milk, 8 to
10 da}s.

Experiments have been made to demonstrate how
long bacilli would remain alive when dried on the
external parts of the fly. From flies caught in an
autopsy room at Hamburg during a cholera epi-
demic, after feeding on cholera bacilli, allowed to
fly around a while and then recaptured, roll cultures
were taken at intervals, giving positive results even
after an hour and a half had elapsed.* and cultures
were obtained from the tubes of the feet after 17
hours. *^

How long organisms will remain alive in the gas-
trointestinal tract of the fly has been investigated
by several experimenters. Although the number is
not sufficient to be conclusive in each instance, still
their results are entertaining.

136

MEDICAL RECORD.

[Jan. 26, 1907

Cholera bacilli were found in flies' dejections as
early as 17 hours after feeding and as late as 4
days.-^ The bacilli of typhoid fever were found in
the dejections as late as 23 days,^" and tubercle
bacilli as early as 18 hours.'"

If the secretions of the gastrointestinal tract be
not inhibitive, and bacilli remain long enough in the
same at a proper temperature, there is a possibility
of their increasing in number. This has been noted
at least twice. Lord'" found that the bacilli in {\y
specks had increased m size and showed evidences
of branching. The bacilli in the field numbered 10,
and in the dejections 150.

The strongest evidence, and the one least con-
troverted, is the trinity of laboratory experimenta-
tion, the finding of pathogenic germs in the interior
of the fly, the development of the same by cultures,
and the production of disease conditions through
inoculation. Numerous observers have taken the
trouble to verify their suspicions.

Zollinger- proved tlie presence of anthrax bacilli
in the stomachs of flies. Marpmann-* squeezed
fluid from the proboscides and ani of flies which had
fed on erysipelas bacillus, and found cocci and ba-
cilli. He also fed them with nutriment containing
the bacillus prodigiosus and bacillus fetidus, with
like results. Maddox" (1885) found live bacilli in
their dejections.

Spillman^^ and Haushalter^* found tubercle bacilli
in the abdominal cavities of flies caught in a con-
sumptive's room, also in specks scraped from the
walls and windows of hospital wards for consump-
tives. They fed flies on tubercular sputum, and
proved the presence of tubercle bacilli in the intes-
tines of flies and in their excrements. Hofmann'
made similar experiments and found bacilli in 4
out of 6 flies. Anthrax bacilli were found in flies'
dejections by Celli"* and Alessi.-* Stiles"^ found the
eggs of the ascaris in the larvae and in the adult fly.
Simmonds* (1892) examined flies present in an
autopsy room at Hamburg and found bacilli in large
numbers. Recognizing the source of danger, he
ordered the bodies sewed up and the tables cleansed,
after which no bacilli were found in the flies in the
room.

Ufifelmann^ allowed a cholera-infected fly to drink
out of a glass of sterile milk, and, after keeping the
latter at 70° F. for 17 hours, found each drop to
contain about 100 organisms. Yersin-^ (1894) also
found living bacilli by microscopic examinations.
Billings^' found anthrax bacilli in the stomachs and
intestines of flies collected from the body of an
infected steer. Raimbert'* made the first micro-
scopical experiments concerning anthrax in flies in
1862. He kept flies in a bell-jar containing a vessel
of anthrax blood diluted with water. .A.fter the
flies had drank the fluid and soiled their bodies, he
found bacilli in their proboscides in 2 hours, and
later in the excrements.

Grass!-* fed flies on water containing taenia
sodiimi. The eggs came away unaltered in the flies'
dejections. He also experimented with the oxyuris
and trichocephalus, and caught some flies whose in-
testines were full of eggs. Similar results were
obtained with the oidiuin and botrytis. Macrae,-*
in India. 1894. exposed boiled milk in different parts
of a jail where cholera and flies prevailed. High
walls separated the male from the female depart-
ment. There were no cases of cholera on the female
side, but the milk on the male side became infected
with cholera germs. The milk in the cow-shed was
also infected.

Lord^" made sections of flies fed on tubercular
sputum and found bacilli in the intestines, but there

was no invasion of the other parts. On the exami-
nation of fly specks the bacilli appeared in the stools
within at least 18 hours. Examination of many
specks showed that the number of bacilli to a field
increased from 3,000 to 5,000 bacilli. About 2,000
specks had been deposited by 30 flies in 3 days;
thus from 6,000,000 to 10,000,000 tubercle
bacilli had been transferred from the sputum to the
inner side of the flies' cage during this period.

Raimbert's-* investigations prove that house flies
which live upon flesh and blood carry the poison
on their feet, wings, and in their dejections. In
1862 Davaine-* made observations on the spoiling
of fruit and vegetables, which he traced to flies that
carried the spores of penicillium and mucor, and
infected the wounded places on apples, etc. Tiz-
zoni-* and Cattani"* caught flies in cholera wards,
secluded them for some hours, took cultures, and
found cholera bacilli. Swatchenko-* culturally
found spirilla in flies' dejections after 2 hours.
Uffelmann''' experimented with 2 flies ; the first
yielded 10,500 colonies, and the second 25.

Hart" and Smith" cited an experiment by Bur-
gess, who fed flies on bacillus prodigiosus and then
allowed them to fly into a large room. After a few
hours they were recaptured and made to walk over
slices of sterilized potatoes, on which later were
found vigorous growths. Smith^' experimented
with house flies walking over alternately sterile
Petri dishes, and one with diphtheritic growths;
thereby inoculating the sterile.

Veeder^* made cultures of bacilli from fly tracks
and excrements, the flies having fed on the dejec-
tions of typhoid and dysentery patients, thus show-
ing the possibility of these diseases being spread by
flies. Sangree-" experimented with anthrax cultures
on a wingless fly, allowing it to walk over first the
culture plate and then over sterile agar, demon-
strating the colonies which grew from the same.
Ficker^" isolated typhoid bacilli in bodies of flies
caught in houses where people were ill with typhoid
fever. He experimented to determine how long
bacilli would live within the bodies of flies, and
found the extreme limit to be 23 days after feeding.
Hayward^' fed flies on bacilli contained in tuber-
cular sputum, cultures developing the same.

Chantemesse,*' writing on the propagation of
cholera from hou.se to house, makes flies the most
important factor. His experiments proved that one
could obtain cultures of cholera after 17 hours from
the feet of flies and from their intestinal contents.
Similar experiments and results were obtained by
Celli-* and Alessi.-* Davaine-* inoculated guinea-
pigs with proboscides, legs, and wings of flies re-
moved directly from a jar. The animals died of
anthrax. He also fed flies on anthrax blood for 24
hours, then after that sugar water for i^ to 3 days.
Four flies died of anthrax and three survived. He
believes that flies are a most important means of
spreading anthrax. Proboscides from flies which
had sucked upon the erysipeiatic leg of a horse were
inoculated into healthy horses, and produced effects
similar to inoculations made with the excretions
themselves, and the proboscides contained bacteria
similar to those seen in the wounds."*

Celli" and Alessi-* proved, both by cultures and
bv inoculations, that flies' contents give off virulent
anthrax bacilli. In their experiments on domestic
flies they proved that the Sfaphylococciis pyogenes
aureus was unaffected in its virulence bv its passage
through the fly's intestines. Celli (1888) fed flies
with tubercle bacilli and inoculated the anterior
chamber of the eye of a rabbitt, developing tuber-
culosis in that animal. Fliigge^* experimented with

Jan. 26, 1907]

MEDICAL RECORD.

137

the bacilli of anthrax, typhoid fever, spirilla, and
Staphylococcus pyogenes aureus and found them
virulent after passing through the intestines of the
fly. Simmonds^ proved that bacilli retained their
virulence when adherent to flying insects for an
hour and a half after drying.

Swatchenko"* experimented on flies with pure
cultures of cholera bacilli, and the bacilli were found
in the excreta and bowels as late as 4 days later.
When inoculated they were found to be as active
as pure cultures. The same results were obtained
when the flies were fed on choleraic dejections.
Hoffmann^ fed flies on tubercular sputum, and
24 hours after being fed bacilli appeared
in the excreta of the flies, and 3 guinea-pigs
inoculated with their intestines died with tubercu-
losis. The presence of plague bacilli in the intes-
tines of flies has been demonstrated repeatedly.
Yersin,-" in 1894, noting the large number of flies
where victims were being autopsied, crushed one
fly and inoculated it into a guinea-pig, which died
of the disease in 48 hours. Twelve hours
after flies had been infected, Marpmann-* (1897)
inoculated their contents into mice. His experi-
ments were not complete, in that although the mice
died, not all of them died from the infection. Hay-
ward''* fed house flies on bacilli contained in tuber-
culous sputum and proved it by inoculation.

To test the virulence of bacilli in specks, Lord^"
protected glass jars from direct light. Guinea-pigs
were inoculated with 100 specks each, scraped from
the flies' eggs at intervals of i, 8, 15, 28, and 55
days. The first inoculation was made subcutane-
ously and the other intraperitoneally. The animals
were killed after 5 to 7 weeks. Tuberculosis was
produced bv the inoculated material in the first
3 animals, showing that virulent bacilli were
present in the specks for at least 15 days. The pig
inoculated with specks which had dried for only i
day showed generalized tuberculosis. The pig in-
oculated with the specks which had dried for 15
days presented large, isolated, tuberculous lesions
of the spleen and of two lymph glands, one in the
gastrohepatic omentum, and the other in the anterior
mediastinum. Tubercle bacilli were demonstrated
in these lesions.

An interesting condition which occasionally oc-
curs is due to the ingestion of fly larvae by human
beings. Certain species of the larvae of flies are
capable of reproducing larvse," ° which accounts for
the gastroenteric condition with which they are
associated. Bachmann" found larvre of the com-
mon house fly in the vomitus of a hard drinker, and
the same were found by Cohen'- in the dejections of
a nursing infant. Another writer" cites a case in
which fly larvJe in large masses were passed in the
stools, and a case is cited by Cattle''"" in which large
quantities of dipterous larvae were passed per anum.

Stiles-'' found the eggs of the ascaris in the larvae
of flies.

Disease conditions and associated states accu-
rately observed must be considered scientifically as
trustworthy experiments as those done in labora-
tories. A change in the water supply from foul to
pure, with the incident reduction in enteric condi-
tions, demonstrated as positively the source of
typhoid fever as any inoculation of pigs.

Not until the Spanish-.Xmerican War, in 1898,
did we realize the importance of the fly question in
the dissemination of typhoid germs. The Civil War
gave us modern hospital construction, so this latter,
the Spanish-American, may result in proper relega-
tion of aerial diffusion of disease, and the placing' of
diffusion by flies more prominently. Sanitation in

the army at this time was not as carefully pre-
arranged as it should have been, and as it was at
the time of Moses." The fly factor was not un-
known, and yet no provision was made in the sani-
tary regulations to prevent the dissemination of the
ever-present typhoid fever by these agents. Not
only were the contents of the latrines exposed, but
the men wandered through the woods defecating
indiscriminately.

Quoting from Reed, Vaughan, and Shakespeare's
Report on the Spread of Typhoid Fever in the
United States Military Camps during the Spanish-
American War of 1898:''* "Typhoid fever pro-
gressed even in those who did not drink the sus-
pected water. Notwithstanding the purity of the
water supply, and contrary to the opinion generally
accepted by the medical profession, we find typhoid
fever, having been imported into various company
organizations, now steadily advanced. The disease
is attributed to the fouling of the ground, inevitable
in camps, the lack of sufficient conservancy estab-
lishments, and the contamination of food through
the agencies of dust and flies. . . Flies swarmed
over fecal matter and then visited and fed upon the
food prepared for the soldiers in the mess tents. In
some instances, where lime had recently been
sprinkled over the contents of the pits, flies with
their feet whitened with the lime were seen walking
over the food."

Not until a spade and an armed soldier were
placed at each latrine did the fly menace cease and
typhoid fever diminish. As each man defecated, he
was compelled, with his spade, to dig up enough
earth to cover his excrement, the sentinel seeing that
such order was carried out. No sadder, more hu-
miliating, yet successfid experinient has ever been
noted.

Buchanan" relates an attack of cholera in the
Burdwan jail, where the water supply was above
suspicion, and the same for all the inmates, who
were divided into groups, separated bv a high wall.
One group had their victuals cooked separately and
were fed in separate places. The ones fed close to
the latrines, where choleraic discharges were
thrown, became infected with cholera, while the
other group escaped. It was fly year, and flies were
seen to come and go between the food of the inmates
and the discharges in the comjiounds.

In 1850 the ship Superb had cholera on board.
She was at sea for six months. On putting to sea
flies were in great force, but after a time disap-
peared, and with them the epidemic. Going into
Malta the flies again appeared from the shore and
cholera increased. Again putting off to sea, the
flies disappeared, with the coincident subsidence of
the disease."

Alice Hamilton^- sums up the result of her study
into the part played by the connnon house fly in the
recent epidemic of typhoid fever in Chicago, which
could not be explained wholly by the water supply
nor on the grounds of poverty and ignorance of the
inhabitants, as the section infected did not differ in
these respects with several other sections. The
streets in which the sanitary arrangements were
worst had the larger number of cases. Flies caught
in undrained privies, fences, walls of the houses,
and rooms of tvphoid fever patients, showed typhoid
bacilli in 5 out of 18 cases. Further, _ she
states that when the dejections of a typhoid victim
are left uncovered in privies or yards, flies may be
an important agent in the dissemination of the dis-
ease.

Hewlett" noted an epidemic of flies coincident
with an epidemic of enteric diseases among children.

138

MEDICAL RECORD.

[Jan. 26, 1907

in which the diseases affected alike all classes, under
conditions sanitary and unsanitary.

How diseases are transmitted, and the most prob-
able source in each circumstance, have naturally
been the cause of much argument. As the science
of medicine has become more exact, and as the
methods of experimentation allow of more logical
deductions, so have some of the opinions once
thought worthy lost in favor. Naturally, several
channels exist, some ahvays dangerous, others oc-
casionally so.

The possibilities of aerial dissemination of patho-
genic germs, once holding the confidence of the pro-
fession, has been seriously attacked. How impor-
tant flies may be in the dissemination of diseases
will largely depend upon other existing conditions.
The observations referred to herein conclusively
prove the possibility of the spread of any tvpe of
infectious disease by this insect. It has been
aphoristically stated that "the three great means for
the transmission of typhoid fever are fingers, food,
and flies,"'" and the authors hold the last to be the
most important. If this be true of typhoid fever,
why not of any other microbic disease?

The part of the fly most active for harm is un-
doubtedly the portion which most carefully protects
the contained microbe from sunlight and desicca-
tion. From the experiments recited the relative
danger is as follows : the dejecta, the proboscis, the
crushed or ingested insect, and the outside parts.

Scientifically speaking, the number of flies in a
community is in direct proportion to the carelessness
of its sanitation. The housekeeper will spend a day
rummaging over a bed for a bedbug, and give little
notice to a kitchen full of flies. "The presence of
flies in a house is a reproach, falling away from the
high iiygienic standard, for the fly is a pestilential

fellow

Fly epidemics are generally local ones

spreading slowly from the source of first infection.
Winds, by carrying the flies, allow of spread in
their direction. As a working hypothesis, which
is hoth logical and reasonable, one can explain the
sporadic occurrence of epidemic diseases, such as
remote cases of cholera, which are not native and
existing in quarantine. Further, it has been re-
peatedly asserted that in the zone immediately sur-
rounding a smallpox hospital new cases are more
frequent than at a distance. There are two ways to
explain this condition — the wafting out of the build-
ing of infected particles, or the carriage by flies.
The latter seems more probable, for outward drafts
are never vigorous, and hardly sufficient to carry a
distance.

Every privy, every open window, every dead ani-
mal in the street, expectorations of people suffering
or incompletely recovered from any infectious dis-
ease, the nares of scarlatinal patients suft'ering from
catarrh or acquired colds ; in fact, all conditions
where pathogenic bacteria or intestinal parasites
may openly exist, make possible, and even probable.
the spread of disease by flies. This, being known,
should be acted upon. There are few Boards of
Health as intelligent and far-sighted as that of
Philadelphia, which has taken vigorous measures to
protect the public against infection of food bv flies.
Inspectors are directed to visit all milk houses,
butcher shops grocery and candy stores, and in-
struct the owners to place a covering over all
articles. The order reads :*' "The chiefs of divis-
ions of nuisances, milk and meat, and cattle inspec-
tors are hereby instructed to visit all retail dealers
exposing for sale in front of their properties meats,
fish, vegetables, fruit, candies, and cake and instruct
the proprietors that a covering of some suitable

material must be provided to protect the goods so
exposed from flies and insects generally."

When mosquitos were discovered to have a part
in the dissemination of malaria and yellow fever,
it was thought that a prevention of their breeding
was too great a proposition, yet it has been satisfac-
torily accomplished, so that now one case of yellow
fever in all Cuba will create more comment in the
daily papers than at one time an epidemic in
Havana. Certainly when the profession and the
laity become alive to the dangers incident to the
presence of flies, and recognize in them a receptacle
and a carrier, then will the problem be attacked and
solved.

.Attached to all .stables there should be built a pit
of sufficient size, closed tightly with the exception
of a ventilating window properly screened, and so
constructed that little direct light may enter. Ma-
nure, as soon as dropped from the animal, should
be pushed into this pit, and chloride of lime or crude
oil frequently scattered over its contents. All
organic filth, such as human manure, if conditions
do not allow of a sewerage system, should be covered
immediately by sufficient earth. All offal and
organic debris, in which flies can lay their eggs and
propagate, should be disposed of. secluded, or
screened. Hospitals, particularly where contagious
diseases exist, and rooms containing the same,
should have all windows and doors carefully
screened, and every effort be made to rid the interior
of such flies as may enter. All food, particularly
milk and such articles as are eaten uncooked, should
receive full attention and protection.

REFERENCES.

0. Holy Bible: Deuteronomy, x.xiii., 12-13.

1. Sydenham (1666) : Works, Society Ed., Vol. I., 1848.

2. Bollinger: Ziemmsen's Cyclopedia of the Practice of
Medicine, Vol. III., 1875.

3. Hofmann : Ueber die Verbreitung der Tuberkulose
durch unsere Stubenfliegen, 1888.

4. Simmonds : Deutsche viedisinische Wochenschrift,
1892.

5. Uffelmann : Berliner klinische Wochenschrift, 1892.

6. Biggs: American Journal of the Medical Sciences,
January, 1893.

7. Moore : Medical Magazine, July, 1893.

8. Battersby : British Medical Journal, August 10, 1895.

9. Buchanan : Indian Medical Gacette, March, 1897.
9a. Henschen : American Journal of the Medical

Sciences, June, 1897.

10. Bachman : Deutsche medisinische Wochenschrift,
March 24, 1898.

11. Billings: Twentieth Century Practice of Medicine,
Vol. XV., 1898.

12. Cohen : Deutsche medisinische Wochenschrift,
March 24, 1898.

13. Ernst : Twentieth Century Practice of Medicine,
Vol. XIII., 1898. Citation: Packard.

14. Hart and Smith : Twentieth Century Practice of
Medicine, Vol. XIII.. 1898. Citation: Burgess.

15. Howard: United States Bureau of Agriculture,
Division of Entomology, Bulletin No. 10, 1898. Citation:
Busck.

16. Nicholls : Twentieth Century Practice of Medicine,
Vol. XVI., 1898.

17. Smith : Public Health, December, 1898.

18. Veeder : Medical Record, September 17, 1898.

19. Knopf : Pulmonary Tuberculosis, 1899.

20. Sangree: Medical Record, January 21, 1899.

21. Veeder : Medical Record, January 7, 1899.

22. Bulletin New York Board of Health, September,
1900.

23. Hervioux : Lancet. June 16, 1900.

24. Nuttall : Johns Hopkins Hospital Reports, VoL
VIII., 1900. Citations : Knud, 1493, Davaine, 1862, Leidy,
1872, Nicholas, 1873, Marpmann. 1^4, Maddox, 1885, .Alessi,
1888, Celli, 1888, Cattani, 1886, Tissoni, 1886, Spillman and
Haushalter, 1887, Stiles, 1889. Flagge, 1891. Swatchenko,
1892, J. F., 1853, Francis. 1893. Macrae. 1894, Joly, 1898,
Raimbert. 1869, Grassi. 1883, Joseph, 1887.

25. .Abbott: Hygiene of Transmissible Diseases, 1901.

26. Harrington: Practical Hygiene, 1902. Citations:
Mercurialis, 1577, Yersin, 1894.

Jan. 26, 1907]

MEDICAL RECORD.

139

27. Parke: Practical Hygiene, 1902.

28. Rosenau: Disinfection and Disinfectants, 1902.

29. Veeder : Medical Record, July 26, 1902.

30. Ficker: Arclii. fiir Hygiene, Vol. XLVL, 1903.

31. Geddings: Public Health Reports, August 28, 1903.

32. Hamilton; Journal of the American Medical Asso-
ciation, February 28, 1903.

33. Martin; Public Health, August, 1903.
33a. Lancet: August 8, 1903.

34. Nash : Lancet, January 31, 1903.

35. Perry : Report of the Surgeon-General, United
States Army, 1903.

36. Sedgwick and Winslow : Memoirs of the American
Academy of .'\rts and Sciences, 1903.

37. Aldridge; Journal of the Royal Army Medical
Corps, December, 1904.

38. Hay ward: Nezv York and Philadel[>hia Medical
Journal, October i, 1904.

39. Lord: Boston Medical and Surgical Journal. De-
cember 15, 1904.

40. Nash : Lancet, September 24, 1904.

41. Caldwell : Military Hygiene, 1905.

42. Chantemesse: Journal of the American Medical As-
sociation. December 9. 1905.

43. Chantemesse : Medical Record, December 16, 1905.

44. Cobb : Ne-M York Medical Journal, Augiist 26, 1905.

45. Hewlett: Journal of Preventive Medicine, August,
1905.

46. Howard: United States Bureau of Entomology,
Circular No. 371, 1905.

47. Philadelphia Board of Health, Lancet, September
16, 1905.

48. Reed, Vaughan, and Shakespeare. Report on the
Spread of Typhoid Fever in the United States Military
Camps During the Spanish-American War of 1898 — to the
Surgeon-General of the U. S. Army, 1905.

49. Braisted: Report on the Japanese Naval, Medical,
and Sanitary Features of the Russo-Japanese \\'ar, to the
Surgeon-General, United States Army. 1906.

50. Braun : Animal Parasites of Man, 1906.
Soa. Cattle : British Medical Journal, 1906.

51. Cobb: Florida Health Notes, July, 1906.

52. Florida Health Notes, July. 1906. Citation: Healthy
Home.

280 MONTGUMERY STREET.

PHYSIOLOGICAL ACTION OF AIASSAGE.

By GUST.^V N'ORSTRuM, M.D. (Stockholm),

KEW YORK.

When by careful observation the efficacy of massage
had been demonstrated in several affections and mor-
bid states which had nothing in common, apparently,
at least, it became desirable to explain its action.
Empiricism paved the way, which later on was
widened by reasoning and experimenting. As late
as the last century it had been observed that fric-
tion accelerates the venous circulation and dimin-
ishes existing stagnation.

The affections in which massage had yielded the
best results, and in which it had been most used
and luost recommended, was in cases where the
•normal relations of the tissues or their elements
were altered. In sprains we find vascular ruptures
and sanguineous effusions. The presence of hem-
orrhages, or extravasated leucocytes, in a region,
gives rise to disturbances if their absorption requires
a long time. In hyperplastic arthritis, hydrarthrosis,
inflammation of the tendinous sheaths, we have to
deal with new solid or liquid products, and we
can only expect an entire functional restitution, a
real ctire, if we cause them to disappear. From
this point of view massage is really useful.

The first condition which is necessary to obtain
a clear idea of the physiological action of maesage
is to become familiar with the laws of nutrition of
the tissues, of which absorption is one of the main
factors.

The living cell is an organic center, which under-
goes development, lives, and then dies.

Certain liquids are as indispensable to organic
elements as salt water is to fish, fresh water to

mushrooms, vinegar to inycoderma aceti. They
contain water, albumen, and salts. No doubt, their
composition varies in the different tissues, but we
do not know the character of these variations. It
is from these liquids that the cells derive their
luitritive material. These liquids are known under
the generic name of "parenchymatous juice." This
latteV is absorbed by the tissues. To this imbibed
liquid the tissues owe their essential properties. Let
us compare a piece of tendon, of cartilage, or of con-
nective tissue, in the normal state, with a fragment
that by desiccation has lost its imbibed water; the
volume, color, and consistency, in a word, all that
may be rendered manifest b\ the naked eye, has
been altered.

One might, to a certain extent, compare the liquids
containedin the imperceptible lacunas to the crystaj-
lization water of certain inorganic bodies, with this
reserve, however, that the proportions of the former
are not fixed and determined like those of the latter.
The part which such liquids play in our economy is
easily perceived when we reflect that most tissues
contain inore than 75 per cent, of water. The
parenchymatous juice is contained in spaces of mi-
croscopic size. These spaces, called lymphatic
spaces, are of many shapes, such as lacunas, chan-
nels, sacs, etc. The fluid is found in nearly all parts
of the body, but above all it is in the connective
tissue, which may be considered the true reservoir
of parenchymatous juice.

Having obtained this conception of the parenchy-
matous juice and the part it plays, it is easy to deduce
from it its importance for the economy. An ani-
mal cannot indefinitelv live in a small room, her-
mcticallv sealed up ; when the exhaled air reaches
too large a quantity life ceases. A periodic renewal
of the air is necessary; that is to say, an addition
of respirable elements and an evacuation of expired
air. The phenomena in the interior parts of the
tissues are exactly similar.

The terminus of the nutritive channels is the capil-
larv plexus ; the chaimels of evacuation are the
veins, and especially the lymphatics. The differ-
ence in pressure in the interior of the centripetal
and centrifugal \-essels play such an important part
in the flow of the liquids that it cannot be altered
without impeding the current. If the venous tension
is increased bevond a certain coefficient, the Ivm-
phatics suffice no longer to accomplish their task,
and the region becomes edematous. The same phe-
nomenon is produced if these lymphatics themselves
are altered and have become partly impermeable.
When it is desirable to obtain very quickly edema
of a limb by venous compression one ought to pass
a ligature arounrl a big lymphatic trunk, as has
been shown by Cohnheim. Massage, which is, as
we have already said, a powerful adjuvant to absorp-
tion, acts on the venous and especially on the absorb-
ing svstem. It accelerates the current of the liquids
in all directions, and bv diminishing the tension in
one part, facilitates, by the production of a sort of a
vacuum (suction force), the circulation in the next
succeeding one. This theory will allow us to under-
stand most phenomena and will justify the manceu-
vers resorted to, though they may seem strange and
their application present difficulties. For instance,
ill articular affections, massage acts on absorbing
vessels, but we know scarcely anything about the
Ivmphatics of the joints. What is their origin?
How do thev behave as regards the synovial fluids?
Do they end in cul-de-«acs, without epithelium, as
was generally believed a few years ago, or do they
open into the cavity b\' stomata 'f

When Mosengeil set to w rk to study the phys-

140

MEDICAL RECORD.

[Jan. 26, 1907

iological action of massage, he stood amazed when
confronted with all these problems. As histolog}'
had taught nothing, experiment alone remained.

Mosengeil's experiments will forever remain
classic, because they have thrown a new light upon
massage and the origin of articular lymphatics. Be-
sides theoretical difficulties, there are technical ones.
If you desire to study the influence of massage on
the progress of arthritis, for instance, it is quite a
simple matter ; take two animals and introduce into
two similar joints a colored liquid, the progression
of which is possible to observe with the naked eye
and with the microscope. But the selection of such
a Iif|uid is not an easy one. Vermilion grains are
ton l)ig and angular, and when filtered the chemical
products are colorless. Mosengeil, after consider-
able meditation, chose India ink. This must be of
such fine and good quality that its dilution is uniform
throughout, without containing any small particles
and without producing the least sediment. As soon
as the solution had been prepared, a sufficient
quantity was injected into the two femorotibial
articulations of a rabbit ; one of them was massaged,
the other one not. The result of Mosengeil's
experiments were always the same. On the mas-
saged side the dififusion of the liquid took place
rapidly; it was propelled into the lymphatic vessels
and plasma spaces of the thigh, the direction being
from the periphery to the center. On examination
of the unmassaged joint a most striking contrast
was foimd. The joint remained distended. In only
one case was there found a lymphatic ganglion of the
thigh impregnated with the fluid. But one ought
not to conclude from this that the afferent vessels
had carried the liquid from the synovial cavity.

Repeated abundant injections had caused a tume-
faction of the knee. This pressure, due to the in-
crease of the liquid, had not, however, as massage
had done, driven the colored substance into the ab-
sorbing vessels. It had infiltrated places where it
found the least resistance, namely, the neighboring
connective tissue and that which separates the
muscles of the leg. It is possible that the move-
ments and the action of the force of gravity favored
this evolution ; it is also possible that traces of the
India ink found in a ganglion of the thigh, were
brought there by lymphatics of the infiltrated inter-
stices. No ambiguity is possible in the interpre-
tation of these facts. Massage had driven the ma-
teria] into the centripetal vessels, it had stimulated
its absorption to such an extent that there was no
comparison between the massaged side and the other.
Yet the animal was not secured ; it was allowed to
run and jump about ; the muscular contractions were
as active in one as in the other limb. They favored
the progress of the liquids in the right just as much
as in the left lower extremity. .Another argument
in fa\'or of our hypothesis is this, namely, that the
operative procedure is of a serious importance. In
some cases where massage was performed bv un-
skilful iiands there was no liquid in the lymphatic
ducts, hut simpl}- a diffusion into the cellular tissue.

From wli.Tt precedes, we mav conclude that mas-
sage is an energetic agent ; it sometimes brings
about complete resolution, but alwavs favors the
absorption of the preformed products, which it
directs into the Ivmphatic centripetal vessels. Pro-
cedures which at one time may have seemed purely
empirical, are really rational.

Mosengeil was the first one, I believe, to under-
take researches with a definite purpose in view,
namely, to no longer study the phvsiologv of one
or other tissue, and the manner in which it reacts
after various excitations, but to see in what massage

really consisted, to discover the difference between
absorption and diffusion of a colored substance, in-
jected into a limb which had been massaged, and
in one which had not.

This difference is as clear as it can be. In the
first case we have had processes comparable to path-
ological ones, the foreign material has been ab-
sorbed and transported. It is easy to understand
what would have happened if, instead of India ink,
a poisonous substance had been introduced. In the
second case it is useless to suppose the interference
on the part of any vital power, the liquid permeated
the connective tissue by imbibition in the same way
as if it had been infiltrated in any other tissue. These
facts do do not stand isolated; experiments have
yielded results. It was easy to foresee that others
would endeavor to complete them.

Sturm and Sails have obtained exactly the same
results as Mosengeil. Reibmayer and Haffinger have
extended their experiments on articular synovials
to the peritoneum. They injected water into the
peritoneal cavity of several rabbits; one of them
was massaged (petrissage of the abdomen) for ten
minutes, and another one was left alone. An hour
afterward both were killed. In the case of two
other rabbits massage was given for two consecu-
tive hours and then they were killed. During the
first hour there was less reabsorption in the mas-
saged rabbit than in the other. TThe modifications,
in the shape of abdominal pressure and aspiration,
resulting from the maneuvers performed during the
first hour, had altered the conditions during
second. Here are the results as Kleen has recapitu-
lated them :

Proportion per cent, ot the weight of
the water compared to the weight of
the reabsorbed body

Without massage' With massage

4.S7
5-83

10.40

9.09
I 29

10.38

adhour
Total

for

2

hours

Massage modifies the absorption in the uuerstices
of the tissues, as well as in serous surfaces; several
factors contribute to it. We have sufficiently insisted
upon the prominent part which the lymphatics play.
The sanguineous current does not remain inactive
either, the pressure exerted on the veins hastens
their depletion and diminishes stagnation, if there is
any. It has been said that something similar to
what happens in the suction pump is produced. I
would rather compare it to the classical aspirators
used by physicists. The more rapid the current is,
the more energy is developed by aspiration. But is
there any advantage in massaging? The arterial
circulation is centrifugal, and our frictions are di-
rectly opposed to it. No doubt about this ; but the
arterial trunks are deeply seated, their walls have
a contractility of their own, so that, fortunately,
these slight and temporary obstacles are easily over-
come. The zns a tergo remains exactly the same
in the capillary system, whether one massages or
not. The propulsive force remaining constant and
the venous tension diminishing, the resultant is an
increase of the arterial circulation in a given region
and a diminution of the congestions. We may con-
sider the isolated cell as a complete apparatus, en-
dowed with a marvelous power of adaptation, the
phvsiological functions of which are greatly influ-
enced bv our treatment. If the movements of the
fluids in the living tissues are slow, the action of mas-

Jan. 26, 1907]

MEDICAL RECORD.

141

sage will be most potent and sure. The circulation
becomes easier, the absorption is improved, the
chances of exudation, transformation, and organiza-
tion of the exudate diminish. It is also possible that
when an exudate already- exists, it may entirely dis-
appear through our manipulations. But if we have
to deal with a plastic exudate, an additional measure,
not yet spoken of, is necessary to cause its dis-
appearance.

We have placed before us the most simple hy-
pothesis. We ought not to break a fiber, nor reduce
a mass to fragments. Practitioners of massage
must modify their methods to suit the cases ; if
they have to deal with tangible and definite lesions,
they have not only to pass the ball of the thumb or
the palm of the hand lightly over the surface of the
body (cfflenragc), but ttiey have to use friction and
petrissage ; and this simply because in these cases
absorption cannot be accomplished without prelim-
inary fragmentation. The acceleration of the lym-
phatic current is not sufficient to cause an old, or-
ganized exudate to disappear. The latter must be
brought to a very fine state of division, very much
like the diluted India ink of which we have just
spoken. Its particles must be small enough to be
received by the mouths of absorbing ducts. Ener-
getic massage produces all this. There is besides
.another advantage to be derived from this kind of
massage : that of destroying the capillary vessels
which nourish the organized exudate. The accelera-
tion of the blood current is further increased by the
intervention of the nervous system. Sometimes also
Tdv that of the muscular elements.

Very often when we have to deal with nuiscular
lesions we have recourse to the manipulation called
tapotement. The infliction of successive slight trau-
matisms produced by this maneuver is the best
means of producing excitation. Schiff, Kiihne, K61-
liker, have shown that the mechanical irritation
is sufficient to provoke contraction of the muscular
fibers quite independent of the nervous system. This
is quite an excellent means of accelerating the cir-
■culation.

Zabludowski ("Die Anwendung der Massage liir
die Chirurgie und ihre Grundlagen") has proven b>
an ingenious experiment that massage can cause
rapid disanpearance of all fatigue. A person at rest
supported a weight, with the arm flexed, until the
arm was fatigued ; effleurage was performed for five
minutes, and at the end of that time this same person
was able to perform more muscular labor than be-
fore. On the other hand, if no effleurage was
resorted to, he was obliged to wait at least a quarter
■of an hour before being able to resume work.
Besides, the contractions produced reflexly after
massage are more powerful than before. Zablu-
dowski also observed that massage had no influence
on the reflex excitability of the spinal marrow, but
as it increases the power of the muscles, we render
their contractions more powerful.

E. Kleen ("Handbok i Massage") tells us that a
friend of his, a leader of an orchestra, has his arm
massaged by eflleurage every time he conducts his
musicians for considerable time ; he thus experiences
far less fatigue than if he did not have recourse to
this measure.

This action on fatigue may also be explained by
the assumption that absorption is increased. The
sensation of fatigue occurs in consequence of the
oxydation of the tissues and of the accumulation
of phosphates, carbonic acid gas and lactic acid. If
their disappearance is hastened, fatigue ceases
sooner than it would bv rest alone.

Physiology explains the action of massage on
neuralgia, as well as that of pressure, tapotement,
and trepidations, along the course of the nerves.
These manipulations I often had recourse to, espe-
cially in neuralgias of the forehead or the face,
where the nerve is seated sufficiently superficial to
be accessible to them. Slight pressure on the nerve
provokes its excitement and intensifies the pain,
whereas very firm and strong pressure is followed
at first by numbness and then by more or less anes-
thesia. The same thing takes place with the motor
nerves, as Tigerstedt ("Studien iiber mechanische
Nervenreizung," Helsingfors, 1880) has shown that
their excitability is augmented by a very slight pres-
sure, and diminished or entirely suppressed by a
strong one.

122 East Thirty-fourth Street

PROPRIETARY MEDICINES.*

By BEVERLEYj.ROBINSON, M.D.,

NEW YORK.

I WISH to tell you this afternoon a few solid truths
regarding proprietary medicines, to which, like all
truths of science or religion, there may be excep-
tions. I had believed until one year ago in the law
of gravitation, and believe in it to-day ; yet, accord-
ing to the latest scientific investigations, this law
may be questioned.

I wrote editorially in the Nciv York Medical
Journal some two years ago on the subject of "Pro-
prietary Medicines," and have nothing to add, nor do
I know whether I can now say as well what I wish
to say as I did then. However, I wish to emphasize
a few fundamental ideas in a simple way.

What is the reason for the existence of proprietary
medicines, and why are they sold ? On any rational
ground this is difficult to explain, but it is certainly
true that many people, despite reasoning, love
mystery and like to be deceived. I want to empha-
size the fact that nearly all proprietary medicines
are mysterious and some are humbugs.

Another peculiar fact is that many people think
of a disease as a personality, as having an entity
which may be and is properly combated by a certain
remedy, simple or combined. This means to them
that given a disease or even the name thereof, it
must be immediately attacked by its antidote under
the form of some proprietary preparation. No
matter that they know nothing of the maker of
the preparation, of his character, or his capability ;
the medicine is good for all equally and must be
beneficial if taken as advised on the bottle's label.
Manv are killed by drugs or combinations of drugs
about which they know nothing at all. They know
nothing of the patient or his history, antecedent or
present, and conclude that because the medicine
appears to have helped some one else it will he useful
in the case at hand. Such a person might be con-
sidered quite conscientious, but he has very little
brains or else does not use what he has.

Now, with regard to all this literature and those
bottles here before me, it is evident that the number
of proprietary medicines is ever increasing, and that
we are literally swamped with them. Many of
these medicines are not only good to look at,
but sweet to the taste. All these circulars, ad-
vertisements, and so-called scientific reports, whether
written by real or unreal medical brethren, are not
worth a ' whiff. The greatest sinners, however,
are not the persons who interview you in the office

♦Delivered on November jS. igo6, before the class at
University-Bellevue Medical College.

14^

MEDICAL RECORD.

[Jan. 26, 1907

and leave these samples around, but the manufac-
turer and the men of authority in the business world,
men of high position who have so far disregarded
their brains and consciences as to place their signa-
tures at the bottom of circulars, lauding that about
which they actually know nothing. Take the mem-
bers of our faculty ; do you find their names on such
wares ? Such men would never think of sanctioning
the claims of those who send out these circulars and
drugs. Because a man is acquainted with all the
crimes in the world it is not necessary that he
should indulge in them. I am sick and tired of so
many circulars, advertisements, and so-called scien-
tific reports.

Suppose a man who represents a house that I
know about and which has an honorable record,
and I know that I can take his word and rely upon
it as well as upon his bond, now if he tells me that
a certain drug, or combination of drugs, is good, I
can rely upon it. We must rely upon something.
In such a case 1 listen to the man because I want
to learn what I can from him. There are some
firms that have been working for years and years,
getting all the knowledge they can concerning cer-
tain drugs or combination of drugs. If we may
rely upon the character of these firms, and if the
printed formula seems unobjectionable or desirable
for any given case, we may. in my judgment, under
certain circumstances, properly prescribe their
drugs. There are times when to formulate a mix-
ture rapidly, one that is suitable to a particular
patient, is very difficult to accomplish in a satisfac-
tory manner, and if we know or firmly believe that
a proprietar}" combination will do as well as any-
thing that we can write for immediately, on account
of the great care in its preparation and its precise
and accurate combination, we are justified in select-
ing it.

Is it advisable to keep certain drugs and mixtures
at drug stores : does it look too much like commer-
cialism ? It is useful to have on hand at some relia-
ble druggist's a mixture formulated by the physician
himself to meet best in treatment certain aspects of
disease. To do so saves time and thought and
solves more than one perplexity in actual practice.
This plan is resorted to by some honorable special-
ists, and even a few general practitioners, and lias it--
favorable and also unfavorable side. You can go
to a certain drug store in this city and ask for a
certain physician's prescription for rheumatism, for
instance, but you will be told that you cannot have
it unless the doctor gives his consent.

There is another point. There are certain firm>
that put up certain preparations better than other
firms. There are methods of preparation, probably,
or a certain special skill or care as to the nature,
use. and compounding of agents of materia medica,
which render 5 particular remedy of one firm more
active and powerful than a similar preparation sold
by other firms. I advise the patient to go to those
firms which have acquired knowledge which justifies
me in sending them there.

How can we stop quackery ? How can we pre-
vent drunkenness? We may say by stopping tho
manufacture of alcohol. That is radical, but not
practical. We can stop the sale of proprietary
medicines in the first place by never sending the
patient to any house or drug store unless we feel
from all evidence that is obtainable that it is reliable.
Secondly, we need never prescribe any particular
mixture or pill unless on reliable evidence that the
pill or mixture contains precisely what we called for?
which brines one back to the question of reliability
of the firm.

In most proprietary medicines we find document
after document telling what is in the mixture, but
the formula is omitted, and we know nothing about
the firm manufacturing them. There are some men
perfectly correct, proper, high-toned men, who pre-
scribe proprietary medicines, believing that the com-
binations represent what is reasonably true, but one
must know all about them before it is safe to pre-
scribe them. As with the physician, so with the
druggist, the whole matter hinges on the words
honesty, a square deal, character.

Here is a lx)ttle with the written formula which
was given me by a former general practitioner, an
honorable and reliable man, who lived most of his
life ])ractising medicine in a town where the work
was not eas\'. As the result of his experience and
life work he concluded that this formula, as on the
bottle, was a desirable one. He has had the medicine
made up and will vouch for it. I believe in him,
and therefore I believe in the formula. I consider
it a rational one, and I believe it represents the
truth, and that it will be useful. The dose is here
given, and the label states that it is to be given
for neutralizing the substances that have developed
from gastrointestinal fermentation. Of course there
may be some patients on whom this will do no good,
as certain drugs may at times fail us. There are
no two patients precisely alike. I have seen many
cases of pneumonia, yet I have never seen two that
were alike ; and the same may be said of scarlet
fe\-er, measles, and typhoid fever, as well as many
other diseases. .At the same time it is almost im-
possible to explain these things to ignoramuses.
They cannot comprehend them because they have
not had the training.

Yesterday there came into my office one of the
best men that I ever knew, who lost his arm in the
War of the Rebellion. Some one had told him that
he had a leaky heart and this left him in a condition
of mental worry, so that he thought that he might
die at any moment. It took me one hour to disabuse
■ him of this nonsense. It all comes back to the
question of reliability. You select your lawyer and
vour dentist because you have confidence in him,
and you should select your doctor in the same way,
and then say. "T am in your hands: tell me what to
do and I will do it. It is because of your knowledge
that I have come to you." The doctor then sends
him to some reliable place where he can get good
and reliable drugs, and the patient follows the physi-
cian's directions.

I hope I have driven home certain things which
no textbook in the English language will tell you.
The papers have been filled with this kind of material
and I have given you a resume of what has appeared
in them.

AN UNUSUAL NIDUS FOR GONOCOCCIC
INFECTION.

Bv EDG.\R G. B.^LLENGER, M.D..

ATL.4ST.A, G.\.

LECTURER ON GESITOURIN\RV DISEASES, ATL.ANTA SCHOOL OP MBniCIXE.

From a review of the literature relative to the sub-
ject, I have not been able to find record of a condi-
tion similar to the one described in the following
report, which shows that we should be on the look-
out for gonococcic foci in other locations than in
the urethral mucous membrane and the connecting
glands, and is also of interest on account of the
method used in anesthetizing the penis.

The patient. Mr. P.. was a traveling salesman,
nineteen vears of age. Genera! health had been

Jan. 26, 1907]

MEDICAL RECORD.

143

excellent, but he suffered with many nocturnal emis-
sions, often two or three during the night. Thi.^;
condition had obtained sine: puberty, as had also a
severe facial acne. Gonorrhea was contracted one
year ago, and lasted eight weeks, but he thought this
had been completely cured.

The foreskin was very long and adherent to the
glans penis on each side, the middorsal portion
having ruptured and left about half the circum-
ference of the glans free and normal except at each
end of the adhesions. In these two corners were
raw surfaces, from which the prepuce had been
torn during sexual intercourse five days before. A
mucopurulent secretion was oozing from these red-
dened and inflamed points. There was also a ure-
thral discharge which contained many intracellular
diplococci, and the patient had the usual symptoms
of gonorrhea.

An organic silver salt was used as an urethral
injection ; balsams, in small doses, were given inter-
nally, and stearate of zinc was dusted upon the
lesions on the gland after gently cleansing each time.

All the symptoms rapidly improved until there
was no discharge and only a few urethral thread.-^
in the urine. The erosions healed except in a small
pocket on each side, just behind the corona and
under the edge of the adherent portion of the pre-
puce. These exuded a tiny drop of pus, but ap-
peared so nearly well that I gave them no concern
when the patient left the city two weeks from the
beginning of the treatment and took a twenty-mile
drive into the country. This started a profuse puru-
lent secretion from the small pockets, and the fore-
skin and glans surrounding them again became red
and inflamed. Two days later urethral discharge
followed with all the symptoms of gonorrhea. The
treatment as first given wag reestablished and con-
tinued for three weeks, when the urethral shreds, as
well as the discharge, entirely cleared up. There
was still, however, a slight redness in the little pock-
ets under the prepuce which were now not larger
than small peas.

In describing to me the manner in which the first
relapse occurred, the patient did not explain the de-
tails about the discharge having started in the above-
mentioned pockets and two days later involving the
urethra until the appearance of the second reOpso,
while he was here in the city. He came for treat-
ment the first day the inflammation began, and at
this time there was no urethral discharge, but it
appeared the next day. The similarity and course
of these two relapses convinced both the patient and
myself that these pockets were the foci of infection.
Smears were taken from them with a platinum loop
and stained for gonococci, which were found very
abundant from both sides ; they were intracellular,
and would not stain by Gram's method.

The same treatment was again advised, and the
urethral discharge and threads, as well as the secre-
tion from under the foreskin, soon disappeared, only
a little redness remaining in the pockets. Another
smear was taken from their interior, and, although
there was barely enough secretion to examine, it
showed large numbers of intracellular diplococci.
No cultures were taken, but the typical attacks of
gonorrheal urethritis that spread from these little
cavities clearly showed them to be the seat of the
infection.

.A.fter breaking the adhesions and cauterizing
these patches with nitric acid, no further recurrence
has been observed, and three months have passed
since the urethral discharge and shreds cleared up.

Anesthesia was obtained by injecting twenty min-
ims of a one per cent, solution of cocaine into the
region of the ilorsal nerve of the penis close back

at the penopubic angle. This gave immediate and
complete anesthesia, so that no pain was felt while
freeing the prepuce from the glans or in the subse-
quent cauterization.

In November, 1905, I called attention to this
method of procuring anesthesia of the penis,* and
have used it on many occasions with most satisfac-
tory results, and I believe it worthy of more atten-
tion than it has received. In circumcision, cauter-
izing chancroids, replacing the swollen glans penis
in paraphimosis, or in any condition where anesthe-
sia of the penis is desired. I know of no method in
which the result may be more promptly and expe-
ditiously obtained. The nerve can be easily found
with the artery and vein by picking up the tissues
in the middorsal line of the penis back near the
symphysis pubis, and rolling them between the
fingers. The small hard cord is the nerve. The
cocaine need not necessarily be injected into it, but
if the different layers of connective tissue immedi-
ately around the nerve and its branches be infiltrated
the entire penis anterior to this point will be quickly
anesthetized with a very small quantity of cocaine.

So far I have not amputated a penis, using this
method, but see no reason why the operation could
not be done under anesthesia obtained as above
described, where there is no necessity for making
the incision too near the root of the penis. If occa-
sion demands, a few drops of adrenalin chloride
solution may be added to the cocaine to ])rolong its
effect.

An interesting feature of this patient's course,
after breaking the adhesions, was the promptness
with which the nocturnal emissions changed from
one to three nearly everv night to only one in two
or three weeks. There was also a marked improve-
ment in his facial acne, which from the history
seems to have been due to sexual irritation.

1014 CENTURY^BrUDINO

TEN YEARS A NASAL PATIENT. ;

Bv F. K. MacMURROUGH. M.D ,

JERSEY CITV. N'. }.

I WRITE this without notes and without references.
Ten years ago, in consequence of catarrhal and
obstructive symptoms in nose and throat, I sought
relief at the hands of a noted specialist. At the
first examination he expressed professional delight
at seeing the conditions that obtained in the nose.
"It is a remarkable case." said he. "Well," he
added, "we will clean it out for you." Ai that sit-
ting he snared out the left middle turbinate, which
was encysted. He could get only half of it, and I
had to return in thirty-six hours with symptoms of
sepsis and pain, when he removed the other half,
already detached, and also removed eleven polyps of
various sizes from large to small. At the next oper-
ation, a month later, he took oft' with saw a large
exostosis from the left side of the septum, and per-
formed at the same sitting a partial septum opera-
tion, i.e. moving the septum over toward the oppo-
site side. I will state here that I am of a highly
hopeful, optimistic temperament when I think
everything is as it should be, or that such a condi-
tion of things is attainable, or maintainable. I will
state also that I always had a ready voice for vocal,
conversational, or even elocutionary or oratorical
purposes, and that this readiness had been lost or
impaired, and that I was in consequence mentally
and physically depressed. Being of the blood of
the Gael, I suppose it went hard with me to be

♦Strictures of the Urethra: Their P.ithology and Treat-
ment; Mcdii-al Kcivs, November 11, 1905.

144

MEDICAL RECORD.

[Jan. 26, 1907

vocally incapacitated. Now, this optimism of mine
led me to believe that each operation would be the
last and that I should obtain relief and a restora-
liim of my "lost voice."

The right side of the nose was always accounted
b\ me to be the clear side, the good side, and I
! bought the work would be limited to the left side.
W ell, the left side cleared up marvellously, but pari
passti the right side became occluded. I first had
part of the right middle turbinate removed, then
the posterior tip of the right inferior turbinate, then
had the pharynx cauterized with electric cautery for
possible speaker's sore throat, for I had become a
speaker (a political campaigner). These measures
brought some relief. It is true that in many nasal
operations you are "six months sick before you get
v\ell." So I was always either recovering from an
operation or getting ready for a new one. I then
had more of the right middle turbinate removed and
had the right side of the septum sawed and planed
off, and at this time had one large polyp removed
from the right nasal fossa.

I still suffered with catarrhal and obstructive
symptoms and a "ruined voice." I was determined
to persevere. I said to the doctor (God bless him
for his patient, painstaking skill and never-failing
charm, kindness, and courtesy), I said: "Doctor,
I am looking for a perfect result, or at least an
approximately perfect result." "Very well," he re-
plied, "we will keep on until we reach it." Persons
had said to me : "You can never get cured of
catarrh." Doctors had said: "Once a nose patient,
always a nose patient." Well, I was determined to
be always a nose patient until I either enjoyed relief
in life or relief in the opposite way. I always had
abiding- faith in the Doctor's skill and ultimate suc-
cess. About five years ago the operation for sub-
mucous resection of the nasal septum was described.
It was, of course, like all new things a terra incog-
tiifa. It was discussed and tried timidly, reluctantly,
here and there. After a year or two, or three, it
became better known ; results following it seemed
to be satisfactory. I called the doctor's attention to
the condition of the right side of my septum, high
up, i.e. the deflection of the perpendicular plate of
the ethmoid to the right side. He said he would do
a submucous operation on it, and he did so. He
removed considerable cartilage and bone. This
wound healed quicker than any of the others. He
said to leave it alone for a year and we would see
what relief I had obtained. During that year I was
1 letter than I had been for years before as to vocal
power and expression, but I was still crippled, still
a sufiferer. In just a year's time I called up the
doctor on the telephone and told him I had deter-
mined on another submucous operation. "All
right," he said, "come along," making an appoint-
ment. Well, the second submucous was done, this
time taking out a high, bony ridge reaching nearly
to the roof of the nose, and since then I have ex-
perienced the desired relief. The catarrhal condi-
tion has vanished, the voice has its old-time com-
pass and resonance, and the mental picture is bright-
ened again. Optimism is the word. There were
twelve operations in all, covering a period of ten
years. So, "those who persevere to the end shall
be saved."

100 Lafayette Street.

Dupuytren's Contraction Cured by Medical Means. —
Gustavo Ferrari brings forward a case of contraction of
the palmar fascia in an elderly man which had existed for
some time. An operation had been refused by the patient

and he had recourse to applications of cold running water
to the entire hand, with the result of a gradual cure of
the condition and a return to the normal function. There
has been considerable difference of opinion among medical
men as to the origin of this contraction and its treatment
Dupuytren considered it a local malady of professional
nature, seated locally in the palmar aponeurosis, unilateral,
belonging exclusively to old persons, and of the nature
of a dystrophy. By others it has been regarded as a malady
found in the lower extremities, in young persons, having
its origin in a general disease ; according to some of
metabolism, to others of the nervous system, with lesions
in the cerebrospinal axis. The author believes that we
can reconcile these differing views by considering that
there are several forms of the disease, some are profes-
sional or traumatic, others are dependent on alterations
of metabolism, and still others are due to an alteration
of the cerebrospinal axis. These latter cases have also
present atrophy of the muscles of the hand and forearm,
and are thus easily to be distinguished from the purely
local forms. He considers it demonstrated that the dis-
ease may be cured by medical means without having re-
course to surgical interference. — La Riforma Medica.

Salts of Quinine in Typhoid Fever. — G. Basile pub-
lishes the results of the treatment of twenty cases of
typhoid fever by the use of salts of quinine, used by stom-
ach, except when the quinine was rejected by vomiting,
when the h>'podermic method was made use of. Different
salts of quinine were used with identical effects. Drinks
acidulated with hydrochloric acid were given at the same
time to facilitate the absorption of the quinine, and anti-
thermic baths were used. The author concludes his obser-
vations with these results : There are no inconveniences
from the use of this drug in properly selected cases : It
assists the physical antipyresis in reduction of tempera-
ture, but he considers the latter preferable; it does not
shorten the duration of the disease. Hence he does not
find confirmed the observations of various modern authors
who would have us think that with the use of this
drug we are about to enter upon a new era in the treat-
ment of typhoid. — // Policlinico.

Experimental Arteriosclerosis by Adrenalin Inocula-
tions £ind the Effect of Potassium Iodide. — W. Taylor
Cummins .nnd P. S. Stout in their second set of experi-
ments used a series of six rabbits. These animals all re-
ceived adrenalin. The first two as controls received that
drug alone. The third and fourth rabbits were given inocu-
lations of potassium iodide immediately following the ad-
renalin, in order to overcome directly the effects of the
latter drug. The last two animals were to receive no
iodide until the first two had died with manifestations of
arterial disease. Number one was emaciated when the
inoculations were begun and died after receiving the
tenth. Num.ber two died after receiving thirteen inocula-
tions of adrenalin. Number three died after thirteen
inoculations — adrenalin and potassium iodide. Number
four died after thirteen inoculations, having received the
same amount of adrenalin and iodide as did number three.
After the death of the first two animals iodide was com-
menced in the case of number five and six. Later these
two animals were killed. At post mortem number one
showed a small atheromatous plaque in the arch of the
aorta. Otherwise the vessels w-ere normal. Number two
had a rather large plaque in the same location. The aortas
of numbers three and four were free of sclerosis. In
number five there was extensive disease from the aortic
cusps to the bifurcation of the aorta. Number six showed
several small plaques along the thoracic aorta. The writer's
state tentatively that potassium iodide may be effectual in
preventii;g the development of arteriosclerosis after the
inoculations of adrenalin. It seems probable that the
iodide has no effect in its otherwise absorptive properties
after the arteriosclerosis has once appeared. — University of
Pennsylvania Medical Bulletin.

Jan. 26, 1907]

MEDICAL RECORD.

145

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A.M.. M.D., Editor.

PUBLISHERS
WM. WOOD & CO , 51 FIFTH AVENUE.

New York, January 26, 1907.

THE PUBLIC HEALTH DEFENSE LEAGUE.

A BILL has been introduced by Senator Agnew be-
fore the Legislature of this State providing for the
incorporation of a national society with the above
title, under a special charter patterned after that of
the Red Cross Society. As set forth in the charter,
the purposes of the League will be "to obtain and
disseminate accurate information concerning prac-
tices and conditions of every kind that are danger-
ous to the public health and morals, and to work
for the enlightenment of the public on all matters
affecting these subjects: to work for the enactment
of laws in the United States, Territories, and colonial
possessions, for the protection and preservation of
the public health and morals : to assist the consti-
tuted authorities in the enforcement of all laws af-
fecting the public health, including the laws for the
prevention of quackery, charlatanism, and criminal
practices in the healing art; the prevention of adul-
teration and substitution of drugs and food sub-
stances ; the prevention of the sale of narcotics,
alcohol, and dangerous substances of every kind,
whether under the guise of proprietary remedies
and so-called patent medicines and nostrums and
remedies, or whether sold as narcotics in violation
of law; the prevention of admission to the LInited
States mails of all newspapers and printed matter
of every sort advertising any business injurious to
the public health or morals ; and to prohibit the
advertising of such business in any way ; to oppose
and work against the passage of laws detrimental
to the public health and morals ; to work for the
repeal of any law having such an effect ; and gen-
erally to institute proceedings in law and equity to
carry out the objects and purposes of the corpora-
tion.'"

\Miile the Medical Society of the County of New
York has through the activities of its members and
counsel been one of the moving forces which led
to the incorporation of the League, prommcnt
medical bodies in all jjarts of the country have allied
themselves with the cause in a manner indicative
of its importance. Letters approving the call which
led to the formation of the League have been re-
ceived from the American Medical Association, the
New York Academy of Medicine, the American
Public Llealth Association, the American Society
for Sanitary and Moral Prophylaxis, the American
Association of Medical Examiners, the American
Medical Editors' Association, and many others.
Prominent individuals from all parts of the country
have also identified themselves with the cause, and
the League will number among its vice-presidents

such men as Attorney General Bonaparte, Cardinal
Gibbons, Luther Burbank, and others.

The operation of the League will be directed by
an executive committee of six members elected from
the board of thirty-six directors. This executive
committee will meet as often as necessary, to re-
ceive the reports from and direct the work of its
agents. Each sphere of activity as indicated in the
charter will be the special field of a standing com-
mittee, and these committees will be assisted by
experts in law, medicine, chemistry, and all other
lines.

The possibilities for good of a society of this
kind are incalculable, and the League, working along
the lines sketched in the charter, will deserve the
hearty support of the medical profession of the
country. The Medical Society of the County of
New York has long been active in the pursuit of
quacks, and has done good work in keeping down
the number of medical parasites in this city, but
its work, being conducted by a society of medical
men. has not received the measure of public sup-
port which is necessary in such an undertaking.
The League, essentially a lay organization and of
national scope, can carry on this purifying work
more effectively, and the results will be naturally
more far-reaching than those of the labors of any
local organization. \\'e bes]ieak for this society the
cordial approval and cooperation of the medical
profession.

ACCIDENTS FOLLOW IXC TIlOKArE.V-

TFSIS.

ExpL0R,.\T0RY puncture of the thorax is so fre-
quently resorted to, and the results of the operation
arc so generallv satisfactory, that the possibility of
accident is hardly considered. Accidents do occur,
however, of varying degrees of severity, and there
may even be a rapidly fatal result. The removal of
quite moderate amounts of fluids is well known to
have produced sudden death, but the fact that this
may also follow simple exploratory puncture is not
so well known. Some ten instances of this accident
have already been reported, in eight of which a con-
solidated lung was the cause of the ambiguous
signs, having been punctured by the needle. The
explanation which has been accepted in most of
the cases is that the sudden syncope is due to
afferent impulses conveyed to the medulla along the
vagus nerve, the terminal fibers of which have been
rendered unduly sensitive by compression or inflam-
mation. Russel, who advances this theory, con-
siders that the pulmonary fibers are a more likely
source of the impulse than the pleural. Death may
be preceded for several days by unconsciousness or
convulsions, due to the cerebral anemia produced by
cardiac inhibition and extreme lowering of the blood
pressure. That there are other causes which bring
on sudden death in these cases is shown in one re-
ported by G. G. Sears in the Anicrican Journal of
the Medical Sciences for December, K)o6. in which
the exploring needle could hardly lia\e reached the
pulmonary branches of the vagus, as a subsequent
autopsy showed that the two surfaces of the pleura
were separated by a considerable layer of fluid. The
patient presented a pleurisy with effusion, and
aspiration had already been performed. When this

146

MEDICAL RECORD.

[Jan. 26, 1907

operation was resorted to a second time the man
immediately collapsed, becoming cyanotic and
almost pulseless. He died fifteen hours later and
there were no evidences of any cerebral lesion.

Another accident which may result from thora-
centesis is the production of a pneumothorax, of
which a moderate number of instances have been
reported, including four recent ones by Sears. The
latter thinks that the comparatively small number of
cases recorded by no means represent the frequency
with which the accident probably occurs in practise,
and he suggests that it often escapes recognition,
as the patient usually recovers. Where a doubt
exists it may be cleared up to a large extent by a use
of the .i-rays. When a fatal issue ensues it is
probable that the pneumothorax did not contribute
to this result, as there are ordinarily a sufficient
number of other factors to bring this about. Vari-
ous theories have been proposed to account for the
accident, among which may be mentioned the
entrance of air through the aspirating pump or an
unguarded needle.

The causes of pneumothorax just enumerated
may be avoided by a more careful attention to
technique, but there seems to be no way of over-
coming the danger of puncture of a solid lung by a
needle used for diagnostic purposes. The fact
should serve as a warning, however, against the
reckless use of the exploring needle before the
resources of a physical examination have been ex-
hausted. When fluid is to be removed, the dangers
of a pneumothorax may be avoided by allowing the
fluid to drain away very slowly, and not insisting
that every dropJ:>e evacuated. Especially in chronic
cases, where the lung does not expand promptly to
take the place of the evacuated fluid, the precaution
should be observed. Sears thinks that siphonage is
decidedly safer when the efifusion is large or has
existed for a long time, and refers to Forlanini's
method as being still safer, according to which
sterile air is introduced to replace for the time being
the fluid removed.

THE AIEXIXGOCOCCUS .\XD THE GONO-
COCCUS.

Thk exact status of these two organisms towards
each other has long been a problem that has occupied
the attention of bacteriologists, and recent develop-
ments appear to show that the interrelationship is
a very complex one. Ruppel has succeeded in show-
ing that it is possible to obtain by means of cultures
of the gonococcus an immune serum which is not
only specifically but quantitatively equal in protective
power against virulent meningococci to specific
meningococcus serum itself, while, on the other
hand, meningococcus sera can be obtained which
are specific against gonococcal infections. Bruck-
ner and Cristeanu have produced a gonococcus im-
mune serum from horses which was equally agglu-
tinating for gonococci and for typical meningococci.
The same authors have also shown that gonococcus
and meningococcus immune sera possess precipitins
for the bacteria-free products of both varieties of
organisms. It therefore appears that gonococci and
meningococci produce agglutinins, precipitins, tox-
ins, and antitoxins of the same character.

In view of this discoverv considerable interest

attaches to some experiments reported in the Ber-
liner klinische IVochenschrift, December 31, 1906, by
Zupnik, who with four other physicians inoculated
the urethra with meningococci. In one experiment
several loops of a pure culture of a typical meningo-
coccus were put into the urethras of two of these
gentlemen, but only an evanescent local irritation
was caused which had subsided completely within
tvvent\'-four hours. Then a growth of meningococci
of a strain which bacteriologically could not be dis-
tinguished from the gonococcus was inoculated
into the urethra of a physician who had never suf-
fered from gonorrhea. The result again was nega-
tive. In the third experiment meningococci con-
tained in the still warm cerebrospinal fluid of a
patient who in addition to the meningitis was also
suffering from acute gonorrhea were introduced
into the urethras of two physicians, one of whom
had had and the other of whom had not had a pre-
vious gonorrheal infection ; the result of this experi-
ment was also negative, although the fluid contained
numerous cocci in every microscopical field. While
the negative result obtained in these experiments is
perhaps not very astonishing from the clinical
standpoint, the demonstration of the fundamental
difference in pathogenicity of the two organisms is
certainly very interesting, in view of the other evi-
dences of relationship that they can be made to
manifest.

F[;nctiox.\l Albuminuri.\ ix Athletes.

Ix a recent paper read before the Medical Society of
London, W. Collier presented the results of his
experience in examining Oxford students as to their
fitness in taking part in athletic contests {Lancet,
December 15). He found it necessary to "advise
far more men against submitting themselves to the
strain because of pronounced albuminuria than on
account of any weakness in either the heart or the
lungs. For the past twenty years at Oxford, al-
most every term, he had examined men, apparently
in the very best of health, whose urine would, after
athletic struggles, contain a verj- definite amount of
albumin. After a night's rest all trace of albumin
would have disappeared. In the past he had advised
these men to give up hard athletic competitions, and
his opinion had over and over again been endorsed
by London consultants. He now believed that this
advice was quite unnecessary and therefore wrong.
Last February he had examined specimens of urine
of 156 undergraduates training for the 'Torpids,'
and had found that with the cold nitric acid test
eighty-one specimens showed a very definite amount
of albumin, or 51 per cent. Of this year's Oxford
University crew, after rowing a trial from Putney
to Mortlake, every member's urine contained al-
bumin ; half the crew's urine contained a very large
quantity of albumin. The same thing occurred in
the case of the 'Torpid" crews ; specimens examined
of crews who had been rowing a full course almost
invariably showed albumin, and frequently a very
large quantity. In the case of the running men,
the quantities of albumin thrown down were even
more pronounced. In view of these facts Dr. Col-
lier argued that it was no longer necessary to ad-
vise men to give up athletic competitions because
of albuminuria, and that just as they might expect
to find a physiological hypertrophy of the left ven-
tricle and emphysema of the lungs in the athlete, so
they might expect to get a physiological albuminuria.

Jan. 26, 1907]

MEDICAL RECORD.

147

He further asked whether the insurance societies
ought any longer to refuse to consider the accept-
ance of the lives of young men between the ages of
twenty and thirty years whose urines had been
found to contain albumin after exercise when it
could be shown that no albumin was present after
rest and after a meal." In the discussion following
the reading of Dr. Collier's paper there was in the
main an admission of the truth of his contention,
but it was also shown that persons suffering from
transient albuminuria of the nature indicated, died
at an earlier average age than those not thus
affected.

Further Experience with Opsonins.

Reports are now beginning to come in from various
observers relative to the matter of opsonins and the
positive value of the new theory. In the Lancet of
January 5 is a report of a recent meeting of the
Manchester Pathological Society, at which Professor
A. H. White of Dublin related the results of his
experiences of inoculation on the lines laid down l.iv
Wright, and explained the necessity of repeated
blood examinations in order (a) to regulate the size
of the dose and thus to eliminate the negative phase
effect as far as possible: and (b) to determine tlie
length of time its effects lasted. He detailed the
effects of surgical jirocedure on the opsonic index
and showed how clinical improvement following a
surgical operation where only a part of the disease
was removed was coincident with a rise of opsonic
index, and that relapse with involvement of a fresh
area resulted when a fall in the index occurred.
Moreoveu, he showed that such cases might be com-
pletely cured by inoculation, as soon as the opsonic
index fell, of suitable and properly interspaced dose*
of tuberculin. In the course of the discussion. Dr.
Loveday showed that an attempt to find a small dose
of tuberculin which could be used empirically in all
cases failed. Different doses of T.R. had verv dif-
ferent actions in the same person. A very small dnsc
might give a curve of opsonic indices very similar to
that obtained by too large a dose. In some cases it
was really too large and still smaller doses were re-
quired, while in others a larger dose gave satis-
factory results. There was an optimum dose for
each patient only to be determined by frequent ob-
servations of the o])sonic index. The cjuestion was
still further discussed liy Dr. Ramsbolton, who
spoke of the therapeutic use of inoculations of
staphylococcus vaccine in certain comiuon affections,
and emphasized their value in cases of furunculosis
and the severer forms of acne, when the pustular
eruption was plentiful and the individual pustules
were large, in contrast to the milder cases of acne
consisting of a "few spots on the face"' which did
not seem to \ield so readily to this treatment. In
quoting the actual cases treated stress was laid on
the fact that the opsonic index, before treatment,
in the cases of furunculosis and the severer forms
of acne, was below noriual, whereas in the milder
forms of the latter affection the index was about,
or just above, normal.

Kven the condition which used to be called stercoral
typhlitis is really appendicitis. In 11X83 Pepper de-
scribed the relapsing form of appendicitis. Fitz in
1886 cleared up the wdiole subject in his scholarly
paper. Willard Parker was the first one to advise
early operation. Other .Vnierican surgeons, among
whom are Bull, McBurney, Keen, Morris, Senn,
Deaver, and others, have done much in perfecting
the technique of the operation. Amon.g the English
surgeons, Treves has emphatically advocated the
proper surgical treatment of this offection. Juste-
ment in the Annalcs de la Societe Medko-Chirnr-
i^icaJe d'Anvcrs of October, 1906, gives an interest-
ing review of the appendix in relation to laparotoiuv.
The ileocecal appendix has no useful function in
man. This fact has been proved many times. After
the removal of the appendix health and the various
functions contituie unaltered for )'ears. According
to Ribbert, one-fourth of the human race possess
an obliterated appendix, principally those between
the ages of fifty and eighty vears inclusive. In
man the appendix has become a rudimentary organ.
Rudimentary organs are in general distinguished bv
their congenital weakness. They are subject to the
contraction of maladies, as has been pointed out by
Darwin. The human appendix conforms clearly to
this rule. The appendix is not only useless, but it
is the cause of much trouble in the human or.ganism.
The youn^ are tnost often attacked by appendicitis.
Justement has had occasion recently to examine
thirty-five appendices which were removed in the
course of laparotomies. The normal apjiendices
were found in the youngest subjects. Kiimmel of
Hamburg in his examination of this organ has found
that in many cases it undergoes profound altera-
tions which give rise to only insignificant symptoms.
It would seem, then, that the affection of appendi-
citis is frequent and susceptible to spontaneous cure.
But it is not less true that the patients have been
in real danger. Accorrling to Bovis, appendicitis
is at its maximum frequency from the age of twen-
ty-one to thirty years inclusive. Justement thinks
that it is logical to conclude that since the appendi.x
is not only useless but also the cause of much
trouble it should be removed whenever this is found
\n be possible during the course of a laparotomy.

The Appendix .\nd I.ap.arotomy.

It is chiefly the work of .-Vmerican physicians that
has brou.ght about the recognition of the importance
of appendicitis. Some years ago, according to
Osier, the "iliac phlegmon"' was believed to be due
to disease of the cecum. It is now known, how-
ever, that the cecum itself is verv rarelv affected.

The \^.\h'e of the Cgc.mne Sin;.STiTUTES.

One of the leading fields of pharmaceutical en-
deavor seems to include the production of remedial
agents which shall serve as suljstitutes for the drugs
from which they are derived because the latter
possess, or are assumed to possess, various toxic
properties. The whole gamut of well known drugs
has been subjected to this so-called purifying proc-
ess, anrl in most instances, it triust be said, without
any signal success wdiich might give an excuse for
abandoning the original remedv. Not long after
cocaine became recogni.-?ed as one of the most valn-
alile flrugs in ophthalmic practice, efforts were ma<le
to overcome its toxic properties and other obiectioii-
able features, among which were the production of
midriasis aiid paralysis of accommodation, its ef-
fect on the intraocular pressure, and the difficulty
of obtaining perfectly sterile solutions. \ series of
derivatives was the result, for each of which perfec-
tion was claiiued as the ideal local anesthetic. That
claims of this kind will not always bear the test of
actual practical ap|ilication is shown in a recent
article by Wintcrsteiner {Wiener Idiuisclic Jl'ocheii-
schrift. 1906. No. 45!. who comes to the defense
of cocaine, as regards its employment in ophthalmic

148

MEDICAL RECORD.

[Jan. 26, 1907

practice particularly, and demonstrates that the sup-
posed disadvantages are largely overestimated. It
is admitted that cocaine may exert an injurious ef-
fect on the epithelium of the cornea, and when there
is a tendency to glaucoma it may also cause unfavor-
able symptoms. But aside from this there is very
little in the character of the substitutes which would
satisfactorily balance these shortcomings. As the re-
sult of prolonged observation and experiment, Win-
tcrsteiner concludes that although each of the numer-
ous derivatives of cocaine may have its advan-
tages, these are not of sufficient moment to cause an
abandonment of the original drug. Their acknowl-
edged inferiority in many respects seems to be in-
dicated by the fact that it is sometimes necessary
to combine them with cocaine itself in order to
obtain the desired efifect.

The E.^RLy Di.\gnosis of Carcinoma.

.Although through a better understanding of how
to interpret the results of analysis of the stomach
contents, and especially through the recognition of
the importance of searching for occult hemorrhage
as suggested by Boas, great progress has been made
in the diagnosis of cancer of the stomach, it is still
unfortunately comparatively rare for the diagnosis
to [)e made at a sufficiently early stage of the disease
to make the prognosis of operative treatment other
than doubtful. Modern surgery has established the
dictum that the patient should be brought to the
operator before there is any palpable tumor, in order
to reap the benefits of the technical advances that
have been made in this department of operative
work", but the problem is ^till an excessively difficult
one. .'\lbu calls attention to the great importance
in suspected cases of keeping careful records of
the patient's weight, and believes that a steady, even,
though slight, loss of flesh from week to week, when
taken in conjunction with other suspicious features,
such as a diminishing acidity of the gastric contents,
is a symptom of the greatest importance. In the
Deutsche nicdidnische Wochenschrift, December 27,
iQoC), he reports two cases in which the diagnosis
was made early enough for the laparotomy to reveal
tumors of very small size. In one of these the
growth was smaller than a walnut, and Albu thinks
that it is one of the smallest gastric cancers that
has been diagnosticated during life. No doubt an
important reason why such early diagnoses are not
macle oftener is that patients are not apt to consult
the physician until their subjective symptoms have
reached a considerable grade of severity, and the
conrlition has already passed beyond the opportune
stage. By endeavoring to educate the public in this
regard the practitioner can do a great deal toward
improving the prognosis of gastric cancer.

Tkeat.mext of Tuberculous Ulceration.

The successful treatment of laryngeal phthisis by
means of sunlight suggests the thought that this
therapeutic agent may also be employed in other
tuberculous affections of the mucous membranes
in which local applications are feasible. In a recent
communication by Weisz in the Wiener kliniscke
Wochenschrift, No. 46, 1906, a case is described in
which, in a patient afflicted with pulmonary tuber-
culosis with laryngeal involvement, an ulcer devel-
oped on the mucous membrane of the lip. This was
swabbed with i per cent, eosin solution and exposed
to the sunlight, but showed no tendency to heal.
Treatment with lactic acid was likewise ineffectual.

A combination of the two, however, was followed
by a very satisfactory outcome. The ulcerated area
was first swabbed with lactic acid (25 to 50 per
cent.) and the next morning, after the slough had
been removed, was exposed to the direct rays of
the sun for varying periods. During the course of
two months the ulcerated area was thus exposed for
a total of eighty hours, and complete cicatrization
resulted. The laryngeal lesion was entirely cured
by the sunlight alone, but in the other case the com-
bination treatment was necessary in order to remove
the slough from the surface of the ulcer, so that
the sun's rays could become eflfective. But in the
treatment of laryngeal lesions, where there is much
necrotic tissue present, it would appear advisable
to resort to a similar measure when a prompt effect
fails to appear from the application of sunlight alone.

Cardiac Trauma.

The fact that cardiac disease may be dependent
upon a traumatic basis is well shown by a case re-
ported by Roncagliolo in the Medizinische Klinik,
No. 38, 1906. The patient, a young man, fell from
a considerable height and struck on his left side.
He sustained a slight cerebral concussion and sun-
dry abrasions, from all of which he promptly re-
covered. Soon afterward he developed evidences
of cardiac disturbance which became progressively
worse, and necessitated his entry into the hospital
five months later, when a diagnosis of chronic myo-
carditis was made. Before the accident the patient
had always been perfectly well, neither smoked nor
drank, so that none of the usual factors in the pro-
duction of cardiac disease were present. The heart
involvement coming directly after the injury made
it most probable that the latter served as the direct
cause of this condition, and although the case is
unusual, it should serve to call attention to the fact
that such a complication may occur.

Difficult Labors and Epilepsy.

The search for etiological factors in the production
of epilepsy has animated Volland to investigate the
subject from the standpoint of obstetrics {Zeitschrift
fiir Psychiatric und psychisch-gerichtliche Medizin^
Vol. 63, No. 5). For this purpose he carefully ex-
amined 1,500 cases of epilepsy to determine whether
the occurrence of abnormal labors had any bearing
on the subject. In forty-five cases (3 per cent.)
such abnormalities were found, but a thorough
search into the facts of the history in each case
showed that the disturbances in question constituted
a very subordinate predisposing factor in the pro-
duction of the epileptic seizures, and in all but a
very small proportion of cases they could apparently
be entirelv discounted.

Public Lectures at the Academy of Medicine. —
The second meeting of the public lecture series of
the New York Academy of Medicine will be held
on Thursday evening, January 31, at 8:30 o'clock.
The subject of the lectures will be the Public ]\Iilk
Supply. Dr. Rowland G. Freeman will speak on
"The Risks and Safeguards of Public Milk Sup-
plies," the lecture being illustrated with lantern
slides. This will be followed by a short address on
"The Milk Work of the Department of Health,"
by Dr. Thomas Darlington, Health Commissioner
of New York City. "How Can the Layman Co-
operate?" is the title of the third discourse, by Mr.
William H. Allen, General Agent of the Associa-
tion for Improving the Condition of the Poor.

Jan. 26, 1907]

MEDICAL RECORD.

149

Nfuis of tlie Wttk.

Medical Legislation in Pennsylvania. — A bill

has been introduced into the Pennsylvania Legis-
lature directed toward prohibiting the practice of
Christian Science, osteopathy, and other systems of
treating the sick outside of the three legally recog-
nized schools of medicine. A counter bill also has
been introduced into the Legislature. This is virtu-
alh the same as that passed by botli branches of the
Legislature two years ago, but vetoed by Governor
Pennypacker. It provides for the recognition of
tlie eligibility of osteopathic practitioners to take ex-
aminations before the State Medical Board in all
branches but materia medica, and to be represented
on the State Medical Board, and requiring that none
shall be eligible for the State Board examinations
except persons who have taken a four-years' course
at a school or college, and who have a diploma certi-
fying to this fact. Another bill provides for changes
in the manner of examining applicants for license
to practise medicine, and also contains a provision
to the effect that any person offering services as a
practitioner of the healing art, without complying
with the provisions of the act, without being gradu-
ated from a medical school, and passing the ex-
amination of the regular, homeopathic, or eclectic
examining board, shall be guilty of a misdemeanor.
The bill also changes from three to four years the
minimum term of study in medical colleges, re-
quires midwives to undergo the same examinations
as phvsicians, authorizes the State Medical Council
to revoke the licenses of physicians guilty of unpro-
fessional practices or unduly addicted to narcotics,
and increases from $2,000 to $5,000 the biennial
appropriation for the expenses of the State Medical
Council.

Festschrift Number of the "Annals of Otology,
Rhinology and Laryngology." — The issue of this
journal for December, 1906, takes the form of a
"Festschrift," in honor of Prof. B. Fraenkel of Ber-
lin, who recently celebrated his seventieth birthday.
It contains nearly fifty articles on topics connected
with nose, throat, and ear practice, opening with
a congratulatory address to Prof. Fraenkel by Dr.
C). T. Freer of Chicago, following which are con-
tributions by Dr. W. Freudenthal of New York on
"Bernhard Fraenkel — what he has done for Rhino-
Laryngology," and by a bibliographv of his con-
tributions to medical literature by Dr. Freudenthal
and Dr. Landgraf of Berlin. Several of the re-
mair.ing contributions have already appeared in
other journals, but the issue is a notable one, and
reflects great credit on the Editor-in-Chief, Dr.
H. .\. Loeb of St. Louis.

Typhoid Fever. — What is considered the most
serious outbreak of typhoid fever that has occurred
in Philadelphia since that of 1898-9 is in progress in
that city. There are said to be more than 1,500
cases in the city, of which 500 are being treated in
hospitals, all of which are overcrowded. Last week
342 new cases and 27 deaths were reported. The
epidemic is attributed to delay in finishing the city's
filtration system, upon which millions of dollars
have been spent. In Scranton the morbidity from
typhoid fever is diminishing, but both diphtheria
and scarlet fever are very common.

Scarlatina and Diphtheria in Chicago. — Both
of these diseases are epidemic in Chicago and its
suburbs, and the health authorities have stated that
there are several thousand cases at present in the
city. In Evanston and Oak Park the schools have
been closed on this account.

Census of the Blind. — The New York State

Commission to Investigate the Condition of the
Blind, which is undertaking an inquiry into the
cause of blindness and the means to be taken to
assist the blind, is engaged in the preparation of a
census of all those so afflicted. It is requested that
the names of all blind adults, children, or infants
be sent to the secretary of the commission. Mr.
O. H. Burritt, Batavia, N. Y. It is the purpose
of the commission to obtain data on which to make
recommendations to the Legislature concerning the
establishment of industrial schools for the blind.

Famine and Pestilence in China. — The foreign
relief connnittee at Shanghai reports that smallpox
has broken out in the camp for famine sufferers at
Tsingkiangpu, and that on this account the officials
have broken up the camp, which had several hun-
dred thousand inmates. The eft'orts to cope with
the situation are said to be hopelessly inadequate,
and immense loss of life is expected. The institu-
tion of relief work is greatly hampered by the lack
of means of communication, and the fact that the
wealthy are deterred from making large contribu-
tions through the fear of official peculation.

Tea as a Beverage for Soldiers. — As the result
of observations made while with the Russian Army
in Manchuria, bv Col. Valery Havard, Assistant
Surgeon General in the United States Army, tea is
much more suitable as the routine military beverage
than coffee. It is considered easier to transport,
[ireserve, and prepare, and has been adopted by the
English, Russian, and Japanese Armies. Col.
blavard recommends that it be substituted for coft'ee
in the United States Army rations.

Medical Practice Bill in Massachusetts. — An
effort is being made by means of a bill now before
the Massachusetts Legislature to restrict or stop
altogether the practice of Christian Science in that
.State. While this sect is not specifically mentioned
in the bill, which provides simply for the control of
the practice of medicine, it is so drawn up as to
militate directly against the Christian Science
healers.

Suicide in Vienna. — This center of medical
study still retains an unenviable prominence among
the capitals of Europe in the records of suicides.
In the year which has just ended 425 persons — 313
men and 112 women — committed suicide, while
707 men and women attempted unsuccessfully
to do so. The victims were of all ages, ranging
from an old man of eighty-seven to a little girl of
eight years. Sickness was the motive alleged in
one hundred cases, unhappy love affairs in sixty-
three, family strife twenty-three, satiety of life thir-
ty-three, and poverty thirty-one. Twelve women
and one hundred and eighteen men shot themselves,
nineteen men and thirty-two women took poison,
while ten men and twenty-eight women threw them-
selves from top story windows, a form of suicide
common in Vienna.

Bee-Sting as a Cure for Rheumatism. — To
demonstrate the good effects of bee-sting in the
treatment of rheumatism, an enthusiastic believer
at Middletown, Pa., permitted himself to be stung
recently bv eighteen Cyprian bees before the Penn-
sylvania State Beekeepers' Association at the De-
partment of Public Instruction at Harrisbm-g. The
treatment was applied by the State Zoologist, from
whose apiary the bees were produced, and he was
assisted by a representative of the State Health
Department.

Advertising Condemned. — Stringent resolu-
tions were adopted at the quarterly meeting of the

I50

MEDICAL RECORD.

[Jan. 26, 1907

Coles t'oiinty (Illinois) Medical Society, at Charles-
ton, with reference to the appearance of the names
of members of the society in the lay press, in con-
nection with accidents, operations, etc.

Women Doctors in Germany. — Prof, von Berg-
maim of Berlin is reported to have recently said
to a medical editor in substantiation of his opinion
that women should not engage in the practice of
medicine, that so long as women were unable to
beat cooks and tailors at the vocations which women
are apt to regard as their own specialties, so long
would they be unable to compete successfully with
men doctors.

Harvey Society Lecture. — -\n invitation is ex-
tended to those interested to be present at the
seventh lecture in the Harvey Society course, which
will be given by Professor Edmund B. Wilson of
Columbia University at the New York Academy of
Medicine, on Saturday evening, January 26, at 8 :30
p. M. Subject: "Recent Studies of Heredity."

Alvarenga Prize. — The College of Physicians
of I'hiladelphia announces that the next award of
the Alvarenga prize will be made on July 14, 1907.
The prize is the income from the bequest of the
late Senor Alvarenga, and amounts to about $180.

Plague in Rio Janeiro. — During one week re-
cently there were reported in Rio Janeiro thirty-
tw-o cases of bubonic plague, with eight deaths ;
three cases of yellow fever, with one death, and
three deaths from leprosy.

Anti-Noise Bill Favorably Reported. — The Sen-
ate Committee on Commerce has authorized a favor-
able report on the bill authorizing Supervising In-
spectors of Steam \'essels to regulate the blowing
of whistles. The bill has already passed the House.

Red Cross Relief for Kingston. — The Xew York
State branch of the Red Cross, acting under author-
ization from Washington, has sent relief supplies
to Kingston. Jamaica, to the value of $5,000. and
consisting of salt beef and pork, canned goods, and
soup-;.

Overcrowding in Hospital for the Insane. — As

a result of the formal inspection of the Pennsylvania
State Asylum for the Insane at Warren, made re-
cently by a special commission for investigating the
conditions prevailing in the insane asylums of the
State, it was found that, while the institution is in
other respects most admirably conducted, it
is greatly overcrowded. With accommodations
for a total of 734 patients. 598 men and 582 women
have been crowded within its walls, many patients
being compelled to occupy cots in long, narrow, ill-
ventilated corridors, with low ceilings. There are
only 180 employees to take care of the patients, and
as these work in shifts, only a small number are on
duty at one time. An infirmary for men is badly
needed.

Gift to Philadelphia Hospital.— Mr. P. F. Ker-
nan. a real estate broker of Philadelphia, has given
$5,000 to St. Joseph's Hospital for the endowment
of a free bed. The money was bequeathed by the
late Miss Harriet Richards, to be given to any
worthy charity selected by the donor. A similar gift
was recently made to St. Mary's Hospital.

Muhlenberg Hospital. — The sum of $1,000 has
been contributed to this hospital by Mr. and Mrs.
Everett Colby of Orange, in the name of their
daughter, Elizabeth Colby, who died last summer.

Bequests to Chicago Hospitals. — Five hundred
dollars has been bequeathed to the IMichael Reese
Hospital, and $200 each to St. Luke's and the

Alexian Brothers Hospitals, and to the Home for
Incurables, by the will of the late Bernard New.

Cincinnati City Hospital. — The medical profes-
sion of Cincinnati, as well as the lait>', are indignant
over the dismissal of Dr. C. R. Holmes, who was
serving in an advisory capacity to the Board of
Public Service in regard to the building of the new
City Hospital. Dr. Holmes has devoted a great
deal of time, money, and ability to the work, and is
thus summarily dismissed without any recognition
of his services.

Jewish Hospital for Deformities and Joint
Diseases. — This hospital, which was opened on
November 4, in a building on Mount Morris Park,
has been so w-e!l filled that it has been found neces-
sary to purchase the adjoining property at 1919
Madison Avenue. The new building, which is a
brownstone private house, will be remodeled as
rapidly as possible.

Meeting of Chicago Children's Hospital So-
ciety.— The annual meeting of this society was
held January 6, when $1,300 was ordered to be dis-
tributed to the various hospitals where children have
been cared for.

College of Physicians of Philadelphia. — This
institution has received from Mr. Andrew Carnegie
$100,000 towards the erection of its new building,
on condition that a like sum be raised, of which
$80,000 has already been subscribed.

Annual Meeting of the Illinois State Board of
Health. — At a meeting, held January 15, Dr. Geo.
W. Webster of Chicago was reelected President
of the Illinois State Board of Health, and Dr. James
A. Egan, Springfield, reelected Secretary and Treas-
urer.

Philadelphia County Medical Society. — At a
stated meeting held January 16 the following officers
were elected for the ensuing year : President. Dr.
James B. \\'alker : Vice-Presidents, Dr. William S.
Xewcomet. Dr. Joseph O'Malley, Dr. Wendell
Reber, Dr. Robert H. Chase, Dr. Maurice J. Kar-
peles, and Dr. Franklin Brady : Secretary, Dr. Wil-
liam S. Wray; Assistant Secretary, Dr. Ross H.
Skillern ; Treasurer. Dr. Collier L. Bower ; Censor,
Dr. Charles A. E. Codman : District Censor for the
State Society. Dr. Albert M. Eaton.

The Obstetrical Society of Cincinnati, at its an-
nual meeting, elected the following officers for the
ensuing year : President. Dr. Wm. Gillespie : Vice-
President. Dr. M. A. Tate : Recording Secretary,
Dr. J. H. Landis; Corresponding Secretary, Dr.
F. S. McKee : Treasurer, Dr. L. S. Colter.

Medicolegal Society. — At its annual meeting,
held January 16, this society elected the following
officers : President. Mr. Clark Rice ; Vice-Presi-
dents, Dr. J. Mount Bleyer and Dr. W. B. Fletcher;
Secretary. Mr. John R. Abarbanell.

Winnebago County (111.) Medical Society. —
Officers were elected as follows at the annual meet-
ing of this society, held in Rockford on January 8:
President. Dr. T. H. Culhane ; Vice-President, Dr.
W. E. Park ; Secretary and Treasurer, Dr. R. C.
Bourland.

Dubuque (la.) Medical Society. — The follow-
ing were elected as officers at the recent meeting
of this society: President. Dr. W. P. Slattery ; Vice-
President, Dr. F. J. Wieland ; Second Vice-Presi-
dent, Dr. Kearney of Farley : Secretary, Dr. Mary
Killen : Treasurer. Dr. Lily Kinnier.

Buchanan County (Mo.) Medical Society. — At
a meeting of this organization, held on January 9,
officers were elected as follows : President, Dr. 0.

Jan. 26, 1907]

MEDICAL RECORD.

151

G. Gleaves ; Vice-Presidents, Dr. W. J. McGill and
Dr. S. F. Kessler; Secretary, Dr. Chas. W. Fasset :
Treasurer, Dr. J. M. Bell.

Western Massachusetts Ophthalmological and
Otological Society. — A society with this name
has recently been formed, and the followins; officers
were elected at a meeting held in Springfield : Presi-
dent, Dr. Clarence R. Gardner of Northampton ;
Vice-President, Dr. Charles R. Chapman of Spring-
field; Secretary and Treasurer, Dr. V. J. Irwin.

York County (Me.) Medical Society. — At the
thirteenth anntial meeting of this society, which was
held in Biddeford on January 9, officers were
elected as follows: President, Dr. M. H. Ferguson,
Biddeford: First J 'ice-President, Dr. O. \V. Pills-
bury, Saco ; Second Vice-President, Dr. R. S. Gove.
Sanford ; Secretary, Dr. C. E. Thompson, Saco ;
Treasurer, Dr. H. L. Prescott, Kennebunkport.

Obituary Notes. — Dr. Henry Kost of this city
-died on January 12, at the age of seventy-six years.
He was a native of Germany, and received his med-
ical education in the universities of Jena, VViirz-
burg, and Vienna. In 1855 he held a commission
as assistant surgeon in the British-German Legion,
and served through the Crimean War : later he held
a position in the German hospital at Dalton. Eng-
land. In 1868 he came to this city, and had prac-
tised here ever since.

Dr. Lym.\n' a. Noves of Chicopee, Mass., died
on January 10, at the age of si.xty-seven years. He
was born in Tunbridge, Vt., and received his med-
ical degree from the University of Pennsylvania in
1862. During the Civil War he served as surgeon
with the Second \'ermont Volunteers and the Nine-
teenth Pennsylvania cavalry. In 1880 he was ap-
pointed post surgeon at Seal Island, .Maska, hut of
late years he had spent his winters in Chicopee.

Dr. John J. Blacki.ock of Morrisburg. Ont.,
died on January 9, at the age of eighty-three years.
He was a son of Dr. Ambrose Blacklock. a surgeon
of the Royal Navy, and was born at Williamstown,
Glengarry-. He was a graduate of McGill I'nivcr-
sity, and had served as coroner of the United Coun-
ties for over forty years.

Dr. W. M. Cr.\wford of Lancaster. S. C. died
suddenly of heart-disease on January 9. at the age
of forty-six years. Dr. Crawford was graduated
in medicine from the Charleston Medical College,
and had practised in Lancaster for many years.

Dr. R. H. McDoN.\LD of Pittsburg, Kansas, died
on January Q, at the age of fifty-three years. He
was born in Hallsville, Mo., and was graduated fmm
the Marion Sims Medical College in St. Louis
thirty-three years ago. He practised for some years
in Colorado Springs.

Dr. J. ^^^ Johxsox nf Xorrington. Conn., died
on Januarv 12 of typhoid fever, at the age of forty-
two years. He was born in Pikesville. Md., and
received his medical education in the College of
Physicians and Surgeons, Baltimore, being gradu-
ated in 1892.

Dr. J. S. Ci.EMENT.s of Edison, \'a.. after a pro-
tracted illness, died on January 13, at the age of
eighty-three years. He was one of the oldest physi-
cians in the .State, and had retired some years ago.

Dr. E. M. Sii.vw of Victoria, Tex., died recently
of heart-disease, at the age of forty-seven years.
He had practised in \'ictoria for about twelve years.

Dr. Solomon D. Meredith of Carthage, Mo.,
died on January 10, at the age of thirtv-eight years.
He came to Missouri in 1898, and began practice at
Ritchey. Four years ago he removed to Carthage.

Dr. R. B. Price of Kingston. Ont., died in Chi-

cago on January 4 of pneumonia, at the age of
sixty-nine years. He was a Queen's graduate, and
had practised in Bath, Kingston, and Lonsdale.

THE SIXTH HARVEY SOCIETY LECTURE.

The sixth lecture of the Harvey Society's present
series was given by Prof. F. G. Benedict of Wes-
leyan L'niversity on Saturday, January 12, at the
Academy of Medicine, the subject being "Metabol-
ism During Fasting." It had been planned to have
present the professional Italian long-period faster,
Succi, who was subjecting himself to experimenta-
tion by Prof. Benedict, but he had been compelled
to return abroad. However, one of the speaker's
subjects on whom numerous observations in fasting
periods as long as seven days had been made, was
present at the lecture, and informally discussed his
experiences at the close of the meeting. Prof. Bene-
dict confined himself for the most part to describ-
ing the experiments completed under his direction
on normal fasting men. Owing to the immense
expense involved in the undertaking the work was
being done under the auspices of the Carnegie In-
stitution of Washington, and the results would ap-
pear in the publications of that body.

It had been found, the speaker said, that in adults
living under normal conditions there was a constant
replenishing of the fats, carbohydrates, and proteid
burned for the production of bodily euergv or re-
sulting from the wear and tear on the tissues. In
inanition, where such a replenishment was not pos-
sible, there was a marked loss of weight from day
to day. If water was awailable this loss rejjresented
the destruction of the body's store of proteid, carbo-
hydrate, and fat, from which was obtained the
energy necessary for the continued existence of life.
Extensive observations had been made in the study
of metabolism under tliese circumstances, but at-
tention had been devoted for the most part to the
cataboHsm of proteid as indicated by the nitrogenous
constituents, and . by the sulphur and phosphorus
of the urine. This gave a rather one-sided view
of the subject, since the metabolism comprised as
well the utilization of fat and carbohydrates. This
method would have to be supplemented by a study
of the heat production. Luciani and also Tigerstedt
had had fair success in studying metabolism in the
more complete manner, but their experiments were
more or less interrupted, and had not the complete-
ness and the refined accuracy of the observations
made in the respiration calorimeter chamber at Wes-
leyan University. This calorimeter chamber, as
perliaps all knew, had been constructed and per-
fected under the direction of Prof, .Atwater, who,
had conducted numerous noteworthy nutrition ex-
I-ieriments by means of it. ( There was a similar ap-
paratus, the speaker said, at the Pennsylvania State
.Agricultural Station, where nutrition studies were
being carried out on the large domestic farm ani-
mals.) The calorimeter chamber consisted of an air-
tight, copper-lined box, ventilated by forcing a cur-
rent of air through by means of a blower. As the air
left the chamber it was passed through concentrated
sulphuric acid to remove the moisture, and then
through jars containing ^oda and quick lime to ab-
sorb the carbon dioxide. Tbe quantities of carbon
dioxide and water eliminated by the subject imder
observation for an\- given time coidd then be de-
termined by the increase in weight of the acid and
the soda-quick lime jars. The deficiency of oxygen
in the air was made up by replenishing from cylin-
ders of oxvgen gas: the oxygen consumption there-

152

MEDICAL RECORD.

[Jan. 26, 1907

fore was a known factor. In order to prevent loss,
through radiation and conduction, of the heat given
off by the subject, i. e. to make the chamber a calori-
meter, there were two walls outside the copper lin-
ing; one was of zinc, the other of wood, and there
were air spaces between. The chamber was cooled
by passing cold water through a series of tubes in
copper discs, which served as heat absorbers. From
the amount of water passed through in a given time
and its increased temperature, the loss of heat by
the man in the chamber could be calculated. .A.ccess
and communication to the interior of the chamber
was through a small double window. The chamber
contained a telephone, a chair, a couch which folded
up against the wall, a chair which could be sus-
pended from an exterior scale, so that the body
weight could be determined, and finally, if desired,
a bicycle machine for exercise tests. Respiration
and pulse of the subject were recorded on a smoked
drum by a pneumograph with a long rubber tube
connection, and the individual's temperature was
recorded by an electrical resistance thermometer re-
tained constantly well up in the rectum, and con-
necting with the outside world by wires.

The subjects were students and young profes-
sional men. The calorimeter was entered some
hours before the beginning of the experiment. Dur-
ing the stay in the apparatus there was a more or
less prescribed routine of life, with little muscular
work. The only thing given was distilled or tap
water. In all fourteen experiments had been made
lasting, in fasting periods, from two to seven days,
and covering an aggregate of forty-three days.

Prof. Benedict gave" the main facts brought out
bv the investigations as follows : The most notice^
able thing was the loss in weight, but the values
fluctuated, and were not accurate indices of loss of
body tissue. The variations were associated with
extra elimination or retention of water, and were
often considerable, ranging from 44 grams to i.i
kilos. The average losses on the first and second
days were about a kilo, on the third about 787
grams, on the fourth 682 grams, and on the fifth,
sixth, and seventh days about 500 grams per day.
The body temperature was lower and more con-
stant than in normal individuals. Pulse and respira-
tion tended to be much slower, but the degree of
change varied in different individuals. With the
resumption of food there was a rise of temperature
and a marked increase in pulse and respiration.
There was a diminution in the red cells and the
leucocytes. Differential counts showed no change
in the relation of the various types of cells except
for some increase in the lymphocytes. The speaker,
however, said that these blood tests were not en-
tirely satisfactory. There was a noticeable falling
oft" in strength as indicated by dynamometer tests;
with the resumption of food the strength rapidly
returned. After a fast of only two days' duration
the body weight was rapidly regained, in fact, the
original weight was somewhat exceeded, and re-
mained at the higher level. This fact could be
applied practically as a method of increasing body
weight. No special discomfort was noted as a result
of fasting. It had been noted, however, that a good
mental condition was essential for a successful fast.
In short fasts the degree of emaciation was slight.
No fasting faces had been obtained in any of the
experiments.

The nitrogen eliminated daily in the urine varied
on the first' day from 5.8 to IS.,'^ grams. It was
usually about 10 grams in longer fasts, after the
third day. The water output per day in respiration
and perspiration amounted to from 600 to Soo grams.

The carbon dioxide output was reasonably uni-
form : it was higher on the first two days and therv
gradually diminished. While this figure was an
approximate estimate of the total oxidation, the
oxygen absorbed was a much more exact measure.
The proteid catabolized was essentially represented
by the N output (times 6%) in the urine. Know-
ing the CO^ given off, the oxygen absorbed, and
the nitrogen of the urine per day, it was possible to
calculate the amounts of fat and carbohydrate
burned. At rest during inanition it was found that
about 150 grams of fat was utilized; but before
this the glycogen store was drawn upon, 181. 6 grams
having been utilized. Later the glycogen used
might be as low as 20 grams per day. The amount
of heat produced was largest on the first day, and
tended to diminish. It was not far from 1800
calories, though with absolute muscular rest prob-
ably about 1500 calories. A day of sleep would
amount to about 1300 calories, as shown by calcula-
tions based on six-hour periods. In different in-
dividuals the heat production was apparently par-
allel to the pulse rate. A balance between the heat
produced and the energy as calculated from the
oxidations gave close results, showing the reliability
of the deductions.

The rest of the lecture was taken up with a de-
scription of the detailed results of a single seven-
day fasting period. The results were essentially
those given above.

At the conclusion of the lecture, the chairman.
Prof. Graham Lusk, announced that the studies
of Prof. Benedict would probably be extended to-
observations of various pathological conditions.
These would doubtless throw much light on some
still verv obscure metabolic disturbances.

TRYPSIN FOR THE CURE OF C.\NCER.
To THE Editor of the Medical Record:

Sir: — Replying to Dr. Morton's letter appearing in the
Medical Record of January 19, 1907, commenting on my
"facts," I would like to make the following ob.servations.

It is very refreshing to learn that Dr. Morton is willing,
to adm.it that one-third of my claims are founded on fact,,
and that in so far his statements were not strictly correct.

In answer to Dr. Morton's statement, substantiated by
the unreliable letter of the patient, to the eiTect that I did
not "attend the patient at her home and did not examine
her during this time, except at my (his) office, and in the
early stage of treatment," I have to say that, during the
seven weeks in question. I examined the patient at her
home, and with her consent measured the tumor to leant
what were the eflfects of the ;r-ray in the hands of a special-
ist. The period in question is the seven weeks following
July 3, when the patient first visited Dr. Morton. The
dates of my visits were July 3, 6. 7, 10, 14, 17, 21, 24, 28, 31,
and August 4, 7, 10, li, 14, 16, 18, 21, 23, 24, 25, 28, and 29.
I stated in my letter that the tumor increased or decreased
in size according to the menstruation. I drew a diagram
of the tumor July 7, when largest diameter was four
inches : diameter at right angles to this was three and one-
half inches. July 14 the patient menstruated, and the tumor
measured in the same diameter? nearly one-half inch larger.
.\fter that the tumor diminished in size till .August 4.
when it began to enlarge, and remained larger til] men-
struation again occurred, when it began to diminish in size.
Perhaps even Dr. Morton will believe that I had opportu-
nities to make these "careful notes'' when I state that from
them I am able to tell him what drugs he or his associate
gave the patient, who showed me the prescriptions.

Dr. Morton asks what has this to do with trypsin. In
my first letter T avoided any discussion of trypsin, saying
that I was using it, as are many other men. Trypsin
doubtless furnishes certain ferments which enable the body
to assimilate more of the food taken, thus prolonging the
struggle between the tissues and the cancer. My purpose
in writing these communications is to guard against hasty
and misleading conclusions in experiments with remedies
which follow one another in such quick succession^ as to be
a menace both to the public and to the profession. No-

Jan. 26, 1907]

MEDICAL RECORD.

153

personal animus actuates my letters, but a conscientious
desire to record my observations for the value other sur-
geons may find in my experience.

Edward W. Peet, M.D.

HYOSCINE AND SCOPOLAMINE.

To THE Editor of the Medical Record :

Sir: — In the Medical Record of January 12 is an article
by Dr. Birchmore, of Brooklyn, on "The Hyoscine Sleep in
Obstetric Practice," in which the writer warmly advocates
the use hypodermically of morphine and hyoscine hydro-
bromate as a means of producing profound and anesthetic
sleep during the painful period of labor; this he recom-
mends as being "without risk to mother or child." In the
latest revision of the U. S. Pharmacopoeia, hyoscine hydro-
bromate is said to be identical with scopolamine hydrobro-
mate, and the latter is said to be identical with the former.
Potter, in his "Materia Medica," seventh edition, page 340,
says "nearly all the hyoscine hydrobromate supplied by
manufacturing chemists consists of scopolamine hydro-
bromate (Schmidt)."

A number of articles have recently been published on the
use of morphine and hyoscine hydrobromate in obstetric
practice, and in every instance the procedure is recom-
mended as being perfectly safe. From the number of deaths
reported from the use of morphine and scopolamine hydro-
bromate anesthesia, which have caused it to fall quickly
into disrepute, I feel that attention should be called to the
identity of these drugs before we begin to hear of accidents
from this anesthetic which is "without risk."

H. W. Chapman. M.D.

White Hall. III.

A COMPLETE EDITION OF THE ANCIENT GREEK
MEDICAL WRITERS

To THE Editor of the Medical Record:

Sir: — In the Greek journal, Medical Progress, the edi-
tor. Dr. J. Phoustanos, writes : "The complete edition of
all the ancient Greek medical writers which we have been
preparing for many years will go to press within a few
months, all the preliminary work being accomplished.
We give this good news to our readers, wlio, for a very
insignificant amount, can acquire now a complete and
most precious library in which will, within a few years,
be collected all the works of the ancient Greek physicians,
tiot only those already pubhshed and of which some aie
out of print and difficult to obtain, but also some which
exist only in old manuscripts and will now appear in
print for the first time. The attempt of this publication
involves enormous expense, but it will honor greatly our
country to which alone belongs the right to preserve and
to transmit thus the admirable work of some of her best
men. We hope that this undertaking will be brought to
a successful end by the aid of Greek physicians in all parts
•of the world, who will tinis bring honor on themselves
and on their country."

I know from Dr. Plioustanos that he began the prepa-
ration of this edition about ten years ago, and has had
the assistance of the leading medical men and pliilolo-
gists of Greece in the work. The patriotic men of
science who cooperate with Dr. Phoustanos are not only
honoring their country, but render an exceptional ser-
vice to true lovers of science all over the civilized world.

A. Rose, M.D.

OUR LONDON LETTER.
(From Our Special Correspondent.)
ARMY MEDICAL ARRANGEMENTS — MANAGEMENT OF NATURAL
LABOR — JOURNAL FOR TUBERCULOSIS — APPENDICITIS — LIV-
INGSTONE COLLEGE — INQUESTS — OBITUARY.

London, January 4, 1007.
The army would seem to be always in need of re-
organization— or is it rather that every new war min-
ister thinks he must alter what his predecessor has
done? Not a few ollicers complain that the force
suffers from these constant changes, and some of them
say it is just a round of meddling and muddling.
When one considers the subject attentively it does
seem remarkable that every civilian who takes the re-
sponsible office of a minister seems to imagine him-
self at once qualified to set at nought the views of
military experts. It accords with our parliamentary
system to set a politician over the army that he may
be responsible to parliament for administration, but it
IS an abuse when a civilian is permitted to override
the judgment of the most distinguished soldiers with-
out stating in writing his reasons for such supersession.
The medical department of the army is dealt with on
similar lines, and it is now officially stated that the
War Secretary lias decided to reconstruct the advisory

board and to make it more distinctly advisory in its
functions. This probably means that the politicians
shall be at liberty to set aside the advice of the medi-
cal board without question. It would be no novelty
were such the intention, and the way in which former
administrations have been ignored is not encouraging.
Still it is possible that Mr. Haldane may intend to
follow the advice of his reconstructed medical board,
in which case he should see that his successors in office
shall be compelled to do so or to record their reasons
for not doing so. The necessity of leaving a record
for the guidance of their successors would be a most
valuable safeguard against the propensity to meddle
and muddle. If Mr. Haldane is in earnest he might
gain the confidence of the department by replacing
its director-general on the army council. His new
advisory board is to have that officer for chairman, and
he could represent the opinions of it with authority
and explain its recommendations to the council as
occasion might require. The other members are a
civil sanitary expert, a civilian physician, a civilian sur-
geon, an officer of the R. A. M. C., with special knowl-
edge of tropical diseases, an officer of the R. Engineers,
the president of the Indian Medical Board, and the
deputy director-general, who will act as vice-chairman.
The .^rmy Hospital and Sanitary Committee is to be
dissolved and its duties transferred to the Medical
Advisory Board. An officer of the R. A. M. C. is to be
appointed to act on the staff of the inspector-general
of the forces, as an inspector of hospitals and army
sanitation.

The management of natural labor is a subject of
interest to every practitioner and which it might be
supposed is well understood in this century. It came
up for consideration last month at the Harveian Society
and produced some interesting observations. Dr. Box-
all opened with a reference to the mortality in lying-
in hospitals thirty years ago, which then averaged four-
teen per cent. This rate has greatly diminished, but
it is still high in cases treated in hospital, the main
cause being, according to Dr. Boxall, septic absorption
from lacerations, or the use of instruments or imperfect
methods of employing antiseptics. It was, he said, not
merely the use, but the proper use of antiseptics which
had led to such a great improvement in statistics of
hospital cases. Training in the use of antiseptics he
declared to be as necessary for students as for mid-
wives or nurses, and neglect of such training might ac-
count for the comparatively high mortality of private
cases.

Dr. llnrrocks said that 100 years ago pyrexia after
delivery was the rule, and lying-in hospitals were hot-
beds of infection. The proper use of antiseptics had
effected a great improvement. Syringing was tried, but
abandoned when it was seen that the hand of the
accoucheur introduced septic material. He thought
nature managed delivery better without artificial aids.
He did not approve of chloroform or the use of for-
ceps unless absolutely necessary. Even with strict an-
tiseptic precautions forceps might produce lacerations
or tears, which gave trouble later on. At Guy's Hos-
pital forceps were resorted to only in four or five per
cent, and the mortality was low. He did not consider
gonorrhea gave rise to puerperal fever, though it did to
ophthalmia neonatorum, but he depreciated the routine
dropping of irritating lotions into the eyes of new-
born children, for in the absence of gonorrhea they set
up ophthalmia.

Dr. H. Phillips said his case mortality was only one
per cent. He usually examined more than one, but used
strict antiseptic precautions. He left delivery as far as
he could to nature, only douched after instrumental de-
livery and then only once.

Dr. Adams disapproved of chloroform as having a
marked effect in diminishing the pains and as often
necessitating the use of instruments.

Dr. Bluett said rupture of the perineum should not
often occur, even in primiparx. when forceps were used
or sufficient care was taken.

Dr. Payne asked about the use of ergot as a routine
measure.

Dr. Handfield-Jones referred to the difference be-
tween hospital and private cases. He found chloroform
seldom necessary in hospital, hut often beneficial in
private practice. In moderation it did not interfere
with the progress of the first and second stages, in the
third it might prevent rupture nf the perineum. So
with ergot, seldom required in hospital, but often in
private cases. He could not agree with Dr. Boxall as
to deficient training of students in the use of anti-

154

MEDICAL RECORD.

[Jan. 26, 1907

septics, fiir statistics showed that the mortality of cases
treated at their own liomes by students at the large
hospitals was very low. Where high mortality occurred
was in the unsanitary surroundings of the poorest
classes, and still more fatal was examination by igno-
rant midwives, wlio infected patients before they were
seen by a doctor.

Dr. Lewers said vaginal c,xan;ination was a source
of risk, as it was impossible to render the hands abso-
lutely aseptic. It was therefore desirable to make out
the position of the child as far as possible by external
e.\amination. When it was possible sterilized rubber
gloves should be worn. Some cases of sepsis occurred
in spite of all, perhaps from organisms from the vulva,
by douche or finger.

Dr. W. F. Cock (president) said most cases of
sepsis were due to infection by a midwife. He said to
all: "Mark well your hands — there the danger lies."

The British Journal of Tuberculosis has made its ap-
pearance as H quarterly under the editorship of Dr. T.
N. Kelynack. Contributions from our leading authori-
ties on the subject are included in No. I.

Sir James Sawyer attributes the increase of appendi-
citis of late years to chips of enamel from cooking
vessels getting into the food and finding their way to
the appendix. He says the enameled cooking ware
came into use coincidently with the increase of ap-
pendicitis. An eminent medical friend of mine used
to assure me that tomato seeds were the real culprits,
and he arrived at his conclusions by precisely the argu-
ments put forth by Sir James Sawyer. Tomato seeds
are very hard and indigestible. It is known that they
will pass unchanged through the bowels, but neither
they nor enamel have, I think, been found in the ap-
pendix.

The report of Livingstone College for last year has
been issued. It appears that there is a larger deficiency
than in the previous year, perhaps due to a special
appeal in the latter. Mr. J. Cantlie. editor of the lour-
nal of Tropical Medicine, who has had long experience in
the tropics, has emphasized the advantages of the
training at the college, and the report says: "If only
Mr. Cantlie's views were fully understood and acted
upon Livingstone College would soon need to enlarge
its borders."

The Imperial Cancer Research Fund has received a
donation of £40.000 from Mr. and Mrs. Bischoflfsheim,
who have chosen this method of celebrating their gol-
den w'edding.

At an inquest this week on a laborer w^ho died of
consumption evidence was given that he doctored him-
self, as he had no faith in doctors. Asked what he
took his widow said anything he was told of. The
last thing he tried was an inhaler for the nose, for
which he paid ^ guineas and 8 shillings a bottle for
the fluid. It was said the whole lot would not cost
more than three or four shillings. The coroner said
he had had many cases in w^iich credulous people were
deceived by quacks. They saw the government stamp
on quack medicines and thought it was a guarantee.
The government gained by the stamps, but the public
were deceived.

The death of Dr. Andrew Balfour, J. P., on the 26th
of December, at the age of fifty-seven, has cast a gloom
over the district of Portobello. and indeed of all Edin-
burgh. He graduated in \?'77, as M.B., CM., and pro
ceeded to M.D., 1877. He had a large family practice
and held many appointments in his district hut his
energies were also directed to all philanthropic work
in the district. He was president of the Workingmen's
Institute and directed its Sunday Bible class. He found-
ed a branch of the Boys' Brigade and organized other
valuable social and religious efforts, and has left a name
which will long be clierislied bv his fellow citizens.

Dr. Herbert Kendall. F.R.C.S.. surgeon to the Royal
Hospital for Children at Bristol, died on December
22, aged only thirty-nine. He was busily engaged in his
practice when he was attacked with abdominal pain and
high temperature. There was some abatement of symp-
toms, which proved deceptive, and in a few days oper-
ation became necessarv. This was successful, but pul-
monary symptoms followed and he died unexpectedly
of thrombosis. He was described by his pastor at
the funeral as "the friend of all who knew him. true,
able, highminded. strong, and tender, very fit for life
or for death."

Dr. T. H. Cheatle. J, P.. died on the 15th ult.. at Bur-
ford. Oxon, where he had spent his professional life,
taken part in all social and religious work, and en-
deared himself to the population far and near. He was
in his seventv-sixth vear.

OUR VIENNA LETTER.
(From Our Special Correspondent.)

INDIGURI.^ — FU.N'CTIONAL EFFICIENCY OF THE KIDNEY — CAi;-
TERIZ.^TION OF THE LARY.NX BY ETHER — MUSCULAR ATROPHY

AND JOINT DISEASES — UNIVERSAL CIGANTISM — ADENOMA-
SEBACEUM.

ViE.N.vA, December 23, 1906.

A CASE of indiguria has been reported by Dr. .A.dolph
Hecht, who observed it in Escherich's clinic. The patient
was an otherwise normal boy, three and a half years old,
who, according to the statements of his mother, had not
suffered from intestinal disturbances. A few hours before
bringing him to the clinic the mother had noticed that the
child was passing green urine. Urine voided in the clinic
showed the same tinge, though to a less marked degree.
The urine was clear, acid, of normal odor, and on standing
a green sediment composed of urates and amorphous blue
masses was deposited. Chemical examination revealed
nothing except a marked indican reaction. On shaking the
urine with chloroform the latter acquired a distinct blue
color, and the urine became lighter in color while the in-
dican reaction was lessened. The chloroform gave the ab-
sorption spectrum of indigo. The occurrence of indigo in
undeconiposed urine is very unusual. One autopsy reported
by Wang appears to show that the oxidation takes place
in the kidney; at any rate the cut surface of one of the
kidneys became blue on exposure to the air. In the present
case it was not possible to demonstrate the presence in the
urine of an cxydase.

Interesting observations on renal functions have been
made by Dr. Schur. Both pathological and clinical observa-
tions indicate that arteriosclerosis is usually accompanied
by clianges in the kidney. In order to investigate the mat-
ter of renal insufficiency, Schur tested the dilution capacity
of the organ, that is, the changes in diuresis caused by the
administration of water in the healthy, in those with renal
disease, and in those with arteriosclerosis. The persons
under observation were directed to void at 6 o'clock in the
morning, and after that once every hour. At 9 o'clock,
one half liter of water was drunk and the urine collected
during 3 or 4 hours more. These different specimens were
then tested physically and chemically, and the reaction of
the kidney to diuretin was also investigated. The follow-
ing results were obtained : In the normal individuals
pronounced diuresis followed the ingestion of the water,
so that the entire quantity of fluid had been excreted within
four hours, but the process of elimination was delayed in
the nephritics. and in most of tlie persons with arterioscle-
rosis. The administration of diuretin gave similar results.
It was found that in a large number of cases of arteri-
osclerosis the same conditions were observed as in dealing
with nephritics. The chemical examination of the urine
did not reveal anything characteristic. While a test of this-
sort is not of direct value in determining the anatomical
disease of tlie kidney, it is of importance when it is desired
to discover any possible disturbance of renal function in
cases in which no other evidence of disease is present, for
example, in arteriosclerotic changes of the organ. Accord-
ing to the results of these investigations we are justified
in referring to renal insufficiency those symptoms which are
common to both arteriosclerosis and nephritis, and also in
applying the same mode of treatment to both conditions.
In explaining the phenomena of urinary secretion and of
renal insufficiency. Schur suggests a theory according to
which processes of imbibition and deimbibition of the renal
epithelium form the most important feature in urinary se-
cretion.

Dr. Menzel has observed a case of cauterization of the
larynx by ether during anesthesia. The patient was a man
of advanced years, who was subjected to a severe opera-
tion requiring ether anesthesia for an hour and a half.
The anesthesia was stormy and the patient repeatedly suf-
fered from asphy.xia so that artificial respiration became
necessary. When the patient became conscious he was
totally aphonic and also suffered from dysphagia. Exam-
ination of the pharynx showed that the palate and tonsils
were reddened, and on inspecting the lar>'nx it was seen
that all parts of this organ were swollen and congested,
while the vocal cords were covered with a thick white
eschar. The pharynx also showed such white patches
shortly after the operation so that the possibility of a diph-
theritic infection was considered, but evidently these lesions
also were the results of the cauterization.

Observations on animals have been carried on during
several years by Anton Bum in the Institute for General
and Experimental Pathology, in order to determine the
mode of causation of the muscular atrophy w-hich nearly
always promptly appears after diseases and injuries of the
joints. The question is whether these are to be regarded
as trophoneuroses or as the consequence of the inaction of
the member produced either by pain or the surgfical dress-

Jan. 26, 1907]

MEDICAL RECORD.

'JD

ing. His experiments seem to show beyond a. doubt that
the most important part is played by the muscular inac-
tion. Possibly, however, reflex stimuli may be concerned
in articular atrophies, but it is a question whether they are
of great importance in this connection. While it is true
that acute trophoneurotic changes in the skin, hair, nails,
subcutaneous tissues, muscles, and bones occur in articular
disease, these are not constant, or even very frequent.

A six-year-old boy, presenting universal gigantism was
demonstrated by Dr. Knoepfelmacher before the Gesell-
schaft fiir Kinderheilkunde. The child has been under
observation for three years, and now has a height of 146
cm., the upper extremity has a length of 57 cm., the lower
of 67 cm., the hand measures 15 cm., and the foot 16 cm.
The entire skeleton is extremely heavy and broad, and the
body is developed proportionally in all respects. The mus-
culature is well developed, and the strength is far in excess
of what corresponds to the patient's age. Particularly
conspicuous is the enormous development of the genital
organs, the penis being about 10 cm. in length, the testicles
of the size of a pigeon's egg, and the pubic hair being
present in abundance. There is no axillary' hair, but there
is a suggestion of nuistache and beard. The child is an
imbecile. Examination with the j'-rays showed advanced
ossification of the hand and foot, but the epiphyseal lines
are still open. Knoepfelmacher considers that the case is
one of gigantism secondary to precocious puberty.

Five cases of what is called adenoma sebaceum, Pringle,
have been observed by Prof. Riehl. This observer has
already pointed out that in these cases there is neither an
adenoma nor a disease of the sebaceous glands. Two of
the patients were twin sisters, and a similar occurrence of
the disease in four brothers and two sisters has already
been reported. In most cases the disease has begun in
infancy, in others it has commenced at the time of puberty,
or in connection with some acute infectious disease. Par-
ticular interest attached to two of the patients, a girl and
her father, because they demonstrated in a striking man-
ner the hereditary nature of the disease. Three brothers
of the father, the daughter, and he himself, as well as his
own father and grandfather, suffered from the same affec-
tion. The brothers died without leaving any descendants.
From his observations in these cases Riehl believes that
the underlying condition is a much more deep-seated one
than has heretofore been supposed, and he regards it as
being embryonal in its inception and becoming manifest
congenitally or later on in life. It is an abnormality of
structure depending on an inherited tendency. According
to this view the other terms applied to the disease, such
as nsevus sebaccus. or multiple symmetrical facial nevus,
do not at all express the true nature of the disease.

OUR LETTER FROM THE PHILIPPINES.

(From <^)iir .Special Correspondent.)

F.\T.\L I.\'0CUL.\TI0XS WITH PL.\GUE-CONT.\MIN.\TED CH0LER.\
V.\CCIN'E.

.M.\\[!..\. .November ^c. igor,

Wkue Dr. R. p. Strong, chief of the Biological Labo-
ratory of the Bureau of Science, was making inocula-
tions with cholera vaccine upon prisoners confined in
Bilibid Prison, he was unfortunate enough to use a
vaccine that in some way had become contaminated
with other organisms, possibly plague. In all twenty -
four prisoners were inoculated, and ten have died, all
with symptoms which have been attributed to the
inoculation. The matter became so serious that the
Governor-General issued the following official state-
ment:

"On November 16 Dr. R. P. Strong, Chief of the
Biological Laboratory of the Bureau of Science, in-
oculated twenty-four prisoners in Bilibid Prison with
an anticholera vaccine, with which he made inocula-
tions before, and the use of which is well known in
several countries in Europe, particularly in Spain,
where inoculations of this kind have been made with
beneficial results. On November 18 and 19. two and
three days after the inoculation, a number of these
prisoners became acutely ill, and on the evening of the
following day, November 26, two of them died, ap
parently from the results of the inoculation. Sub-
sequently, on various days, seven more prisoners died
in the prison hospital, and one prisoner, whose sen-
tence had expired and who had been released from
Bilibid. died on November 21 at 152 San Jose. These
inoculations were made bv Dr. Strong under authority
dated March i, 1904, which authority was for 'the
carrying on. under the supervision of the Director of
the Biological Laboratorv. of the investigation among
inrnates of Bilibid Prison with reference to diseases
which prevail among them, as outlined within.' Since

this authority was granted, over half the prisoners
at Bilibid have been inoculated against cholera with-
out any harmful results whatever.

"All these cases of death were promptly referred
to the Coroner for proper action by him. and under
his instructions autopsies had been made in each in-
stance. An investigation is now being made under
his direction to determine the exact cause of death In
each instance, and upon that information being ob-
tained, the coroner will render the verdict required by
law.

"It appears that probably these deaths have re-
sulted from the anticholera vaccine which was used,
having in some way become contaminated with plague
germs while the vaccine was being prepared in the
government laboratories. A number of years ago
thousands of inoculations with this same anticholera
vaccine were made by Dr. Ferran in Spain, and simi-
lar instances of contamination occurred and some
deaths resulted. I wish it understood, however, that
the accidents which resulted from this inoculation
were not due to the method itself, but to the con-
tamination of the vaccine just before final preparation.
No test as to whether the vaccine has been contami-
nated can be made on animals, for the reason that
the Ferran virus must be prepared for use and used
while fresh. Immediately after being notified that the
prisoners inoculated had become sick. Dr. Strong
laid the matter before the proper authorities for in-
vestigation and action bv them.

"It is needless to say that Dr. Strong is grieved
beyond measure at the unfortunate accident which oc-
curred with these twentv-four inoculations. Dr. Strong
has made, in the past few years, thousands of inocula-
tions with anticholera and anliplague vaccine, and
never before have anv. untoward results followed.
These particular inoculations were made on his own
responsibility, under the authority above described, and
were in no way authorized by or participated in by
the Director of Health or by the Director of the
Bureau of Science. I am immeasurably grieved at the
unfortunate result of this accident, and it is unneces-
sary to add that every possible step has been and will
be taken by the government to care for the other
patients who have suffered from this inoculation, and
to relieve, as far as possible, anv distress which may
have been caused the families of those who have been
affected."

Since the statement was made by the Governor-Gen-
eral another prisoner has died, and the thirteen re-
maining are still in a verv serious condition. The
cases have all been isolated and every reasonable pre-
caution has been taken to guard against the spread of
the infection among other prisoners.

Ncxi.' York Medical Journal, January 12, 1907.

The Untrained Nurse: Her Legitimate Field and Her
Opportunity for Self-improvement. — J. H. W'iegms dis-
cusses the question of nursing as it affects small com-
munities in which the patients are unable to pay the usual
city price for nursing. He declares that so far as re-
muneration is concerned, the city nurses are practically
maintaining a trades-union state of affairs in that they are
not willing to work for less than twenty-five dollars per
week, a price prohibitive for most people in small com-
munities. He believes that there is a field for the nurse
who has not had the training of a city hospital and that
the correspondence schools for nursing ha\e a legitimate
field in supplying the theoretical portion of instruction.
The practical portion must be given by the country physi-
cian at the bedside of his patients, and he claims that if
physicians will take the trouble to do this in case of such
women as may show an aptitude for this work, he will
go far to solve the question for small communities and
make his own work much more satisfactory by developing
the material at hand.

The Insanity of Inebriety. — .\ccording to T. D.
Crothers the term inebriety describes a pathological con-
dition demanding alcohol for its anesthetic effect and
refers to some depressed state or psychic condition which
consciously or unconsciouslv calls for relief winch alcohol
gives with satisfaction. Alcohol is not the cause, but
merely a symptom. Hence the condition must be one of
disease and organized de.generation. The author then goes
on to describe various tvpes of this form of insanity and
the proper methods which should be followed in con-
trolling it. He notes that to all ordinary observation a
periodical drinker resembles the insane in conduct and rea-

156

MEDICAL RECORD.

[Jan. 26, 1907

soning. Such persons use spirits to extreme toxic states
for a brief period, then rigorously abstain for a while and
then relapse. This resembles acute mania in the dominance
of the drink impulse overwhelming the mind and body
for a period, then subsiding. It also resembles epilepsy
in its sudden convulsive onset, and inability to reason
and control up to a certain p'oint. Often the periodical
drinker is unconscious of the import and meaning of these
symptoms. He will suffer from insomnia, headaches, great
irritability, intense nervous anxiety, and dread of loss. He
will consult physicians, believing he has serious organic
diseases, go off on vacations, make changes in his surround-
ings and business relations, then all unexpectedly, will
drink to great excess, when all these symptoms will dis-
appear. In most cases there are distinct premonitions of
the drink storm in conduct, reasoning, and appearance,
which the friends recognize, but the victim does not. A
large class of the periodical drinkers seem to have some
consciousness of the coming attack, and use means to
avert it. They often go to hospitals and sanatoria, par-
ticularly where they have had some experience before,
appearing in a state of great fear and excitement, which
quickly disappears. The storm is averted for the time
being, and such cases are alwavs very hopeful. In many
persons of this class of periodical drinkers, the premoni-
tory symptom.^ take on the form of reasoning manias. Thus
they make elaborate preparations in business affairs, pro-
viding for their absence .during drink attacks. Many of
these persons are active in social and religious work, but
a period of unusual fervor is often a precursor of a drink
storm. Some show great exaltation of mental activity ;
others take on a different personality while drinking. With
some certain atmospheric and electric conditions bring
on an attack. In all there is an unstable highly sensitive
brain and nerve organization with a tendency to e.xhaustion
on the slightest occasions. A clinical history shows that
heredity is a very large factor in this instability and feeble
pain resistance, it also shows that injuries, irregularities of
living, defective nutrition, sleep, and e.xcessive strains and
drains with other causes predispose to a convulsive con-
dition of nerve energy and depression, for which spirits is
a grateful narcotic.

The Pathogenesis of Facial Hemiatrophy. — -'\. Gor-
don reports a case occurring in a negro male, aged forty-
two years. He cannot believe in the exclusivism of the
sympathetic origin of the malady, as his own case seems
to controvert such a theory. According to some observers
a prirnary atrophy of the subcutaneous cellular tissue is the
essential feature of the condition. Others believe that it is
of a nervous origin and may follow aft'ections of either
the_ sympathetic, trigeminus, or facial nerves. The ma-
jority of cases reported point to an involvement of the in-
ferior sympathetic ganglion. Concomitant pulmonary le^
sions are found at the apex in many of these cases. This
is accounted for bv the relations between this ganglion
and the pleura at its apex. The author's case presented
not only a trophic disturbance of the facial muscles, but
also sensory disturbances over the area covering these mus-
cles. That the lower cervical ganglion did not play a role
in the causation of the disease in this case was evident
from the fact that there were no pupillary changes nor
vasomotor disturbances on the affected side. It is possi-
ble that the sympathetic fibers found in the lifth nerve may
play a certain role in the disturbance of nutrition of the
facial muscles, but association of sensory disturbances and
the neuralgic pain in the same area immediately preceding
the beginning of atrophy present a strong presumption in
favor of the trigeminal pathogenesis of the affection, .^s
to the question of facial nerve it cannot be admitted in
this case, as there was no genuine palsy of the affected
muscles. The patient had preserved the ability of contract-
ing them, but the degree of contraction was. of couj:se,
smaller by reason of the atrophy. The sensory disturbances
also were against this view. The author concludes that
hemiatrophy of the face may be caused bv the lower sym-
pathetic ganglion with its nerve, by the fifth nerve, bv'the
Gasserian ganglion, finally by a central lesion. The ten-
dency of some writers to attribute Romberg's trophoneu-
rosis exclusively to the sympathetic nerve fibers is errone-
ous.

Certain Diseases of the Peritoneum.— J. G. Mumford
considers acute, subphrenic, diffuse, chronic, and exudative
peritonitis, chronic adhesive sclerosing peritonitis, and tu-
berculosis of the peritoneum. He describes the pathological
changes in each of these conditions, their symptoms, and
gives his own ideas as to the proper treatment of each.
Referring to the old tnedical treatment by opium, he notes
its modification by some physicians who limit the dose of
opium to that which will allay pain and they give the
remedy hypodcrmatically. They attempt to relieve the in-
testinal distention by giving high enemata of salts, glycerin,
or turpentine; they nourish the patient by enemaTa or by

small quantities of liquids by the mouth ; and they allay
thirst by allowing the patient to suck cracked ice. The
author believes that if a physician proposes to treat a case
without operation no such half-way measures are permis-
sible. The proper nonoperative method is to put the in-
testines at rest by emptying the stomach through lavage,
and then keeping it empty. The stomach washing may be
repeated if that organ fills up again with material regurgi-
tated from the intestine. After washing out the stomach,
put into it nothing until convalescence is established, no
water, no food, no cracked ice. Give morphine for pain,
if there be pain. Nourish the patient by nutrient enemata,
in four ounce doses every four liours. Relieve his thirst
by subpectoral infusions of normal salt solution, or by
intravenous infusions. Stimulate him with strychnine. SucB
treatment, heroically follow'ed, often will head off and sub-
due an advancing peritonitis. Most surgeons, however, are
loth to adopt these measures as a routine, because they
feel that the fountainhead of the trouble, the local lesion —
perforated appendix, duodenum, or whatever it may be —
is thus left to keep up its contribution of poison to the
peritoneum. The author expresses himself as in heartv
sympathy with this latter view.

Journal of the American Medical Association, January
19, 1907.

Blood Cultures in Children. — T. M. Rotch and H. C.
Low have been particularly impressed with the value
of blood cultures in children in cases with indefinite
and misleading histories, in their hospital service. In
some obscure cases it may be the only means by which
one can say whether sepsis is or is not present, and it
may also reveal the etiological factor. They have found
the method more practicable in children than has been
supposed, though least so in the younger ones. In the
first four years of life it was found possible to obtain
sufficient blood for a culture in 21 per cent, of the cases
tried, in the second four years 72 per cent., in the third
86 per cent. Their technique is described in detail ; the
blood is taken from a vein in the arm with all precau-
tions against contamination, and directly inoculated into
the culture medium. With this technique, they believe
a negative culture is of value in prognosis, if not in
diagnosis and treatment. The cases in which it prom-
ises to be of most help are the obscure conditions of
so-called cryptogenic septicemia and autointoxication.
The uncomplicated cases of endocarditis, chorea, arthritis
and obscure septic infections offer a large field for its use.

Improved Technique in Otology. — W^. S. Bryant re-
views the improvements that have been made, but not
yet incorporated generally into practice. These include:
(i) The complete mastoid operation; (2) the improved
instruments, such as electric burrs, Richard's curette,
and the author's hand-driven front-bent gauge, which
greatly increase the safety, speed, and facility of the
operation; (3) rational disposal of the soft parts; (4)
preservation of the sound-conducting mechanism in se-
lected radical cases; (5) ligation of the jugular vein as
high up as infection will allow before opening the sinus
and exenteration of the jugular bulb; (6) management
of brain abscess by the open method; (7) blood clot,
drained blood clot, and the author's modification of
the drained blood clot in the simple mastoid operation;
(8) Reik's "protective sheet"; (9) blood clot in cases
of epidural abscesses; (10) cosmetic results of the blood
clot, drained blood clot, and evened-up bone wound ;
(11) lessened shock and jar; (12) shortened conva-
lescence; (13) elimination of secondary operation; (14)
avoidance of accumulated cicatricial tissue to interfere
with the sound-conducting mechanism. All these meas-
ures, he thinks, tend to encourage earlier operations
and favor better results than could be secured witiiout
them.

The Railroads and Tuberculosis. — J. R. Haynes advo-
cates, as protection for the public, that purchasers of
long-distance tickets should be questioned as to
whether they have a cough, and if they have, that pas-
sage be refused, unless the applicant can show a certifi-
cate from the Board of Health or some reputable physi-
cian stating the cause of the cough, and that for those
allow-ed to travel, special cars on specified trains should
be provided. For consumptives traveling short dis-
tances cars with special nonupholstered compartments
might be provided on certain trains. "Sentiment must
be brushed away and tuberculous passengers must
travel in such a manner as society may prescribe, in
order that the many shall be protected." He would
have it provided that any tuberculous passenger evading
b3' false representations these provisions should, if dis-
covered, be put in the hospital car, or if there be none,
be put off at a station where he can be cared for and
compelled to wait until the first hospital car going his

Jan. 26, 1907I

MEDICAL RECORD.

157

way arrives; and Haynes would have a heavy fine im-
posed on any physician who would connive at any eva-
sion of these protective regulations. The hospital cars
should be specially constructed and upholstered with
leather or washable fittings, and carry a trained nurse
and apparatus for disinfection. All comparlment? that
have been occupied by the tuberculous should be
thoroughly disinfected as soon as vacated.

The Sanatorium in the Tuberculosis Crusade. — C. L.
W'heaton considers the sanatorium one of the most im-
portant aids in the crusade against tuberculosis; climate
can no longer be considered the one great factor in the
cure. The sanatorium has shown that pure air in any
climate is the essential thing in the arrest of this dis-
ease. It is not, however, through the private sanato-
rium that the most beneficial results are to be obtained,
there should also be public sanatoria for indigent con-
sumptives, without depending altogether on antituber-
culosis associations taking the initiative and asking only
for a certain amount of government aid. While a future
successful serum treatment of the disease is a possi-
bility, we sliould at present rely on the rational methods
at our command and discourage the tendency to faith in
nostrums and quacks.

Aerotherapy and Tuberculosis. — S. A. Knopf de-
scribes a window tent for the fresh-air treatment of the
patients with tuberculosis, wiiich is practically an awn-
ing put up inside of the window, instead of out of doors,
to cover the patient's bed. By lowering or raising the
window sash, sufficient air space can be left to ventilate
the room also, without interfering with the open-air
treatment, the air of the room not being allowed to mix
with the air breathed by the patient. A transparent
pane is made in the tent so as to enable the patient to
be observedj without disturbing the arrangement. Knopf
describes the advantages of the contrivance at length,
its inconspicuousness, the shelter from room draughts,
the opportunity for observation to natient, the preven-
tion of drop infection by coughing, and chiefly its com-
parative inexpensiveness. The contrivance, tiiough now
obtainable from the manufacturers, tlic Kny-Scheerer
Company, is not patented, and a similar arrangement
can be improvised if necessary. In conclusion, he refers
to the value of carefully conducted respiratory exercise
and of solar therapy, in the treatment of consumptives.

Painful Heel, — In defining this condition, J. J. Nutt
says the term is not exactly descrintive or distinctive,
as not all pain referred to the heel is due to the same
condition. Young's definition, which is clear and exact,
is "severe pain, accompanied by tenderness, in the cen-
ter of the heel about the posterior attachment of the
plantar fascia." It is probably not a rare condition, the
milder cases are likely to be self-treated, and therefore
do not come to the knowledge of the physician. Usually
the only abnormality found on examination will be a
limited range of flexion of the ankle; in other words,
nondeforming club foot, or as he prefers to call it
"Shaffer's disease" exists. He admits that other causes
are possible; exostosis, bursitis, or neuroma may be the
primary lesion, but he believes they are more often
secondary to the traumatism to the plantar fascia. Nutt
thinks that it is usually produced in those cases, in
which the shortening of the gastrocnemius — the sine qua
non in Shaffer's disease — exists to a slight e.xtent,
and that the plantar fascia, instead of becoming weak-
ened and lengthening throughout its extent, has given
way at the calcaneum attachment. This he does not
find due to any sudden traumatism, but rather to the
repeated slight strains of continuous stepping. The
rational treatment is the relief of the strain on the
shortened gastrocnemius by Shaffer's traction shoe with
its steel arch, and by directions as to tlie proper method
of walking.

Tlic Lancet, January 5, IQ07.
Pathology of the Liver in Cardiac Disease, — R. N.

Salaman presents a paper based on the post-mortem rec-
ords and detailed clinical histories of over sixty cases. He
speaks of the ordinary case as the "back-pressure" liver,
discussing the general "nutmeg" appearance, with its fat
absorption through the hepatic lobule and its fresh fat
deposition as the center. The main factor predisposing to
the accumulation of fat in the central zone is undoubtedly
stasis. The capsule is generally thickened, although this is
slight in tlie case of Glisson's capsule. Fibrosis is found
in varying degree about tlie sub- and central lobular and
hepatic veins. His division of these livers is into three
classes: first, the engorged liver; second, the nutmeg liver
proper, and, third, the cirrhotic nutmeg liver. The author
believes that the liver acts as a safety valve to the heart
and that the various changes in structure undergone after
prolonged back pressure niodifv that safety-valve action

and seriously alter the clinical course of a given case. His
experiments (detailed in the paper) show the following
results: (i) that under conditions of cardiac stress the
liver will draw off a large volume of blood from the right
auricle; (2) that after a time certain changes take place
leading to fibrosis which very materially afl'ects the disten-
sibility of the liver; (3) that the fibrotic process, by in-
creasing the force of the liver's recoil, prevents the use of
the latter as a reservoir in which blood may accumulate;
(4) that in complete compensation there are no engorge-
ment of the liver and no back pressure; and (5) that while
the liver may be looked upon as a spongelike safety valve
to the heart, continued use of this safety-valve action leads
to its own abolition. The author then takes up the familiar
clinical signs, such as superficial tenderness from extreme
liver distention, tenderness of the liver on palpation, deep
abdominal tenderness, onset of edema, etc., and claims that
they bear out his theories. He divides the ascites of car-
diac disease into (l) that of acute, and (2) that of chronic
back pressure. The first type is characterized by the fol-
lowing features: (i) small in quantity, averaging one pint
or in one exceptional case four pints ; (2) it is of a high
color and often bloodstained; (3) the peritoneum of the
gut is opaque with engorged veins marked on it, or of its
normal seraitransparency, but with engorged veins, and (4)
in all cases there will have been edema at the time of
death, and in nine out of ten cases it will be of such
amount as to be found post mortem. In this type meager
ascites only appears after the utmost expansion of the liver
has taken place, and this failing entirely to relieve
congestion, the pressure has been transmitted tlirough into
the portal vein and its tributaries, some of the fluid com-
ing from the intestinal peritoneum and some from the
liver capsule. Ascites of the second type is characterized
by: (l) being very large in amount, often requiring tap-
ping; (2) of a clear yellow color; (3) the peritoneum of the
intestines is invariably opaque and thick, peritoneal adhe-
sions are very common (the veins may not be engorged to
any great degree) ; and (4) the liver is invariably of the
cirrhotic type. Ascites associated with this condition of
liver is not necessarily the result of an increase in back
pressure; it may and does often occur while the heart is
compensated, so that some cases, notably one of the au-
thor's, spent the last year of his life being tapped and ended
it witii septic peritonitis, the heart being compensated the
while. The effusion of fluid is in this type cornparable to
that in ordinary cirrhosis of liver, due to the difficulty ex-
perienced by the portal blood in making its way through
the fibrosed' organ, a difficulty that may be doubtless in-
creased by some degree of back pressure.

Hyperplastic Tuberculous Pericolitis. — Three cases
are reported by F. S. Kidd, who reviews the literature of
the disease and gives a general description of it. The main
points brought out are the following: first, that there
arises a peculiar form of localized chronic hyperplastic
inflammation in the submucous, muscular, and subserous
coats of the bowel, which may lead to intestinal obstruction
and its consequences, and which affects the mucous and
serous layers to but a small extent. Secondly, that this is
in all probability due to a localized infection of the wall of
the gut with an attenuated form of the tubercle bacillus.
Thirdly, that this form of inflammation is very liable to be
mistaken for carcinoma or sarcoma either at operation or
at necropsy. Fourthly, that by careful examination with
the naked eye this form of disease can often be distin-
guished at tiie operation from a malignant growth, when
once it is realized that such disease exists and the appear-
ance it presents is borne in mind. Fifthly, that it can
always be recognized with certainty by microscopical exam-
ination, which will prove of advantage in prognosis and
treatment. Other features are that the thickening of the
bowel consists of firm connective tissue and fat, affects the
muscular, mucous, and subserous coats of the bowel, and
rarely shows any "tubercles" or caseation.^ The ileocecal
region is the most common site for this disease, but it is
found at times in any part of the large bowel, especially the
sigmoid flexure and rectum, and less commonly in the
ileum. The mesenteric glands which drain the area of gut
affected undergo a similar change or may present the usual
picture of gland tuberculosis. In the rectum it has been
mistaken for tertiary syphilitic thickening. _ A precisely
similar hyperplasia caused by the tubercle bacillus occurs in
other parts of the body, such as in the larynx, peritoneum,
pleura, joints, and lymph nodes. The condition is not
usually discovered until the peritoneal cavity Is opened.
Apart from excision, or after it, the treatment to be fol-
lowed is that usually adopted for tuberculous lesions, per-
haps combined with tuberculin injections. In one case the
tumor was brought out on to the skin at the first operation,
and was removed later. By this mcans^ all shock was
avoided in the patient, who was in a condition of low vital-
it v.

158

MEDICAL RECORD.

[Jan. 26, 1907

Bronchiectasis in Childhood with Some Observations
on the Condition Known as Honeycomb Lung. — C. R.

Box notes that the cavities in a so-called "honeycomb" lung
may be of at least three different kinds. Some are bron-
chiolectases ; some are atriectases combined with emphy-
sema, and some are formed by necrosis of lung tissue. The
frequency with which the bnllre project beneath the visceral
pleura is in itself evidence that all are not simple bron-
chiolectases, for the bronchioles do not abut upon the serous
membrane. The formation of a honeycomb lung is due to
bronchopneumonia. Pleural adhesion plays no part in the
initiation of the condition, altliough it may develop later,
for in many cases there is no pleural adhesion at all. The
question naturally arises whether these lungs are the ante-
cedents of the chronic bronchiectases of childliood and
later life. There is strong presumptive evidence that some
at least of the cases do arise in this way. Comparison of
a honeycomb lung with a saccular bronchiectasis from an
adult makes it appear almost certain that the latter is but
an advanced condition of the former. The shape, group-
ing, and communications of the cavities are similar, even
the falciform septa may be recognized, but in the adult the
walls and septa are thicker and the lining membrane more
opaque in consequence of the long duration of the inflam-
matory process. Concerning treatment, the author notes
that since most of the cases follow the bronchopneumonias
of measles and pertussis, the indications are suggested by
the features of these diseases. While the bronchiectases
themselves represent permanent changes, much can be done
to render the patient comfortable. The routine procedure
should consist in regularly emptying the cavities as far as
possible, and the administration of such drugs as are ex-
creted by the lung and presumably e.xert an antiseptic
influence on the bronchial tubes and their contents. The
best method of emptying the cavities is by the process of
inversion. Children can easily be taught to invert the body
by leaning, face downwards, over the side of the bed with
the hands resting on the floor. By this method considerable
quantities of pus may be evacuated which would otherwise
stagnate in the tubes and infect adjacent areas of lung.
The best times to practise inversion are on rising in the
moming, to get rid of the accumulated secretions of the
night, and on retiring to bed, in order to avoid as far as
possible overflow of the contents into adjacent bronchi and
the irritating and disturbing cough excited by the presence
of the pus. An alternative method of getting rid of the
secretions is by the use of emetics, but in comparison with
the method of inversion emetics are both uncomfortable
and uncertain. The emetic usually advised is vmum Ipeca-
cuanhre, and it is surprising what amounts of this prepara-
tion children will swallow without any result at all. The
drugs which yield the best results in practice are garlic,
creosote, turpentine, and cod-liver oil.

Bntisli Medical Joiinia!, Jnitiiarv 5, 1907.

Functional Albuminuria in Athletes. — W. Collier pre-
sents the results of his observations on Oxford University
students in training for boat racing. Tests were made of
the urine of 156 men With the cold nitric acid test 49
showed no trace, 24 a slight ring, 54 a definite ring, and
27 a very thick ring; in other words, with this particular
test 81 specimens out of 156 contained a very definite
amount of albumin. With the heat and nitric acid test
24 showed no trace, 41 a faint trace, s8 a definite cloud, and
31 a thick cloud; that is, 89 out of 156 showed a very defi-
nite amount, or 57 per cent, of all the cases. The better
the crew the more constantly did the albuminuria show
itself. The author is aware of the incompleteness of his
observations, for he says it would have been more satisfac-
tory to have examined the men in the morning, before their
rowing, and again in the afternoon, after it. He asks, ought
we longer to advise young men who pass large quantities of
albumin after severe muscular exertion to give up all hard
athletic competition? He thinks not. It would appear that
just as we may expect to get evidence of hypertrophy of
the left ventricle and emphysema in the man who habitually
indulges in violent athletic contests, so we may expect to
find a definite amount of albumin in his urine" for a few
hours after violent exercise. Finally, he asks, ought the
assurance companies to continue to refuse to consider the
acceptance of the lives of young men between the ages of
say 18 and 30, whose urines are found to contain albumin
after exercise when it can be shown that no albumin is
present after rest or after a meal ? He thinks not.

Age Incidence of Gastric Ulcer in the Male and
Female. — W. Cahvell notes, regarding the age incidence in
the female one fact of importance, namely, the sudden
and profuse hemorrhage occasionally attacks the
adolescent female who has made little or no
complaint of stomach trouble ; it is quite
possible that this blood may come from an oozing,
but in other cases it has been clearly demonstrated that it is

from an ulcerated blood-vessel. The author regards it as
very credible that small ulcers form and heal with great
rapidity. Clinical histories would lead to the belief that
they may break down in a few hours, and it can be under-
stood how healing might occur in the same period of time
if the edges of the ulcer could be kept in apposition, assum-
ing that the pathological changes had ceased. The author
presents a chart showing the age incidences in 200 cases,
the time taken being that of the onset of symptoms. In
many cases of hematemesis it may be possible that repeated
bleeding may be brought about by alternating distention
and contraction of the stomach, and that attention is to be
paid to the extent of gastric resonance, and frequent sip-
pings of a mild carminative tried as a treatment. Such
cases are not rare, although a fatal termination is rare;
but there is still the much larger class of cases, whiuh re-
semble this case in their often slight, evanescent dyspepsia,
and in their chlorotic condition, but do not complete the
picture by an attack of hematemesis; they are mostly classi-
fied as "tea," "anemic," or "neurotic dyspeptics." The
simplest explanation seems to be that many of these cases
are really cases of ulcers, and that the accident of hema-
temesis depends on whether the ulcer is situated on a vessel
or not, and tiie accident of perforation, which also occurs
unexpectedly, on the depth of the ulcer. In such acute
cases where, as happens in the very large majority, no com-
plication occurs, recovery is rapid with rest and a little
starvation. Each time, however, these attacks recur, the
symptoms of chronic ulcer become more apparent. Nearly
every one of these female patients is chlorotic, and if we
pursue our investigations, nearly every chlorotic, in marked
contradistinction to the adolescent male, has, or nas nad,
some stomach trouble. The author's chart shows that ulcer
in the female increases in frequency coincident with the
increase of chlorosis, .^fter the ages of 25-30 the onset of
ulcer is about the same in the two sexes. The author
declares that there is presumptive evidence that if we
exclude all cases of ordinary gastric catarrh or dyspepsia
from irritant food, and of dyspepsia of neurotic origin, we
have still a large number of cases of "dyspepsia" in the
adolescent female which are really due to ulcer; that these
ulcers rapidly form and probably as rapidly heal, and that
it is only by the accident of hemorrhage or of perforation,
or of repeated relapses leading to chronicity that we recog-
nize their real nature ; and, lastly, that there are apparently
two kinds of ulcer — one connected in some mysterious way
with chlorosis and frequently with amenorrhea, probably
being a developmental disease : and the other being a type
which occurs pretty equally in both male and female, and is
not often seen till after 20.

Pythogenic Pneumonia. — H. Freeth reports the case
of a woman of 28 years with a severe catarrhal throat.
The pkimbing in the house in which she lived was not
properly flushed. The day after she was first seen her hus-
band came down with a lobar pneumonia, which ran a
favorable course and defervesced on the ninth day. The
wife's throat had meanwhile become well, and she nursed
her husband, but on the ninth day after his defervescence
she was attacked with pneumonia at the right base, and in
about another week the left lung became involved, but she
recovered without incident. The author notes the following
points: (i) The almost simultaneous infection of the wife's
throat and the husband's lung at a time when the house
drains were dry and foul, favoring the opinion that the
nature of the infection was the same in both (septic?), and
fixing the incubation period of the pneumonia to within
three days. (2) The infectiousness of the disease, as
proved by the wife's attack, unless it be supposed that her
system had been infected from her throat, and that the dis-
ease had developed later in the lung — a supposition, I
think, rendered of little value by the fortnight of health
she enjoyed between the two complaints. (3) The influence
of insanitary conditions as a source of the infection, lend-
ing weight to the term "pythogenic pneumonia."

Filaria Among the Troops in Jamaica. — C. F. Wan-
hill presents the following conclusions : .-Mthough the ma-
jority of the dogs of the island are infected with Filaria
iminitis, human filariasis is comparatively unknown. Al-
though, since the slave days, the disease must have been
continually introduced into the island, there are some
local factors which are against the successful development
of the parasite in the human body. One factor may be
the malarial poison, which must be present in most of
the native population at some period of their lives. Dogs
do not suffer from malaria, and their universal infection
with filaria may be thus accounted for. The disease is
so rare that no special precautions to permit its introduc-
tion among the British troops on the island have been
thought necessary. — Journal of the Royal Army Medical
Corf's.

Jan. 26, 1907]

MEDICAL RECORD.

159

The ]\Iedical Student's Manual of Chemistry. By R. A.
WiTTHAUS, A.M., M.D., Professor of Chemistry, Physics,
and Toxicologi' in Cornell University. Sixth Edition.
New York : William Wood & Co., 1906.
It is only four years since the fifth edition of this work
appeared. On that occasion the section on chemical physics
was enlarged and that on organic chemistry was rear-
ranged and largely rewritten. At the same time a section
on physiological chemistry, consisting of over one hundred
pages, was added. In the present edition the section on
chemical physics and general chemistry has been entirely
rewritten and rearranged, and also considerably extended
in scope. The section on inorganic chemistry is practically
unchanged ; and tliat on organic chemistry has been ex-
tended and rearranged where necessary. The section on
physiological chemistry has been greatly enlarged and al-
most entirely rewritten; it is a subject of vast importance,
and is here treated most admirably ; and although the sec-
tion occupies two hundred pages, it is difficult to see where
condensation or elimination could have been effected. In-
deed, the student will probably find that the matter here
presented is already in a sufficiently concentrated form. The
book has, for a long time, been well known as a first-class
textbook ; and those who have made acquaintane with
the earlier editions can be assured that the present volume
exceeds even the high standard attained by its predecessors.
The book is literally full of chemistry; and if physicians
expect to be able to understand present-day medical prob-
lems they must be well equipped in this branch of science.
We know of no book which will give the physician as
much solid information on this line as the volume before
us. The arrangement of the subject is logical, the typog-
raphy is excellent, and the book contains everything on
chemistry that the student or practitioner is likely to re-
quire. At the same time the volume contains nothing ex-
traneous or superfluous, and nothing that will have to be
unlearned. In addition to its scientific value, the book has
literary merits of a high order which go far toward making
the study of the subject more attractive. To the physician
in search of an up-to-date chemistry, which is adapted to
his particular and peculiar needs, and is also authoritative
and readable, and which is neither weighted down with
academic discussions nor diluted with the facts, fancies, or
fictions of pharmacy and therapeutics, — we would say, get
this book, and study it.

The Pathology of the Eye. By J. Herbert Parsons.
B.S. D.Sc. (London), F.R.C.S. (England), Assistant
Ophthalmic Surgeon, University College Hospital; As-
sistant Surgeon. Royal London (Moorfield) Ophthalmic
Hospital; Ophthalmic Surgeon, Hospital for Sick Chil-
dren, Great Ormond street. Volume III. General Pa-
thology.— Part I. New York : G. P. Putnam's Sons.
1906.
The third volume of "The Pathologj- of the Eye," by J.
Herbert Parsons, contains 352 pages of text. It treats of
the ''genera!" pathology of the eye. The consideration of
congenital abnormalities occupies 137 pages. The different
parts of the eye are considered separately. A short bibliog-
raphy, which in the rarer conditions covers all of the pub-
lished cases, is found at the end of each article. The de-
scription and the known facts are given completely but
briefly. The deductions drawn are logical and show evi-
dence of a wide grasp of the subject and a rare discern-
ment. The illustrations, which are in black and white, are
sufficiently numerous, are well chosen, and properly supple-
ment the text. A chapter is devoted to the pathology of
myopia, one to hypcrmetropia and astigmatism, one to the
normal circulation of the eye, including the arterial, venous,
and lymphatic systems, and one to the nutrition of the eye,
taking up the nutrition of the cornea, lens, and conjunctiva.
The theory of immunity, normal intraocular pressure, and
glaucoma receive a chapter each. This volume is one of
much interest, the descriptions of congenital anomalies pre-
senting rare conditions. The consideration of the circula-
tion and nutritional conditions introduces questions that are
of the greatest importance in the study of the morbid
processes of the eye. This series of books is of exceptional
worth to the ophthalmologist, and is also of value to the
general pathologist.

Pre\-.\lent Diseases of the Eye. By Samuel Theobald,

M.D., Clinical Professor of Ophthalmology and Otology,

Johns Hopkins L'uiversity. Philadelphia and London ;

W. B. Saunders Company, 1906.

The matured experience of a well-informed, careful worker

in ophthalmology is manifest in the pages of this excellent

work. While the optical part of ophthalmology may be

written, and well written, by one who has but recently

completed the study of physiological optics, the clinical

part cannot be well presented by any other than one who

has had many years of practice with abundant material for
observation. The volume before us is one of 551 pages. It
is well printed and abundantly illustrated. Chapters on
"Methods of Examination" and "General Observations
Upon Treatment" are followed by chapters on "Diseases
of the Eyelids and Orbit," "Diseases of the Lacrymal
.■\pparatus," and diseases of other parts of the eye in
natural sequence. A special chapter is devoted to glaucoma.
.\nomalies of refraction and anomalies of the muscles are
then described. Then comes a chapter devoted to injuries
of the eye and its appendages. .'Kn appendix devoted to
formulas and an index follow. The descriptions of the
diseases of the eye are concise and up to date; facts with
very little theory are set forth. The operations on the eye
and adjacent tissues which have been proven to be of
greatest value are described at considerable length and the
technique is made sufficiently plain to enable any one pos-
sessing general surgical skill to perform them with promise
of success. The work is an excellent one of its kind and
may be read w-ith profit by all who are doing practical work
in ophthalmologi'.

.\iDS to Gynecology. By .*\lfred S. Gubb, M.D. (Paris),
M.R.C.S. (England), Late Senior Obstetric Physician,
Westminster Hospital, etc. Fourth Edition. Tenth Thou-
sand. New Y'ork : William Wood & Co., 1906.
.•\s an outline for further study, or in the place of notes of
lectures, this volume will serve a useful purpose. As a
rule the salient features of each disease are presented in
such a way that they may impress themselves upon the
memory of the student. There are several tables of classi-
fication and of differential diagnosis, and illustrations are
inserted where necessary.
Buff. A Tale for the Thoughtful. By a Physiopath.

Boston: Little, Brown & Co., 1906.
This is a farrago of nonsense, antivaccination rot, and
tirades against scientific medicine, yet it contains some
50und doctrine regarding diet, fresh air, and exercise. It
will probably do a lot of harm to the ignorant, just as
Christian Science does, but it contains some nuggets which
might be of service to the physician who is too wedded to
the materia medica and neglects the dictates of common-
sense. But the man who is in sucli a parlous state is not
likely to be converted by a book with so much error and so
little sense as this.

Saunders' Pocket Medical Formulary. By William M.
Powell. M.D., Author of "Essentials of Diseases of Chil-
dren"; Member of Philadelphia Pathological Society.
Containing 1.831 Formulas from the Best Known Author-
ities. With an Appendix Containing Posological Tables,
Formulas, and Doses for Hypodermic Medication, Pois-
ons and their Antidotes, Diameters of the Female Pelvis
and Fetal Head, Obstetric Table, Diet Lists. Materials
and Drugs used in .'\ntiseptic Surgery, Treatment of
.•\sphyxia from Drownin,^ Surgical Remembrancer,
Tables of Inconipatibles, Eruptive Fevers, etc.. etc. Eighth
Edition, Adapted to the New (1905) Pharmocopceia,
Philadelphia and London : W. B. Saunders Company,
1906.
It is a poor physician who has to resort to ready-made
prescriptions in his treatment of disease, yet a formulary
of this kind is not without its uses. Even the best of ther-
apeutists sometimes fails to get the results he expected
from the remedies provided, and he may in such a case
find a hint in looking over the formulae in this book which
will put him on the right track. The diseases are arranged
alphabetically, and under each are given a number of reme-
dies and combinations of remedies which have been found
serviceable in treatment. The book is interleaved with
blank pages, upon which the possessor may record his
"favorite prescriptions" and those which he has found of
service in special cases. A thumb index facilitates ready
reference. In addition to the formulse there are a number
of useful tables indicated in the title of the book.
Blakiston's Quiz Compends. A Compend of Genito-
urinary Diseases and Syphilis; Including Their Surgery
and Treatment. By Charles S. Hirsch. M.D., Assist-
ant in the Genitourinarv Surgical Department, Jefferson
Medical College Hospital. Illustrated. Philadelphia:
P. Blakiston's Son & Co., 1906.
This is the latest addition to the well-known series of quiz
compends, and it is up to the standard of the best volumes
of the set. The book contains all that the student is likely
to want on the subjects in question. The text is clear,
concise, and readable; and the illustrations are well se-
lected. In case another edition is called for, the publishers
should have the ten pages of prescriptions, at the end of
the vnlume, thoroughlv overhauled. Chemical formulae,
English, and Latin (often incorrect) seem to be thrown
together in haphazard fashion, and the result is a style of
prescription writing which should be carefully shunned by
students and authors alike.

i6o

MEDICAL RECORD.

[Jan. 26, 1907

f'nrbtii IS^poxtB,

NEW YORK ACADEMY OF MEDICINE.

Annual Meeting, Held January 3, 1907.

The President, Dr. John A. Wveth, in the Chair.

Address of the Retiring President.— Dr. Charles L.
Dana cho.se for the subject of his address "The Academy
of Medicine," and said that the custom of having a retir-
ing address was not a widely prevalent one, but that it was
not an unwise one if the President retired without too
much forensic effort, and used the opportunity chiefly to
tell what his experience as an executive officer had sug-
gested for guidance and inspiration. Bearing upon the
latter, he said that the dominant feeling created in him by
his two years association with this body was one of enthu-
siastic conviction that this Academy did extraordinarily
important work for the profession and community, and
had the capacity to do more. Few could realize how far-
reaching and effective this organization had been. The
management of so complex a body, with its thirteen con-
stituent societies, its building, its books, involved no small
amount of anxiety and responsibility. He confessed that
after these years of rather strenuous attempt to bring out
all that was possible in the Academy, there had come to
him a real affection for what was technically only a soul-
less corporation. As he left the Presidency this was his
feeling: That the Academy of Medicine was an organiza-
tion wisely planned and unselfishly and effectively organ-
ized to bring out what was best in scientific and practical
medicine in this community, and he said he could not finish
his task without expressing his awakened enthusiasm in
the Academy, knowing so well the work it did for pro-
fessional progress and the betterment of the entire com-
munity. He was imbued with the Academy idea, and
thought that all communities large enough to form a
nucleus of physicians would be better off if the physicians
organized on basic Academy principles. It was the Acad-
emy or its equivalent that humanized and elevated the
medical profession. He did not mean to belittle the regular
and necessary State and County organizations. We must
have these, but must not stop with them. The doctor needed
to have his social instincts properly satisfied. The change
in the conditions which affected medical societies in their
work was a matter which must seriously interest those
who were responsible for their success. The demands upon
the doctor's time made it necessary that a medical meet-
ing should mean something to him, or he would not come
to it. This had led to the appointing of a Council of the
Academy, which met twice a year at least and formulated
lines of work and subjects likely to be most interesting
and important. It had to be taken into consideration that
to a large extent clinical or descriptive medicine, and
even gross pathology, was a finished story. The modern
clinician had to work with the laboratory at his side in
order to make progress in the knowledge of disease. There
was still a field of prevention and therapeutics where much
work remained to be done. It was true that we had not
yet learned to interpret accurately what the patient said he
felt. It was easy enough to recognize a crepitant rale or a
cardiac dilatation, but not so easy to explain what was
the matter when a patient said he had a persistent pain in
the back, a continual pressure on the top of the head, or
nervous indigestion, etc. Some, indeed many, doctors as-
sumed that if nothing could be seen, heard, felt, or precipi-
tated in a test tube, there was nothing the matter with
the patient, whereas exactly the contrary was true. The
exact interpretation of subjective complaints furnished a
wide and perhaps the only wide field left, calling for
original, careful, and acute clinical investigation. The
annual reports had shown the prosperous condition of the
Academy at the present time. Soon they would have a
waiting list, although the limit of membership had been
increased. Three new sections had been organized and

had begun work. The attendance and interest in the sec-
tions had never been greater. Although it cost much
money to run the Academy, yet its income paid its cur-
rent expenses, and had allowed money to be put away
this year in the sinking fund, and over $5,000 to be added
to the library fund. There had been established a course
of public lectures. Fresh interest was shown in the mu-
seum and historical department of the library. In closing,
Dr. Dana said they needed the sum of $200,000 with which
to enlarge the Academy and furnish room for the grow-
ing library. They also needed $200,000 as an endowment
fund with which to publish a monthly bulletin of the work
done.

Address of the Incoming President. — Dr. John A.

Wyeth gave this inaugural address and spoke on "The
Value of Organization in Medicine." He said that intelli-
gent cooperation between individuals for the accomplish-
ment of a given end had marked every step in human
progress. Beginning with the organization of families inta
tribes, and these into States and nations, the more enlight-
ened people of the earlier days became masters of the
world about them. Scarcely a page in history failed to
convey the lesson of the value of organization, but it was
left to modern times, to a higher civilization, and chiefly
to the profession of medicine, to apply the lesson to the
amelioration of suffering and the saving of life. Toward
the latter part of the eighteenth century and in the earlier
years of 1800 there were signs of dissatisfaction with exist-
ing conditions in the profession, but there was really no
great awakening until our own times. At the annual
meeting of the Medical Society of the State of New York,
in 1844, attention was strongly directed to the subject of
medical education and the necessity of a higher standard
of qualification, both preliminary and medical ; at the meet-
ing of this society in February, 184S, Dr. N. S. Davis, a
delegate from Broome County, introduced a resolution,
recommending a National Convention, to convene in the
City of New York in May, 1846, for the purpose of adopt-
ing some concerted action towards elevating the standard
of medical education in the United States. In 1846 the
proposed organization of a national body took definite
shape, and in 1847 the American Medical Association was
organized. Among the definite subjects then stated were
the following: (i) The standard of preliminary or pre-
paratory education should be greatly elevated, or rather a
standard should be fixed, for there was none then, either
in theory or in practice. (2) They should elevate the
business of private teaching to that position which its in-
trinsic intportance demanded. (3) A more uniform
standard of qualification should be required of the candi-
dates for medical honors. (4) They should devise some
mode to stimulate the ambition and arouse the energies^
of the profession to a higher state of intellectual activity
and scientific inquiry. While this proposed organization
of a national association was exciting much interest, a
number of distinguished physicians in New York City, on
November 18, 1846, met and proposed the foundation of
the New York Academy of Medicine, and this organiza-
tion was completed on January 13, 1847. From these
dates the influence of these two bodies made itself
felt in the profession. As far as the history of the med-
ical profession in the United States was concerned, in his
opinion the most important event occurred in 1900, when
the American Medical Association appointed a committee
on reorganization, which committee submitted its report
at the annual meeting of the Association at St. Paul, in
1901. Dr. Wyeth then reviewed some of the difficult prob-
lems connected with this great undertaking, especially the
differences which had divided some of the State societies
into factions, and especially that which had prevailed in
the Empire State. The real value of organization in med-
icine was in the influence they could bring directly to bear
upon the body politic, and through this medium secure
the legislation which would solve these serious problems.

Jan. 26, 1907]

MEDICAL RECORD.

161

and they could only do this by intelligent cooperation and
hy the sacrifice of much of their material interests to tlie
public good. Organized medicine should take more note
of politics than it had hitherto affected.

Reminiscences of Surgical Practice in New York
During the Period of the Early History of the Academy,
— Dr. Stephen Smith said that they could get a good idea
of surgery as a science and an art in New York City in
the middle of the last century by a study of the qualifica-
tions of the representative surgeons of that period, by the
character of the teaching in the medical colleges, by the
methods of practice in the hospitals, and the surgical liter-
ature. The three groups of representative surgeons were
according to their ages, those over 50, Valentine Mott, J.
Kearney Rogers, and Willard Parker; those over 40,
Alfred C. Post, John Watson, and Guerdon Buck; those
over 30, James R. Wood, John M. Carnochan, and William
H. Van Buren. The first group represented the teaching
and practice of the school of Hunter.

Valentine Mott owed his success to his aptitude, train-
ing, and opportunity. He gave extraordinary attention to
order, detail, and cleanliness. He prepared for operation
even of an unimportant character by the most painstaking
dissections and review of the simplest details. He invari-
ably cleaned his instruments before, as well as after an
operation. His operative wounds rarely suppurated, which
was the result sought by the school of Hunter, but never
completely secured by other operators as by Mott. We
now discover that his habits of personal cleanline.';s and
attention to minute detail secured, in a large measure,
asepsis. His pioneer work began with the ligature of the
innominata in 1818. This was not only his greatest
achievement in operative surgery, but the most brilliant
operation ever undertaken by any surgeon up to that date.
It was by no means suddenly conceived and executed as
an emergency operation, but was the ripe fruit of years of
study and preparation. They who knew him honored him
for the breadth of his studies, his love of scientific truth
in every department of research, his humanity as shown in
his lecture on the condition of the tenement population,
and his efforts to secure our present Health Department,
his patriotism so conspicuous during the Civil War, and
his devotion to the highest interests of his profession. J.
Kearney Rogers' reputation rested upon a single operation
of ligation of the left subclavian artery within the scaleni
muscles, in 1845. This operation was only second to that
of ligation of the innominata in the difficulties attending
the dissection necessary to expose the artery. Sir Astley
Cooper had attempted the operation and failed. In oper-
ating, Rogers was very dextrous and expeditious, two
qualities most prominent in the preanesthetic period. Wil-
lard Parker was professor of surgery in the College of
Physicians and Surgeons. He was not a scholar nor an
investigator, but an intensely practical surgeon. His
teaching was also practical rather than theoretical and
speculative.

The second group of surgeons was different from the
first. They were all connected with the New York Hos-
pital, but none of them took special interest in operative
surgery. Post's clinica were of interest chiefly because of
his accuracy of statement in explaining the nature of dis-
ease. Buck was a laborious and painstaking practitioner,
whose clinics were entirely wanting in everything like
glamour. His success depended chiefly upon the extreme
care of his patients. He would often awaken the house
surgeon at the hospital at a late hour at night by a visit
to a patient in a critical condition. Watson was generally
regarded as the most scholarly surgeon of the entire
series, his reputation resting on an address on the history
of medicine in the early times.

The third group of surgeons found their opportunities
at Bellevue Hospital. Wood's great service to the profes-
sion was the conversion of Bellevue from an almshouse
into a modern, well organized hospital, and then making

it a clinical school. His clinics were made attractive by
the variety of operations performed, the brilliant display
of instruments, and the frequent dramatic instances which
occurred. Carnochan received his education at Edinburgh
and London, and was a brilliant scholar, thoroughly
equipped by nature and training for a great career, both
as a teacher of the science and a practitioner of the art of
surgery. He was acceptable in the former, and eminently
successful in the latter. Van Buren was regarded as giv-
ing promise of a career second only to that of the senior
Mott. He descended from a long line of eminent physi-
cians, and no surgeon in the entire list combined so many
qualities making for success, whether as a teacher or as a
practitioner. He was more thoroughly familiar with the
advanced opinion of surgeons than any other clinica! lec-
turer, and his classes were always large and attentive.

In the medical schools of New York were found as
professors of surgery, Willard Parker in the College of
Physicians and Surgeons, and Samuel D. Gross in the
University Medical College. Parker's lectures were almost
wholly devoted to practical subjects, the principles of
surgery being very briefly discussed. Scrofula was much
dwelt upon as a dangerous complication in surgical dis-
eases, but syphilis received only a passing notice. Gross,
unlike Parker, was a student and investigator, and dis-
cussed broadly the principles of surgery as illustrated by
the pathology of diseases, and hence, he gave less time to
the details of practice.

The most accurate knowledge of the status of surgery
at any time or place was gained from the viewpoint of
the wards of the hospitals. The New York and Bellevue
Hospitals were, in 1850, rival centers of surgical instruc-
tion and practice. They were very unlike in organization
and management. The New York Hospital had been
established on the basis of tlie London hospitals, and
everything about it had the air of age and respectability.
The practice of surgery was along conservative lines estab-
lished by Wright, Post, Mott, and Stephens. In the
wards the greatest interest was manifested in fractures.
Compound fractures of the leg were treated in boxes par-
tially filled with bran, as an absorbent of the abundant flow
of pus. Fractures of the thigh and its neck were treated
with the long side splint, extension and counterextension
being made from its extremities by straps and bandages
which created such excoriations as greatly to impair its
usefulness. Ligation of arteries, trephining for fractures
of the skull, excision of bones were major operations. At
Bellevue many of the vices of the almshouse still persisted,
and the service was largely confined to chronic diseases.
Abscesses, ulcers, caries, syphilis in every form and stage,
and similar pus-generating affections filled the wards.
There was pus everywhere. Healing of wounds by first in-
tention was unthinkable. Amputation was the favorite
operation, and the clinics were most brilliant and spec-
tacular affairs.

Looking backward from the viewpoint of half a century
the surgeons of 1850 appeared like men of heroic mould,
and their achievements, under conditions almost absolutely
prohibitive of success, even more marvelous than the re-
markable deeds of to-day.

Reminiscences of Medical Practice in New York Dur-
ing the Period of the Early History of the Academy.—
Dr. .-\. Jacobi read this paper (see page 129).

Fracture of the Clavicle.— It is frequently difficult
especially in children, to secure adequate fixation of the
fractured bone by any of the ordinary methods. Cordua
says that in many instances good results may be obtained
by putting the arm of the injured side behind the back ni
such a position that the finger tips touch the angle of the
opposite scapula. It is not necessary, in most cases, to
continue this form of dressing longer than the first few
davs, and it should not be kept up any longer than is re-
quired, as the patient is thereby prevented from sleeping
either on his back or on the injured ^n\e.—Zeiitralblatt fur
Chirurgie.

1 62

MEDICAL RECORD.

[Jan. 26, 1907

SOUTHERN SURGICAL AND GYNECOLOGICAL
ASSOCIATION.

Nineteenth Annual Meeting, Held at Baltimore, Md.,
December 11, 12, and 13, 1906.

The President, Dk. Charles H. Noble of Atl.'\nt.\, Ga.,
IN THE Chair.

(Concluded from />. 122.)

Puerperal Thrombophlebitis of the Pelvic Veins. —

This was the title of the President's address, delivered by
Dr. George H. Noble of Atlanta, Ga. Attention was
directed to the surgical aspects of this question. Of the
32 cases of puerperal sepsis collected the infection was
divided as follows, with reference to location : Metrophle-
bitis, II; metrolymphangitis, 4; abscess in parametrium, 8;
thrombophlebitis (suppurating) of broad ligament, 2; sup-
purative peritonitis, 7; and deep laceration of vagina, 7.
Thus of Oie entire number there were thirteen cases of
pelvic phlebitis, two of which were in the large veins of
the pelvis. If thrombosis of the pelvic veins occurred in
6 or 7 per cent, of puerperal infection, the mortality being
high, the author thought considerable saving of life might
be brought about by early recognition of the disease and
prompt interference. He thought the showing should be
greater, for the number of cases coming under his observa-
tion did not correspond with the percentage given in the
above list. Thrombosis might begin early, but usually
the symptoms were not clearly defined until late in the
puerperal state, making a distinction between it and other
clinical manifestations of sepsis, excepting intramural ab-
scess of the uterus. But exceptionally the symptoms
might appear earlier. In one case the chill came on on
the third day, and on the ninth the thrombus had advanced
to such an extent that resection of the left side of the
uterus and of the corresponding broad ligament was ac-
quired. The disease was often complicated with other
septic conditions, such as involvement of the tubes, ovaries,
suppuration in the parenchyma of the uterus, parauterine
tissues, or the clot itself might be permeated with pus,
the latter escaping directly into the circulation. In differ-
entiating between thrombosis and intramural abscess of the
uterus, uncomplicated by peritonitis and adhesions, small,
rounded, flat elevations on the surface of the uterus might
be felt in patients with very thin or relaxed abdominal
walls. Such cases presented the ordinary septic pulse and
temperature curves, and did not have the distinct interval
of nonsuppurating thrombus. When complicated by ad-
hesions, or diseases of the appendages with tense abdom-
inal walls, exclusion of intramural abscess, and detection
of tortuous veins, were extremely difficult. Suppurating
thrombosis very likely might be overlooked when com-
plicated with peritonitis, pus tubes, etc., unless the symp-
toms of pyemia supervened, or the pulse showed a tendency
to become climbing in character. These were suggestive
of the true condition. Any puerperal case with pelvic
lesions, variable temperature, and climbing pulse of three
to four weeks' duration, without signs of improvement,
justified an operation of some kind, especially if the uterus
proved negative as the source of trouble. If a mistake
was made in diagnosis, and the location of the infection

was ■' ' in the Fallopian ■ tubes or abscesses in other

par- pelvis, no surgical error was committed, for

they too were in need of serious attention. There were
several plans of procedure. First, excision of the throm-
bosed veins ; second, ligation of the thrombosed veins ;
third, hysterectomy. In addition to these, attention should
be given to the complicating conditions. One author ob-
jected to excision on account of the liability of reinfecting
the wound by soiling the parts with the clots. In two of the
author's cases in which the veins were lacerated by digging
the clots out of the broad ligament with the fingers, the tem-
perature range for two or three days was quite irregular
and reached high marks at short intervals (i03°-i05°), but
some of this temperature might have been due to the exten-

sive surface involved. Each of these had numerous abscesses
in the uterus, ovaries, and pus collections between the coils
of the intestines; besides, the omentum and intestines were
softened and adherent from the umbilicus down. As the
chill was not rc-pcated in either case, it was likely that soiling
the wound with clots had little to do with it. The number
of cases in which excision had been resorted to was too
small to draw accurate conclusions. Ligation of the veins
was not satisfactory, especially if the clots became infected
with pyogenic cocci. Hysterectomy was extremely danger-
ous in this condition. In the first place, it was often de-
layed too long to remove successfully all the infected
centers. ' When thrombosed vessels were confined to the
uterus, tliere were some chances of success, but propagation
through the vessels into the broad ligament extended the
infected field into the pelvic veins, and at times the uterus
might not be at fault, for the thrombi might lie exclusively
in vessels outside of that organ. Removal of the uterus
under such circumstances was worse than useless, as it
would leave the thrombosed vessels undisturbed. On
the other hand, excision of the diseased veins without
hysterectomy was promising- except in extreme cases.
In the summary of the small number of cases accessible,
the results were as follows : Resection of vein, a mortality
of 284-7 per cent.; ligation of veins, 444-9 per cent.;
hysterectomy, 64 1-4 per cent. He ventured the assertion
that until further experience shall have worked out the
solution of this problem, the opinion must be accepted that
early recognition of septic thrombosis of the pelvic veins,
followed by prompt e.xcision, was the best method of relief
we could offer our patients in this disease.

Surgical Treatment of Tuberculosis of the Kidney. —
Dr. Howard .-X. Kelly of Baltimore reported a surgically-
treated series of sixty-two cases of kidney tuberculosis
from the gynecological clinic at the Johns Hopkins Hos-
pital and from his private sanatorium. This list embraced
fifty-seven nephrectomies — including simple nephrectomy,
and those combined with removal of the ureters, and in a
few cases also parts of the bladder — four nephrotomies,
and one partial nephrectomy. The extreme rarity of a
spontaneous healing, even by a complete destruction of
the kidney and occlusion of its ureter, was 'emphasized.
The author in a large experience had never met with this
condition, which agreed with the statements of most others
who had extensively observed the disease. With the rare
exception of a kidney so sequestrated, the disease in all
cases sooner or later involved the bladder, and from that
led to death, either by infecting the sound kidney, or by
extensively metastasing to other parts of the body. Of
the operative procedures considered, nephrotomy must be
regarded as merely a palliative measure to be employed
in pyonephrosis cases. When the second kidney was sound,
it was preliminary to a subsequent nephrectomy; when
the sound kidney was diseased, it relieved suffering, and
to some extent prolonged life. In the four cases in which
it was the sole operation, the second kidney was involved,
and all of these patients died within a year. Of the seven
cases in which it was performed as a preliminary operation,
and nephrectomy done later, all had recovered and were
cured. Partial nephrectomy was indicated in cases where
both kidneys were involved by tuberculosis, and both were
secreting about equal amounts of urine. In the one case,
where the author employed it, the patient died eight months
after operation. A study of the specimens obtained by
nephrectomy showed that in five kidneys the disease was
localized to one pole, and that a partial nephrectomy some-
times offered the hope of eradicating the disease. Tuber-
culosis involving one-half of a horseshoe-shaped kidney
presented another condition where partial nephrectomy was
positively indicated. Nephrectomy was the operation of
choice, and it should be employed first under all circum-
stances if the second kidney was sound ; second, even when
the second kidney was diseased, if the kidney to be removed
was not functioning or only slightly functioning, and the
other but slightly involved. The presence of albumin

Jan. 26, 1907;

MEDICAL RECORD.

163

and casts in tlie urine from the kidney not tuberculous was
not a contraindication to operations. They usually dis-
appeared after the removal of the tuberculous kidney.as was
shown in four of tlie five cases. In the fifth case they
persisted, and demonstrated a genuine nephritis, but this
patient was actively engaged in teaching school seven years
after her operation. Infection of tlie second kidney by
the ordinary pyogenic organisms was not a contraindication
to a nephrectomy, as was shown by three cases of the series.
One of these was living, thirteen j'ears after operation,
another seven years, and another four years. Involve-
ment of the bladder, far from being a contraindication to
operation, was a most urgent indication, as bladder tuber-
culosis was not healablc in the presence of a tubercular kid-
ney above, whereas it did heal under proper treatment after
nephrectomy. Coexistent involvement of the genital organs
was not a contraindication. The author's experience in
this class of cases was confined to women; five such cases
were treated; three were permanently cured; one had only
been recently operated on, and one died from the operation.
Tuberculous genitalia must be removed as well as the
kidney. This same complication in men, as shown by
Rovsing's report of ten cases cured, could not be held as
a contraindication to the operation. The presence of tuber-
culosis in the lungs, glands, joints, bones, and elsewhere,
provided it was not very active, was no contraindication
to the operation. Out of eighteen such cases treated by
nephrectomy, and subsequent general treatment, thirteen
were permanently cured from periods of two to ten years,
and two had only been recently done. As tuberculosis of
the kidney once started destroyed the kidney, and as the
cases became more unfavorable after bladder involvement,
a nephrectomy should be done just as soon as the diag-
nosis was made. The importance of this early operation
was shown by the results in the twenty-one cases treated
comparatively early in the course of the disease, i.e. witli
no bladder involvement, or only slight involvement around
the ureteral oriiice of the affected side. There had not
been a death in this group, and all had been cured. Con-
trasting with this thirty-six cases with extensive bladder
involvement, there were four primary, and within four
years five secondary deaths, making a total mortality rate
of 25 per cent. By reason of the fact that some of the
author's cases were private patients, it had been possible for
him to follow them all after operations. These observa-
tions after operation did not consist only of the reports
of the patients, but also of careful urinary examination.
The statistics from the nephrectomies were : Fifty-seven
cases, 4 primary deaths, or 7 per cent, mortality; a total
of 7 deaths within six months, 12.2 per cent, mortality; and
a total number of deaths of g, 16 per cent, mortality.
E.xcluding from the series nine cases with residual bladder
trouble still present, all of which except one had been oper-
ated on within a year and a half, there remained forty-
eight cases, with thirty-nine complete cures, and nine
deaths, a cure rate of 76.93 per cent. It was only by a
knowledge of the frequency of such permanent cures that
a just estimation of the operation could be arrived at,
since the vesical irritability, owing to involvement of the
bladder and other disagreeable symptoms, might be as
great after the operation as before, unless a cure was
obtained. As to the method of operating, when it was
possible to do so without adding to the dangers of the
operation, the ureter should be removed with the kidney,
as by this means it had been found that the incision healed
more promptly and the bladder tuberculosis, if present,
was more amenable to treatment. In view of the remark-
able results of surgical treatment, and the hopelessness of
all medicinal measures, tuberculosis of the kidney more
positively indicated operation than did acute appendicitis,
and the realization of this fact by the profession, with the
consequent possibility of early operations, woulij lead to
better and better results.
Tuberculosis of the Kidney. — Dr. Charles P. Noble

of Philadelphia reported ten nephrectomies for tubercu-
losis, nine of the patients being women and one a man.
In each of the ten cases the tuberculosis of the kidney was
primary, but in the man the lungs were also involved.
This case ended fatally six weeks after nephrectomy in
the natural course of the disease. The nine women not
only recovered from the operation, but were restored to
health. Three of them suffered from permanent loss of
capac'ity in the bladder, due to the healing of extensive
ulcers. In most of the cases the complicating cystitis and
ulceration underwent a spontaneous cure after the nephrec-
tomy. The following points were emphasized: No evi-
dence of ascending tuberculous infection had come under
the writer's notice. In each of the cases the tuberculosis
of the kidney was primary, and the bladder, when in-
volved, was infected by pus discharged through the ureter.
The results of early nephrectomy for tuberculosis of the
kidney were very satisfactory. The profession should be
educated to appreciate these facts and to diagnose tuber-
culosis of the kidney at an early stage, before extensive
mvolvement of the bladder or general dissemination of the
disease had occurred.

A Study of Vaginal Cesarean Section With Especial

Reference to Subsequent Pregnancy and Labor. Dr.

John F. Mor.vn of Washington, D. C, after referring to
the literature of this subject, stated that at the last meeting
of the association he reported two cases of vaginal cesarean
section, performed for eclampsia, both successful, and he
now reported a subsequent pregnancy and labor occurring
in one of them. He said it could not be denied that com-
plications and sequel.-e attended vaginal cesarean section,
but that was also true of all the methods of accouchement
force. Each had its value, and should be employed only
after a thorough examination had determined its suitability.
.An exact knowledge of the condition of the cervix before
acting was the essential prerequisite to success. The bougie,
tampon, and metreurysis might be used when the cervix
was undilated, provided time was not a necessary factor.
Manual and instrumental methods should be applied only
when the internal os was effaced or effacing. If applied
while the cervix was intact they acted by divulsion, rather
than by dilatation, with its consequent dangers of hemor-
rhage, laceration, and infection. It was in the latter class
that vaginal cesarean section was particularly indicated,
and, further, had the advantage that in case of urgency the
uterus could be emptied at any period during pregnancy or
labor in a given time. It was therefore a meritorious oper-
ation, and a valuable addition to our obstetrical resources.

Dystocia Following Fixation and and Suspen-
sion of the Retroilexed Uterus. — Dr. J. Whitridge Wil-
liams of Baltimore, in a paper on this subject, reported
four cases in his own experience, and collected thirty-four
from the literature, in which cesarean section had to be
done following some method of fixation for suspension of
the uterus.

Dr. Henry O. M.arcy of Boston gave a brief sketch of
one of Baltimore's greatest men — Dr. Horatio Gates Jame-
son, whose greatest contribution to surgery, he said, was
the occlusion of .irteries by buried animal ligature.

Hodgkin's Disease; A Typt of Sarcoma. — Dr.Wii. B.
CoLEY of New York referred to the fact that at present
both pathologists and clinicians were widely at variance
as to what constituted Hodgkin's disease. The theory
that Hodgkin's disease was a form of tuberculosis, strongly
advocated a few years ago by Sternberg and others, had
been practically disproved by the work of Dorothy Reed.
The theory which at the present time received the greatest
support both by pathologists and clinicians was that Hodg-
kin's disease was a separate entity in the nature of an
infectious process. This was the position held by Reed
and the majority of recent writers. The only other theory
that had received much consideration was that Hodgkin's
disease was in the nature of a malignant tumor, or a vari-
ety of sarcoma. While this was the view originally held

164

MEDICAL RECORD.

[Jan. 26, 1907

by Virchow, who called it lymphosarcoma, and Billroth,
malignant lymphoma, the same had been practically aban-
doned by later writers, and only recently had again begun
to receive serious consideration. In favor of the infec-
tious theory of the origin of the disease, Reed cited the
facts: (i) That fever was frequently associated with
Hodgkin's disease; (2) that the frequency with which
the disease started in the cervical region suggested the
possibility of infection gaining entrance through the mucous
membrane of the mouth ; (3) the absence of capsular infil-
tration and implication of adjacent structures; (4) the
peculiar giant cells found in the tumors. Finally, and
most important of all, the fact that metastases occurred
only in preexisting lymphoid tissue. Dr. Coley, who
strongly believed in the malignant nature of Hodgkin's
disease, in answer to these objections, stated that his obser-
vation had been that fever was not an infrequent occur-
rence in malignant disease; especially in sarcoma if generali-
zation had taken place. As to the neck being the frequent
starting-point of Hodgkin's disease suggesting the possi-
bilit)- of infection, he stated that the same reasoning would
apply to cases of sarcoma of the neck, which bore such a
large proportion to the total number of cases. Coley had
observed seventy cases of sarcoma of the neck in a total
of 61S cases. As to the absence of capsular infiltration,
this was by no means a universal characteristic of the
tumors of Hodgkin's disease, as shown by the recent
and very valuable contribution of Gibbon of San Francisco,
whose report covered nine cases. His cases showed marked
evidence of capsular infiltration and also answered a more
important objection: that metastasis occurred only in pre-
existing lymphoid tissue. In some of Gibbon's cases
metastases occurred where there was no possibility of the
presence of lymphoid tissue and not only infiltrated the
capsule but the surrounding structures, even tlie periosteum
and bone. As another reason for regarding the process
of the nature of a sarcoma, Coley cited several cases in
which the clinical diagnosis was sarcoma, while the patho-
logical report read Hodgkin's disease. Cases of Hodgkin's
disease pursued a clinical course identical with that of
sarcoma, infiltrating the surrounding tissue and causing
death in precisely the same way. The recent work of
Banti went far toward proving that not only Hodgkin's
disease but also leukemia, both lymphatic and myelogenous,
were really forms of sarcomatosis. Coley's conclusions,
based upon a study of upward of six hundred cases of
sarcoma, of which seventy originated in the b-mph glands
of the neck, are that Hodgkin's disease was merely a
special variety of sarcoma, representing a fairly definite
clinical and pathological type, but in many cases shading
off into other types that corresponded most closely with
that of an ordinary round-celled sarcoma. The evidence
brought forward by Reed and others in favor of the infec-
tious origin of Hodgkin's disease need not be disproved.
Most of it held true in the case of sarcoma, and all of it
but added to the slowly-accumulating mass of evidence in
favor of the infectious or microparasitic nature of sarcoma,
a conviction which the writer had long held.

The Surgical Aspects of Gastric Carcinoma. — Dr.
John B. De.wer of Philadelphia said that from twenty-five
to forty per cent, of all cancers of the body were primary
in the stomach. Bryant, quoted by Van Valzah and Nisbet,
showed that in Baltimore there were 200 deaths annually
from cancer; Boston, 300; Philadelphia, nearly 500; New
York City, nearly 900. Of these, perhaps almost one-half
were directly due to cancer of the stomach. Chronic gas-
tric dyspepsia was the chief predisposing cause of cancer.
Cancer of the stomach presented clinically two forms. In
one, a patient past middle life, without having suffered
previously from indigestion, suddenly lost appetite, especial-
ly for meats, grew progressively weaker, more emaciated,
developed epigastric pain, possibly a palpable mass; be-
came subject to vomiting spells; vomiting a mass of foul-
smelling and fermented coffee-ground material, and quickly

developed cancerous cachexia. This was the classical pic-
ture of gastric carcinoma. The second and much larger
class was composed of patients who had been lifelong suf-
ferers from dyspepsia. Usually there were no definite
symptoms, the patient having been treated for chronic
gastritis. Patients who presented symptoms of gastric in-
digestion, which would not yield in a few weeks to medical
treatment, should be subjected to operation. Timely resort
to gastroenterostomy would save many patients from the
development of gastric carcinoma. Until operation was
more frequently undertaken in the verj' early stages of
gastric carcinoma, gastroenterostomy must still be the
operation most often adopted. It was rare in the author's
experience for a patient, in whom cancer had been cer-
tainly diagnosed before operation, to present conditions ad-
mitting of gastrectomy. A palpable tumor felt before oper-
ation would naturally suggest cancer, yet these tumors had
been known to disappear after a gastroenterostomy; there-
fore, all palpable tumors were not carcinomatous in nature ;
and it was in this class of patients that exploratory laparo-
tomy found its most legitimate field. Total gastrectomy
must remain an operation of the utmost rarity. Person-
ally, he did not approve of it. Subtotal gastrectomy was.
in his opinion, as extensive an operation as it was wise
to adopt. To sum up : By timely operation for the various
causes of persistent indigestion, many a patient would be
saved from developing gastric carcinoma. Early diagnosis
of gastric carcinoma being so extremely difficult, and rad-
ical removal being only highly promising when an early
diagnosis had been made, partial gastrectomy should be an
operation limited to cases of malignant disease operated
on for symptoms of pyloric obstruction or other gastric
affections supposedly benign, in which the existence of
cancer, though perhaps suspected, could not be certainly
diagnosed before operation. Partial gastrectomy was the
preferable treatment for these cases. In cases moderately
far advanced gastroenterostomy should be preferred. Where
the indication was to prevent starvation, jejunostomy was
to be performed.

Vaginal Section as an Operation of Choice. — Dr.
Henry T. Byford of Chicago called attention to the fact
that whereas vaginal section became quite popular among
gynecologists a few years ago on account of its low mor-
tality, the improved technique of abdominal section soon
brought the latter into favor again and relegated the former
to a comparatively limited field of usefulness. The cases
adapted to vaginal section were mostly those in which the
parts affected were more accessible from below, namely,
those connected with prolapse and retroversion of the
uterus, with prolapse of the ovaries, or with adhesions low
down in the pelvic cavity, and cases of hysterectomy or
myomectomy for small fibroids as well as hysterectomy
for other small neoplasms and malignant diseases of the
uterus. When the uterus was not to be removed the
author preferred the incision posterior to the cerv-ix for
those cases in which the uterus was retroverted or readily
retrovertible, and the cervix could be drawn well down
near the vulva. The anterior incision had the advantage
of enabling the operator to deliver the fundus into the
vaginal entrance and also to draw the ovaries and round
ligaments forward within easy reach. Among the dis-
advantages of the latter were a complicated wound which
could not always be as satisfactorily sutured as the pos-
terior incision, and the presence of the fundus in the
vagina to interfere with manipulations, etc. When there
were special reasons for avoiding abdominal section, the
field of vaginal section might be extended by removing
the uterus or if it be desirable to preserve the uterus by
lateral colpotomy in connection with the anterior or poste-
rior incision, or both. By ligating and severing the uterine
artery, or by skirting or shaving the edge of the cervix
with scissors or a sponge, and separating the broad and
sacrouterine ligaments from the cervix, space could be
obtained for the introduction of the whole hand into the

Jan. 26, 1907]

MEDICAL RECORD.

165

peritoneal cavity and for the employment of intraperitoneal
illumination. The author had even extended the incision
•completely around the cervix, as for vaginal hysterectomy,
separating the bases of both broad ligaments as well as of
the sacrouterine ligaments and bladder, and afterward
suturing the parts back to their original relationship with
out any bad results. Through the opening thus made the
torn or perforated rectum could be successfully sutured.
The author believed that while the utility of vaginal sec-
tion would diminish with the perfection of the technique
of abdominal section for pelvic conditions, there would
always be a place for it, and the time had not yet come
when a special training in gynecological surgery could be
considered as superfluous.

Dr. John C. Munro of Boston reported an unsuccessful
case of aneurysmorrhaphy for abdominal aneurysm.

Appendicitis in the Negro. — Dr. Hubert A. Royster
of Raleigh, N. C, said that in order to obtain some infor-
mation on this subject he wrote to several surgeons prac-
tising in southern cities having a large proportion of negro
inhabitants; the replies were unanimous in regard to the
rarity of the disease in this race. During the ten years
in which the author had practised he had removed the
diseased appendix from negro patients fifty-four times.
In forty of the cases a pathological appendix was found
while operating for other conditions, such as pus tubes,
fibroids, etc. Besides a few of these which contained pus,
over one-half of the others were filled with fecal matter,
usually soft. Practically none of these cases presented a
definite history of appendicitis, but only that of the original
lesion. Fourteen cases of primary appendicitis in the negro
were operated on, three in the first seven and a half years,
and eleven in the past two and a half years. During the
latter period, two and a half years, the total number of
appendix operations on both whites and negroes was 123,
giving ;i relative frequency of practically 9 per cent, in
the colored race.

Injuries and Diseases of the Hyoid Bone. — Dr. Ran-
ipolph Winslow of Baltimore reported six cases, one that
had come under his own observ.ition and in his practice,
and five from the literature. He said that tumors of the
hyoid bone were both malignant and innocent in about
equal proportion, and both required thorough removal with
as much of the contiguous tissue as might be necessary.
An early operation was as much to be desired in neoplasm'^
of this bone as in those occurring in other parts of the
hody. The author's case was one of sarcoma of the hyoid
hone and larynx. He excised the tumor of the hyoid and
base of the tongue, larynx, and part of the pharynx under
local anesthesia. The patient recovered from the operation,
hut died two months later from metastasis. The patient
was a man forty-five years of age, who entered the hospital
on January 9, 1906, suffering from dyspnea due to a growth
in the region of the hyoid bone on the left side, which ob-
structed the larynx. Thirteen years ago a lump was re-
moved from the hyoid bone and the side of the larynx,
and patient was discharged cured in six days. It began
to recur in three years, and had been in existence for ten
years and slowly increasing in size. The voice was
altered ; there was dyspnea with .stridor, cough, dysphagia :
pulse rapid and weak. There was a lump found in the
region of the hyoid bone projecting more to the left than
to the right side; it was globular, and as large as a goose
egg, hard and movable, but not painful. A skiagraph
failed to show the hyoid bone, but a shadow of a growth
was seen between the jaw and the larynx. On January
. II tracheotomy under cocaine was done to relieve the
urgent dyspnea. Patient improved somewhat and desired
a removal of the growth. It was thought inadvisable to
administer an anesthetic; hence morphine-scopolamine was
injected hypodermically and the skin infiltrated with
Schleich's solution. Operation on February i, 1906. Hyoid
bone, base of tongue, whole larynx, and part of pharynx
were excised without difficulty whilst the patient was ron-

-cious. ihc trachea was attached to the skin at the lower
part of the neck and a large tracheal tube introduced;
pharynx and skm sutured. There was no shock. At
first the patient was fed through a large, soft catheter
passed from the mouth into the esophagus; but later the
pharynx opened and a tube was passed from the neck into
the esophagus. Patient did well and soon sat up and was
able to walk about the ward ; but recurrence occurred in
the neck, and he gradually failed and died in eight weeks.
\n autopsy showed extensive metastasis in the lungs,
bronchial glands, liver, and mesenteric glands, whilst the
microscopic examination of the growtli showed it to be a
round-celled sarcoma.

The following papers were also read : "Conservative
.Method of Managing Undescended Testicle," by Dr. Joseph
Price of Philadelphia; "Gallstones without Symptoms and
.Symptoms without Gallstones," by Dr. Maurice H. Rich-
ardson of Boston; "Two Simple Surgical Tricks Worth
ICnowing, with Instruments Used," by Dr. Ap Morgan
Bance of Louisville, Ky. ; "Report of a Case of Ruptured
Ovarian Tumor with Complications," by Dr. Rufus B.
Hall of Cincinnati; "Hodgkin's Disease — A Type of Sar-
. oma," by Dr. William B. Coley of New York City; "Cysts
"f the Omentum," by Dr. R. E. Fort, of Nashville; "Some
Disjointed Observations upon Our Technique," by Dr. A.
.Morgan Cartledge, Louisville; "Influence of Respiration
apon Development of the Chest Deformity in Scoliosis,
with Its Relation to Application of Plaster Jacket," by
1 )r. Michael Hoke of Atlanta ; "Some Suggestions in
i'iegard to the Surgical Treatment of Empyema," by Dr.
.Samuel Lloyd of New York; "Normal Involution of the
.Vppendix," by Dr. Robert T. Morris of New York; "Splen-
ectomy, Indications, and Results : Report of Five Success-
iul Cases," by Dr. W. P. Carr of Washirtgton, D. C.

Officers. — The following officers were elected for the
ensuing year: President, Dr. Howard A. Kelly of Balti-
more, Md. ; Vice-Presidents, Dr. R. E. Fort of Nashville,
Tenn., and Dr. Hubert A. Royster of Raleigh, N. C. ;
Secretary, Dr. W. D. Haggard of Nashville, Tenn., re-
elected; Treasurer. Dr. Charles M. Rosser of Dallas, Tex.,
reelected.

New Orleans, La., was selected as the place for holding
the next meeting; time, second Tuesday in November, 1907.

THE MEDICAL ASSOCIATION OF THE GREATER
CITY OF NEW YORK.

Stated Meeting. Held December 17, 1906.

The President. Dr. Thomas E. S.^tterthwaite, in the

CHAIK.

A Modification of the Obstetric Forceps, Eliminat-
ing the Danger of Excessive Compression. — Dr. A.

Ernest Gallant read this paper, in which he described a
safety lock on the obstetric forceps for the prevention of
dangerous compression of the fetal head. After a brief
historical review of the development of the obstetric
forceps since 1733. Dr. Gallant demonstrated that thc
great danger of the so-called English lock lay in the fact
that after the forceps were locked and traction applied the
lateral pressure exerted by the uterine and vaginal walls
on the convex surface of the blades forced them together
to a degree which was highly dangerous to the fetal head,
especially at those portions within the grasp of the tips of
tlie blades, and frequently caused depression, fracture, and
intracranial hemorrhage. The speaker presented two de-
vices for avoiding this otherwise uncontrollable pressure:
On the long-shanked forceps, by placing a "shoulder" at
the junction of the shank with the blade of the left for-
ceps, which prevented them from overlapping, and the
blades from coming together any closer than it was origi-
nally designed that they should. For the same purpose,
on the forceps made with the Chapman or loose lock, as
was usually found on the Elliott forceps, he had combined

i66

MEDICAL RECORD.

[Jan. 26, 1907

the English with the French locl<s, the thumb-screw of
the latter being inserted, free, through a hole in the
flange of the left blade, and screwed into the main por-
tion of the shank. The right blade was provided with a
notch on its inner side, partially countersunk, which em-
braced the thumb-screw, and when that was screwed
home it fastened the blades together as in the Hodges
forceps, and in that way maintained the fulcrum at the
lock and prevented compression of the head. With this
combination lock it was claimed that we could secure the
head from injury and have all the advantages of the loose
lock, the button lock, the set-screw lock, and at tlic same
time bring into play Elliott's pivot at the extremity of
the handles for holding the blades as widely apart as was
deemed advisable.

Immediate Repair of the Soft Parts after Labor. —
Dr. Henry C. Coe introduced his paper with the remark
that the subject was so trite that it was impossible to do
more than to emphasize anew old, familiar teaching
There could be little room for difference of opinion among
obstetricians as to the advisability of repairing lesions of
the soft parts after labor, but writers by no means agreed
as to the best time at which the operation should be per-
formed, nor did they all adopt the same technique. In
discussing the subject, therefore. Dr. Coe said he would
limit himself to his own experience. Immediate repair of
laceration of the cervix was still a mooted question. In
the presence of arterial hemorrhage there could be no
doubt that it should be at once controlled by the passage
of deep sutures. He did not believe it was necessary to
repair every lacerated cervix at the time, but it was now
his custom in every case of difficult delivery (high forceps
or extraction) to be prepared to suture at once the
extensive bilateral tear which was to be expected. With
the present aseptic technique primary union was to be
looked for, nor was drainage from the uterus interfered
with if the operation was properly performed. It was
exceedingly simple. The speaker said he preferred to
operate as soon as the placenta was delivered, and not to
wait until several hours, or even days afterwards, as some
writers advised. Of course, there were cases in which
the conditions would render it inadvisable to add even
a few minutes to the anesthesia. Lack of assistance, bad
light, and other complications incident to private practice
might also prevent the accoucheur from repairing a torn
cer\-ix, excepting as a life-saving measure. But in the
class of cases in which extensive tears were apt to occur
no one should attempt a difficult obstetric operation with-
out the assistance of a colleague. With regard to lacera-
tions of the vagina, the speaker said he wished to empha-
size the fact that their extent was often not fully realized
until the parts were thoroughly exposed with a speculum
and retractors. This applied especially to occipitoposterior
cases in which the head ''was rotated with the forceps.
Not only were deep and ugly rents produced by the most
skillful hands, but they were too often only partly sutured,
with the result that healing by granulation took place, and
the production of extensive cicatrices. It was important
not only to expose the entire length of the tear, but to
keep the field of operation clear by placing a tampon
against the cervix. One must not neglect to examine the
anterior, as well as the posterior wall, for many lesions of
the former were overlooked. Dr. Coe said he had nothing
to add to his paper on "Immediate Repair of Injuries of
the Pelvic Floor," printed in the Transactions of the
American Gynecological Society, Vol. 29, page 219, and
would only reiterate his opinion that it paid to do the
work thoroughly, having ever in mind that the object of
the operator was not merely to suture raw surfaces, but
to go deeper and to pick up the torn fascia and muscles
outside of the vaginal tube. It was now a truism that the
submucous lacerations of both the anterior and posterior
vaginal walls were of far more importance than the visible
superficial lacerations. He believed that the time had come

when, even in the absence of the latter, the careful accou-
cheur would seek to prevent subsequent cystocele and rec-
tocele, and prolapsus by performing at once the operations
usually done months later to correct these conditions, pro-
vided always that the patient's condition was such as
permitted one to spend an additional quarter of an hour
in the work after delivery was completed. He had, of
course, had good results in intermediate operations, but
he preferred the immediate.

Dr. Ch.\rles Jewett of Brooklyn said he respected the
rule that the obstetrician should, if possible, dismiss his
patient in as good condition as he found her, but his ex-
perience with cervical lacerations led him to refrain from
immediate repair, owing especially to the risk of infec-
tion. Directly after labor, in addition to the fact that
the wounds were all fresh, the general resistance was low-
ered, the local resistance in the bruised and greatly soft-
ened cervical tissue was at a minimum, the operative field
was in close proximity with the wounds of the uterine
cavity, and the resorptive activity was at a maximum. For
these reasons he dreaded the possible consequences of
much intervention in the upper part of the birth canal
immediately after labor. Ample experience had shown
that the best puerperal results were attained only when
the parturient tract had not been invaded at all during
the birth, or at its close. In case of arterial hemorrhage
from the torn cervi.x. usually immediate suture was of
course imperative. In other parts repair was better .de-
ferred, at least until the tissues had in great part recovered
their normal resistance, and the wounds of the uterine
cavity were healed, or healing. In one case in which he
had sutured the cervix the day following labor, and with
the usual aseptic care, the woman developed a mild septic
phlebitis. One of his colleagues had a similar experience.
He preferred to wait not less than two or three weeks.
Dr. Jewett said he agreed with Dr. Coe as to the impor-
tance of carefully searching for the location and extent of
lacerations at the vaginal orifice at the close of labor, both
anterior and posterior injuries, and of their immediate
repair. This part of the tract could immediately be re-
stored without risk of infection. The consequences of
neglect were worse than in ordinary injuries of the cervix,
mary of which did not require repair at all. With refer-
ence to the time for operation on pelvic floor lacerations,
the speaker said that some years ago, for teaching pur-
poses, he adopted the plan of operating in most of his
hospital cases several hours or days after delivery, and
he had found that even after as many as seven days union
occurred, and the results were entirely satisfactory. When
necessary, the wounds were revivified by rubbing them
with a gauze sponge. While he would not recommend
this plan for general use, in simple cases he thought it
had many advantages in dealing with extensive tears. It
was often difKcult to restore the parts properly at the close
of labor, with perhaps a poor light and scant help, when
the structures were badly distorted and the work obscured
by the bloody flow from the uterus. .\ few hours or days
later the operation was usually found to be a very simple
matter. The condition of the patient sometimes contra-
indicated immediate repair. She might be too much
exhausted. If the wounds became infected they would not
unite, and the danger was increased by suturing. With
reference to methods of repair, it was very essential in
complete lacerations that the internal, as well as the
external sphincter be restored. The norma! control of
the bowel depended in no small measure on the integrity
of the internal sphincter. Instead of suturing the rent in
the rectal mucosa, he liberated the lower portion of the
rectal mucous membrane anteriorly, drew it down, and
stitched it at the anal orifice. This shut off the wound
from the rectum, and insured almost certain union.

Dr. Francis Foesster said the immediate repair of the
soft parts after labor depended primarily upon the sur-
roundings and environment of the patient, as well as her

Jan. 26, 1907]

MKDICAL RECORD.

167

condition. The proper method of procedure in the hospital
could not always be carried out in private practice, espe-
cially in tenement houses. Hemorrhage, of course, de-
manded immediate attention. The speaker referred to the
fact that after tears of the cervi.x of even considerable
extent the organ apparently resumed its normal appearance
when the congestion had disappeared, and for that reason
he did not always consider it essential to repair these rup-
tures. In dealing with lacerations of the pelvic floor,
they should, under favorable conditions, be repaired imme-
diately. If that was impracticable, it was better, he
thought, to wait two, three, or even four months before
undertaking the operation. By that time the parts would
be restored to their normal condition, having undergone
similar changes as the uterine muscles, and better results
could be obtained.

Dr. Frank R. Oastler said that personal observation of
several thousand cervices in women wlio had had children
demonstrated, (l) that a very large majority of cervical
tears healed, leaving the laceration present, but giving no
symptoms; (2) that of the others there were some where
bilateral tears had extended to the vaginal vault and had
healed, causing eversion of the cervical mucous mem-
brane, and consequent disagreeable discharge and irrita-
tion; some where there was considerable scar tissue in the
angle of the healed tears, accompanied by cervical metritis,
leaving a large, congested cervix ; and still others where
the tear had extended deep into the broad ligament on
one or the other side, causing considerable scarring. Ex-
tensive bilateral tears should be repaired immediately after
labor, for by approximating the torn surfaces with one or
two sutures the resulting eversion of mucous membrane
was avoided. Where lacerations, however, extended into
the broad ligaments it was better to pack and drain, for
sutures were very apt to catch the uterine artery or
ureter. There was no difficulty in obtaining free drainage
following suture. Dr. Oastler said he believed that the
ordinary bilateral and central tears involving the perineal
body and extending into the lateral sulci for a short dis-
tance were of minor importance in causing perineal relaxa-
tion. The relaxation was found not at the vaginal outlet
as a rule, but in the upper two-thirds of the vagina. He
was inclined to attribute the latter to a weakness of the
levator ani muscle resulting from minute subcutaneous
muscle fiber tears in the upper two-thirds, or by partial
paralysis of the muscle itself. This condition was caused
by the constant pounding of the child's head upon the
perineal floor, and stretching of a poorly developed muscle
in a poorly developed patient. This stretching, or paralysis
of the levator ani, could be avoided to a considerable
extent by hastening the second stage of labor, even at the
expense of a tear of the perineal body or its extension
into the lateral sulci. The latter condition could be re-
paired immediately and successfully, but the former was
often repaired with extreme difficulty. All vaginal tears
should be repaired immediately after labor, unless the
condition of the patient contraindicated it. They healed
rapidly and well.

Modem Obstetric Technique. — Dr. George L Brod-
HE.\D, in this paper, limited himself to a few of the more
important points in obstetric technique. Normal labor,
naturally, received first consideration, and this subject, for
convenience, he divided into three subdivisions: first, the
preparation of the patient ; second, the preparation of the
accoucheur, and, third, the preparation of the lying-in
chamber. In speaking of episeotomy. Dr. Brodhead said
that in properly selected cases, and correctly performed,
the operation deserved a distinct place in obstetric tech-
nique. Where there was need of haste, or when the head
was large and the perineum began to tear when there was
but little distention of the vulva, the operation was so
easy and the results so good that he felt it ought to be
performed more frequently. After discussing version, the
various kinds of forceps operations, and the dangers inci-

dent thereto, Dr. Brodhead said that craniotomy had been
regarded too long as a procedure so difficult and danger-
ous that it was considered only after all other measures
of extraction had failed. As a matter of fact, the opera-
tion was frequently much easier than the high forceps
operation, and, again, it was much safer for the patient
than podalic version. In any labor where the child was

'dead craniotomy was to be preferred to a difficult forceps
or breech extraction. For the induction of labor, of the
three well-known methods, the gauze tampon, the bougie,
ind the hydrostatic dilators, the speaker said his prefer-
ence was for the latter. The bags of Champeticr de Ribes,
in their present modffied form, had given so much satis-
faction that he used them almost exclusively. Under the
heading accouchement force Dr. Brodhead discussed the
various methods for the rapid dilatation of the cervix,
namely, maiuial or digital dilatation, the use of a steel
dilator sucli as the Bossi. and third, the use of rubber
dilating bags. When there was no need of great haste,
the Champeticr de Ribes bags had been very useful, but
for rapid dilatation the digital method was preferable. In
speaking of cesarean section. Dr. Brodhead said the opera-
tion had grown steadily in popularity, and the results,
for both mother and child, were sufficient to justify it.
-Symphyseotomy was now performed very seldom. Hebot-
iimy or pubiotomy had been done about 300 times since
1894, when Gigli first proposed the operation as a substi-
tute for symphyseotomy. Jewett claimed that it offered
no advantages over the latter operation, and that it was
'ipen to all the objections which obtained in the usual
median section. Personally, the speaker said, he believed
ihat the field for the operation was very small, and that
more satisfactory residts were to be obtained by the induc-
tion of premature labor; or, if the patient had gone to
full term, by the operation of cesarean section.

The Urine in Pregnancy.— Dr. Frederic E. Sondern
read a paper on this subject, in which he stated that recent
advances in the chemical investigation of urine in preg-
nancy had resulted in much of value to the obstetrician as
an aid to his work, and in the correction, or, more properly
speaking, modification of previously held views. When
dealing with laboratory aids in diagnosis or prognosis, to
prevent being misunderstood, it seemed necessary to fre-
quently repeat that they were aids only, and it was well to
add with all possible emphasis that all laboratory pro-
cedures, no matter how important, never took the place of
clinical observation. It was the clinician who was the most
acute bedside observer that received the most help from
laboratory aids, for he was generally also well informed
as to the value and significance of the changes from the
normal noted in laboratory investigations. While the
periodic examination of the urine in pregnancy, for grav-
ity, albumin, sugar, and "casts no longer met with the exact-
ing demands of present day diagnostic methods, on the
other hand no specified change from the nonnal in any
respect could be accepted as a prime indication for dras-
tic therapeutic measures or operative procedure, though it
was oftentimes a material help in concluding the existing
necessity for such. The demonstration in genera! that in-
testinal intoxication, intestinal toxemia, or faulty intestinal
inetabolism, whichever term or view one might prefer to
accept, was the cause of a distinct train of symptoms, and
often e-xplained other obscure manifestations, was now a
recognized fact. When it was recalled with what facility
disturbances of the gastrointestinal tract were occasioned
in pregnancy, and mindful of the experience that intestinal
autointoxication frequently seemed to be the forerunner of
the toxemia of pregnancy, if not more closely allied in the

etiology, the necessity for early diagnosis of this condition
was evident. The clinical manifestations which directed
attention to this intestinal autointoxication were not within
the province of this paper, but the laboratory aid in its
diagnosis was imporant, and it was the recognition of a
relative excess of ethereal sulphates in the urine. As

1 68

MEDICAL RECORD.

[Jan. 26, 1907

indoxyl sulphate and skatoxyl sulphate were the varieties
most frequently present in excess, a test for this excess
should form part of every urine examination in preg-
nancy. As in general medicine, so in obstetrics, the oc-
currence of albumin in the urine, alone or associated with
casts, was no longer the bugbear it formerly was, as we
knew that it did not necessarily indicate an inflammatory
lesion of the kidney. While the occurrence of a so-called
physiological albuminuria was open to question, on the
other hand, with comparatively slight disturbances in cir-
culation, in innervation, or in the quality of the blood
offered it for the exercise of its function, the kidney
passed smaller or larger amounts of albumin, with or with-
out casts, indicating disturbed function not necessarily due
to an inflammation of its parenchyma. It was essential to
keep these general considerations in mind when attempting
to interpret a urinary picture. The frequency with which
albumin was now found in the urine as compared with
former times was due to more diligent search, rather than
to its more common occurrence. Recent investigations
had shown that approximately 50 per cent, of pregnant
women showed albumin in the urine at some time during
pregnancy. These high figures were easily understood
wlien considering the many causes occurring in pregnancy,
such as circulatory disturbances, faulty innervation, irri-
tating excretory products, and increased functional activity,
in addition to the presence of actual renal lesions. The
numerous possible causes rendered the differential diag-
nosis by no means an easy matter, and the apparently
physiological retention of nitrogen toward the end of
pregnancy added another difficulty. Dr. Sondern said that
continued experience in the analytical work in connection
with these cases would seem to indicate that the practical
conclusions were that the routine urine examination of
pregnant women should include a search for evidences of
faulty intestinal metabolism, so that this apparently pre-,
disposing factor might have early attention. On occur-
rence of any of the clinical signs of toxemia of pregnancy,
the degree of acidosis should be determined, and should
this increase, then a repeated nitrogen partition would
lend aid in determining the point beyond which it was not
safe to allow the patient to go.

Dr. Samuel M. Brickner said he agreed essentially
with Dr. Sondern, and referred to the recent advances
that had been made in our knowledge of the urine of
pregnancy. As late as 1850, Schroeder, in referring to
this subject, simply said that most pregnant women had a
little albumin in the urine, and that the urine was apt to
be a little more watery than usual. Now, in addition to
the search for albumin and casts, it was essential to obtain
an accurate determination of the nitrogen partition, and
the actual chemical examination of the urine during preg-
nancy had become such a complex matter that it was
scarcely within the field of the general practitioner or of
the obstetrician. In connection with this subject. Dr.
Brickner said, there were two or three points that he
wished to emphasize. One was that there could be no
decided pathological change in the urine without some cor-
responding clinical manifestation. Whether the reverse
of this held true he was not prepared to say, but where
the urine showed an acidosis, or where the relation be-
tween the total amount of nitrogen output and ammonia
was at fault, we could expect to find corresponding clini-
cal manifestations. They would be revealed by close ques-
tioning, although the patient may not have complained of
them. There would perhaps be headache, mostly frontal.
nausea, or vomiting, or both: or we might find scotomata
or some abdominal pain in the epigastric or hepatic region.
These he regarded as the cardinal symptoms in cases of
this kind. Some of the most serious cases he had seen
were in elderly primiparx, and they were more apt to
be met with in women above the age of 30 or 32. The
speaker said it had occurred to him that the various types
of the so-called toxemia of pregnancy were apt to merge
into each other.

Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious diseases reported to
the Sanitary Bureau, Health Department, New York
City, for the week ending January 19, 1907 :

Tuberculosis Pulmonalis

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis
Malarial Fever

Totals

Cases

Deaths

450

181

313
186

37
6

239

9

125

—

34
68
16

13

9
9

I43I

263

Traumatic Decapsulation of the Kidney. — M.K. Helly

reports tliis case. The patient, a young man twenty-one
years old, fell from the first story of a house and was
carried to the hospital with symptoms of abundant intra-
peritoneal hemorrhage. Laparotomy revealed the exist-
ence of an extensive rupture of the liver. The patient
succumbed soon afterwards. At autopsy there was also
discovered a total decapsulation of the right kidney with-
out any other lesion of this organ. This decapsulation had
probably been produced by the strong compression made
ijy the floating ribs at the time of the fall. The kidney
had been expelled from its torn capsule as neatly as the
stone from a cherry. — La Presse Medicate.

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the Surgeon-General, Public Health and Marine-
Hospital Service, during the week ended January :8,
1907:

SMALLPOX — UNITED STATES

Arkansas, Fort Smith Dec.

Georgia, Auj:rusta Jan.

Illinois. Galesburg Jan.

Sandwich Dec.

Viola Oct.

i-Jan 8.

6-12

S-! =

20-Jan s ■

Indiana, Indianapolis Dec. 30- Jan 6.

South Bend Jan

Louisiana, New Orleans Jan

Michigan. Detroit Jan.

Missouri, St. Jo.scph Dec.

New York, New York Jan.

Wisconsin, La Crosse Jan. 5-12.

SMALLPOX — FOREIGN

Africa. Cape Town Dec. 1-8. .

Brazil, Pemambuco Nov 15-30.

Canada, Nova Scotia:

Colchester County Jan 7. . . .

Cumberland County Jan. 7....

China, Chefoo Nov. 13

CASES. DEATHS

26

Present
Present

. . I (From S.
S. Raleigh

Shanghai Nov. 24-Dec. 2 . . . i

Cuba, Habana Jan. 5 From Kronprr -

zessin Cecilia.
I Fr. S. S.
Pu'to Rico

Cuba, Habana Jan. 7

France. Paris Dec. 15-29. .

India. Bombay Dec. 11-18. .

Calcutta Dec. 1-8. . .

Madras Dec. 8-14..

Italy, General Dec. 13-20. .

Netherlands. The Rotterdam Dec. 30-Jan-

Russia, Moscow Dec. 8-15 . .

Odessa Dec. 15-29. .

St. Petersburg Dec. 1-15. .

" " Dec. 16-22..

Spain, San Feliu de Quixols Dec. 22-29 . .

Syria. Beirut Dec 15-29- •

YELLOW FEVER

Salvador. Republic Jan. 14

CHOLERA — IXSULAR

Pli:l=ppine Islands. Manila Nov. 18-24. .

P^o^-inces Nov. 18-24 . .

CHOLERA FOREIGN

India, Bombay Dec. 11-18..

Calcutta Dec. 1-8. ..

Rangoon Dec. i-S . . .

I 1 Imp' ted

7 4

S I

I
Present

Epidemic

PLAGCB

Brazil. Bahia Nov. 2s-Dec. 8... '

China. Hongkong Nov. 25-Dec i . . .

Egypt, Alexandria Dec. 22-26

Keneh Dec 22-27

Menoufith Dec. 21-27

India. General Nov 25-Dec 8. . .1604

Bombay Dec. 11-18

Calcutta Dec. i-S

Rangoon Dec. i-S

Peru, Ch'cama Valley Dec. 11 1

8

3

12090

13

19

13

Medical Record

A Weekly Jo7iriial of Medicine and Surgery

Vol. 7 J, No. 5.
Whole No. I89I.

New York, February 2, 1907.

$5.00 Per Annum.
Single Copies, lOc.

(iPrtginal Artirbs.

THE INTERLUDE OF CANCER.

Bv JOHN BEARD, D.Sc,

EDINBURGH.

In preda al duol non mi lasciar!

Intermezzo in Cavalleria Rtistica»a.—MAZzo>!i.

It is a wise child of investigation which knows its
own scientific godparents. Mine were two men of
supreme brilliance and great eminence, Johannes
Miiller and Carl Ernst von Baer. What I owe to
their examples and to their work can never be ex-
pressed adequately, and as little can it ever be esti-
mated to what extent mankind is indebted to them.
These deeds of theirs, which as I write pass through
my mind, were all determined attacks, prolonged
and well-sustained assaults upon the problems of
the nature and mode of animal development.

Neither Miiller nor Baer, it is true, laid down
any law of the life-cycle from generation to genera-
tion, because each of them in his final research
stopped just short of the point, at which the crux
of the problem would have asserted itself. Neither
investigator spared himself in the task. Indeed,
von Baer writes : "Thus, it came about in a certain
year, that I shut myself up in my shell, when the
snow still lay on the ground, and that later on,
going for the first time to a wall a few hundred
steps away, I beheld the barley in the ear and
almost ready for harvest. At this sight I threw
myself on the ground, and made myself reproaches
for my foolishness. 'The developmental laws of
Nature will be discovered,' said I to myself in Epi-
curean or Mephistophelean fashion, 'and it is a
matter of indifference whether it be by you or by
others, whether this year or some time in the
future.' "

Miiller died in 1858, before my birth, and,
although von Baer lived into the seventies, from the
time of the Konigsberg researches (1819-1834) he
never again worked seriously at the problems of
animal development. In a sense it looks like a
mere accident that the thread of research, dropped
by Carl Ernst von Baer so long ago, should have
been taken up enthusiastically, under far more
auspicious circumstances, by a young man of less
than thirty years of age in 1888, who was working
in the Anatomical Institute of the University of
Freiburg, Berlin. Prior to then he had been trained
severely by A. M. Marshall, Huxley, and Semper.
At that time, and for many years afterwards, he
little dreamt that, regarding the work from its
human aspects as opposed to the far wider, higher
scientific ones, he was really working out the prob-
lems of cancer. Indeed, without then knowing it.
these had actually been solved in researches pub-
lished by him in 1896 and 1897.*

The embryologist never tells the story of his work
in the order of his researches. He cannot, for in

*J. Beard, On Certain Problems of Vertebrate Embry-
ology (The Critical Period), and tlie Span of Gestation
and the Cause of Birth. 1896 and 1897. Jena, Gustav
Fischer.

these he pushes his way little by little, step bv step,
from the known to the unknown, and at any given
time he may be working in two directions, upwards
from the starting point of the fertilized egg, and
downwards from the finished embryo. Thus, it
happened, that what, logically regarded, should have
been the first investigation in 1888, the history of
the germ-cells, was actually the last, as it was also
the coping stone, which crowned the work, and made
it lasting.

The actual cancer-researches have been a mere
interlude in the whole — an intermezzo. "The prey
of pain let me not be!" The solution of the prob-
lems of cancer was but a corollary of what had
gone before, and it followed naturally and irresist-
ibly out of the germ-cell results, the course of the
life-cycle, and tlie conclusions as to germinal con-
tinuity and heredity. Since the embryological theo-
ries of the textbooks are, to apply the words of
Pastetu-, a mass of baseless hypotheses, it follows

Fig. I. Fi" 2-

Illustrating the Germ-cells ot Fishes and Their .Migrations into the

Embryonic Body.

Fig. I. — Primary germ-cell of a small dog-fish, Frisliurtii, mt-lano-
stomus. The cytoplasm is glassy in character, and contains a large
number of (blackened; yolk-plates. The nucleus exhibits duplication.
i.e. autonomy of paternal and maternal portions.

Fig. 2. — A similar primary germ-cell from the skate, Rajj !)i/i.s.

that the solution of the problems of cancer can be
grasped properly only by a comprehension of the
course of the cycle of life from generation to genera-
tion, as my researches of the past eighteen years
have revealed it.

The starting point of a new cycle is the fertiliza-
tion of an egg and the outline history of the cycle
is not complete until we have shown how new
eggs, new reproductive elements, arise, and until
we have reached the point at which these are ready
for fertilization, to start the cycle anew. An egg
is fertilized and development begins by its cleavage,
an ever-increasing number of cells is formed in this
way, and anon we reach a point at which the ortho-
dox embryologist says that the egg-cleavage is
finished. What has then come into being ?^ The
usual reply is "a new organism, an embryo." No
such thing! At the close of cleavage in none of
the higher animals is any trace of an embryo present.
Something is there, but not an embryo. I will ask
the reader to regard this developing egg from the
start of cleavage as a living organism, but not an
embryo.

The criterion of anything in embryology is the
fate or destination of the cells. In a worm's egg,
which has cleaved five times, giving 32 cells,_ or m
a skate's egg, which has undergone ten divisions,
resulting in 1,024 cells, there is not a single cell

I/O

MEDICAL RECORD.

[Feb. 2, 1907

present which is embryonic in destiny. Nearly all
the cells are predestined to form portions of an
asexual foundation or larva, termed by me the
"phorozoon," or bearing animal. This is a transient
organism, for as a rule its life is very brief. It has
a part to play in the cycle, and, like the Moor, when
it has done its appointed task, it can go. The re-
sults upon which, generally speaking, my conclu-
sions are founded have been obtained by what my
late friend and teacher, Professor George Bond
Howes, Huxley's assistant and successor, was wont
to term the comparative morphological (and physio-
logical) method. Under it there is but one mode
of development for all the higher animals, in es-
sentials the life-cycle is always similar, not only from
fishes to man, but from worms and even lower forms
to fishes. These "phorozoa," or asexual generations
of various marine organisms, have long been known.
Often, and until a connection therewith was estab-
lished, they received names distinct from those of
the sexual generations. Thus, the larva, "phoro-
zoon," or asexual generation of a brittle star is still
known as a Pluteus, and so on.

The late Professor N. Kleinenberg first set up
(1886) the doctrine of development by substitution
of organs. Under this every organ of the larva
(asexual generation) was ultimately replaced by a
corresponding, but differently developed, organ of
the adult form (sexual generation). For a variety
of reasons, into which space forbids entry here,
it soon became clear to the writer that Kleinen-
berg's doctrine was inadequate, and that, instead of
a substitution of organs, there was in development
in reality a substitution of organisms. The sexual
organism replaced the ase.xual one. This was seen
to be an alteration of generations, and as there was
no homology or close likeness between the ase.xual
generation or its organs and the sexual form or
its organs, it was an antithetic alternation of genera-
tions.

Now that we have the first mention of the word
"antithetic," it may be permitted in passing to point
out how Pasteur's researches started in the antithesis
of the two sorts of tartrate crystals, mine in that of
two nervous systems in the life-history of a fish.
Here we are dealing with anatomical antitheses;
later we shall come to recognize physiological an-
titheses, that of two ferments.

The tracing of the asexual generation in the
backboned animals or vertebrata, from fishes to
man, was not without its own special difficulties.
These were due rather to expecting too much, and
to failing at first to realize that the higher one as-
cended in the scale of life, the greater became the
organization of the sexual form or generation, and
the more insignificant the asexual one, until in the
highest animals, the mammals and man, the ase.xual
generation became reduced to the almost structure-
less chorion or trophoblast, as Professor A. W.
Hubrecht named it in 1889. Many people, quite
ignorant of all the embryological advances of the
past twenty years, appear to imagine that I not only
introduced the name "trophoblast," but also invented
the thing to which it is applied in embryology.
These things are not true. The name was invented
for a thing defined by Hubrecht in 1889. and the
thing itself has existed for untold millions of years !
Quite eleven years ago, in 1895, the standpoint
had been attained that in every life-cycle of a higher
animal, such as man, there were two generations,
an asexual one, the trophoblast, and a sexual one,
the metazoan individual or person. The puzzle was
not how the first of these arose, for clearly it could
be demonstrated anv dav in the week that it was

the direct product of the cleaved or segmented egg
(vide Fig. 5, phorozoon or larva). Somehow
or other there arose gradually upon it the sexual
generation, by a process of evolution or unfolding.

TABLE OF RKVISED COMPARISON OF ANIMAL AND
PLANT LIFE-CYCLES.

O

o

ANIMAL.

Zygote or fertilized
egg (2n).

Phorozoon Or tropho-
blast.

I.
Formation of primi-
tive germ - cell
(2n).
I
Formation of pri-
mary germ -cells
(2n).

"Apospory" (reduc-
tion postponed).

A primary germ-cell
(2n).
I

Origin of embryo by
unfolding of a pri-
mary germ-eel!, in-
clusion of rest in
the individual of
the sexual genera-
tion (2n).

Ripening of germ-
cells.

Reduction and sex
determination.

Sperm Egg

PLANT.

Zygote or fertilized
egg (2n).
I
Sporophyte or flower-
ing plant (2n).
I
Formation of primi-
tive spore - mother
cell (2n).
I
Formation of spore-
mother cells (2n).
(Reduction and sex
determination.)
I
Spore-formation.

A spore (in).

I
Origin of sexual gen-
eration or gameto-
phyte from one
spore (in).

Ripening of germ-
cells. Reduction pre-
viously effected.

O

Sperm

n
X

B

O

Zygote Zygote

In the above table "n" equals the reduced number
of chromosomes, and "in" signifies the emancipated
cell, "2n" the duplicated or conjugated cell, the
"conjugation" or joining together being carried out
at fertilization. The "reduction" is the undoing of
the previous duplication effected at conjugation.

How ? Something resembling the spore-mother-
cells of plants was required. That was very ap-
parent. (See the table of Revised Comparison.)
It was not until towards the close of 1900, when the
first harvest of the germ-cell-researches had been
reaped, that the problem was cleared up. The germ-
cells arose before the embryo, as products of a
single cell, the primitive germ-cell (U.K.Z. of the
diagram, Fig. 5). They came into being upon the
asexual generation or trophoblast. To contain and
to nourish these germ-cells for a brief span of time
another organism was needed, a sexual one, en-
dowed with sexual organs.

How was the se.xual organism obtained? In
embryology things do not come into e.xistence out
of nothing ! True, there are embryologists who
look upon holes or cavities as the sources of im-
portant organs, but the writer at all events is not a
■'hole-morphologist" ! The unit from which any-
thing arises is the single cell. There was only one
source from which such a sexual generation could
arise ; this was by the evolution or unfolding, the self-
sacrifice, of one germ-cell for the well-being of the
rest, and to contain them. At the epoch of the
formation of the primary germ-cells all were alike
in origin and potentialities. All were so many po-
tential individuals of the species. If two developed
independently, the result would be identical twins,
if three, triplets, and so on.

Feb.

1907]

MEDICAL RECORD.

171

'^

ji' ...

■my

9 R/ \[©l l^l

Reviewino: matters, starting with the fertilized
*igZ. this gives rise to an asexual generation, the
trophoblast, upon which there arises an "apical cell,"
the primitive germ-cell. This latter divides a certain
limited number of times, this number being a fixed
one for the species, but while it is n in the male, it
is n plus one in the female. The products are 2, 4,
8, 16, 32, 64, 128, 256, 512, etc. In the diagram it
is depicted as 12S. These 128 germ-cells are the
primary germ-cells. It is they which enter the em-
bryonic body (Fig. 4) when this arises, and it is
some of them which come to occupy all sorts of
abnormal positions. But all the line of primary
germ-cells are not destined for future generations.
Some few of them, i, 2. 4, or 8, are embryonic in
destiny. At least one of these must unfold to form
an embryo. If an\- of the others do so, the result
is idc-iitical twins, triplets, etc. If any of these "em-
bryonic" germ-
cells lie dor-
m a n t within
the developed
en'.bryo, they
m a y become
the seed of fu
t u r e tumors,
as will appear
later on. The
line of heredi-
ty so far re-
vealed leads
from fertilized
egg to the pri-
m a r y germ-
cells. and
thence through
all the history
of the germ-
cells within
the "reproduc-
tive glands'" to
new eggs and
sperms. That
is, all things
considered, the
cycle is one of
unicellular or-
ganisms, the
germ-cells, in
the history of
which the sex-
ual generation
of individual is
but an inci-
dent.

.'\nother im-
portant ques-
tion to be solved more than ten years ago was
the how and the wdien of the suppression of the
asexual generation. This latter, whether repre-
sented by the transient nervous apparatus and other
structures of a fish, or by the trophoblast of a
mammal, went on flourishing for a certain, not
very long, space of time, and then, quite sud-
denly, all growth was stopped, and its degenera-
tion was initiated. In years long gone by how
often have I not watched these asexual struc-
tures under the microscope, seen them flourish
and blossom, and then — siibito. as the Italians say —
begin to fade away, as though blighted ! The cor-
relation of phenomena is often of the greatest im-
portance to the embryologist in his work, and when
this sudden fading away was first established, it was
also noted that the commencing formation of the
posterior fissure of the spinal cord was a con-

"^

Fig. 3. — The conditions seen in two transverse
sections of a 4* mm. embryo of Pristiurus. The
lettering is as follows: ^y?. c., spinal cord; h., noto-
choid: my-, myotome; g. «., germinal nidus; tne.,
mesoblast; ep.. epiblast; hy.. hypoblast; y. s.,
yolk-sac; g. c, germ-cell.

-^'

£■''

conntant phenomenon. This led to one of the many
little research excursions I have made right up the
backboned series to the mammals, and to the study
of human embryos themselves. A whole array of
interesting and connected events was soon un-
earthed, and the putting together of these .cul-
minated in the discovery of the critical period — one
of the most momentous finds ever made !

"There is a period in the development of every
vertebrate embryo, during which, and only then, it
resembles the embryo of any other vertebrate in a
corresponding phase in certain general features.
Hut, while it thus agrees exactly with any other
embryo of this period in characters, which are com-
mon to all vertebrate animals, it differs from the
embryo of any other class in certain special class
features, and also from any other embryo of the
same class, but of a different order in other and
ordinal characters. Immediately before this period
is reached it begins
to put on generic
and specific char-
acters, and thus it .^^r.
then begins to dif-
fer from all other i/'
embryos in these." wy-
In otiier words, the ^.
embryo then first
asserts its pres-
ence, annoimces its
own individuality.
It is then first pres-
ent as a complete
thing. It then first
begin."; to use its
own digestive ap-
paratus, especially
its pancreas gland,
and in a higher
mammal to feed it-
self by means of
the allantoic pla-
centa. This critical
period is common
to all backboned
animals in their de-
velopment. At this
period the average
marsupial is born
into the world, and
then it first begins
its long mammary
luttrition. In so great a hurry is it to get into
the world that it forms its anus in the act of being
born. The human embryo does the same at the
like period, in the seventh week of gestation, as
though it were a marsupial, although it has no
use for this aperture for many months to come.
Then the allantoic placenta, an organ of the embryo
or sexual generation, like the pancreas-gland, first
begins to function, and then normally the tropho-
blast begins to fade, to be suppressed, and to de-
generate.

Though ferments first made their appearance in
my published writings in 1892, for I pride mvself
on having been one of the very few pupils the
late Professor C. F. W. Kruken'berg ever had, it
was not until 1904 that their all-important bear-
ings upon the critical period were evident. In
human gestation, if at the critical period the em-
bryo he wanting or very abnormal (a very ab-
normal human embryo can only persist as one of
identical twins), the phenomena of the critical period
are lacking, and the normal trophoblast, which
alwa\'s begins its life by eroding the uterine epithe-

■/'-

r -<^'

Fig. 4. — A di.n'.ramDHitic section of an
early skate-embryo. To illustrate the
migrations of the germ-cells along the
germinal path, ^' p., and showing germ-
cells m various abnonnal position situa-
tions. The lettering as in Pig. 3, except-
ing so. m.. somastic mesoblast ; sp. m.,
sj.ilanchnic mesoblast: ao., aorta.

172

MEDICAL RECORD.

[Feb. 2, 1907

Hum and wall, may go on with this process, exhibit
indefinite powers of sfrowth, and cat its way through
uterus and other organs, finally blocking the lungs
and brain of the mother. This is chorioepithelioma,
recognized to be a form of cancer by Professor
F. ilarchand, in 1895. This is without doubt the
most deadly form of cancer. Flere the sexual gen-
eration being unable to suppress the asexual one or
trophoblast, the latter exhibits the characteristics
of asexual generations, the powers of indefinite
growth and increase. Pathologists at present dis-
tinguish wrongly between two forms of chorio-
epithelioma, a malignant one and a benign one.
The latter has no real existence, for in it the tropho-
blast cells are all dead and undergoing the charac-
teristic degeneration due to the action of pancreatic
ferments. A "benign" chorioepithelioma, as Pro-
fessor Schmorl found, may happen in any gestation,
for the trophoblast cells of the precritical periods,
wliich have invaded the maternal organs, even the
lungs, are normally also brought to commencing
degeneration at the critical period.

In 1902 the conclusion was reached that cancer
was an irresponsible trophoblast, and in these words
for the first time in human history the nature of
cancer was laid bare.

Its origin was not at first so clear, but by the
year 1904 it was recognized that the problems of
like or identical twins, upon which the writer was
then and since engaged, threw light upon its origin.
Owing to their extraembryonic origin aberrant
germ-cells are quite common, and they may be met
with anywhere in the embryonic body. The ordi-
nary aberrant germ-cells, which usually degenerate.
were much too abundant a source to furnish the
origin of a cancer. Entia non sunt multiplicanda.
The etiology of double monsters and of malignant
tumors was traceable to the phenomena of like
twins. The facts concerning these, as well as those
relating to Hermann von Jhering's finds in the
armadillo, Praopus hybrid us, which my work has
fullv confirmed, furnished the key. This arma-
dillo, the "tatu," produces all its young in one
chorion or trophoblast, and therefore they are all
identical, of the like sex, and all products of one
egg. The whole doctrine of the tumors, benign and
malignant, centers in the phenomena of like twins,
that is, in a former multiplicity of embryos, all
products of one egg. To-day the "tatu," Praopus
hybridus, produces 7 to 12 such, all derived from
a single egg, all of the like sex, and some of them
more or less rudimentary !

These latter tell a very significant story* to the

*Because hypothetical, the following may find a place as
a foot-note : From the con,sideration comparatively of a
variety of embryological phenomena, well known to the
investigator, it is obvious that the procedure where only a
single embryo is going to arise from one of the primary
germ-cells will not be quite the same when two or more
embryos are destined to unfold. The setting apart of one
cell will be preceded by one or two divisions, giving one
functional cell and possibly three abortive ones. But if
the development shall result in, say, triplets, there will be
not merely two divisions, but at least three, if not four.
Of the products, which are all primary gcrni-cells, three
will unfold as embryos, three may be abortive or rudi-
mentary, and. if there are eight all told, two will remain
as "embryonic cells,'" which later on in some or other of
the individuals arising may become the seed of tumors,
benign or malignant. But these cell divisions have a curi-
ous tendency to be in twos or pairs, or even in threes, so
that in the' formation of triplets, instead of eight cells,
there may be sixteen concerned. How many of these w'ill
be abortive, and how many "embryonic" in potentialities,
it is at present impossible to say. The armadillo, Praopus
hyhridns. with its seven to twelve young in one chorion or
trophoblast, aflords an instance where at least sixteen cells
must originally in every case have arisen at the line of
primarv germ-cells and in addition to those cells destined

embryologist. They recall to him other similar
phenomena in embryology. Reductions in numbers
of units (cells), formerly of importance, but which
now persist, not because they are really required,
but because their existence and persistence are parts
of an old scheme of the cycle of animal life.

The writer has had abundant opportunities of
noting the liability of identical twins to cancer, but
to state the matter in this way is misleading. Those
individuals who develop malignant growths are as
liable to such as are identical twins, and for the same
reasons. Without doubt cancer is hereditary. This
is abundantly borne out by clinical histories in my
possession. There are records, where both parents
died of it, where even one or other grandparent
developed cancer, and it is only too commonly told
the writer that in some particular case the father

Fig. 5. — Diagrar- 'i'eK^ycle of a backboned animal, such as

a fish or a mamr. -i^ the i:nion of egg and sperm, E. and

S.. to form the z> .- origin of the phorozccn or asexual

generation (trophoi ia?:). the germinal track from Z. to U.K.Z., -the
latter being the primitive gei-m-cell. The divisions of the latter are
carried to seven mitoses or cell-di\^sions. as in some male dog-fish,
(in a potential female embryo there would be an additional division,
gi\*ing 256 primary germ-cells). Diagrammatically, the unfolding of
one primary germ-cell, the fi'th. ;s depicted as forming an embryo or
sexual generation. To c: " track of heredity from generation

to generation through t: ^xal continuity of the germ-cells

a diagram of oogenesis ■. ation has been appended to the

Q6th germ-cell, and one o: 5: t niiatogenesis or sperm-formation to
the 32d. In the loimer the formation of a male-egg and of a female-
egg is shown, in the latter the two forms of sperms (as in the fresh-water
snail. Paludina, after the statements of F. MevesJ i.e. the hairltke
or fimctional. and the wormlike or functionless sperm. The additional
division in the formation of functional male eggs should be noted.
It accords with the additional division to form primary germ-cells in
the de\^lopment of a female.

or the mother was a victim of cancer. The most
remarkalile example known to me at present is in
the family of a master-carpenter in Edinburgh. His
mother died of uterine cancer, and he has lost all
his brothers and sisters, seven in number, by some
form or other of malignant disease. Embryologi-
cally regarded, persons suffer from cancer because
they are at the basis members of a group of identical
twins or triplets. It is, therefore, not from any
and every aberrant germ-cell that a cancer takes its

to become the sexual products. Of these si.xteen cells,
seven normally give rise to fully developed embryos, five
to more or less rudimentary ones, and there still remain
four, which, as cancer is not known here, may be abortive.
But !i ' ;'!er of young here arising at every gesta-

tion V reduced, while all the preliminaries were

retainei... ,-, .i.ii a rich harvest of tumors might be the
result ! In a case of identical triplets, cited by Prof. H. H.
Wilder, at least two of the sisters died of cancer.

Feb.

1907 J

MEDICAL RECORD.

173

start, but from one ur other of some few i^erni-
cells, embryonic in destiny, cells which should have
given rise to twins, triplets, etc., identical with the
embryo, which arose in any particular g^estation.

The line of primary o-erm-cells of the diagram
(Fig. 5) is not made up of one only, destined to
form an embryo, and of n minus one, destined foi'
a future generation, but it is composed of a limited
number, 2 or 4 or 8 — often not so many — embry-
onic in destiny, of which, as a rule, one onlv becomes
a normal embryo, and n minus 2, or n minus 4, etc.,
are set apart to provide for the cycle of unicellular
organisms or germ-cells. Such a persistent em-
bryonic germ-cell, encapsulated within the indi-
vidual, may at any time, by illness, injury, irritation,
or other cause, such as declining years, weakening
the system, be awakened into activity. The "age-
incidence" of cancer is scientific nonsense, for it is
only relative. Whenever this happens, the time is
long past when it should have unfolded as an em-
bryo, it attempts to resume the cycle, and its "un-
conscious memories" onl)' enable it to try to repeat
the asexual portion of the cycle. Such an encap-
sulated germ-cell can only do one or other of two
things in the end, and live. It may develop, and
it only does this congenitally with the developing
individual, or it may attempt to go on with the life-
cycle. Skipping the formation of conjugating cells
or gametes, it is brought to the next portion of the
life-cycle, trophoblast. In this way it becomes an
irresponsible trophoblast, and it may imitate or
mimic anything in its environment. Whatever it
mimic, something existent or non-existent, it is al-
ways an "imitation tissue,'' and behind the domino
or mask an irresponsible trophoblast.

In nearly all the foregoing morphological aspects
have been under consideration. It now behoves us
to take account of the physiological and functional
ones. The critical period in a fish or mammal or
man is that at wdiich the embryonic organs as a
whole first begin to function. The fish begins to
feed itself, digesting the yolk by intestinal diges-
tion. The mammal or human embryo begins to do
the like (in the absence of food-yolk) by means of
the commencing functional activities of the allantoic
placenta. At this epoch in the fisJi the pancreas-
gland manifests its activities by the presence of
abundant zymogen granules in the cytoplasm of its
cells. That these result in the secretion of pan-
creatic ferments is shown by the digestion of yolk
within the gut. Owing to this digestion the fish,
like the mammal, gets ever bigger and bigger.
None of the yolk enters its stomach, for this has
then as little functional activity as the stomach of
a mammal has during fetal life. An internal yolk-
sac is formed for the reception of the volk from
the external one, and the yolk duct opens into the
duodenum. This fact alone indicates to the cm-
bryologist that the pancreas gland is functioning.
In an average marsupial at the critical period this
gland certainly begins its functional activities, for
the animal is then born, begins its mammary nutri-
tion, and digests the milk. If a certain thing hap-
pen at the critical period of a fish, or a marsupial,
I know from experience that something correspond-
ing to it will take place at the like period in a higher
mammal or a man. A fish forms its anus at this
period, so does a marsupial, while in the act of
being born, and so does a man. although he does
not need it for some seven months more. As- the
pancreas gland begins its functions in a fish or an
average marsupial, so it must do in the develop-
ment of a man. Otherwise there would be no t*s-
sential unity in the mode of the development. Un-

doubtedly, under the action of the pancreatic fer-
ments, the asexual structures of a fish development
begin to degenerate,, and, as represented by the
trophoblast, they do the like in a mammal or a man.

This leads to an inquiry as to modes of nutrition,
regarding wdiich the reatler may find much interest-
ing information in \'"erworn's "General Physiol-
ogy," and still more in Otto von Fiirth's "Vergleich-
ende chcmischc Physiologic der hiederen Tiere,
Jena, IQ03. The unicellular organisms or protozoa,
all asexual generations of animals, such as inverte-
brate larvs, fish blastoderm, and mammalian tropho-
blast. not forgetting cancer cells, nourish themselves
intracellularly and by means of a ferment acting in
slightly acid medium. On the other hand, an extra-
cellular digestion, bv means of ferments, pancreatic
enzymes, acting in slightly acid, neutral, or alkaline
n;cdia, is restricted to the sexual generations or in-
dividuals of the higher animals (Metazoa) and
man. In the former the ferment is possibly always
the like one, and it would possibly be, to my mind.
identical with the cancer-ferment, discovered by
Eugen Petry in 1899, and which I have named
"malignin." The ferments of the sexual genera-
tions being much more powerful than the intra-
tellular one found in the forms referred to above,
being, indeed, the most jiowerful things in the whole
range of organic nature, it would follow that just
as these higher ferments destroy in life the living
cells of malignant tumors, pulling down their al-
bumin, so also Ihey must destroy the organisms,
usually asexual generations, of tuberculosis, sleep-
ing-sickness, malaria, yellow fever, etc., when in-
jected into the blood by means of hypodermal
medication. Regarded from the strictly scientific
standpoint of the embryologist, who is "not even a
medical man," the tubercle bacillus, like the trypano-
some, or the organism of yellow fever, or that of
malaria, etc., can no more live in the presence of
these higher ferments than the cancer cell can. This
has apparently been shown, in one case at least, clini-
cally and pathologically for the tubercle bacillus by
my friend. Dr. Margaret A. Cleaves of New York
City. The first case of cancer which it fell to her able
brain and skilled hands to treat by means of injec-
tions of ijancreatic ferments, was also complicated by
tuberculosis of the bowel. When, in August, 1906, the
first communications passed between us, I informed
Dr. Cleaves that, in my scientific opinion, whatever
happened to the large masses of rectal cancer
present, which appeared too great to leave room
for hope of their entire removal, the tubercle bacilli
would be bound to go. They disappeared, and after
amylopsin had been injected for some little time
the |.)athologists failed to find a single tubercle ba-
cillus in the discharge, where previously they had
lieen abundant. In our joint opinion the result
was due rather to amylopsin than to trypsin, for
the former is the medium of all others, in which
the leucocytes can act. As in the treatment of
cancer, the injection used against any of the above
human inflictions should be an extract, freshly
prepared from the pancreas-gland direct, and con-
taining all the ferments especially the one in the
presence of which the leucocytes act, amylopsin.

Of the ferments of the sexual generations by far
the most important is that first discovered by the
Court physician. Baron Corvisart, and to which
afterwards Prof. W. Kiihne gave the name of
"trypsin." It is this enormously powerful ferment,
trypsin, upon which Nature relies for the suppres-
sion of trophoblast in normal mammalian gestation.
Lower down in the scale than the mammals she
associates with it its complement, amylopsin. Fetal

174

MEDICAL RECORD.

[Feb. 2, 1907

ulood of a maniinal does not contain this latter, and
the fetal pancreas-gland does not produce it. In
the human pancreas-gland amylopsin is not formed
until some few months after birth. The reason of
this is not far to seek. When in the ancestral mam-
mals uterine development was initiated, along with it
and following its close there was evolved the mam-
mary nutrition. In this amylopsin is not needed,
and its production by the pancreas-gland was post-
poned until the milk-nutrition was done with. The
mammary nutrition is (on the testimony of more
than one embryologist, thus on that of my friend,
J. P. Hill, as well as on my own) older in time
than the allantoic placenta. The latter was intro-
duced to defer the birth period, and by prolonging
the gestation, as detailed in my "Span of Gesta-
tion," to bring the young into the world in a more
perfect state. In prolonging the gestation, the
mammary nutrition was postponed, and in this way
the appearance of amylopsin u])on the scene put
oif to an even later period. This has led to grave
difficulties and dangers in human gestation, for
there is no such thing in nature as a ferment possess-
ing both proteolytic and amyolytic powers.

The proper scientific treatment of cancer is the
enzyme or pancreatic one. If trypsin alone be used,
bad symptoms very soon arise, all of which recall
the vomiting of pregnancy and eclampsia. Trypsin
alone is a very deadly remedy for cancer! The
reason being that in killing the cancer albumin this
enzyme does not split it up to harmless simple
products. What the products of the action of
trypsin alone are it is impossible to say, for they
may quite conceivably vary with the amount of
the injection and with its strength. Anyway, some
of them are rank poisons to the organism, and
they lead to nausea, vomiting, pain in the back,
drowsiness, high arterial tension, albuminuria,
edema, etc., and even to convulsions lasting several
hours. The cause of such symptoms and of the
eclampsia of pregnancy did not long puzzle the
embryologist, who perceived that it was the absence
of the complementary ferment, amylopsin, which
induced them. Nature had committed a grave error
in omitting amylopsin from fetal blood, and in rely-
ing solely on trypsin. In normal gestation if any-
thing went wrong with the maternal pancreas-
gland, and if the maternal supply of amylopsin be-
came diminished or ceased, then serious symptoms
were bound to follow. To my knowledge at the
moment of writing injections of amylopsin have
not yet been given in any case of eclampsia, but
they have, whenever used in cases of cancer, re-
moved all the bad symptoms named.

The preparations employed in the enzyme treat-
ment of cancer should be like the sole ones in use
in America, the Fairchild preparations. That is
to say, they must be potent extracts, scientifically
prepared from the fresh gland direct. The trypsin
injections must contain all the enzymes and be
especially rich in trypsin and amylopsin. The in-
jection of amylopsin is to be used at all times to
meet and remove all bad symptoms, and in the later
periods of treatment, when all the cancer albumin
has been destroyed, and it must be an extract of the
pancreas gland free from trypsin.

This treatment is not intended for use against
benign tumors, which are composed of real or
somatic tissues and which are not killed or broken
up by trypsin. Owing to this the injections furnish
a chemical test of the true nature of a tumor,
whether it be benign or malignant. Thus, some
pathologists look upon adenomata as benign, or
at all events as only potentially malignant. To my

mind they are "imitation tissues," and I should
anticipate that any and every adenoma would yield
to the chemical test.

Owing to the circumstance that the cycle of life
is really a continuous procession and succession of
unicellular organisms, germ-cells, from which there
arise asexual generation or trophoblast, and embryo
or sexual generation, the tumors can be classified
into three groups, as follows :

( 1 ) Embryoiiiata. Benign neoplasms. Patho-
logical manifestations of some greater or less por-
tion of the sexual generation, "the embryo." They
are composed of real tissues, that is, normal or
somatic ("embryonic"), cells or tissues. At its
basis each is a greater or less portion of a twin,
triplet, etc., identical with the individual containing
it. They are now endowed with indefinite powers
of growth, and they nourish themselves like other
normal tissues.

(2) Ampliimixomata. Malignant neoplasms.
Combinations of embryomata and trophoblastomata.
Pathological manifestations or attempts to repro-
duce the whole life cycle, including trophoblast and
embrj'o. They are transitional forms. (The mixed
tumors of Wilms are not all malignant, some being
merely embryomata.)

(3) Trophoblastomata (cancer and sarcoma).
Malignant neoplasms. Pathological manifestations
of the asexual portion (trophoblast) of the life
cycle. They are not known to differentiate func-
tional gametes, eggs, or sperms. They never in-
clude or repeat any part of an embryo. They are
never composed of somatic ("embryonic") cells,
though they may mimic such or even resemble no
other cells in the body. As Fleischmann, Paget,
and Bland Sutton pointed out, they are "imitation
tissues." They exhibit powers of unlimited growth
and increase, and they nourish themselves by erod-
ing and destroying normal cells and tissues in a
manner exactly like that of the trophoblast of
normal gestation, and by means of a ferment acting
intracellularly, viz., malignin.

As the two latter divisions are made up of malig-
nant tumors, it is for them, and not for the members
of the first group, that the enzyme treatment is
intended.

In the foregoing simple story I have endeavored
to the best of my ability to give in outline some
idea of the course and nature of my scientific work
and conclusions since the days of May-June, 1888,
when I worked on the shores of Black Lake, New
York. Much has happened since then, not only in
my own little field of work, but outside of it. It
is since that time, that is, in 1889, that Hubrecht
set up the name "trophoblast" to replace with a
different significance the older term "chorion."
Long after then came the period of my germ-cell
researches, not yet completed. These have, how-
ever, extended so far that they are revolutionizing
embryology. In the light they throw on phenomena,
the old Wolffian idea of epigenesis, and the allied
Cohnheim hypothesis of embryonic "rests" as the
sources of tumors, along with man}' other things,
become memories of the past in science. The night
is far spent ; a new sun is arising. Epigenesis,
somatic origin of germ-cells, and recapitulation in
development are fading away into thin air before
the mighty powers of Evolution with predestina-
tion, an actual tangible continuitv of germ-cells
from generation to generation, and an antithetic
alternation of generations as the mode, the only
possible one, of animal development.

This present writing is not the record of my
scientific work. It is b"t a brief sketch of some of

Feb. 2, 1907]

MEDICAL RECORD.

'/3

the things my "brigades" and "divisions" have done
or can do. He who would venture to attack them
may be invited to turn his attentions to the original
memoirs, representing the military "brigades" and
"divisions," for these are in the field and ready to
meet all comers.

Let not the reader imagine that my main scientific
work has been the elucidation of the problems of
cancer. Xot at all ! This portion of the work was
a mere side-issue — an interlude. One. undoubtedly,
of overwhelmingly momentous import for human
interests, but one, regarded in the cold, clear light
of science, which had to the investigator as such,
and not as a fellow-creature, merely the import of
furnishing a confirmation of the truth and validity
of his conclusions in other and more fundamental
directions. When I think of this there passes
through my mind the picture of Carl Ernst von
Baer, groping year in, year out, always groping to
discover the laws of animal development. What
was denied him has in the fullness of time been
vouchsafed to one who, in admiration of his genius,
followed humbly in his footsteps.

THE THEORY OF THE TOXIC ORIGIN OF
PERNICIOUS ANEMIA.

Bv .\USTI\ W. MOLLIS, M.D .

XEW YORK.

ATTENDING PHYSICIAN TO ST. l.UKE'S HOSPITAI :

AND

NORM.-W E. DITMAN. A.M.. M.U..

NEW YORK.

ASSISTANT ATTENDING PHYSICIAN TO ST. LUKe'S HOSPITAL, INSTRUCTOR IN

PATHOLOGY. COLLEGE OF PHYSICIANS AND SURGEONS. PATHOLOGIST

TO SLOaNE maternity HOSPITAL, CLINICAL PATHOLOGIST

TO ROOSEVELT HOSPITAL.

Pernicious anemia is defined by Sidney Coupland'
as "a variety of primary anemia which arises insid-
iously, and is characterized by progressive diminu-
tion in the number, and changes in the form, of the
red corpuscles of the blood, together with similar
but generally less marked diminution in the amount
of hemoglobin ; which changes apparently depend
upon undue hemolysis combined with inadequate
compensatory hemogenesis — a condition which, in
the majority of cases, passes more or less rapidly
to a fatal termination, the progress being, in some
cases, interrupted by periods of improvement, fol-
lowed by relapse, but rarely resulting in permanent
restoration to health, whatever the method of treat-
ment." This definition, while verj' satisfactory in
many ways, is not as concise and complete as that
of Ewing-, who calls attention to the changes in
the bone marrow which have come to be considered
characteristic of this condition.

To make complete the definition of that form of
pernicious anemia which it has frequently been the
custom to describe as "primary," "idiopathic,"
"crj'ptogenetic," or "essential," attention might well
be called to evidence of a to.xic element entering as
a cause into the symptom complex.

Most authorities now exclude from the type of
disease known as pernicious anemia those forms
of anemia the causes of which have been well estab-
lished, and reserve the term pernicious anemia, or,
more frequently, primary progressive pernicious
anemia, for that type long known as idiopathic or
cryptogenetic. StriimpelP is among the most promi-
nent of those who hold this view. On this basis
would be excluded the grave anemias due to anky-
lostoma and bothriocephalus latus, repeated hemor-
rhages, and pregnancy. Wood* classifies these under
the head of secondary anemias of the pernicious

type, and considers them as more aggravated forms
of the anemias to which group belong those due
to chronic hemorrhage, tumors, lead poisoning,
syphilis, malaria, typhoid fever, and chronic atrophy
of the stomach. All of these ditl'er in some way
symptomatically from primary pernicious anemia.

That repeated hemorrhage is a cause of pernicious
anemia was claimed by Habershon", Quincke",
Schepelern', Finney*, Greenhow", Stockman'", and
is still affirmed by some ; but since the morpho-
logical changes in the blood and bone marrow have
been required to establish completely the character
of these anemias as pernicious very few have been
seen. Ewing- states tiiat he has never seen a case
oi pernicious anemia directly referable to hemor-
rhage.

Pregnancy as a cause of jiernicious anemia is also
fast becoming less important. Eichhorst" claimed
that 35 per cent, of the cases published by him
were caused by pregnancy. The genuineness of
some of these cases may now be doubted ; and at any
rate the patients suffered from a variety of severe
svmptoms not at present regarded as belonging to
the disease, so that Lazarus'- classes many of them
as examples of secondary anemia and exhaustion.
Cases of progressive anemia accompanying preg-
nancy have gradually disappeared from recent lit-
erature, Ehrlich being able to find only one case of
this description (Laache, Case 9)''. At the Sloane
Maternity Hospital, from 1892 to 1899, Ewing saw
no cases of anemia of the progressive pernicious
type, and from 1902 to the present time none has
been seen by the iircscnt pathologist of that insti-
tution.

That ankylostoma and bothriocephalus latus may
of themselves give rise to a progressive pernicious
anemia is possible ; but the fact that the latter exists
frequently in the intestinal canal without producing
this result would imply a variation in virulence of
the ]jarasite, an increased susceptibility of the host,
or a coexistence or symbiosis with some other organ-
ism in the intestinal tract. There remains then a
group which to the present time has still been desig-
nated idiopathic or primary progressive pernicious
anemia.

Addison'* classed as idiopathic those cases where
there had been no previous loss of blood, no exhaust-
ing diarrhea, no chlorosis, no purpura, and no renal,
splenic, marantic, glandular, strumous, or malignant
disease. Musser'^ cites as other occasional preexist-
ing causes, great physical overexertion, exposure,
great shock or fright. Stockman'" suggests that
repeated small capillary hemorrhages — chiefly inter-
nal— play an im])ortant role in the causation of idio-
pathic pernicious anemia, and also claims that as a
result of anemia, fatty degeneration of the walls of
the small blood-vessels occurs, .giving rise to greater
hemorrhage, which by increasing the anemia com-
pletes a vicious circle, terminating ultimately in the
pernicious grade of anemia and death. Stockman's
views, however, have never been widely accepted.

The infectious origin of pernicious anemia has
been advanced by Klebs'", who claimed to have
found an organism — Ccrcoiiwnas globulus — in the
blood ; by Frankenhauser'^ who found an organism
which he identified as Cercomonas navicula, and by
Petrone", who reported the isolation of leptothrix in
several cases. The fact that pernicious anemia is
more frequent in some countries than in others
StriimpelP considered to be one argument for as-
suming that the disease is an infectious one.

It has been maintained that unfavorable hygienic
surroundings and insufficient nourishment promote
the development of the disease. In this connection

176

MEDICAL RECORD.

[Feb. 2, 1907

it is well to consider that when an individual obtains
insufficient nourishment that nourishment is also
liable to be poor in quality, thereby creating greater
opportunity for the introduction into the intestinal
canal by tiiis means of deleterious bacterial and
chemical agencies.

F. P. Henry'", Stephen Mackenzie'-", and Rind-
fleisch-' are advocates of the view that the essence
of the disease is in defective hemogenesis, in conse-
quence of which the red blood corpuscles are abnor-
mally vulnerable. Such a case was cited by P.
Grawitz"- of general sarcomatosis of the bone mar-
row accompanied by typical changes in the blood.
Litten-^ and Waldstein-* presented two cases which
were obscure and of doubtful diagnosis.

The hemogenetic theory of the origin of tlie dis-
ease, as suggested by the remarkable reversion of the
bone marrow to its fetal condition, first observed
by Pepper-^ and Cohnheim-'^, is one which has been
advocated by some with considerable vigor. The
significance of these bone marrow changes has been
materially affected by the recognition of the part
played by hemolysis in the disease as well as by the
fact that they are not invariably met with, nor differ
in kind, if they do in degree, from the changes in
the marrow which occur in anemia e.xperimentally
produced by bleeding. Whenever these marrow
changes are met with side by side with the character-
istic liemolytic features of pernicious anemia they
are more likely to be of a secondary nature, indi-
cating an effort on the part of the hemogenetic
organs to repair the waste that is in progress else-
where.

Osier'-'' believes that to explain the hemolysis,
attention must be called to the condition of faulty
gastrointestinal digestion which is so commonly as-
sociated with these cases, and that poisonous materi-
als are developed which, when absorbed, cause
destruction of the cor])uscles. In Coupland's' opinion
also the hemolytic doctrine assumes the operation
of a specific toxic agency ; and it is interesting to
note that those who have studied the degenerative
changes in the spinal cord, which are apparently
more common in pernicious anemia than might be
supposed from the clinical phenomena, believe also
that these changes are best ex])lained by a toxic
influence.

Schuman-" advocates the theory of the toxic origin
of pernicious anemia, but believes with Immer-
mann-", Quincke-''". Lichtheim^S and Fr. Miiller-'-
that it is not an etiological entity, but only a symp-
tom complex which is brought about b_\- various
causes.

To suggest further the toxic nature of the disease
it is only necessary to consider briefly some of
the more marked and constant symptoms. And
here it may be cautioned that toxic symptoms are
not necessarilv the result of the activity of organisms
within the blood stream or tissue spaces alone, but
may result from absorption of the products of bac-
teria which are on the surface of the body or in
the aliment,ir\- canal — the most familiar type of
surface absorption occurring, of course, in the in-
fection by the diphtheria bacillus.

A peculiarity of the disease is the occurrence of
fever of an irregular type which, though not con-
stant, .sometimes rises to 102° or 103° in the even-
ings, and is followed by a morning remission. A
characteristic is its intermittence with fluctuations
under slight influences. .Another condition which
occurs with even greater regularity is the digestive
disturbance, which of all factors appears to point
most closely to the toxic and gastrointestinal side
of the etiology. Not only are the earliest symptoms
connected with the digestive tract in a considerable

proportion of the cases, such as vomiting, diarrhea,
or irregularities of digestion, and loathing of food,
but many cases exhibit also definite changes in the
gastric or intestinal mucosa.

The reports of Sandoz^^ were apparently the first
to strengthen the impression that some of the most
typical cases of pernicious anemia are of intestinal
autotoxic origin, this observer finding that appa-
rently genuine cases were sometimes cured by vigor-
ous gastric lavage, enteroclysis, and the administra-
tion of intestinal antiseptics and laxatives. This
observation has since been verified and the opinion
has steadily grown that the most frequent, if not
the essential, cause of progressive pernicious anemia
is found in a peculiar toxemia of intestinal origin,
with or without organic lesions of the mucosa. The
evidence supporting this opinion has accumulated
from many sides. The results of intestinal anti-
septic treatment have steadily pointed in this direc-
tion. -Signs of increased intestinal putrefaction have
been noted in the excessive indicanuria of the dis-
ease, and in the presence of cadaverin and putrescin
in the urine of certain cases (Hunter'"*).

Hunter's studies (1901) in this field were un-
doubtedly the most important experimental contri-
bution to the etiology of the disease made up to
that time. His conclusions were, briefly, that per-
nicious anemia was a specific clinical condition re-
sulting from excessive hemolysis, occurring chiefly
in the portal system and brought about by intestinal
intoxication in which the products of growth of
specific bacteria are probably concerned.

Along this line Herter, in a lecture before the
Harvey Society, entitled "The Common Piacterial
Infection of the Digestive Tract and the Intoxica-
tions Arising from Them." has recently demonstrated
the more or less constant presence of certain forms
of anaerobic bacteria in the contents of the large in-
testine. These bacteria are Gram positive in their
staining capacity and are represented most fre-
quently by the Bacillus a'crogenes capsidatus. These
bacteria are able to break down proteids into a
form suitable for the use of other putrefactive bac-
teria, among w hich are the indol-forming organisms,
indol being a substance which, as stated before,
occurs quite uniformly in e.xcess in pernicious ane-
mia. The significance of the presence of this excess
of indol was shown by Dr. Herter by the production
of toxic symptoms in aninials whose oxidizing ca-
pacity had been reduced by small injections of po-
tassium cyanide, causing a condition of diminished
oxidation which it is more than likely occurs in
conditions of blood poverty.

These anaerobic organisms produce substances
which are strongly hemolytic, so that it only has to
be assumed that these substances pass through the
intestinal wall more or less intact to have access
with destructive effect to the blood of the portal
system — where Hunter has found the greater part
of the hemolysis to occur. But the observation of
greatest practical value which Herter has made in
this connection w^as obtained by the demonstration
of the action of methylene blue, which changes to
a colorless leucobase upon reduction. By this
means he foinid that oxygen occurred in the intes-
tinal canal as far dow'n as the ileocecal valve, but
no further. .\s these anaerobic bacteria are confined
for their place of residence to regions free from
oxygen, they must be limited to the large intestine
where they are within reach of therapeutic measures
directed from the lower end of the gastrointestinal
canal : hence, the possibility which he affirmed of
removing them by irrigation of or local applications
in the colon.

l^pon his suggestion two cases of undoubted per-

Feb.

1907 J

MEDICAL RECORD.

177

nicious anemia were treated in this way in the wards
of St. Luke's Hospital in New York, and the results
obtained in these cases by means of colon irrigation
were sufficiently noteworthy to merit permanent
record.

The first case occurred during- the medical services
of Drs. Hollis, Norrie, and Janeway, and the late
Drs. Davis and Spalding. The second case occurred
during the fall service of Dr. Austin W. Hollis.

The first case was that of a man twenty-nine years
of age, a laborer, born in Ireland. \\"hen he first
came under observation. December 25, 1902, he
gave a history of having had for three years short-
ness of breath, swelling of the feet and about the
eyes. He complained of headaches and dizziness in
the morning, numbness of the legs, constipation,
and progressive weakness. Soreness and pain in the
abdomen had caused him considerable discomfort.

admission, and these were kept up coniiiuiously with
lavage, and after February 2 atOxyl was given hypo-
dcrmatically in doses of 25 minims.

The following table shows the course of the blood
changes :

pir cein. Red Blood CelU. , 928,000

1.612,000
1.310,000
" 1,776,000

828,000
1,080,000
1 .292,000
1,696,000

There was moderate impr(_ivcmcnt at the time he
left the hospital, but during each succeeding summer
he was compelled to return for treatment, complain-
ing of dvspnea, palpitation, dizziness, headache, and
weakness. Each time his blood condition had dete-
riorated since the preceding stay in the hospital,

Dec.

2y.

Hniglb. 25

Jan.

3-

27

Jan.

10.

?■?

Jan.

18

Feb.

2.

20

Feb.

17-

26

Mar.

II.

30

Apr.

3-

30

>-ov.

I>r^ceirilTi.T

.Jan viiiry

Febrtiur:\-

M.ir.U

Hemo-
globin

Red B;.;od
Cs 'i

•^n so

n 0 1.- "23

2 10 IS SG

1 7- 1:! SI

1 r i:!

Indican
Very Strong

Strong

Modei.Jte

i

100°<

5,000,000
4,500.000
4,000.000
3,50.1,000
3.000,000
2.500.000
2.000.000
1.500.000
1,000,000

500.000
0

90%'

/

/\

80"o'

1

1

/i

TO'^

i

/ f

60"u

1
I

1 /

! /

C 1 /

:> /

r
/
/

50",.

\

1 / /

/ i

/ 1 1 ■

40 "0

A

\

\
\ \

c
0

/

1

/
/

30"o

\

\
\

\

4/

20%

/

/

V

\
\
\

--,/

10%

1

\

\

0 ".,

Momr,n-lohm R.-rl Rioorl Ti^lk

Indi

=

Chart i.

His skin was pale, yellowish in color, and his tongue
was slightly coated. His lungs were normal. A
hemic murmur was heard over the heart. His feet
and legs were edematous : knee jerks were not ob-
tained. His physical examination otherwise showed
nothing abnormal. The urine was normal.

At the time he was placed under observation his
hemoglobin was 25 per cent. ; red blood cells, 928,-
000. The differential leucocyte count showed 59
per cent, of polynuclears, 38 per cent, of lympho-
cytes, 2 per cent, of eosinophiles, and i per cent, of
mast cells. Morphologically his blood was typical
of pernicious anemia. A test meal showed an ab-
sence of free hydrochloric acid in the stomach.
During the early part of his stay in the hospital his
temperature occasionally rose as high as 101.6°. He
was given arsenious acid and Blaud's laminoids upon

although at one time his hemoglobin rose to 50 per
cent, and the red blood ceils to 2,372,000.

The gastrointestinal symptoms became more
marked and during the year previous to the last
term of treatment he suffered especially from con-
stant morning vomiting, dizziness, headache, fever,
weakness, and pain in the legs. A strong indican
reaction was found in the urine. His medication
had included from time to time Fowler's solution,
iron, nux vomica, sodium cacodylate, and dilute
hydrochloric acid.

The above symptoms were present on his admis-
sion to the hospital on November 23, 1905, and were
accompanied by a hemoglobin percentage of 45, and
900,000 retl blood cells. His condition was unim-
proved by the administration of arsenic and strych-
nine up to January 8, igo6. Irrigation of the colon

178

MEDICAL RECORD.

[Felj. 2, iyo7

was then commenced, using once a day a double
current of warm saline solution until the return flow
was clear. Reference to the accompanying chart
will show the almost immediate response to this
measure with an ultimate rise in hemoglobin to 85
per cent, and in red blood cells to 3,400,000.

Since leaving the hospital this man has had daily
colon irrigations, and eight months after his dis-
charge from the hospital his hemoglobin was still
85 per cent, and the red blood cells 3,800,000. His
health remained perfect.

Another case of a similar nature was that of a man
aged fifty-three, a publi.sher by occupation, who,
with the exception of habitual shortness of breath
which prevented his taking any active exercise, had
nothing in his previous historv which could have
any bearing on the disease. For a year previous

but the edge of the spleen — soft and thin — was just
palpable below the free border of the ribs. Knee
jerks were not obtained. Shortly after admission
he suffered from pain in the legs, which was of about
two weeks' duration.

On admission to the hospital his hemoglobin was
28 per cent., red blood cells 1,320,000, leucocytes
5.200. The differential leucocyte count showed 36
per cent, polynuclears, 64 per cent. lymphoc>'tes.
The red blood cells stained deeply, the central de-
jiression being very slight. Normoblasts and mega-
loblasts were present ; poikilocytosis and polychro-
matophilia were marked. Indican was present in a
trace in the urine and albumin was present to the
extent of 10 per cent, by bulk.

His medication at first consisted of nux vomica
and Fowler's solution, and dilute hydrochloric acid.

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to a(lmi.--sion to the hospital he had been gradually
losing energy and strength. This had been accom-
l)anied by a loss of twenty-five pounds in weight.
The .«kin had become much pigmented. His appe-
tite constantly decreased, and there was a good deal
of distress after eating, with eructations of gas and
frequent vomiting. Shortness of breath and head-
ache became continuously more troublesome. .\
few days before admission weakness caused him to
discontinue work and finally became so marked that
walking was impossible. There had been slight
fever f 101°). His bowels were regular.

On admission his physical examination showed
pallor and yellow tinge of skin ; nutrition fair ;
tongue coated ; pupils, pulse, lungs, liver, and abdo-
men normal. A hemic murmur was heard at the
apex of the heart. The kidneys were not palpable.

y )n September 8, after slight diminution in the
hemoglobin and red blood cells, colon irrigations
were commenced. The trace of indican disappeared.
The albumin was diminished to a faint trace in four
days and disappeared in a week. Reference to the
.iccompanying chart will show clearly the marked
iinprovement in this man's blood condition.

On the 5th of November he left the hospital feel-
ing perfectly well. One month later he had gained
ten pounds in weight and his blood condition con-
tinued to improve as shown by the chart.

That these cases have been permently cured it is
impossible at this time to say. It is evident, how-
ever, that since the introdviction of the treatment
hv colon irrigation in these cases more marked im-
provement was obtained than by any other method
employed. It is also evident that the fact that two

Feb. 2, 1907]

MEDICAL RECORD.

'79

very severe cases of anemia of the pernicious type
have been restored to perfect health and a normal
blood condition by high colon irrigations, would
seem to imply, for these cases at least, the absorp-
tion of some toxic substance from the bowel as a
causative agent.

The practical difference between the old and more
recent results is no more striking, however, than
that between some of the older and newer theoretical
conceptions upon which the therapy is based. This
is very well illustrated by the fact that while in
former times it was taught by some of the most
prominent men of the time that the more food the
patient could take the better, in the view of modern
developments as emphasized by Herter, smaller
amounts are better, especially of proteid food. For
any excess of proteid food reaching the part of the
intestinal canal occupied by the proteid splitting-
anaerobic bacteria of the lower bowel, simply fur-
nishes material for subsequent decomposition into
toxic and hemolytic substances as the result of bac-
terial activity.

The great value in the discovery that such a con-
dition as pernicious anemia can be so benefited by
removing intestinal bacterial matter lies in the fact
that it emphasizes the possibility of attacking other
obscure diseases on the same ground. The agency
of bacteria in disease seems to be well appreciated
when they occur in contact with the surface of the
body, in the oral or genitourinary or respiratory
cavities. Even the deleterious effect of the absorp-
tion of the products of the activity of nonpathogenic
or saprophytic bacteria is appreciated when occur-
ring within the uterus, to produce a sapremia. Yet
few seem to appreciate what a great amount of ab-
sorption must occur where the area of absori)tion
is as great as that of the intestinal mucosa, or what
a diversity of chemical products, many the result
of bacterial activity, present themselves for absorg ■
lion. It is, however, of extreme importance to rec-
ognize this diversity of chemical products, many of
which in conditions of health may not be toxic, but
under conditions of slight impairment of the detoxi-
cating or oxidizing action of the liver or intestinal
mucosa, or when acting through long periods of
time may be responsible for many of our unsolved
symptom complexes of disease.

We take pleasure in expressing to Drs. A. D.
Mittendorf, L. Hutton, and W. W. Herrick of the
medical staff of St. Luke's Hospital, to Drs. F. Gi-
rard, C. Vail, and C. E. Lieb of the pathological
staff of St. Luke's Hospital, and to the staff of Dr.
Herter's laboratory, our appreciation of the assist-
ance which thev have rendered. To Drs. V. H.
Norrie, T. C. Janeway, and the late Drs. G. A.
Spalding and A. A. Davis we are indebted for the
use of notes on the first case.

REFERENCES.

1. Coupland : Allbutt's System of Medicine.

2. Ewing: Clinical Pnthology of the Blood, 2ri Ed., 1903.

3. Striimpell : Text Book of Medicine.

4. Wood: Chemical and Microscopical Diagnosis, 1905.

5. Habershon ; Medical Times and Gazette. 1S76.

6. Qnincke : Volkman's Vortragc. 1876, No. 100, p. 22.

7. Schepelern : Schmidt's Jalirbiichcr. Bd. clx.xxvi, 1880,
p, 22.

8. Finney: British Medical Journal. 1880, vol. i, p. -13.
g, Greenhow : Ibid., 1871, vol, ii, p, 613.

10, Stockman: Ibid.. 1895, vol. i, p. 965,

11, Eichhorst : Die progressive perniciose .\namie, 1878,

12, Lazarus : Die An.-emie, 1900.

13, Laache : Die Anptmie, 1883.

14, Addison: Constitutional and Local Effects of Dis-
ease of the Suprarenal Glands. London, 1855.

15, Musser : Medical Diagnosis,

16, Klebs : XI Congres fur innere Medizin. 1892.

17, Frankenhauser : Centralblatt fiir die niedisinischc
WisscnschaftcH, 1883,

18. Petrone : Lo Sperimentale, 1884, T, liii,

19, F, P. Henry : American Journal of the Medical
Sciences, 1S86, vol, xci, p, 498.

20, Mackenzie: Lancet, 1878, vol, ii, p, 834,

21, Rindfleisch: Virchow's Archiv, Bd, cxxi,

22, P, Grawitz: Virchow's Archiv, Bd, Ix.xvi, p, 353.

23, Litten : Berliner klinischc IVochenschrift, 1877, p,

-57-

24. Waldstein : Virchow's Archiv, Bd, xci,

25. Pepper: American Journal of the Medical Sciences,
vol. Ixx, 1875.

26. Cohnheim : Virchow's Archiv, Bd. Ixviii.

27. Osier: Practice of Medicine.

28. Schauman : Die perniciose Aniimie im Lichte der
modernen Gifthvpothcse. Sammlung klinische Vortrage,
1900. N. F. No.' 287, Innere Med., No. 84, P- 231,

29. Immermann : Progressive perniciose Anamie, Hand,
d. spec Path, u, Ther,, von Ziemssen, Bd, xiii, Leipzig,

1875-

30, Quincke : Weitere Bcobachtungen uber perniciose
\namie, Deutsche Archiv fiir klinische Medizin, Bd. xx,

1877-

^i. Lichtheim: Zur Kenntnis der perniciose Anamie.
Vi Cong, f, inn, Med., 1887,

32, Fr, Miiller: Zur Aetiologie der perniciose .\nijmie,
Charite-Annalen, Bd, xiv, 1889.

33, Sandoz: Correspondenz-KUiit fiir sclnceizer Aerzte,

1887,

34, Senator u, Muller : Virchow's Archiv, Bd, cxxxi,

Snppl.

35, Brieger: Ueber Ptomaine. Berlin, 1885,

36, Hennige: Cited by v, Noorden, Path. d. Stoff-
wcchsels, p, 347- , „ , , , ,

37, Schauman: Zur Kenntnis der Bothnocephalus

.\namie, 1894,

38, Hunter : Pernicious Anemia.

THE ELECTRIC PSYCHOMETER.

By FREDERICK PETERSON, M.D,.

NEW YORK.

CIINICAL PROFESSOR OF PSYCHIATRY IN COLUMBIA UNIVERSITY; CON-
SULTING ALIENIST TO BELLEVUE HOSPtTAL,Sj

Ix Pfliiger's Archi'c' fiir Physiologie, 1890, Prof. J.
Tarchanoff published a paper on "Galvanic phenom-
ena in the human skin in connection with irritation
iif the sensory organs, and in various forms of
psvchic activity." Like many discoveries of great
importance, his remarkable work lay buried for
vears. Only lately has the full import of his ex-
jieriments begun to be realized. They deserve a '
recapitulation here. The apparatus used was the
minor galvanometer of Aleissner and Meyerstein.
The deviations of the mirror were noted by means
of a telescope upon a .scale three meters distant from
the galvanometer. The scale was divided on each
side'of the zero point into 50 cm., and these again
into millimeters. The galvanometer was so sensi-
tive that the nerve-stream of a frog's sciatic nerve
sufficed to deviate the mirror to such extent that
all the divisions -on the scale vanished from the
visual field. Tubular unpolarizable electrodes of
clav were brought into contact with the skin by
means of hygroscopic cotton pads 10 to 15 cm.
long, saturated with saline solution. The electrodes
were applied at different times to various parts of
the body, such as the hands and fingers, feet and
toes, face, nose, ears, and back. The results ob-
tained were as follows :

Light tickling of the face, ears, or soles of the
feet \vith a camel's hair brush or a feather pro-
duced, after a latent period of one to three seconds,
a deviation of the galvanometer to the extent of the
whole 50 cm. of tiie scale. The same results were
obtained by irritating the skin with a faradic brush,
h\ applying hot and cold water, and by pricking with
a' needle. "The other senses— hearing, smell, taste,
and sight — responded in the same way on the

i8o

MEDICAL RECORD.

[Feb. 2, 1507

galvanometer scale when similarlj- irritated. The
experimenter thus discovered that the irritations
themselves were not necessar}-, but that their pres-
entation to the imagination also sufficed to induce
the same deviations of the mirror of the galvano-
meter. Furthermore, he found that the recollection
of some fear, fright, or joy, in general any kind
of strong emotion, produced the same result. The
next ])oint of interest brought out by TarchanofT
was that ordinary abstract mental exercise, such
as multiplication, had no effect upon the galvano-
meter, unless accompanied by exertion. He also
found that the emotion of expectation or anticipa-
tion deflected the galvanometer. Tarchanoff ex-
plained the phenomenon observed as due to a sec-
reton,- galvanic stream connected with the sweat-
glands. He was probably unaware himself of the
extraordinary value of his brieflv described ])iece of
work.

1 li.'- report remained unnoticed for seven years,
until Sticker ( Wicrncr kliniscbe Rundschau, 1897,
Nos. 30-31) again brought the subject into medical
literatiu-e, if not to the attention of medical men.
He repeated the experiments of Tarchanoff, and
came to the conclusion that the capillary system of
blood-vessels was a factor in the perturbations of
the galvanic current, by changing the conditions of
resistance. He opposed Tarchanoff's idea of a
centripetal excitation of a secretory stream, be-
cause he found that the same deviations in current
were to be obser-\-ed when the electrodes were ap-
plied to anesthetic and analgesic areas (functional
or organic).

Five years more passed before this interesting
topic again appeared in literature. Sommer of
Giessen {Beitrlige ziir psychiatrischen Klinik, 1902,
p. 157) made experiments in the same direction,
but seems to have failed altogether to grasp the
really important feature of the situation, losing him-
self in details of a physical character. .At the same
time he arrived at the erroneous conclusion that,
except for a reaction on tickling, no psychic influ-
ence on the current was to be established with
certainty. He observed fluctuations which he as-
cribed to changes in contact between skin and
electrodes, and to changes in resistance of the skin.
Any apparent psychic influences he thought due to
involuntar}- muscular contractions inducing in-
creased pressure on the electrodes. He therefore
missed the one essential point.

About two years ago E. K. Muller, an electrical
engineer at Zurich, read a paper before the Swiss
Society of Natural Sciences. Medical Section
(1904), on "The Influence of Psychic and Physio-
logical Phenomena Upon the Electrical Conductivity
of the Human Body." Happening to make certain
experiments upon himself in relation to the resist-
ance of the human body in the alternating magnetic
field, he rediscovered the extraordinary variability
of the mirror-galvanometer under psychic or nerv-
ous conditions, as established by TarchanoiT four-
teen years before. Mr. Miiller then induced Dr. p.
Veraguth, a neurologist of Zurich, to experiment
on the same lines. Veraguth gave the name "gal-
vanic jisvchophysical reflex" to the phenomenon, and
he published the results of his researches in the
Archives de Psychologic (Geneva), in August.
1906. Veraguth employed the Deprez-d' Arson va!
mirror galvanometer, nickel-plated brass cylinders
for electrodes, a feeble current, a horizontal glass
scale on which a light reflected from the mirror
registered its movements, and an apparatus for
photographic registration of the curve. \'eraguth
corrchorated the findinc;< i-t Tarchanoff. One or

two of his experiments are especially striking. If
the individual under observation is read to, devia-
lion is noted when passages of particular interest
are reached, that is, when accompanied by any emo-
tional tone. Or, if a series of unselected words is
lironounced, a test suggested to him by Jung of
Zurich, the words associated with an emotional
complex produce an effect upon the galvanometer,
whereas others without emotional tone have no ef-
fect. Veraguth concludes from his studies that
only such irritations as are connected with suf-
ficiently intense and actual emotional tone produce
a galvanometric deflection. He states in his report
above mentioned that he is not yet in a position to
explain tiie phenomenon, but if it is to be explained
by simple change in resistance, then it presents
manifold contradictions to our present conceptions
of the resistance of the human body. He felt it not
to be due to changes in the quantity of blood in the
hands of the individual experimented upon, for the
phenomenon occurs whether the hands be emptied
of blood by an Esmarch bandage, or overfilled with
blood by artificial venous stasis. Veraguth excludes
the participation of perspiration in the effects, for
the results he found to be similar after drying the
hands with formalin.

In the Psychiatric Clinic at Zurich, under the
direction of Prof. Bleuler, Dr. Jung has of late
been studying the relation of the galvanometric
deviations to psychic processes, and in conjunction
with Dr. Jung, Dr. L. Binswanger has been ex-
perimenting upon the physical and physiological
problems connected therewith. In a forthcoming
number of The Journal of Abnormal Psychology
of Boston, Dr. Jung has an article upon association
experiments in which he employed the galvano-
meter, and the apparatus and curves obtained are
therein illustrated. Dr. Binswanger's paper is not
yet published. Both of these gentlemen placed at
my disposition all of their own work and con-
clusions, as well as the apparatus of the laboratory,
and Dr. Jung and myself have gone over together
many experiments with the instrument in normal
individuals and in cases of dementia praecox, while
I have reported with both of them some of the
physical and physiological experiments. Dr. Jung
and I are now using the galvanometer in these
cases, together with Morey's pneumograph and re-
action time apparatus for kymographic curves with
various irritations, both sensory (pricking, noises,
and the like) and psychic (series of words and
questions which are either indifferent or calculated
to induce emotions or arouse emotional reflexes).
This work involves so much study and detail that
it will be some time before it is published.

As far as the physical side of these galvanic re-
actions is concerned, the problem cannot be said
to be solved, but Drs. Jung and Binswanger have
certainly excluded some of the alleged causes, viz.,
muscular contractions and variations in blood sup-
ply, and their conclusion so far is that the cause is
probably a variation in resistance, depending upon
changes in the amount of secretion in the sweat-
glands. Thev consider that the formalin experi-
ments are not sufficiently certain to exclude the
perspiration theory.

The apparatus we are using is a Deprez-d'.\r-
sonval mirror galvanometer ; and a horizontal glass
scale (made in Zurich) placed about one meter
from the galvanometer (divided into centimeters
and millimeters), to which a lamp is attached. The
light shines upon the mirror, and is reflected back
upon the scale, on which the ray of light travels to
:md fro like a magic finger, marking the fluctua-

Feb. 2, 1907]

MEDICAL RECORD.

181

tions in the or^niiisni of the individual experimented
upon. We usually put the galvanometer into cir-
cuit with one or two Buiisen cells and a rheostat to
reduce the current if necessary, the patient's hands
making contact upon copper plates on clasping nick-
el-plated brass electrodes. Sometimes no cells at
all are used, but the patient places one hand upon
a zinc plate and the other upon a carbon plate,
these plates with the warm, moist hand sufificing to
produce a current. But like results may be ob-
tained simiily with monopolizable electrodes as es-
tablished by Tarchanoft and corroborated by Jung
and Binswanger (with another species of galvano-
meter). By an ingenious mechanism devised by Dr.
Jung, the movements of the finger of light upon the
scale may be registered in curves on the drum of the
kymograph. The manner of contact with the body
makes no particular difference in the phenomena ;
whether in the manner just described, or by water
electrodes, or whether by thimbles placed upon the
fingers and connected with the theophores.

Now, I am .going farther than my conservative
Swiss friends, in proposing the name "electric
psychometer" for this apparatus, but it is a name
that I feel sure, from my own observations, is war-
ranted, and that it is a remarkable adjunct to work
in normal and morbid psychology is not only already
assured, but will ere long be firmly established.
One is, in fact, overwhelmed with astonishment at
its manifestations, as this ray of light glides to and
fro in response to the emotional changes going on
within an organism.

There are minor oscillations, which practice and
observation exclude, due to the usual familiar fac-
tors which modify resistance, such as hot and cold,
and dry and moist skin, varying surface of con-
tact, and varying pressiu-e, but these are, as stated,
minor movements, and do not interfere, when under-
stood, with the extraordinary deflections in con-
nection with the emotions. These emotions must be
actual and real. The emotion of expectant atten-
tion or anticipation (as in the threat of a needle-
prick or apprehension of a noise') has a voluntary
influence on the psychometer. There is usually a
latent period of one or two seconds before the devia-
tion begins, after the irritation has occurred, but
the latent period is reduced by the intensity of the
emotion aroused.

It is almost like sorcery to oliserve the behavior
of the instnmient with a series of words, some pur-
posely chosen to be emotionally indifferent and
others to strike some emotional complex deep in
the soul of the individual experimented upon. The
patient is required to respond to any word uttered
with the first word that comes into his conscious-
ness. Indifferent words produce no effect upon the
finger of li.ght in the psychometer, but words asso-
ciated with an emotional complex send the light
along the scale for a distance of one centimeter up
to six or eight or more, in proportion to the in-
tensity and actuality of the emotion aroused.

Using these series of words is like fishing. Each
word is bait on a hook throwm into the sea of the
unconscious, and the species of fish that likes the
bait is immediately cau.ght and brought to the sur-
face. This method of study of associations in the
mind of man, so effectually' carried out by Jung be-
fore the discoverv of this new instrument of pre-
cision, is now doubly efficient in that the emotional
value of each word may now be seen and accurately
recorded.

I have not observed anything thus far in my
Stiidienreise that has interested me quite so much,
and I felt that I shonjit at once place the matter

before my colleagues as a new field for their re-
search, a new avenue by which to aj^proach the
secrets of the nervous system.

A FEW REMARKS ON MEDICAL EXPERT
TESTIMONY.*

Bv GEORGE FRANKLIN SHIELS, M.D.. C.iM.. F.R.C.S.E.. L.R.C.P..

ETC..
NEW YORK.

PROii.\KLV there is no subject in the medical curric-
ulum which is so much neglected as medical juris-
prudence, and no branch of it so little considered as
that which deals with medical evidence. As a result
the graduate begins practice with practically no
knowledge in this direction, and, if he be lucky, may
go through life without being placed in a position
to regret his lack of learning ; on the other hand, he
may at any moment be called into court as an expert
witness, and in the hands of a clever lawyer may
be made the object of ridicule. Remembering this,
it would seem that an occasional paper on some
branch of the subject is not amiss, and so I shall ask
you to bear with me while, out of the many, I try
to point out a few of what seem to me important
phases of the question. This I will do under the
following headings :

(A) Compensation of the medical expert.

(B) Points referring to the attitude and rights
of the doctor while on the witness stand.

(C) Especial points in trials involving the ques-
tion of insanity.

(D) The value of medical expert testimony as
now introduced.

Before going further it will be necessary to make
clear the difference between a witness, as to fact,
and an expert witness, since the laws which govern
these classes are widely different.

A witness as to the fact is one who sees, hears, or
knows either actual facts connected with the case at
issue, or facts from which legal inferences applica-
ble to the case may be drawn. This witness,
whether ignorant or learned, poor or rich, young
or old, must give evidence when called upon, and
should he refuse to answer questions which the court
rules proper to be answered, he is liable to be pun-
ished for contem.pt of court.

An expert witness is one who, through especial
study or experience, is particularly instructed in
some art or trade, and may give his opinions on
questions of science or skill relating to such art or
trade.

Now, since everv business or employment which
has a particular class devoted to its pursuit is an
art or trade in the legal sense, it can be readily
understood that a medical man, when called upon
to give his opinion evidence connected with his pro-
fession, is an expert witness.

(A) Compensation of tJie Medical Expert. — In
civil actions the question of compensation rarely
arises since the attorneys usually call tipon the wit-
ness and make a definite business arrangement with
him regarding his fee. In criminal procedures com-
pensation is a common cause of misunderstanding
and trouble, and in such cases I strongly advise
medical men to demand their fee before .going on
the witness stand and giving their opinion evidence.
In spite of the fact that the common law has estab-
lished the understanding that the professional
opinion of a physician is to be regarded in the light
of property, and that the scientific or expert wit-
ness must be paid just as the merchant is paid for

*Read at a meetins of the Bridgeport, Conn., Medical
.'\ssociation, December. IQ06.

1 82

MEDICAL RECORD.

[Feb. 2. 1907

his wares or the farmer for his crops, still in many
States he is offered the common witness fee, and is
told he must be satisfied with that or nothing.
Where the doctor has contested the matter it has
been found that the court opinions for and against
extra compensation are about equally balanced, and
that should he claim an exception exists exempting
him from the general rule which requires all wit-
nesses, on the payment of the fee allowed by statute,
lo testify as to matters within their knowledge, then
the burden is on him to establish the exception.

Another and interesting phase of the subject of
compensation, and one which often comes up, is as
follows : A doctor sees, for instance, an assault in
which a man's leg is broken, and is subpiinaed to
give evidence as to what he saw. During his exam-
ination the attorney directs his questions to obtain
opinion evidence concerning the natures, causes, and
effects of fractures. In this case there is no ques-
tion as to the witness having to testify as to what
he saw, but he can and should positively refuse to
give his opinions relative to fractures unless he
receives especial compensation as an expert witness.
This holds equally good in civil actions, such as
street car accidents, etc.

(B) Points Referring to the Attitude and Rights
of the Doctor zvhile on the Witness Stand. — While
we know that there are many phvsicians and sur-
geons who, through association wath railroads, mills,
accident insurance companies, etc., are cool and self-
possessed while on the witness stand, still the aver-
age practitioner looks on such an experience with a
certain feeling of dread ; hence I feel that I may
draw attention to a few points which may be of use
in this regard.

(i) Let the witness at all times remember that
he is, by virtue of his diploma, an e.xpert opinion
witness, that he is in court to express his own opin-
ions irrespective of any author or authority to the
contrary.

The tendency on the part of attorneys is to borrow^
or buy numerous supposedly authoritative works,
and to study them diligently over night. They
come into court full of wdiat they conceive to be
medical knowledge, but, as a rule, knowing less than
before they burned the midnight oil in cramming up
for the trial. Knowing this, a doctor need not fear
their attacks, and by maintaining a cool and quiet
demeanor he will in the large majority of cases
come out right in the end.

(2) Let him always keep in mind that he has an
inalienable right to explain any answer he may give,
even though it be simply "yes" or "no." By keep-
ing this in mind he will often be able to set at
naught the efforts of an attorney to make him stul-
tify himself.

(3) Let him at all times be ready to frankly
acknowledge ignorance should he be ignorant on
any point. Anything like evasion will at once be
noticed by the attorney, who w'ill do his best to
show ignorance, and will enlarge on it to the dis-
comfiture of the witness. This he will do, even
though the subject of the question be trivial, irrele-
vant, and immaterial since his object is to belittle
the doctor in the minds of the jury, and thus lessen
the value of his other testimony.

(4) Let him always, when asked, freely acknow-l-
edge that he is paid for his services. It is an axio-
matic fact that the laborer is worthy of his hire, and.
though the lawyer always tries to show that by
being paid a witness is biased, still a frank state-
ment that one is paid for his time and skill will
never weaken a man's status before any court.

(7) He should avoid as far as possible the use of

technical terms, and, if it is necessary to use them,
explain their meaning in plain English.

(9) Let the witness always remember that should-
he feel that an attorney has gone too far, and has
become insulting, he may turn to the judge ami
request his protection against such insult. In the
experience of the writer this has never failed to
have an immediate effect.

(10) Let the witness go on the stand with the
absolute promise to himself that he will not lose his
temper, for the lawyer takes great delight in trying
it sorely.

(11) Let him never permit himself to becocme so
iMascd that he will allow himself to avoid an honest
answer to any question, even though the question
is asked by the attorney on the opposite side, and
may seem to be against the best interests of his
own side.

(12) On answering the usual hypothetical ques-
tion asked by the law'vers, let him thoroughly under-
stand it, and, should it be needful, let him explain
his answer .should he think that such answer places
biim in a false light before the court.

(13) Xo medical man should ever allow himself
to be drawn into a trial where he is in doubt as to
the real merit of the case from a medical or sur-
gical point of view.

(C) Especial Points in Cases Involving the
Question of Insanity. — My remarks under this head-
ing are directed to the question of the criminal re-
sponsibility of the insane. It would take volumes
to go into the discussion of the subject of insanity
in all its medicolegal aspects.

In trials where the question of soundness of mind
is the issue a complicated condition of affairs gen-
erallv results, and, while the jurors are the final
judges, the phvsician is alwavs called to aid them
bv the e.xpression of his opinion, and by giving them
the benefit of his experience and study. The reason
for these complications is not far to seek since the
view point of law and medicine is entirely different.

No well-balanced medical man would attempt to
unqualifiedly define insanity. The very definition
that it is a disease of the mind naturally leads to
the question, "\\'hat is the mind?" And even such
an authority as Herbert Spencer frankly states that
lie does not know. In order to be able to definitely
Slate the nature of insanitv. it would be first neces-
sary to define the meaning of the word sane. This
is practically impossible, since it is a conventional
and approximate term applied by use and custom to
a class of individuals who think and act in a certain
way regarding themselves, and toward society at
large. While a distinct departure from this stand-
ard would easily be established as insane, who would
venture to draw a distinct line between sanity and
eccentricitv. or betw'een eccentricity and insanity?
We all can say "this is day," or "this is night." Who
can say "here day ends." "iiere night begins." There
is the twilight, which is iieither day nor night, but
in part both, and which cannot be described or de-
fined. Oftentimes so it is with the change from
sanity to insanity. Gentlemen in our profession,
there is no such thing as an absolute definition of
insanity. Each case must be taken and studied as a
separate entitv. and frequently the most careful
study leaves the physician in doubt.

On the other hand, it would seem necessary to
I'lave a legal definition of insanity, since the insane
cannot be held responsible for their acts, and since
insanity is very frequentiv used as a plea in the
defense of prisoners who have committed criminal
acts.

Out of the multitudinous eft'orts to reach a satis-

Feb. 2. 1907]

MEDICAL RECORD.

183

factory understanding, there has been evolved the
following postulates : ( i ) A sane individual can
distinguish between "right" and "wrong" in the
concrete case; (2) he is possessed of will power ade-
quate to control his impulses, and to control them
in the light of that knowledge of right and wrong.
The law presumes a man to be sane according to
this standard.

From these postulates the law has constructed a
definition of insanit)-, which holds good in most of
our States, and which is as follows: ".A. man or
woman is insane who does not know the difference
between right and wrong in regard to any specific
particular act, and who further does not know the
consequences of committing such act." The
question must be relative to the particular
act done, and the accused's knowledge of
the situation in which he did it. Did he know it was
wrong at that moment ? Was he impressed with the
consciousness of guilt and the fear of punishment?
If he did not he is insane according to the law.

It is easy to see from what I have said that no
physician could possibly agree with this legal defini-
tion of insanity and that were it applied to a large
proportion of the inmates of our State asylums,
they must be held to be sane. For instance, witness
the insane patient who knows that it is wrong,
and against the laws of the institution, to smoke in
the wards, who knows that he will be punislied if
he does it, and who still, with great cunning and
forethought, plans his smoking to escape detection
by the officials of the hospital.

In closing this portion of niy paper, I wish em-
phatically to advise the medical witness to refuse at
all times even to attempt to give a general definition
of insanity.

As to the legal definition, it is purely a matter of
personal opinion whether he approves or disapproves
of it. No matter what the doctor may think to the
contrary, the legal definition stands as the law. and
is not question for argument. The jury will decide
whether the case at issue fits it.

{D) The Value of Medical Expert Testbiioiiy as
Nozv Introduced. — Expert testimony is no more con-
clusive to the jury than the testimony of witnesses
as to fact, and no matter how learnedly a doctor
may descant upon a technical point, the jury has a
perfect right to accept or reject any or all of the
evidence given by such opinion witnesses. How-
ever, judges will as a rule instruct juries that expert
evidence, if from a high source, and if delivered
without bias and with proper caution, must be given
great weight. For my own part, I beg to say tliat
medical expert testimony as now introduced can, in
the large majority of cases, be of little value, anil
for these reasons : There are few men who, when
employed in the interest of an individual or a cor-
poration, can resist the tendency toward bias, and I
have actuallv seen cases where such witnesses have
sworn to opinions to which in their calmer moments,
when free from bias, they could not have given tlieir
support, .\gain, it is almost laughable to hear the
flat contradictions which occur where medical ex-
perts are put on the stand by contesting parties. <'.nd-
it must lead the intelligent mind to formulate a very
poor opinion of our profession. Certainly were T on
a jury which had to consider such evidence, I should
give it little or no weight. Further, since to be a
doctor is a sufficient ground to establish a man as
a medical expert witness, one can easily see how a
graduate of a two-year irregular college, with a glib
tongue and a positive and convincing manner, can.
by contradicting it, cause a jurv to practically throw
out the opinion evidence of a weightv authoritv who

is not blessed with the ability to express himself
with force and clearness.

But, gentlemen, expert medical evidence could be
made of the greatest value in forwarding justice
were it properly introduced. JMay I suggest two
perfectly feasible plans : ( i ) Let the attorneys of
each side select two experts, and let the four thus
chosen agree on a fifth. These five men could, after
careful deliberation, bring in a full and useful report
on any technical ]joints placed before them. Or (2)
leave the matter entirely in the hands of the court,
who could call one or a dozen medical men to eluci-
date, with absolute freedom from bias, any technical
points which might arise in a trial. I incline
strongly to favor the court having the control, since
it would entirely do away with the possibility of par-
tisanship, provided always that the court is what it
should be — learned, dignified, and absolutely im-
personal. Under this rule the verv best men in
the ranks of the medical profession would always
be ready and glad to give their services, instead of
shunning the courts on account of the false position
in which they are so frequently placed by the war-
ring attorneys.

Lawyers may urge that mv plan places too much
power in the hands of the judge. I do not think so.
The more responsibility and power vested in the
judicial office the more readily will the man sink
his own personalitv and rise to a full appreciation
of the grave, dignified, honorable nature of the posi-
tion which the people have called upon him to
occupy, and the confidence placed in him will be a
sacred and inviolable trust which nothing could
cause him for a moment to forget.

VARICOSE VEINS OF THE LOWER EX-
TREMITIES AND THEIR TRE.\TMENT.*

Bv P. T. Q-CONNOR, .M.D.,

WATERBURY. CONN",

L\ order to discuss intelligently the surgical treat-
ment of varicose veins of the lower extremities, we
must admit that all treatment, in order to rise above
the plane of mere empiricism, must rest upon a
threefold conception: (t) of the etiology of the
disease, (2) of the pathology of the disease, and,
finally, (3) of its natural tendency, or a foreknowl-
edge by which a cure may be accomplished. These
principles will apply with special pertinency to the
treatment of varices, and before we can expect to
treat the disease rationally we must first know its
cause and then its inevitable course.

Without going into unnecessary detail, it will
suffice to know that the causes of varicose veins
may be divided into predisposing and exciting. The
valves of the veins play an important part in the
etiology of varix, and in this relation their great
variability in number, position, and develoimient is
to be noted. In the internal saphenous vein, the
valves vary in number from seven to twenty. One
of these valves is situated just at the termination of
the vein and another at the outer side of the cribri-
form fascia, but both of these valves are sometimes
imperfect or absent. The valves of the external
saphenous vein vary in number from nine to thir-
teen. In relation to the liackwarij pressure in the
saphenous vein, it is to be noted that the femoral
vein, above the entrance of the saphenous, and the
external iliac vein are frequenth'. and the superior
vena cava constantly, devoid of valves. Soborofif
has demonstratetl that the veins wiry in thickness

*Read before the Xcw Haven Comity Medical .\ssocia-
tion. October 25. 1906.

i84

MEDICAL RECORD.

[Feb. 2, 1907

and strength in different individuals from birth.
When a vein with weak walls has few valves, the
tendency to varix is increased ; and when the vein
wall is of average strength, if the valves in the vein
are few in number, this condition alone may act
as a predisposing cause. That is, with few valves,
each segment of the vein between the valves will
have to support a longer column of blood than
would be the case if the valves were more numer-
ous and nearer together. In consequence the strain
will be greater upon both the valves and the vein
walls, and should an exciting cause occur, the veins
or valves would have to yield to the increased blood
pressure. These factors of inequality in vein
strength and inequality in the number of valves
play an important part in the asymmetry of varix.
It is also important to remember that any exciting
causes which produce increased intravenous pres-
sure tend to the production of varicose veins. The
affection is seldom seen in youth, but is very com-
mon in middle and advanced age. .\ccording to
Billroth, women are more apt to suffer from vari-
cose veins than men. The disease in this class of
patients arises from interference with the free re-
turn of venous blood from the obstruction offered
by physiological or pathological enlargement of the
uterus. The venous obstruction caused by tight
garters is also a factor in the production of this
lesion.

Occupation plays an important part in the pro-
duction of varicose veins. Those whose occupation
keeps them habitually upon their feet are apt to
suffer. There also seems to be an hereditary influence
which predisposes to this condition. Members of
the same family, through several generations, will
often suffer from varicose veins. Grav-
ity increases the intravenous pressure, and its effects
are most marked at the lower end of the blood
column.

The first pathological condition in vari.x is the
permanent localized dilatation of a vein. Veins
which are so affected are said to be varicosed, and
present an enlarged, elongated, tortuous, and knotty
condition. The superficial veins of the lower ex-
tremity are those most commonly involved, the in-
ternal saphenous and its branches being most often
affected. The deep veins are usually free from the
disease, though Verneuil says that varix is as com-
mon in the deep-seated as in the superficial vessels
(Bryant). Recent observers, however, do not en-
tertain this view, particularly Borden, who claims
that when the deep veins are involved they are
usually secondary to superficial varicosities, but
occasionally the communicating branches between
the deep and superficial veins may be affected, and
a varix is not infrequently observed at the point.
The disease begins with the slow dilatation of a vein.
It is not only enlarged transversely, but is also
elongated, and as the ends of the vein are fixed
points, the increase in length causes it to become
very tortuous. In other cases, dilatation is most
marked, and elongation does not occur to any great
extent. The coats of the involved veins are mor-
bidly thickened, the endothelial coat presents longi-
tudinal stride, and in long-standing cases atheroma-
tous changes or calcification may sometimes be ob-
served. The external coat is also very much thick-
ened by reason of connective-tissue infiltration and
inflammatory new-formation, to which the name
periphlebitis is attached. The valves are shortened,
or often disappear, and become insufficient to sup-
port the column of blood. As a result of increased
exudation of serum in the perivascular and lymph
spaces, the lymph channels are unable to carry away
the excessive exudate and edema occurs in the im-

mediate neighborhood of the varix. From these
observations it will be seen that a varix may arise
from the local insufficiency of a vein, or from an ex-
cessive blood pressure within a vein, or from a com-
bination of these factors. It will also be seen that a
vari-x is at the beginning generally localized and
confined to one or several parts of a vein ; that it is
usually a progressive disease, and that the disease
condition is apt to continue or extend until the
whole vein and its branches are involved. These
factors are of importance from the standpoint of
treatment, in that, considering the tendency of a
vari.x to increase, the necessity for interference in
the early stages of the trouble becomes evident.
Through swelling of the limb, pain, soreness, and a
feeling of fatigue in the affected member, a small
varix will frequently produce great discomfort and
almost incapacitate one for manual labor. Inflam-
mation and thrombosis are not infrequently com-
plications of varices. Ulcers occurring in connection
with varicose veins are often spoken of as vari-
cose ulcers, but the relation of the ulcers to the
varices seems to be rather accidental than casual.
One of the greatest dangers to the patient suffering
from varicose veins is the danger of sudden rupture
which usually follows a scratch or a bruise over a
thinned portion of a vein. The bleeding is profuse,
and unless checked may cause a fatal termination.

In view of the foregoing clinical facts, what, may
we ask, would be the indication for treatment ? The
subject, however, seems to resolve itself into two
important questions : Shall we resort to palliative
treatment, which offers temporary relief only; or
shall we have recourse to operative measures by
which a permanent cure can be obtained ? We be-
lieve the latter plan of treatment is the only one
worthy of our consideration, and the choice by elec-
tion regarding the operative procedure will depend
entirely upon the form, character, and duration of
the varicosities involved. It is generally conceded
by the profession that the lower extremity is more
accessible to thorough manipulation than any other
portion of the body. Therefore we are sometimes
at a loss to comprehend why patients thus afflicted
are neglected in general practice, unless it be out of
respect to tradition, or the dread of sepsis. Surgical
interference in vari.x was so disastrous in preanti-
septic days that the traditional timidity that still
obtains to a certain extent and has been a potent
factor in preventing the more general use of ra-
tional measures, is in part accounted for. With the
safeguards of modern aseptic methods this attitude
should no longer be maintained. In fact, the milder
forms of the disease, in which palliative treatment
is usually the only measure thought of. are fre-
quently the very ones in which operative treatment
should be adopted. The course of the disease is so
generally progressive that this characteristic of the
trouble is one of the most important reasons for
earlv surgical interference. By doing away with
the trouble before the entire main trunk and its
branches have become involved, extension of the
disease may be prevented, as well as the necessity
for a large operation in the future.

While with Dr. Arpad G. Gerster at Mount Sinai
Hospital in iSg6. the writer had a favorable op-
portunity to observe a large number of cases of this
nature and he arrived at the conclusion that it was
not alone the greater degree of surgical skill and
dexterity that determined one's success in the man-
agement of such cases, but what appeared to be a
factor of equal importance in this, as in many other
operative procedures, was the aseptic precaution
necessary to be carried out before, during, and after
manipulation. .Asepsis, once mastered, soon be-

Feb.

1907

MEDICAL RECORD.

185

comes a matter of routine, and is the key to rational
measures, which will invariably lead to successful
results.

Of course, in preantiseptic days, the surgical
manipulation in operating on varix was not infre-
quently followed by septic infection, with the result-
ing endophlebitis extending along the vein and
causing intiammatory changes in the intima, which
led to thrombosis and obliterative phlebitis. In
aseptic ligation the changes ought not to occur, and
the obliteration of the vein can be accomplished
only by placing the ligatures so close together — not
more than two inches apart — as entirely to obliter-
ate the vein as a blood channel. The operation of
multiple ligation is a simple one, only requiring care
in regard to the asepsis and in so placing the liga-
tures as not to include the nerves which accompany
the vessel. The writer has performed this operation
in a number of cases with gratifying results, and
believes it ought to be resorted to in cases of local-
ized varices in which the more elaborate measures
of partial or complete excision are contraindicated,
or where the patient will not submit to an operation
of magnitude.

In a certain number of cases, with involvement
of the main trunk of the vena saphena magna, the
greatest dilatation is always situated just above the
valves. The latter are often destroyed or rendered
incompetent and cause the vessel to support a col-
umn of blood extending from the lowest dilatation
to the heart. In such cases, high ligation or the
operation of Remi and Trendelenburg may be re-
sorted to. Ligaturing the vessel relieves it of the
pressure of the column of blood below the point of
tying, and permits the restoration of vascular tone.
In doing this operation, G. Perthes recommends
excision of a short portion of the vein between two
ligatures, thereby preventing reestablishment of the
patency of the vessel, for Minkewitsch has shown
that no restoration of a vessel can occur after a
portion of it has been excised. Most modern sur-
geons, by reason of the etiology and pathology of
varix, do not consider Shede's operation a proper
procedure, as the damage it does to the nerves and
the uncertainty of cure make it of doubtful pro-
priety in any case.

The surgeon has his choice of a number of oper-
ative procedures. In certain selected cases he must
have recourse to Phelps's operation, partial excision,
or to the still more radical method of complete ex-
cision. The writer first ijerformcd the latter opera-
tion six \-ears ago in the case of a woman 35 years
old, who was rendered almost a practical invalid
by reason of an aggravated form of varices of both
the internal and external saphenous veins, which
communicated with the deeper vessels, and which
was made more complicated bv a large ulcer on tiie
interior surface of the leg, a condition which ex-
isted over a period of eight years. The patient had
submitted to all manner and forms of palliative
treatment and was informed by reputable physicians
that her condition could not be cured. The internal
and external saphenous veins were dissected out,
ligated, and excised. The patient made an unexent-
ful recovery. Shortly afterward she secured a po-
sition which necessitated considerable activitA' on
her part and has continued to perform her duties
without the least return of her former trouble.

Influence of Chocolate and Coffee on Uric Acid. —

Rene Fauvel declares that the metliylNanthiii'; (thcnbro-
mine and caffeine") of chocolate and coffee distinctly in-
crease the urinary purins. but not uric acid, and they pre-
vent its precipitation by acids. Their influence, especially

tliat of theobromine, is far le>s injurious to the organism
than that of the purins of meat and of the lesimiinous
vegetables which give a large proportion of uric acid which
is easily precipitated. These conclusions concern alone
tlie actions of theobromine and caffeine on uric acid and
the urinary purins and not their influence on digestion,
circulation, or the nervous system. — -Gazette dcs Hopitaux
Cirils ct MiUtaircs.

Early Electrical Treatment of Acute Poliomyelitis of
Children. — Ezio Luisada has treated 170 cases of acute
poliomyelitis of children in the hospital at Florence, and
states that the results of treatment are much better when
the electrical applications are begun as soon as the fever
has passed over, lie believes that it is a distinct disadvan-
tage to wait as long as is commonly done before beginning
electrical treatment. Patients are rarely seen in the stage
of invasion, and the diagnosis is difficult before the paraly-
sis appears, which is after the fall of temperature. The
period of regression begins in from one to three weeks.
When the inflammation lessens, and the hyperemia of the
spinal cord, with its compression and injury lias passed
away an electrical examination should be luade. and mild
.ipplications of electricity begun. With the indifferent elec-
trode on the brachial ple.xns or the lumbosacral region the
current does not pass near the inflamed spinal cord, and
no injury can be done to it. Children in whom the treat-
ment is begun in from fifteen to thirty days from the be-
jjinning of the illness, recover more quickly and more
thoroughly than those in whom the applications are de-
layed. The progress of the patient is affected by the season
of the vcar, spring being most favorable. Cold w'eather
with its poor circulation prevents repair. In very young
children the nervous centers are not yet developed, and the
dcstructinn of certain portions may be replaced by new de-
velopment of other regions. If the muscles and peripheral
nerves be kept in good condition by electricity, they will be
ready to respond when the centers are regenerated. — An-
iiali di Elcttricita Mcdica c Tcrap'xa F'u'ica.

Murphy Button. — K procedure that is used by many
surgeons in order to shorten the time required for secur-
ing the Murphy button in position is referred to by Gelpke.
Murphy's original direction was to make a purse-string
suture and to incise the center of the circle so outlined
for the introduction of the half of the button. Instead of
this, the slit through the gut may be made first, the button
slipped into place, and then fastened by a single inter-
rupted suture at each side. To prevent the button from
dropping into the stomach instead of into the intestine
in gastroenterostomy, a silk thread four inches long and
attached to a small metallic ball may be tied to the in-
testinal half of the button. — Corn-spoiidenc-Blatt fiir
Schzvciccr Acrctc.

Scorbutic Symptoms Caused by the Bacillus of
Eberth. — Giovanni .Vrpa .\uverny describes a rare hem-
orrhagic form of typhoid, in which all the symptoms were
niuch more suggestive of scurvy than of typhoid fever. The
fever had not the typical curve of typhoid, rising to 40° for
five days, and then remaining at 38" for five days, after
which, accompained by a hemorrhagic eruption over tlic en-
tire body, it rose again to 40°, and remained at about that
until the patient's death on the ei,gthteentli day of the dis-
ease. There were no symptoms connected with the diges-
tive tract, but after death there were found multiple ulcera-
tions of Fever's patches. There were at no time hemor-
rhages into the intestine, but there was epistaxis. swellmg,
sponginess and bleeding of the gums, and hemorrhage
from vagina and bladder. E.xamination of the blood showed
the presence of short bacilli, which proved to be the bacilli
of Eberth. The condition was one of scurvy caused by
the typhoid baccillus. The author believes that the bacillus
exerted its influence mechanically, and by its presence in the
blood, rather than by its poisonous products.— La Riforma
Medica.

i86

MEDICAL RECORD.

[Feb. 2, 1907

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A.M.. M.D., Editor.

PUBLISHERS
WM. WOOD & CO . 51 FIFTH AVENUE.

New York, February 2, 1907.

FORMIC ACID IN DIPHTHERIA.

The signal success which has marked the intro-
duction and employment of diphtheria antitoxin has
led to a feeling of such general satisfaction that very
little efifort has been made in recent years to improve
or add to present methods of treatment. It must
be admitted that the mortality has been reduced
within a comparatively short period to a remarkable
extent ; and yet the disease works much havoc, for
if not immediately fatal, the after-effects in many
instances are such as to cause much alarm. Tox-
emia is the word which will best define the cause
of these sequels as well as that of death itself, and
it is in the treatment of this condition that enlight-
enment is very greatly desired. It would appear that
a sufficiently powerful dose of antitoxin adminis-
tered at an early stage of the infection, so that the
toxins could be antidoted before the tissues would
be devitalized or degenerated, would comprise the
proper conception of perfect treatment. Such is
probably the case, but so varied is the individual re-
ristance that we have no means of knowing what
the exact antitoxic gauge may be in any given case.
The three main complications which are met with
in the course of the disease are cardiac failure,
paralysis, and renal involvement, of which the more
important are paralysis and cardiac failure. Apart
from the local treatment and the administration of
antitoxin, the method hitherto employed has been
one of stimulation, mainly by strychnine, strophan-
thus, and digitalis. The main action of these is to
raise the blood pressure by increasing the cardiac
force, contracting the arteries, and in lesser degree
stimulating the vasomotor centers in the medulla
and cord. It has been shown that these drugs are
not ideal, for they increase the amount of work re-
quired of a heart w^iich already manifests a tendency
to degeneration. As a substitute for these measures,
Croom {Edinburgh Medical Journal, October, 1906)
calls attention to the value of formic acid and the
formates, the stimulating properties of which are
not attained at the expense of the blood pressure.
Their action is muscular, while their effect is much
more lasting. Clement and Huchard have already
shown that formic acid is a powerful stimulant of
striped muscle, and also improves the appetite and
general nutrition. In concentrated form the drug
produces a rise in blood pressure, but in the form of
a 25 per cent, solution the increase is so slight as to
be of comparatively no importance, even in advanced
arteriosclerosis. The formates also possess a diu-
retic action, and in sclerosis of the kidney have been

found to exert a marked influence in diminishing
albuminuria.

From this experimental evidence it would appear
that formic acid and its salts might be of consider-
able value in diphtheria, and the statistics of one
liundred cases presented by Croom seem to bear out
this fact. All the patients received the 25 per cent,
formic acid solution in 5 to 20 minim doses for ten
to fourteen days after admission to the hospital (the
Edinburgh Fever Hospital). Otherwise the treat-
ment was the usual one for diphtheria, including
the use of antitoxin. This series of cases was com-
pared with an equal number which were treated in
previous years without the formic acid. The death
rate from cardiac failure was apparently reduced
from 8.6 per cent, to 2 per cent., and some of these
cases had shown evidences of such cardiac involve-
ment as to warrant a very bad prognosis. In the
two patients who died the toxemia was profound
before the first administration of the drug. The
main features in all the cases were the marked reg-
ularity of the pulse, even after a previous irregular-
ity had been present, and a noticeable improvement
in the general nutrition, which points to a success-
ful combating of the toxemia. The number of in-
stances in which paralysis occurred was very small,
only 3 per cent., so that, considered with the other
favorable factors, we seem to be quite safe in con-
cluding that in formic acid we have a remedy which
Is worthy of more extended trial.

NEPHRITLS OF PRENATAL ORIGIN IN
THE YOUNG.

NoTWiTHST.-\NDixG all that has been done to dis-
cover the etiology of the nephritis of pregnancy, we
are still far removed from a solution of the problem.
And this uncertainty also extends to our knowledge
of the changes which take place in utero in the kid-
neys of the fetus in cases in which the mother is
suffering from any one of the many manifestations
of renal diseases. That some definite relation exists
between these conditions is shown by scattered re-
ports of observers who have found a tendency to
nephritis in several generations. The appellation
"heredity" will hardly serve to account for these
phenomena, and "hereditary tendency" is also insuf-
ficient. It seems reasonable to assume that in cer-
tain cases these lesions may be instituted during
fetal life, or, as expressed in a recent article by Gill-
more in Surgery, Gynecology, and Obstetrics, No-
vember, 1906, "the lesions in the fetal kidney occur
1 ecause the toxins in the nephritic mother have dam-
aged the kidneys of her fetus" before the latter has
been born.

In support of his claim, Gillmore refers to the
pathological examinations in fetuses from eclamptic
mothers in which distinct evidences of renal lesions
were found. In some the kidneys showed a necrosis
of the cellular elements, in others well-marked acute
nephritis was present, and in none was there any
doubt of this fact. There may be some ground for
doubting that a fetus whose kidneys are compara-
tively passive during uterine life, dying before or
soon after birth of an eclamptic or uremic mother,
succumbed to the direct results of its own nephritis.
This has no bearing, however, on the assumption

Feb. 2, 1907]

MEDICAL RECORD.

187

that it is possible for an antenatal impairment of
the kidney to occur. Gilhnore claims that the latter
is an important factor in producing- an early post-
natal form of nephritis.

The fact has frequently been referred to in recent
years that there are many more instances of insidi-
ous affections of the kidneys in the very young- than
was forn-ierly believed. In many of these it is of
course impossible to know in what condition the
mother's kidneys were before the birth of the child,
and it therefore can only be surmised how far she
mav be responsible for the damaged kidney in her
offspring. But in view of the knowledge of such a
possibility, the careful, conscientious, routine exam-
ination of the urine of every pregnant woman be-
comes more than ever a solemn duty, for not only
are we dealing with important disturbances in the
mother, but also with a probable renal involvement
in the fetus.

This brings us to the question of therapeutics,
and it is -here that Ballantyne's views on prenatal
treatment will find an appropriate application, for,
admitting the possibility of fetal nephritis in every
instance of maternal renal disease, the former may
be influenced by treatment directed to the mother.
If this does not prevent, it may at least modify
nephritic lesions in the fetus. The subject is one
of extreme interest, and further investigations
should be instituted for the pur|3ose of a better
understanding of this important matter.

"RACE SUICIDE."

Our strenuous and versatile President deserves well
of his country in that he has provided topics with-
out end for discussion in the newspapers, clubs,
and debating societies. The Panama Canal, the
negro problem, universal peace and general war,
trusts, railroad rebates, pure food, political ex-
pediency, labor combinations, race suicide, the civil
service, spelling reform are only a few of the innu-
merable questions he has sprung from time to time
upon the attention of the expectant nation — and he
has still two years of activity. Such is the diver-
sity of these subjects that no class of the commu-
nity is without something to discuss. Among the
topics of special interest to medical men, as well as
to reformers in general, is that of "race suicide,"
by which is meant the restriction of child bearing.
When this was first broached the country accepted
the pronouncement with acclaim, and anathema was
the man who dared affirm that a large family was
anything but a blessing. The quiver was there
and it must be filled, and blessed was the man who
filled it. The fact was not recognized, however,
that this question, like that of spelling reform, was
one of sentiment z'ersus natural law, and that no
presidential bull could settle it.

There are two factors at work in the reduction of
the birth rate — one artificial, the other natural. It
is, of course, a deplorable fact that the number of
children in some families is kept down by artificial
means of prevention, but this cuts a small figure in
the general falling off in the birth rate; the real
factor and the one that counts is a normal sterility
due to the working of Nature's law. This has been
well put by Major Charles E. Woodruff in an article
contributed to a recent issue of the Nezv York

Times. The writer recalls the well-known fact that
in all living things, whether plants or anin-ials, the
number of progeny is directly proportional, in the
long run, to the risks to which the young organism-
is exposed during the period preceding maturity,
and also to the normal length of the reproductive
life of the particular species. In order to maintain
an equilibrium there must be an effective birth, that
is a birth of an individual which will reach matu-
rity, for every death — no more, no less. If condi-
tions change so that more of the oft'spring of any
two individuals reach maturity than Nature intended
or expected, there will be overcrowding and the
result will be a weakening of the species and a
reduction in its reproductive power. Man can
thwart Nature, in the case of the domestic animals,
by protecting the young and supplying them with
an abundance of nutriment, but he fulfills the natu-
ral law nevertheless by killing the superfluous young
for food or restricting the increase by eating the
eggs. The same is true in respect of the vegetable
species cultivated by man.

In general, this natural law rules the human
just as certainly as it docs the lower animals
or plants. In former times, and at the present
day among uncivilized races, large families were
the rule because all but the most robust of the
progeny died of disease before reaching matu-
rity and many adults died of violence as well as of
epidemic disease. If the race were to survive, under
those adverse conditions, the number of children
must be large. With the advance of civilization
came better housing, better feeding, and protection
from violence and disease, and so the population
tended to increase. But the increased luxury of
modern times and the development of the intellec-
tual side of man have conduced to bring about a
proportionate weakening of the physical side and
a lowered productiveness, aided in a comparatively
slight degree, no doubt, by a voluntary restriction
of child bearing.

The working- of this law is still to be seen in the
civilized world in the difference in the number of
children born to the wealthy and to the poor. The
birth rate varies, as a general rule, to which there
are the usual exceptions, in direct proportion to
social conditions. The very poor and the ignorant,
those who live in misery and abject want, breed
like rabbits and the poor children die like flies, but
the birth rate among the wealthy and those of
highest intellectual development is small. This is
not always, indeed not usually, intentional, and there
is many a couple living in luxury and with no
material want unmet who would gladly give half
they possess to have children to perpetuate their
name. The artificial restriction of the family, so
far as it is practised, is an evil and moreover en-
tirely unnecessary so far as the race is concerned, for
Nature will see to it that the world is not over-
populated. So far as the prevention of conception,
and especially of the destruction of the fruit of con-
ception, is concerned, the President is to be com-
mended for declaiming against the evil, but such
practices are less operative than he seems to believe.
The declining birth rate in the higher classes of
the community is Nature's work, not nian's, and
cannot be prevented by legislation or the writing
of essavs.

1 88

MEDICAL RECORD.

[Feb. 2, 1907

PoSTUK.\L Al-IUMIXUKIA.

OuTiHrnc or orth.static albumimiria i.s .still one of
tlic puzzles of physioloijical patholojjy. AJaiiy clini-
cians, such as Senator, do not attempt to dififer-
entiate the condition from other forms of so-called
cyclical albuminuria which are evoked by physical
exercise, diet, cold bathing, etc., whereas others en-
deavor to make of it a distinct clinical entity. Most
authorities, however, agree in considering; that if not
directly due to a demonstrable renal lesion it at
least indicates a functional incapacity of the renal
filter, which sooner or later is likely to be followed
by an actual nephritis. How largely theoretical
what has so far been written on this subject really
is is shown by the fad that Heubner {Berliner
kliiiischc ll'oiiifiisclirift, January 7, 1907) states
that until now^ no autopsy on a patient suffering
from orthotic albuminuria has been reported. Un-
usual interest, therefore, attaches to the description
which he gives of the clinical coiu-se and post-
mortem examination of a case of this afiection oc-
curring in a girl of ten years, who eighteen months
after she fir.st came under observation died as the
result of a cerebellar tumor. The urinary condi-
tion was typical of i)ostnral albuminuria, the urine
remaining perfectly normal as long as the child
remained recumbent, but sliowing considerable
amounts of albumin when she was up and about ;
casts were never present. .\t the autopsy the kid-
neys were found to be microscopically normal, and
the microscopic sections, although they were
searched through most carefully, revealed no
changes, except such as Heubner considers are
referable to the nature and duration of the terminal
illness. These consisted in a well marked hyperemia
of the small veins and of the capillaries, and in a
slight degree of fatty degeneration of the paren-
chyma. In addition in one kidney a minute spot
of atrophic kidney tissue was found, but the author
expresses the conviction that these abnormalities
liad nothing to do with the tendencv to albuminuria
and that accordingly this condition may exist with ■
out there being any gross or microscopic renal le-
sion. An interesting point in connection with the
case is the fact that the autopsy revealed evidences
of an old pulmonary tuberculous lesion, although
this had not been diagnosticated during life. French
authors have pointed out that postural albuminuria
not in frequently- is a pretuberculous manifestation.

'1"hk Ixfluexce of Thyroid Extr.-\ct ox the
Development of the Embryo.

Clinical and experimental evidence is steadily
accumulating to show what far-reaching an effect
on metabolism must be ascribed to the thyroid
gland. A novel suggestion emanates from Bleibtreu
who. in the Deutsche inedicinische IVocIienschrift,
January 3, 1907, describes the results obtained on
administering thyroid extract to pregnant rabbits.
-Although the author's experiments are not yet ter-
minated, sufficient work has been done to enable him
to come to the conclusion that the effect of the
extract is profoundly to modify the development
of the embryo and apparently in some cases not
only to prevent its development, but even to cause
absorption of the newly formed tissues to take
place. Bleibtreu presents his views somewhat as
follows : Substances of mucoid or myxomatous na-
ture normally are constantly being formed in the
tissues, but are broken down again at about the
same rate. This decomposition takes place in con-
sequence of the action of a substance formed in

the tliNToid gland as is shown in the absorption of
myxomatous material which takes place when thy-
roid extract is administered in myxedema. Such
myxomatous substances are necessary, however, for
the building up of the embryo, and therefore it is
desirable that the action of these catabolic thyroid
bodies should be inhibited at this period. Accord-
ingly, during pregnancy there is a partial retention
of thyroid products as is suggested by the swell-
ing of the gland sometimes observed. In the same
connection the author points to a somewhat simi-
larly destructive eft'ect on embryonic growth, which
is manifested when the prep-nant animal is sub-
jected to the action of the Roentgen rays or to
cholin injections, and he suggests that possibly
these agencies may have the effect of stimulating
this particular function of the thyroid gland. The
possibilities suggested by this hypothesis are cer-
tainly very striking, even though they are as yet
supported bv but little actual evidence, but the pro-
found influence on metabolism that thyroid extract
is capable of exerting, in obesity for example, seems
to justify an attitude of reserve in considering a
theory that appears even as fanciful as this.

Disientiox of the Bladder with Oxygen.

R.ADioGR.\PHEKS have discovered that by injecting
oxygen into joints that are to be examined by means
of .the Roentgen rays, especially the knee joint,
the distention produced enables more satisfactory
pictures to be obtained than is the case under ordi-
nary conditions. A somewhat similar suggestion
is now made to facilitate the examination of the
bladder by means of the cystoscope. Sometimes,
notably when the bladder is very intolerant of dis-
tention, or when the urine is very turbid or there is
a tendency to hemorrhage, it is difficult to secure
a satisfactory view through the instrument when
the bladder is distended with fluid. Nitze attempted
to cope with this difficulty by injecting air instead
of the customary boric acid solution, but abandoned
the practice because of the possibility of producing
air embolism or of causing infection by germs
carried into the viscus with the admitted air. Burk-
hardt and Polano (Milnchener medisinische Woch-
cnscbrijt, January i, 1907) hit upon the idea of
employing oxygen for this purpose, because its use
would be free from the two objections just men-
tioned, and on trial they found that another suppo-
sititious drawback, that of lessened clearness of the
cystoscopic picture in the absence of fluid, did not
exist. The oxygen was generated from peroxide of
hydrogen by the use of potassium permanganate
and was therefore sterile. Its introduction into the
bladder was found to be much less uncomfortable
to the patient than the use of fluid, especially in
cases of vesical irritability. If the gas is admitted
slowly and only to the point of moderate distention
as evidenced by the patient's feelings, no danger to
the bladder need be apprehended, and the heat of
the electric bulb of the cystoscope is also not
found objectionable. Roentgen ray photographs of
the bladder distended \vith oxygen were found much
more satisfactory than those made when the organ
was distended with fluid, and the authors regard
the method as a distinct advantage in making radio-
graphs when the presence of calculi is suspected.
They even go so far as to suggest that more satis-
factory radiographs of renal calculi mav be ob-
tained by slightly distending the pelvis of the kid-
ney with oxygen admitted through a ureteral cathe-
ter.

Feb. 2, 1907]

MEDICAL RECORD.

189

The Etiolugv of Epilepsy.

Among the many causes assigned for the produc-
tion of epileptic seizures considerable interest at-
taches to the theory which ascribes the condition to
the presence in the blood of a to.xin. An Italian
investigator, Ceni, injected the blood serum derived
from epileptic subjects into other epileptics and
found that the injections were without effect or pro-
duced symptoms of acute poisoning. Injections
made with blood from healthy subjects had abso-
lutely no effect on epileptic patients. Ceni con-
cluded from this that the blood of epileptics con-
tained some toxic material and claimed that by
continued injections immunity against this particular
poison could be obtained. In some of the patients
the clinical symptoms became worse, but in the
majority he claimed to have obtained a beneficial
effect. Schuckmann, writing in the Monatsschrift
fiir Psychologic iind Neurologic, Vol. 19, No. 4, says
that he has subjected the serum from epileptics to a
similar series of tests and obtained results completely
in opposition to Ceni's, for in no instance was any
specific reaction obtained. In this instance Ceni's
theory seems eft'ectivelv contradicted, and it there-
fore fails to offer any solution of the problem of
the etiology of epilepsy of which a satisfactory ex-
planation is still desired.

Burkhart's figures were obtained from the larger
public institutions and indu.strial centers in a class of
the population in which tuberculosis is particularly
prevalent, and the results cannot therefore be applied
to the race as a whole.

Radiotherapy in Trachoma.

Among novel methods for treating this form of
conjunctivitis attention may be called to a sugges-
tion made by Dinger in the Wiener klinische Woch-
enschrift, No. 42, 1906, who employs radium bro-
mide for this purpose. Five milligrams of the salt
was enclosed in a glass capsule two millimeters in
diameter, and this was fastened to a small hard rub-
ber rod. At first the radium was applied for one
minute at a time twice a week, and later the time
of application was extended to ten minutes. A
well-marked reduction in the granules could be
noticed after a few sessions, and no injury to the eye
occurred. Among sixteen cases treated by this
means a complete disapjiearance of the evidences
of the disease resulted in seven. The vounger the
patient the quicker the effect was obtained. When
a complicating pannus was present a longer term
of treatment was required, but here also a cure
lesulted. Among the advantages which favorably
distinguish this method of treatment from others
which are at present employed are the ease and pain-
lessness of application and the fact that it can be
carried rnit without confining the patient.

The Frequency of Tubercueosis.

Statements as to the relative frequency of tuber-
culous disease in the human subject vary within wide
limits. This is particularly evident in an examina-
tion of autopsy statistics. Heller and Orth. for ex-
ample, find tuberculosis present to the extent of from
-7 to ?<^ per cent, in 8,770 cases examined by them,
while Naegeli and Burkhart, in a series of 1,546
cases, place it at 91 to 98 per cent. Although there
is little doubt about the frequent occurrence of this
disease, figures so enormous as these last can hardly
be accepted without restriction. In a recent article
on this question in the Zeitschrift fiir Hygiene und
Infectiosc Krankhciten, Vol. 50, Kraemer states,
and with truth, that it is hardly fair to base our
conception of the frequency of tuberculosis on au-
topsy statistics of this character. Both Naegeli's and

The Mentally Unst.\ble in Illinois.

According to the biennial report of the State
Board of Charities of Illinois, there are 58,000 men-
tally unstable persons in Illinois who are likely,
under the stress of life, to become insane and be
added to the wards of the State. The chapter
of the rejHjrt dealing with the new State psycho-
pathic institute at Kankakee gives the first authori-
tative estimate of the number of "unstables." A
careful attempt has been made to approximate the
number of people in Illinois who are rated as
mentally and nervouslv normal, but who are pre-
disposed to insanity. Then follow the figures of
the board, basing the estimate on those who are
unstable because of hereditary weakness, or those
with habits, such as the unwise use of alcohol,
morphine, cocaine, etc., and those who suffer from
certain infections. "This figure (58,000)," the re-
port continues, "is a minimum. Twelve thousand of
them are now in institutions. Probably there are
more than 58,000 such persons in Illinois who to-
day are productive memljers of society in some way.
It is little short of calamitous that American medi-
cal education has not equipped the general prac-
titioners to recognize the early symptoms of in-
sanity in these unstable persons and give proper
treatment in the early hopeful stages preceding and
immediately following the onset of nervous and
mental breakdown,"

News nf lltp Mtt\\.

Officers of the Medical Society of the State of
New York. — .\t the annual meeting of this so-
ciety, held in ,\lbany this week, a report of which
is presented in another column, the following offi-
cers were elected : President, Dr, Frederick C. Cur-
tis of Albany; rice-Presidents, Dr. Julius C. Bier-
wirth of Brooklyn; Edward Torreyof Clean, and
Nelson G. Richmond of Fredonia ; Secretary, Dr.
Wisner R. Townsend of New York, reefected ;
Treasurer. Dr. Alexander Lambert of New York,
reelected.

Public Lectures on Problems of Insanity. —
The second lecture of this series, arranged for by
the Psychiatrical Society, will be delivered by Dr.
August Hoch (of Bloomingdale Hospital) at the
.-\cademy of Medicine, on Saturday evening, Feb-
ruary 2, 1907, at 8.30 P.M. The 'subject will be
"The Manageable Causes of Insanity," concern-
ing which Dr. Hoch will present the modern facts
and views. The aim of these lectures is to arouse
in the public a sound interest in questions of mental
hygiene, and all interested in sociological work are
invited.

The Section on Public Health of the New
York Academy of Medicine, after having been
discontinued for eleven years, has been reorganized.
The first meetine was held on January 8, when vari-
ous problems relating to the health of New York
Cit\- in the past and present were discussed hv
Drs. J. G. Bryant, and H. M. Biggs and Mr. Geo. \.
Soper. The next nieetins:;- will be held on February
12, the subject being "Disinfection." Papers will
be read by Dr. R. J. WilsoiL in charge of disinfcc-

190

MEDICAL RECORD.

[Feb. 2, 1907

tion, Department of Health, New York City ; Dr.
A. C. Abbott. Chief of Bureau of Health, Philadel-
phia, Pa., and Dr. L. E. La Fetra, New York City.
All physicians and others interested in the subject
are cordially invited to attend. Dr. John S. Billings,
Jr., is Chairman of the Section.

Report of the State Lunacy Commission. —
The annual report of the State Lunacy Commis-
sion shows that at present there are in the State
in.stitutions 28,302 patients, and there was during
the last year an increase of 5,761 in the number
of insane' in the State. The report states that 1,468
patients were discharged as recovered, while 1,142
had recovered sufficiently to resume a life of un-
restraint. The State last year expended $5,722,429
in caring for the insane, which was at the rate of
$35,1 per capita, including salaries of employees and
medical attendance. The so-called after-care sys-
tem inav liy the State Charities Aid .Asso-
ciation 1:.- - found very successful, and a defi-
nite plan has been adopted by this organization for
looking after patients discharged from State hos-
pitals in order to tide them over the first period of
stress to which they are subjected upon resuming,
life in the community. The needs of the metropoli-
tan district are made the subject of a special recom-
mendation, for the State's lease of Ward's Island
expires within the next six years, and the commis-
sion requests an immediate appropriation to pro-
vide a site for entirely new establishments. The
commission specially favors the extension of the
plan of farm colonies in connection with the exist-
ing State hospitals and speaks highly of the results
of treatment at such of the hospitals as have these
rustic adjuncts. Excellent results in the treatment
of tuberculosis in the new sun pavilions recently
erected at Binghamton and Ogdensburg are re-
ported. The commission also makes a special plea
for appropriations to permit the construction of
nurses' homes on the grounds of the three State
hospitals. Each of these homes is designed for 150
nurses and is estimated to cost $75,000. The com-
mission reports the finishing of the large nurses'
home at the Kines Park State Hospital, which now
accommodates 200 employees of this class.

A New Child Labor Bill. — An effort to meet
some of the objections to the Beveridge child labor
bill has been made in a measure, introduced by
Senator Simmons of North Carolina. This bill
makes it unlawful for an interstate carrier to trans-
port from the State of production into another
State products of a mine or factory in which child
labor is employed or permitted to work in violation
of the child labor laws of the State in which the
factory or mine is situated. The bill differs from
the Beveridge bill in that it does not imdertake to
make a Federal child labor law, but recognizes the
child labor laws of the several States and seeks to
make them effective. It is based upon the idea
that nearly all the States have child labor laws
and that thev are largely ineffective and will re-
main so as long as they can onlv be enforced by
local prosecutioii for their violation.

Medical Legislation in Hawaii. — Dispatches
from Honolulu state that the local medical associa-
tion is endeavoring to have the legislature enact a
law requiring all examinations for licenses to prac-
tise medicine to be taken in English. This move-
ment is said to be the result of the granting of a
license to a Japanese physician. The law as pro-
posed is not aimed specifically against the Japanese,
but as these constitute the preponderance of foreign
candidates, the intention is clear.

Appropriation for Medical Inspectors in Chi-
cago.— This city has appropriated $15,000 for
the appointment of one hundred additional inspec-
tors to cope with the epidemics of scarlet fever and
diphtheria. The health department publishes fig-
ures relating to the results of school inspection, as
regards diplitheria and scarlet fever. There was at
first a gradual falling ofi' in the number of cases of
scarlet fever and diphtheria following the appoint-
ment of additional inspectors, but an increase in the
violence of the scarlet fever epidemic has since oc-
curred, 407 new cases of the disease having been
reported on January 29.

St. Lazare Prison of Paris to be Torn Down.
— The famous prison of St. Lazare, which has
been one of the historic landmarks of Paris, is to
be pulled down and its site to be covered with
open squares and fine modern buildings. St. La-
zare, as its name indicates, was built as a leper's
hospital in the eleventh century, but on the dis-
appearance of the disease from France was con-
verted into a religious institution and later into
a prison for women.

Behring's Tuberculosis Cure. — Prof. Behririg
is taking the first .=teps toward making his method
of antituberculosis immunization available for gen-
eral use. He calls his remedial agent tulaselactin,
and has instituted a course of lectures and practical
demonstrations to illustrate its method of admin-
istration. The courses are being followed by medi-
cal officers of tuberculosis sanatoria throughout
Germany, and for all who seek to employ the new
treatment attendance is an essential condition be-
cause Prof. Behring intrusts the preparation only
to those who have qualified under his own super-
vision. The cable states that Prof. Behring is on
the verge of a nervous breakdown and will soon
enter a sanatorium for treatment.

Red Cross Aid for China. — The Red Cross of-
ficials announce that $17,000 has been collected
for the China famine fund, and that of this amount
$5,000 has been cabled to the American consul at
Shanghai. It is also planned to send 5,000 bushels
of wheat to be used for the spring planting.

Smallpox on Shipboard. — Owing to the pres-
ence on board of a case of smallpox the steamer
Gallia, which arrived last week from Alediterranean
parts, was detained at Quarantine and fumigated,
and all the passengers who had been exposed were
vaccinated.

Surra in the Philippines. — The Department of
Agriculture is making great efforts to prevent the
introduction into this country of surra, which is
common among the live stock in the Philippines.
As it is considered possible for an insect to con-
vev the infection even after an animal has been
found healthy on being taken on board of the ves-
sel in which it is to be shipped, the department
has forbidden the sending to this country of any
animals from the Philippines, and even the pet
dogs of officers are considered as coming under the
ban.

Nitric Acid from the Atmosphere. — It is an-
nounced in the London papers that Sir William
Crooks, in conjunction with some of the scientists
of the L^niversitv of Freiburg, has succeeded in
discovering a process by means of which nitric
acid may be extracted from the atmosphere in such
a wav as to make it available for commercial, indus-
trial, and agricultural purposes.

Quick Professorship of Biology. — Dr. George
H. F. Nuttall has been appointed to the Quick Pro-
fessorship of Biology, University of Cambridge,

Feb. 2, 1907

MEDICAL RECORD.

191

England. The chief duty attaching to the chair is
the advanceliient of the study of ■"protozoa," espe-
cially such as cause disease.

Dr. Alfred Wiener has been appointed attend-
ing surgeon in the aural and laryngological de-
partment of Sydenham Hospital.

Stony Wold Sanatorium. — At the annual meet-
ing of the managers of this institution held last
week, under the presidency of Mrs. James E. New-
comb, it was stated that of the 193 patients treated
in 1905 at Stony \\'oId 113 were discharged and 80
remained at the close of the year. The receipts
were $111,463 and expenditures $107,000. There
is $26,000 as a nucleus for a permanent endowment
fund. Many improvements have been iTiade and a
model dairy supplies milk at three cents a quart in
summer and four cents in winter. Mr. John D.
Rockefeller and Mr. Anson F. Flower have each
made a conditional offer of $12,500 if the insti-
tution succeeds in paying off its indebtedness,
amounting to about $36,000. before March r.

Dedication of the Ossining Hospital. — The
formal dedication of the New Ossining Hospital
took place on January 22. The new building, which
cost $100,000, was erected in memory of the late
Helen Ward Potter by her husband, Frederick
Potter, a son of the late Congressman Orlando B.
Potter of New York, and his sisters, Misses Blanche
and Martha Potter, and Mrs. Walter Gerr.

Jewish Hospital for Deformities and Joint Dis-
eases.— This institution has just been opened in
this city. In connection with the regular hospital
work there will be a course of lectures to teachers,
instructing them in the causes of this class of dis-
eases. They will also be instructed how to recog-
nize the earlv symptoms of deforming diseases, so
that the children may receive treatment during
the earlier stages. The phvsician and surgeon in
chief and chief of clinic is Dr. Henry W. Frauen-
thal of 783 Lexington avenue.

Maker of "Magic Boots" Acquitted. — After a
trial lasting two weeks, in which large numbers
of witnesses were called by both sides, the jury
before whom the case of the so-called "magic boots
doctor" was being tried handed in a verdict of
not guilty. The defendant had claimed to be able
to cure a long list of diseases by means of elec-
trical and other curative properties alleged to be
contained in boots which he sold at very high prices.
The Harlem Eye, Ear, and Throat Infirmary.
— The secretary of this institution. Dr. C. B. Med-
ing. states that there are several vacancies on the
staff of assistants in the infirmarv. Clinics are held
daily from 2 to 3.30 and 6,000 patients are treated
yearly. Those interested are requested to apply
at the clinic, 144 East 127th street.

Indian Territory Twenty-third District Medi-
cal Society. — At the regular annual meeting of
this society the following officers were elected for
the coming year: President , Dr. Frank Bates: I 'ice-
President, Dr. A. S. Spangler ; Secretary and Treas-
urer. Dr. L. S. ^^"illour. There w'ere twenty-five
members present.

Androscoggin County (Me.) Medical Associa-
tion.— At the annual meeting of this association,
held in Lewiston. it was voted that the minimum
fee for life insurance examinations be fixed at $5.
The officers were elected as follows : President, Dr.
C. E. Norton : Vice-Presidents. Dr. H. H. Purinton
and Dr. E. S. Cuminings : Secretary, Dr. D. A.
Barrell : Treasurer, Dr. B. F. Sturgis.

Dodge County (Neb.) Medical Society. — At

the annual election of officers for this society, the
following were chosen at the recent meeting held
in Fremont: President, Dr. J. J. Metzinger, Fre-
mont; Vice-President, Dr. Tandy Wigglesworth,
Hooper; Secretary. Dr. A. P. Overgaard, Fremont;
Treasurer, Dr. E. W. Martin, Fremont.

Union County (Ark.) Medical Society. — At
the recent meeting of this society at El Dorado,
the following officers were elected : President, Dr.
Jno. Moore of Lisbon ; / 'icc-Prcsidcnt. Dr. S. E.
Thompson; Secretary, Dr. J. B. Wharton; Treas-
urer, Dr. J. ^I. Sheppard.

Nashua (N. H.) Medical Association. — Officers
were elected as follows at the annual meeting of
this society held last week: I'resident. Dr. Albert
E. Brownrigg; First Vice-President. Dr. Joseph A.
Charest; Second Vice-President, Dr. James S.
Black; Secretary. Dr. Eva M. Locke; Treasurer,
Dr. Arthur L. Wallace.

Memorial to the Late Dr. Macdonald. — At a

recent meeting of the New York Psychiatrical So-
ciety a memorial notice of the death of Dr. Alex-
ander E. JNIacdonald, presented by Drs. Carlos F.
MacDonald and William Mabon, a committee ap-
pointed for the purpose, was unanimously adopted
and ordered to be spread upon the minutes of the
society. The notice was in part as follows : "Alex-
ander' E. :\Iacdonald, LL.B., M.D.. a member of
the New York Psychiatrical Society, died Decem-
ber 10, 1906. For thirty-five years Dr. Macdonald
had been intimately associated with the insane. He
commenced the study of medicine at Toronto Uni-
versity and was graduated AI.D., Medical Depart-
ment, New York University, 1870 ; LL.B., Law-
School, New York LTniversity, 1881. Lecturer upon
Medical Juri'sprudence in 1874; subsequently, Pro-
fessor of Medical Jurisprudence, Professor of Psy-
chological Medicine and Medical Jurisprudence,
and was Emeritus Professor at the time of his
death. House Physician, Hospital for Epileptics
and Paralytics, Blackwell's Island, 1870; chief of
staff, Charity and Allied Hospitals, Blackwell's
Island, 1S71. Resident Phvsician. New York City
Asylum for the Insane, Ward's Island, 1874. Medi-
cal superintendent of the same from 1874 to 1904.
the title of the asvlum having been changed in the
meantime to Manhattan State Hospital, East,
Ward's Island. In 1901 he established the tent
treatment of the tuberculous insane, removing them
from all communication with any unaffected pa-
tients. Dr. Macdonald was one of the most dis-
tinguished alienists of this country and a man pf
striking force of character. His far-seeing powers,
his unswerving integrity, and his great executive
ability qualified him in an extraordinary degree
for his responsibilities. .\t all prominent medical
meetings his activities were conspicuous. His com-
manding presence and lofty sense of duty will al-
ways be remembered by those who had the privi-
lege to be acquainted with him, and his pupils in
all parts of the country will pav inany tributes
to his memory. The Psychiatrical Society desires
to spread upon the minutes this tribute to the
memory of their late associate."

(Signed) C. Macfie Campbell. M.B.,

Secretary.

Obituary Notes. — Dr. Arnot Spence of this
city died on January 26 at the age of forty-two
vears. He was graduated from the Bellevue PIos-
pital Medical College in the class of 1884. He was
a surgeon in the Ninth Regiment and was visit-
ing phvsician to St. Toseph's Flome for Tonsump-
tives.

\(.J2

MEDICAL RECORD.

[Feb.

1907

Dr. CiiAHLES W. TowNSENU ol New Brighton,
S. I., died on January 27 as the result of injuries
received at the hands of a supposed burglar who
entered his house the night before. Dr. Townsend
was a graduate of the College of J^hysicians and
Surgeons in 1890, and also of the School of Mines
of Columbia University. He w^as vice-president
of the Richmond County Medical Association and
was a prominent figure in medical affairs on Statei,i
Island.

Dr. Henky a. Le Bareier of Larchniont, N. Y.,
died of erysipelas on January 21 after an illness
of about si.x months. Dr. Le Barbier was a native
of this city and was fifty years of age.

Dr. Joseph Manning Cleveland of Pough-
keepsie, N. Y., died on January 21 of pneumonia.
He was born in Charleston, S. C, eighty-two years
ago and received his medical degree from the Col-
lege of Physicians and Surgeons in 1850. He was
superintendent of the Hudson I-iivcr State Hospital
from 1S67 until 1893.

Dr. Robert \V. Gray of Boston, Mass., died on
January 19 at the age of seventy-one vears. He
was born in Paris, Ale., and received his medical
degree from Bowdoin Medical .School. He served
in the Civil War and had practised in Pittsfield,
Mass.. and Kennebunk, Me., and for the last twenty-
five years had been a resident of Boston.

Dr. Benjamin Hubbard of Plymouth, Mass.,
died on Januarv 12 at the age of eighty-nine years
He was born in Holden, Mass., and received his
medical trainin"- under the tutelage of his brother,
Dr. Levi Holden of Plvmouth and in the Westmin-
ster Medical College. He began practice in South
^^'eymouth in 1844, but later removed to Plymouth,
where he has resided ever since. About fifteen
years ago he retired from active practice.

Dr. T. E. NoTT of Spartanburg, .S. C, died on
January 9 at the age of seventy-six years. He was
graduated from the South Carolina Medical Col-
lege of Charleston in 1852 and began practice in
LTnion County. He served as surgeon in the Con-
federate service through the Civil War, and in 1873
he removed to Spartanburg, where he practised for
over thirty vears.

Dr. Adam Shirk of Oakland, Cal., died on Janu-
ary 13 at the age of sixtv-six years. He was a
native of Pennsylvania and had been assistant su-
perintendent of the Harrisburg (Pa.) Hospital for
the Insane and assistant superintendent of the State
Hospital for the Insane at Austin, Tex., before
coming to California twelve years ago. For the last
five years he had been superintendent of the .Ala-
meda Countv Infirmary.

Dr. Carl P. Proegler of Fort Wayne, Ind., died
on January 16 of apoplexy at the age of seventy
years. He was a native of Germany and served as
assistant surgeon in the Franco-Prussian war. In
1877 he came to this country and located in Fort
Wavne. He was prominent in medical circles and
served for a number of vears as secretary of the
-•Mien County Board of Health.

Dr. Franz Kuckein of San Francisco died of
appendicitis on January 10 at the age of fifty-four
years. He was born in Danzig, Germany, and re-
ceived his degree from the University of Munich.
In 1888 he came to this country, and, after practis-
ing for a time in Oakland, he removed to San Fran-
cisco in 1891: He was consulting physician to the
German Hospital, and in igoi organized the Ger-
man-.'\merican League of California, of which he
was the president for three years.

Dr. William F. Hovey of Bay City, Mich., died
suddenly on January 18 at the age of eighty-two

years. He was born in Warsaw, N. Y., and re-
ceived his medical education from the Cleveland
Medical College and the University of Michigan.
In 1865 he was detailed to the military hospital at
Louisville, and later settled in Fenton, Mich., but
removed to Bay City in 1876.

Dr. E. L. Wemple of San Francisco died sud-
denly on January 15 at the age of fifty-nine years.
Dr. Wemple was a native of Jamestown, N. Y.,
and had practised in San Francisco since 1889.
He was attending physician to the Qara Barton
Hospital, of which he was president at the time
'if his death.

SEVENTH HARVEY SOCIETY LECTURE.

The seventh Harvey Society lecture was given at
the .\cademy of Medicine on Saturday, January
26, the speaker being Prof. E. B. Wilson of Colum-
bia University. The subject of the lecture was
"Recent .Studies in Hereditv ;" but this, the speaker
said, was really too broad a title as he intended to
devote himself to certain phases only of this in-
teresting subject.

In the study of heredity three principal methods
had been followed. The first of these was the sta-
tistical, which consisted in recording observations
on a large number of variations, etc., as they occur
in nature. Perhaps the best work of this descrip-
tion was that embodied in Galton's "Law of Ances-
tral Inheritance." The second method was the ex-
perimental. This consisted especially in crossing
different types and observing the effect of this on
the progeny. While there was little doubt that the
same rules held for the crossing of pure bred forms,
it had been found to be far simpler to study the
crossing of hybrids, for then the different charac-
ters could be easier observed. The best studies
along these lines were embodied in the work of
Mendel, the formulator of the well-known Men-
delian law. It niiglit be mentioned in passing that
the Mendelian phenomena were probably not so
general as at first thought; they were extremely
valuable, however, in having given us a new view
of the subject. The third method, and the one to
which the speaker had devoted some attention, was
the indirect one. in which attempts were made to
follow out the physical aspect of the subject from
the side of the germ cells.

Before going on to the subject of this lecture
proper, Prof, ^^'ilson said it would be well to review
briefly some of the more prominent facts in Men-
delian heredity. One of the most important ad-
vances was made with the recognition of "unit
characters," the transmission of which was abso-
lutely different from "blending." A great many
characters were blended ; the result of crossing a
negro and a white person was a mulatto. In many
characteristics, however, inheritance was by means
of unit characters instead of blending. In these the
hereditary properties behaved as though they were
material bodies. Prof. Wilson here exhibited sev-
eral mice to illustrate the point in question. In
the first jar was an ordinary wild gray mouse : this
had been bred to the white albino mouse shown
in the second jar. The result of this mating was
shown in the third jar, and was a hybrid, looking
iust like the gray parent. Not a trace of white
was visible, and yet within this gray hybrid the
white of the other parent was latent. On breeding
two such gray hybrids there were a pure white mouse
and three gray ones. This white offspring was
spoken of as a white "extracted" mouse. The re-
sult of breeding a large number of the gray hybrids

Feb. 2, 1907]

MEDICAL RECORD.

i>'3

of the third generation resulted in pure white mice
and gray mice in the proportion of i :3. If sev-
eral characters were taken the result while more
complex was still quite mathematical. This was
typical "Mendelian Inheritance." By a close study
of the subject it had been found possible to work
out in advance what the result of certain breedings
svould be, just as a chemist could predict b}' a
study of his formula what the result of a chemical
reaction would be.

The principle imderlying the Mendelian law was
very simple. When two characters were put to-
gether in a hybrid, e.^. G and W, the formation of
the germ cells in this hybrid, was such that the char-
acters w'ere again taken apart, half the germ cells
being G and the other half W. This was true both
for the eggs of the female and the sperm of the
male. When tliese hybrids then were bred we liad
the following possible combinations :

GG, G\V, WG, WW

And as G (gray) dominated over A\ (white) this
meant that there were three gray oftspring to one
white.

.Mthough this was the essence of the Mendelian
law, recent developments had shown that the subject
.>-as not quite so simple ; certain qualifications were
necessary. It wmild lead too far afield, however,
to go into these, and so the speaker would go on
to the subject proper.

It was now everywhere admitted that the physical
basis of heredity was contained in the nucleus of
the combining cells. In the nuclei, then, must be
contained the unit characters, which we had just
seen behaved almost as if they were material bodies.
Now it had been found that the nucleus of the
egg or of the sperm contained bodies, the history
of which actually ran verv close to that of the unit
characters. These bodies were the chromosomes.
These appeared in the fertilized egg and whenever
the cell divided partook of this division. They were,
therefore, the lineal descendants of those present
originally in the fertilized egg.

Until recently it had been thought that all chro-
mosomes were alike ; now this was known not to be
the case. C)ne of the most striking differences w'as
one in size. Disturbances of the chromosomes were
followed by disturbances in the progeny, i.e. mon-
sters were produced. It w-as therefore believed at
present that the chromosomes were of a complex
organization and that they had within them the
various factors of heredity. It was thought, for
example, that the part plaved by one of the smaller
chromosomes was different from that played by one
of the larger ones. The chromosomes were always
in a double series, though this series w-as not often
complete. It had been found, for instance, in the
germ cells of the squash bug that those of the fe-
male contained 22 chromosomes, while in the male
there were only 21. The double series just alluded
to w^as now regarded as being made up of chro-
mosomes respectively from the male and from the
female parent, i.e. half from the e^^ and half from
the sperm. There was considerable evidence for
this assumption, and quite recently Prof. Monk-
haus, by crossing species whose chromosomes were
of different size and therefore readily distinguish-
able, had succeeded in tracing the two kinds of
chromosomes throughout a considerable period of
development.

Prof. Wilson then showed, bs' means of diagrams,
how these cytological studies offered an easv ex-
planation of the Mendelian phenomena. At a peri-
od just before the germ cells were formed the chro-

mosomes paired. This process was called synapsis.
This was followed by a cleavage or "reduction," as
it was called, in which the maternal and paternal
chromosomes again separated. As a result half
of the germ cells were maternal in origin and half
W'ere paternal. The same held true of the sperm
cells. Un pairing it could be shown that this gave
results which agreed mathematically with the Men-
delian law. The speaker then reviewed and pointed
out which of the foregoing were proved facts and
which probably were pure assumptions.

These cxtological considerations also offered a
satisfactor}' explanation of certain forms of inheri-
tance which did not conform to the Mendelian law.
Blends, for example, could be explained by assum-
ing that in the process of synapsis the pairs of
chromosomes fused so closel\' as actually to become
one. The germ cells resulting would then have
those characters blended whose chromosomes had
so united.

In closing the speaker said that if these con-
clusions possessed any considerable amount of truth
they would probably be of great interest to physiol-
ogists and pathologists. The physiologist would
be compelled to recop'nize that in the nucleus he
was dealing not with one set of protoplasm, but
with man\- dift'ercnt ones. To the pathologist the
subject might iirove applicable to the subject of
tumor formation, for, as already stated, disturb-
ances in the chromosomes resulted in the develop-
ment of monsters. At the present time, to be sure,
the cytologist could not oft'er much help to the
pathologist ; he still had enough troubles of his own.
Finally, the speaker said, he wished his hearers to
know that in inheritance we w-ere dealing not with
vague questions, but with clear, concise mathemati-
cal prolilcms.

OUR LONDON LETTER.

(From Our Special Correspondent.

IIOSPIT.AL SU.ND.W FUND — LIVERPOOL CHILDREN'S HOSPIT.AL —
COUNTY council's HE.\LTH REPORT — THE DIET OF TO-D.\Y —
SPINAL ANESTHESI,\ — OBITUARY.

London. January ii, 1007.

1 HE Lord Mavirr presided yesterday at a meeting of the
Counci! of the Hospital Sunday Fund, when the committees
and honorary officers for the ensuing year were elected.

Yesterday the Duchess of Albany went to Liverpool and
opened tlie new building of the Children's Llospital, pro-
vided by the citizens at a cost of i68,ooo. In the course of
the proceedings Mr. Maxwell, president of the hospital,
traced its progress from its inauguration in 1851, as the
pioneer children's hospital, to the opening of tlie building
now demolished in 1866, on to eight years ago, when it was
decided to pull it down, Medical and sanitary experts were
consulted, and the present site pronounced the best in the
city for the purpose. The building comprises two pavilions
with accommodations for 100 beds, an administrative block,
an observation block, a nurses' home, and laundry. The
corporation has granted £1.000 during the last five years.

The report of the Health Committee of the County
Council has appeared, and contains the report of the Med-
ical Officer for the county for the year IQ05. The death
rate for that year is the lowest on record. It has fallen
from 21.0 to 15. 1 per 1,000, or nearly 30 per cent, since the
Public Health act for London of 1S91. But a high infan-
tile mortality remains. It is suggested that this may be
in some degree due to a more complete registration of
infants surviving their birth for only brief periods. There
is, further, an increase in the number of deaths registered
as premature, or with congenital defects, etc. Some sup-
port of this view is afforded by the fact that while social
conditions, as measured by overcrowding, seem to govern
infant mortality in several districts, this is not observable
for the first few weeks of life— a fact perhaps due to the
less complete registration of the new born. The rate of mor-
tality from phthisis in 1905 was only half tliat of the decen-
nial'period 1861-70. Tlie mortality from cancer has been

194

MEDICAL RECORD.

[Feb. 2, 1907

practically the same for several years. The increase in the
last twenty years of the nineteenth century is probably due
to more precise diagnosis. The Medical Officer devotes
considerable space to the subject of food inspection and
the absence of regulations of meat markets and abattoirs,
which it is hoped legislation will soon provide.

On Wednesday, Professor Halliburton lectured at the
Institute of Hygiene on "The Diet of To-day." We have
of late been strongly exhorted to return to a "simpler life,"
to weigh Carlyle's opinion on "low living and high think-
ing." The Professor seems to think it is time to put in a
word on the other side, for he began by saying that it was
certainly unwise to overeat. He was of opinion that it was
safer to eat rather too much than too little. The least one
could do with was not the best, for nature did not, as a
rule, work in minimums. He would not accept Professor
Chittenden's views to the lull, for the minimum diet was
not necessarily the optimum. The terms nitrogenous and
nutritious were sometimes erroneously used as synonyms.
The nonnitrogenous foods are as essential as the nitrogen-
ous, though utilized in another way by the system. Milk
is such a perfect food because it contains both classes of
nutriment. P>ut milk, when tampered with, as it often is in
the prei)aration of patent foods, loses its perfection, some
of its constituents being removed from it. The lecturer
admitted that a large amount of the proteid food we take
is not utilized lor tissue repair, but is thrown out as waste
material, at the expense of undue work for the digestive
and excretory organs. No doubt the majorit\' of well-to-do
people sin on the side of excess, and a reduction in the con-
sumption of meat and alcohol would be a feature of the
diet of the future. The Professor then referred to the
dietary of the poor in large cities and the low nitrogenous
intake in vegetarian nations, and said he held that they
show less resistance to privation and disease than meat-
eating people. This conclusion will no doubt be questioned,
but I leave the Professor to the vegetarians. He next
pointed to the good eit'ect of extra feeding in the open-air
treatment of consumption and in the rest cure for various
nerve diseases. He thought the limitation of proteid to
subserve the repair of tissue waste would mean living dan-
gerously near the margin, and he quoted Dr. Leathes as_
saying that in infants ten times the minimum quantity of
nitrogen necessary to serve this purpose was provided by
nature, even allowing for growth. The explanation of this
apparent waste, he said, was that certain constituents oi
the proteid molecule are essential for building up the
tissues, and the amount in the proteid molecule is very
limited, so the body must put up with waste material. The
large size of the liver appeared to him an express provision
of nature for dealing rapidly with this waste material.
The easy digestion of animal proteids rendered them
superior to those of vegetable origin, and the so-called
vegetarians recognized this by taking milk, eggs, cheese.
This sort of vegetarianism would perhaps spread if bad
cooking could be excluded, for badly-cooked vegetables
were more indigestible than equally badly-cooked animal
food.

The subject of spinal anesthesia was rather fully dis-
cussed last month at the Gynecological Society. Interesting
papers were read detailing cases, and specimens of tumors
removed under its influence exhibited. Dr. Macnaughton-
Jones .gave some account of what he had seen in the
clinics of Heidelberg and Freiburg. As he observed, the
method was introduced by Bier in 1899, who used cocaine
— experimenting on himself and assistant (Hildebrandt).
Results were not encouraging, but Tuffier, in France, fol-
lowed up the plan, and in igoo reported 250 operations,
142 being Laparotomies. In 1901, Hahn reported 1,708
cases, with 8 fatalities ; Morton of San Francisco, 673. In
IQ04 Bier made the next advance by adding adrenalin
and substituting stovain (first employed by Sonnenburg")
for cocaine. Doenitz was associated with Bier in this work.
From this time a host of workers have been reporting their
experiences. Franz has had no death or serious symp-
toms in 180 cases. It is obvious that there are dangers
to be reckoned with in this method, e.g. arrest of respira-
tion from involvement of the medulla and motor nerves,
collapse, spinal paralysis, sepsis, all of which have been
fatal. The advantages claimed for this method are : avoid-
ance of general anesthesia in cardiac disease and arterio-
sclerosis, also of the late and post-operative effects of
chloroform and ether, as well as of the action of the ab-
dominal muscles in laparotomies, etc. On the other hand,
the disadvantages are vomiting (rather frequent"), move-
ments of the bowels in operations on the perineum, etc.,
insufficient narcosis at times, perhaps from rapid dispersion
of the drug, collapse, respiratory paralysis, injury to motor
nerves, headache, sepsis.

Dr. Swanton's paper detailed a case of hysterectomy for
fibromyoma under spinal analgesia in a patient of 44.
There was no pain except when the vessels in the broad
ligament were seized preliminary to ligature. Then the

patient felt a twisting and dragging, which also came on
whenever the parietal layer of the peritoneum was drawn
forward. There was also some nausea and straining.
Peristalsis, too, came on and interfered with suturing, so
A. C. E. was given. The convalescence was complicated
with nausea and paralytic ileus requiring enemata of tur-
pentine.

Mr. Charles Ryall's case was also one of hysterectomy,
the patient aged thirty. During the operation the
patient did not complain of actual pain, but when the
uterus was drawn up said she felt something being
pulled. She was nervous, had some vomiting, causing the
intestines to bulge into the wound, and so making the
operator wait until this passed off. The operation occupied
forty minutes, and convalescence was uninterrupted.

Neither of these surgeons seem to regard the method
with enthusiasm, but both consider :t as useful in cases in
which general anesthesia is contraindicatcd for any reason.
Turning now to the discussion evoked, there was a good
deal of agreement with this view. Mr. Canny Ryall said his
experience extended only to thirty of forty cases, but he
would not use a general anesthetic for operations below
the level of the diaphragm when spinal anesthesia was
available. In such a formidable operation as Kraske's
he had had complete success with this method and no
shock, although the patient was under the influence of
the drug altogether for about si.x hours. Many opera-
tions on the lower limbs, appendix cases, and radical cure
of hernia had been equally successful. Ihe absence of
shock impressed him most forcibly. He had also watched
the effect on mucous membranes, and had seen no ill
effects. Patients rarely suffered from sickness after novo-
cain, and only a few had headache.

Mr. Spanton confessed he had no experience, but he
gathered that 5 deaths had occurred at one of the roreign
clinics, and at Freiburg, in 380 cases, 2 deaths — a very high
rate of mortality. In most cases, too. vomiting was re-
ported, and this is one of the drawbacks of .general an-
esthetics in abdominal cases. He had not the dread of gen-
eral anesthesia that some entertained.

Dr. Plerbert Scharlieb, as an anesthetist, said stovain,
novocain, etc., had come to stay. They were of great value,
though they were only analgesic — not anesthetic. It might
impede the operator, on the one hand, and increase shock
on the other, for the patient to be aware of every touch.
■ The objection to chloroform was its lethality, but he held
that to be due to improper dosage. The present death rate
of chloroform was I in 4,000, and up to the present that of
novocain and stovain had been higher. He would avoid
-praising the new analgesics too highly as quite safe, or con-
demning them as dangerous.

Mr. B. Jesselt (President) mentioned a case in which he
performed appendectomy under spinal analgesia con-
ducted by Mr. C. Ryall, when the pulse was observed by
Dr. Swanton. It went at one time to 150, and the ques-
tion was whether that was caused by the drug or by the
operation, or the nervousness of the patient, who certainly
seemed calm enough and was chatting all the time.

Dr. Giles congratulated Mr. Canny Ryall as a pioneer
and told him not to feel discouraged if his colleagues
waited further experience, for an open mind was the true
scientific attitude.

Dr. E. A. Fardon died on the 2d inst. He was identi->
fied throughout his professional life with the _ Middlesex
Hospital, to the service of which he gave all his energies.
He was born in 1846. Some early years he spent in busi-
ness, and entered the hospital as a student rather late. He
took the double qualification in 1S78-9. and then was
appointed successively house physician, house surgeon, and
obstetric assistant (resident). The resident^ medical ofiicio-
ship then became vacant and was offered him. and he held
it for some thirty years, with the greatest satisfaction to
all concerned. Indeed, many reforms in the hospital school
were due to his initiative. AH supporters of the Middlesex
attribute much of its progress to the unwearied work of the
late resident medical officer.

Surgeon-General R. C. Lofthouse, M.D.. who died on
Monday, entered the Army in 1854, and retired after thirty
vears' ser\-ice. He was in the Crimean War and the Indian
mutiny, was mentioned in dispatches, and was awarded sev-
eral medals and clasps.

A New Retroversion Operation. — Freund suggests
the following modification of some of the older procedures.
The round ligaments of either side are shortened by a
suture approximating two points a short distance from
the inguinal and uterine attachments respectively; the
loops thus formed are placed in front of the uterus, and
are then sutured both to this and to the anterior abdominal
wall. The author claims for this operation all the_ benefits
belonging to ventrosuspension, with none of its disadvan-
tnse^.—Z ciitralhlatt fiir Gynakologie.

Feb. 2, 1907]

MEDICAL RECORD.

195

OUR LETTER FROM THE PHILIPPINES.

tFrom Our Special Correspondent.)

FILARI.V PHILIPPINENSIS — ITS POSSIBLE ROLE IN THE SPRE.^D
OF M.\L.-\RIA — PLACUE-CONT.^MINATED ANTICHOLERA SERUM
— PERSONAL.

Manila. December 14. lootj

The regular montlily meeting of the Manila Medical
Society took place at 8:30 p.ji., December 3, 1906, at the
St. Paul's Hospital. Dr. Musgrave, a member of the staff
of that institution, gave a talk upon the use of the .I'-ray
and a practical demonstration of the machine that is in use
at that hospital.

A paper was next read by Captain Percy M. Ashburn,
Assistant Surgeon. \J. S. Army, and First Lieutenant
Charles F. Craig. U. S. Army, upon the Filaria philip^i-
iiensis. This paper was supplemental to the one which was
recently published in the Journal of Science for Septem-
ber. Four additional cases were reported, the findings of
which went to confirm the statements made in the previous
paper written by them. A very important point was
brought out by the writers, which has not heretofore been
mentioned in connection with the spread of the blood dis-
eases, that is, the role which the filaria or other animal
parasites may play in acting as intermediate host for
malarial or other protozoa. It is thought that, for instance,
the Filaria {•hilit'pincnsis might harbor the malarial para-
site, the filaria might be ingested by the niosquito, and
perhaps the mosquito might inoculate man with filaria that
contained malarial organisms. The filaria in the blood
stream of man might undergo change or disintegration,
or even without disintegration the malarial parasite might
be set free. If this were true, considerable additional light
might be thrown upon the transmission of disease, and our
present views of the period during which malaria may re-
main in the resting stage would pcrliaps be considerably
changed. It may be readily understood that if the fore-
going hypothesis proves to be correct it would perhaps
serve to explain some of the obscure cases of malarial
infection which now do not seem to be fully covered by
the mosquito theory alone. The writers promised to inves-
tigate this phase of the question and make the result of
their work known later on.

The additional cases of filaria which were reported were
found among native troops who are stationed in Cavite
province, near Manila, after being reported by the medical
officer in charge. They were removed to the First Reserve
Hospital. Manila, where thorough studies were made and
the diagnosis confirmed. It will be remembered that Drs.
Ashburn and Craig claim that their filaria differs from
others heretofore described, in that a tight sheath is pres-
ent, that the head forms a serrated retractile band, and
that the viscus forms a separate tube or cylinder, whereas
in other forms it is either negative or shows in the form
of a granular mass, and, with the exception of the Filaria
Persians, the motility is lashing and progressive, and that
it has no periodicity, being found with equal facility at any
time of the day or night.

The lamentable accident, wdiich was reported previously,
which occurred among the prisoners who were inoculated
by Dr. R. P. Strong, of the Government Laboratory, has
so far resulted in 13 deaths among the 24 cases inoculated.
The Governor-General, in order that a complete investiga-
tion of the accident might be had. appointed a .general
committee, composed of Senor Rafael del Pan, Dr. Gre-
gorio Singian, Dr. Jose Donelan, Senor Carlos Ledesma,
and Dr. .A.riston Bautista Lim. In addition to the fore-
goin.g committee, a technical committee was ap|)ointed,
consisting of Captain and Assistant Surgeon Percy M.
Ashburn, U. S. Army, Dr. Luis Guerrero, and Dr. Juan
Miciano.

The instructions to the general committee were ns fol-
lows : "This committee will investigate and report in de-
tail on the following subjects: (i) Is any anticholcra
prophylactic manufactured and properly prepared by the
Bureau of Science, or used by the Government, or any of
its authorized officials, dangerous per sc to human life?
(2) Is the anticholera prophylactic manufactured by the
Bureau of Science properly, carefully, and scientilically
prepared, and was the anticholera prophylactic used to
inoculate the prisoners referred to properly, carefully, and
scientifically prepared? In case the prophylactic used to
inoculate said prisoners w-as not properly, carefully, and
scientifically prepared, what person or persons are re-
sponsible for such improper, careless, or unscientific prepa-
ration of the prophylactic used? (3) Did the anticholera
prophylactic used to inoculate said prisoners deteriorate or
become contaminated after preparation, and if it did de-
teriorate or suffer contamination could such deterioration
or contamination have been avoided by the use of proper
care, and who or what was responsible for such deteriora-
tion or contamination? (4) Was there any carelessness or

negligence in making the inoculations in question, and, if
so, who is responsible for such carelessness or negligence?
(5) What was the direct and the indirect cause of the death
of said prisoners?"

The instructions to the technical committee were as fol-
lows : "The technical committee shall investigate the
method of the preparation of tlic cultures that were used
in inoculating the prisoners in Bilibid, their nature, and
the possibilities of contamination, and the result that would
follow the use of a prophylactic prepared by the method
used in these inoculations; also the literature relating to
cholera vaccinations and tlie results obtained therefrom in
the past. To make a scientific investigation as to the cause
of death of the prisoners in question, which must include
a complete biological and pathological study by experiment
and literature, and for this purpose authority is hereby
granted to investigate, by autopsy or otherwise, any deaths
that may hereafter occur among the inoculated prisoners,
and to make blood examinations of the blood of the vac-
cinated prisoners still living. The technical and scientific
investigations of the technical committee shall not exclude
the consideration of technical and scientific investigations
made by others, or the consideration of such other expert
evidence as may be presented. The general committee is
respectfully requested to hold a meeting as soon as possi-
ble, and jointly with the technical committee to take such
steps as may be necessary for the making of the investiga-
tion and report required by this order."

Dr. W. S. Washburn, Chief of the Philippine Civil
Service, who recently returned to the Philippines after
spending leave of absence in India and the United States,
has again been compelled to request six months' leave of
absence, for the purpose of proceeding to the United
States on account of ill health.

frngrfSB af iKriitral ^rtntrr.

.Vi"i' York Medical Journal. January 10, 1907.

The Ocular Complications of Mumps. — J. H. Wood-
ward completes the history of a case previously reported.
The patient was a girl of eleven years with left optic neu-
roretinitis followinc; infectious parotitis, which resulted in
blindness of the affected eye. Proptosis caused by anterior
staphyloma called for enucleation three and one-half years
later. Enucleation and possibly evisceration of the orbit
was advised because it was not possible to state positively
that malignant degeneration had not begun within the eye-
ball. The probabilities, however, were strongly against
that supposition, for there was no history of prolonged
pain, the intraocular tension, alth.ough greater than normal,
was not liigh, the proptosis was evidently not due to an m-
crease in the contents of the orbit behind the eyeball, the
development of the anterior staphyloma had been very
slow (one year), and the general health of the patient was
and had been, with the exception only of acute illnesses, ex-
cellent. There was some swelling of the ri.ght optic disk
at the upper and lower borders. The vessels of the right
fundus were tortuous, but the function of the eye was not
affected; vision was normal. The report of the pathologist
on the enucleated eye is given in full. Although carefully
searched for, no evidence whatever of malignant disease
was found. The case was one of proliferating neuroretinitis
due to mumps. The proptosis was a consequence of the in-
creased intraocular tension from secondary glaucoma pro-
duced by obliteration of Fontana's spaces and Schlemni's
canal.

Gastroptosis a Causative Factor of Tachycardia. —
H. Weinstein outlines the characteristics of paro.xysmal
tachycardia. The etiolo.gical factor is often difficult to find
in a' given case. It may be that it is of a reflex n.iture
brought about through interference with the proper func-
tioning of the vagi. The author gives the history of a
woman of twenty-six years, married and extremely anemic,
who had suffered from palpitation for eight months. .A.
soft systolic murmur was heard at the apex. The abdomen
presented on inspection a considerable depression m the
epigastric region; the lower abdomen bulging forward and
roimded ; the abdominal walls soft and flabby. The greater
curvature of the stomach was found to occupy a position
about midway between the umbilicus and the symphysis
pubis; the lesser curvature somewhat above the umbilicus.
A splashing sound was easily elicited, the stomach contain-
ing considerable gas and fluid. There was no visible per-
istalsis of the stomach as is sometimes observed in severe
gastroptosis. The liver was palpable somewhat below the
costal margin, and the right kidney was freely movable.
The deep reflexes were only sli.ghtly exaggerated 1 ne
pulse was small and rapid (120 per minute) and easil.y com-
pressible. The urine presented no abnormalities. It was

196

MEDICAL RECORD.

[Feb. 2, 1907

conjectured that the i)rolapsed stomach stood in a causative
relation to the tachycardia. The wearing of a proper ab-
dominal bandage promptly relieved all untoward symptoms.
It appears reasonable to assume that the prolapsed stom-
ach, dragging upon the vagi, interfered with their proper
functioning, thus causing tachycardia.

Education, Considered from a Medical Point of
View. — R. Parsons condemns the modern forcing sys-
tem of education of girls and claims that they are called
on to do too much indoor studying and are not allowed to
take the proper .amount of e.xercise in the open air. The
higher educational methods do not develop girls into
healthy or refined women. Large numbers of young girls
who are blossoming into womanhood and who will in the
course of tiine become the wives and mothers of the .'\mer-
ican people, suffer from more or less impairment of the
general health. Instead of being strong and robust, they
are threatened with a physical breakdown. The nervous
system is developed at the expense of other bodily organs.
Moreover, the girls become masculine and slangy. They
may be learned in certain forms of book knowledge, but do
not exhibit that modesty of demeanor which is one of the
most admirable traits of the feminine character. They tend
to become eccentric. Parents are largely to blame for this
state of affairs. They warn their daughters who are in
the grammar grades that active play is unbecoming to a
young lady. This fact, together with long hours of study
in school and at home, deprives the growing girl of the
opportunity of taking a sufficient amount of physical exer-
cise in the fresh air and sunshine, of which she is so much
in need. .\s time goes on the already overtaxed girl is
expected to take up the study of some accomplishments,
such as painting or music, and as the result of the constant
effort to keep up with her studies at school and at home,
the young girl is obliged to sit up late at night poring
over her books, and is thus deprived of the proper amount of
sleep. Soon the appetite is impaired, and she becomes list-
less and fretful, while it is not uncommon for her to de-
velop symptoms of anemia. Moreover, parents must bring
pressure to bear upon the educational authorities so that
the conventions may be properly modified.

The Chemical Value of the Differential Blood Count
in Operative Otology. — J. F. McKernon believes that
in septic cases and particularly when distinct symptoms
and physical signs are absent, the differential blood count
is of practical value in enabling us to complete a diagnosis,
and in cases of sepsis, when the physical signs and symp-
toms are distinct and definite, it is then only confirmatory
of what is already present, and gives us an added link to
complete the chain of evidence. In doubtful cases, when a
differential count is taken and found to be negative, other
daily counts should be taken in order to verify or disprove
that which has formerly been taken. Another fact of im-
portance brought out in this series of cases is that when
cellular bone structures, like the mastoid bone, are in-
volved in a septic inflammation, without involvement of
the adjacent blood currents, we find that in the majority
of cases the differential count shows a relatively lower
polynuclear percentage than when a septic process is pres-
ent in the soft tissues of the body. This can be explained
on the theory that an absorption of toxins is less rapid
when such a process takes place in a bone cavity than
when the soft tissues of the body are involved, for in a
number of the cases operated on, an abundance of pus was
found, when the count show-ed a polynuclear percentage of
between 72 and 80.

Journal of the American Medical Association, January
26, icx)/.

Osteoatrophic Changes in Chronic Joint Disease. — R.
S. Lavenson reports a case of chronic joint disease involv-
ing practically all the joints of the body. The most striking
feature of the case was the wasting of the bones, w-hich
was especially marked in the hands. All the fingers were
greatly shortened and some entire phalanges had appar-
ently been absorbed. Before the appearance of her disease
the patient, a woman, had been about 5 feet 3 inches in
height, weighing in the neighborhood of 135 pounds. In
her present condition her height, as nearly as it can be es-
timated in her crooked state, is not over 4 feet 10 inches.
Lavenson has found but one case in the literature that
seems closely to resemble this, that reported by Watson
{British Medical Journal, March 10, 1906). Lavenson re-
marks that the extraordinary degree of atrophy in this
case suggests some influence other than that of the local
joint disease as playing a part in bringing about the con-
ditions. The most rational consideration is naturally of
some trophic disturbance, either primary or reflexly induced
by the joint disease.

Frontal Sinus Variations. — Vi. H. Cryet^l'ustrates and
describes a number of variations, in the front\' sinuses, in-

cluding cases of multiple, unilateral, irregular, exaggerated,
and absent frontal sinuses. He remarks that the frontal
sinus is subject to infinite variations ; it may be wanting, it
may be very small, it may be single or multiple, and it may
vary greatly in extent in different individuals and on dif-
ferent sides in the same individual. He has found two cases
in which the internal plate or wall of the sinus was lack-
ing, or incomplete, and also cases in which the so-called
ethmoid cells have pushed upward into the space of the
frontal sinuses. He considers all these variations are not
the rare exceptions as some may claim, but thinks that any
thousand skulls, if carefully examined, would show equal
variations with those he describes, and if a series of a
thousand skulls with diseased pneumatic sinuses were ex-
amined, the variations would be found much greater and
more common. External evidence of these anomalies is
generally wanting, and examination through the nasal fossae
will give but a sli.ght idea. Transillumination does not give
sufficiently accurate information, and clinical experience
counts for little. A good radiogram, particularly if stere-
oscopic, is one of the most reliable witnesses for the sur-
geon's dependence in diagnosing the character of abnormal-
ities and disease in the frontal region.

The Right and Left Frontal Lobes. — VV. C. Krauss

gives an abstract of the previously reported history of a pa-
tient with glioma of the right frontal lobe of the brain, in
which the symptoms were merely severe pain and optic
neuritis, most pronounced on the right. He also reports
in full detail the history of another case of glioma of the
left frontal lobe, in which, together with the symptoms of
headache and optic neuritis, there was marked mental
apathy resembling a mild type of acute dementia, with the
consequent symptoms of slowness and hesitancy of speech,
loss of memory and ideation, but no paralysis or localized
spasm. There was vertigo and, possibly allied to this,
atactic gait, as pointed out by Bruns as existing in frontal
lobe tumors, was very noticeable. A very important symp-
tom was agraphia both for printing and writing, but more
marked for printing, before operation. .A.fter the removal
of the growth the agraphia partly subsided, although a large
part of the second frontal convolution, accepted by Gordi-
nier as the localizing center for writing, was removed. The
cause of this is only conjectural. Krauss discusses at some
length the question of the function of the frontal lobes, and
simimarizes his conclusions as follows : I. The prefontal
lobe of the left hemisphere is in all probability the seat of
memory, reason, intuition and judgment, or the higher in-
tellectual faculties. 2. .A distinct center for writing and
printing exists in the base of the second frontal convolution
of the left hemisphere.

The Opsonic Content of the Blood of Infants. — S.

.\mberg has tested the opsonic content of the blood in in-
fants, breast-fed and otherwise, and in different conditions
of health and nutrition. The bacillary species used was
Staphylococcus citrcus, and the results in the different
groups are given in tabulated form. His results do not al-
together support Moro's finding that the blood of breast-
fed infants always exceeds in bactericidal power that of
other infants ; while the kind of food may exert an influ-
ence, other factors must enter into consideration. One of
these appears to be the state of nutrition, but there are indi-
cations that there are still other factors that come in play in
certain cases. While he admits the insufficiency of the data,
the small number of cases (45), and the fact that dispensary
material is not altogether ideal, he offers tentatively the fol-
lowing conclusions : i. The opsonic content of the infant's
blood does not seem to follow the rules laid down by Moro
for the bactericidal power of the blood. 2. The average
values for the opsonic content of infants' blood exceed
those laid down by Simon for normal adults. 3. A distinct
advantage seems to exist in favor of the breast-fed infant.
This advantage does not seem to be dependent so much on
the breast feeding as such, as to some extent on the state of
the nutrition of the infant and perhaps on the constitu-
tion.

The Roentgen Rays and Malignant Disease. — E. G.
Williams suggests the possibility of a close relation be-
tw-een the vibration period of x-rays and that of atomic or
subatomic activities that constitute the vital principle in
protoplasm. It is the cells, and these in proportion as they
exhibit the manifestations of life, that are principally acted
on by the r.ays, and this explains the selective action on
malignant growths, especially carcinomas, that have the
largest proportion of vitally active cells. In the treatment
of tumors, therefore, the result depends on their constituent
cell tissues and their accessibility to the proper quality of
radiant energy. Hence the adaptability of the rays for su-
perficial malignant growths, while for deeper ones excision
is indicated, followed, of course, by sufficient exposures to
the ravs to destroy malignant cells that may be left. Ex-

Feb. 2, 1907]

MEDICAL RECORD.

197

cision should also be practised in the case of cancer of the
lips or of any mucous niemhranc, as he has found such for
some reason especially resistant to the rays.

Antigonococcus Serum in Epididymitis. — G. K. Swin-
burne has employed the antigonococcus serum of Rogers
and Torrey in thirteen cases of epididymitis. He was able
to trace eleven of the patients through the whole course of
their ailment. Eight were treated within twenty-four hours
of the beginning of their symptoms: three had had the
trouble three or four days. Three patients received two
injections, four received three, two received four, and two
received five injections. In three patients who received two
injections twciity-four or forty-eight hours apart, there
was apparent complete recovery in a few days, then a slight
relapse requiring another injection (which, if used before,
might have prevented the relapse). The injections were
given as Dr. Rogers gave his, on the back of the arm, with
due aseptic precautions. In all the cases but two the pa-
tients had no pain after the fourth day. e.xcept in the three
who relapsed. In five there was left no trace of the disease,
in four there was a slight nodule, and in two there was a
rather soft mass left about the epididymis. Four of the
cases were severe from the start. Swinburne believes the
serum had a distinct effect in all the cases, markedly modi-
fying the course and shortening the duration of the disease,
and in several of the cases the quickness of the recovery
was remarkable.

The Lancet. January \2, 1907.

Persistency of Infection in Scarlet Fever. — H. P.
Berry gives some facts derived from an epidemic in (jrant-
ham. In addition to the usual hospital isolation a nurse
was employed to isolate and subsequently disinfect the
cases remaining at home. The disease continued to spread
and the author's attention was drawn to the possibility of
infection being conveyed by means of those patients who
had apparently recovered, and he has been forced to the
conclusion that the infection may in certain cases remain in
the patient very much longer than has been generally sup-
posed. According to his investigations there were nineteen
cases which, after apparejitly complete recovery and disin-
fection, gave rise to twenty-eight other cases, and he has rea-
son to suspect that not a few others were due to this cause. It
is also evident that this persistency of infection was not
confined to patients treated in hospital, for three at least of
these "infecting" cases were treated at home. Comparing
these results with his previous experience, it appears neces-
sary to presume that this persistence of infectivity may
exist in some epidemics and not in others. Some twenty
groups of cases are summarized illustrating the theory
above advanced. The author notes the prolonged infectiv-
ity of a gleet after a gonorrhea is reco.gnized as existing for
an unknown length of time, and is inclined to the belief
that the scarlet fever infection may similarly persist, lodged
possibly in some of the nasal chambers, and that, more-
over, it may lie dormant for some time until some suitable
condition may render it capable of transmission. He is
also inclined to the view that in some of those instances
constantly referred to in text-books, when the poison is
presumed to have been harbored in infected garments for
a length of time, the spread of the infection may not im-
probably be due to the harboring of the infection in the
convalescent patient rather than, as has been presumed, in
the infected garments.

Treatment of Chronic Sciatica and Similar Forms of
Neuritis. — A therapeutic suggestion is made by J. C.
Webb, who reports four cases, and commends the use of
static electricity. He calls attention to the fact that this
form of electricity differs radically from currents derived
from battery or dynamo on the one hand — wdiether continu-
ous faradic, sinusoidal, or polyphase — and from "high-
frequency" currents on the other. Its voltage is enormous,
its amperage infinitesimal, and its frequency of pulsation
(for it is not alternating in ordinary circumstances") any-
thing that the operator wills. He employs for the class of
cases under discussion the wave current, the brush and in-
direct sparks. With regard to early sciaticas and other
forms of neuritis the author claims that invariably, if the
patient be not too old, one can effect a rapid cure provided
the case can be brought under treatment right from the
onset. .'Ml forms of neuritis or neuralgia, provided they
are not due to tumor pressure or other unremovable c.iuse,
are among the most satisfactory of the many causes that
can be cured or relieved by this most potent therapeutic
agent.

Gallstones in the Appendix. — H. .A.. Ledraid reports
the case of a m.m of twenty-six years who one month be-
fore entering hospital had had an attack of acute pain
over the lower abdomen, from which he recovered. He re-
sumed work and remained well for a while, but seven days
before entering the hospital pain again returned about the

umbilicus and gradually localized itself in the appendical
region. There were no symptoms suggesting any trouble
with the bile producing or conducting apparatus and no
.gallstones had ever been seen in the stools. His symptoms
justified abdominal exploration, and the appendix was
found to contain eleven gallstones, together with some tur-
bid mucus. The patient made an imeventful recovery. The
author stales that as a general rule the size of stones met
with in the gall-bladder or separated from fecal discharge
is too large to enter the canal of the appendix, and the
same is true for the stones of fruit, formerly supposed to
get into the appendix; the stercolith having simulated an
orange pip or a damson stone. Here again a chemical an-
alysis would effectually serve to get rid of a fiction which
has been repeated in all books and is still believed in by
some. The author suggests that all concretions found in
or near the appendix, or in an abscess or otherwise, should
be systematically examined by section and by analysis in
order to settle definitely whether a concretion is a stercolith
or gallstone, covered or not by fecal deposit.

Sclerodermia and Myositis. — Four cases are reported
by J. A. Nixon, who liriefiy details others already in liter-
ature. He notes a polymorphism existing in the disease
called sclerodermia similar, or rather analogous, to that of
rheumatism. In the cases examined after death the muscle
changes have been reported to be of either an inflammatory
nature or of what may be interpreted to be a later stage of
the nature of a fibrous degener.ition or infiltration. The
dependence of the disease and the allied muscular atrophies
upon nerve lesions is but a matter of conjecture. No posi-
tive and definite nerve lesions have been described that
could be regarded as standing in a causal relation to the
malady. Rut the evidence of primary inflammation in the
muscles of either an acute or chronic variety, ending as a
rule in a fibrosis, is amply corroborated both by clinical and
pathological facts. Beyond this it is difficult to penetrate
clearly: the indications seem to point to an acute or chronic
infection which affects mainly muscle and subcutaneous
tissue, resulting in a sclerosis of the skin and the muscle,
an infection to which perhaps persons suffering from
other general diseases are peculiarly liable and especially the
subjects of Graves' disease, myxedema, Raynaud's disease,
Addison's disease, and nerve degenerations. It seems prob-
able that myositis of a localized nature going on to sclerosis
and contraction of a single muscle or isolated groups ;s
commoner than gaierally supposed: and that the disease, of
which this is only one manifestation, may run an acute,
subacute, or chronic course, and on occasions may involve
the skin, giving rise to one type of sclerodertnia.

Pathology and Treatment of the Ocular Complica-
tions of Gonorrheal Infection. — W. T. McEttles believes
(hat the Crede method of prophylaxis in ophthalmia neona-
torum is too well established to call for more than mention.
The incubation period of gonorrheal ophthalmia is sixty
hours. We may have a true metastatic or endogenous in-
fection due in some instances to the presence of the gon-
ococcus or its toxin — this in addition to direct infection.
He regards gonorrheal iritis as far more common than is
generally supposed. In the usual conjunctivitis the progress
(lepends on the condition of the cornea. If it is clear we
may hope for good results. It is the author's practice at
once to irrigate the sound eye and then instill a silver
solution before putting on the Bullcr shield, since we have
no ground for assuming its freedom from infection. The
affected eye is then irrigated thrice daily with 200 cubic
centimeters of a solution of nitrate, i in ,^00, in warm dis-
tilled water, .•\fter each irrigation, applied by a glass un-
dine, he instills two drops of 2 per cent, nitrate and does
not neutralize with salt solution. In all adult cases he di-
vides the external canthus. This may seem a heroic pro-
ceeding, but in view of the extreme danger to si.ght it is
insignificant. One blade of a pair of strong scissors is
pushed under the commissure as far as it will ,go, and the
intervening tissues are severed at a single stroke. The
outer tarsal ligament is very resilient and will elude tlK.
grasp of any but sharp blades. It is remarkable how
greatly this facilitates the proper handling of a case. I'he
cornea is at once removed from pressure as the edem.ii'^ns
lids are depleted by the free bleeding and orbicular spjsm
is also done away with. Even more valuable is the tree
access to the retrotarsal folds. Contrary to what one .vMild
expect, when all swelling has subsided, there is very little
wound left and blepharoplastv is not needed, althou.gh that
would be a simple matter if it were. During the interval be-
tween the irrigations it is usual to employ frequently re-
newed dressings kept moist and cold on a block of ice. ."^s
a general surgical measure, the use of cold topical applica-
tions is diminishing as a result of our increased acquaint-
ance with the pathology of inflammation. This applies with
unusual force to ophthalmic surgery, where there is ab initio
a lessened vitality, in the face of which it is illogical to

198

MEDICAL RECORD.

[Feb. 2, 1907

reduce the corneal temperature, and where, moreover,
owing to the thinness of the intervening tissues, the tem-
perature can be influenced to an unusual degree. Warm ap-
pHcations, on the other hand, maintain an impaired nu-
trition and are much more grateful to the patient than
cold ones. When the stage of ocular gleet has been reached
it will be found, as in urethral work, that simple astringents
are of more use than the antiseptics.

British Medical Journal, January 12, igo".

Peliosus Rheumatica. — M. W. Williams reports a
case occurring. in a boy of thirteen years with rheumatism in
one knee. Two days afterward spots appeared on his leg.
Still later on the right cheek, with a swelling of the eye-
lids and brow. N^arious other areas became involved. The
joint trouble became polyarthritic, the boy had gastric and
abdominal pain, and finally on the eighth day a free hem-
orrhage from the bowels, while he also spat blood. The
gums were not spongy and did not bleed readily. On the
following day the fever, which had run up to over 102°
(mouth), disappeared. The urine showed no blood or al-
bumin. The joint and abdominal pains disappeared and he
was altogether better. During convalescence an urticarial
rash appeared on the trunk and right leg, freely sprinkled
with purpuric petechia;. The entire illness lasted one month.
The remedies given were salicylate of soda for the rheu-
matic symptoms and calcium lactate in ten-grain doses for
the bowel bleeding.

Partial Dislocation of the Larynx. — H. Walker's pa-
tient was a male adult who while driving in a high dog-
cart ran against a double clothes-line stretched across the
road at the level of his neck. He was throw'n over backward,
had a feeling of suffocation, heard something "click" in his
neck and became very dizzy and almost blind in his left
eye. He was a veterinary surgeon with some knowledge of
human anatomy and appreciated the nature of his accident,
finding that the thyroid cartilage displaced toward the left.
This displacement he was partially able to reduce. E.xam-
ination four or five hours later show'ed an indentation but
no fracture of the right ala. The hyoid bone was in po-
sition. The cricoid and upper part of the trachea were
carried slightly to the left. No good view of the cords
could be obtained with the inirror. The thyroid could be
easily brought back into its normal position with a distinct
grating sound. Voice was but little affected and there was
no swelling, hemoptysis, edema, or emphysema. He was
placed on his back with a straight splint to his nape.
Strapping was firmly but gently applied and an ice bag laid
against the left side of his neck. He recovered without
special incident. The pomum Adami seemed to be perma-
nently turned somewhat toward the left.

Anomalous Cases of Pernicious Anemia. — G. L. Gul-
land summarizes the histories of a group of cases in which
prominent features were variously amaurosis, symptoms
suggestive of peripheral neuritis, aphasia, gastrointestinal
disturbances, kidney disease masking the anemia, acute
Bright's. intermittent pyemia, long continued symptoms
with acute terminal attack, etc. He believes that the dis-
ease is more common than fifteen or twenty years ago. He
states that it is not essentially a blood disease at all. but
rather a toxemia of largely unknown, possibly very various,
origin, which affects the blood, the blood-forming organs,
the nervous system, and the gastrointestinal tract, in pro-
portions which vary infinitely in different cases. The old
idea of pernicious anemia, that it is a condition of rapidly-
advancing anemia leading within a short time to a fatal
issue, inust be given up, for cases are on record of very
prolonged duration, and there are many in which almost
from first to last the anemia is quite in the background,
and the prominent symptoms are those due to the affection
of one or other of the other systems mentioned. Treatment
is of value only in cases in which a diagnosis is made early.
The author does not believe that the streptococcus or any
other organism is responsible for the malady. The blood
of pernicious anemia represents in some ways a throw-back
to the blood of early fetal life, and it seems possible that
in the people who become affected there may be an inherent
weakness of the resisting power and of the blood-forming
organs which allows the bacterial processes which go on in
every intestine to get out of hand, so that quite ordinary
organisms acquire an unusual virulence, and set up the
hemolytic and other to.xic processes which one sees in per-
nicious anemias. The author has been strengthened in this
feeling by the fact that within the last few months he has
come across three cases of people in middle life whose
fathers had died of pernicious anemia, in one case ten. in
another twelve, and in the third eight years before. This
seems to point to an inherited weakness of the bone mar-
row. He advances no new ideas as to treatment. Special
stress is laid on diet. This is to be arranged w-ith care to
suit each case, but the broad principles are that as long as

the blood count is low it should consist entirely of milk and
farinaceous food ; no meat of any kind should be permitted.
Of course, this change of diet partly meets the second in-
dication, the diminution of bacterial processes in the intes-
tine. It is not uncommon to find that patients wdien they
are first seen have large quantities of indican and similar
substances in the urine, and that after a week or two on
a farinaceous diet these practically disappear. In some
cases it may be necessary to supplement this by giving in-
testinal disinfectants, of which in the author's experience
calomel and salol are the most efficient, and in still others
it may be necessary to wash out the bowel daily with large
enemata of normal saline .solution. Theoretically, the stom-
ach might be washed out as well, but patients who are so
seriously ill as to require this are seldom in a condition to
stand the strain which it involves. The secretion of hydro-
chloric acid in the stomach is practically always deficient
and usually absent in this disease, and he had sometimes
found marked improvement from giving hydrochloric acid
and pepsin in several doses after meals.

Berliner klinische JP'ochcnschrift, Jainiaiy 7, 1907.

When Should Laparotomy Patients Get Up? — Hartog

says that during the last few years it has become the cus-
tom in Landau's gypecological clinic to allow leparotomy
patients to leave their beds earlier and earlier. The present
rule is to allow patients whose incisions were sutured with-
out drainage, if no complications arise, to get up toward
the middle or end of the first week, both after abdominal
and vaginal celiotomies. The subjective feelings of the pa-
tients are largely used as a guide, and if the patient in reply
to the question of whether she would like to get up replies
in the affirmative there is no objection to her doing so even
two days after the operation. An exception is made only
in the case of plastic operations and hernia operations, but
the getting up early is regarded as of especial importance
and value when there are complicating constitutional dis-
eases, such as diabetes. The author furnishes the details
concerning a very considerable number of operations after
which the patients were allowed to leave their beds very
early, and states that no disturbances in the healing of the
wounds were noticed and that all the patients left the hos-
pital with firm scars and without any form of binder. Al-
though the patients are apt to complain somewhat of dis-
comfort in the wound on getting up early, they are all glad
to put up with this in return for the satisfaction of leaving
bed so soon. An especial advantage is the greater respira-
tory activity that is obtained, and this is of importance, par-
ticularly in dealing with old persons. Other points of ad-
vantage are the increased appetite and better digestive con-
ditions as well as a lessened tendency to thrombosis and
embolism.

French and Italian Journals.

The Serum Diagnosis of Tuberculosis. — .\ccording to
the observations of G. Ferre and P. Courmont the positive
value of the serum reaction, if it is furnished by the serum
of apyretic individuals, constitutes in the great majority of
cases a presumption of the existence of tuberculosis equiva-
lent to certainty. On the other hand, in individuals sus-
pected of tuberculosis the negative serum reaction is a sign
of real value in relation to the absence of tuberculosis.
.\lthough this method cannot completely replace clinical
diagnosis, it has a very useful application in the early diag-
nosis of tuberculosis. In addition to clinical diagnosis, it
reveals the first stage in the evolution of tuberculosis.
Seroreaction fails especially in very severe forms or in very
advanced cases of tuberculosis. It is seen at its maximum
in the cases which are on the road to recovery. — Association
Fran^aisc pour I'Avancemeiit des Sciences. Lyon, .August
2-7, 1006.

Multiple Primary Cancers. — F. Ravenna calls our
attention to the commonly made statement that malignant
tumors develop from a single primary lesion, from which
the other lesions arise by diffusion. The author believes
that there have been enough cases reported to determine
definitely that there are a certain number of cancers in
which there are two different primary foci resulting in two
entirely different types of new^ growth. He cites numerous
cases collected from literature, and to these he adds a case
observed by himself, in which there was a stenosis of the
esophagus of neoplastic origin and a tumor of the colon at
the same time. The two tumors were of entirely different
structure, one originating from the flat epithelium of the
esophagus, the other from the glands of Lieberkuhn. The
germs of cancer could hardly have been carried through the
entire intestine, passing the digestive juices of the stomach
and intestine without injury, and they could hardly have
been carried by the lymphatic vessels through so_ roundabout
a course as they must have followed to be carried from the
esophagus to the colon. — // Policlinico. November, 1906.

Feb. 2, 1907]

MEDICAL RECORD.

199

^anrtg Erimrta.

MEDICAL SOCIETY OF THE STATE OF NEW
YORK.

One Hundred and First Annttal Meeting, Held in Albany,
January 28, 29, and 30, igo".

Joseph D. Bry,\nt, M.D., President.

Monday, January 28 — First Day.

HOUSE OF DELEGATES.

The niocting of the House of Delegates took place at 8:30

P.M.

Report of the Secretary. — Dr. Wisnek R. Townsexd,
ill this report, stated that there had heen four meetings of
the ad interim House of Delegates during the year 1906
and one meeting of the Council. There were now 57
county medical societies in the State, all of which had
adopted new constitutions and by-laws in conformity with
those of the State Society. Three counties — Essex, Ham-
ilton, and Putnam — had no societies, and two counties^
Queens and Nassau — had one combined society. The total
membership in these societies on December 31, 1906, was
6,588. There had been no meetings of the District
Branches, as it had been impossible to organize them in
time, many of the county societies not having held their
elections until December. In the future, the report stated,
there would be nine meetings held in the State each year,
eight by the District Branches and one by the State Society.
The expenses of all these meetings would be paid by the
State Society, after a satisfactory agreement between the
Society and its Branches had been arrived at. During the
past year effort had been made to secure the registration
of two hundred and fifty legally qualified physicians in the
State who had hitherto neglected this fornvility, and all but
se\cnty were now registered in the County Clerks' offices.
In view of the fact that a failure to register not only en-
tailed certain legal penalties, but might render the indi-
vidual liable to prosecution as an illegal practitioner, it
was hoped all would see the importance of complying with
the laws and promptly effecting registration.

Shortening of the Session. — Dr. Leo H. Neu.\i.\n,
chairman, reported that the Committee on Scientific Work
had decided to have the scientific program completed in
two days, instead of three, as heretofore

Committee on Arrangements. — Dr. Willi.\m J. X'el-
i.is made this report.

Report of the Treasurer. — Dr. Alex.\nder L.\.\ibert
made this report, in which it was shown that the finances
of the Society were in a satisfactory condition.

Report of the Committee on Public Health. — Drs.
John L. Heffron, chairman, Henry C. Hopkins, and
H.'k.viiLTON D. Wey were the members of this committee.
The report stated that during the past year there had been
an awakening of the public mind upon some of the funda-
mental facts in public hygiene, such as no similar period of
time had witnessed. The people had been aroused to the
importance of pure food, and had enacted a law for self-
protection which, if efiicicntly carried out, would effect an
enormous diminution in the death rate. They had also
come to a realization of the necessity of protecting the
sources of the water supply from contamination with the
excrement of animals or man, and from chemical pollu-
tion from factories. The committee commended the action
of the American Society for the Advancement of Science
looking to the formation of a National Department of Pub-
lic Health, and suggested that the State INIedical Society
pledge its influence to carry into effect the plan which the
committee of the American Society for the Advancement of
Science should adopt. The committee recommended the
establishment in every county of the State of a bacteriologi-
cal laboratory, under the charge of a bacteriologist of
recognized ability, to which every physician might send
specimens for analysis. The appointment of health officers

was at present in too great degree a political matter, and
the committee recommended that the Regents should
create the degree of Doctor of Public Health, and should
grant it to such as have taken special post-graduate courses
in the Science of Public Health in recognized schools of
medicine, and that the State should enact a law making
only such as have such a degree eligible to appointment as
Medical Health officers. It was also rccommencled that
the State medical license law should be amended so as to
replace the three examining boards by a single board, before
which all candidates should be examined in all branches,
save only materia mcdica and therapeutics. By demanding
the same education of all those who would practise the art
of healing, the State would unify the profession of medi-
cine, while, at the same time, it would deprive no man of
his right to use any method of applying remedial measures
that appealed to his reason, nor would it take from any
individual the right of selecting the physician he might pre-
fer.

Report of the Committee on Legislation. — Dr.
Arthur G. Root, chairman, reported that thirty-six bills
pertaining to the public health or the practice of medicine
had been introduced in the Assembly last year, of which
four w-ere passed and approved by the Governor, and one
was vetoed. In the Senate sixteen bills had been intro-
duced, only one of which had become a law.

Report of the Committee on Publication. — Drs. E.
Eliot Harris, chairman, Floyd .M. Crandai.l, Hermann
M. Biggs, Alexander Lambert, and .A. T. Bristow com-
prised this committee. The report was concerned chiefly
with the rules which had been adopted regulating the ad-
mission of advertisements to the pages of the Directory and
the State Journal.

Report of the Editor of the "Journal."— Dr. James P.
Warbasse presented a report on the ten numbers, March-
December, 1906. appearing since he took charge. There was
at first a deficit while the Journal was undergoing develop-
ment, but it was now self-supporting. The paper could
well be increased in size, the question being one of expense
only. Every advertisement appearing in the Journal had
first been favorably passed upon by the Committee on Pub-
lication.

Report of the Counsel. — James Taylor Lewis, Esq..
presented brief synopses of forty-four malpractice suits
which had been brought against members of the Society,
fourteen lying over from 1905. and thirty instituted (hir-
ing the year. Many of these resulted in a victory for the
physicians.

Officers. — The election of officers resulted in the fol-
lowing choice: Prr.udcnt, Dr. Frederick C. Curtis of Al-
bany: First I'iee-President. Dr. J. C. Bierwirth of Brook-
lyn; Second I'iee-President, Dr. Edward Torrey of Olean :
Third Vice-President, Dr. N. G. Richmond of Frcdonia ;
Secretary, Dr. Wisner R. Townsend of New York : Treas-
urer, Dr. Alexander Lambert, of New York.

Tuesday, January 29 — Second Day.

scientific sessio.n.

The first scientific session, held in the Common Council
Chamber of the City Hall, was opened by a prayer by the
Rev. Dr. J. A. Jones of the Madison .\venue Reformed
Church.

President's Address. — Dr. Joseph D. Bryant delivered
this address.

Danger Signals from the Skin.— Dr. L. Duncan Bulk-
ley of New York read this paper, considering the impor-
tance of the skin as an emunctnry organ of the body and as
a regulator of heat. He considered briefly syphilis,
eczema, acne, psoriasis, chronic urticaria, erythema multi-
forme and bullous eruptions, pruritus, xanthoma diabeti-
corum, boils and carbuncles, dermatitis maligna or Paget's
disease of the breast, acanthosis nigricans with imiltiple
capillary angiomata. lupus vulgaris, purpura rheumatica
and erythema nodosum, petechial and erythematous rashes.

200

MEDICAL RECORD.

[Feb. 2, 1907

purpuric lesions, rose spots, pigmentary alterations, sweat-
ing, and dermatitis medii-anicntosa. lie sliowed that the
skin had vital relations with many parts of the body.

Dr. Frfjjekick C. Curtis of .Albany emphasized the fact
that !;kiii affections were largely connected with malaction,
functional or otherwise, of internal organs.

Dr. L. Bolton Bangs of New York said that the danger
signals in innocent infection from syphilis, especially as
regards deafness, could not be too strongly emphasized.
It wa.- in tlie early stages, if it could be discovered, that
prcvenlion ra' deafness might rt-snit from properly applied
treatment.

The Importance of Aural Examinations and Func-
tional Tests for Healthy People.— Dr. W. Sohier Bry-
AXT sail! that periodic examination of the ears should be
made and functional tests applied at all ages, and after any
general disease or affection of the upper air tract, inasmuch
as serious dainage to the ears might take place without the
knowledge of the patient, due to inroads of insidious affec-
tions. When the individual was aware of the impairment,
the pathological changes had advanced far enough to ren-
der recovery difficult. Whereas the early detection of the
aural disturbance allowed adequate treatment, with the
expectation of the prevention of aural vertigo, tinnitus,
deafness, the danger of systemic affection, and intracra-
nial lesions from middle ear suppuration.

Dr. Bl'Sby Allex said a very large number of patient?
learned that one ear was almost gone before they became
aware of it. Such could so easily be prevented if the
parent would from time to time test tlie child's hearin.g with
a watch. Deafness prevented by sucli a means would be a
large asset to the State.

Dr. E. EriWARtj Davis of Xow York .said that, in cases of
a hereditary tendency to deafness, the patient should be
examined every two years.

Practical Legislation for the Prevention of Blindness
from Ophthalmia Neonatorum. — Dr. E. Park Lewis of
Huftalo said that tlio purpose of his paper was not to dis-
cuss the merits of different prophylactica in ophthalmia
neonatorum. In a scientific medical society the following
fact- were accepted without discussion : That ophthalmia
neonatorum wa- dependent upon an infection. That it was
almost absolutely preventable by cither keeping the cocci
from entering the eyes of the newborn child, or by de-
stroying their virulence by the use of some germicide
before they had had time to propagate themselves. Any
one of several measures was effective, and the choice
might safely be left to competent Boards of Health. While
owing to better protective measures in the hands of hos-
pital obstetricians and others, disastrous results were prob-
ably less frequent than formerly, the exciting cause of the
ophthalmia was quite as common as ever, and in the hand-
of careless practitioners and midwives no protection what-
ever was afforded the child. Hence arose the necessity of
protecting the helpless infant through legal measures. Of
the means advised were (l) bills in the legislatures of the
several States providing for the registration of births with
the Boards of Health; (2) the distribution gialuitonsly by
the Board of Health of lightproof. sealed ampoules con-
taining the selected germicide to all physicians doing ob-
stetric practice, as well as to midwives and to others mak-
ing application for them, with advice as to the possibility of
ophthalmia neonatorum developing, measures of protec-
tion, the necessity of immediate treatment, etc.; (3) re-
quirement that on each birth certificate should be a signed
statement that the germicide provided by the Board of
Health, or some other accepted prophylactic, had been used
in each eye of the child on the day of birth ; (4) penalty
in the event of the child losin.g the sight of one or both
eyes, when the statement was not made that some measure
of protection had been taken. Dr. Lewis asked for the
indorsement of the Society as to the propriety of the enact-
ment of the laws recommended.

Dr. Peter .'\. Call.\n of New York thought it was a sad

commentary that it was still necessary to have a paper like
the one just read before the Society, and the reason lay,
he believed, in the indifference displayed by the general
profession. It was all very well to have certain penalties
on the statutes, but who was going to make it a business to
carry out the provisions? He told of his efforts to have
incorporated a contagious eye hospital a few years ago, and
he was unsuccessful because of the lack of cooperation of
his confreres. He believed that a society must be estab-
lished for the prevention of blindness in New York City,
with branches in every prominent city in the State.

Dr. L. Bolton Bancs of New York referred to the edu-
cational propaganda that all should engage in,regardingnot
only eye conditions, but dangers from other sources, espe-
cially syphilis and gonorrhea. It might be all right to enact
laws to compel midwives and obstetricians to make use of
jirophylaxis, but how about, he asked, the sources of in-
fection or contagion? How about the infected husband?
These questions pertained not alone to the moral side, but
to the economic as well, and they were questions, therefore,
with which the State and society might well concern them-
selves.

A Plea for New Methods for the Prevention of Blind-
ness.— Dr. LrciEX Howe of Buffalo read this paper, the
plan of which was (i) to show that ophthalmia of infancy
was the most important cause of blindness, and what that
meant to the State or the United States ; (2) to show that
from data thus far obtained the best preventative of this
disease was a 2 per cent, solution of silver nitrate (the
Crede method) ; (3) to show that more recently there had
been furnished several other silver compounds ; some of
them were said to have the advantages of silver nitrate
without its disadvantages ; most of them probably were
overestimated as germicides, and concerning all of them
there was a vast amount of ignorance ; (4) obstetricians
and not oculists were the practitioners who could best
decide as to the value of any of these drugs as prophylac-
tics; (5) the plea was to obstetricians to test the value of
these various compounds of silver in a large series of cases
in order to decide what superiority anyone might present
over silver nitrate. This could be done (a) by obstetri-
cians who were in attendance at large hospitals; (b) by
collective investigations of those in charge of smaller hos-
pitals; (c) by collective investigations by members of ob-
stetrical societies or members of county societies. He
closed his paper by emphasizing the advantages that would
accrue from these investigations.

Chloroma, with Special Reference to the Ocular
Symptoms. — Drs. C. S. Merrill and A. J. Bedell of
.-\lbany reported the case of a patient with double exoph-
thalmos, orbital tumors, leukemic blood, and rapid emacia-
tion, terminating in death. Photographs were shown and
the history, with the pathological report of the tumor mass
removed during life, was given. They also presented a col-
lection of statistics of ocular involvement in cases of chlor-
oma.

The Pathology of Nontuberculous Joint Infections. —
Dr. E. H. Nichols of Boston read this paper. He spoke of
a series of changes affecting joints in the young or old. m
one or many joints, causing suffering or loss of function.
He classified them into the following types: (i) Serous;
(2) ulcerative: (3) joint tending to become ankylosed;
(4) joint showing tendency to formation of new bone; (s)
fungous type with overgrowth of membrane and papillo-
matous growth extending in cavity, which might entirely fill
the joint. In the treatment of the serous type it was de-
sirable to find the original cause. In the majority of cases
these cases could be cured by operation. In the treatment
of the ulcerative type, moderate use and increasing the cir-
culation by massage, etc. This applied to the fourth type.

Pneumococcus and Typhoid Infections. — Dr. Roswell
Park of Buffalo read this paper. He first gave some his-
torical data. There were two or three ways in which joint
affections occurred. First, primarily, the purely toxic syno-

Feb. 2, 1907]

MEDICAL RECORD.

201

vitij; secondly, the embolic or truly septic form. Of
typhoid joint affections, there may be the mono- or poly-
articular forms. Typhoid complications may occur in the
spine, or even m temporo-maxillary articulation. It ap-
pears at times insidiously. Complications of typhoid not
painful; if due to pneumococcus it is painful. Attention
was called to a peculiar position assumed by patient from
hip involvement. It was rather startling to find a hip
dislocated without known cause. These cases should be
handled with great care. A joint already compromised
will be dislocated with very little applied force. A
large number of cases occur. Typhoid joint complica-
tions were not so infrequent as believed. He called
attention to the possibilities of these cases. In
pneumonia joint complications the conditions were not so
greatly different. Some cases occurred early in pneumonia,
with very serious complications. .\ doctor in Liverpool
collected 31 cases, of which 24 died. They might be polyar-
ticular. There was a furious outset, with more serious com-
plications, and lhe~e cases were exceedingly painful.

The Symptoms and Diagnosis of Syphilitic and Gon-
orrheal Affections of the Joints. — Dr. Rhxi.NALD H.
S.-\VRE of New York said that in all iirohahility many
syphilitic joints were not recognized as such, being mis-
taken for tuberculosis, rickets, scurvy, and other diseases.
He described the different varieties of lesions found in
hereditary and acquired syphilis. .\s aids in diagnosis there
was the presence of discharge and there was a history of
present or prior attacks shortly antedating occurrence of
joint symptoms. He told of microscopical examination of
fluid from the joint. The administration of antisyphilitic
treatment which was followed by a cure did not mean the
patient was syphilitic: many cases might get well in spite
of, as well as in consequence of. treatment when not syphi-
litic. Gonorrheal synovitis might be primary or secondary.
The spine might be the seat of gonorrheal inflammation.
Such cases might be diagnosed and even cured by injec-
tions of antigonorrheal serum.

Staphylococcus and Streptococcus Joint Infections. —
Dr. Lucius HoTi.HKiss of New York read this paper. The
acute form-^ iif joint infection came quite as frequently
under the care of the general practitioner and surgeon as of
the orthopedist, and formed a group of cases of the great-
est importance. He emphasized the importance of early
diagnosis. There was a tendency to classify all acute joint
inflammations as rheumatism, a fruitful source of danger
in pyogenic joint infections. He gave the general diag-
nostic features of the whole group, and special features
as applied to different articulations. There was
the necessity of e.xploratory punctures and bacteriologi-
cal study, in order to make the diagnosis with greater cer-
tainly, and to provide the patient early and appropriate
treatment. Accurate and early diagnoses were the ba^is of
all rational treatment.

Diagnosis and Symptoms of the Rheumatoid Dis-
eases.— Dr. R. R. Fitch of Rochester read this paper. He
followed the nomenclature proposed by Dr. Goldthvvait of
Boston. There were four common types of nontuberculous
joint disease, viz., (l) atrophic arthritis; (2) hypertrophic
arthritis; (3) chronic villous arthritis; (4) infectious ar-
thritis. He considered only the first three types. The
prevention of, and relief from nontuberculous diseases was
a problem not easily solved, but the division of such dis-
eases into distinct types was the first step toward rational
therapeutics.

The Mechanical Treatment of Nontuberculous Joint
Infections. — Dr. Henry Ling T.wlor of New York read
this paper. He said that the value of mechanical treatment
of nontuberculous affections was not fully appreciated by
the medical profession, because as ordinarily practised it
was often ineffective. The fear of atrophy and ankylosis
was groundless. Joint pressure or motion, or both, was
injurious in the active stages of joint infections, and might
be controlled by splints and apparatus with or without

crutches, or recumbency, according to the indications. Ade-
quate and timely mechanical control promptly relieved pain,
allayed the irritation, prevented deformity, and favored re-
covery, e.xcept in active suppuration, and in those cases
where the original focus, or general infection, was of pri-
mary importance. After the irritation had subsided, vibra-
tion, massage, and movements, active, passive, or forced,
might be required to increase motion. If from imperfect
management deformity remained, it could be readily cor-
rected by mechanical or sm-gical means. The properly
adopted mechanical treatment was the main reliance in
most cases of infectious arthritis, and when thoroughly and
intelligently applied it gave perfectly satisfactory results.

Operative Treatment of Nontuberculous Joint Affec-
tions.— Dr. Walter Wood of Brooklyn considered this
part of the symposium. He took up the topics. "When to
Operate ; Why Operation Was Delayed." He gave the results
to be obtained by early operation. He told of the methods
useful in draining ankle, knee, elbow', and shoulder joints.
The Medical Department of New York State
Library. — Dr. .\Lr.ERT Vaxder Veer of Albany said that
of the many factors entering into the advances that had
been made in medicine and surgery during the past two dec-
ades that of medical libraries held a most important po-
sition. Through their aid many members of the profession
had had access to literature bearing upon every conceivable
subject in medicine that otherwise would have been denied
them. One great value of these libraries had been in com-
pleting the sets of medical journals, and this branch of the
work, through exchanges and gifts from the libraries of de-
ceased members of the profession, had been accomplished at
a comparatively small expense. The procuring and preser-
vation of rare volumes and of a large number of reprints
that were constantly accumulating had proven of ines-
timable value. Repetition in writing upon the same sub-
ject had been avoided to a certain extent. Writers had
been able to note just what had been said upon the various
subjects in the past, and this knowledge had also been of
the greatest value. New York State was particularly for-
tunate in havin.g several of these important centers pos-
sessing medical libraries. With the completion of the State
Educational Building at .\lliany it was very desirable that
this interest should be continued, for the success of medi-
cal work could here be brought about with a minimum ex-
pense to the .State and could be administered to the ad-
vancement of the medical profession in a manner that must
result in great good to the public.

State Aid for Medical Libraries. — Dr. Smith Baker
of Utica read this paper. According to the Medical Direc-
tory of the State of New York, there were at present in
the State some sixteen incorporated medical libraries, with
an additional one at Utica but just started, and the New-
York State Medical Library at Albany. Tabulating the
lunnber of volumes in the ten libraries heard from, they
found a grand total of about 180,086 volumes. For the pur-
chase of new books and periodicals there was used an-
nually a sum derived from private and corporate sources
of something under eleven thou,sand dollars, while the
State contributed additionally to the University of Buffalo
for a like purpose the magnificent sum of just $100. With-
out taking these figures as accurate totals, they would yet
suflice well enough to bring to view and illustrate three im-
portant facts. I, That there were now but a very few pub-
lic medical libraries in the State, when there might be and
ought to be many more. Why this was so they need not stop
to discuss, although the fact itself, upon careful considera-
tion, was a matter for greater regret than any sort of cursory
notice justified. 2. That the libraries now in existence, w;th
the exception of that of the State, located in Albany, and
the $100 appropriated to the University of Buffalo, had
been paid for originally and were now maintained by funds
notice justified. 2. That the libraries now in existence, with
out help from the State beyond certain amuial reports and
the like. This, too, was a significant revelation t') one who

202

MEDICAL RECORD.

[Feb. 2, 1907

had never before investigated or given thought to the sub-
ject. 3, That for the purchase of books, periodicals, etc.,
there was e.xpendcd in the whole State a sum total of over
$11,000 annually, and yet of this amount over $9,000 came
from the same private sources as the original provision.
When this was thought of in connection with the $2,000
spent by the State for a like purpose, it became a third
revelation of equal or greater significance than the others.
It seemed strange that medical men outside of .\Ibany must
rely upon themselves alone, or upon some arrangement
with the State Library, for assistance in their
professional literary extremity. Practically, to the vast
majority of the profession of this State, the books in the
State Medical Library were not available, and never would
be; for even the loan of books which might be secured
could only be for tcmjiorary purposes, and, generally speak-
ing, practitioners found this arrangement too bungling and
unsatisfactory to be of much use. He saw no reason w-hy,
when it came to instituting here and there little collections
of books and periodicals for the daily inspiration and in-
struction of the local profession, they should not urge upon
the State with all their might the absolute justice of its
lending a very material and otherwise encouraging hand,
especially wherever the profession itself should take the
proper initiative, and thus do its part iu commanding right-
ful recognition and respect.

The Physiological Therapy of Sanatorium Treat-
ment.— Dr. Beverly O. Kinxe.ar of Clifton Springs read
this paper. He gave a concise statement of what a sana-
torium was upon a large scale, and the diseases most fre-
quently met with in large sanatoria. He also treated of
the advantages of sanatorium treatment over those usually
employed in the large cities, but chiefly in reference to the
chronic forms of disease. He called attention to the mod-
ern sanatorium treatments and their effects upon excretion
and secretion, upon the cerebrospinal centers and system,
upon the systemic circulation, the sympathetic nervous sys-
tem, upon arterial hypertension, not due to known organic
lesions. He reported special illustrative cases and gave an
exposition of why the successful results were obtained. He
specially emphasized the importance of a careful study of
the sympathetic nervous system.

Syphilitic Lesions of the Eyelids, with Reports of
Cases. — Dr. Frank Judson P.\rker of New York read this
paper. He said that the appendages of the eyes might be
the seat of any or all of the lesions of the different stages
of syphilis. The most common were the exanthemata
which varied as in other parts of the body; on the eyelids
they were of rapid growth, and they might occur at any
age and period of the infection. Inflammation and
swelling of the tarsal cartilage was nearly always syphilitic.
Chancre of the eyelids was among the rare forms of extra-
genital infection, and might be easily mistaken for lupus,
epithelioma, a suppurating hordeolum, or chalazion. In
the eye clinics of the Manhattan Eye, Ear and Throat Hos-
pital, of 33,960 eye cases treated in two years, five were
diagnosed as chancre of the eyelid. This condition was
much more common in males, and the right eye was the
more liable to infection. Ocular infection was frequently
due to accidental causes. Physicians became infected by
the coughing of patients while the throat was being exam-
ined ; Fournier had reported five such cases that came
under his personal observation. The use of public towels,
sponges, etc.. was a frequent cause of chancre of the eye-
lids, the tender epithelium of the edge of the lids being
easily abraded by rubbing. The chancre most frequentlv
occurred on the conjunctival surface and rapidly involved
the entire lid. F.idargement of the preauricular or the sub-
maxillary glands always occurred in chancre of the eyelids.
The prognosis was good. and. if treated early, there was no
destruction of tissue or deformity. Two cases were re-
ported, one a syphilitic granuloma of the lower lid, the
other a chancre on the margin of the upper eyelid.

The Spirochaeta Pallida. — Dr. J.\mes Hwing of Xew

York siK>ke on this subject, illustrating his remarks with
a lantern slide demonstration.

Symposium on Cancer. — The remaining hours of the
session were taken up with a discussion on cancer.

A Synopsis of the Work of the Buffalo State Labora-
tory During the Past Eight Years, Retrospective and
Prospective. — Dr. Roswell Park of Buffalo gave a brief
review of the history of the State Cancer Laboratory at
Buffalo and the work accomplished. He told of the diffi-
culties in securing State cooperation, and of the impossi-
bility of turning out results to order. He gave comparisons
of its work with that accomplished elsewhere, and he made
brief references to Cancer Laboratories under foreign gov-
ernmental auspices. He indicated what the future might
reveal, and what might be accomplished by continued work
in the same direction.

Parasitism and Infection — The Etiology of Cancer in
the Light of Recent Laboratory Advances. — Dr. Harvey
R. Gayloku of Buffalo called attention to the observations
made in the New York State Cancer Laboratory where
.1 cage had become infected from sarcoma rats and in
which in the course of two years three cases of sarcoma
had developed in eight rats thus exposed. These cases
developed a year apart and the cage was known to have
been infected for a period of three years. Heredity
played no part in these occurrei.jes. He further described
an infected cage which was purchased from a dealer and
brought to the State Cancer Laboratory, out of wrhich
sixty or more tumor mice had been taken in the course
of three years by the dealer, and in which five cases
of cancer had developed after the cage was brought
to the State Cancer Laboratory. \Yith these facts so
strongly indicating the infectiousness and contagiousness
of cancer, a typical small spirochete was to be found in
all the transplanted tumors thus far examined. Up to
date some twenty odd mouse tumors had been cut, giving
positive results, using the silver method of Levaditi. In
the more virulent tumors the organisms were present in
great numbers distributed in the consecutive tissues
around the margins of the tumors and in the connective
tissue stroma. They were occasionally found between the
epithelial cells and were known to have been present in
one of the strains in 1905, when they were first detected
in large numbers in vacuoles in the epithelial cells of
one of the transplanted tumors. They were now ap-
parently constantly present in three separate strains of
transplanted tumors, one being the Jensen tumor and two
tumors of American origin. The presence of these organ-
isms was interesting from the fact that they had con-
stantly accompanied these transplanted tumors for so
long a time and that in preparations stained in the ordi-
nary way there were no alterations in the histology oT
the tumors which could be deliberately attributed to the
presence of the spirochete. Having found the organisms
over twenty times consecutively by the Levaditi method,
three primary mouse tumors which did not communicate
with the air, being entirely enclosed and movable be-
neath the skin, of small size, were removed aseptically
and carefully sectioned after impregnation with silver.
In two of these tumors the impregnation method was
obviously not successful. In one of these occasional badly
fixed organisms could be found. The condition of the
tissue in the other made it obvious that the method
was not successful. The third tumor examined was prop-
erly impregnated and contained large numbers of or-
ganisms scattered through the tumor, but most plentiful
in the actively growing portions. Here they were found
among the epithelial cells, usually surrounded by small
vacuoles. They were invariably present in the larger cysts
of the tumor, which was an adenocarcinoma. They were
characteristic in appearance, from 4 to 6 microns long,
with very closely round, abrupt gyrations, each measuring
not over one-half a micromillimeter. Involution forms
were not infrequent and fields showing active phagocytosis

Feb. 2, 1907]

MEDICAL RECORD.

203

on the part of the epithelial cells were to be found. In
these cells the organisms were found curled into rnigb
or irregular masses, making mclusions such as had al-
ready been described by Prowazek for the organism pro-
ducing spirochetosis in the fowl (Brazil). By careful
examination of the transplanted tumors this organism
could be seen in the fresh state. It was very small, very
actively motile, moving rapidly forward and backward.
It occasionally came to rest, when the gyrations could be
seen, but its dimensions were so minute that neither
flagella nor an undulating membrane could be seen. .\n
attempts to stain this organism with Giemsa or utlier
aniline stains had been fruitless. In this respect it ap-
peared to differ from similar organisms seen in ulcerating
tumors described by Loewenthal and Borrel in unulcerated
mouse tumors in the Pasteur Institute, one from Ehrlich's
laboratory. Similar organisms had been found by Freu-
dentbal in an unulcerated human cancer. Loewcnlhal
and Ewing and Beebe had found them in smears from
dog tumors, and there was every reason to believe that
this organism or similar organisms were widely dis-
tributed. In connection with the possibility of these or-
ganisms having an etiological relation to these tumors.
Dr. Gaylord pointed out that the recent work of Fischer,
showing that Scarlet R would induce proliferation of the
epidermal epithelium of the rabbit's tar when injected
beneath the skin, might afford a possible explanation of
how an organism like a spirochete could induce prolifera-
tion through the medium of some toxic substance. The
distribution around the periphery of the transplanted
tumors of the organisms, in the light of Fischer's work,
was suggestive, and the evidences of phagocytosis on the
part of the epithelial cells would e.xplain how the organism
could be transported by the cells and continue the irrita-
tion necessary to the development of metastases. The
reader suggested that the task before them consisted in
careful examination of uncontaminated human tumors
for the purpose of determining with what regularity these
or similar organisms were present, bearing in mind that
in the light cf Fischer's work very few organisms could
produce extensive proliferation, and that inasmuch as
Scarlet R affected only the epithelium of the epidermis in
the rabbit and had no effect upon the epithelium of other
regions in the rabbit, it was highly probable that they
were dealing with a large group of organisms, each of
which produced a toxin, or, as Fischer called it, an at-
traxin, for certain kinds of epithelium. It was. therefore,
not necessary to look for a specific organism, but rather
an organism of a specific group, and it must be borne
in mind that there were difficulties in distinguishing be-
tween the different spirochetes thus far described.

Experimental Research in Connection with the Trans-
plantation of Carcinoma in Mice. — Dr. H. G. A. Clowes
of Buffalo presented this communication, which was a sum-
mary of his remarks made at Cleveland January 11, 1907.
He said that experimental research in cancer had received
an enormous stimulus in the course of the last few years
through the discovery of the ease with which mouse tu-
mors might be transplanted from one individual to another.
A large number of primary tumors had come into the pos-
session of the New York State Cancer Laboratory in the
course of the last three years. During this period numer-
ous experiments had been carried out in this institution.
having in view the determination of the exact conditions
under which physical and chemical agents inhibit llie de-
velopment of rapidly proliferating tumor material, and
also of the conditions under which immunity against can-
cer occurred. Three main types of tumor had been em-
ployed, possessed of low-, of intermediate, and of extremely
high virulence, respectively. In the latter scries a yield
of over 95 per cent, of tumors was obtained and the aver-
age period of time required for a fata! development was
twenty-five days from the date of inoculation. In ordT
that records of the experiments carried out might be ren-

dered permanent, a system of making charted diagrams of
the tumors in individual mice was adopted from the start,
and owing to this system it was discovered at an early
stage that a considerable number of mice recovered even
after their tumors had reached considerable dimensions.
The occurrence of such spontaneous recoveries was found
10 be most frequent in those groups inoculated witli the
least virulent materials and less frequent in those treated
with the highly virulent, rapidly growing tumor referred
to above. The subsequent inoculation of mice which had
recovered spontaneously with tumors of an equal or even
greater virulence than that first employed demonstrated
that the animals in question were possessed of a marked
immunity, practically no tumors occurring in such cases,
while control animals showed a normal percentage. The
tumor cells had been shown to be very resistant to the
action of chemicals, withstanding the treatment with mer-
curic chloride, potassium cyanide and other bodies of this
nature, of a concentration sufficiently great to destroy bac-
teria. I hey also showed a considerable resistance when
inoculated at relatively high temperatures, ranging from
40^ C. to 45° C. ; in fact, tumors possessed of a very low
grade of virulence might be stimulated to increased activ-
ity by inoculation at temperatures ranging from 38° C. to
41° C. for half an hour previous to inoculation. Evidence
of the existence of immunity against cancer was presented
as follows: (,1) The occurrence of spontaneous recovery
from true cancer. (2) Such spontaneous recoveries were
not reinoculable. (3) The reduced percentage of tumors
obtained on reinoculation of those mice w-hich failed to
take after the first injection of tumor material. (4) The
reinoculation with highly virulent materials of mice which
had been previously treated with a weak strain, which, ac-
cording to Ehrlich, lead to a considerable reduction in the
percentage of tumors, as compared with normal untreated
mice. (5) An experiment was carried out as follows: ico
mice were inoculated in the neighborhood of the head with
the virulent tumor strain referred to above, with the result
that over 95 per cent, showed tumors of considerable size
in ten to fourteen days, at which time they were reinocu-
lated in the region of the tail with tumor strains of an
equal or greater virulence than that originally employed,
while in all cases a series of unused mice were employed as
control. After a further period of ten days it was found
that large tumors had developed in all the control ani-
mals, but that those animals in which tumors were already
developed before the second inoculation showed relatively
little signs of tumor development at the second point of
inoculation. This experiment, together with the fact that
metastases seldom occurred in the early stages of tumor de-
velopment in mice, would indicate the probable existence of
antibodies in the serum antagonistic to development of iso-
lated tumor cells. (6) The serum of spontaneously recovered
mice appeared to exert a slight effect upon growing tumors
when injected directly and also to interfere to a certain ex-
tent with the development of tumor cells when admixed
with the latter previous to inoculation. In their experience
no immunity had so far been obtained by means of inani-
mate materials as, for example, tumor cells destroyed by
heat, tumor cells treated with an overdose of chemicals,
and nucleoproteids extracted from virulent tumors follow-
ing the procedure adopted Ijy Beebe in his work on exoph-
thalmic goiter. The evidence so far obtained might be said
to harmonize most readily with the parasitic theory of can-
cer. F.hrlich's recently advanced tlioor\- that cancer cells
proliferate in virtue of their iiossessinp; side chains having
greater affinity for food than those of the normal body cells
was perfectly compatible with the parasitic theory, pro-
viding the parasite or its excretory products be looked upon
as the .r-body of Ehrlich playing the part of a
stimulating or sensitizing agent. In conclusion he said
that it should be stated that all the evidence thus far ob-
tained of the existence of an immunity against cancer
would indicate that that immunity was brought about by

204

MEDICAL RECORD.

[Feb. 2, 1907

a process analogous to vaccination, the individual infected
with an attenuated or mild form of the disease from which
it recovered being found on subsequent inoculation to pos-
sess an immunity against cancer strains of equal or even
greater virulence.

Cancer as a Biological Problem. — Dr. Gary N. Calk-
ins of New York discussed the question from this point of
view, illustrating his remarks with a lantern-slide demon-
stration and the exhibition of specimens.

\V cdncsday, January jo — Third Day.
Sahli's Desmoid Reaction. — Dr. 11. C. C.\rf.y of Troy
read this paper. After describing the method employed by
Sahli, he reported upon the w rk done by him in the use
of capsules, tied at either end with catgut. The capsules
contained methylene blue, which he considered to be su-
perior to iodine or salicylic aciil. When the catgut was
dissolved by the acids in the .stomach, this liberated the
methylene blue, and its presence was noted by an examina-
tion of the urine. This method was of value in determin-
ing the digestive sufficiency of the gastric juice and its abil-
ity to digest a meal with which the capsule was given. This
method vi^as not at all suited to differentiate the functional
disorders and did not take the place of the stomach tube
and test breakfast.

A New Disease; History, Symptoms, and Pathology
of a Hitherto Unreported Lesion. — Dr. Henry P. De
Forest of New York read this paper. He reported the case
of a man with inflammation of the thoracic duct. .A-t
Autopsy all the organs were found to be normal e.xcept the
kidneys and the liver. On careful search a mass the size
of a bologna sausage was found. In the center of it was
an abscess cavity, which easily admitted the finger. The
mesenteric glands were greatly enlarged. This mass w-as
at the recepticulum chyli. and the condition extended from
there up to the ju.gular vein. Several masses were noted,
all distinctly nodulated, and all the size of a finger. The
pus could be squeezed from the thoracic duct into the jugu-
lar vein. The clinical history showed that there was first
a ptomain poisoning from shell fish. Then aggravated
.symptoms followed the eating of cold storage duck, greatly
lessening the resistance of the intestines, therefore allow-
ing ptomains to gain access to the system and bacteria as
well, the pyocyaneus showing the blue pus. When each
valve was overcome there would be a chill, and, when
finally the abscess perforated into the jugular vein, the
symptoms of septicemia developed as shown in last week
of life.

Blood Pressure Study: Some Unexpected Revela-
tions.— Dr. Henry L. Elsner of Syracuse read this paper.
He spoke of the importance of arterial tension for diag-
nostic and therapeutic purposes. He did not underestimate
the fact that we were not always able to determine the vas-
cular tension of man with absolute precision, but held that
the sphygmomanometer of to-day gave sufficiently accurate
information of systolic, diastolic, and pulse pressure to jus-
tify safe conclusions. A large part of the paper was de-
voted to the consideration of chronic arterial hypertension
and the baneful results which followed unless the under-
lying process was controlled. Hypertension was usually a
compensatory measure, and it was often a mistake to give
drugs which lowered blood pressure without considering
primary causes. Longevity depended on cardiovascular
competence. Hypertension was usually accidentally dis-
covered. In 600 consecutive examinations chronic arterial
hypertension was present in VA per cent. This gave no
idea of the frequency of this condition, and the writer was
certain that a larger number of cases would be discovered
if an equal number of supposedly healthy individuals en-
gaged,in active pursuits between the a.ges of 35 and 50
were subjected to blood-pressure study. This condition of
hypertension was found in the strenuous and active. Its
early recognition and control were of economic importance
to the State and to the nation. The rapid development of
arteriosclerosis in professional men after short periods of

hypertension was a depressing and alarming fact. Worry
as a factor in causing hypertension was considered. It
was shown by clinical e-xperience that exophthalmic goiter
was, as a rule, a disease of hypertension; that its persist-
ency was often associated with, or led to arteriosclerosis.
Diabetes was very likely to be associated with hyperten-
sion, leading to deep changes in the walls of arteries. Peri-
tonitis and typhiod fever, with its complications, were con-
sidered, and it was demonstrated that with the former,
during the early hours of its existence, blood pressure was
likely to be raised. Localized peritonitis with typhoid, also
the early hours following the perforation of the typhoid
ulcer, were associated with rising blood pressure, a fact
which was of great importance in diagnosis. The effect of
drugs on blood and pulse pressure was considered and its
importance demonstrated. It was shown that in spite of
high blood pressure, pulse pressure might be very low;
thus W'ith the high blood pressure and low pulse pressure
valuable indications for cardiac stimulation were given.
Tlie effect of filling the splanchnic vessels in the presence of
pulmonary edema was considered. The use of nitro-
glycerine with adjuvants for this purpose was recommended
in the presence of an insufficient heart with peripheral
arterial obstruction and associated pulmonary edema.

The Classification of Blood Pressure Cases. — Dr.
Louis pAUGiiRES Bishop of New York read this paper. It
was not his intention to attempt a complete classification
of circulatory diseases, all of which were dependent in their
ultimate analysis upon the distribution of blood pressure,
but rather to advocate that a particular set of cases, which
he described as hypertonia vasorum idiopathica, had a place
in such a classification. On former occasions he had classi-
fied departures from the normal in blood pressure under
three principal classes, primary low arterial tension, high
arterial tension, and secondary low- tension. He had also
described certain special cases under the name "Constitu-
tional Low .\rterial Tension," etc. He now wished to sub-
divide our high pressure cases into those due to nervous
causes, and those due to other causes. As high arterial
tension in connection with the classical cases of kidney
disease had been so often described, he passed them over
to go on to the description of the other type. Hypertonia
vasorum idiopathica stood for a class of cases in which
high arterial tension often existed, but which evidently were
neither of nephritic origin, nor had their origin in changes
in the blood-vessels. The causes were found in changes in
men's habits. The present time w-as characterized by over-
work and worry on the part of a larger proportion of the
community than formerly. Men live in a state of mental
tension that we believe to be the cause of the increasing
number of persons who suffer from this disorder of the
circulation. The treatment of this condition must of neces-
sity be by creation of such influence as would counteract
the tendency. This was possible by the employment of
drugs, which for the time being will prevent damage, but
other means must be employed. It had long been known
that physical exercise virould prevent or postpone the break-
down that eventually fol!ow-s overwork and w-orry. This
was due to something more than the indirect general good
effect of exercise on the health. It was due to the fact
that there existed a muscle tone maintaining function of
the central nervous system that had a close relation to the
blood-vessel tone maintaining function. By bringing into
healthy activity the one by exercise of the voluntary mus-
cles, the other was favorably influenced. While this was
true of ordinary use of the voluntary muscles, it seemed
to be more true when resistance exercises were employed.
Walking down stairs seemed to be a resistance exercise,
and had undoubted value in cases of weak heart with a
tendency to hypertonia. Diet was also an important ele-
ment, and must usually take the form in these cases of re-
stricting certain articles of food. Sugar and red meat could
be pronounced as a matter of experience to be harmful. Red
meat might have some direct influence on the tone-maintam-
ing function of the muscles of the blood-vessel? We had

Feb. 2, 1907]

MEDICAL RECORD.

20

.■5

called the disease idiopathic because that i'i tlic cusioni when
the exact causes had not been definitely traced out. There
was nothing wrong in the early stages with the circulatory
system. There was only something wrong with the way
in which it w'as acting. The cure of hypertonia vasoruni
consisted in regulating the functional activity of the brain,
heart, and blood-vessels so that they should run smoothly.
In some cases this was easily accomplished, and in others
only with great difiiculty, but it was never accomplished
by a single prescription or any other single measure. It
would be just as irrational to employ a physician to cure a
circulatory disorder by a single prescription as to employ
an engineer to start an engine, and then dismiss him only
to be employed again in case of a breakdown. The only
successsful treatment was by the regulation of the circula-
tion and the gradual adjustment of measures to this end.
until finally the vicious habit was broken up and the ten-
dency to hypertonia overcome. The most valuable drugs
could not be given in efficient doses, except under con-
stant supervision. It is easy also to carry exercises too
far, which at the time when they were ordered were en-
tirely correct. Nowhere else in medicine do they como
more forcibly to the consciousnses of the wrong position
in which the physician was placed when he is only called
upon to repair damage — in this case damage which never
should have occurred.

Dr. Theodore Schott of Bad-Naubeini, German), after
referring to the various instruments ni use for determin-
ing the blood pressure, said thai what was revealed by
them was of little if any value without further clinical
observations; it was only just one help. In the use of
the instruments, these sphygtnomanometers, a difference
of from 30 to 40 mm. of mercury would be noted in some
cases when they were applied above the level of the
heart or below it and in one minute's time. High blood
pressure w-as only a symptom, and must be combined with
further observations of the case. He emphasized the
point that this was only one of the signs, and nothing else.

Dr. DeLancey Rochester of Buffalo emphasized the
importance of becoming an expert with one instrument.
and not attempting to use many of them, and of making
several observations. By the use of the sphygmomano-
meter he had been able to save, without doubt, some
lives from perforation in typhoid fever. He called at-
tention to the fact tliat nitroglycerin was very evanescent
in its effects.

Dr. .'\. Jacobi of New York said that the New York
City Health Department had collected samples of tablets
of nitroglycerin from various parts of the city and from
the wholesale druggists, and they found that tablets call-
ing for a certain dose ranged from i-iooth of a grain to
i-2S00th. One who used these tablets was continually
in danger of getting that which was worthless.

The Criminal Lunatic: His Status and Disposition. —
Dr. Robert B. Lamb, Medical Superintendent of Mattea-
wan State Hospital, read this paper, dealing largely upon
the present New York practice of dealing with the crim-
inal insane. The different forms of commitments on
criminal orders were discussed, and certain apparent de-
fects in the prevalent system were pointed out, with
remedies therefor. Dr. Lamb regretted that no legal
cognizance was now taken in cases of diminished respon-
sibility or constitutional inferiority, the old legal defini-
tion of insanity being the only interpretation generally
permitted in the Courts. The customs of permitting lay
juries to pass upon the mental condition of criminal luna-
tics, and of constituting commissions of lunacy with a
medical minority, were strongly condemned. Mention
was made of the general attention this special line of
work was now attracting, both the bar and medical so-
cieties recognizing the need nf betterment of present con-
ditions. Now was the movement active in this country,
since Dr. Lamb stated that his paper was suggested by a
series of inquiries made by the authorities of Germany.
The Visions of Mary Czajka. — Dr Francis E. Fronc-

zAK, Assistant Health Officer of Buft'alo, presented this
communication by title. A nineteen-year-old Polish girl
gained a reputation of being able to foretell the future, and
to communicate directly with heaven and the saints.
Great crowds visited her at certain hours while she had
these "visions." She would sit in a chair, suddenly stift'en
out, become perfectly unconscious of all her surroundings,
and in a few seconds repeat slowly what the Blessed
Virgin or the saints would toll her. She was held in
great admiration until after a thorough medical examina-
tion, when she was declared to be suffering from hysteria
and exaggerated hallucinations. At present only a few
people saw her, and she seldom had the "visions."

The Importance of the Routine Examination of the
Urine for Indican. — Dr. Joseph D.ay Olin" of Watertown
presented this conuiiunication, in which he emphasized
the importance of a routine test for indican, from the
.standpoint of its significance and frequency of occurrence
in some of the more common ailments.

Underfeeding and Its Associated 111-. — Di Dudley D.
Roberts of Brooklyn read this paper, in which he said
that the determination of underfeeding was to be made
only by the effect of an increased diet. Certain sug-
gestive criteria were !■' be found in the physical condition,
the symptomatology and accurate determination of the
food habits, and this determination could only be reached
by painstaking cross-e.xamination of the patient. He con-
sidered the fundamental causes of underfeeding, the saving
of time and money, the loss of appetite, and the sub-
jective disturbances of digestion, .^mong the clinical types
were the gastric, the intestinal, the anemic, and the nervous.
He told of the cure in forced feeding, and the moral and
suggestive aids.

Dr. Heinrich Stern of New York stated that when
.speaking of underfeeding wc should at first know who was
underfed. Was that individual underfed who had but a
few pounds in body weight? Was not that individual
to be considered as underfed who could not perform his
accustomed amount of work without e.xertion, and who
had deteriorated in so far as his specific gravity, his cor-
poreal d'ensity had declined? Might not the supposed loss
of absolute weight be a physiological phenomenon, might
the individual not have been too heavy for his various
digestive and assimilative organs? Dr. Stern said tliat he
had pointed out, some years ago, that it was not the abso-
lute weight alone which determined a man's obesity, but his
specific weight, his body-density. Accordingly, he demon-
strated four different types of obesity: (i) That charac-
terized by increased body-density, when one had a surplus
of muscle tissue; (2) the type in which the specific gravity
remained about stationary, when one had an increase of
both muscle and fat tissues; (3) the type when one had
loss of body albumin, but increase of fat structures, when
one had a decrease of specific gravity; (4) the type in
which loss of body albumin was going hand in hand with
increase of fat and water, when the specific gravity of the
organism was at the lowest point. We had to reckon
with an analogous condition in the underfed. It would
lead him too far. Dr. Stern continued, to dwell at length
on these points on this occasion. He had frequently com-
mitted his thoughts and experiences to print. Suffice it,
he said, that we must first know whether an individual
w-as underfed before we attempted to cure him. There
was a cardinal factor always to be remembered, namely,
that most so-called underfed individuals ingested sufficient
material, but that they did not utilize it properly. That
is to say, they filled up the stomach and intestines with a
great deal of food, but their intestinal functions were
deficient in so far as they did not suffice to elaborate
properly the real nutrients from the crude ingesta, and
that assimilation was not carried on in a physiologically
sufficient manner. These individuals might starve even if
their stomachs were loaded with food. In his opinion, all
treatment of the underfed lay in the treatment of the
underlying deficiency of the intestinal functions. This must

206

MEDICAL RECORD.

[Feb. 2, 1907

be attended to firit, before one could think of upbuilding
the organism. All feeding, without this preliminary treat-
ment, he continued, would be useless. In overconnng the
marasmus of children, it was specially the fat which was
not absorbed. In such instances, fat substances which
ihd not yield fatty acids of low meJting degrees, should
be prescribed. For infants, nothing, Dr. Stern concluded,
was worse than the fat of cow's milk, which contained
10 per cent, and more of volatile fatty acids, which were
liable to be converted into acetone substances ; and noth-
nig better than the uncooked yolk of the hen's egg, which
yielded only fatty acids of high melting power.

The Technique of the Ablation of the Breast. — Ur.
Parker Svms of New York read this paper and said that
the modern methods of removing cancer of the breast
were far m advance of the older ones, and, while much
more extensive and radical, they might be done so as to
cause less shock and risk to the patient. The death rate
from the operation was very low, and the final results
as to permanent cure were far better than under the
old regime. Dr. Syms preferred the method of Dr. Willy
Meyer to all others. It was anatomical, never atypical,
and, if properly done, was bloodless. The blood-vessels
were all cut at their trunks and not at their small branches.
One half a dozen to a dozen artery clamps were ample.
The method did not consume too much time, for one hour
to one hour and a quarter should complete it. The car-
cinoma was not cut into, the lymphatics and veins were
removed from above downwards and not in the direction
of their current. There should not be any shock, and
the patient might be out oi be.l within forty-eight hours.
Death from the operation should be very rare. ]Motion and
proper function of the arm were not interfered with and
the blood circulation of the arm was seldom impaired.
Dr. Syms regarded this method of operating as one of
the greatest advances in modern surgery.

Dr. Bonner of Brooklyn said that during the last five
months he had operated upon three cases of carcinoma of
the breast, doing the operation according to the method
of Dr. Meyer. All were in the early stages and well nour-
ished. He thought it was a mistake in the technique to
permit the oozing to settle down without permitting drain-
age, which might occur in the method pursued by Dr.
Sj-ms. Grafting was better than cicatrization of the wound,
"because it permitted of better motion afterwards.

Dr. Joseph D. Bryant said that the principles involved
in the operation were most profound and of significant
benefit, contemplating the removal widely of the diseased
tissues and all the tisuses that were likely to become
involved; but he wished to supplement what had been
stated by saying that operative procedures should be
continued when there were the slightest manifestations
of return ; in other words, the disease should be fought to
a finish.

Dr. Gregor of Watertown said that he always carefully
packed the axilla and used rubber drainage, which re-
mained in one week, and the patient was discharged as a
rule on the tenth or twelfth day.

Dr. Syms said that he would drain the posterior space
if he was not absolutely sure that all oozing had ceased,
and that he drained more than one-half of his cases.
The question of grafting must be left to the decision of
the individual operator. The supplementary incision of
Warren, or better yet, that of Jackson, would provide a
flap which could be so slid to close the defect made.

Surgical Treatment of Goiter. — Dr. Martin B. Tinker
of Ithaca read this paper. I!e said the relatively infre-
quent occurrence of goiter in .\merica partly accounted for
lack of acceptance of operative treatment. Sudden deaths
from appendicitis or extrauterine pregnancy aroused the
public and profession to realize the necessity for radical
measures, but the slow development of alarming symptoms

of goiter had made all concerned ready to temporize
with goiter. In Switzerland goiter operations were more
common than appendectomies in this country and less
dangerous. The term goiter was used to include various
tumors, benign and malignant as well as simple, hyper-
trophic and exophthalmic goiter. Little that was definite
was known as to the etiology of goiter; it was more
common in women at puberty or pregnancy, sometimes
followed nervous strain, and was far more prevalent
in mountainous districts. The symptomatology was briefly
discussed ; pressure symptoms occurred with all large tu-
mors, and when difficulty in breathing and swallowing,
changed voice, cough, or even bloody expectoration oc-
curred, with small tumors, malignancy should be suspected.
In operating local anesthesia was advised; a low transverse
incision avoided visible scar; placing the incision be-
tw-een the branches of distribution of the superficial cer-
vical and supraclavicular nerves made local anesthesia
simple ; the sternothyroid and thyroid group of muscles
were divided high to avoid injuring the nerve supply;
arteries were secured first, then all veins; the recurrent
laryngeal was carefully avoided. Charts and dissections
illustrating the anatomy were presented. Statistics of
prominent internists showed a mortality much higher than
the operative mortality of experienced surgeons. Per-
sonal experience without deaths and with highly satisfac-
tory results was quoted. Operation should be urged after
thorough trial of palliative measures had failed to give
relief.

Clinical Features and Operative Treatment of Thy-
roid Affections. — Dr. George E. Beilby of Albany pre-
sented this paper, in which he made a classification of the
diseases of the thyroid gland, clinical features, and diag-
nosis. He gave reports of illustrative cases and dis-
cussed the operative technique, with special reference to
the management of Grave's Disease, or e.xophthalmic hy-
pertrophy.

Dr. Joseph C. Bloodcood of Baltimore, Md., said that the
good results of the treatment of exophthalmic goiter de-
pended more upon the early stage of the disease when it
was begun than upon perhaps any particular method of
operation. If one expected to get permanent results by
the removal of one-half or two-thirds of the gland, it
must be done in the early stage. A few years ago it was
noted that after operation the patients improved very
rapidly and the results were supposed to be beautiful;
but after a few months it remained stationary. In some
cases operated upon late there was no improvement, but
recurrences. With regard to the so-called aberrant tumors
of the neck, frequently they cut down upon them, re-
moved them, and later the tumor proved to be made up
of thyroid tissue, and the surgeon was surprised to find
myxedema develop. In eight per cent, of such cases
myxedema had developed. As far as malignant growths
of the thyroid were concerned, he had never known of
a cure after the picture of malignancy had developed.

Some Recent Clinical Observations in Intestinal Ob-
struction, Both Acute and Chronic, vrith Demonstra-
tion of Specimens and Illustrations. — Dr. Joseph C.
Bloodgood of Baltimore addressed the Society on this topic.
Intestinal obstructions was not a common disease. In
Dr. Halsted's clinic only 106 cases were on record. In
a large clinic in Germany they only averaged 70 during
the last 20 years. As a rule the general practitioner saw
these patients first, and it should be impressed upon them
that the mortality of intestinal obstruction was very great
if operation was delayed more than 48 hours. The mor-
tality of operation 48 hours after the onset was about 70
per cent. ; within 24 hours -he number of recoveries was
70 per cent Therefore, the results were a matter of
time. The question arose as to the possibility of recog-
nizing obstruction of the intestine within that limit. He
said it was possible if certain rules, which were difficult

Feb. 2, 1907]

MEDICAL RECORD.

207

to follow, were followed. Every individual suffering from
abdominal pain might be developing intestinal obstruction ;
yet out of 100 so suffering only two or three would
develop it. lii looking over his cases his experience taught
hun that any patient who had pain enough to require the
use of morphine, if the pain was not in the region of the
kidney or gall-bladder, and not followed in a few hours
by watery stools, might be presenting the symptoms of a
bcguining obstruction of some form. According to the
pathology he divided these cases into two groups : first,
strangulation in which the lumen was not only obstructed,
but the circulation interfered with as well, and, secondly,
obduration, in which the lumen was blocked, but with no
interference with the circulation. In the first, the symp-
toms were more acute, an inmiediate operation was mora
demanded, and the diagnosis easier. In the second, the
symptoms were less acute, the importance of early opera-
tion was not so great, but unfortunately the diagnosis
was more difficult. The cause of abdominal pain was not
yet known. Whenever a patient suffered acutely from
abdominal pain, initial vomiting, and shock, he advised
against the giving of morphine. Give no treatment except
a rectal cnemata and wash out the stomach.

Toxic Nephritis Dependent Upon Surgical Con-
ditions.— Dr. Nathan Jacciuson of Syracuse read this
paper. He presented three cases. The first one was
presumably of staphylococcus infection in which the pa-
tient suffered from septic endocarditis as well as from
nephritis; the second was a case of intestinal obstruction
without septic disturbance of any kind, and in which in
consequence of the complete arrest of intestinal function
a very serious and all but fatal form of nephritis was
awakened ; the third was one in which there was compli-
cating gallstone disease, a subacute pancreatitis, and in
consequence of the disturbance of the secretory function
of this gland a toxic condition was aroused, causing not
only a nephritis, but also glycosuria. In each of these
three cases, after the removal of the causal condition, all
evidences of renal disease disappeared.

The Surgery of Foreign Bodies in the Respiratory
Tract. — Dr. W. G. Macdonald of Albany presented this
communication. He said that foreign bodies aspirated into
the respiratory tract would always be an important chap-
ter in emergency surgery so long as infants were per-
mitted and adults voluntarily used their mouths as store-
houses for an infinite variety of foreign bodies. Until
very recently the mortality associated with this accident
was very great, being from 15 to 27 per cent, in operated
cases and from 23 per cent, to 51 per cent, in the non-
operated cases. The material improvement in the mor-
tality might be attributed to the greatly increased skill
of those who were especially interested in the field of
the respiratory organs. The discovery and universal
employment of the Roentgen ray for diagnostic pur-
poses, the inventions in mechanism of the direct in-
spection of the laryu-K. trachea, and bronchi, and the
recent development in technique had conspired to make
diagnosis more certain and operative technique more sim-
ple, sure, and successful. Dr. Macdonald then referred
to the striking features which presented in fourteen opera-
tive and two nonoperative cases and gave a cursory review
of the literature. A very striking feature lay in the size
of the bodies aspirated. In one case was a hatpin, four-
teen cm. long and having a glass head more than one
centimeter in diameter; artificial tooth plates having as
many as four teeth had been aspirated, etc. From his
clinical experience Dr. Macdonald said that the normal
plan of treatment of foreign bodies lodged in the deep
trachea or bronchi was a preliminary inferior tracheotomy.
If the body was mobile, a wide tracheal incision, well held
open, would lead to the expulsion through the violent
attacks of coughing. If the body was fixed in the bronchus
or the lower trachea the bronschscopem, usincr a shorter

tube, might be employed. With bodies fixed deep within
the trachea there was failuic to secure their removal
at the primary stage in about ten per cent, of the cases.
Under such circumstances the edges of the tracheal wound
should be sewed to the skin, a large tube introduced, and
the operation ended.

Foreign Bodies in the Utenis.— Dr. B. S. Tai-mhv of
New York read this paper. He said that the occurrence
of foreign bodies in the uterus was relatively rare, and
hence every case should be reported. The cases might be
divided into three classes as follows: (i) Those intro-
duced into the uterus for the purpose of emptying the eon-
tents of conception; (2) those introduced into the uterus
by accident; (3) those introduced for onanistic purposes.
To the latter class belonged the first case, a girl, 19 years
old, in whom was found a hairpin sticking in the cervical
canal. The second case belonged to the first class, where
a bougie 22 centimeters long was introduced into the uterus,
perforating the same. The laparotomy showed the bougie
to be buried under the loops of the intestine. Dr. Taliney
said that, although these cases were rare, still it would be of
use to make the practitioner familiar with the question.

Further Observations Upon the Treatment of Diffuse
Septic Peritonitis Following Appendicitis, with a Report
of One Hundred and Forty-five Cases Treated by the
Elevated Head and Trunk Positions.— Dr. Russell S.
Fowler of Brooklyn read this paper, and in conclusion
stated the salient points in the treatment of these cases
were as follows ; r. A small incision and the avoidance of
eventration. 2. Thorough cleansing of the primary focus
of infection and removal of the appendix. 3. Va'cualion
and clean,sing of all accessory abscess cavities and the pel-
vis before washing out the peritoneal cavity. 4. A rapid
systemic flushing of the peritoneal cavity with hot saline.
5. The continuance of the saline flushing until the sutures
were placed, and for the most part tied. 6. The provision
of proper drainage for the pelvis, cither by means of a
large glass tube containing a capillary drainage strip
emerging through the lower angle of the wound, or in
females by a large caliber rubber tube filled with wicking
passed through a posterior colpotomy incision. 7. The
drainage of accessory abscess cavities with gauze or wick-
ing. 8, The elevation of the head of the bed to accelerate
the drainage of septic fluid into the pelvis, whence it could
be removed through the tube, or in case of vaginal drain-
age find a ready exit. He stated that there were a few
cases of diffuse septic peritonitis which might be safely
closed without drainage.

A New Operation for the Radical Cure of Femoral
Hernia.— Dr. A. V. Moschcowitz of New York presented
this paper. In his introductory remarks he reviewed the
large number of operations that had been done hitherto,
and pointed out their shortcomings. These shortcomings
were due to the fact that they did not permit a high
closure of the peritoneum, and that they did not close up
the internal femoral ring. In order to obviate these faults,
he operated through an incision in the inguinal region,
and converted the femoral into a direct inguinal heniia.
The sac was then ligated or sutured in the usual manner,
which could be readily done under the guidance of the eye,
and so high up as to obviate the formation of a peritoneal
dimple. The internal femoral ring was then closed In-
suturing Poupart-'s ligament to Cooper's ligament and to
the periosteum of the pubic bone. The subsequent steps
of the operation were those of the Bassini operation for
inguinal hernia. Dr. Moschcowitz then poinied out the
ease and facility with which the operation could be done,
and the other advantages, particularly in cases of strangu-
lation. He said he had operated by this mclhod upon
twenty cases, the first case having been operated on in
May, 1905. All the cases were kept under continuous
observation, and thu« far there w-as not the slightest trace
of a recurrence.

2o8

MEDICAL. RECORD.

[Feb. 2, 1907

^tatf Mplitral iCtrpitstng loar^s.

STATI-; BOARD IIXAMI.XATION QUESTIOXS.*

Board isr Mrmcai. Examineks kor the State of Texas.
October 16. 17, and 18, 1906.

(flic applicant will answer ten questions of his own se-
lection in each of the following papers.)

ANATOMY.

1. Describe a dorsal vertebra.

2. Ciive origin, insertion, and action of the pectoralis
major nmscle.

},. Xanie the nerves that supply the tongue and .give
their function.

4. Give the relations of the radial artery. an<l name its
branches.

5. Describe the spleen.

6. Xanie the points oi special interest of the popliteal
space.

7. Xame the ligaments which suspend the uterus.

8. What area is drained by the right lymphatic duct?

9. Describe the elbow joints.

10. Describe the artificial divisions of the abdomen, and
name the contents of each subdivision.

11. Describe the great sciatic nerve.
12 Describe the rectum.

I'ilVSIOLOGV.

1. E.xplain what is meant by "blcod pressure" and
"peripheral resistance."

2. At what point in the circulatory system does the
blood flow most rapidly?

3. Which travels with greater rapidity, the pulse or the
blood stream?

4. In what organ is lymph most rapidly formed?

5. How is digestion modified by the absence of hydro-
chloric acid from the gastric juice?

6. To what kind of diet is the addition of sodium chlo-
ride of most importance?

7. What are the limitations to the use of milk as the
sole article of diet?

8. What is meant by "internal secretion"?

0. What is the chief source of urea?

10. What are the functions of the red blood corpuscles?
IT. Why does the injection of a large quantity of nor-
mal saline solution into the vessels cause diuresis?

12. What are the functions of the pancreatic juice?

CHEMISTRY.

1. Define molecular weight.

2. Define potable, hard, and temporary hard water.

3. How is H:S prepared? Write formula.

4. Describe the bismuth test for sugar in the urine.
What is the objection to this test?

5. Mention chemical and physical properties of arsenic.

6. Upon what reaction does the cooper test for sugar
in the urine depend?

7. What do you understand by diffusion of gases?

8. What is the chemical antidote for bichloride of mer-
cury ?

9. What are the chemical incompatibilities of iron and
antipyrine?

10. What are fats, what are soaps?

11. Give atomic weight and valence of hydrogen, lead,
sulphur, and mercury.

12. What is the relation between albumin and the spe-
cific gravity, and sugar and the specific gravity of the
urine ?

HISTOLOGY.

1. To what part of the anatomy does histology apply?

2. What relation does a knowledge of histology bear to
physiology?

•It is proposed in this department to publish from time to
time the examination papers of the various State Boards,
in order that a candidate may become familiar with the
character of the examination and so in some measure free
himself in advance from the nervousness and dread which
the unknown inspires. Tn furtherance of the same object
answers to some of the questions will be published in order
to show the candidate what the examiners expect of him.
Not all the questions of all the papers will be so treated,
for the nnswers to many, especially in the anatomical papers,
are obvious or can be found in the index of any text-
cook on the subject: the answers to other questions, especially
in the sur.sical papers, must sometimes be omitied because of
the space they would demand. The candidate for a medical
license will not find in these answers a short and easv road to
success in the examination, for he is not likely to meet the
same questions in the papers placed before him bv the
examiners. The object of publishing the questions and
answers is only, as noted above, to acquaint the candidate
with the general character of these examinations and to
Inspire him with confidence in the result of his trial.

3. Describe in a brief way the histology of the kidney.

4. Give the minute anatomy of the liver.

5. Name the minute endings of the bronchi.

6. What are Haversian canals and where found?

7. Mention the communication between the great sys-
tem of blood-vessels.

8. Mention the three great groups into which the tissues
of the body are divided.

9. What arc the principal forms of fibrous tissue?

10. Mention principal difference between cartilage and
bone.

11. What structures compose secreting glands?

12. What are lymphatic glands, and where are they
found?

PATHOLOGY.

1. Describe in a brief way the pathology of yellow
fever.

2. In what part of the system would you expect to find
primarily the infectious element in yellow fever?

3. From results of 'recent investigations, what, in your
opinion, is the infectious element in yellow fever, and how
is it conveyed ?

4. What other infectious disease, common in the coun-
try, the morbid appearances of which sometimes so much
resemble those of yellow fever?

5. What, in your opinion, is the source of infection in
malarial diseases?

6. In malarial cachexia, or chronic malarial poisoning,
what morbid conditions are usually found?

7. A case — age 26. Recurring hematemesis, profuse —
enormously enlarged spleen. Anemia- — lemon-tinted skin —
moderate general dropsy. Sclera bluish white ; digestion
poor, with inclination to costiveness. History : Two or
three terms of chills in boyhood, each lasting one year
nr more. Diagnosis made without microscope. Gave him
quinine in acid solution for six or eight weeks — nearly
400 grains in all. Spleen reduced like magic to almost
normal size, no more hemorrhage, dropsy disappeared, skin
resumed more natural tint, when he passed from under my
care. What, in your opinion, was the morbidity causing
the hemorrhage; and what caused this morbidity?

8. Where would you expect to find oathological lesions
in hydrophobia, and mention some of the most pronounced.

9. What pathological lesions to be found in simple acute
endocarditis?

10. How does endocarditis dififer from acute plastic
pericarditis pathologically?

11. Which of these will likely afifect most seriously the
circulation of the blood, and w'hy?

12. Mention some disease which is most commonly the
cause of either or both of these morbid conditions.

1. What is intestinal obstruction and its pathological
anatomy ?

2. In acute indigestion resulting in cholera morbus,
what would be your first plan of treatment?

3. What are biliary calculi, their cause and treatment?

4. How would you diagnose and treat a case of gastric
cancer?

5. What is sciatica, symptoms, and treatment?

6. What are the symptoms and treatment of acute ca-
tarrhal laryngitis?

7. How would you diagnose and treat a case of diph-
theria ?

8. What are the methods employed in making an ex-
amination of the heart? Describe the same in normal con-
dition.

9. What is epilepsy, its cause, and varieties?

10. What is interstitial nephritis?

11. What is anemia, its causes, and pathological
anatomy?

12. How would you diagnose a case of croupous pneu-
monia?

SURGERY.

1. Give the principal methods of abdominal drainage
with which you are familiar. What method do you con-
sider best?

2. How would you treat a case of ingrown toe-nail?

3. Mention the most important symptoms of an acute
synovitis involving the hip-joint.

4. Give your treatment of a large varicose ulcer of the
leg.

5. What are the principal si.gns of a simple fracture
involving the femur?

6. What important tissues may be accidentally wounded
during an operation for femoral hernia?

7. What are the symptoms of acute intestinal obstruc-
tion?

Feb.

1907]

MEDICAL RECORD.

209

8. How should an aiieiirysiu of the femoral artery be
treated?

9. How would you treat a large varicocele?

10. Describe in detail how you would correct the de-
formity and dress a case of CoUes' fracture.

11. Describe in detail how you would proceed to control
hemorrhage during an amputation of the hip-joint.

12. How would you treat a carbuncle?

EYE, EAK, NOSE, AND THRO.XT.

(.Four questions to be answered.)

1. What are the dangers of otitis media?

2. How would you make a differential diagnosis be-
tween a case of diphtheria and a bad case of follicular
tonsillitis?

3. Upon what would you base a diagnosis of suppu-
rating disease in the antrum of Highmore?

4. Describe in detail how yon would proceed to remove
a small foreign body embedded in the cornea.

5. Upon what symptoms would you make a diagnosis
of mastoiditis?

OBSTETRICS.

1. (a) What is the connection between ovulation and
menstruation? (b) What is the average duration of men-
struation? (c) What is the interval between the men-
strual periods? (d) Give the average age at which men-
struation first occurs.

2. Describe the axis of the inlet and the outlet of the
pelvis and the axis of the cavity.

3. How are the organs of generation divided, external
and internal?

4. Describe the changes which occur in the ovum after
impregnation.

. 5. (a) What are tlie uses of the liquor amnii during
pregnancy? (b) During labor?

6. (a) What is puberty? (b) Describe the changes
that take place in the female at puberty.

7. (a) What comprises the puerperal state? (b) De-
scribe the maternal changes during that period.

8. Describe the lochia and the conditions that change
its composition and quantity.

9. Give the diagnosis and treatment of trunk presenta-
tions.

10. In what way may delivery be arrested in twin
births? Describe the management of the same.

11. Give the causes, diagnosis, and treatment of puru-
lent ophthalmia neonatorum.

12. Give causes, pathology, and treatment of thrush.

1. What is the difference between a contagious and an
infectious disease?

2. Describe two of the best methods of fumigation to
prevent the spread of contagious diseases.

3. What steps are essential to prevent tlic spread of
typhoid fever from a patient to other members of the
household?

4. Describe a good plan for ventilating a sleeping-room
in a temperate climate during winter.

5. What are the normal constituents of atmospheric
air?

6. What are the deleterious ingredients of exhaled air?

7. What is meant by absolute and relative humidity?

8. What symptoms are produced in some persons by
sudden changes from low to high altitudes?

9. Why should the principles of hygiene be observed
in construction of dwellings?

10. In the selection of a building site, what things are
to be sought and what avoided?

11. How would you guard against the bowel disturb-
ances of infants during their first and second summers?

12. From what foods does ptomain poisoning arise?

MEDICAL JURISPRUDENCE.

1. Dctme forensic medicine.

2. Briefly enumerate the difference between an ordi-
nary and a medical expert witness.

3. Enumerate the general rules to be observed in testi-
fying as an expert witness.

4- Define criminal and civil malpractice.

5- Briefly enumerate what you would do if called to
vievv the body of a person found dead.

6. What do you understand by personal identity?
/■ Give a practical and reliable test for human blood

8. State what is considered a live birth bv law and
what manifestations of life would establish it medico-
legally.

9. If called to see a person before death suspected of
having been poisoned, state what steps you would take to
determine this fact both before and after death

10. What do you understand by a dying declaration, and
what is its value in court?

11. Give a differential diagnosis between opium poison-
ing, acute alcoholism, and apoplexy.

12. If called to view a person found dead from gunshot
wound, state how you would determine as to whether it
was probably suicide or murder.

ANSWERS TO STATE BOARD EXAMINATION

QUESTIONS.

Bo-^RD OF Medical Examiners for the State of Texas,

October 16, 17, and 18, 1906.

physiology.

1. Blood pressure is the pressure on the blood due to
the ventricular systole, the elasticity of the walls of the
arteries, and the resistance in the capillaries. This latter
is called peripheral resistance.

2. At the beginning of the aorta.

3. The pulse travels at the rate of about fifteen to thirty
feet per second in the arteries; the blood stream travels at
the rate of about one foot per second in the arteries.

4. There are two theories as to the formation of lymph :
— (i) That it is formed from the blood plasma by the
processes of filtration, difi'usion, and osmosis. (2) That
in addition to these, the endothelial cells of the capillaries
exercise some influence.

5. Proteid digestion may be slightly delayed.

6. Vegetable foods.

7. During the earliest months of life milk is a perfect
food. Later on it will not suffice, as it contains too little
iron ; further, tremendous quantities of it would have to be
ingested in order to ensure an adequate supply of carbon
and nitrogen.

8. It is generally held now that the glandular organs,
chiefly the pancreas, liver, and the ductless glands, produce
a secretion, peculiar in each case to the particular gland
producing it, and which is supposed to be given off to
the blood or lymph, and to have some peculiar value in the
general metabolism of the body. Such secretions are called
internal secretions, in contradistinction to the previously
known secretions, which are carried off by a duct, and are
known as external secretions. Very little is definitely
known of these internal secretions, but much work is being
done on the subject.

9. Urea is produced from the proteids of the food and
tissues. It is chiefly formed in the liver.

10. To carry o.xygen from the lungs to the tissues.

11. The normal salt solution abstracts water from the
tissues of the body and causes a condition of hydremic
plethora; the capillaries of the kidneys thus contain a
greater quantity of blood, and capillary pressure is in-
creased. The result is:— (i) more rapid filtration, and
(2) an increased amount of urine.

12. ( I ) It changes proteids into proteoses and peptones,
and afterwards decomposes them into leucin and tyrosin ■
(2) it converts starch into maltose; (3) it emulsifies and
saponifies fats; and (4) it causes milk to curdle.

CHEMISTRY.

1. Molecular weight is the weight of a molecule of z
substance as compared with the weight of an atom of
hydrogen. It may also be said to be the sum of the weights
of the atoms composing its molecule.

2. A potable water is one that is apparently fit to drink.
.A hard water is one that forms a curdy ' deposit with
soap. In a temporary hard water the hardness is due to
the bicarbonates of magnesium and calcium, and can be
removed by boiling and filtering.

3. H:S may be prepared by treating ferrous sulphid with
dilute sulphuric acid. Thus :— FeS -F HiSO, = FeSO. -f

H:S.

4. Albumin, if present, must be removed. Add to the
urine enough Na^CO., to render it strongly alkaline. Put
about three cubic centimeters of the urine into a test tube,
add a very small quantity of powdered bismuth subnitrate*
and boil. If sugar is present the bismuth powder be-
comes black. The test is not reliable, for other substances
than sugar will produce the reaction.

5. .A.rsenic is a brittle gray solid with a metallic lustre,
or a black amorphous powder. It is insoluble in water, and
IS either odorless or has the odor of garlic. It is tarnished
by moisture; in dry air it is not altered; heated in air it
becomes arsenic trioxide. It combines with most metals,
also with chlorine, bromine, iodine, sulphur, and with nas-
cent hydrogen.

6. The boiling alkaliui solution converts glucose into
substances which are very easily oxidized, and are there-
fore good reducing agents. If cupric sulphate is present it
is converted into cuprous sulphate, which latter is decom-
posed, and curprous oxide is deposited.

2IO

MEDICAL RECORD.

[Feb. 2, 1907

7. \\ hen two gasc-s arc plactd side by side, or are sep-
arated from each other by a porous substance, the gases will
pass into one another, and a homogeneous mixture is the
result.

8. White of egg, m moderation, and followed by an
emetic.

9. The chief incompatibles of Iron are: acids, acid
salts, vegetable astringents, alkalies, and their carbonates.
Of Antipyrinc: nitrous compounds, ferric salts (in solu-
tion), nitrites (in solution), chloral hydrate, tincture of
iodine, mercuric chloride, and tinctures containing iron or
tannin.

10. Pals are mixtures of the glycerol esters of stearic,
palmitic, and oleic acids. Soaps are the sodium or potas-
sium salts of stearic, palmitic, and oleic acids.

11. Hydrogen: atomic weight, i; valence, i. Lead;
atomic weight, 207; valence, 2 or 4. Sulphur: atomic
weight, 32; valence, 2 or 6. Mercury: atomic weight, 200;
valence, 2.

12. (i) Tlie presence of Albumin may have no material
effect upon the spccitic gravity of the urine, but (2) a
specific gravity lower than normal has been held to denote
the presence of albumin. Sugar in the urine causes a
higher specific gravity.

HISTOLOfiV.

1. Microscopically, to all parts.

2. Histology treats of the minute or microscopical struc-
ture of the various tissues and organs of the body ; physiol-
ogy is concerned with the functions of the same. Hence,
a knowledge of the former is supposed to be an aid to the
proper understanding of the latter.

5. The alveoli.

7. The capillaries.

8. Epiblastic, mesoblastic, and hypoblastic.

9. White fibrous, yellow elastic fibrous, mixed fibrous,
mucous, and retiform; areolar and adipose tissues also con-
tain some fibrous tissue.

10. Bone tissue is impregnated with lime salts.

11. A basement membrane, epithelial cells, vascular tis-
sue with lymphatics, nerves, and capillaries, secreting cells
which are capable of elaborating the elements proper to the
particular secretion.

P.'^TIIOLOGV.

1. Rigor mortis is well marked, and appears early; the
muscles are dark and dry; the skin is yellow or very dark,
yellow green ; subserous hemorrhages are found in the
iungs and heart, and the blood may be thin and fluid. The
gastric mucosa is strongly congested and swollen, and hem-
orrhages into the membrane and in the cavity are common ;
the blood is dark and thick; in the upper part of the small
intestine similar lesions may be found, and in the colon
there may be dysenteric necrosis. The liver is swollen, or
moderately decreased, soft, and of a color varying from
dark red to light yellow, with bile staining; the gall-bladder
contains a small amount of dark, thick bile. The spleen
may be small. The kidneys show acute nephritis, often
hemorrha.gic. (Thayer's Pathology.)

2. In the blood.

,V Probably Bacillus ictcroidcs of Sanarelli. It is
conveyed by the Slcgomyia fasciata mosquito.
4. Severe bilious or remittent malarial fever.

3. The Plasmodium or hcmato:oon mclarice. conveyed
by the anopheles mosquito.

6. Secondary anemia; diminislied number of white blood
corpuscles ; spleen enlarged, hard and pigmented ; liver
enlarged ; kidneys pigmented ; skin, dirty yellow color, and
sometimes paraplegia and orchitis may be present.

7. Chronic malarial poisoning or malarial cachexia.
Caused by the Plasmodium malaria.

8. The upper part of the spinal cord. pons, medulla, and
cortex of the cerebrum. Hemorrhages, and dilated and
congested blood-vessels.

9. Vegetations occur on the valves or on the lining mem-
brane of the cavities of the heart. These vegetations con-
sist, at first, of fibrin and leucocytes, later of connective
tissue, ^ticroorganis^ls are also generally present.

11. The endocarditis; because the vegetations present
may become broken off and carried by the circulation to
distant parts of the body, thus causing embolism or infarc-
tion.

12. Both of these diseases may be caused by acute artic-
ular rheumatism.

PRACTICE.

2. Remove any irritant or offending matter ; give calomel
in fractional doses, and, to allay the pain, a hypodermic of
morphine (grain Ya) and atropine (grain 1-120).

3. The predisposing causes are: age, sedentary habits,
and obstruction of the bile ducts. The exciting cause is
microbic infection of the gall-bladder. The treatment dur-
ing an attack: inhalation of chloroform, a hypodermic of

morphmc ami atropine (as in question 2 above), application
of heat, and diffusible stimulants if shock is present. Prophy-
laxis includes : plain and easily digested food, the ingestion
of plenty of good drinking water between meals, sufficient
outdoor exercise, salines, and the avoidance of indigestion.

7. For diagnosis, see below, Eye, Ear, Nose, and Throat,
question 2.

SURGKRV.

I. Gauze; rubber tubing; glass tubing; strands of gut,
or horsehair, or silk. There is no one method that is uni-
versally best. For blood or serum, capillary drainage along
a strip of gauze is best; for pus, the tubes arc better em-
ployed.

3. Pain; limited movement of the joint; the limb is

flexed, abducted, and everted ; there may be tenderness and

fullness in Scarpa's triangle and in the gluteal region ; the

. muscles controlling the movements of the joint may

undergo tonic contraction or become atrophied.

6. The oliturator artery, if abnormal; the deep epigas-
tric artery ; the spermatic cord, in the male ; the round
ligament in the female. This latter is not of much conse-
quence, but, if the spermatic cord is cut, the vas deferens
and spermatic artery are also severed.

8. It may be treated by (i) extirpation, or (2) ligature
of the common femoral or superficial femoral artery, or (3)
by compression in the groin.

EVE, EAR, NOSE, A.MD THROAT.

1. Deafness or impairment of hearing; necrosis of the
ossicles; caries or necrosis of the temporal bone; polypi;
inflammation of the mastoid cells and antrum ; choleste-
atoma; facial paralysis; subcranial abscess; cerebral com-
pression; meningitis; thrombosis of the lateral sinus;
abscess in the cerebrum or cerebellum ; death.

2. In diphtheria the onset is more gradual; the temper-
ature rises to about 101° to 103° F. ; the tonsils are not
much enlarged ; there is an exudate of a thick grayish mem-
brane which is very adherent, is removed only with difli-
culty, and leaves a bleeding surface ; this membrane soon
re-forms and may be found on the fauces and pharynx as
well as on the tonsils ; in the exudate the Klebs-Loffler
bacilli may be found.

In follicular tonsillitis the onset is more sudden; the tem-
perature may be a little higher than that of diphtheria;
there is no membrane, but the tonsils are red and swollen,
and in the crypts are seen white cheesy spots or plugs,
which consist of broken-down epithelium, and are easily
brushed away; Klcbs-Loffler bacilli are never found.

3. Pain; a periodic purulent discharge from the nose;
the presence of pus on puncturing the antrum; and, some-
times, transillumination will be of service.

4. '"The eye is cocainized ; the patient is seated facing a
good light, with the surgeon standing behind and support-
ing the head ; the lids are separated and the eyeball is
steadied by the fingers of the left hand, the index finger
is applied to the margin of the upper lid, and the middle
finger to the lower lid, and the two fingers are separated,
at the same time gently pressing backward. The instru-
ments used are either the blunt spud, the gouge, or the
foreign-body needle. When the foreign body is super-
ficial, the blunt spud will answer. When it has penetrated
into the corneal substance, it must be picked or dug out
with the gouge, or the needle : in such cases, the instru-
ment is passed behind the foreign body. The wound which
results luust be kept clean by frequent irrigation with solu-
tion of boric acid ; frequently a protective bandage is indi-
cated. If a ring of rust is present, this also should be
removed. Care must be taken to inflict as little injury as
possible, and when the foreign body is deep, not to per-
forate the cornea." (From May's "Diseases of the Eye.")

5. Intense pain of a boring character in the ear or mas-
toid process ; a depression and tumefaction of the postero-
superior wall of the auditory canal ; great tenderness on
pressure over the mastoid region ; swelling, redness, and
edema over the mastoid process.

OBSTETRICS.

I. (a) The connection between ovulation and menstrua-
tion is not yet definitely settled, but the two functions seem
to be closely associated. It has been held that ovulation is
dependent lipon menstruation ; also that menstruation is de-
pendent upon ovulation; it has also been proved that
each may occur without the other, and it is possible that
they are both dependent upon some common (and as yet
unknown) cause.

(b) ."Vbout three or four days.

(c) .'\bout twenty-eight days, from the beginning of one
period to the beginning of the next.

(d) In this country, about fourteen 3'ears; in warmer
climates it occurs earlier.

5. (a) (i) .-^s a protection to the fetus against pressure

Feb. 2, 1907]

MEDICAL RECORD.

211

and shocks from without. (2) As a protection to the
litems from excessive fetal movements. (3) It distends
the uterus, and thus allows for the growth and movements
of the fetus. (4) It receives the excretions of the fetus.
(5) It surrounds the fetus with a medium of equable tem-
perature, and serves to prevent loss of heat. (6) It pre-
vents the formation of adhesions between the fetus and
the walls of the amniotic sac. (7) It has been supposed.
by some, to afford some slight nutrition to the fetus.

(b) It acts as a fluid wedge, and dilates the os uteri and
the cervix; it also slightly lubricates the parts.

HYGIENE.

I. An infectious disease is one that is caused by bacteria.
A contagious disease is one that can be communicated to a
healthy person by contact with one who is infected.

3. Oxygen, nitrogen, carbon dioxide, water vapor,
argon, ammoniacal compounds, hydrocarlxjns, ozone,
oxides of nitrogen, and solid particles.

6. Carbon dio.xide, crowd poison, organic matter given
of? from the skin and lungs, fatty acids, and pathogenic
bacteria.

7. Absolute humidity is the amount of watery vapor
contained in the atmosphere, irrespective of the temper-
ature. Relative humidity is the proportion of watery vapor
in the atmosphere at a certain temperature, as compared
with air completely saturated (which is expressed by 100).

8. Any of the following : giddiness, dyspnea, palpitation
of the heart, headache, gaspine for breath, dryness of the
throat, intense thirst, general malaise, fatigue, loss of appe-
tite, nausea, vomiting, tinnitus aurium. slight elevation of
body temperature, and occasionally epistaxis, bleeding from
the gums, bloodshot eyes, and hemoptysis.

MEDICAL JURISPRUDENCE.

1. Forensic Medicine has been defined as the application
of medical, surgical, or obstetrical knowledge to the pur-
poses of legal trials.

2. The ordinary witness testifies only to facts. An
expert witness, in addition, gives his opinion on facts or
supposed facts as noted by himself or asserted by others.

3. The following, which admirably answers this ques-
tion, is from Witthaus and Becker's "Medical Jurispru-
dence" :

(i) A physician should refuse to testify as an expert
unless he is conscious that he is really qualified as an ex-
pert.

(2) After accepting the responsibility, his first duty
should be to make a diligent examination and preparation
for his testimony, unless it be upon a subject with which
he is familiar, and which he is satisfied that he has already
exhausted, by reading the best authorities that he can find,
and by careful reflection upon particular questions as to
which his opinion will be asked.

(3) Where he is to make an examination of facts, such
as the post-mortem e.xaminaLion of a body, a chemcial
analysis, or an examination of an alleged insane person,
he should insist upon having plenty of time and full op-
portunity for doing his work thoroughly. He should take
particular pains to make his examination open and fair,
and, if possible, should invite opposing experts to cooperate
with him in it.

(4) He should be honest with his client before the trial
in advising him and giving him opinions, and upon the
trial should observe an absolutely impartial attitude, con-
cealing nothing, perverting nothing, exaggerating nothing.

(5) On the preliminary examination as to his qualifica-
tions as a witness, he should be frank and open in answer-
ing questions. He should state fully the extent and the
limits of his personal experience and of his reading upon
the subject, without shrinking from responsibility, yet with-
out self-glorification.

(6) He should be simple, plain, and clear in his state-
ment of scientific facts and principles, avoiding the use of
technical language, and trying to put his ideas in such form
that they will be grasped and comprehended by men of
ordinary education and intelligence.

(7) He should avoid stating any conclusions or princi-
ples of which he is not certain, but having an assurance
that he is right he should be firm and positive. He should
admit the limitations of his knowledge and ability. Where
a question is asked that he cannot answer, he should not
hesitate to say so, but he should refuse to be led outside
the subject of inquiry, and should confine his testimony to
those scientific questions which are really involved in the
case, or in his examination of the case.

(8) He should always bear in mind that at the close of
his testimony an opportunity is usually given to him to
explain anything which he may be conscious of having
said which requires e.xplanation, and partial statements
which need a qualification to make them a truth. This is the
physician's opportunity to set himself right with the court
and with the jury. If the course of the examination has

been unsatisfactory to him, he can then, by a brief and
plain statement of the general points which he has intended
to convey by his testimony, sweep away all the confusion
and uncertainty arising from the long examination and
cross-examination, and can often succeed in producing for
the first time the impression which he desires to produce,
and can present the scientific aspects of the case briefly and
correctly.

8. To constitute a "live birth," there must be (i) com-
plete extrusion of the child from its mother's body, and (2)
some certain sign of life. The latter would be established
by one or more of the following: pulsation of the cord,
beating of the child's heart, motions of the limbs, twitchings
of the muscles, wrinkling of the brows, puckering of the
face, opening of the eyes, even if respiration does not take
place. (From Witthaus and Becker's "Medical Jurispru-
dence, etc.")

10. By a "dying declaration" is understood any state-
ment made by a dying person who believes that he cannot
recover, and that he is, at that very time, in actual danger
of death. The statement need not be sworn to; it should
be voluntary and sincere, and it is admissible as evidence
in a court if the individual making it dies.

BULLETIN OF APPROACHING EXAMINATIONS.t

STATE. N.\ME AND ADDRESS OP PLACE AND DATE OF

SECRETARY. NEXT EXAMINATION.

Alabama* W. H. Sanders. Montgomery. . Montgomery. .March i-

.■\rizona* Ancil Martin, Phoenix Phoenix April

Arkansas* FT. Murphy, Brinkley Little Rock. . April

California Chas. L. Tisdale, AJameda. . . .San Francisco , April

Colorado S. D. Van Meter, 1 7 2,^ Tre-

mont Street. Denver Denver April

Chas. A Tuttle New Haven.. .New Haven. . March

J. H. Wilson. Dover Dover. June

W-C. Woodward. Washington. Washington. . .April
J. D. Fernandez. Jacksonville. Jackson\ille. . .May

E. R. Anthony, Griffin Atlanta Apnl

J. L. Conant, Jr , Genesee Boise April

J. A- Egan, Springfield Chicago April

W. T. Gott, iro State House,

Indianapolis Indianapolis. . May

J. F. Kennedy. DesMoines.. .. Des Moines .. .March

Kansas. ...... .T. E Raines, Concordia Topeka Feb.

Kentucky* ... .J. N. McCormack. Bowling

Green Louisville April

F. A. La Rue. zii Camp St..
New Orleans , .New Orleans.. .May

Wm, J. Maybury, Saco .Portland March

J. McP. Scott, Ilaperstown.. . . Baltimore June

State House.

Boston. Mareh

Mic+iigan B. D, Hanson. 205 UTiitney

Building. Detroit Ann Arbor . , .June

Minnesota. . O. E. Linier, 24 South Fourth

Street, Minneapolis St. Paul April

Mississippi J. F. Hunter, Jackson, Jackson May

Missouri J. A. B. Adcock, Warrensburg, | Kanj;°" c,ty !'

Montana* Wm. C. Riddell. Helena Helena April

Nebraska Geo. H. Brash, Beatrice Lincoln Feb.

Nevada S. L. Lee. Carson City Carson City. Feb.

N. Hamp' re*. . .Henry C. Morrison. State Li-
brary, Concord Concord

New Jersey J. W. Bennett, Long Branch. .Trenton June

New Mexico.. . .B. D Black, I a-^ Vegas

Connecticut*.
Delaware. . . .
Dis. ofCol'bia

Florida*

Georgia

Idaho

Illinois

Indiana

I.

Louisiana.

Maine. . . .
Maryland.
Massachusetts*. E. B. Harvey.
Boston.

. Apnl

New York .

N, Carolina*
N. Dakota. .

Ohio

Oklahoma* .
Oregon*. . . .

.C.F.Wheelock Univ. 01 State
of New York, Albany. . . .

Ma

Santa Fe June

New York,
Albany,
Syracuse.
Buffalo.

G. T. Sikes, Grissom Morehead City. May

H. M. WHieeler, Grand Forks. .Grand Forks.. .April

Geo. H. Matron, Columbus... .Columbus Tune

J. W. Baker. Enid Guthrie March

B. E. Miller, Portland Portland April

' Pl»la'1e!pWalj^„g

Pennsylvania. . N. C. Schaeffer, Harrisbiirg. -

Pittsburg.

Rhode Island. . .G- T. Swarts, Providence Providence, .

S. Carolina W. M. Lester, Columbia Columbia. . .

S. Dakota H. E. McNutt. Aberdeen .Sioux Falls,.

Tennessee* T. J. Happel, Trenton..

1 Memphis.
Nashville.
Know'ilU'.

.April
June .

-JuIV

May
April

Texas T. T. Jackson. San Antonio. . .Austin

Utah* R. W.Fisher. Salt Lake City. Salt Lak-? City, April

Vermont W. Scott Nay. Underbill EurlinL-ton . . . July

Virginia R. S, Martin. Stuart Lynchburt: . . June i

Washington*,. .C. W. Sharpies. Seattle Sjiokane July

W. Virginia*. . .H. A. Barbee, Point Pleasant.. Wheeling. . . April

Wisconsin J. V. Stevens, Jefferson .Madison. , Tnly

Wyoming S. B. Miller, Laramie Clieyenne,

*No reciprocity recognized by these States.^^

tApplicants should in every case write to the secietary for late
details regarding the examination in any particular State.

Illinois and Indiana. — The reciprocity in medical licenses
which has existed between these two Stales is no longer
in force. This is not the first time that disagreement on
this subject has occurred between Illinois and Indiana.
Reciprocity was originally established between these States
in 1902; in January, 1904. the IIHnois State lioard broke off
reciprocal relations with Indiana. Reciprocity was reestab-
lished on January i. 1905, but la.^ted only until July. 1906.
when Indiana returned the compliment and broke off recip-
rocal relations. Illinois wa^ notified ni this in Novem-
ber. 1906.

212

MEDICAL RECORD.

[Feb. 2, 1907

^tm SnstrumeutB.

A STERILE EYE BATH.

By C. EVERETT FIELD, M.D.,

RICHMOND HII.I,, L. I.

In ophthalmic practice we sometimes neglect to
make full use of the common eye bath for irriga-
t i o n purposes. Objections
have been raised many times
against both glass and hard
rubber devices ; still they have
done good service.

An eye bath fashioned from
a single piece of aluminum
has been made for me by the Kress & Owen Com-
pany. That this little device will be well received
by the medical profession is not to be questioned
when one considers the many points of advantage
this metal cup has over the old style glass con-
trivance. It is cleanly, unbreakable, and can be
sterilized instantly by dropping into boiling water.

Ill Lefferts Avenue.

ilrlitfal StPtua.

Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious diseases reported to
the Sanitary Bureau, Health Department, New York

City, for the woek ending January 26, 1907 :

Tuberculosis Pulmonalis

Diphtheria

Measles

Scarlet Fever

Smallpox.

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis
Malarial Fever

Totals

Cases

Deaths

420

197

273

34

iSi

6

268

7

2

263

—

35

9

54

5

14

14

I4I0

A Case of Pick's Disease. — E. Tranquilli describes a
case of peridiaphragmitis, or Pick's disease. This is a mor-
bid entity of complex nature, not a pure and simple peri-
tonitis. It may result from tuberculosis or from syphilitic
inflammation with sclerosis. The central tendon of the
diaphragm is the structure that has to do with the absorp-
tion of corpuscular substances. The disease begins as an
inflammation of the diaphragm, which ends in sclerosis of
the central tendon and pressure on the inferior vena cava.
In the author's case there was marked ascites, the fluid
being confined to the abdomen, with no edema of the limbs.
The quantity of fluid was sufficient to require frequent tap-
ping. The patient had mediastinal pericarditis, left exu-
dative pleurisy, chronic peritonitis with exudate in the
abdomen, and perihepatitis, due to stasis of peripheral
origin. In this disease the kidneys are not diseased and
the urine is normal, although often increased in amount.
The heart is usually normal, and hence the long resistance
to the disease which is essentially chronic, and may run on
for fifteen or more years. The sclerosis begins in the
diaphragm and is propagated toward the pericardium and
pleura. Treatment requires paracentesis to relieve the pres-
sure of the fluid. Aside from this tubercular remedies when
it is of tubercular nature, and iodide of potassium and arse-
nic when regarded as of syphilitic origin. — Gazetta Medico
di Roma.

Obstruction of the Ileocecal Orifice and Appendicitis
Proper: Treatment. — W'. C. .Abbott calls attention to
the confusion sometimes existing in the diagnosis of ap-
pendicitis proper. He cites several cases in point. Al-
though the typical case of true appendicitis is not diffi
cult to diagnose, it is not always possible definitely to
differentiate mild cases of appendicular inflammation from
other conditions having similar symptoms. Tenderness
upon pressure about McBurney's point or in the right
iliac fossa, with nausea and diarrhea, or obstinate con-
stipation, with rapid pulse and a rise of temperature, may

all be caused by disorders outside of the appendix entirely.
The writer believes that in certain cases inflammatory
conditions exist about the ileocecal orifice that are diag-
nosed and operated upon for appendicitis, which would,
if the bowels were freely opened and spasm and congestion
relieved, recover within a short time. — The American Jour-
nal of Clinical Medicine.

Bier Treatment in Acute Purulent Otitis and Mas-
toiditis.— Basing his experience on seven cases of acute
otitis media purulenta with acute mastoiditis and one
case of distinct subperiostea abscess, S. J. Kopetsky
offers the following conclusions as to the value of arti-
ficially induced hyperemia (Bier method) in this class
(if cases: (i) If used early it will greatly increase the
probabilities of curing the condition without resort to
major operative measures. (2) In cases cured under its
influence the reestablishment of ear fimction will occur
quicker than under the usual line of treatment. (3) Its
use by the inexperienced is absolutely dangerous. (4) Its
employment should be limited to the young and the other-
wise healthy. (5) Finally we submit that when the indi-
cations are kept in mind and when properly and intelli-
gently used, induced hyperemia will be found a meas-
ure destined, when its scope and limitations are better
understood, to find a permanent place in otological thera-
peutics.— Ardnvcs of Otology.

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the Surgeon-General, Public Health and Marine-
Hospital Service, during the week ended January 25,
1907:

S-MALLPOX — UNITED STATES.

Georgia, Augusta Jan. 8-15..

Illinois. Chicago Jan. 12-19..

Galesburg Jan. 12-19 . .

ntiiana, Indianapolis Jan. 6-13 . .

La Fayette Jan. 14-21 . .

South Bend Jan. 12-19. ■

Louisiana, New Orleans Jan. 13-20. .

Michigan, Ann Arbor Jan. 1 2-19. .

Detroit Jan. 12-19- ■

Missouri, St. Joseph Jan. 5-12. .

St. Louis ,!?"■ 12—19. -

Montana, Chouteau County Dec. 1-30, .

Dawson County Dec. 1-30. .

North Carolina. Greensboro Jan. 12-19. .

Ohio, Cincinnati Jan. 11-18. .

Texas, Houston Jan. 5—12- ■

^V'ashington, Spokane Dec. 29-Jan.

Wisconsin, Appleton Jan. 12-19. ■

La Crosse Jan. 12-19..

Milwaukee Jan. 5-19. -

CASES. Di \. TH

3

3 2 import'd

i6'7 import'd

S.MAI.I.POX — FOREIGN.

.\frica. Cape Town Dec. S-i 5 .

Brazil, Bahia Dec. 8-15.

Pemambuco Nov. 15-30.

Rio de Janeiro Dec. S-22.

Canada. Cape Breton, Sydney Jan. 12. . . .

Chile, Antofagasta Dec. 24....

Coquimbo Dec. 24. . . .

Iquique Dec.

China, Chefoo Nov.

24.
13-

Shanghai Nov. 26-Dec. 2 .

26
zo

Present

3
19 2

Present

I On U.S.S.

Raleigh

Ecuador. Guayaquil Dec

Great Britain, Hull Dec. 22-29.

Sheffield Dec. 3 i-Jan

India, Bombay Dec.

Calcutta Dec.

Italy, General Dec.

Persia Nov.

Russia, Odessa Dec.

St. Petersburg Dec.

Spain, Barcelona Dec

S-is

20-27 I

30 In 9 localities.
29-Jan. s . • ■ S

iS-29 14

23-30.

Present

San Felicu de Guixols Dec. 29-Jan. 5 .

YELLOW FEVER.

Ecuador, Guayaquil Dec. i-is

CHOLERA — INSULAR.

Philippine Islands, Manila Nov. 25-Dec. 1 .

Pro\Tnces Nov. 25-Dec. i .

Dec. 1-8

"5

34

CHOLERA — FORBIGX.

India, Bombay Dec. 18-25.

CalcutU Dec. 8-15.

Rangoon Nov. 1 7-24 .

Dec. 8-15.

77
8

3

100

IS

.\ustralia, Brisbane Nov. 17-24

Brazil. Rio de Janeiro Dec. 8-22

Chile. .\ntofaRasta Dec. 24

Egypt, .■Mexantlria Dec. 0—31

Keneh Pro\'ince Dec. 30

Menoufaih Dec. 3 1 — Jan. i

India, Bombay Dec. 18-25

Calcutta Dec. S-is

Rangoon Nov. 17-24

Dee. S-15

Mauritius Nov. 22-Dec. 6.

Peni, Chicama Valley Dec. 22

Mollcndo Dec. 4-18

14
2?
iS
53
Pr sent
3

Medical Record

A Weekly foiiriial of Medicine ajid Surgery

Vol. 71, No. 6.
Whole No. 1892.

New York, February 9, 1907.

$5.00 Per Annum.
Single Copies, JOc.

(irigmal ArtirlrH.

FRESH AIR TREATMENT IN HOSPITAL
WARDS.*

By W. oilman THOMPSON. M.D.,

NEW YORK.
VISITING PHYSICIAN TO THE PRESBYTERIAN AN'[> BEM EVUE HOSPITAL^.

The general medical hospital ward as exemplified in
most of the hospitals in this city is a most uncom-
fortable and irrational place for the proper care of
the sick. In the same long, narrow room are
crowded a miscellaneous collection of ailments, all
submitted to identical conditions and surroundings,
without the slightest attempt at appropriate adapta-
tion of environment. The pneumonia patient, with
a temperature of 105° F., sorely in need of fresh,
cool air, lies in the next bed to the uremic patient
with a subnormal temperature and high tension
pulse, who needs warm air and a hot pack ! The
typhoid fever patient, with a racking headache
and photophobia, lies facing a glare of sunlight,
which is doubtless beneficial to the man with per-
nicious anemia in the next bed (because the trained
nurses think the ward looks better with the shades
all at the same, height). The neurasthenic with
insonniia lies ne.xt to the patient with alcoholic
cirrhosis and delirium tremens, who keeps the en-
tire ward awake most of the night. The conva-
lescent patient has nowhere to go during the day
for a change of air and scene, and the poor old
woman with a little chronic cough, who needs to
rest in an easy chair toasting her feet at a heater,
sits gazing wistfully and pathetically at a hole in
the wall near the ceiling, where some architect (who
never built a hospital before) has seen fit to place
a hot-air register. But these are minor incon-
sistencies. The greatest evil of all is that the ward
is "ventilated"' by a thermometer, a little instrument
which from October to May is kept steadily at
68° or 70° day and night, without regard to the
moisture of the air, its freshness, its CO, content,
its nitrogenous waste, its pollution with fetid odors,
emanations from foul stools, foul breaths, and foul
perspirations. Without regard also to the fact
that during the visiting hours, or during the ad-
mission of classes of students or probationer nurses,
the ward air, which ought to belong primarily to
the patients, has been breathed for them by double
and sometimes treble their number of outsiders.
In some very much "up-to-date" institutions, the
thermometer is replaced by an electric thermostat,
comnuniicating its valuable data to the superin-
tendent's office, so that he may rest assured that in
the wards above the air is always .at 70° F., no mat-
ter if it is 15 per cent. COo or hydrogen sulphide,
for all he knows. The functionary usually placed
in charge of this ingenious system is the hospital
engineer, who is about as much of a ventilation

*A paper read before the New York Academy of Medi-
cine, January 17. 1907.

e.xpert as a hibernating dormouse. The nurses
(who are given elaborate lectures on hygiene, and
"how to ventilate the sick-room") are not allowed to
raise a window as much as a crack from October
to May, and as for the house staff — why, of course
it is not for mere doctors to stoop to such details 1
One of our representative hospitals in which that
most pernicious of all ventilating systems, known
as the "closed system," was placed some eighteen
years ago, with the endorsement of the Medical
Board and at extraordinary cost, originally had locks
and keys attached to its windows, and in lavatories
the windows were, in addition, screwed down with
bolts! Would anyone of us consent to live from
October to May in a house in which his bedroom
windows were locked fast and his lavatory window
screwed to the sill? But we are in and out, getting
the stimulus of a change of air, a change of tem-
perature, as well as of air composition. The bed-
ridden patient, on the other hand, lies perpetually
at the mercy of the superheated air which is
supplied him. The fundamental fault of the "closed
ventilation" system is that heating and ventilation
are made inseparable, and to deliver through long
conduits air hot enough to warm a large number
of distinct wards, it must be first superheated to
about 406° F. and then all doors and windows
must be kept tightly closed, for the opening of a
single window in one ward "short-circuits" the
entire system, and temporarily cuts out all the
wards from both heat and air supply. This system
may work in large assembly halls, such as churches
or theaters, but there it is not continuous, and the
people come and go, and refresh themselves with
normal outdoor air. Superheated air is like super-
heated or sterilized milk — one can live upon it, of
course, but there is nothing "uplifting" about it
(as Walter James has said, in writing on this topic),
and it admits of no advancement in health. I am
convinced that there are properties which, for lack
of better term, we call "vital" in the outdoor air that
are not measurable by any of our present instruments
of precision, such as the thermometer, hygrometer,
thermostat, barometer, etc. It is only a few years
since it was supposed that all was known about
the chemical composition of atmospheric air. Then
argon and other new elements were discovered.
It is not unreasonable to believe also that some of
the iihysical properties of the air are more or less
permanently altered by its confinement and super-
heating.

Being unable to find any recorded scientific data
upon the quality of hospital ward air, I undertook
to obtain some a }ear ago in the wards of the
Presbyterian Hospital. A study of the COj con-
tent of the wards was made under varying condi-
tions. The analyses were performed for me by Dr.
C. G. L. Wolf (Instructor in Chemistry and Physics
in the Cornell University Medical College in New
York City), and the results were very illuminating.
The experiments were carefully made, unusually

214

MEDICAL RECORD.

[Feb 9, 1907

large quantities of air were used to lessen liability
to error, and control tests were made upon the
hospital roof air and that of Dr. Wolf's laboratory,
in which the chemical analyses were conducted.
Without going into details, I will quote briefly from
the conclusions of our report, which was submitted
to the managers of the hospital: (i) Pure, normal
atmospheric fresh air is admitted to contain 4
volumes of CO, per io,ocxD volumes of air; 4.5
parts CO2 represent highly impure air, 5 parts in-
jurious air, and 6 to 7 parts air wholly unfit to
breathe. (2) When the fresh air on the roof was
practically normal (4.06 parts CO,) that in the
wards, with the most complete closed ventilation
system in full operation, contained as much as 4.71
parts CO,, and after twenty visitors and four nurses
had spent one hour in the word this content rose to
5.13 parts. Immediately thereafter the ward win-
dows were opened for ten minutes only, and the CO2
content fell to 4.34 parts, although on a cold De-
cember day the ward temperature was lowered
thereby only 3° F. Hence, with almost impercep-
tible change, as shown by the pernicious thermome-
ter, the air impurities, which had been increased
more than 20 per cent, by the visitors, were nearly
eradicated by ten minutes of zmndozv opening.
(Truly the nose is mightier than the thermometer
as a ventilation guide!) (3) Of course the CO,
content is only one of the many forms of atmos-
pheric vitiation, but it is known to rise and fall
pari passu with other impurities, and is therefore
a fair index of the other conditions of vitiation.
(4) In connection with these experiments others
were made by Dr. G. A. Tuttle in the bacteriological
laboratory of the hospital to demonstrate the in-
jurious effect of raising dust by dry sweeping, so
common in American hospitals. On an exposed
agar plate 26 colonies of bacteria were deposited in
quiet ward air. When the air was agitated by dry
sweeping the number rose to 532 colonies, or more
than twenty times as many colonies of streptococci,
staphylococci, diplococci, with spores, fungi, and a
variety of miscellaneous organisms. This was in a
ward thoroughly cleaned every day.

Several years ago, while simultaneously visiting
in two hospitals, I observed a very striking differ-
ence in certain classes of patients, especially those
with marked anemias, chronic sepsis, pulmonary
and chronic cardiac diseases, etc. In one the pa-
tients were supplied solely with superheated air
forced through thousands of feet of metal con-
duits, and during their entire stay in hospital never
received one single breath of unbaked air. Some of
them improved, others grew well, to be sure, but
thev were a very long time about it. The other
hospital is one of our oldest. The windows have
settled, gusts of air and even the snows blow in
through wide cracks. The wards are heated by
steam pipes, and when too hot or too close the
windows are opened, and even in midwinter are
sometimes left open all day. Each patient receives
good daily allowance of pure, fresh, unroasted air.
The difference was really very striking in the greater
promptness of recovery in favor of the old, tumble-
down hospital that used to be an almshouse ninety
odd years ago. It was so striking that we sought
to do better, and as the old almshouse is the only
hospital in this entire city that has adequate balcony
accommodations attached to the wards we began to
move the patients' beds out on the verandas. First
the tuberculous were moved out, later the pneumo-
nias, and later still any case that could be distinctly
benefited by air which had never been in anyone
else's lungs. .\\. the Presbyterian Hospital we have

as yet no balconies ; but we have small rooms
opening off the wards. In these we have sealed
up the artificial ventilation system so that the win-
dows may be kept open day and night, and a
patient at the corner of Madison avenue and Seven-
ty-first street who is dying for lack of fresh air, can
get it without freezing out a surgical patient on the
corner of Park avenue and Seventy-first street by
short-circuiting his air supply ! In these small
rooms, as far as their capacity admits, we now place
all those needing uncooked air, and the effect in
certain cases is truly magical. We have made
further improvement in the wards themselves by
requiring that the windows be simultaneously
opened widely at least twice a day to thoroughly
air the ward, like any other bedroom, and by requir-
ing that the night temperature be kept five degrees
lower than that of the day, for there is something
stimulating to respiration in such change which is
lacking at the monotonous 70° F. level.

The most striking benefit of the uncooked air
treatment is shown in cases of pneumonia. Deliri-
ous alcoholic patients, with profound cyanosis, when
taken out of the general ward and placed at win-
dows open day and night, become much less nervous
and restless, and distinctly less cyanosed. I for-
merly gave such patients oxygen sedatives, whiskey,
and other stimulants. In the open air they, of
course, receive no oxygen, and require far less of
stimulants and sedatives. During 1906 we treated
in all at the Presbyterian Hospital 128 cases of acute
lobar pneumonia. Of these patients 47, or 36.7 per
cent., received absolutely no drugs whatever — no
stimulants, no narcotics, no inhalations, no "spe-
cifics," nothing except the occasional laxative, which
anyone in bed with fever may require, and they all
recovered, in the usual way, when the time came.
Some defervesced by crisis, some by lysis, some in
five days, some in 12 days, or other intervals. .\
large proportion of these patients received the un-
cooked air treatment and enjoyed it. The air tem-
perature was often as low as 35° F. or 40° F. They
never complained, e.xcept when some emergency
required them to be taken back to the ward, as
when the room was needed for some other patient
in more urgent condition. They were not all thus
treated nierel\- from lack of sufficient isolation rooms
or balconies. The remaining ward patients who re-
covered received various drugs or stimulants, solely
because certain complications arose which needed
treatment. But I would again emphasize the fact
that of 128 patients with pneumonia, 36.7 per cent.
made complete recovery in the usual time, without
any medication, and for the most part with their
heads lying close to open windows in midwinter
weather.

Other diseases that do remarkably well with open
window treatment are cerebrospinal meningitis,
chronic sepsis, and all forms of anemia. The menin-
gitis patients become very much quieter, sleep much
better, and look better in every way. A patient
with a pernicious anemia in which the red blood
corpuscles numbered only 828,000 gained over a
million red cells in a week when I took her out of
the general ward and placed her in a small room
with wide open windows. She left the hospital a
few weeks later, with over 4,000.000 red cells, and
a hemoglobin estimation that had risen from 20 to
80 per cent.

\Mien the pneumonia or other febrile cases re-
quire a cold bath, or the use of a bedpan, or any pro-
cedure necessitating exposure, they are temporarily
taken into the ward, or the windows of their rooms
are closed, and the rooms warmed.

Feb. 9, 1907]

MEDICAL RECORD.

215

All this is nothing' new, but it is well sometimes
to preach again from old and well established texts.
Forty-two years ago there was an epidemic of
typhus and typhoid fever in New York City. As the
wards of Bellevue Hospital became overcrowded,
520 patients were transferred to Blackwell's Island
and placed outdoors under tents, in the late autumn
and early winter. Dr. Austin Flint in his Practice
of Medicine (5th ed., p. 978), in writing of this
incident stated : "The average death-rate in the
hospital wards was i in 5.97; in the tents i in
16.77." "Making the fullest allowance for the
conjecture that the cases in the tents were milder
than those in the hospital wards, it can hardly be
doubted that the superior ventilation in the tents was
the means of saving many lives." Fifty-six years
ago Dr. John H. Griscom reported in this Academy
the treatment by open air in Perth Amboy, New
Jersey, of 82 cases of typhus fever. The patients
who were derived from an immigrant ship, had the
additional advantage of being soaked by a thuntler
shower, and all made good recovery from the fevei.
(Flint, loc. cit.) Eighteen years ago, during a
reconstruction of the Presbyterian Hospital after
the fire, I treated a number of cases of erysipelas,
with high fever, in open tents on the hospital
grounds, with excellent results. Every midwinter
army campaign in which the sick and wounded have
had tent treatment has shown anew the advantages
of outdoor air. In answer to those who object to
giving a pneumonia patient first-hand, unbreathed.
uncooked air (and such objectors have usually never
seen the treatment tried), it should be stated that
this form of treatment is not a temporary fad or a
"fresh-air crusade,'' but a very old, well tried, and
widely tried, common-sense method, from which
we have been somewhat led away of recent years.
The undesirable necessity of building large met-
ropolitan hospitals of the "sky-scraper" type, the
idea of massing all manner of heterogeneous cases
with a series of long wards, all precisely the same,
like sheep corrals, and the inhumanity of architects,
who strangely prefer mansard roofs and straight
ornamental facades to roof gardens and ward bal-
conies, pernicious application of wholesale ventila-
tion "systems" for the air supply of the air-hungered
— these are some of the factors which have led us
to turn from the open window and fix our exalted
gaze upon the cast iron heater in the wall !

In Continental Europe they are far ahead of us
in modern hospital construction in many diflferent
countries. Closed ventilation systems are practi-
cally unknown. Windows are built with transoms
of different sizes, permitting easy regulation of the
ward air. Heaters, porcelain stoves, and even open
fires, are placed where patients who feel cold and
need warmth may sit and be comforted. Numerous
small rooms of variable sizes admit of the scientific
classification of patients, especially as regards their
individual requirements for ventilation and air tem-
perature (two essentially different things). At-
tractive day rooms are provided next the wards, so
that convalescents not only obtain change of air,
scene, and occupation, but leave fresher air in the
wards for the benefit of the very ill. Many visitors
are thus kept out of the wards by being admitted to
the day rooms instead. The evil of dry sweeping
in the wards is unheard of. Finally, broad, open
corridors abound, and attractive grounds, with shel-
ter tents, are so arranged that patients have free
access to them at all times. In all these things we
have very much to learn, especially just now, while
propositions are already before us to spend $29,000,-
000 (see Medical Rfxord, January 5, 1907, Stephen

Smith on "A Hospital System for New York") of
the taxpayers' money for new public hospitals.

I have purposely thus far omitted mention of
tuberculosis, because the object of this meeting is
lo stimulate interest in the application of fresh air —
not necessarily cold air, but always fresh air — treat-
ment to a very large variety of other diseases. Tu-
berculosis has demonstrated for us that fresh air acts
not as a specific for any one disease, but by increas-
ing the resisting power of the organism against
many diseases. To this end we should learn to
adapt our modern hospital construction as well as
that of our own homes.

The following conclusions for the betterment of
ward ventilation in this cold and very changeable
climate are submitted :

1. Ward heating and ward ventilation should be
capable of independent adjustment at all times.

2. The night temperature of the ward should be at
least 5° F. below the noon day temperature, which
latter should not be above 68° F. or 70° F.

3. The ward windows should be furnished with
transoms and one or two movable separate panes, to
admit of easy regulation and ventilation.

4. No window should be so heavy that it cannot
be readily handled by the nurse.

5. The ward should be in communication with
l)alconies or porches, on to which patients' beds can
be moved through windows of the casement type.
Such balconies need not interfere with the adequate
lighting and ventilating of the ward, as proved at
the Bellevue and other hospitals in which they have
been used. (They are being put upon all the wards
of the new Bellevue).

6. The building of very large wards should be dis-
couraged and a greater number of small adjacent
rooms should be provided to admit of the scientific
adjustment of the ventilation and temperature to suit
the requirements of different patients.

7. The windows of the ward, even on the coldest
(lay, should be opened at least twice daily, in the
early morning and late afternoon, for a few minutes
to thoroughly change all the air in the room. During
this time any patient may be covered temporarily
with extra bed clothing if there be fear of exposure
fnjin draft. The same procedure should be carried
out immediately after visiting hours.

8. Day rooms should be provided for convales-
cents where they can obtain change of air and
scene, and leave more fresh air for the bedridden
patients in the wards.

9. The ward should have at least one accessible
heater, where patients temporarily sitting up may
gather and warm their feet if desirable.

10. It is entirely unnecessary to have all the ward
windows precisely alike, except from some fanciful
esthetic standpoint. Thus certain windows of the
casement type should spring from the floor and give
on to balconies. Obviously heaters cannot stand in
front of these windows as they should in front of
other shorter windows of the ordinary height.
Windows should be grouped with more reference
to sunlight exposure, ordinary wind exposure, etc.,
than is usually done.

11. House staff and nurses should not only be
taught ventilation theoretically, but made to put it
into practice in the wards, and should be made to
regard fresh air as of equal importance with fresh
food.

Where these simple common-sense principles are
in daily practice it is possible to use fresh air as a
definite therapeutic means and secure most gratify-
ing results. Finally, air temperature and ventilation
are not synonymous terms !

34 East Thirtv-fikst Street.

2l6

MEDICAL RtXORD.

[Feb 9, 1907

RESECTION OF THE SIGMOID FLEXURE.

By JOHN J, McGRATH, M.D.,

NEW YORK.

PROFESSOR OP OPERATIVE SURGERY AT THE NEW YORK POST-OKAOUATE

SCHOOL AND HOSPITAL; VISITINO SUHCEON TO THE HARLEM ANIJ

COLUMBUS HOSPITAIS; CONSULTING SURGEON TO THE NEW YORK

FOUNDLING nND BRATTLEBORO MEMORIAL HOSPITALS.

Tins case is reported primarily for the purpose of
calling attention to a simple method of end-to-end
intestinal anastomosis which has been practised by
the writer upon numerous occasions durin.sj the past
two or three years.

Joseph J., aged sixty-three, native of the West In-
dies, was admitted to the service of Dr. J. T. Joseph
Bird in the Harlem Hospital, November 20, 1906,

FiG.li. — The'^mesentericjsuture has been introduce<i; when drawn
tight and tied it obliterates the "dead space" seen between the d:
verging layers ^o( the mesentery it also opposes the serous layers,

suffering from acute intestinal obstruction. The
diatjnosis of volvulus was made and operation ad-
vised.

Operation November 21. Chloroform anesthesia.
An incision made in the middle line e.xposed the
greatly distended gangrenous sigmoid flexure, which
was twisted upon its mesentery through four com-
plete turns. The twisted portion of the bowel cor-
responding to the entire sigmoid flexure was re-
sected. An end-to-end anastomosis was made be-
tween the end of the descending colon and the end
of the rectum by the method which is described in
detail below.

After the lapse of three weeks the patient was
discharged cured.

Description of the Method. — Two straight needles
are threaded upon a piece of silk thread about twen-
ty-four inches long, and with this as a suture the
two ends of the bowel are joined together at their
mesenteric border. In order to facilitate the de-
scription of the application of this mesenteric su-
ture, we shall speak of the two ends of the bowel
that are to be joined as the first and second ends.
The suture is passed through the edge of the first
end of the bowel entering upon the mucous surface
near the mesenteric border ; it passes across the mes-
enteric "dead space" and pierces the mesenteric
serous layer ; it then passes through the edge of
the second end of the bowel, piercing its mesenteric
serous layer, and after traversing tlie "dead space"
emerges upon its mucous surface. The suture is
then passed back in reverse order through the edge
of the second end of the bowel entering upon the
mucous surface alongside of the point where it had
just emerged, and after traversing the "dead space"
it pierces the mesenteric serous layer of this second
end of the bowel : finallv the suture is carried

through the edge of the tirst end of the bowel, pierc-
ing the mesenteric serous layer, passing across the
"dead space," and emerging upon the mucous sur-
face of the bowel alongside of the point where it was
first entered. The ends of the suture still carrying
the two needles are left long for the purpose of con-
tinuing and completing the union of the two ends
of the bowel. When the mesenteric suture is drawn
tight it brings the two ends of the gut together,
obliterating the "dead space" absolutely and bring-
ing the corresponding mesenteric serous surfaces
into accurate apposition. When the suture is tied
it retains the parts thus closely applied permanently.
The proper application of the mesenteric suture is
the most important and essential step of the entire
procedure.

The edges of the t\\x> ends of the gut are now
secured with a silk tractor suture at a point nearly
half way around their circumference — nearly oppo-
site the mesenteric border. Making traction with
one tail of the mesenteric suture and the silk tractor,
the edges of the two ends of the bowel are sewed to-
gether with the other tail of the mesenteric suture
as far along as the silk tractor, thus joining the two
ends of the bowel for nearly half their circumfer-
ence. The tractor being of no further use is cut
and removed. A second silk tractor is applied so as
to secure those edges of the bowel which still re-
main unsutured at a point about one-third of the
circumference of the "'Ut distant from the mesenteric
border, and these edges of the bowel are sewed to-
gether with the second tail of the mesenteric suture.
After this portion of the suture has been introduced,
it will be seen that the edges of the bowel have been
united for more than two-thirds of their circum-
ference. The second tractor is of no further use
and is cut away.

The gut is now spread out lengthwise, and it will
be seen that there remains an opening to be closed
corresponding to less than one-third of the circum-
ference of the bowel, and this final step of the opera-
tion is accomplished with a nonpenetrating Lembert
stitch, using the remaining portions of the two tails
of the original mesenteric suture which still carry

FiG- 3. — The edges of the two ends of the gut have been joined from
the mesenteric suture as far as the tractor T.

the two needles for this purpose. Each of the two
needles, which had last emerged upon the mucous
surface of the gut, is thrust through the edge of the
gut, so that it emerges upon the serous surfaces,
and with these the opening that remains (corre-
sponding to less than one-third of the circum-
ference) is closed. A Lembert stitch is used for
this purpose, with each thrust of the needle taking

Feb. 9, 1907]

MEDICAL RECORD.

217

a good secure bite in the serous and muscular coats,
but not penetrating the mucous membrane layer.
Finally the operation is completed by tying the two
ends of the suture together.

Fig. 3. — ^The gut ha been joined for more than two-thirds of its cir-
cumference, and the sutures have been broueht out through the edges
of tile But for the purpose of completing the anastomosis with the
Lembert stitch.

\Micn the suture is applied at the mesenteric bor-
der and tied the mesenteric "dead space" is obliter-
ated and the serous mesenteric layers are brought
right down into close contact with the wall of the
gut — two conditions that are absolutely essential to
a successful end-to-end intestinal anastomosis. The
ends of this same mesenteric suture are used to
accomplish the union of the two ends of gut, using
the tractors to facilitate the application of the suture
as far as possible and finally completing the union
with the Lembert stitch. For that portion of the
anastomosis which is made with the assistance of
the tractors a through-and-through stitch is used.
The suture line should be placed at least one-quar-
ter-inch below the edges of the gut, and the indi-
vidual needle thrusts should be made about one-
eighth-inch apart. Each stitch is drawn fairly tight,
and at every fifth or sixth thrust a back-stitch is
made so as to prevent "pursing" of the suture.

The advantages of this method of anastomosis are
its simplicity and efficiency and the fact that no ap-
paratus, button, clamp, or other mechanistn is neces-
sary to its accomplishment.

104 West Seventy-first STREEr '- * ;

CONSERVATIVE SURGERY TN SEVERE

INFLAMMATORY AFFECTIONS OF

THE UTERINE ADNEXA.*

By HIR.^M N. VINEBERG. M.D..

NEW VOKK.

It was with readiness that I accepted the kind invi-
tation of your chairman to participate in the dis-
cussion of the subject that is placed before you
to-night.

From the outset of my active career in gynecolo-
gical surgery I was deeply interested in the subject
of conservative surgery in pelvic diseases. At that
time it was not so much in vogue as it is now. Then
it was customan- if both tubes were markedly
diseased to take little heed of the ovaries and to
make a clean sweep of the pelvic organs. It was
then held that in the face of so much inflammatory
disease of tlie tubes the ovaries were disorganized
or secondarily involved through adhesions, and that
it did not pay to try to save them. There are a
good many prominent gynecologists at the present
day who still hold that view. But all are beginning
to have more respect for ovarian tissue, so as to
maintain the function of menstruation if the patient

*Read at a meeting of the Section on Obstetrics and
Gynecology of the New York .\cademy of Medicine, De-
cember 27, 1906

is under forty years of age. Whether or iK)t we
accept the theory that the ovary has the capacity of
providing an internal secretion, we all admit that it
is of considerable moment to the woman's economy
to preserve her menstrual function if she be still
several years on this side of the average age of the
normal climacteric. All have ceased some time since
to remove so-called microcystic ovaries for various
nervous disorders and for vague pelvic symptoms.
But in the subject before us a serious question
arises. Is it wise, or even justifiable, in the presence
of extensive inflammatory affections of the pelvic
organs to retain a part of or an entire ovary tliat
has been bound down by adhesions and is in a
ragged and more or less pathological condition ?
This question will be answered variously by differ-
ent operators. Some who have had unfortunate
experiences and have had to do a second laparotomy
a short time after tlie first to remove the ovarian
structures that they left behind at the first, will
be strong in their condemnation of what they term
"false conservative surgery." Others, again, who
have been chagrined and disappointed with their
results in their eft'orts to do conservative surgery,
will be equally strong in their condeinnation. They
will tell you the patient was not benefited thereby,
that she continued having the same symptoms as
before the operation, although on bimanual exami-
nation no marked changes could be foimd. To the
latter I would say that they operated upon wrong
indications. To my mind one of the most common
causes of disappointment in conservative surgery
upon the adnexa is the negligence of taking into
account the condition of the uterus itself.

Let me cite a case. A young, healthy woman
goes through a normal gestation, has a normal labor,
and apparently a nonnal puerperium. Six months
or a year later she begins to suffer from pelvic
uneasiness, has a feeling of weight in the hypo-
gastrium, a soreness or a burning in one or other
groin or in both, has more or less backache. She
is examined by a prominent gynecologist who may
also be the obstetrician who delivered her. He finds
everything apparently normal. There may be some
tenderness over one or other adnexa on pressure.
He puts the case down as one of neurasthenia. The
symptoms, nevertheless, persist and she goes from
one specialist to another. Later on she mav have
an attack laying her up in bed. attended with mod-
erate elevation of temperature. The pelvic exami-
nation still does not show any marked changes. The
patient grows tired of being treated locally without
any relief, and clamors for an operation if it holds
out any proinise of cure. The abdomen is opened,
the adnexa themselves are found fairly normal,
there are evidences of more or less perisalpingitis
resulting in membranous adhesions. These are
broken up, and one or more cysts of varying size
from a kidney bean to an almond in either otary
are found and excised. The patient makes an
afebrile recovery. But she is no better afterward.
In fact, her symj)toms persist and grow steadilv
worse. In the course of a year or longer the abdo-
men is opened again, this time for the purpose of
doing a radical operation. The portion of the ad-
nexa left at the former operation seems to have
vmdergone but little change. More adhesions are
probably met with, some, no doubt, as a result of
the prior interference, and the uterus now is so large
as to arrest attention. The patient is cured after
the second operation, although she may suffer very
markedlv from the nervous disturbance attending
the artificial climacteric. This is not a fanciful case,
but is the exact portrayal of an actual one, and is

2l8

MEDICAL RECORD.

[Feb 9, 1907

illustrative of numerous cases I meet with operated
upon by others, and, I am frank to admit, by myself
occasionally. A conservative operation should never
have been performed upon that patient. Her condi-
tion was one of chronic metritis, either as a result
of a subinvolution or gonorrheal or other infection,
and the slight periadnexitis was only a secondary
affair. ^\ hat to do with these cases does not come
under the head of this discussion, but in my opinion
one thing is certain : they should either not be oper-
ated upon, or if operated upon, the uterus, the prime
cause of the trouble, should be removed. In the
discussion that followed the reading of my paper, it
was stated by one of the participants that in case
of chronic metritis he could not concur in the alter-
native of noninterference or hvsterectomv. In such
cases he would curette and treat palliativelv. The
gentleman failed to grasp the point I endeavored to
make. I was in favor of trying to benefit these
cases by all the palliative means we have at hand,
although curetting is seldom of much value. What
I did try to emphasize was that these patients were
.usually subjected to two major operations, with all
their risks and ordeals. If one were forced to oper-
ate upon these patients, after all palliative measures
had failed, it wa.s a mistake to attempt conservative
surgery upon the adnexa, as they were not the
organs at fault. It was the diseased uterus that
was causing the symptoms, and would continue to
do so until removed. The laparotomy for remov-
ing the one or the other adnexa would prove simply
futile. I feel quite sure of niv ground in this con-
nection.

Next comes a series of cases that can scarcely,
with propriety, be placed in one class, but which
we must do for the purpose of a discussion of this
kind. I refer to pus tubes of various sizes, with
varying degrees of adhesions, and in which the
ovaries are more or less involved as a result of the
extensive inflammatory process that has gone before.
To my mind it makes little difference in these cases
as to the pathological microorganisms that were the
direct etiological factors. In this I find mvself
differing from a leading and prominent operator
who took part in a similar discussion before the
New York Obstetrical Society a few weeks ago.
He stated he always endeavored to do conservative
surgery in inflammatory disease of the adnexa.
excepting where he knew or suspected that there
was gonorrheal infection. In that case he alwavs
did a radical operation. If one were to adopt that
stand the cases of suppurative disease of the adnexa
that would be appropriate for a conversative pro-
cedure would be very limited indeed. We all know
that at least 75 per cent., roughly speaking, of the
suppurative cases of the adnexa that we meet with
are of gonorrheal origin. The remaining 23 per
cent, of other causation than gonorrheal are usuallv
of so serious and extensive a nature that fre-
quently anything short of a radical operation is
entirely out of the question. Further, as far as
my own experience goes, the most gratifying results
that I have had have been just in such cases of
pus tubes of long standing, and of undoubted gon-
orrheal antecedents. In this class of cases also
we have less fear of peritonitis following the less
ideal operation (for such we must designate the
conservative operation to be, at least, from a purely
surgical standpoint) than in the cases due to staphy-
lococcus or streptococcus infection.

It has been and is my custom, therefore, when
operating on a patient much younger than the
climacteric age to make every effort to save as
much of the ovarian tissue as possible, and if

feasible to do a plastic on the less diseased tube,
indepenflcnt of the microorganism that may have
been the etiological factor. And if we be ver>- de-
termined to pursue such a course it is remarkable
in what a number of cases we will be able to put
the method into practice, that at first sight seemed
unsuitable for anything short of a radical operation.
Cases that looked hopeless from the standpoint of
conservative surgery when the abdomen was first
opened with care, patience, and, I may add. some
experience, will gradually be disclosed as lending
themselves to that procedure. I may have something
to say of the technique later.

I have not the time at my disposal to discuss
the methods to pursue to tide over acute cases of
suppurative disease of the adnexa to a period when
conservative surgery may be called into play. We
are all pretty well agreed that acute cases lead
themselves but poorly to conservative surgery, as I
understand the term in this discussion. I would
not designate a Vaginal incision and drainage of a
pus tube or an ovarian abscess as conservative
surgery, that is "palliative surgery,'' and may be
all that the case may ever require. But this dis-
cussion I fear will go far afield if we do not adhere
strictly to an exact meaning of the term "conserva-
tive surgery upon the adnexa." By it I w^ould
understand the opening of the peritoneal cavity, be
it through the vagina or through the abdominal
parietes, and excising under the sight of the eye the
most diseased structures, leaving such behind as
are fairly normal, or present the prospect of restitu-
tion to the normal.

I have not had the time to investigate all the
cases coming under this head that I have operated
upon during the past ten years ; I have, however,
gone over, as well as the time would permit, the
cases that occurred in my own private practice from
January, 1896, to January, 1906. There were fifty-
one cases. All cases of minor disease or cases of
one-sided ovariotomy for ovarian cysts, or cases
of ectopic pregnancy, in which conservative surgery
was done, on the opposite adnexa were excluded.
Some of the fifty-one cases were in acute stage when
operated upon. There were two deaths. Case i
occurred in March, 1898. It was in a young woman
who had been ill for several weeks as a result of
infection following a criminal abortion by a mid-
wife. The whole pelvis was filled with irregular
inflammatory masses. The temperature ranged from
101° to 104°, pulse from 120 to 130. .^n attempt
was first made to reach the pus focus through a
posterior vaginal incision, but this was unsuccess-
ful. The abdomen was then opened, the large intes-
tine was found covering, and extensively adherent
to the pelvic organs, which were matted together
into an indistinguishable mass. After separating
the adhesions of the sigmoid the left adnexa were
enucleated, the tube being the size of a bologna
sausage, and filled with pus. the ovary completely
disorganized and no ovarian tissue distinguishable
with the naked eye. The tube and ovary were
excised. The right adnexa were also firmly and
extensively adherent to the floor of the pelvis and
to the posterior aspect of the broad ligament. When
they were enucleated after great difficulty some
ovarian tissue was recognizable ; this was left behind
after cutting away the diseased tube and the dis-
organized portion of the ovary. The posterior por-
tion of the uterus was raw and irregular from
adhesions. The uterus was ventrofixated and iodo-
form gauze was packed lightly in Douglas' cul-de-
sac, the end of which was carried through the

teb. 9, 1907J

ivir!>un„/\L t^[Lv.^i\Lj.

'y

vaginal incision originally made. The patient with-
stood the operation poorly, but reacted fairly well
later. The symptoms of septic peritonitis set in
on the second day, which gradually progressed and
proved fatal on the sixth day. Two criticisms
readily occur to one : ( i ) The patient should not
have been operated then, but tided over until the
acute stage had been passed. It did not seem to
me to be safe to wait any longer. That was over
eight years ago, but I have learned better since ;
(2) having been forced to operate, either through
the severity, threatening character of the symptoms,
or through other exigencies such as the advice
of other counsel, etc., a radical operation should
have been done preferably through the vaginal
route and with as much expedition as possible.

The second fatal case occurred in a young un-
married woman of twenty-one, who contracted an
acute gonorrhea which was very virulent and ex-
tended rapidly to the tubes on both sides. For
two weeks she was running high temperature, rang-
ing from 101° to 105°, pulse 90 to 130. Tlie pain
was very severe in the right side of the abdomen,
so that acute appendicitis was feared. On bimanual
examination both tubes were found to be as large
as the index finger and moderately fixed. A promi-
nent surgeon was called into consultation by the
family, who concurred in the opinion that an opera-
tion was imperative. On opening the abdomen
both tubes were found enlarged at the outer two-
thirds to the size of one's thumb. They were open
and pus was flowing from the fimbriated extremi-
ties. The left ovary was excised with the tube.
The right ovary was in fairly good condition, and
it was left in situ. The appendix was adherent to
the right tube, and its peritoneal coat was con-
siderably injected. It was also excised. Drain-
age was carried out through the vagina. The oper-
ation seemed to have no influence for good or bad
upon the patient's condition. The symptoms merely
progressed. Manifestations of profound toxemia
accompanied by delirium finally developed, and she
died on the seventh day following- the operation.

In this case I don't think it would have made
much difference what course would have been pur-
sued. It was evidently a mixed infection (although
I had no positive evidence of that) which would
have run a fatal course, whetiier it had been left
alone or submitted to a radical operation. If we
knew how to distinguish these cases early we might,
perhaps, save some of them by timely operation,
as we are able to do in cases of appendicitis. The
remaining cases recovered from the operation.

A third patient (Case 3) was under observation
only for two months. The menses had recurred
twice, but the patient continued to suffer a good
deal from abdominal pain, although the pelvic ex-
amination was negative.

A fourth patient (Case 19) failed to menstruate
during the year she was under observation, al-
though the left tube and ovary were not removed.
They were bound down by firm adhesions, which
were broken up. The patient was free from pelvic
symptoms.

A fifth patient (Case 39) developed a cystic mass
to the right of the uterus which disappeared and
recurred several times since the operation. At the
present time it is in abeyance. The whole pelvis
was found filled with small inflammatorv cystic
collections at the time of the operation. The left
adnexa were completely disorganized, and removed.
The right seemed in fairlv good condition, and was
left. Menstruation has been regular, but scanty.
It has been nearly four vears now since the opera-

tion. A sixth patient (CascX) had ectopic gesta-
tion in the left tube (the right adnexa were excised
lor tuboovarian abscess) two years after the oper-
ation.

The remaining forty-three patients are practically
cured and have menstruated regularly and normally
since the operation. They have all been under obser-
vation or have been heard from for periods varying
from two to ten years.

One patient (Case 5) became pregnant twenty-
one months after the operation, and was delivered
of a living child at full term. She has since mis-
carried twice, probably owing to a retroversion
which recurred after the birth of the child, other-
wise she has remained in good health. This, as
far as I know, is the only case of pregnancy follow-
ing the operation in the series of cases that I have
presented.

In several cases of the series both tubes were
filled with pus and the ovaries were extensively
adherent to the intestines and the pelvic structures.
In some of these' so extensive was the disease that
it was only the comparative youthfulness of the
patient, being under twenty-five years of age, that
induced me to refrain from a radical operation,
which to my mind seemed to be the safer procedure,
after all of the diseased structures had been enu-
cleated and the field of operation investigated. Still
the boldness of my practice was justified by the
recovery of the patient, and her enjoyment of good
health afterward, and by the continuation of men-
struation regularly and normally.

.V word or two in reference to the technique.
While I have been, and am still, a strong advo-
cate of the vaginal route, for many operations on
the pelvic organs, the abdominal route, in my opin-
ion, is the only legitimate one for the class of cases
under consideration now. To carry out successfully
conservative surgery upon extensive and marked
disease of the adnexa requires easy accessibility,
plenty of room, and good exposure to light. One
needs to be in a position to be able to meet the
complication of extensive injury to the intestine
by careful surgical technique, as I had to do in two
of my cases. In one case the tuboovarian abscess
was extensively adherent to the sigmoid and had
l)roken into the bowel by a small opening. After
I removed the structures of the abscess a good sized
hole in the gut had to be repaired. The patient
made a good recovery.

In some of the worst of my cases, when the ad-
hesions have been very thick and their separa-
tion has left a large, irregular, and ragged area
in Douglas' cul-de-sac or on the posterior aspect of
either broad ligament or of the uterus, it has been
my custom to pack the area lightly with iodoform
gauze and carry the end through the posterior
vaginal vault into the vagina. I am aware of the
tendency nowadays to discard this procedure, which
is falsely termed "drainage." But I am certain
many operators in this w'ork at the present time
have allowed the pendulum to swing too far. In my
opinion the ultimate successful issue of conservative
surgery upon the adnexa depends in a great measure
upon many details in the technique, and this is
something that to my mind has a great bearinsr.

I think we operators have a solemn duty devolv-
ing upon us in every operative case in women nnicli
under the climacteric age. We should strain every
power we possess to cure our patient without sac-
rificing all her pelvic organs, and we should make
everv effort to ensure preservation of the menstrual
function.

751 Madison Avenite.

220

MEDICAL RECORD.

[Feb 9, 1907

THE CAUSE OF COMMON BALDNESS.*

By DELOS L. PARKER, M.D,

DETROIT. MirillGAN.
LECTURER ON MATERIA MEDICA, DETROIT COLLEGE OP MEDICINE,

This report relates to an investigation of the sub-
ject of Common Baldness that has been carried on
since 1887, and is still in progress.

The forms under which baldness presents itself,
with extremely rare e.xceptions. are three in num-
ber, as follows : Common baldness (alopecia vul-
garis), alopecia areata and alopecia secundaria.
These forms all differ one from anotlier in origin,
symptoms, and other important particulars.

Common baldness (alopecia vulgaris) includes
all cases of baldness in which the hair shedding oc-
curs independently of any other disease, and, in
addition, is limited as to its field of operation to
the portion of scalp occupying the top of the head.
What might be termed ordinary, every-day baldness
is common baldness. Common baldness accounts
for more than 90 per cent, of all cases of baldness.
Alopecia areata, on the other hand, refers to a
form of baldness in which the hair shedding occurs
sometimes in one, but oftener in several round or
oval patches, which are located as a rule on the
sides or back of the head.

Finally, alopecia secundaria is loss of hair occur-
ring as a symptom or sequel of another disease.
There are several diseases that tend to cause this
form of baldness, among which are typhoid fever,
scarlet fever, and erysipelas.

At different times in the course of the investi-
gation that is under consideration, progress of the
work has been reported to different medical and
pathological societies. The last comprehensive re-
port of this kind was contained in a paper entitled
the "Etiology of Alopecia," which was read at a
meeting of this society in June, 1901, and pub-
lished in the Medical Record in the following
July.

At this time it is intended first to review, in a gen-
eral way, the conclusions presented in the paper
of 1901, and then, with somewhat more attention
to detail, to set forth what the investigation has
developed since.

In this paper the fundamental cause of common
baldness was declared to be a form of respiration
that leaves residual air undisturbed in the air
cavities of a portion of the lungs; or, to be more
explicit, since the residual air of any portion of the
lungs that is not made use of for breathing jnir-
poses must necessarily lie undisturbed, and since
the function of respiration can be carried on with-
out the upper portions of the lungs being utilized
but cannot be carried on without the lower portions
being used, the fundamental cause of common bald-
ness is absence of upper chest breathing.

The connection between absence of upper chest
breathing and the existence of common baldness
was explained in the following manner: In the
first place attention was directed to the circumstance
that residual air is warm, that it is saturated
with moisture, that in amount it is five times greater
than the tidal air, and that it contains among its
constituents oxygen, nitrogen, carbon dioxide,
argon and organic matter. Attention was also
directed to the fact (previously proven) that when-
ever residual air (or what is the same thing, ex-
pired air) is kept chambered in the presence of
warmth and moisture, it invariably undergoes
change and develops a soluble poison that is capable,

♦Read at a meeting- of the Detroit ."Vcademy of Medicine.
September 11, 1906.

when present in the blood, of exerting a disturbing
effect upon hair growth.

With this introduction it was explained that ab-
sence of upper chest breathing is the fundamental
cause of common baldness, because it establishes
conditions that permit the above-mentioned soluble
poison to be formed from the residual air contained
in the air cavities of a portion of the lungs, whence
by a process of absorption it is taken up by the
blood and is thus placed in position to exert its
specific effect.

That a poisonous substance circulating in the
blood should limit its destructive action to the hair
of the top of the head, as must be the case if the
theory that is being considered is correct, was ex-
plained by the statement that the roots of the hair
of the top of the head, by reason of lying over the
hard, glistening and practically bloodless occipito-
frontal aponeurosis, are deprived of the nourish-
ment that the roots of the hair of other portions
of the head and of the face derive from the soft,
blood-saturated muscular tissue with which they
are in close relationship ; and as a result the hair
roots of the top of the head are of comparatively
low vitality.

In support of the contention that absence of up-
per chest breathing is the fundamental cause of
common baldness evidence was presented that had
been derived: (i) From observing cases of com-
mon baldness; (2) from treating cases of common
l)aldness ; (3) from experimenting on animals.

Obser-jation. — It was stated that an observation
extending over a period of many years and applied
to thousands of persons had developed not a single
exception to the rule that persons aft'ected with
common baldness do not employ upper chest breath-
ing, while those not affected with this disease as
regidarly do employ this form of respiration. It
may be added that during the years intervening
between the time the paper was published and the
present no exception to this rule has been dis-
covered.

Results of Treatment. — In describing the evi-
dence derived from treating cases it was stated that
during a period of ten years successive groups of
persons had been treated for common baldness by
means of directions to practice continuously upper
chest breathing. These persons followed the direc-
tions thev had received with widely differing de-
grees of thoroughness. Some followed their in-
■-tructions to the letter, others not at all. and still
others to different degrees between these extremes.
The results received from the treatment were de-
scribed as being satisfactory in direct proportion to
the thoroughness with which the treatment had
lieen ajiplied. The results from a case in which
the treatment had been followed closely were de-
scribed as follows : After one week dandruff, when
present (and this affection is present in about 80
per cent, of all cases of common baldness) entirely
disappeared. At this time. too. the hair, which is
frequently either dry and harsh, or unusually oily
when common baldness is present, asstf.med a nat-
ural appearance. Then some weeks later, usually
five or six weeks from the time of starting the
treatment, new hair began to make its appearance.
The ne\v growth as a rule appeared first among the
hairs about the margins of the bald areas, and after
multiplying there invaded the bald patches by ex-
tension. The new hair growth, even after being
well started, developed slowly, so that months or
even years were passed before even a moderately
sized patch of uncovered scalp became covered with
new hair. In all cases any interruption in applying

Feb. 9, 1907]

MEDICAL RECORD.

221

the treatment was accompanied by a corresponding
interruption in the progress of the case toward re-
covery. As a result of treatment that involved noth-
ing but the continuous performing of upper chest
breathing it was declared that hair had been seen
to appear on portions of scalp that had been bald
for upward of twenty years.

Vic. I. -Malenal isolated liurri expired air X S"

Results t'l Experiments Applied to Animals. —
These experiments were based on the supposition
that if expired air should be kept chambered in
the presence of warmth and moisture outside the
lungs, it would imdergo the same change as when
kept under the same conditions within the lungs;
and that the products resulting from such change
injected artificially into the blood of animals, would
exert the same effect upon such animals as would
have been the case had these products been ab-
sorbed by the blood from the lungs.

Accordingly a two-liter (half gal.) flask was
sterilized and filled with distilled water. When this
had been done all but a small portion of the water
in the flask w-as displaced w'lth expired air. This
was accomplished by having two glass tubes of
unequal length passed through the stopper of the
flask, after the manner of those of an ordinary
laboratory wash bottle, and crowding the water out
by forcing expired air either directly from the
lungs, or from a rubber bag, into the flask through
the shorter tube.

When charged wdth expired air and a small
amount of water, the flask was closed by connecting
together by means of a piece of rubber tubing the
outside ends of the tubes, then agitated so as to
bring the inclosed water and expired air into close
relationship (in imitation of the conditions that
prevail in the lungs) and finally kept at body tem-
perature in an incubator. Ten days were allowed
for the change in the expired air to take place.

When the flask was placed in the incubator the
expired air within, both as to condition and sur-
roundings, was very similar to residual air left un-
disturbed in the lungs. Moreover, after the flask
had been in the incubator some hours this similarity
became more marked by reason of the circumstance
that drops of water gathered upon the inner sur-
face of the flask to such an extent that the air
within was in contact only with a wet surface.
In these circumstances it could be affirmed that the
principal difference between the expired air cham-

bered in tile flask and the same air chambered in the
lungs lay in the fact that in one case the air was
held in a single cavity, while in the other it was
held in a great number of small cavities. An at-
tempt was made to overcome this difference by agi-
tating the flask occasionally so as to bring all parts
of the air in contact with the water. This maneu-
ver also made it certain that any soluble material
in the expired air, whether there originally or
whether formed by reason of the expired air's being
in a warm and moist place, would become dissolved
in the water.

The animals used for the experiment consisted
of dogs, hens, and pigeons. The injecting material
was the water that had been kept in the flask with
the ex* ired air. This water in appearance differed
in n-^ iCspect from ordinary distilled water. It was
colorless, odorless, neutral in reaction, and appar-
ently of the same specific gravity as when placed
in the flask. It was found also not to deviate
polarized light.

. In making the injections the flask was first agi-
tated and then from 5 to 10 c.c. (i'/4 to 2^ drams)
of its inclosed water injected with an ordinary
serum syringe beneath the skin of each animal.
This was done once a day and continued for five
months. At the expiration of this time the hens
and pigeons had lost completely their coats of
feathers, while in the case of the dog, the abdomen,
sides, and hind legs had become denuded of hair.
During the time they were being treated the ani-
mals showed no signs of disturbed health, and in
six weeks after the injections had been discontinued
all had gained new^ coats to take the place of those
lost. _ .

In addition to these experiments other like ani-
mals were treated with other substances closely
related to the preparation already described. In
one case water from a flask in which atmospheric
air was made to take the place of expired air, was
used. In another case, distilled water by itself
constituted the injecting material. .\nd in still an-
other case, water impregnated at the time the

Fl,i 2- — .\nothcr tield ot sa

lal shown in (ig. i-

injeclion was made with lreslil\- expired air, was
used. In this instance the injection was the same
as that of the experiment first described, except
that the flask was uot placed in the incubator and
no time was allowed for change to occur in the
expired air.

The iniections in tliese control experiments were

MEDICAL RECORD.

[Feb 9, 1907

given daily and continued five months. At the
time they were discontinued no effect of any kind
had been observed in any of the treated animals.
These control experiments showed that in the first
experiment described above the shedding of hair
and feathers had been caused not by the water as
such, nor by the expired air as such, but by some-

Fic. 3. — Pigeon above received injections of material from expired air
not soluble in absolute alcohol ; pigeon below recei ved injections of mate-
rial from the same source soluble in absolute alcohol ; the results"are
shown in Fig. 4.

thing that had developed in the expired air during
the time it had been in the incubator.

The skin coverings of fur-bearing animals, such
as guinea-pigs and rabbits, were found not to be
affected by injections of the material that caused
the shedding of the skin coverings of the animals
above mentioned. There is an anatomical reason
for this that need not be explained at this time.
It is only necessary to state that fur differs in
many important particulars from both hair and
feathers.

As to the nature of the change that takes place
in expired air when such air is chambered in the
presence of wamith and moisture, nothing at the
time the paper was published had been determined :
but as organic matter is a constituent of expired
air, and as organic matter is prone to undergo de-
composition when kept moist and warm, the change
was considered (without warrant, however), to be
putrefactive in character, and the organic matter
of the expired air the material acted upon.

The paper that is being considered coincided in
point of time of appearance with the concluding of
the experiments above described.

In the closing portion of this paper the following
words were used : "The results of the experiments
just described show that when expired air from
human beings is kept chambered in the presence of
warmth and moisture long enough for decomposi-
tion of its organic matter to take place, there is
developed a substance, which, when introduced into
the blood of certain animals, exerts a selective poi-
sonous action upon the hair, or tissues analogous
to hair, with which such animals may be endowed,
and that beyond this, so far as careful observation
can determine, it produces no eft'ect whatever."

Trichotoxin. — With the existence and action of

the substance under consideration demonstrated, the
need of a word, to take the place of a phrase or
sentence, in making reference to the substance it-
self, is apparent. To meet this want, the writer
presents "Trichotoxin," from the Greek '^i"' hair,
and '"«""'■ poison. So much for the paper pub-
lished in IQOI.

Since that time the work of the investigation
has been devoted chiefly to the study of the agent to
which the name trichotoxin had been given. The
work itself represents a series of experiments car-
ried on partly in the bacteriological laboratory of
the Detroit College of Medicine and partly in the
Detroit Clinical Laboratory. The first task under-
taken in this connection consisted of an effort to
isolate trichotoxin from its aqueous solution.

As has been said, the agent at this time was
looked upon as a product formed by putrefactive
changes taking place in the organic matter contained
in expired air, or, in other words, as formed by
bacteria acting upon such organic matter. This
view made it necessary to consider the possibility
of the agent's being a ptomain.

A ptomain, as defined by Vaughan and Novy
(Cellular Toxins. 1902, p. 29), "is an organic chemi-
cal compound, basic in character, and formed by the
action of bacteria on nitrogenous matter."

In undertaking to isolate trichoto.xin as a ptomain
it w-as found that there are several methods of ex-
tracting ptomains. The so-called Stas-Otto meth-
od w-as used. This was applied by placing 60 c.c.
(about two ounces) of water containing trichotoxin,
previously rendered slightly alkaline with sodium
carbonate, in a separatory funnel with an equal

Fig. 4. — Pigeons shown iu fig. 3 after three and one-half months o£
treatment .

amount of pure ether. \\'hen this had been done,
the funnel, tightly stoppered, was agitated for some
time and then left to stand twenty-four hours to
allow the fluids to separate. When this had taken
place the water was drawn from the funnel and the
ether transferred to an open glass dish and allowed
to evaporate spontaneously. When this had oc-

Feb. 9, 1907]

MEDICAL RECORD.

223

curred the bottom of the dish was found to be cov-
ered with a thin, tightly adherent residue much
resembling a light coating of frost on a window-
pane. To determine whether or not this residue
contained trichotoxin, the whole deposit was re-
dissolved in distilled water and introduced by means
of small dailv injections beneath the skin of a small

Fig. s- — Trichotoxin crystals. X 87.

bird. As a result of this procedure at the end of
six weeks the bird had lost completely its coat of
feathers. This experiment showed that trichotoxin
can be extracted from watery solution by ether, and
also that it exists as a solid.

It did not, however, prove trichotoxin to be a
ptomain. Many substances not ptomains can be
extracted with ether. It showed that the possi-
bility of the agent's being a ptomain still existed,
and that the applying of further tests was in order.
Accordingly, reagents considered capable of pre-
cipitating ptomains from aqueous solutions were
added to ditTerent portions of the preparation tliat
was being tested. Potassio-mercuric iodide, potas-
sium iodide, mercuric chloride, picric acid, sulphuric
acid, tannic acid, and phosphomolybdic acid were
used. None of these reagents caused a precipitate
to appear.

Eiiforts were then made to demonstrate the pres-
ence in the liquid of the bacteria that should be
there in case a ptomain was present. The liquid
was centrifugalized and examined, both in thin
layer and in a hanging drop, with the aid of a micro-
scope provided with a 2 mm. (1-12 inch) oil im-
mersion objective. This procedure brought no
tacteria to light.

Next, portions of the centrifugalized liquid were
evaporated to dryness on cover glasses and the
residues thus secured stained, one with Loffler's
methylene blue, another with cold aqueous fuchsin,
another with cold carbol fuchsin, and a fourth with
hot carbol fuchsin. An examination of these prod-
ucts with a high power oil immersion objective
•did not disclose the presence of bacteria.

Finally an experiment was undertaken to deter-
mine whether or not expired air, from which tricho-
toxin is developed, contains bacteria.

This was done by keeping at body temperature
two flasks, one containing sterile agar and atmos-
pheric air, the other sterile agar and expired air.
The results were as follows : In a few hours col-
onies of bacteria developed on the surface of the
agar in contact with atmospheric air, which in a

few days were in sufficient quantity to render the
whole of the agar cloudy. In the other flasks, on the
other hand, the agar remained unchanged for two
weeks. This showed that so far as the ordinary
bacteria of atmospheric air are concerned, expired
air is practically sterile.

The results of these tests, taken as a whole,
proved trichotoxin not to be a product resulting
from the decomposition of the organic matter of
expired air, a finding that made it necessary to
abandon the idea of its being a ptomain.

Trichotoxin is Non-Volatile. — Coincidently with
the performing of the experiments just described,
others of a different character were carried on.
In one a bird was treated with daily injections of
trichotoxin-bearing liquid that had been left for
,^ome time in an open dish. This bird lost its
feathers as promptly as those treated with material
from closed receptacles. This showed trichotoxin
to be a nonvolatile substance.

Trichotoxin Given by the Mouth is Inert. — In
another, a bird was permitted to drink nothing but
water charged with trichotoxin for a period of sev-
eral months. No effects of a disturbing nature fol-
lowed. This showed that the characteristic effects
of trichotoxin cannot be secured by introducing the
agent into the system by way of the stomach.

Trichotoxin May Be Isolated by Evaporation. — •
Returning to the isolating of trichotoxin, when this
substance was found to be nonvolatile the idea at
once presented itself that it might be isolated by
evaporation. Accordingly, water was charged with
trichotoxin in the usual way and then evaporated
to dryness on a water bath. As a result the bottom
of the dish used to hold the liquid was found to be
thinly covered with a residue appearing in all re-
spects but color like the residue obtained when
ether had been used to extract trichotoxin. The
evaporation product was yellowish in color. This
residue was redissolved in water and shown to con-
tain trichotoxin by the results obtained from its
use in treating pigeons.

Thus the efforts made to isolate trichotoxin had

Fig. 6. — Trichoto.\m crystals. X 87.

discovered two methods of accomplishing this re-
sult, one by using ether, the other by evaporating
the mother liquor to dryness. The latter was
found to be the more satisfactory on account of its
greater simplicity. The residue obtained by evapo-
rating the mother liquor, as said above, resembles
frost on a window pane except that it is tinted yel-

MEDICAL RECORD.

[Feb 9, 1907

low. Viewed under a microscope with a 16mm.
(2-3 inch) objective, which magnifies 87 diameters,
the deposit was found to consist of different-shaped
crystals, with a wa.xy substance eitlier clinging to
the crystals, or lying in separate masses. Figs. 1
and 2 represent different fields of the same deposit
as seen w^ith the microscope.

Trichoto.xin Docs Xot Develop Singly.- — After
inspecting its external appearance an effort was
made to learn something of the behavior of the
residue under the influence of different reagents.
With this end in view, scra[3ings of the substance
were placed on glass slides, and with the aid of a
microscope were watched while different reagents
were applied to them. .Xs this continued nothing
occurred to attract attention until absolute alcohol
was used. When this substance was brought in
contact with a specimen of the deposit, part of the
crvstals disappeared in solution and part remained
unacted upon. This showed that an original de-
posit of the material contains at least two constitu-
ents, one soluble, the other insoluble, in absolute
alcohol. This information also raised the follow-
ing questions: Had the specific eft'ects that had
followed the injecting of the material into animals

Trichotoxin crystals. X 87.

been caused by one of these constituents, or by
their combination? And if by one of them, which
was the one? ^Manifestly there was but one way to
secure answers to these questions. This was to
treat different animals with the dift'erent constitu-
ents and note the results. This plan w'as adopted
and carried into effect.

Two pigeons were made the subjects of the ex-
(leriment the work called for ( Fig. 3). The pigeon
occupying the upper position in the illustration was
treated with a watery solution of the body not
soluble in absolute alcohol, the other with a like
solution of the body soluble in alcohol. The injec-
tions were made once daily, and continued for a
period of three and a half months. .-Xt the expira-
tion of this time the pigeon receiving the substance
not soluble in alcohol had lost completely its coat of
feathers, while the other was unaff'ected. so far as
losing its protective coat was concerned (Fig. 4).
Thus it was shown that of the two known constitu-
ents of the material that had been employed to
destroy the skin coverings of animals in previous
experiments, only the body not soluble in absolute
alcohol had exerted a destructive eft'ect on the skin

ai)pendages of such animals. It was shown also
that the word trichotoxin, taken in the sense in
which it had been adopted, should apply to this con-
stituent alone, and not to the combination of sub-
stances it had previously been employed to desig-
nate.

Figs. 5, 6 and 7 represent different fields of the
material not soluble in alcohol (trichotoxin) as seen
w ith the aid of a microscope magnifying 87 diam-
eters. The heavier shaded parts seem to be com-
posed of the waxy material mentioned above in
connection with the description of the original de-
liosit, while the crystalline portions resemble spi-
cules of newly formed ice. Whether the crystals
and the waxy part are diff'erent forms of the same
substance, or are different substances with differ-
ent properties, has not been determined. In the
form in which it is here represented the prodyct is
permanent in the air. Specimens have been kept
for months on glass slides without cover glasses
without undergoing appreciable change in appear-
ance.

The body soluble in alsolute alcohol has been
named "stearotoxin.'" Its properties will not be con-
sidered in this paper.

When the pigeon that lost its feathers in the last
experiment had served the purpose mentioned above
it was made the subject of another experiment for
the purpose of learning if absence of feathers for a
considerable time tends to delay the forming of a
new cron. By means of repeated injections of
trichotoxin the bird was kept denuded of feathers
for a period of six months, when, upon discontinu-
ing the injections, a new crop of feathers developed
as promptly as had been the case in any of the ex-
periments already described. In this way it was
shown that the structures that develop the skin
covering of birds may be subjected to the action
of trichotoxin for a considerable length of time
without suffering permanent injury.

Time Required for Trichotoxin to Develop.- — By
means of experiments information was gained con-
cerning other points in the inquiry- as follows : By
evaporating at short inter\'als successive specimens
of water kept in contact with expired air, and ex-
amining microscopically the residues thus secured,
it was found that expired air kept chambered at
body temperature, begins to develop trichotoxin in
about six hours, and that the process is completed,
so far as a fixed amount of expired air is concerned,
in four or five days.

Proportion in Which Trichotoxin Develops. — By
|)lacing a know'n quantity of expired air — 240 liter>
(about 60 gallons) being the amount — under condi-
tions that favor the forming of trichotoxin, it was
found that one liter of expired air developed Gm.
0.0003 of trichotoxin, and Gm. 0.000054 of stearo-
toxin ; or, to use a different standard, one gallon
of expired air developed grain 1-53 of trichotoxin.
and grain 1-300 of stearotoxin.

The Constituents of Expired Air That Develop
Trichotoxin Soluble in Water. — By forcing air di-
rectly from the lungs through a glass tube placed
so that the air rose in bubbles through a column
of distilled water, ' it was found that the water
takes from expired air the constituents that are con-
verted into trichoto.xin. and that water thus treated
develops trichotoxin even when kept in an open
receptacle.

Reagents That Precipitate Trichotoxin. — .\s a
result of efforts made at different times during a
p<eriod covering several months it was finally found
that trichotoxin may be thrown out of its aqueous
solution by adding any of the following reagents :
Barium chloride barium sulphide, barium nitrate.

J. cu. y, iyv-"/j

iTi.J_/l^X \^J 11_<

i\J .**>\_' iX A--'.

barium hydrate, barium dio.xitle and strontium ni-
trate. The barium preparations vary with respect
to the amount of precipitate they cause to appear.
They are arranged here in the order of their activi-
ties, the most active being first. Strontium nitrate
corresponds in precipitating jiower to the most ac-
tive of the barium preparations. Calcium and mag-
nesium, the other members of the alkahne earth
group of metals, so far as tested, do not form a
precipitate when added to a watery sokition of
trichotoxin.

By utilizing a precipitating reagent the finding
previously made, that under favorable conditions
a fixed quantity of expired air begins to develop
trichotoxin in about six hours and completes the
conversion in four or five days, was confirmed.

Warmth Not Essential to the Forming of Tricho-
toxin.— That expired air does not necessarily re-
quire the presence of warmth in order to undergo
the change requisite to the forming of trichotoxin
was brought out by finding that the different re-
agents that precipitate trichotoxin, upon being added
to water charged some days previously with expired
air, cause a precipitate to appear even when such
water has not been subjected to heat.

Water from a laboratory wash bottle that has been
in use for some time has as a rule absorbed enough
expired air to give this reaction. It is altogether
probable, however, that the presence of warmth not
only hastens the forming of trichotoxin, but also
tends to make the process of conversion more
complete.

Present Status of the Investigatiun. — At tlic
present time the attempt is being made to clear up
two of the more important points of the inquiry
that remain undetermined. One involves the deter-
mining of the chemical formula of trichotoxin ; the
other, the ascertaining of the nature of the change
that expired air undergoes when trichotoxin is de-
veloped. The first of these tasks, that of finding
the chemical formula of trichoto.xin, is under the
direction of W. H. Allen, Ph.G., while Thaddeus
Walker, M.D., and Jo,seph Sill, M.D., of the De-
troit Clinical Laboratory, are aiding in the endeavor
that is being made to accomplish the second. It
has already been found that when expired air has
been heated to 80° C, the temperature at which
practically all known ferments are destroyed, it
cannot be made to yield trichotoxin. Also that
when water charged with expired air has a large
surface exposed to the atmosi>here. it develops
trichotoxin more readily than when it has only a
small surface thus exposed. These two facts seem
to show that the change referred to is dependent on
the action of an aerobic enzyme. Other tests must
be applied, however, before a definite conclusion
in regard to this point can be reached.

The work of analyzing trichotoxin was begun
some months ago, and thus far has consisted chiefly
of efforts to secure material in sufficient quantity' to
meet the demands the work imposes. For this pur-
pose a specially constructed apparatus has been de-
vised. This consists of a 36 liter (8 gallon) crock,
a bell-jar, an iron table, and a bunsen burner, all
arranged as in Fig. 8. In using the apparatus the
crock is filled with distilled water, the bell-jar, open
at top, submerged in the water, and the burner
lighted and the ilame regulated so as to keep the
water at a temperature" of 37° C. (98^2° F.).
Next a glass tube, bent at a right angle at one end
and connected with a piece of rubber tubing pro-
vided with a glass mouthpiece at the other, is passed
down between the side of the crock and the bell-
jar and turned so as to bring the end beneath the

jar. W hen tliis has been done, as many persons a--
can be secured, are assembled and one after another
directed to force air directly from the lungs through
the tube. While this is being done the vent at the
top of the bell-jar is kept open until all but three
or four of the persons have forced expired air
through the tube, when it is closed. By proceed-
ing in this way a comparatively large volume of ex-
pired air is made to bubble up through the water,
and by so doing to give up to the water a greater
or less porti<->n of its convertible constituents, while
in the end the bell-jar is left filled with expired air
resting in contact with the water. In concluding
the charging operation the glass tube is removed
and the crock screened from dust by means of a
cloth cape.

For a period of five months the apparatus was

Fill .s — ,\pi'aratus for developing trichotoxin from exjiired air

chargeil and recharged with expired air at intervals
of eight or ten days, and the water in the .crock
then eva])orated to dryness. The residue thus se-
cured, containing both trichoto.xin and stearoto.xiu,
weighed Cm. 0.867 (grains 13.38). When split nj)
with absolute alcohol, the trichotoxin thus secureil
weighed Cm. 0.718 (grains 11.08), and the stcaro-
to.xin, Cm. 0.149 (grains 2.30).

This yield of trichotoxin is now available for the
purpose of the examination. The apparatus will be
kept in constant use, however, in the lu)i)e that a
deficiency of material may be avoided.

Snnunary. — I'rom what has been written al)o\e
it will be seen that the theory discussed in this
paper makes common baldness depend for its ex-
istence on a double cause, one being the remote or
fundamental cause represented by the absence of
upper chest breathing, a condition that allows a
poisonous substance to develo|) in the lungs; the

226

MEDICAL RECORD.

[Feb 9, 1907

other, the direct or exciting cause, represented by
the effect produced by this poisonous substance
circulating in the blood.

Conclusion. — The evidence here submitted in
support of the theory that absence of upper chest
breathing is the fundamental cause of common
baldness cannot yet be said to be complete. Its real
value has not been demonstrated to be that of its
face value. Before its real and face values can be
said to correspond, the evidence itself must be
vouched for by many times more than one person.
That this condition of affairs was bound to prevail
was fully understood when the task of preparing
this paper was entered upon, a circumstance that
caused the attempt to be made so to describe any
evidence made use of that the testing of its value
might become as simple a matter as possible.

550 Jefferson' Avenue.

SOME POTENT ETIOLOGICAL FACTORS
IN BACK\^'ARD CHILDREN.*

Bv .M. NEUSTAEDTER. M.D.. Ph.D.,

NEW YORK.

Much stress has been laid upon such physical de-
fects as enlarged tonsils, adenoids, refractive errors,
and carious teeth, as the most prominent etiological
factors in backward children. But when we survey
the statistics and find on the one hand 85 per cent,
of all school children are suffering from some physi-
cal ailment, and among the suft'erers 95 per cent, are
bright pupils, when we think of the vast army of
graduates who yearly leave schools and in spite of
their physical defects become bright men and women,
and we are reminded by history that such great men
as Rousseau, Kant, Mendelssohn, Darwin, and
others were physically incapacitated, that great sing-
ers suffer from incurable diseases of the vocal cords,
and on the other hand some of the most vicious
children whom I have personally examined pre-
sented no physical defects that I was able to detect,
it seems to m.e to be imperative that we look further
than tonsils and other physical defects. Apart from
the fact that with the adenoids and enlarged tonsils
out of the way, every pupil is not yet supplied with
pure air in his badly-ventilated dormitory nor pro-
vided with wholesome food, we have to contend with
other factors that are far worse and create greater
havoc in the physical and mental make-up of the
child, than all the physical defects combined. These
defects are certain drug habits to which all these
backward children are addicted.

After having carefully studied ninety-five cases
of backward children between the ages of ten
and sixteen years in one school, without any
prejudice as to the etiological factor or factors, I
have come to the conclusion that it is the addiction
to alcoholic stimulants or strong decoctions of tea
or coft'ee. or to the smoking of cigarettes, or to a
combination of two or all the poisons enumerated,
that far outweighs in importance as etiological fac-
tors all the physical defects combined.

Before going into a discussion of the physiological
action of these drugs, permit me to pass a review of
the examination of the ninety-five backward chil-
dren mentioned. Of these (the figures representing
percentages) 22.8 were badly nourished, 66.5 had
enlarged cervical glands, 1.9 had chorea, 3.8
were suft'ering from cardiac disease, 1.9 were
suffering from pulmonary disease. 2.7 had skin
disease, 0.95 deformity of the chest, 32.3 had defects

* Read before the Society of Medical Inspectors of the
City of New York, December 4, 1906.

of vision, 28.5 had defects of the ear, 9.5 had nasal
defects, 34.2 had bad teeth, 2.7 had deformed palate,
20.9 had enlarged tonsils, 71.25 had bad mentality,
6.6 were drinking strong decoctions of tea or cof-
fee, 3.8 were drinking coffee and smoking cigarettes,
36.1 of all and 98 of boys were addicted to the use
of tobacco, coffee, and alcoholic stimulants, 25.65
were addicted to the use of tea and beer, i.i claimed
to have partaken of none of these drugs, 16. i had no
physical defects at all, 54.0 had a two-inch chest
expansion during the act of respiration, 18.0 had
three-inch expansion, 12.0 had one-inch expansion,
99.0 were underweights.

These statistics speak for themselves. I then
examined seventy-two pupils of the same school
whom the teachers termed the brightest, and found
total abstainers 7.2, users of tea 5.6, of coffee 23, of
beer 0.72, of tobacco 4.3, of tea and coffee 8.6, of
coft'ee and beer 11.5, of tea, coffee, and beer 0.72.

Let us now consider the effects of alcoholic stimu-
lants : The experiments of B. W. Richardson, Dc^iel,
and others indicate that alcohol, even in very small
quantities, affects protoplasm, and therefore the
entire system. It tends to cause cessation of the
ameboid movements of the leucocytes, destroying
their function. These are driven in masses by in-
creasing rapidity of the heart's action and become
blocked in the capillaries, forming centers of ob-
struction and injury.

Prout, Edward Smith, Harley, Schmiedeberg,
Vierordt, Kerr, and others have proved that alcohol
lessens the absorption of oxygen by the red blood
corpuscles and the exhalation of carbonic oxide. It
favors the growth of many pathogenic organisms,
including those of pus and diphtheria ; Lancereaux
enumerates cases showing marked inhibitory influ-
ence of alcohol on the growth of children, and in
mj^ ninety-five cases we had 99 per cent, of under-
weights. It inhibits or even entirely destroys the
food-dissolving action of the gastric juice. Inflam-
mation of the mucous membrane of the stomach,
with increased secretion of a thin tenacious mucus
and a loss of secreting power, as a result of the
ingestion of alcohol, is known to every one. The
appetite becomes impaired or even lost. Ptyalin of
the saliva and pepsin are precipitated, the gastric
vasodilators are paralyzed, while the constrictors
are stimulated, preventing the flow of gastric juice
and accounting for irritability, anorexia, etc. Duo-
denal and pancreatic function is prevented. Stearin
is dissolved out of the fat by alcohol, and remaininig
elements are contributing to fatty degenerations of
various organs. Wilkins holds that the continued
use of alcohol will prevent the rehydration of .glyco-
gen and its transfer to the blood and oxygenation
of bilirubin to form biliverdin. In this sense even
small quantities of alcohol are inimical to life.

That the liver suffers organic changes from the
continued use of alcohol is well known to us. Lan-
cereaux reports the findings of an histological ex-
amination in two rabbits, which were subjected to
small doses of wine. There were traces of an irri-
tating influence upon the liver, which were found
principally in the central parts of the lobes. The
connective tissues of the portal spaces did not pre-
sent lesions that were very clear, but the subhepatic
veins and the capillaries were filled with leucocytes
and proliferated endothelial cells. The glandular
parenchvma was remarkable for the considerable
size of its nuclei, which were vesicular : the cellular
protaplasm seemed to be intact. One had died at
the end of twenty days, without presenting any
visceral alterations. The other had died after thirty
davs, and presented hemorrhage of the stomach.

beo. 9, i')07J

MtUlLAL KtLUKJJ.

The liver was of a pale-grayish color and the spleen
was tumefied.

The intestinal tract bears the brunt of the irritating-
action of improperly digested food, and this condition
is frequent, especially in children. Koplik claims
that many children suffering from acute or subacute
gastrointestinal disease are the victims of unre-
strained administration of alcoholic stimulants.
Wintz and Hudelo hold that the ingestion of alcohol
causes migration of microbes from the intestines to
the peritoneum and to the blood of the vena porta.

The habitual ingestion of alcohol interferes with
the functions of the kidney structures and the prod-
ucts of metabolism are retained in the system. The
various forms of nephritis are the natural conse-
quences of the irritation produced. Glaser observed
that uric acid and calcium o.xalate crystals are found
in the urine of persons in good health after taking
alcoholic drink, besides an increased number of
leucocytes with cylinders and cylindroids. From
this premise we may conclude that, even in moderate
quantities, alcohol irritates the kidneys, the aug-
mented leucocytes, cylinders, and crystals being due
either to the increased metabolism of the tissues or
an alteration by alcohol of the relations of solubility
of urine salts.

The direct action of alcohol upon the involuntary
muscular system would indicate that the heart
muscle and blood-vessels will suffer on account of
their continuous overdistention. By lowering the
vitality of the entire system, alcohol exposes its
victim to the danger of tuberculous infection of the
lungs. It is a well-known maxim to even the recent
college graduate that the prognosis of pneumonia
in one addicted to the use of alcohol is invariably
bad. Tharain holds that one of the most efficient
prophylactic measures against tuberculosis would be
the repression of alcoholism, and Lagneau states that
the increase of tuberculosis is proportionate to that
of alcoholism in France.

As regards the action of alcohol upon the nerve
tissue and cells : ( i) It changes the granular matter
of the nerve cell, breaking up its nutrition and
thereby inhibiting its dynamic force. (2) This
action is followed by contraction and atrophv of
the dendrites, shrinking of cell walls, as in fatigue :
and coalescense and disappearance of the granular
protoplasm. (3) The special injury from alcohol
seems to be in protoplasm and terminal fibers of
nerve trunks ; the irritation and inflammation of
the nerve walls and fibers ending in sclerosis are
common. There is a marked sensorial palsy and a
slowing of all mental operations. The use of
alcohol produces an apparent temporary increase
of brain activity, which is hut an evidence of its
paralyzing and deleterious efifect. It destroys the
special functions of the cerebellum and produces
tremor and weakness of the lower limbs. Rust
states that a large percentage of insanity in children
in Germanv is due to habitual drinking.

Mental disorders and crime are shown by sta-
tistics to have in alcohol one of their most potent
etiological factors. J. J. Ridge shows that from
one-fourth to one-third of the lunacy of the United
Kingdom is the result of the custom of drinking
alcoholic liquors, and in every country where the
habitual use of alcohol prevails there is an increase
in lunacy and degeneracy. The literature of the past
three years has fully demonstrated that fact. Neu-
rological and pathological, together with recent ex-
perimental work, show that in the earlv stages of
the insanities there is a profound nutritive and
dynamical failure in the nerve elements of the
brain, which finds expression in the insomnias, the

melancholias, and the commencing loss of memory,
with easily induced mental fatigue which their
subjects experience and the pathological facts
ascertained insofar as they afford any light, force
on us the conviction that we are dealing with serious
nutritive and dynamical changes in the central nerv-
ous organ.

The manner in which the pathological lesions
and the symptoms correspond with one another is
as follows : The sensory disorders, the exaggera-
tion of the sensibility of the skin, the anesthetic
troubles, and the ocular and auditory disorders
would correspond to the beginning of the vascular
disturbances, when the nerve cells, irritated by an
insufficient supply of proper nutriment, the presence
of a poisonous stimulus, overact for the time; then,
as nutriment is still withheld from them, altered
metabolism results. The beginning swelling of the
dentrites of the sensorimotor region is marked by
paresthetic symptoms, those of the purer sensory re-
gion by visual and ocular troubles, and some am-
nesia, especially for recent events ; or, in other words,
cells that have the function of evolving and trans-
mitting thought cannot work properly, and defective
memor\- results ; later, as the motor cells are more
and more involved and nuclear changes begin,
continuous tremor becomes apparent, the muscles
no longer coordinate perfectly, unless for a moment
under the direct influence of the will. Still later,
when a portion of the cell structures have become
highly degenerated and the altered cells have become
more numerous, the already tottering will-power be-
comes more and more deadened, memory and judg-
ment fail, and when the degenerative process is
far adx-anccd an incomplete dementia is the final
result.

Alcohol is a narcotic poison, its food value under
ordinary conditions is practically nil, and put in
the most advantageous light can only be temporary,
and then of an exceedingly slight and wasteful
character.

The injurious effect of tobacco upon the system
is admitted even by the habitual smoker, and it is
my aim to show the extent of the injury and manner
in which it affects the system of the child and
thereby constitutes an etiological factor in his back-
wardness. The physiological effects of tobacco are
exerted through its alkaloid, nicotine, and the alka-
loids produced by the combustion of the tobacco and
its destructive distillation in the act of smoking, such
as pyridine, callidine, picoline, and an oil. It acts
especially on the spinal and sympathetic system of
nerves as well as, in a minor degree, upon the cere-
brum and cerebellum, the nerves of special sense,
the medulla oblongata, and the vasomotor system
producing slight stimulation at the beginning, fol-
lowed soon by a depression. Many a smoker re-
members the first "smoke," followed by vomiting,
dizziness, profuse cold, clammy perspiration, diar-
rhea, sense of alarm, and feebleness of pulse. These
effects become lessened as the habit of smoking is
acquired. The physically healthy child, addicted to
its use, loses the power of resistance ; how much
more harm then is done to the child with physical
defects already established? We are familiar with
effects of other poisons ingested in small quantities
for a long period of time, such as lead, mercury,
arsenic, iodine, etc., and we hardly doubt that to-
bacco will produce a deleterious effect upon the
organism. Various experiments, recorded in medi-
cal literature, show that the presence of the alkaloids
of tobacco in the system diminishes the amount
of feces, lessens the quantity of urine and the amount
of uric acid, phosphoric acid, and sulphuric acid

228

MEDICAL RECORD.

[Feb 9, 1907

eliminated through the hiiii^s, and that retrograde
metamorphosis is stopped. This shows concUisively
that tissue waste is excessive, especially the waste
of nerve tissue is shown by the increased elimina-
tion of phosphorus.

Cirasset and Parent/, have studied the physiological
action of nicotine o.xalate, which is eight times less
to.xic than nicotine. The constant symptoms were
contractions of the ])U])ils, paralysis and convulsions,
salivation, cerebral anemia, iieriiiheral vasomotor
constriction and cardiac asystole. N^ot only does
tobacco produce insomnia, but it renders sleep less
deep, and consequently less refreshing. The result
of an inadequate amount of refreshing sleep is to
render the child irritable and heavy during the day,
and the feeling of lassitude and incapacity for in-
tellectual work is especially pronounced during the
forenoon. Tobacco acts as a cerebral irritant, and
interferes with the vasomotor centers of the brain
to such an extent that the vessels are unable to
adjust themselves forthwith to the condition re-
quired for healthy and untroubled sleep. Every
smoker is aware that a change of tobacco or a
strong cigar will rob him of his sleep.

.A careful study of this subject by Dr. J. W.
Seaver of Yale, based upon the observation of one-
hundred and eighty-seven students during their first
and final college years yields the following results :
He claims that the nonuser of tobacco increased 10.4
per cent, more in weight than the regular user, and
6.6 per cent, more than the occasional user. In
growth the nonuser increased 24 per cent, more
than the regular user, and 14 per cent, more than the
occasional user. In the increase in chest measure-
ment, the nonuser had an advantage over the regular
user of 26.7 per cent., and over the occasional user
of 22 per cent., but in capacity of lungs the growtli
was in favor of the nonuser by 77.5 per cent, when
compared with the regular user, and 49.5 per cent,
when comjiared with the occasional user. He con-
cludes that tobacco has a dwarfing effect, and he
is corroborated by Prof. Hitchcock of Amherst Col-
lege, who has published the following ; Of the
class of '91 75 per cent, increased in their measure-
ments and tests during the whole course, while 29
per cent, remained stationary or fell ofif: In separat-
ing the smokers from the nonsmokers. it appears
that in the item of weight the nonsmokers increased
24 per cent, more than the smokers ; in height they
surpassed them 37 per cent., and in the chest girth
42 per cent. : in the lung capacity there was a differ-
ence of 8.36 cubic inches (about 75 per cent, in
favor of the nonsmokers), which was 3 per cent, of
the total lung capacity of the entire class.

The knowledge of the pathological effects of to-
bacco is rather meager. The only anatomical lesion
claimed to be due to tiie eft'ect of tobacco is that
incidental to a chronic form of retrobulbar neuritis
of the optic nerve, which generally affects both
nerves and is caused by certain poisons, chief among
which nicotine has been claimed to be an efficient
factor. Dr. G. E. De Schweinitz. in his treatise
on the To.xic Amblyopias, includes this substance
among the etiological factors. In Germany this
is regarded as the most potent agent. The result,
then, of our study of tobacco as a factor in the
production of functional or organic disorders is that
the use of tobacco bv children retards not only
their proper physical develojiment, but also their
mental progress.

The coffee bean, when green, contains caffeine,
caffeotannic acid, and, according to Palladine, an
alkaloid caffearine. During the roasting process,
however, a volatile oil is developed, which with other

substances is collectively termed "caffeone." Be-
sides there remain some astringent acids, as caffeo-
tannic acid, and caffeic acid. The empyreumatic oil
modifies the action of the coffee bean, inasmuch
as before roasting, caffeine alone acts. Marshall,
Hare, and T. Lauder Brunton have studied the
action of the empyreumatic oil of coffee and report
that 1 1 .0 ]jer cent, of oil is obtained from an average
browned bean ; in consequence, an ordinary break-
fast cup of coffee contains about 45 minims of
the oil, provided all the oil in the coft'ee used is
extracted, in their opinion the oil directly increases
cardiac action in small doses and depresses it in large
doses. On the spinal cord of the frog it causes in-
creased reflex activity, but on the mammal with a
well-developed brain, drowsiness and sleep. Cohn-
stein and (iaetano Vinci have formulated the fol-
lowing conclusions with respect to the physiological
action of coffee : ( i ) In small doses caffeine in-
creases arterial pressure while a larger amount
prevents this increase. (2) The influence upon
the blood pressure is the result of the changed con-
dition of irritability of the vasomotor center, caused
by caft'einc. (3) It has a direct action on the heart,-
showing itself in the jiulse-frequency and wave-
height, first as an irritant and then as a paralyzant.
(4) The heart muscle is affected by caffeine in pre-
cisely the same maniier as the skeletal muscle.

Pavinski holds that caffeine exerts its stimulating
action chiefly on the nervous system and Germain
See and Lapicque concur in this view that muscular
labor is aft'ected only iiiasmuch as the correspond-
ing cerebrospinal center is affected and not the
muscle itself. T. Lauder Brunton and Bennet con-
tend that its effect on the spinal cord is in lessening
the conducting power of the sensor\' columns of
the cord. This they proved by irritating the pos-
terior roots of the cord before the injection of caf-
feine into the circulation ; this caused violent
struggles and loud cries ; a like irritation after the
injection caused only a slight quiver. This is the
characteristic difference between the action of caf-
feine and theine. the alkaloid of tea. The first acts
most prominently on the sensorium, while the latter
acts on the motor tract. Irritation of the motor tract,
after the injection of caffeine into the circulation,
caused violent muscular contractions, the same as
before the injection. Its action on the brain is the
same as that of theine, causing a local dilatation of
the arteries supplying the brain, and therefore a
hyperemia. The respiration center stimulated by
caffeine quickens respiration, a most undesirable
phenomenon in the growing child. Respiration be-
comes superficial and shallow, there is an increased
amount of tidal air. and a consequent diminution of
the exhalation of CO™. .\s regards heat-production
and tissue metamorphosis the investigations of E. D.
Reichert are of great interest. He concludes that
caffeine increases heat production, and as a corollary
increases destructive tissue metamorphosis, and
therefore coffee is injurious to health, especially
when taken daily at frequent intervals. He also
states that the assumed ability of coffee to replace
food or to increase the power for work without cor-
responding tissue destruction is entirely deceptive,
and the conditions produced bv it are comparable to
those occasionally observed in the insane, in hysteria,
or in fright, when the individual may be capable of
performing prodigious feats of strength and endur-
ance, but nevertheless at the direct expense of his
tissues.

As a causative factor in nervous disorders we can
say that its role is that of a stimulant or depressant.
It causes such disorders of the nervous svstem as

Feb. g. iQOj]

MEDICAL RECORD.

229

insomnia and restlessness, fullness and heaviness
of the head ; disturbances of special senses, as flashes
of light before the eyes and ringing in the ears;
frequency, irregularity, and intermittence of the
heart's action, and muscular tremor.

W hen we come to consider tea as an etiological
factor in backward children, it must be borne in mind
that I allude to a strong decoction ot tea, the form
usually drank by those who habitually partake of
the beverage. In the form of weak infusions drawn
off from the leaves, I believe tea is harmless. Very
little, if any, of the alkaloid or the tannin is dis-
solved, and its action is purely that of boiled water.
The chief constituents of tea that exert a harmful
effect on the system are theine, tannic acid, some
volatile oil, and some less soluble ingredients. Its
action on salivary and gastric digestion and upon
the tubules of the kidneys is due to the large amount
of tannic acid, upon the nervous system, and through
that upon the muscles, to the alkaloid theine.

Dr. McKechnie reports some experiments to de-
termine the influence of tea upon the digestion. He
carried out these experiments by means of test tubes
and of a gastric fistula formed in a monkey's stomach
and found that tea infusion retards digestion. He
is of the opinion that this is due not to the tannic
;,cid alone, but also to some less soluble extractive
matters. T. Lauder Brunton declares that the tannin
in tea interferes very considerably with the digestion
of fresh meat, but not with that of dried meat, such
as ham or tongue. According to Roberts, tea has
an intensely inhibitory effect, on account of the large
amount of tannin, on the salivary digestion.

That tea prevents sleep is an experience with
which every tea drinker has met. It quickens the in-
tellect both in thought and imagination. As a result
of the overstimulation a |)eriod of depression fol-
lows. In a report upon insanity in Ireland, in 1894.
attention is called to the immoderate use of tea as a
cause of mental diseases among the poorer classes.
"While the moderate use of properly prepared tea,"
the report states, "is regarded as innocuous and
even beneficial in its action on the nervous system,
its ill effects, when decocted or overinfused, on
persons who make it their staple article of diet, are
dwelt on by almost all the resident medical superin-
tendents in their several reports. Undoubtedly, the
method of preparation adopted, and the excessive
use of this article of diet, now so general among
the poorer population, tend to the production of
dyspepsia, which in its turn leads to states of mental
depression highly favorable to the production of
various forms of neurotic disturbances. Incidentally
I want to mention that the report also states that
the excessive use of tobacco, especially among the
young, is thought to contribute in a minor degree
to swell the statistics of mental failure. Dr. W. P.
Spratling, in speaking of a case of multiple neuritis,
mentions the significant fact that in Japan and
India multiple neuritis is endemic, because of the
habitual use of strong tea decoctions.
' Dr. Thomas J. Mays, in contrasting the physiolo-
gical action of caffeine and theine, states that his
experiments made on frogs lead him to the following
conclusions : ( i ) Theine produces spontaneous
spasms and convulsions while cafTeine does not.
(2) Theine impairs the nasal reflex in the poison-
ing process, while caffeine does not, if at all,
until the very last sta,ge. Dr. Mays also claims
that theine is a powerful local anesthetic. Thus we
see that all the phenomena observed by Dr. Mays
that were induced by theine, including spasms, con-
vulsions, abolition of nasal reflex, and anesthesia,
were purely of nervous origin.

With regard to its action on the structure ol the
kidney, Bartels states that tea acts sometimes as a
diuretic due partly to its stimulant action on the
heart and the rise of blood pressure, and partly to
its stimulant action on the cells of the urinary
tubules. As to its effects upon the urinary excre-
tion, the following facts are given by Dr. W. J.
Morton of New York. He made experiments on
himself covering seven days: (i) A decided in-
crease in the sulphuric and phosphoric acids and
:i moderate increase in the uric acid, while NaCl.
remained stationary. (2) A steady daily decline in
the amount of urine excreted, on an average of 2 oz
daily. (,3) A large daily decline in the amount of
urea excreted, on an average of 24 gr. per day. The
most marked decline was that on the first day of 95
grains, when he suft'ered for twelve hours from
extreme toxic effects of tea.

These results seem to point to nerve depression
and a decrease of normal metabolism.

To sum up. then, tea in moderate doses is a stimu-
lant to the nervous system, and in excess a de-
pressant to the functional action of the nerve cells
of the cerebrum, medulla, spinal, and vasomotor
systeiTis ; and the nervous disorders produced bv itsi
use are such as are due to overstimulation and de-
|)ression.

\\'ith such knowledge of the poisonous action of
these drugs and from a study of the statistics as well
as of the results obtained by my own investigations,
1 do not hesitate to say that the use of alcohol,
lohacco, and coffee, or tea is an immediately exciting
cause of backwardness in children.

Ill Hast Second Street

\ CASE OF EXTEXSIVE LEUCOPLAKIA
BEGINNING IN CHILDHOOD, ACCOM-
PANIED IN THE EARLY STAGES
BY FOLLICULAR KERATOSIS
OF THE SKIN, AND FOL-
LOWED BY CARCINOMA -
OF THE TONGUE.*

Bv M. B. H.-\RTZELL, M.D ,

PHIL.MJELPHIA.

.\5SOCUTE IN DERMATOLOGY IN THE UNIVERSITY OF PENNSVI VAMA
DERMATOLOGIST TO THE PHII.ADEIPHTA HOSPITA!

While, as a rule leucoplakia must be regarded as a
strictly local aft'ection due to some locally actin.g
cause, yet, in exceptional cases, it seems probable
that it is but the local expression of a widespread
lcndenc\' on the part of the epithelium to increased
cornification resulting from some constitutional
fault, congenital or acquired. In the following
case an extensive buccal leucoplakia was apparently
unly a part of a widespread disturbance of the proc-
ess of cornification, since the skin as well as the
Iniccal mucous membrane was aft'ected.

Miss X., at that time a girl eleven years old,
was brought to me in December, 1891. on account
'if an affection of the skin which consisted of irre-
gularly shaped, variously sized patches of dirty-
gray spines situated upon the sides of the neck,
and hemp-seed sized, flat, sli.ghtly elevated, scaly
lesions scattered over the back. The spines upon
the neck projected considerably above the surface
of the skin, giving it a grater-like feel, and were
evidently situated in the dilated mouths of the se-
baceous gland ducts from which they could readily
1ie extracted with forceps. The exact nature of
the lesions upon the back was somewhat less ap-
parent, but they were regarded as also keratosic.
Unfortunately the one excised for microscopic ex-

*Read before the College '■! Physioinn^ of Philadelphia,
December 5, 1906.

!3o

MEDICAL RECORD.

[Feb 9, 1907

ainiiKilion was hjst l)cfore the examination was com-
[:)letccl. In addition to the cutaneous disease the
entire mucous membrane of the hps, tongue, and
cheeks was a bluish white, looking as if painted
over with a strong solution of nitrate of silver.
The disease of the skin, which was slowly spread-
ing to new regions, had lasted eighteen months ; the
duration of the leucoplakia was somewhat uncer-
tain, but it had lasted for a considerable time.
.After local treatment, extending over a period of
ten months, which consisted chiefly in the ajiplica-
tion of fairly strong ointments of salicylic acid and
pyrogallol. the latter being used only on the back,
the skin affection disappeared ; but the Icucojilakia.
for which mouth washes of various kinds had been
prescribed, changed but little if at all. U'ith the
disappearance of the eruption upon the skin the
patient was seen infrequently and only at long in-
tervals, and the treatment of the disease of the
mouth was soon practically abandoned, as it caused
little or no annoyance. In February, 1906, she
again came under observation, complaining of some
soreness of the tongue and of a lump upon the
side of it. Inspection revealed extensive and
marked disease : the entire surface of the tongue
was a yellowish white, with here and there irregu-
lar areas of superficial ulceration, and a small wart-
like nodule upon the right side posteriorly. A diag-
nosis of epithelioma having been made, the patient
was referred to a well-known surgeon, who, agree-
ing in this diagnosis, advised the removal of half
the tongue, which was done a few weeks later.
Unfortunately, after doing well for twenty-four
hours, she died suddenly and most unexpectedly
from what was supposed to have been pulmonary
embolism, but as no autopsy was performed the
cause of death must remain somewhat uncertain.

Microscopical examination of the nodule on the
side of the tongue fully confirmed the clinical diag-
nosis of epithelioma. Long, branching, and anas-
tomosing processes of squamous epithelium ex-
tended from the epidermis deeply into the corium.
and here and there were rounded and oval masses
of epithelial cells containing numerous pearly
bodies, the whole presenting a characteristic pic-
ture. Other portions of the tongue presented in-
teresting microscopical changes. The entire epi-
dermis showed pathological alterations : in certain
areas there was a marked increase in its corneous
layer, while the rete mucosum was everywhere
thicker than normal. Here and there the inter-
papillary prolongations of this latter layer were
greatlv enlarged in all directions, extending an un-
usual distance downward into the corium, represent-
ing, probably, a very early stage in the transforma-
tion of the morbid process into carcinoma. Imme-
diately beneath the epidermis there was an abundant
cellular infiltrate made up, for the most part, of poly-
nuclear leucocytes, but also containing many plasma
cells and an unusual number of small "mastzellen."
This cellular infiltrate was most marked where the
alteration of the epidermis was greatest, and was
present to a greater or less degree in all the sections
examined : indeed, the entire tongue showed evi-
dences of an extensive glossitis of moderate se-
verity.

Apart from the unusual association of keratosis
of the skin and mucous membranes the case presents
other features of more than common interest. The
earlv age at which the leucoplakia began is most
unusual. Mr. Butlin, in his well-known treatise on
diseases of the tongue, states that this affection is
practically unknown before the age of tw-enty, and
is very rare in women. As already noted, my
patient was of the female sex, and was only eleven
rears old when first seen, and it is quite certain

that the leucoi)lakia had already existed for a con-
siderable time. The occurrence of carcinoma of
the tongue in an individual so young (26 years
old) is also decidedly rare. Of eighty patients
with cancer of the tongue observed by Mr. But-
lin. but two were under thirty years of age.

Cases of the kind just reported are rare in litera-
ture, but it is not likely that the number of pub-
lished cases represents, even approximately, the
frequency with which leucoplakia is associated with
keratosis of the skin, since, owing to the absence
of annoying subjective symptoms, mild degrees
of the latter readily escape the notice of both patient
and physician, ^lorrow, some years ago (Journal
of Cutaneous and Venereal Diseases, 1886), re-
ported the case of a sailor, 31 years old, in whom,
along with a very extensive follicular keratosis, the
entire follicular apparatus of the skin being in-
volved, there was a marked leucoplakia of the
tongue with fissuring, the disease having lasted
five years.

\\'hile this peculiar form of keratosis is observed
most frequently in the mouth, it is not limited to
this region, but may occur upon other mucous
membranes adjoining the skin, such as the vulvo-
vaginal, the anorectal, and especially the balano-
preputial, presenting the same appearances found
in the buccal and lingual mucous membranes and
pursuing the same course.

The proportion of cases in which carcinoma fol-
lows leucoplakia is large. In the series of eighty
cases of cancer of the tongue already referred to,
Mr. Butlin found that a more or less marked leu-
coplakia had preceded the appearance of the can-
cer in 20 per cent., and this autlior believes that
the frequency of this sequel is under- rather than
overestimated.

Owing to the frequency with which it is fol-
lowed by malignant disease more definite and exact
knowledge of its etiology- than we possess at pres-
ent is greatly to be desired. Smoking and syphilis
are the etiological factors to which it is most com-
monly attributed, but it seems to me very doubtful
whether any considerable number of cases arise
from these causes ; it is much more likely that any
frequently repeated or long-continued irritation,
joined with a special tendency on the part of the
epithelium to hyperkeratosis, may produce it. That
it is, in the beginning at least, an inflammatory af-
fection is quite evident from a study of its histo-
pathology, but it is equally evident that the inflam-
mation must possess some special characters since
ordinary inflammatory processes do not give rise to
keratosis and carcinoma.

Leucoplakia is notoriously rebellious to treatment,
and few local applications cause any perceptible
improvement. For this reason it seems to me
worth while to call attention to two remedies which
have been of real sen'ice in my hands in the past
year or two. These two remedies are w-eak oint-
ments of salicylic acid, 3 to 5 grains to the ounce,
applied several times a day, and the -t'-ray, the latter
having proved especially beneficial in two cases.
In a long-standing and very marked case affecting
the mucous membrane of the lower lip, in which
there were several small, thick, horny patches and
superficial ulceration, the careful use of the ^-ray
was followed speedily by a complete cure. I feel,
however, in recommending this agent, I should
urge the utmost care in its use since the mucous
membranes are extremely susceptible to its action,
and too long exposures or too frequent repetition
will surely do harm. The duration of the exposures
should rarely exceed three minutes, and they should
not be repeated oftener than every five days.

3644 Chestkot Stkbkt.

Feb. 9, 1907]

MEDICAL RECORD.

231

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A.M.. M.D., Editor.

PUBLISHERS
WM. WOOD St. CO . 51 FIFTH AVENUE.

New York, February 9, 1907.

A PROPOSED ORGAXIZATIOX OF ARMY
SURGEONS.

It is reported on good authority that there is no
prospect of the passage of the bill for increasing
the efficiency of the Medical Department of the
Army, which is again to be sacrificed in favor of
some other branch of the service. In the Spanish
war the Medical Department was hampered until
the public became frantic over the fever camps.
In 1901. it was sacrificed to lessen opposition to the
increase of the Army. In 1906, Speaker Cannon
decided that only one military bill should pass, and
the preference was given to the ordnance officers,
and now the artillery is to be increased and the
sanitary service again sacrificed. Congress seems
to feel the weight of public opinion, which is natur-
ally and properly against a large standing army.
Increase of the force is deemed bad politics, and
all changes towards greater efficiency must be care-
fully considered and grudginglv granted. Never-
theless, it seems remarkable that changes the least
demanded by public opinion should be authorized,
but that one for which there is the greatest clamor
should be refused. The evidence of the urgent need
of a better Medical Department is so great and
overwhelming, it is amazing that Congress ig-
nores it.

The cause of the lack of influence of the medical
profession, and of the military part of it in par-
ticular, should be discovered. It has been suggested
that the army surgeons are weak as a class because
they have no organization. All their efforts are
individual affairs, and lack the strength of concerted
union. Their duties scatter them in all parts of the
country, and now indeed of the world, thev rarely
see each other, there is no opportunitv to organize,
and they have made no advance in cooperation since
the army was first organized.

There seems to be some truth in this suggestion.
The cavalry and infantry officers are also scattered
abroad, but each class is organized in associations
for professional advancement. The military sur-
geons of the National Guard created an association
which has taken in the Army, Navy, and Marine-
Hospital services, but it is not exclusively interested
in the Army Medical Department, and its members
ar,e mostly civil practitioners only temporarily at-
tached to the local State militia as a side issue, and
not as a profession. It does seem as though there
were urgent need for the Army surgeons to orga-
nize for their own professional advancement, like
all other specialists the world over. Indeed it would

appear to be a duty. Congressmen are overwhelmed
by private letters on thousands of subjects, and indi-
vidual appeals to them are wasted effort. They really
demand to know what an organization wants, and not
what its individual members may suggest. Legislation
is an impersonal and not a personal affair. The Army
surgeons, then, should get together and work en
masse for that increased efficiency which the good
of the .'\rmy demands, and the absence of which
was so deplorable in 1898. The public really look
to the surgeons themselves to do this work, for no
one will do it for them. Too much selfishness is
always injurious in the long run, while a little self-
sacrifice for the common good is often more bene-
ficial to the individual himself. There is profound
silence from most of the medical officers, so that
we find it difficult at times to discover what are their
wants, and what they think the .Army needs. Con-
gress wants the information, and so does the public.
Organization would accomplish the purpose of in-
ducing the surgeons to work in union and harmony,
for the common good, and we see no reason why
it should not be effected.

THEDANGERSOFGASTROENTEROSTOMY.

Gastroenterostomy has been favored to such an
extent for the relief of a great variety of gastric
conditions, that in the intense desire for its execu-
tion the conservative indications against such a
procedure may only too often be forgotten. It is
a matter of experience that the interference with
the physiology of digestion which this operation
entails is not well tolerated. The motor functions
of the stomach are also disturbed by the procedure,
for the churning power of this organ not only guar-
antees a thorough mixing of the food with the di-
gestive fluids, but, as has been shown by experi-
ment, the coarser particles of food are constantly
being thrown back from the pylorus to the fundus
and only the finely divided foods allowed to pass
through the former. Portis summarizes the disad-
vantages and dangers attendant upon gastroen-
terostomy in a recent article in the Annals of Sur-
gery for December, igo6, and, judging from his
conclusions, it would appear that our general con-
ception of the procedure is in need of revision.

The functional disorders of the digestive tract
already referred to, which occur after gastroen-
terostomy and may seriously interfere with nutri-
tion, and also the severe diarrheas, are due, not only
to the premature emptying of the stomach, but also
to the failure of neutralization bv the bile and pan-
creatic juice of these acid secretions. This is duf
to the absence in the duodenum of the hydrochloric
acid, which stinnilates the flow of both of these.
Jejunal ulcer following gastroenterostomy, which
frequently occurs, and often with a fatal termina-
tion, should lead us, the writer believes, to advise the
operation in question only as a last resort. It has
also been suggested as a relief in certain cases of
chronic dyspepsia in neurasthenic individuals where
the condition is mainly due to imperfect mastication.
Portis finds from a careful study of the reported
results that here, as well as in the so-called atonic
dilatation of the stomach and in gastroptosis, no
benefit is derived from gastroenterostomy. In acute

232

MEDICAL RECORD.

[Feb 9, 1907

ulcer of the stomach the operation is hkcwise not
indicated unless perforation is imminent or has
occurred, and in chronic ulcer only when repeated
small hemorrhages menace life or there are ex-
tensive adhesions and the symptoms persist after
prolonged and thorough medical treatment. The
writer thinks that gastroenterostomy should always
be done when the natural evacuation of the stomach
is impossible and pyloroplasty or gastroduodenos-
tomy is not feasible. This would include those cases
in which there is mechanical obstruction due to
pyloric stenosis and malformations due to hour-
glass contractions or disabling perigastric adhesions.
When the operation is done, however, it is best to
close ofif the pyloric opening. Although these views
may not be in accord with the tendency which has
been manifest within recent years to treat digestive
disorders in great variety by operative procedures,
they are eminently conservative, and if they should
serve as a check to indiscriminate operation this can
only act as an incentive to a more careful selection
of cases in which such a covirse of treatment would
actually be of value.

THE IN7ECTION TREATMENT OF
SCIATICA.

Since the method of subcutaneous injection was
first brought out by Wood of Edinburgh in 1853 it
has been largely employed in the treatment of neu-
ralgic affections. Various fluids of a narcotic or
irritating character were used and met with favor
for a time, only to be superseded by others.
Schleich's name is also closely associated with the
successful treatment of neuralgic conditions by the
injection of his specially devised cocaine solutions
into the perineural tissues. Sciatica was treated in
this manner with very good results by a number
of clinicians, cocaine or its derivatives being used.
The toxic action of the drug continued to keep it
more or less in disfavor, however, and as the re-
sults of the injection were deemed by many to be
due to entirely mechanical causes the experiment
was made of using physiological salt solution in its
place, and Umber reports nine out of a total of four-
teen cases cured by this means.

Notwithstanding the good results and the sim-
plicity of the technique, these infiltration methods
have not been very much used in actual practice, so
that any new series of clinical observations should
prove of interest. Among the latest of these is a
report by Grossmann in the Wiener klinische IVoch-
enschrift. No. 42, 1906, on fifteen cases of sciatica
treated by infiltrations of salt solution. By means
of a long needle (8 cm.) from fifty to one hundred
grams of solutions may be injected, the needle be-
ing introduced directly down to the nerve at a point
midway between the tuberosity of the ischium and
the greater trochanter. The patient experiences a
severe pain and paresthesia of the lower extremitv
as soon as the nerve is reached. The good effects
of the injections are said to have been immediate,
so that patients who were practically crippled could
walk away from the operating table without assist-
ance. In no instance were any unpleasant sequelae
observed. The effects on the disease in general were
unfortunately not equal to the mere anodyne action

of the injection, and in the majority of the cases
the pain returned, but in a lessened degree, so that
a second injection w-as necessary. The use of
adjuvant measures such as hot air baths and hot
packs was followed by excellent results, eleven of
the fifteen patients being cured and tliree improved.
It is evident therefore that although perineural in-
jections cannot be looked upon as an absolute cure
for sciatica, they do in combination with physical
methods, produce a favorable result in most cases.
The anodyne action of the procedure should cer-
tainly commend it for the alleviation, if only tem-
porary, of this most painful affection.

APPENDICITIS AND JAUNDICE.

The appearance of icterus during the course of an
appendicitis or following an operation for the relief
'jf the latter condition has probably been observed
by most surgeons, yet we find but scant notice
taken of this complication in the very volumi-
nous literature on the subject of appendical disease.
That the condition is not infrequent is shown by
the statistics of Reichel {Zcitschrift fiir Cliiriirgie,
Vol. 83, No. i), who found that among 165 of his
cases of appendicitis jaundice had been noted in
18, and of these 10 resulted fatally. These mortality
figures seem to afford sufficient reason for us to look
upon this complication as indicating a very unfavor-
able prognosis. The type of jaundice under consid-
eration is neither catarrhal nor obstructive, but is an
indication of a general septic infection, the origin
of which must be sought for in the inflamed appen-
dix or its mesentery. Of quite a -number of patients
op'erated upon during the interval. Reichel found
jaundice occurring in onlv one, and here the wound
had suppurated.

Icterus, as a complication of appendicitis, usually
occurs within from thirty-six to sixty hours afte»
the beginning of the attack, and unless it subsides
in a short time is rapidly succeeded by a condition
of restlessness accompanied by a rise in the pulse
rate, but not of the temperature. Reichel compares
the clinical picture to that which we find associated
with acute iodoform poisoning. In most cases the
patients became delirious, then deeply comatose,
and death followed in twenty-four hours. The fatal
issue can only be ascribed to a severe and virulent
septic infection, and this may be unaccompanied by
peritonitis. In such cases not even an early opera-
tion will avert the unfortunate outcome. Reichel
claims that the liver becomes involved by the trans-
mission of masses of bacteria or infectious thrombi
through the medium of the portal circwlation. It
would seem wise, therefore, to restrict all handling
of the affected organ during an operation as much
as possible, and the writer even urges that after
forty-eight hours operative interference be limited
to the evacuation of any abscesses which may be
present.

Pancre.\tic Digestion ix Man.

Thanks to the ingenious methods introduced into
the physiological laboratory by Pavlov and his pu-
pils, the processes of digestion have now been pretty
thoroughly investigated, at least in animals whose
functions are supposed to have a good deal in com-

3K:

Feb. 9, 1907]

MEDICAL RECORD.

-'33

mon with those of man. Through the impetus that
gastric surgery has received of late years it has be-
come possible in not a few cases to obtain confirma-
tion in man of observations originally made in ani-
mals, usually dogs, and for the most part it has been
found that the discrepancies in the results obtained
are not very great. This is true particularly of gas-
tric digestion, for opportunities of studying the
physiology of the pancreas in man have so far been
very infrequent. Such a case has, however, come
under the observation of Wohlgemuth {Berliner
klhiische IVoehenschrift, January 14, 1907) and lias
afforded material for some interesting studies. The
patient was a man who was struck in the abdo-
men by a wagon pole and suffered a tear of the liver
and a rupture of the head of the pancreas. He re-
covered from the injur)-, but a pancreatic fistula re-
mained, and Wohlgemuth 's observations were made
on the juice collected from the sinus. It was found
that, as in dogs, alterations in the composition of
the diet caused great variations in the amount of
juice secreted ; for example, when fats predominated
such as cream or milk, the flow was almost com-
pletely checked, meat caused it to increase, while
carbohydrates gave rise to a very profuse secretion.
Pavlov found in dogs that the secretion produced
in response to either one of the three varieties of
food stuffs would be richest in the particular fer-
ment, i.e. amylopsin, steapsin, or trypsin, required
for its digestion ; but apparently this automatic
adaptation does not take place in man, for it was
found that the juice following the ingestion of fats
was richest in all three ferments, while that accom-
panying the digestion of carbohydrates was weakest
in its enzyme content. On the other hand, the effect
of hydrochloric acid in stimulating pancreatic secre-
tion and of alkalies in inhibiting" it was the same in
man as it had already been found to be in the dog.
These observations would appear to justify a num-
ber of practical deductions, but Wohlgemuth so far
restricts himself to the one suggestion that in deal-
ing with cases of pancreatic fistula the diet should be
a strictly antidiabetic one, and that alkalies should be
administered, as in this way the secretion of pancre-
atic juice would be reduced to a minimum.

The Renal Origin of Increased Blood Pressure.

It is a commonly accepted belief that a constant
elevation of blood pressure which may be associated
with a nephritis is due to an adenomatous hyper-
plasia of the suprarenals and a marked stimulation
of the functions of these organs. Ambard, in a re-
cent communication {Semaine Medicate, No. 31,
1906), denies this and claims that the condition is
entirely renal in origin. Although he admits that
in nephritis this condition ^f the suprarenals is often
found, it may also be present, he believes, when
no elevation of blood pressure exists. In order
thoroughly to comprehend the matter it is necessary
to distinguish carefully between transitory and con-
stant hypertension. The former is found in tabes,
lead colic, eclampsia, epilepsy, exophthalmic goiter,
and other conditions. Here the kidney is unchanged
in its anatomical structure, and the tension is due
entirely to functional disturbances. When the in-
crease in arterial tension is permanent it is invaria-
bly associated with renal disease and may be either
"reducible" or "irreducible." The former is found
in connection with acute and subacute forms of
nephritis, whereas those conditions of increased
tension which are found with atroohic nephritis and
advanced sclerosis of the glomeruli are irreducible.

Ambard shows that increased tension in nephritis
is not entirely dependent directly upon the changes
in the vessels, but is caused also by the mechanical
disturbances which result in a reduced permeability
of the organ. Of importance in this connection is
the relation between blood pressure and chloride
metabolism. An increase in the blood pressure is
favored by the retention of the chlorides, a decrease
by an increased excretion of the same. Diuretics,
such as theobromine, produce their effect on the
blood pressure by stimulating the excretion of the
chlorides. As controverting the usual ideas on the
subject, Ambard's paper is of considerable interest
and importance.

Education of the Couch in Tuberculous
Patients.

The nature of cough varies from a slight irritable
hacking commonly called "hemming" to the par-
oxysmal attack which may end in retching and
vomiting. There is also a wide variation in the
phonetic quality of cough. A cough may be metallic,
stridulous, barking, or aphonic. .\ cough may oc-
casion pain or this exertion may be painless. Some-
times a cough is frequent and continuous ; in other
cases it occurs only at certain times. Sometimes a
patient coughs only on rising in the morning ; again
exertion may bring on a paroxysm. Change of tem-
perature is another etiological factor to be consider-
ed. In 1878, Stoerk published a pamphlet in Vienna
in which he discussed the existence of certain
"cough-spots" — the posterior wall of the trachea, the
interarytenoid fold, the under surface of the vocal
cords, and the bifurcation of the trachea. This in-
vestigator does not believe that cough is caused by
the accumulation of mucus in the small bronchi, but
he believes that it must first reach one of the above-
mentioned points. He does not, in this pamphlet,
explain the cause of cough by refle.x irritation. In
La Pressc Medicalc, January 9, 1907. Ch. Mantoux
discusses the cough of tuberculous patients. A tu-
berculous patient is nearly always a cougher. Since
the remarkable work of Dettweiler, a distinction has
been made in the case of pulmonary ])atients be-
tween the useful cough and die harmful cough. The
useful cough is the one which serves to expel mucus.
It ought to be reduced to a minimum ; sometimes
a "hem" which may at times be scarcely perceptible
is sufficient to bring the mucus into the buccal cavity.
The useless cough is one which does not end in ex-
pectoration, and every useless cough is harmful.
Coughing fatigues the patient : it disturbs his repose
and often his sleep. In some cases digestion is up-
set. It fatigues the muscles of the thorax and of
the abdomen ; it may even distend the abdominal
walls to such an extent that hernia develops. It con-
tjests the larynx and the trachea. It disturbs the
lungs by sudden and repeated changes in pressure
when it is most advisable to immobilize these organs.
It is a matter of common knowledge that a patient is
often able to control a cough to a great extent by
the exertion of his will power. He takes especial
pains to do this when he is in the company of others,
but when he is by himself there is not the same re-
straint, and he gives way to useless coughing. In
order to prevent this the suggestion is made that the
patient be instructed to indicate on a sheet of paper
the number of times he coughs. In many cases this
works like a charm, for these records are to be given
to the physician at every visit, and the pride of the
patient is bestirred to give a good account of him-
self.

234

MEDICAL RECORD.

[Feb 9, 1907

The Recognition I!V Congress of Dr. Carroll's
Services to Science.

The Senate Committee on Military Affairs lia.s
voted to support a bill authorizing the promotion
of Lieut. James Carroll of the .'\rmy Medical Corps
to be a Major, and all who believe that devoted
service in the cause of science is deserving of
recognition will hope to see the bill passed. Dr.
Carroll enlisted as a private thirty-three years ago,
and was soon promoted to be a sergeant. He
served as hospital steward for iifteen years and
then, having in the meantime studied medicine and
received a degree, was appointed contract surgeon
in 1898. He was one of the commission under
Major Walter Reed appointed to study yellow fever
in Cuba, and was the first to submit to the bite of
an infected mosquito in order to test the theory of
the transmission of the disease. The severe attack
of vellow fever which followed was the first link
in the chain of evidence confirming Finlay's theory,
and this example inspired others to submit to like
tests. In 1902 he was appointed first lieutenant
and assistant surgeon, the age limit having been
waived to permit him to appear for examination.
In the normal course of events, had he entered the
medical corps at the usual age, he would now have
reached the rank of major, and it is in recognition
of his high scientific attainments and notable
achievements in experimental medicine that this
Senate bill has been introduced to give him the
rank which others in the service of his own age
have reached but which, by means of his late en-
trance into the medical corps, he could not attain
in regular course. The highest rank which he could
hope to reach before coming to the age of com-
pulsory retirement would be that of captain. The
proposed legislation is exceptional, but the circum-
stances calling for it are exceptional, for though
Dr. Carroll's years in the medical service have been
comparatively few they have been crowded with
work of a high order, and of inestimable value to
medical science and to humanity. The bill should
be passed, if onlv to show that republics are not
ungrateful.

Nems of ti|p MppIu

Scholarships and Fellowships of the Rockefeller
Institute for Medical Research. — This institute
purposes to award for the year 1907- 1908 a limited
number of scholarships and fellowships for work
to be carried on in the laboratories of the Institute
in New York City, under the following condi-
tions : The scholarships and fellowships will be
granted to assist investigations in experimental
pathology, bacteriology, medical zoology, physi-
ology and pharmacology, and physiological and
pathological chemistry. They are open to men
and women who are properly qualified to under-
take research work in any of the above mentioned
subjects, and are granted" for one year. The value
of these scholarships and fellowships ranges from
eight hundred to tw^elve hundred dollars each. It
isexpected that the holders will devote their en-
tire time to research. Applications accompanied
by proper credentials should be in the hands of
D'r. L. Emmett Holt, 14 West Fifty-fifth street.
Secretarv of the Rockefeller Institute, not later
than April i, 1907. The announcement of the ap-
pointments is made about May 15. The term
of service begins preferably on October i, but,
by special arrangement, may be begun at another
time.

Cocaine Selling and Bottle Washing. — At its

regular meeting last week the Board of Health
added two sections to the sanitary code, the one
prohibiting the sale of cocaine except upon a
l^hysician's prescription, and the other requirmg
the exercise of proper cleanliness in dealing with
milk and cream containers. This clause reads
that it shall be the duty of all persons having in
their possession bottles, cans, or other receptacles
containing milk or cream, which are used in the
transportation and delivery of milk or cream,
to clean or cause them to be cleaned immediately
upon emptying; and no person shall use or cause
to be used any such receptacles for any purpose
whatsoever other than the holding of milk or
cream, or receive or have in his possession any
such receptacle so used or which is unclean or
in which milk or cream has been allowed to stand
until offensive. Offenders will be liable for mis-
demeanor. This regulation is aimed principally
at the wholesale and retail milk dealers, though
housewives also come under its provisions.

New York State Child Labor Law. — The Sen-
ate Judiciary Committee on January 30 decided
to report favorably and without amendment the
.\nti-Child Labor bill introduced by Senator Page
and drafted in accordance with recommendations
in the governor's message. The bill makes it
a misdemeanor to employ minors under sixteen
years of age in factories for more than eight hours
in each twenty-four, and stipulates that the hours
of employment shall be between 8 in the morning
and 5 in the evening. The presence of a minor
in a factory would be considered presumptive
evidence of a violation of the law.

New Health Department Dispensary. — Last
Monday the Health Department opened its third
tuberculosis clinic. The new dispensary is in the
Bronx Health Department Building, at Third
avenue and St. Paul's place, and wmH be open
Monday, Wednesday, and Friday afternoons,
from 2 to 4 o'clock. Later it will be opened on
Tuesday. Thursday, and Saturday afternoons,
and possibly in the evenings also. The other two
dispensaries are at the Health Department build-
ing. Fifty-fifth street and Sixth avenue, and in
Brooklyn. Only consumptives are treated in
these clinics.

Anti-Noise Bill Passed. — The bill intended to
suppress unnecessary whistling by steam vessels
plying in harbors about large cities, which was in-
troduced through the efforts of ]Mrs. I. L. Rice of
this city, has passed the Senate and is ready for
the President's signature. Supervising Inspector
Harris issued an order last November providing
for the correction of the abuse, but until the bill
becomes a law he is without authority to enforce the
order if a case should be carried into the courts. The
particular waters referred to in j\lr. Harris' order
are Boston Harbor, west of Castle Island ; Philadel-
phia Harbor, betw-een the uppermost and lowest
lines of ferries, and in New York Harbor, the East
River. Harlem River, North River, Spuyten Duyvil
Creek, and Buttermilk Channel.

Lectures for Cancer Homes. — Dr. James J.
Walsh of this city will give his third series of Lenten
lectures in aid of the two homes for destitute cancer
patients, managed by The Servants of Relief for
Incurable Cancer. The lectures will be held on
Thursday mornings during Lent at Mendelssohn
Hall and will have as their subject "Some Women
WTio Did." The two homes of the organization, one
at 426 Cherry street, New York, and the other at

Feb. 9, 1907]

MEDICAL RECORD.

235

Hawthorne, N. Y., are entirely dependent on char-
ity, as no pay patients are treated.

New Medical Inspectors Appointed. — Twenty
new medical inspectors have been appointed by the
Health Department. Eleven of these will be as-
signed to lirooklyn, five to Manhattan, two to the
Bronx, and one each to Richmond and Queens.
There are at present thirty-two inspectors in Brook-
lyn and fifty-seven in New York. With these ad-
ditions it will be possible to make the examinations
of school children more systematically, and es-
pecially to investigate the sicknesses of absentees.
Last year over one thousand cases of unreported in-
fectious diseases were discovered in this way.

To Test Hudson River Ice. — Five chemists and
bacteriologists in the employ of the Merchants'
Association of this city have been sent up the
Hudson to examine samples of ice taken from
the various fields along the river where ice har-
vesting is going on, with a view to determining
the healthfulness of the supply.

Contagious Diseases in Chicago. — It is esti-
mated that the total number of cases of con-
tagious diseases, particularly diphtheria and scar-
let fever, that have occurred in Chicago during
the present epidemic is not far from 15,000. New-
cases of both diseases are still being reported in
great numbers, though it appears that the mor-
bidity is beginning to decrease, and the later cases
are of a somewhat milder type than the earlier
ones had been. In particular many instances
of the aberrant form of scarlatina sometimes
called Duke's disease have been observed. In an
effort to restrict the dissemination of the disease
the health authorities have requested the citizens
to abandon for the time being social engagements,
such as balls and parties, though the schools and
Sunday schools are not interfered with. .A. move-
ment is also on foot for the establishment of a
new isolation hospital.

Poisonous Embalming Fluids. — Senator Breit of
the Illinois Legislature recently introduced a bill
for the purpose of prohibiting the use of arsenic
and strychnine in embalming fluids. He has pre-
pared two bills, one of which reads that no under-
taker or other person shall embalm or inject into
the dead body of any person any fluid or prepara-
tion of any kind before obtaining permission from
the coroner when such body is the subject of coro-
ner's inquest. The second bill provides that, "if any
undertaker or other person embalms with, injects.
or places on any dead human body any fluid or
preparation of any kind which contains strychnine
or arsenic, he shall be fined not e.xceeding $50
for each offense."

State Sanatorium for Tuberculosis in Illinois. —

A bill recommended by Governor Deneen, and in-
troduced by Mr. Glacken, of Cook County, ask-
ing for an appropriation of $150,000, for the estab-
lishment of a State sanatorium for tuberculosis.
is expected to pass.

Bureaus to Prevent Suicide. — The officials of
the St. Louis Salvation Army have announced their
intention of forming a department for the purpose
of discouraging suicide. The project is founded
on a similar plan which has been put in execu-
tion in London by Gen. Booth, and which it is
said has prevented much loss of life through self-
destruction. The plan is to give practical and
friendly advice to distressed persons. This ad-
vice will be given daily, free of charge, to all who
need it. Letters will be individually treated.

-Absolute secrecy is to be maintained in all cases,
and no inquiries are to be made.

Insanity in Connecticut. — The biennial report
of the Connecticut Hospital for the Insane, just
published, shows that there are now 2,487 patients
in the institution, and that the annual increase of
insane persons in the State is about 120.

Woman's Army Canteen Club. — This organiza-
tion of Washington, D. C, is making active efforts
to have the canteens reestablished at army posts
and is now engaged in founding branch clubs
throughout the country in order to popularize the
movement. A delegation which recently called upon
President Roosevelt received the assurances of his
personal support in the work, with which he is thor-
oughly in sympathy.

Death Penalty Abolished in Kansas. — Kansas,
which has never had a legal execution, will prob-
ably never have one in the future, as a bill was
liassed by the Legislature on January 29 abolish-
ing capital punishment. No Kansas governor has
ever signed a death warrant, and the prisoners
condemned to capital punishment have been
treated as life convicts.

Report of British Tuberculosis Commission. —
The Royal Commission on Tuberculosis appointed
^ome years ago has issued a second ad interim re-
port confirming the conclusion reached in the first
(((/ interim report to the effect that Koch was mis-
taken in alleging that bovine tuberculosis was not
a menace to the human race. The commission has
arrived at the conclusion that there can be no
doubt that a certain number of cases of tubercu-
losis occurring in the human subject, especially
children, are the direct result of the introduction
into the human body of the bacillus of bovine tuber-
culosis. There is also no doubt that in a major-
ity of these cases the bacillus is introduced through
cow's milk. This opinion is founded on a very
extensive series of observations and experiments,
which are described in the report. The late Sir
-Michael Foster was chairman of the commission.

Meningitis in Great Britain. — Cerebrospinal
meningitis, which has hitherto been rather rare
in the British Isles, is very prevalent in Scotland
and the North of Ireland. It appears to be epi-
demic in Glasgow, where 103 cases, with 47
deaths, occurred in January.

Cocaine in India. — The Bureau of Commerce
and Labor has been informed that the Govern-
ment of India has prohibited the bringing in of
cocaine by means of the post, and has restricted
its importation by any other means to cases in
which it is imported by persons, or bv their au-
thorized agents, who have been especially per-
mitted to import the drug by a local Government
or administration. The Government has also em-
powered the postal ofificials to search for any
cocaine in course of transmission by post, and to
deliver all such to the nearest excise officer.

Famine in China. — The reports from China
continue to show the danger of a widespread epi-
demic that is accompanying the famine. It is
estimated that 10,000,000 people, living in an area
of 40,000 square miles, are affected to a dangerous
degree by the lack of food, clothing, medical
supplies, and proper shelter. In the huge con-
centration camps formed by refugees from the
stricken districts the sanitary conditions are as
bad as possible, and the authorities are over-
whelmed by the task confronting them. An out-
break of plague is reported from Niu-chwang.
which, however, is not in the famine district.

236

MEDICAL RECORD.

[Feb 9, 1907

A New University in Frankfort. — A recent
issue of the Lancet notes the besjinning of a move-
ment to estabhsh a university in that city. Rich
citi/cens are said to have collected funds for the
purpose, but since the creation of universities
belongs exclusively to the State and not, as in
America, to private initiative, the funds will be
given to the Government if it approves of the
objects of the contributors. Frankfort has for a
long time possessed the nucleus of a medical
faculty; the old Senckenlierg Institute, founded
by a wealthy citizen, contains a number of well-
furnished chemical, physical, anatomical, and
other laboratories ; the Royal Institution for Ex-
perimental Therapy under the direction of Pro-
fessor Ehrlich attracts every year a great many
graduates from other parts of Germany and from
abroad ; the hospitals of Frankfort are of the first
rank, and contain an immense amount of clinical
material which has not hitherto been used for
teaching purposes. The establishment of a uni-
versity will therefore be easy, so far as the med-
ical faculty is concerned. No new universities
have been founded in Germany for about a cen-
tury, except at Strasburg, where the old univer-
sity existing previously to the French occupation
was reestablished in 1872.

Maine Academy of Medicine and Science. — In
view of the fact that there is a bill relating to medi-
cal expert testimony now pending in the State Leg-
islature of Maine, the Maine Academy of Medicine
and Science has decided to devote its next regular
meeting on February 13 to medicolegal subjects,
and Mr. Clark Bell of this city has accepted an
invitation to deliver an address.

Springfield (Mass.) Academy of Medicine. — At
a meeting of the leading physicians of western
Massachusetts, held in Springfield on January 24,
preliminary steps were taken toward the founding
of the Springfield Academy of Medicine, a post-
graduate institution for the teaching of medicine
and its advancement generally on a cooperative
basis. The officers elected are: President, Dr. J.
A. Houston, Superintendent of the State Hospital
for the Insane at Northampton; First J' ice-Presi-
dent. Dr. R. H. Seelye; Second Vice-President, Dr.
A. O. Squier; Secretary, Dr. W. R. Weiser; Treas-
urer, Dr. W. H, Van Allen. Articles of incorpora-
tion will be filed and a charter applied for under
the laws of Massachusetts. It is also planned to
erect a handsome academy building.

The American Society of Sanitary and Moral
Prophylaxis. — The next annual meeting of this
society will be held at the New York Academy of
Medicine on Thursday, February 14, at 8:30 p.m.
Papers will be read by Drs. Herman G. Klotz,
James Pederson, A. D. Mewborn, FoUen Cabot. Jr.,
and Frederick Holme Wiggin.

The Medical Society of the County of Kings. —

.At the annual meeting of this society, held January
16, 1907. the following officers were elected.: Pres-
ident. Dr. Glenworth Reeve Butler; J ice-President.
Dr. Onslow A. Gordon ; Secretary, Dr. Henrv G.
Webster; Treasurer. Dr. John R. Stivers; Associate
Treasurer. Dr. H. M. Mills ; Associate Secretary,
Dr. W. A. Jewett ; Directing Librarian, Dr. James
P. Warbasse.

Annual Meeting of the Chicago Medical Exam-
iners' Association. — At the annual meeting of this
association, held January 31, Dr. J. M. Patton was
elected President, Dr. E. Eisenstaedt Secretary, and
Dr. Ulysses Grimm Treasurer. The society adopted

a resolution advocating the establishment of a Na-
tional Department of l*iililic Health.

Santa Barbara (Cal.) County Medical Society.
— The officers for this society for the year 1907 are :
President, Dr. C. S. Stoddard ; ^ice-President, Dr.
E. A. Dial ; Secretary, Dr. VV. T. Barry ; Treasurer,
Dr. D. A. Conrad; First Vice-President-at-Large,
Dr. W. A. Rovvell, Goleta : Second Vice-President-
at-Large, Dr. R. W. Brown, Santa Maria.

Muscatine County (la.) Medical Society. — The
election of officers of this society for the ensuing
year has resulted as follows : President, Dr. F. H.
Little, Muscatine ; Vice-President, Dr. C. B. Kim-
ball, West Liberty; Secretary-Treasurer, Dr. T. F.
lleveridge, Muscatine.

Nueces County (Texas) Medical Association. —
Officers as follows were elected at the recent meet-
ing of this society, held at Corpus Christi : Presi-
dent, Dr. Henry Redmond ; Vice-President, Dr. W.
E. Carruth ; Secretary and Treasurer, Dr. C. H.
Veager.

Trumbull County (la.) Medical Association. —
At the meeting recently held in Warren officers were
elected as follows by this society: President, Dr.
D. E. Hoover; Vice-President, Dr. T. O. Clingan;
Secretary and Treasurer. Dr. F. K. Smith.

Aroostook (Me.) County Medical Society. —
The medical societies of northern .-Aroostook and
southern Aroostook have united in one organiza-
tion— the Aroostook County Medical Society, which
met at Houlton last week and elected officers as fol-
lows : President. Dr. A. D. Sawyer, Fort Fair-
field ; Vice-President, Dr. H. L. Putnam, Houlton ;
Secretary, Dr. F. H. Jackson, Houlton ; Treasurer,
Dr. W. E. Sincock, Caribou.

Iowa Clinical Surgical Society. — Under this
name a new society has been formed in Des Moines,
with the following officers : President, Dr. Pond,
Dubuque ; Vice-President, Dr. AlcCarthy, Des
Moines ; Secretary and Treasurer, Dr. Fairchild,
Jr., Clinton. The State is divided into four districts,
which will be in charge of the following counselors:
Dr. Brockman, Ottumwa ; Dr. Knott, Sioux City;
Dr. Macrae, Jr., Council Blufifs ; Dr. Hegebeck, Du-
buque.

Sir Michael Foster, K.C.B., died on January 30,
at the age of seventy-one years. At the time of
his death he was Unionist member of Parliament
from London Universit)^ his election dating from
1900. He held at various times the posts of pro-
fessor of practical physiology at University Col-
lege, London ; prcelector of physiology. Trinity
College, Cambridge ; president of the British As-
sociation ; professor of physiology. Cambridge ;
and secretary of the Royal Society. He was joint
editor of "Scientific iMemoirs of Thomas Henry
Huxley."

Prof. Dmitri Ivanovitch Mendeleef of St.
Petersburg died on February 2 at the age of
seventy-three years. He was for many years
professor of chemistry in the University of St.
Petersburg, and had made numerous discoveries
in that branch of science. He was best known
for his researches on the periodic law in relation
to the elements, and by its means was able to
predicate the existence and general properties of
the three elements, gallium, scandium, and ger-
manium, before thev were discovered.

The Late Dr. William P. Brandegee.— The fol-
lowing minute has been adopted by the New York
Otological Society: Whereas, During the past
summer death suddenly called from us our friend

Feb. 9, 1907]

MEUILAL KtCUKU.

237

and fellow member. Dr. William P. Brandegee ; and

whereas, in his professional and private life he was
known to us as an excellent example of all for
which this society stands ; then be it Resolved, That
we place upon record the deep sense of sorrow
which we feel at the loss of our colleague, and that
we extend our sincere sympathy and condolence to
the bereaved family. Resolved, That a cop)- of these
resolutions be sent to them, and a copy be sent to
the medical journals for publication. (Signed.) Ar-
thur B. Duel, James F. McKernon, Joseph A.
Kerefkk.

Obituary Notes. — Dr. E. Elsxer C. Gunther
of this city died on Jaiuiary 31 at the age of forty-
two years after an illness of several months. He
was born in this city and graduated from Harvard
in 1889. He then entered the Harvard Medical
School, after which he completed his professional
education abroad.

Dr. George Douc;i..\ss of W'hitmire, S. C., died
on January 22 at the age of fifty-six years. He
was graduated in medicine in Baltimore in 1897
and had practised in W'hilmire ever smce.

Dr. Abs.\lom W. Adair of Des Moines died sud-
denly of apoplexy on January 22 at the age of
seventy-eight years. He was a pioneer physician
of Jasper county, and had practised in the town of
Kellogg until five years ago. when he removed to
Des Moines.

Dr. B. F. Crummer of Omaha, Neb., died on Jan-
uary 24 at the age of fifty-nine years, as the result
of an attack of paralysis begiiniing ten months ago.
Dr. Crummer was born at Elizabeth, 111., and re-
ceived his medical education at the L'niversitx' of
Ann Arbor and Eellevue Hospital Medical College
in this city. He went to Omaha in 1888 and had
practised there since that time.

Dr. Augustus V. L. Brokaw of .St. Louis died
on January 25 of a gastric affection at the age of
forty-four years. He was born in St. Louis, his
father. Dr. F. V. L. Brokaw, being the superin-
tendent of the St. Louis City Hospital. He was
graduated in medicine from the medical department
of Washington University in 1883 and then spent
some years abroad. He held several teaching po-
sitions at the time of his death and was well known
as a raihvay surgeon.

Dr. Elliott H. Wooi-sey of Oakland, Cal.. died
on January 21 of pneumonia, after a brief illness.
Dr. Woolsey was born near Rochester, N. Y., in
1843 3nd was educated at Hamilton College. He
served as a surgeon in the regular army during the
Civil War and shortly after its close he went to
California, beginning to practise in Oroville. In
1873 he removed to < )akland and soon became
prominent in medical circles. -\t different times he
was president of the State Medical Association,
Health Officer of Oakland, and member of the
Oakland Board of Health, and for a number of
years he conducted a free clinic for the poor. He
retired from practice eight years ago, since when
he had spent most of his time in travel.

Dr. J. Henry McNeel of Fond du Lac, Wis.,
died on January 23 of a|inplexy. He was born in
Essex county. N. Y.. in 1S38. and in 1854 his fam-
ily emigrated to Wisconsin. He received his medi-
cal degree from Rush Medical College in 1863 and
began practice at Greenbush. Sheboygan county,
where he remained until 1872, when he removed to
Fond du Lac. He was for several years a member
of the State Board of Health and had also served
as a member of the State I^egislature.

Dr. JosTAH P. Sugg of Tarboro, N. C, died on

January 24 at the age of sixty-six years. Dr. Sugg
was a native of North Carolina and received his
medical education in the College of Physicians and
Surgeons of this city.

Dr. Halsev B. Jenks of Ypsilanti, Mich., died
on January 22 at the age of sixty-four years. He
was a veteran of the Civil W'ar, having served in
the Twentieth Michigan Infantry, and was gradu-
ated from the L'niversity of Michigan Medical
School in 1870.

Dr. Thomas F. Mayiiam of Fond du Lac, Wis.,
died suddenly on January 21 at the age of seventy-
seven years. He was born in Blenheim, N. Y., but
removed to Fond du Lac in 1854. After serving for
some years as a school superintendent, he was grad-
uated from the medical department of the Univer-
sity of Ann Arbor in 1859. He was elected Mayor
of Fond du Lac in 1882 and held the office during
several terms.

Dr. Wm. E. Ard of Westchester died on Janu-
ary 24, 1907, aged forty years. He was a gradu-
ate of the LTniversity of Maryland, was formerly
house surgeon on the staff of the Woman's Hos-
pital in this city, and attending surgeon to the City
Hospital in Binghamton. He was practising in
Westchester, New York City, until a few months
before his death, when failing health compelled him
to give up his work.

Dr. William Clawson Lott died at Philadel-
phia on January 22 at the age of forty-seven years.
He was graduated from Brown LIniversity in the
year 1882 and from the medical department of the
University of Pennsylvania in the class of 1885.
His earliest ancestor in America settled in New
England in 1635 and he came of distinguished
Revolutionary stock. He was a member of the
First Troop, Philadelphia Cavalry, in which he
served as quartermaster sergeant in Porto Rico
during the Spanish-American War.

Dr.' Wm. H. H. Miller died at Williamsport,
Pa., on February 2 at the age of eighty-two years.
He was graduated from the Pennsylvania INIedical
College in the class of 1849.

(UnrrrHtmuJifttre.

THE N.\TURE OF JENSEN'S MOUSE TUMOR.

To THE Editor of the Medical Record :

Sir: — My attention has just been directed to a letter in
your issue of January S, from Dr. Beard of Edinburgh. I
welcome criticism even when it is adverse, but I deprecate
gross misrepresentation such as enters largely into his
communication.

Dr. Beard's special point against me is that I have not
adduced my scientific reasons for denying the cancerous
nature of Jensen's mouse tumor, but have, instead, en-
deavored to get the matter decided by an unscientific ipse
dixit. Considering that the publication he refers to is
a closely reasoned argximent in support of my thesis, in
which every special fact bearing on the subject is duly set
forth and appraised, I must repudiate his suggestion as
being neither reasonable nor fair.

The great mistake of those who have so prematurely
identified "Jensen's tumor" with cancer is that, in making
their diagnosis, they liave placed far too much reliance on
histological appearances — the fallaciousness of which has
so often been demonstrated in recent times — and far too
little on the ensemble of the indications available for diag-
nostic purposes. Dr, Beard's so-called "chemical test" for
cancer belongs to the same order of fallacious experience;
for chemical analysis has hitherto failed to reveal the
presence of any specific cancer substance. The claims of
Petry, Bergell.' Blumenthal, ct a!., to have discovered a
special cancer ferment, have very little basis in ascertained
fact, but are rather the outcome of apriori considerations,
which difi^er but little from Rokitansky's "kakoplastic al-
bumin," and rither kindred speculations, long since for-
gotten. The tissues of malignant tnmnr;. like the n.Trmal

238

MEDICAL RECORD.

[Feb 9, 1907

tumors, probably teem with enzymes ; but there is no
proof tliat their specific qualities or quantities are in any
way proportional to malignancy. ."Xs Buxton has judi-
ciously remarked : "It has been shown that a number of
enzymes are commonly present in cancerous tumors, but
their amount and kind are independent of the character
or malignancy of the growth, and are very similar to
those found in the normal tissues of the same part." In
short, it is evident that until we know more about the en-
zymes of normal tissues it is impossible to arrive at any
definite conclusion as to the special significance of the
enzymes of cancerous tumors. It quite accords with this,
that cancerous tumors originate fairly often in the pancreas,
and that their constituent cells secrete trypsin — "the killer"
of cancer, according to Dr. Beard — as the important re-
searches of Waring and others have clearly proved. In
the light of the long-continued and oft-repeated failure
of morphology and chemistry to reveal the presence of any
specific cancer substance, we shall probably not be far
wrong in concluding that there arc no specific cancer sub-
stances, other than such as are concerned in determining
the specificity of the various physiological tissue elements.
Now wdiat are the plain facts in respect to which "Jen-
sen's tumor" differs in toto from cancer or any form of
human malignant tumor? They are briefly these: The
disease is highly contagious ; thus, when infected animals
are introduced into cages with healthy animals the latter
take the malady, as if by local contagion ; and sometimes
the proportion thus infected is so considerable as to con-
stitute veritable epidemics. Nothing like this occurs with
human cancer — at least, not outside the Munchausen
sphere — ■ but in the contagious venereal malady of dogs
analogous conditions are commonly met with. "Jensen's
tumor" is readily transmissible by implantation to other
mice, the proportion of successful e.xperiments often being
as high as 30 per cent. No such property is ever mani-
fested by human cancer ; but, with the contagious venereal
pseudoplasms of dogs similar conditions obtain. A con-
siderable proportion of w-hite mice are immune to the
contagion of this disease, whether in its spontaneous or
experimentally determined form, and sometimes whole
families manifest the peculiarity. The same phenomena
have often been noted in the contagious malady of dogs.
Moreover, "Jensen's tumor" fairly often (over 20 per cent.
— Clowes) undergoes spontaneous cure ; and the cured
animals are then immune to further contagion, and give
only negative results when inoculated, as Gaylord has
specially pointed out. With human malignant tumors no
such spontaneous curability has ever been scientifically
demonstrated, although sometimes alleged ; but, in the
several pseudoplasms of dogs, this phenomenon is of com-
mon occurrence. "Jensen's tumor" is circumscribed and
easily enucleable, the tissues of the host forming no part
of it; moreover, the latter do not acquire cancerous proper-
ties, nor do they become interpenetrated bv injurious proc-
esses of the neoplasm ; and besides this. "Jensen's tumor"
causes no cachexia. Finally, according to Apolant and
Ehrlich. "Jensen's tumor" in the course of experimental
transmission often changes its type — from the epithelial to
the sarcomatous, etc., and Morau found, under similar cir-
cumstances, that its physiological type also changed, with
corresponding alteration in its power of inoculability.

In all of these vitally important respects, which, taken
together, are crucial for diagnostic purposes, "Jensen's
tumor." whatever its real nature may eventually turn out
to be, is totally unlike any form of human malignant tumor.

W. Roger Willi.\ms.
Clifton, Bristol, England.

UNNECESSARY OPER.A.TIONS THE OPPROBRIUM

OF MODERN SURGERY.
To THE Editor of the Medical Record:

Sir: — It cannot be denied that at the present day many
operations are performed that are not only unnecessary but
unjustifiable. This is especially true of abdominal and pel-
vic surgery. Time was when ovaries were removed by the
peck for all sorts of nen.-ous disturbances, which had no
more to do with the condition of the ovaries than with the
change of the moon. This was the era of Battey's so-called
"normal ovariotomy," than which no greater outrage could
be perpetrated upon a confiding woman. To-day it is not
fashionable to remove the ovaries for an attack in which
the globus hystericus is the most prominent symptom, but
those organs are still subjected to certain operative pro-
cedures for pathological conditions which exist only in the
mind of the operator. At times the ovary is removed for
what the operator is pleased to dignify by the term of
"ovarian cyst." This cyst is sometimes no larger than a
cherry, and very often much smaller. At times the ovary
, is not removed, but the cyst is punctured with knife or

cautery, and the fallopian tube, which he claims is the seat
of salpingitis, but which may be perfectly normal, is re-
sected. What justification is 'there for opening a w'oman's
abdomen for such conditions? The operator may justify
himself by saying that the woman sulTered from pelvic
pain which justified the operation. Now, every experi-
enced gynecologist knows that this is not true; such con-
ditions do not give rise to pain. If the woman really suf-
fers pain she is probably a neurotic subject, wdiosc pains
and aches are due to anemia and general malnutrition. If
she did not have pain in her pelvis she would have it some-
where else. Anstie has truly said "neuralgia is the cry of
the nerves for healthy blood," and such patients require
iron, fresh air, sunshine, and good food — not a mutilating
operation.

The uterine adnexK are not the only organs sub-
ject to atrocious assault, the uterus itself comes in for
more than its fair share. To say nothing about the injury
so often indicted on it by the ignorant, through bungling
attempts at dilatation and curettage, or maladroit trache-
lorrhaphy, the organ is often extirpated for no apparent
reason, except the undying fondness of some men for
notoriety or money. The uterus is often removed for a
small myoma the size of a w-alnut. The writer saw two
such cases during the past month. In one case abdominal
hysterectomy was done by a prominent New York surgeon ;
in the other an inexperienced man performed a vaginal
hysterectomy, which was attended by so much hemorrhage
that he opened the abdomen in the hope of controlling it.
In this he was not successful ; more or less bleeding con-
tinued until the death of the patient about two days later.
.\t the December meeting of the Obstetrical and Gyneco-
logical Section of the New York Academy of Medicine, Dr.
Henry C. Coe protested against the performance of hyste-
rectomy for insignificant benign growths, and the writer,
in indorsing Dr. Coe's protest, stated that in his opinion
such operations should be looked upon as pure surgical
quackery. The overzealous gynecologist seems to be con-
stantly in search of an opportunity to extirpate the uterus.
If a woman has a large subinvoluted uterus with catarrhal
endometritis attended by profuse menstruation, he scrapes
the uterus and sends some of the scrapings to a personal
friend — a soi-disant microscopist, who would not know a
cancer cell from a load of hay. His friend, the "micro-
^copist." having been told what the would-be operator
"fears," proceeds to find "suspicious-looking cells." That
is enough — out comes that uterus, .-^gain, a woman has
a badly lacerated cervix with ectropion and erosion. The
cervix has certainly an angry look, but the experienced
man knows that it is not cancerous. He has operated on
scores, yea, perhaps hundreds, of similar cases by Emmef s
method, and they have been permanently cured. But our
enthusiastic confrere is ultra scientific. He is not willing
to trust to his naked eye, or anybody else's naked eye; so
he chips off a piece of the cervix and sends it to the same
microscopist, being careful to tell him what he himself
thinks. The microscopist is either again "suspicious" or
"in doubt," and, as Cavendish says in regard to whist,
"when in doubt play trumps," our friend plays trumps, and
out comes that uterus also. Far be it from the writer to
disparage the well-trained, intelligent, honest microscopist,
whose assistance is invaluable in many doubtful cases. He
makes reference to those who, without proper qualifica-
tion, pose as experts, and w-hose opinions are often used by
those who are overanxious to operate as a_ make-weight in
overcoming the objections of patients' or of the family phy-
sician, to operations which should never be performed. In
a paper entitled "A Plea for Early Operation in Caiicer
of the Womb," the writer has denounced the criminal
neglect and procrastination which allows a woman with
cancer of the uterus to drift into an incurable state before
she is referred to an operative gynecologist, and he sin-
cerely hopes that nothing contained in this communication
will detract from the force of what he then said. Every
available means at our command should be brought to bear
that may enable us to diagnose cancer in its incipiency.

It is one thing to make an honest search for the truth in
the interests of the patient and quite another thing to
play the charlatan, while pretending to base one's practice
upon scientific accuracy. Next to the uterus and adnexas,
the appendix vermiformis and kidney are the most abused
organs. With some practitioners every belly ache is called
appendicitis, and an operation for the removal of a normal
appendix follow^s forthwith. The writer has seen the ap-
pendix removed in a number of cases in which it was
absolutely normal, and within the past five years he has
been consulted by many women who had been told that
thev should submit to an operation for what was said to
be appendicitis, but the subsequent history showed that no
operation was necessary in most of the cases ; and in those
in which abdominal section was necessary it was found
that the appendix had nothing to do with the symptoms

reb. 9, 1907J

M£LU1L,/\L KliV-UKU.

^39

complained of. In times gone by, when a physician was
too indolent or too ignorant to make a diagnosis, he labeled
the disease "malaria," and everybody was satisfied. Now
the so-called surgeon calls everything appendicitis, and cuts
out the appendix, with equally gratifying results. The
furor for unnecessary operations has spread to the laity,
and the cheerfulness with which the would-be fashionable
man parts with his appendix is only equaled by the
abandon with which the modern woman submits to the
evisceration of her pelvis by her pet gynecologist. Practis-
ing fantastic operations on the kidney l;eeps some men in
the profession busy. A poor, thin, neurotic woman, whose
circumrenal fat has been absorbed, leaving the kidney
anchored only by its moorings, consults one of these men.
With wonderful sagacity he diagnoses "floating kidney"
and at once performs nephrorrhaphy. If from rest in bed
and general improvement in health therefrom a layer of
fat is deposited around the kidney the woman is cured,
and the doctor gives the credit to the operation.

If the patient does not gain flesh after the operation, in
a few months the kidney "floats" again as badly as ever.
But the operator may remain ignorant of the fact, for the
patient may consult somebody with common sense enough
to put her in bed, feed her generously, remove all sources
of worry, and thus put her in the way of gaining flesh,
and after a time the kidney stays where it belongs. Split-
ting the capsule has been advised and practised as a pan-
acea in Bright's disease. The writer has no knowledge of
any authentic case in which a cure has been effected, but
he knows of one case reported as a cure, although the pa-
tient died a short time after the operation, and the kidneys
are in pickle in a jar which is the property of a well-
known pathologist. Prostatectomy seems to be the latest
fad, and the man of sixty who is still carrying his prostate
where nature intended that he should, is looked down
upon by his contemporaries who have yielded theirs as a
contribution to extend the popularity of this surgical inno-
vation. Let us hope that the interest shown in the prostate
may result in giving a much needed rest to the appendix
and the kidney.

From long experience the writer is fully aware of the
difficulties and responsibilities involved in the diagnosis
and treatment of serious abdominal and pelvic lesions, and
is ever ready to deal charitably with the errors of judgment
of a professional brother. We all make mistakes— we all
are liable to sins of omission and sins of commission; but
there is a vast difference between the honest mistakes of
the well-trained, intelligent surgeon, who looks upon every
case with an eye single to the good of the patient, and the
stupid blunders of the inexperienced or meddlesome oper-
ator, whose ignorance of pathology and of the natural his-
tory of disease causes him to see in every case an indica-
tion for operation, and who is ever willing to sacrifice the
good of the patient to his own love of self aggrandizement.

G. H. B.^LLERAY, M.D.

Paterson, N. J.

the point would be to keep up the eliminative treatment

until the urine shows less and less, or only the normal
trace of indican. Louis Fischer, M.D.

New York City.

RECURRENT CORYZA IN CHILDREN.

To THE Editor of the Medical Record:

Sir : — In your issue of January 5, 1907, there appears an
abstract of my paper entitled "Rhinitis in Children, Includ-
ing Recurrent Coryza, Due to Intestinal Autointoxication."
In this article I am quoted as saying: "When this form
occurs in children the urine invariably contains indican.
The peculiar gastric and intestinal disturbance arises from
overeating of meat. It should be prohibited in every form as
soon as any evidence of the rhinitis appears. Saline ca-
thartics should be given, sodium phosphate being admin-
istered in sufficient quantities to produce liquid stools, and
the administration kept up until the urine contains indican."
In the article referred to, I say:

"When the intestine contains stagnant fecal matter a
general autointoxication results, frequently ending in rhi-
nitis These attacks last but two or three

days. They recur, unless a general cleansing of the gas-
trointestinal tract, as often as once a month in some cases,

is given When recurrent rhinitis is seen in

dyspeptic children then the urine invariably contains in-
dican Not only is the presence of indican an

important aid in eliciting the etiological factor in this type
of recurring rhinitis, but the presence of indican assumes
a very important role in determining the proper therapeu-
tical measures to be pursued. From what has just been
said we can easily see that if indican exists, associated
with stagnant feces (chronic constipation) then the treat-
ment is one of distinct elimination."

From the above it will be seen that the diagnosis is
strengthened by the presence of either large or small quan-
tities of indican in the urine, and the stronger the blue
reaction of indican the larger the amount present. Hence

OUR LONDON LETTER.

(From Our Special Correspondent.)

HOSPITALS AND THE C0MPENS.\TI0N ACT — TROPICAL DISEASES
• — MUNICIPALITIES AND INF.ANTILE MORTALITY — ARMY AND
NAVY AFFAIRS — MEDICAL OFFICERS OF HEALTH ; PRESIDEN-
TIAL ADDRESS — SIR C. DOYLE ON EDALJi's CASE — PROPOSED
BILL FOR THE KINc's HOSPITAL FUND.

London. January i8, 1907.

The friends of hospitals are concerned to know what will
be the effect of the extension of the principle of compensa-
tion for injuries to whole classes of the population under
the new Act. The King's speech at the Prorogation of
Parliament put the enlarged scope of compensation as em-
bracing "over six million persons not included under the
benefits of preceding Acts." The added burden to our hos-
pitals will be obvious on the slightest thought on the sub-
ject. Most of those entitled to compensation are likely
to become patients at the hospitals. In minor cases the
injured workman can get the best medical and surgical aid
at the nearest hospital without cost, and this help tends
to reduce to a mininumi the period of his incapacitation.
In graver injuries he will become an in-patient, and receive
in addition free maintenance. But neither he nor the
employer need give a penny to the hospital which has bene-
fited both, nor can the amount received for compensation be
attached for the expenses incurred by the hospital.

This hospital grievance has been felt more or less acutely
ever since the compensation of workmen was rendered
compulsory by law, and at intervals it has been made the
basis of a claim that the great insurance compatiies should
give pecuniary help to the hospitals, for these institutions
enable the companies to reap large profits from the diminu-
tion of their risks through medical skill. This applies
specially to those companies which do the largest business
among the working classes. I do not mean to deny that
insurance companies, or some of them, subscribe to hos-
pitals, but I think no one can maintain that they afford
adequate financial support considering the benefits they
receive.

Another point is giving some concern to hospital man-
agers and others. It seems as if the new .Act will render
the governing bodies of hospitals responsible for injuries
occurring to "all persons in the regular employ" of these
authorities. If so, it will be prudent for them to insure
such persons, and this will be an additional burden on hos-
pitals and an equal benefit to ins\irance companies. The
outlook for the hospitals is not pleasant.

In the report of the Advisory Committee of the Tropical
Diseases Research Fund for last year, the objects are said
to be, on the one hand, provision of instruction for medical
officers in the Colonies and Protectorates; on the other
hand, the furtherance of research work. The first of these
ends is said to have been in great measure attained by the
provision of lectureships in entomology and parasitology,
in helminthology and protozoology, at the Liverpool and
London schools. jMedical officers appointed to posts in the
Crown Colonics or Protectorates are now required to take
a three-months' course in one of these schools. It has
lately been suggested that the course should be six months.
The committee, however, think the expense and delay
would be serious, and if any change be made it should be by
enabling those medical officers who display exceptional
promise to attend a more advanced course on the occasion
of their first leave of absence in England. As to research,
the Colonial Secretary, on consultation with expert advis-
ers, sent a circular to the Governors of Colonies and Pro-
tectorates, suggesting that when they have an adequate
staff, and can devote some funds, a sum might be voted
for detailing one or more medical officers to study modern
scientific research at the best known centers, and possibly
afterwards to carry out further researches in the Colony
before reverting to ordinary work. The committee express
satisfaction that the appointment of a professor of protozo-
olo.gy at the London University has been followed by a
siniiiar step at Cambridge. They are considering a pro-
posal to establish a post for investigation and instruction
in pathological entomology in connection with the London
Universitv and Tropicaf School. The work done in the
Tropical 'Schools is certainly most satisfactory, and the
report seems to recognize this, especially in relation to
prophylactic measures suggested as the result of their
labors. , _.

At the dinner of the African Society last week, bir
Patrick Manson was the guest of the evening, and m his.

240

MEDICAL RECORD.

[Feb 9, 1907

speech referred to the progress in the study of tropical
diseases in the last eight or ten years, before which time
quite half a dozen were lumped together as malaria. Sleep-
ing sickness having crept into the Congo and devastated
Uganda, now threatened the upper Nile, and might possibly
reach India and tropical Asia, ''a calamity to mankind too
terrible to contemplate." lie considered it of the utmost
importance for immediate steps to be taken to guard
against that as far as possible, and a liopeful sign was that
people were beginning to learn the value of research on
these diseases.

Some of the municipalities, including Glasgow, which
calls itself the second city of the Empire, will seek powers
in the coming session of Parliament to deal more effectually
with infantile mortality and the decline in the birth-rate.
Among the proposals made is one enacting that the father,
or, in his absence someone in attendance on the mother,
shall, within forty-eight hours of a birth, give notice to
the medical officer of health, and shall be paid by the mu-
nicipality one shilling for so doing, but lined twenty shil-
lings for neglecting to do so. Public notice is to be given
in the papers and by handbills, and medical practitioners
and midwives are to be informed by registered letters.
This proposal is not as a substitute for ordinary registra-
tion, but as an addition thereto. The time allowed for
informing the Registrar would be too long for the pur-
pose of this proposal, which is to enable the local authority
to do more effectually what has been done in some places
by volunteers, viz., to have poor mothers visited at once
by ladies in order to assist them, instruct them when neces-
sary on the feeding and management of the infant, and do
all they can to secure it the best chance of survival during
the first weeks of life — the most dangerous period. In con-
nection with this subject, the London County Council, with
its omnivorous propensities, could not be behindhand. It
has, in fact, deposited a bill of ninety-two clauses extending
its powers in various directions. One clause proposes that
any Metropolitan Council may carry on milk depots and
provide plants and laboratories for sterilizing or treating
milk so as to make it suitable for infants under two years.
But our Council doe? not stop here; it has a scheme for
running a sort of restaurant in connection with its several
lodging houses, selling "every description of food, solid or
liquid," but the latter not into.xicating. This last proposal
is being denounnced by many. It is very well, they say,
to set up the milk depots, which seem successful, but that
is no reason for opening shops to compete with rate-payers
by means of rate-payers' money, and there is always a risk
of loss, as the Council knows from its speculations in
steamboats' and other business failures. The electors may
have something to say on these matters.

The amalgamation of the .'\rmy Medical Advisory Board
and the Army Hospital and Sanitary Committee is now
completed, and the War Minister announces that the re-
constituted "Army Medical Service Advisory Board" is
composed of the Director-General and Deputy-Director-
General. Army Medical Department, as chairman and vice-
chairman. Col. Bruce, F.R.S.. is a member as "expert in
Tropical Diseases," and Lieut.-Col. Melville, M.B.. as
"expert in Sanitation." Col. MoncrieflF, C.I.E., Assistant
Director of Fortilications, also has a seat. The civilian
member.? are Sir F. Treves. Dr. Rose Bradford, Dr. Louis
Parkes. Dr. Pembrey, and Sir C. .\. Cameron. As a rep-
resentative of the India office, Surgeon-General Branfoot
is appointed, and the secretary is Lieut.-Col. Melville, M.B.,
the "expert in Sanitation."

The report on the Health of the Navy in 1905 is out
this week. Compared with the averages of the last eight
years, there are decreases in the ratios of cases, invaliding?,
and deaths, the death ratios being the lowest since 1856.
The ratio for the year was 3.0 per i.ooo. a decrease of 1.42
compared with the eight years. The daily average ratio
of sickness was 30.31 per 1,000, which is a decrease of 1.04
compared with 1904.

The report of the .-Xmiy Medical Department is also just
published, but the statistics are not comparable with those
of the Navy. There; is a decrease in the admissions, mor-
tality, and sick rates. The decrease in the admission rate
is partly traced to the practice of treating cases in bar-
racks, which under old rules would have been dealt with
in hospital. The death rate for the }-ear shows a decrease
on the previous year, as well as on the average for decen-
nium 1805-IQO4. It is also to be observed that the death
rate is not that of sickness originating solely in the United
Kingdom, but by that contracted while serving abroad, and
here I have only referred to the statistics of the Army
serving at home.

The new president of the Societv of Medical Officers of
Health is Dr. D. S. Davies! :\Iedical Officer of
Health _ for Bristol and lecturer on hygiene at the
University. In his inaugural address he referred
to the conception of disease prevention as a

general formula having undergone great modification, and
to the early notion on the discovery of pathogenic bacteria
that they entered, permeated, and then passed out of the
body like an army without stragglers. Had this been true,
isolation hospital? would have been efficient. But diph-
theria was more or less prevalent in all large towns, the
periods of prevalence recurring, not after the manner of
measles, at fairly constant and rather short intervals, but
at long, uncertain intervals after comparative and often re-
markable quiescence. During the first months of an out-
break hospitals might be more useful than later in prevent-
ing its spread, of course in conjunction with the treatment
which restrained the diffusion of the infection. Having
referred to school examinations in infected classes, he said
that in Bristol they had not found the difficulty met with
in London, of the inaction of some authorities when out-
breaks were referred to them. Contrasting smallpox with
diphtheria, he said its course and habits made it easier to
control, in spite of its high infectivity. A patient either
had, or had not smallpox, but he never carried it about in
an inert but potentially infective form. The essential con-
ditions of isolation could therefore be fulfilled. The fact
which must impress all who studied the progress of the
past sixty years was the replacement of broad generalization
in regard to the causation and control of communicable
disease by intimate study of each disease in detail, and
specific adaptation of means to secure success in respect
to each. The result was advance. But scientific advance
is necessarily slow, and does not satisfy impatient critics.
The public might weary of recurring changes in the atti-
tude of scientific medicine towards disease through failing
to recognize that every check of reconsidered knowledge
is but the backwash of a single wave upon a rising tide.

Sir A. Conan Doyle has taken up the case ot .Mr. Edaiji,
who was convicted of maiming cattle at Wyrley, as some
of your readers may remember. .After three years he was
released by order of the Home Secretary, and it may be
presumed that this means he is thought to be innocent. All
this time the Medical Press and Circular has held that he
was either a lunatic or the circumstantial evidence, on
which alone he was convicted, led to a miscarriage of jus-
tice. Sir Conan Doyle reports that Edaiji is myopic with
astigmatism, and he appeals to ophthalmologist? to say
whether it would be possible for him to have set forth on
a dark night, with neither moon nor stars, to have crossed
country for half a mile, climbing fences, finding gaps in
hedges, and passing over a broad railway line, to have
mutilated a pony which was loose in a large field, to have
returned, and done all in thirty-five minutes. Such a
task would not be easy with perfect vision. It should be
said the man had never worn glasses. The point raised by
Sir C. Doyle is interesting. But many people will think it
more important that similar outrages took place at the
same place while Edaiji was in prison.

Among the bills to be brought forward in the coming
session, and which have fulfilled the necessary formalities,
is one to incorporate King Edward's Hospital Fund and
establishing its administration on a permanent basis.
H.R.H. the Prince of Wales is nominated President during
the pleasure of the Sovereign, and it is further provided
that "every succeeding president shall be appointed by and
hold office during the pleasure of the Sovereign." The
general council of management is to consist of such and
so many persons as the President shall from time to time
appoint. Thus the King, and with his sanction the Prince.
may do just as he pleases, as it may be said he does at
present. What then is the need for an Act of Parliament?
The people are willing to give their money for King
Edward to allot to the hospitals. It therefore seems in-
advisable to provoke comment on such an autocratic pro-
posal, or to ask them to endow a future monarch.

PrngrpBS of iHrbiral ^riritrr.

Nczf York Medical Journal, January 26, 190".

Empyema of Some of the Accessory Sinuses of the
Nose Complicated by an Orbital Abscess. — J. Gutt-
man's patient was a girl of fifteen j-ears, whose initial
symptom was toothache followed by a swollen jaw.
Later the swelling extended to the eyelid and the
author was called to see the girl. Pus was found in
the antrum. .A radical operation was done on the
antrum, the middle turbinal removed in front, and the
ethmoidal sinus entered. Pus escaped from the latter
cavity. Before the operation there were evidences of
an orbital abscess. The latter was opened through
the inner canthus and the communication between the
orbital abscess cavity and the ethmoidal sinus enlarged
by breaking through the lamina papyracea, which had
already been partially destroyed by the suppurative

Feb. 9, J907]

MEDICAL RECORD.

241

process. The whole process of infection was very
short, only forty-eight hours having elapsed from the
beginning of the toothache to the swelling of the eye-
lids. It is not improbable that the primary cause
of the onset of the disease is to be found in an in-
flammation at the root of the tooth, which spread to
the maxillary sinus, from there to the ethmoidal sinus,
and thence to the orbita* cavity.

Treatment of Chronic Urethral Discharge.— S. L.
Gans describes the methods which have commended
themselves to his judgment. He uses the teim uror-
rhea to signify the sticky discharge which follows a
prolonged or severe attack of urethritis. Tliis is the
product of overactive mucous glands or relaxed ves-
sels. All local treatment has a tendency to increase
the condition, except in some cases which will re-
spond to the local injection of a few minims of 1-2000
adrenalin solution. General tonics and hygiene are
called for, and cold spinal sponges in the morning will soon
effect a cure, if the patient can be persuaded to aban-
don the pernicious habit of constantly "stripoing" the
penis. The author takes up the details of instrumen-
tation in cases of gleet dependent on a patch or errosion
independent of a stricture. Concerning strictures, he
says, dilate all strictures except those that are resilient,
cartilaginous, irritable, or bleeding, allowing that the
technique is correct. Where a stricture reaches a
certain point and persistently refuses to dilate further;
where there is repeated and excessive bleeding, or
urethral fever, then, regardless of the caliber, a cutting
operation is advisable. Internal urethrotomy is indi-
cated when the lesion is at or near the meatus, but
external urethrotomy or perineal section should always
be done when the stricture is at or near the bulb. A
departure from this rule is to invite infection, as the
bulb represents the base of a U-shaped tube (urethra")
with its consequent bad drainage.

The Management of Laparotomy Patients and their
Modified After-treatment. — The general conclusions of
H. J. Boldt are summarized in the following proposi-
tions: No particular preparatory treatment is neces-
sary for patients upon whom it is intended to do an
abdominal operation, unless the operation involves the
opening of the stomach or the l)0wels. Stomach lav-
age is of benefit at the conclusion of the operation.
Patients should not be kept unnecessarily under an
anesthetic. The application of a tight bandage around
the upper part of the thighs, to keep a blood reservoir
in the lower extremities, in exsanguinated and very
weak patients, is excellent. The same may in excep-
tional cases be done with one of the upper extremities.
These bandages are taken ofif as soon as the operation
has been completed, and thus more blood is thrown
into the trunk. The administration of strychnine dur-
ing and after an operation should be conducted with
more care than is usually done. The intravenous in-
fusion of a 0.9 per cent, saline solution should not be
too long delayed when the condition nf the patient
makes it evident that its employment may be of benefit.
In instances of large myomata, where the p,ftient has
been much exsanguinated by bleeding, it is desirable
that the infusion be begun as soon as the patient
is fully under an anesthetic, so that by the time the
operation has been completed about i.ooo to 1.500 c.c.
may have been infused. The application of a very sim-
ple dressing over the wound, and the adjustment of a
snugly fitting Scultetus bandage made of oxide of zinc
plaster; the administration of a dose of morphine if
restlessness or pain makes this desirable, the medica-
tion then acting as a heart stimulant; the allowing of
regular diet and unrestricted mobility within twenty-
four hours after the operation, unless specially contra-
indicated; the getting patients out of bed as soon as
possible after an operation; the avoidance of forced
catharsis before the first four or five days after an
operation unless there is a special indication for it. In
instances where resort to vaginal drainage is had, or
where it is evident that there will be some secretions
intraperitoneally after an operation (purulent cases,
and oozing from torn adhesions"), the emnloyment of
trunk elevation as soon as the patient is nut into
bed. For this the employment of a bed-lifter such
as described, or the placing of high blocks or chairs
under the head of the bed. is preferable to back rests.

Journal of the American Medical Association. I'etiruarv 2.
1907.

Diagnosis of Rheumatoid Joint Disease. — The differ-
ential diagnosis of chronic arthritis deformans and
gout is discussed by J. B. Herrick. He points out
that there are many exceptions to the rule that ar-

thritis deformans is always chronic, afebrile, and begins
in the smaller joints. In fact, the recurrence or acute
exacerbations of supposed chronic rheumatism are fre-
quently arthritis deformans or gout. In the acuter type
of arthritis, however, there is not the shifting of the
process from one joint to another. The excessive
sweating is lacking and cardiac complications are very
rare. The acute process is slower to subside than in
acute rheumatism. With the passing of time the ten-
dency to deformities begins to be apparent and in the
larger sometimes as well as in the smaller joints.
.Arthritis deformans is iliore likely to attack the tem-
poromaxillary. sternoclavicular and vertebral joints
than rheumatism and there sometimes may be con-
siderable fluid in the joints. Various nervous symp-
toms, such as burning, weakness, numbness, may be
present. The .r-ray may help the diagnosis. As re-
gards gout, he holds that it is commoner in the United
States than is generally supposed and is by no means
confined to the "high livers." Beer drinking, lead
intoxication, heredity, intemperance in diet, and a
sedentary life seem to be the most common causes in
this country. The suspicion of gout should be present
in all cases of typical rheumatism. Herrick remarks
that the typical febrile big-toe attack, or a history of
such, excepting tophi, is the most valuable aid to diag-
nosis. Tophi are usually sought for in the ear. They
should be looked for also in the cartilages of the nose
and larynx and in the joints. They are often over-
looked, he thinks, not only if they are small, but also
vv-hen they are large and soft. If one watches for the
points mentioned, looks out for cardiovascular ac-
companiments of the disease, studies the uric and phos-
phorus acid output, and employs the .r-ray, he can gen-
erally make a sure diagnosis. There are, neverthe-
less, some cases without tophi that are pretty baffling.
The Physiological Action of Alcohol.— W. S. Hall
discusses the relation of alcohol to living protoplasm,
pointing out that it is a normal product of metabolism
of the yeast fungus; that it belongs to the class of sub-
stances that are completely metabolized and is passed
out because its existence is destructive to the livmg
cell; in short, that it is an excretion toxic to the or-
ganism that produces it. An excretion of this type is
also toxic to higher organisms, and this is the case
with alcohol. Admitting that it is oxidized m the liver
and produces heat and that it inay lead to decrease in
the catabolism of carbonaceous foods, the heat pro-
duced is not a normal catabolism. but is simply the
result of a protective oxidation, which is insufficient,
the toxic action showing in its narcotic effects. The
decreased catabolism of carbonaceous and nitrogenous
foods following the ingestion of a narcotic is a uni-
versal fact depending on the drug effect and giving
to the oxidized narcotic no significance as a food. It
may be said, he says, without reservation that ethyl
alcohol is not a food in the scientific significance
of the word.

Alcohol in Its Relation to Degeneracy.— E. S. Talbot
holds that alcoholism is often the expression of an
existing degenerative taint rather than its causal factor,
and that ignoring all but the alcoholic factor in de-
generacy is often the source of error. He points out
that the effect of alcohol on the individual is much like
that of the chronic contagions, but with a greater de-
teriorating action on the nervous system, and that m
its degeneracy-producing action it is aided by poverty
and other bad environmental conditions. The routine
prescription of alcohol for various ailments is un-
doubtedlv responsible for much inherited degeneracy,
and this 'way an immense amount of harm is done by
alcoholic no'strums. The precursor of degeneracy is
a neurasthenia induced bv alcohol in these cases, and
the neurasthenia of the ancestor becomes the neurosis
of the descendant.

The X-Rays in Lupus Vulgaris.— H. W. Van -\lien
has emploved the .r-rav in tlic treatment of lupus, using
for the treatment of the general surface a tube w-ith an
air-spark gap of from one to two inches and a distance
of the anode of about ten inches, and duration ot
twenty minutes. Application is made twice a week till
the first indication of hyperemia is obtained. this
is usually a month or less, and then the treatnients
are given about once a week for a month longer. Alter
this the patient is told to return in a month when
the surfaces will usually have a healthv pinkish color
and nodules can be clearly discerned. The intervening
tissue is protected and the nodules are alone treated
with a tube of less than an inch air-spark gap, the
distance being six inches and the duration twelve min-
utes The amplications are made three times a week

242

MEDICAL RECORD.

[Feb 9, 1907

until reaction takes place, when the cumulative effect
IS produced, with scabbing and slight ulceration. As
soon as the active cautery action begins to subside, he
finds the high frequency discharge given off from a
low vacuum tube excited by a Tesla coil and resonator,
attached to the static machine, to have great value in
hastening repair and cicatrization. Other special de-
tails are given, but the above are the essentials. He
compares the x-ray treatment with the Finsen method,
pomting out the disadvantages of the latter as regards
time required and the need of special personal atten-
tion. A table is appended giving the results in fifteen
cases, selected on account of the certainty of diag-
nosis, and giving a percentage of 80 per cent, of cures,
with an average duration of treatment of six months
and a lapse of time since discharge averaging eighteen
months, indicating, he thinks, a permanent cure.

Further Study of the New Infectious Disease.— L. K.
Hirschberg defines this disease as an acute infection
of sudden onset and unknown bacterial origin, char-
acterized clinically by fever, constipation, absence of
blood parasites, agglutination with the usual bacteria,
rose spots, enlarged spleen, and tympanites. Its pa-
thology is unknown, as there have been no deaths, and
there was no way to ascertain its incubation period
from the histories; the onset was always sudden. The
duration was from ten to twenty days. Constipation
was a conspicuous symptom, and the slowness of the
pulse was a striking peculiarity. No epistaxis, chills,
or sweating. In no case were there any abdominal
tenderness or characteristic eruption; the fever was
rapidly ascending, reaching even 105.4° without delirium
or nervous symptoms in some cases. Cultures and ag-
glutination tests were failures. The diagnosis is sim-
ple; there is little chance to confuse the condition with
other diseases; it seems, he says, to be a distinct
clinical entity. In all cases thus far reported the pa-
tients have recovered without apparent sequelae, ex-
cept one, who had. some weeks later, an attack of
typical typhoid with Widal reaction. The general
management of the disorder, like typhoid, consists in
good nursing, attention to diet, and hydrotherapy.
The constipation is stubborn and should be closely
watched.

The Lancet, January 19. 1907.

Some Limitations of Medical Evidence.— S. B. Atkin-
son notes that limitations of medical evidence mav
arise in two directions: First, limitations of medica'l
knowledge, and, second, limitations imposed by the
policy of the law. The former restrictions become
fewer with the advance of time, research, and medical
education. Limitations imposed by rules of law are
enlarged much less easily. Modern statutes are no-
torious for the strictness of their definitions. All defi-
nition implies limitations. Limitations of medical
knowledge may be relative to the witness concerned
or they may be absolute. Thus the diligence, skill, and
knowledge of medical men vary from age to age and
from person to person. So variable is this range that
a man is expected to treat a patient only to the best
of his ability and not in the best manner possible by
an authority on such matters. Recognizing personal
limitations, it is wise for all professionals to be on
their guard and to risk no disgrace, when in doubt
by a delay in applying to a superior authority at once.
Another relative limitation arises when some restric-
tion is imposed upon the medical witness while, wit-
tingly or unwittingly, he is qualifying to give his evi-
dence. Thus when a full physical examination of a
person cannot be obtained, or when consent to conduct
a post-mortem examination is withheld, there are sev-
eral matters which otherwise might be made patent,
but which will in the circumstances remain obscure.
A second variety of limitation owing to the lack of
sufficient medical knowledge is not relative to the
medical witness personally, but is a general inabilitv to
make a positive declaration owing to the uncertainty,
insufficiency, or inconclusiveness of the facts available.
Even real authorities in this variety of limitation may
have to confess that they do not know certain facts,
or will, when pressed, offer a very guarded opinion.
The last variety of limitation is that imposed by the
rules and policy of the law ; it arises on account of the
essential strictness of tlie presumptions and of common
law or statutory definitions which become more rigid
with modern legislation. Thus crimes must be* defined
in e.xact terms and the medical facts must, to be of anv
avail, be capable of being pigeon-holed — counsel will
endeavor, as they did in the bad old davs of special
pleading, to fit the facts into a loophole if possible.
Loose popular phraseology has led to occasional sur-

prise in this connection; thus, in a moment of righteous
anger we may say of drunkenness: "It's a crime," but
as a matter of fact the law books do not recognize
it as such, although it may incidentally or conse-
quentially lead to the commission of crime.

Opsonins and Treatment by Bacterial Vaccines. —

J. L. Bunch discusses the opsonin theory and in clos-
ing his paper refers to two cases, one of lupus of the
face and the other of testicular tubercle cured by
injections in accordance with this theory. Nothing par-
ticularly new is brought out. Concerning the "nega-
tive phase," which is such an important factor, the au-
thor says that if the right dose has been given the
phase will not be too marked or unduly prolonged and
will soon be followed by a well-marked positive phase,
and in succeeding inoculations the negative phase will
be still less. But if too large a dose be given or it be
injected when the index is falling, the positive phase
will make its appearance very late or not at all. The
author purposely lays stress on this point because
some of the first injections which he gave more than
eighteen months ago were too large, and he has known
an injection of i-500th or l-400th milligram to be
followed by a negative phase which was so marked as
to last for weeks. It seems to be generally agreed that
only the minimal dose must be employed which will
produce a satisfactory response, and this must not be
increased until it ceases to produce its effect. The
dose, moreover, must not be repeated until the effect
of the preceding dose is passing off. If it were possi-
ble to produce a summation of positive phases it would
be advantageous to give successive doses at short in-
tervals, so as to produce a maximal favorable effect,
but such summation is not possible in the case of
tubercle. Each inoculation, therefore, produces its ef-
fect independently, and it remains to take the greatest
advantage possible of the increased elaboration of prO;
tective substances which the artificial stimulus has pro-
duced. It is obvious that this can only be done by
bringing the protective substance as closely as possible
into contact with the bacteria which are the cause of
the disease. This is simple enough when the bacteria
lie within easy access of the blood stream, but when
they are flourishing in the tissues in circumstances
most favorable to their growth, remote from the blood
stream and in contact only with a lymph which is natur-
ally poor in antibacterial substances, the mere in-
crease of the opsonic pow-er of the blood is not suffi-
cient. The opsonin must be brought into direct action
with the bacilli in the diseased focus, and this can
only be done by increasing the lymph flow through
that focus. When it is situated near the surface this
may best be brought about by the application of coun-
ter irritants, rubefacients, or heat, either dry or moist,
in the form of hot-water bottles, hot-water tins, or the
commonly used hot boric fomentations. When the
focus or disease is in a joint Bier's method of passive
congestion is one of the greatest service. The effusion
of lymph produced by each of these methods is very
consideraWe, and, in addition, the viscosity and coagu-
lability of the blood can be greatly diminished by the
internal administration of decalcifying agents, such as
citric acid.

Scepticism in Therapeutics. — \. H. Bampton de-
clares tliat man is ,in organized collection of differen-
tiated and highly specialized cells, and that cellular ac-
tion is governed by physical laws and chemical proc-
esses and is profoundly influenced by slight causes,
and that nine-tenths of disease is due to the interac-
tion of cells and their products and germs and their
products, chemistry being the interpreter of these
phenomena. Barely 50 years ago belief in drugs and
energetic treatment was the faith and practice of the
majority of the profession. It was the rise of the path-
ological school and the study of morbid anatomj' that
shook the faith of the succeeding generation of prac-
titioners, viewing only the last stages of disease and
seeing structur.1l alteration in the mass. It was thought
unreasonable to imagine that any pharmaceutical prod-
uct could have any influence whatever on such profound
structural changes in vital organs. It was argued that
the cause of many diseases being unknown, therefore
the remedies were irrational. But we do not know
but that remedies given early may affect some of these
earlier cell alterations, which eventuate in familiar gross
pathological changes. So the administration of the
remedies is logical and proper. The author remarks
that if the mystery of life is to be solved it will be by
the experimental examination of the simplest form of
life. The discovery that every tissue, every cell, has
its own special ferment, is of far-reaching importance

Feb. 9, 1907]

MEDICAL RECORD.

243

in explaining much that was mysterious in physiology
and pathology and accentuates again the importance of
chemistry in explaining vita! phenomena. When med-
icine and physiology are written anew, we shall be told
the rejations that one ferment bears to another. And
it is by virtue of this special ferment that each cell is
able to select out of the food-stuffs such material as it
can transform into energy. The corollary of this is
true, that an organ or tissue may fail to perform its
function from lack of special fuel to make the ferment.
It has been pointed out that during the involution or
atrophy of an organ the symptoms which arise may be
due to the absorption of the tissue and its passing into
the general circulation; absorption of kidney tissue, for
example, produces increased arterial tension; liver sub-
stance lowers it. Recently, the involution of an en-
larged thyroid has been noted to give rise to all the
signs attributable to large doses of thyroid extract.
Finally, the author expresses the hope that as phar-
macology advances, mechanical or empirical prescrib-
ing will become less and less frequent. .^t present
we know that drugs produce their effects either by
chemical combination or by their physical properties
interfering with oxidation processes, as sand puts out -
a fire, and their ability to penetrate a cell may depend
upon the size of the molecules of which they are com-
posed. Instances of chemical combination are shown
in the exhibition of alkalies in diabetic coma and sul-
phonal poisoning, in the action of sulphate of soda in
carbolic acid poisoning, and of sodium hyposulphite in
combining vvitlt prussic acid to form the nonpoisonous
sulphocyanide. The most powerful narcotic substances
are those which combine a very slight solubility in
water with a very high solubility in ether, olive oil, or
brain lipoid. The cerebral cells are more sensitive to
alterations in their composition than other cells and
they contain a much larger percentage of "lipoid mat-
ter" or fat, so that these drugs tend to accumulate in
them. Here we have an instance of the physical action
of remedies.

Some Observations on Fat Necrosis. — J. E. H. Saw-
yer has noted eight cases of fat necrosis in a
two years' service as pathologist to the general
hospital at Birmingham, and summarizes their clinical
histories and autopsy findings. Three occurred in con-
nection with acute hemorrhagic pancreatitis ; two with
subacute and one with gangrenous disease of the pan-
creas ; one followed hydrochloric acid poisoning and
one occurred in connection with mitral disease. The
paper describes the distribution and appearance of the
areas of fat necrosis and the changes found in the
pancreas, .'\nalysis of the fat particles was made in one
instance, and it was found that they consisted of the
calcium salts of a mixture of fatty acids superfatted.
There was no glycerin, leucin, tyrosin or any other
amido acid found. Consequently they could not be due
to proteid decomposition. In one instance bacterial
cultures were made of the fat necrotic areas, which
were found to be sterile. Tissue sections in other cases
showed no bacteria. In some cases examination was
made of the fluids from the pancreas, and associated
peritoneal cysts. In all of these the Bacillus coli com-
munis was invariably found, associated with various
other organisms. The author believes that in order
to produce fat necrosis some other factor must be in
evidence than mere obstructions of the pancreatic duct.
It would seem that some destruction of pancreatic tis-
sue is also necessary. Then there occurs a leakage of
the pancreatic secretion into the surrounding tissues
and its fat-splitting ferment produces the necrotic
changes.

British Medical Journal. January 19. 1907.

Yellow Fever in the Chimpanzee. — H. W. Thomas
reports the following experiment: Fifty-seven stegomyia
mosquitos were allowed to feed on two yellow
fever patients. On the twenty-first day thereafter the
twenty-nine surviving insects were allowed to bite a
chimpanzee. In twenty-seven hours the animal's tein-
perature began to rise, and during the succeeding nine
days he went through what was regarded as a benign
attack of yellow fever from which he recovered. Mos-
quitos were allowed to feed on him during the infection
period, it being the intention to apply them later to a
nonimmune individual to complete the cycle of iiian-
chimpanzee-man. Details of the experiment are given
in the original paper. [What all this proves or is
meant to prove, is. in the abstractor's mind, a bit hazj'.]

Papain in Malignant Growths. — C. W. Branch relates
his personal experience in five cases seen at St. Kitt's
West Indies. .\ papain emulsion was injected under
local anesthesia by partial freezing. The emulsion

was made just as it was about to be used, and contained
I gr. in every 5 minims of cold distilled water. From
5 to 20 minims of this emulsion were introduced at one
time, according to the size of the nodule or tumor;
Vz gr. was the smallest dose given. This destroyed a
hard nodule about the size of the kernel of an almond.
The instrument used in all the injections was a Gee's
hypodermic syringe fitted with its largest needle. This
was sterilized and a drop of emulsion made to appear
at its point before its insertion. If the tumor was
large, the needle was made to pause two or three times
while some of the emulsion was ejected, so as to estab-
lish two or three foci of action along the one line of
insertion. Only a slight puncture was made. The
operations were repeated at intervals of from two to
four weeks. Following the injections a burning sen-
sation came on and a curious feeling as if some small
animal was nibbling at the flesh. Nausea was at times
present. The tumor softened around the site of punc-
ture in two or three days. There was a slight rise of
temperature. In about ten days the tumor began to
discharge freely through a small hole a thick, greenish
stuff, but the discharge ceased in a week or two, at
which time the growth was found noticeably smaller.
The general results were favorable, but the cases
were too few and too recent to permit of any sweeping
conclusions. The author states that it seems possible
that papain injections may be admissible in the treat-
ment of some cases of primary cancer and other tu-
mors. He has lately come across a statement that
papain has been applied, he supposed externally, to
epithelioma; but there was no mention of the result.
It is very likely that it was satisfactory. He rubbed the
fresh juice of the root of the papaw tree on two small
growths, neither of which was malignant. They were
both entirely eradicated by a few applications. The
little operations were perfectly painless, surpassing in
this respect similar ones done with sodium ethylate.
Perhaps leprous tubercles might be removed in this
way with less pain and disfigurement than by the acid
juice of the cashew.

Immediate Microscopical Diagnosis of Tumors Dur-
ing Operation. — This general question is considered by
C. B. Lockwood. who commends the following tech-
nical method as elaborated by E. H. Shaw. The method
may be divided into two parts: (l) The arranging and
fixing up of the apparatus required. The microtome
must be fixed on a firm table, and all the instruments
arranged in a convenient manner. A mental survey of
the cutting, mounting, and staining of a section is then
made, in order to make sure that everything is present
and in its proper place. This ensures that no time will
be wasted when once the process is begun. (2) Prepar-
ation of the microscopic section, (a) The selected piece
of tissue received from the surgeon is placed directly
on to the brass disk of an ether-freezing microtome,
and is surrounded by gum solution, (b) The tissue and
gum are frozen, and sections made by a razor on a
carrier, (c) The sections are transferred to a dish of
cold water, and, after separating them with a glass
rod, a suitable section is lifted out. (d) It is dipped for
a moment into pure methylated spirit, and (e) Then
placed in another larger dish of cold water; the cur-
rents set up by the spirit in the water cause the sec-
tion to spread out flat, (f) A glass slide is dipped in
the water under the section, and the latter is lifted out
as the slide is slowly drawn up out of the water again,
(g) The water is drained off the slide, and a drop or
two of stain (Lofi^er's methylene blue) is allowed to
fall directly onto the section. Oi) A thin cover-glass
placed on the stain and section after three to five sec-
onds; it is lightly pressed down so as to drive out e,x-
cess of stain; this is then blotted off, and the specimen
is ready for examination under the microscope.

Etiology and Prophylaxis of Dracontiasis. — R. T.

Leiper refers to a common ailment in West .\frica.
He believes that most of the cases are infected from
the water of village ponds through an organism \vhich
lives on the cyclops. The author began his experiments
by selecting cases of the disease in which the vesicle caused
by the inoculation by the fully developed parasite
was still whole or had recently burst. If a damp
compress was bound for a few hours over this
area it was found on removal to be smeared with
an almost solid mass of embryos. The details
of his experiments are too elaborate to he repro-
duced here. Leiper believes that the young must
be discharged directly into fresh water soon after the
parent worm has succeeded in creating a break in the
overlying skin and before the wound has become _ mark-
edly 'septic. The embryos must find a cyclops within a

244

MEDICAL RECORD.

[Feb 9, 1907

few daj's. They must, moreover, succeed in entering
its body cavity. Five weeks later they will have devel-
oped into mature larva.'. These must, thereafter, be
taken into the human stomach, and having been set
free from its host by the gastric juice, reach the con-
nective tissues by penetrating the gut wall. The life-
cycle of the parasite will necessarily be broken: (l)
By the death of the embryos, cither from sepsis while still
within the parent worm, or after their discharge, by
saltish water or drying. (2) If cyclops are not present
ni the water, or if the infected cyclops die or are not
taken into the human stomach. (3) If the larvje, in-
gested by the final host, are immature or fail to escape
from the chitinous sheath of the cyclops. Though they
do gain their final habitat, the cycle will still be incom-
plete if (4) there are not both males and females among
the matured adults, and if in their wanderings the
females are not impregnated. It will at once be seen
from the above summary that the isolation of infected
man from healthy cyclops and of infected cyclops from
man must be the object of any organized effort to
stamp out dracontiasis.

Berliner klinisclie U'oclicnsclirift. December 31 and Jan-
uary 14, 1907.

The Effect on the Rabbit's Aorta of Intravenous In-
jections of Suprarenal Extract. — Kaiserling states that
after considering the results published by the many
authors who liave experimented on tlie etiology of
arteriosclerosis by injecting suprarenal e.xtract into
rabbits, he was impelled to repeat the observations on
his own account. Although most of the workers have
reported the production of lesions more or less like
those of human aortic atheroma, there are many minor
differences in their published statements, but Kaiserling
was astonished to find that, in a series of eight rabbits
which he treated according to the recognized technique,
the results were practically negative as regards the pro-
duction of aortic lesions, even though in the one case
forty-four injections, amounting to 19.3 c.c. of I- 1,000
suprarenin hydrochloride were given in the space of
ninety-four days. He, therefore, assumes a skeptical
attitude toward the question, and expresses the opinion
that much larger series of results must be reported
before the etiological relationship between such injec-
tions and aortic disease in rabbits can be accepted. He
suggests that it is possible that rabbits are more subject
to spontaneous calcification of the aorta than is gen-
erally supposed, and describes a case of this sort which
he himself discovered by accident. It is also possible
that questions such as those of diet, of age. and of
breed may require consideration, and he recommends
that observations be made on large series of animals to
determine whether spontaneous aortic disease occurs,
whether other methods of raising the blood pressure
than the use of adrenalin evoke similar changes, how
other animals behave in this respect, etc.

Myasthenia Gravis Pseudoparalytica. — Sitsen says
that so far about thirty cases with autopsy of this disease
have been reported. The examination of the material has
been rather insufficiently described, he says, and he urges
that in future cases greater care should be used to record
all possible abnormalities. Of the cases tabulated by the
author the one type of lesion that appears most prominently
(in nine cases) is an involvement, in one way or another,
of the lymphatic system, and Sitsen suggests that in new
cases an endeavor to trace a relationship between lesions of
this system and the disease be made. In a case of his own
there were found small recent hemorrhages in the cerebral
cortex, lung, and liver, there was hematin-stained lymph in
the perivascular lymph spaces of the pons, there were accu-
mulations of leucocytes in the liver, there was slight en-
largement of the spleen, there was degeneration of the renal
tubules, a colloidal goiter, and an increase in the leucocytes
of the blood.

Miinchener medizinische IVocheiischrifi, January i and
8. 1907.

Methods for Reinforcing the Knee Jerk. — Rosenbach
reviews the various methods, such as Jendrassik's and
Kronig's. which are intended to facilitate the testing
of the knee jerks by diverting the attention of the
patient, and so eflfecting the desired rela.xation of the
lower extremities. Xone of these methods is altogether
satisfactory, and Rosenbach has found that the follow-
ing expedient is applicable to the greatest number of
cases. The patient is given either a book of consider-
able size, or a newspaper, and is told to read aloud.
The muscular effort required to hold the volume or
paper, and the mental attention involved in the reading,
produces the ideal conditions for obtaining the knee
jerk, and the method is applicable even to children who

are able only to name the letters. In some cases it is
difficult for the patient to cross the knees owing to some
physical cause, such as obesity, ankylosis, or uncon-
sciousness. For such cases the following expedient,
first suggested bv Guttmann. is recommended. With
the patient lying llat, a towel is passed under the calf of
the leg and the limb is raised a little from the bed by
this means. A second towel is then passed under the
ihigh a little above the knee, and the thigh is elevated
~<j that an obtuse angle is formed at the knee and the
entire limb is supported by the two towel loops. The
patient, if conscious, is directed to allow the leg to rest
with all its weight on the supnorting slings.

The Early Diagnosis of Pulmonary Tuberculosis. —

.Vrnsperger says that although the value of the jr-ray
as a means of determining the extent of advanced
tuberculous lesions and of observing their progress is
universally admitted, the method has not yet received
the recognition it deserves for the purpose of diagnosing
incipient cases. The normal radiographic picture of the
chest is much less subject to individual variations than
is the picture obtained from the physical signs, and
after a little experience has been gained the use of the
r-ray is found a most trustworthy adjuvant to the cus-
tomary diagnostic measures. The author discusses the
type of tube to be employed, and states that he attaches
great importance to the use of a properly constructed
diaphragm, which should preferably be of the iris
variety. He then describes the evidences of apical infil-
tration that may be discerned in the earliest stages, and
observes that he disagrees with those authors who have
found that restricted mobility of the diaphragm on the
affected side is a frequently encountered sign in incipi-
ent tuberculosis. He recommends the x-ray examina-
tion especially in selecting cases suitable for sana-
torium treatment, and points out other advantages that
should cause it to be more universally resorted to,
although he admits that during the early stages it
should be used only in conjunction with the customary
methods of diagnosis. In another article on the same
subject by Pforringer and Bunz, the use of the rays is
also well spoken of, and, like .\rnsperger, these authors
state that they do not attach very much importance
to lagging of the diaphragm as an early symptom. The
chief value of the radiographic method seems to lie in
the ability by its means to confirm the correctness of a
diagnosis made in other ways.

The Treatment of Gastric and Intestinal Hem-
orrhages with Fluid Gelatin. — Mann reports excellent
results in tlic treatnioiu of this condition by the interna!
administration of a preparation of fluid gelatin. The his-
tories of nine cases are briefly abstracted to show the
prompt effect of the remedy in such conditions as typhoid
fever, gastric carcinoma, ulcer of the stomach, and melena.
In none of tliese cases was any other medication resorted
to except the gelatin treatment, yet prompt cessation of
the bleeding followed in all except one case, which was
an unusually severe typhoid infection. In this instance the
autopsy revealed the presence of extremely numerous and
deep ulcers, so that it would have been rather too much to
expect any remedy to effect a cure. The formula for the
gelatin mixture is as follows: 20 g. of gelatin is boiled
during six hours with enough water to make 180 c.c. It
then remains fluid and 2 g. of citric acid is added. It may
be flavored with a little syrup of orange and is given in
doses of one or two tablespoonfuls every two hours.

The Presence of Diphtheria Toxin in the Blood of
Patients. — Fraenkel says that UfTenheimer has stated
that on injecting serum obtained from children sufltering
from diphtheria into guinea pigs he obtained lesions in the
animals, such as edema of the skin over the thora.x and
■ibdomen and pronounced hemorrhagic lesions, which ap-
peared to indicate that free toxin was present in the blood
of these patients and that therefore this toxin should be
neutralized as promptly as possible by the injection of anti-
toxin. Fraenkel repeated these experiments with blood
obtained from twenty-three cases of the disease, but on
making a post mortem examination of the animals, which
were killed forty-eight hours after the injection, he was
unable to discover in any except one alterations tliat could
be ascribed to the introduction of diphtheria toxin. In
the case of the one animal that did not give a wholly nega-
tive result Fraenkel believes that the reddening and swell-
ing of the abdominal skin produced was an accident due
to the possible puncture of a larger blood-vessel by the in-
jection needle. The author does not attempt to explain
the discrepancy between his results and those of Uffen-
heimer, but affirms his conviction that the circulating blood
in cases of diphtheria does not contain sufficient toxin to be
demonstrable on the injection of small amounts of serum
(about I c.c.) into guinea pigs.

ly^/J

i>ii_ii^i\_jn.j-^

l\ll,y^\^ l\LJ,

-45

Snok ilUtrtrmfl.

A Syllabus of Materia Medica. Compiled by Warren
Coleman, M.D., Professor of Clinical Medicine and In-
structor in Materia Medica and Therapeutics in Cornell
University Medical College ; Assistant Visiting Physician
to Bellevue Hospital. Third Edition, Revised to Con-
form to the Eighth Decennial Revision of the U. S.
Pharmacopceia. New York : William Wood & Co., 1906.
This edition has been revised to bring it into agreement
with the late revision of the U. S. P. At the same time
the requirements of the various State Boards of Exain-
iners throughout the country have made it necessary to
include all the official preparations. Most of the unofficial
drugs have been omitted. The book is a useful compilation
and will prove a serviceable companion to any textbook on
materia medica.

Retinoscopy (or Shadow Test) in the Determination of
Refraction at one Meter Distance, with the Plane
Mirror. By James Thorington, A.M., M.D., Author
of "Refraction and How to Refract"; Professor of Dis-
eases of the Eye in the Philadelphia Polyclinic and Col-
lege for Graduates in Medicine ; Ophthalmologist to the
Ehvyn and Vineland Training School for Feeble-Minded
Oiildren. Fifth Edition, Revised and Enlarged. Fifty-
four Illustrations, Ten of Which are Colored. Phila-
delphia : P. Blakiston's Son & Co., 1906.

This valuable work now appears in its fifth edition,
thoroughly revised. The author has carefully described
this method of objective examination of the eye in as brief
and concise a manner as possible. The source of light and
the most favorable surroundings and conditions for the
examination are discussed. The various appliances neces-
sary are mentioned and the phenomena observed are eluci-
dated. A sufficiently comprehensive index accompanies the
work. The volume, which contains only sixty-seven pages,
can be studied with profit by any medical man who wishes
to obtain quickly a working knowledge of retinoscopy.
International Clinics. A Quarterly of Illustrated Clini-
cal Lectures and Especiallv Prepared Original Articles.
Edited by A. O. J. Kelly, A.M., M.D., Philadelphia,
U. S. A. Vol. Ill, Sixteenth Series, 1906. Philadelphia:
J. B. Lippincott Company, 1906.
The third volume of this year's issue of "Tnternational
Clinics" contains much that is interesting and valuable.
Among the most important articles is that of Bradford of
Boston on the Hyperemia Treatment of Swollen Joints,
an excellent resume of the subject, illustrated with photo-
graph? of cases, apparatus, etc. Saingery's review of Four-
nier's recent modifications in the treatment of syphilis is
also of especial interest, as it discusses a subject which
has come up recently with renewed force, the question as
to the proper means of preventing such sequels as loco-
motor ataxia, etc. The other three articles on medical
treatment — by Stevens of Philadelphia on Acute Pleurisy,
by Patton of Chicago on Bronchitis, by K.Ttzenbach of New
York on Cardiac Dilatation — are full of practical points
attractively presented. .A.n article of exceptional interest
is that of Pirie of Edinburgh on "Life in the Antarctic from
a Medical Point of View," the author having taken part
in the Scottish Antarctic Expedition of 1902-1904. The
article on Leukemia and Sarcomatosis by Banti of the
"University" of Florence (the Institute for the Advance-
ment of Science of Florence is probably meant) discusses
the probable nature of the leukemias which, according to
the famous Italian clinician, are infectious sarcomatoses,
though he has not been able to find their specific agent.
Aids to Obstetrics. By Samuel Nall, B.A., M.B., D.P.H.
Cantab., M.R.C.S. England, etc. Sixth Edition. New
York : William Wood & Co., 1906.
There is probably no subject for which a compend is less
needed than obstetrics. Still, if a student feels that he
requires a help in preparing for examination he will find
this little book of service. In the present edition a few
minor alterations and additions have been made, otherwise
the book remains unchanged.

L'Autointoxication Intestinale. . Par le Dr. A. Combf,,
Professeur a I'LTniversite de Lausanne. Paris : J.-B.
Bailliere et Fils, 1906.
Dr. Combe has written an exceedingly practical, at the same
time a highly scientific, book on autointoxication from the
intestine. A lecturer on diseases of children, he has taken
up within the past few years the study of intestinal diseases
in a large number of adults, whom he saw in private
practice. In the course of this study he has developed
certain original methods of diagnosis and treatment, and
has paid much attention to diet. While he acknowledges
his indebtedness to Strauss, Albu, von Jaksch, and others,
his work has been carried on independently and his results
are carefully recorded. The chemistry, bacteriology, etiol-

ogy, pathology, and diagnosis of intestinal autointoxication
form the first part of the book, while the rest is taken up
by a detailed study of the treatment of this condition. In
the chapters on diagnosis will be found all the modern
methods of studying the various autointoxications through"
the medium of the urine, including several methods original
with Amann and Combe himself. Under the heading of
Treatment the author presents an admirably written, prac-
tical, and systematic study of all the measures that may
be useful in combating intestinal autointoxication. Full
and explicit directions are given for each therapeutic
method, and detailed menus and dietaries are introduced,
making the handling of this class of cases plain sailing for
the practitioner. Even the modes of preparing and cooking
certain foods are described, and among other articles Combe
recommends a number of popular American "breakfast
foods." Space will not permit to enter further into details,
but we can strongly recommend this latest book on auto-
intoxication to physicians who are progressive enough to
study their cases and to apply modern dietetic and hygienic
measures in the treatment of disease.

The Practical Medicine Series. Comprising Ten Volumes
on the Year's Progress in Medicine and Surgery. Under
the General Editorial Oiarge of Gustavus P. Head,
M.D. Volume VII. Pediatrics. Edited by Isaac A.
Abt, M.D., Assistant Professor of Medicine (Pediatric
Department), Rush Medical College. Orthopedic Sur-
gery. Edited by John Ridlon, A.M., M.D., Professor of
Orthopedic Surgery, Northwestern University Medical
School, with the Collaboration of Gilbert L. Bailey,
M.D., Instructor of Orthopedic Surgery, College of Phy-
sicians and Surgeons. Series 1906. (Chicago: The Year
Book Publishers, 1906.
The seventh volume of this popular series of year books
continues the series of 1906, the previous volumes of which
have been noticed in this column. It deals with two closely
allied special branches, pediatrics and orthopedics, and is
a concise epitome of progress in both these fields. The
general method of treating the subject is the same as in
the other volume, and the book is replete with useful and
practical data and summarizes the work done during the
past year. Nothing very startlingly new has developed in
the field covered by this volume in the year 1905, but the
book records the slow and painstaking trend of research
along various lines which may lead to much that will be
of value.

Guide Pratique Pour le Choix des Lunettes. Par le
Dr. A. Trousseau, Medecin de la Clinique Nationale des
Quinze-Vingts; Medecin en Chef de la fondation ophtal-
mologique Adolphe de Rothschild. Deuxieme Edition

The author of this little work, which appears in a second
edition, endeavors to give the essentials of the knowledge
required for the satisfactory fitting of glasses in the simplest
way and in the fewest words possible. The information is
contained in one hundred 4x6 pages. The indications for
the use of glasses in youth, adult life, and old age are
first set forth. The quality of frames and lenses required
IS mentioned. Forms of refractive errors are then de-
scribed. Subjective and objective methods of examining
the eyes are explained. Then follow short chapters on
hypermetropia, presbyopia, aphakia, myopia, astigmatism,
anisometropia, and the visual requirements for military
service. A short index concludes the work.
The Masters of Fate. The Power of the Will. By

Sophia P. Shaler. New York: Duffield and Company,

1906.
It is always inspiring to read of the achievements of those
who have done great things, but it is doubly so when the
doers were handicapped by the greatest of all obstacles— ill
health or bodily infirmity. Mrs. Shaler presents in charm-
ingly written narrative more or less extensive accounts of
the struggles against physical ills of a very large number
of those who have contributed to the world's progress —
and it is astonishing to realize how much of it has been
due to the toil of those who had every excuse to remain
mere onlookers. The list of illustrious invalids is indeed a
long one, and incltides many names which to the ordinary
re;ider do not connote the idea of chronic illness or disa-
bility. The difficulties under which Milton, Heine, Steven-
son. Mrs. Browning, Darwin, and many others labored are
well known, but Mrs. Shaler reminds us that Alfred the
Great. Kant, Pasteur, James Watt, Nelson, and Parkman
were but a few of the many, much of whose work was done
under conditions that the avera.ge mortal would consider
prohibitive. A sympathetic interest ;ittachcs to the author's
desire to place on record the adversities that have beset so
many great men, for her husband, the late Prof. Nathaniel
S. Shaler, was the victim of a long series of physical bur-
dens that, in view of all that he accomplished in his profes-
sion, renders him well worthv of high rank among the
"Masters of Fate."

240

MEDICAL RECORD.

[Feb 9, 1907

^orMy l^linrta.

NEW YORI-', ACADEMY OF MEDICINE.

Stated Meeting. Held January 17, 1907.

The President, Dr. Joh.v A. Wveth, in the Chair.

The evening was devoted to a consideration of "Open-Air
Therapeutics."

Open-Air (Roof) Wards on Metropolitan Hospital;
Details of Arrangement and Administration; Class oi
Cases to be Treated. — Dr. \V. P. Northrui> read this
paper and presented ilhistrations. He said that the open-air
treatment had come to stay, and the managers of hospitals,
the medical staff, the nnrsing staff, the professional staff,
and staffs in general were now using it systematically.
After one year's observation of the out-door treatment at
the Presbyterian Hospital the results had been so good that
they were now building on the roof a structure which was
to cost $15,000, and this, too, in an unendowed hospital.
This showed that the systematic open-air treatment of pa-
tients was of value and had come to stay. Dr. Northrup
then gave the details in part of the structure and manage-
ment of the hospital. The medical pavilion of the Presby-
terian Hospital was demonstrated on the blackboard, and
the old solarium was shown, being the dead end of a long
shaft that ventilated the cellar. Conditions were now
changed. Concrete or cement, four inches in thickness, had
been placed on the roof, and over this boards or flooring.
The structure that was raised upon this was of steel
throughout. He closed his remarks by giving a few rules
for the management of this structure on the roof.

Open-Air Treatment of Septicemia in Lying-in Hos-
pitals.— Dr. William S. Stone read this paper. During
the period Dr. Stone was connected with the New York
Lying-in Hospital he had daily opportunity of observing
the course of severe puerperal septicemias treated in the
glass-covered solarium as compared to the course of the
disease in the closed wards, and he gave a few general con-
clusions based on his own observations. From the patient's
point of view it was surprisingly satisfactory. The rest-
lessness and delirium were less frequent and less marked.
To the casual and untrained observer the sight of these
patients on the roof under their green-lined sunshades
might suggest a number of well-to-do convalescents enjoy-
ing the advantages of a southern climate, rather than tene-
ment dwellers filled with unnumbered streptococci striving
to destroy their host. Like typhoid fever, puerperal septi-
cemia was accompanied by high fever, whether treated in
the open air or in the closed ward, but in some cases the
duration of the fever seemed to be shortened, and in all
cases was better borne as expressed by the pulse and tem-
perature. Pneumonia appeared to be less common and
more transitory when it did occur. One of the strongest
impressions made upon Dr. Stone w-as the difference in the
general appearance and strength of the patients soon after
the disease had run its course. Some cases got well, about
which even the most sanguine observer would ordinarily
only express a hopeless prognosis. The general conclusion
tliat the reader of the paper drew from these observ-ations
was that any lying-in hospital that failed to provide suit-
able accommodations for the open-air treatment of child-bed
fever was lacking in one of the most important means for
promoting the comfort and the saving of lives that were
intrusted to their care.

Fresh-Air Treatment in Hospital Wards. — Dr. W.
Oilman Thompson read this paper. (See page 213").

Open-Air Treatment in Psychiatry. — Dr. Wm. Ma-
BON. superintendent Manhattan State Hospital, Ward's
Island, read this paper. Li June, 1901, the late Dr. A. E.
Macdonald introduced tent life for the care and treatment
of the tuberculous insane at Ward's Island, and three years
ago the late Dr. Emmet C. Dent inaugurated the open-air
treatment tor the acute insane. The camps now used for

the acute insane were situated on high, dry ground, which
sloped gently toward the waters of Hell Gate, giving a
southern exposure and an ocean breeze. The rush of water
through Hell Gate and the passing of vessels of navigation
through the channel made a scene varied and picturesque,
relieving the mind of ennui of many otherwise tedious and
wearisome days. The average period of residence in camp
life for each acute case was about three months, so that in
a year the present capacity accommodated 400 patients, or
about 50 per cent, of the entire number of admissions for
women. Drawing from the poorer classes of people in the
crowded districts of Manhattan Island, stress and strain
with physical disability must of necessity enter very largely
nito the etiology of a large proportion of their acute and
recoverable cases. In the 150 cases treated in two of their
camps, examination upon entrance showed the hemoglobin
to be as high as 95 per cent., as low as 55 per cent. — an
average of 70 per cent. In addition to the hemoglobin
reduction, the other evidences of marked physical break-
down were constant reduction in weight and evidences of
decided disturbances of the gastrointestinal tract. Sleep
was insufficient, and delirious states were very frequent.
The indications for treatment in these cases were usuall5
clear, and the camp life met the situation better than any-
thing yet tried. He gave abstracts of a few cases to
iUustrate the results of this method of treatment. Gain in
weight was most pronounced. The percentages of the vari-
ous forms of insanities under treatment in the two camps
connected with the reception service were : manic de-
pressive or exhaustive types, 40 per cent. ; dementia praeco.x,
where the general health demanded individual attention, 30
per cent., and the alcoholic, hysterical, depressive, and
anxiety types, 30 per cent. Among the admissions were a
comparatively large number of the e.xhaustive type occur-
ring during the puerperium, and the majority of them did
extremely well under the method of treatment. The most
marked improvement under camp treatment occurred in
the infective and e.xhaustive groups, the manic depressive
cases, and the undifferentiated depressions. Cases of
marked deterioration following overstrain were oftentimes
much improved by camp life. After the patients had been
under treatment sufficiently long to improve the general
health, it was noticed that in the recoverable cases the
insanity was either well on toward recovery, or they were
in a position to accurately make a prognosis. In the group
of cases where exhaustion was the main etiological factor
there was no more important restorative than the reestab-
lishment of the proper amount of sleep. Under treatment
in the camp, the constant exposure to fresh air and sun-
light very frequently brought about a more normal condi-
tion. It was emphasized that no drugs were used to relieve
the insomnia. The hot pack and the continuous bath, in
connection with the open-air treatment, were far more
efficacious, trustworthj-, and desirable. Aside from the
hygienic advantages from these camps, the moral effect
upon the insane had considerable influence toward their
recovery. The freedom from restraint of bars and locked
doors was appreciated to such an extent that vacancies in
the camp brought a premium among the more intelligent
class of patients, and it was to be wondered at when
■'scarcely more than a score of years ago our asylums were
still prison-like structures, gloomy without and gloomy
within. With few exceptions, the walls were guiltless of
ornamentation, and the barred windows and locked door,
the crib bed, the massive furniture fastened to the floor,
and the dozen or more inhuman devices for mechanical
restraint, made up a picture well calculated to strike terror
into the heart of the newcomer and to fill with despair the
unhappy victim of prolonged incarceration." Dr. Mabon
closed his paper by stating that the experience of the Man-
hattan State Hospital for the past five years showed con-
clusively that the open-air treatment was particularly bene-
ficial for the following classes of the insane: (l") the
tuberculous: (2) the feeble and untjdy: (3^ the retarded

y, lyiJ/j

iviiZ/Un^riL Jt^xl^^WI\iJ.

247

convalescent; (4) the acute insane, in whom the psychosis
was associated with aneinic blood states, dehrium, and
loss of sleep.

Dr. Alfred Meyer said that some might be present who
attended a meeting held in the Academy a few years ago
when the subject of tuberculosis and its treatment was
considered; at this meeting Mr. Dcvine stated that he
heard for many months the need of educating the masses
regarding the transmission of tuberculosis through the
sputa, but, after a certain experience of his in Albany, he
thought it would be wise first to educate the medical pro-
fession. This same, he thought, could be applied to the
subject now before them, fresh air and sunlight. Even in
the section rooms, if one of the doctors opened the window,
he was liable to be called a fresh-air fiend or crank. Dr.
Northrup was doing educational work where it was at
present most needed — among the medical profession. Theo-
retically, all agreed with it; as a rule, it seemed to Dr.
Meyer, they had adopted it in theory, but had not applied it
in practice. The question of overheating was related to
this subject; it seemed to be a national defect to overheat,
particularly in the winter time and in places of public
amusement. There seemed to be. as well, a prevailing
dread of rain and snows. Dr. Meyer believed there was
less danger from rain and snow than when the sun was
shining, with the dust flying in the eyes, mouth, throat,
and perhaps the lungs. If a child had diphtheria he should
be covered with blankets and have plenty of fresh air; it
was not necessary to have draughts in the room where the
child was lying, but plenty of good, fresh air should be
allowed the patient. This same could be applied to cases
of neurasthenia and convalescence from scarlet fever. .\
bed-ridden case of sciatica, and other chronic diseases,
should be treated by placing near the open window. Sur-
gical diseases should be more frequently treated by this
method, and he referred to Dr. Halsted's cases of tubercu-
lous joints treated in the outside air. There was great
difficulty experienced in supplying the proper amount of
fresh air in hospital wards. A larger number of patients
would be benefited by a free change of air compared to
those which might possibly be injured. He quoted Mr.
Dooley's statement, which was quite apropos of this sub-
ject: "If the doctors would open fewer bellies and more
windows there might he a fewer number of Christian
Scientists." He called attention to the results obtained by
the out-door life at Flick's sanatorium at White Haven,
Pennsylvania, at the State Sanatorium in the Adirondacks.
at Bedford, Massachusetts, and other places. He also
called attention to the building of piazzas in country homes
and to the utilization of fire escapes ia the crowded cities,
and how to treat these patients on the roof of their own
houses in the fashionable parts of the city.

Dr. D.'WID Bov.MRD, Jr., said that emphasis should be
placed on the fact that not only fresh, but cold air was
necessary. The value of cold air and fresh air had been
brought home to him in dealing with children suffering
from diarrheal diseases. Children suffering from severe
ileocolitis, if they could be kept alive until the beginning of
October, could almost be guaranteed a recovery, and this
was due to the change in the temperature of the air during
the fall months ; this tended to give these children appe-
tites, improved their digestion, and enabled tliem to gain
upon the disease. This autumn he had occasion to note the
changes that occurred in the Presbyterian Hospital. .A.t
the end of the sunmier there were many poor, anemic,
wasted children as the result of various diarrheal diseases ;
their lives seemed to hang by a thread. But witli the ad-
vent of autumn, the appetites became good, digestion im-
proved, they slept better, and the contrast was very marked,
all due to the change in the temperature from the summer
to the fall months. Fresh air and cold air were agents of
great therapeutic value, but should not be used universally.
The change in ventilation had done away with so-called
hospitalism. A few years ago if a child was kept in the

hospital four or five weeks he became flabby and became
the subject of hospitalism. To-day the best-looking child,
on the other hand, was the one who was the oldest inhabi-
tant of the hospital by reason of the change in matters of
ventilation.

Dr. Henry Piff.-\rd said that because they required a
minimum of sunshine in summer, and a maximum of sun-
shine in winter, the exposure of solaria for tuberculous and
other patients should not be directly East and West, as Dr.
Northrup had demonstrated on the board. He referred to
the epidemic of typhus fever some years ago, when he was
an interne at Bellevue Hospital. The wards became so
crowded that the island was utilized for the overflow, and
they were there placed in tents. The result was that
the mortality was less by one-half than it was in the
hospital wards. He also recalled some recent visits made
to places near New York City where the patients went
"back to Nature," going about perfectly nude, etc.

Dr. Robert J. Wilson said that they had been forced to
treat 400 cases of scarlet fever, bronchopneumonia, and
measles between April and (3ctobcr in the open air, and
these cases did far better than those within the closed
wards.

Dr. Louis Livingston Se.\m.^n called attention to the
fact that all over the tropics, in the Arabic cities, the out-
door system of treatment of diseased conditions had been in
vogue, even before the days of the Romans. This was
also in vogue in the days of Solomon, and in Jerusalem.

Dr. John H. Huddleston referred to the epidemic of
typhus in iSgj in this city, when so many of the cases
were treated on Blackwell's Island. i\Iany were placed in
tents, and they all did exceedingly well. None of the order-
lies, the nurses, or visiting physicians suffered from the
disease. There were some disadvantages and risks attached
to this treatment which should not be lost sight of. For
instance, it had been his misfortune to see two bad results ;
two children had been placed on the balcony during con-
valescent pneumonia, and in both sunstroke developed as a
result of the exposure.

Dr. William P. Northrup called attention to what edu-
cation would do, there being so little spitting in this city
to-day compared to what there was when this was first
brought up in the New York Academy of Medicine. The
education of the laity to him appeared to be easier than the
education of the medical profession.

MEDICAL SOCIETY OF THE COUNTY OF NEW
YORK.

Stated Meeting, Held December 28, 1906.

First Vice-President, Dr. H. Seymour Houghton, in
the CiI-MR.

Notes on the Urine in Early Life. — Dr. Henry Dwight

Ch.^pin read this paper. He first presented and described
a urinal which enabled one to collect the urine of male
and female babies. He also showed a photograph of the
urinal in position. He said he had hoped to be able to
collect the full twenty-four-hour amount of urine in babies
for the purpose of studying questions relating to metabo-
lism ; he was unable to do this because of slight unavoid-
able leakage in the apparatus. Heretofore the urine of
babies had not been studied in a routine way. Dr. Chapin
said that the kidneys functionated before birth, and that
the kidneys were relatively of larger size and more lobu-
lated than in older life. The kidneys of infants passed a
relatively larger amount of urine than adults, and the quan-
tity and composition changed but little. The consensus of
opinion was that during the first few days of extrauterine
life the infant excreted from one to two ounces a day, and
then the quantity increased in amount, as Dr. Chapin
showed with figures. The specific gravity was low, aver-
aging 1003 to 1004 during the first few days because urea
and salts were not found; the specific gravity was not apt

248

MEDICAL RECORD.

[Feb 9, 1907

to rise to l.oio until after the tenth year. Uric acid crystals
might form concretions in the pelvis of the kidney. In
proportion to body weight there was less urea in infant's
urine than in the child's urine. Infant's urine was neutral,
or faintly acid. The question of the presence of pathologi-
cal ingredients was interesting. Some stated that traces
of albumin and hyaline casts in the urine in the early days
of life were without significance. .\ slight glycosuria in
the early months of life had been reported, especially when
sugar was given so freely in the food. When there was
gastrointestinal irritation indican was found. All knew of
the rapid metabolism and the vulnerability of the kidneys.
As the result of investigations carried on in the babies'
wards of the Post-Graduate Hospital, Dr. Chapin gave
the following figures : In a scries of 86 cases in which
there was some disturbance of the gastrointestinal tract,
such as indigestion, fermentative diarrhea, catarrhal in-
flammations, and marasmus, albumin was found in 75 ;
casts were present in 37 ; of the 16 deaths in this series 14
had albumin and 10 had both albumin and casts ; in 32
cases examined for indican, it was found present in 22. In
a series of 75 cases of pulmonary disease, such as severe
bronchitis, pleurisy, and pneumonia, albumin was found in
49; casts in 32; of the 17 deaths, 15 had albumin and ID
both albumen and casts; of 23 cases in which an exami-
nation was made for indican, it was found to be present in
16. In a series of 45 cases of general illness other than
mentioned above, albumin was found in 31. In 11 cases
of cerebrospinal meningitis, heavy traces of albumin and
casts were noted in 9. In a number of cases of cerebro-
spinal meningitis with coma, where an effort was made to
collect the twenty-four hours urine, there was a slight vari-
ance between 1.7 per cent, and 2.7 per cent. Dr. Chapin
asked what significance could be placed to this. Did it
really mean that there was actual renal disease present?
Or was there somt irritation of the renal tubules? From
the cases reported he rather favored the latter view. He
concluded his paper by saying that infant's urine could
contain traces of albumin and casts without grave results.
The Significance of Albumin and Casts in the Urine
of Children. — Dr. Frederic E. Soxdern read this paper
He said that in children, even more so than in adults, the
occurrence of albumin in the urine, alone or associated
with casts, was not the absolute indication of a nephritis
once believed, as we knew that its presence did not neces-
sarily indicate an inflammatory lesion of the kidney. The
occurrence of a so-called physiological albuminuria was
open to question. On the other hand, not only an inflam-
mation of the renal parenchjmia in its broadest sense, but
also comparatively slight disturbances in circulation, in
innervation, or in the quality of blood offered the kidney
for the exercise of its function, occasioned the passage of
smaller or larger amounts of albumin in the urine, with or
without casts. The amount of albumin and the number
of casts, while possibly significant at times in estimating
the acuteness in a given case of nephritis when comparing
repeated examinations, were no guide to the severity of
the lesion in general. Modern research had demonstrated
that a knowledge of the daily excretion of solids or of
urea was not an accurate basis for an opinion on the sever-
ity of the renal lesion. It was well to keep in mind the
normal urea excretion figures: Qiildren 3 to 6 years, 1
gram per kilo body weight; 8 to 11 years. 0.7 gram per kilo
body weight; 13 to 16 years. 0.3-0.5 gram per kilo body
weight. The changes in a given case on the same diet should
be noted. Kreidl and Mandl concluded that under normal
conditions the fetus excreted no urine, but on impairment
of the excretory ability of the mother the fetus made
effort? to clear the blood by renal action. The class of
cases in which the albuminuria, with or without casts, was
due to functional and not inflammatorj- renal disorder
formed an interesting subject for consideration. While
the excretion of albumin seemed to be directly due to
changes in the circulation, in the innen'ation. or in the

composition of the blood offered the kidney for the exer-
cise of its function, without appreciable kidney lesion, it
seemed a misnomer to call this physiological albuminuria,
as in the majority of the instances there was a fault else-
where if not in the kidney, and the term functional albu-
minuria, as distinguished from albuminuria of nephritis,
would seem more appropriate. In the differentiation be-
tween functional and nephritic albuminuria the mere con-
sideration of albumin and casts was not sufficient. The
albuminuria, with or without casts, associated with the dif-
ferent types of anemia without circulatory disturbances
and due to the changed condition of the blood only, or to a
possible toxin, was often most confusing. The demon-
stration that acute autointoxication, intestinal toxemia, or
faulty metabolism was not only the cause of a distinct train
of symptoms and frequently explained "otherwise obscure
manifestations, but was also the direct instigation of a
long-continued functional albuminuria, with or without
casts, often difficult to differentiate from a true nephritis,
was a recognized fact. When it was recalled with what
facility disturbances of the gastrointestinal tract were occa-
sioned in the young, and mindful of the fact that intestinal
toxemia was particularly prone to cause complicating dis-
orders in them, the necessity for early diagnosis of this
condition was evident. The laboratory aid in the detec-
tion of intestinal toxemia was important. Albuminuria
implied the presence of serum albumin in the urine, and
the occurrence of other albumins should not be called by
the same name to avoid confusion.

The Urine in Some of the Specific Infectious Diseases.
— Dr. Flovi) M. Cr-^ndall read this paper. The frequency
or severity of kidney complications were not in proportion
to the gravity of the infection. Such complications, while
rare in chickenpox, German measles, whooping-cough, and
mumps, were equally rare in measles and smallpox. The
frequency of nephritis in diphtheria and scarlet fever must
be due to some particular quality in the to.xins, and not
to the fact that they were among the more severe of the
infectious diseases. In parotitis, pertussis, varicella, and
rubella albuminuria was not infrequent in the more severe
cases. The late occurrence of nephritis was peculiar to all
the infectious diseases. His own experience would show-
that nephritis and albuminuria were less common in Ger-
man measles than in mumps, whooping-cough, or chicken-
pox. .\lbumin and a few hyaline casts might occasionally
be found in these diseases, but nephritis was rare. In
practice it should not be forgotten, however, that in the
more serious cases nephritis of grave type was possible,
and might prove a serious complication. In measles
nephritis was extremely rare, either as a complication or a
sequel. In smallpox it was agreed that albumin might be
found in a considerable proportion of the confluent cases,
but a true nephritis was exceedingly rare. In diphtheria
albumin appeared in the majority of the cases, even the
mildest, and it could be said that it always appeared in the
severe cases. Diphtheria was sometimes ushered in with
complete suppression of urine. The nephritis of diph-
theria, unlike that of scarlet fever, was rarely marked
by edema or general dropsy, and the classical symptoms
of uremia were far less common than in scarlet fever.
During the febrile stage of scarlet fever traces of albumin
were found in all of the more severe cases, and frequently
hyaline casts. This was a febrile albuminuria, due to de-
generative nephritis, and subsided as the temperature fell.
It was not .accompanied by dropsy or by suppression. A
true kidney complication might occur during the first stage ;
in grave, septic cases of scarlet fever the urinary findings
of the first few days should not be disregarded. The most
characteristic and common kidney lesion in scarlet fever
was post-scarlatinal nephritis, which was a true diffuse
nephritis, and developed most frequently during the third
week, but often occurred in the fourth, and was some-
times delayed until the sixth week. The first symptom to
be noticed was edema of the face, which was usually

Feb. 9,' 1907]

MEDICAL RECORD.

249

accompanied by feverishness and restlessness. Dropsy
and all the characteristics of acute nephritis rapidly devel-
oped. The faintest appearance of albumin after the sec-
ond week of scarlet fever should be a vi'arning of danger.
Daily examination of the urine was very important. He
was convinced that there was much truth in the state-
ment that one could do more to prevent the occurrence
of nephritis by care and proper diet than by any other
means at command. Dr. Crandall always kept scarlet
fever patients in bed for twenty days, no matter how mild
the attack, and did not sanction leaving the bed for at
least a week after the fever had subsided. Patients who
had developed nephritis should not only be kept under
observation until every symptom had disappeared, but for
several years thereafter they should receive special care
as regarded diet, clothing, exercise, and the urine should be
occasionally e.xamined. In closing, he said that even in
the mildest infectious disease the occurrence of septic con-
ditions of any kind should be a warning sign and the kid-
neys should be watched with special care.

The Urine of Pregnancy. — Dr. J. Clifton Edgar
asked, what did the study of the urine of pregnancy offer?
Had it any decided value? He believed that such a study
had a certain diagnostic value, and that such study pointed
the way to the prognosis and treatment. During preg-
nancy urinalysis enabled one to determine that the urine
was nontoxic in character; that a given case of persistent
vomiting was toxemic in character ; that a patient was in
the preeclamptic state of the toxemic or nephritic variety;
that a given eclampsia was nephritic or toxemic ; and,
finally, that after delivery it was possible to forecast the
tardy or prompt recovery from a toxemia or nephritic con-
dition. Possibly, moreover, urinalysis enabled one to de-
termine the presence of a complex disturbance or tox-
emia, namely, where the symptoms of toxemia due to
faulty metabolism and those due to nephritis were com-
bined. Nine months ago he presented to the Society a
paper on "Clinical Manifestations of the Toxemia of
Pregnancy" (see Medical Record, Vol. LXIX, page 809),
a study of 62 complete urinalyses on 24 patients. To-day
he could add to this number, making 86 in all, and his con-
clusions to-day, while somewhat modified, were practically
those of nine months ago. Normal pregnancy urine should
not be persistently small in quantity, the urea output should
not be persistently low, and it should not contain albumin,
casts, or excessive quantities of indican. Moreover, the
total nitrogen should be represented by proper proportions
of the nitrogen compounds. The presence of serum albu-
min, especially when accompanied by casts, had a greater
significance for him in the pregnant than in the nonpreg-
nant state. The belittling of the importance of albumin
and casts in the urine of pregnant women had cost many
valuable lives. They had two, possibly threefold signifi-
cance, (i) They might be the only diagnostic sign of the
presence of a defective kidney condition, a chronic or an
incipient nephritis, a danger signal that the preeclamptic
state was already upon them, or that eclampsia was already
imminent. (2) They might be the result of a pregnancy
toxemia, as indicated by a faulty urinary excretion of
nitrogen; the nephritic condition appeared to be the result,
and not the cause of the toxemia. (3) Possibly large
quantities of indican in the urine might result in nephritic
changes and the appearance of albumin and casts ; the
nephritic condition might be the result, and not the cause
of the intestinal intoxication. His observations did not
lead him to attach much importance to the presence of an
acid or an intestinal intoxication as causative factors in
the production of pernicious vomiting or coma. Another
urinary sign of diagnostic value was the relation of the
nitrogen of the nitrogenous compounds in the urine to the
total nitrogen. The persistent vomiting of pregnancy was
with few, if any, exceptions toxemic in character, as shown
by faulty urinary excretion of nitrogen. Clinically, he dis-
tinguished two varieties of preeclamptic states, one largely

toxic in character, the other nephritic. liuher of these
might result in eclampsia with nothing clinically to distin-
guish them, except that the nephritic yielded more readily
to treatment and gave a better prognosis.

Dr. Harlow Brooks confessed that, like many others,
he knew very little regarding the urine in children and
infants, and then called attention to the discrepancies in
the findings of albumin in the urine. One should not make
a diagnosis of renal disease simply because of the presence
of albumin in the urine; and, too, the total absence of
urinary findings should not exclude the presence of serious
renal disease. At autopsy many cases had been noted of
marked renal disease which gave no evidences during life.
He had seen several such cases, even where the urine had
been carefully examined day after day, failing to find
anything abnormal, yet the patient died from renal dis-
ease. While all recognized the enormous value of urinary
examinations, and the significance of certain foreign bodies
in the urine, one should not forget that the absence of
'abnormalities in the urine did not exclude the possibility
of the presence of serious renal disease.

Dr. Henry Koplik said that it was a fact that general
practitioners examined the urine more carefully and more
frequently than they did formerly. As his diligence
increased, so did his responsibility towards his patients;
the public expected more from him than the mere report of
the presence or absence of albumin and casts. It was
undoubtedly true that grave insults to the kidneys could
be recovered from with marvelous celerity. Again, all had
met with cases in which a nephritis developed quietly, and
still no severe etiological factor could be determined. One
cannot always trace the peculiar infectious element in the
case. Dr. Crandall had sounded a warning in regard to
cases following infectious diseases, especially scarlet fever.
Leaving scarlet fever out of the question, there was no
doubt but that sometimes a perfectly normal kidney would
not respond and recover from repeated insults ; appar-
ently slight infectious cases might develop a nephritis later
in life. When one found albumin and casts in the urine
of children and infants, even in those cases that clear up,
every opportunity should be given for observation ; one
should never forget to examine the urine repeatedly in
these cases to learn if they have made a permanent re-
covery. Dr. Sondern had called attention to a form of
albuminuria occurring in childhood, and he was candid
enough to say that sometimes it was impossible to say
whether there was a nephritis present or not. These were
the cases that should never be lost sight of. He did not
think they should be too optimistic in this matter, yet
they should by no means overestimate importance of the
occasional appearance of albumin and casts temporarily
appearing in infectious or intestinal into.xications.

Dr. Frederic E. Sondern. discussing Dr. Edgar's paper
on the urine in pregnane}', said that the great trouble
encountered in doing a complete nitrogen partition test
was the immense amount of work required. It was a tre-
mendous undertaking to get the total nitrogen, the urea
nitrogen, the ammonia nitrogen, the nitrogen of other
types, and the undetermined nitrogen. It was a time-
consuming operation, and it was not feasible to make these
tests every few days in every case. It might take three
men an entire day to make one determination, if it was
done properly. Every time there was faulty nitrogen par-
tition, invariably there was a diminution in the urea nitro-
gen. As a routine matter, it might he well to get the total
nitrogen and urea nitrogen; then, if the urea nitrogen was
depressed one could go ahead and determine which of the
other nitrogens were increased. Of chief importance was
to find if the urea nitrogen was depressed comparing this
with the total nitrogen. The persistent vomiting and
other symptoms he did not believe to be due to excess of
ammonia. In diabetes, where the urine often contained
from 15 per cent., and often 20 per cent, ammonia nitro-
gen, there was not a sign or symptom that looked like

250

MEDICAL RECORD.

[Feb 9, 1907

nausea or vomiting. Therefore, he believed that the per-
sistent vomiting was not caused by an excess of ammonia,
but due to that which accompanied it, the toxins, and it
was these which did the damage.

MEDICAL SOCIETY OF THE COUNTY OF KINGS.

Stated Meeting, Held November 20, 1906.

Dr. W. F. Campbell in the Chair.

The Medical Treatment of Those Gastric Disorders
in Which the Help of the Surgeon Is Often Demanded.
— Dr. Charles G. Stockton of Buffalo read this paper.
In the treatment of disease one had to avoid the two
extremes, a leaden-footed timidity, and a frenzy for ex-
ploitation. There were many diseases for which surgical
intervention was advised, which were formerly thought
amenable solely to medical measures. Had the pendulum
swung too far toward the surgical side? In the treatment
of gastric disease it had to be remembered that frequently
there was much complaint of the stomach when the latter
was actually without pathological change. In these cases it
was necessary to remove the refle.x disturbing cause.
Then there were some of the severest disturbances of
gastric function, forms of indigestion really due to an
e.xcess of gastric activity. One of the diseases for which
surgical intervention was frequently advised was achylia
gastrica. This had the following peculiarities : The appe-
tite was good, but the stomach had no digestive activity.
In mild cases the bowels were constipated, but in severe
cases there was a post-prandial diarrhea and the stools
were lienteric. The victims of achylia gastrica were like
persons on whom gastroenterostomy had been performed.
In the treatment of these cases the speaker recommended
small amounts of hydrochloric acid for its stimulating
•ffect on the intestine. Such patients might have the ap-
pearance of good health, but they lacked resisting power,
like those having a gastroenterostomy. If there was nar-
rowing of the pylorus it was better to drain through the
duodenum by means of pylorope.xy rather than to perform
a gastroenterostomy. Some of these cases that had lasted
from ten to fifteen years responded to medical treatment
Such was true of pylorospasm and extreme dilatation. One
of the speaker's cases, that of ulcer of the pylorus, had
occurred eighteen years ago, responded to medical treat-
ment, and had no recurrence. Medical treatment served to
put certain patients in good condition for operation ; as a
result some of these frequently felt so well that no opera-
tion was necessary, or the operation was deferred. With
peptic ulcer at the pylorus or in the duodenum operation
was advised. There was less danger from early operation.
Ir- ulcer, diet was to be liquid or pultaceous, meals were
to be given frequently ; bismuth suspended in mucilage
was to be administered, and gastric lavage with water
containing resorcin was frequently of value. The speaker
had found good results from the administration of ichthyol
in two or three-drop doses, and iodoform in doses
of one-half to one grain. If hyperchlorhydria was
present, occasionally a poultice gave comfort, and some-
times ice water. Of late years the speaker had used
the stomach tube. In hemorrhage from the stomach
he had good results from the use of the stomach
tube; the stomach was irrigated with a weak solution of
adrenalin one-half a teaspoonfu! of the I to 1,000 solution
added to a glassful of tepid water; the later irrigation was
by means of a solution of an equal quality of adrenalin to a
quart of water. Recently Ewald had recommended ice
water or gelatine water. It was necessary to educate all
these patients to be content with long-contin\ied treat-
niejit. For perforation it was imperative to operate. For
shock due to perforation the drug to be used was morphine.
This relieved pain, but at the same time it produced an
unwillingness on the part of the patient to permit operation.
Hemorrhage was also checked by morphine. Complete

rest in bed was necessary. Recurrence of hemorrhage
could be caused by introduction of large saline enemata.
Careful rectal alimentation was indicated. In exploration
for hemorrhage at the pylorus or into the duodenum it was
frequently found that the oozing came from a turgescent
gastric mucosa. Dilatation of the stomach second to atony
did not indicate operation. Frequently the condition was
one of ptosis and not of dilatation. The measures of treat-
ment included an improvement of the general health, elec-
tricity, hot and cold needle baths, cold affusions, and atten-
tion to the psychology of dietetics. The diet had to be
selected to suit the individual patient. In cardiospasm
temporary benefit was obtained from emptying the sac and
passing an electrode through the opening. Perigastritis
came from other causes than inflammation of the gall-
bladder. The pylorus was often the seat of inflammation,
of a true perigastritis. For this it was necessary to employ
rest, careful diet, and hydrotherapy. For cancer the medi-
cal treatment was only palliative.

Certain Surgical Aspects of Chronic Gastric Diseases.

— Dr. James G. Mumford of Boston, Mass., read this
paper. He said that the facts were well known. He con-
fined his remarks to only a few of the conditions of gastric
disease for which surgeons operated. Surgeons had strug-
gled for many years against the opposition of conservatives
and their work had already borne fruit. Technique had
been perfected. It was surprising how little one knew
before the stomach was opened. The profession at large,
however, was not impressed with the advantages of sur-
gical interference in gastric disease. He usually shrugged
his shoulders when gastroenterostomy was suggested for
chronic dyspepsia. There was a multitude of cases of
long standing that presented themselves to general practi-
tioners, cases presenting symptoms of pain, nausea, heart-
burn, etc. ; among these cases there were certainly some
that would be benefited by surgical interference. It had
to be remembered that some cases of distress after eating,
with gastric pain, might be due to gallstones. He cited
a case that had come under his care seventeen years ago.
It was that of a young house physician of a Brooklyn
hospital, suffering from neurasthenia, and who experienced
heartburn, flatulence, and distress in the epigastrium. He
had been advised to go away for a long rest. He went
to Boston, but did not improve. Shortly afterward, while
in a general hospital, he showed sudden collapse, due to
the perforation of a duodenal ulcer, as subsequent opera-
tion showed. At that time there was little known about
duodenal ulcer, but it was evident that the gastric symp-
toms of which this patient had complained had been due
to the adhesions about the duodenum. The ulcer had
set up a localized peritonitis. In such cases drainage of
the stomach might obviate a long period of invalidism.
.\nother case cited was that of a lady who had suffered
from dyspepsia for twenty years. After partaking of food
she had experienced pain and tenderness in the hypchon-
drium. Hysteria was one of the diagnoses that had been
m.ide. .''in exploratory operation revealed the stomach
attached to the transverse colon. There was a deep cica-
tricial infolding of the anterior wall of the stomach, which
was of the characteristic hour-glass type. The deformity
was similar to that seen in cases of pyloric obstruction. The
patient was supposed to have had a peptic ulcer, of which
she had manifested symptoms during pregnancy twenty-one
years before. The speaker next alluded to the fact that
gastric stasis was more common and more intractable than
usually recognized. He cited the case of a lady aged thirty-
five who had suffered from pain after eating, nausea, and
vomiting. There was no hematemesis and the patient lived
solely on peptonized milk. A diagnosis of pyloric stenosis
was made. Upon operation nothing abnormal was found,
but an anastomosis was made with the intestine to insure
free drainage. The operation was followed by a careful
supervision of the diet for at least one year. She was
cured. The speaker next discussed the question whether

Feb. 9, 1907]

MEDICAL RECORD.

251

the presence of a pyloric tumor in tliis class of cases con-
traindicated operation. This he answered in the negative.
Moreover, small tumors of the pylorus could be removed.
Of course, in the cases of simple gastric atony the objection
could be legitimately urged that the patient was exposed to
danger in an exploratory laparotomy. But after many ot
these operations it was possible to get the patient out of bed
as early as the fourth day. Moreover, long-continued dys-
pepsia due to gastric ulcer was frequently the cause of
malignant disease.

Stated Meeting, Held Deeember 18, 1906.
Dr. VV. F. C.\mpbell in the Chair.

Compulsory Vaccination and Anti- Vaccination. — Dr.

George Dock of Ann Arbor, Mich., read this paper. He
referred to the fact that there was no branch of preventive
medicine that exceeded in importance the subject of vac-
cination. In 1890 occurred the first case at law against
compulsory vaccination, and since that time litigation was
on the increase. During the past eight years there was an
epidemic of smallpox. The present laws were not satis-
factory, inasmuch as they were not backed up by public
opinion. Even those who admitted the right of the State-
to enact sumptuary laws regulating the use of tobacco and
alcohol frequently disputed its right to inoculate healthy
individuals with the virus of cowpox. The prevailing
methods of public vaccination were eminently unsatisfac-
tory. There was no definite record of vaccinations. Indi-
viduals sometimes washed the virus out of the wounds.
In lieu of the present haphazard methods of public vac-
cination the speaker recommended an organized scientific
procedure, having the support of the people. The anti-
vaccinationists were troublesome. Recruited notably from
intelligent ranks, their arguments were only too sadly forti-
fied by the untoward results in their own personal experi-
ence from the use of impure virus. It was necessary to
consider better methods of vaccination. The country was
now in the latest stages of the smallpox epidemic that
began shortly after the Spanish-American War. There was
no guarantee, however, that there might not be a sudden
recrudescence in the near future. The decline in the epi-
demic did not signify that the disease had been stamped
out. The view had been advanced that the mild character
of the recent epidemic was due to the fact that the public
had inherited a certain immunity. This view was not
proved. In Cleveland, in 1901, the mortality was 1.6 per
cent. In 1902 it jumped to i" per cent., althougli there were
the same number of cases. The mild type was probably
due to causes separable from inununity. It was to be
expected that a country that was indifferent to the huge
mortality from typhoid and from accidental causes would
not be very much concerned about the comparatively few
deaths from smallpox. It was a scandalous condition that
permitted the lawlessness, the shotguns, the wrecking of
houses, that frequently occurred when smallpox broke out
in a community. If to this were added the unfit pesthouses,
the special physicians, the guards, and other requisites, one
could conceive the economic disadvantages of even a few
cases of smallpox. Moreover, in the presence of such
crises, vaccination was performed hurriedly and inefficiently.
The experience of Germany furnished the best argument
in favor of organized vaccination. Statistics showed that
smallpox was always more prevalent in Austria and Russia
than in Germany, which also showed a much lower mor-
tality in proportion to its population than in this country.
When smallpox was raging throughout Europe the Ger-
man Army was but little aft'ected by the disease. This
was undoubtedly due to the careful performance and super-
vision of vaccination. The German law compelled vaccina-
tion before the second year, again at tjifelve years, and
again all recruits, that is, all males between eighteen and
twenty years of age, had to be revaccinated. In Germany
general vaccination had created such a sense of security

that some cases of smallpo.x were ireated in houses, and
some in general hospitals, even in the same wards with
other patients, without the disease spreading beyond the
first cases. It was noteworthy that the worst systems of
public vaccination prevailed in the countries that spoke
Jenner's language. A recent investigation of patients in
his wards in Michigan showed that of 2,000 individuals
only 60 per cent, had been vaccinated, and of these the
majority of scars were unsatisfactory. In 1905 one-third
of all his hospital cases had been unsatisfactorily vaccinated.
Voluntary vaccination as a public safeguard was not satis-
factory. In New York and Chicago the public school regu-
lations certainly insured a thoroughly general vaccination,
but this was not true of the greater part of the country. It
was difficult to decide whether vaccination should be sub-
ject to police regulation or should become a part of
Federal law. It might not have been necessary to do
away with State rights in order to insure perfect vaccina-
tion. This latter necessitated not only the vaccination of
all individuals at stated periods, but also their registration
in public archives; the supervision of all vaccinated cases
so as to determine whether the inoculation was successful
or not ; the maintenance of public stations for the prepara-
tion of aseptic vaccine; and the training of physicians
competent to perform and recognize the- successful outcome
of proper vaccination.

Chicago Medical Society.

At a meeting held January 16, 1907, Dr. A. P. Ohlmacher
of Detroit, Michigan, by invitation, detailed a series of
medical and surgical affections treated by artificial auto-
inoculation according to Wright's theory of opsonins. He
reviewed Wright's theory of opsonins and spoke of the
beneficial therapeutic effects of proper doses of the "cor-
responding" bacterial vaccine, or of the autogenous one
prepared from the patient's own lesion. But less impor-
tance was attached to the theory than to the practice of
artificial bacterial inoculation as a therapeutic procedure,
which the author regarded as Wright's great gift to med-
ical science and to humanity, for Wright has shown how
practically all subacute and chronic diseases caused by the
pyogenic bacteria, and luckily, too, the tubercle bacillus,
could be improved and brought to recovery by small, infre-
quent doses of the corresponding bacteria. The author's
personal e.xperience in the clinical application of Wright's
principles included a series of cases of obstinate, intract-
able, or even incurable affections in which the results have
been most surprising, and, judged by any other therapeutic
standard, entirely beyond the ordinary range of possibility.
Among staphylococcic affections were included examples of
chronic acne, both vulgaris and rosacea, subacute and
chronic furunculosis, both localized and generalized, axil-
lary adenitis, palmar abscess, impetigo, and a very remark-
able case of so-called "rose psoriasis," but what actually
proved to be an extensive stapliylococcic dermatosis due to
the Staphyloeoccus aureus. In all of these cases pro-
gre^sive improvement and ultimate recovery had been the
rule, together with splendid gain in appetite, weight, and
spirits. A case of colon bacillus pyuria, cystitis, and pyelo-
nephrosis with profound sepsis had been apparently perma-
nently cured by five injections of the autogenous bacterium.
Pneumococcus empyema by intercostal puncture and small
drainage was brought to a complete recovery in seven days
with two injections of the pneumococcic vaccine. A case
of genitourinary tuberculosis with tubercle bacilli and
pneumococci in the urinary pus had been progressively im-
proving during the five successive injections of a mixed
tuberculin and pneumococcic vaccine. With subacute and
chronic gonorrheal infections, Dr. Ohlmacher's work began
last August, and he had pcrfeted a vaccine from one of
several strains of gonococcus which appeared to be of wide
therapeutic usefulness. The results obtained in such con-
ditions as balanoposthitis. epididymitis, proctitis, ophthal-

252

MEDICAL RECORD.

[Feb 9, 1907

mia, conjunctivitis, vaginitis, and gleet liad been most grati-
fying and unparalleled by any previously established mode
of treatment. This consideration applied also to gonorrheal
arthritis (gonorrheal rheumatism ), in which the specific
and highly potent effect of the gonococcus preparation was
demonstrated by the immediate and steady improvement of
the local and constitutional conditions. In these gonorrheal
infections the same gain in tone, weight, and spirits as
evidenced in staphylococcic diseases was marked. The
address concluded with the statement that in these artificial
bacterial inoculations we possessed therapeutic agents of a
specificity and potency exceeding anything heretofore em-
ployed in the treatment of disease, except possibly the anti-
toxin of diphtheria.

iHrlJtral ilt^ma.

College of Physicians of Philadelphia: Section on

General Medicine.

At a stated meeting held December 10 Dr. Joseph Sailer
presented a patient with "Probable Congenital Disease of
the Heart." The condition occurred in a girl, fourteen
years old, in whom it was known that some disease of the
heart had existed from the age of six years. On palpa-
tion a marked thrill could he felt in the pulmonic area,
while on auscultation a loud, rumbling murmur, continuous
throughout both systole and diastole, was audible and
transmitted into the carotid arteries. There was neither
cyanosis nor clubbing of the finger ends. The lesion was
thought to be a persistent ductus arteriosus or pulmonary
obstruction. Dr. David Riesman read a paper entitled
"Preicteric Itching," and he reported three illustrativt
cases. The condition was first described by the great
Irish physician. Graves. In some instances it disappears
when jaundice sets in, so that it must be concluded that it
is not due to biliary pigment. It has been observed in cases
of benign and malignant disease alike. Dr. Riesman also
presented a communication entitled "The Development of
Cardiac Murmurs During .A.ttacks of Biliary Colic." He
reported several cases in which heart murmurs developed
during attacks of biliary colic in persons previously known
to be free from such murmurs and disappearing with the
termination of the attack. The manifestation must be con-
sidered as due to different causes, in some instances to
anemia or other change in the blood related to the at-
tendant jaundice, in other instances to dilatation of the
heart. Dr. David L. Edsall presented a communication
entitled "Further Observations on Metabolism in Purpura."
He was able to confirm, observations previously recorded
to the effect that loss in nitrogen occurs in cases of hem-
orrhagic purpura, indicating that the affection must be at-
tributed to a toxic state and the resulting blood destruction.
Dr. A. P. Francine read a paper entitled "A Review of
the Therapeutic Use of Koch's Tuberculin." Reports in
the literature would seem to show that, employed cau-
tiously and intelligently in properly selected cases, treat-
ment of tuberculosis with tuberculin yields more favorable
results than other methods of treatment. The patients
should be free from fever and the doses used should be
almost infinitesimal. Reaction should, so far as possible,
be avoided, and, of course, all recognized hygienic and nu-
tritive measures should be observed. Tuberculin has
further great diagnostic value. Dr. Robert N. Willson
read a paper entitled "The Pathogenesis and Treatment
of Neurasthenia in the Young." He maintained that neu-
rasthenia is due to impairment of tissue nutrition, and that
any mode of treatment, to be successful, must be aimed
at improvement in this direction. Often profound inertia
on the part of the patient has to be overcome and the ut-
most personal effort on the part of the physician will be
required. No case need be considered helpless, but the
treatment must be determined for the individual case, and
it should be carried on with unremitting persistence.

Contagious Diseases — Weekly Statement. — Report of

cases and deaths from contagious disease reported to
the Sanitary Bureau, Health Department, New York
City, for the week ending February 2, 1907 :

Deaths

Tuberculosis Pulmonalis .

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis .
Malarial Fever

Totals

Appendicitis in Nurslings. — Kirmisson and Guimbel-

lot have been able to collect twenty-three cases of this na-
ture. Nine of these were observed in the first year, four-
teen in the second year. There were sixteen deaths and
seven recoveries. The patients who recovered were all
over eighteen months old. Surgical intervention was prac-
tised in ten cases, once on a patient in the first year and
nine times on patients in the second year with seven re-
coveries and three deaths. The writers believe that appen-
dicitis in the first years of life is not as rare as is gen-
erally thought. Its evolution is rapid, its prognosis ex-
tremely grave. Diagnosis is difficult. It would be of
interest to have all the facts relating to these cases, which
have been observed, collected and published. — La Presse
Mi'dicale.

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the Surgeon-General, Public Health and Marine-
Hospital Service, during the week ended January 4,
1906.

SMALLPOX — UNITED STATES.

CASES. DEATHS.

California, Quincy Dec. 1-15 10

Florida, Marion County .Tan. 19-26 6 ..

Polk County Jan. 19-26 10

Georgia, AuHusta Jan. 15-22 11

Illinois, Chicago Jan. 19-26 i

Galesburg Jan. 19-26 11

Peoria Jan. 19-26 6

Indiana, Indianapolis Jan. 13-20 12

South Bend Jan. 19-26

Terre Haute Jan. 10-26

Louisiana. New Orleans Jan. 19-26

Missouri, St. Joseph .Tan. 12-19

New York, New York Jan. 19-26

Ohio, Cincinnati Jan. 18-25

Virginia. Hanover County Jan. 31

2 Imported

SMALLPOX — FOREIGN.

.Argentina. Buenos Ayres Dec. 1-22

Brazil, Pemambuco Dec. 1-15

Rio de Janeiro Dec. 23-30

Nova Scotia, Colchester County. . . Jan. 19

Cumberland County. .Jan. 19

Pictou County Jan. 19

China. Shanghai Dec. 19-16

France, Marseille Dec. 1-3 1

Paris De--. 29-Jan. s

Italy, General Jan. 3-10

Malta Doc. is- 22

Mexico, Tamaulipas, State of (On

line of Mexican Central R. R. . ..Jan. iS

Russia, Moscow De'. i.s-zo

Spain, Barcelona Jan. 1-10

Cadiz Dec. 1-3 1

YELLOW FEVER

Brazil. Rio de Janeiro Dec. 23-30 i I

CHOLERA.

India, Bombay Dec. 2S-Jan. r 8

Madras Presidency Nov. 1-30 10.700 6.305

Dec 1-15 S.'Sft 3.293

Rangoon Dec. 15-22 39

35

Present
Present
Present
Present
88

Epidetric
I
7
8

.\rabia, Djeddah Jan. 0 1

Brazil, Bahia Dec. S- 29 13 s

Rio de Janeiro Dec. 22-30 12 8

Egypt, .Mexandria Jan. 4 1

IshmaiHa Jan. 5 i

Keneh Jan. 9 ' i

Gibraltar Dec. 16- Jan. 13.. .. 7

India, Bombay Dec. 25-Jan. 1 13

Rangoon Dec. 15-22 15

Tapan. Formosa Nov. 1-30 100 84

Peru, Catacaos „ Dec. » 10 7

Mollendo T Dec. i 7

Pacasmayo Dec. 1 4 2

Paita Dec. 1 2 i

Truiiilo Dec. 1 48 2

Medical Record

A JJ\xk!v fonrnal of Medicine and SurQ-ery

Vol. 71, No. 7.
Whole No. 1893.

New York, February i6, 1907.

$5.00 Per Annum.
Single Copies, lOc.

(iPriginal ArtUlrj

SUPERNUMERARY CERVICAL RIBS AND
THEIR EFFECTS OX THE BRACHIAL
PLEXUS AND SUBCLAVIAX ARTERY.-

Bv COLIN K. RUSSEI., M D .

MONTREAL.

CLINICAL ASSISTANT IN NEUROLOGY; CLINICAL ASSISTANT IN MEDICINE,
ROYAL VICTORIA HOSPITAL.

Cervic.xl ribs are not particularly uncommon anil
have frequently been demonstrated at autopsy and
in the dissecting room/ but the clinical symptoms
which may be caused by the pressure of super-
numerary cervical ribs on the cervical plexus have
been given little attention. Thomas and Cushing,-
in 1903, reported one case and Thorburn." in 1904.
published a series of four cases with their clinical
histories in which there were definite signs of pres-
sure on the ple.xus. In Thomas's case, and in two
of Thorburn"s, the symptoms were particularl}- well
marked, consisting essentially in paralxsis of the
intrinsic muscles of the hand with pain and some
sensory loss about the region of distribution of the
first dorsal root. In these three cases the offending
rib was removed with relief of the pain, and in Tlior-
burn's case ree-stal'lishnu-nt nf the funciinns nf t'-e
paralyzed muscles.

Previous to this Tillman' rejiorted the case of a
woman, aged forty-four, with a cervical rib on the
left side, causing atrophv of the muscles of the ball
of the thumb and pains from the neck down the arm,
but in this case no loss of sensibility was found. The
case was operated on by Bardelebcn. Two other
cases were operated on in von Bergmann's* and three
others in Hoffa's clinic, where there was said to be
pressure on the plexus but the only symptom re-
ported was pain in the arm.

These are the only reported cases that 1 liav^'
found in a fairly thorough revision of the literature.
More or less complete occlusion of the subclavian
artery, on the other hand, seems to be more common.
Tillman in his revision of the literature collected
twenty-si.x cases, in thirteen of which the presence of
the rib caused symi'.tonis : in the other thirteen it was
found accidentally. In ten of these cases the svmp-
toms disappeareil under syni|itriniatic treatment ;
three only were operated on ( Coate,' Fischer,''
Planet") and all successfully. Babcock * of Phila-
delphia and Murphy'" of Chicago have also recently
published cases in which operation was successful
in removing the symptoms.

The following cases will. I think, be of general
interest. It is interesting to note also that these
patients are brother and sister :

C.\SE I. — Miss B., aged twenty-seven, nurse, was
seen for Dr. Martin on the 24th of .A.pril, 1906.
Complaints: I'ain and crani]) in the right hand and

* Read before Montreal Meilico-Chinirsical .S.iciety.
November 16, !go6.

arm : wasting of the thumb muscles, and general
weakness of the right hand.

Present Illness: Started five or si.x vears ago with
the sensation of pins and needles in the ulnar side of
the right forearm and hand, especiallv when she was
exposed to cold. .\t the same time she often had
cramps in the little and ring fingers of the same
hand with fle.xion of these fingers. Weakness and
cramps in the thumb muscles when grasping objects
was next noticed, always worse in very cold or very
hot weather. About three years ago the definite
wasting in the small thumb muscles was first noticed,
and at this time she complained of frequent cramps
in the hand with flexion of the fingers and wrist.
The right hand is alwavs colder than the left, but
no change of color has been noticed. These svmp-
toms have been gradually progressive till the pres-
ent time.

Personal History: Patient has always led a rather
active out-of-door life and enjoyed very good health;

Fig I — .\tror>hy of small muscles of thuinb.

I'aniily History: Xothing similar has been ob-
served in her parents. Her brother, however, has
somewdiat similar complaints. (See Case II. )

The patient's intelligence and training enabled
her to describe her symptoms clearly and to mark
out with precision the areas of subjective pain. The
pupils were e(|ual and reacted to light and accmii-
modation, and the other cranial nerves normal.

In the right arm there was some wasting of tlie
forearm muscles, chiefly on the flexor and ulnar
surfaces, there being a dift'erence of half an inch
in the circumference three and a half inches above
the radial condyles. The abductor brevis pollicis
was entirely atniphied. The addnctnr ]iollicis and
abductor indices were also much wasted. There was
no definite weakness in flexii m of the right wrist, ex-
tension was also about e(|ual right and left. Flexion
of fingers slightly weak. There was very definite
weakness in all the muvements of the thumb and
some relative weakness in seiiarating the fingers and

254

AIEDICAL RECORD.

.[Feb. i6, 1907

in extending the distal phalanges when the proximal
ones were semiflexed, and definite weakness of the
grasp of the right hand as compared with the left.
Some fibrillary twitchings were noted in the small
muscles of the thumb and in the hypothenar muscles,
also in the flexor muscles of the forearm. (See Fig.
I.)

Fig. 2. — Subjective distribution of pain.

Sensory System : The patient complained of sharp
aching pain, like toothache, coming on in attacks
and radiating down the inside of the arm, quite
localized, so that she was able to mark out for me
the areas to which it was confined. ( See Figs. 2 and
3.) Objectively there was an area of complete
anesthesia on the ulnar border of the forearm be-
tween the elbow and wrist in the areas supplied by
the first dorsal root. (See Figs. 4 and 5.) The
reflexes were all normal. There was no spinal cur-
vature. The radial pulse was equal on the two sides
and no diminution of the pulse was noted on deep
inspiration. The right hand was cooler than the
left, but there were no trophic disturbances. The
abductor pollicis did not react to either faradic or
galvanic stimulation. The flexor brevis and ap-
ponens pollicis showed relative diminution in their
reactions to faradism.

Skiagraphs showed bilateral supernumerarv cer-
vical ribs. (See Fig. 6.)

During the two months before an operation could
with convenience be undertaken there was definite
though slight increase in the atrophv of the thumb
muscles.

The operation for the removal of the rib, per-
formed by Dr. Garrow, has proved so far very suc-
cessful in that the patient has had no return of the
neuralgic pain or of the cramps in the arm. Im-
mediately followine the operation, owing to the
unavoidable contusion of the nerves, there was in-
creased paralvsis of the small muscles of the hand
and of the flexor profundus digitorum and flexor
carpi ulnaris, with later some increased atrophv of
these. There was also an increase in the area of
anesthesia and analeesia over the ulnar border of

The patient continues perfectly free from the pain
and cramps.

Case II. — Brother of the preceding patient, clerk,
aged thirty-five. Complaints: Inability to use the
right arm properly ; paresthesiae in hand and fore-
arm.

Present' Illness: Nine years ago he had some diffi-

Fig. 4. — Area of analgesia and anesthesia.

culty in writing: he did not seem able to control his
pen properly. Thinking he had gotten into careless
habits of writing he tried taking lessons, but in spite
of this he did not improve. After writing for some
time his hand and forearm felt thick, swollen, and
heavy, and he had sensations of pins and needles
in the ball of the thumb. It was considered to be
writer's cramp and eventually he had to learn to
write with his left hand, and since has used either
hand, but preferably the left, as he cannot yet con-
trol his pen with the right hand for any length of
time. Otherwise he has ahvavs enjoyed good health.

Present Condition: Patient is an intelligent
though somewhat neurotic man. The pupils were
equal and active to light and accommodation, the
other cranial nerves were normal. Apart from some
flattening of the thenar eminence in the right hand
there was no muscular atrophy. There was some
slight relative weakness in abduction, flexion, and
opposition of the right thumb as compared with the
left. There was no definite weakness in separating
the fingers of the right hand.

There was no objective disturbance of sensibility;
electrical reactions were all normal : reflexes all nor-
mal, and no spinal curvature. Skiagraph shows
bilateral supernumerary cervical ribs. (See Fig. 7.)

Case III. — B. I'., female, aged twenty-four, sew-
ing girl, came to the medical outdoor department
November 8. Kjoh. Complaints: Pain in right
shoulder and down inside of arm to hand ; cramps
of fingers and wrist with flexion. Wasting of small
thumb muscles.

Present Illness came on with pain in the shoulder
four years ago after a fall in which the patient struck
her shoulder. She has had this pain off and on
ever since, and lately it has been getting more severe
and frequent. It is brought on bv allowing her
arm to hang bv her side or when she wears a heavy
overcoat in winter. The pain is not only in the
shoulder, hut radiates down the inside of the arm
to the wrist. She prefers to hold her arm flexed at
the elbow in walking, as this prevents the pain.

Fig 3. — Subiective disti-ibution of pain.

I'iG. 5. — .\rea of analgesia and anesthesia.

the hand, the little, and tlie ulnar surfaces of ring
fingers. This has. however, all cleared up, and at
present, four and a half months after operation, the
condition of the muscles is about what it was pre-
vious to operation, and the area of loss of sensibility
is about one-third smaller than it was at that time

About four months ago she noticed the wasting and
weakness of the small muscles of the thumb and
first finger of the right hand, and pins and needles
sensation in the ball of the thumb, and about three
months ago she first had cramps in the hand, with
flexion of the fingers and wrist.

Feb. I'l, 1907^

MEDICAL RECORD.

255

Personal History: Otherwise healthy. Family
History: Negative.

Present Condition: Cranial nerves negative.
Pupils equal and react to light and accommodation.
Muscular S\'steni: Wasting of abductor pollicis and
indicis of right hand and in the hypothenar mus-
cles, weakness in abduction, and opposition of thumb

Fig. 6- — Bilatera' cervical nbs.

and in the separation of the fingers, especially the
first two. Sensory System: Apart from the subjec-
tive complaints is negative ; there is no area of anes-
thesia nor analgesia to be found anywhere. The re-
flexes are normal in all extremities, and there is no
curvature of the spine.

Her neck is long, with sloping shoulders forming
what has been described as the champagne bottle
type. There is no difficulty in palpating the ends of
the cervical riljs, which are shown bv skiagraph
Fig. 8.

In Case I tlie atrophy of the small muscles of the
thumb and the weakness of the intrinsic muscles of
the hand pointed to involvement of the first dorsal
segment, as did also the area of anesthesia and anal-
gesia and the neuralgic pains. The pupils being
equal and unaffected placed the lesion distal to the
communicating branch of the sympathetic ganglion.
Also the fact that her brother w-as similarly affected
rendered it probable that the lesion was not in the
cord, but due to some anomaly in the neighborhood
of the roots and led to a skiagraph being taken,
as in neither case I nor IT could we be sure of the
presence of the rib by palpation.

Cervical ribs are doubtless a species of atavism
and are sometimes found in children of parents who
show some stigmata of degeneration. Israel, in his
discussion of r.orchardt's'- paper, spoke of having
operated on a |)atient whose sister also had cervical
ribs with symptoms, so that heredity seems to be
a factor. Doubtless thev are often present without
causing anv symptoms whatever. According to Ries-
man'^ cervical ribs are more commonly present on
the left side, but certainly the symptoms are most
often seen in the right arm. They are more fre-
quently met with in women than in men, and first
make their apijcarance between the ages of nineteen
and thirty.

It would seem probable then that the more fre-
quent use of the right arm must in some way have
an etiological bearing, and the fact that the epiphysis

of the head and that of the tubercle of the rib only
make their appearance between the sixteenth and
twentieth years, and are not united to the rest of
the bone until about the twenty-fifth year, would sug-
gest a possible cause of the late development of the
symptoms. Certainly in neither of these cases was
there any history of previous illness or poor health
or loss of weight to bear out Tillman in his conten-
tion that this is always a causative factor. In fact
the brother has only recently recovered from typhoid
fever, and in spite of some loss of weight, etc., shows
no increase in his symptoms.

The theory of muscular use and development as a
causative factor seems to be borne out in his case.
His occupation as clerk involved a great deal of
writing, and as soon as he .gave up using his right
hand altogether and began to use the left there was
a dimimition in the symptoms.

In our Case I the roots of the brachial plexus were
certainly not stretched over the rib as Thorburn
suggests as the explanation of his cases. It seems
more plausible to suppose that the first dorsal root
was pressed on by either the distal end of the rib or
its tendinous attachment immediately proximal to
its junction with the eighth cervical root, where they
unite to form the inner cord of the plexus.

In cases where there is only a slight degree of
pressure one may simply find comjilaints of neuralc^ic
|)ain radiating down the inner side of the arm, with*
perhaps some awkwardness in coordinating finer
movements of the thumb. Where the pressure is
greater it is exerted chiefly on the first dorsal root,
causing definite paralysis, with only an irritative
condition of the eighth cervical root as shown by
the paresthesia- in the ulnar border of the hand
and in the spasmodic cramps of the flexors of the
fingers. It seems probable that the center for the
flexor profundus digitorum is at the lowest part of
the eighth cervical segment, and the cells which sub-
serve flexion of the fourth and fifth fingers have
the lowest representation in this center. It is inter-
esting to note that after the operation the flexor carpi

Fig.

-Bilateral cervical ribs

ulnaris was temporarily paralyzed and the area of
analgesia extended to what is usually looked upon
as the distribution of the sensory fibers of the eighth
cervical segment ; this, ht.iwever, only lasted a week
or ten days.

The suggestion oft'cred by Case II. of a cervical
rib as an organic basis for writer's cramp may be

256

MEDICAL RECORD.

[Feb. 1 6, 1907

one of some importance. It certainly has not yet
been advanced as an etioloi;ical factor of this malady
in an\ of the modern textbooks.

C.\SE i\'. — Mv fonrth case ditTers from the three
previous ones. Here, with a certain deformity of
the ribs, which ma\- be seen in the skiagram, there
was more or less complete occlusion of the subclavian
artery. Tliis patient was |)resented to the society
in January, igof), by Dr. .\rchibald for diagnosis,
he having made the ijovisional diagnosis of endar-
teritis obliterans.

M. T.. female, aged ihirt\-one. came to the Royal
\ictoria Hos]jital complaining of "burns" on the
fingers of the right hand, shooting pains in the right
hand and fingers, and numbness in the left inde.x
fingers.

woman with sloping shoulders. Above the clavicles
there was a definite mass on either side of the neck,
over which the subclavian arteries could be seen
l>ulsating. The right hand was swollen, tender, and
reddened. The superficial layers of the skin were
coming off in areas. The tips of the third and fourth
fingers were gangrenous. The viscera were normal.
Apart from the fact that she was stui)id and neurotic
the nervous system was normal. Skiagraphs showed
what was thought to be undevelo])ed first thoracic
ribs. ( Fig. 9.)

In sjiite of treatment the fingers did not heal.
She com])lained of considerable pain in the fingers
preventing her sleeping and also of cold feet, al-
though at no time did her feet become cyanosed.
A s;?iall area of gangrene now developed on the tip

Fio. ?. — Cervicn! ribs.

Present illness commenced about nine years ago
with numbness in the fingers of the right hand, ac-
companied by alternating cyanosis and stone wdiite-
ness. For the past year this has increased in
severity, and she was advised to put her hand in a
solution of carbolic acid, one half ounce to the pint.
She admits that she did not stir this up at all, and
after using it her fingers became very red, painful,
and swollen, and have since become gangrenous.
Four years previous to this she came to the hospital
with wdiat was probably a cystitis due to gpnococcus
infection, but did not stay. Otherwise she has always
l^een fairly healthy, though delicate. Has been mar-
ried nine years.

Her familv history is negative.

On admission she was found to be a thin, anemic

of the index finger of the right hand, and the
other fingers and the hand were cyanosed. The
index, middle, and ring fingers of the left hand also
occasionally became quite cyanosed. The right radial
pulse became almost imperceptible and the right
brachial was smaller than the left.

On account of the progressive gangrene, in spite
of all treatment, it became necessary to amputate
first the fingers and later the arm at the level of
the insertion of the deltoid. Dr. Klotz found the
brachial and radial arteries in the amputated part
almost completelv obliterated. The vessel showed a
proliferation of the inner wall of the vessels and an
organized thrombus with formation of canaliculi.

It was at this stage that Dr. Archibald presented
the case to the societv. In the discussion which fol-

Feb. 10, 1907;

MEDICAL Rl^CORD.

257,

lowed he considered the question of the occlusion
of the arterv being due to its abnormal course.

(^n his departure for England in May last, know-
ing that I was interested in the case, he very kindly
asked me to take charge of her. At this time there
was very evident involvement of the left hand with
alternating blueness and stone-whiteness of the
fingers and a small area of commencing gangrene
of the ring finger. It was found that when the
shoulder was elevated, as by putting the left hand
on the right shoulder, the pain in the hand was alle-
viated. She stated that she always slept with her
arm raised, under her head, thus elevating the
shoulder, .\lthough operation for the removal of the
rib was urged the patient would not hear of it. Do-
mestic worries being added to her trouble, she com-

subclavian artery proximal to the thyroid axis was
large and soft, laut distal to this it was contracted
and almost cord-like for a distance of about two and
a half inches. In the axilla it widened out again and
became more normal looking;-. In the left side above
and below the cla\'icle the ve^sel was apparently
about normal in size but underneath the clavicle it
was enlarged and nn palpation firm and evidently
partially thrombosed.

( )n the left side the upper edge of the vein only
could be seen above the level of the clavicle, and be-
low the clavicle there was a huge enlargement and
anastomosis of veins over the first space. On both
sides the arter\- extended much higher into the
neck than normal. In the second part of its course
it lay pi>steriorly on the scalenus medius, which was

Fig,

-Skiagram apparently showing nniieveloped cervical ribs.

mitted suicide on July 7 by taking Paris green. She
was taken to the jMontreal Cieneral Hospital and died
next day.

By the kindness of Dr. R. P. Campbell, Superin-
tendent, and Dr. Duval, Pathologist, I was given per-
mission to dissect out the neck on both sides. An
autopsy had already been performed by Dr. White,
but nothing bearing on the point in question here
was found. \'ertical incisions were made on both
sides of the neck and the vessels and brachial plexus
dissected out carefullv so as not to disturb their re-
lation to the hard parts more than necessarv. The
clavicles were then sawed through and the vessels
and nerves followed into the axillae and arms.

On the right side (i.e. the side of amputation) the

attached to this anomalous rib and the second rib,
and above the level of this upper rib. It then turned
sharply around the scalenus anticus to descend be-
low the clavicle.

The first dorsal nerve root ran upward over the
ventral surface of the second rib present to join the
eighth cervical root which, emerging from between
the two ribs just before their junction, formed with
it the inner cord of the brachial plexus.

On section, the right subclavian at the level of the
thyroid a.xis showed obliterating endarteritis with
an organized thrombus completely blocking the
lumen save for a few canaliculi which had formed
in the thrombus. The vessel just above the level
of the clavicle showed the same condition.

258

MEDICAL RECORD.

[Feb. 1 6, 1907

III the axilla the vessel wall showed merely a slight
thickening and proliferation of the inner coat. On
the left side, at the level of the thyroid axis, the
vessel wall showed practically no changes. At the
level of the clavicle it was almost completey occluded
by an organized thrombus which seemed to have
originated and was most advanced on one side of
the vessel. In the axilla the vessel was again about
normal.

Sections of the radial on the left side and of the
posterior tibial on both sides showed no thickening of
the vessel walls.

Whether this is really a cervical rib or an unde-
veloped first thoracic rib remains in my opinion
somewhat doubtful. The skiagraphs seem to pouit
to the latter, showing only twelve ribs in all. with
apparently only five vertebra between the last rib-
bearing vertebra and the sacrum. On the other hand,
the eighth cervical nerve root certainly came out
below "the first rib present and the first dorsal below^
the second rib. These joined on the upper anterior
edge of the second rib present to form the inner
cord of the plexus, and Lane reports cases in which
with a cervical rib present the twelfth dorsal rib
is very small or absent, merely represented by long
transverse processes, and considers that the cause
which determines the presence of the cervical ribs
also causes a want of development of the lower ribs.
Again, in the skiagraph, the first rib articulating
with the sternum is flat and broad looking, like a first
thoracic rib, although possibly not very much weight
can be attached to this point, as in a specimen of
Dr. Shepherd's in the McGill Museum showing what
is evidently a deformed first thoracic rib. the second
thoracic has more or less this character. Certainly
on dissection this rib seemed relatively very high
above the clavicle. It is possible that here there
may have been a fusion of the seventh cervical and
first dorsal vertebra:, in this way accounting for the
deformitv of the rib and the anomalous course of
the eighth cervical nerve root.

Whatever its real nature is — and it is to be re-
gretted that owing to the shortness of time at our
disposal we could not make it out more clearly — this
deformity has evidently been the cause of the throm-
bosis and occlusion of the artery. The modus oper-
andi seemed to be this : The arch of the vessel ran
very high in the neck, being bounded behind by the
scalenus medius and the upper border of this anom-
alous rib, and in front by the scalenus anticus. Its
downward and lateral curve was limited laterally
by the anterior end of the rib and its junction with
the second rib present. Its downward and outward
angle, as it dips under the clavicle, increased on ac-
count of the relatively low position of this bone. It
is here that the greatest obstruction seemed to be
present, as shown in the vessel of the left side, where
the process is less advanced, although it is probable
some obstruction is ofifered to the blood stream
bv the sharper turns which the vessel has been com-
pelled to take in the second part of its course, as well,
causing slowing of the blood streams, gradual block-
ing of this, and closing off the thyroid axis and loss
of the collateral circulation.

The obliterating endarteritis and organized throm-
bus which were present in the radial vessels after
amputation of the right arm may. I think, be ac-
counted for without supposing that such a condi-
tion was a general one. .\t this time there must have
been an almost complete occlusion of the subclavian
arterv with a maintenance of the blood supply to the
extremitv through the thyroid axis. This was nec-
essarilv insufficient, as the obstruction to the blood
stream, if this theorv be correct, was exerted on this

part of tlie vessel as well. The blood pressure was
consequently very much diminished, and at last, as
the thyroid axis itself also became partially occluded,
it was only sufficient to maintain the circulation in
the proximal parts of the vessels.

The onset of symptoms relatively late in life is
probably due to the same causes which produce
symptoms of pressure on the plexus at about this
same period of life. It is conceivable also that other
etiological factors were present, e.g. the action of
the carbolic acid, or the loxines of the gonococcus
circulating in the Ijlood ; these points we hope to
iiring up in another paper in conjunction with Dr.
Archibald.

In considering the matter of operation for the
removal of the rib, in Babcock's case, which was
very similar to this one, having beginning gangrene
of the fingers and almost complete obliteration of the
radial pulse, removal of the rib restored the circu-
lation and entirely cured the condition. One cannot
imagine this interference affecting the thrombosis
which had occurred under the clavicle, but it seems
more probable the effect was to relieve the condition
by maintaining the collateral circulation by way of
the thyroid axis and its branches.

REFERENCES.

1. Halbertsoma : Archiv. f. d. Holland. Beitrage,
Utrecht, 1858.

Liischka : Denk. der Kaiserl. Akad. der Wissen-

schaften, Wein.. 1859.
Grublcr ; Mem. de I'.Acad. Imp. des Sciences de St.

Petersburg;. Tome xiii, 1869.
Turner: Jour, of Aiiot. and Physiol., Vols, iv and

xvii.
Shepherd : American Journ. Med. Sc, dxix, p.

112, 1883.
Lane : Guy's Hospital Reports, 1883-4.

2. Thomas and Gushing: Johns Hopkins Hosp. Bull.,
Vol. xiv, p. 152, November. 1903.

3. Tliorburn : Trans. Royal Med. and Surg. See, Lon-
don, 1005.

4. Fracnkel : Verh.-indlungen der Deutschen Gesell-
schaft f. Orthopaed. Chirur.. Fiinftcr Kongress, April, 1906.

5. Coate : Medical Times and Gazette, August 3, 1861,
p. 108.

6. Fischer: Deutsche Chirurgie. Bd. 34.

7. Planet: Tumeurs osseuses du Cou. These, Paris,
1890.

8. Tillman : Deutsche Zeit. f. Chirur., Bd. xli, p. 330.

9. Babcock : .'Unerican Medicine. Vol. x, No. xv, Octo-
ber 7, 1905, p. 616.

10. Murphy: Annals of Surgery, 1905. and Journ. of
Surg.. Gynecol, and Obstet.. October. 1906.

11. Riesman: L^niv. of Pennsylvania Med. Bull., March
I, 1904. No. I.

12. Borchardt : Berliner klin. JVoch., No. 51, 1901, p.
1265.

13. .'\dams : Dublin Jour. yjed. Sc. \ ol. xv, 1836, p. 494.

14. Poland: Medico-Chir.. Trans, i. 52, p. 278. 1869.

15. Pepper: Amcr. Jour. Med. Sc, 1867, ii, p. 121.

THE APPROACHING CONQUEST OF
CANCER.

By ROBERT BELL. M.D..

LONDON, EXGI AND.

^\"^ILE all who are interested in the treatment of
cancer will hail with satisfaction and pleasure the
record of those gratifying results said to have
been obtained by the introduction of trypsin into
the blood stream, it would be fooli.sh in tlie extreme
to imagine for a moment that trypsin or any other
isolated agent will ever per se prove an antidote to
cancer. It is not my intention at this time to extol
any other method of treatment of this disease,
though I am well acquainted with such and have
observed many instances in which cancer has not
onlv disappeared but has not recurred for a period
of ten vears and still shows no tendencv to recur-

r-'eb. ib, 19071

MEDICAL RECORD.

259

rence. My object is rather to discuss the rationale
of this Hne of treatment in what I consider to be a
fair and unbiased manner.

Dr. Beard, the author of the trypsin treatment of
cancer, if I understand him aright, was led to infer
from certain experiments that the disease had some
connection with a deficient production of trypsin. I
say production of trypsin, as I think this can hardly
be termed a secretion of the pancreas, seeing it
may not be present at all in the gland at the time
the latter is removed from the body ; but when it is
allowed to remain exposed to the air for some hours
trypsin makes its appearance in considerable quan-
tity. In short, there is a conversion of zymogen
into this ferment, and as we know this change
takes place in circumstances where it is an im-
possibility for secretion to be coincident, we are
bound to admit that it is a derivative of one of the
most important constituents of the pancreatic juice.
This fact does not of course detract in the least
from its value as a digestive agent, but it points
to the conclusion that if cancer is due to the ab-
sence or deficiency of trypsin then we must look
upon a disabled condition of the pancreas as the
primary cause of cancer. To get at the root of
the matter, however, we are under the necessity
of going further back still to ascertain the cause
of this morbid condition of the pancreas. In this
wav we may possibly arrive at the foits ct origo
liuili, and thus be enabled to deal with the disease
satisfactorily as a whole and not confine ourselves
to the treatment of a s\niptom which the local man-
ifestation of cancer undoubtedly is. It is this short-
sightedness which has been the stumbling block
to previous methods of treatment, and will con-
tinue to prove fatal to all methods which do not
aim at removal of those factors which have been
insidiously sapping the integrity of the organs
which exert such an important influence upon
healthy cell life. It is to this oversight that thou-
sands of painful deaths are annually due, and which
will continue to be perpetuated no matter what
local treatment be devised, if this does not go hand
in hand with dietetic and general measures which
hold in view the relief and restoration to health of
those organs whose functional activity has been
prostrated by the persistent neglect of hygienic
laws.

It must be obvious to every observer how miser-
ably surgery has failed to give relief in cancer, and
the result has been very much the same, whatever
local measures have been adopted, when sole re-
liance is placed upon them. For example, I have
known of cases when the subcutaneous injection of
a I per cent, solution of caustic potash has had a
temporarily marked beneficial effect in epithelioma,
and Dr. Webb has reported several cases of breast
cancer which have been arrested by the injection
of a solution of soap into the tissues ; but I have not
heard of any permanent relief being obtained by
these measures.

It is not my intention to refer in this paper to
my own method of dealing with this disease. This
has been freelv dilated upon on many occasions.
What I wish to prevent, if possible, is the booming
of a treatment which has not been in existence for
anything like a long enough period to place it be-
yond the experimental stage. The public have had
so many disappointments that it would be a pity
to add another to the number, and though treat-
ment bv trypsin may, and I trust will, prove a valu-
able adjunct to dietetic and constitutional measures,
I fail to apprehend how it can possibly by its sole
nifluence have any permanent eflfect. Cancer is not

a disease, so far as I can judge, due to any one
cause, but to a chain of causes and effects made
up of many links, each of which requires special
attention. Two circumstances have impelled me
to communicate my views on this important sub-
ject: First, the optimistic articles which have ap-
peared in the lay press, and second, the fact of a
lady coming to my consulting rooms who was suf-
fering from recurrence of cancer in the right side
after two extensive operations had been performed
within one vear, and when the condition of the parts
was infinitely worse than it would have been had
the breast been left alone. Well, this lady had just
returned from Edinburgh, where she had been un-
der the trypsin treatment for ten weeks, during
which period the other breast had become involved,
while the original site of the disease could hardly
look worse than it did that day. This, however,
being the only case I have seen after this treatment
had been employed, I certainly would not condemn
it on that account. Indeed, I ain convinced there
is value in it. as I have stated in my last book on
the subject, as an adjunct to other methods which
are of proved value — and the manner in which I
trust it will prove of immense service is that the
ferment by attacking the weaker cells of the mor-
bid growth may destroy them, and thus arrest the
local increase of the disease. If this can be accom-
plished while the healthy condition of the neighbor-
ing tissue is improved by judicious measures, an
important advance will have been made, because
the colony or colonies of malignant cells are thus
rendered innocuous and will disappear by absorp-
tion. The vitality of the tissues will not there-
fore be diminished as would be the case if the
disease had been removed by the knife.

It would be well, I think, in this connection, to
glance for a little at the functional utility of the
pancreas, especially in relation to the incidence of
cancer. This gland, as we know, is possessed
of certain important functions, these being supple-
mentary to those of the salivary glands and the
stomach, so that it, as it were, is placed as a sen-
tinel to watch over the contents of the stomach as
the}' escape into the duodenum and complete the
process of digestion where it has been deficient.
This it will succeed in accomplishing provided the
food has not been in excess of the requirements of
the body and of such a character as can be efficiently
dealt with by the digestive organs. On the other
hand, it should be borne in mind that if the blood
is in a vitiated state, the pancreas, as well as other
important organs, will in consequence have its func-
tional activity seriously reduced, and if this con-
tinues indefinitely the organs may possibly be ren-
dered incapable of fulfilling their duties even to a
limited extent. If the food is in excess in quan-
tity or' contains a superabundance of albuminous
material in an indigestible form, such as butcher's
meat, then as a matter of course that portion which
is not dealt with by the digestive fluids will pass into
the intestine as effete matter in a highly decom-
liosable form. There we know it will be liable to
undergo fermentation of a most noxious description.
Now if this putrid mass is retained in the colon for
an undue length of time — and this is invariably the
case in persons prone to cancer — absorption of the
fluid portion takes place and autotoxemia is the
result. The various organs of the bodv are there-
fore deprived of their normal pabulum and instead
are supplied by a vitiated blood stream. Is it to be
wondered at then that they fail to fulfill their im-
portant duties? And when it is remembered that
the nervous system is necessarily handicappP'l I'rnin

26o

MEDICAL RECORD.

[Feb. 1 6, 1907

the same cause we can easily conceive to what
extent the resisting power to disease of any descrip-
tion is reduced. We are unable, therefore, to look
upon trypsin as an antitoxin so far as cancer is con-
cerned, though we are aware that the secretion of
the pancreas, like that of the stomach and liver, is
antiseptic to a certain extent. This antiseptic, how-
ever, is quite incapable of preventing the forma-
tion of toxins in the intestine, for the reason that
as a rule the quantity of the food consumed is far
in excess of the requirements of the body and of
a character which the various gastric secretions are
quite unable to deal with in a satisfactory manner.
It would therefore, I think, be inaccurate if trypsin
were described as an antitoxin which I am informed
has been suggested. The thyroid gland, on the other
hand, possesses decided antitoxic properties which
fact has been frequently demonstrated. It was only
yesterday I was told by a gentleman a surgeon had
said that a motion of the bowels was necessary
only once in three days. One can hardly imagine
it possible that any intelligent man would counte-
nance so flagrant a contempt of such an important
hygienic law as the daily evacuation of the intes-
tinal canal most assuredly is. The very idea of
carrying about in one's inside for three days a
putrescent mass, which he would not tolerate for
three minutes were it in sight, is beyond my com-
prehension. Depend upon it, it is ignorance regard-
ing this maxim and wanton disobedience to it
which constitute the primary factor in disease of
all kinds, and in cancer in particular. When, super-
added to this, the most flagrant errors in diet are
of daily occurrence, the danger is accentuated to a
most serious degree. It is to these causes that
must be attributed to a great extent the failure of
the organs of nutrition and the blood glands to
perform in an efficient manner the important duties
that have been allotted to them. The result is a
departure from the healthy to a morbid condition
of cell life in various parts of the body, and we
know this morbid tendency appears to be increased
at the seat of an injury or prolonged irritation, by
which the cellular tissue has been still further
weakened. It is in such circumstances that cells
which have departed from the normal standard are
enabled to assert their depraved individuality and
commence a new role of existence.

Now the effect trypsin is said to exercise upon
these morbidly affected areas goes to prove the
correctness of the views advanced by those who
for a long period have maintained that a malignant
cell is intrinsically weaker than a normal cell. It
goes without saying, therefore, that if we can by
any means instill an increase of vigor into the latter
we shall be enabled to subdue the former, and
this is one of the chief objects we should aim at
in our endeavor to subjugate cancer. But by far
the most desirable object to attain is its prevention,
and this I hold is within the grasp of any one who
will obey implicitly those laws which nature has
so explicitly formulated for our guidance.

The question naturally arises, does trypsin act
only on the local manifestation of the disease, and
does it exert such a beneficial influence as to reduce
the tendency to recurrence of the disease at a more
or less remote period ? Does it favor cell metabolism
to the extent of removing the tendency to revert
again to any future manifestation of malignancy
either in its previous seat or in any other locality ? I
fear not, as so far as is known trypsin or any other
ferment is incapable of exercising this power. It
is then on restoration of the functional activity of
the thyroid gland, together with a judicious diet.

alnmdance of fresh air, and careful attention to
the hygienic condition of the lower bowel that we
mu.st depend for recovery and maintenance of vig-
orous and healthy cell life. So far we have no
grounds for assuming that trypsin is capable of
exerting any influence whatever upon cell metabol-
ism, whereas we have the most conclusive evidence
to prove that the thyroid gland not only possesses
the power of inhibiting the effect of autotoxemia,
but also exercises a most potent influence upon
healthy cell metabolism. It is therefore of the first
importance in the treatment of cancer to aim at
restoring the functional activity of this gland and
at the same time to adopt measures whicJh will re-
duce the tendency to the introduction of to.xic ma-
terial from the intestines. Now the latter can only
be accomplished by adapting the dietary to the re-
quirements of the body and the capability of the
digestive organs to effect complete digestion and
assimilation, together with the thorough evacuation
of the effete matter at least once in twenty-four
hours. By this means the blood will be relieved of
an incubus which otherwise would exist, and the
various organs be enabled to obtain an uncontam-
inated blood supply which would enable them to
resume their functional activity, and possibly restore
their wonted efficiency. That the thyroid has an
important relationship to the incidence of cancer is
borne out by the fact that in cancer subjects it
is invariably found to be more or less atrophied,
hence it is necessary to supplement the modified
dietetic measures recommended by the administra-
tion of either thyroid gland substance or its active
principle. By these means we have reason to hope
the gland may recover its lost power and thus be
enabled to resume its physiological activity, which
is quite within the range of possibility.

It must not be inferred, however, that the thyroid
is the only organ whose utility is impaired in these
circumstances. The salivary glands as a rule be-
come more active, while hydrochloric acid is present
in the stomach in very much diminished quantity,
if it does not disappear entirely, and it is only rea-
sonable to suppose that the pancreatic secretion is
likewise to a certain extent in abeyance from the
same cause. In this way we may account for the
serious loss of weight which is so prominent a
feature in cancer, seeing the digestion must obvi-
ously be seriously handicapped, and therefore the
products available for assimilation reduced in quan-
tity. And if the proteids have not been converted
into peptones, but have passed into the intestines in
a condition which favors decomposition and there-
fore the development of enterotoxins. these, finding
their wav by absorption into the blood, will assist
largely in giving rise to that condition which we
term the cancerous cachexia, and as a matter of
course will perpetuate the disease process by depriv-
ing the various organs of their healthy blood supply
and substituting a toxic fluid. It is not the first
time that I have sought to draw attention to the
importance of this factor as a most potent pre-
disposing cause of cancer, though perhaps not ex-
actly in connection with the treatment of this disease
as suggested by Dr. Beard. And I am convinced
that no treatment can ever prove successful unless
it is removed and not permitted to reassert itself.
It matters not what treatment we adopt, even though
it may appear to prove of ser^-ice for a time, if we
tail to restore the functional activity of those organs
which have been permitted to lapse into an un-
healthy condition.

No machine can possibly act efficiently unless all
its parts are in good going order. So it is with

Feb. 1 6, 1907]

MEDICAL RECORD.

261

the human organism. Doubtless it is capable of
submitting to considerable ill-usage with an elasticity
which is marvelous, but the breaking strain will
assuredly be reached sooner or later, and coincident
with it those morbid changes which we term dis-
ease, be it malignant or otherwise.

On December 12 Mr. Edmund Owen delivered a
lecture at the Royal College of Surgeons on "Can-
cer, Its Treatment by Modern Means," in which he
did not mention any of the modern means even by
name. The only method referred to was that of
surgery, which everyone knows has seldom given
permanent relief and usually succeeds only in aggra-
vating the suffering and shortening the life of the
patient. He also spoke in anything but a charitable
manner of those who have studied not only the
local symptom of the disease — which is all the sur-
geon takes cognizance of — but the conditions which
have led up to this. He would appear to apply the
term quack to those who are just as well aware
as he is that surgery has proved quite incompetent
to deal successfully with cancer, but who have
relied upon dietetic and therapeutic measures, and
who in consequence have received much more en-
couraging results than surgery has ever been able
to achieve. For my part, I would feel much more
inclined to apply the term "quack" to a man who
takes a fee for an operation which he knows for
a certainty will only result in failure. The surgeon
ought to be aware of the fact, if he is not, that long
prior to the local tangible appearance of the disease
the conditions which have permitted this to assert
itself were latent in the system and that in the
majority of instances a direct injury or prolonged
irritation, weakening the part, permitted the disease
to proclaim itj presence in the enfeebled tissue.
How then, may I ask, can it be reasonably expected
if no measures are adopted to remove the casus
morbi, that the greater injury caused by the knife
will not have a much more disastrous effect upon the
vitality and resisting power of the mutilated tissues,
thus inviting recurrence which almost invariably is
the sequela.

We have now learned that cancer, as we recognize
it, is the culminating point of a series of changes
which have taken place, seriatim, in certain impor-
tant organs, consequent in the first instance upon
their being compelled to rely upon a vitiated blood
supply, this having been brought about to a great
extent by gross negligence of hvgienic laws and
overindulgence in articles of diet which are unsuit-
able to our digestive apparatus.

IS Half Moon Street. W.

INTRANASAL CONDITIONS AS BEARING

UPON THE ETIOLOGY OF DISEASES

OF THE EAR.

By G. HUDS0N-M.\KVEX. M.D..

PHILADELPHIA.

PROFESSOR OP DEFECTS OF SPEECH IN" THE PHILADELPHIA POLYCLINIC

HOSPITAL AND COLLEGE FOR GRADUATES IN MEDICINE; AND LAR-

Y.N'GOLOGIST AND OTOLOGIST TO THE CHESTER HOSPITAL AND

TO THE FREDERICK DOUGLASS MEMORIAL HOSPITAL.

It is now nearly twenty years since Wilhelm
Meyer first pointed out the close relationship be-
tween nasopliaryngeal obstructions and diseases
of the ear. and his monograph on the subject was
epoch making and exhaustive. It called attention
for the first time to the interdependence not only
of nasopharyngeal and aural diseases, but also of
nasopharyngeal and laryngeal diseases: and it
served to make clear the utter uselessness and folly
of attempting to cure the great majority of diseases

of the ear and larynx without at first taking into
consideration the conditions in the nose and pharynx.
It did as much as any other one thing to divorce the
eye and ear in the common practice of specialists,
and to join the nasopharynx with both the ear and
the larynx.

Formerly we had eye and ear specialists and laryn-
gologists, but no rhinologists. Now a more fitting
and comprehensive title, both from an anatomic
and pathologic point of view, would be rhinopharyn-
gologists, because the rhinopharynx not only oc-
cupies a position midway between the other four
important cavities, the nose, mouth, ear, and larynx,
but is itself the starting point of many, if not the
majority, of the diseases of these cavities.

In the light of recent experience and in these days
of preventive medicine, it is to the rhinopharyngo-
logist that we look for the best results, for if we
can keep the nasopharynx in good condition and the
nasal accessory cavities well drained and ventilated
we shall eliminate not only the majority of aural and
laryngeal diseases, but also many of the ophthalmic
diseases as well.

The purpose of this paper is not to add anything
new to the literature of the subject, but to refresh
our memories of the things that are old, and to
direct attention to a few points of value that have
come under my observation bearing upon the rela-
tionship between the nose and ear.

That diseases of the ear, especially in their initial
stages, are largely dependent upon intranasal con-
ditions, is a fact well known to otologists, but it is
not generally recognized by practitioners of medi-
cine. In this connection the following points in the
anatomic and physiologic relationship of the ear and
nasopharynx can not be too often or too strongly
emphasized. The tubotympanum is a cul-de-sac or
sinus, occupying exactly the same relation to the
nasal cavity that the sphenoid, ethmoid, maxillary
and frontal sinuses occupy, and the lining membrane
of the tubotympanum is merely a continuation of
that which lines the nasal and accessory cavities.
Moreovet:, the physiologic relationship of the middle
ear to the nasal cavity is also similar to that of the
other sinuses. It has its drainage through the naso-
pharynx and it is aerated by means of naso-
pharyngeal respiration. There is a slight excursion
of the drum membrane during each respiration, the
motion being inward during inspiration and outward
during expiration.

The conditions in the nasal cavities giving rise to
acute diseases of the ear are, first, those causing dis-
turbances of nasal respiration ; second, those attend-
ed by suppurative intranasal and sinus inflammation,
and third, any condition which by pressure or other-
wise may give rise to reflex disturbances. The first
class includes hypertrophic and atrophic rhinitis, in-
tranasal growths, septal deflections and spurs, and
nasopharyngeal hypertrophies and tumors ; and the
damage to the ear is chiefly mechanical in its origin.
The second class includes all catarrhal conditions of
the nasal and accessory cavities, and the damage to
the ear is usually by continuity of structure. The
rhird class includes those conditions which give rise
to irritation of the terminal nerves in the nasal and
accessory cavities and set up ear complications by
so-called reflex action.

The tubotympanum is especially liable to damage
by mechanical forces acting upon its sensitive and
flexible membranes. The air pressure within the
normal middle ear being about equal to that in the
external auditory canal, and varying onl\' slightly
with each respiratory movement, the integrity of
the drum membrane is maintained ; but, when for

262

MEDICAL RECORD.

[Feb. i6, 1907

any reason, such as muscular insufficiency, or inflam-
matory deposition, tlie Eustachian tube becomes par-
tially or wholly occluded, the air pressure in the
middle ear diminishes, and the result is a retraction
of the drum memljrane and the beginning of a
catarrhal process in the tyni))anum and mastoid
cells. This condition may Ije so insidious in its
onset as to be scarcely noticed by the patient, but
to those of a sensitive nature there is generally a
feeling of fullness in the side of the head. The
Germans call this condition a "locked ear." It is
often accompanied by tinnitus and dullness of hear-
ing, and sometimes by pain.

The tubotypanum being an offshoot, so to speak,
of the nasopharyngeal cavity, the rationale of the de-
velopment of ear affections from the nasopharynx
by continuity of structure is readily recognized,
and calls for no special comment.

We now pass to the third class ; namely, that
in which intranasal conditions produce ear compli-
cations by means of reflex nervous action. This
part of the subject is none the less interesting be-
cause it is somewhat theoretic and problematic.
Reflex nervous affections, however, are established
facts. Every otologist, for instance, is familiar
with the nasal, pharyngeal and laryngeal irritation
arising from the use of a probe in the external audi-
tory canal, and, it being a poor rule that will not
work both ways, it is not unreasonable to suppose
that irritation or pressure upon the sensory nerves
of the nasal and accessory cavities will occasion
aural disturbances, such as deafness, vertigo and
pain.

An interesting and unusual case has come under
my own observation. The patient had a slight af-
fection of the septum with an exostosis, impinging
upon the inferior turbinal bone at the junction of the
posterior with the middle third. The symptoms
for many years were of little account, barring an oc-
casional attack of rhinitis when there was some
conscious obstruction to nasal respiration, but at
about thirty years of age there developed slight
tubal symptoms. There were brief sensations of
fullness in the ear and occasional vertigo. So tri-
vial had been the nasal symptoms that no connec-
tion between them and the aural disturbances was
at first suspected, but as the trouble continued it
was thought best to correct the nasal irregularity.
The spur was removed by my friend and colleague,
Dr. \\'alter J. Freeman ; the symptoms at once sub-
sided and have not returned. The above is a re-
port of my own individual experience, and I can,
therefore, vouch for its authenticity.

Severe pain in the ear may also be the result of
pathologic conditions in the nasal and accessory
cavities. Many illustrations of this fact might be
given. At the recent meeting of the British Med-
ical Society, in Toronto, Dr. St. Clair Thompson
said, that in several of the many cases reported of
aural pain due to sphenoidal disease, the mastoid
was suspected and even opened before the real
cause of the trouble was determined. This one re-
port, it seems to me, emphasizes in a striking man-
ner the importance of this discussion, and the neces-
sity for its frequent revival on occasions of this
sort.

The fact that so many diseases of the ear are of
nasal origin, however, must not lead us to over-
look those that develop in the ear itself, and the
fact that such brilliant results are obtained by treat-
ment directed to the nasal cavities must not lead us
to underestimate the value of treatment applied
directly to the ear. In other words, the otologist

should look beyond the ear in all cases of ear disease,
and the rhinologist should look beyond the nose
when aural symptoms present themselves.

1627 Waln'ut Street.

STREPTOCOCCUS PNEUMONIA.*

By G. W. McCASKEY. M.D.,

PORT WAYNE, IND.

i ROPESSOH OF MEDICINE AND CLINICAL MEDICINE, PURDUE UNIVERSITr:
PHYSICIAN TO HOPE HOSPITAL.

The role of the streptococci in general pathology
is very important. This is well recognized in sur-
gical practice, but in internal medicine not as much
so as it should be. Not long ago I reported in
the Cincinnati Lancet-Clinic a case of general-
ized fatal streptococcus infection, probably of in-
testinal origin, the incidence of the attack being de-
termined by a severe chilling of the body from
exposure, just as Pasteur's hen contracted charbon,
after being forced to stand with its feet in cold
water, by a dose to which it had been immune before
the resistance had been lowered by this treatment.
The intestinal tube contains streptococci in a large
proportion of normal individuals, and I have occa-
sionally found the numbers excessive without any
clinical manifestations. Under conditions of a favor-
able environment, created by altered secretions, con-
stipation, etc., their number may enormously in-
crease, making them, as they were in the case just
referred to, the predominating organism. The bac-
teriolysins of the blood, the phagocytes, and the liver
are ordinarily equal to the task of destroying the
not inconsiderable number of these and various other
microorganisms which run the gauntlet of the intes-
tinal epithelium and enter the portal circulation.
With lowered resistance, incidental to fatigue, expo-
sure, etc., this protection may fail and infections
occur which may be general in character or. sec-
ondarily localized in more or less distant areas, or
both.

It is thus that abscesses sometimes result from
latent foci of infection, their incidence being deter-
mined by local disturbances of the circulation from
various causes. In one case, for instance, in which
I made a diagnosis of brain abscess which was
opened and drained, I was able to demonstrate the
Eberth bacillus as the pyogenic organism, although
the patient had certainly not had typhoid fever for
eight or ten years before. This organism, as well
as others, may remain innocuous in deep seated
tissues for years and set up pathological processes
under favorable conditions. Streptococci, however,
are very nearly always present in some part of the
digestive canal. Several observers have found them,
for instance, in the mouth as well as in the intestines.

Streptococcus infection of the lungs is not a very
rare occurrence in generalized septic processes oc-
curring in the puerperal state as a result of trau-
matisms, etc. Such infections are usually localized
in character perhaps in the form of an abscess, or
may simulate the type of lobular pneumonia. In
fact, the clinical investigations of Finkler fully es-
tablished the occurrence of a tN'pe of pneumonia
caused bv streptococcus infection. Streptococcal
bronchitis had already been recognized, but his ob-
ser\-ations demonstrated clinically and pathologically
the occurrence of a cellular inflammation of the
lungs decidedly characteristic in type produced by
the streptococcus. In no case coming to autopsy
was the inflammation croupous in character, showing
a definite anatomical distinction between the lesions

*Read by title before the Ohio Valley Medical Associa-
tion, Louisville, Ky., October, 1906.

Feb. i6. 1907]

MEDICAL RECORD.

263

of this disease and those of lobar pneumonia. While
the anatomical distinction was clearly defined the
physical signs were not equally characteristic. In
one of his cases, for instance, he says, "Percussion
gave dullness over a wide area on the left side below
over approximately the lower half of this lobe. Aus-
cultation revealed bronchial breathing with very
fine crepitant rales." This would certainly fit a case
of genuine lobar pneumonia fairly well. The gen-
eral clinical course, however, was very erratic, some
of the cases showing a subnormal temperature,
others at times 103.5°.

If with physical signs, such as those above de-
scribed, a sharp rise of temperature would occur
simulating the initial stage of lobar pneumonia, the
distinction between the streptococcal and diplococcal
tvpes might be difficult or impossible. Such a tem-
perature curve in some cases of streptococcus infec-
tion is familiar to everv clinician. In fact, the case
referred to at the opening of this article began with
a chill and a temperature of 104° or 105°.

Such a case of pneumonia with the characteristic
onset and physical signs and clearly due to a strep-
tococcus infection has actually come under my own
observation. Following is the case

The patient, Mrs. , seen in consultation with

Dr. Kithcart, of Columbia City, February 17, 1905,
was the mother of four children, the youngest
being four months old. Was always healthy until
one week prior to my visit, when she was suddenly
taken with a chill after exposure during a long drive.
She was found by her physician with a tempera-
ture of 103°. For two days there was no cough nor
rales, although the temperature continued at about
103° to 104°. On the third day crepitant rales
were heard in the base gradually extending up-
ward, dullness on percussion onlv appearing a couple
of days later. At the time of my visit the patient
was mildly delirious, and had been for about three
days. Temperature, 103.5" • P"lse, 120. Blood ex-
amination showed leucocytosis of 27,300. The ex-
amination of the urine revealed both albumin and
casts due, as the sequel showed, to transient toxic
nephritis. I did not see the patient again, but the
course of the disease was favorable, the severe symp-
toms subsiding bv crisis. Two or three days later
the temperature suddenly dropped from 102° to
9Q.8°, and the pulse below 100, remaining so through
convalescence, which was uneventful, the lung clear-
ing up completely in about the usual time.

The bronchial secretions were found to be almost
a pure streptococcus infection. On the most careful
search not a single diplococcus was found, although
there were other cocci not arranged in either chains
or pairs.

The proof of the streptococcal nature of this case
appears to be conclusive, and is, in fact, precisely
the same as that upon which Finkler's decision was
based in his cases, yet clinically it corresponded very
closely to the ordinary type of lobar pneumonia. It
not only began with a chill and a sharp initial rise of
temperature, but defervescence occurred by crisis.
^\"ith regard to this latter point, however, a con-
siderable number of cases of lobar pneumonia disap-
pear by lysis instead of crisis, so that crisis cannot
be regarded as either essential or pathognomonic of
lobar pneumonia. Whatever may be the biochemical
explanations of crisis there seems to be no reason
why it might not occur with other than diplococcal
infections, and it actually did so in this case.

It seems quite probable that if bacteriologic ex-
aminations were more frequently made the dis-
ease clinically diagnosticated as lobar pneumonia
might often be found to be due to other infections.

The diplococcus is said by observers to be found
in only about seventy-five per cent, of the cases of
lobar pneumonia, which raises a very proper ques-
tion concerning the bacteriology of the remaining
twenty-five per cent. It is perhaps possible, although
it seems quite improbable, that an active agent in the
production of a pneumonia would not be found in
the sputum. Xetter found the l^iplococciis pneu-
monia: 82 times in 82 autopsies of lobar pneumonia,
although other observers have failed to find it with
the same uniformity. The possibility of the infect-
ing agent disappearing from the sputum is well il-
lustrated by a case of what was probably a strepto-
coccus infection of the lungs which I recently saw
in consultation with Drs. M. V. Replogle and J. U.
Riggs, of Bryan, O. There was localized consolida-
tion of the lower lobe of one lung with the indica-
tions of general sepsis, and yet the sputum failed to
show dipiococci or streptococci or any other active
pathogenic organism in numbers sufficient to justify
the assumption of their causal relationship to the
pulmonarv process. When I saw the case it was in
the twelfth week of a puerperal infection, which
a little later proved fatal. In another case which
I saw in consultation with Dr. N. T. Dean, of Hicks-
ville, O., the patient had been subjected to a minor
surgical procedure which had healed perfectly by
first intention, but there was an entirely groundless
suspicion on the part of the patient's friends that
the pneumonia might have been secondary to a
wound infection. I was able at the bedside to dem-
onstrate that the infecting germ was theDiplococctis
pnenmonice, which, although sometimes pyogenic,
has never, so far as I know, been demonstrated as
the agent of wound infection.

As illustrating the erratic manifestations of pneu-
mococcal infections, I might mention another case
seen in consultation with Dr. Powell, of Defiance,
O., in which the later clinical picture was that of an
intense septic infection. When seen by me in the
fourth week there had been chills occurring once
and sometimes twice a day, followed by high fever
(104°) and profuse perspiration, the temperature
preceding the chill being usually close to normal.
There was a leucocytosis of 28,000. Notwithstand-
ing this picture the sputum was very nearly a pure
culture of the Diplococcus pncuinonicc, which in all
probability had assumed a pyogenic role, and the
case was really one of sepsis due to this organism,
which proved fatal.

In some of the cases of streptococcus pneumonia,
as pointed out by Finkler, there is no expectoration
at all.

In conclusion attention should be called to the fact
that streptococcus pneumonia may simulate other
diseases as well as lobar pneumonia. In a series of
cases observed by Wasserman practically all had
been sent to him with a suspicion of tuberculosis,
and in some of Finkler's cases the resemblance to
tvphoid fever was verv striking.

Rapid Recovery from Dry Pleurisy by Treatment
with Iodide of Potassium. — L. Jacquet and Luzoir
have observed three reniark.ible cases of resohitioii in dry
pleurisy from the action of iodide of potassium. In one of
tliem especially the friction sounds were extraordinary in
tlieir intensity and could be heard quite a distance from the
thorax. These bruits disappeared in some days under
the exclusive influence of this drus. The phlegrmasia dated
back three weeks, and the loud sounds extended over a
large part of the right pleura. Iodide of potassium was
administered at first in the dose of one gram and two
days later pronounced improvement was evident. The
treatment was continued with increasing improvement.
Although this method is not entirely new, it deserves to be
emphasized. — Lc Bulletin Medical

264

MEDICAL RECORD.

[Feb. 16, 1907

REPORT OF THREE EPIDEMICS OF MEA-
SLES, WITH PARTICULAR REFER-
ENCE TO KOPLIK'S SYMPTOM
AND ITS RELATION TO THE
RASH AND THE INITIAL
FEVER.*

Bv CHARLES J. DILLON, M D..

NEW YORK.

Ten years ago Koplik^ first published his observa-
tions on the occurrence of a buccal eruption in mea-
sles, and, fullv conscious that this is a late hour to
attempt to supplement his studies, it is only for
whatever of interest you may find therein that I
wish to present the followin.gf statistics compiled
from the records of three epidemics of measles in
institutions for children.

The diagnostic value of Koplik's symptom seems
to be quite generally conceded by the pediatrists of
America and England, but not bv any means so well
credited by the French and German diagnosticians,
if we are to judge from the communications on the
subject in the technical periodicals for the last three
or four years. .'\n idea of the confusion which ex-
ists concerning the value of Koplik's symptom may
be formed from a brief consideration of the recent
observations of a few prominent investigators.

In England, Balme," in the fall of 1904 published
his observations of 214 cases of measles, in which
he found the spots 209 times ; in 95 cases examined
in the prodromal stage they were present in 93, an
unusually favorable report. Although English phy-
sicians as a whole have regarded Koplik's symptom
with more favor than have those of the continent, it
is worthy of note perhaps that as late as January.
1904, Eustace Smith,^ in describing two cases of
second measles infection, did not include observa-
tions of the buccal mucosa for this diagnostic sign.

.■\bout the same time Variot,'' writing from Paris,
asserted that the buccal eruption described by Kop-
lik was of very doubtful value as an early diagnostic
sign of measles, and claimed that the majority of his
associates in the S^ociete de Periatrice agreed with
him.

Manassa° had stated, a few months previously,
that he believed the spots to be a very valuable diag-
nostic sign and present in the majority of cases ;
curiously, though, he describes the spots as occur-
ring on the palate as well as on the mucosa of the
cheeks and lips, a description which does not agree
with that of Koplik.

.■Kronheim," on the other hand, in July. 1903, from
his studies of 130 cases, manv of them in the pro-
dromal stage, concluded that Koplik's symptom was
of no great value, he having found it only in 9 cases.

Miiller,' in 1904, reported his observations during
an epidemic at Marburg, where he found the symp-
tom in 134 out of 166 cases examined; he recorded
the observations of Perkel. who found the spots in
32 out of 33 cases examined in the prodromal stage,
and in 67 out of 92 cases examined in the eruptive
stage. ISIiiller also noted the observations of Roily,
who found the spots in 67 out of 78 cases, in 24 of
which they were seen from six hours to four davs
before the ."^kin eruption.

P)riinning,'' in March, 1905. declared that Koplik's
svmptom was of great value, that it was seen in no
disease but measles, and that it was frequently over-
looked. Briinning believed that the earlv detection
of the spots would be of service as a prophylactic
measure, but Cotter, some time before, while de-

*Paper read at a meeting of the Pediatric Section of the
New York .Academy of Medicine, December 13, 1906.

scribing a measles epidemic at the New York
Foundling Hospital, had demonstrated that this
hope was hardly warranted.

Cotter" published an analysis of 187 cases, in 169
of which Koplik's spots were positively present,
their occurrence was doubtful in 10, and they were
absent in 8 ; he noted that they appeared from five
days to twenty-four hours before the skin eruption ;
in two cases, however, the spots appeared after the
rash, and one case presented the spots and ran a
febrile course without a rash.

Merk,'° Professor of Dermatology at Innsbruch,
late last year (1905) recorded a series of cases, five
in all, occurring in one family, in none of which had
he found Koplik's. 'Slerk was interested in the
cases l)ecause only three exhibited a rash, two run-
ning their course without a rash, but subsequently
developing urticaria.

Piallico," assistant to the chair of Pediatrics at
Parma, in 1905, reported that in the examination of
63 cases of measles he found the symptom with cer-
tainty only thirty-four times ; he does not accept
the spots as very definitely diagnostic, and points to
several reports of their having been noted in cases
of rubella, pertussis, varicella, and tonsillitis. Bal-
lico also sums up the experiences of several observ-
ers in the following truly motley array of percen-
tages : The symptom was noted by Sippel in 98
per cent, of the cases ; by Averbach in 85 per cent. ;
bv Widowitz in 86.6 per cent. : by Michellozzi in
18.7 per cent. ; by Havas in 8.25 per cent. ; by Aron-
heim, in the series mentioned before, in 6 per cent.

At the New York Foundling Hospital in the
spring and summer of 1905 a small epidemic of
about 60 cases, and an epidemic of about 200 cases
in the spring of 1906. furnished the bulk of the ma-
terial for this studv. .\n additional opportunity for
observation was aftorded by an epidemic of about
85 cases in another institution for older children,
ranging from five to fourteen years, during the
recent summer (1906).

Frequency. — From the records of 230 of the
Foundling Hospital cases in which the presence or
absence of the spots was noted, they were definitely
present in 217, doubtful in 2, and absent in 11. But
owing to a tendency of the buccal eruption to fade
early, sometimes, indeed, before the appearance of
the skin eruption, and frequently before the rash has
fullv bloomed, it is only fair to state that in 8 of the
1 1 cases in which the spots were not found they
were not sought until the rash had begun to fade, in
one other case the rash was just at full bloom, leav-
ing only 2 cases in which the spots were definitely
absent throughout the whole course of the disease.

In the 85 cases studied in the institution for older
children the symptom was found in every case, with
the exception of a few that were not examined until
the skin eruption had begun to fade.

The sequence of Koplik's symptom and the skin
eruption was studied in 154 of the Foundling Hos-
pital cases and it was noted that the Koplik spots ap-
peared four days before the rash in 5 cases : three
days before the rash in 5 cases : two days before
the rash in 29 cases; one day before the rash in 70
cases ; less than one day or synchronous with the
rash in 42 cases ; twenty-four hours after the rash in
3 cases.

In these chiklren the very first erythema on the
forehead or behind the ears was taken to be the be-
ginning of the rash, and it will be seen that the spots
on the buccal mucosa preceded the appearance of the
exanthem by only twenty-four hours or less in the
majoritv of the cases (112).

The duration of Koplik's symptom in 112 cases

Feb. i6. 1907]

MEDICAL RECORD.

26.:;

in which the condition of the buccal mucosa was
observed during the whole course of that disease
was found to be one day in 4 cases ; two days in 28
cases ; three days in 48 cases ; four days in 28 cases ;
five days in 2 cases; six days in 2 cases; the major-
ity of the cases exhibiting- the symptom from two
to four days.

Early Disappearance. — It was found at the same
time that in 99 cases in which the spots had been
noted before the appearance of the rash they had
disappeared in 5 cases before there was any sign
of a rash, a significant fact when we reflect that if
these cases had come under observation only with
the appearance of the rash they would have been
classed as cases in which Koplik's symptom was
absent. It was a very common occurrence to have
the spots disappear before the rash had reached the
maximum intensity. In 141 cases with a full-blown
rash the spots had already faded in 55 cases, more
than a third ; disapi^earing three days previously in
2 cases, two days previously in 2 cases, twenty-four
hours before in 13 cases, and less than twenty-four
hours before in 38 cases.

Altogether there can hardly be a doubt that Kop-
lik's symptom is a valuable and consistent early
symptom of measles and a diagnostic aid" of the
greatest importance. As to the value of the symp-
tom in prophyla.xis, the observations at the Found-
ling Hospital during the last two epidemics did not
tend to confirm the hopes of Briinning and others
on this point.

Frequent and careful examinations of exposed
children were made and cases presenting suspicious
spots on the buccal mucosa were immediately re-
moved from the nurseries but without avail, the epi-
demics were not checked, and it seemed certain that
infected children were capable of spreading the
contagion long before they presented Koplik's spots.
Instances where epidemics have apparently been
checked by the removal of cases presenting the spots
might have their explanation in an unusual degree
of resistance possessed bv the children exposed.

In the course of an ejjidemic in an institution it
would seem that greater possibilities in the way of
prophylaxis are offered by the thermometer test
than by any other. For instance, at the Foundling
Hospital about forty-eight children in a nursery,
few of whom had already had measles, were acci-
dentally exposed to infection ; the primary case
when detected showed a number of Koplik's spots
and a beginning rash, and was immediately re-
moved. .\fter a period of seven davs the tempera-
ture of each child in the nursery was taken per rec-
tum twice a day and any child showing a rise in
temperature was immediately removed and isolated
as a suspected case. By this plan six children were
removed from the nursery from nine to tv^^elve days
after the removal of the primary case, all subse-
quently developed measles, and no other cases oc-
curred in the nursery. One of the 6 cases had fever
five days before the Koplik's spots and six days be-
fore the rash ; two had fever thirty-six hours before
the spots ; two twenty-four hours before ; and one
less than twenty-four hours before the spots.

In all probability the febrile movement of the
prodromal stage almost invariably precedes bv a
considerable period the appearance of Koplik's
symptom, and its recognition would be of greater
prophylactic value than the detection of the spots.

From these observations it would seem that :

I. Koplik's symptom is a constant, definite, earl\-
diagnostic sign of measles, of greater diagnostic
value when present than even the rash. The con-

stancy of the symptom is indicated by the fact that
in 221 cases observed from the period of incubation
well into convalescence it was definitely absent only
twice.

2. Koplik's spots sometimes disappear before
there is any sign of a skin eruption, and frequently
before the rash has fullv bloomed.

3. Cases seen in the earliest stages and present-
ing but few Koplik's spots as yet are known to have
infected exposed children, and for this reason the
earlv detection of the spots can hardly be expected
to prove a prophylactic measure of any great value.

4. Koplik's symptom is usually, if not always,
preceded by a febrile movement, and the thermome-
ter would seem to be the best aid to early diagnosis
when dealing with an epidemic in an institution.

REFERENCES.

1. Koplik: Archives of Pediatrics. December, 1906.

2. Balnie ; Practitioner, London, October, 1904.

3. Smith: S)(/i.!/i il/rrfica/ /()»r)m/. January, 1904.

4. Variot : Gazette des Hopitaux. ]s.\m3.Ty, 1904.

5. Manassa: Die Heilkunde. October, 1903.

6. Aronheim : Miinchencr mcdizinische ]Vochenschrift,
July, 1903.

7". Miiller: Ibid.. 1904.

8. Briinning: Deutsche mcdizinische Wochenschrift,
March 9, 1905.

9. Cotter: Archives of Pediatrics. December, 1900.

10. Merk: Zeitsehrift fiir Heilkunde. 190$.

11. Ballico: La Pediatria, igos.
206 West Ninetv-fifth Stref.t.

TFIE RADICAL CURE OF TRIGEMINAL

NEURALGIA BY MEANS OF PE-

RIPHER.\L OPERATIONS.*

Bv ALEXIS v. MOSCHCOWITZ, M.D.,

N'EW YORK.

.\DJUXCT ATTE.VDING SL'RGEO.N. MOUNT SINAI HOSPITAl..

In an article entitled "The Surgical Treatment of
Trigeminal Neuralgia," which appeared in the
Medical Record. September 29, 1906, I discussed
in detail the reasons for the recurrences after opera-
tive treatment, and also made suggestions as to
the best methods of obviating these post-operative
recurrences. At that time my arguments were based
on a rather limited experience and on a careful
study of the literature in regard to the pathological
findings in cases of reported recurrences. Since
then it has been my good fortunte to operate on
three cases of trigeminal neuralgia by the methods
suggested in that article, which I wish to place on
record.

Before describing these cases, it will perhaps
not be amiss to again recall in brief the most salient
points whereby I have arrived at mv conclusions.

I. We know nothing of the pathological anatomy
of trigeminal neuraltjia. 2. All proof is lacking,
that the neuralgia originates in the Gasserian gan-
glion. 3. All proof is lacking, that the neuralgia
is of central (cerebral) origin. 4. Cures, so-called,
for a longer or shorter oeriod, have been reported,
even after minor peripheral operations. 5. Re-
lapses, after a shorter or longer period, have been
reported, even after such major operations as the
extirpation of the Gasserian ganglion, even in the
most competent hands. 6. In the present state
of our knowledge we know of no positive cure ; all
our treatment must be symptomatic, and we can
best attain this by interrupting the conduction of
the sense of pain from the affected area. 7. All
recurrences have been found to be due to a regen-

*Cases presented at the Surgical Section of the Academy
of Medicine, December 7, 1906.

266

MEDICAL RECORD.

[Feb. 1 6, 1907

eration and reunion of the divided nerve tissues.
Every one of these points is an absolute fact, as
far as our present knowleds^e permits, and does not
require theorizinsj or Icn.sjthy arg-ument ; it follows,
therefore, that : 8. The desideratum at present is.
to prevent reg^eneration and reunion of the divided
nerves.

Fortunately, most of tlie terminal endings of the
trig-eminal nerve make their exit from the skull
throug-h bonv foramina. This naturally suggests
the possibilitv of dividing the nerve in the canal,
and preventing the reunion by permanently plug-
ging up the foramen of exit.

After discarding various methods I have devised
the following means for a permanent closure of
the foramen : Messrs. Tieman & Co. prepared for
me silver buttons, each consisting of a flat top not
more than perhaps one-sixty-fourth of an inch in
thickness, and of a diameter of about one-quarter
of an inch ; it is sufficientlv firm to retain its shape,
and yet sufificiently malleable, so that it will give,
if lightly hammered upon. In its center there is
annealed a silver rivet, ranging in thickness from
one-thirtv-second of one inch to one-eighth of one
inch, and about three-eighths of one inch in length.
These buttons are shown in the accompanying illus-
tratiiin.

The operation in appropriate cases consists in
the following steps : Through an incision of suitable
length, half to one inch, the foramen in question
is exposed. The nerve is then carefully isolated
from the accompanying vessels ; a short length is
drawn out of the foramen, in order to be sure that
the nerve will retract sufficiently from the surface,
and it is divided. The accompanying vessels are
treated in a similar manner, after double ligature.
--\ button of suitable diameter is selected and driven
into the foramen, so as to fill it completely. As
some foramina are not absolutelv round, the over-
hanging flat top is now moulded to the underlying
bone, so as to make the closure absolutely tight.
The small cutaneous incision is closed with fine
silk. If necessarv the entire operation can be
done in local anesthesia.

The cases I have operated in this manner are
the following :

Case I. — Mrs. B. C, fifty-eight years of age,
was referred to me by Dr. Wilonski, with the diag-
nosis of left-sided trigeminal neuralgia. The pain
had existed for a number of years, and had been
variously treated both bv local and internal medica-
tion : most of the teeth, both of the upper and

lower jaw, had been extracted. On my first exami-
nation I discovered a large polypus filling the left
naris, and in order to exclude this as a possible
source of the neuralgia it was removed, but with-
out benefit. One month later she was admitted to
Mount Sinai Hospital, in the service of Dr. Gerster.
During her preoperative stav at the hospital we
found that the attacks of neuralgia occurred at very
frequent intervals, sometimes every few minutes ;
that the pain was very severe, and was distributed
over the entire left side of the face and scalp, in-
volving all three divisions of the fifth nerve. Press-
ure upon the supraorbital, infraorbital, and mental
foramina was particularly painful. The left half of
the tongue was also painful. Physical examination
otherwise was negative ; the patient w-as emaciated,
weak, and decrepit in appearance, so as to preclude
the possibility of any major operation. The patient
was operated upon September 17. The mental, in-
fraorbital, and supraorbital foramina were exposed
in the order named, by small transverse incisions ;
the nerves divided, and the foramina plugged by
means of silver buttons. When the patient reacted
fully from the anesthesia, the pain had completely
disappeared, and has not returned since. Primary
union resulted, and patient was discharged entirely
free from symptoms on September 23. The patient
presents herself from time to time ; thus far there
is no return of the neuralgia. The buried metal
causes no discomfort wdiatever.

Case II. — j\Iiss A. G., sixty-seven years of age,
was referred to me by Dr. H. S. Hart of Cam-
bridge. N. Y. The neuralgic pains date back some
six years, and for a long time were localized to the
left cheek : gradually thev extended upon the fore-
head and scalp; as far as could be ascertained the
third division was not involved. .A.t present the at-
tacks come on at very frequent intervals ; the
slightest touch of the face or scalp being sufficient
to bring on an attack. All the teeth had been ex-
tracted. I operated November 22. After exposing
the left infraorbital foramen, and after division of
the nerve, I plugged up the foramen with a silver
button. I then exposed the supraorbital nerve, but
finding only a notch instead of a foramen, had to
content myself with an evulsion of the nerve. After
the operation, the patient was free from pain, ex-
cepting in a verv small area upon the cheek, proba-
bly supplied by the malar nerve. Primary union re-
sulted and patient was discharged December i. On
account of an absence of the supraorbital foramen,
this case cannot be considered as cured, not even
tentatively. It is, however, not impossible, in view
of the fact, that the second division was primarily
and mainly involved, that the neuralgia in the
frontal region w'ill cease entirely, after the iritation
from the second division has been excluded.

My third case, though chronologically the first
one, was not operated upon with the silver buttons;
it should, however, be mentioned in the same class,
because the underlying principle is the same.

C.\SE III. — H. F., fortv-six years of age, was ad-
mitted to the hospital in the service of Dr. Gerster
September 26, 1904. He gave a history of neural-
gia, involving the left inferior dental nerve, extend-
ing over a period of several vears. All of the teeth
had been extracted in vain efforts to modify the at-
tacks. He was operated ipon September 29 in the
following manner : Through an incision about one
inch in length, extending from the agle of the jaw
forward, along the inferior border, the attachment
of the masseter was exposed, especial care being
taken to avoid any injury of the branches of the
facial nerve. The masseter and underlying perios-

Feb. 1 6, 1907J

MEDICAL RECORD.

267

teum were peeled up from the bone and retracted ;
a groove was now chiseled into the outer surface
of the ascending' ramus of the jaw, exposing the
nerve in its canal ; about one inch was then resected,
and the wound closed without drainage. Primary
union resulted, and patient was discharged October
16, relieved of his symptoms. The unusual length
of stay at the hospital was due to the fact that at
the same time he was operated for a right inguinal
hernia. The patient was entirely free from symp-
toms for nine months, when the neuralgic pains re-
turned in their original severity. He was readmit-
ted in July, 1905. The preliminary steps of the old
operation were repeated ; when the groove in the as-
cending ramus of the lower jaw was exposed, a re-
generated ner\e. of apparently normal appearance
and size was found : about one and one-half inches
of it were again resected. Just before closing the
wound, the idea occurred to me, that just as the pa-
tient was not cured by the first operation, the
second one would also be inefifectual, unless some-
thing were done to prevent regeneration and re-
union. Horsley"s wax occurred to me at first, but
I discarded it, because I feared that it would be ab-
sorbed too quickly. I thought of silver foil as a
suitable material, and therefore packed the cavity
full of this material. Primary union resulted, and
patient was discharged two weeks later. Again his
stay at the hospital was protracted by a radical
operation for inguinal hernia, this time on the left
side. The patient was again free from all symp-
toms for about nine months, when the pain re-
turned, though in a considerably diminished de-
gree; gradually the pain became severer, particu-
larly at night. He was readmitted July 16, 1906.
The patient was prepared for and willingly as-
sented to an intracraneal operation, but finally a
peripheral operation was again decided upon. .V
skiagraph at this time failed to show the presence of
the silver. Operation July ig. The preliminary
steps were the same as in the two previous opera-
tions. When the groove in the ascending ramus of
the lower jaw was exposed, some silver foil was
found in it, but evidently insufficient to give a
shadow on the skiagraph, and insufficient to pre-
vent regeneration and reunion ; it was intimately in-
corporated with the cicatrical tissue filling the canal.
It was again extirpated, and the groove firmly
plugged with silverfoil, taking particular care to
exert firm pressure into each angle, where presuma-
bly the ends of the nerve were. Primary union re-
sulted, and patient was discharged July 25, free
from all pain.

He presents himself from time to time; thus far
there is no recurrence. He still complains of a
paresthesia in the region supplied 1iv the lingual
nerve, but only in a very slight degree.

I do not present these cases as cured cases of
trigeminal neuralgia : the period of observation is
altogether too short to admit this deduction. It can
be safely argued, howevei . that theoretically, at all
events, there is no reason whatsoever why there
should be a recurrence of the neuralgia.

Laryngeal Tuberculosis.— The local application of
formalin is very highly spoken of by Lockard, who
states that the remedy possesses the following advan-
tages: It surpasses all other bactericides in solutions of
a strength which can be tolerated. In tuberculous ulcers
It is fully the equal of, and probably superior to, lactic
acid. Its effect upon vegetations is prompt and pro-
nounced. It possesses some anesthetic properties. It
is the only remedy of the curative class that can with
safety be placed in the patient's" hand, thus maintain-
iii.g a continuous cleansing, germicidal, and stimulant
action. — The Laryngoscope.

PNEUMONIA IN CHILDREN: ITS SUC-
CESSFUL MANAGEMENT BY HYDRI-
ATRIC MEASURES.

WITH AN ILLUSTRATIVE CASE.
By W. PARKER WORSTER, A.M., M.D,.

NEW YORK.

INSTKrCTOK ON ELECTROTHERAPEUTICS NEW YORK POST-GRADUATE
MEDICAL SCHOOL AND HOSPITAL.

It is most notable that pneumonia yields with
promptitude to treatment intelligently applied at
an early stage of the attack. Or if the physician is
not called until absolutely too late, he can readily
save the patient by proper means of management ;
but his best efforts will be futile most certainly if
he starts out \yith the false idea that he has to cope
with a case of lung disease. Wherever, whenever,
and by whom the doctrine is adopted that pneu-
monia is not an inflammatory process ; that pneu-
monia is not a lung disease, any more than typhoid
fever is a bowel disease, but that it is an infectious
disease whose chief manifestation is in the lung,

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Chart of Case ot Piicumnnn

dependent upon a toxemia evolved in an infection
proces.s, then the disease will cease to be treated,
and the physician is prepared for the more etfective
management of the patient suffering from it, with
the result of promoting rapid recovery and saving
life. That effective management is by means of
water judiciously and properly applied. It is to be
regretted that there are some ph\'sicians who, emu-
lating the fireman who quenches a fire by drowning
it, think they should do the same thing in pneu-
monia, by pouring at the spot where the symptom
seems most troublesome sledge-hammer blows of
allopathic medicine, or if their school forbids that,
they must anoint that spot homeop.-ithicall)' ; either
method adds fuel to the fire, and the fiatient dies,
of heart-failure. This feart feebleness arises from
a paralysis of the vasomot'Tr nerve centers, ami not
of the heart itself, by reason of which the capillary
blood-vessels lose their elasticity- and normal tone,
which are essential to a properl\ acting vasomotor

268

MEDICAL RECORD.

[Feb. i6, 1907

system ; the poor heart which is laboring to com-
pensate for that loss of elasticity becomes worn out,
resembling- the driving wheels of the locomotive
which have lost their resistance by slippery tracks,
and fly around ineffectually, racking the machinery
and destroying its usefulness.

Hydrotherapy counteracts collaj)se of the vascular
walls, consequently there is no such thing as heart
failure : the pulse has always gained in tension after
each treatment, ajid no patient is too weak to bear
hydrotherapy properly administered, varying it ac-
cording to his condition. Nature has provided its
own simple and effective remedy for pneumonia —
water. Water will promptly and effectively execute
its functions whenever proper, just as reflex action
will promptly respond to any proper call. The toxic
agent circulating in the blood in pneumonia (the
diplococcus) produces a toxemia, and that toxemia
spends its full force upon the nerve centers which
govern the functions, thus impairing the organs
dependent upon them. The object of treatment is
to bridge over the danger which would arise from
the failure of these functions by enhancing the
patient's vital powers until the life period of the
diplococcus is terminated, which is about seven days.
The cold bath comes to the rescue, because cold
applied to the peripheral nerve terminals of the skin
produces a shock to them, and a stimulus to the
sensory fibers of the skin which is conveyed to the
central nervous system, which in turn sends out a
reflex stimulus to the nerve centers which govern
respiration, circulation, digestion, tissue building,
and excretion, the five life-saving functions upon
whose capacity the patient depends to withstand the
toxic agents circulating in the blood. The mere
lowering of the temperature is a secondary consider-
ation, but the temperature is reduced, respiration
deepened, cardiac action improved, and pulse slowed
and rendered less dicrotic.

In the earlv stages of pneumonia in children we
give the full bath, begiiming when the temperature
reaches 102.5° with a bath at 95° every four hours,
reducing the temperature of each bath two de-
grees until it reaches 80°, but not going below 80°,
with due regard to the effect produced. \\'ith the
bathing there should be plenty of good, hard thermic
friction, which is the sine qua n07i in all cold baths.

If dyspnea, somnolence, stupor, and delirium
should occur, a little different method is used. The
child is held in water enough to cover its hips at
100° for five minutes : after which several basins of
water, having been prepared and in readiness at 70°,
are held high up (the operator standing preferably
upon a chair so as to get as much w^eight to the water
as possible) are poured upon its shoulders. This can
be repeated every two hours if necessary, but it is
seldom necessary, for the effect is magical ; the
patient is aroused to consciousness, the eve bright-
ens, inspiration is deepened, and the nervous system
is refreshed as by no other remedial agent. This
procedure is called an affusion, and should be used
when any head symptoms make tlieir appearance.
The following case illustrates exactly how a child
can be successfully managed when affected .with
pneumonia. Hydrotheraphy furnishes always the
safest and most reliable antithermic results. Each
bath generally reduces the temperature two or three
degrees, and through the temperature, of course,
rises again, it is generally not so high, although it
may exceptionally be somewhat higher than it was
before. Ijut, whatever the immediate effect may
be, the baths are repeated until the temperature is
finally reduced to normal, and remains there in the
morning.

On the morning of November 26, 1906, at 4
o'clock, I was summoned to see C. — S. — . aged
seventeen months. I found her temperature only
101.6"", with jactitation and dyspnea. The mother
told me that the day before it had some poncorn
in its mouth, and while it lay on its back on her
lap, by some sudden movement it had choked and
began to strangle. She held it up by the feet and
slapped its back violently for some minutes, head
downwards. I did nothing at that visit, but ordered
a teaspoonful of castor oil. At 8 a. m. I called
again, and found the child with all the symptoms of
croupous pneumonia, with a temperature of 102. 8°,
and I settled right down to the treatment of the
child. A bath at 95° was given for ten minutes, with
good, hard thermic friction. Also at 12 m., 4, 8, and
IIP. ii., reducing the temperature of the water 2°
each bath. That ended the first day.

November 27, baths at 2:30 and 9 a.m.; 12:40,
4, and 7:15 P.M.; the last three baths at 80°; no
bath all night. Slept well.

November 28, baths at 12:30, 5 and 8:30 p.m.. at
80°. Slept well all night. Coughed a good deal,
and painful.

November 29, baths at 2 and 9 p.m. at 80°. Slept
all night. Ordered compresses at 60°.

November 30, 7 p.m., the temperature having
risen to 103.2°, I gave a bath at 80°. Slept all night,
coughed a good deal.

December i. Bath at 4 :30 p.m. at 80°. Tempera-
ture 104.6°. 6:30 p.m. feet cold, delirium slight,
lies on its mother's lap face downw-ards, arms ex-
tended down over the head ; insomnolence and
stupor. Gave an aft'usion at 7 p.m. of five panfuls
of water at 65°. At 9 p.m. it was sitting up in bed
playing with its dolls. Ordered abdominal com-
presses at 60°. She slept well all night.

December 2. 9 a.m. temperature normal; child
sitting up in bed playing with its sister and toys.
8 p.m. temperature 101°. Ordered compresses at
60°. Slept all night; no compresses after 11 p.m.

December 3. 8 a.m.. temperature normal, and
child sitting up at breakfast table : she made a beau-
tiful recovery.

-A^ny W'atchful physician can obtain the same re-
sults, and every case of a child with pneumonia
can be managed successfully by the same means.
This child took in all seventeen baths, and one
affusion at 65°, and compresses at 60°. No medicine
of any kind was given except several small doses of
castor oil. more as a placebo to the parents than
for anv other reason. The diet, of course, was of
milk administered with precision in the proper
quantity every two hours.

If the temperature chart is followed, it will be
readily seen how the cold bath knocks the tem-
perature down 4^/2° in twelve hours, with no de-
pressing effect at all, such as always follows the use
of coal tar antipyretics, but. on the contrary, showing
a clear gain in favor of the patient. Just as the
physician varies the dose of strvchnine or any other
medicinal agent to suit the indications of his case,
so may the dose of water as regards variation of
temperature, duration, pressure, and method, be
varied to suit the reaction, age, and vital powers of
the patient.

Hydrotherapy is a power for good in infectious
diseases, before which all other remedies must stand
aside, and the physician who follows out the above
line of action need never fear for the final result,
for the reason that he is giving his little patient
the very best if not indeed the only chance for
its life,

621 We?t iroTH Street.

Feb. i6, 1907]

MEDICAL RECORD.

269

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, AM., M.D., Editor,

PUBLISHERS
WM. WOOD &. CO., 51 FIFTH AVENUE.

New York, February 16, 1907.

THE PURE. MILK PROBLEM.

It is a hopeful sign that the milk supply of New
York city is being made the subject of frequent dis-
cussion at public meetings and in the daily press.
There is a general agreement that there is danger
in the milk furnished to the city, but opinions differ
widely as to the best means of overcoming this dan-
ger. The newspapers call for pasteurization of all
the milk consumed, while the Health Commissioner
is quoted as opposed to municipal pasteurization and
as favoring a system of inspection of the sources of
the milk supply.

The milk which is brought to Manhattan every
day comes from some 30,000 farms scattered
through several States, some of these farms be-
ing 400 miles distant from the city. The milk
reaches the consumer from fourteen to forty hours
after it has been drawn from the cow. Some of
these places are regular dairies, with large herds
of cattle, others are small fanns, with from one to
half a dozen cows. A few of these dairies are
owned by wealthy men and are in the nature of
fads, their proprietors caring more for the scientific
keep of their cows and the absolute puritv of the
milk they produce than thev do for the profits of
their venture. Yet in order to maintain some sort of
relation between the debit and credit columns of
the ledger it is necessary to charge a price for the
products of those dairies which is prohibitive to all
but the rich. The milk from these model dairies is
as unobtainable by the poor as diamonds. The same
is true of the milk from the commercial dairies
which is certified by the Milk Commission of the
County Medical Societ}'. Twelve cents a quart,
which is the price of certified milk, puts it beyond
the reach of the poor, even if there were enough of it
to supply them at any price. There arc 1,600,000
quarts of milk consumed in New York City every
day, and of this the total amount of certified milk
is only about 10,000 quarts — literally a mere drop
in the bucket. The work of the Milk Commission
is most commendable as insuring milk of good qual-
ity to those who can afford to pay for it, but it sug-
gests no solution of the problem of a pure milk sup-
ply for the masses. The minute supervision of a
portion of the milk supplied by a few of the larger
and better class of dairies is impossible of extension
to the thousands of few-cow farms supplying the
city. At present the Health Department has a force
of fourteen inspectors and the Commissioner has
asked for an appropriation to enable him to increase
this force to about one hundred. If he gets his
hundred inspectors, each one will have to look after

3(X) farms, and if he is able to inspect five every day
in the week he will call at each place once in two
months ; if he rests one day in the week and takes
a two weeks" vacation in the year, his visits will be
ten weeks apart, or five in the year. The hope that
such angel visits will keep the milk free from
tubercle or typhoid bacilli, or even from cow dung,
is, we fear, Utopian. The inspector, in his hurried
call, may be able to suspect the evidence of ad-
vanced tuberculosis in a cow or in a milker, and he
may by good detective work learn that there is a
case of typhoid fever in the farmer's family ; he may
even form a judgment as to the observance or non-
observance of the ordinary rules of cleanliness
about the cow barns, though it will be impossible
for him to inspect the actual process of milking in
more than two places in one day. Time will be
lacking for him to detect tuberculosis in the early
stages in either man or beast, and he can only sur-
mise from the general appearance of the place that
the milk cans are properly cleansed in boiling water.
If he is conscientious and filled with enthusiasm, he
may do good missionary work, but the inculcation
of habits of cleanliness in the average farm hand,
who hardly knows the meaning of the word and is
a stranger to all it implies, will be a work of time —
and in the meanwhile the rivulet of milk from this
contaminated source will carry its dirt and its germs
of disease to foul the great river of 400,000 gallons
which flows into the city at every dawn.

^^'e do not belittle the value of the inspection of
milk by the health authorities of this city. It is ab-
solutely necessary as a sanitary measure, and its
place cannot be filled bv pasteurization. Pasteuriza-
tion alone, for which the newspapers are crying, is
insufficient : the milk that is pasteurized must be
reasonably pure if the finished product is to be ac-
counted safe. The process destroys the pathogenic
bacteria present in the milk, but it does not affect
the toxins already elaborated by these germs, and
these toxins are poisons that may cause sickness and
death. In the course of time — years it may be —
the needed reforms in milk protection may be ef-
fected by the system of inspection ; but only after
repeated warnings and punishment by rejection of
the milk will the honest farmer be gradually brought
to a realization of the fact that obvious filth is ob-
jectionable and doesn't pay. Inspection is necessary
and will doubtless, if conscientiously performed,
bring about in the course of time betterment in the
milk supply ; it can never make it perfect, and so
long as a great part of the supply is derived from
small farms with one to half a dozen cows, where
economic conditions and tradition render scientific
methods impracticable, if not impossible, it will be
safer for the babies of this city if the essential in-
spection of the sources is supiilemented by pasteur-
ization of all milk sold, let us say, at less than ten
or twelve cents a quart. Such a price limit will ex-
empt the product of the certified dairies from the
necessity of pasteurization, and those who believe
in the nutritive superiority of raw milk will be
able to get what they want if they can alTord to
pav for it. Others, under a system of conscientious
inspection and pasteurization, will be assured
that the milk offered for their consumption is, if
possibly not so nutritious, at least free from the
germs of disease — a food and not a poison.

270

MEDICAL RECORD.

[Feb. 1 6, 1907

AN IMPORTANT DECISION REGARDING
THE PRACTICE OF MEDICINE.

The Appellate Division of the Supreme Court of
this State has recently handed down an opinion af-
firming the conviction of a self-styled "mechano-
neural therapist" of the illegal practice of medicine.
The appellant contended that he was not guilty
of the crime charged, namely, of ]jractising medi-
cine without being lawfully authorized and regis-
tered, inasmuch as he was not practising medicine
within the meaning of the statute, in that he neither
gave nor applied drugs or medicines nor used sur-
gical instruments. In his comment upon this con-
tention Justice Clarke said :

"To confine the definition of the words 'practice
medicine' to the mere administration of drugs or the
use of surgical instruments would be to eliminate
the very cornerstone of successful medical practice,
namely, the diagnosis. It would rule out of the
profession those great physicians, whose work is
confined to consultation — the diagnosticians, who
leave to others the details of practice. It is a well-
known fact that the disease popularly known as con-
sumption may, if discovered in time, be arrested, if
not entirely' eradicated from the system, by open air
treatment in the proper climate, and that in such
cases use of drugs has been practically given up.
Would the physician, in such a case, who by his
skill discovered the incipient disease, advised the
open air treatment, and refrained from administer-
ing drugs, not to be practising medicine ? It may be
difficult by a precise definition to draw the line
between where nursing ends and the practice of
medicine begins, and the Court should not attempt,
in construing this statute, to lay down in any case
a hard-and-fast rule upon the subject, as the courts
have never undertaken to mark the limits of the po-
lice power of the State or to have precisely defined
what constitutes fraud. What the courts have done
is to say that given legislation was or was not
within the limits of the police power, or that cer-
tain actions were or were not fraudulent."

The appellant had relied upon the case of Smith
vs. Lane, which was an action brought to recover
a sum which it was alleged the defendant had agreed
to pay the plaintiff for treatment of certain bodily
disabilities by means of manipulation. The referee
dismissed the complaint because the plaintiff was
imanthorized to practise medicine or surgery. The
case was appealed and the judgment was reversed,
Justice Daniels holding that what the man did in
no just sense constituted the practice of either medi-
cine or surgery. This was, however, a private con-
tract to perform certain .services for a certain sum,
and the public was not represented, and Justice
Clarke was of the opinion, based upon the general
current of the authorities throughout the country,
and upon an examination of the history and growth
of our own public health statutes, that the rule as
claimed to have been laid down in Smith vs. Lane
could not here apply.

"When we find," he concluded, "as in this case, a
defendant holding himself out by sign and card as
a doctor, with office hours, who talks of his pa-
tients and gives treatments, who makes a diagnosis
and prescribes diet and conduct and remedies, sim-

ple though they be, and who asserts the power to
cure all diseases that any physician can cure with-
out drugs, and also diseases that they cannot cure
with drugs, and who takes payment for a consulta-
tion wherein there was an examination and deter-
mination of the trouble — that is, a diagnosis — as
well as payment for subsequent treatment, even if
no drugs are administered, we must hold that he
comes within the purview of the State prohibiting
the practice of medicine without being lawfully au-
thorized and registered."

The importance of this opinion is greater than
may be apparent to those who do not know the dif-
ficulty that is often encountered in securing the con-
viction of an illegal practitioner through the ab-
sence of any judicial definition of wdiat constitutes
the practice of medicine and surgery. Mr. Champe
S. Andrews, counsel to the Medical Society of the
County of New York, has for years been trying to
get .some court of record to define the practice of
medicine. Though there have been a number of
appeals to the Appellate Division, the question was
never squarely raised there until the present case.
This opinion at last substantially establishes such a
definition, which will do more to help the County So-
ciety in its war against irregular practice and quack-
ery than can readily be imagined.

THE MANNER IN WHICH TUBERCULOUS

INFECTION OF THE LUNG

TAKES PLACE.

The question of why the pulmonary apices should
form sites of predilection for the growth of the
tubercle bacillus has given rise to much contro-
versial writing and many observers have endeav-
ored to furnish a plausible explanation of this clin-
ical fact. There are weak places in most of the
hypotheses that have been suggested, however, or
at least no one of them has seemed sufficiently
well grounded to justify its universal acceptance.
This is perhaps in some measure due to the fact
that it is still by no means settled in just what way
the infection of the lung takes place, for all the pos-
sible avenues through which invading organisms
can be conceived of as approaching the lung have
been championed by different investigators who
have each been able to advance arguments of more
or less validity in favor of their views. Most of
the current theories are subjected to a critical
analysis by Tendeloo of Leyden {Mitnchener medi-
zinische Wochenschrift. January 13. 1907), who
rejects the hematogenous theory, the theory that
tubercle bacilli become entangled in the nasal
passages, are swallowed with the nasal mu-
cus and then find their way to the lungs via the
mesenteric lymph nodes, the belief that infection of
the lung may occur through the cervical lymphatics,
etc.. and adheres to the older view that the infec-
tion is. in most cases, excluding general miliary in-
fections, the result of the deposition in the lung of
tubercle bacilli taken in with the inspired air.

The special proneness of the upper and po.sterior
portions of the lung to form the starting points
of the tuberculous process is explained by con-
sidering the fate of the pigment particles that
are constantly being inhaled and that are found in
such large quantities deposited in the lungs of all

Feb. 1 6, 1907]

MEDICAL RECORD.

271

city dwellers. The pigmentation is most pronounced
in the upper and posterior parts of the lung;, and
this is because in these reg:ions the lymphatic stream
whose function it is to carry away the forei,s;n
particles is most slu,a:,s:ish. The slowness of the
current is largely dependent on the fact that in
this part of the lung- there is least respiratory activ-
ity and consequently the conditions are not favor-
able to the movement of the lymph through its chan-
nels. For this reason any tubercle bacilli which
have entered the lung and are b^ing swept on by
the lymphatic stream in attempt to prevent infec-
tion are likely to become arrested at these points
and be enabled to proliferate. This is all the more
likely to be the case because it has been shown that
tubercle bacilli do not grow well in a moving cur-
rent of broth. The reduced respiratory activity in
and near the apices also encourages the deposition
in these situations of tubercle bacilli that may have
been borne in by the inspired air, and it is to the
author's belief that primary pulmonary tuberculosis
is usually the result of an aerolymphogenous infec-
tion.

This is merely the outline of Tendeloo's very de-
tailed dissertation, and while perhaps it presents
nothing actually new to most readers, it is inter-
esting because it forms a comprehensive and critical
survey of much of the modern work in this highly
important field. In connection with Tendeloo's
statements in regard to the pigment deposits one
is reminded of the importance that has been
ascribed by Hodenpyl, and more lately by Ribbert,
to these same lesions.

.SUBGLOTTIC LARYNGOSCOPY.

Attempts have not been wanting to perfect the
technique of laryngoscopic examination in one re-
spect in which it has always been deficient. The
ordinary mirror affords a satisfactory view of the
parts above the glottis and of a small portion of
the beginning of the trachea, but the lower surface
of the vocal cords and the parts immediately ad-
joining have been inaccessible to the eye of the ex-
aminer. Several instruments have been designed to
overcome this deficiency in the armamentarium of
the laryngologist, notably by Rosenberg, Mermod,
and Kuile, but apparently their apparatus has been
lacking in either simplicity or ease of operation, so
that their methods have not come into any great
popularity. Gerber, however, has devised an intra-
laryngeal mirror which seems to promise better
things. In its perfected form (Monatschrift fiir
OhrenhcUkunde, 1906, No. 10) it consists of an oval
mirror measuring 10 mm. in its longest diameter, af-
fixed to a handle having the form customary to
instruments intended for intralaryngeal use. The
mirror is so arranged that it is introduced between
the well-cocainized vocal cords in the vertical po-
sition and can then be made to assume a position
more or less nearly approaching the horizontal by
means of a suitable mechanism. The image formed
in this small mirror is viewed in the ordinary
laryngoscopic mirror.

Gerber has reported only one case in which
information was obtained by means of the
new instrument which could not have been
secured in any other way, but this is perhaps

owing to the infrequency of suitable cases rather
than to any inadequacy of the method. The patient
in point was a man suffering from hemoptysis, the
cause of which remained a mystery until by means
of the subglottic laryngoscope a varicosity, which
bv repeated ruptures had given rise to the hemor-
rhages, was discovered on the under surface of the
right vocal cord. The same procedure has been
successfully applied by Max Senator, who in the
Berliner klinische IVoehenselirift. January 21,
1QO7, describes the case of a tenor of considerable
reputation, whose vocalization had become seriously
impaired through lack of purity in the upper reg-
ister, particularly in the falsetto notes. The or-
dinary laryngoscopic examination revealed a very
■flight thickening of the edge of one vocal cord,
but it was not until an examination had been made
with the subglottic laryngoscope that it was dis-
covered that the source of this thickening was a
minute new growth surrounded with dilated blood-
vessels situated on the under surface of the vocal
cord. The growth was successfully removed by
cauterization and the singer's voice restored to its
former quality. Although, no doubt, the experi-
enced laryngologist can in most cases dispense with
the use of a second mirror of this sort — and the
technical difficulties in its use will probably restrict
the subglottic laryngoscope to the hands of only the
most expert — in exceptional instances such as those
recorded it is quite conceivable that the instrument
should prove of much practical utility.

Nonsurgical Treatment of Appendicitis.

In view of the almost universally accepted dictum
that appendicitis is from the beginning a surgical
disease, and that the time to operate is immediately,
it is not without interest to read a communication
from a clinician who takes the opposite standpoint,
;ind is able to justify his position with statistics.
Pfister, in the Deutsche medidnische IVoehenselirift,
January 10, 1907, deprecates early operation in the
average case, and gives a resume of seventy cases
treated expectantly in the medical department of the
Cniversity Hospital at Heidelberg during the past
two years, in order to illustrate the safety of thi=
plan. The seventy cases included thirty of sligh*
severity, twenty-five of medium gravity, and fifteen
serious cases. In this series all the patients were
discharged free from symptoms, except one, w^ho
died after transfer to the surgical side, though, as
there was delay in operating after the transfer had
been made, this death cannot be charged to the
medical treatment. Four other patients were trans-
ferred to the surgical service and operated on, but
the remainder recovered under purely medical treat-
ment. The author's position is that all cases of
afipendicitis that do not from the first create an im-
pression of great severity should be treated with
opium and the ice bag, though, of course, if begin-
ning peritonitis or perforation is suspected imme-
diate operation is required. Otherwise, surgery
should be resorted to only if the condition is dis-
tinctly becoming aggravated, or if recovery is slow
and there is delay in the absorption of the exudate or
persistent pain. If attacks recur the interval opera-
tion is to be recommended. If it were likely that
Pfister's statistics could be duplicated regularly
there would be little ground for criticism of his
recommendations, but if the history of appendicitis
has taught any one thing with especial insistence, it

MEDICAL RECORD.

[Feb. i6, 1907

is that the disease is essciuial!_\ a treacherous one,
prone to abrupt changes for the worse, and often-
times manifesting lesions out of all proportion to
the symptoms or physical signs. It typilies to the
extreme the Hippocratic apothegm that experience
!.< fallacious and judgment difficult, and until more
acciH-ate means of diagnosis shall have been evolved
we believe that all surgeons and most medical men
will concur in advising early operation.

P.^XCRE.vnC Dl.^BETES DUE TO AUTOINFECTIOX.

The pathology of the pancreas has especially in late
years interested various observers. Among the re-
cent writers and investigators on this subject are
Lancereaux, Gelle, Oser, and Opie. No one dis-
putes at the present day the frequency and impor-
tance of pancreatic lesions in diabetes. A. Gilbert
and P. Lereboullet in the Kcriie dc Medecine of
November 10, 1906, present an interesting contri-
bution to the study of pancreatic diabetes due to
autoinfection. The nature of these lesions, say
these writers, has been clearly determined, thanks
to the knowledge of the structure of the pancreas ;
and a particular significance is attributed to the
alterations in the islands of Langerhans which are
regarded by some authorities as the agents of the
internal secretions of this organ. Gilbert and Lere-
boullet. from the numerous anatomical and clinical
facts which they have observed during their study
of this subject, are impressed with the great im-
portance of the alteration of the pancreas. They be-
lieve that diabetes when it is not severe, and when it
shows the characteristics of that form of diabetes
called by the French "arthritic" is often of pancreatic
origin. The pancreatic change consists of a sclerosis,
inter- and intraacinous, which ordinarily but not
constantly or exclusively attacks the islands of Lan-
gerhans. If the characteristics of this pancreatic
sclerosis are analyzed it is often observed that there
exists a sclerosis of canalicular origin due to an as-
cending infection. The infection appears to be a
primary autoinfection, the development of which is
explained by the predisposition of the patients to
digestive autoinfections. The proof of this predis-
position is found in their personal and family ante-
cedents and in the anatomical study of the various
digestive organs which show the lesions of canali-
cular inflammation. The lesions of autoinfection of
the pancreas produce effects only when the gland is
involved seriously. This explains why diabetes
appears frequently only at an advanced age. Dia-
betes results in these cases from a hyperfunctioning
of the liver. Inversely one can conceive theoreti-
cally of a diabetes due to hepatic insufficiency con-
secutive to hyperfunctioning of the pancreas.

The Specific Gr.wity of Urine.

Ix a recent letter to the Lancet (January' 26) Dr. A.
W. Brand calls attention to the fact that the specific
gravity of the urine varies greatly with its tempera-
ture. He notes that probably in the great major-
ity of cases specimens of urine are examined when
it has become cooled — i.e. when it is at the temper-
ature of the surrounding air, since these specimens
generally reach one in bottles which are allowed to
stand some little time — but he has frequently had
occasion to examine urine which has been freshly
passed, notably in cases of examination for life in-
surance, when it is voided at the time of examina-
tion. He has often been struck with the low gravity
of such freshly passed urine in many cases of young

and healthy lives and has been disposed to attribute
it to the influence of the ingestion of fluid pre-
vious to the examination. On one occasion, lately,
a specimen showing a specific gravity of 1015, when
freshly passed, was left standing over night, with
the urinometer in situ. On looking at it ne.xt day,
before emptying the test glass, he was surprised
to find the specific gravity to be 1020, thus showing
a rise of five points. His attention being thus
directed to this discrepancy, he made a series of ob-
servations, noting the temperature and specific
gravity of the urine when it was freshly passed,
and later when it had cooled down to the tempera-
ture of his surgery. As a result he found that
the specific gravity of urine varies inversely with
the temperature and that it rises, on an average, one
point for every fall of eight degrees of temperature.
He says he has found no allusion to this in any
text-book of physiology or clinical medicine, and he
considers the recognition of the fact is of import-
ance. Urine which at 60° F. shows a specific grav-
ity of 1020, will at 96° show one of only 1015.

Npuih of tijp 50epk.

Public Lectures on Insanity. — Dr. C. L. Dana
will deliver the third of the series of public lectures
on the above topic, arranged for by the Psychiatrical
.Society, at the Academy of ]\Iedicine, 17 West
Forty-third street, on Saturday, February 16, at
8:30 P.M. The subject will be: '"The Facts of
Heredity and Their Relation to Mental Disorders."
These lectures are intended to place before the med-
ical profession and the general public facts with
regard to mental disorders which indicate the pos-
sibility and duty of initiating a wide movement to-
wards general preventive measures.

Report of the State Board of Charities. — The
report of the -State Board of Charities shows that in
1906 the State appropriated $1,945,089.27 for the
charitable institutions, of which amount $1,347,-
271.32 was for maintenance and $428,375 for extra-
ordinary expenses. It recommends for 1907 that
the Legislature appropriate for maintenance $1,415,-
000 and for new buildings and improvements $467,-
920. There were 30,618 dependent children re-
maining in institutions at the close of the fiscal year,
an increase of 371. During the year 18,119 had
been discharged. During the last ten years the
number of institutions for dependent children has
remained practically the same, but the population
has slowly increased from 27,769 in 1896 to 30,618
in 1906. The larger proportion of these children
are in institutions in and about New York City,
all under private control. There were 7,753 in-
mates in the alsmhouses of the State at the close
of the fiscal year, and the number seems to be
increasing. Among the recommendations the board
advises the establishment in the eastern part of the
State of a custodial asylum for demented epileptics
and feeble-minded persons who cannot be properly
cared for in the existing institutions, and of a hos-
pital pavilion for the Soldiers and Sailors' Home.

Report on Milk Supplies. — A committee of five
of the New York Association for Improving the
Condition of the Poor, having Dr. R. G. Freeman
as its chairman, has issued a report on the milk sup-
ply question in this city. In it the importance of
inspection of dairies and creameries is upheld,
and it is stated that eighty more inspectors are
needed to do the work for this city. The conditions
under which the milk should be produced and

Feb. i6, 1907]

MEDICAL RECORD.

273

handled are detailed and it is emphasized that in-
spection must then follow the milk every step of
the way to the consumer, protecting it from con-
tamination and never permitting its temperature to
rise at any stage above 50° Fahrenheit. The ex-
pression was unanimous that nothing can render
such inspection unnecessary or reduce its im-
portance. The establishment of infants' milk depots
is considered of prime importance. The commit-
tee declares for a campaign of education on the
value of protecting milk and favors legislation reg-
ulating its sale. A milk committee of thirty-eight
members has been appointed to. continue the efforts
to improve the quality of the city's milk.

Control of Tuberculosis. — In the report of
the subcommittee of the Charity Organization So-
ciety appointed to consider the tuberculosis question
in this city it is estimated that the number of tuber-
culosis cases in Manhattan in 1910 will be 19,596
and that dispensary provision should be made for
4,626 of these. It is also estimated that for the
treatment of the tuberculous poor 2,734 hospital
beds will be required and that the cost of maintain-
ing the system of dispensaries and the hospitals
will be $1,269,400. The report states that the treat-
ment of the tuberculous poor of the city is being
carried on by three city departments, each acting
independently of the other, and that there are five
public and four private special dispensaries giving
treatment. The committee suggests a plan for the
centralization of the efforts to combat the disease.
This plan calls for the establishment of fifteen
dispensaries and for a central distributing tuber-
culosis hospital, on the river front on the Belle-
vue Hospital grounds. It is recommended that
a special Board of Tuberculosis Hospitals be
formed to consist of the Commissioner of Charities,
the president of the Bellevue and Allied Hospitals
Board and the Commissioner, or the chief medical
officer, of the Board of Health, which shall have
entire supervision of the management of the central
hospital and dispensaries.

New Bellevue Hospital Plans Filed. — Plans for
the six-story and basement pathological building
which is to form the northwestern section of the
new Bellevue Hospital have been filed by the archi-
tects, McKim. Mead and White. The pathological
building is to cost $800,000 and will have a frontage
of 142 feet and a depth of 120 feet, with a main
entrance facing the south. The building is to be
of ornamental brick, with a base of granite and
trimmings of limestone. The second story will con-
tain the pathological museum and a series of au-
topsy chambers. The third and fourth stories will
be fitted with laboratories, the fifth will contain the
library, and on the sixth will be special laboratories
for bacteriological experiments and special pho-
tography work. On the roof will be the animal
operating room and three rooms for the observation
of inoculated animals. Each of the five upper floors
will also contain dormitories for the hospital at-
taches of the various departments.

Osteopathy Bill. — The osteopathy bill now be-
fore the Legislature differs in some respects from
those that have been previously presented. It cre-
ates a board of osteopathic examiners under the
public health law, the provisions following those of
the State medical examining boards, excepting those
referring to materia medica and therapeutics, and
substituting the theory of osteopathy and its prac-
tice. Provision is made for the appointment of
the osteopathic examining board by the Regents,
and all osteopathic schools are to be under the reg-

ubtion (jf the Regents. Dr. Arthur S. Root and
Albert Vandeveer of Albany have appeared before
the Senate and Assembly committees on public
health in order to oppose the passage of the bill.

Legislation in Pharmaceutical Matters. — Rep-
resentatives from pharmaceutical organizations and
schools of the State are in Albany for the pur-
pose of discussing the pending pure food legislation.
They will vigorously support the measure regu-
lating the sale of cocaine in any form or compound,
and have also decided to take steps to include in one
measure all the bills affecting pharmacy before the
Legislature and to make this measure conform to
the national pure food law.

New York State Child Labor Bill Passed.—
The Senate has passed Senator Page's bill carrying
out Governor Hughes' recommendation that chil-
dren employed in factories should have an eight-
hour workday. The bill provides that no minor
under sixteen years of age be employed, per-
mitted, or suffered to work in any factory before
8 o'clock in the morning or after 5 o'clock in the
afternoon of any day, or for more than eight hours
in any one day.

For State Ice Inspection. — Dr. E. H. Porter,
State Health Commissioner, has sent to the Legis-
lature a request for a larger appropriation than the
$57,000 the department received last year, in order
that a systematic inspection of the ice fields on the
Hudson and in the Adirondacks may be instituted.
The present resources of the department do not
permit the proper safeguarding of the ice supplies.

Pure Food and Drug Bill for Illinois. — In the
lower house of the Illinois Legislature Represen-
tative Lindly has introduced a pure food bill at the
instance of Pure Food Commissioner Hanby Jones.
The bill covers both food and dairy products, and
proposes in some cases stricter regulation of food
stuffs than is attempted in the national pure foc>d
bill, which it proposes to supplement by giving State
application. It provides an annual appropriation of
$125,000 for the enforcement of the law. The
standard of purity for drugs is that adopted by the
L'nited States Department of Agriculture, and it
is stipulated that where no standard has been
adopted by that department, then the standard shall
be that given in the last edition of the United
States Dispensatory. Definitions of adulteration
and misbranding follow closely the requirements of
the national act, and explicit restrictions are made
in the use of drugs in the manufacture of liquors.

The Oak Park (111.) Hospital and Training
School for Nurses is said to be the most complete
institution of its kind in Illinois. It will be dedi-
cated in March. The structure will have a capacity
of sixty patients. Ready for occupancy the building
will have cost $150,000. The operating rooms are
two in number and are lighted by large north win-
dows and skylights. The floors are of white tile
and the walls are wainscoted with heavy white plate
glass to a height of seven feet. The hospital
grounds contain one acre, the money for which
was raised bv Dr. J. W. Tope of Oak Park. About
$5,000 additional for the equipment of the surgical
department was secured by the physicians of the
staff. The balance of the construction fund was
supplied bv the Sisters of Misericordia.

Infectious Diseases in Chicago. — The Chief
Medical Inspector of Chicago, Dr. Heman Spald-
ing, reports that "during the week 292 cases of
diphtheria were reported to the Department of
Health, being six fewer than were reported the

MEDICAL RECORD.

[Feb. i6, 1907

prcviou> week. In the same time 1,686 cases of
scarlet lever were reijorted — an increase of 681
cases over the preceding week, and 190 cases of
measles were rejiorted — an increase of fifty-one.
The 350 newly appointed medical inspectors in their
visits to schools have uncovered a large number
of cases unattended by physicians and unreported to
the department. In numerous instances they have
found children in school recovered from a mild at-
tack of scarlet fever and still in an infectious con-
dition. Numerous instances were found in which
children were in school coming from a house where
i\ mild case of scarlet fever e.xisted unattended by a
(ihvsician. The finance committee has recommended
till'; erection of a municipal hospital for infectious
diseases. This hospital is an absolute necessity, and
the lack of it has long been a reproach to the city."

A Testimonial to Dr. Pardee. — The .Alameda
County (Cal.) Medical Society, on January 28, ten-
dered a banquet to ex-Governor Dr. George C. Par-
dee, one of its members, to commemorate his re-
tum from official life to the profession. About fifty
members of the society were present. Dr. D.
Crosbv, president of the society, served as toast-
master, and Dr. Charles .A. Dukes, the treasurer, as
chairman of the committee of arrangements. Re-
sponses were made by Drs. Hubert N. Rowell,
D. D. Crowley, George C. Pardee, X. K. Foster,
Secretarv of the State Board of Health, Frank
.A.dams, and J. Maher. After the banquet a gen-
eral reception was held, in which many others came
to renew old friendships and to express apprecia-
tion of Dr. Pardee's faithfulness to his profession
while serving the State.

Paths and By-Paths in California. — The na-
turopaths, the osteopaths, and even those of the
"straight and narrow" path are besieging the State
Legislature for more law^ They want recognition
as "distinct schools of practice. The law recognizing
osteopathy was recently declared to be unconsti-
tutional. The State Board of Medical Examiners,
it is understood, is preparing a bill w'hich, if made
law, w^ill admit to it an osteopath and do away with
the examination in materia medica and therapeutics.
The members of all schools w-ill then be required to
pass the same examination in anatomy, chemistry,
phvsiolog}-, bacteriology, pathology, toxicology,
surgery, obstetrics, and probably other branches.

Antivaccination in California. — Xow that a
layman has become Governor of the State, the anti-
vaccinationists are making strenuous efforts to have
the law repealed which requires all scliool children
to undergo vaccination. Two years ago they w-ere
successful in having a bill pass the Legislature, but
met w-ith defeat atthe hands of the Governor. Dr.
George C. Pardee, who could not conscientiously
attach his signature.

Bequest to the Pasteur Institute. — It is an-
nounced that the Pasteur Institute of Paris is to re-
ceive the sum of 85.000,000 bequeathed to it by the
will of the late Daniel Osiris. In addition to other
public benefactions, Mr, Osiris in 1899 presented to
the Institute of France a sum representing an an-
nual income of about 86,500 for a triennial prize of
$20,000, open to citizens of all countries, for the
most remarkable work or discovery of general in-
terest, especially in the fields of surgerv and medi-
cine.

"A^Monument to Theodor Schwann. — On De-
cember 7, 1910, a century will have elapsed since
the founder of the cellular theory was born at
Neuss on the Rhine. His native town has decided
to honor his memorv bv the erection of a monument

to be unveiled on that day with suitable ceremonies.
The medical profession is under a deep obligation
to this investigator, who laid the foundations on
which our present concepts of disease are so largely
based, for he was a worker no less successful than
indefatigable in the domains of histology, physiol-
ogy and biology ; an authority on the processes
of fermentation, decomposition, spontaneous gen-
eration, and digestion, and last, not least, the dis-
coverer of pepsin. His master, Johannes Miiller,
and his collaborator, Schleiden, have lately been
honored by the erection of statues in Coblentz and
Jena, respectively, and the members of the medical
profession are invited to contribute to this memo-
rial to Schwann. Communications are to be ad-
dressed to : Schwanndenkmal StJidtische Sparkasse,
Neuss am Rhein, Germany.

Health Conditions in Panama. — The report of
Col. W. C. Gorgas for the month of December has
been made public by the Isthmian Canal Commis-
sion and shows that health conditions continue ex-
cellent in the canal zone. In the total force of 8,200
whites there were eight deaths, giving a rate for
the year of eleven per thousand. C)f these whites
6,000 are Americans. Among these Americans
there were no deaths from disease. There are 800
.American women and children, the families of these
6,000 employees, and among them there was no death
from any cause. The death rate among the general
population has also been satisfactory. In the town
of Colon in November there were 77 deaths, in De-
cember 48. The sick rate among the employees was
about what it was in the previous month, thirty per
thousand. During the month no quarantinable dis-
ease of any kind was reported.

Warning Against the Dangers of Spitting. —
The school children of Brooklyn have been provided
by the Board of Education with Board of Health
circulars setting forth the dangers of spitting in
public places. The circular is printed on gummed
paper, so that it may be posted inside the back cover
of the school bonks.

Cigarette Smoking by Youths. — The Illinois
Senate has passed a bill prohibiting persons under
eighteen years of age, pupils in schools, and students
in universities from smoking cigarettes in any pub-
lic place.

Grip is reported to be so common in Paris that
the postal authorities have issued a notice tiiat cer-
tain deliveries of mails have been suspended owing
to the prevalence of 'the disease among the postmen.

Prof. Behring of Marburg has issued an open
letter to the press in which he indignantly denies
the reports that he is suffering from insanity, or is
nn the verge of a mental breakdown, and charges
that the reports were fabricated by his personal en-
emies with the object of injuring him.

Medical Men Popular in Germany. — .\ popular
newspajier vote taken in Germany on the twelve
greatest Germans now- living accorded to Dr. Rob-
ert Koch, Professor Ernst Haeckel, Professor Kon-
rad Rontgen and Professor Ernst von Behring,
respectively, the third, fourth, fifth and eleventh po-
sitions in this list.

Dr. Alvah H. Doty has been reappointed as
Health Officer of the Port of New York, a post he
has held since 1895.

Dr. W. Freudenthal, of this city, requests us to
add to the report of the meeting of the Section on
Public Health of the .Academy of Medicine, pub-
li.shed in the Medical Record of February 2, that he
also participated in the discussion pertaining to the
health of New York Citv.

Feb. 1 6, 1907]

MEDICAL RECORD.

-/D

Fasting for Pleasure and Profit. — What is as-
serted to be the world's record for fasting- has been
made by Sacco, the Hungarian professional faster,
who has completed an exhibition test in London
lasting forty-six days and four hours. His wish to
continue and complete a period of fifty days could
not be carried out on account of extreme weak-
ness. The newspapers also report the voluntary
fast of a Toledo, O., physician, who is stated to have
taken no food and no liquid but water during thirty-
four days.

St. Gregory's Hospital. — The State Board of
Charities has granted a charter to St. Gregory's Hos-
pital on Gold street, which was taken over sev-
eral months ago by the \'olunteers of America and
is now managed by that organization. An applica-
tion will now be made to the police to set aside a
separate ambulance district for the hospital.

Beth Israel Hospital has received the sum of
$2I,CX)0 contributed by guests at a recent dinner
given by the directors and medical staff in honor
of the president of the hospital, Joseph H. Cohen.

Bequests. — By the will of Lady Martha E.
Kortright. who died recently at Florence, Italy, per-
sonal property valued at $100,000 is to be divided
equally among the following beneficiaries : Presby-
terian Hospital of Philadelphia, Board of Education
of the Presbyterian Church in the L'nited States.
Presbyterian Board of Relief for Disabled IMinis-
ters and Orphans of Deceased Ministers, and the
Board of Home Missione; of the Presbyterian
Church in the L^nited States.

International Congress on School Hygiene. —
The preliminary program of the second Inter-
national Congress on School Hygiene, to be held
on .\ugust 5-10, 1007. at the I'niversity of London.
South Kensington, has been issued. The work of
the Congress will be divided into eleven sections.
each presided over by an authority on the subject
dealt with. The president of the Congress is Sir
Lauder Brunton, F.R.S., and the secretaries are
Dr. James Kerr and Mr. E. White \\'allis.

Republican 'Valley (Neb.) Medical Associa-
tion.— Officers were elected as follows at the re-
cent meeting of this society : President, Dr. Cone.
Oxford : J''ice-Presideut. Dr. Sherick, Bertrand :
Secretary. Dr. Campbell, Stamford; Treasurer. Dr.
Sunbury, Holdrege.

Medford (Mass.) Medical Association. — The
following are the recently elected officers of this
organization: President. Dr. J. Walter Bean ; Vice-
President, Dr. Norman F. Chandler : Secretary and
Treasurer. Dr. Frank S. Smith.

Obituary Notes. — Dr. Robert T. Wood of
Paris, Ky.. died on January 26 at the age of fifty-
four years. He had been in poor health for some
time, but had lately been able to resume his practice
and his death was unexpected. He was a graduate
of the Ohio Medical College and had practised in
Paris since 18S1.

Dr. George H. Thom.v of Reno, Nev., died of
cerebrospinal meningitis on February i at the age
of sixty-five years. Dr. Thoma was a native of
Montgomery county, N, Y., and studied medicine in
the Albany Medical College. He served as assistant
surgeon through the Civil War. He settled in .Aus-
tin, Nev., in 1867, and twenty vears later removed
to Reno, where he had practised ever since.

Dr. O. M. Sherid.an of Roxbury, Mass.. died on
February 2 at the age of forty-three years. He was
born in Randolph and was graduated from Boston
college in 1885. Three vears later he received his

medical degree from the New York University
-Medical School.

l-)r. R. P. Comfort of Nashville, Mich., died on
January 27 at the age of fifty-nine years. Dr. Com-
fort was born at Moscow, Mich., and received his
degree from the Michigan University Medical
School. He had practised at McBrides, ^lason and
Hudson, and for the past fifteen years in Nashville.

Dr. AuGU-ST L. Justice of El Paso, Tex., died
on January 30 at the age of sixty-si.x years. He
was born in Virginia and after serving in the Civil
War studied medicine in Rush Medical College,
Chicago, .\fter practising for some time in Den-
ver and Santa Barbara, he finallv settled in El Paso
in 1881.

Dr. D.wiD .\. CoLLixs of Roxbury. Ma.-s., died
on February 5 at the age of forty-four years. He
was graduated from Holy Cross College in 1882
and four years later received his medical degree
from the Harvard Medical School. He had prac-
tised in Ro.xbury for over ten years and was med-
ical supervisor of the Eliot School District.

Dr. .\. C. Sincl.mr, formerly of Winnipeg, died
on January 23 at Colborn, Ont. Dr. Sinclair was
born in Glengarry county seventy-seven years ago
and had practised in Toronto, Winnipeg, and Ross-
land, B. C.

Dr. WiLLi.xM J. Ch.\ppell of Baltimore died
suddenly on b'ebruary 7 at the age of forty-nine
years. Dr. Chappell was graduated from a Balti-
more medical college in 1S84 and had practised in
that city ever since.

Dr. Everett H. Merwin of Kansas City, Mo.,
died suddenly on February 9 at the age of thirty-
eight years. Dr. Merwin received his medical edu-
cation in London and had spent several years on Brit-
ish steamships as surgeon. He was treasurer of
the Kansas City Homeopathic College.

Dr. Wm. C. Pickett, Professor of Diseases of
the Alind and Nervous System in the ]\Iedico-Chirur-
gical College, died at Aldan, Delaware county. Pa.,
on February 6 at the age of thirty-eight years. He
was born in Meadville, Pa., and was graduated
from Jefferson Medical College in the class of 1889.
He was successively surgeon to the schoolship
Sarafofia. resident physician in the Philadelphia
General Hospital, resident ph\sician in the Insane
Department of the Philadelphia Hospital, demon-
strator of neurology in Jefferson Medical College,
and visiting neurologist to the Philadelphia Hos-
pital.

Dr. Fr.\m<lin Wheeler of Farmington, Conn.,
died on February to, aged eighty years. He had
lieen physician at the Porter School in Farmington
for over fortv vears.

Cnrrrs|inuDrurp.

.\ SINGLE EX.\MINING BOARD FOR NEW YORK
STATE.

To THE Editor of the Medical Record:

Sir: — Year after year the medical profession of New
York has been called upon to oppose the passage of laws
creating State Examining Boards in osteopathy, derma-
pathy, optometry, and so on. Year after year we have
succeeded in convincing the legislature that the passage of
such laws would be unwise: but in answer to the inquiries
of Senators and .Assemblymen, "what are you going to
do with these people who besiege us each year?" we have
answered: "Let them comply with the present law and
then practise any method they choose." Then has come
the second prtinent query: "The homeopaths hvae a sepa-
rate board, why should not the osteopaths be granted the
same privilege, if they will comply with all the require-
ments excepting treatment'" .As the result of all this

276

MEDICAL RECORD.

[Feb. 1 6, 1907

a bill has been drawn up, uiiicli is indorsed by the State
Department of Education and many leadnig members of
the legislature, accurately defining the practice of medicine
and providing for a single examining board, before which
all who desire to practise the healing art must come and
pass a common examination, eliininating the subject of
practice, assuming that all who have the other necessary
qualifications will be able to practise intelligently the method
which seems to be indicated in the cases they meet.

It is not expected that the enactment of this law is going
to bring about an immediate leveling of all the barriers
now existing between "allopathic," homeopathic, and other
"pathic" physicians, although doubtless that will be the
ultimate result. Nor will it prevent the demands in the
future of peculiar classes desiring separate recognition
for conimercial and other reasons. It will, however, place
the legislature in a position to say, when future efforts
to secure class legislation along medical lines are made,
that the State of New York recognizes only the ordinary
educated physician, and the method of practice is some-
thing the individual physician must determine for himself.
It will place medical practice in a higher plane than has
heretofore been accorded it, and will accomplish what our
present law was designed lo do, and has failed to do,
namely, properly protect the people of the State of New
York from incompetent physicians.

Will you please request your readers to write their rep-
resentatives in the Legislature at once urging the defeat of
osteopathy, optometry, and all similar bills, and the pass-
age of the single board bill, which is Senate Bill No. 154;
Assembly Bill No. 160, and to use these numbers when
v.riting.

Frank V.\n Fleet. M.D.

Chairman Committee on Legislation of the Medical So-
ciety of the County of New York.

HE.\D.\CHE .\ND EYESTR.\IX.

To THE Editor of the Medic.\l Record:

Sir : — .'^n article under the above caption by Dr. George
M. Gould, in the Journal of the American Medical Associa-
tion of November 10, 1906, caught my eye, and greatly im-
pressed me. I was struck by liis indictment of the profes-
sion for the "narcotism," as he styled it, of its members.
What attracted me most forcibly was his statement that
ophthalmic specialists denied the effect of eyestrain in caus-
ing headaches and otherbadconsequences. The general prac-
titioner might be excused for a certain degree of ignorance
of such results of defective vision, for he usually has no
means of ascertaining or measuring it, nor would he know
how if he had. But that specialists generally should scout
so evident a fact seems to me extraordinary. That eyestrain
causes headaches is well known to even many of the laity,
for they have the knowledge based on personal experience,
having proved the pudding by the eating of it. Their ac-
quaintances are told of it, and believe it. Many of them, in
turn, go to the optician for relief — and get it. So much
the worse for the doctor who is ignorant or prejudiced.

"Are our eyes getting worse?" is the query heard from
many in view of the increasing prevalence of spectacles. By
no means. As evolutionists we must believe that they are
gradually growing better in each succeeding generation.
Why, then, so many eyeglasses or spectacles? Merelv '
cause there are so many defective eyes. Nor are t
statements irreconcilable. We use the eyes more now i.ia..
formerly in a way to bring out their defects. The illiterate
day laborer usually is without glasses until he becomes a
marked presbyope quite late in life — at least late for his
class, for they age sooner than do those more favored by
occupation and environment. If he learns to read and
write, and scans the paper daily, he wears glasses sooner.
The illiterate woman likewise first wears glasses for pres-
byopia late in h'fe unless she darns socks, sews, or does
other near work requiring distinct vision, in which event
she begins the use of them earlier. A fine sieve is not
needed to screen coarse coal. Even a perfect eye requires
aid when the object to be seen is very minute. Hence the
microscope. Who could do without its aid to see the
minute world it reveals? .\re our eyes degenerating on
that account? It is a question of degree on the one hand,
and of defects on the other. A bundle of mail, such as is
usually handled by letter-carriers, is not very heavy for the
ordinary man. but it feels heavier the longer it is borne.
These men are not losing strength because they avail them-
selves ofabag slung over the shoulder to ease the burden.
Nor is civilized man becoming weaker because he uses a
chair with a back against which he can comfortably lean,
rather than sit on an old-sty-le four-legged stool without
this restful ad"dition.

Considerable derision first met the systematic examina-
tion of the eyes of school-children, and even of many cor-
poration employes. Y'et no one realizes better than the

child with its lirst set of glasses how it eases the work and
brightens the world. I am not an ophthalmologist, but a
general practitioner. Nevertheless, I do look into eyes that
seem to me to need it, and I test them for errors of refrac-
tion, and I prescribe glasses when satisfied that I know
\yhat I am doing. When in doubt, I send them to the spe-
cialist. Many a child has been made happier by me for
detecting and correcting defective vision. An occasional
dunce in school is so because he cannot sec his work on
either the blackboard or desk. How can he become inter-
ested or learn under the circumstances e.Kcept by the little
that filters in through the unusual channel of the ears?

Why do scliool-children find glasses so useful only to
fliscard them after leaving school? Simply because they
have greater need for them while studying. The younger
the child, the more does its greater illiteracy require visual
accuracy to distinguish the separate letters of each word,
which it can identify and pronounce only after analysis
into its component parts. As its familiarity with smaller
words grows, larger ones are continually being learned
while the memory gradually acquires a hold upon the
smaller and earlier learned word forms. As the child
progresses in its studies, it reads more, then begins to write
and to manipulate figures, .\rithmetic is a greater strain
than reading, because each figure must be carefully noted.
Penmanship is also a strain upon the eyes. When the
pupil is far enough advanced to read by word forms and
write automatically, the lessons at school and the home
work in reading, figuring, and composition keep up an in-
creased demand upon the muscles of accommodation, so
that it is a wonder that even a perfectly normal eye does
not tire and make itself known in some disagreeable way.
.'\dd to all this required strain the reading of books and of
newspapers, and the wonder is that so many get along as
well as they do without glasses.

So much for the simple defects of vision that arc correct-
able by the accommodation, vision equally deficient in all
meridians. The muscles make a successful effort, being
rewarded by corresponding easement and clearness of
vision. When, however, the defect is meridianal, efforts
at accommodation aggravate the trouble, for the correction
of the defect produces a corresponding disturbance of the
opposite meridian. If there is relaxation, the original
trouble reappears. Thus may the accommodation find
Itself seesawing back and forth betwixt the devil and the
deep sea, or the proverbial two horns of a dilemma, every
effort worse than useless, for the muscles become tired, the
vision remains defective, and annoying reflexes follow. Eye
quacks are reaping a harvest, and the general practitioner
loses his opportunity because of failure to recognize these
facts and act accordingly.

I would advise all physicians to get some good book on
the eye, and then a set of test lenses and cards, an ophthal-
moscope, and a retinoscope. They should carefully read
the book, especially the part explaining the physics of re-
fraction, before going further into the subject. Then prac-
tical instruction should be sought in the use of these imple-
ments, if only for a week. Work should be done under a
mydriatic of ?hort effect. To attempt this kind of work
without it is folly except for the expert.

A patient never comes to me complaining of habitual
headache (m'an, woman, or child) without a prompt in-
quiry into the ocular sufficiency. It is the rule to find re-
fractive defects that are proven the cause of the trouble
■ 'Cause of its prompt disappearance upon the use of suitable

..;ses. I could turn to my histories and cite scores upon
:ores of cases, but the list would be monotonous and a
waste of space. To the doubter I simply say. examine
your patients and see for yourself. If you cannot do it,
have it done. I examine the urine of most patients, espe-
cially in subacute and chronic cases, no matter what the
symptoms. Not to do so is to my mind as negligent as it
would be not to look at the tongue, or feel the pulse, or ask
about the appetite, or the character and frequency of the
stools. Likewise should the eye be ever under suspicion.

But it must not be supposed that headaches due to eye-
strain are located only at the eyebrows, as pictured in
Butler'? book on diagnosis. Eyestrain headache may exist
in any part of the head. Nor is it noticeable, necessarily,
at any particular time. The man who thinks it comes only
after reading or in the latter part of the day. will overlook
many cases, and some of them the most interesting, in-
structive, and thought-engendering. The practice of medi-
cine is indeed a science as well as an art wheii one can
reason back from effect to cause as unerringly as is possible
in this class of patients. I have metaphorically PTii"f^
the malefactor in these obscure eyestrain cases after diligent
search with as much gusto as Sherlock Holmes was ever
portraved bv his creator as feeling when he caught his
quarry, and with the same self-satisfaction for work well
done and amply repaid.

Eyestrain mav cause other than head pain. It may give
rise to a diversitv of svmptoms, of which nausea is quite
a common one. Then there is the head tilting due to un-

Feb. 1 6, 1907]

MEDICAL RECORD.

^//

suspected peculiar monocular vision that persists until the
spine is correspondingly twisted. Dr. Gould has said this,
and has been laughed at for this one of his many keen
analyses of eyestrain effects. Nausea may grow to emesis.
this to malnutrition, and that to anemia and other ills that
I confess myself reluctant to enumerate lest the little I
have said be wholly discredited.

Mental irritability is quite a common accompaniment of
eyestrain. So also, very naturally, is a disinclination to
read, to study, to visit the theater, or to attend other public
functions, for all may be a visual strain that causes unpleas-
ant effects decidedly felt but not interpreted. Spectacles
thus sometimes alter the habits of years. I have seen it,
not once, but many times. What the ultimate effect of
such relief may be upon the patient and those with whom
he associates can be imagined, for even associations may be
entirely changed.

It has often occurred to me that many men become ther-
apeutic nihilists by seeing deep enough to realize that their
drugging is on wrong lines, but not so deep as to see the
simple cause of which the removal would result in prompt
cure, even as Dr. Gould has cured a crooked back with the
use of suitable spectacles. By the detection of eyestrain
effects it is at times possible to achieve a well-merited
reputation for acumen, sagacity, and good judgment. Pains,
headaches, nausea, dyspepsia, irritability, insomnia, ano-
rexia, mental sluggishness, and a host of other complaints
have repeatedlv yielded in my experience to suitable glasses
after other efforts at relief by preceding consultants had
failed. To all who doubt and are unable to make a proper
examination of the eye, I would suggest sending persistent
headache cases to an ophthalmologist for examination.

\. H. P. Leuf, M.D.

116 South Eighteenth Street, Phil.5,delphi.al.

TREATMENT OF ACUTE SEPTIC PERFORATIVE
PERITONITIS.

To THE Editor of the Medical Record:

Sir : — In a communication to the Medic.xl Record. Janu-
ary 12, 1907, Dr. A. E. Isaacs states that he is very much
disturbed for fear that the readers of your journal will mis-
judge some of my conclusions in a recent article on Ap-
pendicitis, and that possible assistance through operative
interference be denied some one. I take it that the members
of the profession who peruse a valuable journal like the
Medical Record are competent to decide whether state-
ments are misjudged or not, and to this intelligent audience
I am perfectly willing to trust the observations on appendi-
citis which have done so much to save life, and place the
treatment of this disease upon a scientific surgical basis.
The letter says "the conclusion regarding hopelessness and
contraindication of operation in cases of general peritonitis
are those generally accepted eight years ago. 'To operate —
in every case, if there is a radial pulse, is up to date.' "

The truth is that the above statement is just the reverse
of the facts, for it is well known that eight or ten years
ago the dictum. I might say craze, was to operate in every
case without regard to the period of the disease or the
condition of the patient. Under this rule the mortality was
so great and apparent, even to the laity, that its most ardent,
advocates were forced to modify their eagerness to "cut,"
which led to the more modern and scientific treatment of
to-day. In support of this statement, it is only necessary to
quote from the standard work of ten years ago. ".A.ppen-
dicitis," by Deaver, published in 1896. page 116, which reads :
"Remove the appendi.x as soon as the diagnosis is made."
A well-known and experienced surgeon says : "When a
man proposes to operate on all cases of appendicitis, no
matter what the condition of the patient, the extent of the
disease, or its stages, provided only he can feel a pulse, he
shows his lack of judgment and lack of ability to recognize
the 'already dead' patient."

It is evident that Dr. Isaacs is ignoring the question of
acute septic perforative peritonitis from the bursting of an
appendical abscess, the subject I was discussing, and con-
veys to the profession an erroneous idea of the class of
cases which I have called "inoperable." He says my de-
scriptions are less definite, and would have us infer that
there are no such cases with temperature of 105° or 106°
and pulse of 140 or 160. etc. And yet with the next breath
he says : "if permitted to last long enough, become general
septic perforative peritonitis, with temperature of 105° or
106° and pulse of 140 or 160." etc. Everyone who reads
these articles knows that general peritonitis, diffused peri-
tonitis, purulent peritonitis, etc., as Dr. Isaacs describes
them, means cases where nature is still holding the disease
at bay; has her barriers up, as it were, and is still strug-
gling to throw off the matcries morbi, while in the condi-
tion I have described as acute septic perforative peritonitis
from the bursting of the abscess, the sepsis is no longer
limited. Nature is overwhelmed, annihilated, and capitu-

lates in death, and these are the kind of cases in which I
have said surgical interference is a "forlorn task." If Dr.
Isaacs believes in operating in these cases, because "nothing
is lost by operation," why not on this principle operate in
all cases of tuberculosis of the lungs, all cases of advanced
cancer of the stomach, etc., all along the IJne — as according
to our author, '^lothing is lost by operation" except the
"surgeon's reputation." Besides, as Dr. Torey says : "Every
faiktre tends to discourage surgery and discourage those
who could and should be operated on with safety and
benefit." I emphasize this because the wide publicity given
Dr. Isaacs' statements by your journal "might result in the
acceptance, here and there, of misjudged conclusions and
consequent deprivation to many of the chances of possible
assistance through operative interference."

Dr. Isaacs further writes at length, regarding the time of
operation and the various pathological conditions of the
appendix found when the abdomen is opened. There is
nothing new in these cases, as we have all met with them,
and they are, to a great extent, in the nature of surgical
accidents similar to perforation of the stomach, intestines,
gall-bladder, etc., either by ulceration or by perforation of
foreign bodies. They are fully described in my former
articles under the head of fulminating cases, and I need not
take up the space to reiterate them here, but refer those
interested to former reports. The cases of peritonitis Dr.
Isaacs describes are like those reported by Dr. Murphy, ex-
cept that in operating. Dr. Isaacs remoyed the appendix.
These cases usually end in recovery with drainage, and
the technique of removal of the appendix adds to the risk
of the operation and is of no practical benefit,; since the
process that forms the abscess removes the portion of the
appendix that is diseased, in the same manner that all
morbid material is eliminated in diseased conditions where
suppuration and evacuation take place.

In conclusion, let me hope that all my readers will observe
carefully cases of death following operation for appendicitis,
not only in their own, but in the practice of others. They
will then see that the condition of the patient and the period
of the disease must be taken into consideration, if we wish
to give the patient with appendicitis the benefit of the
wisest, most successful, conservative, and modern philo-
sophical treatment. As one of the greatest authorities on
appendicitis in this country writes, "It is only a question of
time when all will be forced to accept this theory, as facts
will overcome prejudice and tradition."

J. J. Brownson, M.D.

Dubuque, I a.

OUR LONDON LETTER.

(From Our Special Correspondent t

infants' health society — LONDON POOR LAW GUARDIANS —
carcinoma in mice — AGGLUTINATION — BIER'S TREATMENT
OF JOINTS — PANCREATIC DISEASE — ABSCESS OF LUNG — PARA-
THYROIDS— TET.ANY — DEATH OF DR. PEDDIE.

LoNliOX, January 25. 1007.

The Infants' Health Society is opposed to the sterilization
of milk, and last week a deputation from it was received by
tlie President of the Local Government Board to urge, in
view of his proposed bill, an investigation by a committee of
experts. The Society was formed by laymen, but has a good
deal of medical support. Sir T. Barlow said the deputation
held that sterilization was only a "second best process" and
might bring evils in its train. Once sterilized it was not
possible to certify the purity of milk, and there were cases of
immediate harm having resulted. Children fed on sterilized
milk developed scurvv and rickets. As an alternative fresh
milk should be cooled down immediately it was taken from
the cow and kept cool in sterilized vessels. They therefore
asked for an investigation on the methods of cooling. Sir
Lauder Brunton followed, and strongly deprecated the en-
forcement of sterilization of milk, which in the long run
was injurious. The addition of preservatives should be
penalized. Mr. Burns, in reply, said there were only_ seven
or eight sterilized milk depots in the country, and it was
only just to extricate the local -authorities from their ap-
par'entlv illegal position. The superiority of refrigeration
had been put before him. but he did not think that the last
word on the subject, and he did not see why local authori-
ties should not be autlmrized to try either method.

Representatives of Metropolitan Boards of Guardians inet
last week to confer on the present methods of dealmg with
phthisical patients. Dr. Toogood said guardians had no
power to alter conditions outside their own institutions.
But as to patients in the infirmary their duty was to allevi-
ate, or if possible cure, and, secondly, prevent a patient be-
coming a center of infection. Some boards were giving a
modified open-air treatment, but that had its disadvantages.
The number of cures would be small, for nearly all cases
were far advanced before entrance. For the safety ot
other patients and of the officers, consumptives should not

278

MEDICAL RECORD.

[Feb. 1 6, 1907

be treated in ordinary wards. A separate block, with air
space of 2,500 feet per bed, would be better. The said
cases of patients and officers contracting the disease from
those in the infirmary were frequent, and ought not to occur
from a preventable disease, as phthisis was, if the commu-
nity had the pluck to tackle the problem. Too much should
not be expected from the open-air treatment ; at the most,
the disease would be checked, but it would infallibly resume
activity on a return to the conditions of living which pro-
duced it. It was stated that the a.syluni's board has 2,000
beds at present empty, which it was recommended should
be utilized for phthisical patients.

.•Vt the Pathological Society. Mr. F. W. Twort stated that
in a stock of mice, not exceeding; at any time 150, he had
met a number of cases of cancer in the female breast; also
two of the pylorus and one of the lung. The sarcosporidia
of the mouse were found in the tissues around many of the
tumors. The disease occurred in the older animals, and
inoculation failed to propagate it.

Dr. T. J. Horder recorded a case of typhoid in which
agglutination was absent. Diagnosis was made on the sixth
day by grow'ing the bacillus from the blood. Spots ap-
peared on the eleventh day. Death occurred from heart
failure. Sir A. E. Wright, president, suggested as explana-
tion that agglutinat'on is not a test of infection, but of
immunity ; if it failed in typhoid the prognosis was very-
bad, as it showed the patient was not immunizing himself.
Drs. Patch and Wells reported cases of tuberculosis of
joints treated ( Bier's-(method) by compression above. The
opsonic inde.x was found to rise, a fact they attributed to
the passage of the exuded serum through the lesion taking
back with it into the blood an amount of the toxic sub-
stance— a sort of auto-inoculation comparable to injection of
tuberculin. Similar results followed massage or use of the
diseased limb.

Pancreatic disease occupied the Medical Society on the
14th. Dr. Sidney P. Phillips remarked that an increasing
number of cases of cancer of the pancreas might be ex-
plained by the decrease in cancer of the liver. It was said
biliary calculi did not predispose to cancer of the pancreas,
but his cases did not support this statement. The impor-
tance of fat and undigested muscular fibers in the tissues
was recognized. Chronic interstitial pancreatitis, involving
the head of the gland, simulated malignant disease. Jaun-
dice without ascites indicated pancreatic rather than liver
disease, tliougli secondary nodules might appear in the
liver before the end of the case. Cancer of the bile ducts
also simulated pancreatic disease. Simple malignant dis-
ease of the head of the pancreas frequently could not be
distinguislied, even at the operation. Enlargement of the
cervical glands, when present, was an important point.
Glycosuria was rare in malignant cases. The so-called
"salol test" w'as useless. He thought catarrhal jaundice
was more frequently due to inflammatory sw^elling of the
head of the pancreas than to duodenal catarrh. He
thought drainage of the gall-bladder might be done pre-
maturely, as many cases of catarrhal jaundice subsided
after eight weeks.

Mr. iNiayo Robson did not advise operation when a defi-
nite diagnosis of cancer of the head of the pancreas could
be made. Some exception might be made when only the
tail or body was involved.

Dr. Cammidge remarked that the reaction known by his
name, although not pathognomonic by itself, would gen-
erally, in connection with clinical symptoms, enable a cor-
rect diagnosis to be made.

A case of abscess of the lung and acute endocarditis in
acute pneumonia was related to the Clinical Society on the
14th by Dr. F. H. Hawkins, who remarked on the rarity of
the complication, especially when, as in his case, the
abscesses (there were three found in the inflamed lobe at
the post mortem') had a distinct lining membrane. Dr.
C. T. Williams said he had seen four similar cases of lung
abscess, two influenzal. He had also seen abscesss and
endocarditis in pneumonics. He did not think surgical in-
terference offered a good prospect in such cases.

A paper was then read by Dr. David Forsyth on a fatal
case of myxedema with changes in the parathyroid glands
in a woman of fifty-eight.- w-ho had been developing the
disease about four years before coming under observation.
.\s the condition of the parathyroids found at the post
mortem has not been previously described, the report nat-
urally proved of interest. The six parathyroids found
show-ed a marked tendency for the cells to form vesicles
lined by cubical epithelium, an exceptionally profuse se-
cretion of colloid not only filling the follicles, but lying
among the masses of cells and distending the lymphatic
channels ; an abnormal increase in the connective tissue,
which formed coarse trabeculae, and even penetrated be-
tween the cells : thickening of the arterial walls. The
changes might perhaps indicate excessive activity of these
bodies, to supplement the deficient colloid consequent on
the atrophied thyroid, which presented the sclerotic changes
usual in mvxedema. The alterations in the stroma and

arteries were probably pathological changes allied to those
of the thyroid.

Mr. W, L. Harnett said he had examined many para-
thyroids, and considered the colloid as indicating increased
activity; he could always correlate changes in the o.xyphile
cells with this, and asked their condition in this case. Dr.
Walter Edmunds said expcrirnent gave contradictory re-
sults, an'd our knowledge of the subject was very imper-
fect. Animals deprived of thyroid and parathyroids gen-
erally died, but a small percentage seemed to suffer no
ill effects. In cases that recovered no traces were found
of gland tissue which had been left. He thought work on
the secretory nerves might yield information. He inquired
if there had been any evidence of tuberculosis. In reply
to these questions Dr. Forsyth said the oxyphile cells were
scattered uniformly, and not in clumps, as in the normal.
There was no active tuberculosis, but a calcified focus was
found at one apex. Experiments had shown no effects fol-
Towing section of the secretory nerves.

Dr._ F. Langmead then read notes of three cases of tetany
associated with dilatation of the large intestine in children
(ages 6, 3, and 2J/2), and which he thought formed a toler-
ably definite but unrecognized group, to which four attri-
butes w-ere common, viz., (i) obstinate relapsing tetany;
(2) abdominal distention; (3) oft'ensive unhealthy mo-
tions; (4) dilated large intestine. In all the cases the
tetany disappeared after the bowel w-as irrigated, but it
returned when accumulation of the feces was allowed.
This. Dr. Langmead thought, showed toxic absorption to be
the cause, and so far favored the toxemic theory of tetanus
in general. Malnutrition, prominent in these, as well as
previously recorded cases, seems to point to undue irrita-
bility of the nervous system. Some remarks were made
by Drs. Turney and Garrod as to the possibility of dis-
tinguishing dilatations of the sigmoid and the colon. The
president. Mr. Clutton. said he had operated on two cases
in adults. He favored preliminary drainage of the colon
for about a month before attempting resection.

Dr. .■\lexander Peddie of Edinburgh died on the 19th
inst. at the great age of 97. He took his M.D. and
L.R.C.S., Edin,, in 1835, and was reckoned the oldest doctor
in Scotland, perhaps in the United Kingdom. He had filled
various posts in his time, including the presidency of the
Royal College of Physicians, Edinburgh, and was F.R.S.
.ind member of various other societies. His recollections of
Dr. John Brown, the author of ''Rab and His Friends,"
were a constant source of pleasure to the literary coteries
of "-\uld Reekie," and some were embodied in his Edin-
burgii Harveian Oration (1890). He wrote also an ac-
count of Brown's life and work, and contributed papers
to the medical societies and journals. Of course, he has
been retired for some years, but Edinburgh will miss him
still more than during the time the veteran was still among
her living notabilities.

OUR PARIS LETTER.

(From Our Special Correspondent.)

SPON'T.^NEOUS GEXER.-\TI0X — ELECTRIC SLEEP — TRE.MMENT BY
CAT.^PHORESIS — THE TRE.^TMENT OF V.\RICOSE VEINS —
.\L0PECI.\ .^RE.\T.\ — SPLEXECTOMVFOR IXjL-RY OF THE SPLEEN
— LiRETEROV.\GIXAL FISTULA.

P.\Ris, December 2E. 1006.
A SERIES of very interesting lectures on the origin of life
in general have just been held in Paris by Professor Leduc
of the University of Nantes. The important studies that
he has made, and the curious results obtained again bring
forward the question of spontaneous generation, for his
experiments seem to indicate the possibility of a transition
from the mineral kingdom to the vegetable. By a chemical
process that he has devised he appears actually to create
artificial plants. This is the method: To make a seed he
takes tw-o parts of saccharose and one of sulphate of cop-
per, which he pulverizes and mixes. He takes a pinch of
this powder and with a drop of water makes it into a
little grannie. Then he prepares a culture medium com-
posed of water, ferrocyanide of potassium (2 to 4 per cent.),
chloride of sodium (i "to 10 per cent.), and gelatin (2 to 4 per
cent.). He puts a small amount of this medium in a
test tube and drops into it the artificial seed; in a few
minutes this seed begins to swell, elongates and finally
forms a sort of stem, and later on several trunks and
branches, which, in a few hours may reach a length of
twenty-five to thirty centimeters it the dimensions of the
tube permit it. The structure so obtained has the appear-
ance of an aquatic plant, and presents the semblance of
roots, stems, of structures that to some extent resemble
leaves, and enlargements which' suggest fruit. The stems
on reaching the surface of the liquid spread out like float-
ing leaves. If. in place of using a tube, the experiment is
performed in a wider and deeper vessel, the cultures have
a different appearance, and resemble algae or sometimes

Feb. i6, 1907]

MEDICAL RECORD.

279

moulds. This curious product of growth which resembles
a plant may have several hundred times tlie bulk of the
original granule, and the material necessary for this in-
crease in size is obtained from the culture medium, that
is, there must be growth by absorption. The structure is
a complicated one, since in addition to the differentiation
of horizontal roots, vertical stems, leaves, and terminal
organs there must e.xist some special mechanism by means
of which the membranogenous substance and sugar can
acquire a length up to thirty centimeters. These three
functions, nutrition by absorption, growth, and differentia-
tion, which so far have been considered characteristic of
life, are, therefore, reproduced by purely physical forces.
The growth of these artificial cells is very susceptible to
physical and chemical stimuli, they cicatrize their wounds,
and, when a stem is broken before its development is
complete, the fragments reunite and growth recommences.
Only a single function is still lacking to the synthesis of
life — the faculty of reproduction.

These interesting experiments were made by Professor
Leduc in the lecture room of the Societe de Chirurgie de
Paris, and' the same speaker also presented two other im-
portant discoveries. By a special method he has succeeded
in producing electric currents of a hitherto unknown form
by means of which it is possible to cause artificial sleep.
Leduc first subjected himself to the action of the current
and made careful notes of the sensations experienced. He
found that although consciousness persisted during a long
period, the subject undergoing the electric sleep was en-
tirely unable to give any evidence of his conscious state by
movement or other means. The graduation of the current
can be effected slowly and systematically, but if carried too
far death may be occasioned. As Professor Leduc points
out, in order to do this comparatively weak currents are
sufficient, which is in contravention to the custom in coun-
tries, such as America, where, for the execution of crimi-
nals, extremely strong currents are used.

Finally. Professor Leduc has also perfected a method
of electric medication. It is well known that the electric
current decomposes chemical compounds, and that it may
be used to cause remedial agents to penetrate into the
living tissues. When a current is passed into a solution
that is not a nonconductor the acid radicals are always
set free at the positive pole, while the metals and bases are
set free at the negative pole. By employing this principle
Leduc caufes active substances to penetrate the tissues,
and he has especially studied sodium salicylate, which is
of value in the treatment of tic douloureux, and also iodide
of potassium. In the latter case the solution is placed at
the negative pole. Sulphate of quinine is used with the
positive pole as is also chloride of zinc, which has been
found to be a powerful hemostatic and antiseptic.

A new method for treating varicose veins of the leg
was described by Dr. Pierre Delbet before the .\cademie de
Medecine. It is generally considered that the production of
varicose veins is principally due to the insufficiency of
the venous valves, and attempts have been made to over-
come this deficiency by ligature and by resection of por-
tions of the interior saphenous veins. These methods
have not proved satisfactory, however, and Delbet pro-
poses to remedy the condition by a new operation which
consists in anastomosing the saphenous vein with the
femoral vein, which latter is well provided with valves.
The juncture is effected in the middle third of the femoral
vein, and is said to have given excellent results.

At the Conseil d'Hygiene the conclusions of Dr. Dnguet
concerning alopecia areata were officially adopted. This
observer founding his conclusions on the experiments and
studies of Sabouraud and Jacquet, advocated the adoption
of the theory of the nonconta.giousness of this form of
baldness. Formerly, children suffering from alopecia
were kept out of the Parisian schools, but in Duguet's
opinion this is not necessary, and there is much experimen-
tal evidence to sustain his view. The parasitic theory of
the disease has been abandoned by most observers, and
the condition is generally considered to be one of tropho-
neurotic origin.

An unusual case of injury of the spleen treated by sple-
nectomy and followed by cure was reported to the Societe
de Chirurgie by Dr. Barnsby of Tours. The patient was
a butcher, aged twenty-eight years, who was stabbed with
a knife in the eighth intercostal space in the left side. Six
hours later he manifested si,gns of extreme internal hem-
orrhage, with pain and muscular rigidity in the left flank.
The operation was done nine hours after the injury. By
means of a transverse incision parallel with the costal
border the peritoneum was opened and found full of blood,
the spleen was so severely injured that a fragment repre-
senting about one-quarter o'f the organ was almost com-
pletely detached. Splenectomy was performed, and the
patient recovered.

Another interesting case was reported by Dr. Jeanbrau

of Montpellier. The patient was a woman of twenty-one
years who, as the result of pelvic peritonitis had been sub-
jected to a posterior colpotomy by means of which an ab-
scess cavity had been drained. Four days later she noticed
that urine was voided through the vagina. Jeanbrau, after
having first made use of the segregator of Luys, discovered
that there was a fistula communicating with the left ureter,
and some time later, by means of the direct vision cysto-
scope of Luys. he succeeded in introducing a catheter into
the injured ureter. Eight days later the catheter was re-
moved, and since that time no leakage has taken place.
Jeanbrau stated that a search of the literature had failed
to reveal any case of ureteral fistula following pelvic peri-
tonitis similar to this.

OUR LETTER FROM COPENHAGEN.

(From Our Special Correspondent )

NOMA — LIGHT TRE.\TMENT IN AFFECTIONS OF THE MUCOUS
MEMBRANES — LIGHT BATHS IN ANGIX.V PECTORIS — NEW
HOSPITAL BUILDINGS.

Copenhagen'. January 25, i.,o7

The etiology of noma has frequently been studied, but
as yet the question cannot be regarded as settled. It may.
therefore, be of some interest to draw the attention to a
research regarding this point by Dr. E. Hellesen of Chris-
tiania. The case of noma examined by our Norwegian
confrere was in so far somewhat unusual, as it occurred in
a child that had been in entirely good health until it began
to suffer from noma. Dr. Hellesen found in this case a
well-defined diplococcus. which he believed caused the
affection. He was led to this conviction by the following
circumstances. In the first place he found the microbe in
question to be constantly present in all preparations from
the diseased tissues. Secondly, having succeeded in iso-
lating the diplococcus, he was able to produce a typical
necrosis of the skin and adjacent tissues by inoculation of
the pure culture in rabbits, just as when particles of the
original noma were used for inoculation. As far as re-
gards this one case, the question of the etiology must be
said to have been solved. But the author is cautious
enough to admit the possibility of several microbes being
able to occasion the clinical picture of noma.

In the Copenhagen iSIedical Society, Dr. K. K. K. Lunds-
gaard read a paper on light treatment of affections of the
umcous membranes. He had treated seven cases of lupus
and two of primary tuberculosis of the conjunctiva with
very good results. The difficulty that the light treatment
of such diseases had hitherto encountered was that the
light could not be made to act directly on all points of
the affected mucous membrane. But Dr. Ltmdsgaard had
now been able 10 do this by using the complete reflection
of the light rays in prisms with the angles 90°, 60°, and
,TO°. The sides of the prisms were formed by plates of
rock crystal with plane and parallel surfaces,^ the prism
being kept cool by cold water runnin.g through its interior.
The prism was inserted between the bulbous center and the
eyelid, and the light rays directed perpendicularly against
the free surface of the prism, so that it was completely
reflected from the hypothenuse and passed out' into the
tissues through the surface opposite to the angle of 60°.
In order to secure a total reflection, it was essential to
avoid the moistening of the reflecting surface, wdierefore
the latter was covered with an air-ti.ght metal cap. and
the space between the reflecting surface and the_ metal cap
filled with thoroughly dry air. When using this kind of
prisms the only drawback was that this air in the course
of the treatment absorbed some moisture from the tissues
against which the prism was pressed, so that it was neces-
sary from time to time to replace the moist air by a fresh
supply of dry air. Experiments (with promising results")
had also been made with prisms of a less complicated
structure. As investigations had shown tl.at a mirror made
of amalgam of mercury on a rock-crystal plate only ab-
sorbed .about 30 per cent, of the chemical rays, the cap-
protected hypothenuses of the aliove-meutioned prisms was
in other prisms replaced by such a mirror. The cases
treated with these less complicated prisms had ^linwn satis-
factory progress.

At the same meeting the director of the Fiii«cu I.i-^lit In-
stitute. Dr. H. Forclihammer. ^:r.i\ lliat he had seen very
promising results in upwards of one linudred cases of lupus
of the upper respiratory tract treated in the institute by
Dr. Lundgaard's prisms. The best results were seen in
affections "of the anterior part of the nasal cavity (good
results in 38 out of 47 treated case.O, in affections of the
mucous membrane of the interior surface of the cheeks.
and in affections of the tongue. Here he especially men-
tioned a case of lupus of the tongue, which had formerly
been treated for vears by other methods, but had now

28o

MEDICAL RECORD.

[Feb. i6, 1907

been cured in a relatively sliort space of lime. He sought
the explanation of the good results in the fact that it had
now become possible to realize the conditions of an efficient
light treatment, laid down by Finsen. viz., that the light
rays were directed perpendicularly against the diseased tis-
sues, which at the same time were kept cool and anemic
by the pressure of tlie water-cooled prism.

Some months ago I mentioned Dr. 1 lasselbalch's work
in connection with the Finsen light batlis. At a meeting
of the Copenhagen Medical Society, Dr. II. Jacobous read
a paper on angina peclori.s, and said that of fifteen cases
he had seen fourteen improved or cured by the light baths.
He explained the efficiency of this treatment by the dilata-
tion of the cutaneous vessels and the accompanying de-
crease in the arterial pressure, whereby the work of the
heart became less ta.xing. An animated discussion arose on
this point. Prof. Chr. Gram said that the cases were too
few in number, and the lime of observation too short, to
allow of defmite conclusions; besides, one often saw im-
provement by other methods of treatment, as well as long
periods free from attacks; also, it was difficult to e.xclude
the effect of suggestion. As an apt illustration of the last.
Prof. Israel Rosenthal communicated the observation of a
patient who h.ad the sensation of a pronounced improve-
ment, but in whom nevertheless the disease made rapid
progress after every light bath. Prof. Friedenreich drew
attention to the difficulty of prognosis. A patient of
his, whom he had sentenced to death, lived for fifteen or
twenty years. Prof. Henriques thought the theoretical
foundation of the treatment to be of little value. The de-
crease of the arterial pressure in the brachial artery, found
by Dr. Hasselbalch in his investigations into the effects of
the light baths, was in itself very small, and not equivalent
to a decrease of the aortic pressure, wdiich latter only was
of importance. But even if the light baths caused a de-
crease of the aortic pressure, the treatment might be harm-
ful in many cases, for example in hypertrophy of the
heart muscle in connection with kidney diseases. Prof.
Jobs. Bock also thought the theoretical basis of the treat-
ment weak. Dr. Hasselbalch, who was present at the
meeting, did not speak.

In our largest and most up-to-date hospital, the Kom-
munehospital. which harliors upwards of 1,000 patients, a
new and beautiful building has just been opened as a home
for the nurses in the hospital service. The house shelters
126 nurses and has cost $80,000 to erect.

Prnijrrss of iBrfttral ^rmtr^.

-Vt'ic York Medical Journal, February 2, 1907.

Age Limitation of Sports. — H. Toeppen makes a
plea for the continuation of gymnastic and athletic sports
beyond the age at which they are usually given up. He
declares that as to the hardening of tissues, rigidity of
arteries, etc.. as a consequence of age, there is no rule of
general applicability. Naturally if arteries are left un-
disturbed and are just e.xpected to keep up a sluggish cir-
culation sufficient to supply the wants of a more or less
(bodily) lazy business man. they will assume considerable
rigidity about the fortieth year; but if they are made to
respond to sudden and energetic calls for increased and
lively circulation (without frequent excessive demands
and these calls on them are made daily) they will last a
good deal longer in consequence of improved nutrition of
their walls and a more lively excretion of waste and stag-
nation products. He then goes on to apply the
foregoing principles to such common sports as running,
skating, and to gymnastic work, concerning which he says
there is no limit for anyone and no excuse for its omission.
Only, he says, we must individualize with reference to
each particular patient. Some very sensible and practical
rules are given.

The Surgical Application of Blood Examinations. —
This subject is considered by J. B. Deaver, who considers
the findings with reference to the red cells in acute
post-hemorrhagic anemia and symptomatic anemia. He
is not inclined to attach much value to the findings in
the first because the surgeon's immediate task is to stop
the bleeding, whereas the histological changes in the red
cells in such conditions are not found until the end of
twenty-four hours. As to the findings in cases with small
but frequent hemorrhages in connection with chronic sup-
purative processes or tumors, a hemoglobin percentage
below twenty-five, a paucity of small distorted red cells,
and a disease-spoiled body, the author thinks that the con-
dition calls for the most serious contemplation before any
operation is undertaken. Concerning the white cells, he de-
clares that the familiar count cannot always be relied on.
Leucocytosis is usually found, however, in infections leading

to suppuration in any part of the body. It is to be looked
upon ui general as a measure of bodily resistance. He
does not find the count of much value in acute pyosalpinx,
e.xcept in differentiating from uterine fibroids, ovarian
cysts, etc., and one should constantly bear in mind that
these may give a leucocytosis when suppurating. The
average hemoglobin index is much lower in tubal disease
than in appendicitis, and the finding of only fifty or fifty-
five per cent, of hemoglobin and a moderate leucocytosis
corroborates strongly in making a diagnosis when the clini-
cal signs point to a pelvic collection. The differential
count is of value if carefully performed with properly
stained films and a count of at least 500 cells. Theo-
retically, it should always be made, but it is not always
possible. He accepts the general conclusions of Sondern
on this point, and adds that in lead colic a differential
count would be of great value, as the basophilic granulation
of the red cells would at once attract attention and decide
the diagnosis. But one should remember that lead workers
may get appendicitis, and that a leucocytosis is sometimes
encountered during the acute stage of plumbism.

Common Misconceptions in the Pathological Physi-
ology of the Circulation and Their Significance. — T. C.
Janeway refers in tliis mteresting paper to the great value
of the observation of blood pressure in such diseases as
typhoid fever, pneumonia, nephritis, etc. In many cases
of these diseases the danger lurks not so much in the heart
itself as in the vasomotor apparatus. Much of the drug-
ging which is done in the crimes of these diseases is
utterly useless and even harmful. Effects produced by
various valuable therapeutic measures, such as the tub in
typhoid, are of value just in proportion as they bring the
blood pressure up to normal. Concerning abnormally high
pressure, lie says that it is found independently of chronic
Bright's in at least ten per cent, of all cases. Its causa-
tion in these cases is unknown. It has been suggested
that the anatomical changes in heart and vessels are sec-
ondary to the increased blood pressure, as most of us have
believed, though a few have dissented ; secondly, that the
hypertension is due to widespread vasoconstriction, of toxic
origin, from retained metabolic products. That a general
increase in vasomotor tone is responsible for the hyperten-
sion agrees well with the facts of clinical observation.
Heightened blood pressure may be a necessitj' in many
cases of Bright's in which secondary arteriosclerotic
changes have taken place in the smaller vessels, which add
a permanent element of increased resistance ; hence the
futility, to say no more, of attempting to keep down the
pressure in such cases. In the presence of peril, however,
such as uremia, angina, hemorrhage, etc., the vasodilators
should be used freely. In the ordinary case with edema
and diminished urine excretion, the freshly made infusion
from good English leaves is urgently indicated. Rest in
bed should be insisted on and the fluid ingested limited.
Under these circumstances a rise in blood pressure is to
be looked on as a good sign and usually coincides with the
establishment of diuresis and relief of the dropsy.

Journal of the American Medical Assocmtioii, February
9. 1907.

Experimental Chronic Nephritis. — W. Ophiils con-
siders that the te.vtbooks may convey- a somewhat in-
sufficient idea of the amount and value of the work that
has been, done in the study of experimental chronic
nephritis. He refers to Ehrlich's and Lexaditi's ex-
periments with vinylemin as showing that if time
enough is given in the experiments, the lesions of
chronic Bright's disease are likelj- to be developed,
and also to those of Heinecke and Passler as likewise
instructive in this regard. He reviews the literature of
the experimental production of chronic nephritis by
poisons that directly affect the renal cortex and are
reported to cause interstitial changes, such as aloin,
boracic acid, cantharidin, potassium chlorate, chromic
acid and the chromates. lead and other heavy metals,
oxalic acid and oxamid, sulphuric acid, and various
bacterial toxins. He also gives an account of his
own experiments. He first employed lead, because
it is the only substance that we know with certainty
to produce chronic nephritis in man. Of course, the
smallest possible doses had to be employed to repro-
duce a disease of such chronicity. but even then the
lead anemia produced was the greatest obstacle to the
experiments being carried out for a sufficient length of
time. In all cases the lead was administered by the
mouth, as this comes closest to the natural conditions,
in guinea-pigs, to which from 1.5 to 3 grams of car-
bonate of lead had been given in the course of from
two to five months: only the incipient stages of chronic
nephritis were found, but in one dying about four
months after the discontinuance of the administration,

Feb. i6, igo/]

MEDICAL RECORD.

281

more advanced lesions were observable. The samo
incipient lesions as in the guinea-pigs — necrosis and
desquamation of epithelial cells of the convoluted
tubules and ascending loops of Henle, cellular infiltra-
tion around the blood-vessels near the glomerules —
were observed in one dog that had taken only 0.85
gram of lead acetate in six weeks. In other dogs that
had taken larger amounts given over longer periods
a marked chronic interstitial nephritis was manifest. In
spite of careful and repeated examinations, neither
albumin nor casts were found in the urine, which gives
support to the suspicion that similar conditions may
exist in man without such evidence. In order to sup-
plement the experiments with lead, two dogs were
given small doses of bichromate of potassium in milk.
One of these was lost in the confusion following the
earthquake, but the autopsy of the other, which had
received nearly 11 grams of the bichromate during the
course of four and one-half months, showed more
pronounced lesions than those dogs that had been
dosed with lead and under observation for a year or
more. The bichromate, therefore, seems to promise
well for future experimentation along these lines.
Ophuls proposes to continue the research with hope
of obtainin.g more definite disturbances in circulation
with consecutive cardiac hypertrophy, and of obtainnig
some information about the relation of renal and
vascular disease in chronic nephritis.

Rheumatism in Children. — J. Ross Snyder questions
the present tendency to widen the conception of rheu-
matism in childhood. He says that, eliminating scurvy,
pyemic arthritis, and the soreness and stiffness of
muscles and joints from clothing, coddlings, and bounc-
ings, the cases of rheumatism in nurslings are almost
nil, and from the eighth year onward an attack of rheu-
matism in a child resembles more or less closely the
adult type. He gives a list of a number of conditions
that have been regarded as occasional manifestations of
rheumatism, and some of these have in certain cases a
connection that cannot be denied. The most important
of these arc the cardiopathies, especially endocarditis,
but in view of the nimiber of infective processes that
are capable of causing both arthritis and endocarditis.
Snyder thinks preconceived notions as to the associa-
tion of the two disorders will cause many mistakes in
diagnosis. As regards chorea, tonsillitis, and erythema
nodosum, he is inclined to think the evidence as yet
insufficient to prove their relations to rheumatism. As
regards the many other conditions considered to be
manifestations of child rheumatism, his opinion is that
they will "one by one be taken away from this con-
nection until rheumatism will come to mean, not every-
thing, but something or nothing."

Rheumatic Fever in Childhood. — C. H. Dunn crm-
cludes that at present it seems advisable to accept the
Micrococcus rhcumaticus of the English investigators.
Poynton and Paine, not as the absolutely proven, but
as the probable cause of this disorder. A careful study
of some three hundred cases treated at the Children's
Hospital, Soston, during five years, brings out the
following points as characteristic of the disease, as
here conceived, in early life: (i) The comparative mild-
ness of the articular manifestations. (2) The relative
frequency of cardiac manifestations. (,^) The large
number of cases in which only cardiac manifestations
occurred: an actually greater number than those with
only articular symptoms. (4) The frequent primary
occurrence of endocarditis or pericarditis. (5) Cardiac
manifestations are the most severe. In acute endo-
carditis, and even more in acute pericarditis, the severity
of the case and dan,ger to life are greater than in acute
arthritis. (6) A notable feature was the tendency to
recurrent attacks with varying manifestations, arthritic,
pericardial, etc., and not following any particular order,
one form one year and another form for another year.
What is called "broken compensation," and generally
attributed to overexertion, was observed in 121 of
the 300 cases. Dunn attributes it here to a fresh infection
rather than to overstrain. .A.s regards diagnosis, he
says, given any case of arthritis, especially if with
the physical signs of endocarditis, or any case of acute in-
fectious disease without other localization than in the
pericardium or endocardium in childhood, the prob-
abilitv is that it is a case of rheumatic fever. Previous
attacks, chorea, sore throat, etc., strongly increase this
probability. Endocarditis, and other infections from
the pyogenic cocci or as complications of other recog-
nized infections are readily diagnosable. As regards
pro.gnosis, he says, many physicians do not recognize
that the chances of death may be as high as one in five.
The cardiac complications arc more frecpient than in

the adult. The severest form is pericarditis, with a
high mortality. In conclusion, Dunn points out that the
general characteristics are those of a definite clinical
entity, and most probably a specific infection to be
placed in the same rank as scarlet fever and measles
as definite disease species.

Autointoxication in Relation to the Eye. — G. E.

de Schweinitz discusses the question of autointoxica-
tion, more especially that from the gastrointestinal
tract, in relation to the eye. He finds that a number
of morbid ocular conditions, including optic neuritis
and retinitis, ocular muscle anomalies, at^'ections of
the cornea and sclera, and disease of the uvea, may
possibly or probably be referred to this cause, and
points out the importance of accurate and thorough
urine investigation by the latest clinical methods of
diagnosis in these cases. He summarizes as follows:
".\ithough we do not know the entity of a single autoin-
toxication, except the acidosis of diabetic coma, and
although we know that no known autointoxication is to
be attributed to any known end product of any known
metabolism, to quote Alunzo Taylor,_ we do know, from
clinical analogy at least, that 'autointoxications exist,
even if their true nature is as yet a secret.' We do
know, too, that after food is swallowed and before the
end-products of assimilation are eliminated there may
be processes arising under abnormal conditions which
yield poisonous products foreign to normal metabolism,
the reabsorption of which may be followed by definite
symptoms. We have reason to believe, in the absctice
of other causes, that ocular troubles may also arise
largely in the corneoscleral and uveal tracts, and prob-
ably in so far as the nervous apparatus is concerned,
in inanifestations to which we apply the term acute or
chronic retrobulbar neuritis. We do not know whether
these toxins, whatever they may be, actually are the
only and sole cause of these conditions, but such ex-
aminations as have been made by Elschnig, by Kraus, by
Grayer, by Edsall, and by myself at least indicate that,
to use El'schnig's term, they may be considered acces-
sory causes. As Edsall and I have said, they may be
able to play a certain part in the production of the
symptoms, and at times are probably the direct cause
of their continuance, even when other more conunonly
accepted etiological factors have ceased to be active."

The Lancet, January 26, 1907.

Glandular Extract from Immunized Animals as a
Curative Agent in Plague. — S. Mallannah reports the
results of experiments in fifty rats and guinea pigs. Healthy
rabbits were inoculated with Haft'kine's prophylactic fluid
in sufficient degree to ,give them a slight immunity. Later
they were inoculated with the plague bacillus and then
while still quite sound chloroformed. Microscopic exami-
nation of the juice of glands of such animals did not
reveal the presence of any bacteria and no growth was
obtained on the media inoculated. The details of pre-
paring the glandular juices are given in full He was
led to these experiments from consideration of the well
known clinical fact that the cases of the plague which
recover are those in which the glandular reaction is most
marked, while the most serious cases are those in which
the glandular reaction is hardly observable. It is also noted
in the laboratop,- that marked pathological changes are
found in the lymphatic glands, spleen, and liver, especially
in those animals in which for some unknown reason the
disease runs a chronic course.

A New Sugar Test. — H. J. H. Fenton describes this
test which is delicate enough to detect one-tenth per cent,
sugar in urine and other body fluids, or even less. The
reaction depends on the fact that all carbohydrates of the
hexose. or polvhexose. type (such as dextrose, la»vulose,
cane sugar, milk sugar, or maltose) vield a certain amount
of hromomethylfurfural, CH^Br— C4H.O— CHO, when
acted upon bv hvdrobromic acid under appropriate con-
ditions; and further, that the latter substance reacts with
malonic ester in presence of alkalies, giving rise to a product
the solutions of which exhibit a powerful blue fluorescence.
The conditions most favorable for the action of hydro-
bromic acid are obtained when phosphorus tribromide is
dissolved in some inert solvent, such as toluene, and the
solution is heated with the carbohydrate m presence of
water; excess of water, however, must be avoided. For
the examination of urine the test is most conveniently
applied in the following way: Pour a small quantity (four
or five cubic centimeters) of the liquid on to an excess of
solid anhvdrous calcium chloride so as to form a semisolid,
or pasty,' mass. Add to this ten cubic centimeters of
toluene containing two or three drops of phosphorus tri-
bromide and then carcfullv boil the mixture for a few mm-

282

MEDICAL RECORD.

[Feb. 1 6, 1907

utes, bearing in mind the inflammable nature of toluene.
Pour off the toluene solution and, after cooling, add to
it about one cubic centimeter of malonic ester and a little
alcohol. On neutralizing the mi,xture by adding alcoholic
potash, drop by drop, a characteristic pink color will
usually be observed. The mi.xture is now considerably
diluted witli alcohol and a few drops of water when, if
sugar was originally present, the solution will exhibit a
beautiful blue fluorescence. The reaction appears to be a
specific one for carbohydrates which contain six or more
atoms of carbon in the molecule and may therefore be
used to distinguish hexoses from pentoses or other lower
sugars.

Observations on the Induction of Autovaccination in
Tuberculosis and other Chronic Glandular Infections by
the X-Rays. — These observations are recorded by H. D.
McCullough, who bases his work on the revelations of the
opsonic chart in the tuberculous cases. Their purpose is
to demonstrate the theory that the mechanism of the thera-
peutics of the x-rays rests upon the induction of an auto-
vaccination, subsequent to tlie resolvent action of the rays
on the rudimentary neoplastic encapsulating tissues about
the tuberculous glands, thus rendering the vaccine ac-
cessible to the blood-vessels. It is also shown in the
paper how the efl^ects may be observed by minute tempera-
ture reactions, accompanied by similar advances in the
opsonic inde.x without negative phases, tested by the peri-
odic estimation of the opsonic inde.x to the tubercle bacil-
lus. The author refers to the admitted fact that all
neoplastic tissue is a rudimentary replica, almost in every
detail, of the tissue affected and that such tissues are
highly susceptible to the influence of the .r-rays and of the
less penetrating cathode rays. These stop short of dam-
age to the normal and more organized tissues when they
are judiciously applied, and they restore metabolism when
it has more or less come to a standstill. The author states
that he is tempted by the obvious therapeutic parallelism
in the recently reputed medicinal agents in cancer to enter
into their probable therapeutic values as recorded in the
experience of others. He refers to papain, trypsin, and
amylopsin. but adds that these enzymes, when injected in
emulsion into the encapsulating tissues where metabolism
has come to a standstill, bring about active resolution (if
veins are avoided) by virtue of their proteolytic and dias-
tatic properties on those tissues, when the lesions are ac-
cessible and not too deeply situated. They may thus liber-
ate the vaccine when present in the lymphatic glands with
the desired result if thev do not influence it unfavorably
by admixture before neutralization.

X-Ray in the Treatment of Carcinoma and Sarcoma. —
C. Williams notes that all the theories advanced to account
for the influences of the rays on malignant growths seem
to point to a leucocytosis being ultimately produced in or
around the growths. According to one authority, they have
a special selective action on new grow^ths, the cell nuclei
swell, do not stain w-ell, the outlines of the cells become
indistinct and fuse, the protoplasm becomes granular, is
invaded by leucocytes and absorbed, leaving a network of
dense connective tissue containing vessels with thickened
walls from endo- and periarteritis caused by the r.ays. Some
sort of reaction seems to the author absolutely necessary.
This reaction may take the visible form of redness in
the mass if protruding through the skin or round the edges
of an ulcer, swelling or hardness of the tumor, increased
heat, perhaps in some cases increased pain or other vague
undefined feelings to the patients. If a discharge be present
it soon takes on a more healthy nature, both as regards
appearance and odor. Sometimes there is pent-up pus,
with elevation of temperature and night sweats. The
rays should be used both before and after surgical interven-
tion. Failure may result from inexperience of the oper-
ator, vagaries of the apparatus, too weak or too energetic
treatment, the hopelessness of the case, dissemination of
the lesion throughout the internal organs, or the patient's
low vitality. Except in cases in which the growth is
extremely local, the author thinks it best not to screen
the surrounding tissues. The pain of malignancy can be
greatly alleviated by this mode of treatment. The pain
that one sometimes notices in cases where it is obviously
due to the dragging or contraction of the scar does not
seem to vield so readily as "growth" pain. Pain produced
by pent-up discharge or the disinte.gration and liquefaction
of the malignant cells can only be relieved by the patient's
absorptive powers or by an exit naturally or artificially
produced. In uterine cases it is important carefully to
distinguish between the period pain and the pain of the
growth while under treatment.

British Medical Journal, January 26, 1907.

Urethral Abscess and Calculi. — F. G. Hack reports
the case of a man of thirty-four years who was operated
on for perineal abscess. A quantity of pus was evacu-

ated and the presence of a large calculus revealed. This
was extracted with lithotomy forceps, and afterwards
found to weigh over one-half ounce. A sound passed into
the bladder detected no calculi, nor could any communi-
cation between the bladder or urethra and the cavity con-
taining the calculus be discovered, but subsequent to the
operation a small quantity of urine escaped from the
perineal opening during micturition. When seven years
of age the patient had undergone an operation for stone,
apparently by lateral lithotomy, the perineal abscess oc-
cupying the site of the old scar.

Incubation of Scarlet Fever. — Commenting on the
fact that most text-books give the incubation period in
this disease as from one to seven days with an average of
from two to four days, E. L. Jenkins states that it is
often much longer. From an extensive hospital experience
he believes that it is often to three or four weeks. Owing,
he says, to inevitable errors in diagnosis, a certain num-
ber of cases are sent in as scarlet fever which are not
so. A child, for instance, suffering from sore throat, with
a pseudo-rash, and the concomitant signs and symptoms
of some fever being present, the case is diagnosed as one
of scarlet fever, is consequently notified as such, and is
immediately sent for isolation. On the following day,
however, the little patient is found, to all intents and pur-
poses, quite well, with an absence of fever and no trace
of any rash. This change within twenty-four hours is
very marked, while the general appearance of the patient
during the ne.xt few days will serve to prove that an error
of dia.gnosis has been committed. This being so, we can-
not even place such a case among the category of the
"simplex" or mildest form of scarlet fever. Nevertheless,
owing to the absence of an observation ward in the author's
hospital such a child is placed among the genuine cases
of scarlet fever, and is from the moment of admission open
to infection, and yet cannot be discharged just then. Under
such favorable conditions for infection he finds that such
a child does not contract the disease within seven days —
the limit incubation period as generally given — but on
the other hand shows unmistakable signs of infection in
from three to four weeks after admission to the scarlet
fever wards. The type of fever in these cases is somewhat
severe, the si,gns and symptoms being usually typical of
those varieties of scarlet fever recognized as "scarlatina
anginosa" and "scarlatina maligna."

Treatment of Myoma of the Uterus. — J. F. Jordan
believes that uterine fibroids call for active treatment and
that it is wrong to allow the condition to go unrelieved,
providing of course that symptoms are present. Most
frequently we find hemorrhage and, nearly as often, pain
due largely to a complicating inflammation of the appen-
dages with adhesions. Cases die more often than is realized
from the effects of repeated hemorrhages and consequent
debilitv. It is not true that fibroids "do not kill." The
mortality of hysterectomy is not great, certainly not over
five per cent. Myomectomy may be done if the patient is
under forty years, if pregnancy coexists, if a tube and ovary
capable of functionating can be preserved, and if it can
be done so as to leave a uterus practically sound. Re-
currence must be admitted as a possibility. Minor meas-
ures, as curetting and electrical treatment, are absolutely
useless. As to oophorectomy it is not to be compared
with hysterectomy as a routine procedure for the following
reasons: (i) The operation of oophorectomy is attended
by quite as large, if not a larger, mortality than hysterec-
tomy. (2) It is quite as difficult an operation to per-
form, and takes very nearly as long. (3) The immediate
post-operative condition is much more distressing, there
being much more pain after oophorectomy than after
hysterectomy. (4) The general convalescence is longer
and much less easy, (y) The ultimate cure cannot, on
the face of it, be as certain. If we perform a hysterectomy
we remove the stretching on the broad ligaments caused bv
the fibroid. In the Trendelenburg position, wdth all the
bowels and omentum tucked up in the abdomen away from
the pelvis, one can fashion the peritoneal flaps, tie the ves-
sels so that the stumps drop under, and can be easily
buried under the peritoneum. The author never sutures
the cervix. He simply brings the anterior ar ' "-:- --r
flaps of peritiineum together with a continu Ik

suture. .-Vt the end of the operation one can .... ^_.vn
into the pelvis, and there is between the bladder ra front
and the rectum behind nothing but the line of suture
visible, lying in the pelvic floor with no strain whatever
upon it. If the appendages are not diseased he does not
remove them.

The Cause of Acute Illness Supervening During
Menstruation. — .-X series of cases is summarized by
T. Holmes. He refers particularly to three instances in
which an apparently normal menstruation is interrupted by
signs of a sudden pelvic inflammation. Under such cir-

Feb. 1 6, 1907"

MEDICAL RECORD.

2Bt,

ciimstances he has several times found small but very
sensitive ovaries. Tliere may also be accumulation of blood
hematocele. Such cases undoubtedly start as hemorrhage
from a Graafian follicle, engorged with blood as it is, at
the menstrual epoch, the exciting factor being undue exer-
tion, causing intraabdominal pressure. In another case of
the author — recovery from acute lobar pneumonia — men-
struation came on and the patient was seized with acute
pain in the left iliac fossa, together with nausea and vom-
iting. Examination showed a prolapsed, enlarged, and
very tender ovary. In such a case one must consider the
possibility of blood infection by the pneumococcus as either
attacking a healthy ovary and setting up an ovaritis, or at-
tacking an ovary in the substance of which blood has been
effused, owing to the rupture of an engorged Graalian
follicle, causing an infection of it. and so setting up an
inflammation. In still other cases the pelvic inflammation
may result from septic conditions in either rectum or
va.gina. or both. The clinical history of one case in this
category closes the author's paper.

The Food Factor of the Twentieth Century. — G. J.
Sealy calls attention to the increased amount of bowel
disease of the present day. He attributes it largely to the
increased consumption of meat. Those who eat the most
meat are those who want the most meals. The stimulating
property of meat is largely responsible for the fact that
those who have for a time abandoned the use of meat at
breakfast and lunch, and who confine their indulgence in
it to once a day, find that what they were disposed to re-
gard as a mere apology for a meal sustains them better
and for a longer time than what they wrongly thought
was the more substantial and valuable material. Cookery,
in England, says the author, has altered to the extent that
solid foods are made mechanically more digestible, not an
unmixed gain, as excesses are simplified, and indiscreet
indulgers are not warned by the epigastric storm-signals
which formerly brought them to account. Some years ago
the author restricted his proteid intake to one-third of his
former allowance, and found himself greatly benefited in
every way. Proteid restriction has a most beneficial effect
on the peripheral circulation, in the sense of a feeling of
increased warmth and general well-being. Much of the so-
called "nervousness'" of the present day is merely the re-
sult of autointoxication from too great proteid indulgence.
A large amount of energy is used up in passing on nitro-
genous waste products from organ to organ, or from tissue
to tissue, on the way to elimination, and that liver and
kidneys ultimately rebel at the excessive labor is not to be
wondered at. and when the products that result from the
breaking down of nitrogenous waste fail to go through the
processes in the hepatic cells and elsewhere that Nature
intended, very serious symptoms inevitably result.

Bcrliiii-r klinisi-hr U'oclicnschrift, January 21, 190".

The Flotation Test of Infants* Lungs.— Marx states
that it is two hundred and twenty-five years since Johann
Schreycr first made forensic use of the floating test as a
method of determining whether the lungs of a newly born
child had ever been distended with air or not. and the per-
formance of this test is still one of the duties of the
pathologist making an autopsy on a new-born child for
medico-legal purposes. While per sc the fact that a lung
sinks is evidence that the child had never breathed, and
that if it floats air had entered the lung, there are certain
sources of error that must be taken into account. Chief of
these is the effect of decomposition which may cause an un-
expanded lung to acquire buoyancy enough to float. In this
case, however, the bubbles of gas that form beneath the
pleura are different in character from the appearance of
aeration caused by respiration. The decomposition bubbles
'are irregular in size and generally are larger than alveoli,
and gas formed through decomposition is always in the iur
terstitial tissues and never in the interior of the alveoli.
The author then reviews the work of a long series of in-
vestigators who have endeavored to establish the scientific
value of the test or have suggested modifications of it.
Among these is the flotation test of the stomach and upper
portion of the intestine. If respiration has taken place
air will have entered these cavities and the organs will
float, but here again if decomposition has set in the result
is unreliable. The author does not attempt from his review
of the literature to form conclusions regarding the infer-
ences that may be drawn from the flotation test, but docs
state that it is still an important feature of the determina-
tion of the occurrence or nonoccurrence of a still birth.

Miiiichcner mcdiciiiisriic n'ocJicnscJirift. January 15. iqo/.
Finding the Round Ligaments in the Inguinal Canal.

— Reismann suggests the following expedient to facilitate
the isolation of the round ligament in performing the
-■Mexander operation for retroversion of the uterus. Numer-
ous methods for this purpose have already been proposed

but even if the canal is laid open for its entire length, it is
frequently difficult to identify the round ligament, owing
to the infiltration of the tissues with blood, which very
easily takes place and renders it ditticult to distinguish
the "different structures. A simple way of solving the
problem is to pick up the entire contents of the canal with
a blunt hook and put the parts somewhat on the stretch.
The bundle of tissue thus elevated is then pulled apart
slightlv with two pairs of forceps, and the round ligament
will soon be discerned shining through the overlying tis-
sues as a grayish band. The forceps are then used to iso-
late the structure at this point, and it is caught up on an-
other hook. The first hook is removed anfl it is now an
easv matter to free the ligament from adjoining structures
in both directions and to draw out the peritoneal funnel
through the internal ring.

The Treatment of Delirium Tremens. — Ganser is of
the opinion that, it is much better to cut oft' the alcohol
absolutelv in cases of delirium tremens than to make any
attempt to reduce gradually the amount consumed. He
also is averse to the use of sedative drugs, particularly
chloral, which he considers is very dangerous even in doses
much smaller than those that are frequently recommended.
The hot baths and wet packs that have been suggested by
several authors are also looked upon with disfavor by
Ganser. who states that he has seen collapse and death
occur under each of these forms of treatment. In the past
sixteen vears he has treated 1.051 cases of delirium tremens:
during the first eight years 486 patients were treated, with
a mortalitv of 6.37 per cent.; during the succeeding_ eight
years. S65 patients were treated, with a mortality of only
'88 per^cent. During both of these periods the therapeutic
measures were the same in all respects except one, and it is
to this one point of difference that the author attributes
the great improvement in the statistics. .Actuated by the
conviction that all persons suffering from delirium trernens
either alreadv have weak hearts or that this danger exists,
Ganser has adopted the rule of giving digitalis immediately
to all patients of this class brought into his hospital. This
is kept up until all danger seems to be past, while if at any
time evidences of cardiac weakness, such as rapid, small, or
irregular pulse, are observed, the customary stimulants, par-
ticularlv camphor in oil, are given hypodermically. In
such cases also ice cold champa.gne in tablespoonful doses
has been found useful, but this is the only condition under
which he breaks his rule of abstinence from alcohol. The
other features of his plan of treatment comprise careful
nursing with abundant feeding and attention to the bowels,
isolation being resorted to onlv when absolutely necessary.
Sedatives are verv rarelv used, as their elTect has been
found unsatisfactory. In order to facilitate toxin elimina-
tion the patient is encouraged to drink freely a i per cent.
solution of sodium acetate in water to which a little mo-
lasses has been added.

Pt-i(tschc mfdi:inischf IVochrnschrift. January 10 and 17,
1007.
The Treatment of Large Umbilical Hernias.— Figler
savs that ordinarily the very large umbilical hernias of new
born infant? give a bad prognosis. Tlie interferences with
the circulation in the displaced or.gans are apt to cause
such serious disturbances of the digestive processes tlwt
the nutrition of the child suffers severely. He believes that
in these cases radical operation should be resorted to and
the earlier the better, because as time goes on it becomes
increasingly difficult to secure asepsis and avoid infection
of the peritoneum. He describes such a case occurring in
a child which at birth weighed two kg. and suffered from
a very large hernia into the umbilical cord. The operation
was done on the fifth day after birth and the entire
liver, together with coils of small intestine, was found in
the sac. .A radical operation was done and two and a half
weeks later the child had more than doubled it= weight.
Five weeks later the child was seen again and was found
to be well nourished and with a healthy cicatrice.

A Simplification of Heller's Test.— Sachs speaks
highlv i-.i the value of Heller's ring test, which he con-
siders the most delicate and certain reaction for albumin
in urine, but points out the inconveniences that attend
it if it is to be properly carried out. As a simple biit
thnroughlv efficient modification, he suggests the fol-
lowing procedure: .\ glass plate, such as a microscopic
slide, is laid on a black surface, and on thi^; are placed
a drop each of nitric acid and of the urine tn lie tested.
If placed close together the drops soon jnin. nn.l at their
line of iunction a characteristic fihii of albnniin will
form and gradually produce a milky veil ov.-r the fluid
which can he clearly disccrm-d ag;inist thr bbck back-
ground. The test is exceedingly delicate, and. m addi-
tion to its simplicity of performance, has the advantage
that onlv verv small amounts of urine are necessary, a
pr.int that is of service in working with annual urines.

284

MEDICAL RECORD.

[Feb. 1 6, 1907

Travaux de Chirurgie. Par Henri Hartmaxn, Chirurgie

de rintestin. Paris : Georges Steinheil, 1907.
The author has succeeded in giving an excellent sketch of
the diseases of the intestine requiring surgical aid. The
Murphy button is used only in special cases, while, as a
rule, the suture is given preference for anastomosis virork.
The book is well illustrated, and can be higlily recom-
mended,

De l'Apepsie. Par Hex\ri Francais. Paris : G. Steinheil,
1906.

Under the above title Frangais gives a detailed description
of achylia gastrica. Tlie writer gives his own observations
and several^ new experiments relating to the subject. The
book may be recommended as profitable reading for the
practitioner.

Gesammelte Beitr.\ce aus dem Gebiete der Physiologie,
Pathologie und Therapie der Verdauung. Von J.
Boas uxd SEiiXEN Schulern. Berlin: Verl'ag von S.
Karger, 1906.

Having been the first to establish a polyclinic for the dis-
eases of the digestive tract in 1886, Boas decided to pub-
lish in the present two volumes his and his pupils' works
in the last twenty years. Most of Boas' pioneer works are
known to every clinician : his essays on the importance of
lactic acid in gastric carcinoma ; occult hemorrhages in
cancer and ulcer of the stomach ; mechanical insuf-
ficiency of the stomach. In fact, there is hardly an im-
portant subject in the field of digestive diseases on
which the well-known author has not written something
good. In studying the two volumes the reader will thus go
through the entire field of the pathology of digestion with
great profit to himself, and will congratulate Dr. Boas on
his great achievements.

Pulmonary Phthisis, Its Diagnosis, Prognosis, and

Treatment. By H. Hyslop Thomson, ;M.D., Visiting

Physician to the Consumption Sanatorium of Scotland,

Bridge of Weir, N.B., formerly Medical Superintendent.

New York : William Wood & Co., 1906.

The author treats in a most concise manner the whole

subject of pulmonary tuberculosis. The work is in three

sections, dealing with diagnosis, prognosis, and treatment.

In such a brief work it is manifestly impossible to consider

either section exhaustively, and in dealing with diagnosis

the writer emphasizes particularly abnormalities in signs and

symptoms which would lead one to suspect tuberculosis,

in preference to giving a detailed consideration of typical

cases. He cautions against definite prognosis, and discusses

frankly the limitations of open-air treatment. The section

dealing with prognosis will be found to contain many points

of real value to the general practitioner, and could have

been written only by a physician experienced in sanatorium

treatment.

In considering the treatment of phthisis. Dr. Thomson
has brought out little that is new. Many physicians will
differ from him somewhat in the treatment of special
symptoms ; for instance, the value of the use of antiseptic
drugs to overcome secondary invasion by pyogenic bacteria
m'ay be questioned. The chapter on specific treatment,
though short, is a very interesting summary of recent in-
vestigation, and his remarks in regard to tuberculosis in
children are worthy of attention.

The Diagnosis of Nervous Diseases. By Purves Stew-
art. M.A., M.D., F.R.C.P. Physician to" Out-Patients at
the Westminster Hospital ; Joint Lecturer on Medicine
in the ^Medical School ; Physician to the Royal National
Orthopedic Hospital ; Assistant Physician to the Italian
Hospital. London : Edward Arnold, 1906.
Diseases of the nervous system are admittedly among the
most difficult for the average practitioner to diagnose, and
those who see maladies of this description more or less
rarely will find the present volume a very useful guide. It
is written purely from the standpoint of diagnosis, and
without going into any details regarding etiology, pathol-
ogy, or treatment, the symptoms and physical signs that
accompany the various affections of the nervous system are
set forth clearly and logically. Several preliminary chap-
ters are devoted to the most important anatomical consid-
erations, and then the different types of phenomena on
wdiich the physician bases his deductions are discussed
under chapter headings, such as "Coma, Fits, and Other
Convulsive Phenomena," "Reflexes," "Disorders of Articu-
lation," etc. Especially useful and interesting are the sec-
tions on postures and gaits, and on affections of the sym-
pathetic, and the work closes with a chapter in which the
important subjects of lumbar puncture and the cerebro-
spinal fluid are well presented in the light of recent work.
The illustrations are verv numerous, and, as thev are

nearly all original, have the charm of novelty. The author
is to be congratulated on his success in achieving his object
of presenting a concise and attractive treatise on a difficult
subject, and it is a pleasure to recommend it to those inter-
ested.

Elements of Practical Medicine. By .Alfred H Carter
M.D., M.Sc, F.R.C.P. Lond. : Professor of Medicine,
University of Birmingham ; Senior Physician to the
Queen's Hospital, Birmingham; Emeritus Professor of
Physiology, Queen's College, Birmingham; Consulting
Physician to the Corbctt Hospital, Stourbridge, the
Bromsgrave Hospital, the Smallwood Hospital, Red-
ditch, and Guest Hospital, Dudley. Ninth Edition. Lon-
don : H. K. Lewis, 1906.
This is an excellent compendium of the practice of medi-
cine, well adapted to the needs of the advanced student, the
busy practitioner, and anyone who wishes to review the
broad tacts of medicine without going into the minute de-
tails of pathology or a discussion of the differing and often
conflicting views of various writers. The author describes
the various diseases in turn, following the generally
accepted teaching and avoiding reference to other authori-
ties. In this way much ground is covered in a few pages.
The book is not a treatise on medicine, but rather a plain
narrative of the course of disease, with suggestions regard-
mg the management of the patient, and a statement of the
generally accepted treatment. Following an introductory
chapter on General Pathology are chapters on Specific
Infectious Diseases, General Diseases, Diseases of the
Blood and Glands, of the Respiratory, Circulatory, Alimen-
tary, Urinary, and Nervous Systems, and of the Skin.
There are no illustrations ; they are not needed in a work
of this kind, and their omission is commendable in these
days of many picture books. A practical and not too long
therapeutic index completes the work. We like this book,
and we think others will find it a useful guide to medical
practice ; indeed, others must have found it so, for the
work is now in its ninth edition.

The Diseases of the Nose, Thro.a.t, and E.\r. By
Charles P. Grayson, M.D., Clinical Professor of Laryn-
gology-, Medical Department, University of Pennsylvania.
Second Edition, revised and enlarged. Philadelphia and
New York : Lea Brothers & Co., 1906.
The first edition of this manual was favorably noticed in
these columns. The various topics have been brought up
to date in the new edition and some excellent colored plates
added. The characteristic feature of the work is, in our
opinion, a wise selection of therapeutic measures, so that
the beginner is not confused by too many suggestions. So
also particular stress is laid on the relations of nasal and
throat to other bodily functions. The writer impresses one
as a good, all-around physician, as well as a skilled rhinolo-
gist. He realizes that there is a medical as well as a surgical
side to the question of nose, throat, and ear therapy. We
know of no better work for the student or the practitioner
beginning this special line of work. Of the 518 pages of
text (excluding formulary and index), 225 are devoted to
the nose and accessory cavities, 96 to the nasophao'nx and
pharynx, and 195 to the ear.

Abdominal Pain. Its Causes and Clinical Significance.
By A. Ernest Maylard. M.B., B.S. (Lond.), Surgeon to
the Victoria Infirmary. Glasgow ; late Examiner in
Surgery to the University of Glasgow, and Victoria Uni-
versity, Manchester; formerly Demonstrator of Anatomy,
Guy's Hospital. London, and ex-President of the Glas-
gow- Pathological and Clinical Society ; Author of a
"Treatise on the Surgery of the Alimentary Canal."
Second Edition (revised). London: J. & A. Churchill,
1906.
In view of the fact that, although pain is one of the com-
monest symptoms of disease, it is also, owing to its subjec-
tive nature, one of the most difficult to interpret, it is
rather strange that medical writers have not devoted more
attention to the subject. Compared w-ith other topics, it
would seem that semeiographers had given it but scant
consideration, and any contribution to a study of its nature
and practical bearing deserves the gratitude of the profesr
sion. What may be accomplished in this field by a thought-
ful investigator is well illustrated by the present work,
which is devoted to the symptom as it occurs in the abdom-
inal region. Owing to the thoroughness with which the
origin of referred pains has been taken up, the scope of the
volume is much greater than its title at the first glance indi-
cates, particularly as pain in the sides, and dorsal, lumbar,
and sacral regions is included. While such chapters as
those on post-operative pains caused by different types of
causes, such as incisions and ligatures, flatulence, peritoni-
tis, and adhesions, and the character of certain operations
are of especial interest to surgeons, most of the book should
be found of great value by internists as well. By means
of a series of well-compiled tables, the work is made very
convenient for use as a reference book.

Feb. 16. 1907]

MEDICAL RECORD.

285

NEW YORK ACADEMY OF MEDICINE.

SECTION ON rEDI.\TRICS.

Stated Meeting, Held December 13, 1906.
Dr. Matthi.\s Nicoll. Jk., in the Ch.mr.

Splenomegaly, with Special Reference to Etiology. —

Dr. Eli Ldxr, presented three cases uf splenomegaly.
Cases I and 2 were twins, boy and girl, nineteen months
old. The father and mother were healthy, and gave no
specific history. These were the last of nine children, all
living except two, one having died from diphtheria, the
other having been killed in an accident. The mother had
never had a miscarriage. These babies were breast-fed
entirely till one month of age, when they were given sup-
plemental bottles of Borden's bottled milk, modified, not
pasteurized or sterilized. The children were kept out of
doors. They had never before been ill. On examination
the most striking feature was their very pale skins, espe-
cially that of the girl. They were well nourished, with
slight rickets. The spleen of the little girl extended about
2V2 inches below the free border of the ribs, that of the
boy about i inch. The livers were slightly, if at all, enlarged.
The spleens were firm, but not hard to the touch. Exami-
nation of the blood showed the following : Specimen from
the girl, according to Dr. L. B. Goldhorn's examination,
revealed many nucleated red cells, half of which were
megaloblastic in type. There was marked poikilocytosis.
a marked lack of hemoglobin, but no malaria. The red
cells numbered 2.200,000, the color index was 0.5, the
hemoglobin 22 per cent., leucocytes 18,700. Differentially,
the polymorphonuclears 32.1 per cent., lymphocytes 498
per cent., transitionals 15. i per cent., eosinophiles 10 per
cent., basopbiles .8 per cent., and myelocytes 1.2 per cent.
The specimen from the boy was practically the same, with
less anemia and less leucocytosis. Case 3. This boy, two
years old. was the -youngest of three children, the others
living and well. The parents were German, healthy, no mis-
carriages, or other specific history. The baby had been en-
tirely breast-fed, although the mother had menstruated for
the past six months. The first tooth appeared at twelve
months. There was a .great deal of bowel trouble, especially
each summer. The child had been sickly and weak from
birth, and had never walked. Examination showed an ex-
tremely rachitic infant, much emaciated. Pie had six teeth.
He was markedly rachitic, and the epiphyses \vere greatly
enlarged. The spleen extended two inches below the costal
arch, was fairly hard to the touch. The liver was enlarged
to within a finger's breadth of umbilical level. Examination
of the blood by Dr. Goldhorn showed a very grave second-
ary anemia. There was a very marked variation in size of
the red cells, a moderate poikilocytosis, many normoblasts,
a few megaloblasts, and kariokynesis was present. The
red cells numbered 3,200,000, the color index was 0.8.
hemoglobin 52 per cent., leucocytes 18.200; no malaria.
Differentially, the polymorphonuclears 42.2 per cent., lym-
phocytes 42.5 per cent., mono and transitionals 9.2 per
cent., eosinophiles 6.1 per cent., basophiles l.O per cent.,
myelocytes 0.0 per cent.

Dr. Long said that these cases of enlarged spleens and
anemia came to one even in private practice with this
condition already established, and one did not know how
or when it began and could only surmise as to the probable
cause. In a few one got a definite history of malaria, but
one did not anticipate such a result from malaria, nor in
a very large majority of malarial cases did one get it.
He asked who would feel justified in saying that infants
with healthy brothers and sisters, with no family history
of syphilis, and no other evidences of specific disease, had
congenital syphilis which had caused the present condition ?

.\iid as to certain kind of diet as an etiological factor, it
was just as indefinite.

Dr. Charles Herrman believed that the cases presented
by Dr. Long pointed to the correctness of the theory of
the congenital anomaly of the blood-forming organs. He
had seen three sets of twins with this condition. When
there were two children the amount of iron was insufficient,
and one child might be more anemic than the other because
one received a smaller amount of iron through the placenta.

A Case of Congenital Syphilis.— Dr. Charles Herr-
man presented this child, nine weeks old, who at birth
had edema, especially marked on the dorsum of the feet
and hands. According to the mother, the condition of their
first child, who died when eleven d.ays old, was similar to
the condition of this, their second child. The patient was
poorly nourished, weighing 4 pounds and 4 ounces, tem-
perature 97.4°, skin dry, somewhat brownish, buttocks
excoriated, a slight rhinitis, and a congenital systolic mur-
mur over the precordium. No specimen of urine was
obtained, but so far as he was able to judge there was no
lesion of the kidneys. The mother had been given bichlo-
ride of mercury, and there had been some improvement,
the child having gained some in weight and the edema
having diminished somewhat. He now expected to place
the baby on antisyphilitic treatment.

Urinal for Infants. — Dr. Henry Dwight Chapin pre-
sented this urinal which made the collection of infants'
urine comparatively easy.

Pyelitis in Infancy and Childhood, with Remarks on
the Urine. — Dr. Lot is Fischer read this paper, and said
that in a series of cases observed by him three groups of
symptoms stood out prominently: (I) The fever, inter-
mittent in character, progressive emaciation, and constipa-
tion or coprostasis ; (2) bed-wetting and pains evidenced
by crying while urinating, passing of small quantities of
urine at a time, as though afraid to pass more because of
pain, absence of fever throughout the whole course of the
disease: (3) distinct digestive disturbances mostly marked
by the passage of scybalous masses and feces intermingled
with shreds of membrane, and with it marked anorexia,
fever very rarely present. The diagnosis of these cases
was made by the microscopical examination of the urine.
It emphasized the importance of securing a specimen of
urine in every case of infantile disease. The presence of
continued fever in an infant was a very distressing symp-
tom, and when it assumed the type so well known as an
intermittent fever a diagnosis could only be made by resort-
ing to laboratory aids in conjunction with the current
methods of physical diagnosis. All cases seen by him had
shown marked disturbances of the gastrointestinal tract.
In one of the cases Dr. Fischer reported the noteworthy
features were that the child was playing out of doors and
in apparent good health up to the day he saw this case.
Had it not been for the catarrhal rhinitis the family would
not have sent for him, although the child had enuresis
nocturna for several days prior to the rhinitis. This case
illustrated forcibly the necessity of examining the urine
fur morphological elements, and also showed that a pyelitis
could exist without causing severe systemic disturbances,
as this child had no fever and nothing that indicated kidney
disease. Three other cases were reviewed. A review of
these four cases showed the following: First, the pyelitis
presented a variety of symptoms resembling intermittent
fever with marked exacerbations and remissions in the
temperature. Second, that pyelitis was occasionally met
with in infancy as an afebrile type, and were it not for
the presence of the enuresis no symptoms associated with
the genitourinary tract would have been present to direct
attention to the kidneys. It was well to remember that
pus might be found in the body without showing the
presence of fever; hence too great stress should not be
placed on the absence of fever as a guide to the presence
or absence of pus. An interesting point in connection with
these cases was that tiny all occurred in female children.

286

MEDICAL RECORD.

[Feb. i6, 1907

One should never rely upon the examination of one
specimen of urine as a positive guide to diagnosis. The
general plan of treatment consisted in rest in bed, good
ventilation, sponge or warm baths. To allay the pain
during urination and the irritation of the genitals a warm
demulcent bath was used. The diet consisted of milk
diluted with alkaline waters, cereals, fruits and fruit juices,
and gelatin puddings. Meat and eggs were excluded during
the acute stage. The use of phosphate of sodium or
bicarbonate of potassium in five-grain doses, taken with
an abundance of water, was recommended. A urinary anti-
septic in moderate doses three times a day was also pre-
scribed in most cases.

Dr, He.nry Dwight Ch.^pix said that it was very diffi-
cult to make a diagnosis of pyelitis from the clinical history
alone, and he emphasized the importance of constantly
examining the urine. There was no doubt that many cases
that puzzled them so were cases of pyelitis. At the hospital
by means of the instrument for collecting infants' urine
he had been enabled to make diagnoses of pyelitis which
could not have been made from the clinical symptoms. He
said he had not been as successful as Dr. Fischer in collect-
ing urine by the old methods ; frequently the catheter
would make excursions into the vagina before getting into
the urethra.

Dr. Henry Illoway said that he had read about the
diagnosis of pyelitis, but he was yet in the dark as to how-
to make a differential diagnosis ; he asked if there w-as
anything distinctive about pyelitis, and why they called it
pyelitis.

Dr. E. L. La Fetra showed a chart with an intermittent
curve of temperature. The baby when first seen was one
of fourteen months, and had been ill one week. The
course of the disease was five weeks. He presented this
chart in connection with Dr. Fischer's paper.

Dr. Charles G. Kerley said that the five cases he had
had differed from those of Dr. Fischer. All were under
eighteen months of age, and all were girls. There was a
marked onset in all, and the excursions of temperature were
very wide, varying from three to five degrees. In all cases
the colon bacillus was found.

Dr. M.\TTHiAS XicoLL, Jr., said he was puzzled to know
upon what Dr. Fischer based his diagnosis, after examining
the microscopical charts of the patients recorded in the
paper.

Dr. Louis Fischer said that every specimen of urine
was sent to Dr. Sondern and every case showed pus and
blood, a diagnosis of pyelitis being made positively. He
thought the cases reported by him were typical ones. He
had never seen such cases as reported by Dr. Kerley with
such an acute onset with chills. He recalled one case of
pyelitis of severe form ; the child was playing on the
street, and he was called because the child sneezed so and
coughed. Examination of the urine revealed the presence
of pus

Dr. L. E.MMETT Holt reported the case of a child seven
or eight months old with pyelitis in which chill was th;
most striking s\-mptom. The patient would have a chill at
12 o'clock, the teeth would chatter, and two hours later the
temperature would be 106°. The chills recurred sometimes
twice a day. This was a symptom that he had not seen
often. In another case the amount of pus in the uiine
was the largest he ever saw', beinsr '-"i- '^ne-sixth the
volume of the urine on standing. I '• i that chills

were rather exceptional, but did occi:r occasionally with
severity.

Report of Three Epidemics of Measles, with Par-
ticular Reference to Koplik's Symptom and its Rela-
tfbn to the Rash and the Initial Fever. — Dr. Charles J.
Dillon- presented a communication witli this title. (See
page 264.)

Election of Officers. — The election of officers of the
Section resulted in ;he choice of the following: Chairman,
Dr. Godfrcv Rodger Pisek : Sccretarw Dr. Eli Long.

SECTION ON OBSTETRICS AND GYNECOLOGY.

Stated Meeting, Held December 27, 1906.

Dr. Arnold Sturmdorf in the Chair.

Case of Ovarian Pregnancy. — Dr. Sidney D. J.icob-
SON presented this specimen, one of true primary ovarian
pregnancy. Such an impregnation, he said, was supposed to
take place by the union of the spermatozoa with the ovum
in the follicle, and was an exceedingly rare condition. The
first report of such a case was made in the seventeenth
centurj-. In 1835 Velpeau published a work on this sub-
ject when ovarian pregnancies were believed to be common,
and he showed that the cases reported to be instances of
ovarian pregnancy were not entitled to that name. The
Germans had always admitted the possibility of ovarian
pregnancy, but the English had opposed that view. In
1891 Bland Sutton was the last to hold out that there was
any such thing as ovarian pregnancy. So many cases were
reported that in 1878 a gj'necologist postulated the for-
mulae, viz., (i) the tube had to be normal; (2) the fetal
sac must occupy the position of the ovary; (3) the ovarian
ligament must connect with the uterus ; (4) definite
ovarian tissue must be found in the sac of the growth.
The specimen showed a little fetus in a small cavity almost
in the center of the ovary The woman was 28 years old,
married eight years. She menstruated at 14 and about
every thirty days since. She became pregnant in the third
year of her married life and had a normal full term preg-
nancy and delivery. She was curetted when seven months
married for stenosis of the OS. She had had three miscar-
riages since. On the nth of October she was supposed to
menstruate. Four days later she began to "spot." On the
20th a severe hemorrhage occurred, and she passed a piece
of flesh the size of a walnut, whitish in color, probably
decidua. Dr. Jacobson saw her on the 21st, advised her
removal to the hospital, and, on the 23d, twelve days after
her supposed period had taken place, operated. The opera-
tion was not at all difficult. The diagnosis of ectopic
pregancy had been comparatively easy.

Dr. George H. Balleray" believed that time should be
taken to have the specimen thoroughly examined by a
committee to find out if the specimen presented by Dr.
Jacobson was truly one of ovarian pregnancy. These
cases were so extremely rare that his diagnosis should
not be accepted until a more thorough examination had
been made by fully qualified experts.

Dr. H. N. 'Vineberg did not believe that they should
accept the specimen as one of ovarian pregnancy on macro-
scopical evidence alone. There should first be a thorough
examination of the specimen by two or three experts.

Specimen of Calcified Ovary. — Dr. Henry C. Coe
presented this specimen. The patient from whom it was
removed was 29 years old, single, and was admitted to the
hospital October 23. She had never been pregnant. She
was told ten years ago that she had a tumor. She had no
symptoms until two years ago. She had a large fibroid
which extended to within two inches of the umbilicus. She
had no pain. The only indication for operation was the
rapid growth of the tumor and hemorrhage. Operation
was performed on October 25, a supravaginal hysterectomy
being done. The appendix was also removed. Both
ovaries were diseased, the right being cystic, the left calci-
fied, as shown by the specimen. She was discharged cured
on the twenty-fifth day. An interesting point arose as to
whether this was an osteoma of the ovary. Such a case
had never been reported. Calcification of the corpus
luteum was a rare condition. He presented such a speci-
men in 1899. The condition was first described many
years ago. Dr. Coe then read extracts from the report of
Williams' case. The specimen presented showed the ovary
to be filled with calcareous material, and was probably of
inflammatorj- origin.

Dr. H. X. Vineberg said he co e more to the

list. This woman had inflammatory symptoms for two

Feb. 1 6, 1907]

MEDICAL RECORD.

2S7

years, and he found the uterus retroverted ; behind the
uterus a hard nodule was to be felt which he thought to be
a fibroid undergoing calcification. At operation this proved
to be an ovary; both ovaries were involved. He e.xcised
the calcareous part and left some ovarian tissue behind,
and the woman had menstruated since. The pathologist's
report proved this to be an undoubted case of calcified
ovary.

Dr. SiDXEY D. J.AcoEsox said that it would be well to
bear in mind the possible existence of calcified ovaries in
making radiographs for the purpose of determining calculi
in the kidney or ureters.

Conservative Surgery in Severe Inflammatory Affec-
tions of the Uterine Adnexa. — Dr. Hir.\m N. Vinebekg
n-ad this paper. (Sec page -i/-)

Dr. Henry C. Coe said that when this subject came up
he thought of his experience extending back twenty years,
when he began his work, and observation on a large num-
ber of cases on whom he had performed the radical opera-
tion, i.e. removal of tubes and ovaries. No one with such
an extended experience with young women 25 or 30 years
old, from whom both ovaries had been removed, could
help but be impressed with the serious consequences which
followed this radical procedure. To-day they believed it
to be absurd the wholesale ivay the ovaries were sacrificed,
not only for disease but when prolapsed. Some of these
individuals had climacteric disturbances which lasted ten or
twenty years. Operators to-day agreed that it was best,
whenever possible, to leave in some of the ovarian stroma.
Numerous cases of pregnancy following this operation
have not been reported. Dr. Coe always tried to save some
ovarian stroma, but with little hope of pregnancy follow-
ing; if the patient menstruated, he felt very well satis-
fied ; it was very rare for pregnancy to follow. In most
of these cases the end of the tube became occluded. No
matter how careful one was in the technique, or how great
an experience one might have, there was a great uncer-
tainty as to what the ovarian tissue would do afterwards ;
some patients menstruated normally for two or three years,
and then menstruation would cease. In young married
women, with chances of conceiving, it was very disappoint-
ing for menstruation to cease, even though there be no
climacteric disturbances. Every effort should be made to
save ovarian tissue, even in cases where the ovaries were
buried in adhesions, or in pus cases; but in so doing he
sutured them so that they would not drop down. In
some cases menstruation had gone on normally, although
there were no chances of pregnancy. Dr. Coe said he
wished to protest against the growing habit of extirpating
the whole uterus for fibroids. He had five or si.x cases in
his office with absolutely no symptoms, not even pressure
symptoms, and in all extirpation of the uterus had been
advised. Dr. Coe now consistently practised conservative
surgery, but not so much so as formerly.

Dr. James N. West felt that they knew comparatively
little about this subject, and he could not agree with the
statement that it had been thoroughly worked out. Many
authors had reported pregnancy following conservative
work on the tubes and ovaries, but they all failed to note
the nature of the operation. He believed that when they
did conservative work upon the tubes and ovaries the
operation should be carefully recorded and a very careful
record of the case kept. The accumulation of such knowl-
edge would be of great value. Dr. West had practised
conservative surgery all his professional career, but he
believed there was much of interest on this subject not yet
worked out. In looking over the literature on this sub-
ject, he was unable to find recorded a single case where,
after a double pyosalpinx, the patient had become preg-
nant. In general it was wise, in women before the age of
forty, to leave the ovaries behind when possible. He said
they might divide these cases up into groups: Women
approaching the menopause, women in the active period
of menstrual life, and women wdio had patesed the meno-

pause. In women in active menstrual life they should
always consider the possibility of conservnig the tubes
and ovaries, and here the element of personality entered.
Sentiment should not be wasted over tubes and ovaries in
women of 40 or 45 years of age. If they were sufficiently
diseased to demand opening the abdomen, remove them.
In women passed the menopause, if the abdomen was
opened to remove a uterine tumor, then he believed in
removing both ovaries. Me empliasized the importance of
leaving a portion, if possible, of one ovary when operating
upon women in active menstrual life. But if one ovary
was the seat of a benign tumor, the other being compara-
tively healthy, he believed it best to remove the entire
ovary with the benign tumor. If one or the other ovary
became the seat of malignant disease it was wise not only
to remove both ovaries and tubes, but much of the broad
ligament and uterus as well, unless the disease was semi-
malignant.

Dr. S.\ML-EL W. B.ANDI.ER s.iid that in the case of papil-
lomata or papillomatous degeneration of an ovarian
cystoma the other ovary should be removed, even if it
appeared normal. In the case of unilocular or multilocular
cystomata or dermoid cysts, the other ovary, if apparently
normal, should be retained. If, however, it showed struc-
tural changes, resection should be practised in younger
women. In older women no such risk should be taken.
When, however, involvements of the tubes and ovaries
with adhesions, or marked inflammatory affections of the
adnexa, were the indications for operations, he believed
the question entered a different phase. The character of
the surgical procedure was materially altered by the indica-
tions which prompted the operation. The indications were
sterility and pain. He said he had yet to perform his first
conservative abdominal operation solely for primary or
secondary sterility without pain or without some malposi-
tion of the uterus, or without tangible involvement of the
adnexa. That pregnancy might result after mild inflam-
matory affections of the tubes was shown by uterine preg-
nancy following or complicating ectopic gestation, but, in
such cases, adhesions were not present. They represented,
in his opinion, very mild cases of salpingitis. Again, there
were many cases in which the opposite tube was markedly
involved by inflammation, so that he had removed the tube
on the opposite side, because of its involvement and closure
by adhesions. In any involvement of the tube and ovary
associated with adhesions when pain furnished the indica-
tion for operation, the tubes were the main consideration.
It should not be forgotten that the tubes furnished the
path for peritoneal infection. If the tubes were closed
by adhesions, the value of resection was associated with
the danger that the inner half of the tube might continue
the formation of new adhesions, Jind only complete
removal of the entire tube would insure against this com-
plication. If no adhesions existed he failed to see the
value of resection of the tube. The results that were
desired in the performance of conservative surgery were
pregnancy, freedom from pain, and from constitutional
annoyance. A conservative operation on the tubes, with
retention of ovarian tissue, assured the continuation of
menstruation, the possibility of pregnancy, and freedom
from constitutional annoyance, but did not assure freedom
from future adhesions with pain. He said he was not
aware of a single case where a patient, primarily sterile
for years, and in whom conservative operation in the form
of resection of the tubes or the formation of new ostia
were done, had resulted in pregnancy. He was not aware
of a case where conservative surgery was done for puru-
lent involvement of both adnexa with adhesions that was
followed by subsequent pregnancy. If they contrasted the
relative advantages and disadvantages of the conservative
and radical procedures, the results in the performance of
conservative operation for an inflammatory condition were
poor as regarded future pregnancy, they were very uncer-
tain as to freedom from pain or extension of inflamma-

288

MEDICAL RECORD.

[Feb. 1 6, 1907

tion. He believed that ovarian tissue should be left or
transplanted if one of the ovaries showed no marked in-
volvement. He had yet to observe in his cases incurable
annoying symptoms resulting from double ovariotomy ;
almost all these annoying symptoms of the artificial cli-
macteric might be overcome by the early and consistent use
of ovarin. All conservative operations for inflammatory
conditions were accompanied by the risk of no cure of the
symptoms, and possibly an extension of the inflammation
in the structures operated upon, or extension of the in-
flammation to structures not touched at operation. There-
fore, the only legitimate reason was the desire for ma-
ternity. Any patient desirous of pregnancy, and who was
willing to take the risk of failure, or to chance a possible
return of the annoying symptoms, was entitled to consid-
eration. Only the practical experience of individual sur-
geons who compiled and compared the results of like cases
would eventually furnish a definite basis for future action.
In his hands the immediate results of conservative opera-
tions on the adnexa for inflammatory conditions had been
most unsatisfactory.

Dr. G. H. Baller.w said that cases like those referred to
by Dr. Vineberg were not to be taken as illustrations of
conservatism, but rather of extreme radicalism. Opening
the abdomen to puncture two or three small cysts of the
ovary, and possibly resect a very slightly diseased tube,
was anything but conservative. Those cases should be let
alone. Cases of pyosalpinx should not be operated upon
during the acute stage, as the operation was liable to be
followed by fatal peritonitis. Later, when the diseased
adnexa had become walled off from the peritoneal cavity,
and the pus was more or less sterile, the operation was
much safer. In nearly all bad cases of pyosalpinx the
ovaries were so badly diseased that their complete extir-
pation was imperative. In these cases the patient was an
invalid as the result of the pathological condition of the
uterine appendages, and they should be removed in to to.
The object of an operation in such cases was to cure the
patient — not to increase her capacity for breeding. Leaving
a portion of diseased ovary in the pelvis in such cases, in
the hope of a subsequent pregnancy, was sentimental non-
sense. The fear of a stormy artificial menopause follow-
ing the ablation of badly diseased appendages was not
well founded. He had never seen violent nervous symp-
toms occur after such operations. The rule was that the
patients were cured of their sufferings, and gained rapidly
in flesh and strength. So far as sterility was concerned,
those patients were already sterile before the operation
was performed, having been literally unsexed by the de-
structive disease of their uterine appendages, and the oper-
ation did not aggravate their condition in that regard. A
few years ago normal ovaries were removed by the peck
for all sorts of nervous ailments, real and imaginary, which
were supposed to be due to some sort of occult telepathy
originating in the ovaries. Many of these patients were
made worse by the operation. Removal of normal ovaries
might be followed by serious perturbation of the ner\'0US
system, but when the ovaries were so diseased that their
function in the economy was destroyed, their removal was
not followed by any violent nervous disturbance. Patients
who ceased to menstruate after the removal of their ap-
pendages were, according to his experience, better off than
those who continued to menstruate. In all cases of double
pyosalpinx both tubes and ovaries should be removed. He
indorsed the protest entered by Dr. Coe as regards the
removal of the uterus for small fibroids the size of a wal-
nut. He had seen several such cases, and in some the
patient had died as the result of the operation. This
was pure surgical quackery, and should be condemned by
all reputable members of the profession.

Dr. George H. M.\llett said he distinctly remembered
the many discussions on radicalism and Dr. Lawson Tait's
statement that when one ovary was diseased the other
always became so. and should, therefore, be removed.

Then the pendulum swung the other way, and now it was
customary to save all that was possible in operations upon
the uterine adnexa. A great difficulty was in determining
whether or not an ovary was diseased. In determining
upon the proper treatment many things were to be con-
sidered, such as the age of the individual and the condition
of each ovary. All to-day practically practised conserva-
tive surgery on the tubes and ovaries, and he did not know
an operator who removed tubes or ovaries if it was possi-
ble to save them.

Dr. Sidney D. J.\cobson referred to the mutilating oper-
ations that were being done and the ablation of the cervi.x
uteri, and said the tendency of gynecologists was to am-
putate the cervix because of few tears.

Dr. Arnold Sturmdorf said that conservatism for him
did not exist, and that he removed all that he thought to
be actually diseased.

Dr. H. N. Vineberg said that these cases which had been
objects of conservative treatment, and which gave so much
trouble were those which had been subjects of much spec-
ulation, and had been permitted to go on for three, four,
five, or six years, becoming hopeless because seen so late,
that was, after the process had gone oh for years. In case
of pus tubes, they ought to be removed, as this removed
the source of a possible subsequent infection. Even though
the pus be walled off and become sterile, toxins might
develop which would set up inflammatory changes in the
surrounding structures. With regard to conservative sur-
gery in cases of malignant disease, he recalled a case seen
ten years ago, a woman with an enormous carcinoma of
the ovary. He removed that one. She later was married,
gave birth to a child, and had been well ever since. Where
one had a clean-cut case, with the growth not extending
through the capsule, one would be safe in leaving the
ovary. With regard to the occlusion of tubes after plastic
operation, he said all knew the difficulty of occluding a
tube when it was desired to prevent pregnancy.

Election of Officers. — Chairman, Dr. Howard C. Tay-
lor: Secretary. Dr. William S. Stone.

SECTION' ON medicine.

Stated Meeting. Held January 15, 1907.
Dr. W.\rren Coi,em.\n in the Ch.mr.

Two Cases of Cerebrospinal Meningitis. — Dr. C. H.

Lewis reported these cases.

The first case was in a male, 54 j'ears old, a laborer.
Two days prior to his admission to St. Vincent's Hospital
he was well and working. That night he returned home
with a slight headache. The following day he became irri-
table and violent and was sent to the hospital as a case of
"acute mania." On admission his temperature was 101°,
pulse 80, and respirations 34. He required forcible re-
straint, and, during his lucid moments, complained of head-
ache. The next day his temperature had dropped to nor-
mal, his pulse was 82, and respirations were 24, and he
said he felt well and wanted to go home. He was urged
to remain until the next day. That night a stuporous state
came on. and the next day he had injected conjunctivae,
slight photophobia, some mental irritability. The temper-
ature was 100°. .A.side from these symptoms there was
nothing to indicate the gravity of his condition. The white
count was 18,000, with 81 per cent, polynuclears. The fol-
lowing day deep coma supervened. A lumbar puncture re-
moved half an ounce of very turbid fluid which contained
many pus cells and a large number of the Diplococciis in-
fracelltilaris. He died that evening, just four days after the
first symptoms were noted. This case was notable, first,
in the absence or late appearance of characteristic symp-
toms, and, secondly, in the disappearance of all physical,
mental, and psychical signs and symptoms thirty-six hours
before death, and, thirdly, the rapid and virulent course
during the last twelve hours.

Feb. i6, 1907]

MEDICAL RECORD.

289

The second case was that of a 'longshoreman, 42 years
old, wlio was admitted to St. Vincent's Hospital, Decem-
ber II, 1906, with a history of vomiting, and complaining
of great pain in the metatarsophalangeal joint of the left
little toe. He had been ill nine days prior to admission
(the last five days in bed) with gastric pain, constant vom-
iting, and general indefinite and dissociated syniptoms look-
ing toward an influenzal infection as much as anything.
He had taken no alcoholic drinks for the past six months.
On the night before entering the hospital he was awakened
by stabbing pains in the little toe joint, which he described
"as though hot irons were driven into it." The temperature
was 103.6°, pulse 100, and respirations 28. The leucocytes
numbered 16,000. A soft systolic heart murmur was heard
at the ape.x, but nothing further was found relevant to this
report on careful physical examination. From the swollen
and reddened joint, the sudden and characteristic onset of
the pain, the chronically deformed finger joints, and two
small trophi in tlie right ear, he made the diagnosis of acute
gout, attended with a gastritis of unknown cause. On the
night of the following day the right elbow joint was
seized with an attack similar to the one affecting the toe
joint, and on the ne.xt day the elbow presented relatively a
small tophi in the right ear, he made the diagnosis of acute
hospital, the vomiting ceased. No new joints were in-
volved, but the pain and inflammation persisted in those
already affected. The temperature, which had risen to
104° shortly after admission, had remained about this
point. On account of the heart murmur and the rising
leucocyte count, now 18.000. with polynuclears So per cent.,
a blood culture was made with negative results. The next
day. the fourth in the hospital, symptoms presented which
suggested the true nature of the disease. There appeared a
mild delirium, unequal and stifli pupils with a moderate in-
jection of the right conjunctiva, herpes labialis, tache cere-
brale, and slight neck rigidity. On the day following the
delirium he became noisy, then stuporous. Photophobia,
sluggish pupils, increased injection of right eye, and neck
rigidity were added to the picture. Up to this time the left
eye was unaffected. The next day, the sixth in the hos-
pital, the left pupil was greatly dilated. There was a con-
junctivitis, opacity of the cornea, and choroidoiritis, and the
eye resembled an extreme case of panophtlialmitis, with
considerable protrusion of the eyeball. Purpuric spots
appeared on the trunk, and for the first time a Kernig sign
was elicited in the right leg only ; this was not marked.
The leucocytes now numbered 24.000. A lumbar puncture
withdrew two and a half ounces of a clear fluid under con-
siderable pressure, which, after centrifuging, revealed a
small number of the Diflococcus iittraceUularis. The
patient died shortly after midnight, the last temperature
being 104.8°. the highest point reached, the lowest being
103.6° on admission. Dr. Lewis was inclined to believe
that true gout complicated the specific infection, although
the possibility of an infective arthritis must be considered.
The complications of the disease, the late appearance of
cardinal symptoms, and the entire absence of some, the
protracted and excessive vomiting, twelve days in all, a
symptom alluded to by Osier, the rapid destruction of the
left eye, the continuously high temperature, and the clear-
ness of the spinal fluid and sparse number of diplococci so
late in the disease, m.ade the case of particular interest, and
emphasized once more the protean nature of this dread
disease.

Acid Intoxications. — Dr. C. G. S. Wolf read this
paper.

Dr. M.\x EiXHORX spoke of some experiments he had
made some time ago to find out how certain animals acted
in different solutions of sugar, etc. In the first experi-
ments he added simply acid and water, and at the end of
twenty-four hours the frogs became comatose, could not
move, and acted very differently from others. Upon the
addition of alkalies those frogs became lively and recov-
ered their normal condition. He believed without doubt

that some conditions of acidosis could be cured by the
addition of alkalies. The acid condition in diabetes did not
necessarily depend upon starvation. He thought it was
rather due to the increase in the animal food, which, as
a rule, was taken in diabetes. All vegetables were rich in
potassium salts, and animal foods were rich in sodium salts.
A patient on a vegetable diet would excrete alkaline urine;
on a meat diet, acid urine. Therefore, if the defect was
due to lack of alkalies, the patient should be fed on alka-
line material. Of course, if there was some present, there
might be other factors causing it.

Dr. Heinrich Stern said that he was glad that sotne-
body else had expressed similar opinions as regards the
acetone bodies, as he himself had done for a number of
years. However, to substitute another substance for the
hypothetical toxicity of the betaoxybutyric acid derivatives,
as Dr. Wolf had done in bringing forth oxalic acid, did
not bring us one step further in the proper understanding
of acid intoxication, acidosis, or acid coma. Oxalic acid
w'as not present in the blood serum of diabetics when in
the comatose state in any larger amounts than one would
expect in any morbid state in which metabolism was more
or less seriously interfered with. With much greater justi-
fication could we fasten the train of untoward phenomena
in so-called acidosis to formic acid, or at least to the vari-
ous exceedingly toxic combinations of formic acid which
might arise in the organism in considerable amounts. He
had again pointed out in his book on the autotoxicoses that
betaoxybutyric acid was not that important factor in the
production of acid intoxication, so called, which it was
supposed to be by Studelmann and others, and especially by
vou Noorden. .-Ml acid principles seemed to contribute
toward the causation of an acidosis, which latter, however,
was a term by no means denoting the true condition pre-
vailing at the time in the body fluids. At the foundation
of acidosis. Dr. Stern maintained, there was a faulty alkali
supply. Normally, the withdrawal of alkali was soon fol-
lowed by a new supply. Such a renewal did not take
place, or to an insufficient degree only, in fasting organ-
isms or in underfed individuals. On the other hand, how
were they to explain the alkali deficit in the face of abun-
dant and even overabundant alkali ingestion? He had
made up his mind long ago that we could experiment until
doomsday without being able to fasten the various coma-
tose states to a chemically-active poison or poisons. He
was of the opinion, which he had already maintained in a
number of articles and discussions, that the entire question
involved was of a physicochemical or physicoelectrical na-
ture, that bodily activity, etc., was dependent upon an intra-
systemic osmotic equilibrium, and that the concentration of
the body liquids and the degree of ionic activity displayed
therein were without a shadow of a doubt at the bottom
of most comatose conditions.

Dr. Joseph C. Roper said that at the New York Hos-
pital acid intoxication was not taken as the cause of death.
It was merely an associated condition.

Dr. Wolf, in reply, said that one might get up acidosis,
but not an acid intoxication. They usually distinguished
sharply beween acidosis, which was a distinct entity, and
acid intoxication, which was not a distinct clinical entity.
If a suliject was fed on saccharal and carbohydrate ma-
terial, the subject would have acidosis, but not acid intoxi-
cation.

Dr. RnrER accepted the corrtctiou.

Localized Intestinal Atonies and Their Relation to
Neurasthenia. — Dr. G. R. Lockwood read this paper. He
said that constipation was roughly divided into two classes.
the spastic and atonic form, and he gave in a few words the
characteristics of these two forms. He then called atten-
tion to a form, standing between these two, a definite clin-
ical entity, a form commonly seen, productive of annoying
symptoms of intestinal toxemia and neurasthenia, a form
readily amenable to treatment, to which he applied the
name "cecal atonv.'' Examination showed the first part of

290

MEDICAL RECORD.

[Feb. 16, 1907

the ascending colon to be in an atonic condition. The
bowel could not be readily palpated, but palpation elicited
spla.shing and scrunching sounds quite pathognomonic.
Especially were these sounds elicited by rapid vibratory
massage, with the knuckles of the flexed fingers perpendicu-
larly applied. The transverse portion was normally pal-
pable, but no succussions were noted, unless an enema was
given just prior to the examination. The descending por-
tion might be readily rolled under the finger, well
contracted, often as much as in the spastic
form. In this form he had a local stasis in the cecum,
with normal propulsion in the transverse and descending
portion. The stools varied in a number of ways. There
might be intermittent attacks of diarrhea, the stools being
large, fermenting, fetid, often of acid reaction, and con-
taining mucus and small liardened feces, like uncooked
beans in a porridge. This appearance to him was quite
characteristic. This variety of stool was due to an e.xaccr-
bation of the local catarrhal colitis of the cecal region, due
to the prolonged presence of fermenting fecal masses in
the ascending colon. In the majority of the cases there
was a history of the overabusc of carthartics. In the
form of cecal atony, autointoxication symptoms of intes-
tinal origin were common, varied, in many cases resulting
in prolonged invalidism. It was the cause of a great many
cases of so-called "primary neurasthenia." The treatment
consisted of diet, drugs, massage, and irrigations, and
attention to the general nervous state. Without reference
to any catarrhal state of the bowels, the diet should con-
sist of coarse particles of food and in a generous amount of
fat. The worst diet was a limited one. The drugs to be
used were the muscle toners. Irrigations were indicated
when there were marked autointo.xication symptoms. The
ordinary form of high enema, in which two to four quarts
of water were introduced at one time into the bowel, was
to be deplored, for it overdistended the bowel and increased
the atony. He showed the section the irrigation outfit
he used. Massage constituted the most important part in
the treatment. The general health must always demand
the closest and most detailed attention.

Dr. M.^x EiNHORN called attention to the recognition of
the atonic condition of the bowel by means of the .I'-ray.
The treatment which would be the most successful was the
one directed towards building up the system. He gave
plenty of good, plain food, with an increase in the amount
of vegetables which would increase the food residue and
give more for the bowel to work on. Massage was of
great value.

Dr. A. Rose said that in cases of atony there was a re-
laxation of the abdominal muscles. The function of these
muscles was twofold : first, to keep the abdominal organs in
their proper physical condition, and. secondly, to control
the innervation and circulation. When the abdominal
muscles were relaxed there must be ptosis of different
organs ; if then these muscles be supported, these organs
would return to their proper position and remain there.
Therefore, in these atonies one should consider the treat-
ment of the abdominal muscles. The books said nothing
about these muscles controlling the innervation and circu-
lation, and the importance of these abdominal muscles had
not been considered sufficiently.

Dr. S. J. Meltzer said that from a clinical point of view
the observation was interesting, that possibly there should
be an area in the colon, wliich behaved differently from
the balance of the colon. He was interested in this state-
ment, because they knew there was a physiological basis
for that assumption. Cannon found years ago that the
ascending part of the transverse colon behaved differently,
inasmuch as there was both antiperistalsis and peristalsis.
These observations were made on cats : later on Smith and
Elliot found this to be so in some, but not in all animals.
Dr. Lockwood had apparently observed this antiperistalsis.
He called attention to the fact that the part of the bowel
supplied by the hypogastric and that supplied by the sacral

plexus behaved differently. Eserine he considered to be
one of the worst drugs to give; he had seen it given to a
dog, and it resulted in a distention of the gut to the size
of an arm. With regard to the atonic condition of the
colon in connection with neurasthenia, if one treated the
colon to cure the neurasthenia, one must assume the con-
dition in the colon to be a cause of the neurasthenia. That
was only one symptom of neurasthenia. As yet they did
not know what neurasthenia was, but he did not believe
that the condition in the colon was a cause of it.

Dr. Lockwood said that he had had splendid results from
the administration of eserine in these cases, and placed
much reliance upon it.

Diagnosis and Treatment of Acute Intestinal Ob-
struction.— Dr. M.\x Ei.xHORx presented this communica-
tion. The recognition of this condition was based on the
absence of stool and flatus in conjunction with symptoms
of collapse, tympanites, abdominal pains and vomiting of
intestinal contents. The fecal vomiting of ileus must be dif-
ferentiated from that of hysteria, as well as of cholelithiasis
and nephrolithiasis, which often took a similar coarse. In
both these diseases the symptoms of occlusion would mod-
crate after relieving the pain. In true ileus this would not
be true, for, although the pain might be relieved, the in-
ability to pass wind as well as abdominal distention would
remain. If the obstruction was in the small intestine all
the symptoms were usually much more violent than in oc-
clusion of the large intestine; furthermore, there was in the
beginning a marked indicanuria. In obstruction of the
large intestine fecal vomiting occurred late, and indicanuria
usually on the fifth day of the disease. If the occlusion
was well down in the large intestine, the quantity of water
which might be introduced into the rectum gave a clew as
to the location. The use of the .v-ray fifteen to twenty
hours after giving bismuth was of value in localizing the
obstruction. In all cases of obstruction absolute rest should
be insisted upon, rest in bed, abstinence from food, absolute
rest for the bowel. The patient might be given small
quantities of water or small pieces of ice, but no food. If
the obstruction was high up in the small intestine, small
nutrient enemata were permissible. Subcutaneous salt-
water injections were the best means of introducing liquids
into the system. Cathartics were to be avoided unless one
was fairly certain that he was dealing with a case of
obturation by gallstones or hard fecal masses. In order to
put the bowel at rest it was best to use morphine or opium.
During the last two years the use of atropine in ileus had
again been revived and highly recommended. Dr. Einhorn
had used it during the past tw'O years in six cases, of which
four got well. He believed atropine should be tried in
every case. If the patient was not too much weakened,
lavage of the stomach should be given, and w-as of special
value if the obstruction was high up. Injections of rather
large quantities of water under considerable pressure was
at times of value, although some clinicians did not recom-
mend this. Massage was of special benefit w^hen the ob-
struction was due to fecal impaction, and electricity in the
dynamic form of ileus. In grave cases, in which the tym-
panitic distention was of a very high degree, in which all
procedures had failed, and in which operation could not be
done, an attempt to relieve the bowel by means of puncture
was justifiable.

Dr. S. J. Meltzer and Dr. G. R. Lockwood discussed the
paper.

Renal Decapsulation in Eclampsia. — This has already
been advocated by several authorities, and Polano also
speaks strongly in its favor, although he admits that
he is unable to explain the manner in which the opera-
tion brings about its results. He recommends that in
all cases of severe eclampsia bilateral renal decapsula-
tion should be resorted to, and urges that too much time
be not allowed to elapse before making use of this
measure, as its chances of effectiveness are greatly in-
creased the earlier it is employed. — Zentralblatt fiir Gynd-
kologie.

Feb. 1 6, 1907]

AiEDlCAL RECORD.

2gi

While the Medical Record « f leased to recek'e all new
publications 7i.-hich )nay be sen! to it. and an aekno-jeledg-
ment zeill be promptly made of their receipt tinder this
heading, it must be ivith the distinct understanding that its
necessities are such that it cannot be considered under
obligation to notice or review any publication received by it
which in the judgment of its editor zeill not be of interest
to its readers.

Animal Micrology. By Michael F. Guyer, Ph.D. 8vo,
240 pages, illustrated, muslin. The University of Chicago
Press, Chicago. Price, $1.75.

The Practical Medicine Series. By Gust.wus P.
Head, M.D. Vol. VIII. 121110, 358 pages, muslin. The
Year Book Publishers, Chicago.

The Di.^cn'osis of Nervous Diseases. Bv Purves
Stewart. M.A., M.D., F.R.C.P. 8vo, 380 pages, 'illustrated,
muslin. Edward Arnold, London.

Progressive Medicine, A Quarterly Digest. Edited by
HoBART Amory Hare, M.D. 8vo, 349 pages, illustrated,
paper. Lea Bros. & Co., New York. Per annum, $6.

The Practice of Obstetrics. By J. Clifton Edgar.
Third edition, 4to, 1071 pages, illustrated, muslin. P.
Blakiston's Son & Co., Philadelphia.

Tropical Medicine. By Thomas W. Jackson, M.D.
8vo, 536 pages, illustrated, muslin. P. Blalciston's Son &
Co., Philadelphia. Price, $4.00.

The Harvey Lectures. Delivered under the auspices
of the Harvey Society of New York by various authors.
8vo, 337 pages, illustrated, muslin. J. B. Lippincott Com-
pany, Philadelphia.

A Treatise on Orthopedic Surgery. By Royal Whit-
man, M.D. Third Edition, Revised and Enlarged. 8vo,
871 pages, illustrated, muslin. Lea Brothers & Co., New
York.

Syllabus of Lectures on Human Embryology. By
Walter Porter Manton, M.D. Third Edition, Revised
and Enlarged. i2mo, 136 pages, illustrated, muslin. F. A.
Davis Co., Philadelphia.

Conservative Gynecology and Electrotherapeutics. By
G. Betton Massey, M.D. Fifth Revised Edition. Svo, 467
pages, illustrated, muilin. F. .\. Davis Co., Philadelphia.

Self-Propelled Vehicles. By James E. Homans. .'\.M.
8vo, 598 pages, illustrated, muslin. Theo. Audel & Co.,
New York.

Tumors of the Cerebrum. By various authors. 8vo,
illustrated, muslin. Edward Pennock, Philadelphia.

Physical Chemistry in the Service of Medicine. By
Dr. Wolfgang Pauli. First Edition. 121110, 156 pages,
muslin. John Wiley & Sons, New York.

Diseases of Children. By George M. Tuttle, M.D.
Second Edition, Revised and Enlarged. 8vo, 392 pages,
muslin. Lea Brothers & Co., New York.

Who's Who 1907. Fifty-ninth year of issue. i2mo,
*957 pages, muslin. The Macmillan Company, New York.

Studies in the Bacteriology and Etiology of Oriental
Pl.-^gue. By E. Klein, M.D., F.R.S. Svo, 301 pages, il-
lustrated, muslin. The Macmillan Co., New York.

A Practical Treatise on Materia Medica and Thera-
peutics. By John V. Shoemaker. M.D., LL.D. Sixth
Edition thoroughly revised. Svo, 1255 pages, muslin. F.
A. Davis Co., Philadelphia.

The Toxins and Venoms and their Antibodies. By
Em. Pozzi-Escot. First Edition. i2nio, loi pages, mus-
lin. John Wiley & Sons, New York.

Die Therapie der Haut-und Geschlechtskrankheiten
fur praktische .^rzte. i2mo, 31S pages, illustrated, mus-
lin. Von Dr. Reinhold Lederniann, Verla.g Von Oscar
Coblentz, Berlin.

A Guide to Diseases of the Nose and Throat. By
Charles A. Parker. F.R.C.S. Edin. Svo. 624 pages, illus-
trated, muslin. Longmans, Green & Co., New York.

Diseases of the Stomach and Intestines. By Board-
man Reed, M.D. Second Edition. Svo, 1021 pa.ges, illus-
trated, muslin. E. B. Treat & Co., New York. $5.00.

Voice Production in Singing and Speaking. By Wes-
ley Mills, M.A., M.D., F.R.C.S. Svo. 282 pages, illus-
trated, muslin. J. B. Lippincott Co., Philadelphia, Pa.

Woman. By Bernard S. Talmey. M.D. Svo, 22S pages,
illustrated, flexible morocco. The Stanley Press Corpora-
tion, Publishers, N. Y.

TuMoKS. Innocent and Malignant. By J, Bland-
Sutton, F.R.C.S. Svo. muslin. 675 pages, illustrated.
Fourth Edition. W. T. Keener & Co.. Chicago. $500.

Anatomy. Physiology. Pathology, Dictionary. W. A.
Evans. M.S., M.D., Adolph Gehrmann, M.D., William
Healy. A.B., M.D. Vol. IX. Series 1006. i2mo. 236
pages, illustrated, muslin. The Year Book Publishers.
Chicago. $1.25.

STATE BOARD EXAMINATION QUESITONS.

Medical Exa.mininc Board of Virginia.

June 19, 20, 21. and 22.

chemistry.

1. Define valence, base, a salt, dialysis, alloy.

2. Describe the chemistry of alcohols and ethers.

3. Give formula of ainnionia. The sources and uses
of ammonia in medicine and the arts.

4. Give chemistry of respiration, showing what is
inhaled, what is exhaled, and how the gases enter and leave
the blood.

5. Show by equation how nitric acid is formed by the
action of sulphuric acid on potassium nitrate.

6. Complete the following equations:

AgNOa + NaCl. =
4HF-f-SiO:^

toxicology.

1. Give symptoms and treatment for carbolic acid poi-
soning.

2. State symptoms of chronic arsenic poisoning with
treatment for same.

3. Describe the difference between alcoholic, uremic
and opium coma.

medical jurisprudence.

1. Define medical jurisprudence.

2. Give the reliable signs of death.

3. How would you distinguish between insanity and
idiocy.

obstetrics, gynecology, and pedi.\trics.

1. What signs are brought out by abdominal palpation
in the last stages of pregnancy, and their relative value?

2. Detail briefly the hygienic measures necessary for the
successful issue of pregnancy?

3. Define pelvimetry; what measurements obtained
thereby should determine interference?

4. What circumstances, other than pelvic contractions,
may cause dystocia?

5. Describe the management of delivery in breech pres-
entations.

6. Describe brieflv an operation for relaxed pelvic out-
let.

7. Detail the symptoms and possible terminations of
pelvic peritonitis.

8. Treatment of rectovaginal fistula.

9- What therapeutic agents should be cautiously exhib-
ited in infancy, and mention some that thev bear' propor-
tionately better than adults.

10. Slention the most important diseases of the larynx
in children, giving the causes for their greater danger'

SURGERY.

r. Give the diagnosis and treatment of acute osteo-
myelitis.

2. Give the cause and treatment of varicose ulcers.

3. Name the surgical diseases common to man and the
domestic animals.

4. Give the dififerential diagnosis between (a") concus-
sion of the brain so-called, (b) fracture of the skull, and
(c) rupture of the middle meningeal artery.

,=;. Give briefly Cohnheim's hypothesis as to the origin of
tumors.

6. What is hydrocele? Give diagnosis and treatment.

7. Give the nature and treatment of Pott's fracture.

8. Name the dangers and give the treatment of car-
buncle.

0. Give the causes and treatment of cystoureteropyelitis.
10. Name the dislocations of the elbow. Give the
symptoms and treatment of the backward dislocation.
^ 'It is proposed in this department to publish from time to
time the examination papers of the various State Boards
In order that a candidate may become familiar with the
character of the examination and so in some measure free
himself in advance from the nervousness and dread which
the unlinown inspires. In furtherance of the same object
answers to some of the questions will be published in order
to show the candidate what the examiners expect of him
Not all the questions of all the papers will be so treated
for the answers to many, especially In the anatomical papers'
are obvious or can be found in the index of any text-
oook on the subject: the answers to other questions, especially
in the surgical papers, must sometimes be omitted because of
the space they would demand. The candidate for a medical
license will not find in these answers a short and easv road to
success in the examination, for he Is not likely to meet the
same questions in the papers placed before him by the
examiners. The object of publishing the questions and
answers is only, as noted above, to acquaint the candidate
with the general character of these examinations and to
Inspire him with confidence in the result of his trial.

292

MEDICAL RECORD.

[Feb. 16, 1907

ANATOMY.

1. Describe the upper extremity of the tibia.

2. Describe the ligaments of the hip joint.

3. Describe the e.xternal obhque muscle, includmg a de-
scription of the superlicial abdominal ring.

4. Give the commencement, termination, relations, and
branches of the brachial artery.

5. Give the commencement, termination, and relations of
the internal jugular vein.

6. Describe the duodenum.

7. Give origin, course, and distribution of the median

nerve.

8. N'ame the muscles, nerves, and arteries severed by a
cross section of the thigh at the junction of the middle
with the lower third.

EMBRYOLOGY.

1. .^.t what stage of embryonic life does the develop-
ment of the alimentary canal commence, and from what
layer of the blastoderm is it formed?

2. What changes occur in the vascular system of the
fetus at birth?

PRACTICE. ETIOLOGY. AND UlAGXOSIS.

1. To what disorders are persons of a lithemic diathesis
most prone? Outline dietary and treatment of the lithemic

2. State early symptoms and causes of tuberculosis.

3. State physical symptoms and diagnosis of asthma.

4! In what 'conditions is severe pain a prominent symp-
tom, and to what extent does localized pain aid recogni-
tion? , -u ■ c

5. State cause and management of acute milk intec-

tion.

6. Describe the stools of acute enteritis, typhoid, ob-
structive jaundice.

7. Differentiate between scabies and pustular eczema.

8. What is aphasia? Give cause, and differentiate be-
tween the ataxic and aphasic forms.

9. Give symptoms and treatment of chorea.

10. What drugs influence character of stools?

11. What clinical significance attaches to cardiac aryth-
mia?

12. Cause and treatment of stomatitis.

rATHOLOGY.

1. Name the phenomena comprised (changes which
occur) in an inflammatory process.

2. State the systems through which, and how necrosis
is produced bv disordered nutrition.

3. What is leucopenia, and in what important disease
does it occur? .

4. What is an exudate, and what is the character of the
exudate in lobar pneumonia, bronchopneumonia, and acute
peritonitis?

^. Name the histological elements to be found m a hbro-
osteochondromyxo sarcoma. By what route do the metas-
tases of sarcoma generally occur?

6. Give the morbid anatomy of acute articular rheuma-
tism (rheumatic fever), and name the possible complica-
tions of this disease.

BACTERIOLOGY.

1. Define and illustrate the terms, aerobic, obligate, ple-
omorphous. and sporogenous, and name and explain the
two varieties of chemotaxis.

2. I>escribe the microorganism of anthrax, and give its
pathogenicity. . . ■ , .1

3. What special culture medium is required for the
growth of the gonococcus? Give the pathogenicity of the
gonococcus.

KEUROLOGY.

1. Give the etiology of locomotor ataxia.

2. Give the svmptoms of cerebral apoplexy, and name
the conditions the coma of which may be simulated by an
apoplectic stroke. ... , .

-;. Give the prognosis in tubercular meningitis and m
epidemic cerebrospinal meningitis, and the general indica-
tions of treatment in the latter.

MATERIA MEDICA.

1. Name, with dose of each, the preparations of sali-
cylic acid: give its physiological action, and state m what
form it is to be administered. , •. u

2. Give the preparations of belladonna: descrine the
toxic effects and give antidotes. .

3. Give the chief alkaloid of cinchona, its dose, and its
physiological action. , , . , r

4 Name the preparations of the chlorides of mercury;
give dose and differentiate the physiological action of each.

■;. Name the mineral acids and mention the special prop-
erties of each. . .

6. Give the physiological action of opium ; name its most
important alkaloids and give dose of each.

THERAPEUTICS.

1. Into what two classes are bitters divided? Give
therapeutic uses. Contraindications. Time of administra-
tion.

2. How may the two chlorides of mercury be admin-
istered? Give their therapeutic uses. In bilious attacks,
when you give calomel, what remedy often used to allay
nause.i would you be particular not to give?

3. Why would you use a strong solution of arsenic
when applied over large surfaces? In giving Fowler's solu-
tion in increasing doses what untoward symptoms would
indicate that the dose should not be further increased?

4. (a) Give the therapeutic application of drugs in the
different stages of pneumonia; (b) give the comparative
value of chloroform and ether as an anesthetic.

5. (a) Describe the therapeutics of iodine and its salts;
(b) what are the therapeutic uses of diuretics?

6. Prescribe a local application for erysipelas, for rhus-
toxicodendron poisoning. Name some remedies used for
epistaxis, croup, singultus, ptyalism. Write a prescription
for night-sweats of phthisis, for ascites.

PHYSIOLOGY.

1. What are the uses of the blood, and what is the dif-
ference between arterial and venous blood ?

2. What is the effect of the pneumogastric nerve upon
the heart?

3. What is meant by the term vesicular murmur?

4. What are the characteristics of peptones?

5. Name the pancreatic ferments, and describe the ac-
tion of each.

HYGIENE.

1. Name the qualities desirable in water for drinking
and domestic purposes.

2. Give best methods for disinfecting a house in which
there has been a case of smallpox.

3. What precautions should be taken by a physician
attending a case of diphtheria.

HISTOLOGY.

1. What is meant by endochondral formation of bone,
and describe process briefly.

2. Describe formation of an artery, giving coats.

LARYNGOLOGY.

1. What are the symptoms, course, and treatment of
acute laryngitis?

2. Give the diagnosis and treatment, both general and
special, of laryngismus stridulus.

3. Give the symptoms, course, some common complica-
tions, and treatment of acute follicular tonsillitis.

RHINOLOGY.

1. What anatomical arrangements within the nares ren-
der the treatment of chronic rhinitis difficult?

2. Give the most generally accepted theory of predis-
posing and exciting causes of hay fever, and describe its
symptoms.

OPHTHALMOLOGY.

I What are the niacroscopical appearances of the most
common forms of keratitis, and the appropriate treatment!*

2. Give the causes, symptoms, and general and local
treatment of trachoma.

3. Give cause, symptoms, and treatment, both prophy-
lactic and remedial, of ophthalmia neonatorum.

OTOLOGY.

1. Define tinnitus aurium and give the causes of it.

2. Give briefly the diagnosis and treatment of acute
otitis media.

.\NSWERS TO ST.A.TE BO.\RD EX.-\MIN.\TION
QUESTIONS.

Medical E.kamining Board of Virginia.

Jtiitc ig. 20. 21, and 22, 1906.

chemistry.

1. J'aloicc is the combining power of an atom of an
element as compared with that of an atom of hydrogen.

A Base is a compound which on entering into double
decomposition with an acid produces a salt and water.

A Sci!t is a substance derived from an acid when the
hydrogen of the latter has been partially or completely
replaced by an electropositive element or elements (a metal
or metals).

Dialysis is the process of separating colloids from crys-
talloids.

.-\n AHov is a substance composed of two or more metals.

2. .^n Alcohol is the hydroxide of a hydrocarbon radi-

Feb. 1 6,

1 907 J

MEDICAL RECORD.

293

cal. Alcohols are monoatomic. diatomic, and triatomic,
according to the saturating power of the radical. They
are also classified as primary, secondary, and tertiary. The
primary alcohols are characterized by the group CH2OH,
and yield on o.xidation, first an aldehyde, and then an acid.
Secondary alcohols contain the group CHOH, and on oxi-
dation yield a ketone. The tertiary alcohols contain the
group COH, and when oxidized two acids or ketones are
produced, each with fewer carbon atoms than the ori.ijinal
alcohol. Ethyl alcohol, CHs .CH2OH is a primary alcohol;
isopropyl alcohol, CH3CHOH.CH, is a secondary alcohol;
tertiary butyl alcohol, (CHs)3.C0H is a tertiary alcohol.
Etheue glvcol, CHjOH.CHiOH is a diatomic alcohol, and
glycerol, CH=OH.CHOH.CH:OH is a triatomic alcohnl.

An Ether is the oxide of a hydrocarbon radical. In siin-
f>!c , 'thcrs the radicals are the same, as (CiHrii-O, ethyl
ether; in mixed ethers the radicals are different, as CH3.
C2Hr..O, methyl ethyl ether. A compound ether is a sub-
stance derived from an acid by replacing the hydrogen of
the acid by a hydrocarbon radical, thus C:H;..N"0-.0, ethyl
nitrate or nitric ether ; compound ethers are now generally
called esters.

3. Ammonia; formula is NHa ; sources, in nature from
the decomposition of animal or vegetable matter containing
nitrogen and hydrogen: it is manufactured from ammonium
chloride and calcium hydroxide according to the equation :
2NH4Cl+Ca(OH)==2NH3-FCaCU+2H,0. It is used as
a respiratory stimulant, a circulatory stinndant, a counter-
irritant; it neutralizes acids, making definite salts known
as ammonium salts, which are formed by the direct com-
bination of the ammonia with the acid. It is also used in
the artificial preparation of ice.

5. KN03+H=S04=KHSO.+ HN03.

6. AgN0,,-}-NaCl = AgCl-FNaN08.
4HF+SiO:=SiF.H-2H:0.

TOXICOLOGY.

1. Symptoms: — buccal mucous membrane is whitened
and hardened; vomiting; burning pain in mouth, esopha-
gus, and stomach; pulse and body temperature are lowered;
the pupils are contracted; collapse, and finally death. The
urine may become dark. Treatment : — emetics, white of
egg, stimidants. Alcohol is said to be antidotal.

2. Symptoms : — malaise, anorexia, drowsiness, photo-
phobia, conjimctivitis, eczema, weakness, emaciation, local
paralysis, stripping ofif of the skin and dropping of the
hair. Treatment: — remove the causes, give freshly prepare<l
ferric hydroxide, castor oil, diuretics.

3. In alcoholic coma there may be an odor of alcohol on
the breath, the patient can generally be aroused by shouting
in his ear, there is no paralysis, the pupils are normal or
dilated, respiration is practically normal, the pulse is first
rapid and later feeble, and the skin cool.

In uremic coma there may be a urinous odor to the
breath, the urine is scanty and contains albumin, there is
slow pulse with high arterial tension, the pupils are usually
small and equal, respiration is deep and may be quickened,
the body temperature may be above normal or subnormal.

In opium coma the pupils are contracted, respiration is
slow, pulse slow and full, body temperature is normal or
subnormal, there may be the odor of laudanum on the
breath.

MEDICAL JURISPRUDENCE.

1. Medical jurisprudence is the applicatiim of the
knowledge of any of the branches of medicine to the prob-
lems and requirements of the law.

2. The complete and permanent cessation of circulation
and respiration, rigor mortis, loss of body heat, pallor of
the body, putrefaction.

3. Idiocy is congenital.

OBSTETRICS. CYNECOI.Onv . ANV PEDI.\TRICS.

9. The following should be cautiously exhibited in
nfancy : — cocaine, opium, apomorphine, jaborandi, the coal-
:ar derivatives, acids, and some of the preparations of
ron. The following are relatively well tolerated : — arsenic,
lelladonna, chloral, calomel, bromides, iodides, quinine,
md acohol.

SURGERY.

3. Tuberculosis, hydrophobia, actinomycosis, glanders,
mthrax, septicemia, pyemia, cancer and other tumors, cleft
)alate and hare-lip.

4. (a) Concussion of the brain is characterized by sud-
len onset, the patient is unconscious but can be aroused,
he muscles are relaxed and flaccid, the pulse weak and
low. respirations faint and irregular, the skin pale and
old. the sphincters relaxed, the pupils are equal and react,
he temperature is subnormal but is the same on both sides
f the body.

(b") In fracture of the skull (at the base) there will be
emorrhage and escape of the cerebrospinal fluid either
rom the nose, into the orbit, from the ear, or into the loose

cellular tissue of the mastoid or occipital region; there will
be indications of injury to one or more of the cranial
nerves, such as loss of smell, blindness, ptosis, strabismus,
facial paralysis, internal deafness.

(c) In rupture of the middle meningeal artery there will
be first a concussion with its accompanying unconsciousness ;
this will be followed by a temporary return to conscious-
ness, lasting from a few minutes to an hour or more ; this
is succeeded by a gradually increasing drowsiness, ending
in coma.

.S. Cohnheim suggested that, owing to some slight devel-
opmental errors, small portions of embryonic tissue become
misplaced and surrounded by cells belonging to a different
blastodermic layer. These misplaced cells lie dormant, but
are still alive; and later some blow or other irritant acts
as a stimulus and starts them growing, and the result is a
tumor.

8. The dangers of carbuncle are: — hemorrhage, septic
phlebitis, septic clots or emboli, septic meningitis, exhaus-
tion, septicemia, or pyemia.

ANATOMY.

8. Muscles : — Vastus externus, vasttis internus. crureus,
rectus femoris, sartorins, gracilis, adductor longns, adductor
magnus, biceps, semunembranosus, semitendinosus.

Arteries: — Femoral, profunda femoris, external circum-
flex, comes nervi ischiadici.

Keri'es: — Anterior crural, middle cutaneous, internal cu-
taneous, long saphenous, external cutaneous, obturator,
great sciatic, lesser sciatic.

EMBRYOLOGY.

1. The development of the alimentary canal begins at
a very early period of einbryonic life, the enlargement
which later becomes the stomach being noticeable as early
as the fourth week. The alimentary canal is derived from
all three layers of the blastoderm, but particularly from
the hypoblast and the mesoblast.

2. The hypogastric arteries shrink and become imper-
vious, the foramen ovale closes, the eustachian valve atro-
phies, the ductus arteriosus closes, the ductus venosus
becomes obliterated, the umbilical vein becomes obliterated.

PRACTICE, ETIOLOGY, AND DIAGNOSIS.

I. They are most prone to gout, arteriosclerosis, chronic
interstitial nephritis, aneurysm, angina pectoris, acute in-
flammations, apoplexy, and certain skin diseases, such as
urticaria, eczema.

4. Severe pain is a prominent symptom in: — passage of
calculi, burns, aneurysms, angina pectoris, colic, gout, whit-
lows, otitis media, tic doloureux. and acute inflainmations.

Localized pain is of some value as an aid to diagnosis,
but an indication of the different conditions in which such
pains are found would take up too much space ; it should,
however, be remembered that pain is sometimes wrongly
referred, as pain in the knee in hip joint disease, or the
pain of herpes zoster, \vhich is referred to the skin.

6. In acute enteritis, the stools are fluid or semifluid,
and contain particles of undigested food, bile, and tiny
specks of mucus.

In typhoid, the stools are thin, yellowish ("peasoiip"),
and vary in number from one or two up to ten or twelve
in twenty-four hours.

In obstructive jaundice, the stools are clay-colored, pasty,
and offensive.

7. In scabies, there will be the presence of burrows and
of the itch-mite, the eruption will generally be found on
the anterior surface of the wrists, about the umbilicus, in
the mammary region in females, or around the genitals in
males; there is intense itching; it is communicaljle, and is
readily amenable to treatment.

In pustular ec:ema, there are no burrows and no itch-
mites; as a rule, poorly nourished or delicate children are
attacked, and the eruption is found on the face and the
scalp ; after the pustules rupture, yellowish or greenish
crusts form ; the itching is variable.

8. Aphasia is the inability to express ideas by either
speech or writing. It is caused by lesions of the cortical
centers, and is not due to lesions of the peripheral nerves
or of the organs concerned in speech or writing.

In ataxic apliasia. there is loss of speech, owing to lack
of coordination of the muscles concerned in voice pro-
duction.

In sensory or amnesic aphasia there is loss of word
memory, which may or may not exist in connection with
ataxic aphasia. There are several varieties of aphasia.

10. Calomel and colchicum may color the stools green ;
rhubarb, senna, and santonin may cause a yellow color;
iron, bismuth, and man.ganese may give a black color; log-
wood may cause a red color; and sulphur may cause a
very offensive odor.

Ti. Cardiac arrhythmia has no particular clinical sig-
nificance, unless it accompanies some disease. Accordin.g

294

MEDICAL RECORD.

[Feb. 1 6, 1907

to Butler {Diugiwstics of Internal Medicine), search should
be made for one or more of the following; — (i) Valvular
cardiac disease, especially mitral lesions, in which it is
usually, but not always, a sign of beginning failure of com-
pensation, passing in many instances into delirium cordis;
simple dilatation, chronic myocarditis, sclerosis of the
coronary arteries, and fatty degeneration; possibly obscure
changes in the cardiac ganglia, and overstrain or impaired
nutrition in wasting diseases or long-continued fevers. (2)
Poisons circulating in the blood, such as alcohol, coffee, tea,
tobacco, digitalis, aconite, and belladonna, or the toxines of
the infectious diseases, especially of typhoid fever and
pneumonia. (3) Diseases of the intracranial contents,
meningitis, hemorrhage, abscess, softening, concussion,
and not infrequently mental excitement. (4) Neurasthenic
conditions resulting from excesses or overstrain. Brief
attacks of moderate arrhythmia are not uncommon in
neurotic individuals, following even a slight departure from
their usual habits in food, drink, or exertion. (5) Diges-
tive disturbances, acute or chronic, and jaundice or consti-
pation, particularly if associated with an unusually hypo-
chondriacal frame of mind. (6) More rarely arthritis
deformans, exophthalmic goiter, and renal disease.

PATHOLOGY.

2. Necrosis is produced by disordered nutrition through
two systems: — (l) the circulatory, by means of anemia and
of stasis of blood and lymph ; and (2) the nervous, by
means of both vasomotor impulses and the reflexes.

3. Leucopenia is the condition in which the number
of white blood cells is diminished ; sometimes the term is
used to denote merely absence of leucocytosis. It occurs
in : — typhoid, tuberculosis, pernicious anemia, pneumonia,
cachexia, inanition, measles, influenza, malaria.

4. An exudate is the material that has passed through
the walls of the vessels into the surrounding tissues, as the
result of inflammation. In lobar pneumonia, the exudate
consists of fibrin, red blood cells, epithelial cells, polynu-
clear leucocytes, and diplococci, in the stage of red hepati-
zation ; in the stage of gray hepatization the fibrin and
red bood cells liave disappeared, and the exudate now
consists mainly of leucocytes and some pus cells.

In bronchopneumonia the exudate consists of serum, leu-
cocytes and endothelial cells : occasionally there may be
a few red blood cells and a trace of fibrin.

In acute peritonitis the exudate is serous or purulent, and
is generally fibrinous.

5. Fibrous tissue, bone, cartilage, mucous tissue, and
connective tissue of embryonic type. The metastasis is by
way of the blood-vessels.

6. The synovial membrane and ligaments are swollen
and congested ; the synovial fluid is increased in amount,
is turbid, and may contain lymph ; the cartilages are
roughened and may become ulcerated or eroded; the joint
may suppurate or there may be a false ankylosis ; in the
blood there is a diminution in the number of the red cells,
and an excess of fibrin. The possible complications in-
clude:— endocarditis, pericarditis, occasionally myocarditis,
pleurisy, chorea, tonsillitis, pneumonia, cerebral disturbances
such as convulsions or delirium, and certain skin eruptions
as urticaria.

BACTERIOLOGY.

I. Aerobic bacteria are such as require the presence of
oxygen in order to live and grow. Most bacteria are
aerobic.

Obligate means necessary ; and the term is used in op-
position to facultative. Obligate aerobic bacteria are such
bacteria as cannot exist without oxygen ; whereas fac-
ultative aerobic bacteria are such as thrive better in the
presence of oxygen, but still can manage to exist with-
out it.

Plcomorphous bacteria are such as assume more than
one form.

Sporogenous bacteria are bacteria in which reproduction
takes place by sporulation instead of by the more usual
method of fission.

Chemotaxis is the property by virtue of which certain
living cells approach (positive chemotaxis) or move away
from (negative chemotaxis) certain other cells or sub-
stances.

3. The special culture medium required for the growth
of the gonococcus is human blood serum.

NEUROLOGY.

I. Locomotor ataxia is a disease of adult life ; is more
common in men than in women ; is more common in cities
than in the country; syphilis is believed to be the most
frequent direct cause; alcoholism, injury, exposure to cold
and wet. have all been urged as causes, but they are not
now assigned so important a place as etiological factors
as was formerlv the case.

MATERIA MEDICA.

1. Preparations of salicylic acid are:— sodium salicj'late,
dose gr. xv ; lithium salicylate, dose gr. xv; ammonium
salicylate, dose gr. iv; strontium salicylate, dose gr. xv;
phenyl salicylate (salol), dose gr. vijss; bismuth subsalicy-
late, dose gr. iy. Physiological action: — antiseptic, irritant,
diaphoretic, diuretic, antipyretic, and cholagogue. It is
best administered in the form of one of the salts, preferably
sodium salicylate.

2. Preparations of belladonna :— the extract, the fluid
extract, tincture, ointment, the plaster, and the liniment.
.'Vtropine, with its oleate and sulphate, and homatropine
hydrobromide.

Toxic effects:— dryness of the mouth and throat, thirst,
drowsiness, dysphagia, face flushed, pupils much dilated,
eyes prominent, numbness and partial paralysis of the
extremities, and there may be delirium and coma.

Antidotes: — There is no antidote; pilocarpine is the
best physiological antagonist, and opium will counteract
the effect on the pupils.

4. The only preparation of corrosive sublimate or mer-
curic chloride is the lotio hydrargyri flava. or yellow wash.
The preparations of calomel or mercurous chloride, are
compound cathartic pills, dose two pills ; lotio hydrargyri
nigra, or black wash; and compound pills of antimony, or
Plummer's pills, dose one to three pills.

5._ The mineral acids are: — hydrochloric, sulphuric,
nitric, nitrohydrochloric, and phosphoric acids.

THERAPEUTICS.

I. The two classes into which bitters are divided, are: —
(i) simple bitters, and (2) aromatic bitters. Their thera-
peutic uses are : — to promote appetite, to increase gastric
secretion, to act as tonics to the mucous membrane of the
alimentary tract, in atonic dyspepsia, in chronic gastritis,
in sea-sickness, and as vehicles for the administration of
other drugs and preparations. Contraindications: — acute
gastritis and gastric ulcer. Bitters should be administered
shortly before meals.

5. (b) The therapeutic uses of diuretics: — to remove
liquid from the body tissues or cavities, to increase the
elimination of waste products and of poisons, to dilute the
urine, and to maintain the excretory action of the kidneys.

. 6. For erysipelas, equal parts of ichthj-ol, ether, and col-
lodion. For rluis toxicodendron poisoning, grindelia ro-
busta, four drams to a pint of water. For epistaxis. acon-
ite, adrenalin, witchhazel, vinegar, tincture of the chloride
of iron, plugging the nares. For croup, ipecac, apomor-
phine, lactic acid, hydrogen dioxide, potassium citrate.
For singultus, morphine, chloroform, ether, strychnine, ice.
For ptyatism, acids, astringents, potassium iodide, borax,
belladonna.

For night szueats of phthisis:—

5 Acidi camphorici ..." 3ij

Alcoholis 3j

Mucilaginis acacix jiss

Syrupi aurantii corticis q.s. ad. Ji'j Misce.

Signa : — One dessertspoonful one hour before the sweat
is expected.

For Ascites: — B. Pulveris digitalis^

Pulveris scillae aa gr. .xxx Misce.
Fiat in pillulas no. x.xx
Signa : — One every four hours.

PHYSIOLOGY.

1. The uses of the blood are to supply nourishment to,
and to take away waste matters from, all parts of the body.
The red corpuscles supply the tissues with hemoglobin; the
white corpuscles serve as a protection to the body from
the incursions of pathogenic microorganisms, they take
some part in the process of the coagulation of the blood,
they aid in the absorption of fats and peptones from the
intestine, and they help to maintain the proper proteid
content of the blood plasma.

Arterial blood is bright red in color, contains more oxy-
.gen, less carbon dioxide, more water, and is slightly
warmer; z-enous blood is purple in color, contains less
oxygen, more carbon dioxide, less water, and is slightly
cooler (except in the hepatic vein).

2. The pneumogastric nerve conveys inhibitory im-
pulses from the medulla to the heart.

3. By the term vesicular murmur is meant the peculiar
breathing sound which is heard when listening over the
vesicular tissue of the hm.gs.

4. Peptones are characterized by being very soluble in
water, hygroscopic, easily dialyzed. and they respond to
none of the ordinary proteid reactions with the exception
of the biuret reaction, with which they give a red color.

5. The pancreatic ferments are (i) trypsin, which
changes proteids into proteoses and peptones, and after-
wards decomposes them into leucin and tyrosin; (2) amy-

Feb. U). ujo:

MEDICAL RECORD.

-'Of)

lof'sin, which converts starch into maltose; (3) stcaf'sin,
which emulsifies and saponilies fats; and {4) a milk-curd-
ling ferment. All of these act in an alkaline medium only.

I. It should be colorless, odorless, cool, limpid, soft;
it should have an agreeable taste, neither salty nor sweet
nor flat; it should dissolve soap readily without formation
of a curdy precipitate, it should contain not more than
about twenty-five to thirty grains of solids per gallon, and
should not be polluted with sewage.

I. Tinnitus aurium is the name given to any subjective
sounds heard in the ear. The chief causes are : — neuras-
thenia, impacted cerumen, otitis, and other ear diseases ;
Meniere's disease, obstruction of the Eustachian tube,
anemia, leukemia, cerebral hyperemia and anemia, arterio-
sclerosis, gout, digestive disorders, excessive use of alcohol
or tobacco, and the use of certain drugs such as quinine
or salicvlic acid.

uHiFrajifuttr liinti

BULLETIN OF APPROACHING EXAMINATIONS.T

STATE. NAME AND ADDRESS OP PLACE AMD DATE OP

SECRETARY. NEXT EXAMINATION.

Alabama* W. H. Sanders, Montgomery. . Montgomery. . March 1-6

Arizona* Ancil Martin, Phoenix Phoenix April i

Arkansas* F. T. Murphy, Brinkley Little Rock. . April 9

Cahfornia Chas, L. Tisdale, Alameda. . . .San Francisco April 16

Colorado S. D. Van Meter, 1723 Tre-

mont Street, Denver Denver April 2

Connecticut*.. Chas. A. Tuttle New Haven.. .New Haven. . .March 12

Delaware J. H. Wilson, Dover Dover June iS

Dis. of Col'bia. .W.C.Woodward, Washington. Washington.. .April 11

Florida* I. D. Fernandez, JacksonWlle. Jackson \*ille.. .May 15

Georgia E. R. Anthony. Griffin Atlanta April —

Idaho J. L. Conant, Jr., Genesee Boise April 2

Illinois J. A. Egan. Springfield Chicago April i-

Indiana W. T. Gott. 120 State House,

Indianapolis Indianapolis. . May 28

Iowa J. F. Kennedy, Des Moines... . Des Moines.. . .March 19

Kansas T. E Raines, Concordia Topeka June n

Kentucky* J. N. McCormack. Bowling

Green Louisville April 23

Louisiana F. A. La Rue. 211 Camp St.,

New Orleans New Orleans.. .May 9

Maine Wm. J. Maybury, Saco Portland March 5

Maryland J. McP. Scott_, Hagerstown.. . .Baltimore June —

Massachusetts*. E. B. Harvey, State House,

Boston Boston March 12

Michigan B. D. Hanson. 205 UTiitney

Building. Detroit Ann Arbor. . . .June 11

Minnesota O. E. Linier, 24 South Fourth

Street, Minneapohs St. Paul April 2

Mississippi J. F. Hunter. Jackson Jackson... . . . .May id

Missouri J. A. B. Adcock, Warrensburg. |^g^j°"'Qjfy j April 16

Montana* Wm. C. Riddell, Helena Helena April —

Nebraska Geo. H. Brash. Beatrice Lincoln

Nevada S. L. Lee, Carson City Carson City. . ..May 6

N. Hamp're*. . .Henry C. Morrison, State Li-
brary. Concord. . Concord July 9

New Jersey J. W. Bennett, Long Branch, .Trenton Tune :8

New Mexico.. . .B. D Black. Las Vegas .. Santa Fe June 3

f New York. "|

NewYork C.F.WheelockUniv.ol State J Albany, I u=,,

of New York, Albany 1 Syracuse. \ ' '

I Buffalo. J

N. Carolina*... .G. T. Sikes. Grissom Morehead City.May —

N. Dakota H. M. Wheeler. Grand Forks. Grand Forks. .April 2

Ohio Geo. H. Matson. Columbus... .Columbus June 11

Oklahoma* J W. Baker. Enid Guthne March 26

Oregon* B. E. Miller. Portland Portland April —

Pennsylvania. . N. C. Schaeffer, Harrisburg. | pJ'^^buJ.P*''^ } June —

Rhode Island.. .G. T. Swarts, Providence PrtDvidence. . . .April 4

S. Carolina W. M. Lester. Colximbia Columbia June —

S.Dakota H. E. McNutt, Aberdeen Sioux Falls.. . .July 10

i Memphis, ]

Nash\'ille, I May —
Knoxville. J

Texas T. T. Jackson, San Antonio. . .Austin April 30

Utah* R. W. Fisher, Salt Lake City. .Salt Lake City.April i

Vermont W Scott Nay, Underbill Burlington .... July 9

Virginia R. S Martin. Stuart Lynchburg. . .June iS

Washington*. . .C. W. Sharpies. Seattle Seattle July 2

W. Virginia*. . .H. A Barbee. Point Pleasant. .Wheeling April 9

Wisconsin J- V. Stevens, Jefferson Madison July 9

Wyoming S. B. Miller. Laramie Cheyenne. . .

*No reciprocity recognized by these States.

tApplicants should in every case write to the secretary for latest
details regarding the examination in any particular State.

Pennsylvania. — .\ bill has been introduced into the
Pennsylvania legislature substituting for the three State
Medical Examining Boards one board, composed of nine
members, to be appointed by the Governor from lists
of qualified members of State medical societies or associa-
tions. More rigid examinations will be possible under the
new bill, by which the examiners will be empowered to
require candidates for license to do laboratory work, dem-
onstrate on the human cadaver, and even practise at the
bedside in convenient eleemosynary institutions. Edu-
cational requirements are made stricter, and no new license
is to be issued unless the candidate has passed a four-year
course in a medical school and prior to that has taken a
cotirse in some school or college having a four-year course
of instruction.

Trypsin. — An accident sufficiently serious to warrant
its report occurred with a patient, F. J. of B., with carci-
noma of the sigmoid and upper rectum, but who was
entirely free of cachexia and toxins. An injection of
five minims of the drug, diluted with 15 minims of
specially sterilized distilled water, on December 26, was
followed nearly thirty-si.x hours later by an active de-
lirium, lasting with complete unconsciousness about
.sixteen hours. During the day of December 2S con-
sciousness began to return, but at night active delirium
again appeared, in sphe of an injection in the afternoon
of amylopsin. Complete recovery occurred only two days
later, after full doses of potassic bromide. During the
first two nights the patient, a strong n^an. was with dif-
ficulty restrained from injury to himself and others.

C. G. Am Ende, M.D.

Alopecia. — Jessner recommends the following:

Ix Resorcin 2.0

Ac. salicyl 2.0

.'\c. tannici 6.0

Spt. camphor:e 20.0

01. ricini 5.0

Spt. colonien q.s. ad. 200.0

Sig. : Apply locally.

R Chloral hyd.

Ac. tannici aa 6.0

Tr. benz i.o

01. ricini S'O

Spt, vini rect q.s. ad. 200.0

Sig.: .A.pply locally.

5 Ac. tartar lo.o

Ac. salicyl i.o

Spt. colonien 20.0

01. ricini 2.0

Spt. vini rect q.s. ad. 200.0

Sig.: .Apply locally.

Neuralgia. — The following is recommended by Leon-
ard Williams:

Ix Quinin.'c hydrocliloridi gr.y

Acidi hydrobromici diluti TTExx

Tr. gelsemii Trgx

Aq. chloroform! q. s.ad f5ss

M. Sig.: Every twenty minutes till pain ceases. Not
more than four doses to be taken.

— C linictil Journal.

Mouth Washes. —

!> Potassii chloratis 3ij

Sodii biboratis 5j

Potassii nitratis 5ss

Tintur;c arnica; 3ij

Aqua; cinnamomi q.s. ad. 5 viij

M. Sig.: Thoroughly rinse mouth three times a day.

IJ Sodii bicarbonatis.

Sodii biboratis aa 3j

Zinci chloridi gr. vj

Thymol

Menthol aa gr. j

Glycerini 3iv

Alcoholis 3ij

AquR gaultheriae q.s. ;k1 Oj

M. Sig.: Use as a mouth wash.

— Buckley in the Dental Rcviciv.

Ozena. — Lubet says the treatment of ozena should
have for principal object the removal of all crusts from
the mucous membrane, as where there are no crusts
there is no odor. His idea is to stimulate the nasal
secretion so that the crusts become detached of their
own accord. To obtain that end he recommends the
aspiration through the nose several times a day of a
strong boric acid ointment.

IJ Ac, borici 3iv

Menthol 3vi

Petrolati alb 5iss

The boric acid excites the secretion of the membrane,
detaching the crusts, and when the patient blows the
nose with force thej' are expelled.

—The Medical Press.
Prostatitis. —

IJ Tinct. opii camphorat.'e 5'^s

Liquoris potassae 5ii

Tinct. lupulini 3iy

Tinct. hyoscyami 5ii^

Syrupi zingiberis 5"'

M. Sig. : Teaspoonful in half glass of water after meals
and at bedtime.

—Indian Medieal Reeord.

296

MEDICAL RECORD.

[Feb. t6, i(p7

Npw 3Iustrmnpnt0.

FIDDLE-BOW SURGICAL DRILL.

Bv FREDERIC GRIFFITH. .M.D..

NKW VdRK

SI.RGEON, FELLOW OF THE ACADEMY OF MEDICINE.

A SIMPLE device which I think might be used by
surgeons to advantage for the propulsion of drills
when wiring bone fragments, or after bone re-
section work when screw-plates are intended to be
used, consists of a fiddle-bow attachment to the
shank of the drill chuck. I find the implement, as
devised, to be as safe and under as direct control
as is the awl when used for similar work, without
having the objection of cramping or tiring the
surgeon's hands during its use. The bow drill,
requires two hands for its manipulation, but its bor-
ing capacity is at all times under supervision. _ Dan-
ger, therefore, of the drill "running away," with re-
sulting damage to underlving soft parts or vessels,
is not possible, for the number of revolutions de-
pends directly upon the driving power imparted to
the bow.

The Fiddle-bow Surgical Drill.

As pictured in the cut, the implement consists
of a vertical shank, spool, chuck, and handle, with
cord and bow. It may be constructed from three-
eighths or seven-sixteenths (i cm.-i.i cm.) tool
steel eight to twelve inches (20 cm.-30 cm.) 4n
length. A revolving handle caps the upper end and
a drill chuck the lower. Between, immovably set
upon the shank of the implement, is a spool. The
bow is of tempered steel ten to fourteen inches (25
to 35 cm.) in length, one-quarter inch (0.6 cm.)
square, tapering from the handle into which it
is screwed. A hook at the lower extremity and an
eye at the upper end afford attachment for the cord.
A stout, woven linen curtain cord or similar ma-
terial mav be used as the medium for the transfer
of motive power.

All metal parts should be full nickeled. Steriliza-
tion is accomplished by boiling. Ordinary twist
drills or plain, tapering, double ground boring tips
mav be used.

49 E.*=T SiXTV-FOl-RTH STREET.

iHriitral 3ltpms.

Contagious Diseases — Weekly Statement. —Report of

cases and deaths from contagious disease reported to
the Sanitary Bureau, Health Department, New York
City, for the week ending February 9, 1907:

Tuberculosis Pulmonalis

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis
Malarial Fever

Totals

Cases Deaths

350

208

314

57

195

5

261

12

2

—

g2

—

61

7

65

5

10

16

1350

310

Leukoplasia of the Vulva, the Vagina, and the Uterus.

— !•'. Jayle and X. Bender from their study of this subject
cniichide that the leukoplasic plaques may occur on the
nuicosa of the vulva, of the vagina, on the vaginal part of
t)ie cervi.x, and also on the endouterine mucosa when
there is found in this location pavement epithelium as
a substitute in totality or in part for cylindrical epithelium.
Whatever its location may be. the leukoplasia presents the
same macroscopic aspect. Histologically it is characterized
by three essential features : hyperacanthosis. hvperkerato-
sis. and an excess of granulation tissue. One of these
conditions may be far more striking than the other two
in a special case. The variations probably depend more or
less upon the age of the lesion. Whatever may be the
location of this trouble leukoplasia" is frequently the fore-
runner of cancer. — La Presse Mcdicalc.

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been repotted
to the Surgeon-General, Public Health and Marine-
Hospital Service, during the week ended February 8,
1906.

SMALLPOX — UN'ITED STATES.

Georgia. .Xususta Jan. 22-20

Indiana. Indianapolis Jan. 20-27

Michigan, Detroit Jan. 25-Feb. 2.

Mississippi, Xatchez Jan. 19-26

Missouri, St. Joseph Jan. ig-26

Ohio, Cincinnati Jan. 25-Feb. i .

Spokane. Washington Jan. 12-ig

SMALLPO.X — FOREIGN-.

Canada, Caoe Breton — Sydney. . . .Jan. 26

Kent County Jan. 26

Xova Scotia, Colchester Co .Jan. 26

Cumberland

County. . . -Jan. 26

Pictou Co.. . .Jan. 26

Chile, .\ntofaBasta Jan. 6

Coi^uimbo Jan. 6

Iquique Jan. 6

Cuba. Habana Jan. 30

Ecuador, Guayaquil Dec. 1-3 1

France, Paris Jan. 3-12

Gibraltar Jan. 13-20

Great Britain, Cardiff Jan. 12-19

Liverpool Jan. 12-19.

CASES. DEATHS.
3
13 2

6

14 Imported

Present
Present
Present

Present
Epidemic

2

Present

I Imported
3

Malta Dec. 29-Jan. 5 .

Mexico, City of Mexico Dec. 9-13

Xetherlanls, Rotterdam Jan. 12-19

Peru. Lima Dec. 1-3 1

Russia, Moscow Dec. 29-Jan. 5 .

Odessa Jan. 5-12

Spain. Barcelona Jan. 10-20

YELLOW FEVER.

Ecuador. Guayaquil Dec. 1-3 i

CHOLERA IXSUL.AR.

PhiUpiiine Islands, Provinces Dec. 8-15

PLAGUE.

Chile, .\ntofagasta Jan. 6

China. Xiuchwang Jan. 28

Peru, Callao Dec. 31-Jan. 3 ■

Catacaos Dec. 19

Chiclayo Dec. 19

Mollendo Dec. iq

Paita, city and \'icinity. . . .Dec. 19

San Pedro Dec. tg

Truiillo Dec. 19

Present

edical Record

A Weekly Journal of Medicine and Surgery

Vol. 71, No. 8.
Whole No. IS94.

New York, February 23, 1907.

$5.00 Per Annum.
Single Copies, JOc.

(!PrtJ5t«al Artirba.

BRACHIAL NEURALGIA AND ARM PAINS.

By CHARLES L. DANA, M.D..

NEW YORK.

Introductory. — The arm and shoulder are supplied
by the brachial plexus formed from the last _four cer-
vical and first dorsal nerves. This plexus gives off
twelve collateral branches (all muscular but the
last) and six terminals.

The twelve collaterals give muscular supply and
also muscular sensibility to the shoulder muscles,
and are nearly all given off from the upper and
middle cords of the plexus and fourth, fifth, and
sixth cervical roots.

The terminal branches of the brachial plexus
which supply cutaneous sensation to the arm and
shoulder are the circumfie.x, radial, internal cutane-
ous, and musculocutaneous. These all have rep-
resentation also in the fourth to seventh cervical
and arm from the upper part of the plexus, except
the internal cutaneous.

Brachial neuralgia is, then, a malady of the upper
■cords of the brachial plexus and its branches.

It is not my purpose to give a description of the
nerves of the arm, as this is to be found in all
current text-books. I insert here, however, for the
purpose of refreshing the memorv :

I. .\ diagram of the brachial plexus.

Muse. -CUTANEOUS

Median

Musc-SPIRAL

AR
ERNAL CUTANEOUS
ER INT. CUT.

FlO. I

anterior
thoracic

— Tile brachial plexus; i, the subscapular nerves; 2, internal
thoracic; 3. fii'St intercostal; 4, second intercostal; 5. posterior

2. A diagram showing the sensory areas of the
skin of the shoulder and arm (Fig. 2) and showing
the relations of the inferior cervical and first dorsal
ganglia to the brachial plexus (Fig. 7). Also sec-

*R€ad at a meeting of the Practitioners' Society, De-
cember, igo6

tional views of the upper arm and forearm (Figs.
3 and 4).

It will be seen that the collateral branches of
the brachial plexus are all mainly muscular except
the last, the internal cutaneous. They are nearly
all given off from the fourth, fifth, and sixth cer-
vical roots and the upper cords of the brachial
plexus. Hence, pains in the shoulder, except inso-

'-1

4-

A B

Fig. 2 — Cutaneous distribution of the arm nerves; A, anterior
surfacees; B, posterior surface; i, cervical plexus; 2, circumflex nerve;
3, accessory internal cutaneous; 4, 4,' internal cutaneous; 5, musculo-
cutaneous; 6, 6'. 6", musculospiral (radial); 7, 7', median: 8, S',
ulnar.

far as they are muscular and arthritic, are not due
to involvement of these collateral nerves.

The terminal nerves of the brachial plexus are
scnsorymotor and supply cutaneous and muscular
sensation to the shoulder as well as arm. They
are the circumflex, radial, musculocutaneous, inter-
nal cutaneous, median, and ulnar. Now practically,
in most neuralgias of the upper extremity, the
pains are mostly in the upper arm and shoulder,
rarely and secondarily in the forearm and fingers.
Hence, it is the circumflex, radial, and musculo-

298

MEDICAL RECORD.

[Feb. 23, 1907

cutaneous and internal cutaneous that are most in-
volved. These nerves, except the last, come from
the fourth to the seventh cervical. Hence, it is
mostly the upper and middle cords of the plexus that
are most affected. The pains are usually most in-
tense deep in the arm about the shoulder and at
the edge of the scapula, as though it were the col-

Front

Back

,' Fig. 3. — Cross-section ot the upper arm through the middle of the
biceps, sliowing the position and distribution of the nerves; the lines
leading from them show the muscles they supply.

laterals and smaller terminals to the bone joints
and deep tissues that were involved. There are few
darting pains along the whole nerve, to the fingers,
hence, we assume the process is not usually a root
neuritis, or irritation, and not a trunk neuritis, but
a terminal neuritis. It is only late and in severe
types that there is evidence of the large trunks being
involved. The process means, sometimes, an in-
volvement as much of the cellular and muscular tis-
sues as of the nerve in the ordinary cases. Only
in herpes neuritis and in tabetic pains do we get
the posterior ganglia aiTected. At least there are
but few exceptions to this rule.

The Nature of Pains About the Shoulder. —
Pains just above the shoulder and about the acro-
mion are due to involvement of the supraacromial
nerves, which are branches of the fourth cervical.

The deep-seated pains referred to the parts about
the joint and in the deltoid, are caused by the cir-
cumflex nerve which originates from the fourth,
fifth, and sixth cervical, and which is a sensory mo-
tor nerve. The superficial circumflex nerve-pains
are felt more posteriorlv and over the body of
the deltoid ; there is a painful point where the nerve
becomes superficial (Fig. 8).

Pains on the anterior and inner surfaces of the
shoulder and upper arm are due to involvement of
the intercostohumeral, second dorsal. Shoulder
pains, however, generally may be said to be circum-
flex and supraacromial and to mean involvement
of the fibers from the fourth, fifth, and sixth cervical
nerve roots.

The circumflex nerve, which thus causes shoulder
pains, is given ofif from the posterior cord of the
brachial plexus from which comes the other ter-
minal branch, the radial (musculospiral). Hence.

shoulder pains due to this nerve, when severe, radi-
ate down the arm into the fingers, usually the first
and second or third, or second and third fingers.

Just above the origin of the circumflex arise the
collateral branches to the subscapular and latissimus
dorsi ; hence, pains or uncomfortable sensations may
radiate back into the region of the scapula. Still
more frequently pains about the shoulder radiate into
the back of the neck along the nerves of the super-
ficial or deep cervical plexus. There is often a local-
ized pain also just above the interscapular space and
at about the level of the first and second dorsal ver-
tebrae due to sensory fibers of the posterior branches
of the fifth and sixth cervical and seventh cervical,
representing the same segments as those of the cir-
cumflex and radial (Fig. 8).

Summary. — Shoulder pains, then, mean involve-
ment mainly of the circumflex ; if they extend up,
the supraacromial nerves ; if they extend down to
involvement of the radial, and if they extend back
to the collateral muscular nerves going to the
scapular region.

The Nature of Pains in the Upper Arm. —
Pains here are generally associated with pains below
in the forearm and hand, and, still more, with shoul-
der pains. Usually in brachial neuralgia the pain is
most dominant in the arm, often in the upper two-
thirds, and rather more on the inner side along the
biceps, extending to the axilla. The superficial parts
on the inner arm here are supplied by the internal
musculocutaneous and internal cutaneous nerve.
The deeper parts anteriorly by the musculocutane-
ous, which also has a branch to the periosteum and
bone and is the seat of the deeper pains (Fig. 3).
These nerves arise from the inner (internal cutane-
ous and lesser internal cutaneous) and outer cord
(musculocutaneous) of the plexus. The musculo-
cutaneous comes from the fourth and fifth cervical,
while the internal cutaneous from the first and sec-
ond dorsal.

Pains in the outer part of the arm, both deep and
superficial, come from the radial (fourth to eighth

Front

Back

Fig. 4. — Cross-section of the forearm, showing the position and
distribution of the nerves.

cervical). Thus when the whole arm is involved
nerve fibers from a very long series of spinal seg-
ments are under irritation. But generally it is the
musculocutaneous and the radial which are the seat
of the trouble. These come from the outer and pos-
terior cord of the plexus and the fifth to the eighth
cervical roots are represented.

Feb.

1907 J

MEDICAL RECORD.

299

Tender points are felt where the musculocutane-
ous nerve emerges, where the lesser internal cu-
taneous and cutaneous branches of the radial emer.e^e.

Upper arm neuralgias are often associated with
an interscapular pain a little lower down than the
spot found in shoulder pains. It seems to be in the
spot supplied by the first and second dorsal (Fig. 8).

Pains in the Forearm and Fingers. — There
are rarely any neuralgic or neuritic patns confined
to the forearm alone. Here we have only the ulnar
pains following the course of the ulnar nerve, and
very characteristic radial pains following the back
of the arm to the fingers, and least frequently me-
dian nerve pains. Sometimes the whole hand is
involved in neuralgic pain, but this is usually hys-
terical. The hand and fingers have perethesias and
local pains due to local disease, but rarely any true
neuralgia.

Heart Pains. — I have been somewhat specially
interested in two groups of disorders, namely, the
pains in the arms from heart disease, and the pains
of brachial neuritis and neuralgia. Of the cardiac
arm pains I shall not say very much, however, be-
cause the subject has been pretty well studied by
others. I have simply macle a few observations
which I would briefly record now. One of these is
that cardiac arm pains are not very prominent fac-
tors in the ordinary heart disease of the hospitals,
and do not appear so dominant among the laboring
classes. Almost always in persons who have a cardiac
disease, and who have pains in the arm, there is a de-
cidedly neurotic element. This means, T presume,
that the nervous system being more sensitive and un-
stable, the irritating impulses from the myocardium
radiate more freely and arouse disturbances in con-
sciousness more easily. These cardiac arm pains,
in my observation, are generally associated with
some precordial pain, not infrequently with some
pain near the scapula, and also pains on the inner
side and middle of the upper arm and middle of
the forearm. They rarely extend into the fingers
(I^'R- 5)- Sometimes there is distinctly a pain in

Fig. 5.— The location of reflex heart pains.

the elbows, and in one patient of mine, with a pro-
nounced cardiac disorder, whenever the heart be-
came a little overstrained, there were pronounced
pains in both elbows. We sometimes note, also,
pain in the right arm instead of the left. I have
made a diagram on which I have plotted out the
places in which pains were felt in a dozen of mv
cases. I am unable to say that there is anything
so distinctly characteristic in the location or char-
acter of the pain that one could bv it alone sav
that it was cardiac, except, perhaps, that there is
generally a feelinsr that the pain comes from the left

side and runs from there into the arm. The cause of
this reflex disturbance is generally attributed to the
fact that the third or lower cardiac ganglion of the
cervical sympathetic sends fibers which communi-
cate with the first dorsal nerve, which nerve sup-
plies the inner side of the arm (Fig. 7).

Fig. 6,— Pam under tlie shoukler. or the inner side of the arm. and
between the scapula:, due to a lesion of the posterior second dorsal
ganglion, with herpes; this is like certain heart pains.

Brachial Neuralgia and Neuritis.— D^/?«tVton and
Frequency. — Neuralgia of the brachial plexus is a
disease characterized by severe pains centering in
the upper arm and usually involving the whole
upper extremity and shoulder; it runs a course of
several months and is due to irritation or inflam-
mation of the trunks of the brachial plexus and its
roots of origin. This irritation does not usually
reach the degree of neuritis, and the disease does not
show the paralysis and atrophy, anesthesia and
vasomotor symptoms of neuritis as a rule. This

Fig. 7. — Showing the relation of the third cervical and first thoracic
ganglion (blended together)iwilh the brachial flexus.

form of neuralgia, excluding the cases of traumatic
neuritis, is now by no means a rare disease. Among
the neuralgias brought to the attention of the neu-
rologist it ranks third, coming after the facial neu-
ralgias and closely following in frequency the
sciaticas. In the past, however, hrachialgia has re-

300

MEDICAL RECORD.

[Feb. 23, 1907

ceived but scant attention from the writers, both
on general medicine and in special text-books. Even
in works devoted especially to the study of neu-
ralgia this characteristic modern affection, as it
seems to me, is not portrayed, as it is seen at least
by physicians and neurologists in this country.

In Bernhardt's comparatively recent article
(Nothnagel's Special I'athology) the subject is
somewhat extensively dealt with; Bernhardt finds
that among 685 cases of neuralgia there were
108 of the brachial type. But the neuralgias seen
in Berlin by this author are apparently those due
largely to trauma and to occupations which lead to
exposure of the arms, such as those of firemen and
washerwomen, etc. His cases are apparently often
forms of traumatic neuritis and do not all belong
to the class which I propose to describe now.

In support of the point just referred to that the
typical brachial neuralgias have increased in fre-
quency in the last two decades, I can only now
bring forward my own statistics and experience.
In 1888 I made a'coUection of reports of 453 cases
of neuralgia and found that among them there
were of brachial neuralgias only eight, or about
two per cent. These figures, to be sure, were very
largely obtained from dispensary and hospital sta-
tistics, but they do not vary very greatly from
other figures from a similar class of material. Thus,
Eulenberg, in his statistics, places brachial neuralgia
fifth in a list of six different types ; Lechnit puts
brachial neuralgia fourth in a list of five types;
Conrads places it fourth in a list of eight types.
In general, writers seem inclined to make brachial
neuralgias rank in frequency after sciatica, th^
trigeminal neuralgias, the intercostal neuralgias, and
the occipital neuralgias.

Looking over the records of my private cases I
find that among 197 cases of neuralgia the differ-
ent forms are in the following order of frequency :

Tic douloureux 44 cases

Sciaticas 40

Brachial neuralgias 41

Other forms . .*. 73 "

These other types include a good many of thf
inner types of trigeminal, occipital, and spinal neu-
ralgias.

There have, of course, always been a great many
arm pains of various types, and these have added to
the apparent statistical superiority of the brachial
neuralgias in the tabulated lists of different types :
but I am particularly insistent upon the point that
it is the typical brachial plexus neuralgia which is a
prominent, dominant, and probably more frequent
clinical disorder now than it used to be.

In mv private history books I find that I have a
list of 7Q cases of arm pains of various types. These
I have classified as follows, and it shows that, leav-
ing aside all symptomatic troubles and all occupa-
tion neuroses and local troubles, there is still a large
percentage of pure brachial neuralgias :

Total cases of arm pains 79

Total brachial neuralgias 4t

Arm pains associated with distinct neuritis. . . 15

Occupation neuroses with dominant arm pains. t6

Hysterical arm pains 4

Palmar, digital, and hand pains due to local or

reflex causes 6

These do not include arm pains due to tumors,

aneurysm, or cardiac disease, or tabes dorsalis.i^

Brachial neuralgia or neuritis is thus by no m'eans
a rare disease. Its frequency, at least in this city,
is undoubted. There is, I am assured by a patient, a

distinctly neurotic face, characterized by certain ex-
pression's of appreciative elation when the word is
mentioned.

I have been struck with the fact that brachial
neuralgia is seen more frequently in women, and in
women of the leisure classes. They have not per-
haps led idle lives, but they have never used their
arms in domestic or maternal work as the woman
in general is obliged to do, and they have generally
been of a nervous organization, i.e. of a well-evolved
type, and have been good livers. So that I have ven-
tured to advance, with some reservations, a theory,
if you will, that the arms of these modern women
are becoming quasi-vestigial, like the appendix, the
jejunum, and the last molar tooth. That they will
always have some use I do not doubt, and will be
sufficient even in the most advanced period of our
civilization for the purposes of feeding and the
actual uses of the toilet and simple coordinative
efforts ; but that they are becoming rather more
weak and of less importance in the economy of
woman seems to be probable.

The arm bones go with the weakening members,
and it has been shown by Ravenel that the cervico-
spinal cord is relatively smaller in women than in
men, though on the whole the spinal cord of women
is relatively larger in proportion to the brain and the
lumbar cord is larger proportionately than that of
man.

The statements of Ravenel are confirmed by
those of Kollicker and Stilling. These authors find,
for example, that the total square area of the motor
roots of the cervical nerves, from the fifth to the
eighth, is about the same in men and w-omen. While
the total area of the posterior roots is one-half as
large in women as in men, the total area of
both roots is about twenty per cent, smaller in
women than in men. This would indicate that the
sensory supply of the arm in w-omen was only one-
half as great as that in men, and it might be sup-
posed that with this inadequate nerve supply, strains
on the arm would call out trouble more quickly. On
the other hand, the area of the last two lumbar and
first two sacral nerves is much larger in women than
in men, for both the anterior and posterior roots.*
Etiology. — Brachial neuralgia occurs oftenest in
persons in middle life, ranging from thirty-five to
fifty. When it occurs in young people it is (like
the other neuralgias) more often of the hysterical
type, or at least associated with that class who are
neurotic and oversensitive. Besides having an
hereditary neurotic history as the underlying ten-
dency, there is almost alwavs a history of severe
emotional strain, loss of friends, sickness in the
family, or worry over complications of domestic
life. Sometimes in addition there is some physical

In mail. . .
In woman

*Proportionate Length of

Cervical Cord. Dorsal. Lumbar.

22.4% 47.1% 30.5%

21.5% 46.6% 31.9%

— R.WEXEL, in "Merkel's Anatomy."
.\rca of Cervical Nenes from

C. V. to e. VIII. Male. Female.

Ventral (anterior) roots 16.38 mm.' 16.02 mm.'

Dorsal (posterior) roots 40.04 mm.' 21.30 mm.'

Total arm 56.42

.■\rea of Lumbosacral Nerv'es from

L. TV. to S. II. Male.

Ventral 14.36

Dorsal 31.04

47-32

Female.
17.46
33-24

45.40 50.70

Thus, woman has only one-half as many sensory nerve
fibers in her arm plexus as man, but has rather more motor
and senson,- fibers in the lumbosacral nerves. But she
rarely has sciatica.

Feb. 23, 1907]

MEDICAL RECORD.

301

injury or some acute sickness. In two cases I have
seen it follow profuse hemorrhages. In gome cases
it is due to inordinate use of the arms in simple
manual work, like embroidery or knitting; but this
seems to me rather unusual. A mild form of
brachial neuralgia occurs as the result of carrying
a heavy skirt, and it is not unlikely that this kind
of work (skirt carrying) and the use of the arms
in dressing the hair brings on neuralgia in a great
many predisposed cases.

In my experience, then, neuralgias are seen
oftener in the better classes than in dispensary or
hospital patients. They occur, according to my ob-
servation, oftener in women than in men in the pro-
portion of about three to one. This is contrary to
most statistics, because, as I believe, these statistics
include many frankly traumatic and surgical cases.
There is often a predisposing neurotic or rheumatic
taint, and sometimes perhaps an autotoxemia. The
brachial neuralgia of tabes dorsalis and organic
disease is not included in this discussion. In fine
the etiology of brachial neuralgia has always one
or more of three factors : Neurotic constitution, ex-
haustion from occupation or trauma, and meta-
bolic (rheumatic) irritation.

Pathology. — Brachial neuritis proper, nontrau-
matic, in which there are objective evidences of
nerve degeneration, is probably only a severer and
more profound type of brachialgia. The common
form, then, of the arm pain is usually designated
as a neuralgia, though there is probably some low
grade of inflammatory process in the sheaths if the
nerves ; and if it is desired to use the term "neu-
ritis,'' I do not know that serious objection could
be made. So far as I am aware, no post-mortem
examinations have been made of the nerves of per-
sons suffering from this condition. If we may infer
concerning it by analogy, from conditions seen in
sciatica, the existence of perineuritic irritation, and
perhaps slight exudate, is probable. It seems to me
that sometimes the inflammation is not so much in
the nerve sheaths as in the muscular and connective
tissues about it, and that there is a myositis as well
as secondary neuritis. I shall assume that in using
the word "brachial neuralgia" I include both the
neuralgias, with no objective symptoms, and the dis-
tinctly neuritic cases, of nonsurgical origin.

The symptoms of brachial neuralgia are some-
what as follows :

The onset is rather sudden, but there may be
severe preliminary aching in the arm for a few
days, and sometimes there are short preliminary
or abortive attacks. Usually, however, the patient
wakes at night or notices in the morning a distinct
and severe pain involving the upper arm and
shoulder, or perhaps the whole arm. The pain
usually is most acute, however, on the inner and
front side of the arm and in the back between
the shoulders. It is very intense and runs down
the forearm and into the fingers, involving some-
times the whole hand, but usually only the first,
second, and third fingers. It is not a darting,
shooting pain, but seems to be one that is general
and diffuse, involving for a time the whole arm
with a pain of paralyzing intensitv. The pains ex-
acerbate, coming on usually at night more severely,
or more in the morning, and always more after
exertion. Movement makes the suflfering worse : but
the arm can be handled gently without much pain.
Some suffering is present nearly all the time, often
robbmg the patient of sleep ; but it may let up for
a tew hours during the dav and then comes back
agam with paroxysms of great intensity lasting
for one or two hours.

Many patients try at first to work off the pain
by exercise, thinking it a form of rheumatism, or
they get a masseur who rubs the arm, and, as a rule,
makes it worse. There are, however, at times,
attacks that are short and abortive. I have kno\vn
some to last three or four days, and in these in-
stances the massage or the doctor get the credit for
a therapeutic triumph entirely undeserved. Usually
the pains progress and continue for two or three
weeks until the trouble is pretty firmly established,
continuing then for two or three months.

\\'hen the pain first comes on there are no
objective changes in the arm. It looks normal and
is simply tender and sore to the touch. Later the
arm becomes a little swollen and the fingers some-
what edematous, and there is slight flabbiness of
the tissues, showing vasomotor change.

In the typical neuralgias there is rarely much
more than this. If it is a genuine neuritis, of
course atrophies and paralyses gradually develop,
but it is not of this type of the trouble that I speak.
In brachial neuralgias proper the changes in the
arm are only slight — the grip of the hand becomes
weak, the elbow jerk is a little exaggerated at first,
muscular irritability is increased and then dimin-
ished, and there is no anesthesia.

Examination shows points of tenderness along
the course of the nerve on the inner side of the
arm at the elbow and over the deltoid. There is
also a point of tenderness between the scapulae
about at the level of the second or third dorsal
vertebra. This is very painful and is characteristic.
Stretching out the arm and drawing upon the
brachial plexus brings out pain, just as it does in
the extension of the hip in sciatica. Later there is
also weakness of response to the elbow jerk, just as
in the tendo Achillis in the later stages of sciatica.
The tender points that one finds in brachial neu-
ralgia are by no means always identical with the
tender points of Valleix. They vary somewhat and
only correspond in a general way to the distribution
of the cutaneous nerves (Fig. 8).

Fig. S. — The pains and painful points of brachialgia.

It will be found, as we watch the neuralgias
from the back of the neck down to the hand, that
pains in these different segments are associated with
painful points along the course of the spine. For
example : In occipital neuralgia there will be a well
marked tender point close up to the base of the
skull over the second or third cer^dcal spines. With
a cervicobrachial neuralgia the point moves down
to near the first or second dorsal. With a brachial
neuralgia the spinal tender point moves to the neigh-
borhood of the third or fourth dorsal. These spinal
tender points are quite characteristic of neuralgias of

302

MEDICAL RECORD.

[Feb. 23, 1907

the upper cer\ical plexus, and the collaterals of the
brachial plexus.

Diagnosis. — In the chronic and less severe types
of arm pain one may be easily misled in diasjnosis.
The first and obvious name given to an arm pain
is "rheumatism." The patient is always treated
first for this.

It is safe to say that arm pains are never purely
rheumatic, unless there is found some objective evi-
dence of nivositis, arthritis, or periarthritis. The
mcsc difficult thins' is to distinguish between real
neuritis of hish grade and neuralgia. Neuritis has
become a popular diagnosis nowadays, and patients
talk very glibly about the term. It seems as a neu-
rological diagnosis, to please the laity, as having a
certain- distinction that doesn't belong to plain rheu-
matism or neuralgia. It is, in fine, in a diagnosis
a la mode. But a neuritis cannot be recognized
except by some objective signs. There must bt
pain and also tenderness along the nerve; there must
be definite areas of hvperesthesia or anesthesia,
muscular weakness, and perhaps atrophv and elec-
trical changes. There must be some of these symp-
tom:- in an inflammatory process that lasts three
to six months.

In about half of my cases of brachial pains no
such objective svmptoms were present. The con-
dition is not one of actual inflammation, but of ex-
haustion, and in the majoritv of cases brachial neu-
ralgia is an exhaustion neurosis with some rheu-
matic or metabolic irritation of the nerves in ad-
dition.

In brachial neuralgia the rheumatic poison is near-
est to being the common irritant, but antirheumatic
medicines rarely affect the process radically. GoiU
does not cause a general arm neuralgia, but ma\
ittack individual nerves, causing special forms of
^'outy neuritis. Neuralgia of the arm, like lum-
bago and other rheumatic symptoms, sometimes pre-
cedes an attack of melancholia.

\Mien we find a herpes along with arm pain we
know that we have an inflammation of the spinal
ganglion and secondarv neuritis and that the process
is due to an infection.

The question arises, therefore, whether some of
the other cases of brachial neuralgia are not due to
infection, attacking the trunks instead of the ganglia
of the nerves. I am inclined to think that the in-
fection theory will sometimes answer. But the trou-
ble is too often the verv evident result of over-
use of arms, of nervous and mental depression,
and its course is not acute, like that of herpes-
neuritis.

TrL-atnicnt. — I have not found treatment of brach-
ial neuralgia of anv avail without rest. This must
be secured by a sling, and, if necessary, by splints.
In a good proportion of cases some relief is gotten
bv the salicvlates. especially aspirin, but thev mu,;t
1 e given in verv large doses, just as for acute rheu-
matism.

Xeitlicr massage nor hot baths shonld be given at
first. But after two or three weeks hot applications
of mud or flannel can be used. The patient must
understand that, as a rule, it takes ten or twelve
trealments to accomplish results.

After a course of salicvlates. fonics can be given.
I do not know anv drug that is of anv special value,
miless it is strvchnine, in massive doses, and of
its utilitv, I am sure, in chronic cases. Some pa-
tients rush of? to Hot Springs at \'irginia or else-
where when thev find their neuritis coming on.
The treatment here is not abortive, however, and
sonietimes not especially helpful in the acute cases.
The trouble is that at the beginning patients need

most of everything rest, and this is not obtained
satisfactorily at our .American bath resorts or by a
trip to Europe.

Arm pains, which once were due to neuritic con-
ditions, sometimes become habit pains ; the patient
has a "constitutional armache," just as some have
constitutional headache. The best and only treat-
ment for these patients is to ignore the trouble ab-
solutelv. When the pains are rather chronic, i.e.
after four to six weeks, massage and electricity do
some good. The patient gets well anyway in three
to six months as a rule.

The disease may recur, but this is rather rare,
and onlv in about ten per cent, of my cases.

It is rarely double, and when so is invariably an
exhaustion neuralgia, rather than a pure neuritis.

THE TREATMENT OF ACUTE DIFFUSE
PERITONITIS.*

Bv RICH.^RD DOUGL.\S. .M.D.

NASHVILLE, TEN'S'.

In presenting my views upon acute diffuse peri-
tonitis. I am merely publicly accepting the con-
clusions that are forced upon us by the combined
work of the bacteriologists and the surgeon. It
will not appear that I have anything new to relate;
no theories to expound ; no ingenious technique to
elaborate. Indeed, I question much if there is
anything in this subject unknown or omitted by the
nniltitude of scribblers w'hp have oppressed the
press.

Some old fellow once said : "To know a thing and
not to express it is all one as if he knew it not."
This scarcely applies to me, for I do not know my
subject, and I feel the irritation of deficiency, and
"one must needs scratch where it itches."

To the subject of acute peritonitis I have directed
the closest studv. Manv years ago I reported to
the Southern Surgical Association in Charleston a
series of eight cases of general peritonitis treated by
operation : six recoveries, two deaths. I received
the applause of the fellows, and believed that I had
mastered the problem which was the awe of all
abdominal surgeons. I was young then and a pro-
fessor, and did not hesitate to draw conclusions and
dogmatically emphasize them. Encouraged by this
success I some years later, in a presidential address
before the same association, again elaborately con-
sidered the subject of peritonitis. Mv paper seemed
to merit the approbation of the fellows, and upon
motion of Dr. Howard Kelly was ordered printed
in iiamjjhlet form for di.'^tribution. I now felt that
I knew it all : that this immense lymph sac with its
phvsiologv and pathogeny was an open book to me.

After this my opportunities for observation be-
came more numerous : my mortalitv list remained
i-onsistentiv high ; T grew older, more conservative
in judgment, surrendered mv professorship and lost
with it that egoism that beclouded mv studies and
endangered my patrons. I recognized that mj- re-
sults were no better than manv. and not so good as
son-'e. I continued to open tense bellies, pus gushed
forth. I measured mv skill and achievements by the
quantitv of pus found : vet mv mortalities came
unexpected and with frightful frequency from an-
other class of cases.

The acutely infected peritoneum became a cham-
ber of horrors to me, and, though my studies were
considered exhaustive by some, they were, ab initio,

*.\n addrc?^ delivered before the Nashville Academy of
Medicine and S.iirgery, January i, 1907.

Feb.

1907

MEDICAL RECORD.

303

faulty. 1 did not even know the nomenclature of
the disease; I spoke of curing general peritonitis
when neither hand nor eye had reached above the
umbilicus. The published reports of my confreres
excited my jealousy and wonderment.

I have not impugned their integrity, yet I am
frank to confess that there is something in the
environment of the operating room that distorts the
vision and exalts to a superlative degree the patho-
logical findings. It is the unconscious yielding of
weak human nature to exaggerate difficulties that
there may be all the greater praise for the achieve-
ment of overcoming them.

Chemical and mechanical peritonitis were in those
days considered possibilities, and every case was
general peritonitis that was not a distinctly localized
abscess. Surgeons were not familiar with or had
not accepted the teaching of Senn and German au-
thorities. Peritoneal sepsis was hinted at, but not
comprehended. Empyema peritonei was incised ;
quarts of pus evacuated, flooding the operating
arena, the surgeon floundering in pus and ignorance,
raised aloft his knife, exclaimed, like Monte Chris-
to, "The world is mine." He had done only scav-
enger work; the battle was waged before he came
upon the field. Upon the first approach of the
enemy, leucocytes were hurried to the scene of
action ; phagocytes occupied the skirmish line, while
the vital fortress was held by the opsonins.

In mv studies of the various gurgical diseases of
the abdomen I still tried to master the unsolved
problem of peritonitis. This labor brought its re-
ward ; my mortality list fell from eighty per cent,
to perhaps sixty per cent. Prognosis before opera-
tion became more guarded, and, what is more to
the point, it was appreciated that the ultimate issue
of the case does not rest upon the manifest reaction
in the peritoneum to infection found at operation ;
indeed, quite the reverse has been true.

I reached the conclusion that peritonitis is not
always the same disease : that many factors, chiefly
bacteriological, determined its onset, course, and
ultimate termination. Manifqstly then, there is
no one treatment for peritonitis ; no method appli-
cable alike to all cases ; no one man's technique that
I am willing blindly to accept ; no teaching so com-
prehensive, so universally applicable that we should
follow it to the rejection of all others.

I can ask no greater boon than that I may enjoy
that discriminating understanding which will guide
me to select and apply that treatment which meets
the special indications. .Such judgment must rest
upon an intimate knowledge of the pathogenesis
of peritonitis, the behavior, habits, and virulence of
all organisms concerned, and upon nature's com-
bative methods ; therefore, it must be clearly under-
stood that the surgeon is nature's auxiliary, and
I hope to show that rude, aggressive, self-assertive-
ness, sometimes called thoroughness or radical sur-
gery, hopelessly overturns nature's defence.

^^ hen the bacteriologist, after his apparently
fruitless but unremitting labor, presents a conclu-
sion following his investigations which does not
run counter to clinical observations, but strengthens
and su.stains them, if we practical workers reject
his findings, we discredit science and confess our-
selves to be mere votaries of the hippocratic school
of medicine which promulgated theoretical dogmas.

We cannot attribute specific action upon the peri-
toneum to special bacteria, but it can be safely
stated that that virulent form of peritonitis in
which there is but little serous and no fibrinous
exudate, is due to the streptococcus infection ; that
in the great majority of ca.ses of spreading peri-
tonitis the colon bacillus is the active germ.

I would overshoot myself if I attempted to enter
into the bacteriology of peritonitis. We all know
that the Streptococcus pyogenes and the Bacillus
pyocyauens and the pneuniococcus produce rapidly
fatal results when inoculated upon the peritoneum.
Their baneful efifect appears to be in the rapid dis-
integration of the leucocytes.

I shall merely touch upon a new field of thought
in connection with the bacteriology of peritonitis,
that of induced immunity or the increased resisting
power of the jieritoneum.

Many experimenters have shown that the resist-
ing power of the peritoneum can be artificially in-
creased, and I quote from Dudgeon and Sargent
what has been done along this line : "Issaeff, in
1894, was the first to show that various sterile solu-
tions previously injected into the peritoneal cavity
of guinea-pigs could render that membrane more
or less refractory to infection with certain patho-
genic organisms. In the following year Melsome
and Cobbett, working with cultures of 'streptococci,'
showed that an immunity could be produced by
successive minute inoculations. Durham obtained
similar results in rabbits from preliminary infection
of sterile fluids. More recently, Salieri and Miyake,
working under Professor von Mikulicz, have con-
firmed these observations and succeeded in pro-
ducing an artificial immunitv in animals by prelim-
inary intraperitoneal injections of sterile saline so-
lution, nucleic acid, and other substances. The
protection thus afforded is, as Durham pointed out,
due in large measure, at any rate, to the appearance
in the peritoneal exudate of certain phagocytic
cells. It is a general, not a specific immunity against
peritoneal infection. Sargent and Dudgeon be-
lieve that this artificial protection has its counter-
part in the natural events of peritonitis. Their
reasoning is supported by systematic examination of
the peritoneum in two hundred and seventy cases
operated upon at St. Thomas' Hospital. London.

The organism that is first to make its appearance
in the peritoneal cavity under abnormal conditions
is the Sfapliylococcus albiis. As a general rule it
is found on the peritoneal surface at a distance from
the focus of greatest disturbance, and it is usually
associated witii a nuniber of phagocytes at the
site of primar\- infection ; the staphylococcus has
been displaced by more active and virulent germs.

The staphylococcus is the germ that is present
in most cases of intestinal obstruction, tumors with
twisted pedicles, and strangulated hernia. If the
obstruction or cause is relieved, this germ does not
produce a fatal peritonitis : it rarely causes suppura-
tion of the parietal wound. The effect that it docs
produce is the advent of a ninnber of phagocvtic
cells.

Now why the stajjlnlococqus appears first upon
the scene, we do imt know; but it provokes a clear
fluid exudate which soon becomes turbid with leu-
cocytes : and. as Sargent significantly remarks:
"The more turbid it is, the more it appears to the
surgeon that it is something to be washed away."

Later in the sta^^e of inflammation the colon bacil-
lus comes upon the scene. It is on the start, so to
speak, which the white staphylococcus had, and the
ability of the individual to respond to the call b\
supphing phagocvtic cells that the prognosis to a
laree extent depends. The proof of this last state-
ment is that in the simultaneous inoculation of
Staphylococcus albus and colon bacillus there is lit-
tle or no protective action exerted ; that is. there is
no phagocytosis and a quickly spreading fatal peri-
tonitis supervenes.

A second important part played by the Staphy-
lococcus albus is that it assists in the formation of

304

MEDICAL RECORD.

[Feb. 23, 1907

adhesions. Cultures taken from coagulated fibri-
nous exudate show the constant presence of this
organism. The agglutination of the intestine by
fibrinous exudate mechanicaily resists spreading
peritoneal infection. The coagulation of exudate
fibrin deposit upon the peritoneum, limits the ab-
sorption of toxic material and at the same time pre-
vents egress of organisms from the intestine. It
has, therefore, a protective function.

If I grasp the idea correctly, it is now established,
chiefly by the work of Dudgeon and Sargent, that
the Stafhylococcus albas and perhaps other micro-
organisms, when inoculated upon the peritoneum
have the effect of causing a copious serous and
fibrinous exudate, and invite an abundant migration
of lymphocytes into the cavity ; and I may add, this
serous exudate contains the opsonins, that element
in the blood plasma which renders the bacteria
available for phagocytosis.

A patient's resistance to an infection then, de-
pends upon the leucocytic reaction consequent upon
the infection and his opsonic index. Another ele-
ment materiallv affecting the prognosis is the extent
of the area over which microorganisms are diffused ;
for, says J. Walter Vaughan, ''given the same or-
ganisms capable of forming the same toxin and the
same amount of -toxin, the severity of the disease
will depend upon the area involved."

Some of you may perhaps be familiar with
Vaughan's culture experiments in large glass tanks.
The inner surface is lined with a coat of agar agar.
Over this is poured a very small amount of bouillon
culture of microorganisms. It is almost incon-
ceivable the abundant harvest coming therefrom.
We know that germs confined in a test tube soon
lose their virulence.

The peritoneum is likened to a Vaughan tank ;
it is a sterile chamber under ordinary conditions,
but when danger threatens in the form of perfora-
tion from appendicitis or other cause, it attempts
to protect itself by the formation of adhesions.
This limits the area wherein germs can grow. The
circumscribed part of the cavity is converted into
a test tube or local abscess, if you please. The mi-
croorganisms lose their virulenfe, and the area of
absorption is limited. These experiments have a
practical value to which I will again refer in the
discussion of irrigation.

My untrained mind does not grasp the technical
conclusions of the bacteriologists further than stated
above, although I have read with great care and
profit the excellent lectures of Dudgeon and Sar-
gent upon the Bacteriolog)^ of Peritonitis. It is
not yet possible to make a bacteriological classifi-
cation of peritonitis. For precision and clearness I
return to the definite subject in hand, acute diffuse
peritonitis, defined as a spreading infection of the
peritoneum which results from perforation of the
appendix or other viscus. The inflammation is
established and progressive without definite lirpita-
tion ; there is evidence of inflammatory exudate, ex-
tensive redness of the peritoneum, and intestinal
paralysis.

Blake further subdivides diffuse peritonitis into
spreading and general. In spreading peritonitis,
parts of the peritoneum can be shown to be free
from infection. By general, or a better term would
be universal peritonitis, we mean that form in which
no part, possibly excepting the lesser sac, is unin-
volved.

To this I might add acute peritoneal sepsis or
the peracute peritonitis of Mikulicz. This is the
fulminating peritonitis which proves fatal from
septic intoxication or from so-called shock before

there is any real peritoneal exudate, but in which
there is more or less intestinal paralysis. Bacteria,
usually streptococci, are fouod in the bowel wall
and in the omentum and in the lymphatics. This
severe form of infection, so frequently fatal in a
few hours, is mentioned merely to eliminate it from
the discussion and to avoid confusion.

Pardon this preliminary wandering and I will at
once descend to the particulars of my subject, "The
Treatment of Acute, Diffuse Peritonitis."

Opium and sulphate of magnesium have had
their day. To discuss them here would be a tedious
recital of medical history.

After Tate came the years of vigorous surgery.
The natural reaction from this was the Ochsner
waiting policy. He states that no matter in what
stage dift"use peritonitis comes into the hands of the
surgeon, if the stomach is washed out and nothing
administered by the mouth, nourishment and fluid
supplied by rectal injections, in the vast majority of
cases the process will become walled off, the acute
symptoms will subside, and the patient can safely
be operated upon at a later date. His treatment is
especially directed to that form of perforative peri-
tonitis following appendicitis.

Ochsner adduces statistics to support his position.
My personal experience wiih this method has been
peculiarly unfortunate. In every instance in which I
have followed it, and I have judiciously selected my
cases, I have lost not only the patient, but the con-
fidence of the attending physician ; and so I emphati-
cally declare I will have nothing more to do with it.
And yet I do not contemn it, for it is a method em-
ployed by some of the most fortunate, successful,
and ablest surgeons. It is especially popular, how-
ever, with the statistic builder ; it is an avenue by
which the not over-conscientious surgeon may es-
cape from a predicament and preserve his record
and leave the internist with the bag to hold to
answer the accusation that the surgeon was called
too late.

I do not charge that this is done, but it appears
to me as a possible expediency ; but the following
argument I knozv is made : "Why should I operate
upon this desperately ill man ? The chances are
against recovery from operation, and if he dies
it will discredit surgery and cause others yet to be
taken ill to decline operation." So it is argued, the
science of surgery is discredited, and humanity in-
directly harmed. This is not the occasion to elab-
orate further my conception of the surgeon's duty.
Suffice it to say that in private work his highest ob-
ligation is to his individual patient, regardless of
how it may react either iipon him, you, or the com-
munity. A public official, say a sanitary officer,
occupies an entirely different relation toward his
patient. If needs be, for the protection of the com-
munity, he would be justified in shooting down a
pestilential individual.

The Ochsner treatment is popular with some
medical men, usually with the class that have a
quondam affection for the old opium treatment or
the more recent calomel and salts line of manage-
ment. In many cases, as is well known, the inflam-
mation will abate for the time, and he will score a
temporary success. The value of the Ochsner
treatment is "that it permits nature to do her best,
and that is all there is in it." It has not maintained
its popularity.

Simon Young, of Valparaiso, Indiana, addressed
this question to twentv-five of the leading surgeons
in the United States : "Do you make it a rule to
operate upon acute diffuse peritonitis?" Seventeen

Feb. 23, 1907]

MEDICAL RECORD.

305

replied yes, seven gave affirmative replies with qual-
ifications, one avoided operation if possible.

You see that it is impossible to deal with the
subject of diffuse peritonitis without referring to
appendicitis, as the peritoneal infection so commonly
originates from appendicitis. "This waiting policy
has been practised in the city hospitals of Boston
with an occasional success, but more frequently
ultimate operation has had to be done under less
favorable circumstances." (Lund.)

At Roosevelt Hospital, in New York, immediate
operation is practised ; and one of its representative
surgeons so expresses himself upon this point : "The
advocates of the L)chsner treatment by rest will con-
cede that the patient will be better of? with the
appendix out if it can be done without operation.
We have simply to weigh the dangers of toxemia
and shock of operation against the danger of con-
tinued infection, both systemic and peritoneal, from
the appendix itself or the escape of its contents."
(Blake.) John B. Murphy, with his unparalleled
success in thirty-eight cases with one death, has
this to say of the Ochsner treatment: "It is the ef-
fort of the unconquered, nine-lived procrastinator."

See what another surgeon says : "The diagnosis
of perforation, if we are on our guard, is easy ;
and, although it may be difficult to say which organ
is affected, this does not make any difference. The
vital consideration is that it has h.appened. and im-
mediate operation must be performed." These are
the words of William J. Mayo, and I offer them as
conclusive evidence against the Ochsner treatment ;
yet I am aware that this surgeon advocates and
practises delay in certain stages of appendicitis,
and I am at a loss to comprehend a rule that applies
to one portion of the abdomen and not to the other.
The limited absorbing capacity of the lower zone
does not give the claimed immunity ; and the infec-
tious matter escaping from the appendix may be as
abundant as from a perforation in other viscera.

In considering the surgical management of acute
dift'use peritonitis, I shall omit many details that
would prove irksome to the surgeons in the audi-
ence, and uninteresting to the medical men, and
enter at once upon the discussion of certain points
that are under dispute hoping that I may bring out
of much confusion some system, some intelligent ap-
plication of the means at our command.

I would eradicate, if possible, from the literature
of this subject, that empiricism which seems to
possess it. Special steps in the technique are ob-
served; special methods are employed, and why?
Because, forsooth, some surgeon has reported a
small series of cases all successful ; therefore, his
method must be good. Let us ask ourselves the
question before accepting the method of treatment,
why is it preferred? What is its foundaticHi ? But
above all, what is the surge.on's capacity and incli-
nation for intelligent observation? I grant you
such inquisitiveness may lead us into embarrass-
ment; yet I contend it is a search after the truth,
and upon this line I will now briefly pursue this
subject.

All patients with tense bellies and that are vomit-
ing, should have gastric lavage before taking the
anesthetic. General anesthesia is preferred to 'local.
If the patient is too ill to take ether, then I hesitate to
operate upon him. The incision should be over the
supposed site of infection and should be free so as
to permit ready access, for the indication is to re-
move, close, or segregate the source of infection.
If there is ereat accumulation of fluid, the force of
intraabdominal pressure will cause it to spurt from

the cavity when the peritoneum is nicked, and we
must avoid extrusion of coils of intestine from the
wound. Although we find free fluid and distended
intestine under our incision, we must assume that
jieritonitis is limited, and employ gauze to coffer-
dam the field of operation. The gauze so packed
about has a three-fold effect ; it prevents prolapse
of the intestines, avoids needless handling of those
viscera, and while in place absorbs what fluid there
may be, preventing its dissemination, soiling clean
areas should we accidentally break up an adhesion.
If no adhesions are found, the gauze rapidly takes
up free fluid from the general cavity. This pro-
tective packing should remain in place until the
local focus of infection is dealt with.

Finding a great quantity of puruleiU matter and
no manifest adhesions, \ye come to the question of
its removal. It has been uppermost in the minds
of surgeons that the first step after opening the
abdomen and removing the source of infection, is
to cleanse the peritoneum of the exudate or other
foreign material.

Until very recently copious irrigation has been the
method of treatment. Now, in this country, follow-
ing the teaching of Murphy, it is held to be a grave
error of technique to wash out the peritoneal cavity.
How often has it been expressed of late that irriga-
tion is wrong" because it disseminates septic matter
throughout the peritoneum. This is not all; just
a word to refreshen ourselves of the facts in bac-
teriology. In all severe cases of perforation peri-
tonitis the colon bacillus or some more virulent germ
is present at the focus of infection, while in remote
portions of the abdomen the Staphylococcus albus
may be the only microorganism found ; indeed, cul-
tures from remote regions may be sterile.

There can be no doubt in these cases that if we
flood the abdomen we carry from the intensely sep-
tic field a watery solution of colon bacillus, and at
the same time we wash out the phagocytes which
are Nature's only soldiers of defence. We practi-
cally make of the general peritoneal cavity a Vaugh-
an tank, and in a short while there is a universal
growth all over the peritoneum of microorganisms,
and sufficient to.xines are eliminated to carry out
patient away.

I hold that experiments of bacteriologists have
demonstrated this fact, and now for the clinical sub-
stantiation of it. Between the years 1899 and 1903,
there were operated upon at St. Thomas' Hospital,
London, 119 cases of appendicitis with diffuse peri-
tonitis ; 100 were treated by washing the peritoneum
with large quantities of sterile water or normal sa-
line solution. Of these 80 died. The remaining 19
were treated locally; of these 10 died, that is, the
immediate neighborhood of the apoendix was gently
sponged out, while the upper part of the peritoneal
cavity was not interfered with. The mortality
then after general lavage is 80 per cent, in this
series, against 52 per cent, \yhen local measures
only were employed. (Dudgeon and Sargent.)

In another series of 25 cases, 19 were treated by
tiiorough washing, the upper part of the peritoneal
cavity being dealt with as thoroughly as the lower ;
of these 18 died. The remaining 6 cases which
were, indeed, the most severe ones, being too ill for
lavage or evisceration, the appendical region alone
was treated by dry sponging. All six of these cases
recovered. (Dudgeon and Sargent.)

Although it will weaken my argument somewhat,
I must utter a warning against attaching too much
consequence to statistics obtained from a small
series of cases, for I observe that in 1900, George

loG

MEDICAL RECORD.

[Feb. 23, 1907

R. Fowler reported 9 successive successful cures
of general peritonitis by flushing, drainage, and
Fowler posture ; however, in 100 cases of septic peri-
tonitis following appendicitis, reported in 1904 by
this surgeon and K. S. {•"owler, the mortality was
67 per cent.

Up to the end of 1905 it was almost the universal
practice of surgeons to irrigate in diffuse peritoniti-s,
and all were not so particular about the selection
of their cases ; indeed, one ];rominent surgeon of
Louisville, Ky., says, "Even in pelvic abscess I
irrigate under the liver and loin." 1 am pleased to
say this is not the common practice. Such good
men as McCosh, Lund, Blake, Wyeth, Eisendraft,
and AlacArthur still used irrigation.

Of 1069 cases of diffuse peritonitis collected from
the clinics of the best surgeons in America and
abroad between the years 1888 and 1904, the mortal-
ity was 65 per cent. From 1900 to the end of 1904,
of 400 cases the mortality was 55 per cent. In per-
foration peritonitis, Mayo admits a mortality of
about 50 per cent.

Knowing these results, and my own record not
being better, I must express amazement at those
men who claim that the mortality of peritonitis
should not be much over 5 per cent. The whole
trouble lies in our conception of what constitutes a
diftuse peritonitis ; however, in answer to my pess-
imism I quote with pleasure from a letter received
December 11, 1906, from Dr. J. B. Murphy: "I
have had, up to date, 38 consecutive cases of
general suppurative peritonitis, which includes all
the cases I have had since February, 1903, and of
these we have had 37 recoveries." With this as-
toundingly successful record of Dr. Murphy's we
have not the right to question any man's report.

It was Murphy's protest against irrigation that
attracted the attention of surgeons within the last
year. We now note he has many followers. With
the exception of Simon J. Young, I find no one of-
fering an explanation for the change of technique.
It may be stated as a positive observation that those
who do not irrigate have a lower mortality rate
than those pursuing the old practice.

Since I disapprove of irrigation for the reason
that it disseminates infection and removes the phag-
ocytic cells, by what method then is the purulent
matter to be removed? Much of the fluid will be
absorbed by the gauze packing placed about the field
of initial infection. Such fluid as comes within easv
reach should be taken up with gauze pads, gently
pressing the pads into the puddles of pus. The
forcible thrusting of gauze sponges between intesti-
nal coils into peritoneal recesses is especially con-
demned.

Some years ago Finney advocated wiping away
the dirty fibrinous deposits wnth gauze. Consider
for a moment tlrat peritonitis is an inflammation
of the cellular structure below the endothelium, and
when this layer of shingles, as some one has aptly
called the endothelium, is removed with the cling-
ning fibrin, the blood-vessels and lymph channels
are opened for direct absorption. If this is true,
surely Finney's practice is faulty technique ; and if I
mistake not, he admits it.

Placques of fibrin on the intestines should be
left undisturbed. Nature is capable of making
her own toilet of the peritoneum with infinitely
more gentleness, thoroughness, and safety than the
surgeon. The reason for this, I think, I have clearly
set forth.

Notwithstanding the attitude of the question
now, there are conditions under which I would ir-

rigate. When quantities of foreign matter are dis-
seminated throughout the peritoneal cavity, I know
of no way to so gently and effectually remove it
as by irri'i^ation, especially if we employ a Cham-
berlin or Blake's irrigator, introduced tlirough the
incision in the epigastric region and irrigate from
above.

Evisceration produces greater shock and is fol-
lowed by post-operative tympany. When the in-
testines are extruded from the abdomen the mere
handling of them increases the congestion ; and if
they are not already tensely full of gas, they quickly
become so, so we encounter many difficulties in
replacing the intestines. W hen evisceration is nec-
essary, it is one of the ccuiditions in which I think
enterostomy and emptying of the intestines through
a Paul tube is quite the proper thing. As a rule,
enterostomy is not a desirable procedure except in
])ost-operative peritonitis where paralytic ileus is a
conspicuous feature and intestinal toxemia as much
as peritoneal sepsis is contributing to the patient's
intoxication.

In considering the subject of drainage, there are
one or two points that bacteriology has worked out.
In peritonitides, due to the colon bacillus, strepto-
coccus, or any of the more virulent germs, infec-
tion of the parietal wound is almost sure-to occur;
but much less likely to do so if the wound is drained
down from, but not below, the peritoneum.

Of course we can only determine the nature of
the infection by the severity of the symptoms;
therefore in the milder cases of diffuse peritonitis
I would not drain at all. The drainage of the gen-
eral peritoneal cavity is physiologically impossible ;
therefore, "when all peritoneal surfaces look alike,
it is a very good rule not to attempt drainage."

The discharge from the drain is largely due to
the irritation of its presence. W'e have three pur-
poses in introducing drainage: first, it is supposed
to control hemorrhage; second, we use large gauze
drains after the method of Mikulicz for the pur-
pose of segregating a septic field ; and, third, with
the idea of forming a path of least resistance out
of the body. The latter is by far the most fre-
quently attained result, whether desired or not.

W'hen drainage is employed the tube or cigarette
is brought out through a stab and in this way we
avoid infection of the operative wound. Drainage
has some harmful effects upon the prognosis ; natu-
rally you would say only severe cases are drained ;
but this is not the explanation.

In twenty-nine cases of diffuse peritonitis from
appendicitis, drainage was employed in seventeen
cases : that is, drainage down to the peritoneum
only. Of these only one patient died, whereas in
twelve instances where there was deep drainage
there were five deaths. Another series of twenty-
si.x cases that were deeply drained, fourteen deaths ;
twenty-five superficially drained, five deaths. These
facts were taken from Blake of Roosevelt Hospital
and they are significant.

The objections to employing drainage is that
it does not drain : that in a short time we have a
sinus leading into the peritoneal cavity. Of course
drainage increases the tendency to intestinal ob-
struction and to hernia. If it is possible for a
diffuse peritoneal suppuration to subside under the
Ochsner treatment, then that forever and a day
puts an end to anv further debate concerning any
propriety of drainage. Murphy employs deep drain-
age.

The assumption that free peritoneal fluid ahvays
gravitates to the pelvis has more than once led us

Feb. 2T^. 1907]

MEDICAL RECORD.

307

astrav. It was formerly thought that o-enital tuber-
culosis was due to the escape of the tubercular
bacilli throug'h the visceral peritoneum settling by
gravitv in the pelvis, there infecting the uterine
appendages. JMurphy's experiments seemed to con-
firm this, hence he holds to it as a part of his tech-
nique in the management of peritonitis. This idea
induced Flower to place patients in the sitting pos-
ture. Before him, however, Lennander had sought
to secure gravitation to tlie lumbar region. The
line of infection is by no means always in the direc-
tion of gravity ; furthermore, we can sav, upon the
authority of Sir Frederic Treves, that the tendency
of fluid is not to gravitate toward the pelvis. I was
recently impressed with this fact when operating
upon a case of gastric jierforation some sixteen
hours after the accident. After washing out the
abdomen, as T imagined, thoroughly, the irrigat-
ing fluid escaping through a large tube placed just
above the pubis, I believed the cavity comparatively
clean, when, as a last touch in the toilet, I raised
the stomach up. From under it and the region of
the spleen there gushed fvrth a quantity of food
and inflammatory exudate. This fluid had remained
in the upper compartment at least sixteen hours ;
of course had the patient not been operated upon
the agglutination of the intestines would have served
to still further imprison it until the adhesion melted
down under the influence of advancing infection.

It is my observation that Fowler's position does
not snecially facilitate drainage. The theory that
free peritoneal fluid gravitates is held by men of
great authority. Kuster, confident in the belief of
gravity, turns his patients upon their belly, while
Fowler sets them on their butt — "so there vou are"
(Mr. Dooley).

It is amusing to see how unthinking men haye
advocated the Fowler position. We are even led to
believe that recoveries are due to it alone : and
while I think, as above stated, that it has very little
effect upon drainage, it is nevertheless the most
natural, most comfortable, and most desirable pos-
ture after abdominal section. In it the patient is
able to relax himself; the viscera fall auav from
the diaphragm, and deep respiratory excursions are
permitted. The ])atient can move his arms freely,
a thing very essential for the comfort of one that
has been laparotomized ; indeed, I think it cruel
to put a patient to bed with the hands confined
under the cover. All patients that are subjected to
abdominal section should wear a short outing jacket
with large loose sleeves, so that they may, without
exposure, place their hands above their heads, the
favorite posture.

When the focus of infection is removed, the in-
traperitoneal tension taken away by the escape of
the exudate, and drain, if used, put in place, the
operative wound is closed; the patient, if very ill.
should receive a hypodermoclvsis of ph\siological
saline solution from 500 to 1000 c.c, properly
dressed, and returned to bed and placed in sitting
posture well supported.

Now is the time for the proper observance of
those principles laid down by Ochsner. Murphy
prefers continuous rectal instillation of warm saline
solution to intermittent enemata. Many surgeons
give their patients water freelv by the mouth. I
find it best to withhold all water for twenty-four
hours.

If the patient is extremely restless the first twelve
hours. I do not hesitate to administer morphine,
grain 1-8 or 1-16. to be repeated in two hours if
neces.sarv. .Should vomiting be distressing, I per-

mit the patient to drink freely of hot soda water.
When this is ejected the stomach is quiet. If, how-
ever, vomiting persists or .--hould recur with annoy-
ing frecpiency at any time during convalescence, I
wash the stomach out. .Another indication for gas-
tric lavage is distention of the stomach, as shown
by epigastric fullness, frequent belching, or hic-
cough.

Morphine is not repented unless the patient is
in such condition that there is no objection to its
administration.

All drains are removed in forty-eight hours.
There is no great hurry aiiout purgatives or stimu-
lating enemata. When the Murphv method is em-
ployed, patients pass flatus freely, usually within
the first eighteen hours. Vet it is my custom about
this time to administer two grains of calomel. The
saline enemata invite an casv bowel action. Alore
drastic methods are not required and arc of ques-
tionable utility.

If a stimulating enema is used, it should be
administered with the patient on the left side and
the clysis given high into the colon.

Should the patient show reaction from sepsis,
hut develop great tympany, with vomiting and fast
iiulse with absolutely no bowel action, that con-
dition we call paralytic ileus. Then an enteros-
tomy with the aid of Paul's tubes should be done.
This can be accomplished w ith cocaine anesthesia.

When the bacteriologists can produce a serum
antitoxic to the colon bacillus, then much may be
hoped for in the management of certain desperate
inoperable cases of difi^use peritonitis. Perhaps it
is not visionary to predict that the magician of the
laboratory mav entirely displace the surgeon.

Now, gentlemen, I have told mv tale. The paper
is incomplete in many details and original in none.
The giants of our profession have been at woik
in this field ; a dwarf upon their shoulders may see
farther than they. If one's name is not men-
tioned. I question if he has the right to cry "stop,
thief " for he before me was a pilferer.

The grouping, method, and wandering way are
my own ; these no man will lav claim to. therefore
none have I offended. T respect every man's opin-
ion and concede his ri<:dit in this unsettled state
of the case to follow his own method. I will not
decry them if thev haye a rational basis ; hut for
Cud's sake let him think for himself and be no
n^an's flunkev.

KOCH'S I'AIi'T.Sinx (^)F P.XCILLI IX THE

DIAGXUSIS ol' IXCHMEXT THORACIC

TUBERCULOSIS.

Bv WILLI.^M MEYER. M.D.,

WEST HOBOKEX, N', J.

Mv endeavor in this article is the demonstration of
the possibilit\- of a diagnosis of early tuberculosis
by means of Koch's new tuberculin (emulsion)
before we can arrive at a positive diagnosis by any
other means. I therefore choose 28 cases of in-
cipient tuberculosis in private practice. These cases
were collected during the }ears of 1905 and igo6.
Case I. — Mr. S., 36 years of age, 6 feet high,
weighing 186 pounds when he called first. He had
been ailing for about one )ear. He complained of
a sense of constriction in the throat which forced
him to make efforts at coughing and clearing his
throat, while actually there was no expectoration
of any amount present. He consulted two throat
specialists, one uf wlmni treated lii-u fi ir catarrh

3o8

MEDICAL RECORD.

[Feb. 23, 1907

and cauterized his throat by the electric cautery for
about six months, once a week. The trouble did
not improve and the patient went to another special-
ist, who treated him for chronic pharyngitis for
four months ; but also in vain. The patient called to
see me in December, 1905. History: Father and
mother living; neither has ever been seriously ill;
grandfather and grandmotlier died both at an ad-
vanced age, a1)ove 70. He never had any disease,
except measles, when a child. He is married and
has one child, a boy, w ho is healthy. His wife was
treated for tuberculosis four years ago, but is now
well. I examined her and found no evidence of dis-
ease. He indulges in drink frequently. His pres-
ent ailment began in January, 1905, after, what he
called, a spree. He never had pains in the chest;
no night sweats ; no loss of weight. The only symp-
tom was the constriction in the throat, just behind
the upper sternal edge. I made the patient undress
to the skin. Inspection revealed nothing of note ;
w-as well nourished, and good developed chest; ex-
pansion was perfect over both apices. Palpation re-
vealed nothing of note. The percussion resonance
was slightly impaired above the left clavicle an-
teriorly and a little less posteriorly. A few crack-
ling rales at the end of a full expiration were audi-
ble, while normal expiration did not unveil this fact.

The voice was slightly hoarse. Heart normal.
The glands of the body showed no enlargement.
Temperature was normal, it having been taken three
times per day for several days before and after
exercise. Pulse 78. Urine normal. Blood normal.
Sputum could not be obtained. I took a cotton
wrapped probe, passed same down the throat, and
swept all parts that could be reached a luunber of
times ; examined the secretion, but could find no
bacilli. Throat treatment was of no benefit to him
in the past and the patient did not wish any more
of it. The patient consented after a few days to the
injection of tuberculin (emulsion).

I made the first injection on January 9, 1906,
at 8 P.M., the amount injected being 0.0025 mgr. in
a solution of sodium chloride and carbolic acid.
The temperature was taken at 8 a.m. on the follow-
ing day and again at noon and at 4 p.m. No re-
action. Three days later I made the second injec-
tion, consisting of 0.008 mgr. The next morning at
6 o'clock the patient sent for me, complaining of
pains in the shoulders and an increased cough : the
temjierature showed 101° F. at that time. The tem-
perature took a typhoid course for three days, vary-
ing from 99.5° F. .-^.M. to 102° F. p.m. On the
fourth day all symptoms were gone. The patient
was sent to North Carolina, where he was examined
and sent home as nontuberculous. He began to
work again and continued so until March, when
he caught a severe cold. The sputum now could be
obtained and was examined. Bacilli were found
by the Board of Health and myself. The patient
was sent to Saranac Lake, where he stayed four
months and returned home, his throat being well.

C.^SE n. — Miss C, silk worker, twenty -two years
of age. Family history negative. Contracted a lo-
bar pneumonia in September, 1905, from which she
never fully recovered. She was examined bv two
physicians, who pronounced the case pleurisy. I
saw the patient first in January, 1906. Examina-
tion revealed a crackling sound above the right
clavicle. Beyond this there was nothing to indi-
cate any trouble. She coughed and had alwavs
some sputum in the morning, which was examined
eight times : but the result was alwavs negative.
Tuberculin (■0.002s mgr.) at 8 p.m. Reaction oc-

curred at 2 P.M. the ne.xt day, which disappeared in
twenty-four hours. The patient went to Liberty
tirst, then to Denver, Colo., where she is working at
present.

Case HL — Mr. G. R., upholsterer, aged thirty-six,
born in New York. Both parents alive. Mother
had a cough for past fourteen years; father
healthy. Drinks liquor to excess. Was never sick
imtil August, 1905, when a tight feeling of the
chest troubled him. He took cough medicines;
found some relief, and went about his work as
usual. In February, 1906, he consulted me regard-
ing a hacking cough. Examination revealed a
slight depression above the left clavicle. No pain
on that side, but he had pain on the right side in
the clavicular region. Sputum was scant; present
only in the morning. Same was examined four
times; no bacilli present. Koch's emulsion was in-
jected and the reaction took place thirty-two hours
later. Severe pains all over the body and tempera-
ture of 102°, which remained for one day and a
half. Sputum was again examined by the Board of
Health on February 8, four days after the injection,
when bacilli were found to be present. Patient was
lost sight of.

Case IV. — G. B., grocer's clerk, age eighteen.
Father died suddenly. Mother died of pneumonia.
Patient was always well, until three months ago.
Since that time he has had a tickling in the throat;
a morning cough with very little expectorate now
and then ; no blood. Had never night sweats. No
diarrhea. I saw him on March 15, 1906. He had
lost fifteen pounds during the past year. His chest
was well formed, large, and symmetrical. Over the
right apex posteriorly the percussion note was
slightly less resonant and higher in pitch than on
the left side. The breath sounds were rough over
the same area, but not continually so ; there was no
tubular breathing present. On each inspiration a
light click was audible over the ape.x of the left side
anteriorly, the resonance was not impaired, rales
were absent.

The temperature was normal, pulse 80, respira-
tions 18. The cardiac second sound was a little
accentuated everywhere, otherwise the heart was
normal. There was a tender spot on pressure over
the pylorus, some rigidity, and a slight amount of
pain constantly. His breath was garlick-like, a
symptom upon w^hich I place some importance in
cases of tuberculosis. The rest of the examination
revealed nothing. The hemoglobin was 56 per cent. ;
urine normal. I examined him five times in two
weeks but found no change, excepting on two occa-
sions a few fine crepitant rales over the left apex
anteriorly. The sputum contained no bacilli, typical
or atypical, in seven examinations. Diplococci and
streptococci were found the first time. I used new
tuberculin, initial dose 0.0025 mgr. Three days later
0.005 rngr., and four days later 0.012 mgr. Eighteen
hours later the reaction set in, lasting twenty-four to
thirty-six hours. Patient went to France, exact place
not known.

Case V. — A. .\., an Italian, aged thirty-five years,
father had heart disease and the patient suflFered
from mitral insufficiency, with good compensation.
He developed a cough three months ago. had a
frothy expectoration, no bacilli. No physical symp-
toms, but complained of pain, stabbing in character,
underneath the right clavicle. Tuberculin was in-
jected four times, but no reaction took place. This
was on March 26, 1906. Treatment: Ichtalbin,
heroine, and guaiacol carbonate. Patient gained
eight pounds in five weeks and felt better. He re-

Feb. 23, 1907]

MEDICAL RECORD.

309

turned to me in July, with the same complaints, had
also lost six pounds. Examinations, tliree in num-
ber, revealed nothing. Tuberculin was used again,
dose 0.008 mgr., reaction taking place twenty-four
hours later. On July 29 the sputum was examined
again, and a few atypical bacilli were found. The
tuberculin was continued in addition to the previous
treatment, open air and rest with light exercise were
instituted. The dose of tuberculin is 0.008 mgr.,
every three weeks, reaction very slight and at times
none. The patient, being poor, is now working in a
silk-mill, has gained fourteen pounds, and keeps up
the treatment as far as possible, i.e. open windows at
night, liberal diet, and hygienic rules. He still takes
the tuberculin ; he claims it benefits him greatly.

Cases VL, VIII. , XL, XXL, and XXII. are some-
what similar and need no individual description.
Ages: thirty-two, eighteen, twenty-four, twenty-one,
twenty-nine, all working people. Cases VIII. and
XXI. were in women. Two had several attacks of
tonsillitis ; one had occasional night-sweats ; in three
the hands were constantly cold and bluish. Physical
symptoms slight or absent. Sputum, blood, and
urine negative. No heart lesions. Family history
negative as to lung trouble. All complained of a dry
cough. The chest developments were fair. No.
VIII. had slight depressions under both clavicles
and a systolic murmur over aortic and pulmonary
areas (cartilages). Tuberculin was used in all of
them. All reacted with one or three injections. One
has died since with acute nephritis. Two are attend-
ing to their work at present. One has disappeared,
whereabouts not known.

Case VII. — F. S., age twenty-eight, electrician.
Family history negative. Saw me first in December,

1905. Sputum negative, blood normal, heart nor-
mal. Examination revealed a small depression above
right clavicle, no other signs. Tuberculin was used
and reaction set in fifteen hours later. Patient
went to Dr. Hessner, Davos Platz, who confirmed
my diagnosis by tuberculin test.

Case IX. — Swiss, aged twenty-eight years, em-
broiderer. He called on me the first time in June,

1906, had a temperature of 102° and a few rales be-
low the right clavicle anteriorly and posteriorly.
Sputum was negative, urine normal, tonsils highlv
inflamed and enlarged. Tonsils were later on re-
moved. Patient had always been well until December
last, when he caught a cold and had suiifered ever
since from pains in his chest. Lost five pounds ;
coughs only in the morning. Chest is well devel-
oped. Breathing is at times wavy. Tuberculin was
used four times with slight reactions the first and
last time. He went to Dr. Jacobi (sanatorium),
Arosa, Switzerland.

Case X. — ]\Irs. A. L., age thirty-one, married,
three children. No family history. Complained of pain
in the epigastrium and indigestion, for which she
consulted me. Had had occasional night-sweats. No
temperature, no loss of weight. Hands clammy and
cold. Voice was whispering. Pectoriloquy was
present on one side. The percussion note was
slightly impaired over right apex. The rest of the
examination was negative. A little sputum was ob-
tained but contained no bacilli, though it did contain
a little elastic tissue. Tuberculin was injected and a
reaction took place two days later. She was advised
to go to Saranac Lake, from where I received a let-
ter from her, but mv answer failed to reach her,
and I lost sight of the case.

Case XII. — Miss L., aged twenty-eight years, a
nurse. One brother died of phthisis, one sister is
now in California to be cured of lung trouble. She

feels tired and sleepy all the time, poor appetite, has
lost some in weight. Has now a sore throat, coughs
occasionally, never had night-sweats, no symptoms
indicating tuberculosis.

She is anemic. Percussion normal, urine normal.
On one occasion I thought I heard a fine crackling
sound in the right apex, but failed to find it later.
There is a friction sound in the right axilla high up.
Dr. Russel of New York examined this case, but he
did not state the diagnosis : he put the patient on his
emulsions, but the patient vomited the same every
time. New tuberculin was injected and a reaction
took place within twenty-four hours. She is now
taking the outdoor treatment in North Carolina.

C.-\SEs XIII. , X\'., XVI., and XXX. show similar
traits and will be described collectively. All the pa-
tients are silk workers, ages ranging from nineteen
to thirty-four, two men and two women. All had
lung troubles in their families, pneumonia, lung ab-
scess, and one tuberculosis. All complained, when I
saw them first, of fatigue, soreness in the chest, and
an occasional cough. Physical symptoms were : Ane-
mia, poorly nourished, slight depressions above
clavicles, chest asymmetrical. Percussion note
showed slight differences over the apices more or
less in all. Breathing jerky and the expiratory
sounds prolonged. Sputum negative, no night-
sweats. Three" of these reacted to tuberculin. One
was killed the dav after the injection by an accident ; ■
two of these cases are now under the care of Dr.
Janssen, Arosa, who verified my diagnosis ; one of
the four was lost sight of.

Case XIV. — Miss B. v. S., eighteen years old.
Family history : Parents both living. She had never
been ill until July last, when a diarrhea left her ever
since in a debilitated condition with an occasional
cough. I saw her in October, when I made an ex-
amination which brought out nothing to indicate
tuberculosis. Blood was deficient in hemoglobin. I
injected tuberculin four times but gained no reaction.
Still her cough continues up to date, November,
1906, and the case is suspicious.

Cases XVII. , XIX., and XXVIII. have the gen-
eral traits in common, chest poorly developed, shal-
low breathers, pain and tenderness in the epigastrium,
second pulmonary sound accentuated. Cough last-
ing from three months to six weeks, very little spu-
tum, containing no bacilli, urine normal. Two of
these patients were treated for neurasthenia. All
reacted on first injection of tuberculin. One of these
patients is now in San Remo, one in Charlotteville,
and one at Liberty.

Cases XXIII. and XXV. also show similarities;
both had a cough for a few months which did not
vield to ordinary treattnent. I saw them first in
September, 1906. Family history negative. One
has mitral stenosis. Both well developed, one had
interference of percussion note on right side above
clavicle, the other some crackling sounds over the
left apex above the clavicle. Sputum was abundant
and was examined six times for each : in one case
atypical bacilli were found at first examination, but
none since. Both reacted severely to the tuberculin.
One is now in Davos Platz, the other in some Ger-
man sanatorium and is being treated by tuberculin.

Case XVTIL— Mrs. St.! twenty-eight years old,
German by birth, eight years in America: has five
children; no uterine lesion, heart normal. Disea.se
began four years ago ; dr\' cough, which was diag-
nosed by a physician as pharyngitis ; another one
treated lier for kidney trouble, and a third one for in-
digestion, cancer, etc. I saw the patient first in De-
cember, igov Examined her and found no lung

^lO

MEDICAL RECORD.

[Feb. 23, 1907

symptoms, but a sHghl cougb all the time, hacking in
character, very little spntuin which showed no bacilli,
but a few streptococci. Urine negative, blood neg-
ative, slight!}' anemic, no elevation of temperature;
did her daily housework, weight 96 pounds, had lost
considerable weight since she began treatment first.
Appetite fair, sleep restless, dreams at night ; she
is melancholic at times, tired most of the time,
looks pale, ha-, no tremors, no particular pain, is
nervous; her sclcrotics are a whitish blue, breath
garlicky, nails decidedlv curved. Xo edema, pulse
90 after light exercise. I advised sanatorium treat-
ment, but the patient refused. Then I treated her
as best I could at home. Open windows, good hy-
giene, liberal diet, sitting out of doors about eight
hours per da}', etc. In Januar\-. i()o6. her condition
was about the same. Another thorough examination
proved negative. Sputum again examined by the
Board of Health, but also negative ; the sputum was
examined in all nine times, but always negative.
Her bowels were constipated and she complained of
neuralgic pains below the scapulas and under the
right clavicle. Breathing was of a wavv character
over right apex, no rales, there was a murmur in the
right axillary region (friction like, pleuritic?). In
March a nurse was engaged to enable her to attend
better to her condition, as patient was neglectful. On
March 6, 1906, I injected Koch"s emulsion 0.0025
mgr., no reaction. On March 8 I injected her the
second time, 0.005 mgr., no reaction. On March 13
the third time, o.oi mgr., no reaction. On Alarch 16
and 18 again, with no reaction. Lastly, on Alarch
24. 0.005 nigr. ; reaction was severe after thirteen
hours, pains in all joints, locally small erythema.
Fever at 10 .a.m. On March 25. 104° F. (all injec-
tions were made at 8 p.m.) ; this fever increased to
106° F. at 2 P.M. the same day. It showed a typhoid
tvpe. i.e. a morning remission and evening exacerba-
tion. On March 30 she was free from fever. On
March 31 she complained of severe pain in the ab-
domen, increased cough, abdomen distended decid-
edly tympanitic. At night she became unconscious,
bowels constipated, urine deep colored, sputum ex-
amined and bacilli were found, .'^he was sent to
Christ Hospital, Jersey City. Dr. Dickinson exam-
ined her, but found no lung svmptoms, except as
found by me; he advised operation for abdominal
relief and found a great amount of ill-smelling fluiti
which was tuberculous. Tiie patient died a few-
weeks later of tuberculous peritonitis.

C.\SES XXIV. and XX\ai.— Husband and wife
Saw me first on September 21, 1906; both had
severe colds, as they termed it, for about three
months. Both were examined. Husband liad fine
lales over right apex, above the clavicle, and insuf-
ficient extension of chest in that region; the re.st of
the examination was negative. Wife had mucous
rales in the bronchioles of the right apex and right
base deep down : pain in the left apex and shoulder
And a httle blood-streaked sputum : no fever, the
temperature having been taken daily for one week,
twice a day, before and after exercise. Sputum nega
tive ; six examinations each. The husband reacted
on the injection of tuberculin: his wife did not:
the latter received five injections at intervals of
one week, the husband received two injections. Both
are Germans, and I made them aware of the serious-
ness of the disease. The\- decided to po to the old
country. I recommended them to Dr. Fraenkel, and
I expect to hear from him in the near future.

C.XSE XXVI. — This patient, male, twenty-two
years old. claimed he had tuberculosis at one time.
a physician in Brooklvn having made the diagnosis ;

he prescribed a cough medicine, and patient got well.
His s]nitum v\as not examined at that time. The
former ph}sician had made an examination without
removing the patient's clothing. I found no symp-
toms whatever, except a harsh voice (hoarse). Spu-
tum showed no bacilli in eight examinations. Three
injections of tuberculin brought on a mild reaction;
the patient is treated at home and receives regular
injections at definite intervals.

A request of Dr. Camac, New Ynrb, induces me
to publish these cases ; at the same time I thank Dr.
Brown, of Saranac Lake, most sincerely for looking
over my papers and for his suggestions.

In order to present a short view of the results
obtained I have attached two tables at the end of the
article which are self-explanatory. Table I con-
tains in the first column the number of case, next
the sex, then the age, amount of bacillary emulsion
used, number of injections made, and lastly, the re-
action.

Table No. II contains the number of case, char-
acter of reaction, sputum before and after injection.
Wherever two numbers appear under "after" it
means that the first number was soutiim. which con-
tained bacilli, while the second set indicates that no
bacilli were found, i.e. after some treatment. Then
follows the column of the history of the case, and
l;i^tl\'. the occupation of the pat'ent.

TABLE ].

No

Amount of

No. of

of

SeN

Age

Bac. EmuJ.

Injec- !

Reaciion

Case

36

Used

a— 0.0025 rr.i^r .'

tions
2

I

tiale. - . .

zo hours later.

b — 0.008

4

J

emale

22

a — 0.0025

I

18 hours later.

3

male . . -

36

a — 0.0025

I

3 2hours!ater.

4

18

a — 0.0025
b — 0.005
c — 0 .012

3

18 hours later.

5

.«

a — 0.0025
b — 0.005
c — 0 .012
d — 0024
e — 3 mos. later.
0:008 mer..

5

24 hours after last.

6

32

a — 0.0025
b — 0.012

2

S hours later.

7

;8

a — 0.0025

b- ? "

2

15 hours after first in-
jection. The second
injection was made in
Davos Platz. '

8

female

18

a — 0.0025
b — 0.005
c — 0.012

3

slightly after ad and
more after last (about
8 hours).

0

male

28

a — 0.0025
b — 0.005
c — 0.012
d — 0.024

4

slight, 12 hours aftei
ist and'after last.

10

female.. ,

31

a — 0.0025

I

48 hours later.

1 1

male

24

a — 0.0025 "

I

24 hours later.severcly.

12

female. .

28

a — 0.0025

I

24 hours later.

13

19

a — 0.0025
b — 0.008

2

I S hours later.

14

18

a — 0.0025
b — 0 .00 5
c — 0.008
d — 0.012 "

4

no reaction.

15

26

a — 0.0025

I

was killed "24 hour*
later by accident.

16

ma'o.

3>

a — 0.0025

b — 0 .012 "

c — 0.05

3

18 hours later.

17

female -

22

a — 0.0025

I

24 hours later.

18

28

a — 0.0025
b — 0.005
c — 0.02
d — 0.02
e — 0.02
f — 0 .005

6

13 hours after.severely.

to

30

a — 0.0025

I

18 hours later.

20

male.

34

a — 0.0025
b — 0.005
c — 0.012

J

JO hours later.

21

female.. .

21

a — 0.0025
b — 0.005
c — 0.012

3

50 hours later.

22

male.

29

a — 0.0025
b — 0.005

2

S hours later.

23

1 26

a — 0.0025

I

■ 18 hours later, severe.

24

;female.. . .

1 34

1

a — 0.0025
b — 0.00^

c — 0.008 " ,

d — 0.012

5

no reaction.

1

25

male

-8

a — 0 0025

I

24 hours later, severe.

26

j ■'

-325

3

16 hours later, mrld.

27

"

J> ^

J I 2 -"
1 a— 0 0025
1 b — 0.005

2

12 hours later.

2S

24 ] a — 0.002s

I

,10 hours later.

Feb. 21, 1907]

MEDICAL RECORD.

311

TABLE II.

Dura- Character

Sputum

ll.

tion of of

History

Occupat'n

React.
3 days

Reaction

Before

Aftei

In .*

I

Temp. 101®-

neg. I

pos. 1

neg. J

wife tub?..

bookkeep'i

;io2°F. Typ'd

in char.; p'ns

in j'ntssev're.

3

36 hrs.. Temp. 102°:
malaise

■• 8

2

?

weaver

3; 36 hrs. . Severe pains

4

I

father died

Upholster'i

1 all over body:

sud'n; mo'r

temp. 102°. . .

chr'c c'ugh.

4, 36 hrs .

p'ns in chest;
temp. 10 1**-

dip. &

clerk

ro2°

strept.

si ?

o'nsin sh'lder

Neg. 4

I

father's ht.

weaver

joints; temp.

dis.; died.

oo°-ioi°

6j4days..

severe pains
and temp. . . .

■' 6

?

MiJlworker

i 12 hrs. . las't'de; pains

I

neg

Electrician

in left clav'le:

temp. 103 ■ ■ .

8 .2 days..

las't'de' vag'e
p'ns, drowsy;
temp. 99i°-
102°

4

Pos.'i

?

Millworker

0 3-4 hrs.

tired; temp.

.S

2

?

Embroid

twice. . .

lOI*

erer

10 2-3 days

1

hd'che. b'k-
ache; temp.

■' 8

neg

House-
work

" 8 hrs...

i

1

aevereetab'ng
pains under
scap's temp-
ioi°-io3°. . . -

■■ 8

neg

Millwork

»2| J days..

unable to be

4

1

tub. .'

nurse

ab't; very fa-

tig'd; temp.

lOO°-\02°. . . .

•3

5 days. .

severe p'ns in
all joints: s'l'n

6

" 2

father pul.
abscess

weaver

grdsof?g'ns&

neck; temp

I00''-I03°. . .

14 nr* r^iant

8

neg

no work

15

was k'ld
shortly

mother
died of

silk-

worker

after in

pneumonia

iection..

Ifi

0 hrs. . .

p'ns & temp

■■ 8

" ^ !

tub

silkworkei

»7

2i days

tired & dr'sy,

■' 5

I neg. li ?

i"

temp. 59°-

lOl'

iS

8 days..

typ'd char of
temp.; pains
all over, more
in streptoc,
chest & abd'n

" 12

2

neg

house-
work

19

4-5 hrs

tired; temp

I01°-I02°

4

" 1

7

?

teacher

ao

12 hrs. .

pains and

fever

Q

I

I

mother
died of

silk-
weaver

pneumonia

ai

a days..

great fatigue
dull aches.
temp 09°-
102° F

" 6

" 2

2

?

f

g hrs. .

stab'ng pains
in shoulder.

S

laborer

i'ts; sw'l'g of

g'ds in neck.

temp. 102°. . .

33

I day..

very severe
p'ns & temp

once

" 2

" I

neg ... .

no work

I02'-I05**. . -

afp'al

bacilli

34

no rea'n

6

neg

farmwoik

25

3 days.

severe p'ns in

" 6

" I

" I

neg

f

i'ts- unable to

move neck &

,..--

arms; temp

09'*-: 02**

ad

a tew
hours.

light pains;
temp. 99i°. .

8

I

" i

tub.?. .

book-
keeper

a?

1-2 day.

malaise :

•' 6

neg. . .

farm work

temp. 101°. . .

38

6 hrs.. ,

headache and
vague pains;

4

" 2

■• 1 ?

?

tem--). 100° , .

■ !

♦Note. — Numbeis mdicate how many times sputum was examined-
with results; if 'wo sets of numbers follow under '* Alter," it mean.*; thai
the first 1= positive, and second negative, due to treatment.

Conclusion. — This table demonstrates to me the
vahie of the bacillary emulsion for diagnostic pur-
poses, and it shows further that we have a valuable
means of determining- an early tuberculosis which
we could not positively disrovc- without that means.

44ti Clinton Avenue.

Lupulin. — T. F. Reilly finds lujjulin a valuable
mild anodyne and hypnotic and often an excellent
substitute for more active drugs of this class. He
believes it is a safe substitute for the coaltar prepara-
tions. For children it is often a good substitute for
opium, as also for old people suffering from ad-
vanced renal disease, and it is of especial value for
sleeplessness and nervousness following a mild de-
bauch.— JoiiDwl of the Anuvicaii Medical Associa-
tion.

OBSERVATIONS ON AN IDEAL LOCAL

ANESTHESIA FOR SUBMUCOUS

RESECTION.

By F E. MILLER, M.D..

NEW VORK.

Api'keclmixg the value of an ideal method of lo-
cal anesthesia, and believing that there are others
who have had unfortunate experiences, I present
a method that has been found ideal in my practice
and more satisfactory than the solution recom-
mended by me in the International Journal of Sur-
i^ery of February. 1903. I described then a solu-
tion, suggested by Prof. William Kelly Simpson
of the College of Phy.sicians and Surgeons of this
city, of cocaine, 4 per cent., and adrenalin, i to
1000. equal parts, used as a spray, and where this
could not be applied, I used it in a hypodermic in-
jection between the tonsil and its pillars.

A most satisfactory and ideal anesthesia has been
secured since February, 1905, by my associate. Dr.
Artiiur P. Coll, and myself. We have been able to
apply the above-mentioned adrenalin and cocaine
so successfully that any submucous resection of the
sejitum can be commenced within three minutes
and carried on as long as may be required without
pain or hemorrhage and without other help.

The mixture consists of about 20 to 25 grs.
cocaine crystals j)laced in a shallow dish and drop-
])ing sufficient adrenalin chloride solution, i to 1000,
lo dissolve the crystals.

The method of applying this solution is as fol-
lows : By wetting cotton on the applicator so that
there will be no excess of solution, thereby avoiding
paralyzing the constrictors of the pharynx, swab
over the entire field of operation with applicator.
With this solution we have been able to operate for
three-quarters of an hour without the slightest dis-
comfort to the patient.

In the last forty cases of submucous resection of
the septum, this mixture was used with greatest
comfort to my patients, being absolutely free from
pain and with minimum of hemorrhage ; reducing
the former cocaine toxic symptoms, the bane of the
nasal surgeon's operations, without general anes-
thesia.

Formerly, I used a s®kttion of J per cent, resor-
cin and 4 per cent, cocaine as a spray so that the
nostrils could be, as it were, prepared for internal
treatment without hurting or irritating them by in-
strumentation. The resorcin also had the effect of
not only enhancing the anesthetic power of the co-
caine, but changed its excessively bitter and nau-
seous taste, thus relieving to a large degree its
psychic effect.

To further remove this last-named phase and to
better the patient's self-control. I administered ( and
do now administer) immediately before the cocaine-
resorcin solution a nerve sedative and vasomotor
controller, of

I>. Sodii l)romidi,

Potassii bromidi,

Ammonii bromidi, aa. .

Spts. ammon. aromat. .

Aquje q.s. ad

Sig: At one dose.

By this means only two patients had slight or par-
tial collapse and were carried to the end of the
operation bv means of bending the head as far
down and forward as possible, and then massaging
vigorously the nape of the neck.

Formerly, to make the anesthesia complete, three
or four strips of sterilized gauze were introduced,

■,£;''

. X

312

MEDICAL RECORD.

[Feb. 23, 1907

of size and shape to fit the cavity of the nostril
when spread out upon its mucous membrane.
These strips were moistened with 4 per cent, solu-
tion of cacoine to saturation, and inserted (not too
•deep down the pharynx) with forceps having par-
allel blades with handles at right angles, and then
smoothed over the entire circumference with force
and pressure if necessary. In ten to fifteen minutes
these pieces of gauze could be removed and a very
excellent anesthesia would have been obtained.
This is entirely done away with by the aforesaid
procedure.

Sometimes it is very necessary to prolong these
operations which usually take, all told, about thirty
minutes to an hour, or even longer. This can be
perfectly accomplished even without hemorrhage by
dipping a probe, wound securely about with small
pieces of cotton, into cocaine crystals as mentioned
above, and applying it to the membrane when se-
cretion is beginning to return or oozing is occur-
ring. By this means I have taken out without
damage, the entire bony and cartilaginous septum
of a football coach who had been kicked on the
nose, causing a hideous deformity with comminu-
tion of the septum, within one-quarter of an inch
of its entire periphery, and have lost but very lit-
tle of the mucous membrane, and have restored the
nose, internally and externally, to a perfect cosmetic
condition.

22 West Thirtv-pirst Street.

THE TREATAIENT OF LA GRIPPE.

By P J McCOURT, M D..

XEW YORK.

In the Medical Record of December 22, 1906, was
an excellent and conservative article on the above
subject by Dr. Charles E. Nammack, which should
command more consideration than such articles
generally receive. I have delayed this paper in
the hope that others would offer more encourage-
ment, or suggest a better method in the treatment of
that persistent affliction, but none has been pre-
sented— at least not in the journal in which we
expect to find most help.

Dr. Nammack's opening sentence, if it were defi-
nitive, would be a sad confession of our weakness,
and one that should make us blush : "There is
neither a prophylactic nor a specific for influenza.''
In this one particular I am happy to take issue with
the gentleman ; we possess both.

Epidemic influenza invaded the country in a
pestilential wave from the overflowed banks of
the filthy Neva and other open sewers in Russia,
and lesser pest spots of our own perpetuate the
cause and its malign results. Under existing con-
ditions the miasm will abide with us as a constant
foe, and it is our duty to devise means that will
subdue or conquer it. And that duty we shall per-
form, as we have so many others of equal benefi-
cence. Thus far its medical treatment has not re-
ceived adequate or intelligent study, and in this
respect it is not isolated. We have culpably ne-
glected our materia medica for the knife and the
microscope, although the latter has enabled us to
cure practically nothing.

Arsenic- — not in combination, as in Fowler's so-
lution, etc., but simple, pure arsenic — in alcoholic
solution, 1.8000, five minim doses morning and
evening, has aft'orded immunity to a large number
of my patients who had previously suffered from
repeated attacks of influenza. Not a few of those
patients soon became more sensitive to the action of
the prophylactic than they had been to the disease,

and had to suspend dosage at frequent intervals.
The known failures were under 6 per cent.

Gelsemium, tincture of the fresh root, three to
five minims in six ounces of water, drachm doses
every one to three hours, is practically a specific
for almost every step, stage, and variety of la
grippe, when free from serious early complications.
In the control of influenza this form of the drug has
rarely failed me during the past twelve years, and
recoveries have been rapid and complete, usually
free from later complications or sequel. But fluid
preparations of the dry root — infusion, tincture, and
fluid extract — were found to be entirely valueless.
The dose may be much smaller than that just
named, but should never exceed this amount', else
it may markedly increase the existing prostration ;
and, further, it must be reduced as the condition
of the patient improves. The drug is also admi-
rably indicated for the entire train of mental and
nervous phenomena usually common to the disease,
and is the only known remedy for high fever with-
out thirst, whatever may be the pathological condi-
tion. Since it now appears reasonably certain that
all varieties of la grippe originate from a common
infective element, we may infer that the same
remedy should prove curative in all ; and this in-
ference is justified in practice. Hence it would be
but a waste of valuable time to treat its erratic
symptomatology as made up of separate entities.
Approximate specifics of equal efficacy for other
diseases are numerous, but they will not be found
among the juices of withered plants, alkaloids, or
crude, unknown mixtures.

A single minim of a correctly made fresh-plant
tincture is endowed with more, and better, medic-
inal activity than are ten minims of our official
dry-plant fluid preparations, whether "standar-
dized" or not. In the treatment of disease I am a
firm believer in the competence of rational medi-
cine rationally administered. But to me there is
nothing rational in the exhibition of dead or
withered plant-juices, or their alkaloids; and the
latter never represent the true medicinal properties
cif the plant, whether the plant be living or dead. I
also believe that in the process of drying, medical
plants, aside from losing most of their vital proper-
ties, undergo chemical and destructive changes
which render them unfit for medical use. This
belief is strengthened by the recent investigations
of Dr. Cloetta, who could find no cumulative action
from the fresh leaves of digitalis, and that vicious
property he attributes to changes in the dry leaves.

Attentive study and exact comparative tests in
single cases and upon the same patient have fully
convinced me, as such crucial tests must convince
others, that the simple dnig in fresh-plant tincture
— or two simple drugs given alternately when both
are called for — is more eft'ective in therapeutics
than any compound prescription can possibly be.
Even when the latter seems to relieve — for it never
cures any morbid process — its clinical effects afford
no data for future guidance in similar conditions.
Warburg's tincture may be taken as an extreme
type of the compound prescription. On rare occa-
sions it has shown some efficacy; but that efficacy
is limited by the fact that, like all medical mix-
tures, we can never obtain it twice exactly alike.
This irregularity is not always the fault of the
pharmacist. The error is often due to the careless-
ness of our manufacturers, who seldom make a
drug twice the same, chiefly owing to a neglect
of the "law of proportion." Again, the chemical
reaction of several constituent drugs upon each
other is still the unknown quantity, and their united

Feb. 23, 1907]

MEDICAL RECORD.

313

action upon the patient is equally uncertain. Under
our present crude and unscientific practice patients
usually make a slow and imperfect recovery, often
from natural causes or even in spite of our medi-
cine, and we are prone to give undue credit to
whatever drugs we happen to be using at the time.
At best, this is merely assumption, unless it be pre-
sumption. If, on the other hand, we prescribe one
or two separate drugs for a known pathological
condition and a given group of pathognomonic
symptoms, and the patient makes a rapid and com-
plete recovery, we at once possess a valuable guide
for the successful treatment of all similar cases
for all future time. This is medical science, not
mere conjecture, and should be our chief object of
attainment. And that object will ere long be at-
tained in the manner I have suggested, for there is
no other.

Had we devoted as much time and intelligent
thought to the perfection, study, and application of
our materia medica as we have to analyzing patho-
logical shadows and nursing- microbes, there would
be fewer therapeutic nihilists and medical machinists
among us.

233 West Twen'TV-third Street.

The Histology of the Skin Lesions in Varicella. —

E. E. Tyzzcr states that the study of lesions excised from
eleven cases of varicella in adult Filipinos shows that the
initial change consists in the appearance of peculiar eosin-
staining inclusions within the nuclei and cytoplasm of
epithelial and various other cells. Direct division of nuclei
without subsequent division of the cytoplasm is associated
with these inclusions. Cells undergoing these changes
often become enormous during their degeneration. After
these cell changes the typical varicella process consists
of a rapid destruction of small areas of the epidermis
associated with exudation and vesicle formation. The
development of tlie vesicle is attended by the formation,
about the epithelial cells, of numerous fibers. A certain
number of lesions are infected by bacteria, as the result
of which they become pustular. In such lesions there is
more or less destruction of the papillary layer, which ac-
counts for the scars frequently following an attack of
varicella. A conclusion has not been reached concern-
ing the nature of specific inclusions in varicella and no
important evidence has been found in favor of the hypoth-
esis that they are parasitic organisms. Inoculations of
the cornea of the rabbit and the skin of the monkey with
the contents of varicella vesicles have in all cases yielded
negative results, — The Philippine Journal of Science.

Tics in Children and their Educational Treatment. —
Charles Herrman calls attention to the frequency of tics
and the discomfort which these conditions cause. Many
tics have their origin in childhood. As in all the neuroses
of childhood there are two important factors in the etiology
of this affection : the inherited predisposition, the favorable
soil; the environment including the method of training.
Often the movement or gesture was originally performed
with a purpose. Tics may affect almost all parts of the
body ; several may be combined. The mental state of these
patients is characteristic. Equilibrium is lacking. The
will is not under control. There is difficulty in concen-
trating the attention, shown in impulsiveness, restlessness,
impatience, or irritability. As to treatment, any abnor-
malities jiear the site of the muscles affected should re-
ceive attention. Except tonics, drugs are, in most cases,
useless, unnecessary, or contraindicated. The regulation
of the diet and mode of life are of great importance. Vio-
lent exercise should not be indulged in. The essential
treatment, however, is educational. It consists of two
parts: immobilization primarily of the parts affected; active
exercises primarily of the parts affected. The patient is

seated before a mirror and is told to remain perfectly
quiet like a statue for a stated time. An occasional word
of encouragement or praise is often of advantage. Active
exercises of the muscles are then directed by the physician.
These e-xercises should be gone through with three times
a day at stated times. Regularity and punctuality are
essential. The writer has treated ten cases according
to the method which he describes. In six the movements
have entirely ceased. — Archives of Pediatrics.

A Note on Syphilis and Cancer and on Some Proto-
zoa.— J. J. Clarke discusses some of the protozoa
and the spirochetes. The latter had often
been confused. he sa.vs, with .spiral bacteria.
Syphilis is a disease in which (he life cycle of
the parasite is completed within the human host, so
that if Spirochcvta pallida is related to the causation of
the disease other and larger forms must be found in the
tissues. The author figures the various stages of some
of the spirochetes as developed in the intestine of the
common gnat, and claims that some of them were de-
scribed by himself as early as 1894. Since then he has
observed similar bodies in the scrapings from tertiary
ulcers. He is an advocate of the theory that cancer is
caused by protozoa, and is convinced that the common
forms of cancer and sarcoma are caused by more or less
local infections by protozoa and differ from the infective
granulomata only in the more intimate character of the
parasitism and the more complicated life-history of the
parasites. — British Medical Journal.

Bilharziosis. — Roux declares that the portal vein, the
veins of the pelvis and those of the bladder and of the
rectum are the ones in which the bilharzia is most fre-
quently found. It is remarkable that the nortal vein con-
tains only young parasites whose sexual activity has not
yet begun. This infection is rarely seen in those of
the upper classes. The blood of these patients has a
tendency, according to Goebcl, to coagulate ranidiv after
it is drawn from the blood-vessels. This phenomenon de-
pends upon secretion of the parasite as vet unknown.
In regard to treatment prophylaxis is most important.
The writer emphasizes the necessity of instructing the
inhabitants of Egypt concerning this disease. They should
lie told of the danger of drinking impure water and of
bathing in it. They should also be taught the role which
the urine and feces of persons suffering from this disease-
plays in its propagation. Such instruction would be of
inestimable value to the inhabitants of this country. — Lc
Caducce.

The "Home Sanatorium" Treatment of Consumption.

— Joseph H. Pratt gives an interesting report of the work
which he has been doing in relation to tuberculous patients.
The "class" of patients is sometimes spoken of as a "home
sanatorium." It bears about the same relation to a sana-
torium that a correspondence course does to a college
course. A nurse who devotes her time to visiting the mem-
bers of a class is called a "friendly visitor." The writer's
patients have all been poor, some of them not very intelli-
gent. Before any individual is admitted to the class he
must promise to give up all work, live the outdoor life,
and obey all the rules of the class. The clinical history
of the patient is taken and a complete physical examination
made. Once a month the lungs and sputum are reexam-
ined. The nurse looks for suitable tenements for the mem-
bers. The prescribed diet consists chiefly of milk, bread.
fruit, butter, and oil. Cotton-seed oil is a satisfactory
substitute for olive oil. No exercise is allowed for the
first few weelis. When the temperature becomes normal
for the entire day the exact amount of exercise is pre-
scribed. Of the nine patients who have been members
of the class for three months or more all show a gain in
weight. In five of the nine cases the disease has been
arrested. The writer appends the histories of a number
of cases.— Bulletin of the John.'! Hopkins Hospital.

314

MEDICAL RECORD.

[Feb. 23, 1907

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, AM., M.D, Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, February 23, 1907.

THE IXXOME OF THE PRACTISING
PHYSICIAN.

The fact has been evident for some time in Great
Britain that the earnings of the medical practitioner
have been exhibiting a progressive decrease. This
diminution of income has not unnaturally aroused
certain members of the medical profession, who both
in medical and in lay journals have somewhat clam-
orously advertised this unfortunate state of affairs.
Some two months ago one of the leading news-
papers of London devoted a considerable amount
of space in its correspondence columns to a dis-
cussion of the situation, and medical practitioners
from all parts of the country entered with apparent
zest into the task of bewailing their lot and of con-
sidering the reasons for the evil complained of. It
was agreed on all hands that hospital abuse was
an important factor in the lessening of the doctor's
gains, and that there was no prospect of matters be-
coming better in this respect. All large hospitals in
Great Britain are free and many sick persons avail
themselves of the benefits of such institutions who
can well afford to pay a medical man. Another
fruitful cause of diminished income is the multipli-
cation of medical clubs in Great Britain : the com-
petition among physicians is so acute that clubs are
now taken at an absurdly low rate, four shillings
(one dollar) per capita for men, women, and chil-
dren per year being an ordinary fee. Prescribing
by druggists is another means whereby, it is stated,
physicians in England are frequently mulcted of
their just dues.

In America hospital and dispensary abuse is as
flagrant and as prevalent, perhaps, as in Great Brit-
ain, although, owing to the different conditions ex-
isting, it is not exhibited in the same way. Club
practice has not as yet obtained the hold in America
that it has gained in Great Britain, but signs are
I^lentiful that the methods are taking root and be-
coming more and more popular. Of course pre-
scribing by druggists has always been largely in
vogue in this country and a source of very consider-
a])le loss to the medical practitioner. By some phy-
sicians in England it is proposed to put down this
custom by the strong hand of the law, but exactly
how this is to be brought about it is difficult to un-
derstand.

Competition is more severe among .American phv-
sicians than among British practitioners, but on the
other hand medical fees here are on the whole far
higher. While allowing that members of the medi-
cal profession are as a rule underpaid, it mav be

pointed out that two potent reasons for the diminu-
tion of income are usually overlooked. These are
the decrease in morbiditv and the greatly improved
methods of treatment of the present day. Hygiene
and sanitation have abolished many of the great
epidemics of disease which in times past were wont
to bring much grist to the doctor's mill, while
the introduction of new and more scientific modes
of treatment have to a great extent curtailed the
duration of the disease and have in a corresponding
degree reduced the doctor's income.

CORNEAL GRAFTING.

Among the most ingenious applications of the meth-
ods of plastic surgery is the substitution of a trans-
parent membrane for portions of the corneal tissue
which are impervious to light. The operation was
first suggested in the early part of the last cen-
tury, although the act of replacing a clouded human
cornea with that from an animal was not carried
out. During the succeeding years mmnerous efforts
were made to overcome the many difficulties which
surrounded the operation, but without success, so
that the procedure was finally abandoned, only to be
revived again during more recent years. It seems
that the first successful operation was performed
by Sellerbeck in 1878. who replaced the clouded
cornea of a man who had become blind as the re-
sult of a gonorrheal ophthalmia with that from a
small child in which enucleation had been rendered
necessary by a glioma of the retina. Healing took
place without any reaction and the patient could
read print of moderate size in about two weeks, but
unfortunately in another week cloudiness appeared
at the edges of the graft and soon thereafter vision
was again completely lost. Subsequent attempts
made by different operators were likewise unsuc-
cessful and the idea of providing an optically perfect
cornea by this means was practically abandoned. It
was believed, however, that the procedure might
prove of service in another direction, namely to
replace ulcerated or incompletely cicatrized areas
in the cornea with a more substantial tissue basis,
an idea far removed from the original purposes of
the operation. The application of this principle has
been made the subject of a communication by Zirm
in the Wiener klinische Wochenschrift, No. 3,
1907, who reports a permanently successful opera-
tive result in a man who had become almost totally
blind as the result of a corneal opacity due to lime
burns. The material for the grafts was taken from
the eye of a boy, which had been removed on ac-
count of extensive trauma. Although one of the
flaps failed to adhere, the other became firmly united
and the man's vision was sufficiently restored to per-
mit his going back to work at his former occupa-
tion.

An inquiry into the reasons for the failures in
previous attempts seems to show that aside from
imperfections in the technique an insufficient degree
of attention to means for maintaining the nutriment
of die flap was the cause for a majority of the fail-
ures. It is essential that the material for the graft
be obtained from the human stibject. and the cornea
must be well nourished and not the subject of any
degenerative processes. Zirm claims that experi-

Feb. 23, 1907;

MEDICAL RECORD.

31.S

ence has shown that animal grafts cannot be em-
ployed. Deep narcosis, strict asepsis, and the avoid-
ance of all antiseptics are among the most essential
details connected with the operation. The flap must
not be handled with instruments, but with small
pads of moist gauze, and kept warm witli steam
until ready to be applied. It is fixed in place with
two crossed sutures, which are inserted through the
conjunctiva. The cases moreover must be care-
fullv selected, and it would appear that the cen-
trally located opacities furnish the best opportu-
nities for successful grafting, particularly if the
surrounding areas are still well nourished. Plastic
operations on the eye, especially when they aid in
the restoration of sight, must be accounted among
the most useful among this class of surgical pro-
cedures, and although one swallow does not make
a summer, the success attained by Zirm in this one
case should lead to renewed interest in what has
almost been abandoned as a useless operative in-
terference.

ALCOHOL L\ THE NUTRITION OF DIA-
BETIC.'^.

Amon(, the questions of paramount interest in the
study of diabetes is that relating to the source of
acetone, and that this is not merely a theoretical
one is shown by the increasing attention which is
accorded to the idea that the acetone bodies exert
an important bearing on the production of one of
the most feared complications of diabetes, namely
diabetic coma. The ideal method of treatment in-
cludes not only the means whereby the sugar is
made to disappear from the urine, but also that
whereby the ingestion of albuminoids is reduced
and that of the fats increased. In severe cases of
diabetes albumin will often induce more active sugar
elimination than certain carbohydrates, and it is
quite generally believed at the present day to be
the most probable source of the acetone bodies. Fat
on the contrary does not seem to play any consid-
erable part in the production of these substances, but
it constitutes a valuable and harmless source of nu-
triment, by the aid of which the carbohydrates in the
diet mav be readily displaced. This assinnption has
met with some opposition, however, and it is claimed
that the fats may also serve as a source for the pro-
duction of acetone.

Some recent investigations by Benedict and
Torok, reported in the Zeitschrift fiir klinisclic
Mcdhin. Vol. 60, Nos. 3 and 4, seemed to show that
in diabetics this is a fact, although control experi-
ments in nondiabetic patients were by no means
conclusive. Alcohol was then employed as a sub-
stitute for the fat and the result was most favor-
able. The writers found that alcohol will bring
about a marked diminution in the amount of acetone
and also reduce the quantity of sugar, while at
the same time it supports the nutrition. The admin-
istration of alcohol is particularly indicated in the
severe cases in which it is the aim to render the
patient as free from c'hc'isuria as nossible. For
with an exclusive meat diet the danger of acetonuria
and coma is always present, and it is therefore most
desirable to replace some of the fat with alcohol.
The amount of alcohol depends on the severity of

the individual case: from one-half to one liter of
light wine may be administered with impunity daily
for prolonged periods. The exciting or depressing
properties of alcohol seem to be less marked in
diabetics than in others, which reminds one of the
tolerance displayed by diabetics to opium. In order
to avoid abuse of the alcohol it is well to regard
the latter as a medicine and to administer it as such
rather than as an article of diet.

Tliere are of course self-evident contraindications
against the employment of alcohol in diabetes.
Among these are albuminuria, especially when this
is increased during the administration, neuritis,
arteriosclerosis, as well as diabetes in children,
where dietetic precautions are also often without
eft'ect.

The Effect of G.astroenterostomy on G.^stric
Digestion.

Although it is something over twenty-five years
since Wolfler popularized the operation of gastro-
enterostomy, it must be confessed that the beneficent
effects of the operation have not been altogether
satisfactorily explained. It is usually assumed that
the procedure owes its happy results mainly to the
im|.)rovement in the drainage of the or'^an and in its
motilitv that is brought about, and although changes
in its secretory activities have also been predicated,
these do not appear to have been studied with very
fruitful result. The problem has been made the
subject of extended researches by Katzenstein, who
publishes some very interesting conclusions in the
Pnitsche niedhiniscbe Wochcuschrift of January 17
and 24, 1907. By means of operations on dogs, and
digestion experiments, he was able to determine that
after both anterior and posterior gastroenterostoniy
bile and pancreatic juice enter the stomach. During
the first perioil after the operation this flow is very
jirofuse, but later it occurs more or less periodically,
and it has, as a consequence, the reduction of the
gastric acidity, both through its direct chemical
effects and through a reflex inhibition of the produc-
tion of hydrochloric acid. The digestive activity of
the pepsin is also diminished, whereas trvptic diges-
tion is not impaired to any noteworthy extent. The
effect of the gastroenterostomy is, therefore, to re-
duce very largely the value of the stomach as a ili-
gestive organ through inhibition of both pepsin and
hvdrochloric acid formation. The result of this is to
firing about the conditions most favorable for the
cure of peptic ulcer and the prevention of recur-
rences of the condition, and the surgeon, in resorting
to the operation, is making use of a directl'.' remedial

measure. These advantages ma\

lie stil

further

enhanced by a suitable diet, which should be deficient
in proteid in order not to enco'.irace li\'drochloric
acid and pepsin formation, and should consist largely
of fats and carbohydrates, which favor the secretion
of bile and pancreatic juice. The meals also should
be small and frequently repeated, and the adminis-
tration of large quantities of lluids. particularly
water, is also advisable. In spite of these very
strong arguments in favor of gastroenterostomv in
the treatment of ulcer of the stnmncli. Katzenstem
believes that the maladv is essentiallv a medical one,
anrl that patients should be referred to the surgeon
nnh- when the internist has exhausted the resources
at his command. In dealing with cases of gastric
cancer the conditions are somewhat dift'erent, and
here, particularly if there is obstruction, the improve-
ment achieved is largelv the result of the drainage of

3i6

MEDICAL RECORD.

[Feb. 23, 1907

the stomach that is brought about. The author sug-
gests, however, that the remarkable instances of
improvement, or at least arrest of the disease, that
sometimes are observed after gastroenterostomy
may be the result of the local application of trypsin
to the surface of the new growth that is effected by
the entrance of the duodena! secretions into the
stomach.

The Effect ox the Circul.\tion of Pressure on
Painful Points.

The fact that on making pressure over supposably
painful points more or less pronounced changes in
the pulse rate and in blood pressure are produced
in dealing with actual disease conditions, whereas
this is not the case if there be no real basis for the
complaints of the patient, has been found a useful
measure for the detection of malingerers. This
phenomenon, which is sometimes known as the
.Mannkopff or Mannkopft'-Rumpf symptom, is made
the subject of an explanation by Rumpf in the
Miinchener inedhinische Wochcnschrift, January
22, 1907. He states that pressure on, or friction of,
painful points in certain cases of general neuroses
or neuralgias may evoke changes in the domain of
the circulatory system which may manifest them-
selves either as a simple increase in the frequency
of the heart, as a preliminary slowing of the_ pulse
of short duration followed by an increase m its ra-
piditv, or as a decrease in the size of the pulse. In
some' instances cardiac arythmia is observed, and m
others cyanosis of the face or abnormal secretion of
perspiration is noted. The effect of such stimuli
may also be either to raise or to lower the blood pres-
sure. All of these changes subside within a short
time after the cessation of the painful stimulus. In
order to guard against errors in making this test,
certain precautions are necessary, however. The
patient must be in a hospital, and must have been
lying for some time on the bed or couch on which
the examination is to be made. He must also have
no idea of the significance of the test, and must
have been subjected to several previous examinations
in order that the mere unaccustomedness of the ma-
nipulations mav not give rise to error. The 'leart's
action must be regular and the pulse preferably
under one hundred. During the examination the
patient must breathe quietlv and evenly, and must
not hold the breath or make straining efforts. In
addition to the supposedlv painful areas, correspond-
ing spots on the other side of the body should also
be tested, and the effect must be limited to the pain-
ful side. It is also desirable to repeat the examina-
tion on several different occasions.

Andrew L.\ng on Influenz.^.
From being a sceptic, Mr. Andrew Lang, the dis-
tino-uished English litterateur, has become an ardent
convert to the doctrine that there is really such a
disease as influenza. He says of himself, in a recent
number of the Illustrated London Neivs, that he
"has been the victim of a malady in the existence of
which he was an unbeliever. No man." he said,
"however credulous, can believe in ever\^hing, and
I 'took the Wilkes and Liberty' to suppose and assert
that there is no such thing in nature as influenza.
Mv causes of scepticism were the usual causes. I
never had suffered from influenza. No house in
which I ever found mvself was haunted by the al-
leo-ed maladv. I was wrong, and am now in case to
appreciate an argument of the Chinese medical pro-
fession These learned men believe m demoniacal

possession. When their European confreres say,
"Oh, you mean epilepsy, hysteria, and so on,' the
Chinese reply : 'Excuse us, we don't ! We know all
about hysteria and epilepsy, at least as well as you
do ; but demoniacal possession is quite another affair,
with peculiar and distinctive symptoms.' That is
also the case with influenza. It may resemble a com-
mon cold, but its distinctive symptoms, as in the par-
allel affair of diabolical possession, are unmistakable.
Indeed, I rather think that diabolical possession and
genuine influenza are much the same thing. In-
fluenza at once attacks the human mind, and pro-
duces the queerest phenomena. Certainly under the
<lominion of this fiendish malady I exercised men-
tal faculties of a kind which I do not possess when
[ am in ordinary health. A critic, the late Mr.
Henley, I think, once asked, 'What could not Mr.
Lang do if he only had genius?' Nobody was able
to reply, but when I had influenza I had genius.
Unluckily, there was no money in it, and I would
rather be devoid of the genius than have it with
influenza thrown in ; inspiration is all very well, but
one may purchase it at too high a price."

Cardi.\c Suture.

Some ten years have elapsed since the first practical
demonstration of suture of a wound of the heart
was made, one of the earliest cases reported having
been that of Dr. Daniel Williams in the Medical
Record of March 27, 1897. Although at first
unsuccessful in saving life, further experience
with the procedure has shown its feasibility,
and a considerable number of reports are at
hand to point to its value. Thus, among
a series of 128 cases which have been col-
lected by Lenormant {Ga:;ette des Hopitaux, 1906,
No. 104), eighty-one patients died and forty-seven
were cured, a result which must be favorably re-
garded when we consider the extreme danger which
attends this condition. The majority of the reports
deal with cases in which a cutting or penetrating
wound of the organ occurred and only a relatively
small number are concerned with tlie suture of gun-
shot injuries. Another interesting fact is that of
all the cases in which the exact localization of the
trauma was determined only six instances of injur}'
to the auricle are recorded. The remainder relate
to injuries of the ventricle, in which the results of
suture of the left ventricle are apparently twice as
good as in those of the right. Complicating injuries,
such as those of the septum, the coronary arteries,
or the valves, are invariably fatal ; those of the
neighboring thoracic and abdominal organs also
render the prognosis particularly grave, although
two favorable cases have been published in which
there was a simultaneous injury of the heart and
the lung. If death occurs during the first few-
hours after the injury it is due to shock, acute
anemia, or intracardial trauma, but when it takes
place after the second day it is caused by infection
of the pleura, the pericardium, or the lung. It
is found advisable not to drain any serous cavity
which may be opened during the operation of suture,
as the dangers of infection are greatly increased by
this procedure. Needless to say the most rigorous
aseptic measures are necessary to insure a success-
ful outcome, and if these have been adhered to,
both pleura and pericardium may be closed without
fear of subsequent trouble. In opening the pleural
cavity care should be taken not to make the incision
any larger than absolutely necessary, for the pneu-
mothorax which may follow is an element of con-
siderable danger.

Feb. 23, 1907^

MEDICAL RECORD.

317

The Effect of Cooking by G.\s.

Ax editorial in the Lancet of February 2 discusses
this question from both the chemical and chnical
points of view. It is reassuringf to learn that the
differences between this method and the more fa-
miliar ones as to sources of fuel cannot be looked
upon as a serious matter from the point of dietetics.
Cooking by gas brings up the question as to what
effect if any the products of this combustion are
likely to have upon the meat. The chief of these
products are carbon monoxide, acetylene, and sul-
phurous acid. The two former form molecular
combinations with the coloring matter of the blood,
but at the high temperature of the cooking process
it is unlikely that such a combination would take
place. Moreover, a full air supply would prevent
either from being permanently absorbed. Meat dur-
ing cooking is emissive rather than absorptive. Any
difference in cooking must be referable to the man-
ner in which the heat is applied. Open roasting is
undoubtedly superior to close roasting. The article
in question expresses the view that the cooking of
meat by gas is less satisfactory than cooking by the
open roast method, because in the former case the
joint is cooked partly by ascending heat currents and
partly by steam. According to this view, cooking by
gas may be regarded as a hybrid process, that is to
say, part boiling or steaming and part roasting. The
constant stream of steam over the surface of a joint
of meat is calculated to extract some of its flavor
and to exert a toughening effect on the tissues of the
meat.

The Treatment of Auditory Sclerosis.
In sclerosis of the auditory apparatus it is be-
lieved that an increase in the blood pressure is the
primary cause of the attendant symptoms — vertigo,
tinnitus, and deafness. For this reason it has been
suggested by Malherbe in the Bulletin Medical,
No. 81, 1906, that Trunecek's serum be employed in
the treatment of the condition. This serum, which
has been more or less extensively used abroad in
the treatment of arterial sclerosis, has been modified
by Malherbe so as to include nitrate of pilocarpine.
His method is as follows: Three cubic centimeters
of the serum is injected into the gluteal region and
this is repeated at intervals of two or three days
until twelve doses have been given. In two weeks
the treatment is repeated. A strong and a weak
serum are used, the former containing twice as much
pilocarpine as the latter. The injections are fol-
lowed by a well-marked effect on the pressure in
the peripheral vessels through the agency of the
vasomotor nerves and this effect of the original
serum is heightened by the pilocarpine in the modi-
fication. The treatment is particularly serviceable,
according to the writer, in the early cases of the
disease, in which the vessels still possess a certain
degree of elasticity, and in these instances the
tinnitus and the vertigo are greatly helped and the
deafness mav also be improved. In the forty cases
reported by the writer each patient received from
twelve to thirty-six injections ; in twenty-one the
result was excellent, in sixteen it was good, and in
the others it may be called doubtful. But even in
the latter class of cases where, on account of a
sclerosis in the labyrinth, total deafness was present,
some of the patients stated that after treatment they
could faintly perceive certain sounds, the percep-
tion of which had totally disappeared. These ex-
periences would apparently indicate that the
Trunecek serum injections might form a valuable
adjunct to the local treatment.

^ms of tijp Wnk.

State Health Report. — In his annual report to
the Legislature, State Health Commissioner Eu-
gene H. Porter submits that in order to safe-
guard the water supplies of the State more
efficiently the Commissioner should have the au-
thority to order a town to remove its sewage
from the State waters if it seems desirable. He
also suggests that a commission might be ap-
pointed to aid the Health Department of the city
of New York in controlling the pollution of New
York harbor. The inspection of packing houses
and slaughter houses, as well as the examination
of their products, showed serious deviations from
the proper standards, and it is proposed to con-
tinue this work as actively as the appropriations
permit. Twenty-one cities show a lower death
rate than in 1906, and seventeen a higher death
rate. Rome, Ogdensburg, and Troy have the
highest death rate, and Johnstown and Tona-
wanda the lowest. The average city death rate
was 15.9, and birth rate 19.7 per 1,000 population.
Nine cities— Albany, Cohoes, Hudson, Middle-
town, Newburgh, Rensselaer, Troy, Watertown,
and Watervliet — reported more deaths than
births. Albany and Troy show the smallest birth
rate, and Dunkirk and New York the largest.
Last year there were 183,012 births, 140,773
deaths, and 87,870 marriages, while 9,401 still
births were reported. Last year the second high-
est monthly mortality occurred in August, and
was due to 2,339 deaths of children under two years
of age from diarrhea and enteritis. More deaths oc-
curred from this cause in this month than from
any other disease in any other month, and the
Commissioner makes this a ground for recom-
mending that a more efificient system of milk in-
spection be instituted. The subjects of car sani-
tation and of the examination of the eyes of
school children are also discussed.

Hudson River Ice. — The Merchants' Associa-
tion of New York, through Mr. Edward Hatch,
Jr., chairman of the association's committee on
pollution, has sent to Governor Hughes a letter
alleging that much of the ice now being cut in
the Hudson river is unfit for domestic consump-
tion, and is dangerous to health. The statement
is made that it is estimated that 2,500,000 tons
of ice are harvested annually on the Hudson for
consumption in or about Greater New York.
The population of the drainage area of the Hud-
son Valley is not far below 700,000, and the sew-
age from this number of persons is discharged
into the Hudson river or the tributaries thereof.
In addition the farm and barnyard drainage and
surface wastes find their way, eventually, into
the river. Chemists sent out by the association
to examine samples taken from the ice that is
l.ieing cut and stored allege that most of the ice,
at either the top or the bottom of the cake, showed
evidence of contamination with intestinal germs,
as the result of both chemical and bacteriological
examinations. Especially bad is said to be the
ice cut on the fields between Albany and Troy,
and for five miles south of Albany. Near Al-
bany and elsewhere on the river ice is cut close
to the large sewer outlets. Dr. E. H. Porter,
State .Superintendent of Public Health, in his
annual report to the Legislature, complained that
he did not have enough money appropriated for
his department to enable him to put a guard on
the harvesting of ice. and questioned whether he

3i8

MEDICAL RECORD.

[Feb. 23, 1907

had ihe authority to proliibit the cutting of ice
from lakes and rivers wiiere it- was supposed that
polhition existed.

Department of School Hygiene. — J'he estab-
lishment ot a ilc])anmenl with this title, and in-
tended for the greater protection of the health of
school children, is being considered by members
of the Board of Education. The new department
would be independent of the work of the now
existing Department of Physical Training, and
would concern itself with such matters as the
print of the school books used, the nature of the
desks, benches, and other school furniture, etc.

The Milk Question in New York. — The Board
of Aldermen has taken up the milk question, and
an ordinance has been proposed providing that
all milk sold at retail in this city shall be either
sterilized or pasteurized, unless the milk has been
bottled in dairies under the supervisioin of in-
spectors of the Health Department, and each
bottle bears the Health Department's seal placed
on it by one of the Department's inspectors. Sev-
eral public hearings are to be held before the ordi-
nance is to be reported to the Board.

The Milk Question in Illinois. — In the course
of an investigation carried on by the State pure
food authorities in Illinois it was found that only
about 30 to 35 per cent, of the milk sold in the
various cities visited was in the condition it
should, and easily could, have been in if the ordi-
nary sanitary regulations had been observed in
collecting and handling it. In the course of
several weeks' special work 1,400 samples were
analyzed, and, ignoring entirely the question of
the unclean product sold and unclean vessels,
there were brought sevent3'-six suits for cream or
milk adulterated with formaldehyde, seventeen for
skim milk sold as standard milk, five for milk
both skimmed and watered and sold as standard,
tweh-e for milk below standard and sold as stan-
dard, and thirty for watered milk, of which seven
were against farmers delivering milk to creamer-
ies or shipping stations. In most cases the de-
fendants pleaded guilty; the others are fighting
out the issues in court.

Emergency Health Conference in Chicago. —

Criticism of the Chicago City Council and its posi-
tion relative to questions of public health, particu-
larly its opposition during the last five years to the
erection of an isolation hospital for the treatment ol
contagious diseases, marked several of the speeches
at an emergency conference, held in Chicago on
Sundav, February 10. Several resolutions were
introduced at this meeting, the first of which ap-
proved the employment of a large corps of physi-
cians for regular school inspection ; a second
resolution provided for the appointment of a com-
mittee of eight to urge an improved system of milk
inspection, while the third resolution asked for the
appointment of a committee to take further steps
for securing a change in the hospital ordinances.
The committees are to be composed of two repre-
sentatives of each of the organizations represented
in the meeting, namely, the State Board of Health,
Citv Health Department, Chicago ^ledical Society,
and Illinois Federation of Women's Clubs.

Salaried Ambulance Surgeons in Chicago. —
.\s the result of the transference of the Chicas.)
police ambulance to the jurisdiction of the Health
Department, the Chicago City Council has voted to
appoint sixteen ambulance surgeons, at a salary of
$100 per month.

Infectious Diseases in Schools and Colleges. —

In consequence of an epidemic of grip which has
laid up half of its pupils and teachers, the semi-
nary of St. John the Baptist in Brooklyn has been
temporarily closed, and the seminarians sent to
their homes. In Ithaca, N. Y., nearly a hundred
cases of diphtheria and scarlet fever have been
reported in the last few weeks, and though most
1)1 these have Ijeen among the townspeople, many
of the Cornell students have left Ithaca to avoid
infection. Amherst College has been closed until
.March i, owing to the outbreak of scarlet fever
among the students, .-\bout thirty students are
ill with the same disease in Wheaton Seminary at
Norton, Mass., which has been closed for an in-
definite period. Three cases of scarlet fever have
been discovered among the students at Harvard.
Eighteen or more scarlet fever cases have oc-
curred in Williams College, and it is thought that
the authorities will decide to close the college.
In this instance the source of the infection is
thought to have been found in the milk supplied
1)}- a dealer in whose home an imreported case of
the disease was discovered.

The Steamboat Whistling Nuisance. — The
Board of Supervising Inspectors in \\ ashington
is preparing regulations under which will be in-
forced the law passed last month prohibiting use-
less and unnecessary whistling by steam craft.
At a recent meeting of the board the possibility
of requiring vessels to be equipped with whistles
giving forth more melodious sounds than those
now in use was discussed, and it was decided that
iu\-esticatinns relative to this question and to the
carr\ ing power of the sotmds emitted, as well as
the intensity of the light signals used, should be
instituted.

Tuberculosis in the Navy. — According to the
statistics reported tuberculosis in the Xavy and
-Marine Corps has increased from a ratio per
thousand of 3.2 in 1895 to 6.1 in 1905. As one
factor in the effort that is being made to combat
the disease an abandoned Army post in Colorado
has been turned over to the Navy Department,
and is being converted into a tuberculosis sana-
torium. This is New Fort Lyon, situated at an
altitude of 3,800 feet, on the north bank of the
.Arkansas River, five miles from the town of West
Las Animas. The climatic conditions are said
to be excellent, and sufficient buildings are at the
disposal of those in charge to provide adequate
accommodations for the prospective patients.

No Dentists for the Naval Service. — The ap-
propriation of S50.000 for the purpose of providing
thirtv dental surgeons for the Navy has not
passed the House, in spite of the earnest efforts of
those interested in the welfare of the service.

Meningitis in Salt Lake City.— During the past
six weeks cerebrospinal meningitis has been epi-
demic in Salt I ake City, and over thirty deaths
have occurred from this cause.

Cerebrospinal Meningitis in Belfast. — Be-
cause of the alarming mortality from cerebrospinal
meningitis at Belfast, and the generally high death
rate, owing to unsanitary conditions in many parts
of that city, the Government has adopted the un-
usual course of appointing a naval commission to
inquire into the situation.

International Congress on Infant Hygiene.—
The second international congress of "Gouttes
de Lait," an organization devoted to the protec-
tion of child life, will be held in Brussels Sep-

Feb.

1907

MEDICAL RECORD.

')

teinber 12 to 16, 1907. The first congress was held
in Paris two years ago. and a systematic move-
ment having for its object the prevention of in-
fantile mortality was organized. The work falls
under three headings, viz. to give advice to
mothers, to encourage breast feeding, and to dis-
tribute milk to those infants for whom breast
feeding is either impossible or insufficient. The
president is Dr. A. Devaux of Brussels, and the
general secretary is Dr. Eugene Lust of Brussels.
The subscription for members is twenty francs,
and for associates ten francs. The treasurer is
M. Sterckx, 3 Rue Beyaert, Brussels.

The Suit Against Dr. Doyen. — The Public
Prosecutor in the First Tribunal of the Seine has
presented his conclusions in the suit brought by
Mr. Geo. Crocker of San I^rancisco to recover
from Dr. Doyen $20,000 which the surgeon re-
ceived in 1904 as the result of a contract for treat-
ing Mrs. Crocker for cancer. The opinion uttered
was in Dr. Doyen's favor, and it was stated that
Mr. Crocker's contention that at least a portion
of the fee should be refunded was not well
founded, because Dr. Doyen had ceased his visits
only at Mr. Crocker's request, and not of his own
volition. .\ <lecision is to be rendered shortly.
Aid for the Famine Sufferers in China. — Nearly
$60,000 has been collected liy the Red Cross or-
ganization for the aid of the victims <if the
"famine in China. It is reported that smalli)ox has
broken out in the camps of the refugees, and that
the relief measures are wholly inadequate.

"The Journal of Inebriety" begins the fourth
decade of its useful existence with a new department
devoted to the physiological and psychological tlier-
apeutics of inebriety and drug addiction. To this
end arrangements have been completed by which
the Archk'cs of Physiolo^t^^ical Therapy has been con-
solidated with, and will hereafter be published as
a part of The Journal of Inebriety. Henceforth, in
addition to the various phases of this subject which
the journal has iiresented. the therapeutic effects of
hot air, radiant light baths, electricity, massage,
psvchotherapeutic measures, and other phvsiological
means will occupv a prominent space.

Dr. Byron Robinson's Jubilee. — The .liiieri-
■can Medical Compend of Toledo devotes its issue for
January to a celebration of the twenty-fifth anniver-
sarv of Dr. P>yron Robinson's entrance into the pro-
fession of medicine. This well-known anatomist
was graduated from Rush Medical School, Chicago,
in t882, and practised for a while in Grand Rapids.
Wisconsin. After studying in Europe for several
vears, he was called to the chair of anatomy in the
Toledo Medical College, which he occupied for two
years. In 1891 he removed to Chicago, where he
now resides, being professor of gynecology and ab-
dominal surgery in the Illinois Medical College, at-
tending gvnecologist to the Woman's Hospital, and
consulting surgeon to the Mary Thompson Hos-
pital. Dr. Robinson has earned an enviable reputa-
tion as an anatomist, an original investigator, and a
writer, and the storv of his work is told in the Con-
pend by more than a score of his ))upils and ad-
mirers.

Dr. Le Roy Broun of this city, at a recent meet-
ing of the governors of the Woman's Hospital in
the State of New York, was elected surgeon to
the hospital.

Dr. M. D. Lederman of this city has been ap-
pointed .\ttending Aurist and Larvngologist to
the Leliaudn Ibisiiital.

The Ninth Harvey Society Lecture will be
delivered Iiv Prof. W. T .Councilman, Professor of

Patholo.gy. Harvard University, at the New York
-Academy of Medicine, on Saturday evening, Febru-
ary 2.^, at 8:30 P..M. Subject: "The Relation nf
Certain Leucocytes to Infectious Diseases,"

American Anti-Tuberculosis League. — The
next meeting of this organization is to be held at
Atlantic City, N. J., June i to 4, 1907, under the
presidency of Dr. George Brown of Atlanta, Ga.
The •chairman of the Reception and Entertain-
ment Committee is Dr. Edward Guion. .Atlantic
City, N. J.

Saginaw (Mich.) General Hospital. — In con-
licction with this hospital a nurses' home has
been opened, with accommodations for thirty-six
)iersons. The building, together with the ftirnish-
in.gs. is the gift of Mr. and Mrs. Charles H.
I ;a\is of Saginaw, and is to be known as the
Davis Ntirses' Home. Miss Annie M. Coleman
IS superintendent of the hospital.

Brooklyn Home for Consumptives. — By the
will of the late Mrs. Mary H. Pratt this institu-
tion is to receive the sum of $10,000.

Bequests to Hospitals. — St. Luke's Hospital
and the Presbyterian Hospital of this city each
are to receive $7,500 for the endowment of beds
by the will of the late Mrs, Marv L Johnson,

Traill County (N. D.) Medical Society. — .At the
lecent annual meetin.g of this or.ganization offi-
cers were elected as follows : President, Dr. Mc-
Intyre: J'icc-Prcsident. Dr. Haagenson : Scere-
lary. Dr. .Anderson ; Treasurer. Dr. .Schanche.

Fifth District (S. D.) Medical Society. — .At the
meeting of this or.ganization recently held in Sioux
l'"alls, the following officers were elected : Presi-
dent, Dr. Hauge of Howard; i' ice-President . Dr.
Kaps of Winfred ; Secretarv-Treasurer, Dr. Fru-
denfeld of Madison; ( cnsur fur three \ears. Dr.
Duff of Madison.

Hillsboro (N. H.) County Medical Society. —
• officers as fi.illows were elected at the annual tneet-
ing of this society, held at .Nashua on February 7 :
President. Dr. (.leorge D. I .ane of Manchester ; Vice-
President. Dr. .A. S. Wallace of Nashua ; Sccretar\<
and Treasurer. Dr, I'.lla 1 Slav lock Atherton of
Nashua.

Roosevelt Hospital Tax Decision. — The Su-
preme Court has decided in favor of Roosevelt
Hospital a.gainst the city in the suit broti.ght in
its behalf to be relieved from $150,000 in taxes
on property which it owns, but does not use for
hospital purposes. The hospital has contended
that its property was exempt from taxation under
its charter granted in 1864.

In Memory of Pirogoff. — The twenty-fifth an-
niversary of the death (if the Russian surgeon Piro-
.goff is to be coinmemorated by the founding nf an
invalid home for incapacitated physicians and a med-
ical library.

Obituary Notes. — Dr. Aimh rii \\vvv of this city
died on Fel)ruary 14 as the result nf an attack of
.grip. He was horn in Prooklyn in 1X56 and was
graduated from the Medical School of the Univer-
sity of New York in 1877. He served as interne in
the Charity Ho.spital. and comiileted his medical edu-
cation abroad. He made a specialtv of diseases of
the respiratorv and circulator\- svstems, and held
several hospital and dispensary positions. ^ At^the
time of his death he was president of the West Side
Taxpayers' Association.

Dr. WiLLi.\M E, Kkxm---Iiv of Muske.gon, ^Nlich.,
died on Febmarv 7, at the age of thirtv-five vears.
After receiving a legal education, and being admitted

320

MEDICAL RECORD.

[Feb. 23, 1907

to the bar, he studied niedicini:, and was graduated
from the medical department of the University of
Michigan in the class of 1904. He had practised in
Montague and Ravenna.

Dr. John F. English of Providence, R. I., died
on February 9 of pneumonia, at the age of thirty-
one years. He received his medical degree from
the University of Vermont, and had practised for a
time in his native city of Stafford City, Conn. He
had been a resident of Providence for about a year
and a half.

Dr. Omar Routhier of Lawrence, Mass., died on
February 9 of pneumonia, at the age of forty-seven
years. He was born in Cape Rouge near Quebec,
and was graduated from the Montreal branch of the
Laval University about fourteen years ago. He had
practised in Lawrence since 1894.

Dr. Henry A. Gaffney of Salem, Mass., died of
heart disease on February 9. Dr. Gaffney was born
in Charlottetown, P.E.L, in 1847, and, after grad-
uating from St. Dunstan's College, received his med-
ical degree from the Harvard Medical School in the
class of 1870. Two years later he began practice in
Salem, where he continued to reside until the time of
his death. He was a fellow of the Royal College of
Physicians of London, and had occupied numerous
official positions.

Dr. Charles K. Yancey, past assistant surgeon,
U.S.N. , died on February 10 in the Government
Asylum for the Insane in Washington, D. C, at
the age of fifty-nine years. He was born in Culpep-
per County, Va., and entered the naval service
shortly after the close of the Civil War. His mind
became deranged as the result of a period of duty in
the tropics, and he had been an inmate of the Gov-
ernment Asylum for twenty-nine years.

Dr. William H. Donnelly of Worcester, Mass.,
died on February 8 as the result of a brain tumor,
at the age of twenty-seven years. He was gradu-
ated from the Baltimore Medical College in 1905,
and at the time of his death was house physician of
the Providence Hospital in Holyoke.

Dr. Joseph ]\Iitchell of Lynn, Mass., died of
apoplexy on February 7, at the age of fiftv years.
He was born in Oldtown, Me., and was a full-
blooded Indian of the Penobscot tribe. He received
his degree from the University of Ann Arbor, and
was said to have been at one time a very successful
practitioner.

Dr. L. S. Campbell of Los Angeles, Cal., died
on February i, at the a^e of eighty-five years, as the
result of a street car accident. He was born at
Smyrna, Del., and received his professional degree
from the Louisville College of Medicine in 18.^1.
He first practised at Carmel, Ind., but in 1875 re-
moved to Indianapolis. In 1901 he became a resi-
dent of Los Angeles.

Dr. John B. Str.'^chn of Petersburg, Va., died
on February 8, at the age of seventy-seven years.
Dr. Strachn was a graduate of the Jefferson Med-
ical College of Philadelphia, and had practised in
Petersburg for about fifty years. He sensed through
the Civil War as a surgeon in Rhodes's division,
Stonewall Jackson's corps.

Dr. H. Z. Gill of Long Beach. Cal., died on Feb-
ruary 6, at the age of seventy-six years. He was
born in Buck's County, and was a graduate of Jef-
ferson Medical College, Philadelphia.

Dr. John Barker of \\'oodbridge, Conn., died
on February 16 of pleurisy, at the age of seventy-
two years. He was graduated from the Yale Medi-
cal School with the class of i860.

EIGHTH HARVEY SOCIETY LECTURE.

The eighth regular lecture given this season
under the auspices of the Harvey Society was
delivered by Prof. Geo. S. Huntington, the well-
known anatomist of Columbia University, at the
Academy of Medicine, on Saturday, February 9.
In introducing the speaker of the evening the
presiding officer, Prof. Graham Lusk, spoke of the
splendid anatomical school which had been built
up by Prof. Huntington, and which was one of
the very few schools in which highly important
research work was systematically carried on. The
subject of the evening's lecture would be "The
Genetic Interpretation of Variations in the Geni-
tourinary Tract."

The lecturer began by referring to the aims of
the Harvey Society, and then said that the rea-
son for choosing the topic he had was because it
represented a field in which there had been
real, rapid, and constant advances in recent years.
He would endeavor to present the subject accord-
ing to the following general scheme : ( i ) He would
indicate briefly the more important facts in the
development of the genitourinary system as it
could be followed in the embryo. (2) Next he
would point out the analogues of these phases as
they were illustrated in the lower forms. (3)
He would give illustrations of various anomalies
as they were met with in the human subject.

The simplest type of a genitourinary system
would, of course, be a perforation in the colon
wall, so that the excretory products could find
their way out, and the fertilizing cells have ac-
cess to the generative cells. In the very earliest
period of the life of the embrj'o there were two
abdominal cords called the pronephron. These
cords were straight tubes which, in the amphibia,
served for both generative and urinary purposes.
The speaker then went on to say that the orig-
inal pronephron was very evanescent in verte-
brates, lasting only a few weeks. It soon atrophied.
Prof. Huntington next spoke of the develop-
ment of the genital gland, and of the me-
sonephros. The latter persisted, so far as kidney
function was concerned, in male and female am-
phibia. In the subsequent development of the
mesonephros in male amphibia certain of the
mcsonephric tubules associated themselves with
the sexual gland, converting the mesonephric
duct into the vas deferens. In higher organisms
certain structures were referable to the original
mesonephric tubules, and were of interest as
sometimes giving rise to the development of
peculiar cysts and tumors.

The development of the duct of MuUer was
next touched upon. This duct usually developed
as a tube parallel to the pronephric duct. It be-
came the functional genital duct in the female
type of higher forms. From it were developed
tiie Fallopian tubes and uterus.

The speaker showed by means of diagrams
how the early indifferent type could easily be de-
veloped into the higher amphibian type. In one
case the Wolffian for mesonephric) tubules con-
nected w^ith the genital gland — male, while in the
other case these tubules were atrophied, and the
Miillerian duct developed so as to be almost con-
nected to the genital gland — female type. In
either case this type could be developed still
further, as in the mammalia, merely by the de-
velopment of the permanent kidney as an out-
growth from the lower part of the mesonephric

Feb. 23, 1907]

MEDICAL RECORD.

321

duct. In this case, to be sure, the lower or uri-
nary part of the Wolffian tubules atrophied.

The speaker then discussed the migration of the
kidney and of the testes. The latter truly mi-
grated ; in the case of the former the migration
was largely only apparent, due to unequal growth
of tissues about the gland.

The room was then darkened and a magnificent
series of lantern slides thrown on the screen.
These showed preparations, made by Dr. Hunt-
ington, of a large number of animals, from the
very low to the highest forms. Some of the
slides were as follows :

Four pig embryos at different ages, showing in
the youngest the enormous size of mesonephros.
Lying behind this could be seen the pennanent kid-
ney. In the fully developed embryo very little was
left of the mesonephros.

Iguana showed the condition brought about
by retention of common mesonephroic duct
opening into acloaca. It also showed two separate
erectile organs, the analogues of the corpus
spongiosum, but not fused into one structure.

A preparation of the python showed a similar
condition.

In the turtle could be seen the fusion of the
two erectile masses into one structure. The
sexual duct, however, was merely a gutter along
the margin of this, and not a true tube.

A preparation of the Virginia opossum showed
the last remnant of the condition present in
reptiles. In this animal there was a bilateral slit
on the end of the penis.

The series continued through some of the
higher mammals, and ended with preparations
showing the carnivor types. This type was fairly
common in the human subject, e.e. bifurcated
kidney.

An interesting set of corrosion preparations of
kidney anomalies was shown. Among these were
^ double ureters, bifurcated ureters, etc.

Owing to the lateness of the hour the speaker
was unable to take up the final part of the lec-
ture, but invited all those interested to examine
with him the series of preparations of human
anomalies which had been collected for many years.

These were exquisitely mounted preparations,
representing variations of all kinds. In some
there was a persistence to a greater or less extent
of structures originally present and developed
beyond normal instead of atrophying. In others
there was a failure of certain steps subsequent
to the early development — as failure of certain
structures to fuse, of certain septa to disappear,
etc., etc. These anomalies were readily under-
stood in the light of the foregoing developmental
survey.

(llprrffipoitirnrp.

Tuberculosis of the Cecum. — Pauchet has been able
to cure four cases of tuberculosis of the oecum. one by
closed exclusion, another by exclusion treated secondarily
by section, and two by resection followed by laterolateral
anastomosis by the aid of a button. Tuberculosis in this
region may show itself during the period of activity (ulcer-
ative or caseous form) or after recovery, when it appears
in the form of cicatrical lesions, hypertrophic or pseudo-
neoplastic conditions, or as a stenosis. The treatment sug-
gested may be that of closed exclusion, which consists in
isolating entirely or in part the large intestine; open ex-
clusion in which a fistula is formed; or resection of the ileo-
cecal segment with closure of the two extremities, and an
ileocolic laterolateral anastomosis by the aid of a button.
The incision practised is that of McBurney, The patients
who have been operated upon have remained cured, one for
six years, one for four years, and the last for four months.
— Revue de Chirurgie.

THE RADICAL CURE OF TRIGEMINAL NEU-
RALGIA.

'1 0 THE Editor of the Medical Recokd :

Sir: — So much needless suffering to a very unfortunate
class of patients may be caused by the acceptance of such
statements as are made in an article entitled the "Radical
Cure of Trigeminal Neuralgia by }vleans of Peripheral
Operations," by A. V. Moschcowitz, M.D., in your issue
of February 16. that I venture to call the attention of
your readers to the errors in that article.

( 1 ) "We know nothing of the pathological anatomy of tri-
geminal neuralgia." This statement ignores die very
complete and positive results published by Keen and
Spiller in the Amcr. Jour, of Med. Sci., November, 1898,
and subsequently confirmed by them, and by Thomas' of
Paris in connection with liis studies of neuralgia of the
nitercostal nerves— and also by Redlich" in his studies of
tabes. The pathology of trigeminal neuralgia is known to
be a degeneration with vacuolization and atrophy of the
neurone bodies in the Gasserian ganglion, with secondary
degeneration cji their axones, and also a connective tissue
inflammation in the ganglion, and also endarteritis in the
small vessels within the ganglion. The same changes have
been found in the spinal ganglia in intercostal neuralgia
and in tabes.

(2) "All proof is lacking that the neuralgia originates
in the Gasserian ganglion." There can be no better proof
than the fact, of which I have personal experience in
more than a dozen cases, that when operations upon the
peripheral branches of the trigeminal nerve fail to re-
lieve (as they always do fail to give permanent relief) an
excision of the Gasserian ganglion or a division of the root
of the fifth nerve between the ganglion and the pons always
cures. I have never seen a relapse when the ganglion
was completely and properly removed, and the published
records of Hartley, who first did this operation in America,
of Krause, who did it simultaneously in Germany, and of
Keen, whose experience has been extraordinarily convinc-
ing in this line of work, amply confirm this conclusion.

These statements refute absolutely the other assertions
of Dr. Moschcowitz, which therefore require no notice.

I have seen so many patients who have been operated
upon in vain by various kinds of peripheral operations
and recently by osmic acid injections into the nerve
branches, and who have finally come to the radical opera-
tion after months of needless suffering, that I do not
hesitate to recommend the operation for excision of the
tiasserian ganglion, provided I can select the surgeon to
do it. I have seen failures only in incompetent hands.

Dr. Moschcowitz claims that it is to the regeneration of
the divided peripheral nerve that recurrence of pain is
due. That may be true, but I have cases on my records
where the pain has recurred after peripheral operation
too soon to be due to regeneration ; and other cases where
it has recurred when a half-inch of the nerve has been
exsected; and other cases ni which pain has returned and
at the radical operation no evidence of regeneration or
union of the formerly divided peripheral branch has been
found. Keen has similar records.

The cases cited by Dr. Moschcowitz are both too few m
number and are reported far too soon to afford any con-
vincing proof of his statements, but if his suggestions are
followed patients will be only temporarily relieved, if at all.

M. Allen Starr, M.D.

AIR DISTENTION OF THE BLADDER.

To THE Editor of the Medical Record :

Sir: — I hope you will pardon me for taking issue with
vou in regard to several of the inferences and conclusions
given in the editorial on "Distention of the Bladder with
b.xygen" (Medical Record. February 2). Taking them
seriatim: It is asserted that Nitze attempted to ^iise air m
the bladder in connection with cystoscopic work, "but aban-
doned the practice because of the possibility of producing
air embolism or of causing infection by germs carried into
the viscus with the admitted air." Nitze did not abandon
the use of air for the reasons named, but be-
cause (a) his cvstoscope lamps were hot and
would scorch the bladder wall if used with air;
(b) the lenses of his cystoscope receiving a smear
from the mucus of the urethra or bladder, would be put
out of use. The claim of Lewin and Goldschraidt that the
use of air in the bladder was dangerous because of the
possibility of embolism was made later by several years

'Iconographie photogrnphique de la Salpetriere, 1902,
Vol. XV.

■Redlich: Pathol der T.ibes. Jena, 1S07.

MEDICAL RECORD.

[Feb. 23, 1907

than the time of Nitze's attempted use of air; and the
fallacy of the claims of Lewin and Goldschmidt has been
demonstrated, during the last six or eight years, by the
countless times in which it has been used without any such
effect, and also by experimental demonstrations. Since
practically all cystoscopes of the present day are supplied
with lamps that are of low tension and without sufficient
heat to cause discomfort even, ihe a>serlion that the in-
jected oxygen does away with an objection to air on this
score (that "the heat of the electric bulb of the cystosct)pe
is also not found objectionable"), loses its apparent force.

While radiography for vesical calculi is interesting as a
study, its value in the clinic does not compare with the
more definite and satisfactory returns from cystoscopy in
that condition ; so tliat the quoted assertion of the authors
of the use of o.\ygen. that it presents a distinct advantage
in making radiographs "wlien tlie presence of calculi is
suspected" is of questionable practical value. One thought
suggested by the above is tlial if the conclusions of the
authors are as much at variance with the actual conditions
as their premises, their work promises little of value. How-
ever, this is to be determined by applying the o.xygen to
clinical uses.

Br.\.\sfokd Lewis. M.D.

St. Lol'is. Mo.

MED1C.\L TRK.-VTMENT OF .A^PPEMDICITIS.

To THE Editor of thf, Medic.\l Record:

Sir : — Pfister's statistics on appendicitis treated with ice
and opium, commented upon in the Medical Record of
February 16, are in accordance with my own observations.
Very many appendicitis patients will recover from single
attacks, under ice and opium treatment — more in fact than
will recover under unskilful surgical treatment. But are
there not surgeons whose death rate in appendicitis is
only one or two per cent., taking all classes of cases as
they run. and refusing none? The fallacy in statistics like
Pfister's lies in the fact that the report is incomplete. He
does not tell us what happened to the patients in their sub-
sequent attacks, or if they were where ice and opium treat-
ment could be properly carried out by other physicians. He
does not tell us how many of these patients suffered from
gastrointestinal disorders of chronic character, due to peri-
toneal adhesions resulting from the infection. He does not:
tell us of the time wasted in bed by patients who would
have been out proniDtlv after nice surgical treatment.
He does not tell us of the nroportion of patients who may
have post-operative ventral hernia, because of the kind of
'operation that mav he required for cnmnlications in subse-
quent attacks— complications that would have been avoided
by proniot and proper attention of the kind that is based
upon sufficient data. I do not know how the German sur-
geons will accent Pfister's statistics, but in .America they
would be considered as unscientific and incomplete in char-
acter and mischievous in their influence. There are perhaps
few surgical naticnts who are easier to save, or easier to
lose, than anpendicitis oatients. Some time ago I published
letters from ten consecutive appendicitis patients who hacl
been onerated upon, and who had had medical treatment
in nrevious attacks. Everv one of the natients stated that
under surgical treatment ther had suffered less than thev
did under medical treatment nreviouslv. Some of the.sc
patients had_ been treated bv the ice and opium method.
Pfister's statistics do not bring nut points of this character.

Robert T. Morris, M.D.

616 M.\DISON .\VEXUE.

OUR LON'DOX LETTER.

(From Our Special Correspondent.)

THE OKICI.^f OF LIFE — TRAINING OF RECRITITS, D.\KGERS OF
DRILL — CEREBROSPINAL MENINGITIS — OBITUARY.

LoN-DON', February i. 1007-
Those who take an interest in iliscussions on the Origin of
Life may remember the part taken by Dr. Charlton Bastian
in the early seventies, when he showed himself a stout
controversialist and an experimenter. Since then his prac-
tical work as a clinical physician and teacher at Universitx'
College and the National Hospital for Paralvsis has brought
him a great reputation. ?nd his contributions on neuro-
logical subjects are liighlv esteemed. Probably vnu i-^
agree with me that they are of more value than his specu-
lations. He has, however, returned to his e.xperimental
investigations, and last week at the Medico-Chirurgical
Society read a paper on the "De Novo Origin of Bacteria.
Bacilli. Vibriones. Micrococci. Torute, and Moulds." in
certain previouslv suoerhcated saline solutions contained
within hermetically sealed tubes. The solutions contained
amnioniacal salts, and he said the best results were from

two solutions — one having small quantities of sodium
silicate, ammonium phosphate, and dilute phosphoric acid;
the other, sodium silicate and hq. ferri pernit. With these
solutions, he said, exposure to diffuse daylight at only 60° to
65° F. favored the appearance of microorganisms as much
as darkness in an incubator at 95° V. The solutions were
put in superheated tubes, scaled, and again heated to 239''
I", and up to 266° V. for ten to twenty minutes. In all
lubes after this a small deposit of silica or of iron silicate
was thrown down. The tubes were then exposed to day-
light or put in an incubator for periods of five weeks to
four months. When opened he found in varying abundance
one or more kinds of organisms, of which he showed pho-
tographs. No carbon was present in the solutions but
its chemical ally silicon. Such solutions are nourishing
media for organisms — can they engender the living units?
was the question for the experimenter. After careful
search Dr. Bastian said organisms were always found on
or within the substance of the flakes of silica, while the
fluid above was perfectly clear and remained so ior months,
though the organisms were swarming on the silica.
Some were found in flakes taken from tubes from which
all air had been expelled by boiling when they were her-
metically sealed, so that no carbon could be present unless
it had existed in the chemicals or distilled water. Even in
tubes which did contain air this was always separated by a
deep layer of the fluid itself from the deposit. As silicon
replaces carbon in some organic chemicals, it was con-
tended that these experiments give evidence that silicon
may enter into the composition of protoplasm in place of
carbon. As to the larger question of the origin of life.
Dr. Bastian said that if the tubes were opened a few hours
after heating no organisms were detected, but similar
tubes, after longer exposure, contained them. They were
always motionless, so had sprung up and multiplied in the
sites where found. Dr. Bastian argued that they must have
been engendered de novo, because, apart from spores of
bacilli, no organisms could resist boiling for two or three
minutes, and spores were killed by the same exposure to
239° F. The forms assumed he compared to crystals — re-
garding each as the resultant of the molecular constitution
of their initial units on the particular media and surround-
ings in wdiich they occurred. The lucidity of this explana-
tion possibly your readers may appreciate.

Professor Starling lent a certain amount of supoort to
Dr. Bastian's thesis, on the ground that inorganic material
becomes organic in the body, and we call the change as-
similation. Dextrorotatory sugars, he remarked, can be
assimilated, but invert sugar cannot. But he could not deny
that there was a great gulf between such assimilation and
the production of new life. If it be maintained that higher
forms of life are continuously evolved from lower forms,
the process might not stop at the lowest, and it seemed
natural to seek for a bridge to span the gulf that separates
the living from the non-living. Even in the body the red
blood cells were on the border line, and when killed by
formalin gave reactions which were considered character-
istic of livin.g cells. In the fortuitous concourse of atoms
it might be supposed that a substance capable of growth
might occur, and. if it had stability enough, acquire a
power of adaptation to environment indistinguishable from
living protoplasm. Even then it w-ould only be the pabu-
lum for more highly organized bodies, and it could only
s-urvive under such conditions as Dr. Bastian's tubes pro-
vided. The practical question was whether the bodies
found in these experiments were really alive. He did not
admit that this was proved. .A plate culture would be some
evidence, but cultivation would have to be under the same
conditions as those under which the organisms had been
formed.

Dr. E. W. Goodall said he did not feel satisfied that the
tubes had been perfectly sterilized, nor that the motionless
bodies exhibited were actually alive. How could their life
be recognized?

Dr. Bastian replied that his tu.bes w-ere subjected to a
very high temperature and. after being filled, exposed
further to 266° F. for twenty minutes, which would cer-
tainly kill all organisms and spores. In the tubes opened
in a few days nothing could be found, but in those exam-
ined later organisms swarmed in every drop. They not
only increased in the tubes, but multiplied under suitable
conditions after removal to a slide. Some were unlike any
hitherto described.

.At the Roval L'nited Service Institution, on Wednesday,
Lt.-Col. F. .'V Davy, M.D.. late of the .\rmv Medical Corps,
brought a grave in''ictment against the methods of training
recruits Surgeon-Ge"eral T T. Gallwav. P.M.O.. of the
.Aldershot .Army Corps, presided, and an interesting dis-
cussion took place. Col. Davy regarded the setting-up drill
of recruits as a main cause of diseases of the circulatory
system and the invaliding of many soldiers. Mechanical
obstruction and strain were imposed on the heart. There
ought to be nothing in drill that would not benefit even a
defective man. but the system of military drill in vogue

1'

Feb. 23, 1907;

MEDICAL RECORD.

i^i

WAi injurious to the strongest, and was iraininsj with a blot
in it. The measurement of the recruit's chest might be in-
creased by it, but only at the e.xpense of motility and of
vital capacity. Sooner or later it became distressing — ex-
haustion after morning drill indicating danger. Col. Davy
was sure that in the majority of men invalided for heart
disease — excluding rheumatic cases — the early link in the
pathological chain was forged on the drill ground. Before
appearing at the hospital there would be a long period O'
discomfort, heart beating, dyspnea, etc., for which th ■
young soldier blamed his recently-donned pack or valise,
forgetting that before enlisting he could have carried it
easily enough. Tight clothing was bad, but the attitude
was worse. The result of keeping e.xpiration in abeyance
was a disturbance of the balance between pulmonary and
systemic circulations. The chest swelling adopted by drill
sergeants must be followed by injury, for it was in contra-
vention of physical laws. The evil was greater because it
wa; done in the name of good. It produced deserters as
well as invalids. What was often called fine physique was
really deformity. He held that this chest swelling was con-
tributing largely to the waste of the army. The remedy
was easy — merely to abstain from chest dilatation, from
directing the forepart of the feet to bear the weight of the
body and movements designed to "open the chest." Col.
Pollock, at Hounslow, used no breathing exercises.

Col. Rolt, Inspector of Gymnasium, hinted that the- author
was not quite up to date, as the army council lately adopted
a system based on the Swedish, which, he thought. Col.
Davy would approve. The drill book was to be altered
accordingly.

Col. G. M. Fox said in hi* experience soldiers did not
"blow themselves out" except at inspections. Deep inspira-
tions and expirations kept up the motility of the chest.

Dr. Deane thought the position of "Attention !"' was
neither esthetic nor useful. The natural position of a man
was erectness without rigidity. He thought the .A.rmy
Gymnastic Staff should have charge of drilling, under the
superintendence of the .^rmy ^vledical Corps.

JNIaj. Moore said Col. Pollock's company were all picked
men and superior to the ordinary recruits, both physically
and intellectually, so his success proved nothing. He
thought Col. Davy had pointed out the blot on the system.
The root of the evil was hurrying the training too much.
General Sir J. Moody said he never knew men in the
marines to suffer from the effects of setting-up drill.

Cerebrospinal meningitis is causing some deaths. At
Glasgow the Health Office reports that thirty-three cases
were notified during January, and that seventeen proved
fatal. The disease seems making headway among children,
and has been placed under those notifiable. At Leith two
deaths have been registered, one on January 15, the other
on January 29. One of these occurred in the Lcith Hos-
pital. The M.O.H. has had the houses of the patients disin-
fected and taken all precautions. The man who died on
the 29th had been working in Leith Docks on a steamer
which had arrived from .\merica. Notification has not yet
been made compulsory at Leith.

The death of Sir j\Iichael Foster, which took place rather
unexpectedly on Tuesday, while on a visit to London, de-
prives us of a leading physiologist closely identified with the
profession. He was a University College student, whence
he graduated B.A. and M.D. at the University of London.
For five or six years he practised at Huntingdon, where he
was born in 1836, his father being a surgeon in the town.
In 1867 his college made him Demonstrator, and two years
later Professor of Physiology. In 1870 he w'ent to Cam-
bridge as Praelectnr at Frinity College, where he became a
Fellow. In 1883 the University gave him the professorship.
Soon after entering Trinity he was elected F.R.S., and in
1881 he was appointed secretary in succession to Huxley,
who became president. He was knighted in 1899, and the
next year entered Parliament as representative of the Lon-
don L^niversity. He rather disappointed his supporters
there, though on some subjects he was listened to with
close attention. He was elected as a Liberal Unionist, but
when the Fiscal controversy arose he ranged himself with
the Free Fooders, and after a time crossed the House to
the Liberal side. At the last election he lost his seat.

Mr. C. J. Oldham, F.R.C.S.. Surgeon to Brighton and
Sussex Eye Hospital, died on January 24, aged fifty. He
was a Guys student and served in the several resident posts
at that hospital and then became clinical assistant at Moor-
field's and Assistant Surgeon to the Central Ophthalmic
Hospital. At the International ODhthalmological Congress,
in London, in 1872, he read a paper on an improved re-
fracting ophthalmoscope, and demonstrated its value. He
v.-asthen settled at Hove. Brighton, where his skill as an
oculist had secured him a large practice. Outside his pro-
fession his hobby was music and the collection of rare
violins.

The late Dr. Savage, who was killed in the earthquake at
Jamaica, had since his retirement made se\eral trips to the

\\ est Indies. In a long and active career at Birmingham
he had reaped abundant success and distinction. He was
Surgeon to the Hospital for Women from its foundation,
had been lecturer at Sydenham College and Queen's Col-
lege. At the latter he held the Chair of Midwifery, and on
it merging in the University of Birmingham he was made
the first professor of the subject, his colleague at the
Women's Hospital taking the professorship of Gynecology.
Dr. Savage was also Consulting Surgeon to Hospitals at
Wolverhampton and Kidderminster, and had been President
of the British Gynecological Society. His Ingleby lectures
on "Abdominal Section," in 1881, and his papers on "Uter-
ine ?iIyoma," and other points in the specialty, are worth
notice, though his practical skill and success as a Surgeon
in the department overshadow his literarv contributions. He
was M.D.. S'.I., A.M., 1862; F.R.C.S., 1869. Later he
joined the College of Physicians. He was also F.R.S.,
Eden., and became a J. P. and a Countv Councillor for War-
wickshire.

OUR BERLIN LETTER.

(From Our Special Correspondent.)

C.\RCINOM.\ OF THE APPENDIX — A NEW' HE.-\RT DRUG — CRIPPLES
IN GERMANY — HAY FEVER — GOITER — INCREASED FEES FOR
MEDICAL MEN — BIRTHDAYS OF BERGMANN AND WALDEYEK.

Berli.v, January 10, 1907.

.^ PAPER on primary carcinoma of the appendix was read
recently by Landau before the Medizinische Gesellschaft.
In performing a hysterectomy for myoma of the uterus the
appendix was found thickened at one point and it was ac-
cordingly removed. Microscopical investigation showed
that a carcinoma simplex was present. The speaker said
that he had been able to find records in the literature of
only fifty-eight such cases, and that in a quarter of these the
tumor was not diagnosticated before autopsy. In 50-60
per cent, of all cases the new growth originated in the
tip of the appendix, and women were more frequently in-
volved than men. The age of the patients varied from
eight to eighty-one years, though most of them were be-
tween forty and fifty. The symptoms w'cre the same as
those of a simple appendicitis, though the pain had a ten-
dency to be dull rather than acute. Only in six cases has
surgical intervention been carried out on this account, the
organ usually being extirpated because it was discovered to
beiliseased in the course of other operations.

.\ remedy wdnich may possibly be found of use as a
substitute for digitalis always merits the interest of phy-
sicians. Such a remedy, found in the Acoka'ithcra sihim-
t-eri. was described by' Lewin in a paper read before the
same society. In 1888 there was obtained from an arrow
poison named ouahai. a crvstalline glucoside. which was
called ouabain. Recentlv the speaker had been able to
isolate from the leaves of the akocanthera an amorphous
glucoside ouabain which had the same composition as the
crvstalline form, but possessed greater influence on the
heart. The effect of O'.iabain was a hundred times stronger
than that of digitalis, and a rhinoceros could be killed in
twentv minutes by an amount equal in size to a bean. The
glucoside slowed the pulse and increased the heart action,
the systolic impulse being more powerful and causing a
better filling of the vessels. In a dog weighing twelve kil-
ograms the injection of i millogram of ouabain caused the
blood pressure to rise from 153 to 213 mm. of mercury.

A short time ago the first Berlin Orthopedic Hospital
was opened. The building contains only ten beds, but it
is expected that this number will soon be increased In
his opening address the director. Dr. Ricsalski. pointed out
the importance, from the economic standpoint, of a proper
svstem of caring for cripples. In Germany there are about
twentv institutions of this sort, though not all are under
medical control. The statistics of the institution for
crippled children in Munich show that during the past
seventy-five years 93 per cent, of the children treated have
been enabled to earn their own living. In Berlin the last
enumeration of the crippled showed that there were 2,700.
.Assuming that the total for Germany is 100.000. it may
be estimated that if proper measures were taken 90.000
persons now more or less dependent on outside aid could
be made capable of earning their living.

A paper on pollen endotoxin was presented bv Woltt
before the Vcrein fur innere Medizin. He said that hay
fever began a fortnight sooner than usual this year on
account of the earlv spring. The serum treatment succeed-
ed in mild cases, and in those of medium gravity, hut was
without success in very severe ones. The speaker l"™er
stated that the affection was much more widespread than
was generallv believed, because many cases of rhinitis vyere
caused bv pollen, and. therefore, diagnostic inoculations
with pollen antitoxin were of importance especially tor
army nhvsicians. .^s prophvlactic measures he recommend-

324

MEDICAL RECORD.

[Feb. 23, 1907

ed packing the nose with absorbent cotton or some other
form of filter for the air entering the nostrils. .'\s the con-
junctivas were often the starting point of the affection,
the wearing of eye glasses surrounded by a padding of
cotton was advisable.

Hildebrand, at a recent session of the Medizinische Ges-
ellschaft, reported his ob.servations on goiter and its treat-
ment. He pointed out that it was not always the largest
tumors that caused the greatest disturbances. Growths
extending under the sternum and under the ribs could
easily compress the lungs and large blood-vessels. The
external application of iodine was not successful, and its
internal use was effective only in recent cases of follicular
goiter. In older persons operation was the only remedy.
Injections of iodoform were not without danger, they did
not entirely relieve the patient, and rendered succeeding
operations more difficult. The operation was much facili-
tated by using local anesthesia. Kocher's method of skin
dissection, and preliminary ligation of the blood-vessels.
Performed in this way the mortality of the operation was
■3 to .5 per cent. The prognosis of malignant disease of the
thyroid gland was particularly bad, for thrombosis of
the veins occurred early. Out of thirty cases the speaker
had had only one remain free from recurrence for a year.

The medical societies have united in taking a step which
the exigencies of modern life have rendered imperative.
For half a century the honorarium of the physician has
remained the same, although the expenses of living have
increased greatly. The medical societies have, therefore,
announced that with the beginning of this year fees for
medical services would be increased.

The past months have shown that Berlin is not lacking
in evidences of appreciation of its great medical men. On
the occasion of Waldeyer's and Bergmann's seventieth
birthdays a celebration was held which was participated in
by the members of the University and a large number of
physicians. The practitioners especially owe much of their
satisfactory standing to Bergmann's efforts. His merits
as a surgeon are well known, and I will say only that
much of his most important work was done in the province
of military medicine. In 1897 he founded the Berliner
Rettungsgcscllschaft. an organization intended to give first
aid in cases of accident. He also established a bureau for
the providing of adequate nursing and medical treatment
for the poor in their homes. In 1899 he was elected a
member of the Aerztekammer, and he rarely misses a
session. It was through him that the present free courses
for postgraduate study were organized, and the erection of
the splendid new Kaiserin Frederich Haus was also largely
due to his efforts.

OUR CONSTANTINOPLE LETTER.

(From Our Special Correspondent.)

THE RUSSIAN HOSPITAL AND ITS CHIEF, DR. VLADIMIR
STCHEPOTIEW.

CoNSTAKTiNOPLE, January 8, 1007.
One of the most interesting and most admirably equipped
charitable institutions of the Ottoman metropolis is un-
doubtedly the Russian hospital. Its chief. Dr. Vladimir
Stchepotiew, has been kind enough to conduct me through
all its various departments, wards, laboratories, surgical
rooms, etc., showing and explaining things with that un-
tiring sympathetic affability w-hich is characteristic ol
almost every educated Russian gentleman. Dr. Stchepot-
iew is quite naturally very proud of his hospital, because
it is, in all its present working order and efficiency, entirely
his creation. During the sixteen years of his administration
of it many important improvements have been accomplish-
ed, many innovations introduced, many modern essentials
added. All has been done step by step with much judicious
care and circumspection, with unabated energy and gener-
ous though wise expenditure of money, until the charitable
institution has become, what it is now, an up-to-date model
of a hospital establishment, with all the latest requirements
of medical science.

Not without particular interest is the history of the
origin of this establishment. The first foundations of a
Russian hospital in Constantinople were created about 1869
by the then Russian Ambassador, General- Adjutant Count
Ignatiew. He was the first to recognize early the necessity
of an infirmary on the banks of the Bosphorus for the
large numbers of people of Slavonic nationalities, such as
the inhabitants of Macedonia. Albania, Montenegro, Bul-
garia. Russia, etc.. who continually pass through and
flock to the magnificent metropolis on the ever-ine.xhaus-
tible, mighty Thracian stream. In the mentioned year
Count Ignatiew opened, with the sanction of the Russian
Government, in Russia as w^ell as among the Russian sub-
jects resident in the Ottoman Empire, subscription lists

to gather contributions for his hospital scheme. In the
course of four years the free offerings amounted to 39,000
roubles (something about $15,000). In the beginning the
Russian Ambassador experienced some difficulty in ob-
taining proper grounds for the building, as the greater
part of land in Constantinople and in other parts of
Turkey is so-called "vakouf" property, that is to say, it
belongs to mosques and Mussulman religious institutions,
is therefore sacred, and must not be sold to Europeans.
The original piece of ground bought by Count Ignatiew
happened to adjoin a "tekke" (Mahomedan monastery).
The Turkish Government, in consequence of that, objected
to the erection of a hospital on that place, and bought it up
for 5,000 Turkish liras (about $20,000). Other grounds
were bought, more appropriate and extensive, where the
first buildings of the hospital were erected. Soon after-
ward, in 1873, the Emperor Alexander II sanctioned a
grant for the Russian hospital to the amount of 130,000
francs. A committee was there and then appointed under
the presidency of Count Ignatiew, the .Embassador, to
establish rules and regulations concerning the administra-
tion and management of the hospital. The following
points in these rules and regulations are of general interest.
The hospital, which is dedicated to Saint Nicolaus, is to
be under the direct patronage of the Russian Ambassador.
The aflministration is entrusted to a committee consisting
of the Russian Consul-General, the chief physician of the
hospital (at present Dr. V. Stchepotiew), the doctor of
the Embassy, and a secretary appointed by the Ambassador.
The committee has to meet once a month. The hospital
is open to everybody regardless of nationality. Preference,
bow-ever, is given to Russian subjects and to Slavs. Every-
thing concerning the medical management is under the
direct supervision of the chief. . . The present three-

story building of massive stone was erected in 1875 by the
means of Mr. Shabouroff, who some time previously
gained from the Turks, through the assistance of the
Russian Embassy, a very big lawsuit. The then living
Princess Alexandra Petrowna took the hospital under her
patronage and made a generous offering to it of all the
necessary linen, crockery, and bed-covers. She also order-
ed that Russian sisters of charity should be sent to the
hospital to attend to the patients. In 1876 an ukase was
issued that certain taxes should be levied in aid of the
Russian hospital from every commercial sailing vessel and
steamer passing through the Bosphorus and from every
passport of Russian subjects coming to Turkey. All the
poor, however, are exempt from this tax. In 1889 the
committee of the hospital found it necessary to create the
post of a chief medical administrator, which should be
free and independent, and in the following year Dr. Vladi-
mir Stchepotiew, then working with Professor A. A.
Ostroumoff in the university of Moscow, was called to fill
this important post. He has held it now, as already men-
tioned, for sixteen years, with admirable skill and energy.
The buildings of the hospital proper, with all the adjoin-
ing constructions, which are quite numerous, occupy an
excellent position in the most salubrious district of Con-
stantinople called Pancaldi. on an elevation of 300 feet
above the sea level. From the windows of the chief build-
ing a magnificent view unfolds before one's eyes. A
broad, extensive, ever-green valley stretches down to the
deep and pure current of the Bosphorus. Beyond are
seen the famous Scutari cypress woods, the Marmora Sea,
and further still, on the very horizon, the so-called Prin-
cess Islands, summer resorts of the well-to-do inhabitants
of the Ottoman metropolis. Not far from the hospital is
the quarter Nishan-Tash. where are the residences of
the Grand Vizir, ministers of State, and dignitaries of
Yildiz-Kiosk. The extensive grounds of the hospital in-
clude two gardens and twelve different buildings : the
infirmary proper, the houses of the chief medical man
and his "assistant, an ambulatory, a house for the care-taker,
a beautiful church, a house for the priest and his assistants,
a post-mortem room, a separate building for ser\-ant5, a
laundrv. a Turkish bath, and a separate house for venereal
cases. There is also a spacious terrace which is joined to the
principal building of the hospital by a covered glass gallery.
On this terrace patients with chest troubles are able to
promenade in suitable weather, breathe the fresh air from
the Pontus. and enjoy a magnificent view of the scenery
around. There is on it also a veranda which shelters from
the cold north winds. Here spend a greater part of the
day such patients as need much pure out-door air. The
principal building is, as already mentioned, of stone and
consists of three stories. In each story there runs in the
middle from one end to the other a broad corridor well
ventilated and with plenty of air and light. In the lower
story there are a large dispensary and a laboratory. The
second floor contains excellent operating rooms with all
the modern requirements of surgical science, four large
rooms for paying patients, where one receives the best

Feb. 23, 1907]

MEDICAL RECORD.

325

possible treatment fur forty piasters daily (about $2) ; the
reception room of Dr. Stchepotiew, apartments for the
sisters of charity, and a bath room. In the third floor
there are five chambers for paying patients, and the wards,
with thirty-three beds for free patients. The kitchen is in
a separate building. On every floor there is a large filter
apparatus supplying, under pressure, quantities of pure
drinking water. The heating is done with stoves more or
less resembling those seen in Holland, with the only dif-
ference that they contain inside iron tubes. For more
efficient ventilation the windows are provided with frames
of the system of the Swedish authority, Dr. Chastaing.
This system consists in two parallel panes inserted in the
upper part of the window frame at a small distance one
from another, and in a manner that the outer pane leaves
below and the inner one leaves above an open space of
two centimeters breadth. In this way the outer ajr has
free communication with the inner without creating any
draught. The hospital is provided with a thermo-syphon,
which provides in each story a constant supply of hot
water. All the rooms and corridors are oil painted.

The staff of the hospital consists of two medical men,
the chief and his assistant, six sisters of charity, a general
medical assistant, and a care-taker. There are also eleven
servants. For difficult surgical operations the services of
Dr. Cambouroglou Pasha, chief of tlie surgical department
of the German hospital, are secured. From 1881 to 1887
the annual number of patients treated in the wards did
not exceed 300. From 1893 to 1899 the number was over
400. For the last five years the average has been 350. The
average annual number of patients received in the ambu-
latory was in the last few years over 11,000. All these
patients were treated and supplied with the necessary drugs
free of charge. The out-patient department of the Rus-
sian hospital is the most frequented. The numbers are
constantly increasing, and reached last year to about 13,000.
The greatest number of natives consist of Turks, Greeks,
and Armenians. The hospital patients are mostly Rus-
sians. Bulgarians, Servians, and other Slavs, and many
Jews. Some years ago a charitable fund was created for
the purpose of helping the poor patients on their leaving the
hospital after being cured. Contributions are received
mostly from Russian subjects serving in Constantinople.
At present the fund has a little over 2,200 roubles. The
diseases treated are generally typhoid fever, pneumonia,
articular rheumatism, and consumption. The yearly statis-
tics show that, generally speaking, the following five
classes of people form the largest contingent of those re-
ceived into the hospital: Laborers, sailors, gardeners, ser-
vants, and monks. As already indicated, every credit is due
to Dr. Vladimir Stchepotiew's energy and administrative
wisdom and circumspection, as the perfect state of the
Russian hospital, as it is seen and admired at present, is
entirely his work. Mention should be made also of the
valuable efforts of the Russian Consul-General, Mr. Pan-
affidine, whose wife is an American lady, who does all in
his power to advance the prosperity of the hospital.

OUR LETTER FROM THE PHILIPPINES.
(From Our Special Correspondent.)

APPROPRIATIONS FOR NEW HOSPITALS — SANITARY IMPROVE-
MENTS AT BILIBID PRISON — TEMPORARY NATURE OF WOODEN
BUILDINGS — CHOLER.\ — A POSSIBLE EXPLANATION OF PERI-
ODICAL OUTBREAKS — PERSONAL.

Manila. P. I.. December 31. 1906.

The activity of the Bureau of Health in keeping before
the public the inadequacy of the present hospital facilities
in Manila and the great need for additional quarters for
the care of the sick has at last received concrete recog-
nition in a recent appropriation bill of the Philippine Com-
mission. Fifty thousand dollars were appropriated for a
new hospital at Bilibid Prison ; ten thousand for the in-
stallation of a proper sewer system and toilet facilities,
and ten thousand for the installation of sanitary beds,
instead of the present iniserable vermin-ridden bamboo
bunks : and twenty-five thousand for the construction of
an addition to the present San Lazaro Insane Hospital.

The hospital at Bilibid will consist of an administration
building with two wings, one for the care of tuberculous
prisoners and the other wing for general diseases. It is
also the intention to send at least 1,000 prisoners to the
penal settlement on the island of Palawan. With the im-
proved hygienic conditions which will result from the
above mentioned changes, it is thought that the morbidity
and inortality among the prisoners will be materially de-
creased.

With the addition to the insane hospital at San Lazaro
that institution will then be able to care for 350 insane,
which will relieve, at least to a certain extent, the press-

ing appeals which are constantly being made on behalf
of these unfortunates.

The material for the construction of the insane hospital
is to be of reinforced concrete, which will make a per-
manent structure and one that will not suft'er very much
from deterioration. The experience which the Government
has had since the American occupation in the construction
of buildings has been sufficient to show that structures of
Oregon pine, red wood, or other soft wood are most
temporary in character, the destructive influences of a
tropical climate causing their complete deterioration in
a few years. The white ant is probably responsible for
most of the damage, and is a pest which it is difficult
to guard against, because it enters a building through
sniall tunnels and never works in the open. Very often
its presence is not detected until the building collapses,
when it is found that nothing remains but a shell of wood,
the entire core or pulp having been eaten out. Dry rot
is another important factor in the early decay of wooden
structures; so that, while a stone and cement structure
costs more in the be.ginning, it is very much cheaper in
the end. Many of the army posts throughout the island,
which were constructed during the early days of Arnerican
occupation, have been entirely destroyed by the white ant.
There are also numerous other forms of animal borers that
shorten the life of wooden structures.

Cholera seems to have almost entirely disappeared from
the island of Luzon ; in fact, there is very little remaining
anywhere in the Philippines. For the week ended De-
cember 22, 1906. fifteen cases and six deaths were reported
in the province of Capiz, on the island of Panay, and four
cases with four deaths in Oriental Negroes. This would
indicate that the epidemic is about to terminate. The
disease has been reported at a number of places, but upon
investigation it was found that the victims had partaken
of large quantities of green rice. According to native
phvsicians many deaths occur yearly in the Philippines from
this cause. The fact that there has been no spread from
these suspicious cases would seem to indicate tliat the
diagnosis of rice poisoning was correct.

Since Kline's announcement that plague organisms prob-
ably show different degrees of virulence, depending upon
the' condition of the envelope which surrounds the organ-
ism, considerable speculation has been indulged in, in
the Philippine Islands, as to whether the periodical out-
breaks of cholera, and, in some instances, its rapid disap-
pearance, cannot be accounted for upon the same theory.
It would seem possible that certain weather conditions
and an environment favorable to changing the character
of the envelope which might surround the cholera organ-
ism would probably account for the cholera which has
been encountered in the Philippines during the last six
months.

So far there has been no official report made by the
committee appointed by the Governor-General for the
purpose of investigating the responsibility for the deaths
of the prisoners in Bilibid Prison, who were inoculated
for cholera protection, and of which mention has beeii
made from time to time. It is known, however, that of
the twenty-four prisoners inoculated thirteen have suc-
cumbed, and that there are a number of others wdio are
in a very precarious condition.

Dr Jos B. Girard, Colonel. Medical Department, U. i>.
Armv. who has been Chief Surgeon, Philippines Division,
for the past few years, has completed his tour of duty
in the islands and returned to the United States on the
\rmy transport which left December 15. 1906.

Dr. Charles B. Byrne, who has been Chief Surgeon of
the Department of Luzon, was made Chief Surgeon, Philip-
pine Division, on the departure of Col. Girard.

Dr Win. H. Cook. Contract Surgeon, U. S. Army,
recentlv stationed at Camp Bean, Samar, and who was
formerly a medical inspector of the Bureau of Health,
has returned to the United States.

Dr F W. Dudley, Assistant Surgeon, St. Paul s Hospital,
Manila, has returned to the Philippines after an extended
visit to the United States.

Determining the Sex of the Fetus.— In regard to^ this
Sheill says that "a still tongue makes a wise head, _ but
gives the following as the result of his own observations.
The rule followed was that if the fetal heart rate is 141
or less, the child will be a boy; if it is 147 or more a girl;
and if between these two limits the sex is doubtful. In
-500 cases the prediction was correct m 56 per cent; onriit-
tin<r those cases in which the women were already m labor
the percentage of correct predictions was 73 : while count-
ing only primiparas mist.ikcs were made a P^'^t'l'-''' "I "°'
more than one-tenth of the cases.-D»W';i Journal of Med-
iicl Sciencr.

326

MEDICAL RECORD.

[Feb. 23, 1907

A'ezv York Medical Journal, February 9, 1907.

The Scranton Typhoid Epidemic. — J. M. Wainwright
presents a preliminary commnnication on this subject.
Up to Januarj- 31, a period of nearly two months of the
epidemic, 1.121 cases had been reported, with a inortal-
'iy of about y per cent. The epicjemic is now on the
decline, on^y four new daily cases having recently been
reported. The direct source of the outbreak was an
infected water supply, but what infected it has failed
to come to light after a most rigid investigation. Tlie
outbreak was practically confined to persons using
water from a particular reservoir, and to those in per-
sonal contact with such cases. The principal supplying
stream of the reservoir receives a few miles above the
sewage of a town of some eight hundred people. The
city has had in past years comparatively little of the
disease. The cutting out of the water supply from
the infected reservoir from the general citj' water
mains broke the force of the epidemic at once. The
author details the special municipal and household reg-
ulations which were instituted. Nothing is stated con-
cerning any peculiar clinical features of the outbreak.
He pays a handsome tribute to the Mayor of the city,
who seems to have been all that a municipal executive
should be in such an emergency. We are told that "it
is in a very large degree to his singleness of purpose,
breadth of view, and ability for organization that scores
of cases and manj- deaths have been prevented and only
those who have worked with him will ever know the
debt which his city owes him."

Etiological Factors of Invalidism Following Child-
birth.— Some of these factors are reviewed by J. C.
Applegate. Predisposing factors are lack of knowledsre
on the part of the laity as to the importance of hy-
gienic measures and inattention on the part of the ph3'-
sician not especially interested in obstetrics as to the
position of the child, pelvic mensuration, and the effect
of pregnancv on the maternal organism. Factors dur-
ing labor are the influence of posture on mechanism,
the modifyiri"- effect on injuries to the birth canal by
anesthesia, protection of the perineum during the birth
of the shoulders as well as of the head, and instru-
mental delivery. Post partum factors are time for
repair, method of repair, no repair at all. and the gen-
eral management of this period. The paper is an elab-
oration of the above outlines. Concerning repair, the
author follows the following rules: (a) Immediate re-
pair when convinced from the primary examination
that the lesion involves the perineum alone, or the tis-
sues in immediate juxtaposition thereto, when the pa-
tient's condition will warrant it, excepting the coinplete
variety, (b) When deep vaginal or cervical lacerations
demand immediate repair to ' control hemorrhage,
otherwise the cavities are packed with gauze and oper-
ation deferred. The second day rather than a later ne-
. riod is selected for the complete tear or when fistuhe
are cnmolications, at which time all lesions are re-
paired from above downward. The condition of the
patient wijl rarely permit these operations at the end
of labor, nor is the physician prepared for them. While
this is not the best time for cervical repair, it is better
than at the end of labor, also better than to subject
a patient to the second operation during the puerperiuni;

Atypical Manifestations of Paludism. — Ten atypical
cases are detailed by J. J. France of Ports-
mouth. Va. He concludes: First — That chill, fever,
and sweating are not always the mode of onset
of malarial infection. Secondly — That the seat of
pathological change or congenital defect is often the
point of attack of plasmodial invasion. Thirdly — That
periodicity is the one pathognomonic symptom of all
forms of paludal infection. Fourthly — That women are
oftener the victims of malarial infection than men.
Fifthly — That quinine is the standard remedy for
malaria. He also notes that tissues which have
undergone pathological changes and those which
are congenitally defective are more susceptible
to the toxine, which is elaborated in the proc-
ess of segmentation of the hematozoa. What
the factors are which determine the variation
in the mode of manifestation of this toxemia, so
that in one patient it takes the form of a febrile re-
action, in another a painful paroxysm, or a seizure of
some sort in an organ previously crippled by disease
or congenitally defective, are at present not fully de-
termined, but the fact is fully attested by ample clinical
observalion.

Journal of the American Medical Association, Februcry 16,
1907.

Late Phlebitis After Clean Abdominal Operations. —

W. W. Grant says that he has been compelled b}- later
observations and experience to modify his formerly
expressed oninion that phlebitis after abdominal, rectal,
or genitourinary operations is invariably due to infec-
tion. In his paper he considers especially that form
of phlebitis culminating in the veins of the legs (usu-
ally the left leg), and occurring most frequently about
two weeks after simple aseptic abdominal operations,
without preceding fast pulse, fever, pain, or any other
premonition. He refers to the statistics of Cordier and
Haward and gives the account of a typical case occur-
ring after operation for chronic appendicitis. He asks
what was the etiology of this phlebitis, and gives a
summary of the literature of the subject as well as the
opinions obtained by correspondence with a number of
prominent surgeons. These vary somewhat, nearly
half of the answ-ers admitting infection as a possible
cause, the others rejecting it or being noncommittal.
Grant gives his own opinion that it is probably not sep-
tic, and that the specific cause or causes are unknown.
It is not correct, he thinks, to assume an infection
without satisfactory evidence. The cause of the throm-
bus before the inflammation or of the phlebitis preced-
ing the thrombus, is the vital point. It is impossible.
Grant saj'S, to reconcile the facts with the idea that
the cause is the recumbent position or the simple liga-
ture or iniury of small veins, often in a distant field
and on the opposite side of the body, though admitting
that the infection need not come from the site of the
operation. He believes that there is a general con-
dition affecting the composition of the blood, that may,
and often does, exist before operation, which is an
essential factor in the cause of the thrombophlebitis in
these cases. A careful scrutiny of the patient should
be a preliminary and a careful examination of the blood
should be made before and after operation. This, if
thoroughly done on a fairly liberal scale, would, he
thinks, give us interesting and useful information and
throw some light on a puzzling subject.

Opsonic Treatment of Surgical Diseases. — A. P.
Ohlmacher thinks that possibly Wright's comparatively
simple theory of opsonins and its practical application
has been rendered needlessly confusing to the average
practitioner, and gives liis own experience with the use
of bacterial vaccines, preferably autogenous, in various
surgical conditions. While not neglecting to take the
opsonic index when practicable, he was compelled to
rely largely on the clinical manifestations as a guide to
the repetition and size of dose, always endeavoring, of
course, to give the injections at the right time, when
the posiiive phase is beginning to fall, and not in the
negative phase. As Wright points out, the great causes
of failure in previous tuberculin treatment was the giv-
ing of too large injections and too frequent repetition
of the dose, causing a marked negative phase and keep-
ing it up. Ohlmacher thinks that his results might
have been even better than they were had he been abb';
t" make more systematic opsonic determinations, which
often show a fall of resistance before the symptoms
indicate it. He has had remarkable success in various
types of staphylococcus infections: obstinate cases of
acne and furunculosis, impetigo, palmar abscess, and in
a very distressing case of what liad been called psori-
asis, but which he thinks was an extraordinary case of
staphylococcic dermatitis, and which yielded rapidly to
opsonic treatment w'ith an autogenic culture of staphy-
lococcus aureus. He had also satisfactory results with
a case of very annoying bladder infection from the
colon bacillus, similarly treated after other treatment
had failed. A strikin.g case was one of sacculated pneu-
mococcus empyema, in which perfect recovery occurred
in seven days after two injections following a small
puncture. From what he has already seen, he is pre-
pared to say that with proper artificial autoinoculation,
we can obtain constitutional and local improvement in
many subacute and chronic affections entirely beyond
anything previously possible in medicine. He believes
that we have in this method of bacterial inoculations
therapeutic agents of a specificity and potency beyond
anything heretofore employed in the treatment of dis-
ease, except, perhaps, the diphtheria antitoxin.

The Army Canteen. — C. E. Woodruff advocates the
restoration of the .\rmy canteen as a protection or
counteraction against the grog shops that grow up
around an .Army post and entice the soldiers into ex-
cess. He maintains that while the soldiers are as
temperate as any class of laboring men at the pres-
ent time, and have the advantage of being less neurotic

Feb. 23, 1907]

MEDICAL RECORD.

327

as a rule, there are still many that will not be total
abstainers, and lor these, he says, it is better to have
a regulated and orderly place, where they can obtain
the milder into.xicants, such as beer and light wines,
rather than to have them obtain them at disreputable
places, run for profit, and that cannot be controlled.
It is good ethics, he says, to protect the soldiers from
the greater evil by permission, it may be, of a minimum
■of harm. The profits of the canteen, moreover, are not
to the saloonkeeper, but are used for the benefit of
the soldier himself. The discontinuance of the can-
teen has, therefore, been to the soldier's disadvantage
on this account. He further argues that the moderate
use of alcohol cannot be said to be necessarily harm-
ful on scientific grounds, though that is not claiming
that it is a necessary article of diet in the present
stage of human evolution.

X-Ray Treatment of Cancer of the Breast. — George
C. Johnston criticises some of the reports of failures in
this method of treatment as being based on ignorance
and insufficient experience. He insists on the value
of what he calls antioperative radiation, and claims that
during the past year there has been abundant evidence
of the value of the ray in producing retrograde change
in carcinoma, but advocates the use of the ray alone
only in cases in which the condition or age of the pa-
tient is against preliminary operation. His conclusions
are given as follows: i. Results are better and more
permanent, the earlier the treatment is instituted.
2. The value of postoperative radiation has become
more and more apparent. 3. Mediastinal recurrence,
while grave is not a death warrant. 4. Technique is not
an accomplishment, but an absolute necessity. 5. No.
tube is too good to use for treatment. 6. Filters are
a necessity in the treatment of cancer of the breast.
7. Treat no patient who you know can be cured sur-
gically.

Mistakes in the Diagnosis of Pulmgnary Tubercu-
losis.— H. L. Barnes gives an analysis of the histories
of it>5 patients with tuberculosis admitted at the Rhode
Island State Sanatorium for Consumptives, with special
reference to the question of early diagnosis and treat-
ment. Only the cases with reliable and complete rec-
ord were used. He found the presumable duration of
the disease averaged 15.4 months, and that 40.9 per
cent, of the patients delayed seeking medical advice or
treatment, such dela}' avera.ging 7.9 months. Forty-si.x
per cent, were incorrectly diagnosed, the resulting de-
lay in correct diagnosis averaging 1 1.3 months. In
18.1 per cent, of patients the lungs were examined and
pronounced sound,- and in 18.7 per cent, the incorrect
diagnosis was made without sputum examination,
though sputum was available. In 2.4 per cent, the cor-
rect diagnosis was purposely withheld by the examin-
ing physician. Barnes regrets that this practice is still
followed bv some, and holds that it is not warranted
by any valid considerations. The failure to diagnose
tuberculosis after hemoptysis also is surprisingly com-
mon, occurring in 12.7 per cent. 'of the cases here an-
alvzed. Inasmuch as the sanatorium does not receive
the worst cases, it seems possible that those it does
receive have been more wisely handled than the aver-
age of all tuberculous patients in the community,
which gives figures an added significance. He says:
"This optimistic and fatal waiting policy should be
appreciated. A tuberculous history should be souglil
for in all lung diseases, and in atypical and doubtful
cases of grippe, bronchitis, and malaria the diagnosis
should promptly be made by tuberculin when other
means fail."

The Lancet, February 2, 1907.

Hematuria from Sodium Salicylate. — J. D. Marshall's
Patient was a girl of ten years with articular rheuma-
tism. Fifteen grains of. the salicylate with double that
quantity of sodium bicarbonate were given in chloro-
form water every four hours. This was continued lor
four days, when the child became delirious and vom-
ited. The hallucinations were not unlike those of de-
lirium tremens, but stopped immediately on withdrawal
of the remedy. Some days later the salicylate was
resuined in seven-grain doses three times daily. There
was vomitino- again in two days. Delirium' was ab-
sent, but the urine contained blood enough to give it a
deep red color. Previous to this time it had contained
neither albumin nor casts. Symptoms cleared up again
on discontinuance of the remedy. Hematuria fromthe
usual doses of this salt is extremely uncommon, ac-
cording to the literature on this point.

The Present Means of Combating the Sleeping Sick-
ness.— .-X. Kinghorn an.l J. L. Todd thus summarize the

general lines of prophylactic endeavor. Efforts to
check the disease must be directed against the trans-
mitting agent, the flies, either by destroying them or
by preventing them from reaching and biting men.
Then also we must attack the causative parasite, the
trypanosome, by the treatment of persons already in-
fected, and by isolating them so that they shall not
serve as foci of infection for other individuals. Areas
on which the deposition of the eggs of the fly (tsetse) is
suspected should be burned over. Houses can be largely
freed from flies by surrounding them with an area 300
yards on each side free from rank undergrowth or
grass. Wire gauze or netting may be used for personal
protection and prolonged stays in heavy vegetation
near water should be avoided. The only drug for try-
panosomiasis that has proven of any positive value is
the preparation of arsenic known as atoxyl. The value
of any drug is problematical, except after pro-
longed usage and careful observation of the later his-
tory of those to whom it is given. In spite of appar-
ently successful treatment relapses are not uncommon,
and a fatal result may follow just as surely as if the
case had lieen untreated.

Causation and Treatment of Some Headaches. —

\\". Harris refers particularly to paroxismal ;ind pe-
riodic headaches and those dependent on some form of
to.xemia. Many periodic headaches are of the migraine
form, probabh^ referable t(j some temporary vaso-
motor disturbance. These are described in full in their
varying clinical phases. Bromides are often of service
during the intervals between the attacks. The actual
headache is often best relieved if taken in hand suf-
ficiently early by a full dose of butyl chloral
hydrate. Nitroglycerine often brings immediate re-
lief by reducing the blood pressure. The author
next refers to periodic headaches, which may resemble
true migraine somewdiat closely and yet are less de-
pendent upon an hereditary neurosis and paroxysmal
vasomotor spasm than upon some peripheral cause
wliich by its local irritant effects may set up reflexly a
migrainous attack. These cases, pathologically speak-
ing, would be strictly analogous to reflex epilepsy, such
as convulsions dependent upon the peripheral irritation
of worms, the irritation of a scar, etc. In many of
these the removal of its peripheral cause may be fol-
lowed by complete cure. The author considers the
eyestrain theory as overworked and by no means en-
tilled to all the credence it has received. Ocular head-
ache, in which the pain is usually situated over one or
both ej-ebrows, and is due to errors of refraction, es-
pecially astigmatism, is not uncommon. Every now
and then the pain may be more periodic in some pa-
tients and may exhibit the course of symptoms famil-
iar to us as migraine. In these cases we have to do
with a reflex migraine the peripheral exciting cause
of which is the visual defect and constant unequal
strain upon the ciliary muscle, and these oatients will
probably get much relief from proper correclin.g
.glasses. Toxemic headaches arise from a multitude
of causes, and their proper treatment presupposes the
removal or abatement of the exciting causes. The au-
thor declares that the efifect of our open air life has not
received sufficient prominence in the treatment of many
forms of toxemic headache. Persons who are sub-
ject to chronic headaches should cultivate the habit
of kcepin.g their windows widely open, and the harden-
in.g process thus slowlj- applied will not only render the
individual far less susceptible to catching ordinary
colds, but his tendency to frequent headaches will often
com'pletely disappear, and from a listless valetudinarian
with always something wrong with him he will be-
come brisk and healthy in mind and body.

On Opsonins and the Opsonic Index and Their Prac-
tical Value in the Treatment of Disease. — G. -\. Crace-
Calvert considers this question with special reference
10 pulmonary tuberculosis in sanatorium cases. In gen-
eral the results are promising, but as yet not very de-
ei.-ive. The author notes that in thes- cases there is
usually a .iii:-:cd infeclic- an. I that af'er or even whil?
using tubeiculin it may be necessary to give inoeiila
tions of a staphylococcic or pneumonococcic vaccine be-
fore the patient w-ill get well. In tuberculosis it is dif-
ficult to get a vaccine exactly corresponding to the or-
.ganism causing the disease. Good effects noted are
lessening of the disease activity, as shown by physical
signs, and diminished sputa, improved appetite, and in-
creased weight. In ten incipient cases the index has
lieen below normal in four, normal or above in six. .Ml
these cases have done well regardless of their indices.
In active cases with high fever the index varies
from day to day. There is no apparent relation be-

328

MEDICAL RECORD.

[Feb. 23, 1907

tween the fluctnatiuii of the index and that of the tem-
perature. In the ordinary case with a fair amount of
disease the inde.x is usually about normal. In sana-
torium "cures" — more properly arrested cases (four old
cases) — the author has found the inde.x above normal
in three and below in one, the latter having been well
for six years, and possibly appro.ximating to a normal
person. The author considers this question of the
index in a "cured" patient important because if it be
more usually found low it seems as if the patient's re-
sistance was not permanently aflfected by treatment,
and that he therefore runs a risk of further infection,
but before accepting this as a definite statement we
want to know if the cases were truly arrested and not
simply patched up temporarily, and also what their in-
dex was before they started treatment — a point that
cannot be settled yet. as the method of estimating the
opsonic inde.x has not been in existence long enough to
secure any results. The author considers that the op-
sonic theory is a most brilliant one and full of promise,
but considers that its application must be greatly sim-
plified before it can come into general use.

British Medical Journal. February 2, 1907.
The Temperature of Japanese Hot Baths. — L. Hill
refers to the case of a Japanese man who could endure
a bath of 114° F. for only a minute or two while totall"
immersed except the face. The bath was raised to this
temperature from 103° in about five minutes. He came
out from the bath feeling faint and asked to have the
window opened. His rectal temperature had risen tn
103° F. He said that his countrymen usually sit with
the head and arms out of water. Under such con-
ditions thev titay stand a considerably hotter tempera-
ture. They must habituate their skin to stand a hi"-h
temperature, as the ordinary man habituates his tongue
to hot drink. Certain hot baths at thermal sorings are
used particularly for syphilis. The baths range in
temperature from 113° to 128° F. The intense deriva-
tion of blood to the skin induced by these baths must
have a powerful eflfect and ought to be a most efficient
way of increasing the supply of blood and its opsonin,
and the activity of the phagocytes in cutaneous afifec-
tions.

Repeated Abdominal Section for Perforation of Gas-
tric Ulcers. — The patient of \. Cuff was a man of
tw'cnty-seven years who underwent two laparotomies
for the perforation of two totally distinct ulcers, over
four years intervening between the two attacks. In
the first instance an anterior gastroenterostomy was
done. Symptoms began to reappear after seven
months, but over four years elapsed before a second
operation was deemed necessary. His original symp-
toms began at the age of ten years, or thirteen years
before his first laparotomy. The author declares that
the onset of pain a few hours after the taking of food,
when, the digestion of the meal nearing completion,
the beginning relaxation of the pyloric sphincter allows
the contents of the stomach to flow into the duodenum,
and hence over any hyperesthctic spot in that organ
is very suggestive of duodenal ulcer. An interestina;
fact related b- the patient was that indigestible articles
of food like pork pie delayed the onset of the pain, and
this is in strict accordance with this theory, pork re-
quiring four or five hours for its digestion, while mut-
ton requires only two or three hours. This fact of
the possibility of retarding the onset of the pain in
cases of duodenal ulcer by the adininistration of indi-
gestible food, or by eating during the digestion of a
previous meal, has been noted previously. The same
thing has been borne out experimentally by Cannon,
who has shown in the course of his investi,gations on
the movements of the stomach during digestion, by
means of the .f-rays, in cats, that if towards the com-
pletion of the digestion of a meal (the movement of
which, owing to its admixture with a bismuth salt, was
visible on the screen) a hard tablet or button made
principally of bismuth was administered, its impact on
the pyloric orifice immediately caused the sphincter to
contract, and stopped the onward flow of chyme from
the stomach to the duodenum, for some little time.

Some Points on the Diagnosis and Treatment of
Laryngeal Cancer. — F. Semon presents an elaborate
paper on this subject. He saj-s that if the vocal cord
from which a suspected laryngeal growth springs
shows at an early period of the disease a defect of mo-
bility other than due to mechanical impaction of the
growth in the glottis on phonation, this sign is almost
pathognomonic for the malignant character of the tumor.
The author claims tha* the removal, if possible, of a bit
of the suspected growth for microscopical examination
is perfectlv justifiable, provided the patient's consent
has been previously obtained, for immediate radical op-

eration in case the verdict is in favor of malignancy.
He still adheres to the opinion, frequently expressed
in former publications, that in case of an early 6.,
nosis a ihyrotomy is preferable to a laryngectomy. In
thirty-three cases for what seemed to be certain or
very probable malignant disease of the larynx, in eight
the diagnosis was shown either to have been at fault
or remained doubtful. Twice the disease was tuber-
culous. Twice, the tumefaction seemed to be of the
nature of an infective inflammation. In two the diag-
nosis remained doubtful between fibrosarcoma and a
malignant growth. Three ceses ended fatally. Of
twenty-five verifiedl malignant cases one died and
iwenty-four recovered. In four recurrence took place.
In extrinsic cases total laryngectomy will remain a
cruel necessity until some specific shall have been dis-
covered.

Berliner klinische Wochenschrift, January 28, 1907.
Catalytic Influence of Colloidal. Metals on Hepatic
Autolysis. — .\scoli and Izar report on experiments
made in order to determine whether or not autolysis
in the liver cells is modified by the presence of colloidal
solutions of metals. They found that in the presence
of such solutions the autolytic processes were very
much accelerated and that this efifect was produced
no matter whether the fluid tested was acid or alkaline.
Even very small amounts of the colloidal metals suf-
ficed to evoke a pronounced increase in the autolytic
process, and on using more of the solutions the action
rapidly became more intense until a limit was reached,
after which further augmentation was less effective.
In order to determine whether colloidal solutions of
different metals presented different properties in this
respect, comparative tests were made with colloidal
solutions of silver, gold, and platinum, but it was found
that no easily demonstrable differences existed between
the effects of the three metals named.
Deutsche mcdicinischc VVocheitschrift, January 3 and 24,
1907.
Digestive Gastric Hypersecretion. — Boas says that
recently this form of gastric neurosis has been found
to be much commoner than has hitherto been supposed
to be the case. He suggests that when its existence
is suspected a dry test meal be administered in place
of the customary Ewald test breakfast. For this piir-
pose he proposes the sweet crackers ordinarily
known as Albert biscuits ; five of these are given,
and whereas under normal conditions an hour later but
little residue can be obtained from the stomach, if
a hypersecretion exists, 100 to 200 c.c. of a mi.xture
composed of a thin layer of debris and four or five
times the amount of clear supernatent fluid may be
expressed. Among the symptoms of the condition,
which occurs most often in men, a pronounced degree
of emaciation is prominent; this is probably dependerit
in the first place on the very notable waste of gastric
juice, which may amount to tw-o liters or more per
day, and secondly, to the serious interference with
starch digestion. Another troublesome symptom is ob-
stinate constipation, and the patients also complain of
disagreeable sensations about the stomach, feelings of
pressure and distention, belching, and sometimes se-
vere pain. Nausea and vomiting are rare and the appe-
tite may or may not be impaired. While a definite con-
clusion regarding the nature of the affection is not yet
possible. Boas is inclined to consider it as a form of
nervous dyspepsia. The prognosis is not unfavorable
and the therapeutic indications are especially to in-
crease the inadequate body weight, to correct the de-
ficiency in starch digestion, and to avoid all agencies
that may give rise to an increase in the gastric secretion.
This can best be effected by a diet consisting largely
of albumin, fat, and sugar. Fluids need not be re-
stricted, and in fact the use of alkaline beverages is
recommended, .^tropin has not been found partic-
ularly useful, but Boas recomriiends the administration
of alkalis, particularly the citrate of sodium, of which
he .gives a teaspoonful four times a day.

The Mechanical Action on the Body of Lowering the
Atmospheric Pressure. — Jacobi endeavors by means of
a number of models to demonstrate the manner in which
the circulation responds to changes in atmospheric pressure
such as are observed on passing from low to high altitudes.
He concludes that there is a considerable dilatation of the
pulmonary vessels, the veins, and the capillaries, so that
blood is more or less stored in these districts. In conse-
quence of this the patient is, as it were, bled into his own
vessels and the blood-forming organs respond by producing
an increased number of red corpuscles, and in this way the
author endeavors to account for the increased number of
erythrocytes and the high hemoglobin percentage obseri'ed
as a result .of sojourn at high altitudes.

Feb. 23, 1907]

MEDICAL RECORD.

329

look iiSroi^mfi.

Transactions of the Association of American Physi-
cians. Twenty-first Session, held at Washington, D. C,
May 15 and 16, 1906. Vohinie XXI. Philadelphia :
Printed for the Association, 1906.
It is hardly necessary to attempt to point out the great
interest and value of the series of papers that are here
presented in collected form. So many contributions of im-
portance are included among the fifty odd that were read
before the last meeting of the Association of American
Physicians, that it is diiScult to make any selections for
especial mention ; but attention may be directed to the dis-
cussions of the subjects of blood pressure, pentosuria, the
serum treatment of exophthalmic goiter, various blood dis-
eases, and arteriosclerosis. The volume comprises a record
of contemporaneous medical work of much significance,
and embodies the opinions of many of the best known
physicians in the country on problems of the deepest
import.

KosMETiscHE Hautleiden. Von Dr. S. Jessner. Konigs-
berg i. Pr. Wi'trzburg: A. Stubers Verlag (Curt Ka-
bitzsch), 1907.
Under this title Jessner describes the treatment of such
affections of the skin and its appendages as may be consid-
ered more particularly from the cosmetic standpoint. Ac-
cordingly, the little volume of 124 pages is distinctly prac-
tical in its subject matter, and may safely be recommended
to all readers of German as an attractively written treatise
on a subject on which the author is well qualified to speak
with authority.

Des Haarschvvunds Urs.'vchen und Behandlung. Von
Dr. S. Jessner, Konigsberg i. Pr. Fiinfte Auflage.
Wiirzburg: A. Stubers Verlag (Curt Kabitzsch), 1907.
This is a brochure of fifty odd pages, containing the views
of the well-known author on the causes and treatment of
alopecia. Seven varieties of the afltection are dwelt upon,
and numerous prescriptions for local applications are given.

Obstetrics for Nurses. By Joseph B. DeLee, A.M.,
M.D., Professor of Obstetrics, Northwestern University
Medical School, etc., Chicago. Second Edition, Revised
and Illustrated. Philadelphia and London : W. B. Saun-
ders and^ Company, igo6.
Although published but a comparatively short time. Prof.
DeLee's book has won considerable favor. It conveys an
excellent idea of the subject to the nurse, and may also be
regarded as a helpful book to medical students about to
undertake their practical work in midwifery; for, as the
writer states in his preface, many of the duties of the
nurse devolve upon the latter in their early years of prac-
tise. The book is divided in the usual manner into several
parts, in which are considered the anatomy and physiology
of the whole reproductive cycle, the conduct of pregnancy,
labor, and the puerperium, and the pathology of pregnancy.
There is no one part which can be picked out for particular
comment; the subject is presented in clear, concise manner,
and well illustrated by photographs which are of uniform
excellence. The introduction constitutes an important part
of the work, for it calls attention to the importance and
value of proper obstetric nursing, a fact which it is difficult
to get nurses in training to appreciate.

Te.\t-Book of Comp.\rative General Pathoi-ogy, for
Practitioners and Students of Veterinary Medicine. By
Prof. Dr. Th. Kitt of Munich. Authorized Translation
by Dr. W. C. C.\dbury, Assistant Demonstrator of Pa-
thology in the University of Pennsylvania. Edited with
Notes and Additional Illustrations by Dr. A. J. Smith,
Professor of Pathology in the University of Pennsyl-
vania. Chicago : W. T. Keener and Company, 1906.
The need of a book such as the one here translated
is evident, for the impressions gained from a work on
pathology, which is framed primarily on the conditions
found in the human body, are necessarily inaccurate and
incomplete. The fundamental processes of disease are the
same, no matter in what type of animal they occur, but the
variations of the same type of lesions in different species
may be sufficiently marked as to make a description based
upon the changes met in any given animal confusing and
inadequate. An extract from the preface will best explain
another feature of the book. The latter reflects the ten-
dency of modern pathological teaching to direct the
thoughts of the reader along lines of pathological physiol-
ogy, to make the student reason for himself from given
anatomical data and appearances as to the necessary func-
tional faults and failures. A book of this kind also pos-
sesses worth for the student of human medicine, for com-
parative pathology bears an intimate relation to the latter,
and there is great need that experimentalists should be in
the best possible position to appreciate the reactions pe-

culiar to these experimental animals. The translation is
good, though literal, but the illustrations are hardly on a
par with those met with in most American text-books.
Die Tuberkulose der menschlichen Gelenke sowie deb
Brustwand und des Schadels. Nach eigenen Beobach-
tungen und Wissenschaftlichen Untersuchungen. Von
Prof. Dr. Franz Konig, Berlin. Mit 90 Textfiguren.
Berlin : Aug. Hirschwald, 1906.
This book is dedicated to v. Bergmann on the occasion of
his 70th birthday by one of the foremost German special-
ists in bone diseases. It is divided into two parts, the first
of which is concerned with a description of the pathological
anatomy of joint tuberculosis, the knee joint being used as
a basis for the presentation of the subject. The various
forms of tuberculous arthritis and their clinical course are
related in detail, and in conclusion the treatment is dis-
cussed, the author inclining to the idea that this must be
mainly operative. He is not inclined to look with favor on
the mode of treatment developed by Bier, and has fre-
quently observed the formation of abscesses in such
cases, and has also been compelled to resect joints which
were treated in this manner by others.

In the special part of the book he takes up the discussion
of tuberculous disease in the joints of the leg, the arm, the
thorax, and the skull, in its pathological, clinical, and ther-
apeutic aspects, and presents numerous statistical studies
from his extensive clinical material. x\lthough the book
includes less than two hundred pages, it contains a wealth
of material which will ser\-e as an excellent manual for
the student and a work of reference to the practitioner.
For the latter it is of particular value as a means of aiding
diagnosis and presenting the indications for operation.
The radical treatment is usually favored at the expense of
the conservative, but, considering the excellent results
which have been attained by many with the latter, the
writer's contention will probably not find acceptance by any
means universal.

Experiment.\l Psychology. .A Manual of Laboratory

Practice. By Edward Bradford Titchener. Vohime II.

Quantitative Experiments ; Part II. Instructor's Manual.

New York : The Macmillan Company, 1905.

This volume consists of a lengthy introduction on the rise

and progress of quantitative psychology, and chapters on

preliminary experiments, on the metric methods, on the

reaction experiment, on the psychology of time, and on

the range of quantitative psychology. .As indicated in the

title, it is a laboratory manual, and is intended for those

engaged in teaching the subject.

The Treatment of Diseases of the Digestive System.
By Robert Saundby, M.D., M.Sc, LL.D., F.R.C.P.,
Professor of Medicine in the University of Birmingham ;
Senior Physician to the General Hospital ; Consulting
Physician to the Eye Hospital and to the West Brom-
wich Hospital. Philadelphia : J. B. Lippincott Com-
pany, 1906.
This book of 120 pages is based on the author's personal
experience in treating diseases of the digestive tract.
While the volume deals with the subjects under discussion
in a pleasant and satisfactory manner, it contains little or
nothing that cannot be found in any book on either Practice
or Therapeutics.

The Diseases of Women. A Handbook for Students and
Practitioners. By J. Bland Sutton, F.R.C.S. Eng., Sur-
geon to the Middlesex Hospital, and Senior Surgeon to
the Chelsea Hospital for Women, and Arthur E Giles,
M.D., B.Sc. Lond., F.R.C.S. Edin., Surgeon to the Chel-
sea Hospital for Women, and Gynecologist to the Tot-
tenham Hospital. Fifth Edition, with 129 Illustrations.
London and New York : Rebman Company, 1906.
The new editions of this well-known text-book appear
with regularity and rapidity. The present volume is but
little larger than its immediate predecessor; the new matter
introduced deals with chorionepithelioma, extrauterine
pregnancy, and tumors of the ovary, including an entirely
new section on metastatic cancer of that organ. The au-
thors have been unusually successful in their endeavor to
compress all the established facts of gynecology within the
compass of one volume of moderate size, and they have
fully justified the statement made in the preface, viz., "We
still believe that when surgical authors are able to restrain
their vanity, and refrain from publishing notes of successful
cases in text-books, the established facts of the art can be
presented in a very convenient compass." Nothing of im-
portance is omitted ; there are numerous illustrations, all
of a high order of merit, and the paper and press work are
excellent. The arrangement of the subject matter differs
from that adopted in most books, and the operative pro-
cedures are placed together, occupying the last eight chap-
ters of the book. All of these features are to be com-
mended, and as a handbook for the student or practitioner
this volume will be particularly acceptable.

330

MEDICAL RECORD.

[Feb. 23, 1907

g>otirxg WispaxtsL

THE PRACTIT-IONERS' SOCIETY OF NEW YORK.

206th Regular Meeting, Held December 7, 1906.

The President, Dr. T. Mitchell Prudden, in the Chair.

Dr. W . GiL.MAN Thompson presented a case or muscular
atrophy involving the muscles of the arms and shoulders,
with marked tremor, but no sensory disturbances.

Dr. M. Allen Starr regarded the case as one of amyo-
trophic lateral sclerosis. He stated that in this disease the
progress of the atrophy and paralysis was more rapid than
in progressive muscular atrophy, and there was more con-
stant and violent fibrillary twitching of the muscles. The
entire arm was affected simultaneously, whereas in pro-
gressive muscular atrophy the atrophy ascended the arm
and there was exaggeration of the knee jerks, indicating an
affection of the lateral columns of the cord, as well as the
affection of the anterior horn.

Dr. Charles L. Dana thought tiie case was one of
amyotrophy of the Aran-Duchenne type.

A Case of Epithelioma of the Eyelid Treated with
Radium. — Presented by Dr. Robert .-^bbe. The patient
was a man forty-three years old, with an epithelial carci-
noma of the lower eyelid extending from the inner canthus
to nearly the outer canthus, only a quarter inch of mucous
membrane remaining free. It measured one and one-
eighth inches in length, and presented a solid growth a half
inch in thickness and the same in depth, and involved the
entire structure of the lid. Dr. Abbe showed colored
plaster casts of the growth as it was before radium treat-
ment was begun in June, 1906, and stated that a micro-
scopic examination had revealed true carcinoma. Five ap-
plications of the strongest radium tube were made, of one
hour each, and in two weeks improvement began. Pro-
gressive retrogression had followed, until now a small rem-
nant only remained at the ijiner end. To this, after a five-
months' interval, half-hour applications of radium had again
been made, which it was hoped would be enough to com-
plete the cure. Dr. Abbe said he had had six cases of
epithelioma of the eyelid, all either cured or being cured,
and it seemed to him to be a specific to be entirely relied
upon in this type of disease. He also showed casts of the
case of sarcoma of the eyelid exhibited at a meeting of the
Society two years ago, which had remained entirely healed.
Neuralgia and Neuritis of the Arms and Legs. — By.
Dr. Charles L. Dana. (See page 297.)

Dr. Edward G. Janeway drew attention to the two types
of what was considered lumbago. One was situated in the
muscles of the back; the other was dependent upon disturb-
ance of the lumbosacral joint. This was apt to be produced
by standing bent forward for some time, especially in a
cold place. Physicians, as a rule, took this for ordinary
lumbago. It was apt to occur in those with gouty or rheu-
matic tendencies. The speaker said that in his experience
the neuralgia of persons with angina pectoris was more
apt to involve the nerves distributed to the little or ring
finger than appeared to have been the experience of Dr.
Dana. ■ He alluded also to a case where there was intense
pain in the right arm of a patient who died a week later,
and in whom calcification and thrombosis of the right cor-
onary artery and rupture of the interventricular septum was
found.

Dr. Beverley Rodinson said he had found a special mas-
sage roller very useful in a case somewhat similar to those
of cervical neuralgia described by Dr. Dana. The roller
consisted essentially of a series of wooden balls about one
inch in diameter, strung along a properly covered iron wire.
At either end of the roller were handles similar to those
of a pulley apparatus used by athletes. For cases of brach-
ial neuritis, as well as for cases of this disease located
elsewhere, he had found a compound of menthol, salicylate
of methyl, and lanolin at times beneficial. This was rubbed

gently into the skin and covered with a layer of absorbent
cotton and a light gauze bandage. The first effect of the
application was cooling, but in a few moments an agreeable
and marked warmth followed locally. The ointment must
not be used over an abraded surface, or it would occasion
severe irritation.

Dr. V. P. GiBNEY said that one of the causes of neuralgia
of the spine, especially the lower portion, was a displace-
ment or a sprain of the sacroiliac joint. He had found the
small tip of the Paquelin cautery a most efficient remedy
in brachial neuralgia, and, contrary to expectation, the use
of the cautery — small touches, not strokes — did not leave
any scars. Numerous points touched faded out into a rich
brown color, and gave to the shoulder, arm, or forearm
the appearance of one exposed to the sun. For the neu-
ralgia induced by piano playing, the treatment had, in his
hands, been productive of most gratifying results.

Dr. Abbe said he would speak only of the phase of
brachial plexus neuralgia referred to by Dr. Dana as some-
limes hysterical. Ten years ago he reported some cases in
which he had operated six and eight years previously for
intractable neuralgia of the arm where previous stretching
of the nerves followed by resection and finally amputation,
had failed to relieve. He had then made an intradural re-
section of the posterior roots of the brachial plexus as they
emerged from the cord {Boston Medical and Surgical lour-
nal. October i, 1896). Temporary relief seemed to be
afforded, but these patients were still living, and had, to a
moderate degree, the same evidences of pain. In all there
had been a consensus of opinion that there was a consider-
able hysterical element that masked the value of pain as a
symptom of disease or an index of the utility of operating
by this method. Nevertheless, Dr. Abbe said, he would not
hesitate to resort to this novel and beautiful method with
some hope in a suitably defined case.

A Case of Ophthalmoplegic Migraine of Intermittent,
Recurrent Type of Hereditary Origin. — Dr.M. Alle.v
Starr reported this case. The patient was a young man
whose mother had suffered from migraine and who had
been subject to attacks of sick headache since the age of
twelve. In connection with each attack of migraine for the
past five or si.x years, the patient had a total third nerve pa-
ralysis on the left side lasting about five or six days, and
disappearing either as the headache passed off, or perhaps
lasting a few days longer than the headache. When he
was first seen he had a typical third nerve paralysis, ptosis,
immobility of the eyeball, with external strabismus and
dilatation of the pupil. At the end of a week this condi-
tion ITad entirely passed off. Such an intermittent paralysis
of the third nerve. Dr. Starr said, had been described by
various writers, but it was a very rare condition, and was
probably, in a majority of cases, due to an attack of mi-
graine.

Dr. Charles Stedman Bull said he had seen two cases
of ophthalmoplegic migraine, one in a man and the other
in a woman. In both the left eye was affected. In both
the attacks were irregular in their appearance, varying in
frequency from three weeks to two months, and in dura-
tion from four days to one week. In every attack the first
symptom was severe pain in the supraorbital and nasal
branches, followed by sudden paralysis of all the branches
of the third nerve, including those to the sphincter iridis and
ciliary muscle. The secondary divergent squint was marked,
and there was some puffiness of the upper lid. All treat-
ment proved futile in both cases, though the neuralgia
could be controlled by hypodermic injections of morphine.
The attacks ceased as suddenly as they began, the pain first
yielding, and then the ptosis began to disappear, the last
symptom to disappear being the mydriasis.

Three Cases of Ureteral Calculus Detected by X-Ray
and Successfully Removed by Operation. — Dr. Abbe
showed three large calculi removed from the ureters of pa-
tients during the past year, after perfect Roentgen radio-
graphs had located the position of each, which was exactly

Feb. 2^. 1907I

MEDICAL RECORD.

331

opposite the third kimbar transverse process. The history
of pain in each varied frnm t-.vo to eight years, and left
no question but that they had been in the ureter during
that time. A channel had been furrowed down the side of
the two larger ones, explaining the absence of hydro-
nephrosis. In one case there had been but one attack of
hematuria, in another none, and in the third not even the
centrifuge deposit of several urine specimens showed blood
on the microscopic slides. This, the speaker said, was a sur-
prise to him. as he had rather learned to look upon the de-
tection of blood corpuscles in centrifuge specimens after
pain as almost inevitable. Dr. Abbe said the method of op-
eration in these cases was worthy of record. In each he had
used his method of muscle separation, without cutting, with
perfect satisfaction. This ga^e a strong scar, with no
chance of hernia. After separating the three muscle layers,
the linger quickly raised the peritoneum from the psoas
piuscle, and, the periureteral fat being exposed by tearing
through its cellular sheath, the finger instantly detected
the calculus in the ureter. It was removed through
a longitudinal cut, which was sewn up by fine
catgut. Another long piece of line catgut was then caught
into the psoas muscle, near the repaired ureter, and both
ends passed up through a small rubber tube which was run
down to the muscle, and there held by tying the outer ends
over a pin transfixing the outer end of the tube. This was
to be kept in situ to anticipate any need of drainage for two
days, and the outer wound closed layer by layer around it.
On the second day the tube was withdrawn, and on the
following the catgut also. The patients all made a quick
and perfect recovery.

Dr. Edw.\rd G. J.vneu .w said that his experience did not
warrant the certainty Dr. .-\bbe had in the radiograph. He
had in mind the case of a priest who came to him from
Pennsylvania with the clinical evidence of renal calculus,
and that diagnosis was apparently correct. The patient
then consulted surgeons, who had radiographs taken several
times with negative results. In consequence of this, one
surgeon, after a week's observation in the hospital, declined
to operate. Another surgeon later operated, notwithstand
ing the failure of the .r-ray diagnosis, and removed a large
calculus.

Dr. George L. Pe.ahopy asked whether the attempt to get
an A--ray pliotograph of a calculus was not sometimes un-
successful, and expressed the opinion that in his own ex-
perience it had failed to aid in the diagnosis in a kidney
in which surgery had subsequently demonstrated its pres
ence.

Dr. Beverley Ronixsox said he noticed that in one of Dr.
Abbe's cases there was no hematuria; in another, hematuria
was noticed for the first time only three weeks before
operation. These facts were interesting, because we were
accustomed to regard hematuria as usually present when a
stone existed in either the ureter or the kidney. Too much
importance sho'ild not be attributed to .r-ray findings in the
matter of ureteral stone. Sometimes a shadow was found,
and operation failed to reveal a stone ; again, there was no
shadow in the picture, and subsequently an operation might
prove the presence of stone.

NEW YORK ACADEMY OF MEDICINE.

SECTION ON PEnl.MRICS.

Stated Meeting, Held fanuaiy 10. IQ07.

Dr. Godfrey R. Pisek in the Ch.mr.

Case of Diabetes Insipidus. — Dr. Eli Long presented a
boy, eleven years old, a son of a tuberculous parent, whose
disease began with or followed an attack of measles eight
years ago. He drank large amounts of water during the
day and a couple of quarts during the night. He would not
eat his breakfast without drinking two or more glasses of
water. If water was refused him he would climb up and

put his mouth under the faucet. His twenty-four hours'
urine measured fourteen pints, or seven quarts, and often
it was eight or nine quarts. The amount of urine excreted
amounted to one-third his body weight. The specific grav-
ity of the urine was from looi to 1002, and there was no
sugar. There was some edema of the optic nerve on one
side and a choroiditis on the other, probably syphilitic in
origin. The mother had one miscarriage following his
birth, and the father died of tuberculosis. The cough,
bloody sputum, glandular enlargement all pointed to syphi-
lis, or tuberculosis, or to both.

Case of Diabetes Mellitus. — Dr. Eli Long presented a
girl, ten years old, who had a polyuria resulting from a
fall. Three weeks ago, while skating, she fell and struck
the back of her head. She since had lost much flesh, had
wet the bed — a thing she had not done in five or six years.
Her thirst had greatly increased, and she passed large
amounts of urine daily. An ordinary chamber was filled
during the night only. The specimen contained so much
glucose that the chemist thou.ght that there had been some
error made, and asked for another specimen. A further
and complete report would be made later.

Dr. ScHWARz said that he had a case of a boy of twelve
>(ars under observation, who presented features of inter-
est. The father died of cerebral hemorrhage, and he had
always been very nervous. The mother had always been
well. The child was exclusively breast-fed up to fifteen
months of age. Even at this time the mother noticed that
he would crave water ; after taking two or three ounces
of water he would then take the breast. There w'as a great
deal of polyuria. When the child was three years old, the
mother had to go out working, but could get no one to
care for the boy, because he drank so much and wet the
fioors. He had a light attack of scarlet fever when five
years old, and an attack of measles when seven years old.
His general health had been good. His sight was .good and
he excelled at sports. The boy was first seen in August,
Kjos. when he weighed 66 pounds. He then passed 10,400 c.c.
of urine in 24 hours. He passed 39 ounces at a time,
and 344 ounces in 24 hours. On March 3 he passed 11.800
c.c. CJn a salt-free diet he passed 8.000 c.c. The urine had
a specific gravity of 1,0025, and there was no albumin or
casts, and the urea amounted to 310 grains in 24 hours.
Hemoglobin was 85 per cent., red cells 4.800,000, and white
cells 8,000. The question would arise in this case whether
tliere was present simply a polyuria, or a polydipsia, or
whether the condition was due to cerebral syphilis, trauma,
or heredity.

Dr. Henry Koplik called attention to two cases he had
seen with supposed diabetes insipidus ; both ended up with
cerebral growths.

Dr. S.\R.\ Welt-K..\kels reported two cases of interest.
One was a little girl, nine years old, who fell, and she be-
lieved her diabetes insipidus to be due to this injury. She
passed from four to five quarts of urine daily. After having
been under treatment for ten months, with great improve-
ment, she one day came to the dispensary, and she could not
open her eyes. Every branch of the motor oculi were
paralyzed, and she had been taken ill with some men-
ingeal trouble. The other case was a boy, six years old,
who weighed thirty-six pounds, and who passed water in
large amounts, the smallest quantity passed in twenty-four
hours being 8,600 c.c. Both these children took so much
fluid that there was little opportunity for taking nutritious
food.

Dr, H. W. Berg said that many of these cases of so-
called diabetes insipidus were due to causes other than
cerebral or disease of the renal parenchyma. In one case
that was supposed to be typical, the removal of a vesical
calculus cured the condition. In another case the removal
of an enlarged prostate cured the polyuria. Many of these
cases of diabetes insipidus were due to peripheral irrita-
tion, and the general practitioner should be cautioned
against looking upon it as an entity.

332

MEDICAL RECORD.

[Feb. 23, 1907

Two Cases of Visceral Syphilis in Children. — Dr. Sara
Welt-Kakels presented these cases.

The first case was presented to the Section two years
ago. (See Medical Record, Vol. LXVIL, page 335).
At present the hemoglobin (Dare's hemoglobinometer) was
64 per cent., red cells 4,460,000, and white cells, 13,200. The
differential connt sliowed the polynuclears 61 per cent,
small lymphocytes 28 per cent., large lymphocytes 10 per
cent., eosinophiles I per cent. The color index was 0.71.
The child had been placed on intramuscular injections and
had made considerable improvement.

The second case was that of a boy over three years old,
whose parents were healthy, and with no luetic history.
The present ilhiess began five months ago, when he lost his
appetite, had some fever, cough, and profuse perspiration,
disturbances of digestion, profuse diarrhea, was losing
flesh, etc. When first examined the child was very cachec-
tic, moaning and crying when touched, especially when the
abdomen was palpated. The skin and mucosse were pale.
The superficial lymphatics were somewhat enlarged. The
rectal temperature was from 101° to 103°. The abdomen
was moderately protuberant and the superficial veins
markedly distended. There was no ascites. The liver occu-
pied the greater part of the abdominal space, its surface
was hard and uneven, with rounded and thickened border.
The left lobe did not participate in the great increase in size
of the liver. The surface of the spleen was even and hard,
and the lower border projected about two fingers below
the free border of the ribs. There was diarrhea, and the
stools contained fibers of meat and undigested vegetable
matter. The red cells numbered 3,580,000, the white cells
26,600, hemoglobin 46 per cent., color index 0.69. The dif-
ferential count showed polynuclears to be 51.5 per cent.,
large mononuclears 37.5 per cent., the small mononuclears
2 per cent., eosinophiles 3 per cent., and no mast cells. Intra-
muscular injections of mercury produced the most marked
improvement, so much so that the mother regarded the
child as a healthy one. Intramuscular injections of bi-
chloride of mercury were given three times a week.

A Case of Apyretic Pneumonia. — Dr. A. L. Goodman
reported this case. The patient was a girl eight years old,
who, wdiile attending to her regular school duties, was
troubled with a short dry cough of a ver>' persistent char-
acter. The mother took the temperature, and found it
normal. On the third day from the commencement of the
cough, Dr. Goodman saw the patient. The temperature
during the three days varied from 99.2° to 99.7° R, and
the mother's thermometer corresponded with his. The
patient had a frequent, short, dry, cough. The throat ex-
amination was negative. The respirations were 24, and
painless. The left side of the chest on percussion was nor-
mal, and the breathing sounds were somewhat exaggerated.
The right side of the chest, almost from the base to the
apex, was dull; the breathing sounds were distinctly bron-
chial in character, with very few friction sounds. The
vocal fremitus was markedly increased. There was no
pain, the child's only discomfort being the persistent cough,
which disturbed her rest day and night. The temperature
and respirations were noted every three hours. The res-
pirations varied between 24 and 28. The pulse rate ranged
from 88 to 100. The treatment consisted in mild stimula-
tion and rest, plenty of air, and the usual other hygienic
and dietetic procedures adopted in acute lobar pneumonia.
The physical signs diminished day by day, and on the
eighth day the temperature registered 986°, and after that
remained normal. On the twelfth day all the physical signs
of consolidation were gone and the cough also disappeared.
There was no history of syphilis or tuberculosis in the
family.

Enlargement of the Epitrochlear Glands in Infants. —
Dr. Alfred F. Hess read this paper. He said that the data
of which he made use were gathered in the course of ex-
amination of dispensary patients of two years of age and
under, who were treated for various ailments, chiefly for
errors in diet. They numbered 225. He was surprised to

find how few babies had no superficial glandular enlarge-
ments, there being found but si.\ among the 225 cases ; of
these, four were well nourished and two poorly so. Con-
sidering certain facts, it seemed to him that they should
not continue to attribute all these lymphatic enlargements
to minute lesions of the skin, for instance of the scalp, but
must regard them as frequently physiological to infancy.
Among the 197 cases in which posterior cervical glands
were searched for, they were found 173 times. These en-
largements he believed to be due to lesions of the scalp
or pharynx, to be partly of congenital origin, and to a small
degree to systemic infection. The glands next in order
were the inguinal, and they were enlarged in 119 cases out
of 147 examined. Circumcision appeared to play no part.
In infants, as well as in older children, the submaxillary
and anterior cervical were frequently palpable. Enlarge-
ment of the axillary gland was of a common occurrence.
Of all the superficial glands, enlargements of the epi-
trochlear was the most exceptional. Besides the 225 cases
referred to, he also examined 75 more for the presence of
epitrochlear glands. Of these 300 cases numerous infants
were found to have one enlarged epitrochlear gland, but
no importance was attached to this unless this was large.
Minute bilateral glands were found to be very common,
and were found in twenty-six cases. Large bilateral glands
were found, however, in only fifteen of the 300, and six of
these patients had syphilis, two of them being only seven
weeks old. One had an enlargement to the size of a mar-
ble. Of the remaining nine cases, three were probably
syphilitic ; one had a large liver and spleen, and the mother
gave a history of two miscarriages ; the mother of the
second had had three miscarriages, and eight children died
in infancy; the third child had snuffles since birth. Of
the six remaining cases with large epitrochlear glands, two
had tuberculosis with general glandular involvement, and
one had furunculosis of long duration. He was unable to
state the cause of the enlargement in the other three cases.
Possibly syphilis might play a role in these also. How-
ever, the fact that bilateral enlargement occurred so rarely
in infants, and proved of syphilitic origin in the majority
of cases was certainly a striking fact. These figures could
not be applied to older children. Since he had paid particu-
lar attention to the epitrochlear glands he had been given an
opnortunity of examining fifteen cases of hereditary s>T)hilis
in infants. Seven of these had large bilateral epitrochlear
glands, in four they were small, in three they were not pal-
pable. Dr. Hess wished especially to emphasize the fact that
all symptoms of syphilis might disappear under the mer-
curial treatment, but the epitrochlear glands might persist
as the sole objective symptom of the disease. Therefore, in
some cases only a routine examination for these glands
would reveal, or even suggest a previous infection. The
oresence of an enlarged spleen, associated with large bi-
lateral epitrochlear glands, occurring in an infant, was
good evidence of syphilis. In summing up his estimation
of the value of epitrochlear glandular enlargement, he stated
that its importance was not as an early sign of hereditary
syphilis, that its absence by no means cast doubt upon
the diagnosis, but that its presence might serve for a long
period as the sole landmark of previous infection.

A Clinical Study of Congenital Syphilis.— Dr. W. B.
Jennings read this paper. He said that when one consid-
ered the annual infant mortality of New York City in chil-
dren, one year old or under, was more than 16.500, and out
of that number only 78 reported deaths from specific dis-
ease, one would naturally conclude that the latter disease
was not a common one or particularly fatal. But his ex-
perience taught that this was not so. During the year 1905
there were reported to the Health Department 169 abor-
tions, 3.903 "congenital debility," premature birth, preter-
natural births, together with malformations and marasmus
under three months of age, and 6,352 still-births. Consid-
ering these cases, he thought it was reasonable to suppose
that in a large per cent, death was due to specific disease.
Dr. Jennings had a series of 65 cases of specific disease,

Feb. 22,, 1907]

MEDICAL RECORD.

33J

all under one year of age, all seen from time to time during
the past three years. There were 33 males and 32 females.
A positive family history of syphilis was obtained in J5
cases, the greater number giving a paternal infection. From
a table given, it was shown that the greatest number of
cases in this series were only one month old or under, the
second and third months of age being the next most fre-
quent. This corresponded to the observations of Miller of
Moscow, and Holt of this country. As a rule, if pemphigus
was not present at birth, it would appear within forty-eight
hours, if it appeared at all. Pemphigus appeared in 5 per
cent, of his cases, and all had bullae on body and head, as
well as the hands and feet. Snuffles was one of the most
common symptoms, and persisted for a long time. The skin
eruptions might be described as syphilitic dermatitis, not
unlike erythema intertrigo, except that there was a marked
desquamation. It was most commonly seen around the
genitals and buttocks, and inner sides of the thighs ; it often
extended over the abdomen, as well as the extremities.
Macules, papules, superficial ulcers, and condylomata were
the forms of eruption most frequently met with. Ulcers
and fissures of the lower lip and mucous patches in the
mouth were also present. The hair was affected in but a
few cases. One ease had an apparent paralysis of the soft
palate, together with a laryngitis. In only one case was any
joint affected. One or two cases of dactylitis were seen.
Fully 40 per cent, of the cases were well nourished. In
children over six months old there was often a delayed
dentition. INIarasmus was present in about 6 per cent, of
the cases. Rachitis was present in two or three cases, and
in one case, a child of nine years, a diagnosis of gumma of
the liver was made. The glands enlarged were, in order of
frequency, the inguinal, cervical, axillary, and epithrochlear.
Porrot's nodes were not observed in one case. The prog-
nosis was unfavorable if the child was without treatment ;
they all responded rapidly to treatment, mercurial inunc-
tions. Gray powder given internally was of value; if it
caused diarrhea Dover's powder was added. The black
wash was used for the snuffles.

Dr. Henry 'Koplik emphasized the importance of not
placing ranch value on enlargement of the lymph nodes,
unless accompanied by certain symptoms. If one met with
an extensive eruption apparently syphilitic, enlargement of
the lymph nodes was quite significant. Dr. Koplik said he
would not make a diagnosis of syphilis merely on the en-
largement of the epitrochlears. After years of study he
believed that per se enlargement of the lymph nodes was of
little diagnostic value when unaccompanied by other clinical
symptoms.

Dr. H. W. Berg said that Dr. Fessenden Otis, as far
back as 1881, would never allow a clinic to pass in which
he showed syphilitic patients without calling attention to
the fact that the epitrochlear glands were enlarged in
syphilis, and he ascribed so much importance to such en-
largements in the diagnosis of syphilis that he went to the
other extreme and considered such enlargements as almost
pathognomonic of sj'philis, in which, of course, he was
wrong. Enlargement of the epitrochlears meant the sus-
picion of syphilis.

Dr. A. Rose said that in December, 1900, Hochsinger de-
scribed an affection which he named hereditary syphilitic
phalangitis, the first ever given. Within twenty-five years
he had collected fifty-five cases. The reason there were so
few on record was, first, omission of exact examination,
and, secondly, difficulty of recognizing the symptoms in
some instances. This phalangitis was more frequently
found on the fingers than the toes. Hochsinger preferred
the name phalangitis to that of dactylitis because the dis-
ease was exclusively an osteitis. It was a typical and char-
acteristic manifestation of hereditary syphilis, and began at
the proximal phalanges. Hochsinger found, by means of
the Roentgen rays that the osteitis began at the borders of
the bone and cartilage, not only in the phalanges, but in the
metatarsal or metacarpal bones when they were simultane-
ously affected in phalangitis hercditosyphilitica. The char

acteristics were : the predominance of the affection of the
proximal phalanges, the absence of suppuration or perfora-
tion outward, inclination to spontaneous restitution Ann
the subacute course of the disease, the absence of pain dur-
ing its development. The proximal end of the pro.ximal pha-
lanx where the osteitis began became enlarged, giving the
finger a bottle-shaped appearance, the fingers becoming
broader and longer. The soft parts did not participate, only
the skin being stretched became thinner, was shiny and rose-
colored. The affection was multiple, but not symmetric.
The joints remained intact. Hereditary syphilis atTecting
the lingers after the first year of life, as a rule, did not
show the same characteristics ; here caries might set in, as
also arthritis and participation of the soft parts. Heredi-
tary syphilitic phalangitis in infants was one of the best
accessible forms of hereditary syphilis to therapy. Local
treatment was not required. General antisyphilitic means
would accomplish complete and permanent cure within six
to ten weeks.

Dr. ScHWARZ said that what Dr. Jennings had stated
regarding pemphigus was equally true of pemphigus neo-
natorum, and in this latter form the fluid removed from
the blisters would show eosinophile cells which were not
present in the other form.

Dr. Sidney V. Ha.\s said that after investigating the
importance of enlargement of lymph nodes in babies at the
Vanderbilt Clinic, he had given up in despair, finding them
to be the regular thing, and of no particular diagnostic
value.

Dr. Henry W. Hale, Jr., said that the treatment de-
I)eiided somewhat on the time of the infection. The more
recent the infection, the more severe were the cases, and
they required intramuscular injections, not responding so
well under the ordinary methods.

Dr. Henry Heiman recalled some cases where the ordi-
nary method of treatment failed, and which required intra-
muscular injections. The more recent the infection, the
more severe the symptoms, and the more energetic treat-
ment was then required.

Dr. Charles N. Dowd said that the cases he saw were
late ones, and in the older children the bone lesions pre-
dominated, particularly those of the tibia. Joint lesions
were occasionally seen. Dr. Dowd said he had been look-
ing for years for a case of enlarged cervical glands due to
syphili?, so lar.ge as to require surgical interference. He
had failed to find but one case.

Dr. Henry W. Frauenthal said that these glands might
have been syphilitic, but that it was the tubercular infec-
tion which caused their breakdown.

Dr. DowD thought that Dr. Frauenthal was correct, and
he was not sure that the case he referred to was not one
of tuberculous lymph nodes in a syphilitic child.

Dr. B. Lapowski said that in 90 per cent, of the cases
iiijectlng the liver of a syphilitic into an ape would inocu-
late that ape. When certain spirochetes were found the
diagnosis was positive. He never relied upon intramuscu-
lar injections of mercury in the treatment of syphilis; he
never failed if treatment was carried out by inunctions
properly given.

Dr. Hess, closing the discussion, said that enlargement
of the epitrochlears, to be of any value, should be bilateral.
Again they should not be too small. The cases Dr. Otis
showed in 1881 were cases of acquired syphilis, and ii':t
congenital, to which his paper referred.

Dr. Jennings closed the discussion.

section on obstetrics and gynecology.

Stated Meeting, Held January 24, 1907.

Dr. Howard C. T.wlor in the Chair.
An Unusual Specimen of Tubal Gestation.— Dr. H.
r.R.M) presented this specimen, which showed very nicely
Ihe amnion and chorion. Ectopic gestation was not diig-
nosed at the time. She was seen two weeks after a sup-

334

MEDICAL RECORD.

[Feb. 23, 1907

posed abortion, and a retroverted uterus was found. When
the patient was placed under ether, lifting the uterus into
position revealed this mass in the pelvis. The abdomen was
opened and the unruptured ovum was found in the pelvis
and among blood clots.

Specimen of Cyst of the Vagina. — Dr. H. Grad present-
ed this rare specimen. He had not lime to determine just
what variety of cj'st it was. He would attend to this and
report on it later. In all probability the cyst was due to
occlusion of the duct of one of the vaginal glands.

Vaginal Hysterectomy for Septic Peritonitis Follow-
ing an Artificial Abortion. — Dr. .Abram Brothers re-
ported the case of a woman, aged ;io. the mother of two
children, who skipped her usual menstrual period by two
weeks. She visited a midwife, who introduced a catheter
into the uterus. This was associated with much pain, and
was followed by uterine bleeding and fever. The family
physician was called, and she was found to have a tempera-
ture of 104° F., and he at once proceeded to curette her
■ and wash out the uterine cavity. This was followed by a
drop in the temperature to 101°, with a pulse of 90. Dr.
Brothers saw her at this time, and found an area of local
peritonitis beliind the uterus, for which he ordered rest, ice,
and opiates. The prognosis seemed to be favorable. After
the lapse of 36 hours he was called in great haste at night
to meet the family physician, who was greatly alarmed at
her condition. In spite of large and continued doses of
opium and the constant supervision of a trained nurse, the
peritonitis rapidly spread and the woman was evidently
suffering intense pain, which kept her continually moaning
and shrieking. The temperature and pulse became markedly
increased and the abdomen greatly distended, and was the
seat of exquisite tenderness. The woman was hurried to
the Beth Israel Hospital and was operated on at 2 o'clock in
the morning. On opening the posterior cul-de-sac a little
accumulation of pus escaped. Under the impression that
the uterus had been perforated by the catheter, which was
under the circumstances in an infected condition, he did
a rapid vaginal hysterectomy with clamps, draining the
peritoneal cavity with gauze. The temperature at once
dropped and the patient went on to complete recovery. No
perforation of the uterus was discovered.

Laparotomy for Infected Ectopic Gestation. — Dr.
.Vbram Brothers reported the case of a woman who
gave the history of irregular bleedings, cramps, and sensa-
tions of faintness. A local examination revealed an en-
larged uterus, but apparently nothing more. A curettage
without anesthesia was ordered and performed by the
house surgeon, who neglected to have the scrapings ex-
amined. Several days later she complained of slight pain
in the right iliac region, and the chart showed a low grade
of temperature. Examination revealed a small mass in the
right pelvis, which was diagnosed as a parametritis. Noth-
ing was felt .in Douglas' cul-de-sac. At the end of two
weeks, in spile of ice and rest, the mass increased in pro-
portion^ rather rapidly, and, suspecting a purulent process,
operation w-as advised. She was anxious to go home, as
her general condition was not bad. The presence of a low
grade of temperature, with accelerated pulse, induced them
to insist on her remaining, and finally, three weeks after
the curettage, she was induced to submit to operation.
Laparotomy with exsection of the umbilicus was done. No
free Wood was present in the peritoneal cavity. The right-
sided mass was glued to the omentum and anterior ab-
dominal wall. During the manipulation to isolate the tumor
there was a sudden gush of pus of chocolate color. The
tumor was shelled out of its adhesions and removed.
Within the peritoneal cavity it seemed to have the diameter
of an ordinary sized baseball. The abdomen was closed
to the lower end of the incision, where a small drain was
left. Recovery was uneventful. On splitting open the
tumor a small amniotic sac was opened, and within it a
tiny embryo was discovered.

Dr. Howard C. Taylor recalled a case similar to the one

reported by Dr. Grad, in which he curetted for a supposed
miscarriage. After three weeks he opened the abdomen
and the fetus was found. The woman had been bleeding
slowly and lost much blood, and was very anemic, but at no
time did she develop an hematocele.

Dr. Herman J. Boi.dt confessed that ten years ago he
knew more about the diagnosis of ectopic gestation than he
knew to-day. It had occurred to him many times that a
patient presented herself with the typical symptoms of
ectopic pregnancy, and he would open the abdomen
only to find a suppurating tumor. Especially in
pus cases was one liable to trip up on in diag-
nosis. He recalled one case that Dr. Brothers had
seen, and which he subsequently saw two or three times,
with the impression that the slight atypical bleeding that
was present was caused by a postpuerperal endometritis
following an abortion. One morning he was called, and
made a diagnosis of ectopic, and the patient was subse-
quently operated on for ruptured tubal gestation. Dr.
Boldt said that there were cases where it was absolutely
impossible to make a diagnosis. In those cases where one
suspected a tubal gestation he advised operating at once,
and not waiting.

Dr. George H. Ballerav, discussing Dr. Brothers's case,
said that in his opinion it was a difficult matter to say when
to do an hysterectomy in cases of septic uteri, especially
when following an abortion. It was a very difficult matter
to formulate any rules for these cases.

Dr. Herman J. Boldt said that it was absolutely im-
possible to formulate any rules. But where there were evi-
dences of a septic peritonitis, or a general sepsis going on
post-puerperal, and where he knew the interior of the
uterus to be free from debris, and nothing was to be seen
that caused the septic condition, with the patient not get-
ting better in a short time, running temperature of 103°,
104°, or 105°. even if there were no positive evidences from
the blood examination that usually meant enlarged and
relaxed uterus, in other words, the source of infection in
the uterus, the quicker that uterus came out the better. The
matter, though, almost always must be left to individual
judgment.

Four Specimens of Myofibromata Uteri. — Dr. Her-
.MAN J. BoLDT presented these specimens. The interesting
clinical feature of the first tumor was that upon examina-
tion it was so soft that several physicians made the diag-
nosis of an ovarian cyst, although there were irregularities
in the menstrual flow, this occurring at intervals of from
eight days to three weeks, but only of from three to four
days' duration. A steady increase in size of the abdomen
had been observed for the past five years. The pathological
features of interestwerethat the center of the tumor showed
evidences of degeneration, although not indicative of malig--
nancy. The degenerative change caused the softened condi-
tion of the neoplasm. The ovary contained a hematoma,
and the ovarian stroma showed fibroid degeneration. The
endometrium was fairly normal. The tube walls were^
atrophic, but their mucosa was normal.

The chief clinical symptom giving rise to the indication
for operation in the second case was the existence of con-
stant pain in the lower abdomen for the past four weeks.
In addition there were present symptoms of myocarditis.
On microscopical examination of the tumor there was slight
increased proliferation of the blood-vessels about the
periphery, but few blood-vessels in the center of the tumor.
Both tubes and ovaries were enlarged, thickened, con-
gested, covered with adhesions and matted matter together.
The tubes were thrown into nodes, particularly on the left
side, as thick as a lead pencil, and forming a pipe-bowl
shape, with the ovaries at the distal extremities. The
ovaries were dilated into pus sacs ; the broad ligaments
were thickened, congested, and board like. It was evident
that the chief symptoms were caused by the ovarian ab-
scesses.

The pathological features presented by the third speci'

I'd)

1 907 J

MEDICAL RECORD.

335

men were that the interior of the uterus was much en-
larged and lined by a thick sr.cciilent mucous membrane.
The endometritis fungosa caused tlie atypical bleeding. In
some areas the blood-vessels in the mucosa were numerous
and much thickened. The blood-vessels in the uterine wall,
liowcvcr, were normal.

The clinical features of the fourth specimen were that
the tumor was wedged tightly into the pelvis because of
its intraligamentous development on the left side. Path-
ologically, the tumor was beginning to show degenerative
changes in some parts, there being edema present around
these areas. The nuclei of the cells did not take the stain,
and these and some of the cells were disintegrated. The
glandular eleniLiits in the nuicosa were increased.

Limitations of the Surgical Treatment of Uterine
Fibroids. — Dr. Henry C. Coe read this paper. He said
that few subjects had been more discussed than that of the
surgical treatment of uterine fibroids. His te.xt was fur-
nished by no less than six patients with uterine fibroids,
who came to his office within the last fortnight, all of whom
had been advised to undergo a radical operation, but Dr.
Coe advised against operation. In every instance the so-
called tumor was not larger than a small orange, and
caused no symptoms, such as pain, pressure, menorrhagia,
and was, from his point of view, simply of clinical interest.
And yet, these women had been advised to have their uteri
removed, even though they were in the prime of life. He
wished to call attention to one fact, that confidence on the
part of the operator had led to too radical views in dealing
with uterine fibroids. He stated that the mere presence of
a fibroid was not an indication for operation. Excluding
cases of fibroids in which the indications, pain, pressure,
profuse hemorrhage, steady increase in the size of the
neoplasm, evidences of degeneration, complications (local
and general), etc., were so clear that the majority of oper-
ators would advise operations, he said that he would con-
sider only the class of cases in which there were small
interstitial growths, with few if any symptoms, not affect-
ing the general health ; in short, these cases which caused
the patient no discomfort or dii^quictude until she had been
indiscreetly told that she had a "tumor" He earnestly
desired to throw his influence in favor of a higher type of
practical gynecology, of a mutual confidence, not only be-
tween the specialist and the general practitioner, but be-
tween the doctor and his patient He asked why the mere
presence of a small uterine fibroid impelled the examiner
to inform the patient hitherto in blissful ignorance, but
also to advise operation? He found that most of his pa-
tients, whom he passed as not requiring even medical treat-
ment, were told that the "tumor would grow," that "it
would become malignant," that "it would give trouble at or
after the menopause," or the ari>uincnt had been advanced
that the patient had a neoplasm, ergo, it must be removed.
It not infrequently happened that he could find no tumor,
simply a large hyperplastic or asymmetrical uterus. It be-
hooved the general practitioner to be sure that the patient
had a tumor before he informed lier of this fact, or advised
an operation, for once the fatal words had escaped his lips,
all the specialists whom she cons'.ilted afterwards could not
convince her to the contrary. He asked w-hat was the
clinical history of the case, ami had she any symptom?
referable to the increased weight of the uterus, vesical or
rectal irritation, displacement of the uterus, interference
with the normal function of the pelvic organs? Dr. Coe
had been watching many patients from ten to fifteen years
with small fibroids, who had never complained of such dis-
turbances. He said he was far from commending the ultra-
conservative views of those who believed that a patient
'■hould be tided over the period of menorrhagia preceding
the climacteric under the mistaken idea that the tumor
would "disappear" after that time. He did not remember a
case in which the fibroid had entirely disappeared after
either a natural or artificial menopause, though he had
seen it diminish in size and all troublesome symptoms
vanish. The whole question of the treatment of uterine

fibroids turned on the question of the proper recognition of
the variety, the size and sypmtoms caused by the tumor.
It was a reproach to their diagnostic and clinical experience
if they jumped at the conclusion that surgical treatment
was indicated simply because they happened to discover a
tumor.

Dr. Hkkm.vn J. BoLDT said that the section was to be
congratulated on having had presented to it such an ad-
mirable paper on conservatism, and he wished to indorse
all except one statement, namely, the question of curettage
in cases of myomata. With that exception he endorsed all
Dr. Coe had said. He saw no use in removing a uterus, or
even operating, when there was simply a fibroid present,
especially when it was of small size. If there was an
ovarian tumor present, that was a different thing.

Dr. Egbert H. Grandin said that he was entirely in
agreement with the statements made by Dr. Coe. He be-
lieved that every man with any surgical experience would
agree that the mere fact that there was a tumor present
was not sufficient justification for its removal. All knew
that there was a certain period of a woman's existence
when a small fibroid might never become anything more,
but they should be able to differentiate surgically their
cases. Dr. Grandin said he had used the various methods
of treating fibroids. He had been an advocate, and a con-
sistent one, too, of the use of electricity in the treatment
of uterine fibroids. He admitted that he had used all kinds
of methods, and simply because those who taught him did
not know better themselves. Having divested himself of
the obsolete methods he had now reached a definite conclu-
,sion, as follows : Any fibroid that gave rise to symptoms
was a surgical fibroid ; if it did not give rise to symptoms,
why should any woman then come to him to find out what
the matter was? The smaller the fibroid, the less operat-
ing, the less strain upon the kidneys and heart, the less
size of incision, the greater chance for recovery, the less
ch.ance of having an anemic heart, which was associated
with increased growth of the fibroid, and, therefore, more
hemorrhage. The only class of fibroids that Dr. Grandin
feared was the big hemorrhagic ones with the anemic
heart, and the tendency to death from so-called shock, etc.
The mortality rate from small fibroids which gave no symp-
toms should be nil ; from the large hemorrhagic fibroids it
was often 10 per cent. That was his experience. If one
let a post-operative fibroid case, hemorrhagic in type, out of
bed in three days, there was danger of pulmonary embol-
ism. Whenever a woman had a fibroid which gave rise to
symptoms, that fibroid was bound to grow. With regard to
the route, any fibroid which could be made to enter the
pelvis should be removed by the vaginal route, if one was
sure there was no disease of the appendages or of the ap-
pendix. Any tumor which could not be made to enter the
superior strait above the brim, or where there was a
coexistence of tubal or appendical disease, the only route
u;is the one above.

Dr. George H. B.^iLLERAY said that he decidedly favored
conscr\ atisni in these cases, and he even went further than
Dr. Coe. The only indications for the removal of these
liliroids were pain, hemorrhage, and rapidjy increasing
growth of the tumor. Kelly, in his book, had emphasized
the fact that the mere presence of a tumor did not indicate
llic performance of an operation. The conscientious practi-
tioner should show before operating that the tumor was a
menace to life or incompatible with the woman's comfort.
Fibroids that were not causing symptoms should not be re-
moved. He said he could not plead too strongly for con-
dcnmation of this surgery. Such cases as Dr. Coe referred
to should not be operated on. Dr. Coe said the statement
that tumors or myomata of the uterus would disappear
after the menopause was nonsense. But Dr. Balleray had
seen such cases that caused such hemorrhage that the pa-
tient was tamponed and placed in bed. After a while the
tumor ceased growing, and the tumor later disappeared
during a retrograde metamorphosis. For that reason he
lubfvpd that if a woman could safely be carried past the

536

MEDICAL RECORD.

[Feb. 23, 1907

menopause it should be done. He had known of cases
where, after the menopause, the tumors disappeared. He,
therefore, condemned what he called unnecessary operating.
1 here might be in some cases a reasonable doubt as to
what should be done, and then two men might differ.

Dr. Malcolm McLean wished to endorse all that Dr.
Coe had stated. Certain of these growths were as harm-
less as a wart on the hand, and no one had any right to
remove them when no symptoms were referable to them.
I^r. Coe would operate upon those cases if they presented
symptoms. If a woman had a small interstitial fibroid she
should not consult a surgeon who was willing to mutilate
her. He wished to emphasize one point in distinguishing
l)etween those cases that should be operated upon and those
which should not be. He told his patients that he wanted
to see them every three months. When they returned he
made careful examination; if he found the tumor was
growing, he had them return at a shorter interval ; then if
he found they still continVied to grow, he warned them
that an operation was going to come. With regard to
malignancy, in all his experience he had seen but one fibroid
which apparently degenerated into sarcoma or malignant
disease.

Dr. Coe closed the discussion.

Some Further Notes on the Use of Rubber Bags for
Dilating the Parturient Cervix. — Dr. R.\LrH Pomeroy
showed these bags.

Drs. PoLAK and McLeax discussed them.

iirMral 3ltrms.

looks ^£^mmh.

While the Medical Record is pleased to receive all new
publications zvhich may be sent to it, and an acknozvledg-
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heading, it must be zmth the distinct understanding that its
necessities are such that it cannot be considered under
obligation to notice or review any publication received by it
which in the judgment of its editor i^ill not be of interest
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Elements of Practical Medicine. By .Alfred H. Car-
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H. K. Lewis, London,

The Bacteriological E-xamin.\tion of Water Supplies.
By Willia.m G. Savage, B.Sc, M.D. (London), D.P.H.
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A Manual of Pathology. By Guthrie McConnell,
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A ]\La\ual of Normal Histolo(;v and Organography.
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Atlas and Te-\t-Bqok of Dentistry, Including Dis-
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Materia Medica for Nurses. By Emily A. M. Stoney.
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M,D, Second edition, thoroughly revised and enlarged, Svo,
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Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious disease reported to
the Sanitary Bureau, Health Department, New York
City, for the week ending February 16, 1907 :

Tuberculosis Pulmonalis.

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Tvphoid Fever '. .

Whooping Cough

Cerebrospinal Meningitis.
Malarial Fever

Cases Deaths

Totals

356

191

2S2

52

248

6

263

21

; 2

—

91

—

42

12

52

6

13

'3

1340

301

Pyloric Stenosis Consecutive to the Absorption of
Caustics. — Quiinu reports the follow-ing case: A woman
forty-six years old swallowed a concentrated solution of
hydrochloric acid. She was taken with acute pain and
vomiting. Alimentation became impossible. She became
emaciated and entered the hospital six weeks after the
accident. Nutrient enemata kept her alive. Quenu deter-
mined to practice gastroenterostomy. Chloroform was
administered after an injection of serum had been given.
The pulse stopped. An incision was made in the diaphragm
in order that the heart might be massaged, but the patient
succumbed. Autopsy did not reveal severe gastric lesions,
but there was a marked stenosis of the pylorus through
which a probe could sarcely be passed. This stenosis de-
veloped very rapidly, as only six weeks had passed since
the time of the accident. In the region of the pylorus the
mucosa had disappeared. — Gazette des Hopitaux Civils et
Mililaires.

Health Reports. — The following cases
yellow fever, cholera, and plague have
to the Surgeon-General, Public Health
Hospital Service, during the week ended
1907:

SM.'VLLPOX — UNITED STATES,

Connecticut, Stamford Jan. i -31. . . ,

Georgia, .^aqusta Jan, 2<j-Feb, 5

Illinois. Galesburg Jan. 25-Feb. 9

livliana, Indianapolis Jan. 27-Feb. 3

La Fayette Feb, 4-1 1

South Bend Jan, 26-Feb, 0

Iowa. Clinton Jan, 27-Feb, 3

Kansas, Kansas City Feb, 2—9

Louisiana, New Orleans Jan, 28-Feb, 4

Michigan, Detroit Feb, 2-0

Kalamazoo ,"Jan. 26-Feb. 2

Missouri, St, Joseph Jan, 25-Feb, 2

St, Louis Jan, 25-Feb, i

Xew York. New York Jan, 26-Feb, 9

South Dakota. Sioux Falls Jan. 25-Feb, 2

Texas. Houston Jan, 12-Feb, 2

Washington. Spokane Jan. 19-Feb. 2

Wisconsin, La Crosse Feb. 2-0

Milwaukee Jan. 19-Feb, 0

of smallpox,
been reported
and Marine-
February 15,

CASES, DEATHS,

3 2 Imp't'd

30
3
3

SMALLPOX — POREICX,

.\frica. Cape Town Dec,

Brazil. Pemambuco Dec.

Rio de Janeiro Dec,

Canada. Sherbrooke Feb.

China. Hongkong Dec,

Shanghai Dec,

France. Paris, , Jan,

Great Britain. Hull Jan.

India. .Madras Dec.

Netherlands, Rotterdam Jan.

Russia. St, Petersburg Dec,

Spain, Senile Dec,

15-22

15-31

30- Jan, 6, .

9

1—22

23-30

12—19

12-19

I5-SI

19-26

27-Jan, i>,

1-31

48

3
40

YELLOW FEVER.

.\frica. Senegal and Niger Nov, 1-30.

Me.'cico, Vera Cruz Feb, 8 , , , .

CHOLERA,

India. Bombay, ,
Rangoon ,

.Jan. 1-8,.
, Dec, 22-29.

3 5 26

I Imported

4
23

Brazil, Pemambuco Dec. 15-3 1

Rio de Janeiro Dec. 30- Jan. 6.

India, Bombay Jan. i-S

Rangoon Dec.

Peru, Callao Jan.

Chickayo Jan.

Mollendo Jan.

Paita. City and vicinity, . , , Jan,

San Pearo and Pacasmaye, -Jan.

Truiillo Jan.

2^-29-
S-I2.

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 71, No. 9.
Whole No. 1895.

New York, March 2, 1907.

$5.00 Per Annum.
Single Copies, lOc.

©rtginal Artirl^s.

INFLUENZA IN ITS RELATION TO DIS-
EASES OF THE NERVOUS SYSTEM.*

Bv JOSEPH COLLINS, M.U..

NEW YORK.

PROFESSOR OF NERVOUS AND MENTAL DISEASES AT THE NSW YORK
POST-GR.\DUArS URDICAL SCROOL A-ND HOSPILAL: VISITING PHYSI-
CIAN TO THE CITY HOSPITAL; NEUROLOGIST TO MONTEPIORE
HOUB. CONSULTING NEUROLOGIST TO THE HOSPITAL FOR
RUPTURED AND CRIPPLED, AND TO THR MANHATTAN
STATE HOSPITAL, WEST.

The bacillus of influenza and the poison engendered
by its active existence in the body, have a peculiar
capacity to disorder the functions of the nervous
system, and to cause pathological changes in its cen-
tral and peripheral portions. The truth of this has
been especially recognized since 1890, i.e. since the
occurrence of the last epidemic of influenza in this
country and in Europe. To convey an idea of the
literature that has been created setting forth the
nervous sequehe of influenza, it may be stated that
the references alone to the subject take up five closely
printed pages of nonpareil type of the Index Med-
icus. There is scarcely a disease, functional or or-
ganic, of the brain, cord, or peripheral nervous
system, that has not had its causation attributed to
influenza, and I may add, in many instances, quite
improperly. One does not attribute acromegaly to
an occasional inebriation, especially if the symptoms
do not develop for some time after the indulgence.
No more should conditions of absolutely unknown
causation, such as paralysis agitans, or of fairly
well-known origin, such as exophthalmic goiter, be
attributed to an attack of influenza, out of which
apparentlv flowed no symptoms whatsoever save
those of the infection, and which terminated in re-
covery.

The period during which influenza has been
studied scientificallv corresponds to that of my spe-
cial interest in nervous and mental diseases. Wlien
it first prevailed I was in active general practice, but
soon after that began to see nervous disorders in one
of the large clinics of this city. Since that time, and
particularly during the past ten years, I have had
opportunity to study nervous diseases, which has
permitted me to gather the records of upward of
ten thousand patients, personally examined. It is
largelv upon a studv of these records that the state-
ments and conclusions embodied in this paper are
based. In order to make the statement as emphatic
as possible, I shall say in this connection that this
experience teaches me not to share the view of those
who maintain that influenza is a common or im-
portant cause of nervous or mental disease, either
functional or organic; common, I mean, in con-
trast with such causes as syphilis and alcohol. I
do not wish to be understood as underestimating
the disastrous effects that follow successful attack
on the nervous system by the bacillus of Pfeiffer,

* Read at a meeting of the New York Academy of Med-
icine. February 7. 1007.

They are often very severe, and that they do occa-
sionally occur everyone admits. That which I wish
to show is that they occur infrequently.

As an example of the indiscriminate accusation of
influenza as a cause of death without the production
of definite disease, statements from the literature like
the following, which, by the way, is not unique, may
be quoted : Dr. E. A. Cobleigh^ of Chattanooga
says: "Some patients (after influenza), wholly
without regard to age or previous vigor, were too
feeble for any movement or exercise beyond the
minimum of vitality required to stay alive. This
one element of debility was profound, and the sole
cause for uneasiness. Instead of recovering within
ten days or a fortnight, most of these sufiferers lin-
gered for weeks, sometimes even for months, and
not a few dwindled on for a year or two, to die of
sheer exhaustion at last." One of the most im-
pressive and rare complications that he recalled ever
having seen, consisted in extreme clonic, spasmodic
seizures, particularly involving the heart, the dia-
phragm, and the muscles of respiration, with no
mental disturbance except the most pitiable fear of
impending death. Nor do I in any way subscribe
to the following sentiments expressed editorially in
the Medical Record, August 13, 1904: "If an in-
dividual, through the sins and misfortunes of his
fathers, inherits a predisposition to any disease, an
attack of influenza will in most instances develop
this disease. This statement is especially true of
afTections of the nervous system, and renders, in
these times, influenza a maladv greatly to be dreaded.
Considered from almost all points of view, influenza
is perhaps the most deadly disease to which the
modern individual is subject. \Mien it does not kill,
it either cripples or leaves the victim of its onslaught
a worse man physically and mentally than he was
before the attack." Surely, there is no justification
for such animadversion, else I should have been
brought face to face, professionally and socially, with
manv of these wrecks ! Why see red and blue so
vividly when the real causes of nervous and mental
diseases, svnhilis, alcohol, and narcotics, take their
iniquitous way almost unmolested?

I can scarcely hope to do more in the fifteen
minutes allotted me, than barely to outline the re-
lationship of inflivenza to diseases of the nervous
system. Statistics will appear in the published
article, and recitation of cases would not enhance
the value of my remarks.

In a general way, it may be said that influenza
causes chronic disease onlv by causing disorder of
the nervous system and of the special senses. The
best evidence' of the truth of this statement is the
fact that influenza, a well-defined disease of the
latter middle ages and a ravage of the nineteenth
century, was entirely forgotten and had practically
lost its' place in medical literature, until the epidemic
of 1890, when disorders of the nervous system had
become diagnosticable, and neurology the most im-
portant integral part of general medicine.

The bacillus of influenza mav and does cause

338

MEDICAL RECORD.

[March 2, 1907

mening^itis, encephalitis, myelitis, and possibly neu-
ritis. The toxins produced by the pathogenic activ-
ity of the influenza bacillus are adequate exciting
causes of neurasthenia and psychasthenia, of neuritis
ar.d neuralgia, of various forms of insanity, of inde-
pendent nervous symptoms, such as insomnia, ver-
tigo, headache : and they mav be contributory to the
causation of any disease that afflicts the human
being. This practically constitutes the accusation
against influenza from the neurologist's standpoint.
But I repeat neither the bacillus of Pfeiffer nor its
to.xins, i.e. influenza (if what is called influenza is
the equivalent of the existence in the system of
these two things), is a common cause of nervous
disease. I take for granted that it may be assumed
that much that is called grippe by the patient and
physician is not influenza in the strict sense.

The most serious diseases of the nervous svstem
caused by the bacillus of Pfeift'er are inflammations
of the central nervous system and its covering —
encephalitis, myelitis, and meningitis — all extremely
rare and extremely serious complications of influ-
enza. There is very little in the clinical manifesta-
tions of these various diseases that permits the phy-
sician to distinguish them from those caused by
other organisms. Since the utilization of spinal
puncture and examination of the spinal fluid as a
routine diagnostic measure, many cases of influenzal
meningitis have been recognized. Before that time
the bacillus of Pfeiffer had been found in the ex-
udate of certain cases of meningitis.- In many
cases it occurs accompanied by other organisms.
Recently J. S. C. Douglass^ has reported a case of
influenzal meningitis occurring in a female patient
ten months old, whose cerebrospinal fluid obtained
during life by a lumbar puncture, showed many
bacilli situated both intra and e.xtracellularly, of the
shape and size of Pfeiffer's organism. After death
a similar bacillus was found in the meningeal ex-
udate. This case, taken in conjunction with those
reported by Xuthall and Hunter,'' Judson Bury.'
Thomesca and Gracoski.'' and Mya.' adequately
proves that meningitis may result from this bacillus.
Whether or not influenzal inflammation of the men-
inges is ever a primary infection. I mean infection
by the bacillus, is not known. One can infer that
the infection is a primary one in the absence of symp-
toms pointing to involvement of the nasopharynx,
the adjoining sinuses, of the middle ear. and of the
respiratory system.

So far as I know, there is nothing in tlie clinical
manifestations of meningitis, cerebral or spinal,
which permits one to say whether or not it is due
to the bacillus of influenza. It may be presumed
to be of such origin when it occurs in the wake of
influenza at a time when influenza is present, or
when it is sequential to 'disease of any of the cavities
about the head caused by influenza, hut it can be
positively so characterized only when the bacillus
of Pfeiffer is found in the cerebrospinal fluid. Here
it should be said that it has frequently been pointed
out that, although the cerebrospinal fluid at the first
puncture does not contain the bacilli, often a second
or third tapping may reveal them. Cases of
well-marked meningitis that end in recovery always
excite a suspicion in the mind of the physician who
sees the common terminal results of meningitis on
the post-mortem table, that possibly the case was an
example of what the French call pseudomeningitis.
or meningisme, a condition which may be best de-
scribed negatively as one due not to the activity of
the pathogenic organism directly, but to its toxins,
and in which after death there is found only hvoer-
eniia and possibly increase of serum. While I have

seen cases of meningitis apparently typical and fully
developed in every way. occurring in the wake of in-
fluenza with catarrhal manifestations in the mucous
membrane, terminate in recovery, I have never seen
such a case in which the bacillus of Pfeiffer alone
was found.

Influenzal meningitis occurs, as all other forms,
more frequently in children than in adults. In
twelve cases reported by Ghon,* with post-mortem
examination, there were eight children and four
adults.

Acute nonpurulent encephalitis, meaning, as a
rule, hemorrhagic focal inflammation of the cortex
(often of symmetrical areas in each hemisphere), is
a disease that has received recognition only during
the past few years. Its causation, its clinical display,
and its terminations, are now fairly well understood.
That the bacillus of influenza causes it, there is no
doubt. That it has been and is still often diagnos-
ticated as meningitis, is a fact. That its chief symn-
toms are headache, vertigo, irritableness, and stupid-
ity, quickly leading to delirium and unconsciousness,
with comparatively slight constitutional manifesta-
tions, and often unaccompanied by signs of cortical
irritation or destruction (spasms, aphasia, or par-
alysis), all writers are agreed. Particular symptoms
indicative of the exact location of the focus of in-
flammation occur only when a highly specialized
area of the brain, such as the Rolandic area, the
speech area, the cuneus, etc., is the seat of the dis-
ease. That the life of individuals that have even
severe attacks of this disease is often spared, and
that many such cases are later labeled cases of in-
fantile cerebral palsy, organic epilepsy, sclerosis of
the brain, hydrocephalus, idiocy, etc. (and that,
therefore, it may be truthfully said that such dis-
eases or conditions have a genetic relationship to
influenza), can easily be demonstrated. Although
the occurrence of this disease in the w^ake of influ-
enza is good evidence that influenza is responsible
for it, and although this evidence is corroborated by
finding the bacillus in the tissues of cases that have
terminated fatally, it is more difficult even than in
meningitis to say that such and such a case is due to
the influenza bacillus. That such is the case may be
suspected and inferred from its association. The
cerebrospinal fluid may reveal the organism, but I
do not find any case recorded in which it was found
during life.

.Acute hemorrhagic encephalitis is a diagnosis that
was made fourteen times in my clinic last year.
During this period 1.53.^ patients sought relief from
disorder of the nervous system. One may or may
not gather from this an idea of its frequency. I
believe it to be of more frequent occurrence than is
commonlv supposed. I have had no experience that
leads me to share the belief of some writers, that
a disseminated encephalitis (which later in life be-
comes the anatomical basis of chronic organic
chorea, or disseminated sclerosis) is a sequence of
influenza, although a few such cases are recorded.
The grav matter within the brain Miay likewise be
attacked by the bacillus of influenza or its toxins,
and the clinical picture of polioencephalitis superior
and inferior (Opnenheim-Uhthoff) result.

Xaturallv, the cerebellum may be involved as well
as the cerebrum and the brain ganglia. What the
symptoms of such involvement are will depend upon
so manv factors (part of the cerebellum involved,
intensitv and extent of the lesion, etc.), that it is
difficult to particularize them. A case reported by
Guttman.^ under the title of ""Brain Paralysis .After
Influenza," may, however, be taken as an excellent
example of influenzal cerebellar encephalitis, al-

March

1907'

MEDICAL RECORD.

.^39

though there are many symptoms, such as the be-
ginninsf ones, that tend to indicate that there was a
widespread infection. Four weeks after the bctjin-
nincr of the influenza, the patient complained of
weakness of the right leg, tenderness of the calf
muscles, and later of pain and weakness of the righi
arm. Two months later both legs were weak, and
his gait was unsteady. At this time he complained
mostly of vertigo and of headache. Shortly after-
ward the right eye went into a state of convergent
strabismus, and examination showed that it could
not be moved out of that position. The right facial
nerve was weaker than the left ; there was intention
tremor of the right hand, and the tendon-jerks were
much exaggerated. The i:>atient recovered com-
pletely after six months. The ocular palsy and
nystagmus, the tremor of the hands and feet, the
exaggerated reflexes and ankle-clonus, all point to
its being an inflammation of the cerebellum.

The occurrence of myelitis after influenza was
soon recognized after the epidemic of i8go. The
published histories of many patients show that such
myelitis displays itself in one of three forms : as a
transverse or as a punctate disseminated lesion, and
as an acute systemic involvement, the motor tracts
being particularly involved, to constitute a clinical
syndrome resembling that of acute ascending par-
alysis, or Landry's paralysis. In exceptional in-
stances the symptoms display themselves in a way
that indicates that the morbid process is a meningo-
myelitis. The feature of influenzal myelitis that
calls for comment, and the one that sets it apart
from other varieties of myelitis, is its termination,
which, in not a few instances, has been in complete
recovery. There are many such cases on record.
Personally, I have seen but one. In this case the
only sign at the present time that the cord did not
entirely regain its normal state, now five years after
the occurrence of the disorder, is liveliness of the
knee-jerks. In other instances the termination is in
partial recovery, the clinical condition remaining
corresponding to that of lateral or combined scler-
osis. Cases have been recorded to show that in some
instances following upon grippe the spinal cord
becomes diseased in what may be called a subacute
way, the clinical accompaniments being those of
subacute spastic paralysis, or acute spasticity and
spinal paralysis, such as the case reported by
Henschen,^" in which a man thirty-four years old
had the typical symptoms of this condition, which
terminated in recovery. A similar case has been re-
corded bv Koster.^^

That influenza exerts a profound poisonous effect
upon the nervous system, which effect is continuing
after the disorder itself has disappeared so far as
any evidence of its active existence can be made
out, was known long liefore the bacillus of influenza
was discovered b}- Pfeiffer. The poison which the
activity of the bacillus produces is capable of bring-
ing on inflammatory or degenerative processes, at
least in the peripheral nerves and in the muscles, to
produce neuralgia, myalgia, and multiple neuritis,
and this I have spoken of in another part of this
paper. They are not more striking, however, than
individual symptoms, particularly insomnia and
headache, which follow in the wake of grippe. Oi
all the sequelje of grippe, I know of none which is
more distressing and more persistent than these. It
has been suggested that thev are dependent upon
■ cerebral hyperemia, or on change in the meninges,
such as meningeal and cortical edema, but thi= seems
to me an utterly unnecessary hypothesis, and a much
less likely one than that which attributes them to
alteration of blood-pressure in response to the action

of the toxins upon the blood vessels. Naturally, as
we know not how sleep is caused, we cannot very
"ivell know how it is disordered, even though we may
he able to give full enumerations of the things that
disorder it. That it is disordered after influenza is
very well known, and that to relieve it very often re-
quires a therapy directed against circulatory dis-
turbances, evidences of impaired metabolism and nu-
trition, and toxemic conditions, as well as the utiliza-
tion of hypnotics. In other words, tonic baths, mas-
sage, sweat baths, eliminants acting through the in-
testinal and renal tracts, as well as veronal. What
is here said in reference to the post-influenzal in-
somnia applies v,-ith almost equal force to the treat-
ment of post-influenzal headache.

One of the most remarkalile associations of the
clinical symptoms which influenza produces, is that
of bulbar ])aral\sis of the asthenic variety. It may be
permitted me to say that there is a form of bulbar
paralysis which has certain typical clinical charac-
teristics, in which after death no lesion of the
oblongata has been found, and to which the name
asthenic bulbar paralysis has been given. This con-
dition has been noted to occur after grippe, but
whether the influenza is a contributory cause or an
active exciting cause, cannot be said. In a case re-
ported by Pitres,'- the case seems to be a general
asthenia more than a bulbar asthenia.

Disorders of the nervous system that in my ex-
perience stand most frequently in causative relation
to influenza, are those dependent not upon the direct
action of the bacillus of influenza upon the nervous
system, but upon the activity of toxins produced by
the pathogenic activity in these germs. These are
neurasthenia and psychasthenia, neuralgia and neu-
ritis, and diseases and disorders of the nervous sys-
tem attending and depending upon arteriosclerosis.

That after grippe many individuals are enfeebled
mentally and physically, out of keeping with what
has seemed to be comparatively a simple preceding
febrile disorder, there can be no doubt. Just how
much depression, apprehension, inattentiveness, in-
somnia, and impaired physical vigor one must have
before he is entitled to label the individual neuras-
thenic or psychasthenic, no one can say. Nor
does it aid us in the successful recognition or treat-
ment of such condition so to label it. It is probably
far better for both patient and physician if such
cases that terminate in recovery under appropriate
treatment at the end of a few weeks are not thus
labeled. No one thinks of designating similar con-
ditions following typhoid fever, rheumatic fever, and
lung fever, as neurasthenic and psychasthenic, and
probably because in such instances the severity of
the preceding disease seems to be adequate for such
entailment as exists, but the fact that the phenomena
of grippe are often so slight in their severity and
brief in their existence, makes it seem incredible
that such preceding effects may be the result, but
one only has to recall the gravity and innocuousncss
of the infection of anterior poliomyelitis and com-
pare it with the sequelae to have a parallel. Occa-
sionally, but not very often, it is my belief, there
develops after influenza (perhaps oftener than after
anv other disease caused hv a germ whose tendency
it is to find its most favorable development in
mucous membrane) mental, nervous, and visceral
s\mptoms. which are properly designated psychas-
thenia and neurasthenia. The one most character-
istic feature of these cases is that they are h^'^o-
chondriacal. The anxiety tvpe. the obsessional
type, the self-accusatory type, and other well-known
forms, are rarely displayed. In these severer forms
the profound bodily weakness manifested in great

340

MEDICAL RECORD.

[March 2, 1907

fatiguability and symptoms indicative of collapse on
comparatively slight effort, are sometimes noted.
They bespeak, as do the severer forms of neuras-
tlienia and psychasthenia, either a profound intoxi-
cation of the system or an extremely vulnerable cere-
brospinal organism. In these cases, as in the psy-
choses, the intensity of the symptoms of these nerv-
ous disorders does not seem to be proportionate or
in any way connected with the intensity of the phe-
nomena caused by the infection itself. In other
words, a very mild attack of grippe is sometimes
followed by a profound attack of nervous prostra-
tion, but then this is not unlike that which experience
has taught us is common for other post-infectious
involvement of the nervous system, for instance,
after diphtheria.

Many cases of post-inlluenzal hysteria have been
recorded, but what is said regarding the relationship
of insanity to influenza holds good as well for hys-
teria. Hysteria does not occur after influenza, save
in individuals who have a psychopathic or neuro-
pathic foundation. In such individuals, hysteria may
develop or other pathological mental states may
follow, depending upon conditions which are im-
perceptive to the average mind, upon conditions that
indeed are considered far too inadequate and entirely
too trifling, but the pathogenesis of the hysteria in
these cases is the pathogenesis of hysteria in gen-
eral.

Post-influenzal neuritis, either of a single nerve
or of many nerves, is a well-recognized condition.
Influenzal multiple neuritis is fairly uncommon, i.e.
compared witli alcoholic, rheumatic, and gouty neu-
ritis. Any of the nerves of the body may be involved
apparently. Henschen has reported a case of bulbar
neuritis, in which the symptoms were quite typical
of this variety of bulbar palsy. That the spinal
ganglia are sometimes the seat of an inflammatory
or degenerative condition growing out of grippe, is
testified to by the numerous cases of herpes zoster
to be found in the literature. That brachial and
sciatic and generalized multiple neuritis occurs, there
is no dearth of testimony. The motor nerves seem to
have a greater susceptibility to the action of the
toxins produced by the Pfeiffer bacillus than the
sensory nerves, but the same holds true for almost
ever}' variety of infectious neuritis, of polyneuritis,
unless it be that rheumatism is the exception to this
rule. Still, we are not at all sure that neuritis fol-
lows so frequently in the wake of that form of rheu-
matic fever which is due to a diplococcus rheumati-
cus, as it does in the wake of disorders called rheu-
matic which are dependent upon deficiencies of
metabolism, and neuritis dependent upon alcohol,
which are predominantly sensory and sensori-motor
in their manifestations. The one point that has been
impressed upon me in connection with the neuritides
of influenza is that their duration is much briefer
than apparently similar conditions dependent upon
other causes. For instance, I have seen a patient
with extensive multiple neuritis, causing quadri-
])legia, recover within six months. A similar condi-
tion, due to alcohol, would pursue a favorable course
if it recovered in twice that time. This fact, and
likewise a less important one, viz., that the atrophy
attending post-grippal neuritis is in some instances
not very profound, suggests that the lesion is often-
times a perineuritis rather than a parenchymatous
process.

To the neuralgias following grippe. I shall have
little to say, first, because there is nothing specific
aboxit them, and second, because post-toxemic neu-
ralgias are extremely uncommon. They are much
more liable to occur in individuals who are in im-

paired health and when overtaken with grippe, and
in women, particularly those who are afflicted with
constipation and indigestion. In certain cases of
trifacial neuralgia it is probable that the influenza
infection has been the exciting cause of degenerative
changes in the cells of the Gasserian ganglion, and
in this way is to be looked upon as an important
contributory cause. The duration of the ordinary
neuralgias, whether occipital, facial, brachial, or
crural, is usually brief, though now and then we
encounter an example that is most rebellious to treat-
ment. In such cases there is likely to be an underly-
ing condition of ill-health that accounts for it.

One of the most interesting phases of this ques-
tion, i.e. the relation of disease and disorder of the
nervous system to influenza, is reached when we at-
tempt to discuss the relationship of diseases of fairly
well-defined cause on the one hand, and of absolutely
unknown cause on the other hand, to influenza. Such
diseases as tabes, syphilitic spinal paralysis, and the
various forms of cerebral apoplexy, on the one hand,
and disseminated sclerosis, amyotrophic lateral
sclerosis, paralysis agitans. asthenic bulbar paralysis,
etc., on the other hand. Those who have given seri-
ous study to the question of the cause of tabes may
differ as to whether or not syphilis is the sine qua
iioii of that disease. But it can scarcely be main-
tained by anyone that influenza is an adequate cause
of tabes. The literature shows that such allegation
has often been made, and the same may be said of
the other diseases that have been enumerated. One
of the typical cases of that form of myelitis or
meningomyelitis which has been spoken of as Erb's
type of svphilitic spinal paralysis, that I have ever
seen, developed in a young man a few weeks after
a comparatively severe attack of grinne. It may well
be that in this case the individual, coping with as
much poison as he could take care of, viz,, the
syphilis, had his nutrition, or the circulation, of his
spinal cord so depreciated that the pale spirochete
produced the typical pathological reaction there. But
in this case the disease had its origin in syphilis, and
would have developed probably in a similar way
after any devitalizing experience.

I have recently watched the development of a pro-
found generalized arterial sclerosis, and finally cere-
bral thrombosis, in a young man of thirty-six, the
victim of Hanot's cirrhosis. Apparently the arterial
sclerosis had developed within a period of five
months, the time corresponding to the duration of
the jaundice. At least, it may be said that the
diagnostic features of the disease have developed
within that time. That which the cholemia (to give
it a name) has accomplished in the vascular system,
for this man is comparable to that which the toxins
of influenza do for a few, and just as the Hanot's
cirrhosis has been the cause of cerebral apoplexy in
the case that I mention, so is influenza the cause of
some chronic nervous disorders, by mediatin.g
changes in the arterial system.

The relationship of psychoses to influenza has an
enormous literature all its own : still, it is possible to
summarize a knowledge of the subject in a few
lines. There is no specific influenza-psychosis, and
no form of insanity that is particularly likely to be
called into existence by influenza. Individuals who
are liable to develop insanity, i.e. those who are
laden hereditarilv and those who are debilitated bv
alcohol and syphilis, are more likely to develop a
psychosis if they have influenza than if they have
not. In this way influenza may be said to stand in
relationship to manic-depressive insanity, general
paresis, confusional states, and possibly even de-
mentia precox. It is undeniable that psychoses

March 2, 1907]

MEDICAL RECORD.

341

sometimes develop after influenza in individuals who posed of eight or twelve such masses bound together
' " ■'■''■ so that the mucous membrane covering each mass

forms the lining of the spaces between them, which
are the tonsillar crypts. This arrangement of re-
duplication increases enormously the surface of
the tonsil. The embryonic formation of the crypts
isvery interesting. The tonsil is at the border line
of the epiblast, which forms the lining of the mouth,
and the hypoblast, which forms the alimentary canal.
Reterer, in his "Evolution of the Tonsil," shows
that the epiblast folds into the hypoblast and the
epithelial cells become more and more flattened
from pressure. Some of them undergo degeneration
and, being thrown ofif, leave the spaces which are
the crypts. The tonsil afterwards becomes infil-
trated with mesodermic cells. The mucous mem-
brane in common with that of the mouth consists
superficially of flattened epithelial cells. Beneath the
flattened epithelium the cells become more rounded

have neither hereditary nor neuropathic taint, but
so likewise does insanity, not preceded by influenza.
Psychoses develop both during the prodromal stage,
the febrile stage, and after the influenza has ceased
to exist as a disease, causing general svmptoms, i.e.
in the stage of convalescence. It seems legitimate to
believe that the psychosis immediately preceding and
during the active stage of influenza is dependent
upon the action of the toxins upon the cerebral
cortex, and in these instances the psychosis is apt
to be of the nature of acute delirium. There are
cases on record in which this acute delirium has
been very profound, and terminated fatally within
a few days, and in such instances there can- be no
"doubt but that the action of the toxins upon the
brain is to produce an acute hemorrhagic inflamma-
tory condition. In the cases that develop after con-
valescence of the disease the mental condition is
probably the expression of the efifects of the toxins
upon the cortical nutrition, and likewise upon the
nutrition of the entire system, and are to be looked
upon as a combination of causation and intoxication.

It has been pointed out by many that there is no
relationship between the severity of the attack of
influenza and the insanity which accompanies or
follows it. Oftentimes the most severe mental dis-
order may occur soon after or apparently in con-
nection with a light attack of influenza.

In conclusion, I say again, that experience teaches
me that the baneful efifects of the pathogenic activity
of the Pfeififer bacillus upon the nervous system
have been overestimated, and that in reality influ-
enzal and post-influenzal neuroses and psychoses are
not very common. Finally, I trust that this statement
may not be considered as a denial of their occur-
rence.

REFERENCES.

1. Cobleigh. E. .A.. : Menic-^L Record, XLVII, 1905, p. 878.

2. Pfiihl : Berliner k-linisclic W'oehenschrift, 1892;
Dubois. S'teplianc : Tliese de Paris, No. 49, Nov. 27.

1902.

.■;. Doiiolass. J. S. C. : Lancet. January 12, 1007.

4. Niithall and Iltintor: British Medical .I'niruul. II, uioi.
P- 74-

5. Burj-, Judsoii : British Medical Journal, II, 1900, p. 870.

6. Thomesca and Gracoski : Revue Neurologiqne. 1905,
P- 44-

7. -Mya: Ca::ella de.^li Osfedali. XX\'I. igo,^.

8. Ghon : IViener ktinische IVoehenschrift, 26. 27, 1902.

9. Guttmann : Neurologisches Centralblatt, 1900, p. 703.

10. Henschen : Deutsche Zeitschrift fiir NervenheHkunde.
XII. 1898.

IT. Koster: Neurologisches Centralblatt, 1894.
12. Pitres : Journal de Mcdecine de Bordeau.v, 41. 1903.
page 653.

37 West Fiktv-fourth Street

THE REL.VTION OF THE TONSIL TO IN-
FECTION AND INFECTIOUS .DISEASES.*

By ROBERT CURTIS BROW.Y. .\.B., M,D.

MILWAUKEH. WIS.

LECTURER ON GE.VER.^L ETIOLOGY .1XD HYGIENE, WISCOKSIX COLLEGE

OF PHYSICIANS AND SURGEONS; PHYSICIAN To THE MILWAUKEE

COUNTY HOSPITAL. THE CHILDRENs' FREE HOSPITAL, AND

THE MILWAUKEE MATERNITY HOSPITAL.

The tonsils may be described as two elongated,
almond-shaped masses of lymphoid tissue situated
one on each side of the fauces between the anterior
and posterior pillars. They present on their outer
surfaces eight to twelve orifices which lead down
to bhnd pockets or crypts. If the tonsil of a rabbit,
which consists of a single mass of lymphoid tis-
sue, be taken as a type, the human tonsil is com-

*Read before the Milwaukee Medical Societv, nrccmbor
II. 1906.

Fig. I. — Diagram showing the encroachment of the lymph follicles
on the mucous membrane at the bases of the crypts.

and then jjolyhedral, resting upon a single layer of
ci.ilumnar cells. Underneath the epithelium is a deli-
cate endotheloid basement membrane. The mu-
cosa beneath the basement membrane consists of
interlacing bands of connective tissue which, though
verv fine in the normal tonsil, becomes immensely
hypertrophied in chronic disease. Bands of connec-
tive tissue extend from the mucosa into the in-
terior of the tonsil and form the framework for
the adenoid tissue proper. This consists of masses
of lymph corpuscles grouped into follicles surround-
ed by lymph spaces. The follicles, 10 to 12 of
which surround each crypt, encroach on the mucous
membrane at their bases. The lymph corpuscles
are small round cells, each having a distinct special
nucleus surrounded bv a mass of protoplasm. The
unexposed portion of the tonsil has a firm con-
nective tissue sheath and the vessels enter through
it at the base. The blood supply of the tonsil is
\-ery large and is derived from the dorsalis lingtise,
the ascending palatine and tonsillar, the ascending
pharyngeal and descending palatine arteries. The
principal vessels enter the base, branch, and follow
tlie connective tissue framework. Their capillaries
anastomose in an aborescent manner about each fol-
licle: branches are also sent to the papillae of the
mucous membrane. Superficial!}' the tonsil is
covered with an enormous network of lymphatic
\essels which anastomose with the surrounding
lymphatics of the palate and ton.gue. In the deeper
fiortion thev have been shown by Reterer to com-
mence in the perifollicular spaces by a svstem of

34-2

MEDICAL RECORD.

[March 2, 1907

closed canals and leave by the efferent vessels
at the base. The tonsil is abundantly supplied with
racemose mucous glands v.'liich communicate with
the crypts and exposed surface of the tonsil. The
nerves' are derived from the fifth and ,£;lossopharyn-
geal, their minute distribution is not definitely set-
tled, but they probably terminate in the lymph fol-
licles. The lymph follicles of the tonsil are very
similar in structure to the nialpighian corpuscles
of the spleen ; however, the arrangement of the
blood supply is different. In the spleen the lymph
cells are grouped around the terminal capillaries in
masses, while in the tonsil the masses of lymph cells
are surrounded by the blood-vessels. The tonsillar
arrangement. I should think, would favor the more
ready escape of leucocytes from the vessels, which
fact we will see is of great importance in the func-
tion of the tonsil. New Ivmph cells result through
the multiplication and division of lymph corpuscles

Fig. 2. — Diagram showing the arrangement of the blood supply of
the malpighian corpuscle of the spleen (A), and the lymph follicle of
the tonsil (B;.

and likewise of the so-called fixed connective tissue
cells, as has been demonstrated with certainty, espe-
cially in inflammation. They are continually en-
tering the lymph spaces to be taken up by the blood-
vessels or to be carried away from the tonsil by the
efferent lymph channels. Some of them, especially
from the follicles near the surface, enter the crypts.
During inflammation of the tonsil the number en-
tering the crypts is enormouslv multiplied. Just
as there is an entering of lymph corpuscles into
the blood-vessels to become leucocytes, so is there a
wandering from the blood-vessels of leucocytes
which enter the tissue of the tonsil whose loose
structure facilitates their movements. Many of them
also find their way into the crypts, especially dur-
ing inflammation.

The cavitv of the mouth is very much exposed to
microbes which enter with the food and external
air. Miller has recognized In man more than thirty
species. Several, such as leptothrix and spirochete,

are constantly present ; with them are also frequently
found pneumococci, staphylococci, and streptococci,
whose pathogenic powers are well known. Viru-
lent diphtheria bacilli are also found in the throats
of a certain number of quite healthy persons. The
Massachusetts Associated Boards of Health found
that the Klebs-Loffler bacillus was present in the
throats of from i to 2 per cent, of all healthy per-
sons and in 8 to 50 per cent, of those who had been
exposed to diphtheria in families. In spite of these
facts many persons, though exposed, escape in-
fectious diseases, and w'ounds of the mouth heal
very rapidlv. Operations, even though done with-
out aseptic precautions, are usually not followed
by infective complications. How does the mouth
defend itself against so many microorganisms?
Sanarelli came to the conclusion, after extensive
researches, that saliva had an antiseptic power and
destroyed the microorganisms. Hugenschmidt,
working in the laboratorv of Metchnikoff, reaches
conclusions quite at variance with Sanarelli. In
his experiments, the microorganisms grew rapidly
in saliva. It has, however, a mechanical effect simi-
lar to the lacrymal secretion, and washes the micro-
organisms from the pharvngeal cavity into the stom-
ach. It has another indirect action, that of effect-
ing a positive chemotaxis on the leucocytes, which
fact has been proved by introducing capillary tubes
containing saliva into the peritoneum of guinea
pigs ; leucocytes attracted by the saliva entered and
digested the microorganisms in it. The flattened
epithelial cells covering the buccopharyngeal cavity
constitute an important protective factor. The cells
are being constantly renewed. Desquamation, tak-
ing place especiallv during mastication, carries away
innumerable germs which are on their surface and
in the interstices. There is a partial renewal of
the epithelial lining after every meal. The mouth,
in common with the rest of the (Hgestive system,
is furnished with a defensive apparatus against
microorganisms in the shape of lymi)hoid tissue,
viz., the lymph follicles nt the base of the tongue
and the tonsils. Some years ago Stohr demon-
strated that the tonsils are traversed by enormous
numbers of leucocytes, which migrate into the cavity
cf the mouth. This continual and normal condi-
tion is called Stohr's phenomenon. When a par-
ticle of mucus is removed from the surface of
the tonsil of a person in good health, we always find
that it contains leucocytes, the neutrophile cells
especially being filled with organisms of all kinds.
Formerly inflammation was looked upon by
pathologists as always of a destructive and harm-
ful nature. Recent bacteriological research has
demonstrated, on the contrary, that it is of a pro-
tective character, being Nature's means cf limiting
the advance of noxious microorganisms. It is to
Metchnikoff. who in 1883 issued his work on the
comparative patholog}- of inflammation, that we owe
cur present knowledge of the protective reactions
of the human organism. Virchow had advocated
the nutritional theory, namely, that there was an
increased flow of nutritive substances to the in-
flamed part, as well as an abnormal proliferation
of local cells ; in fact, that inflammation began
from the moment nutritional derangement occurred.
This derangement consists of an absorption or
modification of large quantities of nutrient sub-
stances. In this way the cells receive a large
amount of nourishment at the expense of the blood.
Virchow regarded the characteristic phenomena of
inflammation not as a salutary means of reaction,
but as a process dangerous to the organism. Samuel
and Cohnheim held that inflammation consisted in

Marcli 2, 1907]

MEDICAL RECORD.

343

a molecular lesion of the vascular walls of the
blood-vessels, which lost their power of retaining
the blood corpuscles, allowin.sf them to issue to
the places of least resistance. Metchnikoff shows
that, from the point of view of comparative pa-
thology, inflammation is essentially reactive in na-
ture. The organism, threatened by some injurious
agency, protects itself by the means at its disposal.
The lowest organisms struggle against morbid
agents instead of submitting passively to their at-
tacks. The essential factor in inflammatory reaction
is an endeavor on the part of the protoplasm to
digest the harmful object. In the lowest forms
of life the whole organism takes part in the di-
gestion, but from the sponges up the digestion
of the morbid agents is confined to the cells of
the mesoderm. The phagocytic action is slow in
the lower scale of life, for the cells have to depend
entirely upon their ameboid movements to reach
the injurious body; but as soon as, in the course
of evolution, a vascular system makes its appear-
ance, the phagocytic reaction becomes more rapid.
By means of the circulatory apparatus, the organ-
ism can send the defensive cells to the threatened
point in large numbers. When the circulation is
partially carried on by a lacunar system, there is
nothing to intercept the movements of the cells
toward the seat of the injury ; but if the cells are
inclosed in blood-vessels, they must pass through
the vascular walls by diapede.sis. In man the prin-
cipal cells, which have phagocytic action, circulate
in the blood. They are the neutrophile cells which
Metchnikofif calls the microphages and the large
mononuclear cells which he designates as the macro-
phages. They are able to digest by intracellular
ferments called cytases. In cases of natural im-
munity the cytases rid the body of microorganisms
without the cooperation on the part of other soluble
ferments ; in acquired immunity there are other sub-
stances called fixatives, which, though not bacteri-
cidal, render the microorganisms more susceptible
to the action of the cytase.;. The cytases are allied
to the proteolytic disastases in that they adhere to
the cells which produce them : the fixatives, how-
ever, though undoubtedly of cellular origin, pass
readily into the fluids which bathe them. No less
important in phagocytic reaction are some of the
fixed tissue cells, for instance, the endothelial
cells of the blood-vessels which, by their sensibility
and contractile properties, allow the phagocytes to
escape through the vessel walls. Another form of
sensibility which must be mentioned is that of the
nervous system, which aids the cells and the vas-
cular system in their efforts at resistance. The
action of the macrophages and microphages is well
seen in the case of an immunized horse inoculated
with streptococcus serum. In the local edema
caused at the site of inoculation, the phagocytosis
may be observed. In this case the macrophages
or mononuclear cells first appear and devour the
cocci ; in many cases the cocci multiply rapidly
within the macrophages, and, having overcome
them, escape in large numbers from their bodies.
Later the microphages or neutrophile cells come to
the rescue of the macrophages and commence to
englobe and digest the cocci until in a few days
there are none left.

I_ do not wish to go too deeply into the different
varieties pf tonsillar inflammation, but I will point
out certain facts which I'etermine the character of
the inflammation and give some examples. An in-
flammation of a mucous membrane mav be catar-
rhal, croupous, or diphtheritic. We must also con-
sider the irritant and its virulence, the amount

and character of the tissue involved, and its power
of resistance. The peculiar anatomy of the tonsil
determines its appearance when there is much re-
action on the part of the organism. In the disease
called mycosis we have a fungus-like growth on
the tonsil produced by an irritant, namely, the lepto-
thrix, which is able to induce no inflammatory re-
action to speak of, there being simply a multiplica-
tion of the bacillus on the soil where it has chosen
to locate. The streptococcus, on the other hand,
if sufiicientlv virulent, is able to produce a violent
inflammatory reaction in the tonsil. It also has
the power to cause the tissue cells to release a fibrin
ferment, which accounts for the formation of the
pseudomembrane. A virulent Klebs-Loffler bacillus
overwhelms and destroy.s the cells and so rapidly
permeates the tissue that necrosis is produced. This
accounts for the adherence of the membrane. In
all forms of infection, with a few exceptions, there
is a reaction on the part of the tonsil which is
usually described as acute follicular, or better, lacu-
nar tonsillitis. Professor Fracnkel describes the
clinical picture as follows : "The tonsils and ad-
jacent tissues are red and swollen. The tonsils par-
ticularly project prominently into the mouth and on
the surface, which is more uneven than it usually
is ; there are points of white, which a little obser-
vation shows to be rounded drop-like projections
of a viscid whitish substance. After the patient
swallows, the whitish points disappear for a time
or show only slightly and not so numerous as be-
fore ; but if you watch the tonsils for a few minutes
they appear again and grow gradually larger. When
they are removed by the act of swallowing, you
can see that they were situated on the so-called
cr3'pts of the tonsils, the little infoldings of the su-
lierficial mucous membrane of the tonsil that occur
all over the organ." A microscopic examination
shows that the exudation consists of fine fibrillae,
interlaced and containing in their meshes epithelial
cells, leucocytes, red blood-cells, lymph corpuscles,
and bacteria, many of these last being within the
cells.

What has taken place in the tonsil? Under the
stimulation of a morbific agent phagocytosis has
commenced. There are always normally a large
number of leucocytes wandering toward the pe-
riphery of the tonsil and escaping through the
crypts. As we have said before, these, if examined,
will be found to be phagocytes, often containing
bacteria. As a result of increased phagocytosis the
microphages and macrophages are attracted to the
tonsil in large numbers and wander out more plen-
tifully. The result is the approach to the surface
of the mucous membrane of large numbers of cells.
This does not mean the exposed surface of the
tonsil ; for, as we have shown, the mucous mem-
brane lines the crypts entirely, so that the major
portion of the mucous membrane of the tonsil is
within the crypts. This, together with the fact that
the adenoid tissue encroaches on the mucous mem-
brane at the bottom of the crypts, is the reason
why the exudation is first formed there and, ac-
cumulating, is continually filling up the crypts and
escaping from their orifices. P.osworth, in his work
on the diseases of the nose and throat, misses the
point entirely when he says that he knows of no
reason why "the catarrhal inflammation should be
confined to the crypts and offers the suggestion
that, because the secretion is friable and non-
adherent, it is washed from the surface of the rest
of the tonsil. The fact is that the exudation is
formed in the crypts, and it is the exit of the
leucocvtes carrving with them the bacteria that have

344

MEDICAL RECORD.

[March 2, 1907

found their way into the tonsil, tosjether with the
cast off epithelium and other debris, that consti-
tutes the distinctive feature of the disease. The red
and swollen appearance of the tonsil is due to the
increased blood supplv.

What is the fate of pathogenic germs that may
happen to find lodgment on the tonsil ? They may
be washed ofif by the saliva. They may
be carried away by the desquamation of the epithe-
lial cells. If they should attempt to enter the
crypts they may be meclianically washed out by
the mucous secretion and the lymphocytes, or be
devoured by the phagocytes which are continually
passing out of the crypts. If the bacteria are pres-
ent in sufficient quantities to call forth further de-
fen.^ive action, phagocytosis occurs, the lymphocytes
in the follicles rapidly multiply by mitosis, there is
an increased blood supply, the endothelial cells of
the capillaries contract and allow the microphages
and macrophages to escape, and these englobe the
threatening bacteria and digest them. The micro-
phages are the phagocytes that attack most bacteria,
though some, such as tuberculosis, are digested bv
the macrophages. The macrophages are in the main
the scavengers. Thev consume dead blood cells and
the microphages which have been overcome in the
struggle. The dead and living cells, the bacteria,
the mucus, and the fibrin released from the cells
compose the exudation. The crypts act as sewers
or drains bv which the exuded matter is removed
from the body. It is quite probable that the lymph
corpuscles of the tonsils furnish fixatives which
are of the utmost importance in its defense against
toxins. Delazenne of the Pasteur Institute has
proved conclusively that enterokynase, the digestive
fixative discovered by Pawlow, is a product of the
Peyer's patches of the intestine, and we know how
similar in structure Peyer's patches are to the ton-
sil. Chemotaxis must be cjnsidered. It is the name
given to the phenomenon exhibited by certain cells
of moving towards (positive) or moving away from
(negative) certain other cells or substances. When
negative chemotaxis occurs, the phagocytes refuse
to be attracted to the bacteria. Just what causes
this is not yet understood, but virulence has a gre^
deal to do with it. If the virulence of the bacteria
is very great, the phagocytes seem to give up with-
out a struggle and allow infection to occur. This
condition is often seen in infectious diseases. It
has been explained by the theory that phagocytosis
is a struggle for existence on the part of the cells,
and not a means to accomplish an end, so the results
are by no means perfect. If the leucocvtes are
unable to destroy the bacteria and they gain en-
trance into the body, or if enough of their toxins
gets into the blood by absorption, we have the
characteristic symptoms of the disease.

In considering the relation of the tonsil to in-
fectious diseases, diphtheria is the most important
disease to be considered. There is no better exam-
ple of the phagocytic action in the tonsil than is
shown in this disease. Cases have become so nu-
merous in which the process of diphtheria has ex-
tended no further than to produce a lacunar tonsil-
litis that we have given them the name of bacterio-
logical diphtheria, for a diagnosis would not have
been made but for the finding of the Klebs-Loffier
bacillus. Diphtheria also gives us an example of
negative chemotaxis. In 1888 Roux and Yersin
isolated the soluble toxin of diphtheria. If the
bacteria are verv virulent and this soluble poison is
produced in large quantities, negative chemotaxis is
produced and the phagocvtes refuse to act. In
diphtheria we have an example of the specific action

of the bacteria. They produce necrosis of the
epithelium, and the membrane, which is composed
of a fibrous reticulum, in the meshes of which are
found lymphatic cells, red blood corpuscles, and de-
generated epithelium cells, becomes adherent. It is
a fact that tb.ere is no adherence to the surface
where the epithelium is intact. The action of anti-
toxin in conferring immunity opens a m.ost inter-
esting subject. That the antitoxin unites with the
tcxin in the blood to render it innocuous, as claimed
by Erlich, is not incompatible with the theory of
^letchnikoft' that it stimulates the phagocytes to
increased activity. In artificially acquired im-
munity the blood serum undoubtedly has antitoxic
action, but IMetchnikoff h."s conclusively proved it
never has bactericidal action unless phagolysis oc-
curs and the cytases are released from the phago-
cytes. The controversies between the biological and
the chemical schools on the subject of immunity are
far from being settled, but up to the present time
Metchnikoff has most successfullv defended his po-
sition. In scarlet fever we have many examples
of phagocytic action in the tonsil. Children exposed
to scarlet fever develop tonsillitis, and nurses and
parents also have tonsillitis, but no scarlet fever.
The relation between tonsillitis and rheumatism is
of great importance. Rheumatism is so frequently
preceded by tonsillitis that it seems to me to be
a question if there is a specific germ for rheumatism.
The soluble poisons or toxins of several different
bacteria may, on account of faulty elimination, be
deposited in the joint membranes and cause the
arthritis. German observers have caused the symp-
toms of rheumatism in rabbits by inoculating them
with the exudation of tonsillitis, but that does not
prove that it is specific. Regarding rheumatism,
Kiefer has pointed out an interesting fact in the
treatment of tonsillitis. In a series of 120 cases 60
were treated in the ordinary way and 60 were treat-
ed by the local application of acetic salicvlate. The
first 60 were followed by Q cases of articular rheu-
matism, while the second 60 were not followed by
a single case of rheumatism. He observed 2,275
cases of tonsillitis. Of his cases of rheumatism 21.3
Iter cent, could be traced to a previous tonsillitis.
The other infectious diseases in which lacunar ton-
sillitis, or, as it might be called, phagocytosis in
the tonsil, occurs are numerous. I have often seen
it in measles. It occurs in erysipelas, smallpox,
plague, etc., but it will be necessary to discuss
other examples to bring out the point of the paper.
Phagocytosis occurs when any morbid agent excites
a positive chemotaxis in the tonsil.

I have so far considered only the infections.
Phagocytosis in the tonsil is also caused by inor-
ganic and organic particles. Weavers, file-cutters,
needle-grinders, and those working at similar trades,
are especially liable to tonsillitis. Whether the
inorganic and vegetable uarticles are the primary
causes, or whether thev injure the tissue and lay it
open to infection, is a question. W'right, in a verv
interesting paper, has shown that colored dust
passes into the interior of the tonsil when the mi-
crobes do not. He attributes this to a positive
chemotaxis of the cells for the dust particles and
a negative for the microbes. Dr. Wright does not
use the word chemotaxis correctly, as I understand
it. If there were a negative chemotaxis, as he savs,
the bacteria would be unopposed by the phagocytes
and thev would enter and set up systemic infection.
As I look at it, there was, in the case he cited, no
chemotaxis at all, but the microbes were not present
in sufficient quantities or were not sufficiently viru-
lent to attract the phagocvtes or to overcome the

March 2, 1907]

MEDICAL RECORD.

345

normal desquamation of the epithelium and the
phagocytes that normally issue from the tonsil.

The function of the tonsil has been discussed by
many authors and it has been assi,a:ned a role as
insignificant as shaping the bolus of food. Most
writers seem to consider its function in health of
little moment and that it is of no importance except
when diseased. The fact that the tonsil may be
frequently diseased and by hypertrophy become a
menace to the body, is not an argument against
its acting in a defensive role. Defensive power lies
primarily in the cells, especially those derived from
the mesoderm. Cells often defend themselves at
the expense of the tissue and organs, and organs
and tissue at the expense of the body as a whole.
Sclerosis is primarily an endeavor on the part of
Nature to defend itself against irritants and often
causes destruction of the body ; for example, en-
darteritis and the various scleroses of the kidney,
liver, etc. The phagocytes undoubtedly take part
in the formation of connective tissue. They surely
do in formation of granulation tissue. MetchnikofT
has shown that the vascular loops in new tissue are
projected by the phagocytic action of the endothelial
cells of the vessel walls. It is quite probable that
some of the phagocytes become connective-tissue
cells.

The tonsil is frequently spoken of as a port of
entry of infection, but we must not forget two facts :
First, that a generalized infection may determine
the appearance of a secondary tonsillitis, whatever
may have been the port of entry of the infection.
It is quite possible, and indeed must often happen,
that the disease, whatever the port of entry, lowers
the resistance of the tonsil, and allows the germs
of that disease or other pathogenic germs to get
a foothold. The second fact is that the systemic
infection takes place either in spite of the lacunar
tonsillitis, in which case the tonsil attempts to resist
infection, but is overcome, or when negative chemo-
taxis occurs and the phagocvtes give up without
a struggle. It is very probable that the tonsil i^
more bactericidal in its defensive action than it is
antitoxic. This would account for the large num-
ber of cases of rheumatism, muscular rheumatism,
and albuminuria, as pointed out by Adler, which,
I think, are due to the faulty elimination of soluble
poisons ; it would also account for the headache,
pains in the back and limbs, and other systemic
symptoms of poisoning in every case of tonsillitis.

I believe the tonsil is so well defended that it
seldom is the port of entry, as claimed by so many
authors. This would seem to be borne out by the
fact that, although the crypts are always teeming
with pathogenic bacteria, general systemic infec-
tion is comparatively rare. Furthermore, as Adler
has pointed out. systemic infection is more .apt
to follow insignificant anginas and an extensive
inflammatory reaction seems to prohibit general in-
fection. The tonsil must be continually exposed to
the germs of tuberculosis, yet primary tuberculos's
of the tonsil is rare. In a certain proportion of
sections of the tonsil we find tubercles, but this is
only the evidence of the defensive action in local-
izing the disease. MetchnikofT, who has made an
extensive study of tuberculous inflammation, has
shown that the giant cells which assist in walling
of?_the bacilli, are aggregations of macrophages
which have coalesced. In diphtheria we seldom
have a grave infection unless the membrane ex-
tends beyond the tonsil, which would show that the
tonsil was at least better adapted to resist infection
than the surrounding tissue.

Finally it is possible to have a chancre of the ton-

sil and a chancre of the lip five days later, which
I think is convincing proof that there is a de-
fensive action in the tonsil preventing the primary
immunization of syphilis.

I have endeavored in this paper to show :

That the tonsil is anatomically admirably ar-
ranged to resist infection.

That it is continually exposed to the action of
pathogenic germs.

That when we have an inflammation of the ton-
sil it is caused by a pathogenic germ which is
endeavoring to enter, and the inflammation itself is
essentially a defensive reaction.

That when the resistance of the body is lowered
from any cause, or the germs are virulent enough
to overcome the other means of defense, which the
tonsil has in common with the rest of the oral
mucous membranes, or if the tonsil is wounded, a
positive chemotaxis having been produced, there is
a lacunar tonsillitis.

That when a negative chemotaxis is produceci,
either on account of the virulence of the infection
or from some other unknown cause, there is a gen-
eral systemic infection without a tonsillitis.

That when we do have a systemic infection it is
either in spite of the defensive reaction or on ac-
count of negative chemotaxis.

That finally the relation of the tonsil to infection
and infectious diseases is one of protection, and
the disease we call lacunar tonsillitis is an example
of phagocytosis and is a defensive reaction.

REFERENCES.

Delavan ; The Tonsils, Reference Handbook of the .Med-
ical Sciences.

Moure : Diseases of the Tonsil, Twentieth Century
Practice of Medicine.

Bosworth : Diseases of the Nose and Throat.

Northrup : Diphtheria, Nothnagel's Encyclopedia of
Practical Medicine.

.A.dami : Inflammation, Allbutt's System of Medicine.

Jiirgensen: Measles, Scarlet Fever, and German
Measles, Nothnagel's Encyclopedia of Practical Medicine.

Welch & Schamburgh : Acute Contagious Diseases.

MetchnikofT: The Comparative Anatomy of inflamma-
tion.

MetchnikofF: Immunity in Infective Diseases.

Ernst : Infection and Immunity, Twentieth Century
Practice of Medicine.

Landois : Text-book of Human Physiology.

Fraenkel : Lacunar Tonsillitis, International Clinics Vol.
II., Ninth Series.

Kolliker: i\lannal of Histology'.

Emery : Inflammation, Manual of Surgery.

Satterwaithe: Manual of Histology.

Senion & Williams : Diseases of the Pharynx, .-Mlbutt's
System of iledicine.

Gerrish : Text-book of .'\natomy.

Kiefer : The Tonsil and Acute Articular Rheumatism,
American Medicine, September, 1906.

Wright: Difference in Behavior of Dust from that of
Bacteria in the Tonsillar Crypts, N'c-v York Medical Jour-
nal, January 6, 1906.

.'\dler: Remarks on Some General Infections through
Tonsils, Nczv York Medical Journal. March 31, 1906.

Brown : .Acute Follicular Tonsillitis, Medical Record,
l\Iarch I, 1002.

Reports of the Massachusetts Boards of Health.

Rcterer: Ountcd by Delavan, Bosworth, and others.

Virchow. Samuel, Cohnheim : Quoted by Emery, Metch-
nikoff, and others.

Erlich, Pawlow, De!a?enne. llugenschmidt. Miller, Stohr,
Sar.Tnelli : Quoted bj' IMctchnikoff.

Roux & Yersin : ' Quoted by Welch and Shamburgh,
Metchnikoff, and others.

Cerebrospinal Meningitis. — Menschig has found the
following useful, reporting four recoveries out of five
cases :

R Pilocarpin,T hydrochlor 0.03=0.04

Aquae 200.0

Solve. S. A teaspoonful every one to three hours tilJ
sweating occurs. The above is intended for children under
ten years of age. — Mcdizinische Klinik.

346

MEDICAL RECORD.

[March 2, 1907

A NEW STREPTOTHRIX PATHOGENIC
FOR CATTLE.

(STREPTOTHRIX OF BOVINE PNEUMONIA.)

Bv MAJOR CHARLES F. KIEFFER,

SURGEON UNITED STATES ARMY, PORT D. A. RUSSELL, WYOMING; ON

DETACHED SERVICE WITH ARMY OF CUBAN PACIFICATION AT

SANTIAGO DE CUBA, CUBA.

The morphology and classification of the strepto-
thrices is still far from beings settled. As a class
they stand between the moulds and the bacilli, but
the border line varieties are by no means sharply
located. For instance, it seems almost necessary to
class some stems of the B. tuberculosis as strepto-
thrices.

It is, therefore, important that all facts bearing
on the streptothrices. whether in man or animals,
should be reported and sufficient data collected for
a definite classification of these organisms.

Broadly speaking, the pathogenic streptothrices,
both in man and animals, cause two classes of
lesions. The first and most important are the
granulomata, the pseudotuberculous, and the
pseudomycotic lesions. Second, the inflammatory
processes going on to abscess formation and fre-
quently to pyemic states. A large proportion of

to make a diagnosis they brought the organs to
me for bacteriological examination. A few days
later a fifth cow died after being noticeably sick
only four days. The organs of this animal were
also delivered to me.

A careful post-mortem examination of the first
carcase was made by Veterinary Surgeon Sproule,
Artillery Corps U. S. Army. The only epidemic
cattle diseases observed in that vicinity during the
year ( 1904) had been hemorrhagic septicemia and
.symptomatic anthrax. During the post-mortem ex-
amination particular search was made for evidence
of the latter disease. For this reason the carcase
was skinned, but no subcutaneous hemorrhages or
nodules of any kind were found. The spleen was
apparently normal. It was of the usual size and
consistence, and there was no capsular inflammation
or thickening. The liver was normal in appear-
ance and size. Both lungs were markedly con-
gested and contained numerous fairly large con-
solidated areas. These areas on section were found
to be engorged with blood and exuded a grayish
purulent fluid. The heart was considerably hyper-
trophied. The right auricle contained a finely lami-
nated pinkish white and gray clot, the size and
shape of a tennis ball. The center of the clot was

UK.

2 5 4 '-

1

llifii¥T*^^

■■■Hi

%

Fig. 1. — Culture of streptothrix: i, blood ^ serum ; 2, glycerin-agar:
3, plain agar;'4, glucose agar.

Fig. 2. — Smear preparation from the lung of cow No. 5; showing
beading, irregular^staining and two cones: stain, carbol-fuchsin. X 1,100.

the organisms are both acid and alcohol fast ; some
are not. The list of severe, and in large part fatal,
cases in man is growing rapidly. Ashton and Nor-
ris have collected the clinical data of twenty-six
cases. Mayer reports ten cases and I have seen, in
my own practice, two cases. I am convinced that
many more cases would be discovered if a labora-
tory technique more suitable for staining the or-
ganisms were employed. I believe it would be a
good laboratory procedure in all examinations of
sputa to make two series of studies of the speci-
mens. In the first one, using the ordinary technique
preferred by the individual worker for demon-
strating B. tuberculosis. In the second, employ the
same stain, but omit the acid decolorization. This
procedure has been followed in my laboratory for
some time and gives most interesting ba.ses for com-
parison.

The present report concerns a hitherto unde-
scribed streptothrix. The organism was demon-
strated in and isolated from the organs of two
cows. In a small herd of milch cattle, fourteen head,
three cows sickened and died within the space of a
week. Four davs later a fourth cow became sick
and was examined by veterinarians. Being unable

broken down and extremely fetid. Dr. Sproule states
that the clot was just as fetid when removed from
the animal two hours after death.

Smears made from the liver showed nothing.
Smears from the consolidated areas in the lungs
showed numerous streptothrix forms, which will be
described later on. The same organism was ob-
served in the broken down material from the auricu-
lar clot, combined with a short bacillus and numer-
ous cocci.

Inoculations were made on agar, serum, and
bouillon tubes from the lungs, heart, heart clot,
liver, and spleen. The tubes inoculated from the
heart and liver remained sterile. On all of the
others a fine growth was observed in twenty-four
hours. This growth was found to be the same
streptothrix which had been obser\^ed in the smears
from the organs. In the lubes inoculated from the
spleen it was present in pure culture. In the tubes
from the lung and heart there w'as a mixture with
various cocci.

Three days later a fifth cow died after being
noticeably sick three or four days. Post-mortem
examination three hours after death by Dr. Sproule
showed the following: There w-ere no subcutaneous

March 2, 1907]

MEDICAL RECORD.

347

hemorrhag'es or nodules. Both lungs were actively
inflamed. They were filled with consolidated patches
and there were numerous smaller areas of hemor-
rhage. The appearance coincided very closely to
those seen in the lungs of the first cow examined,
excepting tliat there was a much greater proportion
of the lungs involved and there was also a greater
degree of engorgement. The heart was enlarged
to at least twice the usual size. The pericardium
was much inflamed and thickened, the parietal layer
being at least half an inch thick. The inner sur-
face of the entire pericardial sack was covered with
a thick, shaggy, grayish-yellow exudate. The sack
contained six quarts of pus. This pus was greenish
gray in color, peculiarly oily and greasy looking,
and was extremely fetid. In it were found eight
ounces of flabby yellow clol. On the visceral layer
the exudate was not quite so thick as on the parietal
layer : it was slightly adherent, but could be peeled
off with little difficulty. The heart contained both
white and red clots. The liver was slightly en-
larged. The spleen was normal in size and texture.
The kidneys were normal in appearance.

Fig

3- — Streptothrix culture on'^nutrient agar, lo days' old; stain,
carbol-fuchsin. X i.ooo.

Smears made from the lungs and pericardial
exudate showed a streptothrix identical in appear-
ance with that observed in the first case. Inocu-
lations were made on agar, blood serum, and bouil-
lon. A growth of the streptothrix was obtained
from the lungs pure, from the spleen pure, and
from the pericardium and pus mixed.

The herd was quarantined and a rigorous cleans-
ing and disinfection of the stables and outhouses
carried out. No further cases developed.

Fig. 4. — Streptothrix culture glycerin-agar. 24 hours old; stain, carbol-
fuchsin. X 1,000.

The streptothrix grows on all of the ordinary
culture media, but best of all on five per cent.
glycerin-agar. On this medium the growth is very
free._ Numerous round, glue-like colonies develop,
and in the course of 24 hours are about 1-32 inch in
size. In 24 hours more the colonies grow very much
larger and show a faint powderv white surface. In
the next 24 hours the colonies become denselv white
and always show concentric rings. In the first 24
hours the appearance of the growth is like that of

many of the ordinary pathogenic organisms and not
at all like that of many streptothrix cultures. The
colonies are lentil-shaped, tough and tenacious.
They do not break up under the loop, but the whole
colony comes bodily away from the culture medium.
At the end of the first 24 hours a clear coffee-brown
discoloration of the culture medium is observed
around the colonies. This discoloration spreads
and in a few days involves the bulk of the culture
material. After two days the cultures give off a
strong mouldy odor.

4.F t.

Fig. 5. — Streptothrix culture on nutrient agar, 24 hours old: stain
Gram. X 1,000.

On neutral nutrient agar the organism presents
the same cultural characteristics as on glycerin-agar,
excepting that the growth is only about half as
rapid. The same brownish discoloration of the
medium occurs.

On glucose-agar the growth is about intermediate
between the previous two. Otherwise the appear-
ances are identical.

On blood serum small round colonies develop at
the end of 24 hours. These colonies slowly increase
in size and are surrounded by a zone of brown dis-
coloration in the medium 1-8 inch wide. As the
growth becomes older the colonies become grayish
yellow and wrinkled.

On gelatin no satisfactory study of the growth
was made, because the organism will not grow at
all, or only with exceeding slowness, at any tem-
perature in which the gelatin will remain solid.
Transplantation of an entire colony is followed by
a very slow increase in the size of the colony and
scant formation of the brown stain without any evi-
dence of liquefaction.

On potato the growth is very rapid. In 24 hours
small gray colonies develop with faint discoloration.
In 48 hours the growth is very copious, the colonies
powdery gray and wrinkled, and the whole surface
of the potato a deep, muddy chocolate color.

If a small colony is inoculated on bouillon in
24 hours, numerous minute colonies form without
turbidity or any change in the medium. These col-
onies settle at the bottom of the tube, and when
shaken up float in the liquid like small thistle downs
settling very slowly to the bottom. In the next
three days the colonies increase in size up to 3-16
inch. There is no discoloration or other change in
the bouillon.

In litmus milk the blue color is discharged in 24
hours and in 48 hours the fluid becomes distinctly
red.

The streptothrix does not form indol, nitrites, or
gas.

On all of the media it grows at a temperature
between 35° and 40° C, with its optimum at about
37° C. Above 40° C. the growth is very scant,

348

MEDICAL RECORD.

[March 2, 1907

while no growth can be observed in transplanted
colonies kept at the room temperature for two
weeks.

It is aerobic. While growing freely on the sur-
face of all the media, growth is exceedingly scanty
in stabs below a depth of 1-4 inch. At a depth of
1-2 inch it will not grow at all. It shows no
growth in anaerobic cultures nor in an atmosphere
of hydrogen.

On all solid materials the organism seems to
$:row more freely on media of increased spissitude.
Thus it will grow more freely on agar which has
been prepared some weeks, so that slight shrinkage
of the medium from the tube has taken place, than
it will on the same medium freshly prepared.

In hanging drop there is neither motility nor
molecular motion.

The streptothrix stains very freelv with all of
the ordinary aniline dyes. It is not acid fast. De-
colorization is rapid and complete, w'ith dilute min-
eral acids as well as with Gabbett's acid methylene
blue. It is not decolorized by alcohol. It is bril-
liantly stained by Gram. Neisser's method shows
no polar bodies. Special technique (Loeffler and
Van Ermengem) fails to show any flagella.

In the original smears from the lungs a few cones
were seen which seemed to be attached to the ter-
minals of some of the branching filaments. I am
not entirely satisfied as to the character of these
bodies and not at all certain that they are part
of the organism. The appearance of two of the
most distinct cones is shown in Fig. 2. In old
grown out cultures there were some appearances
resembling these bodies. In such cultures the fila-
ments were much shorter, with pronounced club-
bing of their ends (Fig. 3). Fig. 4 gives a very
good idea of the appearance of the organism grown
on glycerin-agar. ^lost of the filaments are uni-
formly stained, but a few joints and branches are
shown which have taken the stain very faintly.
There is no tendency to form coccus-like chains,
and little segmentation is observed in the branches.
Fig. 5 shows the microscopical appearance of a
culture of the same age as the preceding, on plain
nutrient agar. It will be remembered that on this
medium the grow-th was not so profuse as on
glycerin-agar. In this form the tendency to the
formation of coccus-like chains is quite marked.

Inoculation experiments were undertaken on all
of the smaller laboratory animals, but with negative
results. T sent some cultures of this organism to
Professor Warthin for study. He informed me that
inoculations in his laboratory on the smaller ani-
mals were also without result. I think it is quite
likely that inoculations on the bovines might give
a positive result, but I have had neither the oppor-
tunity nor facilities for developing any such re-
search.

I have proposed to name this organism Strepto-
thrix of Bovine Pneumonia {Streptothrix pneu-
vwni(v bovis). A fairly complete working bibliog-
raphy of the subject of oathogenic streptothricosis
is appended.

BIBLIOGR.-\PHY,

Almqvist : Zcitschrift fur Hygiene, 1890, Vol. III., page
189.

.Aoyama and Miyamoto: Centralbl. filr Baktcriot looi,
Bd. XXIX.

.■\shton and Norris: Journal Amcr. Med. Ass'n, Vol.
XLV. page 784.

AsthoflF: Berlin, kliii. Wochensch., 1895. Bd. XXXII.,
PP- 738. 765. 786.

Babes et Levaditi : Sur la forme actinomycosique du
bacille de la tuberculose. Arch, de Med. Experiment, 1897,
page 104 1.

Baumgarten: Lehrbuch der path. Mykologie, 1890, page
875-

Berestueff: Quoted by Hektoen.

Birt and Leishmann : Journal of Hygiene, 1902.

Bollinger and Harz : Deutsche Zeitsch. fur Thiermed,
Leipzig, 1877, p. 354. Innere Medizin, Leipzig, 1879.

Bostrom: Untersuchungen iiber die Actinomycose des
-Menschen; Ziegler's Beitrage, Vol. IX., 1880.

Boyce and Adams: Journal of Experim. Med., 1898,
Nos. 4 and S, Vol. III., page 422.

Brown : Reference Handbook Medical Sciences, Vol. V.,
page 348.

Buchholz : Ueber Menschenpathogene Streptothrix. Ein
Beitrag zur Aetiologie des Acuten Lungenzerfalls. Zeitsch.
fiir Hygiene u. Infectionskrankh, XXIV., 1897, page 470.

Chiari : Zeitschrift fiir Heilkunde, 1900, XXL, page 361.

Cohn': Untersuchungen iiber Bakterien, Bd. II., page
116.

Craig: The branched forms of the Bacillus tuberculosis
in Sputum. Journal of Experimental Medicine, III., 1898,
page 363.

Dorin : Annali del Inst, d'lgiene sper. d. Univ. di Roma,
1892, Vol. I., page 42.

Engelhart and Lohlein: Deut. Archiv. fiir klin. Med.,
Vol. LXXV, page 118.

Eppinger : Ueber eine neue, pathogene Cladothrix und
eine durch sie hervorgerufene Psudotuberculosis (clado-
thrichica) Ziegler's Beitrage, IX,, page 287.

Ferre et Faguet : Streptothrix et abces du cerveau.
Mcrcredi Medical, 1895.

Flexner: Pseudotuberculosis Hominis Streptothricha, a
preliminary note. Johns Hopkins Bulletin, VII., 1897, page
128. Pseudotuberculosis Hominis Streptothricha, Journal
of Experiment. Med., 1898, Vol. III., page 435. Twentietfc
Century Prac. of Med., Vol. XIX, page 754 et seq. Transac,
.Association .'\mer. Phys.. 1898, Vol. XIII.

Foulerton : Lancet, 1899.

Fraenkel : Pathologic der Lungenkrankheiten, 1904.

Friedrich : Ueber Strahlenpilzahnliche Wuchsformen
des Tuberkelbacillus im Thierkorper. Deut. med. Wochen.,
XXIII, 1897. page 653.

Garten : Ueber einen beim Menschen chron. Entziindun-
gerregenden pleomorphen Mikroben. Zeitsch. f. Chirurgie,
XLL. page 257.

Gasperini : Ann. de Micrograph. Paris, 1890, page 449-

Gruber: Miinchener med. Wochen, September 15, 1891,
page 653.

Hektoen : Chicago Medical Recorder. June, 1900.

Kruse: in Flugge's die Mikroorganismen, i8g6, 2-48.

Levy: Cenlralblatt fiir Bakter. Bd. XXVI.. page 187.

MacCallum : Ccntralblatt f. Bak. Parasitenh. und Infek.,
igo2. XXXL, page .^29.

Mayer : Muenchencr med. Wochen., 1901, page 1.775.

Musser: Chicago Medical Recorder, igox. Streptothrical
Infection, Philadelphia Med. Jotirn., 1903. Transactions
Chicago Medical Society, 1901. .American Year Book of
Medicine, 1903.

Musser and Gwyn : Two cases of Streptothrical Infec-
tion. Transactions .Association .American Physicians, VoL
XVI., page 208.

Musser, Pearce, and Gwyn : .Abscesss of the Brain due
to a streptothrix. Ibid., page 210.

Naun>Ti : Mittheilungen d. medic. Klinik zu Konigsberg
in Preussen, 1888. page 296.

Xocard : Annal, de ITnstitut Pasteur, 1888, II.. page 293.

Xorris and Larkin : Journ. Experimental Med., 1890,
Vol. V.

Ohlmacher : .American Medical Association Press, T901.

Ophuls : Journal of Medical Research, 1902.

Petruschky: Deutsche med. Wochenschrift, 1898.

Riviere: Archives Clin, de Bordeaux, 1895, Vol. IV.,
page 469.

Rosenbach : Ueber das Erysipeloid ; Arch. f. klin. Chi-
rurgie, XXXVI., page 346.

Rullman : Miinchener med. IVochcnschr., 1898, XLV.,
page 919. Ibid., XLVL, page 407. Ibid., XLIX, 1902,
page 925.

Sabrazes et Riviere : Sur un streptothrix rencontre dans
un cas d'abces du cerveau et d'infarctus suppure du rein.
Presse .Medicate, 1894, September 22, La Semaine Medi-
cate, 1895.

Sauvageau : .Annal. de I'lnstitut Pasteur, 1892, Vol. VI.,
page 265.

Scheele und Petruschky : Culturen und Praparate einer
menschen pathogenen Streptothrix-art. Verhand. des XV.
Congres f. Innere Medicin., 1897, page 550. Deutsche medi-
zin. Wochensclir., 1897.

Silberschmidt: Annal. de ITnstitut Pasteur., 1899, VoL
XIII., page 841.

Stokes: Amer. Journ. Medical Sciences, November,
1904.

March

1907 J

MEDICAL RECORD.

349

Tuttle: Quoted by Brown; Reference Handbook of the
Medical Sciences, Vol. V., page 347.

Ucke: St. Petcrsburgcr mcd. IVochcnschift., 1901, Vol.
XXVI., page 87.

Vincent: Annalcs de I'lnstitut Pasteur, 1894, Vol. VIII.,
page 129.

Von Hoke: Pragcr mcd. IVochcnschnft.. 1901.

Von Jaksch: Zeitschr. f. Hcilkundc, 1900, Vol. XXL,
page 361.

Von Ziemssen : Referred to as collaborating with RuU-
man. Verhandlung. d. Congres f. Innere Medizin, 1898.

Warthin and Olney : Pulmonary Streptothricosis.
American Journal of the Medical Sciences, October, 1904.

Wolf and Israel: Virchozi.''s Archiv., Bd. CXXVI., page
59-

THE PRESERVATION OF HEARING.*

By W. SOHIER BRY.'VNT, A.M.. M.D.,

NEW YORK.

The object of this paper is to call attention to the
advantages of periodical aural examinations, and
the benefits which would accrue to the patient
through the easy correction of aural defects which,
untreated, would later become serious or incurable,
impairing the hearing and menacing the well-being,
and perhaps even the sanity and life of the indi-
vidual.

Otology can treat of no subject of more vital
importance than the preservation of hearing, yet we
never hear it mentioned. It comprises the whole
field of otopathology, which it attacks with the most
effective weapon, prophylaxis. The general prac-
titioners, when they comprised the whole of the
profession, with the exception of the eye and ear
men, spoke slightingly of our specialty, perhaps be-
cause of their own unfortunate experiences in this
field. They held that diseases of the ear were of
two classes : First, those that would get well without
treatment; and second, those that would not get well
with any treatment. Since that time the surgical
achievements of the otologist have rendered this
ancient view ridiculous. Why, then, does there still
linger deep in the minds of many outside of this
specialty the opinion that the treatment of deafness
is unsatisfactory, if nothing worse?

There is a very simple explanation of this feeling
on the part of these benighted aliens. We must ad-
mit that most cases of chronic extreme deafness
offer little encouragement for the restoration of
perfect hearing. Such cases wrongfully detract
from the fair fame and glory of otolop'v. The otolo-
gist is expected to have a control over vital forces
not even dreamed of by other practitioners. Why
should he be expected to restore lost organs and
tissues, or even to rejuvenate those which have
undergone complete degenerative metamorphoses?
Yet this is the fact in case of loss of hearing from
suppurating ulceration or from calcification of the
drum membrane and ankylosis of the ossicles. A
general surgeon is not expected to restore a limb
which has sloughed away, or an ophthalmologist
to give sight to an eye darkened by neglected cor-
neal ulcers. Why is the hearing mechanism so
often allowed to suffer such vital losses? Is it not
because nature has given man very many times the
amount of perception of sound in normal hearing
needed in dense civilized communities? A voung
person may lose gg per -cent, of his hearing before
he is conscious of impairment. This deficiency may
include the total loss of the hearing in one ear. He
may, and in fact often does, allow a still further
loss before he attempts to improve the condition.

A case in point came under my observation re-

*Read before the Harvard Medical Society of New York.
December 22, 1906.

cently. A man. twenty-three years of age, came
to me to be treated for a "running ear," which pre-
vented his obtaining satisfactory life insurance. He
was totally deaf in this ear and had in the other
only 1-14400 of normal hearing, yet he claimed
to suffer no inconvenience on account of deafness;
in fact, did not consider himself deaf. The hearing
distance of his good ear for a watch was four
inches. The normal distance for this watch was
forty feet at his age, making the inde.x of his hear-
ing 1-120, which when squared to sliow the amount
uf hearing gives 1-14400 or 69-10000 of one per
cent., a rather small proportionate amount.

Why will an intelligent person allow the loss of
such a large part of what is perhaps the most im-
portant of all the senses- — hearing? It is because his
attention is not called to the fact. Sound perception
is largely quantitative. The diminution of sound
perception may not be noted imtil a very large
part has been lost. As long as the requisite quantity
for ordinary use is preserved, the individual remains
oblivious to the deterioration. The conditions are
reversed in the eye where the perception is largely
qualitative rather than quantitive. The volume of
light is of little importance, whereas the definition
or quality is everything. The least deterioration
becomes apparent by indistinctness and blurring of
objects. Defective ear__s require louder sound be-
cause the sound-conducting mechanism is clogged.
Brighter lights are no advantage to defective eyes
because the accommodation or translucent media are
defective. Their refractive not their conductive
properties are at fault.

The layman has not yet learned to practise the
same economy of his ears as he does of his teeth,
for example. He does not go at regular intervals
to the otologist, as he would to the dentist, in order
that commencing defects may be corrected before
they become serious. Nor does he go to the otolo-
gist as he does to the ophthalmologist as soon
as any deterioration has taken place. A slight
deterioration in sight is immediately perceived,
whereas, as we have previously stated, a great loss
of hearing may be brought about entirely unbe-
known to the individual.

This scheme of prophylaxis would ai)ply to all '
car diseases and defects not congenital, atnong
them those originating in the pharynx, the nose,
the tuba auditiva, external auditory meatus, the ear
complications of general diseases, nervous condi-
tions, and trauma. \\'e thus include the stubborn
forms of deafness due to chronic middle ear catarrh,
absolute deafness of labyrinthine, or nervous origin,
as well as those inflammations of the tympano-
mastoid region which threaten entire loss of hear-
ing and even life itself. At greater length we may
catalogue them as inflannnations of the pharynx,
obstructions, adenoids, and tonsils ; inflammation of
the nose and irregularities, hypertrophies, and ob-
.structions : obstructions and inflammation of the
tuba auditiva; inflammation of the middle car and
faulty nutrition and atrophy : deficiency in the nerve
function of hearing, inflammation of the external
canal, obstruction bv foreign bodies, cerumen, etc.,
and new growths, and cspecialh- the common insidi-
ous disturbances of the acoustic balance.

Inflammations of the pharynx involving the naso-
tiharynx, extend to the Eustachian tube and cause
impairment of its functions, drainage, and ventila-
tion. The slight chronic pharyngitis that is often
found in mouth breathers. gout\- or syphilitic people
brings about insidious changes along the tube and
middle ear. Gross obstructions to respiration, hy-
pertrophied adenoids and tonsils, bring about the

350

MEDICAL RECORD.

[March 2, 1907

same conditions. Smaller ones may be large enough
if conveniently placed to cover the mouth of the
tubes or press against them. A very small amount
of adenoid tissue in the fossae of Rosenmuller can
seriously impede the action of the tubes. Irregulari-
ties and impediments to the flow of air and the blood,
and lymph circulation of the nasal fossa; can cause
disturbances of the Eustachian tube and its con-
necting cavities.

The changes which affect the hearing most in-
sidiously are of two kinds : those chiefly inflamma-
tory, and those chiefly due to defective ventilation.
The final results in either case are much the same.
The inflammation first causes congestion and in-
crease of the connective tissue elements, then con-
traction, anemia, faulty nutrition, atrophy, and de-
generation. The choking of the Eustachian tube
causes the same results without intervention of in-
flammation direct through the congestion and stag-
nation of blood and lymph. Defect in the manu-
metric balance of the tympanum directly affects the
drum membrane. When there is negative
pressure the membrane is sucked inwards
flexing the ossicular chain. When there . is
increased pressure in the tympanum, the membrane
is ijushed outward, e.xtending the ossicular chain.
Either of these positions is detrimental to the best
sound transmission, and when continued long the
effect is lasting. Overextension has a detrimental
efi'ect on the elastic fibers of the membrane and the
ligaments of the ossicular articulations, which yield
in time to the overstretching. All these changes
afl-'ect the acoustic balance directly, and render it
less capable of transmiting the sonorous vibrations.
This pathological cycle when once started tends to
progress rather than cease spontaneously, and the
structural alterations have no tendency to repair
without surgical aid. The atrophy, when once well
under way. goes through all the series of changes
consequent to faulty nutrition, involves the drum
and its contents, and even spreads to the labyrinth.

Decrease of sound perception is the most delicate
measure of general nervous exhaustion. It may
indicate the commencing of nervous changes which
later will destroy the hearing or affect the nervous
system very seriouslv. Inflammations of the ex-
ternal canal are often remarkable for the great
amount of pain a comparatively trivial affection
may cause. The drum membrane is sometimes
affected. Occasionally the canal is entirely closed,
cutting: off the hearing. Foreign bodies and im-
pacted cerumen act in much the same way. New
growths sometimes close the canal and cut off hear-
ing _ permanently, as well as threaten life when
malignant. Some of the benign osteomata are easilv
controlled if they are obser\'ed in time. Impair-
ment of the acoustic balance is especially prone to
come on unobserved, whatever its causes, and the
hearino- is seriously affected before the patient notes
any change. Clogging of the Eustachian tube is a
long step on the road to deafness. It is also the
chief determining factor in mastoiditis. When
there is suppuration of the middle ear and an open
Eustachian tube, convalescence takes place before
the mastoid inflammation reaches any importance.
When the tube is clogged, the suppuration is likely
to persist in the mastoid antrum and cells.

Earlv observation will detect these insidious con-
ditions, which cause over g-, per cent, of deafness,
and judicious treatment cure them before serious
impairment has taken place. We suggest that the
otologist should be consulted once a year, after everv
cold, and when anvthing unfavorable is noticed in
the ear. which is often the case in general nervous

affections, exhaustion and general diseases, as well
as when there are any alarming ear symptoms.

ACUTE EDEMA OF THE PHARYNX, WITH

REPORT OF A CASE REQUIRING

RAPID TRACHEOTOMY.

By GOETHE LIXK, .M.D..

IN'DIA.VAPOLIS, IN'D,

ASSOCIATE PROFESSOR OP GEN-ITOUKINARV SURGERY IN THE SIATB

COLLEGE OP PHYSICIANS AND SURGEONS IN AFFILIATION WITH

I.N'DIA.VA U.VIVERSITY.

Ix the following case while it could not be definitely
established that there was no laryngeal edema the
condition was primarily and essentially an affec-
tion of the pharynx. There is no anatomic reason
why complete asphyxiation could not occur from
an acute edema of the pharynx without any in-
volvement of the larynx or its aperture. Semon
and Williams in classifying acute septic inflamma-
tions of the pharynx give as one class "acute edema-
tous tonsillitis, uvulitis, pharyngitis, epiglotiditis,
arytenoiditis, and cellulitis of the neck." As these
authors have pointed out, it is impossible to draw
any definite line between the purely local and the
more complicated cases or between the edematous
and the suppurative forms, all being different stages
or degrees of reaction to infection.

That the more severe symptoms of an edematous
nature may be present without the severe suppura-
tion following is shown in this case. No doubt
it is to the benignity of the infection, the edematous
stage being past, that the patient owes his life. Why

Hard rubber vaginal tip used, two-thirds exact size. At subsequent
removal the end was cut smooth and polished. Sterilization by
boiUng before reintroduction has caused the tube to straighten
from the original angle.

this should have been of such a severe character at
one time and later so mild is hard to understand.
At twelve o'clock at night I was called to see a
patient whom I had never treated before, and, being
told that he was choking to death, went prepared
to deal with an attack of asthma. Upon my ar-
rival in the sick room I found the patient sitting
in a chair with much cyanosis, tongue protruding,
saliva escaping, and laboring at each breath. Pa-
tient was a man weighing 250 pounds, having a very
large neck, and an accumulation of fat constituting
a double chin. His history was hurriedly given me
as follows : One hour before my arrival his throat
had been lanced for the eleventh time in the course
of a tonsillitis with which he had been suffering for
ten days. Thinking I had to deal with a post
pharyngeal abscess, I quickly introduced my finger
into the pharynx. To my surprise I found the
structure so swollen and the opening so tight as to
make the introduction of my finger difficult. On
the left side was a wound in which I could easily
bury a finger. This I cleansed of blood and mucus.
Noting the very feeble pulse I gave hvpodermatically
1-30 gr. of strychnine sulphate. I then emptied
into the patient's throat one-half dram of supra-
renalin, all that I had with me, and dispatched
the only other man in the house to the nearest
drug store for more. Thinking I might intubate
past the swollen pharynx. I asked for a tube of some
kind and finally a vaginal tip to a hard rubber
syringe was handed me. This was elbowed almost
at a rioht ans'le.

March 2. 1907 I

MEDICAL RECORD.

351

I soon found it impossible to intubate, as anything
long enough to reach the larynx, in the swollen con-
dition of the soft palate, could not be turned in
the space present. The syringe tip was laid aside
after a few attempts. The patient's neck was sur-
rounded with cloths wrung out of ice water. ^ To
mv surprise the l:>reathing became more difficult.
"VVhile I was preparing a local anesthetic in order
to do a tracheotomy, the patient ceased to breathe
and became unconscious, making an anesthetic un-
necessary.

All had fled but one woman, and while she kept
his head from falling in my way I performed a
low tracheotomy, fearing to enter higher on account
of the edema, the extent of which I did not know.
As the only light was that afforded by an overhead
gas jet, the operation was for the most part done
by the sense of touch. Kneeling in front of the
patient, who was in a sitting posture. I incised the
skin and deep fascia in the median line two inches
above the sternal notch. Introducing my finger I
worked my way bluntly to the trachea. Feeling
the tracheal rings I introduced my knife, edge
upward, along my finger. The trachea was then
stabbed and cut slightly upward. The knife being
withdrawn a closed hemostat was introduced to the
trachea, was opened, and was pulled out after the
manner of treating an abscess. This enlarged the
wound sufficiently for the introduction of a tube.
This method, while not elegant, was sure and safe.
The intense carotid pulsations on both sides of the
guiding finger served as a warning that blunt dis-
section was to be preferred to cutting. Very little
blood was lost.

Sticking a silver female catheter, which I found
in my pocket case, into the wound, while my woman
assistant held it in place, I performed artificial res-
piration. After some time we were rewarded by a
deep inspiration. This, however, was followed by
a convulsion which made it a very precarious matter
to have such a small instrument in the wound, the
neck being so thick that only a short bit was pro-
truding for a hold. Casting about for something
else to use in the wound, I took the hard rubber
vaginal syringe tip with which I had tried to in-
tulDate and quickly whittling the end inserted it.
The elbowed shape fitted perfectly and left enough
for the threaded end to be tied securely with tape.
In one-half hour the patient asked to be put to
bed", and, breathing entirely through the tube, soon
slept the first sleep for several nights.

The patient progressed to an uninterrupted re-
covery. No sloughing nor suppuration occurred ex-
cept some pus, which came from the surface of the
incisions. These had evidently been made into a
solid tonsil and later infected. Urine examination
next day showed nothing abnormal.

The previous history of this case is interesting as
leading up to a condition so nearly fatal. He had
suffered with a simple tonsillitis ten days. Three
or four days previous to my visit the family physi-
cian incised the left tonsil and repeated this at
each visit until the last incision was the eleventh.
At no time did anv escape of pus follow the incision.
Hydrogen peroxide and a proprietary antiseptic
wash had been used with the salicylates internally.
In the emergency coal oil had been swallowed to re-
lieve the edema until the patient could not swallow.
While the nature of the emergency prevented a
thorough examination, fortunately attempts to re-
lieve the edema gave all the information that could
be gleaned from palpation. Upon introducing my
fingers into the throat four distinct points of press-
ure could be felt. These seemed to be bulgings of

the anterior, lateral, and posterior walls. The lat-
ter especially felt like the half of an orange. This
swelling increased rapidly in the few minutes that
I made several examinations, until finally there was
complete occlusion and my fingers were introduced
only with great effort.

The edema declined as rapidly as it had arisen, so
that witliin three hours the patient could talk, when
the tube was closed and air forced through the natu-
ral channels. No suppuration followed, and one
month later I removed both tonsils. They were im-
bedded so as to be almost entirely hidden bv the
pillars. Carefully dissecting them out, there was
very little bleeding. The tonsils were hard and
fibrous and honeycombed with crypts. No edema
followed this operation and the patient's throat is
now clear of all tonsillar tissue.

743 Virginia Avenue.

BRIEF REPORT OF A CASE OF TRICHIN-
lASIS.*

By JOSfi M. FERRER, M.D..

NEW YORK.
VISITING rHVSlCI-\N" TO THE ST. VINCENT'S AND THE FRENCH HOSPITALS.

A. d'E., an Italian peddler, twenty-nine years old,
was admitted to my service in St. Vincent's Hos-
pital on November 9, 1906. He had been ill a week
with fever, headache, marked prostration, diar-
rhea, occasional chilly feelings, slight cough, and
persistent muscular jisins in the arms and legs.
He had had a nosebleed in the early part of the
week.

On admission he looked very ill, was perspiring
freely, and coughed a little. His temperature was
102°, pulse 84, and respirations 24. The tongue
w^as coated and quite red at the edges ; spleen was
distinctly palpable. There was no eruption and
the abdomen was not distended. There was slight
bronchitis. His heart, lungs, and liver seemed
normal. There was nothing unusual in his throat.
The urine was not scanty. It showed a marked
diazo reaction ; was dark amber, alkaline, of a spe-
cific gravity of 1.028, showed no albumin nor sugar,
and contained numerous triple phosphate crystals.

A tentative diagnosis of typhoid fever was made
and the case was manged accordingly.

During the ne.xt week the patient was very ill;,
dull and apathetic, with a temperature range of 103°
to 105°, slight diarrhea, marked headache, profuse
sweats, and pains in the limbs and occasionally in
the abdomen. The course of the disease seemed,
however, unusual for a typhoid. It was observed
that the temperature, while it rose to 104° and 105°
in the evening, would drop next morning to ioo,'.S°
or 101°, a difference of three or four degrees for
the second week of typhoid. There was no
delirium. There was no sordes nor herpes on the
mouth. There was absolutely no distention of the
abdomen. No eruption appeared. There were no
characteristic fecal movements. The blood was
examined on three different days and the Widal re-
action (i to 20) was negative. The white count
was high, on four different days being 17,000,
18,000, 16,000, and 14,000.

Thinking that the up and down temperature, the
bronchitis, the diazo reaction, the pains, etc.. might
be due to miliary tuberculosis, the sputum was ex-
amined on four' different days and the blood was
also examined, but no tubercle bacilli were found.

*Read at a meeting of the Society of the .'Vhimni of City
(Cliarit)') Ho<;pital on Dcctinlicr T2. IO06.

35-'

MEDICAL RECORD.

[March 2, 1907

As the mail had an enlarj^ed spleen, occasional
chilly feelings, up and down teni]5eratnre of high
range, marked headache, and profuse sweats, it was
thought that there might be a malarial infection.
E.xaminations of the blood for parasites were made
on three different days, but none were found. He
was given thirty grains of ([uinine a day for four
or five days, Init it seemed to have no beneficial ef-
fect on the disease, and it was stopped. The pro-
fuse perspiration continuing and being unaffected
by atropine sulphate and acid sponging, it was
thought tliat the (|uinine might be producing it, but
when this drug was stopped the sweats continued.

On the eighteenth day of the disease the temper-
ature dropped to 99° and remained fairly low. The
diarrhea had ceased. His general condition im-
proved markedly. With wliat had gone before, the
diagnosis of typhoid was no longer tenable, and
he was allowed to eat, without bad results.

The pain and tenderness in the arms and legs,
however, continued, and seemed to be in the muscles
and not the neuralgic pains of typhoid fever. Ema-
ciation was pronounced. The white blood count re-
mained high. In the last few years we have had
in the hospital three cases of trichiniasis which
acted in a similar way, and I suggested examining
the blood for eosinophilia as a possible aid in diag-
nosis. On four different days the blood showed
marked eosinophilia. The differential white count
on November 10 showed the following percent-
ages: Polynuclears, 69: large lymphocites, 12;
small lymphocytes, 4; eosinophiles, 15: no myelo-
cytes, no mast cells. On November 28 the differen-
tial count showed: Polynuclears. 71 : large Ivmph-
ocytes, 4 ; small lymphocytes, 16.5 : eosinophiles. 8.5 ;
no myelocytes, no mast cells. The patient declared
that he was very fond of pork, often partook of it
in many forms, and had eaten some the very day
he fell ill. An incision was made over the right
shoulder and a small piece was removed from the
deltoid muscle and examined carefully. The tri-
chinie were found in moderate number.

The patient continued to improve and was up
and about the ward on November 26. a little over
three weeks from the beginning of his disease.

411 Park .-^venth.

The Application of Galvanism to the Treatment of

Fibroids. — Franklin H. >.Iartin tliinks tliat electricity
may be used with benefit in a small percentage of cases
of fibroids of the uterus. He says that electricity is espe-
cially indicated in small bleeding fibroids in women ap-
proaching: the menopause: in inoperable cases: in incipient,
uncomplicated fibroids in women over forty years of age ;
in small, uncomplicated fibroids of the smooth, interstitial
variety which have no symptoms but hemorrhage ; in cases
not accompanied by pelvic pus accumulation in which the
patients persistently refuse to have an operation. In his
treatment of typical cases tlie writer passes a large corner
electrode of suitable shape and diameter to the bottom
of the uterine canal. The vaginal part is insulated with
a rubber mufif and this electrode is then attached to the
positive terminal of the battery. The other electrode is
placed on the abdomen and is then attached to the negative
pole of the battery. /\s a rule the patient may safely
be given as strong a current as she can bear w^ithout
danger of producing excessive cauterization at the active
pole This varies from one hundred to two hundred milli-
ampcrcs. The duration of each treatment should be five
minutes for the maximum current employed. The treat-
ment should be given as often as every second dav. In
cases in which an intrauterine electrode is not practical
some other form of internal electrode ^hould be used
which will have the effect of causing the current of gal-
vani<ni to pass directly through the largest part of the

tumor. The writer declares that some of his most gratify-
ing results have been obtained in cases- of the apparently
hopeless variety. — 'flu- Archives of Physiological Therapy.

The Roentgen Treatment of Hodgkin's Disease, Leu-
kemia, and Polycythemia. — Henry K. Pancoast declares
that although conservative men are beginning to look upon
the Roentgen specialist as overenthusiastic in his claims, and
perhaps with some justice, nevertheless, at the same time,
these very men stand willing to acknowledge that the
x-Tdy has great value and is the most reliable agent in
treating leukemia. Tissue destruction is doubtless the
greatest factor in the results accomplished in the .ar-ray
treatment of leukemia. In the case of a leukemic pa-
tient, the toxic conditions should be carefully studied and
the tissue destruction should be investigated before and
after beginning ;r-ray treatment. Dangerous effects should
be guarded against. Each case of this kind should be
reported in detail. The writer refers to a case of Hodg-
kin's disease in which all of the superficial lymphatic glands
and the spleen were markedly enlarged. Under prolonged
j:-ray treatment these were very much reduced in size
but whenever the exposures are discontinued for any
length of time there is always a tendency for the re-
currence of the manifestations. In the case of polycythemia
there seems to be as yet no tendency toward a permanent
reduction of the number of red cells to normal. — The Ar-
chives of Pliysiological Therapy.

The Importance of a Microscopical Examination of
All Growths Removed from the Nares, Together with
a Report of Early Diagnoses of Malignant Growths. —
Sylvan Rosenheim calls attention to the great iinportance
of early diagnosis in a case of malignant growth. In no
class of cases is the lack of such diagnosis so serious
and so sure to lead to evil results. When such cases finally
come to the general surgeon they are either inoperable or
do not recover after operation. If all growths from
the nose are systematically examined, they will be cor-
rectly diagnosed while they are still small, and they may,
as a rule, be easily extirpated by the nasal route. When
this route is not feasible the radical operation can be
done at a time when there is the greatest probability of
a cure. The physician will then be on the watch for re-
currences and will be in a position to treat them vigor-
ously. The writer then cites the history of a number of
cases in point. In Watson's series of one hundred and
fifty cases of sarcoma of the nasal passages there was a
previous history of polypi in sixteen per cent. In Blood-
.good's series of cases of carcinoma of the antrum there
was a history of polypi in nine of them, which arose
from the nasal fossae, lasting from one to twelve years
— Bulletin of the Johns Hopkins Hospital, June, 1906.

Concerning Local Anesthesia and Sensitiveness of
the Organs and Tissues. — K. G. Lennander calls atten-
tion to the four methods of contact, pain, pressure, heat,
and cold, to which the skin reacts. Underneath the skin
lie the muscles and aponeuroses with a sensitiveness rela-
tively slightly developed. Underneath these tissues are the
serous membranes, the periosteum and the synovial mem-
branes. The parietal pleura, the parietal peritoneum, and
the adjacent subserous tissues, the periosteum and the
synovial serous membrane are all sensitive to pain. On
the contrary, the writer believes that they are not sus-
ceptible to the other three tactile methods of pressure, heat,
and cold. As far as he has been able to ascertain, the
bones, cartilages, the brain, the lungs, the heart, and the
blood-vessels, after they have 'leen separated from the
connective tissues about them, tl.o thyroid gland, the liver,
the spleen, the pancreas, the renal parenchyma, the internal
female genital organs, and those parts of the testicle which
are covered with serous membrane, do not react to any
of these methods of contact, according to all appearances.
He believes that this is absolutely demonstrated at least
for the stomach, the intestinal tract, and the gall-bladder. —
Ga.:cltc dcs Hopilau.v Cizils et ^filitaircs.

March 2, 1907]

MEDICAL RECORD.

353

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. SIEDMAN. AM., M.D, Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, March 2, 1907.

THE NEW YORK MEDICAL BILL.

It is renorted tliat the homeopathic and eclectic
physicians of this State are strongly opposed to the
bill now before the legislature for the unification of
the medical examining boards. Why this should
be so we cannot imagine, except upon an assump-
tion which would be far from complimentary to
our brethren in the other schools of practice. The
bill provides for a single board, before which all
who aspire to the right to practise the healing art
must appear and pass a common examination on all
the branches of medicine except materia medica and
practice. As members of the eclectic and homeo-
pathic State medical societies are to be represented
on this board, and as the subjects of examination
will be those only on which all educated physicians
must be grounded in order to understand the na-
ture of disease and to be able to recognize its pres-
ence in the individual, there would seem to be no
valid objection on the part of our separated brethren
to the plan. No questions will be asked regarding
the treatment of disease, and the successful can-
didate will be at liberty then, as he is now, to pre-
scribe drugs or manipulations, water or hot air, as
rnay appear to him most appropriate.

It has been suggested that the opposition is due
to the fact that the examinations of the homeopathic
and eclectic boards are more lax than those of
the appointees of the Medical Society of the State
of New York, and that the graduates of the home-
opathic and eclectic schools would be unable to
pass the e.xamination as now conducted by the ap-
pointees of the State Society. We do not think
this can be so, and if it were the adversaries of the
single board would hardly allege it as a reason for
their opposition to the bill now before the legis-
lature. There is, therefore, no valid excuse for
their adverse position, and there are many reasons
why they should favor the bill. In the first place a
common examination would place all the members
of all the schools of practice on an equal footing.
It could not be said, as it is now said, rightly or
wrongly, that the licensees of the regular board
are better educated than those of the other boards,
for all would then be subjected to the same test.

If there is but one board for the licensing of all
practitioners, whatever their therapeutic principles
mav be, a bar will be placed to the admission to our
ranks of uneducated men who know nothing and
care nothing about anatomy, physiology, or patholo-
gy, but seek only for the legalization of the peculiar
system of therapeutics which they profess to fol-

low. If the three-board system is preserved it is
only a question of time when it will be a four-board,
a si-x-board, or a ten-board system. There will be
the regular board — we use the term "regular" as a
synonym for the incorrect word "allopathic," and
disclaim any arrogance in the assumption of the
title — the homeopathic board, the eclectic board,
the osteopathic board, the naturopathic board, the
mechanicotherapeutic board, the optometry board,
the christian science board, and heaven knows what
board, and the whole system of medical licensure
in this State will be reduced to an absurdity. If
there is a single board for e.xamination on all
branches of medical science, e.xcept materia medica
and therapeutics, those who seek recognition for
their peculiar tenets will have equal rights with
all other practitioners. They have only to give
proof that they are grounded in the essentials of
medical science and then they can treat disease by
drugs, by vibration, by replacing dislocated bones
and tendons, by fitting glasses, by denying the exist-
ence of disease, or bv taking the fee and doing
nothing — and will all be equally liable to suits
for malpractice if they mistreat their patients. All
men will then be- born equal in medicine and the
race will be to the swiftest and to the one who is
:he most skilful in the treatment of disease and
the alleviation of suffering. Nothing could be fair-
er than this. There will be then no monopoly in
the art of healing and the door of medical practice
will he open to every man or woman who lias the
educational key.

The single board bill in the Senate is No. 154,
that in the Assembly is No. 160, and we would
urge all our readers of whatever school of practice,
who love their profession and long for its unifica-
tion, to write to their representatives in both Sen-
ate and Assembly begging them to yoto for this
most commendable measure.

A SUBSTITUTE FOR THE CATGUT LIGA-
TURE.

It has been said that the treatment of hemorrhage
is the foundation of all surgery, and this require-
ment has been most fully met by one of Lister's
greatest inventions, the absorbable catgut ligature.
The material so successfully used in arresting
hemorrhage by ligation of the bleeding vessels has
served an equally important purpose in enabling
the surgeon to unite structures severed by opera-
tion or accident by the employment of the absorb-
able buried suture. Catgut was used as a ligature
and suture material before Lister's time, but it was
his mode of rendering the gut sterile which permit-
ted results to be attained never before possible. The
early methods of sterilizing catgut possessed many
drawbacks, but now by a gradual process there has
been evolved a series of procedures which render
the material practically sterile without impairing its
tensile strength. The term sterile must be used
advisedly, however, as localized infections may fol-
low the use of catgut ligatures ■ even under the
strictest precautions. This led to the abandonment
of catgut and a return for a time to the use of silk
for these purposes. This always constitutes a for-
eign body in the tissues, the presence of which is

354

MEDICAL RECORD.

[March 2, 1907

often resented, sometimes months and years after
its introduction. Metallic sutures, silkworm gut,
horsehair, etc., may all be included in the same
class, for they all have the same disadvantages as
buried sutures. Senn, in a recent article in Surgery,
Gynecology, and Obstetrics, for December, igo6,
refers to the ideal suture material as an animal tissue
which can be made sterile by some effective means,
which will not only destroy the existing bacteria, but
will also neutralize the toxins which may have been
generated in the dead tissue. A material of this
kind must also possess the necessary tensile strength
to meet the mechanical indications for a certain
length of time, until the processes of repair have
rendered its presence superfluous.

Catgut by no means fulfils all these indications,
and yet it has held the field against substitutes which
have been introduced successively during the course
of many years. The source of the material and its
preparation ofifer many opportunities for error which
are familiar to every surgeon. Among the sub-
stitutes which have been suggested are the com-
pact nonelastic tendons of some of the larger
land and sea animals. Of these, kangaroo
tendon, championed for many years by Dr. Marcy
of Boston, has been the most widely used,
and with general satisfaction. It may be thoroughly
sterilized, but if used extensively the supply would
soon give out. Dr. Senn in his paper suggests the
use of tendons secured from some of the larger
Arctic mammalia, which he has employed with good
success. Alaterial was procured from the whale,
the narwhal, the walrus, and the seal, and after be-
ing dried and stripped it was treated with iodine in
the usual manner. The results from the employ-
ment of these materials as buried sutures were ex-
cellent, and Senn was impressed to such a degree
that he considers it superior to the tissue of all
land animals, from both the anatomical and the
bacteriological standpoints. It is apparently not
so difficult to procure as would at first appear, for
the natives of these regions use it constantly for
their own purposes. If it can be made commercially
available it is possible that it may be found to be an
efficient substitute for catgut, which is quite gen-
erally acknowledged to be far from ideal.

GASTRIC ULCER IN CHILDREN.

A STUDY of post-mortem statistics shows that gas-
tric ulcer is relatively uncommon in children, as
compared with its frequency in adults, yet it ap-
pears to exist more often than is recognized by
clinical examination. Hemorrhagic erosions, folli-
cular ulceration, tuberculous and simple ulcers have
all been demonstrated in children, but the sympto-
matology is very defective, as the greater number
of cases have been demonstrated only accidentally
at autopsy. Adler, writing in the American Journal
of the Medical Sciences for January, 1907, has col-
lected the available literature and subjected the same
to analysis in addition to reporting a case which
came under his own observation. Pain and tender-
ness were not often noted in the acute cases, but
were present in most of the chronic cases. The
pain was not severe, and was usually localized in
the epigastrium. It was always paroxysmal, came

on after meals as a general rule, and was relieved
by vomiting. Hematemesis was noted in 40 per
cent, of the cases in which histories were obtained,
and in some cases was the immediate cause of death.
Symptoms of indigestion were rarely noted, and
then only in the chronic cases. Diarrhea was a
prominent symptom, being present in almost one-
half of the acute cases. A striking feature of acute
ulcer in children is the large percentage of perfora-
tions, the symptoms of which are sharp, sudden
pain in the abdomen, vomiting, and collapse, with
death occurring in thirty-six hours.

The possibility of the presence of this condition
should lead to the exercise of great care in the
diagnosis of obscure gastrointestinal symptoms in
infants and young children. The finding of blood
in the stools and vomitus is probably the most cer-
tain means, but here care must be taken to eliminate
all the other causes of hematemesis and melena, for
these may be found associated in children with any
one of a number of disease processes. With the
advances which have been made in the recognition
of occult hemorrhages, ulcer of the stomach in
children will probably be more frequently recog-
nized at an early stage in the disease when the ap-
plication of curative measures may still prove of
value. At any rate, in children suffering from
chronic stomach disorders the possibility that their
disease may be gastric ulcer should always be borne
in mind.

THE TREATMENT OF BENIGN TUMORS
OF THE BLADDER.

Refined methods of diagnosis in diseases of the
bladder, particularly the development of cystoscopy
by Nitze and others, have demonstrated that the
number of nonmalignant vesical growths is much
larger than was formerly believed to be the case.
The older statistics have shown that apparently
only 0.39 per cent, of all bladder tumors were be-
nign, whereas Nitze found that among 399 vesical
tumors examined by him 177 (or 44.3 per cent.)
aflforded no evidences whatever of malignancy. This
diagnostic conclusion seems supported by the re-
sult of the therapeutic procedures evolved in accord-
ance with these findings. Nitze has developed the
intravesical operation in order to meet the condi-
tions presented by pediculated. benign tumors, not
too extensive in size, and as a substitute for supra-
pubic cystotomy. His statistics, as shown in a re-
cent paper by Weinreich in the Archiv fi'ir klinische
Cliiriirgie, \ ol. 80, No. 4, disclose that among loi
cases treated in this manner, a cure was effected in
70, and in only 18 did recurrences take place. Of
course these patients were operated upon soon after
the first symptoms were noted, and the growths were
usually small, but the results show the feasibility
of an operation which can be carried out with much
less trouble and annoyance than suprapubic section,
and gives equally good results.

It is generally assumed that the greater propor-
tion of these benign tumors of the bladder soon
become malignant, and for this reason regular
cystoscopic examinations after the operation are in-
dicated. As regards the possibility of postoperative
hemorrhage, experience with this series of cases
has shown that the danger is exaggerated, and that

March 2. np/l

MEDICAL RECORD.

355

it is not necessary to tamponade throug-li a cystotomy
wound in order to control the bleeding, as claimed
by Cathelin. The intravesical method developed
bv Nitze will by no means entirely supplant the
suprapubic route, but with the jiroper indications
present it seems rational to em])loy it before re-
sorting to the more radical procedure. It is self-
evident that it can be done, however, only by a
specially qualified operator, and this seems to con-
stitute the sole drawback to its general adoption
for the purposes indicated.

The Effect of Quinine on the Uterine Con-
traction.

Differences of opinion have long existed among
obstetricians in regard to the value of quinine as an
oxytocic, and while some observers have lauded it
as a useful uterine stimulant others have considered
it either of no value for this purpose or at best
unreliable in its action. A comprehensive sum-
mary of these conflicting views is presented in the
Deutsche medidnisclic Wochcnschrift, January 31,
1907, by Miiurer, who also reports his own experi-
ences with the drug. He administered it in sixty-
three cases during labor and fifteen times in the
treatment of abortion. In 78.2 per cent, of the
cases he considers that an effect was produced which
was the result of the medication and in the remain-
ing 21.8 per cent, it appeared to be without efficacy.
His experience leads Maurer to believe that quinine
undoubtedly strengthens the uterine contractions and
perhaps may induce their onset, but that it shares
with other oxytocics the disadvantages that its ef-
fects cannot be guaranteed in every case. According
to Miiurer's experience its administration is not at-
tended bv any untoward action on either the mother
or child, and the uterine contractions evoked are
physiological in character. In explaining its mode
of action he assumes that, granted a normal uterine
musculature, in cases of inadequate contractions
there is a lessened susceptibility of the muscle to
stimuli and the quinine serves to increase the irri-
tability of the organ to the nervous impulses in
question. It was found that the nature of the
quinine preparation is of no importance and that it
may be given either by mouth or hypodermatically.
Maurer's routine method is to give one gram of
the sulphate by mouth and if no effect is manifest
at the expiration of an hour to give 0.5 gram more.
If there is still no improvement in the conditions this
dose is repeated in half an hour, but if this is in-
effectual the patient is regarded as having an idio-
syncrasy that renders her insusceptible to the in-
fluence of the quinine.

Heredity in Gastric Ulcer.

The ingenuity of theorists and experimenters has
been so severely taxed in endeavoring to furnish
a satisfactory explanation of the etiology and man-
ner of formation of the so-called peptic ulcer of
the stomach that it is a little remarkable that more
efforts have not been made to introduce the element
of heredity into the question. In a recent com-
munication in the Muncliencr mcdhitiisclie ]Vochcn-
schrift, January 29, 1907, attention is drawn to this
factor bv Huber, who gives brief resumes of thirty
cases in support of his opinion that a hereditary
predisposition to the affection frequently exists. His
own cases are eleven in number and form about
fifteen per cent, of all the patients with ulcer of

the stomach treated by him since January, 1905.
The other nineteen histories were furnished by
Bernhard, who believes that the element of heredity
was present in about a third of the cases seen by
him in the course of a long series of years. While
some of the cases quoted by these authors can
hardly be regarded as affording particularly good
evidence in support of their views, in others the
occurrence of the same affection in numerous closely
related persons seems to be the result of rather
more than mere coincidence. Huber dos not at-
tempt to draw direct conclusions from the statistics
he has collected, but offers the suggestion that
possibly the explanation of the mode of origin of
the affection is to be found in an inherited dis-
order of the innervation of the stomach, involving
particularly the trophic impulses and in this wav
through the agency of some immediate exciting
cause giving rise to the ulcerative process. In fur-
ther supnort of his views he points out the much
greater frequencv of gastric ulcer in some regions,
sucii as in the Engadine and in Thuringia, but it
must be admitted that this is a pretty weak argu-
ment, for many other predisposing causes besides in-
breeding may be active in circumscribed geographi-
cal districts.

Physiological Salt Solution as an Irrigating
Fluid.

More doubt is being cast from day to day on the
actual value of antiseptic solutions for purposes of
irrigation in external wounds or in lesions of the
accessible internal organs. The rational procedure
would appear to consist in the use of a nonirritating
fluid, the effect of which would be largely mechan-
ical. These qualities are well met by the, ordinary
physiological salt solution, but in the desire to
gain an antiseptic action, which has been greatly
furthered b}' the numberless remedies of this char-
acter which have been placed on the market, this
has been almost entirely forgotten. Pasteau (quoted
in the Mcdico-tcclinologisches Journal, 1907, No. i)
makes a plea for the use of the decinormal salt solu-
tion, particularly in genitourinary surgery, and con-
siders that its advantages are sufficient to commend
it as superior to all the other drug solutions. Among
these are its absolute blandness and lack of irritating
effect on the mucous membranes, which is present
with the use of even the most dilute solutions of
other materials ordinarily employed for this purpose.
In using salt solution for bladder irrigation, it also
has the advantage of dissolving blood clots and ac-
cumulations of pus, and thus facilitating their re-
moval, whereas the action of most antiseptics is-
one of coagulation. Another point in its favor is
that when some of the solution is left in the cavity
irrigated, whether accidentally or by design, it?
absorjjtion will have no deleterious effect on the
organism. The ease with which the solution may
be prepared is another great point in its favor, as it
is not essential to employ an absolutely sterile solu-
tion, for if used soon after being subjected to a half-
hour's boiling, it fulfils all practical requirements.

Human and Animal Tuberculosls.

Few reports have evoked greater interest than thai
of the Royal Commission on Tuberculosis which
receives lengthv editorial comment in a recent issue
of the /,fl;;cr/, 'February 0, 1907. The commission
has found that "marked differences are met with
between bovine tuI)ercuIosis and certain strains of

?,.S6

MEDICAL RECORD.

[March 2, 1907

human tuberculosis in respect of their infective
abihty to certain lower animals (in particular to
calves) ; but practically speaking the difiference,
where it exists, is always in one direction ; whatever
the animal in question the tubercle of bovine origin
lias the greater virulence. The experiments have
€xtended to anthropoid apes which have been found
readily susceptible to bovine infection. No reason
has been shown for inferring that man alone pos-
sesses a specially lessened suscei^tibility to tuber-
culosis of bovine origin." The writer in the Lancet
further says that "we are forced to conclude that it
is more than ever necessary to take active steps to
minimize the risk which the public runs from tuber-
culous food and tuberculous milk. We cannot be
content to tell the public to boil or sterilize all its
milk. We know from experience the limited utility
of such advice. We want milk free from tuber-
culous infection as its source." This want, like
many other human desires, is at nresent somewhat
difificult of realization. What we want, and can get,
is milk free from tuberculous infection^ — at its source
if possible, but before it is delivered to the consumer
at all events. The finding of the Roval Commission
on Tuberculosis emphasizes the danger of tuber-
culous milk and the necessity of pasteurization of
all milk derived from suspicious sources.

mination of the infusion promises, therefore, to be
of value in cardiac therapeutics.

Till-; Efficiency of Digit.-\lis Prep.\r.\tions.

Although digitalis is one of our most valuable and
widely used drugs, its administration is accompa-
nied by so many uncertainties that it has fallen
greatly in medical estimation and substitutes and
derivatives without number have been brought for-
ward to take the place of the older preparations.
Efforts have at the same time been made to deter-
mine the reason for the uncertain and irregular
action of the drug which is so often noted. Lowy,
a well known Austrian pharmacologist, studied the
effects of the infusion on frogs by injecting the
same into the lymph sacs of the legs and then de-
termining the time at which systolic contractions
ceased {IVie-uer klinische Woclioischrift, No. 39,
1906). In order to study the influence of the con-
stituents of the gastric juice on the efficiency of the
infusion, pepsin and hydrochloric acid were added
to the latter. It was shown that the strength of the
infusion distinctly declined when hydrochloric acid
was added in the proportion found in the gastric
secretions, while the effect of pepsin was compara-
tively unimportant. A solution of strophanthus on
the other hand was not at all affected by even
stronger solutions of the acid. It was also found
that at the ordinary room temperatures an infusion
■of digitalis lost about half of its original efficiency
■within twenty-four hours. This is apparently due
to the presence of an organic acid which is developed
during this time, and it may in most cases be in-
hibited by neutralizing the fluid. This record simply
furnishes another instance of the necessity of pre-
paring infusions of digitalis fresh for every pre-
scription and points also to the need of an addition
of soda solution in order to neutralize the infusison
and prevent, if possible, the changes already alluded
to. In general it is better to use the active principle
of a cirug. when it can be obtained in stable form
and in definite strength, but in the case of digitalis
^nany practitioners believe an effect ca" ^^ obtained
from the use of an infusion of the entire drug
which it is impossible to produce with digitalin or
others of the active principle preparations. Lowy's
■discoverv of the cause and remedy for the deter-

Rei.ation of Birth Rate to Population.

Ix a recently published report on British vital sta-
tistics, the Registrar-General, Sir William Dunbar,
expresses the opinion that moderate birth rates, as-
sociated with low mortality among children, may be
more effective toward keeping up the population than
high rates associated with high mortality. He asserts
that a high birth rate does not necessarily involve
a larger effective addition to the population than
does an average or even a low birth rate. In too
many cases high birth rates are associated with
excessive sickness and mortality during the first
few years of life, the result being that fewer than
the normal proportion of children survive for five
years, while those who do survive have fallen below
the normal standard of physical fitness. The statis-
tics gathered have led to the conclusion that during
the past thirty-five years about seventeen per cent.
of the decline in the birth rate was due to a decrease
in the proportion of voung married women. About
ten per cent, was due to a decrease in illegitimacy,
while regarding the remaining seventy-five per cent.
of the decrease, although a proportion was due to
reduced fertility, ascribable to changes in the age
and constitution of married women, there is little
doubt that the great part was due to deliberate pur-
pose.

5«>tuH of tIjF Bwk.

Army Medical Corps Examinations. — Pre-
liminary examinations for appointment of assistant
surgeons in the army will be held on April 29 and
July 29, 1907, at points to be hereafter designated.
Permission to appear for examination can be ob-
tained UDon application to the Surgeon-General,
U. S. Army, Washington, D. C, from whom full
information concerning the examination can be pro-
cured. The essential requirements to securing an
invitation are that the applicant shall be a citizen
of the United States, shall be between twenty-two
and thirty years of age, a graduate of a medical
school legahy authorized to confer the degree of
doctor of medicine, shall be of good moral character
and habits, and shall have had at least one year's
haspital training or its equivalent in practice. The
examinations will be held concurrently throughout
the country at points where boards can be convened.
Due consideration will be given to the localities from
which arrilications are received, in order to lessen
the traveling expenses of applicants as much as
possible. In order to perfect all necessary arrange-
ments for the examination of April 29, applications
must be complete and in posse.ssion of the Surgeon-
General on or before April i. Early attention is
therefore enjoined upon all intending applicants.
There are at present twenty-five vacancies in the
medical corps of the army.

Examinations for Positions in the Marine Hos-
pital Service. — The Bureau of Public Health and
Marine Hospital Service announces that a board
of officers will be convened to meet at the Bureau
of Public Health and Marine Hospital Service, 3 B
street S. E., \\'ashington, D. C, Monday, April
15, 1007. at TO o'clock A.M., for the purpose of
examining candidates for admission to the grade
of assistant surgeon in the Public Health and Mar-
ine Hospital Service. Candidates must be between
twenty-two and thirty years of age, graduates of

March 2, 1907]

MEDICAL RECORD.

357

a reputable medical college, and must furnish tes-
timonials from responsible persons as to their pro-
fessional and moral character. The examinations are
chiefly in writing, and begin with a short autobiog-
raphy of the candidate. The remainder of the writ-
ten exercise consists in examination of the various
branches of medicine, surgery, and hygiene. The
oral examination includes subjects of preliminary
education, history, literature, and natural sciences.
The clinical examination is conducted at a hospital,
and when practicable, candidates are required to
perform surgical operations on a cadaver. Suc-
cessful candidates will be numbered according to
their attainments on examination, and will be com-
missioned in the same order as vacancies occur.
Upon a^nointment the young officers are, as a rule,
first assigned to duty at one of the large hospitals.
as at Boston, New York, New Orleans, Chicago,
or San Francisco. After five years' service, assistant
surgeons are entitled to examination for promotion
to the grade of passed assistant surgeon. Promotion
to the parade of surgeon is made according to senior-
ity, and after due examination as vacancies occur
in that trrade. Assistant surgeons receive $1,600,
passed assistant surgeons $2,000. and surgeons
$2,500 a vear. When quarters are not provided,
commutation at the rate of thirtv, fortv, and fift\
dollars a month, according to grade, is allowed. All
grades above that of assistant surgeon receive
longevity pay, '10 per cent, in addition to the regu-
lar salary for everv five years' service up to 40
per cent, after twenty vears' service. The tenure
of office is permanent. Officers traveling under
orders are allowed actual expenses. For further
information, or for invitation to annear before the
board of examiners, prospective candidates may ad-
dress the Surgeon-General, Public Health and
Marine Hospital Service, Washington, D. C.

Pasteurization Bill Introduced.- — A bill provid-
ing for the pasteurization of all milk sold in New
York Citv has been introduced before the Assembl\'
at Albany. By the operation of the measure, the
dealing in and selling of any milk in New York
City which has not been pasteurized would bring
upon the parties handling the milk imprisonment
for not less than six months, or a fine of $500, or
both. It is provided that the Commissioner of Health
shall designate pasteurizing stations to which everv
quart of milk brought into the city must be taken and
put throu"-h the process of pasteurization, and that
the citv must construct such stations. Following
the process, a stamp will be put on the receptacle
by the health authorities, whereupon the dairy and
milk comrianies and anv others whose milk has been
subjected to the process mav take their milk and
start oh the delivery thereof. Provision is ma'F-
for the confiscation and destruction of any milk
found to be unpasteurized. Authority is also given
for the appointment of a large number of additional
milk inspectors. The bill is too sweeping in its pro-
visions, for some of the milk supplied to the city is
pure and should not be pasteurized.

Hospital Transfers. — Coroner Harburger of this
city, in the course of the discussion before the
Assembly Committee at Albanv of the Huth bill, a
rneasure providing for the curtailment of the prac-
tice of transferring patients from one hospital to
another on the alleged ground that this is resorted
to in order to keep d'own the mortalitv records of the
institutions, made the astonishing statement that 15.-
000 patients yearlv are transferred from hospitals
while in a precarious condition, and that 5,000 deaths
annually are attributable to this cause.'

Children's Hospital Society of Chicago. — This
Society, with its executive board chosen from the
ranks of physicians and those who are acquainted
with the conditions, in the few years of its exist-
ence has more than doubled the number of beds
for children in hospitals, has improved the methods
of care, and has secured the cooperation of first
rate hospitals and all the prominent charity organi-
zations, and may call upon them for aid from its
central office in the downtown district. It not only
sees that sick children among the poor have places
in hospitals, but it finds homes for the neglected
child, shelters for the street boy, and through a
milk commission provides pure milk in the districts
of tenement houses and has bettered the milk sup-
ply for the city, and is urging the fomidation of a
colonv for epileptics. It has cared for 1,160 chil-
dren in hospitals, and the number of those that seek
its ministrations is constantly increasing.

Los Angeles Medical Library. — The formal
dedication of the new Medical Library building
presented to the Clinical Association of Los Angeles
by Dr. W^ Jarvis Barlow took place on February
8. Dr. Geo. F. Bovard, president of the University
of Southern California, presided, and addresses were
made bv Dr. Barlow, Dr. Joseph Kurtz, president
of the Clinical Association, and Dr. Milbank John-
sen, president of the Board of Trustees. The use
of the library is free to all members of the profes-
sion, though to provide for its adequate maintenance
three graded forms of membership have been de-
cided upon.

Public Lectures on Problems of Insanity. —
The fourth of the series of lectures on the above
topic, arranged for by the Psychiatrical Society, will
be delivered by Dr. Allan McLane Hamilton at the
New York Academy of Medicine, on Saturday,
March 2, at 8.30 p.m. The subject will be: "The
Development of the Legal Regulations Concerning
the In.sane, with Suggestions for Reforms." The
aim of these lectures is to place before the profession
and leaders of sociological work the facts with re-
. .gard to insanity, which point to the possibility and
duty of initiating some broad movement with a view
to preventive measures.

The Death Rate in England and Wales during
1905 was the lowest on record, and onlv four other
European coimtries make a better showing. The
deaths of fiftv-eisrht reputed centenarians, forty-
seven of whom were women, were reported during
the vear.

The Crocker-Doyen Suit. — The First Tribunal
of the Seine on February 23 rendered its decision
in the case of George Crocker against Dr. Doyen,
by which Mr, Crocker sought to recover a $20,000
fee which he paid to the French surgeon in 1904
in the expectation that he could cure Mrs. Crocker
of a cancer, alleging that Dr. Doyen obtained the
large fee from him bv "moral violence." The
court held that the good faith of Dr. Doyen had
been wrongly attacked and condemned the plain-
t\S to pay the costs of the action. The contract,
it was pointed out, had been freely entered into
bv the parties concerned, and, therefore, could not
be annulled unless Dr. Doyen failed to perform
his duty, which was not the case, as he withdrew
at Mr. Crocker's request and was ready at all times
to resume his treatment of Mrs. Crocker. The court
further declared that it could not decide the question
of the reasonableness of the fee, but only that of
the validitv of the contract.

Counter Prescriber Prosecuted. — The first ar-
res> under the New Jersey law providing against

358

MEDICAL RECORD.

[March 2, 1907

the prescribing; for sick persons by drug-gists was
made last week in Bayonne, the City Physician,
actins? in behalf of the Health Board, being the
complainant. The offending druggist pleaded igno-
rance of the law and was dismissed with a repri-
mand.

Centenarians. — A resident of Montreal, Canada,
died on February 20 at the alleged age of in years.
It is stated that' he never had carried an umbrella
and that he was a constant user of tobacco, smok-
ing before breakfast every morning up to his last
illness. The oldest inhabitant of North Carolina
died on the same day in ^^"avnesville at the re-
ported age of 112 years. A daughter, aged ninety,
survives him.

Multiple Pregnancy. — From Middlesborough,
Ky., comes the report that the wife of a Polish
miner living at Fort Ridge on February 21 gave
birth to five children, three girls and two boys, who
are all living.

Meningitis in Great Britain. — The number of
cases of cerebrospinal meningitis m the Glasgow out-
break is now well over two hundred, and more than
one hundred and nineteen deaths have been reported.
In Edinburgh tliere have been twenty-five cases and
twenty-one deaths. The total number of cases in
Scotland this year exceeds three hundred, with a
mortality of about fiftv-five per cent. In addition,
one hundred cases with fifty-five deaths have oc-
curred in Belfast, and cases are also being reported
from Liverpool.

Famine Conditions in Russia. — The Red Cross
makes the statement that as the reports of the
pitiable condition of the famine sufferers of Russia,
who number from twenty to thirty millions, have
been ofificiallv confirmed, the organization will active-
Iv engage in the collection of funds for their relief.
The administration of the relief work will be carried
out by the Russian Red Cross. Contributions should
be made navable to and addressed to Red Cross, War
Denartment, ^^'ashin,gton, D. C.

Smallpox in Missouri. — Four persons attached
to the House of Representatives in Jefferson City
are down with smallpox, the infection having been
conveyed, it is thought, through a member of the
House who was taken ill during a session and was
discovered to be suffering from the disease. The
Jefferson Citv Board of Health states that there are
thirty cases in the city.

Trichinosis on the East Side. — Eight cases of
trichinosis have latelv come under observation in
Bellevue Hospital, all of the patients being residents
of the neighborhood around First avenue and Third
street.

Mica Post Cards Not Mailable. — The Post-
Office authorities have decided that post cards or-
namented with particles of mica, glass, or similar
substance are likelv to cause injury to the postal
emplovees either through inhalation of the detached
particles or in other wavs. and thev have accordingly
been excluded from the mails unless inclosed in
envelones.

Home for the Destitute Blind. — .\. concert for
the benefit of the Home for the Destitute Blind
will be "-iven at the Waldorf-Astoria on Monday,
March 4, at 3.30 p.m. Attached to the institution
is a workshop for the blind inmates, and the pur-
pose of the concert is to aid in enlarging this shop.
x\ll the expenses of the concert will be met bv
some of the managers of the home, and the entire
proceeds will go to the charity.

Dr. Edward W. Ryerson was recently appoint-

ed attending orthopedic surgeon at St. Luke's Hos-
pital and orthopedic surgeon at the Children's Me-
morial Hospital, Chicago.

Dr. Walter J. Marciey, former superintendent
of the Massachusetts State Sanatorium in Rutland,
was presented a loving cu" by patients, former pa-
tients, officers, and employees of the institution
recently.

Dr. Seymour Oppenheimer has bee
laryngologist and otologist to the Syd
pital.

No Canteen for Soldiers' Homes.- :-.j.-

of Representatives, on February 23 by a vote ui
ninety-one to eighty-six, adopted an amendment to
the Sundav civil bill providing for the abolition of
the canteen in all national homes for disabled
soldiers. This was in spite of the statements of
governors of homes, chaplains, surgeons, and other
officials favoring the maintenance of the canteen,
which had been presented to the Committee on Ap-
Ijropriations.

Coming Events Cast Their Shadows Before.
-The following is from the recent presidential
address of Dr. Joseph Decatur Bryant, ex-Presi-
dent of the Medical Society of the State of New
^'ork, but President-elect of the American Medical
.Association : "The editorial policy of a journal of
mutual constituent ownership, like this of ours [the
Xczi' York State Journal of Medicine'\, should be
guided by the composite wisdom of an impartial
committee chosen for the purpose, rather than by
I he notions of the editor himself, as in the instance
of personal proprietorship."

National Association for the Study and Pre-
vention of Tuberculosis. — The third annual meet-
ing of this association will be held at the New
^^'illard Hotel, Washington. D. C, ;\Iay 6, 7, and 8.
The organization of the sections for the meeting is
as follows : Sociological Section, Mr. Paul Kenna-
day. New York, Chairman ; Mr. Christopher Easton.
New York, Secretary; Clinical and Climatological
Section, Dr. George Dock, Ann Arbor, Chairman ;
Dr. Joseph Walsh, Philadelphia, Secretary : Patho-
logical and Bacteriological Section, Dr. F. F. Wes-
brook, Minneapolis, Chairman : Surgical Section,
Dr. W. S. Halsted, Baltimore. Chairman ; Dr. Hugh
H. Young, Baltimore, Secretary ; Section of Tuber-
culosis in Children, Dr. T. M. Rotch, Boston, Chair-
man.

The New York Physicotherapeutic Association.
— An association bearing this title was organized on
February i, 1907, by the adoption of a constitution
and by-laws, and the election of the following offi-
cers: President, Albert C. Geyser, M.D. ; Vice-
President, W. L. Heeve, M.D. ; Secretary and
Treasurer, Hills Cole. M.D. The following were
present at this organization meeting: Drs. Brinck-
man, Boskowitz, Hills Cole. Geyser, W. L. Heeve,
Wm. Harvey King, and H. E. Waite ; and these
together with Drs. Dieftenbach. Meacham. and
Sillo will be the charter members. The constitution
provides for active, associate, and regular honorary
members. Active membership is opened to legally
qualified practitioners of medicine and surgery in
good standing, practising in New York City or its
vicinitv. Meetings will be held on the second Fri-
day of each month, except in July. August, and
September. The dues are two dollars a year.

Cincinnati Academy of Medicine. — E)r. Geo. W.
Crile of Cleveland. Professor of Surgery in the
Western Reser\'e University and Surgeon to the
Lakeside Hospital, was entertained by the Cincinnati
Academy of Medicine on February 18, 1907. Dr.
Crile addressed the society on "An Experimental

March 2, 1907'

MEDICAL RECORD.

359

and Clinical Research on Direct Transfusion of
Blood." He described some brilliant results of his
experimentation in this direction, and reported cases
in detail. The academy will hold its annual election
of officers on March 4.' and a banquet celebrating its
semi-centennial on March 5, at the New Hotel Sin-
ton. The valedictory of the retiring officers and
inaugural of the incoming officers will take place
on March 11.

.erence. — A meeting of the Hospi-
was held at the New York Acade-
,e, on Wednesday, February 27, at
■.M. The following special program
1.,.,. .,__ jared: "The Milk Supply of a Hos-

pital/' Dr." S. T. Armstrong, General Medical Su-
perintendent,. Bellevue and Allied Hospitals. "How
Should the Ambulance Service of Greater New
York Be Organized?" Mr. Homer Folks, Secretary.
State Charities Aid Association.

National Association for the Study of Epilepsy
and the Care and Treatment of Epileptics. — The
next meeting of this association is, by invitation of
the General Board of Directors of the State Hos-
pitals of Virginia, to be held in Richmond on Octo-
ber 23 and 24. A specially attractive program
will be offered, so arranged by topics that it will
be convenient for each member to attend to the
reading and discussion of such portions as especially
interest him, while it will also allow opportunity
for each person to see something of the Jamestown
Exposition, before, during, or after the meetings.
Those intending to present pajiers at the meeting
are requested to communicate promptlv with the
secretary. Dr. J- F. Munson. Sonyea, N. Y.

Congress of Polish Physicians and Scientists. —
The tenth Congress of Polish Physicians and Scien-
tists will be held at Lemberg, Austria-Poland, July
22 to 25, 1907. Dr. Francis E. Fronczak of Buffalo
is to represent America at the Congress.

Mississippi County (Ark.) Medical Society. —
At the recent meeting of this society, held in Blythe-
ville, officers were elected as follows: President, Dr.
C. C. Stevens of Blytheville : Vice-President, Dr.
O. Howton of Osceola ; Secretary and Treasurer,
Dr. T. G. Brewer, Osceola.

The "Long Island Medical Journal." — Under
the editorship of Dr. Paul ^I. Pilcher this new and
attractive publication makes its appearance in place
of the Brooklyn Medical Journal. The Journal
publishes the Transactions of the Associated Physi-
cians of Long Island, the Brooklyn Surgical So-
ciety, and the Brooklyn Pathological Society. The
initial number was devoted to the surgery of the
peritoneum and the current issue is devoted to a
discussion of anesthesia. It has been rebuked by
the Secretary-Editor of the Journal of the Ameri-
can Medical Association because of the advertise-
ments it carries, but as Dr. Bryant, the President-
elect of the Association, is being roundly scolded
by one of the official State medical journals because
he tacitly approves of the "unethical" advertise-
ments in the Nciv York State Journal of Medicine,
the honors seem to be easy.

Clinics at the Elgin (Illinois) Insane Asylum.
— Recently Speaker Shurtleff of the Illinois Legis-
lature introduced resolutions which aimed at the
prohibition of clinics in the Hospital for the Insane
at Elgin.

Obituary Notes. — Dr. J. Clark Thomas of this
city died in Los Angeles, Cal., on February 20 at
the age of sixtv-three years. He was graduated
from Yale in 1864 a"fl fowr years later received
his medical degree from the College of Physicians
and Surgeons in this citv. He served as interne in

Bellevue Hospital and had practised in this city
for about thirty-five years.

Dr. George H. Nichols of Brooklyn died sud-
denly on February 17 in Stamford, Conn. He was
born in Plainfield, N. J., in 1863, and was graduated
from the University of New York. Four years ago
he was a^-^ninted a member of the Board of Edu-
cation.

Dr. A. R. Alley of Atlanta, Ga., died on February
21 at the ap-e of sixty-three years. He was a Con-
federate veteran and' had practised in Atlanta for
many years.

Dr. Joseph O'Shea of Paterson, N. J., died on
February 20 of tuberculosis at the age of thirty-
three years. He was a graduate of Seton Hall Col-
lege and received his medical diploma from the
Bellevue Hospital Medical School in 1896. He had
been for four years medical school inspector.

Dr. Henry Z. Gill of Long Beach, Cal, died on
February 7 at the age of seventy-six years. He
occupied several medical posts during the Civil War
and in 1864 was made surgeon-in-chief of the First
Division of the 20th Army Corps, with the rank
of Lieutenant-Colonel. He wrote a surgical history
of the Civil War and a work on the Confederate
prisons. He had been a resident of' Long Beach for
about five years.

Dr. F. S. CowLES of Essex, Conn., died on Feb-
ruary 12 at the age of thirty-seven years. He was
born in Rome, N. Y., and received his professional
education in the Yale Medical School. He practised
for a time in Durham, Conn., and about four years
ago removed to Essex.

Dr. Thomas M. Woodson of Gallatin, Tenn., died
on February 12 at the ace of seventy-eight years.
He was ""raduated from the L^niversity of Louisville
and practised in Bethpage, Tenn., until 1874, when
he removed to Gallatin. He retired from active
life about five years ago on account of ill health.

Dr. William A. Butman of Somerville, Mass.,
died on February 11 of pneumonia. He was born
in Fairhaven in 1869 and received his medical edu-
cation from the University of Baltimore. He prac-
tised for a time in Boston and removed to Somer-
\-illc a short time ago.

Dr. Oscar Gaudet of Convent, La., died on Feb-
ruary 7 at the age of sixty-eight years. He was
a graduate of the University of Virginia and served
in the Confederate Army. At the close of the war
he began practice in St. James' parish and served
a number of terms as coroner of the parish.

Dr. J. T. Marsh of Kansas City, Mo., died on
February 9. He was born in Clav County in 1833
and was graduated from William Jewel College and
Westminster College, Fulton, Mo. He had prac-
tised in Kansas Citv for over forty-five years.

Dr. C. B. Greenfield died in Honokaa, Hawaii,
on January 18 at the age of sixty-three years. He
was born in England and was a former surgeon in
the Royal Navy. He had lived in the islands many
years.

Dr. Frank W. Tallev died at Philadelphia on
February 17 at the aee of fortv-two years. He
was graduated from the medical department of the
University of Pennsylvania in the class of 1887
and subsenuetitlv served as resident physician in
the PhiladeHhia Hospital. He pursued post-gradu-
ate studies abroad and on returnin"' became assist-
ant in '"■'lecolos-y in the Philadelphia Polyclinic and
!'\'necolop'ist to St. Agnes Flosnital.

Dr. Ellerslie Wallace died at Philadelphia on
February- 17 at the age of fift^'-eight vears. He
was a son of the distinguished obstetrician of the
same name, who was formerly professor of obstetrics
in Jefferson Medical College.

^6o

MEDICAL RECORD.

[March 2, 1907

NINTH JIARXEY SOCIETY LECTURE.

The ninth of the present series of lectures under
the auspices of the Harvey Society was held at the
Academy of .Medicine on Saturday, February 23,
the speaker being Prof. \V. J. Councilman of the
Harvard Medical School. The title of the lecture,
as it had appeared on the announcements, was : "The
Relation of Certain Leucocytes to Infectious Dis-
eases," but this was changed by the lecturer to
"Some Changes in Lymphoid Tissue in Certain In-
fectious Diseases." The original title was very
misleading and certainly gave no clue to the subject
matter of the lecture, which was a highly finished
pathological study along morphological lines.

The speaker began by saying that as long ago
as 1898 he had called attention to a form of ne-
phritis associated with acute infectious diseases. The
condition had been described by others previously,
but not sufficient attention had been paid to the
subject. The speaker then gave a very lucid
account of the morphological changes which such a
kidney manifested. Among these were areas of
greater or less diameter which projected above the
cut surface. These areas were usually situated in
the corte.x, which frequently was three or four times
the usual thickness. The size and weight of the
kidney were occasionally enormously increased,
though, as a rule, the increase w'as only slight. On
section an opaque milky fluid exuded. The areas
protruding above the cut surface were found to con-
sist of a deposit of lymphoid cells. These cells
varied considerably, but could in general be divided
into three classes : ( i ) Small lymphoid cells of the
usual type; (2) the most numerous type w^ere cells
varying from 6 to 15 microns, and having a rathei
vesicular nucleus usually placed eccentrically; (31
cells corresponding to plasma cells.

Prof. Councilman described each type in detail,
giving the staining, reactions, etc. None of the
cells showed any characteristicallv staining granules.
All of them were' ameboid, the lymphoid type cell
probably the least so.

The areas were truly cell deposits, for cells of this
type were not found in the kidney tissue. Similar
interstitial deposits of lymphoid cells were also fre-
quently found in the adrenal and sometimes in the
pancreas and in the lungs. Thev were most common
in children in infections of diphtheria, scarlet fever,
and smallpox.

The immense accumulation of these cells led to a
disorganization of the tissues, though often the latter
appeared entirely normal. The presence of mitotic
figures was evidence of rapid proliferation after
they had been deposited. Since these cells could
not originate locally they must come from the blood.
At first Councilman believed that the reason for
their deposit was mechanical, due to conditions of
pressure in the blood-vessels. He now believed that
there was a positive chemotaxis which attracted the
cells and led to their deposit.

The cells described above had not been described
by the hematologists. The nearest approach to
them was perhaps the cell described by Tiirck under
the name of irritation cells. They had no specific
granules, were mononuclear, and according to Tiirck,
originated in the bone marrow. Prof. Councilman
believed that the cells he had described originated
in the Ivmphoid tissues, and went on to describe
in detail the structure of lymph nodes. In these,
among other cells, were found certain masses of
cells which had first been carefullv described by
His and later by Flemming. Plis regarded them as

masses of germinal cells. Thev were more abundant
in young children, later in life the lymphoid tissue
vv'as much less active. The transition between the
germinal cells and the small lymphoid cells could be
traced.

Oertel had been the first to show that in diph-
tlicria there were small foci of necrosis in the lymph
nodes and that these corresponded to the germinal
masses. A similar condition had since been found
in scarlet fever. The destruction of the cells in
t^iese cases was due not only to the vulnerability of
the cells, but to the large capillary supply leading to
considerable transudation. With this destruction
there was an accumulation of phagocytic cells in
the form of a nodule, which looked something like
a miliary tubercle. It did not, however, caseate.
Most marked changes were found in the germinal
cells in the tonsils.

During this time the lymph nodes showed evi-
dences of marked activity. The new formed cells
entered the blood-vessels, since they w-ere all ame-
boid. From the blood-vessels they passed into the
various tissues, forming interstitial foci, especially in
the kidney, liver, and adrenal body.

The speaker continued by considering the lym-
l>hoid cells as they occurred in the blood. He spoke
of the various theories and schemes which the vari-
ous hematologists had devised and which, after all,
were nothing but theories. He discussed the three
tvpes of cells, polynuclear, lymphocytic, and transi-
tional, and pointed out that the great difference
between the tw^o former was that the lymphocytic
were never phagocytic. The phagocytosis of the
polynuclear was eminentlv microbic, that of the
tiansitional cell chiefly cellular. He stated that
an indifferent cell was apparently the parent of
both the myelocvtic and the lymphocytic type. The
tvpe produced would seem to depend on the loca-
tion.

(EDrrfspottJiiptirf.

IHE RADICAL CURE OF TRIGEMINAL NEU-
RALGIA.

To THE Editor of the Medical Record:

Sir : — In your issue of February 23, Dr. M. .^llen Starr
endeavors to correct many of the "errors" in my article on
■'The Radical Cure of Trigeminal Neuralgia by Means of
Peripheral Operations," published in the Medical Record
of February 16. In the opening sentence of that paper I
referred to a previous communication, entitled "The Sur-
gical Treatment of Trigeminal Neuralgia," which appeared
in the Medical Record of September 29, 1906. This paper
discussed in greater detail points that appear in summary
in the subsequent report. I am sure that, had Dr. Starr
taken the trouble to read this, he would have found his
criticisms in a large measure answered. I shall, however,
lake each of his statements singly, and discuss them in
order.

I. .A.fter first introducing one of my conclusions, "We
know nothing of the pathological anatomy of trigeminal
neuralgia," Dr. Starr says : "This statement ignores the
very complete and positive results published by Keen and
Spiller." I did not intend to imply when I said that "we
know nothing of the pathology of trigeminal neuralgia"
that no workhad been done upon this subject. When I set
out to write iny original article, I collected upon the subject
of pathology of trigeminal neuralgia alone a page and a
half of references on this subject. I read over and sum-
marized the most important of these articles, twenty-eight
in number, and reported them with references in my origi-
nal communication of September 29. igo6. I found that
the opinions were divided about equally as to whether the
disease lies in the Gasserian ganglion or in the peripheral
nerves, or whether any pathological changes exist at all.
In reading over these reports, one fact is strikingly ap-
parent, namelv, that no two observers agree, and that.

March 2, 1907]

MEDICAL RECORD.

361

therefore, there are as many views on the patholo.ary of tri-
geminal neuralgia as there have been investigators. Now.
it is a well recognized axiom in medicine that wherever
there are many views or theories about a disease, none is
conclusive. It is therefore not an illegitimate conclusion
to say that "we know nothing of the pathology of the dis-
ease." Coming more specifically to Dr. Starr's statement
that I "ignore the very complete and positive results pub-
lished by Keen and Spiller. and subsequently confirmed by
them, and by Thomas, and by Redlich," I shall not deny
that the changes observed by Keen and Spiller were noted
by them. In my original article of September 29 I quoted
the results of Keen and Spiller, and even stated their con-
clusions in their own words. It is interesting, however, to
iearn that Dr. Starr finds their results "complete and posi-
tive." If these findings are "complete and positive," and the
disease lies within the Gasserian ganglion, why did Keen
subsequently advise merely division of the sensory root for
the cure of trigeminal neuralgia ? Also, why have their
observations not been confirmed and accepted by subsequent
observers too numerous to mention? I need only name,
among others, such observers as Hutchinson and Gushing.
The statements of these authors are particularly interesting
because they are advocates of the intracranial operations.
Gushing says : "No lesion sufficiently characteristic to con-
sider it typical of a particular disease is present." Nor can
it be overlooked, as has been pointed out by other ob-
servers, that the changes in the Gasserian ganglion or pe-
ripheral nerves may be secondary products, and not pri-
mary. These secondary influences may be (i) traumatism,
due to the necessary manipulations in the course of extir-
pation ; (2) incomplete preservation of the ganglion : ( !
the age of the patient: this could easily account for the en-
darteritis; (4) ascending changes in the nerve or ganglion
as the result of previous peripheral operations. It is rather
significant that ^Ionari,' Schwab," and Goenen' found abso-
lutely normal ganglia in those cases in which no previous
peripheral operation had been performed.

To quote the observations of Thomas and of Redlich
(these studies incidentally were upon tabetic subjects, and
are therefore entirely irrelevant) is entirely a matter of
personal taste. We might just as well quote the names of
any one of the numerous worker? in our list of references,
many of them in the first rank of neuropathologists, whose
findings have differed from those of Keen and S'piller,
Thomas, etc. Not until some definite picture of the lesion
in trigeminal neuralgia has been accepted by neurologists
will we admit that we know the pathology of trigemina!
neuralgia. This condition of affairs, however, is far from
the case at present; nevertheless, if Dr. Starr is willing to
accept the conclusions of the authors whom he quotes, well
and good. The whole question is an academic one, and, as
we shall see, has little bearing on the practical issue in ques-
tion.

2. Dr. Starr quotes again my words : "All proof is lack-
ing that the neuralgia originates in the Gasserian ganglion."
In reply he says : "There can be no better proof than the
"fact, of which I have personal experience in more than a
dozen cases, that when operations upon the peripheral
branches of the trigeminal nerve fail to relieve (as they
always do fail to give permanent relief), an excision of the
Gasserian ganglion or a division of the root of the fifth
■nerve between the ganglion and the pons always cures."
To say that, because removal of the Gasserian ganglion
abolishes the pain, therefore the ganglion is the seat of the
•disease, is an argument that is by no means warranted. It
is rather surprising to note that Dr. Starr shatters his owm
argument by the very next phrase, "division of the root of
the fifth nerve between the ganglion and the pons always
■cures." The reason why this operation and the extirpation
of the ganglion cures is because the sensory imf'uiscs hair
been cut off. This is also the reason why division of the
peripheral branches invariably brings about relief. I claim,
and I am not alone in this respect, that the reason why
peripheral operations fail to give permanent relief is be-
cause sensory impulses in time become restored bv the re-
generation and reunion of the divided nerve. If the dis-
ease is in the Gasserian ganglion, how can Dr. Starr ex-
plain the temporary relief by peripheral operations at all?
.^nd how, also, can he explain the comparative freedom
from neuralgia of the ophthalmic division ?

.3. Dr. Starr states, "I have never seen a relapse when
the ganglion was completely and properly removed, etc."
Dr. Starr may not have seen such a relapse, but I have col-
lected from the literature the reports of nine cases. Of
these, two are reported by Krause himself — a "competent
surgeon" — whom Dr. Starr quotes as not having had re-
currences. In one case reported by Perthes (Deutsche

'Monari : Bruns' Bei/ragc. Vol. XVII.
"Schwab : Annals of Surgery, June, igoi.
'Coenen : Laii.sjfiiZn'r/o'i Archiv, Vol. LXVII.

Zcilschrift j Chirurgic, Vol. LXXVIII.) no less a patholo-
gist than Alarchand confirmed the findings.

4- Dr. Starr says, "These statements refute absolutely
the other assertions of Dr. Moschcowitz, which therefore
require no notice." Granted— if Dr. Starr's claims are
granted— but most emphatically not granted if his other
claims are not granted.

5- Dr. S"tarr says, "Dr. Moschcowitz claims that it is to
the regeneration of the peripheral nerve that recurrence of
pain IS diic. That may be true, but I have cases on my

•records where the pain has recurred after peripheral opera-
1 ion too soon to be due to regeneration." How soon ? What
proof does Dr. Starr offer that the nerve did not regen-
erate? Dr. Starr may be unacquainted with the fact that
nerve regeneration may, and does take place in as short a
unie as two vveeks. (Ramon y Gajal : Comptes rendus de
la Societe dc Biologie, Vol. LIX., pages 420 and 422 ) This
whole statement of Dr. Starr is not sufficiently specific.

6. Dr. Starr says, "and other cases where it has re-
curred when a half inch of the nerve has been resected "

I hat Dr Starr would regard the resection of even as much
as a half inch of nerve, as precluding the possibility of re-
generation, indicates that he is unacquainted with one of the
earliest discovered facts in regard to regeneration of the
peripheral nerves. As long ago as 1845, Dieffenbach aban-
doned Ins method of peripheral resection of laro-e seg-
ments just because of this regeneration. In one of mv early
cases complete regeneration of the inferior dental' nerve
occurred after resection of one inch. Complete regenera-
tions have been found after evulsions of the entire nerve
distally to the foramina at the base of the skull. Perthes
Hoc. cit.) experimentally found regeneration after extirpa-
tion of 9.5 cm.

7. Dr. St;irr says he has seen other cases "in which pain
has returned, and at the radical operation no evidence of
legeneration or union of the formerly divided peripheral
branch has been found." In the first place, I fail to see how
.111 intracranial operation can reveal a condition in such dis-
tant parts as the infraorbital or inferior dental canals Sec-
ondly, I have failed to find one authentic instance in liter-
ature in which recurrence after peripheral operation took
place without regeneration of the nerves The cases of Dr
btarr sliould, therefore, be reported in greater detail

8. Dr. Starr says, evidently in a spirit of adverse criti-
cism that "the cases cited by Dr. .Moschcowitz are both
too few in number and are reported far too soon to afford
any convincing proof of his statement." Compare this with
my conclusion; and was I not just as critical of myself
when I said that "I do not present these cases as cured
cases of trigeminal neuralgia ; the period of observation is
altogether too^short to admit of this deduction"?

E.xchiding all the more purely theoretical questions in the
issue, three facts in regard to the practical treatment of tri-
geminal neuralgia stand out, and these Dr. Starr cannot
deny: (i) The mtracranial operation of Hartley and
Ivrause is one of the severest in surgery, and is attended
by a formidable mortality. (2) Everybody agrees that
peripheral division of the nerves is attended in every case
by temporary freedom from pain in the affected nerves
(,V) Ihe peripheral operation is practically free from risk'
These considerations, and also the apparent possibility of
producing radical cures by peripheral operations, have' led
surgeons in recent years to turn more and more to the
peripheral operations for trigeminal neuralgia, as anyone
who has followed the recent literature may note. These
recent peripheral operations fall into two groups: (i)
those in which no measures are taken to prevent regenera-
tion of the nerves, and (2) those in which measures are
taken to prevent regeneration. In the first group we need
mention onlv the methods of Murphy, who" advocates the
injection of osmic acid: of Laplace, who has resuscitated
the evulsion method of Thiersch, and of Schlosser and Kil-
iani, who advise alcohol injections into the affected nerves
In the second group comes, first of all, the method of
.Abbe (which, although an intracranial operation, is really
peripheral), Perthes, and finally C. H. Mayo. The latte'r
(Peripheral versus Intracranial Operations for Tic Dou-
loureux; Surgery, Gynecology, and Obstetrics. December,
1906) — surely a competent surgeon — has been using practi-
cally the same method that I have described, and moreover
performed his first operation long before I published my
first report. He reports one case in which freedom from
pain existed for a period of seven years ; a period that
ought to satisfy even Dr. Starr's most exacting conditions.
This case is doubly interesting because at the end of this
time recurrence ensued, and at the second operation the
plug that Dr. Mayo had introduced into the infraorbital
canal was found to have slipped out, and the nerve h.id
regenerated.

,-\. V. Moschcowitz, M.D.

362

MEDICAL RECORD.

[March 2, 1907

THE SPECIFIC GRAVITY OF URINE.

To THE Editor of the Medical Record :

Sir:— In your issue of February 16 you refer editorially
to a letter by Dr. A. W. Brand to the Lancet of January
26, in which the writer calls attention to' the fact that the
specific gravity of the urine varies greatly with its tempera-
ture, and states that he has found no allusion to this in any
text-book of phvsiology or clinical medicine.

That this is not an original observation may be seen by
reference to the sixth edition of the work of Dr. Charles ,
W. Purdv on "Practical Uranalysis," page 14. wherein is
'tated; "The temperature of the urine immediately after
being voided ranges from 85° to 95° F. (29.5° to 35 C.) ;
therefore, in taking the specific gravity of freshly-voided
urine, before cooling, its temperature should be observed,
and for every seven degrees of temperature the thermom-
eter indicates above that upon which the instrument is
standardized, one degree should be added to the specific
gravity of the urine, in addition to that indicated by the
instrument." . n 1 » ,.1

In this connection it mav not be amiss to allude to tne
fact that the specific gravity tests as ordinarily made with
the so-called urinometer are so fallacious as to possess very
little, if any, .scientific value. The instruments themselves
are frequently inaccurate, the readings are taken hastily,
and no allowance is made for the temperature or for the
conditions under which the .specimen is voided, as to tinie.
preceding diet, etc. It is the exception, rather than the
rule for the twenty-four-hour average specimen to be
tested Under these circumstances. I contend that the spe-
cific gravity observation is practically useless, and might as
well 'be relegated to the rubbish-heap of other perfunctory
measures. , , , _, , Tir ,»

Properly carried out, with a balance of the Mohr, West-
phal or Sartorius type and a Wiemann thermometer, using
a twentv-four-hour average specimen, the specific .gravity
reading may be a most valuable source of inforniatioii, both
alone and in conjunction with other findings; but 1 wish
to emphasize the fact that it.s value is in direct proportion
to its accuracy, and unless to it is given the same painstak-
ing care in it's estimation that is accorded to other labora-
tory method'^, and unless equally delicate apparatus is em-
ployed, it is manifestly improper to expect of it the same
measure of results. Gilbert Geoffrey Cottam, -M.U.

Rock Ramus. Iowa.

OUR LONDON LETTER.
(From Our Special Correspondent.)
CANCER— tuberculosis COMMISSION— RED CROSS WORK— IM-
MUNIZ.\TI0N DEP.\RTMENTS FOR HOSPITALS PROPOSED— MILK
SUPPLY— AFTER-CARE ASSOCIATION— CEREBROSPINAL MENIN-
GITIS-ITEMS. ^^^^^^^ p^^^^_^^ ^ „_^.^

Cancer in its various respects is still a leading subject
in all directions. Dr. Bashford, superintendent of the Im-
perial Research Fund, in an address at the Epidemiologi-
cal Society, has drawn attention to the real and apparent
differences in the incidence of the disease. Contrary to
a common statement, he pointed out that cancer was ap-
proximately as frequent a cause of death in Japan as m
England, and the notion of its being a result of European
civilization was thereby negatived. One phenomenon _ of
universal occurrence in man and animals had more im-
portance than all variations. The increasing frequency of
cancer in advancine age was a law applicable to the ver-
tebrates, whether short or long-lived. In childhood the
law obtained as to fatal structures. The investigation of
cancer could be profitably carried on from the standpoint
that (i) its incidence obeyed the definite biological laws
which governed the growth and length of life of organisms
as a whole or of their individual organs, because it arose
de novo in each sporadic case; or that (2) sporadic cases
are connected bv an infecting virus which produces its
effects in conformity with the same biological law-. The
apparent increase in the number of deaths in this countr\
is to be attributed to more accurate diagnosis, and differ-
ences in localities may be due to varying age distribution
of the population. The differences between several coun-
tries in this respect were just those of tlie accuracy of
their vital statistics. The great mortality rate of Switz-
erland, for instance, is probably explained hy the rule that
a medical inspection of the body is made. But as the only
trustworthy estimation of the frequency of cancer is the
national death-rate, the collaboration of the Registrar-Gen-
eral's office is most valuable and this has been given
freely, and Dr. Bashford acknowledged his indebtedness
for it.

Dr. Tatham. president, remarked that though there
was little hope that primary growths would be amenable
to other treatment than removal, the fact th.at animals

could be rendered unsuitable for the growth of malignant
tumors was important, as it might eventually be found
that cells disseminated from the site of entrance might
be rendered unable to grow. E.xperimental transference
of cancer from one individual to another was no longer
to be doubted, but it quite contraindicated expectations, as it
was easier to effect in young than old animals. It would,
therefore, seem that the frequency in later life was not
due to increasing suitability of the soil. Mice could be
protected by previous inoculation of cancerous tissue from
another mouse, but not from an animal of a different
species. It was still more surprising that protection could
be obtained by inoculation of healthy tissue, blood, in fact,
from one healthy animal into another of the same species.
That fact was pregnant with possibilities.

Dr. Payne said it was surprising to find young animals
more susceptible than old. Statistics showed indeed a high
mortality rate in early life, but he considered that was
reallv due to sarcoma. In reference to the returns ot
primary cancer of the liver he also thought many of the
cases were really secondary.

Dr. Newsholme said statistics .proved civilization was>
not a factor in causation of cancer, nor was meat eating.
In fish and animals it occurred in about the same pro-
portion as in man.

Sir Shirley Murphy said the incidence was about the
same in rich and poor.

Dr. Dawson Williams said all through fetal life obsoles-
cence of certain tissues was going on and the process
continued after birth.

Dr. J. A. Murray gave a microscopical demonstration of
experimental and of sporadic cancer in mice.

\\'riting in The Hospital, Dr. Shaw-Mackenzie, who has
devoted so much attention to the treatment of cancer, con-
siders the parasitic theory as dead and that the solution
of the etiology of the disease will eventually be found
in the chemicobiological theory. But considering how our
knowledge of cancer is environed with ambiguity springing
from undetermined facts, he supports the suggestion made
by Mr. Percy Dunn in the Nineteenth Century (1893)
for the appointment of a Royal Commission on the disease,
and goes so far as to say that if such an inquiry had been
appointed some years ago we should now have been in
possession of information of which use could be made in
a preventive sense.

That the parasitic theory is by no means dead is, how-
ever, maintained by many. Among them Mr. Jackson
Clarke still holds the view he has so long urged that sar-
coma and cancer are caused by parasitic protozoa, the study
of which he says enabled Schaudinn to discover the
microbe of syphilis. The sections of sarcomas in dogs
made by the late Dr. Washbourn he still believes to be
such in opposition to the views expressed in the report
of the Imperial Research Fund.

A second interim report of the Royal Commission on
Tuberculosis has been issued. It states that there cart
be no doubt that in a certain number of cases, especially
in children, the disease is the direct result of the intro-
duction of the bacillus of bovine tuberculosis and in the
majority of cases this is through cow's milk. Clearly
cow's milk containing the bovine bacillus is a cause of
fatal tuberculosis in man. Of 60 cases of human tuber-
culosis investigated 14 were traced to this cause. If
attention is confined to cases in which the bacilli were
apparently introduced through the alimentary canal, the
proportion is much larger. Of the 60 cases the clinical
histories indicated this entrance in 28. Of g cases in
which the cervical glands and of 19 in which the abdominal
lesions were studied. 10 showed the bovine bacillus. It is
pointed out that the bovine bacillus can be detected, though
with some difficulty, in milk. There is less difficulty
in recognizing clinically tuberculosis in the cow. and a
cow so suffering may yield tuberculous milk. The results
point to the necessity of more stringent measures to
prevent the sale of such milk.

The role of Red Cross Societies was the subject of an
address on Wednesday at the Royal United Service In-
stitution by Lt.-Col. I\Iacpherson. R..\.M.C.. who sketched
the official organization of the care of the sick and
wounded, instancing that of the Japanese which he had
seen at work in the late w;ir and declared to be a mag-
nificent and efficient machine. Voluntary aid played no
part at the front, but a real part at home. The outburst
of sentiment in the event of a great national war had
to find a vent, and the Red Cross Society collected and
retained the flood til! it could be utilized to the best
advantage. The organizations of European countries hav-
ing been described, be turned to that of Japan, where,
he said, groups of relief or nursing sections were formed,
each of 2 doctors, i apothecary, i accountant. 2 superin-
tendent nurses, and 20 nurses. Each such group could
take over 100 patients. At the outbreak of the late war

March 2, 1907]

MEDICAL RECORD.

363

116 groups were ready, by the end 150. The female sec-
tions were 98. In Japan l in 45 of the population was a
member of a Red Cross Society. None of the work
was in the zone of the field army, very little in the line of
communications, but 32 male groups did service there or at
base hospitals. The peace work of Red Cross societies
was to keep ready for mobilization, also to aid in case
of a public calamity. Col. ]\Iacpherson found in this
country e.xcellcnt material and splendid peace organizations,
e.g., St. John's Ambulance Association, the Army Nursh^ig
Reserve, the Soldiers' and Sailors' Help Society, tlie St.
Andrew's Ambulance Association, and the British Red
Cross Society lent those bodies the required coordination
and consolidation of their work. Still more the mode of
keeping them in touch with the military authorities m
time of peace should be carefully studied.

Sir A. E. Wright addressed a distinguished audience
at the Royal Institution on the desirability of establishing
at every hospital a department of inoculation or immuniza-
tion. He told them it was as uncivilized to be carried off
by bacterial diseases as to be devoured by wolves, and
yet no serious effort had been made to get rid of such
diseases. Practically all the work in that direction had
taken the form of hygienic precautions. Inoculation wa^
used against smallpox, but that was merely like a nation
taking steps to defend itself against only one enemy.
The white blood corpuscles had become famous under
the name of phagocytes, because of their power of eating
bacteria, but this function was very limited if the bacteria
were presented to them in a so-to-say raw state. They
needed cooking. It had been known for some time that
the blood contained three elements which could be said
to cook bacteria. A fourth had been discovered by himself
and Dr. Douglas which they had named opsonin. Bacterial
therapeutics should aim at increasing all four, and he
therefore hoped to see an inoculation or immunization
■department set up by every hospital.

Dr. Cameron, M.O.H. for Leeds, reports the result of
an investigation as to the milk supply of the city. He
finds a remarkable disparity between the ordinary supgly
and cooled milk from perfectly healthy cows. In the
latter when fresh there were 16,000 germs to a cubic
centimeter. In samples taken from shops and railway
stations there were 145,000 per c.c. In each case when
the milk was just over a day old the number had enor-
mously increased up to 224.000 and 10.000.000 respectively.
In regard to tuberculous milk Dr. Cameron reports that
by carefully inspecting all cows in the city at frequent
intervals the disease had been practically stamped out
among the animals, but that was not so in the country
farms from which much larger quantities of milk were
brought. Until municipalities had power to inspect farms
outside their boundaries it would be almost impossible to
check the evil. Here is a plain lesson for legislators.

The Worshipful Company of Apothecaries lent their hall
for a meeting of the After-Care Association, which was
established in 1879 to help poor persons discharged from
lunatic asylums. Mr. Parker Young, the master of the
company, presided, and was supported by Drs. Wilks and
Gorden Brown (wardens) and other influential persons.
He described the work and declared no charity was
doing more good in a quiet way. It was true the sum
spent on individual cases was large, but that was un-
avoidable, considering the difficulties s_urrounding the after-
care of the insane. Drs. Savage, Blandford. Om=;den, and
Jones spoke in support of the work, the last named declar-
ing that one out of every ten discharged from lunatic
asylums was absolutely friendless. The Bishop of Bark-
ing testified as an East End clergyman to the care and
wisdom displayed by the association in its prosecution
of inquiries. The report was adopted and the council re-
appointed.

Cerebrospinal meningiti'- has spread during the week. It
has effected a lodgment at Liverpool now: three cases were
reported yesterday to the Health Committee of the city.
The medical officer of health has issued a memorandum
on the disease, advising immediate notification with isola-
tion of both patients and suspects.

At Edinburgh on Tuesday it was stated that nine deaths
had been certified since January 12. some of them being
traced to Glasgow, in which city tlie Registrar-General's
returns for the week ending on the 2d inst. reported
sixteen deaths, as against twenty-two in the preceding week.

At Belfast up to Februarv i there had been fortv-
five cases with nineteen deaths. As I told you the disease
has been made notifiable there, .^n interesting report bv
Dr. Chalmers. Medical Officer of Health for Glasgow, deals
with the disease in that city during the past six vears.

A statement has been freelv circulated this week that
Dr. Donald Mac.\li=fer had been appointed principal of
Glasgow University in succession to the late Principal
Storev. This morning, however, the Press .Association
says it is requested bv the Secretary for Scotland to sav

that the report is unauthorized. I suppose a short time
will reveal the exact meaning to be attached to the phrase.
Dr. S. E. Cockey died at Frome on the .id inst. in his
ninetieth year.

OUR LETTER FROM THE PHILIPPINES.

(From Our Special Correspondent.)

THE M.\NIL.\ MEDICAL SOCIETY — SATISFACTORY HEALTH CON-
DITIONS— CHOLERA — SMALLPOX — CEREBROSPINAL MENINGITIS
— MALARIA AMONG THE PRISONERS IN THE IWAHIG SETTLE-
MENT— PERSONAL.

• Manila. January 14, 1Q07.

Inste.ad of the regular monthly meeting of the Manila
Medical Society, a business meeting was held January 7,
1907, for the purpose of electin.g new officers to serve
for the ensuing year. Dr. Percy M. Ashburn, Captain
and Assistant Surgeon, United States Army, member of
the Board of Tropical Diseases, was elected President,
and Dr. Ralph T. Edwards, Bacteriologist of the Bureau
of Science, was reelected Secretary. Dr. Victor G. Heiser,
Director of Health for the Philippine Islands, was elected
a Councillor for five years.

The general health conditions in the Philippine Islands
have improved so much during the past month that the
Insular Bureau of Health, since January I, 1907, discon-
tinued the daily report of dangerous communicable dis-
eases. This is the first time the health authorities have
felt warranted in taking such a step for a period of over
three years.

The last case of cholera occurred in Manila, November
28, 1906; the last case of plague, April 21, 1906, and,
with the exception of one case of smallpox, the infection
of which was a direct importation, there has been no
case of this disease for a period of several months

This satisfactory condition of affairs is no doubt the
result of the permanent sanitary work which has been
continuously carried out since the American occupation.
The people of the islands are gradually being vaccinated,
many artesian wells are being bored monthly, the pollution
of water supplies is being corrected, the conditions of
living are slowly improving, and the rigid quarantine
inspection of foreign vessels by the Public Health and
Marine Hospital Service is preventing the introduction
of disease. So far as is known there has been no case
of plague imported since looo. On this account the insular
health authorities have always felt that if the disease
could once be eradicated from the islands, and subsequent
cases promptly isolated, and other necessary measures
taken, it would only be a question of a short time before
the disease would disappear permanently from the islands.
This happy result seems now to be an accomplished fact.

With regard to cholera, there are still numerous diverse
opinions as to whether it is freshly imported each time,
or whether the disease is indigenous in the Philippines.

The health conditions are probably better now than at
any time since the American occupation, and also, no doubt,
much better than thev were for many years during the
Spanish regime.

In spite of the favorable conditions with regard to
public health, the native press still continues its attack
upon the Bureau of Health. So far there appears to be
no foundation for these attacks. The articles which are
written usually contain nothing but personal abuse, and
whenever a few items are published which have a
semblance of reflecting upon the Bureau of Health, in-
vestigation has always shown the alleged facts to be
untrue.

It is the general opinion among those who are well
informed that the attacks are purely of a political nature ;
the ultimate obiect being to supplant the American per-
sonnel of the Bureau of Health with Filipinos, and in
order to do this the aid of native newspapers has been
invoked to discredit the American officials in the eyes of
the masses.

The cruiser CImttanonga arrived in Manila from Sliang-
hai, January 9. with a case of smallpox on board in the
person of the navniaster's clerk. It is of medical interest
to state that the entire personnel, including officers, were
vaccinated ^evi-ral inoiiths ago. with the exception of the
pavmastcr's chrk. who evaded the operation and is now
appnrentlv suft'erine the penalty. None of the balance
of the personnel showed any evidence of having con-
tracted the disease, although many of them must no doubt
have been exposed to the same infection. The vessel was
remanded to the Alarivelos quarantine station for treat-
ment.

The cruiser Mai vhiini. wliicli is one of the newer vessels
of the navv. and one which ha- onlv recentlv arrived
in the Philippines, lias had a niinilier of cases of cerebro-
spinal meningitis occur among the crew. The efforts
which have been made so far to eradicate the infection

364

MEDICAL RECORD.

[March 2, 1907

have not been successful, and cases still continue to
occur. It is now proposed to send the vessel to the .Mari-
veles quarantine station an.d have the personnel and ship
thoroughly disinfected with the hope of removing the cause
of the infection.

'Ihe prisoners who have been transferred to the Ivvahig
Penal Settlement on the island of Palawan have suffered
severely from malarial fever during the past year. With
a population of about .300. there have been an average
of about one-sixth of that number of cases per day tn
the hospital, with a pernicious type of malarial fever. It
is understood that the Spanish authorities once attempted
to use the same location for a similar purpose, but had
to give up the plan on account of the malaria which
thev were unable to combat successfully. If will now be
mterestmg to observe whether, in the light of recent dis-
coveries, in connection with the prophyla.xis against ma-
laria, and carried out by an American administration
the prisoners at Iwahig can be kept in a healthy condition.

Ur. William ,1. Mallorv. who has been in charge of the
iienguet Sanitarium Division for the past two veais, has
obtained an extended leave of absence and ha. recentlv
departed for the United States, via Europe

J^m^rsH iif iHrrstrai frintrr.

Nnu York Medical Journal, Fcbrnarv 6

1907.

The Physical Processes of Immunity and Infection.—

J. Wright believes that it is through the oropharynx and
nasopharynx that the majority of^ pathogenic organisms
gam access to the human system, and he has set out "0
investigate the physical factors involved in the struggle a°

'w-P^''^*""'"'"" "'" '"\^:^'"S g^™s ^"d the naturll ban-
ners to their progress. xMuch has been learned in recent

stimT,Ii'°Th"""*^ r' ^^?^''°"^°f protoplasm to various
lu^t: 7 J™«'0" of the air and food tracts, whence
fs .b^^fi ?r«i ''°"'" 'P th?^ organs of active metabolism,
is the first battle ground. There must be some mechanism
by which inert matter is allowed to pass while harmful
Zhf P^°^P'^^™ '^ '.'='lt«d by the epithelial cells. The
author attaches nuich importance to the action of the cilia
which, in keeping bacteria on the move, tends to prevent
their entrance into the tissues, or compel them to traverse
cell surfaces which either destroy them, or arran.'e a
modus Vivendi with them. Another physical factor is the
hmp.d serum which coursing down by gravity, removes
bacteria from the danger .one at the cribriform plate.
Associated with this factor is that of osmosis. The cilia
in the accessory sinuses tend to keep them clear of foreign
ma ter. When they are paralyzed by local inflammation or
systemic depression the harmful matter accumulates and
furnishes an ideal soil for germ development. The author
decries the excessive curetting of these cavity linings which
has been practised of recent years. He further expresses
the opinion that the smus suppuration which is found at
autopsy in more than one-half of the cases of pneumonia is
dependent on a cause it has in common with it, that is, some
paresis Oj the cilia of the air passages, bronchial and sinu-
soidal, which makes their action physiologically inefficient.
Splenectomy; Five Successful Cases.— W P Carr
reviews the literature of the surgery of the spleen, and
considers that the plan he has followed out in his cases
nearly eliminates the chief sources of danger in hemor-
rhage, shock, and sepsis. He tabulates the indications for
splenectomy as follows : (1) Injuries that cannot be safelv
repaired; (2) all chronic enlargements or bvpertrophies of
the organ sufficiently great to cause discomfort or produce
serious symptoms, except in leukocvtbemia ; (?) benicm
tumors and cysts that cannot be readilv enucleated or re-
moved by partial splenectomy; (4) movable spleen, when
enlarged, or causing distress, especiallv when the pedii-'-
becomes twisted; (5) suppurative splenitis, unless the
spleen is adherent to the abdominal wall, so that the absce<;s
may be safely opened; (6) malignant disease or tubercu-
losis, when primary and confined to the spleen, or when
secondary or not confined to the spleen, provic'ed the other
parts involved can be also removed or cured. The author
considers that an enlarged spleen is not only a menace on
account of liability to rupture, but in many cases evidently
furnishes an altered secretion which is more or less to;;ic.
Remarkably good, and even brilliant results >or.ietimes fol-
low splenectomy in cases of simple and syphilitic hvper-
trophy, malarial spleen, Banti's disease, and splenic anemia,
while in other cases apparently similar little or no benefit
follows. In the present state of our knowledge we cannot
always tell certainly which cases will be benefited. In sim-
ple h}-pertrophy and in syphilitic and malarial spleens any
symptoms referable to the spleen may be expected to dis-
appear after its removal. Complete cure may be predicted
in cases of wandering or <Iislocated -pleen and in splenitis.

In any case where diarrhea is severe, cure or great amelio-
ration of this symptom may be expected. The majority of
cases of splenic anemia are cured by splenectomy. The
detailed histories of the five personal cases are appended.

How Long Shall the Patient Stay in Bed After Ab-
dominal Section? — J. Vance declares that there are
many advantages to be gained in getting abdominal patients
out of bed as soon as possible. The personal comfort of the
patient is greatly increased, the catheter is practically always
avoided, and when sitting up they can pass the time agree-
ably by reading or writing. They eat their meals with a
far greater relish than when in bed. Elimination by the
bowels, kidneys, and skin are far better, and consequently
digestion is greatly aided. With the ability of the intestine
to digest comes appetite, strength, and confidence. In the
aged all of these advantages are greatly increased. In fact,
while younger patient^ will do well in bed and better out,
old patients will not do well at all in bed, and getting them
out of bed early becomes, not a procedure of choice, but
of necessity. Recumbency for any length of time embar-
rasses respiration and heart action at any age, but alter
si.xty or sixty-five years of age this embarrassment is so
great as to cause hypostatic pneumonia in the majoritv of
patients. By sitting these patients up early the general
improvement of metabolism gives to the patient that buc>y-
ancy of mental condition which is so very necessary lO the
successful treatment of the aged. There are no disadvan-
tages to the out of bed treatment, but thcit are certain
dangers, the first and greatest of which is rupture of
suture or ligature, causing secondary hemorrhage or
the escape of poisonous material into the peritoneum, as, for
instance, the slipping of a ligature of an ovarian pedicle
or the rupture of a sutured intestine. Those patients best
kept in bed are (a) all pelvic cases in which traumatism
has been very great and the patient is much weakened by
operation; (b) all cases of intestinal surgery in which
healing depends to a large extent on absolute quiet of
parts; (c) patients greatly emaciated and exhausted by
disease prior to operation; (d) cases of profound, acute,
or chronic anemia, and (e) neurasthenics, no matter how
light tlie operation. In a word, all patients in whom
Nature requires rest and quiet should be bed patients.

Splanchnoptosis from the Standpoint of the Physiciein.
— K. C. Mead discusses this question, notes the great relief
of symptoms which follows the reposition of misplaced or
prolapsed organs, and figures the Vermehren bandage for
general application to this class of cases. Clinically, she
has found ptosis of either kidney or stomach, or liver or
bowel, in most of the cases suffering from retroversion of
the uterus, which, she thinks, goes 'o prove the hypothesis
that enteroptosis is caused by a failure of the supporting
ligaments, and that there is seldom to be found simply a
ptosis of one organ ; therefore, whether the cause is heredi-
tary, constitutional, or due to anemia, overwork, improper
dressing, constipation, etc., most of the patients present
more or less displacement of the abdominal viscera. Treat-
ment of all such cases must include, of course, regulation
of diet and of the normal activity of the gastroenteric tract.
The bandage must be carefully fitted to each case witn the
same care and precision as apparatus is applied in ortho-
pedic practice.

Journal of the American Medical Association, February 23,

1007.

The Factors of Safety in the Organism. — S. J. Melt-

zer, noticing the tendency of some writers to emphasize the
economy of Nature in the anim.al organism, both as to ma-
terial and energy, points out that the factor of safety in the
body — the surplus above that which is demanded — is far
greater than that which is required in artificial structures.
For example, he refers to the bilateral organs, each of
which is more than capable of supplying the place of both,
the kidneys, the ovaries, the thyroids, the adrenals, etc. In
the nonpaired organs the same prodigality of tissue and
functional capacity is apparent, some organs possess at
least twice as much tissue as a ma.ximum of normal activity
would require, and in other organs, especially those with an
internal secretion, the margin of safety amounts sometimes
to ten to fiften times the actual need. He does not think
it probable that tissues are usually inactive, such must
he the exception, but they w'ork normally only a fraction
of their capacity. The power of self-repair is, moreover,
a safety factor far beyond anything in human-made ma-
chines. While noting some partial exceptions, the rule
seems to be that the organs of the body are built on a plan
of a surplus of structure and energy, and Meltzer therefore
is inclined to question the theory advanced by some that a
minimum, say of proteid ingestion, is the optimum or ideal.
There are no facts that support it, and, on the other hand,
there are facts that point the other way, such as the abun-
dant secretion of proteolytic enzymes and the excessive
capacitv of the digestive tract for the absorption of proteids.

March 2, 1907]

MEDICAL RECORD.

365

These seem to be fair evidence that Nature intended this
surplus of material and capacity to be used. The function
of supply of tissue and energy by means of proteid food
should, he holds, be governed by the same principle ot
affluence that has controlled the entire construction of the
animal for the safety of its life and the perpetuation of its
species. In conclusion, he remarks that the factors of
safety have an important part in the process of natural
selection. The species best provided with a surplus of
structure and energy, and thus fitted to meet emergencies,
are most likely to survive in the struggle for existence.

The Physiological Conception of Disease in Neu-
rology.— L. Harrison Mettler considers that the an-
atomical or organic conception ot disease, the accounting
for disorders by the structural changes found, though still
dominant in clinical medicine, is passing, and that the
idea that disease is an abnormal physiological process is
coming more to the front. In practical scientific medicine
it is the abnormal physiology, the disturbed functions, that
is the desired goal of study. This is the physiological con-
ception of disease, and while not opposed to the anatomical,
on which it in part rests, it is a higher and more accurate
conception than the latter. It has, nevertheless, been slow
in acceptance, and while recognized by the most advanced
leaders of medical thought, it is still inadequately presented
in the teaching of tlie day. It is in neurology, he thinks,
that the physiological principle is the interpretation of dis-
ease, and its symptomatology is more conspicuous than in
any other department of medicine. The neuron theory,
which jMettler considers as essentially valid in spite of the
modifications necessitated by recent discoveries, has given
us one unit, and that a physiological one. In the nervous
system it has given us a physiological conception of its
diseases, which renders the usual anatomical classifications
of the text-books confusing to the average student and
practitioner. He gives a summarized explanation of his
own tentative physiological classification of nervous dis-
eases, into those of the neuronic or functionating tissues
and those of the supporting or nutritional ones, the former
being characterized by degenerative, the latter by inflam-
matory processes, and these again being subdivided. This
classification w-as published several months before the ap-
pearance of Grasset's more radical and elaborate presenta-
tion of a physiological classification, but Mettler thinks that
perhaps at the present time, when the pathology and neu-
rological status of some diseases are still in dispute, a less
radical change from the older classifications may have its
advantages

Hysteria in Children. — D'Orsay Hecht says that hys-
teria in children has not received the attention it deserves,
and that its frequency is underestimated. He does not
attribute it especially to defective modern methods of edu-
cation or to a luxurious civilization, since statistics show
that it is not confined to those who are specially liable to
be affected by such, but is found as often in the children of
the poor and ignorant as in those of the rich, and that the
major types are recruited more from isolated rural districts
tkan from urban centers. Though too much reverence has
perhaps been given to heredity in its etiology, the potential
force of direct transmission, he states, must be admitted
without reserve. ^ The facts of preceding temporary trau-
matism in some cases and the impressibility and imitative
tendency of children must also be borne in mind. It is
useless to look for all the so-called stigmata and accidents
of adult hysteria in the child; juvenile hysteria in its
objective manifestations is chieflv monosymptomatic, and
a single hysterical symptom, standing out in bold relief in
the child should, from its very prominence, arouse suspicion
as to its functional nature. Motor symptoms prevail ;
sensory S3'mptoms, according to Hecht, are rarely noted in
children, and when they are. are usually of the hyper-
esthetic type. When an anesthetic zone, suggested or not,
appears, it is of the same sharply demarcated, unanatomic
type as in adults. Hysterical motor agitation shows itself
largely in the form of choreic movements, a variety of
facial spasms, convulsive tics and epileptoid seizures. The
graver forms of the latter are frequently mistaken for epi-
lepsy, and those of somewhat lesser degree are conveniently
evaded with a diagnosis of hysteroepilepsy, a practice to
which Hecht objects. .A.s regards diagnosis. Hecht favors
the Mobius dictum in dubious cases that "such symptoms
may be regarded as hysterical, which cannot be voluntarily
produced or which may be simulated." The greatest diffi-
culty is often not so much to avoid mistaking organic dis-
ease for hysteria and Z'icc versu. as in failing to appreciate
that organic disease may, and frequently does, complicate
hysteria. We should study the child's temperament, re-
member its imitative faculty and in all conditions with a
prominence of doubtful symptoms, think of hysteria as a
not impossible factor. The prognosis is infinitely better
than in adults, and, as a rule, the younger the child the bet-
ter. The fundamental law of treatment is that all hvsterical

symptoms are psychic, and the means of cure can only be
psychic, i.e. acting on and through the patient's mind. .\n
early and positive diagnosis favors an early and complete
cure. Isolation is imperative when the cordial and efficient
cooperation of friends and parents cannot be had. After a
cure in isolation has been secured the patients should not
be returned too soon to their former associations. Hecht
refers with some little detail to Bruns' methods of treat-
ment of these cases, the "method of surprise" and the
"method of disregard,'' and considers the objections that
have been made to them rather weak. Unpleasant, and
even slightly painful, methods applied with due judgment
may be successful because of these qualities in properly
selected cases.

The Plague in American Cities. — N. K. Foster re-
marks that in our intercourse with countries where plague
is always in existence, which will increase as our com-
merce extends, the disease becomes a problem that sani-
tarians will have to face. Experience in California leads
him to the belief that the plague is spread by animals, of
which the rat is the chief but not the only one. Circum-
stances point strongly to squirrels as also disseminating the
disease, and he mentions one recent case that is to the
point. He believes that the United States Government
should investigate this point, as it is of importance to the
whole country. While California, from its location, is
exposed to the entrance of the infection, he does not thmk
it affords favorable conditions for its spread. The general
outdoor life of its people, their excellent physical condition,
as a rule, and the good sanitary conditions, will tend to a
minimum of cases. Although filth may nourish the germ,
w^e should not depend solely on general sanitary conditions
for protection. As rodents carry the disease, they must be
particularly watched, and all found dead should be exam-
ined. Of the greatest importance, he says, is the early
and public recognition of the disease and prompt measures
for its suppression.

Tilt- Lancet. February g, Igo-.

Affections of the Lacrymal Apparatus. — S. Stephen-
son gives a general description of lacrymal affections, from
which a few extracts are herewith made, .\fter a general
anatomical consideration of the area involved, he notes the
occasional congenital .ibsence of tears and the occurrence
of acute inflammation or dacrioadenitis. The latter may
terminate in suppuration or resolution. It must be dis-
tinguished from erysipelas, purulent ophthalmia, and cel-
lulitis of the orbital tissues. .\ rare condition is dislocation
of the gland, which may be either traumatic or nontrau
matic. The lacrymal sac may be the seat of either acute or
chronic inflammation, the latter occurring seldom apart
from obstruction in the lacrymal passages. The various
parts of the lacrymal apparatus are by no means exempt
from tuberculosis. Concerning the establishment and main-
tenance of the patency of the duct, the author notes the
disappointing results of probing and the excellent results
following the extirpation of the lacrymal sac, thoup'i the
author does not regard the operation as an easy one. He
thinks it may be properly recomnriiided under the follow-
ing conditions: (i) When ordinary methods have failed,
or cannot be applied owing to the particular circumstances
of the case; (2) when there is a definite and pronounced
distention of the sac, or when fistuls are present; (?,) when
tuberculosis of the sac exists; (4) when a cutting operation
on the eyeball, as cataract extraction, is imminent, and (5')
when a septic ulcer of the cornea coincides with a di eased
condition of the lacrymal sac. It might be expected that
epiphora would continue after excision of the sac but. as a
matter of fact, the removal of a source of reflex -n itation
appears to reduce the secretion from the lacrymal glnid to
a minimum .

Appendicitis in Typhoid Fever. — C. L. Green states
that typhoid fever may give rise to appendicitis in one of
two ways. First, a true typhoid inflammation and ulcera-
tion, possibly going on to perforation, may affect the lym-
phoid tissue of the appendix just as it may any other por-
tion of the intestinal tract, and, secondly, appendicitis may
develop in a patient suffering from typhoid fever in conse-
quence of a general edema and hyperemia of the gut. For
it must be obvious that during the course of the typhoid
fever the whole of the gut which is affected by the tyoiioid
inflammation, viz., the lower part of the small and the first
portion of the large, is in a generally congested and ii\per-
emic state; and the appendix, from its situation in the midst
of this disturbance, must of necessity participate in the gen-
eral congestion and edema. But any congestion of the
walls of the appendix, especially wdien associated, as it
would be in this case, with a greatly increased glandular
activitv, must run the risk of obstructing the narrow out'et
of that organ and setting up an intense local inflaimnation
there. The likelihood of serious trouble arising in this way
uonid nalurallv be greatlv increased should the appendix

•:;66

MEDICAL RECORD.

[March 2, 1907

be stenosed, kinked, or bound down by adhesions the re^nl;
of previous inflammation. There can be no doubt that the
conditions brought about by typhoid fever are those iikely
to rouse into activity a latent or chronic appendicitis. Three
successful cases all coming to operation for the appendicitis
are narrated, and the author quotes freely from the liter-
ature of this association of pathological processes. He
says that there is not likely to be much difference of opinirn
as to the advisability of operative interference in those
cases where the extent to which the appendix is involved
can be assumed from the general symptoms, for it is ob-
vious that if an operation can be avoided or postponed
it is better to do so; the typhoid fever patient already has
enough to tax his strength without a laparotomy being
added. Therefore, so long as there is no reason to be-
lieve that either gangrene or perforation of the apnendix
has taken place a strictly conservative policy is indicated.
But should the symptoms point to perforation, then an im-
mediate operation is necessary. A simple appenacctoniy
in the early stages of typhoid fever has usually a favorable
prognosis, but when it has to be undertaken in the ihiid
or fourth week of the disease the cases recorded show the
heavy mortality that one would expect. Even those opera-
tions, which in themselves are comparative!" slight, have
a high mortality when the patient is exhausted by tlii
typlioid fever.

Sanitary Conditions in Relation to Infantile Mor-
tality.— The observations of T. Devine are applied to
England, but are nevertheless of interest. He advances the
following propositions: (i) The infantile mortality of
rural England is lower than that of urban England. (2)
Taking things as they are in England and Wales, it must
be remembered that a considerable proportion of infants
are hand-fed. This opens up the way, so to speak, for the
play of insanitary conditions through the influence of food.
Fatal diarrhea in hand-fed children is, on this account,
probably proportionate to the degree of insanitation to
which the infant is exposed. Infantile diarrhea is twice as
fatal in towns as in the country-. (3) Measles is a very
fatal disease among young infants, and it is especiHlly so
among those living under insanitary conditions. Deficient
ventilation, in particular, tends to a fatal issue. It is much
more fatal in towns than in the countrj'. Whooping-cough
is less influenced by the same conditions, and hence its fa-
tality in towns is less marked. (4) It can hardly be con-
tended that an infant brought up in the dark, damp, con-
gested areas of slums has not less resistant power than one
brought up under more sanitary conditions. If it has less
resistant power it must more readily fall a victim to dis-
ease. (5) The influence of general insanitary conditions
as they affect great towns may be measured by one or
another of three death-rates at all ages, and the corre-
sponding infantile mortality may be studied. These rates
are: (l) the pulmonary tuberculosis death-rate; (2) the
diarrhea death-rate, and (3) the "fever" death-rate. (6)
The factor "overcrowding" includes many conditions which
must be classed as insanitary, as pollution of air, water,
soil, etc., and overcrowding has been proven to conduce to
a high infant mortality rate.

Continuous Use of Oxygen in a Case of Broncho-
pneumonia in a Cardiac Subject. — The noteworthy
features in the case reported by B. E. Myers are (i) that
a person, aged sixty-two years, w'ith old heart trouble,
recovered from a severe attack of bronchopneumonia; (2)
the excellent effects in this instance of the continuous use
of oxygen for a long period, and (3) the apparent benefit
of strychnine in Cheyne-Stokes breathing. In the course
of the treatment oxygen was given continuously for a period
of no hours. The patient's temperature became normal
on the ninth day, and he made an uninterrupted recovery.

British Medical Journal, February 9, 1907.

Influenza and Epistaxis. — Three cases of influenza
in children, all in the same family, are reported bv H. S.
Brown. The interesting feature of them was that all were
accompanied by epistaxis. varying in direct proportion to
the apparent strength of the invasion, and occurring at the
time of the subsidence of the temperature to normal. Not
one of the children remembered a previous attack, and their
mother confirmed this. Quinine had been given during the
influenza, and the author suggests that the bleeding may
have been an idiosyncrasy with this remedy. Another
suggestion is that the bleeding pointed to a local invasion of
the nasal mucosa by the influenza toxin.

A Pair of Forceps in the Abdominal Cavity for Ten
Years. — While e.xaniining a patient, J. E. F. Stewart
detected by abdominal palpation a body suggestive of a pair
of scissors in the region, and learned that the patient had
been operated on over ten years previously for an ovarian
tumor, A'-ray examination confirmed his suspicion and the
abdomen was opened. Artery forceps were found of the
length of nearly five inches with a handle breadth of nearly

two inches. During this long interval she had had
attacks of sudden acute pain, constipation alternating with
diarrhea, and pains in the lower limbs. The forceps were
found inside the lumen of the bowel. What at first ap-
peared to be a cicatricial band between the rings of the han-
dles kept the forceps in place, and capable only of moving
with the portion of the bowel, into which they had got.
The author incised the gut, and, owing to the patient's con-
dition, had rather hastily to remove the forceps, when he
found that the supposed cicatricial band was the point of
anastomosis of two loops of bowel which had been caught
between the handles of the forceps, and thus caused a "short
circuit" between two points, about 12 inches apart.

The Temperature in Mctlignant Disease of the Liver
and Bile Passages. — J. W. Russell reports on this fact
in fifty-two cases of malignant disease, in thirteen of which
the growth certainly arose from the gall-bladder or bile
ducts. His general conclusion, summarized from a study
of the temperature charts he presents, are as follo'ws :
Nearly two-thirds of the cases of malignant disease of the
liver show some degree of pyrexia, at any rate in their
later stages. The pyrexia is capable of attaining a consider-
able height, but rarely shows genuine intermissions, in the
sense of subsidence of the morning temperature below the
normal level. It is not uncommon to observe successive
periods of fever alternating with apyrexial intervals, and
sometimes these alternations may occur with great regular-
ity. Rigors do not occur in uncomplicated cases of growth
of the liver. Pyrexia seems to occur in a still larger pro-
portion of cases of growth of the gall-bladder and bile
ducts being recorded in more than three-quarters of the
cases investigated. The condition is frequently compli-
cated by the presence of gallstones, and it may be due to
this fact that the pyrexia often reaches a greater height,
with larger excursions, than is seen in the growth of the
liver itself. Ri.gor apparently occur only when gallstones
are present. An isolated high rise of temperature may,
however, be observed in growth of the bile ducts in the ab-
sence of gallstones, but as a rule such a rise is suggestive
of the presence of gallstones. The three cases of combined
growth and suppuration do not present anything in the tem-
perature charts to strongly suggest the presence of pus,
though one case gave a single high rise of temperature.
In hepatic abscess the charts may present little that is char-
acteristic of suppuration, at any rate if observed only for a
short time ; but where high rises of temperature from a low
level are noted these are likely to be repeated at frequent
intervals, and thus to contrast with the isolated rises seen
in cases of stones or growth. It is possible, however, that
the examination of a larger number of cases might not sup-
port this statement.

The Dissemination of Intraabdominal Maligneint Dis-
ease by Means of the Lymphatics and Thoracic Duct. —
This subject is considered by W. M. Stevens, who sum-
marizes the histories of several cases and presents two dia-
grams illustrative of points in his main argviment. His
concluding observations, which sum up his various conten-
tions, are as follows: (i) The thoracic duct undoubtedly
plays an important role in the dissemination of intraabdomi-
nal malignant disease and of tuberculosis. This duct may ,
act as a "simple carrier" of infective material, or it may be
directly involved, and in some cases it may be actually
obstructed. In connection with blocking of this duct, it is
very remarkable that chylous ascites is so rare and also that
dilatation of other lymphatic channels can so seldom be
demonstrated. (2) The supraclavicular glands on the left
side are more frequently involved 'in abdominal malignant
disease than is generally supposed, and in many
cases careful percussion will show the presence of
glandular enlargement in the clavicular and infra-
clavicular regions, and may even thus give a
clue to the nature of the abdominal affection. It
is possible that these glands become infected through "re-
gurgitation." but a more likely method of infection, and one
which can be demonstrated in some cases is by direct coin-
munication of the disease along the walls of the thoracic
duct, extending to the lymphatic vessel coming from these
glands. The right clavicular glands are very seldom in-
volved, and the reason for this is fairly obvious on studying
the lymphatic anatomy. (3) The possible mode of infec-
tion of other parts — chest, liver, inguinal glands, abdominal
wall. etc. — have been discussed. (4) It is probable that
many cases of so-called primary mediastinal growths may
really be of secondary origin, since it is well known that
cancerous disease, especially of the stomach, may be very
"latent," and, moreover, a small grow-th of the stomach,
though it has been the cause of marked secondarv growths,
may even be overlooked at the autopsy unless especial care
be taken.

The Claim of the Surgeon to Conduct the After-
Treatment of Operative Cases. — This claim is main-
t.iined by C. A. Mortun. who say> that the only reasonable

March 2, 1907]

MEDICAL RECORD.

367

view of the matter is that the medical practitioner who has
been in charge of the case up to the time the operation is
performed should hand over the treatment entirely to the
surgeon who has taken the responsibility of operating, for
the success or failure of an operation may, to a large extent,
depend on the after-treatment. This is practically what is
done in hospital service when a case is transferred from
the medical to the surgical service. The author then goes
on to make some observations on the position of the patient
after operation and on flatulent distention after abdominal
operation. Concerning the former, he says that in all cases
in which the drainage of any quantity of fluid from the
abdomen is desired, the patient should be kept in the half-
sitting position — that is, with his chest well propped up on
pillows. This is of the greatest importance in acute sup-
puration in the abdomen, especially when diffused, as in
peritonitis. It has been strongly advocated in such cases by
some of the American surgeons, and is sometimes spoken
of as Fowler's position. In suppurating appendicitis not
only must the chest and upper abdomen be raised higher
than the lower abdomen, but the left side of the abdomen
must also be propped up on pillows, so that the right lower
abdomen, from which the drainage tube will protrude, is
the lowest part of the abdominal cavity, except the true
pelvis. In order to judge if his patient is at a right slope,
it is necessary to inspect the abdomen (of course covered
with the dressing) after or during the adjustment of the
pillows or bed-rest. We must not be content with the ap-
parent position of the abdomen from inspection of the pa-
tient covered with the bed-clothes. We should not leave
the arrangement of the position of the patient to the nurse,
unless we feel sure she knows exactly how to place the
patient, from her experience in other cases. Concerning
the matter of flatulent distention, the author says that his
chief reliance for its removal is very hot turpentine ene-
mata repeated every few hours, and given with a soft rub-
ber tube, left in the rectum for a short time after, to allow
any gas which reaches the rectum to readily escape through
the sphincter. They should be as hot at the moment they
are given as the nurse can bear her hand in, and the turpen-
tine should be most thoroughly made into an emulsion with
soap and a pint of hot water, and, if one pint fails, two or
three pints very slowly introduced by a funnel and small
rubber tube, with the pelvis elevated, may succeed. We
may give a few grains of calomel, followed by a Seidlitz
powder, as well, and repeat it. There is no doubt that in
many cases in which tympanitic distention is marked and
vomiting frequent, and the patient seenrs really very ill. this
line of treatment will, if persisted in, remove the alarmmg
symptoms. Possibly the frequent hypodermic injection of
strychnine may help somewhat. Morphine must be avoided.
Pain is not usually a marked feature in this condition,
and morphine will tend to paralyze the bowel. And it is
no iise putting nourishment, even though it is liquid and
peptonized, into the patient's stomach in such cases. We
must so arrange the time of the hot turpentine pnemata
that nutrients can be retained for some hours.

Berliner klinische JTochenschrift, February 4, 1907,

Juvenile Physiological Albuminuria. — Ullmann ex-
amined the urine of forty-two small children and school
girls between the ages of two and a half and thirteen years.
These children were supposed to be perfectly healthy, and
for the most part were well nourished, and all were sub-
jectively well. Fourteen, or 33.3 per cent., however, had
albumin in their urine without any other evidences of
nephritis, and on the basis of this experience Ullmann
suggests that this condition nmst be considered as a more
or less physiological manifestation of early life. In most
instances the tendency is outgrown, but when it is found
in adults it must be regarded as the persistence of this early
condition. He therefore does not agree with Leube in re-
garding the albuminuria of puberty of this author as a dis-
ease of development with a well characterized clinical pic-
ture, and also does not consider that it should be called
orthotic albuminuria, but rather that the condition should
receive the name of juvenile physiological albuminuria, and
be differentiated as such. This diagnosis naturally can be
made only after long-continued and careful observ.ition.
Treatment is superfluous, for in most cases the tendency
disappears as the individual grows up. and in the others it
persists in spite of all therapeutic efforts. It is without
effect on the patient's health or length of life, and its pres-
ence need not be apprehended by insurance examiners.

Milk Infection as a Cause of Primary Intestinal
Tuberculosis in Children. — Fibiger and Jensen report
at great length two cases of intestinal tuberculosis in
infants which were undoubtedly the result of infection
through milk taken from tuberculous cows. The authors
point out that there is now no longer any doubt that the
tuberculosis of cattle can produce the disease in man, and
that the danger from this source must be guarded against

by rigid surveillance of dairy products. Most cases of
human tuberculosis are the result of infection from other
human beings, but for infants milk infections are of the
greatest importance. Hospital records are demonstrating
that the frequency of mesenteric tuberculosis in infants is
much greater than has been supposed, and it must not be
forgotten that the number of cases in which the infection
originated in this way is much larger than the post-mortem
records show, because the disease frequently produces
widespread lesions in other organs, so that it is no longer
possible to demonstrate the site of the original infection.
There is, therefore, no doubt that the consumption of raw
milk is an important source of tuberculous infection in
infancy.

Miinchencr medicmisclu- IVochenschrift, January 22 and
29, 1907.

The Pathology of Appendicitis. — Flesch is inclined
to doubt the belief that the appendix is a rudimentary organ ,
or one in the course of retrograde metamorphosis, and sug-
gests that it is possible to attribute to it a useful function.
He regards it as a glandular structure placed in the region
of the ileocecal valve for the purpose of in some way mod-
ifying the conditions existing in this portion of the large
intestine where a pronounced change in the character of
the intestinal contents and in the direction of their move-
ment takes place. The inflammatory processes that occur
in the appendix may be compared to those observed 'n other
glandular organs, and are the result of bacterial infection
following local injury or irritation through mechanical or
chemical causes. The greater frequency of the disease m
certain families indicates that through some inherited pe-
culiarities of structure inflammatory changes are pre<iis-
posed to. but the inciting cause is a purely individual one.
Constipation, which appears to be on the increase ^mong
all classes of society, is to be considered as an important
factor, and the prophylaxis of the disease demands con-
certed efforts to combat this tendency by ruitable .nodifica-
tions of diet and mode of life.

Scopolamine Anesthesia in Obstetric Practice. — Three

articles on this subject are presented. The first of
these is bv Gauss and is devoted to a consideration
of the results obtained in 1,000 confinement cases con-
ducted under this form of anesthesia. Gauss is a very
ardent advocate of the method and ascribes the less
favorable opinions of other authors to the fact that
their techninue was lacking, or the preparation used
was unreliable. In his series of 1,000 cases the mater-
nal mortality was zero as far as the anesthesia went,
and in all other respects the method was equally sat-
isfactory. No undesirable effect on the duration of
the labor, on postpartum hemorrhage, or on the wel-
fare of the infants was observed, and the author con-
siders that under conditions which permit sufficiently
careful observation of each patient the method is a
highly satisfactory one. Whether it is desirable for
use in large institutions, or in general practice, is still
a question, as the dosage must be controlled by a care-
ful observation of the patient's perceptive faculties,
which naturally demands a great deal of close atten-
tion.

Preller, in the second communication, also expresses
himself favorably in regard to the scopolamine-morphine
method, though with somewhat more reserve than
Gauss. Out of 120 cases of this sort, in 70 per
cent, the anesthesia was successful, in 18 per cent, it
was for the most part satisfactory, and in 12 per cent,
the effect was poor, principally because the injections
were made too late. In 20 to 25 per cent, of the cases
impairment of the heart's action was noted, and in
about the same proportion of cases the duration of the
labor appeared to have been protracted. Twice symptoms
of poisoning, accompanied by hallucinations, were noted.
The author, therefore, concludes that this method of
anesthesia will pi^obably be restricted to hospital work,
where physicians and trained attendants are constantly
at hand. Before attempting to use the method in pri-
vate work the practitioner should have familiarized
himself with the properties of the combination through
extensive hospital experience, and he will have to devote
to his patient the necessary time for careful super-
vision of the period of anesthesia.

Penkert. in the third paper dealing with this subject,
describes a combination of morphine-scopolamine anesthesia
with spinal anesthesia. A special technique for perform-
ing the injection into the spinal canal is detailed, and the
author expresses the opinion that this method forms the
most humane type of anesthesia for abdominal and
gynecological operations.

368

MEDICAL RECORD.

[March 2, 1907

Bank Srnt^ma.

Lectures for Nurses. Jamestown, N. Y. : The Chau-
tauqua School of Nursing. 1906.
Under the above title there has been received a book which
purports to give a course in general nursing, apparently
on the plan of the "correspondence school." The perusal
of its pages is intended to furnish the candidate with a
knowledge of what has now come to be regarded as a pro-
fession, but we tliink that knowledge gained in this manner
will hardly tit a nurse for the duties she is compelled to
perform, and if such knowledge be the limit of her quali-
fications, few physicians would care to take the risk of
employing her. Practical hospital experience constitutes
the sine qua non of nursing, and nothing can be substituted
for it. As a supplement to the practical knowledge ob-
tained in hospital work, the lectures here presented would
be very useful, for they are well written and calculated
to impart sound information in an easily assimilable form.
But book teaching without practical training, in nursing as
in medicine, gives only the "little learning'' which high
authority tells us is a dangerous thing.

A Practical Treatise on Materia Medica and Thera-
peutics, with Especial Reference to the Clinical Applica-
tion of Drugs. By John V. Shoemaker, M.D., LL.D.,
Professor of Materia Medica, Pharmacology, Therapeu-
tics, and Clinical Professor of Diseases of the Skin in the
Medico-Chirurgical College of Philadelphia; Physician to
the Medico-Chirurgical Hospital; Member of the Ameri-
can Medical Association and the British Medical Associa-
tion ; Fellow of the Medical Society of London, etc., etc.
Sixth Edition. Thoroughly Revised. (In Conformity
with Latest Revised U. S. Pharmacopoeia, 1905.) Phila-
delphia : F. A. Davis Co., 1906.
In this new edition the author has added a section on
pharmacy and pharmacology, with a classitication of reme-
dies, a table of poisons and their antidotes, and directions
for prescription writing. The second section, dealing with
medicinal agents, such changes as were necessary to make
the work conform with the latest edition of the U. S. Phar-
macopoeia have been made. Part III. is devoted to a con-
sideration of the non-medicinal therapeutic agents — to elec-
trotherapy, kinesitherapy, pneumotherapy, hydrotherapy,
psychotherapy, radiotherapy, actinotherapy, niusicotherapy,
dietetic treatment, etc. Shoemaker's Therapeutics has long
enjoyed a well-deserved popularity, and has ranked among
the best of the works of the kind published in this country.
This new edition can but add to the measure of appreciation
of the work.

The Bacteriologic.\l Examination of Water Supplies.
By William G. Savage. B..Sc., M.D.. D.P.H. Medical
Officer of Health, and Public Analyst, Colchester, etc.
London : H. K. Lew-is, 1906.
The size of this book precludes an exhaustive presentation
of the matter with which it deals. It makes no pretense of
bringing jruch that is original, nor does it depart from the
general plan upon which books of this sort are generally
w-ritten. Within the space allotted, however, the little
work is exact and up to date. The chapters on the colon
and typhoid groups are excellent summaries of these diffi-
cult subjects. Too little space is given to the streptococcus
group, though this is excusable by reason of the confusion
in which this variety of organisms still finds itself. Through-
out the book, however, the most recent researches and
methods have been utilized ; though in many places they
cannot be more than indicated. A gratifying feature, all too
rarely found in writings published in foreign countries, is a
thorough acquaintance with the work of American scholars.
The tone of the book is critical and unwarranted conclu-
sions are avoided throughout. For this reason, if for no
other, the little treatise is well worth reading and constitutes
a valuable addition to the literature of the subject.

Voice Production in Singing and Spe.\king, based on Sci-
entific Principles, by Wesley Mills, M.A., M.D.. etc.,
Professor of Physiology in McGill University, and Lec-
turer on Vocal Physiology and Hygiene in the McGill
University Conservatorium of Music. Philadelphia and
London : J. B. Lippincott Co.. 1906.
This book is written by one who is at the same time an
eminent authority in his special field of medicine and a
trained musician. His preface informs us that his purpose
has not been to write an exhaustive work on vocal physi-
ology, but to keep in mind, as he has penned his chapters,
the real needs of the practical voice user, and to give him a
sure foundation for the principles that must underlie sound
practice. The consequence is that his pages are attractive to
the laryngologist. who sees in them sound, common sense,
and attractive also to the singer, who receives much valu-
able information. He considers the lack of good actors and
singers of the present day. as compared with former times.

due to the fact that we do not to-day pursue right methods
for a sufficient length of time. Especially is this true with
reference to breath control. "In this alone singers to-day
are far behind those of the old Italian period, not because
they do not know how to breathe, but because they are
often unwilling to give the time necessary for the full de-
velopment of adequate breathing power and control." In
other words, singers are apt to fall into the "rush" methods
which have come to be characteristic of the present age in
almost every line of endeavor. The book is well illustrated
and well printed. .As is usuallv the case with such a technical
subject, there are here and there statements with which
perhaps not every teacher of singing would agree, but the
range of topics considered is wide, their exposition is lucid,
and the advice given to voice users is intensely practical.

Practical Dietetics, with Reference to Diet in Disease.
By Alida Frances Pattee, Graduate, Boston Normal
School of Household .\rts. Late Instructor in Dietetics,
Bellevue Training School for Nurses, Bellevue Hospital,
New York City. Special Lecturer at Bellevue, Mount
Sinai, Hahnemann, and the Flower Hospital Training
Schools for Nurses, New York City; St. Vincent de Paul
Hospital, Brockville. Ontario, Canada. Fourth Edition.
New York: A. F. Pattee.
This is intended primarily as a dietetic guide to the sick,
but it is an e.xcellent cook-book for those in health as well.
The first part contains a general disquisition on food and
food values, general rules for feeding the sick, direction; for
serving, and a brief chapter on measurements, in which is a
useful table of the equivalents of the saltspoon, teaspoon,
tablespoon, cup, and other domestic units of measure. The
.second part contains numerous recipes for the drinks (soft),
soups, meats, bread, and sweets, which may be needed for
the sick and those with delicate appetites that require coax-
ing. These recipes are excellent, and could be used by any
plain cook or housewife, with gratification to the master of
the house. The only criticism we have to offer is that the
author almost always specifies some particular make of
olive oil, chocolate, grape juice, etc. If there were but one
make that could be relied upon this might be necessary, but
where there are many of each of these just as good and
honestly made as those mentioned, the specific designation
smacks a little of the advertisement. The third part is de-
voted to a combination of the foods and special diets called
for in individual diseases. In this the physician will find
many hints enabling him to prescribe the appropriate diet
without wearying his patient with the monotony of milk
and beef broth. Nurses will also find much that is helpful
in the book, and many a patient, wanting something, yet
not knowing what he wants, will thank the author for the
suggestion of a dainty dish.

Genitourinary Dise.\ses and Syphilis. By Henry H.
Morton, M.D., Clinical Professor of Genitourinary Dis-
eases in the Long Island College Hospital, etc. Second
Edition. Revised and Enlarged. Philadelphia:- F. A.
Davis Co., 1906.
The second edition of this book was made necessary b}' the
numerous changes and advancements which have been made
in this subject within recent years, chief among which are
the developments in the surgery of the prostate and the
kidney. In the treatment of gonorrhea the author favors
the methods used by the Berlin school of investigators,
whose opinions are also largely quoted throughout the book.
The chapters on s\T)hilis are very satisfactory, presenting the
subject in a concise, yet sufficiently complete manner to
afford to the student a very comprehensive idea of this im-
portant subject. The book, although by no means a manual,
presents in a sufficiently complete manner the modern
status of genitourinary surgery.

Die Therapie der Haut und Geschlechtskrankheiten.
Fiir praktische Aerzte; von Dr. Reinholb Leder.mann,
Specialarzt fiir Hautkrankheiten in Berlin. Dritte durch-
gesehene und erweiterte Auflage des Therapeutischen
Vademekum der Haut und Geschlechtskrankheiten. Ber-
lin : Verlag von Oscar Coblentz, 1907.
The changes from the previous edition consist in the addi-
tion of paragraphs on treatment by means of light and
other forms of radiant energy, by cold, and by local hyper-
emia, and in the addition of most of the newer remedies
used in these classes of disease. In his judgment of the
various methods the author is quite fair and impartial. But
the .r-ray treatment of tinea tonsurans, now generallv ac-
cepted as altogether the most efficacious, is barely men-
tioned, and is recommended only for severe cases, while the
treatment of lupus erythematosus by the high frequency
current is omitted altogether. Contrary to the general belief
in this country, electrolysis is placed ahead of the electro-
cautery in the treatment of n?evu3 vasculosus. The char-
acteristics of the book have not been altered with its
change of name : it is still chiefly a collection of valuable
formulae and therapeuiic hints, with enough text to bind
the whole together.

]\Iarch 2. 1907I

MEDICAL RECORD.

369

^omtg Sports,

NEW YORK ACADEMY OF MEDICINE.

Regular Meeting, Held February 7, 1907.

The President, Dr. John A. Wyeth, in the Chair.

Regulations Endorsing State Law to Regulate the Prac-
tice of Midwifery. — The resolution was offered, sec-
onded, and unanimously carried that midwives should be
regulated and supervised by competent authorities. The
resolution favored the enactment of a State law to
regulate midwifery and to provide for examination for
licenses following the precedent set by States in the Union,
by Germany, and other countries. This resolution ad-
vising or indorsing the enactment of a State law was
presented to the Council and was accepted by the Council
and recommended to the .•\cademy of Medicine for its
■concurrence.

The Bacteriology of Influenza. — Dr. Marth.^ Woll-
STEiN read this paper. She said that the organism which
was present in such large numbers in the sputum of in-
fluenza patients was one of the smallest known. It was
two or three times as long as wide, with rounded ends,
sometimes forming threads, Gram negative, and non-
motile. No spores were formed and the organism w-as
strictly aerobic. It grew only upon media containing
hemoglobin. The colonies were small and dewy in ap-
pearance, colorless and transparent, and showed little ten-
<lency to become confluent. The bacillus grew between
42° and 26° C, and therefore in this climate the tem-
perature was too low to permit its flourishing outside
the body. An exposure to 43° C. for a few hours killed
it. Pfeiffer's experiments proved that it quickly died
in water and that in sputum the bacilli were probably
alive and infectious for fourteen days, if protected from
drying. Development outside the body in water or soil
was not possible ; the spread of influenza by means of
dried sputum particles was possible only to a minimum
degree, and contagion took place, as a rule, by means
of fresh particles of moist nasal or bronchial secretion.
The bacilli were present in large numbers in the sputum
in the early stage of the disease. The influenza bacillus
had a special predilection for the mucous membranes
of the ■ respiratory tract, and usually entered the body
through them, attacking, ;is a primary point of infection,
the nose, nostrils, larynx, bronchi, or lungs. Hence the
necessity of disinfecting all linen and all eating utensils
vised by the patient. More rarely the eye might be
involved first. The involvement of the ear was alwa.\s
secondary. The bacillus of influenza was a facultative
pus producer, and suppurative inflammation of the serous
membranes had been reported. The bacillus had never
been demonstrated in the digestive tract. It had been
demonstrated in the blood of living adults in two cases
only. In her e.xperience the influenza bacillus was not
found in the throats of healthy children nor in the throats
of children in whom lesions of the respiratory tract did
not exist. Rabbits were rarely killed by one inoculation
of influenza bacillus, either intraperitoneally or subcu-
lancously ; but they bore repeated inoculations badly, be-
coming emaciated and very weak. The blood of influenza
patients agglutinated influenza bacilli in low dilutions and
rarely in the early days of the disease. The absence
of agglutination with the serum from cases of acute
influenza was to be explained probably by the fact thai
the agglutinins develop slowly. Rabbits required many
inoculations before the agglutinins began to appear. Thus
far all attempts to produce an active immunization to
the toxins of influenzal bacillus had failed.

Dr. Wm. Hallock Park said that Dr. Wollstein had
done a great deal in the study of the bacteriology of
influenza and, therefore, he hesitated in entering upon
a discussion with her. He spoke of the diagnostic import

of finding the influenza bacillus; personally he did not
think it amounted to nnich unless the symptoms of the
disease were present. In cases of suspected influenza
bacterial cultures gave little aid in the diagnosis or
the treatment. If the symptoms were not striking and
characteristic, the finding of the influenza bacillus did not
suggest much, as there were many differences in virulence
of different strains, and cultures showed nothing con-
cerning virulence. Mi.xed infection was always present
and often most important. In bronchopneumonia at pres-
ent the pneumococci gave similar symptoms. During the
pandemic the cases presented markedly typical symptoms;
but in the years between these striking symptoms were
not shown. In the Adirondacks the presence of influenza
bacillus was studied in those living there; in nearly all
the tuberculous cases this bacillus was found. The in-
fluenza bacillus was like the pneumococcus in many things.
It caused meningitis and cerebrospinal meningitis in not
a few cases.

Influenza in General Practice. — Dr. W. H. Katzen-
BACH said that influenza was an acute infectious and con-
tagions disease caused by the Pfeiffer bacillus. This
bacillus was found in all cases of uncomplicated
influenza in the nasal and bronchial secretions in almost
pure culture, and in the bronchial tubes and lungs in
the pulmonic complications. It disappeared with con-
valescence. Epidemics had been frequent since the four-
teenth century, the first one that was carefully described
being in 1577. Since the pandemic of 1889-1890 the disease
had occurred in epidemic waves in this and other cities.
But in the intervals of the epidemics sporadic cases
had been frequently observed at all seasons, which in
every respect resembled those of the epidemic. The ac-
count of the rapidity with which the infection was
carried in epidemic seasons made it appear that the bacillus
was air-borne and entered the human subject through
the inspired air. During an epidemic influenza attacked
all classes and all ages, though the young were less
susceptible. No one could consider himself immune.
Relapses were frequent, and one attack did not confer
immunity against others. The period of incubation was
from one to three or four days. In all epidemics the
local symptoms were so varied that although attempts had
been made by most authors to group the disease into
several clinical types, yet one or more of these types
frequently existed in combination. After describing the
symptoms, diagnosis, and prognosis of these various types
of influenza, he took up a consideration of the treatment.
During the prevalence of an epidemic of influenza, the
old, the chronically feeble, and those sufi^ering with car-
diac, pulmonary, or nephritic troubles should be guarded
against any and all depressing influences. The patient
should be isolated, and confined to bed in a warm and well
ventilated room and protected from draughts. He should
be kept at rest and in quiet, and visits of friends and
relatives should be prohibited. The nasal and bronchial
secretions should be disinfected. The indications were
to control the pain, quiet the cough, control the fever,
maintain nutrition, eliminate the toxins, and induce sleep.
The treatment might be begun with a dose of calomel
and saline unless contraindicated. If pain was severe
and nausea was present a moderate dose of morphine
would relieve, given under the skin. A single dose
of phenacetin with codeine would quiet the cough, relieve
the pain, reduce the temperature, and induce sleep. This
might be followed by one of the alkaline salts. .Mkaline
waters should be freely given. Antipyretics should be
avoided, except possibly a moderate dose at the beginning.
If the temperature was high and delirium present, a
cool pack was of value. If the temperature was moderate
imd the skin moist, baths could be dispensed with. While
fever was present milk and vichy, buttermilk, kumys, or
zoolak in small quantities, and if tolerated, eggnog, later
eggs, raw or cooked, and during convalescence scraped

370

MEDICAL RECORD.

[March 2, 1907

beef, chicken, beefsteak, chops, green vegetables, bread and
butter might be given. Convalescence was often protracted
and was frequently characterized by nervousness, in-
somnia, anorexia, vasomotor, or cardiac weakness.

Dr. Morris Manges believed that we underestimated the
ultimate mortality in influenza. Very little care was
given by physicians to prevent the spread of this disease,
and the more polite use of handkerchiefs should be asked
for. The disease was carried largely in the moist secre-
tions from the mouth. A diagnostic point which he con-
sidered of importance was tlie sticky rales heard at the
base of the lungs ; these rales he believed to be quite
characteristic of the disease. They were rather loud,
bubbling rales and sticky in character. Therefore, when
ever in doubt as to the existence of this affection he
said that we should search for these rales at the base
of the lungs and posteriorly. Dr. Manges said that he
knew of few problems in diagnosis more difficult than
differentiating a case of grippe from the early stages of
typhoid fever. This was especially so as the rash occurs
in grippe more often than usually taught. In a large
number of cases albumin was present in the urine and
this persisted for a longer or shorter period of time
This had been considered by the various insurance com-
panies.

Influenza in Its Relation to Diseases of the Nervous
System. — Dr. Joseph Colli.vs read this paper (See page
337)-

Dr. B. S.^CHS said that any one who had had experi-
ence in studying diseases of the nervous system knew
that the influence of influenza in them had been greatly
overestimated, and so far as his own experience was
concerned he had yet to see a single case in which a
nervous disease could be positively established as being
due to the influence of the Pfeiffer bacillus. A recent
experience helped to indorse this view. A child was sup-
posed to have an influenzal meningitis. A lumbar punc-
ture was done and the meningococcus found, thus dis-
proving the influenzal nature of it. In all probability
there were cases of meningitis due to the influenza bacillus,
presenting all the signs of a basilar meningitis, the
entire course of the disease being milder than they were
accustomed to see in a tubercular meningitis, and the
disease ending in recovery. In speaking of the nervous
symptoms due to the influenza bacillus one should bear
in mind the persistent headache and insomnia, the former
largely due to a subacute meningitis due to the influen;^a
bacillus, the latter due to the active hyperemia in all prob-
ability. Myelitis and neuritis due to the influenza bacillus
were rarely met with, although it was extremely difficult
to prove. In myelitis a diagnostic point w'as the repeated
attacks and rapid recovery.

Influenza in Children.— Dr. Henry Dwight Chapix
said that the difficulty of recognizing influenza in children
depended upon two factors, whether the disease was
prevalent or not, and the age of the patient. Young
children did not seem to be so susceptible to the disease
as adults. The fact that influenza might take on a grave
form or be followed by serious sequellas emphasized the
importance of an early diagnosis. The younger the child
the more severe usually was the infection. Catarrhal dis-
turbances of the respiratory tract predominated in children,
and were more virulent than the ordinary inflammations
met with in this region. This was not only seen locally,
but in the disposition of the catarrhal process to extend
downward. In some ways this was analogous to the
course in measles. The laryn.x, trachea, and bronchi were
quickly involved, but. in many cases, the inflammation
did not extend below the larger or median sized tubes.
In others there was an involvement of the small tubes
and alveoli coming on soon after the onset of the disease.
This- type of bronchopneumonia was much like the ordi-
nary form so far as the physical signs were concerned,
but early prostration was more marked, and the tempera-

ture w'as usually irregular and higher than the local
lesion would seem to warrant. True lobar pneumonia
was also not infrequently seen and, as in other influenzal
conditions, exhibited disturbances of temperature and
circulatory and nervous depression out of proportion to
what would be expected from the pulmonary signs. Per-
haps the most frequent exhibition of pneumonia was seen
in the form of irregular patches with sneaking invasion
and where it was very difficult to decide whether the
process was catarrhal, croupous, or both. Various grades
of pleurisy were frequent accompaniments of all the
forms of pneumonia, and empyema might be the terminal
condition. The latter was even more insidious than usual,
especially in infants, and Dr. Chapin had seen more of
this disease in the past two months than usual. In cases
where the gastrointestinal disturbances predominated there
might be severe vomiting and the passage of loose, undi-
gested stools, which later might contain mucus and even
blood. The cases in which pure nervous disturbances
predominated over the catarrhal symptoms did not seem
to be so common in early life. Some severe cases might
start with convulsions and simulate meningitis, with pho-
tophobia, stupor, and, in older children, headache and
delirium. In influenza the fever was apt to be irregular
and at times very high, especially in young infants. In
some cases fever and prostration with little evidence of
any local inflammation would be the principal symptoms.
In other cases an irregular fever might last for several
days and simulate typhoid fever. The skin was some-
times covered with various forms of erythema, which might
at times simulate measles or appear in scarlet form. The
urine frequently showed traces of albumin. In diagnosing
influenza the bacteriological aid was not as great in prac-
tice as it was in theory. The bacilli were difficult to
discover and frequently disappeared early in the disease.
In the great majority of the cases the physicians must de-
pend entirely on clinical signs for a diagnosis. In some
cases he must depend largely on a process of exclusion.
The disease was highly contagious.

Dr. L. E.MMETT Holt said that influenza was highly con-
tagious, and in the family the adults were apt to be first
infected and the children secondarily. He had seen several
cases of influenza occurring in young children, the disease
having been caught from the nurse. The general practi-
tioner did not sufficiently take into consideration the im-
portance of isolating nurses who had the care of young
children. The catarrhal cold was a menace to the child
with whom the nurse lived constantly. It was impossible
to differentiate the ordinary catarrhal colds from those
due to the influenza bacillus. Therefore, it was better to
isolate half a dozen cases of ordinary colds than to run
the chance of exposing the young to one case of influenza.
In most cases of influenza he had seen the temperature
was out of proportion to the other symptoms. If the
temperature ranged up to 102°, 105°, or even 106°, with
very few local symptoms, or none at all, he always looked
upon a diagnosis of influenza as the most probable. Cases
of persistent temperature with a little ear trouble, the tem-
perature going up because of the influence of the influenza
bacillus, and not because of the ear trouble, were very
important from the standpoint of the otologist. Such a
temperature continuing called for a mastoid operation.
Cases of uncomplicated influenza might run high tempera-
tures for days, and he had seen cases with fever continuing
for five or six days, the temperature being disproportional
to the other symptoms.

Some of the Lesions of the Middle Ear Due to In-
fluenza.— Dr. GoRHAM B.\cON said that at the New York
Eye and Ear Infirmary there had been, in 1897, 161 mastoid
operations ; in 1889 the number had rapidly increased, while
in 190S there had been 555 operations. Influenza played
an important part in the acute inflammations of the middle
ear, and children were more frequently affected than adults.
The pain was slight even in the severer cases. The sticky

March 2, 1907^

MEDICAL RECORD.

371

sangiiinolent purulent discharge was quite characteristic
in children, and in examining the pus or serum, one found
usually a mixed infection. The staphylococcus might be
the cause of the severe inflammation. After incising the
drum membrane the teinperature usually fell, the discharge
became purulent, and the disease ran a course of from ten
days to three weeks, the temperature ranging from 101° to
105°. It was in this class of cases that the otologist should
exercise great care, and if a simple bronchitis was present,
it was not wise to administer an anesthetic for fear of
setting up a pneumonia. Incise the drum membrane with-
out a general anesthetic ; but if it was absolutely necessary
to use one, he advised chloroform. After incising the
drum head the high temperature might be due to mastoid
involvement, or to a deep-seated pneumonia. The knowl-
edge of the exact nature of the infection he considered
important. The mastoid involvement or infection might be
different type on either side. In cases of sinus thrombosis.
Dr. Bacon said he had seen a case in which the tempera-
ture remained high. Since the influenza otitis was apt to
be of a severe type, it was wise to make an early incision in
the drum membrane, even if there was but little bulging.
It was a difficult matter to formulate exact rules for one's
guidance for operating in cases of otitis following grippe;
but, as a rule, it should be performed early if the tempera-
ture remained up. Examinations of the blood should be
frequently made to see if there was a leucocytsis or not.
In some cases a mastoid operation could be avoided by
making incisions into the drum membrane. After mas-
toiditis, septic thrombosis and sigmoid disease were the
most frequently met complication. Attention should be
directed to thrombosis of the jugular bulb in children as
well.

Dr. E. Gruening said that since the discovery of the
influenza bacillus, in 1892, they had looked for it in vain
in the discharges of affected ears. If the diagnosis of in-
fluenzal otitis depended on the bacteriological proof, its
existence would be problematic. In the paper read by Dr.
Martha Wollstein on the bacteriology of influenza, it was
stated that the influenza bacillus affected the ear secondarily.
This, he understood to mean that Dr. Wollstein, in all
her researches, did not find the influenza bacillus in the
ear. This statement he could confirm, inasmuch as in
the epidemics of influenza which they had had since 1890,
the bacteriological department of Mt. Sinai Hospital
never reported the finding of the influenza bacillus in the
ear. What was found was in most cases the streptococcus,
and only occasionally the pneumococcus. It was asserted,
especially by the Halle school of otology, that the otitis of
influenza did not differ in its clinical manifestations from
other forms of otitis. Those who practised otology in New
York before the great epidemic of influenza in 1889-90,
know that the hemorrhagic forms of otitis characterized
by blood containing blebs in the auditory canal and on
the drum head were much more frequently observed during
the prevalence of influenza than at other times. Inasmuch
as the bacillus was not found in the ear, they must ascribe
to the toxins of the bacillus a certain disintegrating action
upon the walls of the blood-vessels. The statement made
by Dr. Holt that the otologist incised the drum-head when
the patient complained of pain in the ear, and the drum-
head showed some redness, was erroneous. Pain in the
ear and redness of the drum were no indications for
paracentesis of the drum-head. The indications for the
incision were given by Dr. Bacon. In order to open the
drum-head, it must bulge, showing that there was fluid
behind it. This fluid was either infected serum or pus,
and the old principle, ubi pus, ibi evacua, held good, espe-
cially in that particular case. Dr. Holt's assertion that,
should pain in the ear and high temperature persist after
incision of the drum-head, the otologist without other in-
dications immediately proceeded to the opening of the mas-
toid process, was again not borne out by actual practice.
He again referred to the paper of Dr. Bacon, who gav?

precise indications for this operation. The otologist who
would open the mastoid merely because pain in the ear
and high temperatures existed, lacked both the science and
the conscience of the true physician.

MEDICAL SOCIETY OF THE COUNTY OF NEW
YORK.

Special Meeting, Held January 30, 1907.

First Vice-President^ Dr. H. Seymour Houghton, in the
Chair.

Presentation of a Specimen. — Dr. Eden V. Delphey pre-
sented a monstrosity.

The Medical Staff and Its Functions; A Study in Hos-
pital Organization. — Dr. S. S. Goldw,\ter presented this
paper. He considered (i) the medical staff in relation to
the needs of the patient; (2) the medical staff in relation
to medical education; (3) the medical staff in relation to
hospital economy ; (4) the medical staff in relation to the
rights of its members. One of the first necessities in medi-
cal organization was a system of examining candidates for
admission which would guarantee a fair and intelligent
treatment of all who applied. This could only be accom-
plished through a physician of first-rate ability and char-
acter, owing to the complex and often vital interests of
applicants. Here rapid changes in office and the intro-
duction of men of immature judgment must be avoided.
Hence, in a large hospital the admitting officer must be
ready to put aside the claims of private practice and to de-
vote a large part of his time to the hospital, and the hospital
should not hesitate to pay him a salary commensurate with
the services demanded. In the grouping of patients and the
assignment of attending physicians the hospital should avoid
any undue exaltation of specialism, and yet there must be
so much recognition of specialism as would encourage the
development of the finest skill in diagnosis and treatment.
The psychological tendencies of specialism furnished one
reason for establishing such sweeping oversight of the
various clinical departments as would promote their active
and continuous cooperation. A single chief in command
of the medical and one in command of the surgical depart-
ment could do much to enhance the efficiency of the visit-
ing staff and its subordinates. A proper organization would
provide a sufficient number of attending physicians to in-
sure prompt and efficient attention to every patient. The
attending physician or surgeon should have only as many
beds as he was able to keep under his eye during every day
of his official duty. Once in every twenty-four hours the
visiting officer must see every patient, and as much oftener
as circumstances required. If this made too much of a
demand on the visiting physician, let him have an adjunct
or associate. Two visits daily constituted the minimum
for the senior interne of the division. If in addition to the
senior resident and his first assistant the house staff included
at least one physician for eveo' ward unit of twenty or
thirty beds, the patient would be on a fair way to receive
proper routine medical treatment. It was a wise
rule which divided equally between the medical and
surgical wards the work of all new men dur-
ing the first year. There should be an under-
standing with members of the house staff that each
subperiod of service would be regarded as a probationary
period, and that advancement depended upon proof of fit-
ness. The efficiency of house and visiting staff depended
upon facilities for scientific investigation. In the patient's
interest there must be a competent pathologist, having con-
trol over all laboratory work of the house staff. The use-
fulness of this department could be enhanced by admitting
volunteer workers under suitable conditions. If specialists
were not included in the regular visiting staff the way
should be open for the utilization of their talents by naming
them as a consulting staff, and they should be subject to
control by the division chief similar to that of the visiting

372

MEDICAL RECORD.

[March 2, 1907

staff. The patient's own physician should not only be tol-
erated in the ward, but should be welcomed both for the
welfare of the patient and because he is entitled to follow
his case. Upon the discharge of a patient from the hospital
it was the duty of the hospital to see that he was guided into
the care of the family physician or directed to the proper
division of the outdoor department. An interchange of
clinical records between the outdoor department and the
hospital was desirable. Unity of control of indoor and out-
door departments was necessary to good hospital govern-
ment. In large hospitals the supervision of the discharge of
patients should be entrusted to an executive officer, prefer-
ably a medical man, who should be. in touch with all chari-
table relief agencies in the community which were capable
of dealing with any phase of physical or social needs of
former patients. Hospitals which were engaged in the pro-
motion of medical education were subject to the keenest
criticism both from within and without, and owing to the
rivalry among teaching institutions, were bound to favor
any policy that would enhance their efficiency. So manifest
were the benefits derived by the inmates of a hospital from
the school atmosphere that hospitals which endeavored to
promote medical education did not need to justify their
policy. We were bound to recognize the training of the
physician, the promotion of scientific medicine, and the dis-
se'mination of its teachings as legitimate hospital functions.
The prejudice against the admission of students to the
wards of the hospital was due to mistaken ideas concern-
ing the functions and privileges of medical students in
hospital wards. A belief existed that students were per-
mitted to do much as they pleased with hospital patients,
and that patients were subjected to dangerous experiments.
Rational experiments in therapy and constant study of the
sciences underlying the treatment of disease marked the
progress of every practitioner who was successful in the
better sense of that term. The presence of the student ad-
monished the physician to exercise his best care and judg-
ment, since to fail before a critical audience was to suffer
injury to his professional reputation. The refusal of the
majority of hospitals to open their doors to the students of
medicine introduced unwieldly groups of learners into the
few hospitals which maintained an educational policy. Once
all the hospitals were brought into proper relation with the
medical schools the necessity for overcrowded clinics would
disappear. There was no great difference between admitting
advanced students to the wards and accepting new gradu-
ates as internes. The value to medical science which lay in
the carefully prepared clinical records and in the intelli-
gent compilation of statistics must not be overlooked. This
work should not be entrusted to untrained juniors or un-
comprehending clerks. The association of the attending
physician and surgeons with medical schools and other hos-
pitals should be encouraged for the purpose of multiplying
the sources from which knowledge might be derived. In
order to extend the privileges and hospital advantages to a
wide circle of the medical profession, it was advisable to
limit the number of beds assigned to individual attendings
and to provide a substitute for each attending. This plan
was superior to one that included larger individual service
with frequent rotation of duty as frequent changes inter-
fered with continuity of study and observation which best
promoted discovery. In regard to hospital economy, Dr.
Goldwater said that true success of a hospital was meas-
ured by the good accomplished, and not by the assets ac-
cumulated, and the only admissible test for appointments
was fitness for work. In one form only was the acceptance
of money from medical workers justifiable, and that was
when fees were paid by medical students in whose interests
facilities for teaching were maintained. This was because
of the high cost of a teaching hospital. In regard to the
admission of private patients from which many hospitals de-
rived a considerable portion of their income, he said that
in charitable institutions the charity patient must not be
sacrificed in the interest of income. In planning the organi-
zation of such a department the hospital would do well to

extend its privileges to a circle sufficiently wide to guar-
antee a self-supporting department. This could be done
without detriment to the charity service. While it was cus-
tomary to assume that the attending staff was careless of
hospital supplies, and while no doubt this was true, the
underlying cause of unduly large expenditure was a disre-
gard of economic facts in the medical organization of the
hospital. There should be a chief executive officer on
economic as well as other grounds. It was not reasonable
to expect visiting physicians and surgeons to devote their
time to a study of the details of hospital expenditure; but
they should be expected to familiarize themselves with
facts ascertained through systematic records showing by
comparison of ward with ward the amount expended for
supplies. As to the question of medical salaries : With
every medical appointment there should go a suitable re-
ward for the service exacted. For the attending physician
who received opportunities for study, teaching, and prestige,
there need be no question of salary; for the house staff the
professional rewards were commensurate with the sacrifices
made; but medical men who devoted all or a large part of
their time to executive work or to laboratory duties were
entitled to be paid in money. .-Vs to the rights of the medical
staff, patients in private wards should pay the attending
physician, but no fees should be tolerated from charity pa-
tients. There should be due recognition in annual reports
of work done by the medical staff; many medical men would
always contribute to the hospitals far more than can ever be
repaid, and to these honor should ungrudgingly be given.
Permanency of tenure should be guaranteed to those whose
duties were faithfully performed. To give freest play to
intellectual powers proper facilities for scientific research
should be provided, and compulsory vacations should be
given both for the protection of the self-forgetful worker
and to give the assistant preliminary training. The physi-
cian should also have a right to participate in hospital
councils.

The Medical Staff in Relation to the Needs of the
Patient. — Dr. A. Ale.xander Smith opened the discus-
sion on this phase of the subject. He said that the admis-
sion of patients was one of the most difficult questions in
connection with hospital administration. At Bellevue it
was found that the work was too much for the House Staff,
and now there were four salaried physicians each on duty
for six hours, thus covering the entire twenty-four hours
of the day. He indorsed the plan of having a general medi-
cal and surgical chief, but thought the place a difficult one
to fiU. The expert surgeon too often thought his work
done after he had performed the operation, while he ought
to see that the patient was properly super\'ised. Applicants
for positions on the House Staff ought not to be chosen
because of their ability to pass a mental examination alone.
Moral qualifications and general fitness were also essential.
The attending physicians were compelled to make daily vis-
its at Bellevue, and each attending physician had his sub-
stitute.

Dr. William P. Xorthrup said one secret of success in
hospital service was to idealize the service. He thought
twenty to thirty beds enough for one physician to visit. If
the service was too large it was bad for both physician and
patient. He sometimes visited his wards two, and even
three times daily. These frequent visits kept nurses and
staff up to the mark. The function of the hospital was to
do the best that possibly could be done by the patient, and
this was done when the student was admitted, as it stimu-
lated the physician to do his work well. The visit of a body
of students stimulated the whole hospital personnel as well
as the physician. He was more hopeful on the subject of
a general manager than Dr. Smith. He thought that the
doctors had enough to do as consultants without looking
out for the financial side of hospital administration. In one
hospital it was the rule that physicians must first agree
among themselves as to what they wanted, and then peti-
tion the lay board. This plan had worked well.

Dr. S. Lloyd disagreed with Dr. Northrup as to the mat-

March

1907J

MEDICAL RECORD.

373

ter of having doctors on the hospital board, and thought
that the board should be composed entirely of physicians and
surgeons. When a physician had once mastered business
principles he was better qualified for hospital management
than a layman. As to having a medical and surgical chief,
he thought the best results could be obtained where there
was such an officer, and the specialist was called in when
needed. He thought there was a need for better discipline
in the hospitals, and that a daily visit from the visiting
physician was not as essential as thorough organization.
The making of histories should not be entirely intrusted to
the junior, but should be supervised by a competent physi-
cian. He thought there was too much hurry and the pa-
tients were regarded as so much machinery, and their indi-
viduality overlooked. The nervous hysterical patient needed
the encouragement of the attending physician. There was
a tendency to reduce the number of members of the house
staffs, while wc should rather seek to increase their number.

The Medical Staff in Relation to Medical Education.
— Dr. Samuel W. Lambert opened the discussion on this
topic. He said that this relation had always existed, and
from the point of the school the desirability was self-evi-
dent and beyond discussion. The necessities of the hos-
pitals themselves called for properly qualified graduate and
undergraduate students. Teaching properly done was a
help to the hospital and to the patient. In Germany both
hospitals and schools were government institutions. In
France their relation was recognized, and in England the
school was the outgrowth of the hospital and not vice
versa. Medical practice was of such a nature that it must
be learned by experience. Most hospitals in New York
City considered the practice of admitting students as a ne-
cessity to be endured rather than an advantage to be fos-
tered. Dr. Lambert suggested that another grade be added
to the regular staff known as medical clerks and surgical
dressers to be filled by fourth-year students. Let the work
of these helpers be such that the medical schools could
accept this service in lieu of part of the fourth year's
course. The mere attendance at a hospital in indiscrimi-
nate service, without any definite relation to the subject
matter being studied, would be of little use ; such work
would have to be arranged so as to supplement the school
course. While the hospital management, as a rule, did not
consider that the hospital had a teaching function, the
visiting stafif recognized that this system was advisable.

Dr. Egbert LeFevre thought Dr. Lambert's plan was not
comprehensive enough. It seemed that under his plan the
student was not in the hospital as a learner or observer,
but simply as a clerk or dresser. The hospital should
establish a regular teaching course that was definite and
comprehensive. If this course could be standardized the
medical college could accept it as part of the regular course.
The fee paid to the hospital should be deducted from the
fourth year tuition.

Dr. William K. Polk said that as the time had come
when the practitioner was expected to know more than
was regarded as necessary a few years ago, likewise sani-
tarjf requirements were becoming more insistent in all
parts. of the country, and if the medical profession was to
hold its position in the eyes of the public we must give
the young practitioner the opportunity to acquire the
knowledge expected of him. The profession, as a whole,
was far too indifferent to medical education ; that it did
not seem to recognize the duty of educating those with
whom it came in contact. The hospital management was
apt to attribute the desire for enlargement of its field of
usefulness as desired on grounds of personal exploitation,
forgetting that personal exploitation was back of all suc-
cess. The crying need, not only of the medical school but
of the County Medical Society, was education, and this
could not be had away from the bedside. It was difficult
to find a satisfactory plan, as many men who were excel-
lent visiting physicians lacked the faculty of imparting
their knowledge. He thought there should be a greater
use of adjuncts and shorter terms for internes as well as

more internes. In regard to the undergraduate question,
those who taught must show that their object was for the
good of the patient rather than for the student. Bellevue
was an illustration of how one of the largest clinics in the
city was built up in the interests of teaching.

The Medical Staff in Relation to Hospital Economy. —
Dr. A. G. Gerster said that lack of economy in hospital
administration was due to lack of stability, the constant
change of staff. The House physician was there for the
purpose of acquiring knowledge, and not of practising
economy. The nurses were also always changing, but he
thought the visiting staff ought to give the subject more
attention, for if they took no interest in economy no one
else would. The visiting staff should not only spend
more time in the hospital, but should have regular visiting
hours. Ho.spitaI expenses were increased by keeping pa-
tients too long under observation in the hospital. The dis-
pensary should form an integral part of the hospital, and
every large hospital should have a convalescent home in
the country, where the patient could be well taken care of
at one-half tlic cost of maintenance in the city.

The Medical Staff in Relation to the Rights of Its
Members. — ^ilr. Leo Arnstein said that the hospital ex-
isted for the communal good in the widest sense of that
expression. If the supposed rights of the staff interfered
with tliis communal good they were not rights. As the
hospital was dependent upon the medical staff, no demand
that staff' could make was too great provided it did not
interfere with the communal good. He did not believe in
a board composed entirely of medical men ; usually it was
safe to leave the good of the community in the hands of a
third party, and this should be the lay board.

NEW YORK ACADEiMY OF MEDICINE.

section on derm.^tology.

Stated Meeting, Held January 8, 1907.

Dr. A. R. Robinson, in the Chair.

Neurotic Eczema with General Alopecia. — Dr. Bulkley
presented this patient, a girl fourteen years of age. Her
father was said to have had eczema in childhood, and her
mother was nervous. The patient had measles and varicella
in childhood, but never diphtheria. For about two years,
from two to four years of age, she had a generalized
eczematous eruption. Her teeth and finger nails had always
been bad, and she had noticed no change in them as a re-
sult of the present disease. She had always been nervous,
but had had no serious illness. Her menses were regular
and painless. She had never noticed either axillary or pubic
hair. The present eruption began last August, coming first
on the abdomen, then on the arms and neck, and in October
or November spreading all over the body. There was no
history of nervous shock, but at the time of the onset she
was overtired from loss of sleep. The hair began to fall
in October, beginning on the vertex, and reached the pres-
ent condition in about si.x weeks. When presented before
the Section, the scalp showed several large, very irregular,
but fairly sharply defined areas over which the skin was
smooth, slightly atrophic, and bald, while between these
areas the skin was thicker, and sho_wed a good many stubs
and a few long hairs. Scattered over the scalp were the
stains and dry crusts left by the antecedent eruption. The
eyebrows were gone, the eyelashes were thin, and there was
no hair in the axillse, or over the pubes. All the finger
nails, .except that of the middle finger of the right hand,
were pitted, the pits being arranged roughly in parallel
horizontal lines. The distal half of each incisor tooth was
badly eroded. Scattered over the whole surface of the
body were irregular, poorly defined areas of eruption, con-
sisting of itching red pupules and papule vesicles. Where
the eruption was more intense the elements ran together to
form weeping surfaces, as in the bends of the elbows and
over the manubrium sterni.

374

MEDICAL RECORD.

[March 2, 1907

Dr. PoLLiTZER said the, case was not one of typical alo-
pecia areata. He thought the condition was due to some
form of intoxication.

Dr. Holder agreed with Dr. Pollitzer that a general toxic
disturbance would account for the universal change in the
skin. The skin on the back seemed to have the follicles
plugged by horny tissues, giving the skin an appearance of
unusual roughness.

Dr. Leviseur, from the anemic appearance of tlie patient,
believed this case to be one of leukemia, and the skin affec-
tion, as well as the loss of hair, to be one of those cutaneous
complications not infrequently appearing in connection with
leukemia and pseudoleukemia. He asked if a blood exam-
ination had been made.

The Chairman believed also that some profound dis-
turbance or intoxication was present to account for some
of the conditions. As regarded the alopecia, the facts
that tliere were no circular bald patches, that bald patches
did not form by falling out of hair at the periphery, and,
finally, that very many of the hairs were broken off, would,
in his opinion, exclude the diagnosis of alopecia areata.
He regarded the alopecia as connected with organisms in
the scalp, and probably the same ones as caused the sebor-
rheal eczema.

Dr. BuLKLEY, closing the discussion, reminded those
present that the structure of the hair, nails, and epidermis
were all much the same, and that they had all shared in
the same degenerative process. He also called attention to
the teeth, which were all misformed, indicating that a de-
praved vitality had been in operation for some time. He
did not look upon the girl's condition as due to toxemia,
or autointoxication, like that found in urticaria, and did
not believe that a toxemic condition could produce such
profound alterations. The entire condition could come
from some nervous shock or strain, affecting the nutrition
of the tissue, a degenerative neurosis. She had an early
history of eczema, at four to five years of age, and the skin
was likely to take on eczema again, so that he would regard
the present condition of the skin as a neurotic eczema, with
possibly alopecia areata of the eyebrows, but the loss of
the hair on the scalp could hardly be regarded as the latter.
The patient had just only entered the New York Skin and
Cancer Hospital, and had had very little treatment as yet.
While the history presented stated that the disease dated
back only a few months, he felt sure from the teeth, nails,
and hair that some disturbance of nutrition, probably of
neurotic nature, had been going on for a long time.

Lupus Vulgaris. — Dr. Bulkley presented this patient,
a woman, thirty-four years of age, from Dr. Fox"s service
at the New York Skin and Cancer Hospital. She had had
the disease since three years of age, and had been subjected
to much treatment. Some of the diseased tissue was re-
moved and skin grafting performed eight years ago. For
two years she had been in the New York Skin and Cancer
Hospital, under the care of Dr. Fox, who had treated many
of the lesions with the dental burr, and more recently had
treated the lesions on the mucous surface of the upper lip
with electrolysis. When shown before the Section, the
condition was largely the result of the past disease and of
treatment, there being few lesions which could be recog-
nized as lupus vulgaris. The nose was greatly disfigured,
a good part of the right ala being gone. The affected area
covered also most of the left side of the face, which was
irregularly scarred, with great ectropion of the left eye, for
which a plastic operation had been performed, with partial
success.

Dermatitis Papillaris Capillitii. — Dr. Leviseur pre-
sented a man thirty-five years old, who five years ago had
what was supposed to be a boil on the vertex of his scalp.
It was an elevation the shape of a cherry, not painful, and
discharged a sticky material. As local applications did not
benefit it, the tumor was opened extensively, the operation
leaving a keloidal scar three inches long and a quarter of
an inch in width. From time to time, in the vicinity of this

bald spot, there appeared rather suddenly pea-sized nodules,
which grew, opened, and discharged a small amount of pus.
Some of them disappeared occasionally; others remained
and became covered with wart-like excrescences rather
hard, and perforated by a number of hairs bunched
together. When the patient first came to Dr. Leviseur on
November 25 he had five distinct lesions aside from the
keloidal scar, two immediately at its border, the others
scattered about, but not far removed. It was quite easy to
puncture the lesions, some of which had no opening, and
the probe went in very deep, particularly on the tumor cov-
ered with papillomatous formations. The patient's hair
was very coarse. He was a letter carrier and wore a tight-
fitting cap. The sebaceous follicles connected with the
hairs all over the scalp presented a comedo-like appear-
ance. The diagnosis dermatitis papillaris capillitii was
made, although the localization was rather exceptional.
The lesions, particularly those covered with warty growths,
were cauterized with nitric acid and disappeared, but a few
follicular nodules formed again, always in the vicinity of
the old lesions. The hair had grown somewhat thin in the
whole region. ^licroscopically there were no changes in
the hair. Thorough destruction of the individual spots
seemed to be the only therapeutic measure which benefited
the patient.

Dr. Lapowski said that he did not consider the case to
be one of Kaposi's dermatitis papillaris capillitii, but thought
it to be an infectious folliculitis. In Kaposi's disease the
lesions were harder and more infiltrated. In cases which
had come under his observation, he had not seen such
lesions as appeared in this case. He would like to see the
appearance of these lesions after being treated for a month
with mild antiseptics only.

Dr. Bulkley said that, while the condition present might
in a measure suggest dermatitis papillaris capillitii. he did
not feel that it could quite properly be classed with those
cases thus described — although undoubtedly there was a
dermatitis. He regarded the trouble simply as one due to
ordinary pus infection, modified by treatment. The seba-
ceous glands of the scalp being very large and deep seated,
there was always deep inflammation when they were thor-
oughly infected, and this he had often seen to be a very
chronic nature: the results of inflammatory action could
readily give rise to the apparently papillomatous condition.
Dr. Leviseur, closing the discussion, said that the papil-
lomatous feature of the lesions was missing on account ot
the removal of the warty excrescences by strong caustics,
and apologized for showing the case in this condition. The
duration of the disease, five years, its localization near the
keloidal scar, its resistance to ordinary treatment alone,
seemed to him to militate against a diagnosis of simple
folliculitis or sycosiform staphylococcus infection.

Raynaud's Disease Probably of Syphilitic Origin. — Dr.
L.\P0WSKI presented a man thirty years of age, a Pole by
birth. He was married and had two children, three years
and one year old respectively, and his wife had had no mis-
carriage. Both family and personal history were negative,
there being no history nor visible symptom of any form of
intoxication in the patient, who was a man of temperate
habits, a clothing-cutter by occupation. His present trouble
had begun in the winter three years before, with pain in
the tip of the middle finger of the right hand. The pains
w'ere remittent, and appeared without any premonitory
symptoms, accompanied by a very cold feeling in the finger
tips. The finger nail was removed by a physician, and
gradually a gangrenous condition developed in the third
phalanx, necessitating its amputation. Dr. Lapowski saw
him for the first time at the Good Samaritan Dispensary in
the winter of 1905, with pain and slight suppuration of the
tip of the middle finger of the left hand. The patient was
then given potassium iodide, but he disappeared, returning
after several months of great improvement; the tips of the
fingers were thinner, only slightly cyanotic, neither ulcer-
ated nor painful. This improvement was the result of anti-

March

1907J

MEDICAL RECORD.

375

syphilitic treatment (inunctions, injections, and potassinm
iodide) which he had received at the Mount Sinai Hos-
pital. Two months later the tip of the right ring finger
became cj'anotic and swollen, but improved under anti-
syphilitic treatment. Two months ago he began to have
pains in the left second toe, accompanied by a cold feeling.
Since 1905 he had been sexually impotent. • When shown
before the Section, he was pale and tired looking. The
middle finger of the right hand lacked the terminal phalanx,
which had been amputated three years before. The stump
was cold to the touch, swollen, slightly cyanotic, and the
skin was tight, so that he could not bend the phalangeal
joint. The metacarpo phalangeal joint was normal. On
the right index finger the nail bed was white from the
lunula to the anterior third ; the surface of the nail was
smooth. The terminal phalanx of the fourth finger of the
right hand was cold and swollen, the peronychium and the
part around the lunula were red. The entire nail was
raised from its bed, the entire matri.x hypertrophied, and
the space between the body of the nail and the matrix filled
with dry, whitish, hard particles. The right little finger
was slightly cyanotic. The left index finger had a thin
conical terminal phalanx, and the patient could not bend the
joint between it and the second phalanx; there was only
the remnant of a nail. The first phalanx of the big toe of
the left foot was swollen, cyanotic, painless to the touch,
and cold. On the lower surface of the toe there was a pea-
sized ulcer, with grayish floor, and sharply cut edges ;
neither the surrounding tissue nor the base was infiltrated.
The sore was painful to the touch. The second toe of the
feft foot had a round infiltration, occupying the region over
the joint between first and second phalanges. In the center
there was a pea-sized ulcer with a necrotic center and
slightly raised edges. The whole toe was cold to the
touch, cyanotic, and painful. The right little toe was
cyanotic. The nose and ears were normal. The pulse was
small and hardly perceptible in either the radial or the
perineal arteries. There was no albumin in the urine. The
heart and lungs were normal.

Dr. Holder said that the case was undoubtedly one of
Raynaud's disease. The improvement under antisyphilitic
treatment suggested a syphilitic origin in spite of the fail-
ure of Dr. Lapowski to obtain a history of syphilis in his
patient. The coldness and cyanosis of the fingers indicated
some interference with the arterial circulation, and were
the most important symptoms in making the diagnosis of
Raynaud's disease.

Dr. BuLKLEV remarked that we did not yet know the
entire clinical histoiy of syphilis. He regarded it as an
important fact that the man, although he denied syphilitic
disease, was born in Russia. There were areas in Russia
where there were great numbers of syphilitics ; indeed in
some districts almost the entire population had been at
some time infected, many being infected in infancy by
household utensils, nursing, etc. These cases were fre-
quently untreated, and showed the results of syphilis in
later life. He recalled the fact that Dr. Fox showed a case
at a meeting of the New York Dermatological Society,
some time ago, in which a similar condition was going on
in the toes. One of the toes had been amputated, and gum-
matous tissue was forming around. The case was origi-
nally shown as a possible case of Raynaud's disease, with
cold toes, etc. This man was entirely cured with anti-
syphilitic treatment, the speaker himself having watched
the case with interest in the New York Skin and Cancer
Hospital. Syphilitic arteritis manifested various symp-
toms, some of which easily resembled Raynaud's disease,
for this in reality was often only a name to cover a certain
group of symptoms. He thought that some of the lesions
on the toes suggested diflfuse form of gummatous syphilitic
infiltration ; he would put the patient at once on a strong
mixed treatment, and believed that he would recover com-
pletely.

The Chairman agreed with the diagnosis of Raynaud's

disease or local asphyxia. He was not so positive that the
gangrenous lesions were to be regarded as simply gum-
matous, that sections would show the anatomical character
of ordinary gumma. .-\s regarded the treatment of these
cases, he would stale that the first case under his observa-
tion had a syphilitic history and was treated by iodides
without any benefit, but perhaps the dose given w.is too
small. The patient was a physician, and the first post
mortem made in this disease was upon this patient.

Dr. Lapowski. closing the discussion, said that when the
patient came to the Good Samaritan Dispensary m 1906
with a gangrenous condition of the finger tips, there was
not the slightest clinical resemblance to syphilis. Never-
theless, a great improvement followed the use of antisyphi-
litic treatment. This showed that in cases of so-called
Raynaud's disease, even if there were no specific symptoms,
it was advisable to use mercury, lie promised to give this
patient inunctions and calomel injections, and to present
him at the next meeting.

Dr. Lapowski reported that the man presented by him
October 30 as a patient with a tuberculide, had received
four calomel injections. There was great improvement
after each injection, but a new eruption appeared on the
arms and thighs, starting with the sudden appearance of a
tubercle under the skin ; the skin itched and the epidermis
was scratched off. leaving a slightly depressed center, which
gradually underwent necrosis. He had never seen such an
eruption in syphilis. He would give him no more injec-
tions, and hoped to present him at the next meeting.

Dr. Lapowski also reported that he had found the Spiro-
clueta pallida in each one of the three chancres on the man
presented at the December meeting.

The WiLLi.\MSBrRG Medical Society.

.\t the first regular meeting of this society, held January
9. 1907, the President, Dr. Leon Louria, in his inaugural
address, explained that the aims of this new society were
not merely to provide a lecture room for favored speakers,
but mainly to establish a forum in which all its members
could voice their opinions. Besides inviting the aid of out-
side medical forces, and the views of specialists in medi-
cine, it was to reserve the larger part of its program for
its own members, who. although affiliated with other or-
ganizations, rarely took part in their discussions. It was
urged that those whose opportunities for hospital and re-
search work were limited, were nevertheless fitted to
speak with the authority that bedside observation con-
ferred, for this observation was the source of most medical
knowledge. The recital of a case was usually the means of
bringing forth new light and discovering new ideas.
Dr. Jacob Fchs presented and gave the history of a case
of "Raynaud's disease." The patient, a .girl nineteen years
old, at the age of four years had an arrest of growth.
Four years later sue was treated for rheumatic pains in
the hands and feet. .'^ little later she complained of her
stomach, had a distended alidomeii, and passed per rectum
as much as a quart of blood. A possibility of typhoid had
been suggested. Four years later, cr.iraplaining of epigastric
pain, she had come under the care of the speaker, and
improved under a diet and with alkalies. L'lider thyroid
medication she had grown four inches. For past two win-
ters she had noticed that when placed in cold water her
fingers and toes would turn white and .get ice-cold. This
had not occurred during the summer. During the past
winter some of the fingers and toes at times became purple,
and subsequently gangrenous spots appeared on the hands
and feet. Apart from tli'ese objective manifestations ot
local syncope, asphyxia, and gangrene, physical examina-
tion revealed nothing except the subnormal height and a
slight enlargement of tlie heart and reduplication of the
second pulmonic sound. There was also anemia. Dr.
Fuiis also read a paper on ■'Memorrhagic Frosions of the
Stomach," based on three cases th.at he had recently seen.

3/6

MEDICAL RECORD.

[March 2, 1907

The lesion revealed a chronic catarrhal gastritis with
chronic interstitial infiltration with, in one case, atrophy
of the glands. Although epigastric pain was not, as a rule,
severe, epigastric tenderness was present in all cases, but
this was not elicited at Boas' point. Usually there was
moderate emaciation. The diagnosis depended on finding
pieces of gastric mucosa in the stomach washes, the epigas-
tric tenderness, and the persistence of the disease for
years. It was necessary to distinguish this disease from
cancer and ulcer. 'I'lic treatment included diet, rest, and
the use of bismuth and silver nitrate. Dr. S.'\muel
M. Brick.ner of Xew York read a paper entitled
"The F<ational Treatment of Fever in the Puer-
perium." He deprecated the promiscuous labeling of most
diverse conditions as "puerperal sepsis," and emphasized
the importance of making a pathological diagnosis. Apart
from other conditions, such as lobar pneumonia, pulmonary
infarct, mastitis, tlirombophlebitis. typhoid fever, malaria,
or any other acute infections, fever in the puerperium was
due to any one of many lesions in the genital tract, which
were classified under the heading intragenital sepsis as dis-
tinguished from extragenital sepsis. Of the former, one
had to consider e.xtrapelvic and intrapelvic lesions. The
extrapelvic lesions included vulvar and vaginal forms of
sepsis and conditions in the abdominal wall. The physi-
cian frequently succeeded in carrying, by means of the
intrauterine douche, an infection from the vulva, where it
was harmless, to the uterus, where it would become fatal.
For the vaginal and vulvar lesions mild antiseptic douches
were all that was necessary, with a gauze drain and a wet
dressing to the vulva. Of the intrapelvic lesions, the
speaker confined his remarks to only three conditions.
One of these was uterine sepsis resulting from premature
rupture of the membranes, with delay in the onset of labor
beyond eighteen to twenty-four hours, and the introduction
of septic material from without. To avoid this he advocated
the induction of labor. The next form was that due to
retained secundines. It was a false theory that advised
entrance into the uterus for a small piece of placenta or a
shred of membrane. These usually came aw-ay by them-
selves. The third condition discussed was that of retrover-
sion or retroflexion of the uterus, causing retention of
lochia.

Status Lymphaticus; Its Significance in Sudden Death
Following Serum Injections and in- the Treatment of
Diphtheria.— .\. P. Ohltitachcr defines status lymphati-
cus as a so-called constitutional disorder whose chief ana-
tomical characteristics are a persistent or hyperplastic
thymus and general lymphadenoid hyperplasia, frequently
associated with hypoplasia of the arteries and heart, and
the osseous or other changes of rickets. Many competent
authorities ascribe to the lymphatic state a distinct rela-
tionship with certain neuroses, including the so-called
"thymic" sudden death. .'\s to the treatment of this condi-
tion, aside from measures indicated for rickets when this
disorder exists, there are no th.erapeutic resources. The
writer believes that it is entirelv justifiable to conclude
that most, if not all. of the fatal accidents of serum
therapy arc examples of ' ' '■ sudden death. The
status lymphaticus predisp n enfeebled resistance

against infections, particularly against diphtheria. Informa-
tion concerning status lymphaticus and its neuroses, espe-
cially those in the category of sudden death, should be
more widely disseminated. The writer concludes that no
questionable case in which death has followed a serum in-
jection should be permitted to close without a thorough-
going autopsy, having in view the possibility of disclosing
the anomalies of status lymphaticus. .And both to protect
the reputation of the specific remedy for diphtheria — the
antidiphtheritic scrum— and that of the physician, the sig-
nificance of status Ivmphaticus as modifying the prosnosi-
course, and treatment of diphtheria should be kept clearly
in view — Detroit Medical Journal.

Rectal Feeding. — The conditions that must be pres-
ent in order for attempts at rectal feeding to be successful
are summed up by Becker as follows: (i) The rectum
must be in a fairly normal condition. Inflammation of
any kind, especially eczema, internal piles, or pressure by
the fundus or cervix uteri upon the rectum, must be ab-
sent. If such conditions do exist, they must be ameliorated
if possible. (2) The rectum and descending colon must
be free from contents. (3) The composition of the food
introduced nuist correspond • • ■•'' ■-■■logical exigencies of
the rectum and colon. (4 d must contain as

much nutrition as possible, . :o as little volume

as possible. The volume should never exceed 250 c.c. (5)
The temperature of the food is of great importance. It
should range between 42 and 45 degrees C. (6) The
rectum and the colon should be quieted an hour before and
a few minutes after the meal with an opium and belladonna
suppository — not morphine, which has a tendency to pro-
duce vomiting. — ll'iscoiisin Medical Journal.

Iodine Catgut. — The value of the iodine method of
sterilizmg catgut is bemg universally recognized, and Bur-
meister states that he has obtained the best results by using
a solution containing i g. of iodine in 15 c.c. of chloroform.
The catgut is immersed in this solution, and is ready for
use at the end of a week. He considers that catgut pre-
pared in this way is superior to that made by using aqueous
or alcoholic solutions of iodine, in tensile strength, absence
of irritating qualities, and in the fact that it does not swell
in the tissues. — Zentralblalt fiir Chirurgie.

Bichloride Gauze. — According to Powell, the follow-
ing is a convenient method of preparing this surgical
dressing: Take ordinary cheese-cloth and boil in water
made alkaline by the addition of common washing soda;
wring the cloth out in hot water; boil again in plain
water; then run through a bichloride solution 1:200 and
pack away moist in sterile jars. This gauze, immedi-
ately before using, should be wrung out in a solution of
bichloride. 1:1000. — The Clinical Review.

Tattoo Marks. — Variot of Paris proceeds as follows:
Apply under antiseptic precautions a concentrated solu-
tion of tannin to the skin and work it in as in tattoo
operation. Then rub skin with pencil (or solution) of
silver nitrate until the tattoo marks stand out as black
points on the silver tannate. E.xcessive fluid should be
removed: the surface turns black and moderate inflam-
mation follows. In fourteen days the eschar drops oflF,
leaving a red superficial cicatrix which fades in seven
or eight weeks." This plan is safe and sure — but pain-
ful and tedious. Ordinary slight tattoo marks (powder
marks, etc.) may often be removed by pricking in perox-
ide of hydrogen. Another plan is to tattoo well over
mark with needles dipped in a solution of chloride of
zinc thirty parts, distilled water forty parts. Eschar
drops in two weeks. Then dress area with simple
cerate. The fact that the insoluble substances which
are used in tattooing become encapsulated explains the
difficulty experienced in their removal. Under the mi-
croscope excised portions of tattooed tissue show large
particles of pigment situated part in the corium but
more generally in the subcutaneous connective tissue
itself. In the method by electrolysis the needle is at-
tached to the negative pole of a battery with a current
of from two to ten milliamperes and inserted at various
points about the periphery of stained area till reaction
is marked enough to insure destruction of involved tis-
sue. The dry superficial eschar falls in a few days and
the process may be again employed over the adjacent
skin. — The .American Jourticl cf Clinical Medicine.

Irritation of the Epiglottis for Resuscitating the Ap-
parently Asphyxiated. — Tickling the epiglottis with the
finger has been found by Friedenthal to be a highly
effective method of resuscitating those who are in a
state of asphyxia from drowning, anesthesia, etc. He
describes the procedure in this way. The method, he
says, consists in introducing the hand into the mouth
of the patient until you feel the epiglottis and. then
moving the index finger to and fro over the epiglottis.
Thus a very powerful effect is exercised directly upon
the nerves to be considered in this connection, ■viz.. the
glossopharyngeal supplying the anterior surface of the
epiglottis and the inner branch of the superior laryngeal
nerve supplying the posterior surface of the epiglottis,
the base of the tongue, etc. The epiglottis is that or-
gan of the human body which is particularly capable of
inducing reflex action on the least irritation, and we all
know how much difficulty we often have to avoid this
irritability in laryngeal work. And this is just what we
need in asphyxial conditions whatever be their cause. —
St. Louis Medical Review.

March 2, 1907]

MEDICAL RECORD.

^tatf JHf litral ICirrusing Soaria.

STATE BOARD EXAMINATION QUESTIONS.

Vermont State Board ok Medical Registration.

January, 1907.

chemistry.

1. (a) Discuss; tlie chemical characteristics of a good
drinking water, (b) State the most important fact about
hydrogen.

2. Name two gases that liave not been iiquilied.

3. (a) How is H20: made? State strength. (&)
Name four alkali metals and give symbol of each.

4. (a) Mention the principal proteids of nerve tissue.
(b) What is saccharin?

5. (a) Define urobilin, uroclirome, uroerythrin. (6)
What leaves the body mainly through urea? (c) Give test
for urea and state number of grains normally e.xcreted in
twenty-four hours.

MATERIA MEDICA.

1. {a) State dose and strength of dilute hydrocyanic
acid, (b) What preparations used in medicine contain it?

2. Give the composition, uses, and dose of the following
preparations: (a) Spirits of Mindererus, (b) compound
syrup of squills, (f) Pearson's solution, {d) Griffith's mix-
ture, (e) brown mixture.

3. Name the alkaloids, preparations, and doses of ipe-
cac.

4. (o) Give the source, dose, and action, of the follow-
ing alkaloids: sparteine, berberine, atropine, narceine. (6)
Give the strength of the following: tincture of capsicum,
tincture of rhubarb, tincture of colchicum seeds, tincture of
digitalis, tincture of aconite, tincture of hyoscyanus, tincture
of veratrum viride, tincture of belladonna.

5. Discuss the composition and physiological action of
ergot.

THERAPY.

1. Briefly explain : — natural therapeutics, empirical thera-
peutics, rational therapeutics.

2. Write a formula for each of the following: acne
rosacea, hysteria, angina pectoris, bronchiectasis, chronic
nasal catarrh, enuresis, diabetes insipidus, hepatic cirrhosis,
hiccough, influenza.

3. How would you treat and manage a case (o) of
infantile convulsions? (b) of renal and vesical calculi?

4. Mention the indications for the following drugs :
potassium chlorate, salicylic acid, phosphorus, cldoral, can-
tharides, carbonate of ammonia, potassium bromide, ela-
terium. guaiacol carbonate, stramonium.

5. Give your drug and dietetic treatment of typhoid
fever.

AN.\T0MV.

1. Describe the bones of the foot, giving their divisions
and articulations.

2. Describe the occipitoatloid articulation.

3. Name the superficial muscles of the neck and scalp,
and give the origin, insertion, and nerve supply of any one
of them.

4. Describe the portal system of veins.

$. Give the origin, course, and termination of the tho-
racic duct.

6. State the origin, course, and distribution of the sixth
pair of cranial nerves.

7. Describe the special organs of taste, and give their
nerve supply.

8. Name the coverings of femoral hernia from without
inward.

g. Describe the prostate gland and give its relations.
10. Give the normal position, size, form, ligaments,
blood, and nerve supply of the uterus.

PHYSIOLOGY.

1. Give the classification of nerves.

2. Of what does the cerebrospinal axis consist?

3. Name the coverings of the brain, and describe them.

4. Describe and give location of the corpora quadri-
gemina, also give function.

5 Describe healthy urine, and .give constituents.

6. What are enzymes? State the special functions of
each enzyme concerned in digestion.

7. Describe the proteid digestion, and name the ferments
concerned therein.

8. Into how many classes are food stuffs divided?
Name them.

g. What is meant by the automatic action of the spinal
cord? Give three examples.

10. Name some of the kinds of cells found in man.
What is epithelium? What are its varieties?

HYGIENE.

1. What is meant by personal, domestic, and public
hygiene?

2. What is the distinction between sewer air and sewer
gas? What gives sewer gas its peculiar odor?

3. Give the hygiene of the secretory organs.

4. How do disease germs produce their characteristic
effect on the system ?

5. What constitutes a thorough inspection of milk as to
food value and purity?

BACTERIOLOGY.

1. Classify bacteria, and state the dilterence between a
saprophyte and a parasite.

2. State the difference between a toxin and a ptomain.
Tiive five sources of ptomain poisoning.

3. Describe the gonococcus, and give method of stain-
ing the same.

4. State microscopical appearance, and staining peculiar-
ities of the tubercle bacillus.

5. What evidences of contamination of drinking water
may be obtained by bacteriological analysis? Compare
the value of chemical analysis with that of bacteriological
analysis.

P.\THOL0GY.

1. Give the pathological difference between moist and
dry gangrene.

2. Give the pathological anatomy of lobar pneumonia.

3. Give the pathology of carcinoma.

4. Give the pathology of typhoid fever.

5. Give the pathology of chronic arteriosclerosis.

1. Give the treatment, including preventive treatment, of
typhoid fever, also that for the more common complica-
tions of this disease.

2. Give the etiology of, and describe the different types
of influenza.

3. Give the differential diagnosis (0) between rubeola
and rubella, (6) between rubeola and scarlatina.

4. Give differential diagnosis between variola and vari-
cella.

5. Give the period of incubation of the diseases men-
tioned in questions 3 and 4, also the proper period for
quarantine in each.

6. (o) Mention the different types of pneumonia; (fc)
give its treatment.

7. Differentiate betwixt cardiac hypertrophy, cardiac
dilatation, and pericarditis with effusion.

8. Write a short article on hemophilia.

9. How would you manage a case of chronic interstitial
nephritis?

10. Give the symptomatology of tabes dorsalis.

1. What are toxins, antitoxins, and phagocytes?

2. Describe four methods of reducing dislocation of the
shoulder.

3. How would you treat a fracture of the elbow joint?

4. What is septicemia and pyemia? Give causes.

5. Differentiate between acute ovaritis of the right side
and appendicitis.

6. Describe the mastoid operation for suppuration.

7. Name and describe four forms of talipes.

8. Describe fistula in ano, and give treatment.

g. .Give symptoms of acute cystitis, and write a pre-
scription for same.

10. Describe in detail Bassini's operation for inguinal
hernia.

OBSTETRICS.

1. Enumerate signs of. pregnancy and indicate relative
importance.

2. Describe the management of a case of R. O. P. pres-
entation.

3. Give symptoms, diagnosis, and treatment of placenta
previa.

4. Give causes and treatment of mastitis.

.-. What, how often, and how much would you feed a
baby one week old?

6.' Name at least six of the most common conditions
calling for the use of forceps.

y. Give management of a case of miscarriage.

8. Give prophylactic treatment of postpartum hemor-
rhage.

g. Give treatment of puerperal sepsis.

10. Give diagnosis and treatment of extrauterine preg-
nancy after rupture.

GYNECOLOGY.

1. Describe the uterus. . .

2. Give causes and treatment of ovaritis, acute and
chronic.

3-8

MEDICAL RECORD.

[March 2, 1907

3 Give symptoms and treatment of retroversion of
uterus.

4. Give contraindications for use of uterine sound.

5. Give symptoms and treatment of acute vaginitis.

LEGAL MEDICINE.

1. Give a definition of a medicine, also of a poison.

2. Give examples of mania, monomania, dementia, and
idiocy.

3. What is the difference between civil and criminal
malpractice?

4. Give your reasons that a child had been born alive.

5. Describe a bullet wound, entrance and exit.

ANSWERS TO STATE BOARD EXAMINATION

QUESTIONS.

VER:iioxT St.vte Bo.ard of Medical Registr.\tiox.

January, 1907.

CHEMISTRY.

I. (a) It should be colorless, odorless, cool, limpid,
soft ; it should have an agreeable taste, neither sweet nor
salty nor flat ; it should dissolve soap readily w-ithout for-
mation of a curd}' precipitate ; it should contain not more
than twenty-five to thirty grains of harmless solids per
gallon, and should not be contaminated with sewage, lead,
or other poisons, or patliogenic bacteria.

(b) There is no most important fact about hydrogen;
the following are all of them facts, the relative importance
of which must be decided by the examiner for himself:
Hydrogen is a necessary element in the composition of all
acids, also of water; the weight of its atom is the unit by
which all atomic weights and molecular weights are meas-
ured ; it is the li.a;htest known substance.

3. (a) H:0- IS made bv adding barium dioxide to a
solution of dilute hydrofluoric acid. The strength is a ten
to twelve volume solution.

(b) Lithium, Li.; Sodium, Na. ; Potassium, K. ; Rubi-
dium, Rb.

4. (a) Albumin, globulin, nucleoproteid, and neurokera-
tin.

(b) Saccharin in benzoyl sulfonic imid, or anhydro-
ortho-sulphamine-benzoic acid.

5. (a) Urobilin is a brow-nish pigment found in the
urine, the feces, and sometimes in the blood.

IJrochromc is a yellow pigment of the urine.
L'locrytliriii is a reddish pigment sometimes found in
the urine.

(b) Nitrogen.

(c) A comparatively easy test is that of Fowler, based
upon the loss of the specific gravity' of the urine after
the decomposition of the urea by hypochlorite. "To apply
this method the specific gravity of the urine is carefully
determined, as well as that of the liquor sods chlorinat<e
(Squibb'sV One volume of the urine is then rnixed with
exactlv seven volumes of the liquor sods chlorinate, and,
after the first violence of the reaction has subsided, the
mixture is shaken from time to time during an hour,
when the decomposition is complete : the specific gravity
of the mixture is then determined. As the reaction begins
instantaneously when the urine and reagent are mixed, the
specific gravitv of the mixture must be calculated by add-
ing together once the specific gravity of the urine and
seven times the specific gravity of the liquor sods chlor-
inat,-e. and dividing the sum by eight. From the quotient
so obtained the specific gravity of the mixture after
decomposition is subtracted : every degree of loss in specific
gravity indicates 0.7791 gram of urea in lOO cc. of urine.
The specific gravity determinations nmst all be made at the
same temperature'; and that of the mixture only when the
evolution of gas has ceased entirely." CWitthaus' Manual
of Chemistry.)

M.•^TERI.^ MEDICA.

1. (a) Dose is one and a half minims: strength is two
per cent, by weight.

ftO Cherry-laure! water. Scheele's dilute hydrocyanic
acid, oil of bitter almond, and Prunus Virginiana.

2. (a) St'irits of Mindererns. an aqueous solution of
ammonium acetate. cont:iining rot less than seven per cent,
of the salt, and also a little acetic and carbonic acids.
Do^e. two to four drams.

(h) Compound syrup of squills contains fluid extract
of squill and of senega, tartar emetic, sugar, calcium phos-
phate, and water. Dose, half a dram.

(c) Pearson's Solution, solution of sodium arsenate,
consists of that salt and water. Dose, three minims.

(d) GritHth's mixture is compound iron mixture, and
contains ferrous sulphate, potassium carbonate, myrrh,
sugar, spirit of lavender, and rose water. Dose, four

drams.

(e) Brown mixture, is compound mixture of glycyrrhiza,
and contains extract of glycyrrhiza. syrup, acacia, wine of
antimony, spirit of nitrous ether, camphorated tincture
of opium, and water. Dose, two drams.

3. Alkaloids: Emetine, cephaeline, and a third, unnamed
alkaloid.

Preparations and Doses: Fluid extract, TlB-xv ; powder
of ipecac and opium, gr. viiss ; syrup of ipecac, Tljxv, as
an expectorant, 3iv as an emetic; wine of ipecac, Tljxv;
tincture of ipecac and opium, TlEviij.

4. (a) Sparteine, from scoparius, sparteine sulphate, gr.
1/5; bcrberine, from hydrastis, calumba, berberis, and other
plants, berberine sulphate, gr. ss. to gr. jss; atropine, from
atropa belladonna, gr. 1/160; narceine, from opium.

(&) The tinctures of capsicum, colchicum seeds, digitalis,
aconite, hyoscyamus, veratrum viride, and belladonna are
ten per cent, strength ; tincture of rhubarb is twenty per
cent, strength.

5. The composition of ergot is indefinite; the chief con-
stituents are : Ergotine, ergotinine. ecboline. sphacelic acid,
ergotinic acid, cornutine. tannic acid, and other substances.
Most of these ingredients contract the blood-vessels ; the
cornutine, in addition, is credited with the chief part in
contracting the uterus,

THERAPY.

1. Natural therapeutics comprises the processes which
may be included under the general heading of the healing
or recuperative powers of the organism itself, independently
of any outside aid. Rest and sleep are examples.

Empirical therapeutics is a term applied to such reme-
dies as are used simply because they have been found
beneficial in certain cases.

Rational therapeutics means the use of remedies based
on a combined knowledge of their physiological action and
of the pathological condition present in the patient.

2. For acne rosacea: — ^ Zinci sulphatis

Potassii iodidi aa 3ss
Aquje rosse, q. s. ad 3iv. Misce
Sig: Use as a lotion.
For hysteria: — R Tincturs asafoetidae

Tincturse valerians ammoniatae aa 3j
Aqus camphors, q. s. ad 5iij. Misce
Si.g: One tablespoonful every hour.
For an^iina pectoris: — ]J Pearls of nitrate of amyl, TIBiij.

No. X.
Sig: Crush one and inhale when required.
For bronchiectasis:- — R Potassii iodidi 3j
Glycerin 3iij
Syrupi senegs 5j
.\qus destillats q. s. ad o'ij-
^lisce.
Si.g: A dessertspoonful one hour after meals.
For chronic nasal catarrh: — R Sodii boratis

Sodii bicarbonatis aa Sss
Phenol gr. xv
Glycerini 3ss
Aqus destillats O. j.
Misce,
Sig: LTse as a spray.
For enuresis: — R Potassii citratis 5ss

Spiritus etheris nitrosi 3vj
Aqus destillats q. s. ad 3ij. Misce
Sig: .A dessertspoonful every four hours.
For diabetes insipidus: — R Fluidextracti ergots 3iss

Aqus destillats q. s. ad $iv.
Afisce
Sig : One teaspoonful, three times a day.
For hepatic cirrhosis: — R Potassii iodidi Sijss

Aqus destillats jij. Misce
Sig: One teaspoonful in a tumbler of water
one hour before meals.
For hiccough: — R Spiritus etheris compositi ^j

Sig: One teaspoonful in a glass of ice-water.
For inAiienza: — R Quinins hydrobromatis
Sodii benzoatis

CafTeins aa gr. xx. Misce, et fiat
massa in pihilas No. xx. dividenda
Sig: Take one three times a day.

ANATOMY.

8. Skin, superficial fascia, cribriform fascia, crural
sheath, septum crurale, subserous areolar tissue, and
peritoneum.

PHYSIOLOGY.

I. Nerves are classified as : — I. Efferent nerves, or
centrifugal nerves, which may be motor, accelerator, in-
hibitory, secretory, or trophic ner\'es. II. Afferent nerves,
or centripetal ner\'es. which include ner\-es of general sen-
sation, special sense and of pain. III. Intercentral nerve
fibers, which connect different parts of the ner^'Ous sys-
tem.

March 2, 1907]

MEDICAL RECORD.

379

4. The corpora quadrigemina are four small rounded
eminences situated over the aqueduct of Sylvius. They
are arranged two on each side behind the pineal body, and
are separated from each other by a crucial depression.
They are white on the surface, but contain gray matter in
the interior. As to their function, they contain centers for
the contraction of the pupils and for the coordination of
the movements of the eyeballs.

6. Enzymes are unorganized ferments which are the
result of the activitv of special cells of the animal body.

ENZYME.

FUNCTION

Saliva

Ptyalin.

Changes starches into

dextrin and sugar.

Pepsin.

Changes proteids into

proteoses and peptones

Gastric juice. . . .

■

in an acid medium.

A curdling

Curdles the casein of

ferment.

milk.

Trypsin

Changes proteids into

proteoses and peptones.

and afterwards decom-

1

poses them into leucin

1

and tyrosin ; in an al-

Pancreatic juice.

1

kaline medium.

Amylopsin

Converts starches into

maltose.

Steapsin.

Emulsifies and saponifies
fats.

A curdling

Curdles the casein of

ferment.

milk.

8. Food stuffs are divided as follows :

I. Inorganic

II. Organic

Water.
Salts.

Non-nitrogenous -: .^

( Fats.

Xitrogenous — Proteids.

( Carbohydrates.

9. By automatic action of the spinal cord is meant that
property of the nerve cells of the cord by virtue of which
they become active as the result of changes within the
cord, and without any external stimulus. Some of the
centers in the cord mav act automatically, but as a rule they
act as reflexes in response to external stimuli. Examples
are parturition, defecation, and micturition.

2. Sewer air is atmospheric air with its oxygen dimin-
ished and its carbon dioxide increased from 0.04 per cent,
to 0.4 per cent., and contaminated with more or less marsh
gas, sulphuretted hydrogen, ammonium sulphide, etc.

Sezver gas "is but a mixture of a number of gases, such
as carbonic acid, carburetted hydrogen, ammonium and
hydrogen sulphide, nitrogen, etc., together with a consid-
erable amount of fetid organic matters, the volatile or semi-
volatile products of animal and vegetable decomposition,
varying according to the condition of the sewer, the kind
of matter received therein, the amount of surplus water,
etc." (Egbert's Hygit-nc and Sanitation.)

4. Disease germs must first effect an entrance into the
body ; they then grow, multiply, and produce toxic sub-
stances which are absorbed and distributed throughout the
system. Sometimes uurelv local effects are produced,
such as the plugging up of small vessels or causing changes
in the cells and tissues. Occasionally, as in anthrax, the
disease germs invade the various tissues, and cause dis-
turbances more by their presence and multiplication than
by their toxic products.

5. The inspection should include : — the color, reaction,
specific gravity, sediment, taste, odor, total quantity of
solids and of water; the percentage of cream, fats, lactose.
casein, and ash ; the presence or absence of preservatives,
coloring matter, added solids, and dilution. There should
also be thorough investigation as to its source, the cows
and their environment, the method employed in carin;; fnr.
milking, storing and transporting the milk.

b.«,cterioij:igv.

1. P>acteria are classified as: — i. Cocci; 2. Bacilli: and
3. Spirilla.

.'^npropjiytcs are bacteria that derive their nutriment from
dead organic substances; Parasites derive their nutriment
from living tissues.

2. "A ptomain is a basic substance, contains nitrogen, is
found in putrefaction of proteid matter, and resembles
alkaloids in its action, combining with acids to form salts;

at one tune considered the essential element in bacterial
intoxication. Toxins are formed by most all pathogenic
bacteria, both by analysis and synthesis, in the livmg organ-
ism; do not act like basic bodies, cause symptoms like
animal and plant alkaloids (snake venom, abrin, strychnin),
and vary with the source, each kind of bacteria havmg its
own .specific toxin; their effect on the human organism is
immense in minutest dosage, not only constitutionally but
also locally to less degree" (.Thayer's Pa/Ac/ogy ).

Conmion sources of ptomain poisoning are; — putrid fish,
meat, sausages, cheese, milk, and ice-cream.

5. The presence of Bacillus coli conununis indicates the
possibility of any organic contamination. Therefore the
finding of this one bacillus, with or w^ithout any pathogenic
bacteria is evidence of the contamination of the water. It
is difficult to make an accurate estimate of the relative
values of a chemical and a bacteriological analysis of water.
Both methods are necessary, neither method is infallible,
and each may help the other. Water mav be pure from a
bacteriological standpoint and yet the chemical analysis
may show that it should he condemned. The chemical
analysis is probably the more valuable to decide as to the
quality of a drinking mater.

I. Toxins are poisonous products of bacteria i See an-
swer to No. 2 in Bacteriology, above).

Antitoxins are substances elaborated in a living bo.ly to
counteract the poisonous effects of to.xins.

Phagocytes are cells that devour and destroy inicrLi.iriJ.ui-
isms.

5. Both conditions are characterized by sudden onset,
pain, tenderness, rise of temperature, and rapid pulse. But
appendicitis will be accompanied by history of intestinal
disorders, rigidity of abdominal muscles, chiefly the right
rectus, possibly vomiting and constipation, the right iliac
fossa is the site of the pain and tenderness ; in acute ovaritis
there will probably be some menstrual disorder, the ovary
will be tender on pressure, and unless there are adhesi<in»
it is mobile, the tenderness and pain are nearer the median
line, there is generally either salpingitis, endometritis, gon-
orrhea, or septic infection. In case of doubt an explora-
tory incision will clear up the difficulty.

7. (i) Talipes varus, in which the inner edge of the
foot is draw^n up. the anterior two-thirds is twisted in-
wards, and the outer edge rests on the ground.

(2) Talipes valgus, m which the outer edge of the foot
is drawn upwards, and the inner side of the foot and ankle
rest on the ground. This condition is the reverse of
talipes varus.

(3) Talipes etfuinus. in which the heel is raised and
cannot be brought to the ground, and the patient walks on
the toes and on the distal ends of the metatarsal bones.

(4) Talipes calcaneus, in which the toes are raised and
the heel depressed, so that the patient walks on the latter.
This condition is the reverse of talipes equinus.

OBSTETRICS.

5. A baby one week old should be nursed at the mother's
breast regularly every two hours between the hours of
5 A.M. and II P.M. It should receive about an ounce or an
ounce and a half at each nursing.

6. Uterine inertia, pelvic deformity, persistent posterior
Iiosition of the occiout. eclampsia, face presentations, arrest
of the after-coming head in breech cases, hemorrhage.

8. During pregnancy the patient should be put in as good
a physical condition as possible; the uterus should not be
emptied too rapidly; the patient should not he allowed to
become exhausted; after the birth of the child the fundus
of the uterus should be grasped and held till the placenta
is expelled ; after the expulsion of the placenta the patient
should receive a dram of the fluid extract of ergot, and an
abdominal binder should be applied. The physician should
not leave till at least an hour after the conclusion of the
labor, and not even then if the patient's pulse i-^ I'M or over.

GYNECOLOGY.

4. (i) The least suspicion of even the possibility of
pregnancy; (2) menstruation; (3) acute endometritis;
(4) malignant disease of the uterus or vagina: 15I acute
pelvic inflammation.

LEG.\L MEDICINE.

I. .X medicine is anything that possesses or 1- suppnied
to possess remedial properties.

.\ poison is anv substance which, on being in solution
in the blood, may' produce <leath or serious bodily harm.

-( Malpractice is a failure on the part of a medical
practitioner to use such skill, care and judgment in the
treatment of a patient as the law requires; and thereby the
patient suffer? damage. If due to negli.gence only, it is
civil malpractice. But if done deliberately, or wrongf illy.

38o

MEDICAL RECORD.

[March 2, 1907

or if gross carelessness or neglect has been shown, or if
some illegal operation (such as criminal abortion) be per-
formed, it is criminal malpractice.

BULLETIN' OF APPROACHL\G EXAMlXATIOXS.t

STATE. NAME AND ADDRESS OP PLACE AND DATE OP

SECRETARY. NEXT EXAMINATION.

Alabama* W. H. Sanders. Montgomery. . Montgomery. -April i

Arizona* Ancil Martin. Phoeni x Phoenix April

Arkansas* F. T. Murphy. Brinkley Little Rock. . .April

California Chas. L. Tisdale. Alameda San Francisco . April

Colorado S. D. Van Meter. 1723 Tre-

mont Street. Denver Denver April

Chas. A. Tuttle New Haven... New Haven. . .March

.J. H. Wilson. Dover Dover June

.W.C.Woodward. Washington. Washington.. .April

Connecticut*. .

Delaware

Dis. of Col'bia.

Florida*

Georgia

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky* —

Louisiana

,T. D. Fernandez. Jacksonville. Jacksonville.. .May
E.R. Anthony. Griffin. *"" " ' '

.W. T,

Atlanta April

L. Conant. Jr., Genesee Boise AprU

\. Egan. Springfield Chicago April

T. Gott, 1 30 Sute House.
Indianapolis Indianapolis. . May

,J. F. Kennedy, Des Moines... .Des Moines... .March

,T. E. Raines, Concordia Topeka June

,J. N. McCormack. Bowling

Green Louisville April

.P. A. La Rue, 211 Camp St.,

New Orleans. New Orleans.. .May

38
10

Maine Wm. J. Mayburv, Saco Portland March

.LMcP. " " _ " '

Massachusetts*. E. B. Harvey. State House.

Maryland j. McP. Scott, Hagerstown.. . .Baltimore June —

Midiigan . .

Minnesota.

Mississippi .
Missouri . . .

. .June

Boston Boston March

.B. D. Harison. 205 WTiitney

Building, Detroit Ann Arbor.

.0. E. Linier, 24 South Fourth

Street. Minneapolis St. Paul April

.J. F. Hunter. Jackson Jackson May

J. A. B. Adcock. Warr^nsbvirg. { ^^l^t^fcity ' ^^

Montana* Wm. C- Riddell. Helena. .... .Helena April

Nebraska Geo. H. Brash. Beatrice Lincoln

Nevada S. L. Lee. Carson City Carson City. . .May

N. Hamp're*. . .Henry C. Morrison. State Li-
brary, Concord. . .^ Concord July

Trenton June

Santa Fe June

New York,
Albany.
Syracuse.
. Buffalo.

• G. T. Sikes. Grissom Morehead City. May

.H.M. W^ieeler, Grand Forks. .Grand Forks.. .April

Ohio Geo. H. Matson. Columbus... .Columbus June

Oklahoma*. . . . J. W. Baker, Enid Guthrie March

Oregon* B. E. Miller, Portland Portland April

Pennsylvania.. N. C. Schaeffer. Harrisburg. | ^tilbi^J?^'^ jj"'^®
Rhode Island... G^T.Swarts. Providence Providence... .April

New Jersey J- W- Bennett. Long Branch.

.B. D Black, Las Vegas

.C.F.Wlieelock Univ.ot State
of New York, Albany. . . .

New Mexico. .

New York .

N. Carolina*
N. Dakota

9

18

3

May

S. Carolina,
S. Dakou.

. . W. M. Lester. Columbia Columbia June

. .H.E.McNutt. Aberdeen Siou.- Falls July

Tennessee*..

Texas.

Utah*

W. Virginia*. .

Wisconsin

Wyoming

May —

30

Memphis,

.T.J. Happel. Trenton i Nashville,

i Knoxville,

. T. T. Jackson, San Antonio . . . Austin April

.R. W. Fisher, Salt Lake City. .Salt Lake City.April i

Vermont W Scott Nay, Underbill Burlington .... July 9

Virginia R. S. Martin, Stuart Lynchburg. ..June 18

Washington*.. .C. W. Sharpies, Seattle Seattle July 2

H. A. Barbee. Point Pleasant.. Wheeling April g

J. V. Stevens, Jefferson Madison July 0

S. B. Miller, Laramie Cheyenne. . .

*No reciprocity recognized by these States.

tApplicants should in every case write to the secretary for latest
details regarding the examination in any particular State.

REQUIREMEXTS FOR MEDICAL LICENSURE.

In the following table the State? requiring of the can-
didate both a diploma from a recognized college and an
examination are printed in roman ; those requiring either
a diploma or an examination, in italics: those requiring an
examination only, in small capitals.

State

Alabama S

Arizona

Arkans.^s

California

Colorado

Connecticut

Delaware

District of Columbia. .

Florida

Georgia

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Fee

10.00

10.00

10.00

20.00

25 .00

15 .00

10. 00

10.00

15.00

10.00

25.00

10.00

25 .00

10.00

15 .00

10,00

lO.OO
lO.OO

15 . 00

20.00
25 .00
10.00
10.00

,00

State Fee

Nebraska S25 .00

Nevada 25 , 00

New Hampshire 10. 00

New Jersey 25.00

Xeiv Mexico 25.00

New York ?i 00

North Carolina

North Dakota

Ohio

Oklahoma

Oregon"

Pennsylvania

Rhode Isi.a.vd

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West \'iKr.i.viA

Wisconsin

Wyoming

10 , 00
20.00

25 . 00

10. 0-5

10. 00
20.00

lO.OO

00

10 00
10. 00

Wisconsin. — The State Board of !Medical Examiners is
actively enforcing the medical laws of the State. \Var-
rants have been issued for the arrest of several illegal
practitioners, some with fake diplomas, and some who in-
■dv.lge in indecent onack adverti^^ins:.

iHfiitral Stpma.

Contagious Disease* — Weekly Statement. — Report of
cases and deaths from contagious disease reported to
the Sanitary Bureau, Health Department, New York
City, for the week ending February 23, 1907 :

Tuberculosis Pulmonalis

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis
Malarial Fever

Totals

Caws Deaths

360

220

277

46

259

lO

298

'3

76

I

45

12

66

5

13

12

1395

319

Verminous Appendicitis. — Ragaine believes that the
presence of worms in the intestine may become the im-
mediate cause of appendicitis. These parasites provoke an
ulceration of the mucosa of the cecum, thus opening a por-
tal of entry for infection. Search should be made in a
case of appendicitis for the possible presence of intestinal
worms. The physician could often discover the presence
of ascaris, trichocephalus, or o.xyuris. This would be a
most valuable indication. Appendicitis of verminous or-
igin may sometimes be cured by the expulsion of parasites
alone. — La Prcssc Medicate.

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been repooted
to the Surgeon-General, Public Health and Marine-
Hospital Service, during the week ended February 22,
1907:

SMALLPOX — l-NITED STATES.

— Florida, Lakeland Jan

eb.

Georgia, Augusta Feb.

Illinois, Chicago Feb.

Indiana, Indianapolis Feb.

Maryland, Baltimore Feb.

Minnesota. General Dec.

^lisso^^ri, St. Louis Feb.

Montana, Helena Jan.

North Carolina, Charlotte Feb.

Utah, Ogden Jan.

Washington. Sookane Feb.

Ohio, Cincinnati Feb.

Utah. Ogden Jan.

Washington. Spokane Feb.

26-Feb.
9-16. .
S-IJ. .
9- x6. .
^-ro..
g— rn. .
r-Jan.
0-16. .
1-3 1 ■ ■
9-16. .
1-31.-
2-9- . .
S-15..
I-31- .
2-0 . .

CASES. DEATHS
6
3
3

3
13

3
13

SMALLPOX FOREIGN.

,\rgentina. Buenos Aires Dec.

Brazil. Bahia Dec.

Canada. Toronto Jan.

China, Shanghai Jan.

France, Paris Jan.

Great Britain. Cardiff Jan.

HuU Jan.

Liverpool Jan.

Southampton J?"-

India. Calcutta Dec.

Rangoon Dec.

Mexico, Vera Cruz Jan.

Netherlands, Rotterdam Jan.

Russia, Moscow Jan.

Odessa Jan.

Turkey, Constantinople Jan.

29- Jan. 5.
29— Jan. 1 2

g~2^.

6-r.v. .-

19-26

19-Feb. 2.

19-26

lo-Feb. 2 .
a6-Feb. a.
ao-Jan. 5 ■
29-Jan. 3 .
26-Feh. 2.
26-Peb. 2.

S-26

i?-iO

20-27

1 2(epid'c)

YELLOW FEVER.

Mexico, Tuxpani Tan. 2^-29 . .

CHOLERA INFULAR.

Philippine Islands, Provnnces Dec. 15-22- •

" Dec. 22—29. •

" Dec. 27-Jan.

CHOLERA FOREIGN.

India, Bombay Jan. 8-n;

.D

Calcutta Dec. 29-Jan. 5 ■ - -

Cochin Dec. 2S

Rangoon Dec. 29-Jan. 5 —

Egypt, Ismailia Jan. 25-29 i

.\ssiout Province Jan. 24-29.. t

India. General Dec. 29-Jan. 5 — 1 29 x 3

Bombay 1^^- ^-'5

Calcutta Dec. 29-Jan. 5

Rangoon ....... Dec. 20-Jan. 5

japan. General .Jan. i-to 0

Mauritius Dec. 13-Jan. 3- •• ^5

Siam, Bankok Nov. 21

76

I

I"*

f3363
33

Medical Record

A U-Ycklv foin-!ial of Media' 7! c and Surgery

Vol. 71, No. 10.
Whole No. J896.

New York, March 9, 1907.

$5.00 Per Annum.
Single Copies, JOc.

(I^iiaiual Arttrlrs.

THE SALT-FREE DIET IN CHRONIC PA-
RENCHYMATOUS NEPHRITIS.*

Bv GEORGE I,. PEABODY. M.D..

NEW YORK.

The benefit to be derived from the administration
of food containing only a minimum of sodium
chloride in cases of anasarca due to |jarenchy-
matous nephritis seems to have been independent!}'
discovered by several observers. My purpose in
drawine attention to it to-ni^ht is to ask its trial
in a condition which is always distressing and
which, by other means, is often rebellious to treat-
ment.

The literature on the subject, which dates only
a few years back, is not voluminous, but almost
all who have published accounts of systematic trial
of the method have been astonished at the good re-
sults which have attended their efforts in properly
selected cases. In this country attention has been
called to it by A. O. J. Kelly and Charles A. Fife
of Philadelphia, and Joseph L. Miller of Chicago.'
Miller gives references to the bibliography. Since
the date of these papers (1905) not very much
has been written upon it.

In opposition to most writers. Ferramini" con-
siders that salt is often beneficial in "kidney dis-
eases," and that its withdrawal is nonsense, although
he admits that its administration is often followed
by a temporary increase in the albumin and in the
kidney elements in the urine.

Rumpf^ undertook to throw light on the etiologi-
cal relation of salt-retention in nephritis lay ascer-
taining by chemical analysis whether in various
organs salt is present in undue amount after death ;
and also whether pericardial, pleural, and peritoneal
fluids contained an undue amount of salt in the cases
of kidney disease that he examined. He did not con-
fine his investigations to cases of parenchymatous
nephritis, however, but used the material from all
sorts of cases of nephritis.

He found (a) that in adults in many cases the salt
content of the kidneys e.xceeded that of the blood and
other organs, (&) in many cases the salt content of
the blood and tissues was increased in amount
beyond the normal; (c) the pericardial, pleural, and
peritoneal fluids showed no uniformity in their salt
content, and (rf) the peritoneal fluid in cases other
than nephritis often showed a high salt content.

WidaP was one of the earliest observers to advo-
cate a salt-free diet in this form of nephritis, and in
a recent article read before the seventh French con-
gress for medicine, he repeats his views and gives
his later experience. He considers the object of the
treatment to be twofold : to free the svstem as much
as possible from salt, and therefore from water;
and when this has been accomplished to bring about

*Read at a meeting of the Practitioners' Society of New
York, on Friday. February i, 1907.

a balance between the salt in the body and the per-
meability of the kidneys for salt. He believes that
the patient's food should contain only the natural
amount of salt, i.e. that none should be added arti-
ficially by either cook or patient. In this way the
patient will take only about one and a half grams a
day.

My experience accords with his, that in many
cases, very soon after the beginning of the treat-
ment, edema, and therefore body weight, will dimin-
ish rapidly. This occurs more promptly and more
completely if the patient remain absolutely at rest in
bed. In some cases edema of the lower extremities
does not entirely disappear, and in these diuretics
must be employed. In general, he says, the eflfect
is much more marked in parenchymatous than in in-
terstitial nephritis. I have had scarcely any suc-
cess with well marked interstitial cases.

In some cases of parenchymatous nephritis, after
the edema had disappeared, he allowed patients to
take a little salt, even as much as five, eight, or ten
grams a day, if urinary analysis showed that it was
all excreted. In my experience, a return to an ordi-
nary diet is likely to be followed by a recurrence of
edema.

It seems to be doubtful if diaphoretics are of much
assistance, for in removing water thev remove but
little salt. Saline purgatives remove salt as well as
water, but they cannot be used with sufficient fre-
quency to be of much assistance. Widai thinks that
some diuretics are of material help in removing
the salt, especially the cardiac diuretics, inasmuch
as the arterial tension is often low. Widal and Javal
found squill of little use. Potassium acetate was
better, but very uncertain. Digitalis alone was often
of no value, and of course was contraindicated if the
tension were high. When this was low theobromin
alone or associated with digitalis was often of great
assistance.

Boyd'' in Edinburgh noticed that a patient with
general anascarca conceived a violent dislike of foods
containing salt, and upon following his inclination
in this matter he was surprised to find a marked
diminution in his edema. Boyd's attention was
attracted to the subject in the literature, and he sub-
jected a patient suffering from diffuse nephritis with
anasarca to the influence of salt- free diet. Besides
the anasarca, his patient had serious effusions in both
pleural cavities and the peritoneum. All his food
was prepared without salt, and his fluids were re-
stricted. In two days improvement was noted. His
urine became doubled in amount and he eliminated
large quantities of chlorides. The diuresis contin-
ued until all edema had disappeared. In this case a
patient who had been edematous for years lost all
edema in seventeen davs.

Miller^ discusses the rationale of the condition
and then records his own experience. He notes that
Widal and Javal" have "called attention to the m-
ability of many nephritics to eliminate sodium_ chlo-
rid in a normal manner. The salt retained in the
tissues required a certain amount of water to main-

382

MEDICAL RECORD.

[March 9, 1907

tain it in the proper molecular concentration, thus
leading to edema, and he suggests this as the prob-
able explanation of dropsy in nephritis. This chlo-
rid retention was found chiefly in acute and chronic
parenchymatous nephritis, and especially in patients
who were edematous. The retention was not found
in the interstitial form, and we know that edema,
when it develops in these cases, is usually of cardiac
origin. They, furthermore, decided that the imper-
meability of the kidney to urea and salts did not nec-
essarily go hand in hand, as in the terminal period of
Bright's disease there may be marked retention of
chlorids, but none of urea, phosphates, or sulphates.
They report a case of uremia with daily elimination
of 28 grams of urea, but only 0.39 gram of sodium
chlorid. For this reason they consider the chlorid
elimination as a better index of the functioning
power of the kidney than the excretion of urea, and
that the unfavorable prognosis of a case is associated
with reduced chlorid elimination."

To quote from another part of Miller's paper:
"Only small a'^'^unts of sodium chloride are essential
for the animal economy. According to Bunge, a
person upon a mixed diet requires daily i or 2
grains; most people, however, consume 10 or 20
grams. The excess of chlorid is eliminated chiefly
through the kidneys."

The feces and skin eliminate relatively very small
amounts. The daily elimination of sodium chloride
varies widely under unchanged circumstances in the
same individual without apparent cause.

If salt is increased in amount in the food of pa-
tients suffering from chronic parenchvmatous ne-
phritis, edema develops or increases, albumin in the
urine increases, headache, nausea, and stupor may
develop. "Widal and Javal were able to make the
edema appear and disappear at will by increasing
or withdrawing the chlorides."'

Numerous investigators have confirmed and am-
plified these statements, and it has been shown that
sodium chloride, however administered, whether in
food or subcutaneously, or by enema, is capable very
clearly of inducing or aggravating many of the
symptoms of these patients.

Patients can become more edematous without any
increase in the intake of fluids or any diminution in
the elimination of water by other channels, particu-
larly by tlie skin.

Miller's conclusions are as follows : "In patients
with moderately severe nephritis associated with
edema, the ingestion of large amounts of sodium
chlorid is followed by chloride retention. The pa-
tient gains in weight, the edema becomes more
marked, the albuminuria increases, and symptoms
may develop resembling uremia.

"In patients with very severe nephritis, and espe-
cially those with uremia, chlorid retention is very
marked, as scarcely any of the extra chlorids ad-
ministered is eliminated.

"Individuals with apparently healthy kidneys,
following the ingestion of sodium chlorid, there is
a chloride retention equal to that of mild nephritis.
The individual gains in weight, but there is no visi-
ble edema, no albuminuria, and no uremic symp-
toms."

A year later than the paper by Widal and JavaH
quoted by Miller, they showed that in a case of
small, contracted kidney albuminuria could be in-
creased or diminished uniformlv by increasing or
diminishing the amount of sodium chloride in the
food. They concluded that the albumin in the urine
was entirely uninfluenced by the albumin in the food,
as has long been believed.

It has been suggested' that an explanation of the

belief of many clinicians that in cases of kidney dis-
ease white meats are better borne than dark meats,
is to be found in the habit of using more salt in the
preparation of the dark meats than in the light ones.

Interesting in connection with the general sub-
ject of this paper is a case of persistent edema in an
otherwise healthy person who had acquired the habit
of eating salt inordinately. This case is reported in
the Practitioner by S. H. Bryant.'^ The patient was
a physician, forty years of age, who sought medical
advice on account of persistent edema of the feet
and legs, fearing that he had kidney or heart dis-
ease. He had never been ill before, but had noticed
trifling varicose veins which had never caused any
trouble. Shortly before he sought medical advice
he noticed, in addition to his edema, a feeling of
weight in his legs and a sense of undue fatigue on
slight exertion. Careful examination showed his
organs to be sound, especially his heart and kidneys.
Inquiry into his habits showed an inordinate fond-
ness for salt, which he added even to salt meat and
salt fish, and he confessed to the habit of completely
emptying the saltcellar twice a day at his two princi-
pal meals. His urine contained nearly three times
as much sodium chloride as normal, and had a spe-
cific gravity of 1. 028. It cost him much effort to
abandon his salt, but in two weeks the edema had
perceptibly diminished, and in three weeks it had
disappeared. He was not weighed, but he felt that
he had lost weight as he lost edema.

My colleagues in the New York Hospital, Drs. S.
W. Lambert and L. A. Conner, and myself have
tried the effect of the salt-free diet as a means of
removing fluid in cases of anasarka of various kinds,
and I am much indebted to their efforts for experi-
ence and for clinical material in this subject, and we
have all been greatly aided by the careful observation
of the cases, as well as by the full and accurate notes
made by a very efficient resident staff, and especially
by the house physicians, Drs. Edward Cussler and
Frederick H. Eartlett. In anasarca due to heart
causes or to combined failure of heart power and
interstitial nephritis, I have accomplished very little
with it. Although the statement has been made that
it causes a lowering of blood pressure in high ten-
sion with arteriosclerosis.'" such has not been my
experience. The results of carefully conducted ob-
servations in cases of this class have been almost
uniformlv disappointing in my wards. The diet is
not unpalatable, and can be made sufficiently varied
to be well borne for weeks if necessary, though ordi-
narily a few days will suffice to remove the edema,
or greatly to diminish it.

Unsalted bread is very palatable, especially if made
with milk instead of water. Made in this way, it
does not become hard or dry, if not too long kept.
The bread that I show you this evening was made
with water and is several davs old, and, except on
the surface, is not dry or hard.

It will be obsen-ed that the expression "salt-free"
is not literally correct. Most of the articles that
enter into the diet contain the small amount of salt
with which nature has supplied them. This is merely
intended to convey the idea that no salt is artificially
added to the food. We have usually made some
attempt at the same time to limit the quantity' of
fluids ingested, but it is not necessary to carrv' this
part of the plan to the extent of making the patient
uncomfortable. The daily bill of fare admits of
great variety. We have generally found the follow-
ing sufficient :

Breakfast. — Coffee or tea, eggs, cereals, cream,
fresh butter, fruits, bread made without salt.

10 A.M. — A orlass of milk.

March 9, 1907]

MEDICAL RECORD.

383

Dinner. — Chicken, fish, potato variously prepared,
bread made without salt, ice cream, jelly, fresh but-
ter, cocoa oviii.

J P.M. — A glass of milk or water.

Supper.- — Eggs, chicken, bread without salt, jelly,
custard, cream, fresh butter, tea oviii-

8 P.M. — A glass of milk or water.

Almost any kind of meat or vegetable can be given
to which salt is not added. I wish again to empha-
size the fact that it is especially in cases of general
anasarca from chronic parenchymatous nephritis,
with failing heart power, that it is to be highly
recommended. In many of these cases its effect is
perhaps enhanced by the simultaneous administra-
tion of heart tonics. Of these I have chiefly used
digitalis and theobromin. Of these two theobromin,
in the form of diuretin, is perhaps to be preferred,
but careful observation in my cases justifies the
belief that they really did not contribute to the relief
of the patients, for they raised blood pressure in
none of them. In some cases its operation is facili-
tated and aided by stimulating elimination by the
skin by hot packs given every other day, although,
as I have already said, but little chloride is thus dis-
posed of. In some cases we have called to our aid
irrigation of the colon by hot water, to which sodium
bicarbonate, half an ounce to the pint, has been
added, instead of the more usual chloride, which is
omitted for obvious reasons. It is important to raise
the density of the water used for colon irrigation by
some such indifferent agent, because water alone is
irritating to the mucous membrane. Catharsis helps
in some cases, for which purpose the compound jalap
powder has been much used, but I am convinced
that the most important agent is the negative one of
which I am writing; and in some cases, without
other aid, it will cause a rapid disappearance of
edema.

After complete removal of the edema I am now
administering progressively increasing daily quanti-
ties of salt to these patients, carefully watching for
any recurrence of this symptom, the endeavor being
to ascertain for each patient what his salt equilibrium
may be, but I am not yet prepared to report results
of these observations.

By far the best way of ascertaining the exact
amount of water lost by such a patient is by
weighing him. Measurement of the circumfer-
ence of his abdomen and of his extremities is
of little relative value. Unless some other illness
supervenes, he loses no weight except water, for he
is very well nourished by the food that he takes, so
that by weighing him we have a fairly exact means
of ascertaining the result that we are bringing about.

The change in his appearance is usually very
striking. In a few days a patient whose eyes were
almost closed by facial edema often shows no puffi-
ness of the face at all.

It is of interest that the disappearance of edema is
not always accompanied by any very obvious increase
in the amount of urine passed, though this some-
times also happens. He must lose water in other
ways, and he often loses both salt and water by the
bowel.

Case I. — William C, age 24, a carpenter, entered
the hospital August 3, 1906. He had edema of the
legs and scrotum, and penis, besides a large amount
of fluid in his left chest. His urine was of high
specific gravity, and contained a large amount of
albumin and hyaline, and granular casts. His blood
pressure was low and continued so, from 100 to 120
mm., as a rule.

Under cardiac stimulation by digitalis, or diuretin,
colon irrigation by salt solution, to which potassium

iodide and purgation were added, his edema fluctu-
ated in amount, and finally returned, and fluid accu-
mulated in both sides of his chest and his abdomen,
necessitating frequent tapping of the chest. On one
occasion two quarts of fluid were withdrawn from
his abdomen.

Up to the 14th of September, 8,850 c.c. of fluid
were mechanically withdrawn from his serous cavi-
ties, and dyspnea had become urgent. He was then
put upon the salt-free diet, and his fluids were re-
stricted to between 40 and 50 ounces a day. His
weight at this time was 160 pounds, in spite of the
fact that within the previous seven days 3,150 c.c. of
serum had been withdrawn from his cavities, or a
little over six pounds in weight.

He had been six weeks under the usual treatment
of the condition without any but transitory improve-
ment in his symptoms. During these six weeks 16
pounds of fluid in all were mechanically removed
from his cavities. After the salt-free diet was com-
menced his chest required only two tappings, by
which 4 pounds of fluid were withdrawn ; and then,
coinciding with the rapid disappearance of edema,
there was no recurrence of fluid in any of his cavi-
ties. Under this diet he lost in twenty days 32
pounds in weight, which I believe it fair to consider
T,2 pounds of fluid ; he felt well, looked like a differ-
ent man, was up and about all day, and left the hos-
pital on the 8th of October without any appearance
of edema, and weighing 128 pounds as compared
with 160 pounds three weeks previously.

In him blood pressure seemed to be uninfluenced
by any treatment to which he was subjected, and this
accords with the fact that he was only little improved
bv cardiac stimulants and the other therapeutic
efforts until the salt-free diet was tried. The re-
sults following upon this fact would seem to justify
the assumption that it was the chief cause of his
recovery.

Case II. — Was an Italian, Antonio G., a gilder by
occupation, 40 years of age. He entered the hos-
pital on the 27th of July with fluid in both chests
and the abdominal cavity, and edema, which was
especially marked in the abdominal wall, genitals
and lower e.xtremities.

His urine. 28 ounces on admission, always con-
tained albumin. Before the salt-free diet was com-
menced this reached the amount of .6 per cent. ;
hyaline and granular casts were abundant, and its
specific gravity fluctuated between 1,008 and 1,025.
His blood pressure was not uniform, but fluctuated,
without obvious cause, between limits as wide as
140 and 210 mm., and when high it failed to respond
to the dilators. Under symptomatic treatment which
was intelligently tried for seven weeks, the edema
was at times diminished in amount, but it always re-
turned to the original extent when he was allowed
to get up. Headache was very troublesome through-
out this period.

The salt-free diet with restriction of fluids was
tried from the 15th of September to the 8th of Octo-
ber, when he left the hospital greatly improved. In
these three weeks he lost 22 pounds in weight, his
headache and dvspnea disappeared, all the fluid left
his serous cavities without tapping, and the edema
vanished. In this case the urine became and re-
mained higher in amount than it had been under
symptomatic treatment, its fluctuation being between
35 and 71 ounces.

' The hot pack was used throughout his treatment,
and in it he perspired freely ; but, as in the last case,
no complete alleviation of symptoms took place
until the salt was withdrawn from his food.

Case III.— Another, .Antonio C, a Spaniard, a

3^4

MEDICAL RECORD.

[March 9, 1907

cook by occupation, 39 years of ajje, was admitted
on November 30, 1906. He had been twice in the
hospital before, and we knew him well. His urine
contained .3 per cent, albumin and hyaline and gran-
ular casts, and had a specific gravity of 1,018, and
he was passing 57 ounces. The last time he was in
the hospital he was discharged improved on Novem-
ber 14, 1906, with the diagnosis chronic nephritis,
chronic myocarditis, and dilatation of the heart, and
cirrhosis of the liver.

His distress was great on his readmission, and
was sufficientlv accounted for by the presence of
fluid in both pleural cavities and abdomen, as well
as by edema in his arms, abdominal wall, genitals,
and lower extremities. His blood pressure was 126
mm. He was at once put upon a salt-free diet,
together with a mi.xture containing in each dose two
minims of the fluid extract of digitalis, twenty of the
fluid extract o! convallaria, and five grains of pota.';-
sium iodide. .\t first he was too ill to be able to
stand on the scales for the purpose of being weighed,
but after three days of treatment he weighed 147
pounds. In four days the improvement in his gen-
eral appearance was very obvious, and in ten days
his edema was practically all gone, and he had lost
fifteen pounds in weight. He was then up and about
the ward without any return of it for five days more,
when he felt so well he went to his work.

His blood pressure was not raised by the treat-
ment, and was usually below the level recorded on
his admission, fluctuating generally between 90 and
no mm. His urine increased from 57 ounces to 72
ounces a day as the edema left him.

He told us that his weight of 132 pounds, which
he reached on the tenth dav of treatment, was his
normal weight.

Case IV. — Andrew K., a laborer, a native of Aus-
tria, 26 years of age. was admitted on October 5. and
remained until December 19, 1906.

He was suflfering from chronic parenchymatous
nephritis with anasarka and double hydrothorax and
ascites. On admission his entire body from his eyes
down was edematous, his genitals being especially
so. His urine was of low gravity and contained .9
per cent, albumin and hyaline, granular and epithe-
lial casts, some blood cells, and some pus. His blood
pressure was 130 mm. on admission, and it usually
fluctuated between that and 160 during his treat-
ment, except during the occurrence of an attack of
colitis, W'hen it fell to 100. and remained between that
and 1 10 for twelve days.

His case is of unusual interest, because while
under treatment, and while showing marked im-
provement in the extent of anasarka, he developed
an acute and severe colitis. Before this occurred he
had lost 51 pounds of fluid, his weight having fallen
from 215 pounds to 164 pounds in about six weeks.
During this time the improvement in all of his worst
symptoms was very marked, in spite of the fact that
he developed incidentally acute pleurisy and peri-
carditis. During the colitis his diet was necessarily
changed, and salt was not withheld. .At first, after
this change, he continued to lose weight — w'hat w-e
might call "good" weight as distinguished from
fluid — and his nutrition suffered severely. He lost
thus sixteen pounds which he could ill afford. Dur-
ing his convalescence from the colitis on an invalid
diet from which salt was not excluded, he gained
twenty-three and a half pounds, and again showed
evidences of considerable anasarka. \Vhen he had
completely recovered from his colitis, the salt-free
diet was resumed, and he sustained a loss of weight
in two weeks of twelve pounds. His total net reduc-
tion in weight was thus fifty-five pounds. This was

not all due to his diet, for the reason that his chests
required frequent tapping, and thus large amounts
of fluid were withdrawn ; but until the influence of
the diet was felt the fluid thus removed reaccumu-
lated rapidly. Besides this, it must be said that, in
this case as in most of the others, reliance was not
placed on the diet as the sole means of treatment,
for hot packs, colon irrigation with hot sodium
bicarbonate solution, and purging with compound
jalap powder were all resorted to. .\s the result of
it all, his edema disappeared, and the fluid ceased to
recur in his chests, and he held the ground that he
had gained, although allowed to be up and dressed
and about the ward. On his discharge he declared
that he felt better than he had for months. The
amount of his urine fluctuated very widely, between
33 ounces on admission and 152 ounces after his con-
valescence from colitis.

C.-\SE \'. — One of our most striking cases was Joe
L., a boy nine years of age, whose kidneys had been
decapsulated four times in the preceding two years
to aid in the removal of general anasarka which was
always associated with almost complete suppression
of urine. On each of these occasions the result had
been satisfactory, though it was in part due to other
means besides the operation, such as hot packs and
cardiac stimulation.

His original kidney trouble was a parenchymatous
lesion follow^ing scarlatina. On this latest occasion,
it was concluded to try, instead of surgery, the salt-
free diet W'ith colon irrigation and hot packs, as well
as cardiac stimulation. It was found by trial that he
did much better on this combination than he did
when treatment was confined to the diet alone. In
a month he lost twelve pounds, which was about 20
per cent, of his total weight. His abdomen contained
a large amount of water when treatment was begun.
This entirely disappeared without tapping and its
circumference diminshed by five inches.

Inasmuch as he was a growing boy of nine years,
and inasmuch as he visibly increased in height dur-
ing the two and a half months that he was under ob-
servation, his total loss of twelve pounds, or 20 per
cent, of his body weight, is probably really much
larger than it would appear to be from the figures.

From a pitiably quiet, somnolent, dull boy, who
could hardly open his eyes at all on account of facial
edema, he became as bright and talkative, and active
as anv child in the ward. His urine increased from
5, 10, and 15 ounces just after his admission to 35,
40, and 50 ounces as his treatment progressed. On
former occasions decapsulation was always finally
resorted to after failure to relieve him by all the
other means to which resort was had on this occa-
sion, except the diet, and it seems fair to assume,
therefore, that on this occasion the diet replaced the
surgical procedure which had become usual with
him. In other children the effect has been more
marked and more prompt.

Case \ I. — John R., age 10. was admitted on the
4th of January, 1907. Five months previously, with-
out know'n exposure to any of the exanthemata, he
began to grow weak, pale, and short of breath. One
month before admission his ankles began to swell,
and soon thereafter his face, eyelids, all of his ex-
tremities, tlie skin of chest and abdomen, as well as
■ if his genitals, became much swollen. His parents
brought him to the hospital on account of the general
anasarca and dxspnea. Besides fluid in the subcu-
taneous tissues, it was found on examination that
there was fluid also in his abdomen and his right
chest. His blood pressure was 100 mm., and it did
not vary materially from that level. His urine con-
tained a considerable quantity of albumin, and hya-

March 9, 1907]

MEDICAL RECORD.

385

line and granular casts. He passed during the first
two days 9 and 16 ounces, respectively. His weight
on admission was 65^/2 pounds. He was put upon
a salt-free diet, colon irrigation, and, every other day,
hot packs. Diuretin, digitalis, and strychnine were
given at different times, but it is very doubtful if
they were of any assistance, for the blood pressure
did not vary appreciably while they were taken.

A few days after his admission 600 c.c. of fluid
were withdrawn from right chest by aspiration.

The fluid did not recur in his chest and disap-
peared from his abdomen, and in less than two weeks
his anasarca had completely disappeared, his color
had improved, he felt bright and well, and was al-
lowed to use a wheel chair, and then to walk about.
His urine increased in amount from 9 to 20, 30, 40,
and as a maximum 51 ounces.

His kidney condition, of course, is not cured, but
his edema has entirely disappeared, and though
somewhat pale he looks like a well boy.

C.»iSE Vn. — Lucy P., age 5 years, was admitted
on January 9, 1907. She was perfectly well until
six months ago. Her father is a telephone operator
in a hospital for the exanthemata, and, though she
is not known to have had any illness since her baby-
hood, one must suspect the possibility of her having
contracted one of the exanthemata without its hav-
ing been recognized.

Six months before her admission she began to
complain of abdominal pains, and then soon after,
puffiness of the eyes was noticed, and later her ankles
and legs, and abdomen had become swollen. Of late
she had been passing only a small amount of urine.

On admission she presented all of the evidences
of anasarca noted above. Her eyes were almost
closed ; her abdomen contained a small amount of
fluid, but not enough to give a fluid wave on percus-
sion. Her urine could not be measured, as it was
in part passed involuntarily, but it was clearly small
in quantity. It contained a considerable quantity
of albumin, and hyaline and granular casts. Blood
pressure was 105 mm. ; weight was 36 pounds.

Treatment, which was begun at once, consisted
in salt-free diet, diuretin, hot pack every secondday,
colon irrigation, and small doses of compound jalap
powder.

Improvement began on the second day, and by the
eighth day the edema had entirely gone, and her gen-
eral condition was correspondingly improved. She
was allowed to get up and play about the ward with
the other children, and left the hospital on the four-
teenth day, looking apparently well, although her
kidney lesion of course persisted.
REFERENCES.

1. Transactions of the Association of American Physi-
cians. Vol. XX, 1905, pp. 428 et seq.

2. Schmidt's Jahrbiichcr, Bd., 285, 1905, s. 246.
3 Munchener mcd. IVocJicnschrift, LII, 9, 1905.

4. Journal medical dc Bruxclles, 1906, No. 2.

5. Scottish Mcd. and Stirg. Journal, igo6, Feb.

6. Pressc Medicale. 1903.

7. Bulletin Medical. 1904. No. 59, p. 695.

8. Fortschritte der Mcdizin, 1904, 22, s. 1071.

9. Practitioner. August, 1905, pp. 168-171.

10. Krehl: Deutsche med. Wochenschrift. XXI, 47, 1905.

Appendicostomy. — Drawing the appendix out through
B laparotomy incision and fixing it in this position after
cutting off its tip has already been found of great ser-
vice for the purpose of performing irrigation of the
colon in cases of obstinate colitis, but Gil suggests that
by tliis means intestinal distention of a serious grade
may be combated, and also that rectal artificial feeding
can be more effectively carried on through the appendix
than through the rectum. — Revista de Medicina y Cirujia
de Madrid.

INFLUENZA: MASTOID ABSCESS; LEP-
TOMENINGITIS; NINE-DAY UNCON-
SCIOUSNESS; THREE OPERA-
TIONS; DEATH; AUTOPSY.*

Bv H. BROOKER HULLS, M.D.,

PHILADELPHIA,

ASSISTANT PEDIATRICIAN TO THE PHILADELPHIA HOSPITAL.

AND

NATHAN G. WARD. M.D.,

PHILADELPHIA.

CLINICAL PROFESSOR OP LARYNGOLOGY AND OTOLOGY IN THE MEDICAL

DEPARTMENT OP TEMPLE COLLEGE; LARYNGOLOGIST AND OTOLOGIST

TO ST. AGNES HOSPITAL; LARYNGOLOGIST AND OTOLOGIST TO

THE SAMARITAN HOSPITAL.

The points of especial interest in the case we are
about to report are the following: Attack of in-
fluenza, followed by mastoid abscess; suppuration
and necrosis of the ethmoid ; relief of symptoms,
except headache, following operation ; sudden de-
velopment of violent pain in the head ; unconscious-
ness for nine days ; restlessness ; high remittent tem-
perature; no palsies or other localizing symptoms;
purulent leptomeningitis ; pus in the cerebral ven-
tricles ; death ; autopsy.

L. J., male, thirty-nine years ; foreman in a cloth-
ing manufactory, first consulted Dr. Mills May 21,
1906. For several days he had had chills, sore
throat, headache, backache, and legache, but no
cough, nausea, or perspiration, and no appetite;
bowels open freely; temperature, 102°; pulse, 102;
diagnosis, influenza. The facial expression was that
of a very sick man ; he was ordered to bed, and treat-
ment prescribed. The following day he was some-
what improved and reported having had a good
night, but was complaining of some aching in the
right ear. The treatment was continued and hot
water bag applied to the ear. The following day
he complained of considerable pain on the top of
the head, and excessive discharge from the right
ear, which, in spite of local and constitutional treat-
ment, continued for ten days, with a temperature
and pulse each averaging about 100. Suddenly, on
June 3, 1906, ptosis of the right eyelid developed,
with increased headache, and Dr. Ward was called
in consultation. The conditions which led to the
decision for prompt mastoid operation were the
ptosis of the right eyelid, the swelling of the right
cheek, excessive and increased pain, radiating over
the right half of the head, and persistence and
increase of the enormous discharge. There was a
large perforation in the posterior inferior quadrant
of the tympanic membrane, but no bulging. The
internal posterior wall of the canal, which forms
the anterior wall of the mastoid antrum, was red
and tender, but no sagging of any part of the canal.
Slight edema over the mastoid and slight tenderness
on deep pressure. Throughout the disease, and
increased that day, there was a continued soreness
over all parts of the cheek, gums, and tongue of a
neuralgic character. On examination of the mouth
there was not sufficient evidence to account for the
pain, and as stimulation of the tympanic nerve in
the tvmpanum caused a nrickling feeling in the tip
of the tongue, we attributed the soreness to the
pus in the tympanum. Uranalysis made just before
the operation was negative, except for an excessive
amount of uric acid,

First Operation. — June 4, 1906, Dr. Ward, as-
sisted by Dr. Carle Lee Felt, operated on the mas-
toid. The cortex was exceedingly thick and dense ;
cells small; septi resistant, ths chisel was required

♦Reported at a meeting of the Philadelphia County Medi-
cal Society. ,

386

MEDICAL RECORD.

[March g, 1907

to break them down : pus was found near the sur-
face at the middle and tip ; it was thick and yellow
and in dro])s, showing recent formation. There
were dark spots in various parts of the bone. No
necrosis and no dead or bare bone in the antrum.
The whole cancellous tissue, includina: the tip, was
removed. The usual dressing was applied. At the
close of the operation the temperature was 98.8°,
pulse 124, respirations 26. .At midnight the tem-
perature was 102.6°, pulse 132, respirations 24.
After a restless night, at 9 a.m. the temperature
was 98.2°, pulse 112, respirations 22; June 6, the
^west temperature was 99.6°, pulse 110, respira-
tions 24: the highest temperature was 103.6°, pulse
108, respirations 22, where it stayed with slight
remissions until June 7, at 3 p..m., when the wound
was dressed for the first time ; in splendid condi-
tion. June 8, at 12 m., the temperature was normal,
pulse 98, respirations 20; the highest for the day
at 3 P.M., temperature, 102.4°; pulse, 96; respira-
tions, 18. The wound was dressed, followed by a
drop to normal on June 9. at 7 .-v.m. At 3 p.m. the
temperature was 99.4°, pulse no, respirations 20.
June 13, at 7 a.m., the temperature was normal; at
I P.M., 99 2-5° ; pulse, 94; respirations, 18. The
patient had been out of bed a part of each day after
June II; had gone to the toilet; was sleeping
through the entire night and feeling comfortable.
The conditions were considered favorable and the
services of the nurse were dispensed with. From
June 13 to 16 no temperature chart was kept;
when the temperature was taken at irregular inter-
vals, it was normal or only a fraction above. The
anpetite was very much improved ; bowels, freely
open : nights, fairly restful, and the patient was
decidedly hopeful.

-After increasing the amount of time out of bed
each day, on June 16, at Dr. Mills" visit, the patient
inquired as to how soon he could go downstairs and
out of doors, and was making plans to take his
family out of the citv. Dr. ]\lills told him that he
could do so the next dav, if it met with the ap-
proval of Dr. Ward. In spite of the patient's good
record, he wore a verv anxious expression, and on
close questioning admitted that he was not feeling
as well as he would have one believe. At Dr.
Ward's visit, four hours afterward, the patient hav-
ing had a short sleep, felt much refreshed, seemed
rather cheerful, and, without referring to the con-
versation with Dr. Alills about going out, asked
when he could do so, and was told, if he felt as
well the next day, he could go downstairs : but if
the exertion caused much fatigue, to at once return
and lie down. The wound was dressed ; it was
in excellent condition : no more discharge than
could be accounted for bv the forming granula-
tions.

During the entire illness and, in spite of local
and constitutional treatnient, at no time was he
apparently free from pain on the top of the head,
worse during the higher temperatures and most
severe during coughing or sneezing.

Sunday, June 17. at abrut S .-\.m., after sleeping
soundly all night, the patient was awakened sud-
denly by a severe and excruciating pain in the head,
which became imbearahle. .\t 7 o'clock a messen-
ger w^as sent to Dr. Mills' office, stating that the
patient was almost insane from pain, and demanding
some relief. Six tablets, each containing T-20
of a grain of morphine, were sent, with instruc-
tions to give two everv half hour until relieved.
Before the messenger returned the wife had given
the patient 1-4 of a grain of morphine which she
found left from a previous prescription. Four

of the tablets sent were given, making total of
Q-20 of a grain of morphine administered by the
mouth in the course of about an hour, following
which the patient went into a sound sleep, from
which he never awoke. I'our hours later, Dr.
INlills called and found the patient sleeping soundly;
pupils evenly and moderately dilated ; pulse rapid,
regular, and strong ; respirations regular and deep ;
skin moist; facial expression that of a man sleep-
ing normally. The family were advised to leave
the patient undisturbed until later in the day. The
inability of the family to rouse the patient, together
with the fact that, the day being Sunday, many
relatives and friends were at the house, and, each
expressing a different opinion, added to the anxiety
caused by the long sleep ; they became alarmed, and
at 2 r.ji. sent or Dr. Mills. As he could not be
immediately gotten. Dr. H. N. Abbott, a nearbv
physician, was hurriedly sent for. and at that time,
and at 6 p.m., when he was called again, the follow-
ing was his opinion: ''The condition of the patient
was practically the same at both visits ; that is, one
of profound stupor, and when aroused he would
at once relapse into his former condition. The
pupils were normal ; he w as slightly feverish ; res-
pirations, somewhat hurried ; circulation in the ex-
tremities not very good. Shortly before my first
visit the patient experienced a severe vomiting spell,
without regaining consciousness. Excluding the
kidnevs and considering the marked drowsiness, my
opinion was that the stupor was due to the effect
of the morphine, and, acting on that assumption,
I recommended the administration, by mouth an(j
per enema, of black coffee."

Dr. Mills called about 6 p.m., and finding Dr.
.Abbott there, a conference was held. It was be-
lieved that the sleep was the result of the morphine,
and the black coffee was ordered continued. Dr.
Mills returned later in the evening and found the
patient still sleeping soundlv. There was no indi-
cation for treatment other than that employed,
which was continued. -At about 11 p.m., a con-
sultation over the telephone was held betw-een Dr.
Mills and Dr. Ward, the latter being out of the
citv and not accessible during the day ; the treat-
ment outlined was approved.

Monday, June 18. The patient had been in al-
most constant motion since midnight, requiring the
closest watching bv two attendants to keep him
from rolling out of bed, and, on this account, a
nurse was hurriedly gotten. There being no local-
izing svmptoms. or other indications for interven-
tion, we decided to continue the expectant treat-
ment. At 12 M. the temperature was 102°, pulse
<S4. respirations 36. Especial attention is called to
the fact that this and all subsequent temperatures
were taken in the axilla. At 3 p.m. and at 9 p.m.
the temperature was 103°, pulse 108, respirations
36. At midnight, temperature 102°. pulse 66, res-
pirations 24. On dressing the wound granulations
were found to be healthv. No swelling along the
line of the internal jugulars, though both sides were
equally tender : the breath w^as fetid ; no discharge
from the nostrils. Beginning, Sunday, June 17,
and continuing until death, there was incontinence
of urine and feces. The pupils varied frequently,
but equally ; sometimes dilated, at others contracted,
with the greater tendencv to dilatation: at all times
acting together. There was no nvstagmus at any
time during the progress of the disease.

Tuesday, June 19. at 6 a.m., temperature 99.5',
pulse 74, respirations 20. At i p.m. a considta-
tion was held between Drs. Mills, ^^'ard, and Felt :
temperature. 102° ; pulse, 88 : respirations, 26. The

March g, 1907J

MEDICAL RECORD.

387

patient resisted the examination, pulled away, and
tried to get out of bed on the opposite side. He was
permitted to place his feet on the floor and sit on
the side of the bed, and was held in that position.
Eyes, nose, and throat were examined. On attempt-
ing to use the ophthalmoscope, the light caused
severe pain, the lids had to be held forcibly open,
the eyes were in constant motion. It was impossi-
ble to get a view of the nerve head ; the media were
clear ; vessels in various parts of the retina could
be distinctly seen ; no abnormal conditions detected.
The breath was very fetid. In the right nostril
the middle turbinal was swollen and edematous ;
pressure produced pain as compared to examination
of the left nostril, which was normal. Examina-
tion indicated suppuration of the right ethmoid,
and possibly involving the sphenoid sinus. When
the examination was completed the patient stood
up, which we permitted him to do in order to de-
termine whether there was any incoordination or
vertigo; he looked around in a vague, staring man-
ner, as if endeavoring to locate the bed, turned,
drew the covers back, crawled into bed, and lav-
down in the proper position : all without any ap-
parent consciousness. There was not the least in-
coordination, nor did he seem to experience the
slightest sensation of vertigo, although assuming
the erect position comparatively suddenly and un-
assisted. There was no evidence of any twitchings,
palsies, awkwardness in movement, or tenderness
in any part of the body, although the sensory re-
flexes seemed exaggerated ; no swelling or cord-
like sensations along the line of the internal jugu-
lars. The patient held his hand on the top of his
head, as if in pain ; but there was no evidence of its
being increased bv exertion or bv pressure or tap-
ping. It was our opinion that there were no indi-
cations for opening the skull ; but, on the contrary,
such a course would have been unwarranted.

Second Operation. — At 4 p.m. the patient was
again etherized, and Dr. Ward, assisted by Dr. Felt,
removed the anterior end of the right turbinal and
opened the ethmoid. Pus and necrosed bone were
found in the posterior ethmoid cells. The dead
bone was removed and the curette forced back into
the sphenoid. The condition of the sphenoid, as
well as could be determined by the sense of touch
transmitted through the probe and curette, was that
the membrane was thickened and swollen ; no ne-
crosed or bare bone. A strip of iodoform gauze
was inserted to facilitate drainage, and not to pre-
vent hemorrhage and thus dam back the pus, free
hemorrhage being rather desired to wash out anv
drops of pus that might have been left after the
curettage. The mastoid wound was dressed and
was in excellent condition. At 6 p.m., at the close
of the operation, temperature 102.4°, pulse 137,
respirations, t,^. The temperature rose, and at 0 p.m.
It was 104.6°, pulse 120, respirations 36. Upon
coming out of the anesthetic, the restlessness again
became very marked, keeping the nurse constantly
going from one side of the bed to the other, not
to keep the patient from getting out of bed, but
to prevent him from rolling out!

June 20, at 7 a.m., temperature 102.2°, pulse 114,
respirations 37 ; there were onlv slight changes dur-
ing the day. During the afternoon the patient
changed the position of his hand, which had been
almost constantly at the vertex, to the forehead.
1 his change was not due to weakness, as at times
he would cross both hands, and rest them on the
pillow above his head, as if to assume a more com-
tortab e position. There was also noticed a modi-
tied Cheyne-Stokes breathing. The respirations de-

clined until very weak ; without a pause the cycle
was terminated by one or more deep full inspira-
tions, when the succeeding decline began. This
character of breathing continued, more or less
marked, until death.

June 21, at 9 a.m., temperature 102°, pulse 114,
respirations 28, with only slight changes during
the day. The patient showed the most rational
signs of semiconsciousness that were present at any
time during the sleep. He apparently recognized
a relative for a moment, and, in response to ques-
tions, repeated the last word of the question. When
requested by the nurse to turn over, would at first
resist, but afterwards made efforts to assist her.
Upon dressing the mastoid wound, the muscles at
the back of the neck were rigid. Attempts to lift
the head from the pillow caused much pain, a min-
ute later the muscles had relaxed, and there was
no difficulty in raising the head to apply the dress-
ings. This was the first time that retraction of
the head and muscular rigidity had been observed ;
it became permanent during the night, and con-
tinued throughout the remainder of the illness. The
nurse noticed that considerable restlessness pre-
ceded such urination, and, after several attempts,
succeeded in collecting a small quantity, which
showed albumin for the first time (about one-half
bulk), and, as before, a very heavy uric acid deposit ;
no casts nor any other abnormalities. There hav-
ing been no improvement in his condition, except
for the more favorable pulse and temperature, mem-
bers of the family becoming more anxious at the
prolonged sleep, and being disappointed that there
should have been so little improvement in his men-
tality, following the second operation, it was de-
cided to have the opinion of a neurologist to assist
in determining the advisability or not of trephining ;
at least there would be the satisfaction of making
sure that the opinions and treatment thus far were
correct and nothing had been left undone. Dr. Lu-
ther C. Peter was called in consultation at 8.30 p.m.
After a careful examination the following was his
opinion :

"(.)n examination of L. J. I find the following-
conditions : He is restless in the dorsal decubitus,
moves extremities constantly, presses hand to head,
and, from the facial expression, it is quite apparent
that he is suffering from intense pain in the head.
His breathing is not heavy; he lies in a semistupor,
from which he can be partially aroused by talking,
and by moving any part of his body, which he
strongly resists, giving evidence of pain. Under
close questioning he can, for a moment, compre-
hend and answers in monosyllables ; but very quick-
Iv relapses into a semiconscious state. There are
no palsies of the arms, legs, or face ; but the left
side of the body is more resistant to passive move-
ment than the right. The deep reflexes are all
present, more marked on the right, and increased
in the upper extremities, as compared with the
knee jerks. The Babinski reflex is absent. Kernig's
sign, inability to flex the thigh on abdomen, with
legs extended, is present, and attempts to forcibly
flex the legs at right angles to the body cause pain.
Touch and pain are apparently recognized. No
muscular rigiditv. save in the post-cervical muscles,
which are in a state of spasticity. Attempts to raise
the head cause the neck muscles to be held rigidly
and the entire bodv is lifted ; there is a tendencA'
to retraction of the neck and head, when the patient
is at rest; incomplete ptosis of both upper eyelids,
but no other extraocular palsies : the left pupil is
larger and responds more sluggishly to light ; res-
pirations irregular : an attempt at Cheyne-Stokes

388

MEDICAL RECORD.

[March 9, 1907

breathing. The marked pain in the head, cervical
rigidity, Kernig's sign, ptosis, and rapid pupillary
phenomena, together with the temperature record,
rapid pulse, and irregular respirations point to a
basal meningitis of the middle fossa. Pus in the
brain itself, if present at all, is masked by the
meningeal symptoms, and in the absence of local-
izing symptoms, other than those of the basal men-
ingitis, operative interference for the intracranial
disease is not indicated. The diagnosis is basal
meningitis, beginning possibly in the temporal lobe
on the right, adjacent to the mastoid area, and a
sequence or a complication of the mastoid disease."

At the time of the consultation it was agreed,
in spite of the absence of indications for intra-
cranial interference, that should the patient show no
improvement or further signs of returning con-
sciousness, at the worst it could do no harm and
might be warranted in an efifort to obtain relief
from the pressure symptoms.

June 22. Starting at 6. p.m. on June 21, the tem-
perature gradually rose, and at 4 p.m., on June 22,
it was 104.8°, pulse 120, respirations 24. At i p.m.
we saw the patient. It was apparent that, since
the time of the consultation with Dr. Peter, he
had lost considerable ground. He was more pro-
foundly unconscious ; restlessness replaced by quiet-
ness, and a continuous rise in temperature. We
explained the conditions fully to the family, who
strengthened our partial decision to take further
surgical measures by urging that we should take
any chance which seemed at all warranted, or in
the least indicated. A uranalysis was made, which
showed considerable phosphatic excess for the first
time : albumin present, somewhat less than at the
previous examination : and, also, for the first time,
a large amount of indican, and an occasional finely
granular tube cast. It was decided to open the
frontal sinus, as all the symptoms had been referred
over the distribution of the fifth nerve, and as
dead bone was found in the ethmoid, although none
in the sphenoid, it was thought that there might
be suppuration in the frontal sinus, with perfora-
tion and extension to the meninges.

Third Operation.- — At 4 p.m. the patient was
etherized for the third time, and Dr. Ward, as-
sisted by Dr. Felt, opened the frontal sinus from
the anterior surface. There was free bleeding ;
no pus, necrosis, or bare bone ; gauze drainage and
dressing applied. The mastoid wound was dressed ;
granulations looked healthy. The drainage in the
nasal cavity had been, and was, satisfactory ; marked
diminution in the fetor of the breath. At 6 p.m.,
at the close of the operation, the temperature ■(yas
103°, pulse 120, respirations 42; at midnight, tem-
perature 100.8°, pulse 116, respirations 38.

Tune 23. The temperature gradually rose from
midnight. At 11 a.m. it was 104.8°, pulse 144, res-
pirations 46, followed by slight changes, until it
dropped at 7 p.m. to a temperature of 102°, pulse
138, respirations 54. During the twenty-four hours
following the third operation, with the exception of
the pulse and temperature variations, there was lit-
tle or no change in the patient's condition. He was
restless throughout the night ; acted as if it hurt
him to swallow. This difficulty in swallowing ap-
peared greater as the night wore on. Examination
of the throat bv Dr. Ward showed marked dry-
ness, but nothing further to account for the diffi-
cultv in swallowing. Respirations, at irregular in-
tervals, became more distinctly Cheyne-Stokes ; the
pain in the head and rigiditv of the neck became
verv marked. He stronglv resisted all efforts to
turn him in bed. The pupils responded to bright

light, but not to that of .a match or candle. We
discussed the advisabilitv of lumbar puncture as a
means of relieving the intracranial pressure.

At I P.M., according to a previous arrangement
made by members of the family. Dr. Frank White,
the wife's physician, met us in consultation. The
history of the case in detail, together with the
nurse's record and the temperature charts, were
gone over with him. He was especially requested to
make any criticisms of the treatment to date, and
particularly to offer any suggestions for further
treatment. Dr. White was inclined to lean towards
more surgical interference. He felt as we did, and
as members of the family had frequently expressed
themselves, that almost anything for which there
seemed to be the least excuse or indication was not
only excusable, but warranted. When pressed, how-
ever, to designate the kind and location of further
surgical procedure, particularly its nature and lo-
cality, he admitted that he felt exactly as we did,
viz., that there was no positive indication for any
intracranial interference.

From 7 P.M. to midnight the temperature varied,
with quick changes, from 102.4° to 104.8°, pulse
120 to 132, respirations 44 to 50. The patient had
several sinking spells, one of them during Dr. Mills'
visit, at 9 P.M.J and the ntirse was instructed to re-
port to him, by telephone, the patient's condition
at II P.M., which she did. Dr. Mills tried to reach
Dr. Ward by telephone, but could not locate him.
He then called Dr. H. P. AIcAniff, and they visited
the patient and punctured the spinal canal at the
juncture of the second and third lumbar vertebrae,
but even after applying suction to the needle not
a drop of fluid was obtamed ; the operation was
repeated, with no greater success. As it was evi-
dent the needle had entered the canal, the failure
was attributed to the coagulated condition of the
spinal fluid. The patient gave slight evidences of
pain upon the insertion of the needle, but offered
almost no resistance ; no signs of discomfort fol-
lowed the operation.

June 24 temperature varied from 102° to 104.2°,
pulse from 130 to 168, respirations 46 to 67. We
called at 12.30 p.m. The mastoid and frontal wounds
were dressed ; the latter was in excellent condition.
The former for the first time showed increased
discharge, which continued until death. No evi-
dence of increased inflammation in or about the
wounds. The breath was again extremely fetid ;
profound general depression. At that time, and also
the dav before, Dr. Ward noticed the right side
of the face was drawn, indicating irritation of the
facial nerve ; in a few moments it was relaxed.
During the afternoon the difficulty in swallowing
grew less, and in its place, when taking nourish-
ment, there was more or less coughing, as if it
gagged him. In spite of this he took his nourish-
ment fairlv well. At Q p.jr. he was unable to swal-
low any food, and did not during the remainder of
the illness, nourishment being given entirely by
enemas, which were all retained.

June 25. Temperature varied between 102° and
103.6°, pulse 150 to 168. respirations 52 to 66. At
2 A.M. the respirations became very shallow, pulse
very weak; the patient was oerfectly quiet: the eyes
were open during the entire night. During the
early morning the patient made several attempts to
clear his throat, but with )ut apparent result. At 8
A.M. the pulse became intermittent. At 11 a.m. shal-
low stertorous breathing developed, which continued
until death, at 3 p.m.

Autopsy. — On the evening of Monday, June 25,
the date of death, an autopsy was performed, Drs.

March 9, 1907'

MEDICAL RECORD.

389

Felt, Mcx-\niff, Abbott, Mills, and Ward being pres-
ent. Unfortunately, it was not possible to locate
Dr. Peter in time for him to be there.

On removing the calvarium there was nothing
particularly striking about the superficial surface
of the brain other than the presence of purulent
leptomeningitis, the pus being diffused over the
whole surface of the brain, extending down into
each sulcus, more particilarly noticeable over the
left frontal and precentral lobes. Careful examina-
tion was made of all the venous sinuses to ascertain
whether or not there had been sinus thrombosis,
with entirely negative results. Upon raising the
brain from the base of the skull, it was observed
that the subarachnoid space was completely filled
with thick, yellow pus, entirelv surrounding the
medulla and extending down the side of the cord
as far as could be observed. The nerves and ves-
sels appeared as if macerated by the pus surround-
ing them, and very little traction was needed to tear
them loose ; the spinal cord alone required to be
cut. As permission to take away any part of the
body was not obtained, histological examination of
the brain structure could not be made. Coronal
sections through all parts of the brain were made
to determine the condition of its interior. The cor-
tex seemed very much softened and pulpy and had
the appearance of pus along the vessel sheaths. The
white matter of the brain was less dense than nor-
mal. The ventricles, especiallv the lateral, were
widely distended with thick, greenish pus, and upon
section of the posterior cornua of the left lateral
ventricle, the pressure of the pus contained therein
pushed out the choroid body. The walls of the ven-
tricles were softened and showed evidences of in-
flammation. Unfortunately no bacteriological ex-
amination was made ; this would have been of par-
ticular interest, as it would have determined whether
it was a pure or mixed infection. The upper end
of the spinal cord, at the point of severance, was
in the same softened, macerated condition as the
superficial surface of the cerebrum. The medulla
was softened, but to a less extent than the cerebrum
or spinal cord. The cerebellum was in fairly good
condition ; far better than any other part of the
brain. The thick pus in the meninges of the cord
at once explained the failure in obtaining fluid from
the lumbar puncture, it being evident that the cir-
culation of the cerebrospinal fluid had been entirely
eliminated. From the examination of the brain
structures it seemed inexplicable how the man had
lived during the last few days.

Upon examination of the interior of the skull no
necrosed areas or perforations were found ; in fact,
the internal table of all ijarts of the skull bore a
normal appearance. The frontal sinuses were nor-
mal. In the sphenoid sinuses the lining membrane
was in an inflammatory condition and infiltrated, but
no pus was found. The left ethmoid sinus was
normal ; the right ethmoid showed a certain amount
of necrosis, as had been revealed at the operation.
The left middle ear and mastoid were normal ; in
the right middle ear no necrosed spots were ob-
served. Not being satisfied as to how the infection
had extended into the cranial cavity, the top of
the petrous portion of the right temporal bone was
cut away, and in several parts, more marked in
the region of the labyrinth, dark spots were found,
varying from slight discoloration to almost black.
These spots followed along the course of the facial
and auditory nerves, determining the fact that that
intracranial invasion had been an extravasation
along the sheaths of these nerves and the lymphatics.
This would seem to justifv Macewen's observations

that infiltration along the sheaths of the facial and
auditory nerves to the cranial cavity is much more
prone to end in purulent leptomeningitis, involving
the internal and external cerebrospinal fluid, and sel-
dom causes brain abscess.

Conclusions. — The question naturally arises,
would intracranial interference have availed any-
thing? It was the unanimous opinion of all present
at the autopsy that it would not, and the pathological
conditions found proved beyond all question that
our opinion, formed while watching the progress of
the case, was correct, viz., that at no time did the
indications warrant trephining. We are aware that
a few cases of suppurative meningitis involving
the subarachnoid fluid have recovered after opera-
tion and drainage. All the cases we found in a
hurried search of the literature, which were three
in number, followed chronic otitis, while those that
followed acute otitis died, autopsy revealing general
leptomeningitis. Symptoms of intracranial disease
are so varied as not to be an index to the actual
conditions present ; this is proven by all statistics,
where the symptoms were recorded during life and
autopsies held to determine those conditions. In
those cases that recovered, we can only conjec-
ture as to the extent of tlie meningitis. The fact
that the pus areas were drained and recovery fol-
lowed undoubtedlv proves the meningitis was local.
Ballance has well asked the question, "How could
the subarachnoid space be drained?" and adds : "The
arachnoid spreads from convolution to convolution,
and every space between each convolution would
have to be opened. When the pus is underneath the
visceral arachnoid drainage is impossible.''

Macewen has observed that "if the pathological
matter enters the subarachnoid space before ad-
hesion with the pia mater has been formed, lepto-
meningitis is apt to he set up; in which case the
whole of the cerebral and cerebellar meninges are
apt to be involved, the inflammation spreading with
the greatest rapidity along the areolar tissue of the
arachnoid. . . . On the other hand, if adhesion
between the different layers of the meninges takes
place before the infective material reaches the sub-
arachnoid, for a time at least the suppuration will
be local."

The symptoms in this case are to be explained
bv : (i) Increased intracranial pressure. (2) Dis-
turbance of cerebral function. (3) Suppurative lep-
tomeningitis, involving the cerebrospinal fluid.

The consistencv of the brain, according to von
Bergmann, is such that pressure exerted at any
part is transmitted and equally diffused to all parts
of the cranial cavity. The effect will be earliest
manifested upon the more easily compressed tissues.
The walls of the veins have less resistance than
those of the arteries and will suffer most. Their
points of exit from the skull are bony foramina,
which prevent sufficient dilatation to permit the
outflow of blood to maintain circulatory equilibrium,
resulting in slowing of the circulation and increased
congestion. The two conditions reacting, each in-
tensifying the other, cause increased intracranial
pressure. So long as the cerebrospinal circulation
is maintained, the greater part of the excess of
cerebrospinal fluid will be absorbed by the capillaries
in the spinal meninges ; but as soon as this circula-
tion is obliterated intracranial pressure will be rapid-
ly increased. "If the circulation of the brain be-
comes gradually slower, the order of the centers
affected is as follows: The cortex, corona radiata,
gray matter of the spinal cord, region of the pons,
and finally the medulla oblongata. . . . Con-
sciousness is more rapidly lost than any other func-

39°

MEDICAL RECORD.

[March 9, 1907

tion, and returns only after tlie circulation has been
fully restored. . . . The persistency of pressure
is as dangerous as an exceedingly high degree of
pressure" (von Bergmann).

The clinical manifestations of cerebral pressure
are divided into two stages : ( i ) The stage of
stimulation. (2) The stage of depression.

We will now attempt to e.xplain the obscure symp-
toms manifest in our case. The sequence of tissues
involved were undoubtedly as given by von Berg-
mann, cited above.

1. Pain. — The pain was due to basilar meningitis.
It varied in degree and character until the morn-
ing of the 17th, when tlie infection probably had
extended to the cerebral ventricles, and the re-
sulting thick pus obliterated the cerebrospinal cir-
culation. The rapidly increasing pressure caused
thereby produced the violent pain, which drove the
patient frantic. The morphia quieted him until the
increasing pressure became so great as to produce
unconsciousness, which continued. The lessened
pressure caused by the hemorrhage at the second
operation was followed by some improvement in his
mentality. We believe the soreness in the mouth
was due to irritation of the fifth nerve by the
ethmoiditis and basilar meningitis.

2. Restlessness. — The pressure produced irrita-
tion and, therefore, stimulation of all centers, w'hich
stimulation caused restlessness and increased sen-
sor}- reflexes to the stage of depression, when finally
all were abolished.

3. Temperature. — High remittent temperature
was due to- meningitis and absorption of the septic
material.

4. Pulse. — At first slow from stimulation of the
pneumogastric, causing cardiac inhibition : later in-
creased pressure destroyed irritability of this nerve
and rapid pulse followed, augmented by the high
temperature : the period of slow pulse was unusually
short.

5. Respiration. — \'aried with temperature and
cerebral pressure ; became Cheyne-Stokes from
pressure upon the medulla bv the pus in the cere-
bral ventricles and subarachnoid space.

6. Absence of Vertifio and Vomiting^. — This was
probablv due to the graduallv increased pressure
with no sudden variations in the circulation

7. Absence of Localizing Symptoms. — The press-
ure was exerted equally over all parts of the cor-
tex and therefore produced no localizing svmptoms,
and was insufficient to cause general convulsions.

TYPHOID FEVER COMPLICATED BY MUL-
TIPLE ABSCESSES OF THE KIDNEYS
AND BY LOBAR PNEUMONIA.

By L. NAPOLEO.V BOSTON. .\.M., M.D.,

PHILADELPHIA.

ADJUNCT PROFESSOR OP MEDICINE, MEDICO-CHIRURGICAL COLLEGE;
PHYSICIAN TO PHILADELPHIA HOSPITAL; AND DIRECTOR LABORA-
ATORIES FOR CLINICAL RESEARCH, AMERICAN HOSPITAL FOR
DISEASES OF THE STOMACH.

The physician is ever alert for the development of
the renal complications common to typhoid fever.
A simple albuminuria (probably febrile in origin)
is to be expected during the fastigium in nearly
every case of typhoid infection. The amount of
albumin excreted through the urine as the result of
fever is always small and usuallv gives a feeble re-
action either by heat or by any one of the contact
methods.

Acute nephritis may develop at practically any
state of typhoid fever, and is placarded by a dimin-
ution in the quantity of urine, albuminuria, and the

presence of renal casts. With the development of
nephritis all the symptoms of typhoid fever are ag-
gravated. Both simple and diphtheritic pyelitis are
known to follow typhoid infection.

Judging from the mention made by the different
authors of multiple abscesses of the kidneys as a
complication of typhoid fever, this must be rather
unusual. I have been privileged to study four cases
of typhoid fever in which there was anuria lasting
for a period of twenty-four hours.

The patient, a clinical and pathological study of
whose maladies forms the subject matter for this
report, was a German woman, twenty-five years of
age, w-ho was admitted to my service at the Phil-
adelphia Hospital, August 26, and died September
10, 1906. At the time of her admission she pre-
sented a clinical picture of typhoid fever, and
while she was unable to speak English the history
obtained pointed rather clearly to the fact that she
had been indisposed for about a week.

A physical examination showed the heart and
lungs to be normal ; the urine was practically nor-
mal, and the temperature was 101.4° Fahr. The
symptoms of typhoid fever grew worse, and three
days after her admission there was pronounced tym-
pany, marked intestinal pain, especially with each
movement of the bowel, and extreme tenderness in
the right iliac fossa and along the ascending colon.
At this time there was a rather liberal eruption over
the abdomen and chest.

During the third day of her stay in the hospital
she was seen to be somewhat cyanosed, respirations
were hurried, the pulse increased from 106 to
120 per minute, and numerous rales were audible
at the base of the right lung. The urine contained
a trace of albumin.

The fourth day (approximately the twelfth day
of the fever) delirium became maniacal, and it was
found necessary to administer a portion of the med-
ication hypodermically every four hours during the
following day. Each hypodermic contained digi-
talin gr. i-ioo, strychnine sulphate gr. 1-48, and
nitroglycerin gr. 1-120. Three or four times daily
she was given an enema of milk, to which had been
added a liberal quantity of milk of asafetida, with a
view to reducing the abdominal distention, which
was perceptibly lessened after each enema. Stimu-
lants and codeine sulphate were given bv mouth
whenever possible.

The lung condition progressed from bad to worse
until there was consolidation of the lower half of
the left lung. Singularly during the fifth day in
the hospital (twelfth or thirteenth day of fever)
the patient did not void any urine, nor was there
any urine found in the bladder upon catheteriza-
tion. The temperature ranged near 103° Fahr. and
was of the continued type.

Early the following day she voided three ounces
of dark urine which was rich in albumin. Through-
out the day cyanosis increased and the pulse be-
came weak, thready, rapid, and irregular. The
delirium ameliorated some, but there was still evi-
dence of a migratory pneumonia which w-as spread-
ing, and anuria obtained most of the day.

In consequence of the temperature having risen
to 104° Fahr. the patient was given a cold sponge
bath, to which she reacted very unfavorably, becom-
ing pulseless, wnth cold extremities, temperature
99° Fahr. (by vagina), and marked cyanosis.

The bath, while it was borne badly, may have
exercised some influence upon the action of the
kidneys, since the following day the patient voided
49 ounces of urine. The patient's general condition

March 9, 1907]

MEDICAL RECORD.

?9i

was much improved twelve hours after the cold
sponge bath, and the kidneys were functionating
activel}'.

The urine w'as highly acid, specific gravity 1.014,
gave a decided reaction for albumin, and the diazo-
reaction was present. Microscopically there were
found many short and long hyaline renal casts, many
both broad and narrow granular casts, numerous
leucocytes, and a few red blood-cells. Epithelial
cells were present in great numbers, but they were
never found intimately connected with renal casts,
consequently it was impossible to say beyond ques-
tion of a doubt that they were renal in origin.

Surrounding the site of puncture of each hypo-
dermic there w'as a small hemorrhage in the skin,
and these hemorrhages varied in size according to
the time since the hypodermic had been given.
Ecchymoses from hypodermics given during the
previous night did not exceed one-eighth ';f an inch
in diameter, while those which corresponded with
the hypodermics given forty-eight hours earlier va-
ried from one-half to one and one-half inches. The
cause of these cutaneous hemorrhages was not sat-
isfactorily explained, since they continued to form
even when digitalin and nitroglycerin were not ad-
ministered with the hypodermics. The cutaneous
hemorrhages must, therefore, have depended for
their production upon the local irritation excited by
the puncture of the hypodermic needle, and further
upon a predisposition of the patient toward the de-
velopment of cutaneous ecchymoses.

Two days later, and for a second time, the pa-
tient displayed the symptoms of uremia, in addition
to those already present resulting from the double
croupous pneumonia and typhoid fever. The res-
pirations, which were 45 per minute, were reduced
to 38, and the pulse of 140 and of low tension be-
came stronger and of better volume at 120 beats
per minute. Increased arterial tension and lessened
frequency in the respirations may be a precursor
of grave renal complications in acute fevers. Again,
for a period of twenty-four hours the patient did
not void any urine, and during this apparent re-
currence of renal involvement she entered into a
semicomatose state, which was soon followed by
general collapse.

The post mortem made upon the body of this pa-
tient was conducted by Dr. Joseph MacFarland,
Pathologist to the Philadelphia Hospital, who gave
a pathological diagnosis of "Typhoid fever, pul-
monary infiltration with atelectasis, parenchymatous
nephritis with infectious emboli of the kidneys,
parenchymatous degeneration of the liver, and acute
splenic enlargement." I have abstracted from the
pathological records such points as have special
bearing upon the general symptomatology of the
case under discussion.

The pericardium and leaflets of the heart were
normal, although the cardiac muscle showed some
evidence of degeneration, but nothing more than
is to be expected in severe febrile conditions.

The left lung weighed 360 gm. The superior lobe
and one-half of the inferior were involved by an
acute pneumonic process, while the remaining por-
tion of the lung was collapsed. Excised fragments
from the consolidated portions of the lung sank
immediately when placed in water.

The right lung weighed 440 gm.. displayed a few
pleural adhesions at the base, and the inferior lobe
was completely involved by an acute pneumonic
process which was apparently identical with that
displayed by its fellow.

The spleen weighed 280 gm. and measured
1 1x14x3 1/< cm. Its edges were blunt and decidedly

thickened, the organ was soft, and upon section the
cut surface was purplish red and fairly characteristic
of that found in typhoid fever.

The condition of the kidneys w'as equally striking
in interest with that presented by the lungs. The
left kidney weighed 230 gm., was slightly enlarged,
and presented a smooth slate-colored surface. Upon
section the organ cut easily and its capsule stripped
readily, leaving behind a highly congested surface.
Both upon the cut surface and underneath the cap-
sule there were seen a number of small septic
infarctions, which appeared to be rather evenly dis-
seminated throughout the greater portion of the cor-
tical (medullary) substance of the kidney. At one
point there was a swelling about i cm. in diameter,
due to an aggregation of minute abscesses. The cut
surface of the kidney was decidedly grayish in color
and displayed extreme congestion at the base of the
])yramids. The pyramixls also showed some stria-
tion as the result of septic emboli.

The right kidney w'eighed 240 gm. and generally
speaking the lesions presented by it were identical
with those found in its fellow.

The liver weighed 1,690 gm. and its surface was
decidedly nutmeg in appearance ; the organ was
somewhat softened as a result of congestion.

The colon, from the ascending portion onward,
displayed only a moderate degree of congestion. The
ascending colon presented a few^ ulcers, which were
about I cm. in diameter. At the cecum there was a
marked aggregation of small ulcers, which covered
more than one-half of the mucous surface, and there
was also extensive ulceration at the ileocecal valve.
The first 10 cm. of the ileum was almost entirely
occupied by an extensive ragged ulceration resem-
bling that found in the cecum, and beyond this
point there were many deep, ragged ulcers, corre-
sponding to the situation of Peyer's patches. -\
few of the ulcers were situated transversely to the
intestine (a feature characteristic of tuberculosis
and not of typhoid fever), but I am inclined to re-
gard this peculiar arrangement of the ulceration as
dependent upon extensiveness of the jirocess and
not due to tuberculosis.

1551 South Broad Street.

THE PREVENTION OF DISEASE.*

By EDW.-\RD E. FEILD, M.D..

NORFOLK, VA.
SURGEON TO ST. VINCENT'S HOSPITAL.

In order to discuss intelligently the prevention of
disease it is necessary to classify all diseases with
reference to their causation. For the purpose of
this paper, all disease is due either to some inherent
degenerative change or error of metabolism, or to
some extraneous cause introduced into the sys-
tem. To the latter class belong the infectious and
contagious diseases, so called. As these terms are
often loosely applied, I shall adopt the suggestion
of Rosenau and speak of them as "communicable"
diseases. In this paper I shall assume that the
discussion of communicable diseases only is in-
tended, as they are from a sanitary standpoint the
only preventable ones. The communicable diseases
I shall divide for convenience into two classes:

1. Those diseases caused by animal parasites.

2. Those caused by bacteria.

The animal parasites are divided into three sub-
classes :

*Read at the "Svmposium on Preventive Medicine" of
the Virginia State' Medical Society at its annual meet-
ing at the University of Virginia. October 9 to II, 1906.

392

MEDICAL RECORD.

[March g, 1907

A. Tlie various parasitic insects, as fleas, bed-
bugs, ])e(liculi, ticks, etc.

B. Tlic helminths, as himbricoides, ascarides,
teniae, ankylostoma, etc.

C. Protozoa, which require for their develop-
ment and transmission a separate cycle of existence
in an intermediary host, as the haematozoa of
malaria, yellow fever, rabies, filariasis, and some of
the trypanosome diseases, and probably smallpox
and relapsing fever.

It is obvious that in diseases of such dissimilar
origin many of the measures adopted for the pre-
vention of one class will be totally useless in the
other.

It is not within the scope of this paper to enter
further into the etiology of these diseases. As far
as possible it will be attempted to deal with a class
rather than with a single disease.

Among the protozoan diseases yellow fever oc-
cupies a prominent part, being the disease most
dreaded in our Southland. It has been demon-
strated to the satisfaction of the large majority of
nosologists that the only method of convection of
yellow fever is through the medium of the Stegom-
yia fasciata. Of course, then, our efforts should be
directed first towards preventing infection of mo-
squitos, and secondly towards their destruction. The
first is accomplished by screening all patients sick
with yellow fever for the first three days of the dis-
ease (after which time they become noninfective to
mosquitos), screening of all doors and windows to
prevent ingress and egress of all mosquitos which
might have become infected, and destroying them
after removal of the patient. The mate'riaf which
seems most efficacious in their destruction is "culi-
cide," a preparation consisting of equal parts of
camphor gum and crystalized carbolic acid (by
weight) rubbed together, forming a liquid which
is colored with methylene blue, eight grains to the
gallon, and volatilized bv heat.

After a room has been exposed to the fumes of
culicide (4 fluid ounces to 1,000 cubic feet), the
mosquitos fall to the floor and are swept up and
burned. Culicide was mainly used in the epidemic
of yellow fever in Louisiana last winter, and I am
informed by one of the ofificers of the Public Health
and Marine Hospital Service, who had charge of
the disinfection of houses, etc., that it was very ef-
ficient in destroying the various forms of animal
life, but was in no way harmful to even the most
delicate fabrics. Of course, the propagation of the
mosquito should be prevented as far as possible bv
.screening cisterns and rain barrels, filling all holes.
and destroying all broken bottles or other emptv
receptaces in which stagnant water might be found,
and oiling those pools of water which cannot be
filled, in order that the larvae may be destroyed.
Upon the appearance of yellow fever in a com-
munity, that community should be quarantined at
once by Federal authority, camps established, and
if, after five days' detention of persons desiring to
leave, no symptoms appear, such persons should be
allowed to travel anywhere without restriction.
Their baggage and the cars in which they travel
should be fumigated in order to destrov all steg-
omyia; present. The method used in yellow fever
for destroying mosquitos should be used in malarial
cases also, as the two diseases have manv points of
resemblance with regard to causation and svmpto-
matolngv. and I believe the time is not far distant
when the yellow fever germ will be discovered and
shown to have characteristics similar to those of
the h;cmamoeba malarias. The Stegomyia fasciata
is a domestic mosquito and does not fly far awav

from its birthplace, consequently, by destroying
their breeding places around dwellings, we practi-
cally eliminate the danger of a spread of yellow
fever.

Authorities differ as to the domesticity of the
Anopheles. Howard says: "They have always
been found in more or less permanent pools of
water, either in the bed of an old canal, or in spring-
fed woodland streams, or in the side pools or shal-
lows of field springs, or in artificial excavations
filled with surface water. They are rarely found
in water in barrels or troughs, and rarely found in
the same water with larvae of Cidex." This would
seem to show that they are to a great extent wind
borne, especially as malaria usually seems worse on
the north side of a stream, the prevailing winds in
summer and fall being southerly.

I am not aware that any experiments have been
made with regard to the period during which a
malarious person is infective to mosquitos, although
that would seem to offer a fruitful and interesting
field for scientific research.

The efificacy of the method adopted for preventing
malaria in the Campagna by administering quinine
and screening patients has been fully demonstrated,
and has accomplished more for that purpose than
all the previous draining of the marshes. The same
method used by the German government in Africa,
has been productive of similar beneficial results. It
would then seem to be an easy matter to rid our
country of malaria by carefully screening patients
and others, rendering them noninfective to the an-
opheles, and destroying the mosquito.

Rosenau has shown that of the chemicals used for
fumigation sulphur fumes are most destructive to
the various forms of animal life, while formalde-
hyde is the better disinfectant for bacteria. Since
that time culicide seems to destroy small animal or-
.ganism even better than sulphur. According to
Councilman, Guarnieri and others, smallpox is
caused by a protozoon, as is also rabies. It is un-
necessary to suggest to this intelligent body that
smallpox can be easily stamped out by vaccination
and isolation ; there are few diseases which can be
so satisfactorily and easily prevented. The limits
of this paper prevent the discussion of the diseases
caused by the other animal parasites. I will, how-
ever, suggest that ankylostoma seems to be threat-
ening the South Atlantic and Gulf States, as shown
especially by the intelligent investigations of Charles
Wardell Stiles.

The Various Bacterial Diseases. — It will be neces-
sary to class under this head many diseases whose
specific germs have not yet been isolated, but whose
symptomatolog}' and course resemble so closely
bacterial diseases as to prevent their being classi-
fied elsewhere; e.g. measles, and diseases caused by
spirochaeta:.

Methods of Convection. — (i) ]\Iediate or imme-
diate personal contact with patient. (2) Through
invected environment (fomites). (3) Food or
water supply. (4) Through medium of rats and
domestic animals, flies and other insects. (5)
Through desiccated or partially desiccated bac-
teria in dust, taken into the system through the
respiratory or digestive tract. (6) Through abra-
sion in the skin, as in pyogenic diseases, diphtheria,
syphilis, ankylostoma, etc.

Our possessions in the Philippines. West Indies,
and Panama, and our increasing commercial rela-
tions with South America and the Orient, consti-
tute a menace to our countrv in the importation of
tropical diseases. Not only may the disease-carrying
animal and various bacteria be kept alive during

March 9, 1907]

MEDICAL RECORD.

393

the continually shortening voyages, but many per-
sons resident in the tropics may bring within their
systems the various trypanosomes and other or-
ganisms and infect the fauna of this country. Tlje
best method to prevent the ingress of these diseases
is to inspect all such travelers at the point of de-
parture, and also upon their arrival at quarantine.
A strict, intelligent quarantine will keep out most
of the so-called quarantinable diseases — cholera,
tvphus fever, smallpox, leprosy, plague, and yellow
fever. Of these the one to be most dreaded is
plague, on account of its greater insidiousness,
greater difficulty of extermination, and higher rate
of mortality.

According to Kitasato the pest bacillus is carried
by raw cotton or grain. The infected grain is
eaten bv rats, which thus contract the disease. The
sick and dead rats are eaten by others, so that in
a short time the entire rat colony is infected. Thus
the bacilli are disseminated and enter the system
through abrasions of the skin or by the respiratory
passages or alimentary canal, or through the bites
of fleas.

Kitasato advises the thorough disinfection and
fumigation of premises, destruction and cremation
of rats, building of rat-proof houses, and cremation
of all persons dead of the disease.

It is assumed that the usual course of fumiga-
tion and disinfection during and after the course of
the communicable diseases is so well understood
by the average practitioner that reference will not
be made to it further than to mention under cer-
tain diseases some special measure peculiar to the
convection and prevention of each.

And here I would state that for the purpose of
fumigation formaldehyde is more destructive to
bacteria than culicide or sulphur dioxide, while
the reverse is true in the case of animal parasites of
all kinds. In the fumigation of houses, ships, and
railroad cars, paper should be pasted over all cracks
around windows and doors to prevent the escape of
the fumes, and the room kept closed for twenty-four
hours, in order that all bacteria may be destroyed.
The methods of generating the fumes of formalde-
hyde adopted by the Illinois and other State boards
of health is so simple and practical that I shall in-
sert it here. It requires no heat, but a somewhat
larger percentage of potassium permanganate should
be used (about 8 ounces to get the best results).
The method is very simple, requiring no apparatus
except a tin pail of sufficient capacity, best made
with flaring top. It is made with a double bottom
with one-quarter inch air space between the lavers
of tin, and is entirely covered on the outside with
asbestos paper. Instead of this apparatus an ordi-
nary milk pail set into a pulp or wooden bucket
will answer every purpose.

•The room is sealed, fine needle-shaped crystals of
potassium permanganate (3 1^2 ounces to each i.ooo
cubic feet of air space) are placed in the container.
Over this salt is poured 40 per cent, solution of
formaldehyde ft pint for ever\- 1,000 cubic feet of
air space). The operator should leave the room
quickly, as large quantities of gas are at once
evolved. The results of laboratory experiments
have shown that the gas thus evolved acts more
thoroughly on account of its great concentration,
and kills very resistant microorganisms, even when
concealed under several thicknesses of cloth. The
Maine Board of Health recommends 6'< ounces of
permanganate and two pints of formaldehyde so-
lutions for every i.ooo cubic feet. Presence of
moisture in the air is essential. The disinfection of
the room, the woodwork, furniture, and floors with

liquid disinfectants (mercury bichloride, I to 1,000)
is as important in this mode of disinfection as in
any other. The method requires the use of common
and relatively cheap chemicals, so that it is esti-
mated that the disinfection of 1,000 cubic feet costs
about 75 cents. Based on this method, proprietary
preparations are on the market under fanciful
names, and for which extravagant claims are made,
but they are in no way superior to the simple meth-
ods, and their use should be avoided because of tlie
uncertainty as to the amount of gas they will evolve.

Next in importance is cholera, but owing to its
severe and easily recognized symptoms, and the
much feebler vitality of the spirillum, its preven-
tion is accomplished with less difficulty. Cholera
is acquired through drinking water. However, the
spirillum is kept alive upon fruits and other edibles.
The usual precaution of isolating the patient should
be taken as far as possible. This is usually easily
done in the more acute communicable diseases, as
smallpox, diphtheria, cholera, etc., but it is not prac-
ticable in the venereal diseas'^s. Pneumonia and
typhoid fever should by all mesons be isolated. Phy-
sicians and others who come into enforced contact
with such cases should disinfect themselves thor-
(lUghly before mingling with other persons. The
patient infects his surroundings through the feces
and urine, expectoration, vomitus, breaking down
of abscesses, as in streptococcus infection and bu-
bonic form of plague, and probably in all of the ex-
anthemata by desquamation. These bacteria are of
varying degrees of vitality, the spore-bearing bacilli,
such as tetanus and anthrax, being the most hardy,
and often retaining their vitality on clothing and
other fabrics, in dust and in water or food. Even
so delicate a germ as the cholera spirillum is not
killed by considerable exposure. The proper disin-
fection of cups and other utensils used by patients,
the destruction of all food left by them, the disin-
fection of all excreta before leaving the sick room,
should be strictly insisted upon. Carbolic acid or
trikresol, rather than bichloride, should be used for
disinfection of stools, urine, or sputum.

Dr. Doty"s method of disinfection of stools, as
quoted by Dr. Grandy in the Virginia Bulletin of
Health, seems to be an admirable one. He makes
the following solution : Copper sulphate, i pound ;
lime (unslaked), i pound; water, 10 gallons. Put
the copper sulphate in cotton bag and hang it in
6 gallons of water. Pour the rest of the water on
the lime, and mix the two solutions. Stir well be-
fore using. This solution should be kept on hand,
and should be poured over and thoroughly mi.xed
with the typhoid urine and stools, which should
stand in it for at least half an hour. It is not only
a good disinfectant, but a deodorant, and might well
be generally used in country privies, from which
germs can easily be carried to the kitchens by flies.
This is a source of typhoid infection which is often
overlooked, but which was responsible for t\phoid
epidemics among our soldiers during the Spanish
War, and which is probably often the cause of cases
which appear in the house with a convalescent ty-
phoid fever patient, whose urine and stools are not
disinfected. While this applies especially to the
rural districts, typhoid urine and stools should also
be disinfected before being emptied into the city
sewers, as these often flow into rivers from which
other towns draw their water, or into l)a\-s from
which oysters are taken.

In all the respiratory diseases the sputum should
he received on cloths and immediately destroyed by
burning. Sweeping should be avoided as far as
possible in a sick room, and all dust removed with

394

MEDICAL RECORD.

[March 9, 1907

a damp clolli. Many germs are doubtless expelled
through the "insensible expectoration" during
coughing in tuberculosis, influenza, and the ]Mieu-
monias, and probably also in typhoid fever. .Since
the latter disease is known to be a septicemia, with
a probable first infection in the lung in many in-
stances, it is fair to presume that its bacillus does
undergo a desiccation or partial desiccation, and it
is to that extent a wind-borne disease. The Bacillus
tyf'lwsiis, accorcHng to Park, has been kept alive
sixty-four days in dust. In cities dust should be
prevented as far as possible by sprinkling the streets
and sweeping and removing the dust before it dries.
It should be remembered that the typhoid bacillus
remains in the urine and feces of a patient for weeks
after recovery.

Droppings from horses should be removed from
the streets at once, as they are a breeding medium
for flies. Flies breed usually in and around stables,
preferably in the dung of the horse, and also in
garbage. It is therefore necessary that garbage be
collected and destroyed as rapidly as possible. Flies
carry infection by lighting upon a patient or the in-
fected excreta and afterwards falling into water or
food and infecting it. There is evidence that some
flies pla}- the pai t of an intermediary host and con-
vey the disease by biting the patient, as in the case
of the Tsetse fly, which carries the trypanosome of
sleeping sickness. Flies should be excluded from
houses as far as possible by screens, and killed by
fumigation with culicide or sulphur. Fleas, bed-
bugs, etc., act as carriers of infection, and should be
exterminated.

Milk being an excellent culture medium for many
of the pathogenic bacteria, is a fruitful source of in-
fection in a number of the communicable diseases.
Rosenau says (Disinfection and Disinfectants, page
214) : "Of all foods, milk is most likely to be in-
fected. It is a very good culture medium for al-
most all the pathogenic bacteria : for instance, fresh
milk contaminated with a few typhoid, diphtheria,
cholera, or plague bacilli, will in a few hours at or-
dinary temperatures have every drop teeming with
nTan>- of these organisms without appreciably alter-
ing the appearance of the milk. It is easy to under-
stand how readily the infection of typhoid fever,
cholera, diphtheria, or plague mav get into the milk.
The exanthematous diseases have frequently been
traced to the milk supply. The possibility of tuber-
culosis being conveyed in the milk is ever present.
The milk supply in a large city is always under sus-
picion, so frequently does it carry disease." The
source of the milk supply should be thoroughly ex-
amined. Every case of sickness among the attend-
ants of dairies and their families should be carefully
investigated. Cows should be examined for tuber-
culosis and other sickness, and all ailing ones killed,
or sent away. They should be well fed, well bedded,
kept thoroughlv clean, and given plenty of good
clean water. No water closets should be allowed
near the dairy nor its water supply. Milking should
be done, after thorough cleansing of the udder, in
a clean separate milking room, into covered buckets,
or the milk should be strained through sterilized
cloth. The inilk should be placed where it cannot be
contaminated by dust, and marketed in bottles ster-
ilized by steam and never refilled from the wagon.

Epidemics. — In the case of epidemics it is neces-
sary to prevent public gatherings. In the smallpox
epidemic in Norfolk, in 1899. it was found that after
a severe cold spell the number of cases of the dis-
ease among the negroes was always increased. This
was attributed to their huddling together in bar-
rooms and other such resorts for warmth.

The schools, public and private, should be care-
fully watched for communicable diseases, and no-
pupil residing in a house where such diseases exist
should be allowed to attend, nor should any person
not vaccinated be admitted. In all schools pupils
should be taught at least the elementary rules of
sanitation and hygiene. They should be instructed
in the danger of expectorating on floors, of swap-
ping chewing gum. and of other sociable but per-
nicious practices. Individual drinking cups should
be used. The same rules should apply to factories,
department stores, and other places where people
most do congregate. Such places should be sup-
plied with fresh air and sunlight as far as possible.

In conclusion I desire to say that in epidemics of
cholera, plague, or yellow fever, the federal govern-
ment should take charge of all cases and be given
full power to stamp out the disease and regulate
travel. Witness the good work done in the yellow
fever epidemic in New Orleans last year, with no-
return. How much delav and interference with
traffic could have been avoided but for the conceal-
ment of the disease in the first intance, and the con-
sequent illogical and useless gunshot quarantine.
Quarantine should mean the maximum protection to-
heahh with the minimum interference with busi-
ness.

THE H.^ND OF IRON IN THE GLOVE OF
RUBBER.*

By ROBERT T. MORRIS. M.D.,

NEW YORK.

In the Middle Ages there was an ogre on the other
side of every hill.

People gradually overcame their fear of ogres,
and began to get scared about witches.

After witches had been duly burned, surgeons
were frightened about opening the peritoneal cavity.
When I was a student, we were taught to have a
chill whenever the subject was broached, and the
textbooks described various ways for avoiding the
grewsome mishap.

After ogres, witches, and normal peritoneum
had been disposed of. we began to enjoy a fear
of pus in the peritoneal cavity. Surgeons passed
through the transition period of washing their
hands after operation instead of before, and ar-
rived at the stage of aseptic preparation of the
hands. Then, in logical sequence, we began to
wear rubber gloves, and employed them in intra-
peritoneal work, even though infection were al-
readv present. What do you think of that?

Charlemagne baptized a lot of Mohammedans
and then laughed up his sleeve when he saw them
gravelv bowing to the East after that, for he knew
that they were securely Christians. We put on
rubber gloves and smiled at the thought of bac-
teria doing a thing to the patient after we had
conscientiously tried to remove infection which
could in fact be removed best by the patient him-
self. Worse than that, when we put on gloves for a
boxing match with the patient's vitality, we rapidly
placed him in an unfavorable position for self-de-
fense. The use of rubber gloves made it necessary
to use such long incisions that we could work by
sight, and this lowered the patient's vitalit)'.

Long incisions are employed for killing bears,
and we chose for saving weak patients the methods
which are in use for killing bears.

Rubber gloves led to slow work, and that further

* .-\ paper read before the meeting of the Surgical Section
of the Xew York .\cademy of Medicnie, February r. 1907.

March 9, 1907]

MEDICAL RECORD.

395

reduced the natural resistance of patients. Tait
without antiseptics or asepsis showed that his facile
fingers could brina: out better statistics than we
can get with an iron-like hand in a glove of rub-
ber. Tait was a thorn in the side for most of us.
Nowadays we understand that he conserved the
natural resistance of his patients, and turned the
management of infections over to them, but in his
dav the only comfort that we could get was in the
forlorn hope that he might be untruthful. Tait
was a perennial insult to us. unless we could get
even by making a retort.

Slow work means a longer period of anesthesia —
a longer debauch with an intoxicant.

Have we not reached the stage of information
where we can drop our fears of ogres, witches, nor-
mal peritoneums, and pus in the peritoneal cavity?
Do we not know that much of this pus is sterile,
in spite of its odoriferous mercaptans and sulphur
ethers, and that bacteria are chiefly at work in the
tissues rather than in the pus? Is it not time for
us to realize that we cannot get bacteria out of the
tissues, but that the patient is finely equipped for
attending to the work if we do not disable him
ourselves ?

Simple, quick work which merely turns the tide of
battle between bacterium and phagocyte is what
the patient needs when he calls us to his aid, and
simple, quick work is not facilitated by the use of
rubber gloves.

The patient with an infection under way is a fac-
tory. His chief business is the manufacture of
opsonins for wounding bacteria, and phagocytes for
disposing of them afterward. The hand of iron in
the glove of rubber throws the belts from the wheels
in this factory.

\\'e must not forget that even in such a disease
as appendicitis, with pus in the peritoneal cavity,
very many patients recover without operation.
How do they manage it? We know. We must
not forget that we know how it is done, when we
step in to improve upon nature's methods.

Let us not commit taxidermy upon valued citi-
zens by stuffing them with gauze, or lower their
natural physiological resistance with the kindly
helpful hand reduced to second grade by a glove.
After the period of infection has passed, can we
separate peritoneal adhesions in the best way by
putting on a handicap, and allow the patient to
escape with a mild attack of surgery? Not ac-
cording to my observations.

There are places in which rubber gloves should
be used. In opening an uninfected knee joint, for
instance. The house staff at the hospital would
transfer too many proliferating colonies of bacteria,
if rubber gloves were not worn on rounds when
dressings are changed.

In some outside work, as in hernia operations,
where we work by sight anyway, rubber gloves
will give the best statistics, unless the slower work
allows more bacteria to fall in from the air than
would be carried in by the hands. That last point
is an important one. Among human faculties the
sense of proportion ranks just above moral sense
in value. Psychologists may not agree with me,
but they do not agree with each other. It is dis-
crimination that we need more than rubber gloves.
The subject allows of pretty good classification in
a general way.

Rubber gloves mav be useful: (i) In cases in
which there is no infection or other disease to call
out the patient's natural resistance to infection.
(2) W'here dressings are to be changed for several

patients in succession, or where the surgeon oper-
ates upon an uninfected patient shortly after opera-
tion upon an infected one. In the latter case, if
the patient were to be consulted in the matter, he
would probably ask to have his operation deferred
until spring anyway. Rubber gloves are not needed
— or worse than that : ( i ) Where infection is al-
ready under way, and the patient is calling out his
own protection. (2) Where a disease like cancer
has already called out such a degree of protection
that the old-time war doctors could amputate a
breast and get primary union under "well-waxed
shoemaker's thread'' that had been held in the
mouth or over the ear while operation was in pro-
gress. (3) Where no infection or other disease is
present, but where slow or extensive operating
necessitated by ungainly gloves will allow more
bacteria to fall into the wound than would be car-
ried in by well-prepared bare hands.

The argument has been made that the surgeon
should wear rubber gloves for his own protection.
For whom are we working?

The coming generation of surgeons, brought up
on rubber gloves, will not do the wizard-like work
that was done by some of the older operators, ex-
cepting in instances where discrimination has been
the rule, and where the fingers have been taught
better tricks than the eye ever knew.

Our surgery is not different from vegetable sur-
gery. For recreation I hybridize hickories. It
became necessary to find an expert grafter. High
and low, all over the country search was made.
Horticulturists all said the same thing. "Hickories
cannot be grafted. Millions of dollars a year would
come to us if we could do that grafting." Finally I
found a man in Massachusetts who could catch
25 per cent, of hickory grafts, and a man in Texas
who could catch 90 per cent, of them. Both said
that there was no trick about it at all. Notliing
was needed but quick, neat work. Surgeons have to
face precisely the same situation. A few will do
with ease what most others say cannot be done at
all. Rubber gloves will debar surgeons from do-
ing some of the most expert work that lies within
the range of their capabilities.

I have no confidence in any man who does not
believe that his own country excels in everything,
no matter where he lives. From that standpoint
of patriotism I want to believe that America has
the best surgeons in the whole wide world, and
that we are to be the first to drop rubber gloves
whenever pathology and mechanics teach that handi-
caps are not desirable.

Rubber gloves are pretty, but let us not put on
these badges of inferiority for every entertainment.
Let us not join with wars and epidemics in doing
honor to the shade of Malthus.

616 Madison Avenue.

Arteriosclerosis. — Devoto says that in arteriosclerosis
there is not an exact correspondence between the anatomi-
cal alterations and the clinical phenomena. He enumerates
the causes that may produce the condition, and states that
in defining the relation between arterial pressure and ar-
teriosclerosis we should not omit those causes which favor
the chronic renal lesions, hypertrophy of the thyroid,
alterations of the respiratory organs, and those which result
from insufficient food. From the point of view of thera-
peutic treatment, he says that the symptoms which show the
existence of arteriosclerosis, such as modifications of pres-
sure, etc., can be favorably affected by iodine and other
chemical and physical means.—/..! Rifonna Medica.

396

MEDICAL RECORD.

[March 9, 1907

INTRAABDOMINAL ABSCESS DUE TO
GONORRHEAL AND BACTERIUM COLI
INFECTION COMPLICATING PREG-
NANCY ; OPERATION WITH COM-
BINED VAGINAL AND ABDOMI-
NAL DRAINAGE ; RECOVERY.*

By S. STR.-^US, M.D.,

NEW YORK.

GVKECOLOGIST TO THE PHILANTHROPIC HOSPITAL; LECTURER ON GYNE-
COLOGY, NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL.

Mrs. L. M., housewife, aged 18, married 6 months,
was never pregnant before. Menstruation began at
12 years of age, regular every 28 days, lasting from
3 to 4 days, with slight pain. Last menstruation
September 4. On December 4 there was a profuse
hemorrhage, which the patient claimed was men-
struation, lasting 10 days, accompanied v/ith head-
ache, loss of appetite, and sleeplessness. The pa-
tient always enjoyed good health until her marriage,
which was in June. Four months later she became
pregnant; she then complained of painful urination,
burning discharge from the vagina, and abdominal
tenderness accompanied with vomiting.

I was called in to see her after she had been lying
in bed four weeks suffering with acute abdominal
pain and occasional attacks of vomiting and consti-
pation which had been treated with ice-bags and
injections of morphine without avail ; she now com-
plained merely of anorexia and extreme weakness ;
no pain; temperature. 99^, pulse, 86.

The patient appeared anemic and had the general
appearance of sepsis, although temperature and
pulse were not elevated. E.xternal palpation le-
vealed a mass which was felt about two inches above
the umbilicus, extending downward into the pelvis,
the Jower border not being definable by external pal-
pation.

Internal examination. Urethra normal, vagina
soft and velvety to the touch, cervix and anterior
vaginal wall very soft, uterus enlarged and ante-
flexed, about two finger breadths above the sym-
physis and markedly fixed. In the left hypochon-
driac region a mass was felt filling out the pelvic
brim and connected with the uterus and drawing
same upward. The diagnosis of a three months'
uterine gestation, complicated by diffuse suppura-
tion, was made ; the cause of the suppuration we
presumed to be left adnexal disease or that infec-
tion of an e.xtrauterine sac had taken place. An im-
mediate operation was advised, and the patient was
taken to a private hospital and prepared for a
vaginal and abdominal section.

On account of the height of the mass from the
vaginal fornix there was a doubt whether we could
reach the same by vaginal section, still an incision
was made in Douglas' pouch with the expectation
of reaching the mass this way, aided by e.xternal
pressure. There were a great many intestinal ad-
hesions, and in one spot the aspirator was thrust in
but no pus was found. At this time the patient's
condition became alarming, the pulse going up to
150. As I did not wish to prolong the operation, a
hasty abdominal section was performed ; on enter-
ing the peritoneal cavity the omentum, intestines,
and uterus were found to be matted together and
adherent to a sac containing a large amount of
fluid. No line of cleavage could be found. In order
to hasten the operation, on account of the precarious
condition of the patient, the adhesions were not dis-
turbed, gauze pads being inserted to shut off the
general peritoneal cavity. The omentum was bluntly

*Read at a meeting of the Harlem Medical .Association,
Kew York Citv.

perforated, being torn through with the fingers, the
sac was incised, and the pus mopped out with gauze
sponges. On investigation the sac was found to be
adherent to the intestines, there undoubtedly having
been a rupture of a pus tube. It was then decided
it would be impossible to extirpate the diseased sac
in toto, therefore drainage was established through
the pouch of Douglas, a large iodoform wick being
introduced through the abdominal incision and
brought down through the vagina. By this time
the patient's condition was wretched, pulse 200, and
she was in profound collapse; a transfusion of
1,500 c.c. saline solution was given in the left
cephalic vein while the patient was on the table and
she was hurried to bed, with the conclusion of all
that she would not live longer than half an hour.
The patient rallied, however, and about midnight ap-
peared to be coming out of shock. Fearing intes-
tinal obstruction, we attempted to establish cathar-
sis, but large doses of calomel and salines were
ineft'ectual ; the abdomen began to swell and symp-
toms of intestinal obstruction, vomiting, and tym-
panites began to manifest themselves; large doses
of eserine also were given without avail. Under
aseptic precautions the gauze was loosened and a
digital exploration was made which revealed a kink
in the intestines ; this was released by the finger,
and so great was the rush of fluid through the gut
that it was feared that it had ruptured ; the tym-
panites slowly disappeared, and within an hour the
patient passed gas and during the night had an
evacuation : from this time she began to improve ;
the gauze in the abdominal wound was changed on
the fifth day.

On the third day she began to have uterine con-
tractions accompanied by much pain in the abdomen
and during the night she was delivered of a three-
inonths' fetus, but the placenta did not come away ;
the fetus was removed and the cord was ligated,
returned into the vagina, and allowed to remain in
order that it might separate of itself, this course
being pursued on account of the extreme weakness
of the patient ; also I did not desire to disturb the
relations of the parts unless compelled to by some
urgent indication. On the fifth day the patient had
a hemorrhage from the uterus which necessitated
the removal of the placenta ; this was a very difficult
task to perform, as it was impossible to make bi-
manual pressure upon the uterus. The only method
that could be employed was fixation of the uterus
with a vulsellum forceps and extraction of the pla-
centa with forceps, taking it away piecemeal, fol-
lowed bv curettage and packing of the uterus to
prevent any further loss of blood. The subsequent
course of the case is explained by the temperature
chart: the pulse remained at the level of 120, tem-
perature 102°, and the patient gave promise of ap-
proaching convalescence, which was somewhat re-
tarded by the abdominal Mikulicz dressing, which
was changed from time to time ; the gauze in the
cul-de-sac was slowly removed and a new pack
introduced, which was changed every five days ; the
bacteriological examination of pus showed gonococ-
cus and the colon bacillus.

The case is unique in that it lacked the usual con-
stitutional symptoms of any pus formation, and the
apparent local signs were only those of uterine
gestation complicated by the gastrointestinal symp-
toms of pregnancy. In the technique employed
attention is called to the fact that it is wiser not to
separate the adhesions over a large area when we
fear pus, but to proceed cautiously with a bhmt
dissection through the omentum until the sac is
reached, emptying same, and then establishing the
relations to the adjacent structure.

March 9, 1907]

MEDICAL RECORD.

397

Medical Record.

A Weekly "Journal of Medicine and Surgery.

THOMAS L. STEDMAN, AM.. M.D., Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, March 9, 1907.

THE PRESENT STATUS OF OPSONINS.

Few of the medical journals of recent issue have
appeared without containing either an original con-
tribution upon, or a reference to the opsonic work
of \\'right and Douglas. Most of these are reports
of favorable results obtained in treatment by the
methods of Wright, and, as such, are bound to
influence the practitioner, breeding in the minds of
those who are too busy with the toil of daily routine
to follow the details of scientific research an impres-
sion that the panacea for all infectious ills has been
revealed, and the road opened toward a revolution
of the science of immunization.

It is natural and altogether beneficial that every
new scientific announcement should be followed, at
first, by an enthusiasm which, in therapeutic appli-
cation and prophecy, may far outstrip the final actual
gain. Thorough scientific comprehension follows
more slowly, and there is much statistical material
gathered by the enthusiastic therapeutists who by
their successes' and failures, honestly observed, aid
much in the final calculation of the net profit. The
problems involved in the application of Wright's
principles to treatment have not reached the stage at
which this final calculation can be made : but it is
well at the present time to consider to what extent
Wright's important discovery has become the legiti-
mate property of the clinician, and how much of it
is still in that stage of uncertainty during which onl}-
patient and conscientious research of trained labora-
tory workers can hope to decide finally upon its
actual therapeutic value.

The problems of phagocytosis have long been the
subject of much laborious investigation by the
French bacteriologists, notably Metchnikofif. The
action of the blood serum in the process of p'hagocv-
tosis has been conceived by Metchnikofif and his
pupils, by Bordet, Denys, Mesnil, Besredon, and
others, as rather a stimulation of the phagocytic cell
than as an influence exerted upon the ingested bac-
teria or other substances. The knowledgebroughtout
by the studies of WrightandDouglas.and those car-
ried on independently, though somewhat later, bv
Neufeld and Rimpau. show us that this phagocytic
power bestowed by the serum is set in motion by an
action upon the ingested objects rather than by the
changes wrought upon the leucocytes themselves.
That the substance which brings about this loss of
resistance to phagocytosis — the "opsonin" — is prob-
ably independent of agglutinin, complement, and the
various other substances present in normal and
immune sera previously described, must, in the light
of our present knowledge, as based on the work of

Hektoen and r.thers, be assumed. Thus a far-
reaching new truth has entered into our knowledge-
of the phagocytic process, a truth the recognition of
which in itself is a great achievement, and which.
by its own weight and indirectly by the great stimu-
lus it has given to research into the phagocytic ele-
ments of immunization, may lead to still greatei:
results.

As to the present therapeutic application of this
new principle, so much is being said by enthusiastic
workers that it is hardly necessary to outline what is
going on. Active immunization with minute dosage
of dead organisms is the principle of Wright's work.
Active artificial immunization in itself is an old
matter, and is obviously limited to subacute and
chronic processes. The mistakes of earlier workers
in this field undoubtedly to a large extent lay in-
overdosage and ill-judged intervals, and others,
without knowledge of opsonins, have been working
toward the correction of these errors. This has been
the tendency in many sanatoria for tuberculosis,
both here and in Europe, and the book of Denys,
published in Louvain in 1904, is based upon this
principle of active immunization by small dosage of
his bouillon filtre of cultures of the tubercle bacillus.
But all these observers have relied upon purely clin-
ical data in their judgment of the reaction to the
treatment and for standards of dosage and time of
repetition. Wright and his disciples, on the other
hand, are basing their judgment in these matters
upon the rises and falls of the opsonic indices of the
patient's serum.

It undoubtedly would seem at first sight that such
actually visible changes in the specific phagocytic
power of a patient would be more delicate than the
rough data of clinical observation of temperature,
physical signs, and general condition, and even the
sceptic will acknowledge that the determination of
the opsonic index in a given case may, together witli
clinical data, be of value. But to obtain this sys-
tematically entails much time, work, and expense,
and it is but fair to inquire whether this addition to
the labor of treatment will justify itself by shedding
a corresponding amount of light upon the condition
of the patient's resistance. This question resolves
itself into an examination of the accuracy of opsonic
estimations.

The details of a technique which is Ijoth intricate
and delicate cannot be gone into here : suffice it to
say that the mere mechanical labor is a matter re-
quiring much skill, in which minute variations of
eye and hand may lead to considerable errors in the
result. The opsonic index is calculated by a com-
parison with an arbitrarily designated "normal," and
these "normals" so-called are subject to great varia-
tions which, as the numerators or denominators of
the final fraction, thus add another and purely arbi-
trary error to the result. The leucocytes used for
these estimations are taken from an indifferent
source, usually the finger of the worker himself; and
we know at present very little of the variations in
the phagocytic activity of various leucocytes. Add
to these things the consideration that we know little
or nothing of the modifying influences exerted upon
the phagocytosis by other immune bodies undoubt-
edly present in the serum, and it does not seem ex-
travagant to assume for opsonic estimations an error
of at least from 20 to 30 per cent. Whether this

'39B

MEDICAL RECORD.

[March 9, 1907

error can be diminished sufficiently to make extended
use of opsonic estimations by Wrifjht's technique
of real value is a matter which only the future can
decide, but at present it seems unlikely when we con-
sider how much of it is due to entirely uncontrollable
influences rather than to imi)erfections of technique.
Furthermore, it will have to be shown that in esti-
mating a subject's immunity we are justified in
making the matter of phagocytosis the sole standard
of judgment with disregard of the various other
immune bodies in the serum. The situation is in
much analogous to that which existed when the
degree of agglutination in typhoid fever was sup-
posed to be entirely parallel with the degree of
immunity.

Much work remains to be done before the thera-
peutic value of opsonins can be defined. Withal, it
must not be forgotten that we are really dealing with
two entirely separate questions when we discuss
Wright's work on opsonins and his therapeutic
efforts with specific bacterial emulsions, and even
should the former investigations be shown to be of
purely academic interest the revival of efforts toward
active immunization inspired by the latter may still
prove of inestimable practical value.

THE GA^IETOID THEORY OF C.\NCER.

At a recent meeting of the Liverpool Medical In-
stitution (Lancet, February 16, 1907) C. E. Walker
presented a paper on this subject. He explained
that as all living matter existed only in the form of
cells, all problems of living phenomena must ulti-
mately be cell problems. As all multicellular or-
ganisms, whether plants or animals, originated from
a single cell (the fertilized ovum), the potentiality
of all the cells subsequently produced from it was
■contained in the fertilized ovum. The author noted
that the reductioninthenumber of chromosomes to
one-half of the number found in the cells forming
the bodv tissues, observed as occurring in sexual
cells, might be compared with a similar phenomenon
occurring in the cells making up malignant growths.
Over ten years ago various observers described
the occurrence of division figures in cancer which
possessed all the peculiar characteristics of the
lieterotvpe divisions ; that is, the form of division
in which the number of chromosomes was reduced
to one-half of the normal number found in the body
cells. A diagram was exhibited showing the results
of an indiscriminate counting of the chromosomes
in the dividing cells of malignant growths. This
diagram when compared with one showing the re-
sults of a similar counting of the chromosomes in
the cells of a testis proved that the relative propor-
tions of cells containing the full and exactly half
the normal numbers of chromosomes was almost
identical in malignant growths and in testes. It
was shown that "Plimmer's bodies," so frequently
described by various authors as being the parasite
■of cancer, were exactly similar in origin, in mode of
development, and in structure to the archoplas-
mic vesicles found in the spermatids of certain
animals, including all mammals, but never in any
other normal cells of the body. Thus there was
another direct parallel between the cells of malig-
nant growths and those of normal reproductive tis-

sue. Emphasis was laid upon the fact that cells
that had entered upon the reproductive phase lived
normally as parasites upon the parent organism,
and that all such cells, whether in animals or in
plants, were out of coordination with the rest of
the body. A true fusion between leucocytes and
tissue cells was described as being one of the earliest
phenomena in the commencement of malignant
growths. Reduction in the number of chromosomes
to one-half of the somatic (body) number was de-
scribed as taking place normallv among the leuco-
cytes, thus making it probable that certain genera-
tions of leucocytes went through a sexual phase.
Basing his views on the foregoing facts, Mr.
Walker pointed out that the malignancy of certain
tumors might be due to the cells forming there
entering upon a sexual phase, and there living as
parasites upon the parent organism, as such cells
always did. On this supposition it would be neces-
sary to seek the cause or causes which induced this
change. This left the leucocytic fusion in the posi-
tion of a mere coincidence of no material impor-
tance. On the other hand, this fusion itself would
equally account for the peculiar qualities possessed
by the cells of malignant growths. They would
necessarily be out of coordination with the parent
organism, and would live as parasites upon it.
Moreover, that some of them should enter upon
the sexual phase was exactly what would be likely
to happen. Here it would be necessary to find out
under what conditions the fusion between the leu-
cocytes and tissue cells was possible. It might be
due to some change in either or both of the two
kinds of cells.

The Bier Treatment of M.\stitis.

The beneficent action of Bier's suction treatment
of inflammatory processes has already been re-
corded many times. The possibilities of the method
in skilled hands appear to be very great, but it is
also certain that when improperly used the results
are likely to be discouraging and even directlv in-
jurious. Hartman (Mihicheiier medizinische IVoch-
ensclirift, February 5. 1907) in discussing the suc-
tion treatment of mastitis refers to a reported case
in which on the first application of the glass bell
the pain caused was so intense that the patient
fainted. The instrument used had a diameter of
only 5 cm., whereas the inflamed area was as large
as the palm of the hand, and had a fluctuating
abscess in its center. Naturally the pain caused by
the pressure over this acutely sensitive spot was
extreme, whereas when correctly applied the suc-
tion gives marked relief from pain. Hartman says
that the three commonest errors in the use of the
suction treatment are the application of bells that
are too small, the omission of early incisions, and
discontinuing the suction too soon. In treating
mastitis the diameter of the bell should never be
less than 10 cm., and frequently one having a diame-
ter of 15 cm. may be required. If there is fluctua-
tion a very short incision under ethyl chloride anes-
thesia should be made. Hartman recommends daily
sessions in which suction is applied four or five
times during a space of five minutes, with an in-
terval of from three to five minutes between the
applications of the instrument. At the close of each
session milk is drawn from the affected gland by
means of a small bell placed over the nipple, and a.
wet dressing of aluminum acetate is applied. It is

March 9, H307

MEDICAL RECORD.

399

■usually unnecessary to leave any drainage material
in the wound, though the insertion of a small tube
may facilitate the aspiration of discharge while the
suction is being applied. Hartman reports in de-
tail the histories of twelve cases of mastitis in which
this method was applied, and he considers that it
represents a decided advance in the treatment. Pain
and fever are lessened, and early cases are aborted
in from three to five days without any incision. If
abscess formation has commenced small incisions
■effect a cure in from four to seven days, though
the average time is sixteen days. The cosmetic and
functional results are excellent, and surpass those
obtained by any of the older forms of treatment.
In dealing with the subacute indurated forms of
mastitis which do not go on to suppuration, the
passive hyperemia produced by the suction treat-
ment is less satisfactory, and the use of wet dress-
ings followed later by massage is in manv cases
far preferable.

The Early Di.xgnosis of Le.\d Poisonixg.

While lead poisoning in its more advanced stages
is ordinarily accompanied by so characteristic a
symptom complex as to make its diagnosis a matter
of no very great difficulty, in early cases the condi-
tions may be extremely hard to recognize. One of
the most reliableevidencesofplumbism.the detection
of the metal in the urine, is unfortunately scarcely
within the scope of the practitioner's laboratory,
owing to the somewhat complicated and very time-
consuming chemical manipulations it requires. Even
in skilled hands negative results are common, and
Frey {Deutsche medidnische Wochcnschrift, Feb-
ruary 7, 1907) states that Seiffert in the course of
seventy-three analyses of the urine of tin refiners
exhibiting the most varied symptoms of intoxication
■discovered lead in only 15.6 per cent. The chemical
investigation of the urine therefore does not furnish
a satisfactory means of diagnosis for mild or early
•cases. The granular degeneration of the red blood
cells described by Grawitz some years ago seems to
be of greater assistance, however. It consists in
the presence in certain of the red blood corpuscles
of minute particles having a strong affinity for baso-
philic dyes, so that in a blood preparation stained
■with one of the methylene blue solutions the cells in
question present varying ninnbers of minute bluish
points. Frey, also working among tin miners and
refiners, arrived at the conclusion that in this pecu-
liarity of the erythrocytes a most useful diagnostic
indication of incipient blood poisoning was to be
found. The other conditions in which it is likely to
occur, such as cancer, pernicious anemia, intestinal
putrefaction, and sepsis, can usually be excluded
without difficulty, but the possibility of their occur-
rence must be kept in mind. The value of routine
blood examinations with this appearance in view
is very great, as in this way individuals may he
excluded from the more dangerous forms of work
until the disappearance of the basophilic granula-
tion indicates that for the time being the danger of
lead poisoning is over. As the granules in the red
cells usually appear before the other svmptoms have
become characteristic, if the blood of those engaged
in occupations that mvolve danger of plumbism is
watched carefully the severer forms of intoxication
can very often be forestalled. There is also another
and very useful application of this discovery in that
by frequent blood examinations one may very accu-
rately estimate the degree of success of any thera-
peutic measures that mav have been instituted.

Electricity in the Tre.-\tment of He.^\rt
DISE.^SE.

Comparatively little attention seems to have been
paid to the use of electricity in its various forms
in the treatment of cardiac affections, but in a
recent article an Italian writer, Galli {Gazzctta
degli Ospcdali, No. 153, 1906) refers to the value
of this measure as an accessory "-o other methods,
including drugs and physic.il agents, which are
commonly employed. Ther',- has existed more or
less of a prejudice against electricity, because animal
experiments have shown that faradization of the
heart produces diminished heart action, incomplete
contraction of the ventricles, reduction of the bloi.id
pressure, and finally paralysis of the organ. These
results seem to have been borne out by observa-
tions made in the human subject, although this
opinion has been somewhat revised by a further
study of the effects of the galvanic, high frequency,
and alternating forms of current. The galvanic
current, for e.xample, was used by Galli in the form
of complete and local baths, which correspond in
their effects to the carbonic-acid baths and may be
substituted for the latter in certain cases. The alter-
nating-current baths may be employed in those cases
where compensatory disturbances of a severe type
exist which are constant even without exertion
on the part of the patient The firadic baths,
however, seem to have a better effect in anemic
nervous patients who are afflicted with diseases of
the vessel walls and also present renal symptoms.
In otherwise strong individuals whose vessels and
kidneys are in gfood condition, the sinusoidal cur-
rent seems preferable and quite harmless. Aw
interesting fact about both of thes-3 currents is that
they appear to possess the property not only cf
reducing abnormallv high blood i^ressure, but also
of bringing back abnorniallv low pressure to tlie
normal condition in a manner similar to that accom-
r>lished bv digitalis. .A general application of the
high-frequency current reduces, and t!ie local appli-
cation of the same elevates, blood pressure, .\notiier
eft'ect which is well marked in the use of the electric
currents for the purposes noted is the favorable
action on the various states of physical and psychical
depression which are prone to occur during tiie
course of chronic heart disease^.

The Serum Treatjiext of Dvsextery.

Since Shiga's communication on this subject in
1898 numerous other observers have published re-
ports on the treatment of dysentery by means of
antito.xic serums. Although the conditions under
which the individual observations were made have
varied in more or less important particulars, such
as the severity of the cases and the manner of ob-
taining the serum, on the whole the conclusions of
these experimentors have been favorable to tiie
method. (Jne of the most recent papers on this
subject is that of Skschivan and Stefansky {Berliner
kliiiische IVochenschrift, February 11, 1907). who
in the summer months of the preceding year treated
by means of a serum fifteen cases of dysenterv oc-
curring in Odessa. The serum used was antitoxic,
and had been obtained by a year's immunization of
a horse with injections of the filtrate from cultures
of the Shiga bacillus. The patients were between
the ages of nineteen and forty-six years, and in seven
the disease was of severe type, while in the others
it was of moderate gravity. Every eft'ort was made
to render the effect obtained by the serum as con-
clusive as possible, and practically no other reme-

400

MEDICAL RECORD.

[March 9, 1907

dial measures of any sort, except, of course, the rest
in bed and suitable diet, were resorted to. The
effect of the injections was manifest within two or
three days, a distinct diminution in the progress
of the disease, as shown by the decrease of pain
and tenesmus, and reduction in the number of move-
ments and improvement in their character being
promptly noticed. In three to four days the stools
harl liecome diarrheal, and usually soon returned to
their normal character. The authors therefore as-
cribe a very distinct and active remedial quality to
the serum, and recommend that its use be more
widely resorted to, especially in dealing with dysen-
tery in children. Complications due to the serum,
such as erythema and joint pains, were observed in
two cases, but apparently were not of a serious char-
acter.

The P..\ssage of Mercury froji Mother to Fetus.

The question of the transmission of drugs and
other substances from mother to fetus through the
medium of the placental circulation continues to
hold the attention of investigators on account of its
great jjractical interest and value. It has been
variously claimed that mercury among other thmgs
is able to pass through the placenta and be dis-
tributed through the fetal organs in a manner sani-
lar to that which takes place in the adult. Conti
and Zuccola {Gazzetta degli Ospedali, No. 153,
1906) believe, as the result of their recent experi-
ments, that mercury as such cannot pass through
the placenta in the manner indicated, and that the
effect which has been observed in the fetus is
brought about in a different manner. In their
tests they made use of a saturated solution of =iul-
phureted hydrogen which had been acidified with
nitric acid, and also examined the tissues micro-
scopically. The experimental sulijects included
not only human fetuses, but also those of guinea
pigs and rabbits which had been poisoned with
bichloride of mercury injections. The three human
fetuses were the products of syphilitic mothers who
were undergoing mercurial treatment for their
disease. In the experimental animals mercury in
the form of a sulphate could readily enougli be
demonstrated in the various organs bv tbe test in-
dicated, but no such result was oltainea in those
of the offspring. The meconium of the human
fetuses gave rise to a positive reaction, but this
could not be confirmed by a later examination of
the intestinal tract. The writers believe that in
previous investigations the demonstration of the
mercury in the fetal tissue was based upon imper-
fect and false technique. No definite proof has
been brought forward of the actual presence of the
drug in the fetal organs, and the therapeutic effect
which has been observed may be explained, accord-
ing lo ("onti and Zuccola, by the fact that the mer-
cury has caused the development m the cells of
the maternal organism of substances which have
the property of exerting a neutralizing influence
on the pathogenic factors in the fetal tissues.

The Relation of the Stomach to Labor Pains.

The fact has long been appreciated that a certain
nervous relation exists between the uterus and the
stomach which manifests itself in a varietv of refle.x
phenomena. This is well shown during the course
of pregnancy, not only the early months, but, as
demonstrated in a recent study by Kehrer in the
Beitmg^e fur Geburfshiilfe und Gynakologie, Vol.
TO, No. 2, up to the time of labor itself. Overdisten-

tion of the stomach or a gastric catarrh seems to
exert a well-marked inhibitory effect on the labor
pains, prolonging the periods of cervical dilatation
and expulsion and thus leading to exhaustion of the
mother and possible asphyxiation of the fetus. Spon-
taneous or induced vomiting will change this condi-
tion at once, and, according to Kehrer, may render
operative delivery in certain cases unnecessary. If
the ordinary means of inducing vomiting are not suc-
cessful, the writer advises gastric lavage, although
the effect of this is less certain. Another interesting
point which is brought out in this paper is the fact
that labor pains rarely come on during the afternoon
because the stomach is usually filled at this time
or digestion of its contents is going on, this con-
dition acting as an inhibitorv influence on the pro-
duction of the labor pains.

Nma of tl)? Wttk,

What a Medical Society Should Be.— Dr.

Joseph Decatur Bryant, ex-President of the Medical
Society of the State of New York, but President-
elect of the American Medical Association, is ap-
parently opposed to boss rule in medical organiza-
tions. In the course of his Presidential address, de-
livered at the recent meeting of the State Society,
he remarked : "It [the State organization] is a free
government in the complete sense of the expression,
one in which the humblest members of the most
cheerless stations of the State have equal privileges
with those of exalted station in the midst of wealth
and power ; one in which the officers are your serv-
ants and not your masters, unless you so will it to be,
and from whom you have the right to demand at
the proper time, and in a suitable manner, a com-
plete accounting of the status of their respective
stewardships, and which, when wisely required, they
have no right to decline. And in all other respects,
your rights and privileges cannot be overshadowed
by those of anotlier unless you, yourselves, lend aid
to the eclipse."

Lieutenant Carroll's Promotion. — The Senate
bill raising Lieut. James Carroll of the Army Med-
ical Corps to the rank of Major, in recognition of his
services to science in the study of yellow fever,
passed the House last week. .'\t a meeting of the
Nebraska Academy of Medicine recently held in
Lincoln a committee of five was appointed to make
an effort to secure a Nobel prize for Dr. Carroll.
The members of the committee are Drs. S. R.
Towne, A. S. von Mansfelde, H. B. F. Ward, R. H.
\\"olcott, and H. ^^^ Orr.

State Pure Food Bill. — A Pure Food bill, which
contemplates cooperation between the State and the
Federal government in the prosecution of violations,
and which in most of its details follows out the pro-
visions of the Federal statute on the subject, has been
introduced in the New York State Assembly. The
bill takes from health officers most of their duties
relative to detection of violations of the health law
so far as foodstuffs are concerned, and transfers
them to the State Commissioner of .Agriculture.

The Milk Question. — At a meeting held last
week in the I'nited Charities Building, the New
York milk committee expressed its opposition to the
general municipal pasteurization of the entire milk
supply, but favored the pasteurization of milk in
feeding bottles for infants as the best means for
reducing infant mortality in summer. Special em-
phasis was laid on the importance of establishing
infants' milk depots before next June, for which the
cooperation of private philanthropy and of the city
authorities should be sought. A committee was also

March 9, 1907]

MEDICAL RECORD.

401

appointed to seek to secure the cooperation of the
State Board of Health and of the Department of
Agriculture in relation to the destruction of tubercu-
lous cattle, and greater activity of local boards of
health in reference to reporting cases of communica-
ble diseases in persons on farms or handling milk.
The same committee was instructed also to oppose
the ordinance now before the Aldermanic committee
and the Reece bill at Albany. A letter from Com-
missioner Darlington was read, in which he stated
that he was opposed only to compulsory pasteuriza-
tion of all the city milk, but not to requiring the
pasteurization of such milk as could not otherwise
pass inspection. The meeting of the Section on
Public Health of the New A'ork Academy of Medi-
cine on March 12 will be devoted to a discussion of
the city milk supply. The following papers will be
presented : "Milk as a Carrier of Infection," by
Charles Harrington, M.D., Secretary Massachu-
setts State Board of Health; "Pasteurization: The
Advantages and Disadvantages to the Consumer,"
bv Rowland G. Freeman, M.D., of New A'ork ;
"Pasteurization : The Advantages and Disadvan-
tages to the Municipality," by Joseph Roby, M.D.,
Rochester, N. Y., Deputy Health Officer ; "Current
]\Iisstatements and Fallacies Regarding the Milk
and Milk Supply of New York City," by William
H. Park, M.D., of New York. The discussion will
be continued by Drs. L. Emmett Holt, Walter Ben-
sel, and Linsly R. Williams.

Hudson River Ice. — Steps are being taken by
the ^Merchants' Association's Committee on Pollu-
tion, to prevent further harvesting of ice in the
Hudson River near the mouths of Rondout and
Catskill Creeks. This section of the Hudson River
is regarded as a particularly dangerous one. as the
nearby village of Catskill is suffering from a typhoid
fever epidemic, and ice is being cut from sections of
the river which are practically at the mouths of both
Rondout and Catskill Creeks.

Suicide Bureau in New York. — At the Salva-
tion Army bureau for preventing suicide, organized
last week for the purpose of giving good advice and,
where needed, material help to those contemplating
self destruction, eighteen would-be suicides applied
on the first two days. Similar bureaus have been
in successful operation in London and St. Louis for
some time, and others are to be started in Boston,
Cleveland, Chicago, Atlanta, Kansas City. Minneap-
olis, and San Francisco. One girl who applied to
the bureau was not thinking of committing suicide,
but needed skin to be used for skin-grafting a deep
wound in her father's neck. The Sun states that
when the request was made known, in a short time
there were thirty volunteers among the young men
of the training and industrial school ready to part
with a portion of their cuticle.

Work of the Children's Hospital Society of
Chicago. — This society in its existence of four
years has done a far-reaching work, and has been
the means of improving the health and saving the
lives of many babies in the crowded portions of the
city. The society's first work was to found a Milk
Commission, and it has distributed 1,043.175 bottles
of the cleanest, purest and best milk that any cow
could give, it is said, which have been of untold
value to sick and convalescent infants. The latest
undertaking of the society is to aid in getting the
State Legislature to appropriate money for the estab-
lishment of a State epileptic colony. For this pur-
pose, under the auspices of the society. Dr. W. C.
Spratling, superintendent of Craig Colony for Epi-
leptics, New York, recentlv gave an illustrated lec-

ture in the Senate Chamber at Springfield, before
the members of the Legislature. It is claimed the
colonv as proposed will be almost self-supporting.
The State Board of Charities has asked the Legisla-
ture for $365,000 with which to found an epileptic
colony.

Contagious Diseases in Chicago. — According to
a recent report of the Chief iMedical Inspector of
the Chicago Health Department, Dr. Heman Spald-
ing, cases of diphtheria, measles, and scarlet fever
show a decided and substantial reduction in number.
This reduction has been steady and rapid, dating
from the week the nev^' medical inspectors were put
to work. This work speaks for itself, and nothing
can be said that emphasizes the necessity of a per-
manent medical inspection corps equal to the results
of these few weeks of medical inspection of schools.

Typhoid Fever on the "Connecticut." — The
battleship Connecticut reached this port last week
from Guantanamo with between thirty and forty of
her crew ill with typhoid. The first cases appeared
early in February, and when the severity of the epi-
demic became apparent, the vessel was ordered north
in order that the patients might be transferred to the
Naval Hospital at the Brooklyn Navy Yard. The
origin of the infection has not been discovered.
It is stated that the disease is not of a severe
type and that none of the men are in a serious con-
dition.

Plague in East Africa. — The German papers
report that two cases of plague have occurred at
Muanza. German East Africa, and also that one case
of plague was discovered on a British steamer which
arrived recently at Muanza. The colonial authorities
are making strenuous efiforts to prevent the spread
of the disease.

Experimenter Contracts Plague. — A cable des-
patch from Ivronstadt states that Dr. Schreiber.
surgeon of the .Second Siberian Regiment, who had
been experimenting with living organisms in con-
nection with researches on bubonic plague, has con-
tracted the disease and has been isolated in the fort
where he carried on his work.

Overcrowding at St. Vincent's Hospital. —

Ordinarily the accommodations in this hospital serve
for the reception of about 400 patients, but lately,
owing to a great increase in applicants of all classes,
there have been 600 patients at a time in the hospital.
Cots have been put up in every available spot, and
both the house staff and nursing corps are severely
overworked. An unusually large proportion of the
cases in the hospital are of pneumonia.

Street Spitters Arrested. — Ten persons were
arrested on one day last week by members of the
Sanitary Squad for spitting in the streets. All the
arrests were made on Fifth avenue, between Four-
teenth and Sixteenth streets. After arraignment in
the Jeftefson Market Court, the prisoners were dis-
charged with a warning.

The State Registration of Nurses. — The Penn-
svlvania State Committee on Nursing, which has for
its object the regulation and advancement of nurs-
ing and the fostering of a proper relation of nurses
to the medical profession and the communitv, has
issued a statement relative to the bill now_ before
the Pennsylvania State Legislature providing for
the registration of nurses. The enactment of such a
measure is deprecated on the ground that State law
for the registration of nurses is not only unneces-
sarv. but is positively harmful. The tendency of
such a law is to lead the average nurse to assume
too much, and to lessen her usefulness. It is

402

MEDICAL RECORD.

March 9, 1907

further stated that such a law would be a menace to
the community, and that under its provisions the
presence of nurses in the sick room might be a posi-
tive danger. The maintenance of a uniform scale
of charges of $25 or $30 a week would also, it is
claimed, result in detriment to the mass of the
people who cannot afiford to pay such rates. The
ultramedical training given nurses in many institu-
tions is also criticised.

Hospital Transfer Bill Passed. — The State Sen-
ate la.st week passed Senator Sohmer's bill making
it a misdemeanor to transfer patients in a critical
condition from one hospital to another. The bill
also compels superinten<lents of New York city
hospitals to admit all patients brought to tliem if
the\- have room and the patients are not suffering
from contagious diseases.

The Kings County Grand Jury for February
has adopted a resolution calling on the Grand Jury
for March to look into conditions in the Brooklyn
Hospital, alleging that the patients in that institution
do not receive proper attention from the orderlies
unless thev bestow gratuities liberally. The super-
intendent of the hospital has denied that any such
condition existed.

Misericordia Hospital to be Enlarged. — Plans
have been filed for a $125,000 addition to the Miseri-
cordia Hospital at Avenue A and Eighty-sixth
street, conducted by the Sisters of Misericordia. A
five and six-story extension is to be added, with a
frontage of 123 feet and a depth of 54 feet, having a
facade of brick and ornamental stone. Part of the
addition will be fitted as a home for the sisters, with
a chapel attached. The building w'ill also have a
roof garden.

For a New Dispensary. — The recently orga-
ized Brownsville Hebrew Dispensary Society will
hold a public meeting on March 18 to appeal to the
residents of Queens County for the establishment
of a dispensary in that section because of the large
number of poor persons living in the district.

Tuberculosis Camp in Plainfield. — The tuber-
culosis committee of the Plainfield Clinical Society
has formed a permanent organization and decided to
establish a tuberculosis camp in Plainfield for the
outdoor treatment of consumptives.

A Chair of Hydrotherapy at Columbia. — At a
meeting of the Trustees of Columbia University on
Monday of this week, it was voted to establish a
chair of hydrotherapy at the College of Physicians
and Surgeons. Funds for this purpose, it was
stated, will be provided bv an anonymous donor.

Dr. Doty's Appointment Confirmed. — The ap-
pointment of Dr. Alvah H. Doty as Health Officer
of the Port of New York was confirmed by the Sen-
ate on February 2S.

Dr. Samuel G. Dixon of Ardmore, President of
the Philadelphia .\cademy of the Natural Sciences,
has been reappointed, by Governor Sturat, State
Commissioner of Health of Pennsylvania.

Dr. Henry Heiman has been elected adjunct
professor in the department of pediatrics of the New
York Po!\clinic.

Dr. Emmet P. North of St. Louis has been ap-
pointed to fill the vacancv made by the death of Dr.
A. Y. S. Brokaw, chief surgeon of the United Street
Railways Company of that city. Fie will be called
the chief medical director, and has appointed a corps
of assistants located in various parts of the city.
Dr. North has sen'ed in the City Hospital, the Mis-
souri Pacific Railroad Hospital, and the South Side
Dispensarv, and has for some time been a division
surgeon for the United Railways Company.

The Interlude of Cancer. — In the article with
this title by Dr. Beard of Edinburgh, in the Medi-
CAL Record of February 2, a misprint occurs in the
first column, in which Freiburg, Baden, was made
to read Freiburg, Berlin. On page 174, under E;n-
bryomata, the last sentence begins : They are now
endowed, etc. For "now,"' one should read "not."

Against Vivisection. — A bill has been intro-
duced into the Pennsylvania Legislature making it
unlawful to vivisect or experiment on any living
animal for any purpose, .scientific or otherwise, and
fixing as a penalty a fine of from $100 to $500, or
imprisonment for from 30 to 60 days, or both.

The Society of Tropical Medicine, which has
existed for a few years, and is especially active in
Philadelphia, will hold its first meeting in New-
York on March 29, 1907, at 8:30 p.m., at the Acad-
emy of Medicine.

Association of American Medical Colleges. —
The next annual meeting of this association will be
held in Washington, D. C, May 6, the day before
the opening session of the American Congress of
Physicians. The Hotel Raleigh is to be used as
headquarters.

The Harvey Society Lectures. — The tenth lec-
ture in this course will be given at the New York
Academy of ^Medicine on Saturday, March g, at
8:30 P.M., by Dr. Friedrich ^liiller. Professor of
Medicine at the University of Munich, Germany.
Subject: "Neuroses of the Heart."' This is the last
lecture of the present year's series.

The Lisbon Congress. — The Portuguese mem-
bers of the Fifteenth International Medical Con-
gress, held last year, have presented Professor
Miguel Bombarda with a gold medal and an address
expressing their appreciation of his services as or-
ganizing secretary of the congress.

Statistics Relating to School Children. — The
figures of a still unfinished census being taken
in this city under the direction of the State De-
partment of Education show that at least 20.000
children of the proper age are not attending
school, as is required by the compulsory educa-
tion law. The census, taken by the police in
October, November, and December, includes all
persons between four and eighteen years of age in
the greater city. Of these, 4,371 are working
illegally; 4,787 are kept at home illegally; 294
are truants ; 8,402 are not attending evening
school, as required, and 1,449 ^re physically un-
able to attend school. The actual total of non-
attendants foimd to date is 19,303.

The Late Dr. Julia W. Russell.— The follow-
ing resolutions have been adopted by the \\'omen's
Medical Association of New York City : Resolved,
That it is with a deep sense of personal and profes-
sional loss that we record the death of Dr. Julia
Wallace Russell. Resolved, That we her friends
and fellow-workers bear testimony to her high char-
acter and useful life. Resolved, That we express
our appreciation of the honor she did our profession
as a practitioner and as the founder of a hospital
for women and children. Resolved. That a copv of
these resolutions be sent to her family with an ex-
pression of our sympathy with them in their great
bereavement. Resolved. That these resolutions be
recorded in the minutes and be published in the med-
ical journals. (Signed) Sarah J. McNutt, ALD.,
Mary D. Hussey. M.D., Committee.

The Late Professor Herman Cohn of Breslau,
well known as an ophthalmologist, bequeathed the
sum of 10.000 marks to each of the universities of

IMarch 9. 1907]

MEDICAL RECORD.

403

Heidelberg, Tubingen, and Breslau. the income to
T^e used for prizes for research in ophtiiahnology.

Obituary Notes. — Dr. Frederick G. Merrill
of this city died on February 24 at the home of his
brother at Skowhegan, JNIe., at the age of fifty-two
vears. Dr. Merrill was born in Harmony, Me., and,
after graduating from Bellevue Hospital Medical
School in 1S79. began practice in this city. He was
for some time on the staff of the Trinity corpora-
tion.

Dr. John G. Keith of Leadville, Col., died on
February 16 in St. Louis, at the age of si.xty-five
vears. Dr. Keith was formerly a resident of St.
Louis, but for eighteen years had practised in Lead-
ville. He was a veteran of the Civil War.

Dr. Herbert B. Willi.'\ms of Gladys, Va., died
on February 20 of typhoid fever, at the age of
twenty-nine years. He is survived by his brother,
Dr. Walter Williams of Brookneal.

Dr. L. W. Bliss of Saginaw, Mich., died suddenly
•of heart failure on February 20 in San Antonio,
Tex. Dr. Bliss was born in Madison County. N. Y.,
in 1836, and, after serving through the Civil War as
surgeon of the Tenth New York Cavalry, settled in
Saginaw in 1866. He w^as prominent in the city's
public affairs, and was Mayor of Saginaw for three
years. In 1891 he was president of the State i\Iedi-
■cal Society.

Dr. \V. J. Kend.\ll of Upperville, Va.. died on
February 20 of pneumonia after an illness of a week.
He was forty-five years of age, and was a graduate
•of the Virginia Polytechnic Institute and the Balti-
more Medical College.

Dr. Joseph A. Loeb of Stamford, Conn., died of
typhoid fever on February 24 after an illness of
three weeks. Dr. Loeb was graduated from the
Yale Medical .School in 1902, and had practised for
a time in New Haven.

Dr. Makel a. Southworth of San Jose, Cal.,
died on February 16 at Wright's Station. Dr.
Southworth was a native of Herkimer. N. Y.. and
Iiad been a resident of San Jose since 1893. He had
heen county health officer and president of the Board
of Pension Fxaminers. During the Civil War he
served as a surgeon, and for a time had charge of
the yellow fever quarantine station at New Orleans.

©bituarg.

GEORGE BINGHAM FOWLER, :\I.D.

NEW YORK.

Dr. George B. Fowler died at his residence in
this city, on March 6, from gastric disease, at the
age of si.xty years. He was born in Montgomery,
Ala., in 1847, and was the only son of a physician,
Dr. Edmund Fowler, of that place. He was sent to
school in Westfield, Mass., and later was graduated
from the "Free .Academy," now called the College of
the City of New York. He studied medicine a\ the
College of Physicians and Surgeons in this city,
obtaining his degree therefrom in 1871. His hos-
pital experience was gained as an interne at Belle-
vue. He was for a number of years after gradua-
tion associated with the teaching staff of the
institution, first as curator of the museum and then
as instructor in physiology. For a time he was an
adjunct professor at the New York Polyclinic, and
later w-as called to a professorship of clinical medi-
cine at the New York Post-Graduate School and
Hospital. In 1895 he was appointed Health Com-
missioner of the city of New York by Mavor Strong,
and Commissioner 'of the State Board of Health bv

Governor Morton. He was for two terms president
of the Medical Society of the county of New York,
and helped establish the Tenement House Commis-
sion in this city. He was associate editor of the
Americau Journal of Obstetrics from 1880 to 1886,
and he was one of the founders of the Dietetic
Gazette. He was a member of the County and State
Societies, of the .\cademy of Medicine, and of the
-American Therapeutic Society, and was, at the time
of his death, consulting physician to the Bellevue
and the French Hospitals.

SIR WILLIAM HINGSTON, .M.D. !

montre.\l.

Sir William Hixgstox, M.D., one of Canada's
most distinguished physicians and philanthropists,
died suddenly on February 19 at his home in Mon-
treal. He was born near Huntingdon, Que., Janu-
ary 29, 1829, and was educated at the Montreal Col-
lege, receiving his medical degree from IMcGill Uni-
versity. He completed his medical training in the
University of Edinburgh, and on his return to Mon-
treal in 1853 began to practise in that city. He
speedily rose to prominence, and for many years was
the leading surgeon of Montreal. He had occupied
numerous official positions, among them that of
governor of the College of Physicians and Surgeons
of Lower Canada, of Mayor of Montreal, and of
President of the Medico-Chirurgical Societv of
Alontreal. During his mayoralty he organized the
local and provincial Board of Health, and in 1895
was knighted for distinguished medical service. He
was a fluent writer, and, in addition to many journal
articles, wrote a work on the climate of Canada and
its relations to life and health, which is considered
one of the best on the subject. He was a member
of the Royal College of Surgeons. Edinburgh, and
had received many honorarv degrees and titles from
universities and medical associations in this country
and Europe.

THE SCIENTIFIC CRITERION OF .\ MALIGN.'\NT

TUMOR .A^ND THE N.^TURE OF JENSEN'S

MOUSE-TUMOR.

To THE Editor of the Medic.\l Record :

Sir: — In your issue of Februarj- 9 (p. 237) Mr. W. Roger
Williams, F.R.C.S., in characteristic fashion accuses me
of "gross misrepresentation" without citing instances. It
is so easy to do that ! He adopts the old familiar attitude
he is so fond of taking up with an opponent, that of mis-
taking bald assertions for arguments and scientific evi-
dences. Possibly the statement he complains of is that
"scientific reasons are not contained in the original report
of his lecture in London." etc., and this he twists ''nto
"Dr. Beard's special point a.gainst me is that I have not
adduced my scientific reasons for denying the cancerous
nature of Jensen's mouse-tumor." No doubt he adduced
what he mistook for scientific reasons, but they were
*uch as would not bear scientific scrutiny. I am a scientific
investi.gator, a searcher after truth, and I never misrep-
resent any person or anythin.g. That I leave to trans-
parently anonymous writers in Britisli scientific and medi-
cal papers. Regarding his recent letter I repeat the
statement. Scientific reasons are not contained in his let-
ter to the JiIedicxl RrroRn of February 9. On page 238 he
recites what he terms "the plain facts." and gathering them
together in a bundle at the close of his letter, he flings
them at my head as "crucial for diagnostic purposes."
The "plain facts" he names, if they be facts, are such
mainly because he says they are. Tliey are not like axioms
of Euclid or laws of mathematics. Most, if not all of
them, are open to challenge not only by me. but by main-
other scientific workers. I will pass them in brief review.

Neither in Edinburgh, nor in London, nor in Copen-
hagen, has the Jensen mouse-tinnor been found to be
contagious at all ! It is only in places where a new
cancer-parasite is in keen request and in urgent demand

404

MEDICAL RECORD.

[March 9, 1907

ihal Jensen's niousc-lumor acquires contagious properties.
Tliese are m direct proportion to the researcher's faith ni
cancer-parasites ! The "contasious venereal malady" of
bulldogs is a true sarcoma. On the facts revealed by the
work of Dr. Anton Strieker and of Dr. H. Wade, m agree-
ment with the former, I stated this a year ago in the
Pathological Club here. The latter observer denied its
truth, and in one of their reports last year the officials
of the Imperial Cancer Research Fund "demonstrated"
at great length that it was an infective granuloma. Now,
because Mr. Shattock has arrived at this conclusioti of
us sarcomatous nature from his own work, and especially
from the occurrence of true metastases, the foregoing sup-
porters of Mr. Roger Williams's view with commendable
and astonishing celerity have abandoned their position!
The artificial propagation of human cancer, a horrible ex-
periment to think of. has never been tried on any ?ca
ill the least comparable to that of the Jensen tumor, which
has been inoculated into countless thousands of mice.
Therefore this comparison is invalid. The transplantation
e.-vperiments were humorously summed up by a prominent
London physician as follows: "Some mice do take the
cancer, and some don't. If you only go on long enough,
those that don't become those that do. You can never be
sure, and you never know- where vou are." It is not a
scientific argument to deny that spontaneous cure has ever
been observed in human cancer. It has not been observed
in spontaneously arising or original cancers in mice. An
artihciallv propagated cancer may quite conceivably be-
have otherwise than a sporadic cancer. What chance is
there of spontaneous cure in human cancers being ob-
served when practicallv every cancer which can be oper-
ated upon is removed at least once, if not six or seventeen
times? Possibly for Mr. Ro.ger Williams's special bene-
fit, one such case was described in the Journal of the
American Medical Association for February 9, page 481.
Of course, of this as of other cases, it will be said that
it was not a malignant tumor at all, "whatever its real
nature." To assert that Jensen's mouse-tumor does not
cause cachexia appears to me to be equivalent to a denial
that it has an influence upon the nutrition or the metab-
olism of its host, which is not true. Certainly it forms
no metastases, but not all human cancers do this. Finally,
the Apolant and Ehrlich mouse-tumor is not _ Jensen's
tumor, but another sporadic neoplasm, not hailing from
Copenhagen. What these observers noted all goes to
demonstrate the identitv of cancer and sarcoma. When
the above are summed up. what is left of Mr. Williams s
"crucial" test? Nothing at all worth picking up I

But more remains to say. My opponent cites some
published observations* on the occurrence not only of
trypsin, but of amvlopsin and of lipase in carcinoma cells
from the pancreas-gland ! Does Mr. Roger Williams mean
to suCTo-est that, because these observations are published,
and in the pages . of the Journal of Anatomy, they are
of necessity true, or indeed, that they can contain a par-
ticle of truth? Will he or any surgeon maintain that
there is or can be in this visible universe, as it is con-
stituted, a particle of scientific evidence demonstrating
that the living cells of any cancer can secrete the pan-
creatic enzymes, trypsin and amvlopsin? As of other
scientific journals, so also of the Journal of Anatomy it
can be said that its volumes contain papers devoid of all
scientific truth. How could it be otherwise in a world
where no sooner does a scientific investi.gator reach a cer-
tain conclusion and publish it than some other "observer"
either tries to annex the find, as, of course, happened with
my cancer results, or by jome curious hurnan mental proc-
ess arrives at the very opposite conclusions? Scientific
men arc fortunate if they have then to deal^ only with these
two "views" and not with a score of rival ones. One
very prominent British physiologist in his book lays it
down that the fresh pancreas-gland contains little trypsin,
but much aniylopsin. A scientific man. skilled in ferment
research, told me not very long ago that there was plenty
of try-psin, but hardly any amylopsin it it; while a third,
a scientific man and distinguished physician, whose con-
clusions I adopt because I have seen and tested his extract
of it, maintains that both enzymes arc present in abun-
dance ! Waring does not go the length of stating that he
found pancreatic enzymes in the specimens examined. It
was reserved for Mr. Roger Williams to make this asser-
tion ! His words are "the same or similar ferments." This
work is not in accord with the findings of Petry, or with
the prolonged chemical researches of Bergell, Blumenthal,
and ■\Volff in Berlin, who found that cancer-cells were
easily digested by pancreatic ferments. The scientific work
of these latter may not be stigmatized as "rather the

*H. J. Waring, the Physiological Characters of Carcino-
mata. Journal of Anatomy and Physiology, Vol. 28, pp. 142-
148. 1893-94-

outcome of a priori considerations." That verdict should
be reserved for my opponent's "arguments," for these are
never based in actual personal scientific researches in the
laboratory. To refer to the work of these German inves-
tigators in terms such as those employed by Mr. Roger
Williams betrays an utter failure to realize the existence
of a science of physiological chemistry. Now, although
it is not common sense to do so, let it be supposed that
Waring did find trypsin and amylopsin in certain cancer-
cells. What then? Was it by means of these ferments
that these cancer-cells were eroding the patient's liver and
causing his death? If not, was the cancer-ferment,
inalignin, the culprit? If so, what were trypsin and amy-
lopsin doing en cette galere? Mr. Williams cannot be
aware that large quantities of potent pancreatic enzymes
can be, and have been, injected beneath the skin of a
healthy dog ; that trypsin in quantity could then be de-
tected in its urine, and that the only effect noted upon
the dog was increase in weight. None of the internal
organs were injured (Dr. S. N. Pinkus). If Waring
actually found trypsin and amylopsin in pancreatic car-
cinoma cells, which had traveled to the liver, then in this
case these enzymes had attacked the liver-cells, which
looked at scientifically is utter nonsense. Certainly, tryp-
sin kills cancer-cells. That is in evidence in specimens
taken from or cast off by several treated cases. Mr.
Williams has only to read the American medical journals
attentively to find it stated again and again. At this
moment these effects of pancreatic ferments upon living
cancer-cells have been seen by many prominent patholo-
gists in New York. Really, the next wonder we may
hear about from the Transactions of some learned so-
ciety or from the pages of some scientific journal, may be
t'nat some cancer-cells produce bile, or excrete urea, or
that in cancer of the breast the tumor cells, true to their
(supposed) origin from mammary cells, the mythical
"tumor germs'' of my opponent, actually go the length of
secreting — milk !

When it suits my convenience I will demonstrate that
these assertions by Mr. Ro.ger Williams contradict some
of the elementary facts of organic chemistry, and that for
these reasons also the statements are false. As to the
existence of "any specific cancer substance," there are
actual evidences of the occurrence of a whole array of
such, and some of these evidences are extant. I decline
to produce further evidences at this juncture, for an in-
vesti.gator has the right to choose his own time for pub-
lishing broadcast new findings and conclusions. That is
part of the strate.gy of science ! Not that this need of
necessity disturb the serenity of Mr. W. Roger Williams,
F.R.C.S., or of his colleague in Chicago! Having abol-
ished the science of physiological chemistry, the annihila-
tion of the elements of organic chemistry may turn out to
be a very simple task ! A new universe, in which cancer-
cells regularly secrete the powerful pancreatic enzymes,
trypsin and amylopsin. may then begin its evolution under
their scientific auspices! In such an amazing field of re-
search a Pasteur would find himself as much out of place
as trypsin and amylopsin would be in living cells of any
existing malignant neoplasms ! J. Beard.

Edinburgh, ScoTL.\xn.

LOCAL ANESTHESJA FOR NAS.\L AND AURAL
OPERATIONS.

To THE Editor of the Medical Record:

Sir:— That considerable interest is taken in the subject
of local anesthesia for submucous resection, is shown from
the number of communications I have received in relation
to my article which was printed in the Medical Record of
February 23, and I wish to add to what I said: (i) That
the exact proportions of cocaine and adrenalin chloride
should be observed, namely, 10 grains cocaine, 20 drops
adrenalin chloride (l to l.ooo). (2) The time to operate
is when the membrane becomes scarlet, and not when it is
"id, as when cocaine alone is used, (.l") Care should
u to express any excess of solution out of the ap-
p.icator, it is necessary only to have the cotton saturated
and then to rub it on the membrane gently.

I also suggest the use of the solution in cases of para-
centesis of the car-drum, for which it acts as an almost
perfect anesthetic, if allowed to remain in the ear some
little time.

Through an inadvertence in my article in the issue of
February 23 credit was not given to Dr. John Leshure,
who first suggested this use of cocaine and adrenalin to
me. and from the stimulus of this idea this (thus far)
most desirable method of application was evolved.

F. E. Miller, M.D.

March g, 1907]

MEDICAL RECORD.

405

OUR LONDON LETTER.

iFiom Our Speci.-^l Corrcsponiiont )

THE HUNTERIAN ORATION — ROYAL COMMISSIONS AM) TUBER-
CULOSIS— LETTSOMIAN LECTURES ON CEREBRAL TUMORS —
EPIDEMIC CEREBROSPINAL FEVER — PROFESSIONAL MISCONDUCT
— GLASGOW UNIVERSITY — OBITUARY.

London, Februarv, 15, 1907.
The Hunterian oration was delivered yesterday afternoon
t)y Mr. H. T. T. Butlin before a considerable audience, and
the festival dinner took place in the evening. The oration
was in the main an e-xamination of Hunter's objects in life
and how he accomplished them. John Hunter saw, said the
orator, long before the men of his time, something was
seriously wrong with surgery, saw further what was needed
to correct it, set himself in the prime of life the task of
doing all he could to set the wrong right, and continued
for the rest of his life to pursue that object, to the impair-
ment of his health and the expenditure of his fortune. In
1748 a young man from the North arrived in London, but
no one could have predicted that this young man would
leave such a reputation as tins celebration proved. He had
to fight for everything he obtained. He saw that surgery
rested on a frail foundation, and could not be carried fur-
ther or practised with confidence so long as it had no firmer
basis. Mr. Butlin expressed astonishment that Hunter
could find time, amid all his multifarious pursuits, to carry
on a large surgical practice, practise and take the first
place as a hospital surgeon in London. But that was his
only means of earning money, and money he must have
for his scientific needs. His collection of specimens, pre-
pared by himself, had grown so that he was obliged to
build a museum for it. His last years were marred by
broken health. He suffered, too, great anxiety because the
catalosue of his museum was not completed. He died in
1793, but it was not until six years afterwards that Parlia-
ment purchased for ;£is,ooo the museum on which he had
spent all his spare time and ruined his health, and which
he estimated had cost him £70,000. Eventually, the museum
was presented to the College, and Mr. Butlin concluded
his oration by asserting that one of the chief objects of the
succession of college councils has been, not merely to
maintain the Hunterian Museum, but to enlarge and per-
fect it, so that at this moment the Council could exhibit it
as the best museum of its kind in the world.

At the dinner in the evening, the President of the Col-
lege, Mr. Henry Morris, took the chair and proposed, in
an appropriate speech, "the memory of John Hunter," the
toast being drunk in silence. The health of the orator was
afterwards proposed, and he briefly replied.

The opening of Parliament this week may suggest to
optimistic sanitarians the hope of fresh legislation on the
prevention of disease, but we are a long way from Dis-
raeli's political cry, sanitas sanitatum, omnia sanitas. and
what has passed since then is not encouraging. Politicians
are more concerned with party than public health. Some
who despair of Parliament have a strange confidence in
Royal commissions. As I mentioned in my last, Mr. Dunn
demanded one on cancer, and I might have added that Mr.
Henry Sewill is advocating one on quackery. I have not
much faith in Royal commissions as remedies for social
evils. They seem to be a convenient method of slielving
what governments cannot quite ignore, but do not want to
be troubled with. Consider their uselessness in respect to
tuberculosis In response to urgent demands by the med-
ical profession and sanitary authorities, a Royal commis-
sion was apnointed in 1S90 to inquire into the eflFect on
human health of food derived from tuberculous animals.
This commission labored for five years at the question, and
in 1895 reported that tuberculous meat and milk did give
rise to tuberculosis in man. Did the legislature proceed to
protect the people from the indicated danger? Not at all.
In 1896 another Royal commission was issued to inquire
into the administrative procedures required for controlling
this danger. This commission, like its predecessor, was
composed of distinguished scientific authorities, who de-
liberated and inquired for two years, and reported in 1898
that various legislative measures were required, among
them the appointment of qualified meat inspectors, notifica-
tion of diseases in cows, and the enforcement of hygienic
conditions in cowsheds, etc. Nine years have gone by since
this report was presented, and not one of its recommenda-
tions has been carried out. In 1901 yet one more Royal
commission was appointed, in response to the outcry pro-
duced by Koch's statement the year before that human and
bovine tuberculosis were not identical. This last commis-
sion is still sitting to "Inquire Into the Relation of Human
and .Animal Tuberculosis." It has, however, published two
interim reports, the first in 1904. summarized for you at
the time, and the second only this month, and of which I
gave vou a brief notice in my last letter. Have I not justi-
fied my want of faith in the efficacy of Royal commissions?

The consequences of this neglect of Parliament to deal
with the prevention of disease are tragic. The absurdity
of appointing commission after commission to inquire into
the same subject, and putting report after report into con-
venient pigeon holes, must be obvious to all except govern-
ments and politicians absorbed in partisan contests.

I hat the public may yet be aroused to take a hand and
compel attention to its dangers is pcrliaps possible on ac-
count of some disgusting revelations lately made — such as
the sale of animals in the last stages of tuberculosis in open
markets for paltry sums — such as 45s. and 50s. which a
butcher paid for two cows, which he was proved in court to
have proceeded to kill and prepare for sale for food. It is
the same with milch cows; in markets where there is no in-
spection tuberculous animals can be sold.

The Lettsomian lectures for this year are being delivered
by Dr. Ch. E. Beevor. and his subject is the diagnosis and
localization of cerebral tumors. In the first lecture (on the
4th inst.) he observed that we have to depend almost
entirely on the effects of pressure, and these may be either
central or peripheral. They are mostly of the nature of
pain, paralysis of action, or loss of sensation, and so the
symptoms are mainly subjective. But some are independent
of the patient, e.g. optic neuritis, paralysis of the ocular
muscles producing strabismus, and the state of the reflexes.
Headache, vomiting, and optic neuritis. Dr. Beevor said,
were frequent in intracranial tumors irrespective of the
position of the tumor. Headache fixed in one spot was
some indication, particularly if attended with tenderness
on pressure. If the headache was general, and accornpa-
nied by vomiting and optic neuritis, it was a help to diag-
nosis, but not to localization. Persistent pain, with tender-
ness, pointed to a superficial origin from the membranes
rather than the cerebrum. "Vomiting must be frequent and
independent of food to be of any assistance, as it often
attends migraine. Optic neuritis, with headache and vom-
iting, was one of the most reliable signs of tumor, but
must be distinguished from the same symptoms in Bright's
disease. Moreover, as Dr. Hughlings Jackson first showed,
this neuritis might be intense, yet not interfere with vision,
unless atrophy had commenced. It has now become of
practical importance to be able to distinguish tumors near
;he surface accessible to operation from those too deeply
seated. Even m these latter, relief could often be obtained
by removal of a large piece of bone, so as to release the
compressed brain from the pressure. The first effect of a
tumor of the membranes pressing on the cortex was an
epileptiform fit beginning in the part of the body repre-
senting the part pressed upon. A fit produced by a coarse
lesion did not aft'ect consciousness, but beginning locally
it might become general, and then could not be distinguished
from idiopathic Epilepsy. The next effect of the pressure
was paralysis, and that permanent on account of destruction
of the cortex, loss of power then replacing the commencing
spasm of the fits. Dr. Beevor then gave details of some
cases in which the ascending frontal convolution, and others
in which the ascending parietal convolution was involved,
and said the question arose whether sensation was more
affected in the latter than the former, and, if so, how far the
difference would assist localization. So far as they went,
these cases tended to show that parietal tumors, particularly
those in the inferior part of the lobe, were more likely to
have fits, beginning with a sensory aura, and to be followed
by more extensive and permanent anesthesia and analgesia,
than those in the frontal convolution, where the sensory
changes were mere defective localization and loss of sense
of position in the part first affected by motor spasm m a
fit.

In the course of his lecture, Dr. Beevor referred to the
history of localization, and mentioned that before experi-
mentalists had established the principle Dr. Hughhn"-s
Jackson had reached the conclusion that unilateral and
localized convulsions were due to irritation by tumors of
particular convolutions of the opposite hemisphere function-
ally related to muscular movements. Dr. Jackson pre-
dicted that certain convolutions would be found excitable.
His views were confirmed by the experiments of Fritsch
and Hitzig in 1870 and Ferrier in 1873. It is difficult to
realize, said the lecturer, that previously there was no such
thing as localization, and one part of a convolution was
supposed to have the same function as the rest. It was,
in fact, only actual demonstration that overcarne the oppo-
sition entertained against the idea of localization. Except
Broca's center for speech, all our knowledge of localization
has been obtained by experiments on animals. It is this
research which has made possible the diagnosis of cerebral
tumors, and with it the surgery of the brain. It is now
over twenty vears since Mr. C^jdlee (thanks to antisep-
ticism) rernoved the first cerebral tumor in London, bir
Victor Horslev soon followed, and has since removed
manv. as have other surgeons. The practical importance
of accurate localization has therefore become immense.

Cerebrospinal meningitis is causing uneasiness to health

4o6

MEDICAL RECORD.

[March 9, 1907

authorities, and the {ecling has extended to tlie people,
as the newspapers report outbreaks of "spotted fever," as
it is popularly called — a convenient name, though inexact,
as the symptoms expressed are by no means constant.
Cerebrospinal fever is used for the epidemic form, but the
distinction is not commonly observed. The authorities do
not exactly anticipate an epidemic in London, but the possi-
bility of such an event cannot be ignored, and sporadic
cases have been reported. Last evening the Medical Officer
of Health for Lambeth reported to his Borough Council
a case in his district in a girl six years of age. She wa.s
removed to hospital, the house disinfected, and the inmates
are under strict observation. The Health Committee in-
tend to recommend the London County Council at the
meeting on the 26th to make the disease notifiable for a
period of six months and to provide facilities for confirm-
ing diagnoses. The City Corporation is in advance of the
County, for at the Court of Common Council yesterday it
was stated the Port sanitary authorities had already made
the disease notifiable, and the Port medical officers were
keeping a very sharp lookout for any case that might occur,
so that appropriate prophylactic measures might be insti-
tuted in season.

In Belfast, Dr. Baillie reported to the Health Committee
yesterday 13 fresh cases during the week, with 8 deaths, and
19 patients in the hospital. The serum supplied from
Berne had been used in one case, and was followed by
much improvement, although that might have been only a
coincidence. Of the total patients, 73, up to Wednesday 39
had died. In Dublin, 2 deaths have occurred and 2 cases
remain m hospital. In Glasgow, 4 additional deaths were
reported on Wednesday and 6 fresh admissions. In sev-
eral Scotch towns cases have occurred. A case in Cum-
berland, fatal in twelve hours, is coniectured to have been
contracted from persons who had arrived a few davs before
from Glasgow.

Professor Osier, being on a visit to Edinburgh last week,
gave a lecture to the University medical students. He
said in New York some 3,000 deaths had occurred in the
last two years from the epidemic. The disease was not
pandemic, but one of its peculiarities was to appear in
widely separated places. Its mortalitv as an acute afifec-
tion almost equaled that of plague. They knew of no dis-
ease which struck a patient with such lightning rapidity.
It had probably the same degree of infectiousness as pneu-
monia in home epidemics. Many instances proved it could
be communicated from one person to another. At present
it was not widespread as an epidemic in Britain, and there
was no reason why it should be. It was not likely to pre-
vail beyond the winter season. As to treatment, it had
been found that frequent hot tubs were a great comfort to
patients. Prof. Osier thought it a hopeful feature that a
serum had been prepared which had rendered monkevs
immune, and it was not unreasonable to look for the elabo-
ration of a similar serum for use in man.

''Conduct infamous or disgraceful in a professional re-
spect" is not the same thing as "professional misconduct."
Such IS the dictum of Mr. Justice Warrington in a recent
trial, after taking time to consider his Judgment. Unless,
and tintil this judgment is set aside by a superior court,
such is the law, and it seems to add one more proof to the
uselessness of the General Medical Council, which in the
case tried had found a dentist guilty and removed his name
from the register. The judge said the employment of un-
registered assistants was not, so far as he could see, con-
trary to any rule of professional conduct, and advertising
was allowed in the dental profession. There were other
points of interest in the case, which was one to decide if
one partner could terminate a partnership in which the
articles gave him such power for "professional misconduct."
A plain man would have supposed the phrase equal to the
st.itutory term, and that the order of the Council should
be received as sufficient evidence. Not so the lawvers, who
have found another opportunity of profitable hair-splitting.
The Medical Council must get fresh power from the legis-
lature or sink into insignificance.

Dr. Mac.\lister is the new Principal of Glasgow Uni-
versity, notwithstanding the Secretary for Scotland's com-
munique that the statement was "unauthorized." The next
day he had to oificially announce that the King had "ap-
proved" the appointment. Perhaps he was shocked at the
press disregarding red-tape in its effort to be previous.
Dr. Mac.A.lister has received many academical honors and
is a strenuous worker. He need not necessarily resign the
Presidency of the General Medical Council. Sir William
Turner held that office and at the same time the Principal-
ship of Edinburgh University.

The death took place on Wednesday of Dr. J. E. Huxley,
in his eighty-seventh year. He was a brother of the late
Professor Huxley and formerly Medical Superintendent of
Barming Health Asylum. He took his M.R.C.S. in 1843
and M.D.. St. .Andrew's, the next vear.

OUR VIEXXA LETTER.

(From Our Special Correspondent.)

THE FIRST SUCCESSFUL PLASTIC OPERATION ON THE COR-NEA —
CASES OF KIDNEY DISEASE — THE FAT DIGESTING POWER OF
THE STOMACH — ECHINOCOCCUS CYST — POISONING WITH
.MALE FERN — SURGICAL TUBERCULOSIS.

Vienna. January 30, 1907,

The possibility of performing a plastic operation on the
cornea was first suggested by Reisinger in the preceding
century, but all attempts to graft corneal tissue from
the lower animals to replace defects in the human cornea
were unsuccessful. A partial, though only temporary, suc-
cess was achieved by Sellerbeck, who in 1878 succeeded
in transferring a corneal flap taken from the eye of a
two-and-a-half-year-old child that had been enucleated
owing to a glioma in order to repair the damage caused by
gonorrheal ophthalmia in an adult. Healing took place,
but on the twenty-first day the graft became cloudy and
vision was again destroyed. Other attempts also failed
and the idea of restoring sight in this way was given up
again. Dr. E. Zirm of Olmiitz is the first one who
has succeeded in carrying to a practical result what
formerly was only a theoretical possibility, and has been
able to bring about not only perfect repair of a corneal
injury, but also the permanent transparency of the graft
and consequent restoration of vision. His patient was.
a man both of whose corneas had been damaged by quick-
lime and Zirm performed his operation by making use-
of grafts taken from the eye of a boy that had been
removed in consequence of injury by a splinter of iron.
In the left eye the power of vision has been greatly im-
proved, so that the patient is able to perform light agricul-
tural work, such as cutting the grass, cleaning the stable,,
and attending to his cattle; he is also able to go on
journeys and find his way about strange places. The graft
is visible as a black disk in the midst of the milky
surrounding cornea and forms a loophole through which,
the most minute details of the retina can be inspected
with the ophthalmoscope. Zirm attributes his success to the
following principles: (i) The use of human cornea, which
must be from a youthful individual and well nourished.
(2) The use of the trepan and of installations of eseriii
before the operation if the anterior chamber is still ire
existence. (3) Profound anesthesia, rigid asepsis, but
no antiseptics. (4) The graft is preserved between two
bits of gauze wet with sterile salt solution over warm.
steam until it is to be used: it is then, without the use o£
instruments, placed in position in the hole bored for its
reception. The transplanted flap is kept in its positioa
by two sutures passed through the conjunctiva so as r>
cross over it.

Three interesting cases of renal affections have been
operated on by Illyes ; the first was one of hypernephroina.
The patient was a man forty-seven years old, who from
time to time during the past two years had sutlcred
from bloody urine. It was found that the blood came from
the right ureter and on investigating the renal efficiency
it was discovered that the right organ had been almost
entirely destroyed. At the operation it was seen that the
upper pole of the kidney was occupied by a tumor the size
of the fist, which turned out to be a malignant hj-per-
nephroma. The kidney tissue revealed the lesions of a
chronic parenchvmatous nephritis. Removal of the growth
and the kidney was followed by a recovery. The second
case was one of renal calculus; this patient was forty -
three years old. and twenty-four years previously a stone
had been removed from his bladder. For about two years-
the urine had been cloudy and colicky pains were com-
plained of on the right side. Bv means of the cystoscope
it was observed that the purulent urine came from me
right ureter. A functional examination showed that *he
organ in question was inefficient, and in a radiograph a
faint shadow was visible in the neighborhood of the kid-
nev. At the operation the stone could be felt in the
kidnev, and after the organ had been removed it was
found that its pelvis was distended by a branched stone,
while in the calyces other small stones were present. Four
weeks later the patient was discharged as cured. The
third patient suffered from suppurative nephritis. He was
fifty-five vears old and for two years had had colicky pains,
sometimes on the one side and sometimes on the other.
The urine was often bloody, and six months previously
tw;o stones were removed from the bladder. Several days
before admission the patient had a chill followed by fever.
With the cystoscope cloudv urine could be seen coming out
of the left ureter and further examination demonstrated
that the organ was functionallv inefficient. At the opera-
tion scattered purulent foci were seen on the surface
of the kidney and it was removed. Section of the organ
showed that it was filled with numerous small abscesses

March 9, 1907]

MEDICAL RECORD.

407

from which Friedlaiidcr's bacillus was cultivated. The
abscesses were of hematogenous origin.

Dr. Stefan Pesthy has carried out observations on the
fat splitting powers of the stomach, which have shown
that steatolysis in the stomach is not a fermentative proc-
ess. Digestive tests made with neutralized .gastric juice-
do not show any differences in the extent and amount of
fat splitting in normal, hvnerchlorhydric, or achlorhydric
stomachs. The. steatolytic power of the cancerous stomach
is extremely slight, however. Pestliy in the course of his
investigation examined nearly a hundred stomachs.

.•\ case of echinococcus in an unusual location has been
operated on by Polya. The patient was a butcher, twenty-
one years old, who had to the right side of the umbilicus
a smooth, tense, fluctuating tumor the size of two fists,
which moved with respiration and filled the space between
the costal arch and the iliac crest. The mass was very
movable. The laparotomy incision was made at the outer
border of the right rectus, and on opening the abdominal
cavity the tumor was recognized as being an echinococcus
cyst. It was adherent to the omentum and took its origin
from the anterior border of the liver near the gall bladder.
At the anterior edge of the liver the cyst was found to
have a prolongation tlie size of a quill, and on following
this up another smaller cyst was discovered on thi surfacce
of the liver. In order to effect the removal of this
cvst it was necessary to resect the ninth and tenth ribs.
Recovery was uncomplicated.

A case of severe poisoning with male fern attended
by total blindness has recently occurred in Budapest. A
young woman suffering from gastric disturbances imagined
that she had a tape worm and obtained from a druggist
whose advertisement she had read a quantity of capsules
of male fern. Following the directions she took nineteen
of these in the course of an hour and a half. Severe
headaches and abdominal colic followed and some hours
later the patient became stuporous. From this condition
she did not recover for about thirtv-six hours, and then
she discovered to her horror that her vision was gone.
On examination it was found that the capsules each con-
tained a gram of the extract ,of male fern, together with
a little castor oil. The apothecary was arrested and con
victed.

A child with fnngousarthritisof theknee and both elbows
has been treated witli tuberculin of bovine origin by Dr.
Hans Salzer. All three ioints presented an extreme picture
of the disease and discharged fetid pus from numerous
sinuses. ^ In addition to treatment by extension of the
knee, injections of the tuberculin were given, beginnine
with a dose of ,1 mg. This was cautiously increased to
2 mg. Very marked improvement has resulted, and in
consideration of the severitv of the lesion Salzer con-
siders the result a very satisfactory one. He is of the
opinion that in dealing with surgical tuberculosis in chil-
dren tuberculin is no more to be dispensed with than is
the congestion bandage of Bier.

Uezii York Medical Journal, February 23, 1907.

Subinvolution as a Primary Etiological Factor in
Gynecological Affections.— J. H. Burtenshaw declares
tliat fully one-half of female pelvic affections are due
directly or indirectly to subinvolution of the generative
organs. This latter condition arises from too great a
blood supply and leaving out infection, this excess is
due in turn to either retained seeundines or irritation
at some point of tlie genital tract which causes en-
gorgement, more or less clironic. Whenever the uterus
fails to undergo the customary involution every organ
and tissue ohysiologicallv concerned in child-bearing is
similarly affected. Laceration of the tissues of the par-
turient canal is by far the most frequent cause of
subinvolution. Long continued congestion ends in hy-
perplasia. No tear of the perineum or cervix is too
insignificant to merit renair. F,ven if nature heals the
open wound the resulting scar tissue may act as an
irritant and keep up the congestion indefinitely. Every
wounded --erineum or pelvic floor should be' repaired
within twentv-four hours and every wounded cervix
within six weeks after confinement. The obstetric
specialist does not always see Iiis patients at the end
of this period. The patient is often unwilling to submit
to examination at this time when she may feel perfectly
well in spite of the lack of nroper pelvic repair. The
author advises against the continuance of the binder
atter the first few days. The breasts should be regu-
larly emptied. Ergot should be given in diminished
doses for several weeks. The bowels should be regu-
larly opened. Hot water douches are of ^-.lUie in pro-

moting involution. If involution is retarded we should
search for clots in the uterine cavity and carefully
e.xamine the cervix. A dull curette may be used to
remove the clots. Finally, if all appreciable causes
of subinvolution have been removed and if at the end
of ten weeks involution is not complete, a thorough
curettage is indicated with the application of pure car-
bolic acid to the endometrium.

The Trypsin Treatment of Cancer. — J. W. Luther
discusses Beard's theories and refers to some of his
experiments. He also refers to and summarizes various
reports which have appeared on this mode of therapy.
He finds a consensus of opinion that the trypsin injec-
tions (i) arrest or shrink the "rowtli, (2) improve the
.general nutrition, increasing appetite, and body weight.
(3) diminish or remove pain, and (4) lessen discharge
and its fetor e.xcept in those cases in which sloughing
occurs.

The Fallacy and Inutility of the So-called "Rapid
Diagnosis of Rabies." — The conclusions offered by N.
G. Keirle are as follows: (l) The presence of the
.ganglionic changes, described by von Gehuchten and
Nelis, or the presence of the structure termed Negri
bodies, is not pathognomonic of rabies (hydrophobia),
since these are often found when rabies does not exist.
(2) The absence of one or both of these appearances
does not prove that rabies is absent, since they may
be present when rabies is absent and absent when
rabies is present; therefore they are not infallible indi-
cations of rabies (hydrophobia). (.•?) In the exigency
of treatment, the results of preliminary examinations
should not be wailed for. When the circumstances are
suspicious, when the animal has been killed or has
escaped, when a person has reason to think that he has
been in contact with the virus of rabies (hydrophobia),
he sliould. as soon as he can, consult his physician, and.
preferably through him, should at once communicate
with some reputable institution treating this disease
preventively, and abide by the advice given.

Live Steam in the Local Treatment of Infection. —

F. Griffiths notes tiie existence of three causati\e fac-
tors in infection after wounds or abrasions, body heat,
moisture, and pus germs. To be efficient, heat must
be taken as hot as can be borne. The part affected
should always be elevated or supported by a sling. Im-
mersion in the hot fluid must be frequent, lasting for
from half a minute to five minutes each time, .^s a
rule the less covering of the part the better. The
bowels must be kept open by calomel and salines, and
some tonic, such as the combinations of iron, quinine,
and strychnine, should be given. Rapid drying should
follow the immersion in the hot fluid. One of the best
methods of applying hot fluid in these cases is the hold-
ing of the part against the steam coming from an
ordinary tea kettle. Rapid drying will occur within
a few moments of each exposure. This method is
simple, inexpensive, and always available. The author
notes that a jet of steam directed into the uterine
cavity has been used as curative in certain disorders
of that organ, and it seems clearly practical to the
writer to employ live steam projected into the general
abdominal cavity through open median incision and
repeated, as a means of battling general septic peri-
tonitis, shock as well as sepsis being met by this means.

Journal of the American Medical Association, March 2,
IQ07.

Herpes Simplex. — J. F. Schamberg holds that herpes
simplex and herpes zoster, while not clinically identical,
are closely related; the histology of the cutaneous
lesions and the observed nerve changes are practically
the same in both. Both are due to a variety of cau-;e=,
but he thinks that the vast majority of all cases are due
to the action of a toxin, and this, of course, presupposes
au infectious origin. The frequency of herpes simplex
in certain diseases and its rarity in others suggest
strongly that the toxin must have peculiar qualities to
exercise such a selective afiinity for sensory nerve struc-
tures. He holds, however, that this toxin cannot be
the result of the action of any specific organism in
the case of herpes simplex, and by analogy not in
zoster. The three diseases in which herpes occurs most
frequently, and in which it is therefore of diagnostic
importance, are pneumonia, spotted fever, and malaria.
Schamberg does not commit himself as to its favorable
prognostic significance in pneumonia, of which there is
considerable evidence, but he does not credit it in
spotted fever nor in malaria in this country. The lia-
bility of some persons to recurring attacks of herpes
must he taken into account in estimating the diagnostic
iiTip("irtaiice of its occurrence.

4o8

MEDICAL RECORD.

[.March 9, 1907

Unusual Ocular Manifestations of Arteriosclerosis. —

The two conditions noticed by Zentmayer are optic
atrophy and spasm of the central artery of the retina.
The literature and theories of optic atrophy from ar-
teriosclerosis are reviewed and a case reported which
seems to him to substantiate the view that with sclero-
sis of the ophthalmic or internal carotid artery press-
ing the nerve upward against the unyielding edge of the
internal end of the fibrous canal, a transverse pressure
atrophy, finally involving the entire diameter of the
nerve, may occur. Such a process, he shows, would
account for the symptoms and appearances in the case
reported. The literature of spasmodic blindness is also
reviewed and a case reported in abstract in which the
spasm of the ocular vessels was repeatedly observed
ophthalmoscopically. It is probably unique in •
respect, as only three similar cases, but of a single
observation of the spasm, were discovered in a search
through the literature: those of Wagenmann, Benson,
and Sachs, all of which are reproduced in abstract. The
patient had arteriosclerosis and probable incipient tabes.
The prognosis in these cases varies according to
whether the spasm is simplv a manifestation of a gen-
eral spasmodic disorder or of a general grave vascular
disturbance. The treatment is that of early arterio-
sclerosis, high tension, and spasm. lodid of potassium
is the only reliable drug for the arteriosclerosis. Mod-
eration in all things is of more importance than regu-
larity of dosing. The nitrites are available for the
spasm, and heart tonics are usually needed. With
symptoms of obstruction, massage of the eyeball should
be tried. The value of iridectomy is questioned. It
may be justified in certain cases, but its efficiency
against future attacks is dubious.

Volkman's Ischemic Paralysis and Contracture.— C.
A. Powers reports a case of this condition in a boy
of seventeen, following a stab wound in the right fore-
arm, and discusses the literature, analyzing the reported
cases. The condition is essentially a myositis and is
quite different from that following the use of Esmarch's
bandage. The characteristic features of both are de-
scribed. It is usually the result of overtight bandaging
in fracture cases, and is most common in children and
in the upper extremity. The prognosis is not very
good for complete recovery, though a fair result was
obtained in a little over half of the cases, and it seems
better in patients operated on bv tendon lengthening,
bone resection, etc., than in others. It begins soon
after the use of the splint, with progressively increas-
ing pain, and if the splint is not speedily removed,
contractures and paralysis follow. The removal of the
cause must be within four or five hours to secure re-
covery. • Primary lesions of the nerves may also exist.
The diagnosis is clear, with a history of the case. The
English authorities advise massage and passive motion
in the slighter cases, continued over a long period if
necessary.

Surgery of the Spinal Cord. — The surgical diseases
and lesions of the spinal cord are reviewed by J. B.
Murphy. He holds that when the axons and ganglion
cells that make up the substance of the cord above the
Cauda are destroyed, regeneration is impossible, and,
therefore, in gunshot or stab wounds with immediate
paralvsis. ooeration is useless as regards hope of repair,
except in the caudal zone, where the possibilities are
the same as in the case of wounds of peripheral nerves.
Hemorrhage, concussion, and contusion without lacera-
tion may give rise to the same immediate symptoms
as division, and a positive differential diagnosis is
impracticable. The time and order of appearance of
symptoms mav be the only guides; there is no direct
relation between the severity of the trauma and the
degree of injury to the cord. .Absence of immediate
paralvtic symptoms is not a o-uide — they may appear
after days or weeks. Early spinal puncture may relieve
paralysis due to hemorrhage which in some cases may
be as complete as that due to division of the cord.
Most patients with incomplete paralysis following frac-
tures recover without operation, and when the dis-
placement is not great the phvsician is justified in
assumiTig that the cord is not sufferin™ continuous com
pression and in refraining from operation. The special
iiidications as regards operation in the various con-
ditiotis above enumerated are pointed out and the
technique of laminectomy is described. The danger of
delay in conditions calling for operation, especially in
non-malignant tumor, tuberculoma, etc., is emphasized.
Late operations after necrosis in the cord has taken
place are worthless.

Turbinate Hypertrophy.— D. .\. Kuyk reviews the
objections to the methods of cauterization and excision
of the t\!rbinatc5. and proposes in their stead the mak-

ing of one or more incisions through the mucous mem-
brane of the hypertrophied turbinate, well down to
the bone, when, with a broad nasal saw, the bone is
cut to a depth depending on its nature, whether can-
cellous or vitreous, which is easily detected by the sen-
sation imparted to the hand. If the bone is dense and
hypertrophied the cut is carried well down into its
substance. Then the nostril is cleansed and the edge
of the incised mucosa carefully tucked down into the
cut which has been made with a wide saw to allow this.
The tissues are kept in place bv a carefully adjusted
r>l(;(it;c! of cotton, saturated with equal parts of com-
no'.md tincture of benzoin and flexible collodion. This
can be left in situ for two or three days, when, after
careful soaking, it is removed, the tucked-in edges not
being disturbed. Repacking is rarely required. The
advantages of this method over cauterization or partial
or complete turbinectomy are claimed by him to be as
follows: 1. Preservation of physiologically active tis-
sues. 2. Freedom from disagreeable reaction or com-
plications. .'S. Absence of shock, since but slight loc;il
anesthesia is necessary. 4. Freedom from aggravation
of existent disease in neighboring cavities. 5. Ease
and speed in performance; the instruments used being
lew and simple.

The Lancet, February 16, 1907.

Operation for Strangulated Congenital Inguinal
Hernia Performed on Shipboard Under Difficult Con-
ditions.— The history of this case is detailed by A. B.
Francis, who was called to see one of the ship's stew-
ards, about twenty-one years old, suffering from a
hernia of the variety indicated in the title. The boy
was on his first voyage and had been quite seasick,
and the laxness of his tissues, together with the force
of his retching, had forced the hernia downward. The
size of the swelling was about equal to that of the head
of a newly-born child. Hot baths, taxis, morphine in-
jections, chloroform anesthesia were all insufficient to
allow of the reduction of the mass. Preparations were
made for operation in the ship's hospital and the case
came to the table about four hours after the onset of
symptoms. The only assistants at hand were some
of the under stewards and one hospital steward who
had some sli.ght knowledge of drugs, but none in opera-
tive procedures. The operator made the usual incision
and dissected down carefully. Meantime the captain
had slowed down the ship to minimize as far as possi-
ble the effect of her motion, and just as the operator
was about to enter with his knife the peritoneal sac,
the vessel was stopped completely for a few minutes.
The operation was successful and the man made an
uneventful recovery.

Reunion of an Almost Severed Leg. — T. Hayes re-
ports the case of a lad of eighteen years who was run
over by a mowing machine. The tendo .Achillis, the
tibia, and the fibula were completely cut through, the
onlv parts escaping amputation being the tendons and
other tissues in front of the bones. The boy was placed
in a cart and started for the doctor's office twelve miles
away. On the journey it was feared that he would
bleed to death, and a stop was made at a town where
a young army surgeon was found who advised imme-
diate amputation. This was refused by the mother,
who accompanied the boy, and finally the author was
sent for. He reached the patient about twenty-four
hours after the injury and found the almost severed
limb turned up to the shin, a lar.ge plug of lint in the
wound, and all well bandaged. Examination show-ed
that the anterior tibial vessels were still carrying on
the circulation, as the foot was warm. The parts w-ere
cleansed, the ends of the tendo Achillis brought tor
gether with some very strong sutures, and a lint and
water dressing applied. The author also put on a
slipper with a strap attached and fixed to the knee
to extend the foot backwards, bent the foot backwards,
and kept the knee also bent. The case did well. At
the end of a year the man was able to walk without
limpine. but with a stiff ankle joint. Thirty-five years
later the patient walked without any apparent lameness.
There was a slight projection of the inner ankle and
a suh--is over the cicatrix.

Value of Bacteriological Examinations of the Blood
in Typhoid Fever and other Bacteriemias. — F. G. Eush-
ness notes that in his district (Brighton) the Widal
reaction for tvphoid frequentlv .gives indefinite reac-
tions, such as slight loss of motility of the bacilli, and a
few- small loose clumps w-ithin one hour, even when
the clinical dia.gnosis is typhoid fever, and this may be
so even in the third week of the illness. The absence
of agglutination mav be due either (l) to defective
formation of affplutinins or (2'! to the infection being

March 9, 1907]

MEDICAL RECORD.

409

due to a bacillus which, though closely allied to, has
specific differences from, the bacillus used to carry out
the serum reaction; for example, paratyphoid infection
would fail to a"-"'lutinate "completely" cultures of the
bacillus tv-hi. He believes that the value of the afr-
glutination test by a iniuimuni serum in establishing
the identity of the bacillus in question cannot be over-
estimated. The cultural tests under those circumstances
are, in his experience, comparatively valueless, being
mostly negative. Details of one case are given, illus-
trating the author's contentions.

British Medical Journal, February 16, 1907.

Deafness in Myxedema. — The patient whose history
is reported by W. R. Kemp was a woman of fifty-five years,
presenting the usual features of myxedema, though her
only complaint was of deafness. When she did hear, ques-
tions were not answered at once, there being some few
seconds spent in hesitation before a sentence was com-
menced. She spoke in a dull, apathetic tone, and had
considerable difficulty in articulating long words. She
was placed on a light, nutritious diet, with laxatives at
bed-time as required, thyroid extract in tabloids of gr.
ijss being given three times a day after each meal during
the first fourteen days, after which the dose was doubled.
After six weeks some signs of recovery appeared, the
swelling of the body decreased, and the hearing and speech
improved considerably. The point which seems to make
the case worth reporting is the deafness, which may h.^ve
been due to the thickness and dryness of both tympanitic
membranes. The author has not found anv reference to
deafness as a feature of myxedema in the text-books or
current literature.

Typhoid Fever Simulating Cerebrospinal Meningitis.
— J. A. Cowie's case was that of a coal miner, seen two
weeks after his initial symptoms and considered as a case
of cerebrospinal meningitis, his symptoms being almost typi-
cal of this malady. Lumbar puncture was done, but no
fluid obtained. The agglutination test was negative and
the Diplococcus intraccUnlaris meningitidis could not be
isolated from the blood. The patient died on about the
sixteenth day of his disease, and autopsy revealed the
abdominal lesions of typhoid. The brain membranes were
in a state of extreme congestion, and pus was seen on the
surface of the brain in the temporal region. At the base of
the brain a seropurulent fluid was found in large quantity,
and a specimen of this under the microscope showed pus
cells and a number of diplococci, and also diplococci in
rows. Examination of a specimen of the cerebrospinal fluid
showed tliat neither the Bacillus typhosus nor the Dip-
lococcus intraceltularis meningitidis were present, but a
Gram-positive diplococcus occurring in chains was isolated.
Two c.c. of a broth culture of this diplococcus were
injected intravenously into a rabbit, but as the animal was
quite well after two days the diplococcus was proved to be
nonvirulent.

The Treatment of Rodent Ulcer by Zinc Ions. —

H. L. Jones says that the apparatus required for this
therapy is simple. An ordinary medical continuous current
battery, with a galvanometer, a pair of wires, a flat pad
for completing the circuit at the negative pole, and a rod
or other electrode of ?inc attached to the positive pole,
completes the outfit. The zinc must be covered with three
or four layers of lint, which serve as a reservoir to hold
the zinc solution, a two per cent, solution of the sulphate
being very suitable. The zinc should be freshly cleaned or
amalgamated, and the solution should be made with dis-
tilled water. It is as well not to touch the zinc electrode
or its covers with the fingers unnecessarily, because every
touch imparts a trace of sodium chloride from the skin,
and tends to reduce the efficiency of the process a little
by bringing in some foreign ions. The circuit is com-
pleted through the usual pad electrode applied to any con-
venient part of the patient, the zinc electrode of suitable
size is held upon the rodent ulcer, and the current is
slowly turned on until a current of five, or eight, or ten
milliamperes is reached, according to the size of the elec-
trode used. Leduc has advisced that a suitable ma.gnitude
of current to use is two or three milliamperes of current
for each square centimeter of the positive electrode, and,
in^ eeneral, patients can bear this concentration of current
without coniplainin.g. The sensation produced is a burn-
ing one. not unlike that of a mustard plaster. In patients
who are sensitive it mav be convenient to introduce a
little cocaine beforehand. When the surface is raw the
cocaine solution can be directly applied on a tuft of cotton-
wool left in contact with the ulcer for a few minutes.
When there is no raw surface the drug can be helped
to penetrate electrolyticallv from the positive pole if. before
using the zinc solution, a tuft of wool moistened with
cocaine solution is applied to the surface of the rodent
ulcer, and the current passed in with the zinc electrode.

exactly as for the introduction of the zmc. The pre-
liminary use of cocaine permits of the use of a somewhat
stronger current. It is necessary to use a pure so ution
of cocaine, and not a solution contammg sodmm chloride
or any other salt. Occasionally the condition of the ulcer-
ated surface ofifers some difficulties to the even distribu-
tion of the zinc ions. Occasionally, also, it may be
necessary to puncture certain areas with the zmc needle
if the application of a flat electrode is not practicable.
Other cases which are difficult are those which have
been operated upon by A'-rays or by the knife, and have
relapsed, for they have a tendency to recur at several
points around the original site, and also to mvade the
subcutaneous tissue. If they have a thickness greater
than two or three millimeters, it is difficult, in a reasonable
time, to drive the zinc ions inwards to a sufficient depth
to influence the deeper parts, unless a zinc needle is used.
The advantage of using a needle is that time is saved,
for if one can push the zinc needle into the depth of the
part to be destroyed, the migration of the ions into the
surrounding layers is accelerated, and this is a great
advantage, because the rate of movement of the zmc ions
is slow.

Ichthyosis and Its Treatment.— W. A. Jamieson gives
the histories of several cases illustrative of the varying
phases of this afliection. He declares that our therapeutic
efforts should be directed toward the promotion of the
regular systematic exfoliation of the unduly adherent
and effete horny cells. There are various substances which
have the power of thinning down, artificially, the epidermis.
Sulphur is one, but if used it not only adds to the abnor-
mal aridity, but is apt to set up exudative and even
inflammatory processes. Salicylic acid, too, in the dilute
form in which alone it can be prudently employed over
extensive areas and for a length of time, fails to accom-
plish what is needed. Resorcin, however, not only favors
continual desquamation, but tends to leave the subjacent
surface polished and pliant; hence its use is specially
indicated. Combined with an oily base it dries up or is
rubbed off. Glycerine from its hygroscopic properties is
the excipient par excellence, but applied alone is rather
irritating. In union with starch it forms a bland, per-
sistent, soothing, and softening medium, and, as has been
seen, while in all cases so used it proves eminently
beneficial, if its application is begun early enough and
steadily persevered in, it can effect what must be regarded
as a cure. At the same time, with all its qualifications,
the resorcinized glvcerite of starch alone would not
enable us to get cont'inuouslv rid of the ever ncwly-forming
accretions of epidermis. We must therefore have recourse
to a medicated soap, and a superfatted one with which
resorcin and salicylic acid are incorporated— that which
is so valuable in shortening the desquamative stage in
scarlet fever— has proved adequate, and prepares the way
for the subsequent glvcerinization. Internal remedies are
of little use in ichthyosis. The only one which aids us
at all is cod-liver oil administered in small doses at night.
Pilocarpine is inoperative in early treatment, unnecessary
in later.

Berliner klinische U'oehenschrift, February 11, 1907.
The Sphygmoscope.— Rheinboldt gives this name to
an instrument he has devised primarily for the purpose
of facilitating the use of the sphygmomanometer. It^ is
intended to render the determination of the point at which
the pulse wave becomes obliterated susceptible of objec-
tive demonstration. In order to effect this the patient's
index fin.ger is inserted into a suitable adjustable collar
supported on a tripod and connected with a double lever
bv which the alteration in the size of the member with
each pulse beat is manifested bv a considerable excursion
of the indicator. It was found that readings of the
sphygmomanometer made by means of the instrument were
somewhat lower than those in which systolic pressure
was determined by the sense of touch, but the difference is
a consistent one and the author considers that it does
not invalidate the appliance. He has also found it very
useful as a means of obtaining information in regard to
the regularity of the heart action and of detecting varia-
tions in rate and intensity of pulsation that _ otherwise
might easily be overlooked. Advantages of the instrument
are its simplicity compared with the sphygmograph and
its consequent ease of adjustment and cheapness.
Miinchencr mcdizinische Wochenscl<rift. January 20. igo6,
and February $, too;.
Nervous Disturbances Accompanying Digestion.—
Kehrer calls attention to the frequency with which^ un-
pleasant dreams, and more particularly the classical night-
mare, occur during the earlv hours of sleep when diges-
tion, in accordance with the German custom of taking
the evening meal at about eight o'clock, is still_ actively
goincr on. He considers that during the period in which
the gastric contents are being expelled into the duodenum,

4IO

MEDICAL RECORD.

[March 9, 1907

nervous disturbances of this naiure are particularly likely
to be induced, and susgt^ts that this may be the result
of the sudden nooding of the circulation with the products
of digestion which may result in evoking these evidences
of stimulation in the brain. Persons who are subject to
disturbances of this sort should allow three or four hours
to elapse between the last meal and going to bed ; should
not let this last meal be too hearty a one, and should make
it a point to avoid all indigestible dishes and alcoholic
drinks with the evening meal.

The Use of Rubber Gloves. — Walther in discussing
this subject admits that by the use of rubber gloves it
is possible for the surgeon to operate with perfectly
sterile hands, but he considers that in spite of the state-
ments made bv many surgeons, even long habituation to
their use does not compensate for the impairment of
tactile sense the gloves entail. Particularly in such ob-
stetrical manipulations as removal of the retained placenta
or in cleaning out the uterus after an incomplete abortion
is it desirable that the operator shall have full possession
of the utmost degree of tactile sensibility, and under these
conditions the use of gloves may be a source of danger
rather than of safety. It is his attitude that the gloves should
be used rather for the purpose of protecting the physi-
cian's hands from contamination in making rectal exami-
nations, handling infectious material, etc., than as a rou-
tine in operative surgery and .gynecology. In regard to a
proposal recently made to have the use of gloves made
obligatory for country midwives, Walther expresses his
unqualified disaoproval of such a measure. It is necessary,
if gloves are to be used, that both the hands and the
gloves be sterilized with all possible care, and if the gloves
are made compulsory, the average midwife is sure to relax
her precautions in the one respect or the other. The
introduction of the glove would form a needless addition
to the appliances to be kept in order by the midw'ife and
would be found an unnecessary, expensive, and dangerous
innovation.

The Treatment of Tetanus. — Glanzel makes the suc-
cessful outcome of a severe case of tetanus the text for a
discussion of the antitoxin treatment of the disease. The
patient was a young man of eighteen years, and the treat-
ment carried out comprised the customary administration
of chloral, morphine, and potassium bromide in large quan-
tities, as well as the use of antitoxin. An unusually large
amount of this was injected, and it is the author's aim
principally to call attention to the necessity for resorting
to much larger doses of the antitoxin than are usually
given. He believes that it has been demonstrated that the
toxin is disseminated through the body by way of tne
blood stream, and not through the nerves, as was formerly
supposed, and therefore the subdural injection of antitoxin
is not necessary. The local treatment of the site of infec-
tion is exceedingly important, and should be carried out in
as radical a manner as possible without causing undue
mutilation, but the early and repeated administration by
hypodermatic injection of large amounts of antitoxin should
never be neglected. Prolonged warm baths are also men-
tioned as a valuable adjunct to the treatment.

Operations on the Hands. — Vogel suggests that in
order to secure more effective sterilization before per-
forming operations on the hands, particularly plastic
procedures the patient be directed for two or three days
preceding the operation to place the hand for one hour,
night and morning, in a hot-air apparatus of the type
devised by Bier. By this means very profuse perspira-
tion is induced and relative asepsis can be much more
easily secured. This is particularly true in dealing
with the hands of mechanics or laboring men whose
skin is apt to he very thick and grimy, .\nother ad-
vantage of the plan is to be that the occurrence of
small areas of necrosis along the line of suture that so
frequently takes place in operations of this sort seems
to be obviated.

Dcittschi' mcdiciiiische Wochcnschrift, January 3, 17, and
31, 1906, and February 7, 1907.

Removal of a Foreign Body Through the Broncho-
scope.— Winckler says that it is no longer permissible
in dealing with a patient supposed to have aspirated a
foreign body to pursue an expectant plan of treatment in
the hope that in the course of time the yitruding sub-
stance will be coughed up. The .I'-ray is unreliable as a
means of locating small bodies in the bronchi, and the
bronchoscope now forms the most satisfactory diagnostic
and therapeutic instrument. .-^ patient whose bronchi
contain a foreign body must be re,garded as a seriou^'v
sick person, even if there is but little disturbance in
general health, and in case there is any suspicion of the
aspiration of a foreign bodv bronchoscopy should be re-
sorted to without delay. \\"inckler describes a case of his
own in which a woman of fifty-eight years inadvertently

drew into her lungs a fragment of bone. Cough with
putrid purulent expectoration ensued and two months later,
when she came under the author's observation, the expec-
toration was extremely fetid. By means of a rather com-
plicated application of the bronchoscope, it was finally
possible to remove two spicules of bone from a portion of
the right bronchus, thirty-four cm. from the lips. One
of the fragments measured 13 by 7 by 1 mm., and the
other 9 by 2 by I mm. The fetor of the e.xpectoration
promptly disappeared, though the other evidences of bron-
chial and pulmonary irritation were slower in subsiding.
Ultimately complete recovery in every way occurred.

The Reflexes During Sleep. — Kutner has tested the
reflexes during sleep in a considerable number of patients
suffering from nervous diseases. He believes that the
opinion expressed by many observers that the deep tendon
reflexes are absent during sleep is erroneous and is de-
pendent largely on the difScuIty of eliciting such reflexes
without waking the patient. He tested the knee jerk in
twelve cases, and the achilles tendon refle.x in twenty-two
cases. The patellar reflex was present in all the patients,
but in three instances the achilles tendon reflex could not
be elicited. It was found, however, that in these patients
even when awake this reflex could not be obtained when the
limbs were placed in the position they occupied during
sleep. The superticial reflexes are easier to test during
sleep, and the various plantar reflexes, the only ones tested,
were found to be normal in the sleeping patients. The
great toe reflex formed an exception, however, and varia-
tions could be distinguished according to the nature of
the patient's malady. In cases of progressive paralysis and
delirium tremens a positive Babinski reaction was found in
from a half to two-thirds of the cases, whereas in psychoses
of a different nature the refle.x was absent. The author
points out that in the first two conditions there are organic
changes in the brain and that the association with these
of the Babinski phenomenon during sleep is very suggestive
in view of the fact that in the waking state the reflex
ordinarily indicates a lesion of the pyramidal tracts.

Fever in Carcinoma. — Alexander gives the histories
of a number of cases in which malignant new growths were
accompanied by more or less persistent and well-marked
fever. These observations, as well as a review of the liter-
ature, lead him to the conclusion that there is a definite
cancer fever which is independent of complications. This
febrile movement may follow various types, and is not
bound to any definite form. It occurs as the result of
autointoxication resulting from absorption of products
formed through the metabolic activities of the new grow-th
itself. In most cases of febrile cancer the new growth is
situated in the abdominal cavity, and is particularly apt to
involve the alimentary tract. While it might appear that
in ulcerating growths the conditions were particularly fa-
vorable for the occurrence of temperature elevations, this
is not so, and clinical experience shows that in such cases
the appearance of fever has no direct relation to this char-
acteristic of the tumor.

Complications Caused by the Therapeutic Application
of the Roentgen Rays. — Engel has compiled a long list
of the varitms niurc serious complications that have been
reported as attending the use of the Roent.gen rays for
therapeutic purposes and calls particular attention to a form
of toxemia that is sometimes observed. In a case of his
own a patient of fifty-four years suflfering from lymphatic
leukemia in the course of a series of .r-ray treatments de-
veloped high fever, collapse, diarrhea, rapid loss of strength,
and heart failure, finally leading to death under the appear-
ance of an intense toxemia. Inasmuch as the leukemia had
been of a pronouncedly chronic type, it seems certain that
the rapid course of the illness must have been the result of
the .v-ray radiation, a view that is strengthened by the
rapid reduction in the number of red and white blood cells
and in the size of the spleen and lymph glands that ensued.
In this case the total length of exposure was 350 minutes
in eleven days, and although the total number of .r-ray
minutes was not very large it seems not unlikely that the
treatments were given at too short intervals. The author
suggests that no x-ray treatment should last more than
two minutes at a time, with the tube at a distance of 20
cm. or four minutes at a distance of 35 cm. ; the same por-
tion of the body should not be treated more than two or
three times daily, and very hard tubes should be used for
therapeutic purposes. The portions of the body surround-
ing the area to be treated should be protected with lead
plates, and after every five or six treatments a rest of a
week or so should be allowed.

The Axillary Regions are recommended by Klose as
being the best situation in which to inject antitoxin or
similar preparations, as the skin is freely movable, is
well padded with fat and connective tissue, and the lym-
phatics are well developed. — Deutsche medimnische Woch-
enschrift.

IMarch 9, 1907]

MEDICAL RECORD.

41 T

The Practice of Oestetkics, in Original Contributions by
American Authors. Edited by Reuben Peterson,
M.D., Professor of Obstetrics and Gynecology in the
University of ^lichigan. Ann Arbor, Mich. Obstetrician
and Gynecologist-in-Chief to the University of ^ilichigan
Hospital. Philadelphia and New York: Lea Brothers &
Co., 1907.
This is the third of the series of books in ''The Prac-
titioner's Library,'' the other two being on Pediatrics, edited
by Dr. Walter Lester Carr, and Gynecology, edited by Dr.
J. Wesley Bovee. These two have already been reviewed in
our columns, and we cannot say more for the present
volume than that it is the equal, in all essentials, to the
others of the series. The contributors to this volume are
Drs. Charles Sumner Bacon and Henry Foster Lewis of
Chicago, Montgomery A. Crockett of Pinehurst, N. C, W.
A. Newman Dorland of Philadelphia, G. Carl Huber and
Alfred Scott \\'arthin of Ann Arbor, Mich., Hugo Ehren-
fest of St. Louis, Walter P. Manton of Detroit, John F.
Moran of Washington, and Benjamin R. Schenck of Balti-
Tiiore. The sections into which the work is divided are on
Physiology and Development of the Ovum, Physiology of
Pregnancy, of Labor, and of the Puerperium, Pathologj- of
Pregnancy, of Labor, and of the Puerperium. Obstetric Op-
erations, and the Newborn Infant. "The book is profusely
illustrated, more perhaps than is expedient, for some of the
subjects do not require such elaborate illustration, and the
pictures take up much room and increase unduly the size
and the weight of the book. The illustrations are. however,
e.Ncellently done and very distinctly printed, and most, at
least many, of them are clearly original. There are 523 il-
lustrations in the text and thirty full-page plates. The arti-
cles are not all of the same standard of excellence, hut as a
whole there is little criticism to be made of the work as a
trustworthy guide to the obstetric art, and we can safely
recommend it to the student or practitioner who wishes for
an up-to-date text-book on this subject.
A Guide to Dise.\ses of the Nose and Throat and Their
Treatment. By Charles A. Parker. F.R.C.S. Edin..
Surgeon to the Golden Square Throat Hospital, London,
with 255 Illustrations. New York: Longmans, Green
& Co. ; London : Edward Arnrold, 1906.
Books on nose and throat diseases are following each other
from the press in such rapid succession that a review be-
' comes difficult, inasmuch as they all cover practically the
same ground, and the differences between their various
statements refer to minor points which are of interest only
to the specialist. Dr. Parker incorporates in this volume
his lectures given at the well-known London institution,
and his method of putting thinss is well e.Kpressed in his
own words in the preface, to the effect that the three most
important objects of a course of study at a special hospital
are "to acquire the necessary dexterity to examine a patient
systematically, so as to overlook nothing, to recognize and
put in its proper place the particular pathological condi-
tion found, and finally, but chiefly, to treat both the patient
and the local abnormality successfully." As suggestive of
his adherence to these principles is the fact that he puts his
chapter on "Complications of the Upper Respiratory Tract
in relation to General Medicine" before instead of after the
detailed maladies of the nose, nasopharynx, and throat. By
this we understand that the author realizes that rhinology
and laryngology are but parts of medical science, and by no
means the whole of it. The book is well printed, the illus
trations are clear, the index is excellent, and this record of
a vast clinical exnerience is worthv of perusal by all inter-
ested in this field of orofessional work.
The Medical Epitome Series : Pathology, General and
Special. A INIauual for Students and Practitioners. By
John Stenhouse. M.A., B.Sc. Edin., M.B. Tor.: and
John Ferguson, M..^., M.D. Tor. Illustrated with 16
Engravings and a Colored Plate. Philadelphia and New
York: Lea Brothers & Co., 1906.

The first half of this book is devoted to general pathology,
and treats of the various topics usually included under this
head. The subject of inflammation is disposed of in some
half dozen pages. The classification of tumors adopted is
the recent one of Adami, which, while possibly scientific, is
likely, with its novel nomenclature, to add to the difficulties
of the student: to the practitioner it will probably be less
sntelligible than the one he learned at college. Two useful
chapters are those on toxemia and immunity. The second
half of the book deals with special pathology, and calls for
no special comment. The volume, as a whole, is of about
the same standard as the rest of the series.
Gheen's Encyclopedia and Dictionary' of Medicine and

Surgery. Vol. II. Bread to Ear. Edinburgh and London:

William Green & Son, igo6.
This is the second volume of this very complete and useful
work. It carries the subject matter along to and including

"Ear." There are 1,758 separate headings, the articles under
each varying from the few words needful as a definition to
an encyclopedic article of more than i,D00 words in length.
The dictionary part of the work is a very valuable feature,
including most of the titles which would be looked for in
and ordinary medical distionary. In the present volume,
for instance, under the head "Disease" are defined nearly
one hundred eponymic terms. The intrusion of the names
of clinicians and others in the designation of special dis-
eases is a great evil in medical nomenclature, but since it
has occurred and careless writers use such terms continu-
ally, a definition is often very necessary. The editor has
met the trouble in the best way, and with the greatest
economy of space, by grouping all these eponymic terms
under the one title. There are not many illustrations, but
such as there are are judiciously chosen and are helpful.
This second volume sustains the character of the work as
one of great utility to the practitioner of medicine.
A Treatise on the Motor Apparatus of the Eyes, Em-
bracing an Exposition of the Anomalies of the Ocular
.Adjustments and Their Treatment, with the Anatomy
and Physiology of the Muscles and Their Accessories. By
George T. Stevens, M.D., Ph.D. Philadelphia: F. A.
Davis Co., 1906.
The work, as stated by the author in the preface, is a sequel
to that on "Functional Nervous Diseases," and is presented
as a further argument to support the central idea, namely,
that "difficulties" of adjustment of the eyes are a source of
nervous trouble and more frequently than other conditions
constitute a neuropathic tendency." The book is one of
496 pages, well printed and illustrated. The text proper is
divided into four parts, and the different topics are con-
sidered in sections. The introduction is an historical sketch
and gives the views of Stromeyer, Dieffenbach, von Graefe
and others on strabismus, and of von Graefe, Soelberg-
Wells. Galezowski, Landolt, and others on heterophona or
"insufficiency of the internal recti muscles."

Part I. treats of the anatomy of the motor muscles of the
eves, and of the parts accessory to them. The comparative
aiiatomv of the eve muscles of fishes, reptiles, birds, and
mammals is described and illustrated. The bony structure,
size, and position of the orbits in man are carefully de-
scribed. A study of the plane of the orbital axes in relation
to the horizontal plane of the cranium, with a view to its
bearing on the visual plane, is here set forth. In the sec-
tions t;reating of the contents of the orbit, the insertion of
the extrinsic eye muscles into the globe and the relation
of Tenon's capsule to the globe, eye muscles, and orbit are
considered in detail.

Part II. is devoted to physiology. The laws of torsion,
.field of binocular vision, the horopter, the normal direction
of the planes of vision in relation to certain cranial charac-
teristics and stereoscopic vision are described and discussed.
Part III. treats of "anomalous conditions of the motor
muscles of the eyes consistent with the physiological state."
An explanation of the terms introduced by the author is
given. In this part are found descriptions of the use of
the tropometer. of the clinoscope. of the phorometer, and
the Maddox rod. A discussion of torsion or declination of
retinal images, also of the various departures from the. nor-
mal in the direction of the visual lines, the uses of prisms,
causes of strabismus, etc., are included.

Part IV. treats of "anomalous conditions of the motor
apparatus of the eyes not consistent with the physiological
state." To these conditions the term "colytropia" is ap-
plied. This Darts treats of spasm, of paralysis, and of ob-
struction to the action of the "motor" muscles of the eyes.

The volume presents the views of one well fitted in every
way for the work, who has devoted many years to the the-
oretical and clinical study of the subject. Much that it con-
tains is original with the author. Many of the views ex-
pressed have been previously published, but they are here
collected and svstematically arranged, making a complete
whole. No one who is studying ophthalmology, or who is
engaged in the practice of ophthalmology, can afford to
neglect to acquaint himself with the contents of this volume.
Inmany respects it marks a distinct advance in our knowl-
edge of some of the subjects of which it treats..
Studies in the Psychology of Sex. Erotic Symbolism;
The Mechanism of Detuinescence ; The Psychic State in
Pregnancy. By Havelock Km. is. Philadelphia : F. A.
Davis Co., IQ06.
With the appearance of this volume, the fifth of the
author's stories of sexual phenomena, the series draws to
a close. The next and last volume, he states, is to be de-
voted to a consideration of the bearings of the psychology
of sex to social problems in general. The first section of the
present work includes a resume of the sexual perversions
and aberrations, the second is devoted to an analysi5_ of
all the phases of the culmination of the various psychical
and phvsical phenomena for which the period of tumescence
has furnished the preparation, and the third deals with
the emotions attending the pregnant state.

412

MEDICAL RECORD.

[March 9, 1907

^nm ty Sparta,

NEW YORK ACADEMY OF MEDICINE.

SECTION ON StJRGERY.

Stated Meeting, Held January 4, 1907.

Dr. John F. Erdmann in the Chair.

A Case of Synovitis of the Sacroiliac Articulation.— Dr.
Henry W. Frauenthal presented this case, a boy, 11
years old, who, on June 26, 1906, was struck by a cable car.
He was in the hospital for some time, and discharged as
cured of his injuries. At present he had synovitis of the
right sacroiliac articulation. He could raise his left leg
with the knee fi.xed. He could not raise the right leg when
the knee was fixed, and, on attempting to do so, complained
of great pain at the sacroiliac joint, when the knee was
fle.xed on the pelvis. The motions of the right and left
hip joints were equal. Pressing the pelvis together pro-
duced pain at the articulation of the right sacroiliac joint
Making pressure on the erector spinas muscles and on the
latissimus dorsi on the right side produced pain at the
sacroiliac joint. Pressure on the same muscles on the left
side elicited no pain. The patient in walking leaned to the
right side. He had a peculiar gait due to the contractions
of the ham-string muscles on the right side.

Traumatic Amputation of Finger; Autoplasty.— Dr.
Herman C. Frauenthal presented a man who, in the
summer of 1903, while cleaning the chain of a bicycle,
turned the wheel with his left hand and caused the inde.x
finger of the right hand to be caught between the sprocket
wheel and chain, amputating the soft parts of the finger at
the second phalanx. He came to the office with the first
and part of the second phalanges stripped of the soft parts,
exposing the bones and first joint. Dr. Frauenthal sent
him back to the stable, about a mile away, for the thimble-
shaped soft parts. After soaking them in hot saline solu-
tion, they were replaced with zinc oxide plaster and balsam
of Peru, and healing took place kindly. The head of the
first phalanx eventually necrosed and came away. The.
absence of the head of the first phalanx could be seen in
the radiograph. Sensation was just returning to the part
of the finger injured, though incompletely as yet.

Motor-Boat Fractures.— Dr. Henry P. DeForest pre
sented this paper and illustrated it with .r-ray photographs.
He said that in most instances the machinery of a boat,
usually with gasoline as a motive power, was started by
hand. The more or less heavy balance wheel of the engine
had a permanent handle projecting from the rim, or a
heavy brass or iron rod sunken in a socket and held in
place with a spiral spring when not in actual use. When
the engine was started this handle was seized and the wheel
turned quickly around. Occasionally something happened
and the engine started, oftentimes witli great rapidity. The
handle might escape from the grasp, might fly around, and
strike one on the hand before the hand had a chance to get
out of the way. The injuries resulting from this impact
were usually trifling, but the speaker cited several cases to
show that some of them might be very serious. Similar
injuries occurred during the "cranking" of an automobile.
The fact that the initial velocity of the flying handle was
much greater than that of the human body, in a case of a
fall, or that of falling timbers, stones, and the ordinary
causes of fracture in every-day life, had a marked effect
upon the lines of fracture, and caused them to resemble
those produced by large caliber projectiles without the
penetrating effects. The fracture, as a rule, was rarely
transmitted to the weaker parts of the bone. So localized
was the injury that fragments of bone might be broken off,
or such small bones as those of the carpus might be in-
dividually broken. As a rule, the line of fracture was
straight and the direction taken quite unusual. Diagnosis
w^s often difficult. The dangers were now becoming

known, and schools of instruction in the complete con-
struction and management of motor boats were now
established.

Duodenal Fistiila; Its Treatment by Gastrojejunos-
tomy and Pyloric Occlusion.— Dr. A. A. Berg read this
paper. A duodenal fistula, unless it was of pin-hole size,
usually occasioned a very rapid death from starvation. The
duration of life after the establishment of such a fistula
depended upon the size of the opening into the duodenum
and upon the readiness with which the duodenal contents
were discharged. All the numerous mechanical devices for
the relief of this condition had proved inefficient. With the
view of preventing the rapid deterioration of patients
afflicted with duodenal fistula, Dr. Berg proposed (Central-
blatt fiir Chirurgie, 1903) that a gastroenterostomy be
established and the pylorus occluded. The proposition at
that time had not been tested in actual practice, but since
then he twice had had occasion to carry it out, and it was his
wish to report on its efficacy in overcoming the otherwise
fatal lesion and to suggest some points of practical im-
portance in the technique of its performance. In the first
case he reported it was evident that impending death was
averted from duodenal leakage by the gastrojejunostomy
and pyloric occlusion. The ultimate fatal issue was not
due to the complicating duodenal leakage, but to cancerous
cachexia. In reviewing the details of the operation, two
important points came up for consideration. First, was it
necessary in order to divert the chyme from the duodenum
into the jejunum to occlude the pylorus, or was it sufficient
to simply make a gastrojejunostomy. Second, if it was
essential to occlude the pylorus, then great care must be
exercised in applying the occluding ligature, lest it cut
through the tissues. Regarding the first point, he said it
was commonly believed that if a gastrojejunal fistula was
established at the lower point of the stomach, the gastric
contents would be emptied directly into the jejunum
through this anastomotic opening, even when the pyloric
opening in the stomach was patent. This was, however, an ■
erroneous belief. Kelling's experiments upon dogs, and
his own clinical observation, conclusively proved that when
the pylorus was patent a gastrojejunostomy would not
divert the chyme from the duodenum into the jejunum.
Consequently, when they had to do with a duodenal fistula,
it was necessary, not only to establish a gastrojejunostomy,
but also to occlude the pylorus. With regard to the second
point, however applicable Kelling's method was when they
had to deal with normal serous coverings of the stomach
and duodenum, it was not applicable when the peritoneal
surfaces of these viscera had become brittle and friable,
and fixed in inflammatory exudate. In such conditions, in
order to occlude the pylorus, one must resort to a circular
ligature. In the application of this ligature the greatest
care must be exercised not to constrict the parts, for other-
wise this ligature would be cut through the pylorus. This
tendency to cut through was all the more prominent
because of the usually poor vitality of such tissues. In
cases of ruptured duodenum that might be followed by a
fistulous opening, was it advisable to resort to a primary
gastrojejunostomy and pyloric occlusion in addition to
repairing the opening in the duocfcnum, or should they con-
tent themselves at the first operation with direct repair of
the perforated viscus? In answer to this. Dr. Berg said
that if the peritoneal surfaces surrounding the perforated
part were normal, not brittle or friable, or fixed in inflam-
matory exudate, they had every reason to expect a success-
ful issue by suture. But, if such was not the case, it was
not likely that the healing by suture would occur, and, in
such cases, it would be wiser at once to proceed to a gastro-
jejunostomy and pyloric occlusion. Again, if by the sutures
they constricted the lumen of the duodenum sufficiently to
interfere with the transmission through it of the chyme,
it was likewise best to at once proceed to gastrojejunostomy
and pyloric occlusion. But, if a primary gastrojejunostomy
and pyloric occlusion had not been done, one should at

March 9, 1907'

MEDICAL RECORD.

413

once perform them when the suture of the duodenal open-
ing proved itself insufficient. Repeated attempts at repair
of the viscus suture would almost invariably result in fail-
ure to effect its occlusion, and would be followed by death.

Dr. Charles H. Peck said that in all the cases of
duodenal fistula he had seen the surrounding walls had
been friable, rendering suturing uncertain. He had been
fortunate in not encountering leakage afterwards. He did
not believe that in all cases where this infiltration existed
they would fail to get healing of the ulcer. He was accus-
tomed to first place a large purse-string suture at some dis-
tance from the perforation before applying the Lembert
sutures. There was no doubt but that the friability of the
tissues caused the sutures to cut through. It seemed to
him that in the acute cases of perforation, tlie cases in des-
perate condition, with leakage and a general peritonitis, that
the performance of a gastrojejunostomy was dangerous
and increased the mortality; he said he would be inclined
to make an attempt to terminate the operation as soon as
possible with a single suture.

Dr. Charles A. Elsberg had had only one case of rup-
tured duodenal ulcer, and he recognized the rationality of
Dr. Berg's suggestion. He exposed the surface of the
stomach and the ulcer, which was situated at the junction
of the second and third portion of the duodenum, and he
sewed the surface of the stomach over the ulcer, and with
satisfactory results. The patient did well and made an
entire recovery. He said he was struck at the time with
the idea, whether it was not possible and feasible in cases
of perforated duodenal ulcer to at once do a gastroduode-
nostomy. If the perforation was high up, he thought Dr.
Berg's method a rational one, but with this exception ; if
the perforation was below the site of the entrance of the
common bile and pancreatic duct, there would still be a
continual leakage of bile and pancreatic fluid, and so be a
decided factor in preventing the recovery of the patient.

Dr. Samuel Lloyd agreed with Dr. Berg that it was
impossible to divert the stream from the pyloric end of the
stomach in such cases by doing a gastrojejunostomy alone.
If the object was simply to cause a rest of the part, gastro-
jejunostomy would not be efficient unless some method
was adopted for closing the pyloric end. He did not agree,
however, that a gastrojejunostomy should be made first,
and before the duodena! fistula was closed ; an attempt
should be made to close the duodenal fistula. These cases
would stand much operative manipulation. The dangers of
peritonitis were not so great when operating in the upper
part of the peritoneal cavity as in the lower part. Conse-
quently, Dr. Lloyd attacked these cases more actively than
if the fistula involved the lower portion of the peritoneum.
Dr. Peck's suggestion of using a purse-string suture and
then the Lembert's suture appeared to him as feasible. Dr.
Elsberg's suggestion also appealed to him strongly. He
recently had a case of duodenal ulcer with the ulcer ex-
tending from the pylorus into the duodenum. There were
multiple ulcers, one of the pylorus and two good-sized
ulcers on the anterior wall of the duodenum. In this case
he carried out the suggestion of Dr. Elsberg, making a
complete removal of the pylorus and brought up the
duodenum into the wound, and with a perfect recovery.
The fistula should first be closed if possible; if they failed,
then they should proceed with the closure of the pylorus.

Dr. Berg believed that he had had seven cases of rupture
of the stomach and duodenum to deal with ; in five of
these he effected a primary closure, knowing the suture
line would remain intact. In two he was not able to effect
this. He thought that in a large majority of these cases
one could be able to tell, with a fair amount of certainty,
whether or not the attempt to close the ulcer by suture
would be successful. When the perforation was situated
high up, the suture method was more likely to be success-
ful, even though there was a considerable inflammatory
exudate. If, however, the same inflammatory mass existed
at the pyloric region, giving less room for bringing the

parts together, attempts with suturing were likely to be
less efficacious. He had absolutely no reason to propose
primary gastrojejunostomy with pyloric occlusion in any
case where the surgeon felt that the suture line would be a
tight one, but where the surgeon felt that the suture would
not be successful, the question of primary gastrojejunos-
tomy with occlusion of the pyloric end should come up.
With regard to the length of time that a patient would
live after leakage, that depended upon the size of the hole
in the duodenum. This question of primary gastrojejunos-
tomy depended upon the character of the tissues surround-
ing the ulcer. If the indurated area was some distance
around the perforation, this operation could not be trusted.
Murphy's button was out of the question. The suture oper-
ation held out such a slight chance for success that the
procedure should not be considered under such circum-
stances.

Stated Meeting, Held February i, 1907.

Dr. John F. Erdmann in the Chair.

Plastic Repair After Removal of Carcinoma of the
Cheek and Left Angle of Mouth. — Dr. Franz Torek
presented this patient. An excision had been done by an-
other surgeon, but the growth had recurred and carcino-
matous glands had developed in the submaxillary region.
Dr. Torek first extirpated the lymphatic glands by an in-
cision from the chin to the hyoid bone, thence outwards
along the boundary line between the floor of the mouth
and neck, thence upward to a point behind the angle of the
jaw. The flap was prepared upward and all the glands
were cleared out. He next excised nearly the whole cheek
and part of the upper and lower lips. The divided ends of
the lips were united, leaving a large hole in place of ths
cheek, Remnants of mucous membrane of the cheek could
not be approximated. As failure to replace the mucous
membrane would result in cicatricial contraction and sub-
sequent impossibility to open the mouth, a plastic opera-
tion had to be performed. Last year Dr. Torek presented
a patient in whose case he had used the skin of tlie neck to
replace the mucous membrane. In this case he took a long
flap from the tongue with its pedicle at the root of the
tongue, twisted it so that the raw side looked outward
and the mucous membrane side inward, and he attached
this to the margin of the mucous membrane of the cheek.
The skin defect w-as closed by utilizing the flap which had
been raised from the submaxillary region for the purpose
of extirpating the glands. The skin was undermined still
further upward into the open cut, thus making a broad
bridge of skin attached in front to the chin and in the
back to the skin over the ascending ramus. This bridge
was moved upwards and sutured to the upper wound
margin. Thus, a large defect was left under the floor
of the mouth, which healed easily by granulation.

Dr. Charles H. Peck reported two instances which
made him doubt, perhaps, the necessity of covering the
inner surface with flaps of mucous membrane to prevent
contraction.

A Cured Case of Cicatricial Stricture of the Esoph-
agus.— Dr. Edward W. Peterson presented a male,
about 22 years old, who had been employed as a "spieler"
for a Coney Island show, and who drank some nitric acid
by mistake, .\bout eight days later he noticed that he
could not swallow so-called hard food except with diffi-
culty, and gradually he was able only to swallow soft
foods. After a few weeks he had to live on fluids and r»t
times even these would not pass down. Dr. Peterson
said that several unsuccessful attempts were made to pass
the stricture with various sized instruments. The stricture
was located nine inches from the teeth. Finally, a small
flexible bougie was introduced and. after a number of days
of treatment, a No. 26 instrument could be passed. Follow-
ing an attempt at divulsion with an esophageal divulsor.

414

MEDICAL RECORD.

[March 9, 1907

the patient developed a cellulitis of the neck, which was
followed by no ill results, but the lesson was taken to
heart and the divulsion abandoned. The patient left the
city, and when he returned he was greatly emaciated and
unable to swallow water, except a spoonful at a time. All
attempts to pass instruments failed. Finally, a thread was
washed through the stricture into the stomach, a tempo-
rary gastrostomy was performed, the end of the thread
fished out, and to it was attached a strong fish-line, which
was drawn up through the esophagus out of the mouth.
Several wire spindle bougies were then drawn up, and the
stricture gradually dilated. Later, with a full-sized instru-
ment in place, an internal csophagotomy was done, using
the Abbe string method to chafe through the stricture. The
patient was now free from any difficulty in swallowing,
and now passed on himself once a week a full-sized esoph-
ageal bougie. The patient demonstrated the ease with
which the bougie could be passed.

The Diagnosis of Imminent Perforation in Typhoid
Fever. — Dr. Forbes H.^wkes read this paper. Without
going into the bibliography of the subject, the established
facts warranted the following statement: The propor-
tion of typhoid fever patients who had perforations varied
in the different epidemics from i to 33 per cent., and
probably from 6 to 10 per cent, was not far from the
average. Osier had stated that one-third of the mortality
in typhoid fever was due to perforation. Of this number
about one-half might now be saved by operation if the
most favorable conditions existed for early diagnosis and
prompt surgical help. These favorable conditions were
necessarily present to a greater degree in those hospitals
in large cities that were provided with a corps of trained
nurses in the wards, trained physicians on the house staff,
and a sufficient number of attending surgeons for a prompt
response to such emergencies. Operators agreed that every
hour that elapsed between the perforation and the time of
operation decreased by so much the patient's chances, and
that other conditions being equal, good results should
generally be obtained in operations done for ulcers that
were either perforating at that moment or that had per-
forated just before. Any marked improvement, there-
fore, in the mortality records of these cases would have
to come through a similar improvement in the diagnosis
of the affection, or of the conditions which led up to the
perforation. The so-called symptoms of perforation, "in-
tense pain, marked tenderness, marked muscular rigidity
or spasm, varying degrees of collapse, variations in the
pulse rate and temperature, etc.," were in reality only thf:
late symptoms of a previous peritonitis which had kept
on developing many hours after the so-called perforation.
It was his experience that the earliest symptoms of peri-
tonitis in typhoid and in many other abdominal diseases
were, as a rule, neither recorded nor noticed, Nurses should
be carefully instructed to report to the house physician
any pain in order that he might examine immediately for
other signs of a beginning peritonitis. In a series of 500
cases observed in Osier's ward, INIcCrae stated that no pain
existed in 208 cases (41 per cent.), and that pain existed
during some time of the disease in 44 per cent, of the
cases. If one considered abdominal pain alone it would
help but little: other symptoms of a beginning peritonitis
should be considered with it. He had seen a number of
patients in whom other symptoms of peritonitis developed
before that of pain : namely, muscular rigidity and tendei ■
ness. and in quite a number of cases the pain left before
the muscular rigidity and tenderness, which persisted until
the peritonitis had subsided. Even a very slight degree of
muscular rigidity, when present zvithout pain, should cause
one to keep a watchful eye on the patient. If pain super-
vened, or if it existed at the time of the first examination,
a surgeon should see the case at once, for two distinct
danger signals were already set, and if they had localized
abdominal pain and abdominal rigidity, they were almost
certain to have one other symptom, tenderness. In many-

cases these were enough to warrant an exploratory opera-
tion if the patient was in good condition. The other dis-
eases that were liable to occur in the abdominal region of
a patient with typhoid fever that would give these three
symptoms, without any peritonitis being present, were
hysteria, lead colic, passage of a biliary or a renal calculus,
and appendicitis without peritonitis (early). After ruling
out these conditions one must look further for corroborat-
ing symptoms, as increased leucocytosis, slight shifting
dullness in the flank, an increase in the blood pressure,
etc. He said they were forced to conclude that a positive
differential diagnosis of a perforative peritonitis or of an
imminent perforation, was a very difficult matter, but a
tentative one should be made much oftener than in the
past at an early date, by examining the abdomen in the
typhoid patients sufficiently often and with the utmost
care. He believed the diagnosis of even mild peritonitis
in a typhoid should mean operation and drainage if the
patient was in a condition to stand it. After reporting
two cases. Dr. Hawkes concluded that in many cases ot
typhoid fever a perforative stage of peritonitis was present
which could be recognized as a beginning peritonitis if a
sufficiently careful and a sufficiently frequent examination
of the abdomen was made. They should divest them
selves of the idea that the absence of pain in a given case
ruled out any appreciable amount of peritonitis. Musculai
rigidity and slight tenderness, usually localized, often pre-
ceded the symptom of pain by several hours. This pre-
algesic period would seem to be the very best period in
which to institute peritoneal drainage of a loop of intestine
with swollen ulcer patches, thus relieving the patient from
tlie extra burden of the secondary infection and giving
the ulcers a chance, if they were going to break down,
to do so through a drainage tract. He stated that he
had not intended taking up the symptoms of perforation
in his paper, but of the preperforative period.

Dr. George E. Brewer believed that Dr. Hawkes had
taken a great step in advance in the recognition of this
preperforative stage in typhoid fever, and the report of
his cases was interesting.

Dr. Joseph A. Blake said he had lately looked up the
literature at Roosevelt Hospital, and found among 500
cases of typhoid fever the proportion of perforation
was 48 to 100. a percentage which he considered quite
high. He never felt sure of his diagnosis of the pre-
i<erforative stage. When the three cardinal symptoms were
present, i.e. pain, muscular rigidity, and tenderness, opera
tion should be done. But it was often difficult to elicit
these symptoms. If patients were apathetic, they would
not complain of pain. Meteorism might be present, giving
such a doughy resistance that muscular rigidity could not
be determined. The diagnosis was exceedingly difficult
One should be satisfied to make a diagnosis of the perfora-
tion itself rather than to attempt the preperforative stage
diagnosis.

Dr. Xydegger, U.S.M.H., called attention to the value
of the leucocyte count in the diagnosis of perforation in
typhoid fever. Often at the end of the third week the
leucocytes number 7,000 or 8.000, some 3,000 below the
normal. He saw a case of perforation two months ago
at the Marine Hospital, where he was not sure of perfora-
tion, although he strongly suspected it. He made a number
of counts, and found the polymorphonuclears had increased
about 20 per cent. That count w"as made about three times,
one hour between each count, and on the strength of this
increase, operation was performed, the perforation was
found, and closed.

Dr. Hawkes closed the discussion.

The Operative Treatment of Fractures at the Elbow
(Lantern Slide Demonstration). Dr. Carletox P. Flint
read this paper.

Dr. Joseph A. Blake said that in fractures around the
elbow-joint a great many complications might occur, and
no one should attempt treatment unless he was cognizant

March 9, 1907]

MEDICAL RECORD.

415

of them. With regard to the time o£ operating upon these
fractures. Dr. Flint took the ground that operation should
be deferred from five to ten days to two weeks after the
injury; Dr. Blake thought it was better to operate earlier.
To be sure, there were certain objections, such as devital-
ized tissues, and one should be governed by the possibili-
ties of infection in these cases. With regard to treatment,
he used a drill which required very little force, and which
did not interfere with the apposition of the fragments, an
ordinary twisting drill. In fractures of the olecranon one
was not so apt to have the interposition of soft parts as
in fractures of the patella. The incision to be used must
depend upon one's own experience in making these in
cisions.

Dr. George E. Brewer could recall no work on surgery
which gave such rules or laid down such principles in the
treatment of these cases, <"s did the paper of Dr. Flint. The
paper covered the ground thoroughly, and would no doubt
be a guide in the future in the treatment of elbow injuries.
The lower end of the humerus furnished a great variety of
injuries; they were very complicated and few could obtain
increased functional activity of the joint, and any aid was
to be desired. A good many of the cases Dr. Flint had
operated upon had been under Dr. Brewer's observation,
and, as a matter of fact, for the past six or eight months,
at Dr. Flint's request, he had turned over to him the worst
cases of vicious union and ankylosis that came in the hos-
pital. It was from this very unfavorable class of cases that
Dr. Flint had gotten his material. By intelligent operative
treatment a great deal could be accomplished in fractures
at the elbow.

Dr. Samuel Lloyd said he was much interested in this
subject, and some time ago he had read a paper on it before
this Section. He had had an experience with thirty or forty
cases of fracture at the elbow, which had been followed
by vicious results ; in his experience he had never had a
case of non-union in the young. He believed they should
get away from the old-fashioned notion that the elbow
should be fixed in cases of fractures; the position of the
joint should be that which best held the fragments in
apposition, no matter what that position might be. They
then would have fewer cases with decreased range of
motion, or fixation at the elbow.

Dr. John B. W.^lker said that oftentimes one would
apparently not get good results in children, but at the end
of three or four years better results followed.

Dr. Joseph Wiener called attention to a suture material,
thin silver wire made into a cable, which made a pliable
material, and was even stronger than a silver wire of the
same caliber. In cases of fractures at the elbow he em-
phasized the fact that any one position could be maintained
for any length of time.

Dr. Flint closed the discussion.

The Hand of Iron in the Glove of Rubber. — Dr. Rob-
ert T. Morris read this paper. ( See page 394.)

Resected Gut; Silver Wire Filigree. — Dr. Joseph Wie-
ner presented a specimen of resected gut showing the
silver wire filigree, devised by Bartlet of St. Louis, in posi-
tion. This filigree consisted merely of thin silver wire
arranged in the form of a figure-of-eight with but one
cross-piece.

section on dermatology.

Stated Meeting. Held February 5, 1907.

Dr. a. R. Robinson in the Chair.

Acne Keratosa. — Dr. W. S. Gottheil presented this pa-
tient, a Russian girl 11 years old. five months in this coun-
try. She had suffered from the eruption since infancy; it
had varied in severity at times, but had never entirely dis-
appeared. Individual lesions lasted a long time (weeks or
months), and then dried up, their hard tops falling ofl;
and occasionally leaving a mark. Her general health was

fair, her internal organs free. The history was defective,
the child being an orphan. Scattered ovei the body were
several hundred lesions, grouped in certain localities, and
identical in appearance, though varymg in size. The
smallest were less than pinhead in size, the largest as big
as a French pea. They wcj. circular acuminate papules
of a dull red color, on a normal skin base, and with a
hard, yellowish-brown plug in their center. The largest
papules tended to become irregularly circular or oval ; and
the central plug was large and hard. Even the smallest
papules showed this central plug, removal of which left
a cup-shaped glistening depression, and usually there was
no pus. A characteristic feature was the formation of »
lesion of precisely similar character, with reddened bas^
and central hard plug, wherever there had been accidental
lesions, such as scratches, these lesions assuming the
elongated or irregular shape of the traumatism. The
eruption was fairly well distributed over the body, but
the papules were distinctly grouped in certain places. The
largest collection of them was on the upper buttocks on
both sides, where there were a hundred or two, mostly
small in size. There were a fair number on the outer
surface of the thighs, and some on the lower legs, espe-
cially about the ankles. The center of the back was free,
but the shoulders and the skin over the shoulder blades
showed large groups of lesions. There were a few on the
upper anterior chest area, and more of them on the lower
abdomen. The arms were markedly affected, especially
the extensor surfaces ; there were some on the flexor
aspects, and many on both surfaces of the wrists. There
were a large number of characteristic lesions on the backs
of the hands. There were a few scattered over the face,
as well as some scars that might have been the result of
previous, possibly infected lesions. Palms, soles, and scalp
were free. In 1904 Dr. Gottheil had described two cases
of this aft'ection, which is identical with the acne cornee of
Hardy, Leloir, and Vidal. the acne keratigiie of Leredde
and Tenneson, and possibly the keratosis foUicularis con-
tagiosa of Brooke. It differs from the ordinary lichen
pilaris or spinulosus, in that the hyperkeratosis affects the
sebaceous glands proper, rather than the hair follicles, and
that the chronic inflammatory process is much more
marked than in the pilous affection. In fact the micro-
scopic e.xamination in his earlier cases showed that the
secretory ducts of the sebaceous glands were chiefly af-
fected ; the distended duct forming a sack that was pointed
below, and broad and crateriform, and filled with masses
of imperfectly cornified epithelial cells above. The se-
baceous cells of the secreting portion of the gland below
were compressed and atrophic. The chronic inflammatory
process affecting the sebaceous glands seemed to be more
nearly related to the acnes than to the pure keratoses ; and
it might be related also to the so-called cutaneous horns.
In one of his earlier cases, the keratotic plugs at one or
two places formed distinct, though minute, horny ex-
crescences. Future study must decide whether it had any
connection with acne necrotica or the tuberculides.

Keratosis of Palms and Soles from Arsenic. — Dr.
Robinson presented a woman, aged twenty-seven years,
who had had psoriasis of the whole cutaneous surface,
except palms and soles, since she was six months old.
The psoriasis was profuse over body. She had been under
treatment ever since childhood. Sometimes the eruption
was slight and again extensive, but had never occupied the
palms or soles. Five years ago she took arsenic in in-
creasin.g doses until she took eighteen drops of Fowler's
Solution three times a day, and continued this amount for
about two months, when an eruption appeared upon the
palms and soles simultaneously, and remained to the
present time, although the psoriasis nearly disappeared two
years ago and again one year ago for a short period. .•\c-
cording to the statement of the patient, an intelligent, edu-
cated woman, the eruption upon the palms and soles had
not changed as regards the number of lesions since their

4i6

MEDICAL RECORD.

[March 9, 1907

first appearance, 'i hey were confined to the palms and
soles, were irregularly distributed, and varied in size from
a pinhead to a small pea. Each lesion upon the palm was
sharply limited, conical or flat in form, firm with a rough-
ened or wart-like surface in central portion. There were no
inflammatory symptoms present. The patient had been in
the habit of cutting off the summit of the conical lesions
when they caused annoyance. At the metacarpophalangeal
junction ridges of calloused epidermis existed. Large areas
of calloused skin were present on the soles in the usual
places for normal thickenings from pressure. The long
continuance of a single lesion in a definite shape without
increasing in size, the warty character of the surface and
the absence of inflammation, excluded psoriasis. Micro-
scopical examinations of a small-pea-sized growth showed
the corneous layer much thickened, with parakeratosis in
parts ; the stratum lucidum thickened, the granular layer
well developed. Even over regions where the parakera
tosis was present, the rete was increased greatly in thick-
ness throughout the interpapillary rete prolongations ex
tended deeply into the corium. The papillas were not
edematous, the papilla blood-vessels were dilated, but there
was no marked infiltration, either of polynuclears or other
bodies. The corium was normal, also the sweat glands
in the corium. The warty character of the surface of the
lesions depended upon the deep and broad furrows in the
corneous layer from the dilated excretory sweat duct.

Dr. Dillingham said that the case was very unusual and
interesting, and that there was no question about the
diagnosis being correct. He added that Dr. Robinson had
not mentioned that the hollows of the feet were not in-
volved, and that there was a marked callosity near the toes
on the left foot about an inch long and one-eighth of an
inch wide, formed by a number of lesions coalescing.

Morphoea. — Dr. Willl^ms presented this patient, -i
woman twenty-eight years of age. She first noticed brown
spots on her abdomen in the spring or summer of 1901,
during her third pregnancy. They were about half an
inch in diameter, smooth, not elevated, and showed no
apparent thickening. They never disappeared, but were
said to have become hard about six months ago : as there
was a fresh outbreak of many sclerodermatous patches at
that time, this statement may rest on faulty observation.
Early in 1903 she noticed a hard, white swelling on the
flexor surface of the left wrist, and others on the back of
the right hand and the dorsum of the right foot. About
two years later, hard spots developed between the shoulders
and below each clavicle. These gradually became brown,
and all softened while the woman was pregnant with her
last child (born in November. 1905), leaving only a brown
stain on the slightly dry but perfectly pliable skin. She
felt very well during her last pregnancy and for some time
after, but about six months ago the present eruption ap
peared. After this she worried about the condition of her
skin, lost flesh and strength, and as she moved around
more, she noticed a beginning prolapsus uteri. The first
thing to call attention to a spot would be the itching, which
sometimes was very severe. Scattered over the trunk
were round, oval or oblong placques of thickened skin,
brownish in color and slightly dry. The surface was even
and firm, sometimes harsh. The border was fairly regular
and faded rather quickly into the normal skin. Neither
enlarged veins nor a violet border was observed. The
spots on the left wrist and the right hand showed only a
brown stain and slight atrophy. The pulse was eighty to
the minute and regular. The thyroid was enlarged, but
there was no exophthalmos. The urine was normal. The
great improvement during the last pregnancy, and the evi-
dent enlargement of the thyroid were very suggestive of
some relation between the secretions of these ductless
glands and the disease, but the data available were too
scanty to warrant any positive conclusion in this matter.

Keratosis Palmas Hereditaria. — Dr. Williams pre-
sented a woman, her daughter, and her granddaughter, all

showing this condition. The grandfather of the oldest
patient was the first member of the family known to have
had this disease. Three of his children, one male and two
female, were affected, while two others, one male and one
female, were free. Of his other children, no record could
be obtained. The mother of the oldest of the patients pre-
sented, one of the affected females of the second genera-
tion, had nine children, of whom five, girls, were affected,
while two boys and two girls were free. The second pa-
tient had two brothers, one affected and one free, and one
daughter, the third of the patients shown. Of the fifty-nine
descendants of whom a history was obtained, twenty were
affected, and the others free. In no case, so far as could
be ascertained, did the disease skip a generation : if any
of the family escaped the disease, his or her children
escaped also. The disease always appeared in infancy, the
hands looking as if they had been soaked in water a long
time, as the patient expressed it. The soles were gener-
ally free, but walking barefoot always excited the disease
there also. Even with great care, sparing the hands as
much as possible, the harshness and blackness persisted to
a certain extent, but they were made much worse by rough
work. The condition of the hands of the three patients
presented was practically the same, differing only in de-
gree. The backs of the hands were free, except over the
joints, where the horny layer was slightly thickened and
the natural lines of the skin exaggerated. On the oldest
of the three the nails were rough and uneven, and there
was a heaping up of horny matter beneath the free border.
One of the little girl's nails was also rough, which was
said to be the result of an old paronychia, and there was
the same condition at the free border of the nails as in
the grandmother. On the palmar surface the disease was
most developed on the finger tips, and least on the hands.
None of the patients showed the thick, horny plate which
was so characteristic of the disease ; instead, the skin was
fairly pliable, the distinguishing features being a mod-
erate thickening of the horny layer, with multiplication
and exaggeration of the usual markings, so that the af-
fected regions were divided by black lines into irregular
polygonal areas.

Case for Diagnosis. — Dr. Williams presented this pa-
tient, an Italian, twenty-two years of age, three years in
this country, a shoemaker by occupation. He denied ever
having had a chancre, and gave no history of alopecia,
sore throat, headaches, or eruption, until the present dis-
ease began. About ten years before, he first noticed a
rounded elevation, about a quarter to a half inch in di-
ameter, near the ulnar border of the dorsal surface of the
right hand, at a point where the skin was irritated by the
pressure of the thread he used in his work. In the next
two months a similar lump appeared on the ulnar border
of the right wrist, and a third about the middle of the
dorsal surface of the right forearm, two inches above the
wrist. This last lesion was cut out when it was about two
weeks old, and has never recurred. Similar masses ap-
peared on the back of the right hand, from time to time, up
to two years ago. He said that none had developed since,
but it was hard to communicate with him, and the details
of the history were unreliable. The eruption was usually
worse in summer, and it never disappeared entirely. For
the past five years the patient had noticed a swelling over
the back of the right wrist. From time to time during
the past three years he had had an eruption on the neck,
chest, and hands. Last year there was a patch about two
inches in diameter on the back of the left hand, which
healed without treatment. Four months before Df.
Williams showed him he had lost the sight of the left eye,
complete blindness developing in a few minutes. Since
that time he had been taking a medicine by drops, first
ten drops three times a day, increasing to thirty drops,
and under this treatment sight had improved. When pre-
sented there was complete loss of vision in the right half
of the field of vision of the left eve, while the left half was

March 9, 1907]

MEDICAL RECORD.

417

much restricted above. The eruption on the right hand had
never been painful or tender, but the swelling and stiffness
interfered considerably with the motion of the fingers. The
eruption consisted of rounded dull red elevations, each
surrounded with a red zone. All presented a crateriform
opening at the top, from which serum oozed out. Two
weeks ago they had discharged pus. Over the greater part
of the area the inflammatory redness was continuous, and
there was a moderate diffuse thickening. The border was
irregular and ill-defined. The patient had taken mixed
treatment for two w-eeks, and in that time the masses had
shrunken greatly. Sections on microscopic examination
showed an epithelioma, extending deeply into the sub
cutaneous tissue, and showing a very marked inflamma
tory infiltration in the corium and subcutaneous tissue.
Cell-nests or pearls were very numerous. Smears from
the largest round spot, and from the thin purulent fluid
discharged from a smaller nodule were negative for tu
bercle bacilli, actinomyces, and Spiroihata pallida. Cul-
tures gave a pure growth of streptococcus. Clinically, tlii.
lesions showed no resemblance whatever to epithelioma,
and in spite "of the pathological report, Dr. Williams be-
lieved that the diagnosis lay between tuberculosis and
syphilis.

Dr. Hlbb.\rd said that he thought this was a case of
mixed infection of a chronic nature ; and that the man'>
occupation, shoemaking, and his nationality, lower clas;
Italian, afforded every opportunity for continued and re
peated exposure to unhygienic conditions. He believed
that treatment with a wet dressing of aluminium acetate
would lead to speedy cure, and reported tw^o cases of a
similar condition, of eighteen months and two years
standing, respectively, the second of which had been diag-
nosed as tuberculosis cutis, both of which healed in six
weeks under that treatment.

Dr. DiLLiNGH.^M said that the case bore no resemblance
to epithelioma or to syphilis, and that he considered it
tuberculosis verrucosa cutis.

THE PRACTITIONERS' SOCIETY OF NEW YORK.

2oy th Regular Meeting, February 1. 1907.

The President, Dr. Robert Abbe, in the Ch.mr.

The Salt-Free Diet in Chronic Parenchymatous
Nephritis. — By Dr. (Ieorce L. Pe.\bodv. (See page 381. >

Dr. Beverley Robinson said he had read of a number
of persons who had been on a salt-free diet, and they did
not seem to like it on account of the lack of palatability
of the food. He a^ked Dr. Peabody whether any of the
cases he had reported had been followed up for any length
of time, and if so. how long the relief from symptoms had
lasted? The speaker saic, that in one case that had been
communicated to him, there had been marked improvement
under the salt-free diet, the patient's edema disappearin';;
almost entirely, and the amount of albumin in the urine
decreasing. This patient was an inmate of the Johns Hop
kins University Hospital, and in order to test the value of
the treatment one of the house staff gave him quite ;i
quantity of salt in the course of twenty-four hours. This
was followed by a rapid recurrence of the edema, and
death. In this general connection. Dr. Robinson said, he
wished to call attention to the important role that sal;
apparently played in the diet of certain animals, especially
cattle.

Dr. Lewis .-X. Conner said that while he was thus far
unable to speak regarding the permanency of the improve-
ment that had followed the use of a salt-free diet in
chronic parenchymatous nephritis, he was under the im-
pression that it afforded more than simple transient relief
.from discomfort. He was inclined to regard it as a method
of relieving the edema rather than the nephritis itself, but
certainly the results of the treatment in these discouraging
and almost hopeless cases had been very surprising. He

recalled particularly two patients in his hospital ward.
They occupied adjoining beds; both were suffering from
general anasarca and severe dyspnea, requiring frequent
tapping of the chests and abdomen, and for weeks every
possible method had been tried to relieve their water-
lugged condition. Then the salt-free diet was instituted,
and in both cases the anasarca rapidly disappeared; the
patients were up and about in a few days, and finally
left the hospital feeling well, although their urine still
showed evidences of the nephritis. Dr. Conner said that
m the cases he saw the patients were not at all disturbed
by the lack of salt in their food. While they perhaps
did not like it, they were perfectly willing to submit to
the treatment. The speaker said that colonic irrigations
of physiological salt solution, wliich had come to be re-
garded almost as a routine part of the treatment of
nephritis, were, he thought, contraindicated in these cases
of marked edema. Instead, a hypotonic salt solution should
be used, or, better still, the sodium bicarbonate solution to
which Dr. Peabody had referred.

Dr. Peabody, in reply to a question as to whether the
abstinence from salt in these cases implied a reduction
in the quantity of fluid taken, said that it usually coincided
u ith a restriction as to fluids. These patients, as a
rule, bore the restriction of fluids very well. In all of
die cases where the treatment had been tried, the albumin
ill the urine decreased in quantity, although it did not
.always completely disappear. No claim was made that
the treatment had any curative eft'ect on the kidneys ;
It had merely a transient effect upon a ^erous and dis-
tressing symptom.

Dr. Andrew H. Smith said we should have to accept
the conclusion that anasarca was due to some condition
of the tissues themselves, and not to the blood pressure
■ >r any condition of the blood or blood-vessels. There
was no reason for believing that under certain conditions
the fluid of the blood transuded more readily into the
tissues, but rather that there was something in the tissues
themselves that led to the accumulation of the fluid, and
perhaps the observations made by Dr. Peabody and others
supplied the necessary explanation for such phenomena.
If there was a quantity of salt distributed all through
the tissues, making them greedy for water, we had reason
enough for anasarca. The beneficial effects of the salt-
free diet also offered a very reasonable explanation of
the good results of a milk diet in the treatment of
certain nephritic manifestations. In confining a patient
to milk, he w'as practically given a salt-free diet.

Dr. Francis P. Kinnicutt said the results of the salt-
free diet treatment reported by Dr. Peabody were very
much in accord with those of Drs. Miller and Kelly, and
while they might not be permanent, they were at least
very desirable, as they relieved these patients of their
most distressing symptoms. Laboratory tests had shown
that in healthy individuals the sodium chloride balance
was easily maintained, even with very rapid and decided
variations in the sodium chlorido intake, and it had also
been shown that this balance was not maintained in
the presence of certain renal disturbance?. Lender the
latter conditions the salt accumulated in the tissues and
edema appeared. Dr. Kinnicutt said that if the salt-free
treatment aft'orded even temporary relief to this class of
patients it would be a great advance in our therapeutics.

Dr. H. Newton Heineman of Nauhcini, Germany, said
the effect of salt upon healthy cattle, to which Dr. Robin-
son had referred, would have no bearing upon its use in
pathological conditions, such as those that formed the basis
of Dr. Peabody's paper. The beneficial effects of the salt
free diet in the treatment of certain kidney lesions would
probably find their explanation along the lines indicated
by Dr. Andrew H. Smith, and outside of tlie blood-vessels
themselves. The weight factor and one that was fre-
quently lost sight of in connection with the facts of
this paper w-as the lymphatic pressure. While the con-

4iS

MEDICAL RECORD.

[March 9, 1907

ditiori of the capillary blood-vc^scls and circulation was,
of course, exceedingly important, and doubtless explained
many pathological conditions, we should not lose sight of
the fact that variations in the lymphatic pressure were
probably a most important factor in the immediate cause
of the exosmotic changes that the reader of the paper had
discussed. The speaker said he thought it not at all
unlikely that a good deal of our advance in medical
knowledge during the next decade would be made in con-
nection with changes in the lymphatic circulation, with
which the tissues dealt more immediately than they did
with the capillary circulation. The osmologists, of which
Zirkel was a brilliant exponent, were doing the work.
Studies by others, such as continued by him for three
years and not yet concluded on urinary cr>-oscopy, with
investigations of the urine freezing point, would certainly
advance renal pathological knowledge. Dr. Heineman said
that in the treatment of heart cases he was no longer
content with producing heart compensation, but tried to
bring about body compensation, which meant a proper
relation between the ebb and tide flow of the entire
circulating medium, of which the heart was an important
part, but still only a part. The results obtained by
Dr. Peabody by his salt-free method of treatment were
certainly excellent. In discussing the ultimate effect of
the treatment, the speaker said there was no question but
that even the temporary relief from pressure of a kidney
that was diseased would give that organ a chance to
recover itself. He had frequently seen examples of this
at Nauheim, where the albumin, with hyaline and even
slightly granular casts, would disappear from the urine
after proper regulation of the patient's diet and habits ;
this would ofttimes effect a proper regulation of the
circulation, without the necessity of resorting to treatmeni
directed toward the kidneys themselves, and he could recall
cases where it had prolonged life in the face of a very bad
prognosis.

Dr. Peabody, in closing, said there was no reason to
believe that salt-free diet in cases of chronic parenchyma-
tous nephritis had any permanent curative effect. On
the contrarj', there was every reason to believe that if
these patients resumed their usual occupations and habits
of diet, the anasarca would return. The most rational out-
look of the treatment was to ascertain in each individual
case how much salt that particular patient could take
without producing edema, and limit the intake to that
quantity. The probabilities were, however, that such a
fixed amount would not be permanent, because, as time
passed on, the kidneys would probably degenerate more
and more. Dr. Peabody said he had never seen a case of
chronic parenchymatous nephritis at any period of life
that fully recovered, and the most that could be hoped
from this method of treatment was to relieve the dis-
tressing symptoms of these patients, and perhaps render
them fairly comfortable and even give them a chance to
resume their occupations. There was no reason why
this treatment should not be maintained more or less
permanently, as the natural food contained a reasonable
amount of salt. Dr. Peabody said that in one of the
cases reported in his paper the patient was a boy whose
anasarca was very marked indeed. The edema involved
the genitals, and the face was swollen to such an extent
that the eves were nearlv closed. The anasarca disappeared
entirely in about two weeks under a salt-free diet. The
boy was then ordered a gram of salt daily, and there
was no recurrence of the edema. He was then given
two grams daily, and there was no recurrence. The dose
was then increased to three grams dailv. 'ind this was
followed by a gradual recurrence of :' This

experiment seemed to indicate that this ci..... ^, ,;'.J safely
take two grams of sodium chloride daily, but that he could
not tolerate beyond that limit, taking no account of the
salt which was present in his meat, milk, and other articles
of food.

Modern Hospital Construction — with Lantern Illus-
trations.— Dr. W. Oilman Tho.mi'son read a paper on
this subject, which he illustrated with numerous lantern
slide illustrations of hospital construction in this country
and abroad. He called attention to certain advantages of
the pavilion type of hospital, of which the Policlinico at
Rome and the new Virchow Hospital at Berlin were
good illustrations. They each were constructed of more
than fifty buildings, one or tw-o stories high, and while
this type of institution increased the original cost for
land, it promised a better classilication and grouping of
cases. Many of the modern hospitals that he had visited
in Europe were remarkable in their completeness, and in-
cluded eyery possible facility for the most advanced meth-
ods of investigation and treatment. Dr. Thompson said
the most encouraging advance in modern hospital con-
struction was that the interests of the individual patient
were considered paramount. It implied an intelligent
consideration of the needs of different groups of patients,
and an appreciation of the fact that fresh air and environ-
ment had to go hand in hand with medication in order to
obtain the best results. The entire subject could be
epitomized in the motto that appeared over the entrance
of one of the great German hospitals, namely, "In the
treatment of the disease, do not omit to treat the man."

College of Physicians of Philadelphia.

.\t a stated meeting, held February 6, Dr. John H. Mus-
SER read a paper entitled "Infections Within the Thorax —
Empyema." He dwelt on the relation of this disorder to
antecedent pneumonia and pleurisy, as well as to typhoid
fever, scarlet fever, measles, and other infectious diseases.
Its presence was to be suspected when the signs of a col-
lection of fluid of greater or lesser extent persisted after
the subsidence of the primary affection, especially if there
was a continuance, and particularly an exacerbation of the
leucocytosis that previously existed, or if such a leucocyto-
sis developed when previously there had been none. The
.r-ray might prove of service here by showing a shadow
that was to be referred to the purulent accumulation.
Often the physical signs were related to the fissures be-
tween the lobes, where collections of pus were prone to
form. In addition, there were likely to be chills, fever,
and sweating, with cough and pain, and emaciation. Ex-
ploratory puncture might fail to disclose the presence of
the pus, and often it was necessary to resect a rib, after
which the introduction of forceps or the finger would suc-
ceed in evacuating an abscess, while the establishment of
satisfactory drainage would lead to eventual recovery. Dr.
Theodor Schott of Bad Kauhcim read by invitation a
paper entitled "The Treatment of Chronic Diseases of the
Heart." He pointed out that adequate results were often
not obtained from the treatment of chronic diseases of the
heart by mere rest in the recumbent posture and proper
restriction of the diet, while the drugs commonly employed,
namely digitalis, strophanthus, strychnine, and the like,
while useful, were not curative. As a result, resort must
often be had to physical methods of treatment, such as
exercises of one sort or another, and bathing. Great care
must be taken in the employment of these measures, and
the needs of the individual case should be always fully con-
sidered. Dr. Schott described the various forms of thermal
and carbonated and saline baths available at Nauheim,
and also the form of gentle resistance exercises applied
in suitable cases. By means of charts he illustrated the
reduction in the size of dilated hearts observed in actual
cases as a result of both the baths and the exercises. In
his opinion, the favorable results of the treatment were
to be attributed especially to the tonic effects produced
upon the muscular system including the myocardium.
While it was to be preferred that the treatment should be
carried out under the most favorable conditions such as
were to be found at Bad Nauheim, it could also be carried

March 9, 1907]

MEDICAL RECORD.

419

out satisfactorily at the patient's home if appHed with in-
telligence and gentleness. An approximate artificial re-
production of the baths could be made by means of the
saline constituents prepared in such a form as to secure
the generation of carbon dioxide, and by adjustment of
the temperature and the proper proportions of the several
saline constituents of the natural waters.

Npw SftiHtrumftttH.

A SUCTION AND INSTILLATION SOUND,
FOR USE IN THE TREATMENT OF
CHRONIC POSTERIOR URETHRI-
TIS WITH INVOLVEMENT OF
THE PROSTATIC FOLLI-
CLES.*

Bv W. D. TRE.N'WITH, M.D..

NEW VORK.

GENITOURINARY SURGEO.N TO OUT-PATIENT DEPARTMENT, NEW VORK
HOSPITAL.

Cases of urethritis in which the prostatic urethra
has been involved, especially those where many of
the follicles have been infected and which have
become chronic, will offer in many instances a condi-
tion exceedingly difficult to overcome, necessitating
a long course of treatment, with the outcome prob-
lematical, and discouraging alike to patient and
physician.

Such a case will present but few subjective symp-
toms ; there is but little if any com-
plaint of pain or discomfort ; the urine
is mostly clear, but floating about in it
are numerous "tack-like" bodies, float-
ing with head down, the contents of
certain of the prostatic follicles, which
have been extracted or expressed dur-
ing micturition. If they are examined
under the microscope they may show
the presence of gonococci and pus
cells, or only pus cells, but if pus
cells alone are present it is probable
that, though gonococci cannot be
demonstrated, they are nevertheless lurking in the
depths of the follicles. There may also be present
shreds and threads, due to erosions, hyperplasias, or
catarrhal conditions of the posterior urethra, or to a
similar state of aft'airs in the anterior portion of the
canal.

The prostate is either normal in size, or some-
what enlarged, or boggy, indicating recent or com-
paratively recent inflammation.

The previous histon- of the case is that of an-
terior urethritis, with extension to the posterior
urethra, and with or without inflammation of the
prostate.

As to the treatment of these cases, the balsams do
no particular good; hand injections are not service-
able, except perhaps to help to eradicate a stibacute
or chronic anterior urethritis, which may exist at
the same time, because the injected fluid does not
reach the diseased area in the posterior urethra.
Benefit is derived from retrojections or irrigations
of silver nitrate and permanganate of potassium, or
instillations of solutions of picric acid, silver nitrate,
or sulphate of copper in varying strengths ; massage
of the prostate ; the passage of either warm or cold
sounds ; suppositories of ichthyol or ice ; rectal irri-
gation with hot or cold water ; general tonics.

^Presented before the Riverside Practitioners' Society,
November 13, and the West End Medical Society, Novem-
ber 24, 1906.

In spite of our efforts, however, progress is usu-
ally at best but very slow, and the reason for this is,
in my opinion, that our methods are faulty in this
respect, that in most of the treatments suggested
above not all of the infected follicles and diseased
areas are brought within the sphere of action of the
medicinal or mechanical measure used at each treat-
ment.

In massage, the follicles on the posterior wall of
the prostatic urethra only are acted upon, while
those on the anterior wall are in no way affected ;
when an instillation is used, because of the appo-
sition and folding together of the mucous meiu-
brane of the urethra, a good many infected follicles
and diseased areas must of necessity escape the med-
ication at a given treatment ; moreover, the medica-
tion will with difficulty penetrate to the depths of
the diseased follicles, and then probably only those
from which the contents have been expressed or
extracted during micturition : suppositories, rectal
irrigations, and tonics are measures which aid in
a general but not in a local way.

Of the methods suggested abo\ e the most good
follows the use of the sound, or retrojections and
irrigations, and the reason is plain, for in both
methods the luucous membrane is acted upon
throughout its whole extent, and consequently a
greater number of diseased follicles, erosions, and
hyperplasias are brought tmder treatment.

Because of these facts and as an aid in the treat-
ment of these cases, I have devised the instrument,

B

^»J=i

^^B ,

3 SIZE

of which a cut is here presented, and which was
made for me by the Kny-Scheerer Co.

The instrument consists of an outer shell (No. 25
of the French scale, in this particular one, but it
can be made in any size from 20 to 30) and two in-
ner tubes, D-I and B-J. Between the outer shell,
which has the shape of a sound, and the inner tube
D-I is a space, the only openings to which are the
fine holes indicated in the narrow but deep groove
at K, and through the nipple at F. The tube B-J
passing through the nipple at B, and the space be-
tween the outer shell and the tube D-I, ends by a
single small opening in the very narrow and deep
groove at J ; it is made of silver and is quite small.
The grooves at J and K are made very narrow and
deep, so that when the instrument is in place it will
be impossible for the mucous membrane to lie in
contact with the surface of the groove, but will
rather be stretched across it, leaving a small cavity
between the membrane and the bottom of the
groove.

When the instrument is in filace in the urethra
the air is exhausted from the rubber btilb H, and
E is firmly attached to the ni[)ple at F, the bulb
is then allowed to expand. A tendency to form a
vacuum is at once produced, a suction is ex-
erted on the mucous membrane covering the groove
K, and the contents of the follicles are drawn out
or at least loosened. The instrument is then slowly

420

MEDICAL RECORD.

[March 9, 1907

withdrawn, at the sann- time, A beins^ firmly
joined to the nipple B, any desired strength of sil-
ver, copper, or picric acid solution is instilled
through the tube B-J, by means of an instillation
svringe attached to the distal end of the rubber
tube A.

The fluid instilled will medicate the mucous mem-
brane covering the groove at J throughout its whole
extent ; moreover, the membrane being still on the
stretch, after the suction exerted upon it at K, and
the follicles being emptied, or, if not emptied, their
contents at least loosened, the mouths of the follicles
will still be open and the fluid instilled will penetrate
to a greater degree into them, and so attack the gon-
ococci which lie at the bottom of the follicle, or
act upon the loosened contents so that when next
the patient voids the contents of his bladder they
will be more readily washed out. Likewise any
ulcerated or denuded areas in the urethra are
stretched and the medication is applied to all por-
tions of the area.

If it is so desired, any solution thought to be
necessary can be introduced into the bladder through
the tube D-I, after the instrumenz is in place, and
before commencing to withdraw it ; the solution
can be prevented from escaping by joining C and
D and closing the distal end of C with either a pinch
or stop-cock.

An occasional patient with a small meatus will
complain of pain when the instrument is introduced,
as the grooves pass the meatus, otherwise patients
tell me in answer to my inquiries that they experi-
ence no more inconvenience or pain than is felt in
the passage of an ordinary sound of the same diam-
eter.

It is not claimed for this instrument that it is a
cure-all, or that it is suitable in every case, but only
that it is suitable in selected cases of the type which
has been described above, and that it is of consid-
erable aid and value when so used.

The points of value which this instrument pos-
sesses are in my opinion as follows :

I — The ability to inject into the bladder any de-
sired solution before beginning further treatment.

2 — The beneficial efifect produced by extracting or
loosening the contents of all of the diseased follicles
on both the anterior and the posterior wall of the
prostatic urethra.

3 — The medication of the mucous rrembrane
while it is on the stretch and the penetration of the
medicinal fluid into the follicles.

4 — The benefit to be derived from the passage of
a sound.

5 — The ability to use anv one or all of the pro-
cedures outlined above in but one manipulation of
the urethra.

147 West Seventh-second Streei.

Cysticercus Cellulosse in the Tongue of a Child.—
L. De Gaetano describes a rare case of cysjicercus cellu-
losae in tlie tongue of a child of ten years. The child had
associated with dogs and other animals, bnt there had been
no symptoms of tenia in the child or any other inembers
of the family. For two years there had been noticed a
nodule on the left side of the tongue, which latterly had
grown rapidly until it was the size of a large nut. It was
covered by normal mucous membrane, hard, and embedded
in the muscle of the organ. When enucleated it was found
to constitute a cystic tumor with a firm capsule, from
which on cutting there flowed a limpid liquid, and the in-
ternal surface was covered by a yellowish-white mem-
brane, at one portion of which was located a small white
mass, the egg of the tape-worm. The larva must have
reached the stomach or duodenum, wdien it was lib-
erated by the digestive juices and the animal must have
migrated to its permanent location by way of several other
organs. — Rivista di Clinica Pcdiairica.

iHrlitral Strms.

Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious disease reported to
the Sanitar>- Bureau, Health Department, New York
City, for the week ending March 2, 1907 :

Cases Deaths

Tuberculosis Pulmonalis .

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis .
Malarial Fever

418

192

326

51
6

297

17

4
86

—

41

9

51

7

14

12

Totals I 1538

294

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the Surgeon-General, Public Health and Marine-
Hospital Service, during the week ended March i, 1907:

SMALLPOX — UNITED STATES.

Caliiornia. Los -Ajigeles Feb. 2-9. . . .

Georgia. Augusta Feb. 12-19.. •

Illinois, Castleton Jan. 12

Chicago Feb. 16-23. . .

Galesburg Feb. 9-16 . . .

Jacksonville Jan. 11-15 . . .

Indiana. Elkhart Feb. 9-16. . .

CASES. DBATBS.

Indianapolis Feb. 10-17.

Lafayette Jan. 27-Feb. 4 .

Feb. 4-iS

South Bend Feb. 9-16

Vincennes Feb. 9-16

Iowa. Mahaska County. Oskaloosa

included May 2S-Feb. 2a

Kansas, Kansas City Feb. 9—16

Louisiana. New Orleans Feb.

Mississippi, Natchez Feb. -9-16..

.Missouri, St. Joseph Feb. 9-16..

St. Louis Feb. 9-16..

Xew York, New York Feb. 9-16 . .

Ohio. Cincinnati Feb. 16-22. .

Washington, Spokane Feb. 9-16. .

Wisconsin. La Crosse Feb. 9-16. .

Milwaukee Jan. 26-Feb

Feb. 9-16..

141
3 Imported

9-16 10 5 imp't'd.

3
30

SMALLPOX FOREIGN.

1-3 1.
2-IS-

.\irica, Lorenco Marquez Dec.

Brazil. Pemambuco Jan.

Canada. New Brunswick Feb.

Nova Scotia, Musquash — Glasgow. .Feb.

Truro Feb.

Chile, Coquimbo Jan.

Iquique Jan.

France, Paris Jan.

Great Britain, Bristol Jan.

India, Calcutta Jan.

Rangoon Jan.

Mexico, Vera Cruz Feb.

Netherlands, Rotterdam Feb.

Russia, Moscow Jan.

Odessa Jan.

St. Petersburg Feb.

Spain, Barcelona Jan.

Turkey in Asia. Beirut Jan.

9-16.
9—16.

12.

26-Feb 2.
26-Feb. 2.

S-19

S-12

2-9

2-0

26-Feb 2 .
19-Feb. 2 .
12-26

68
Present

Present

Present
Present

48
3

21—31

26-Feb. 2 .

6
Present

YELLOW FEVER.

Mexico. Veracruz Feb. 26 . —

Venezuela. La Guayra Jan. 9

West Indies, Trinidad, Port of

Spain Feb. 4-5- •

CHOLERA INSULAR.

Philippine Islands, Provinces Jan. 5-12.

CHOLERA FOREIGN.

Ceylon, Colombo Jan. 15-22.

India. Calcutta Feb. 2-19 .

Rangoon Jan. 2-12.

PLAGUE INSULAR.

Hawaii. Honohdu Jan. 29 , . . .

4

526

IS

I on S. S-
AmMartt.

PLAGUE FOREIGN.

.\ustralia, Brisbane Dec. 15-22

Chile, Antofagasta Jan. 12...

India. General Jan.

Bombay Jan.

Calcutta Jan.

Rangoon Jan.

Japan, Matsuyams Jan.

Csaka Jan

Peru, Callac Jan.

Catacaos Jan.

Chidayo Jan.

Lambaycoue Jan.

Paita Jan.

San Pedro Jan.

Tniiillo Jan.

5-12 I294S

15-22

5-19

10343
43
26
17

Present
Present

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 7J, No. n.
Whole No. J897.

New York, March i6, 1907.

$5.00 Per Annum.
Single Copies, JOc

©rigtnal Artirlrs.

THE OCULAR LESIONS OF GENERAL
ARTERIOSCLEROSIS.*

By WILBUR B. MARPLE. M.D.,

NEW YORK.

OPHTHALMIC SURGEON NEW YORK EYE AND EAR INFIRMARY; CONSULT-
ING OPHTHALMIC SURGEON BABIES' HOSPITAL.

The retinal changes in arteriosclerosis were re-
ferred to first by Hirschberg' twenty-five years ago
(his case showed white lines along the arteries, with
fine glistening points ) . But even before that Loring,
in 1873, Nettleship, in 1879, and others had pointed
out that in the development of circulatory disturb-

other words, that we have a phlebosclerosis as well
as an arteriosclerosis. Strictly speaking, therefore,
the term angiosclerosis would be the proper term
to use. Inasmuch, however, as in general the ar-
terial changes in the retina have the greater signifi-
cance in the diagnosis of general vascular changes,
I shall use the term "arteriosclerosis." These changes
are more apt to affect isolated retinal vessels, or a
short length of one of these while all the other
vessels may be normal. As Mr. George Coats says,
"nothing emerges more clearly from pathological
research than the fact that angiosclerotic processes
are almost always exceedingly irregular in their dis-
triljution."

Let us now consider in detail the various ophthal-

"■■■\

\

Fig. I.— (3, Silver wire arteries; fc. white lines along the vessel; c. tortuosity of the vascular twigs; (f. dilatations of vessels; f. constrictions of
vessels; ;, beading of artery; g, compression of a vein by the overlying artery; /i, h, liemorrages. All of the lesions shown in this illustration were
found in the hemiple!:;ia cases referred to below; same of them in many of the cases Several were sketched from these patients.

ances in the retina local changes in the vessel walls
played an important role. The investigation of
Thoma'-'' have shown that changes in the veins in-
variably accompany the changes in the arteries; in

*Read by invitation before the Medical Association of
the Greater City of New York, in a Symposium on "Gen-
eral Arteriosclerosis," January 21, 1907.

moscopic signs of arteriosclerosis. There may be :
(i) A general change in the size of the arteries
and veins of the eye-ground. The narrowing of
die arteries may be slight in the early stages, or
in marked cases it may be extreme, so much so as
to almost suggest atrophy of the optic nerve, espe-
cially if there should be any pallor of the disc,

422

MEDICAL RECORD.

[^^arch 1 6, 1907

The apparent diminution in size of the arteries ij
associated with chann^es in the coats which have
narrowed the blood stream. As the disease affects
some parts of the artery more than others, irregu-
larity in calil^er takes place, and this has been
found to characterize arteriosclerosis in other parts
of the body.

In contrast to the narrowing- of the arteries, the
veins often appear relatively dilated, and often are
actually so, this dilatation of the veins occurring
in about 50 per cent, of all cases. In sclerosis of the
aged, the veins are apt to be larger on the average
in the periphery than in the vicinity of the papilla,
and on the latter. Normall\- the arteries are about
two-thirds to three-fourths the size of the veins,
whereas in advanced cases of arteriosclerosis (for
example, in contracted kidney), they may be only
one-half to one-third the size of the veins. In addi-
tion to this narrowing of the arteries, there may
be a tortuosity of certain small arterial branches,
especially in the vicinitv of the macula. Often the
larger vessels from which these very tortuous
branches arise are themselves normal. These cork-
screw arterial twigs are apt to appear in the early
stages of the condition, for in the very advanced
cases, with pronounced ridigity of the vessels else-
where, there is apt to be no tortuo.sity.

(2) There may be changes in the color of the
arteries. That is, the central light streak of the
arteries is broader and of increased distinctness.
and the whole surface of the vessel is of a some-
what lighter color than normal, as if there was an
unusually bright reflection from it? coats. It is
usually the secondary and tertiary branches of the
central artery that are mainly affected. These are
the so-called "silver wire" arteries : and the appear-
ance is due to the higher reflecting power from the
arterial wall after it has undergone a hvaline or
fibroid change. (Fig. la. and all arteries in upper
half of figure; contrast with those of lower half.)

(3) There may be changes in the caliber of the
vessels at different points, and this is the most
characteristic phenomenon. The most common
point at which such change is noted is where a vein
is crossed by an artery (Fig. i^^). In the early
stages of arteriosclerosis, the first abnormality noted
is a loss of the light streak of the vein on either
side of the artery, with possibly a trifling diminu-
tion of the venous caliber under the artery. (Fig.
2b.) Often, also, a thickening and opacity of the
arterial walls is evident, inasmuch as the vein is
obscured where it passes under the artery, whereas
under normal conditions the underlying vein can be
detected through the translucent artery. An ar-
tery under a vein becomes visible on account of the
brighter reflex from its walls. In more advanced
cases the vein is very much constricted (Fig. 2a).
winds around the artery, and often the marked
twist is very conspicuous, as oftentimes the rest of
the vein is not at all tortuous. As Raehlmann" points
out, the venous narrowing is the result of a phlebo-
sclerosis, limited to this point, which may be caused
by the mechanical interference with the blood cur-
rent at the point of crossing of an artery, perhaps
by the walls of the latter. It is also probable that
the abnonnallv high tension of the arteries, which
in arteriosclerosis comes with the pulse wave, as-
sists in the compression of the vein under it. That
the vein is here compressed and the current hin-
dered is evident from the venous dilatation back of
the narrow part (see Figs, i and 2), as well as by
the frequent hemorrhages often seen exclusivelv in
the area of an obstructed vein. Sometimes when

a vein passes over a rigid artery, the former flat-
tens out somewhat like a strap. (Fig. 2c.)

As is well understood, the retinal vessels are sus-
pended in a completely transparent tissue, as is the
case nowhere else in the body, and this makes their
examination especially valuable to the clinician.
Under normal conditions the vessel wall is quite
invisible. Only the blood column is visible, and the
wall is recognized merely in the appearance of the
light reflex which is influenced by the form or curve
of the wall. The changes in the vascular walls in
ocular arteriosclerosis may be of two kinds, visible
and invisible. In the latter the vessel walls are still
transparent, but we detect tlie changes by the
alteration in the size and shape of the blood column.
Among the z-isible changes are white lines along
parts of some vessels (it may be for a considerable
distance), arteries or veins or both (Fig. lb).
Sometimes almost the whole diameter of a vessel is
changed into a white cord, and often glistening
points are seen along it. When this change is
limited to the branch of a vessel the diameter here is
greater than that of the normal part of the vessel.
This opacity of the vessel walls can be more readily
made out with a plane mirror and a weak illumina-
tion.

FiG- 2. — a. Marked pressure in late stages (this is from a patient seen
during the last week) , ^, slight pressure of the vein by the arter>*; c,
like appearance of the vein passing over the artery.

Besides these visible opaque changes in the ves-
sel walls, we meet with localized and marked nar-
rowing of the retinal arteries and veins, limited to a
short section of the vessel (called by Raehlmann,
"arteriosclerosis nodosa"), seldom equal in length
to the diameter of the optic nerve, more frequently
one-half or one-quarter this length ( Fig. le). Noth-
ing is seen of the markedly thickened vessel wall,
but the abnormally narrowed blood column points
to the thickening of the walls. There is, then, a
broad and a narrow part of the vessel, the latter
looking as though it were constricted by a band;
sometimes two broad parts are united by an ex-
tremely thin part, and in advanced cases the blood
column seems to be completely broken at certain
points. We may have circumscribed constrictions
of the blood column where the blood column is of a
very minute caliber or apparently disappears (Fig.
ic). As Raehlmann says, where such changes
limited to small portions of a vessel are seen ophthal-
moscopically, the diagnosis of a local vascular nar-
rowing by endarteritis can be positively made.

Sometimes the vessel presents knob-like irregu-
larities in caliber, like a string of beads (Fig. if).

As Mr. George Coats^ has recently pointed out in
a very suggestive paper on "Intraocular A ascular

!March ifi, 1907]

MEDICAL RECORD.

423

Disease," the pathology of these two changes in
the vascular walls is diiTerent. In the cases of
white lines along the vessels ("periarteritis"; "peri-
vasculitis"), we have a "fibrosis" in which the con-
nective tissue wall becomes greatly thickened, and
encroaches more or less concentrically on the lumen
of the vessels. The narrowing of the lumen, on the
other hand, which is indicated only by a narrowing
of the blood column, and not by any visible change
in the walls, is due to proliferation of the endothe-
lium, and this is almost always eccentric, the lumen
being occluded on one side. In one of Hertel's'
cases, fully half of the lumen of the central artery
on the disc, was occupied by such a proliferation
of endothelium springing from one side, as shown
in a section. As Coats points out, the two condi-
tions are probably due to different causes. Disease
(with proliferation) of the intima is most probably
a response to a circulating toxin, which would natur-
ally affect the internal coat ; thickening of the con-
nective tissue wall is probably a strengthening of
the wall to compensate for raised blood pressure.
As these changes tend to strengthen the wall, he
asks why does hemorrhage result? It would seem
probable that it does not occur at the actual seat
of disease, but the changes cause obstruction to the
circulation, damming back of the blood and rupture
at some spot where the wall is unthickened, or in
the capillaries where the wall is incapable of much
thickening. The result is a retinal hemorrhage.

While the "localized narrowing of the arteries" is
only indicated in many cases, by a "localized nar-
rowing of the blood column," there is little doubt
but that we have to do with an endothelial prolifera-
tion and thickening of the walls. Ouite a number
of such cases have now been examined anatomically,
where ophthalmoscopically the artery was very
much narrowed, and microscopically the vessel
showed proliferation of the endothelium. But, as
Mr. Coats says, our knowledge stands in need of
extension by more cases of the same kind worked
out vessel by vessel, with careful reference to the
clinical appearance.

Finally, we have aneurysmal dilatations or vari-
cose ectasia of vessels which may be oblong, oc
sac-shaped, and two to four times the normal cali-
ber (Fig. id). These are occasionally seen in the
arteries, more frequently in the vein. When seen
in the arteries, these dilatations are often seen on
the central side of a constriction, and have been
caused by the increase in blood pressure, due to the
proliferation ahead. In the veins they would be
on the peripheral side of a constriction for a similar
reason.

In addition to these vascular changes we have
the progressive venous pulse, described by Raehl-
mann among the first. This is visible, not only
in the central venous branches, but also in the
periphery of the fundus, and on all the larger
branches of the veins. Immediately after the ra-
dial pulse the diameter of the vessel becomes di-
lated quickly, to collapse slowly, the collapse occupy-
ing most of the interval between two pulsations.
In marked cases the vein when dilated is more than
twice as thick as when collapsed, and the fluctuation
in caliber can be followed in equal rhythm along
the w^hole course of the vessel. When this pro-
gressive venous pulse is conspicuously present, the
physiological venous pulse on the disc is absent.
This symptom is the expression of the pulse-wave
transmitted abnormally far into the rigid vessels of
the sclerosed arteries which act through the dis-
tended capillaries upon the veins.

As the result of these various changes in the ves-
sels themselves, we may have hemorrhages (Fig.
lA) and opacity or infiltration of the retina, espe-
cially in the vicinity of the macula. This superficial
whitish or greenish discoloration of the retina at the
posterior pole appears frequently where the small
vessels running from the papilla to the macula are
diseased. There is often just enough of this to pre-
vent a good fundus reflex, so that often we have to
use a mydriatic to make a satisfactory examination.
It is something like, though much less marked than,
the edema in embolism of the central artery of the
retina. Mr. Marcus Gunn'' suggests as an explana-
tion of this infiltration or retinal edema, that the in-
creased difliculty in arterial circulation w-ill diminish
the rapidity of the blood stream in the capillaries and
veins, resulting in a tendency to the escape of liquor
sanguinis into the surrounding tissues. The walk
of the capillaries become more permeable, and dia-
pedesis of blood cells takes place, and we get hemor-
rhages.

As Mr. George Coats says, it would seem prob-
able that hemorrhages do not occur at the actual
seat of disease, but the changes cause obstruction
to the circulation, damming back of the blood, and
rupture at some spot where the wall is unthickened,
or in the capillaries where the wall is incapable of
much thickening.

Liebrecht, Otto, and others have suggested that
not a few cases of atrophy, also, according to Bull,'"
many of the cases of so-called chronic simple glau-
coma are due to retrobulbar arteriosclerosis of the
internal carotid, ophthalmic, or anterior cerebral
arteries, which by pressure on the optic nerve pos-
terior to the foramen has caused the descending
atrophy.

Considering these various ocular evidences-"^ of
angiosclerosis, de Schweinitz''' in a recent valuable
paper makes a useful division of the lesions into
those which are suggestive and those which are
pathognomonic. In the former he includes uneven
caliber and undue tortuosity of the retinal arteries,
increased distinctness of the central light streak, an
unusually light color of the breadth of the artery.
The pathognomonic signs include changes in the
size and breadth of the retinal arteries of such char-
acter that a beaded appearance is produced, distinct
loss of translucency, decided lesions in the arterial
walls, consisting of white stripes in the form of
perivasculitis ; alternate contractions and dilatations
of the veins, and, most important of all, the indenta-
tion of the veins by the stiffened arteries. This lat-
ter symptom is recognized by all observers as the
one ocular symptom most nearly pathognomonic
of angiosclerosis. As Mr. Marcus Gunn says, how-
ever, it is only when several of these signs which
have been described are present together that we
can assert positively that the arterial change is very
important.

Age. — Angiosclerosis is not confined exclusively
to elderly people, for healthy-looking retinal vessels
are frequently seen in persons seventy or eighty
years of age. While tlie majority of cases are met
with in old subjects, occasionally it is seen in per-
sons under forty, or even thirty years of age, and
it has been seen in a patient under twenty. In the
]iresence of nephritis or syphilis, it can occur even
earlier. As Mr. Coats says, it is in part a senile
change, which we would expect to find in the vessels
of any old person, in part a definite response to a
pathological stimulus, and these two components
are not always clearly separable. Given the stimu-
lus, however, it may appear far in advance of the

424

MEDICAL RECORD.

[March i6, 1907

usual age as, for example, in juvenile nephritis. In
other words, the mechanical conditions of the blood
current only lead to the changes described when a
predisposition exists and the vessel wall is patho-
logically ready for the changes.

Vision. — The vascular changes may be very pro-
nounced in both arteries and veins without any evi-
dence of functional disturbances or defect in the
visual field. In one of Hertel's cases, examined
microscopically, the proHferation on the inner wall
of the central artery was so considerable as to oc-
clude fully one-half of the lumen of the vessel. Yet
the vision was 20/20. If considerable visual im-
pairment occurs, this is apt to come on suddenly ; it
may be from a hemorrhage at the posterior pole or
it may be from venous thrombosis. These cases of
venous thrombosis are especially prone to glaucoma
subsequently. Of sixteen cases of venous throm-
bosis examined microscopically by Mr. Coats, glau-
coma occurred in all sixteen. Sudden loss of vision
may come on also as the result of obstruction of the
central artery of the retina by endarteritis. These
cases were formerly thought to be due to embolism.
But we now know that many, perhaps most of them,
are the result of endarteritis obliterans accompany-
ing arteriosclerosis. (While this is undoubtedly
true, I am in thorough accord with Mr. Coats and
other English observers, who hold that our German
confreres go much too far when they affirm that
embolism of the central artery has never occurred.
Several cases which have been reported are un-
doubtedly of this nature.) Many of these cases
have had prodromal obscurations of vision, possibly
for many years, before the final loss of sight. These
obscurations often come from cardiac weakness, and
in many cases are reparable, temporarily at least,
by cardiac stimulants. Wagenmann" reported an
interesting case of arteriosclerosis (with large veins,
white lines along the arteries, and hard radials) , who
had suiTered from prodromal obscurations for a long
time. Wagenmann saw the patient during a sud-
den attack of complete blindness lasting a half hour
or more. The arteries were invisible except near
the disc (that is empty), and the veins reduced to
fine lines, and there was opacity of the retina, with
a red spot at the macula, as in embolism. Gradu-
ally the circulation returned, with restoration of
vision.

These cases of ischemia and temporary blind-
ness, due to vascular spasm in association with
arteriosclerosis, have been occasionally reported by
others, and have been benefited by nitrite of amyl.

Location of the Lesions. — The central vessels,
those nearer the optic nerve, are the most apt to be
affected, possibly, as Raehlmann suggests, because
it is easier to discover the changes in vessels of a
larger diameter. But Hertel's anatomical investiga-
tions have demonstrated a more marked involvement
of the vesesis in the central portions. While the pro-
liferation of the intima may occur where there is no
nearby bifurcation, yet it is in the vicinity of such
bifurcations, especially where they branch almost at
right angles to one another, that they are most fre-
quently met with.

Frequency ztnth which Ocular Lesions,are Found
in General Arteriosclerosis. — Raehlmann examined
210 cases of arteriosclerosis, and found aneurysmal
dilatations in only two cases. In almost 50 per cent.
of the cases he observed either whitish borders to
some of the vessels (20 per cent.) or aneurj'smal
dilatations, or local narrowing of the caliber (21
per cent.). Hirschberg^ examined fifty persons, be-
tween the ages of sixty and eightv years, and found

that 46 per cent, of the persons examined showed
changes in the retinal arteries (44 per cent, showed
changes in the caliber of the arteries at some points
of their course) ; 2 per cent, showed white lines
along the vessels. FriedenwakP examined twenty-
three patients for Preston, and he reached conclu-
sions practically the same. And yet, in our text-
books on diseases of the eye it is very unusual to
find any reference to this important subject.

The writer has been much interested in the result
of an examination which he recently made of forty-
six patients, most of them suft'ering froiu hemi-
plegia, a few from paraplegia. In such a class of
cases it would be fair to supix)se that the condition
had been attended with arteriosclerosis of the cere-
bral vessels. Of the forty-six patients, six had such
considerable lens changes as to make a satisfactory
examination of the fundus impossible. Of the re-
maining forty (of whom the oldest was seventy-four
and the youngest forty-one), sixteen, or 40 per cent.
showed pressure of the veins by the arteries, often to
a very marked degree. Twelve, or 30 per cent.,
showed this same symptom associated with local
constrictions or varicosities of the vessels. Peri-
vasculitis was seen twice (5 per cent.) and beading
of the vessels twice (5 per cent.), so that out of
forty such cases, pathognomonic ocular symptoms
of arteriosclerosis were discovered in thirty-three
cases, or 83 per cent. In seven cases (or 17 per
cent.) the suggestive symptoms alone were found,
viz., dilated veins and small, brilliant arteries. But
in all of these the symptoms were most suggestive ;
that is, the veins were very much dilated and the
reflex from the arteries was most brilliant. In a
number of cases the lesions were almost as numer-
ous in one and the same individual as is represented
in Fig. I, and the opthalmoscopic pictures were
often exquisite. Yet not many of them could have
been recognized in the indirect method. In not one
case (though I looked very carefully for it) could
I discover Raehlmann's symptom of progressive
venous pulse, and I am not positive that I have ever
seen it in any case, and yet Raehlmann states that
it occurs in 50 per cent, of the cases of arterio-
sclerosis.

Se.v. — As is true elsewhere in the body, these
retinal changes of angiosclerosis occur more fre-
quently in males than in females.

Limitations. — In the first place, the mistake must
not be made of attributing all vascular changes
found in the retina to angiosclerosis, for frequently
such are of a local character. On the other hand,
it would be equally a mistake to consider the ab-
sence of ophthalmoscopic evidence of retinal changes
as positive proof that arteriosclerosis was not pres-
ent in the eye or elsewhere in the body. For we
know how irregular in its distribution arteriosclero-
sis is, and, furthermore, Hertel examined a large
number of old people in whom no abnormality was
visible, with the ophthalmoscope; and nevertheless
the changes of arteriosclerosis could be demon-
strated microscopically in a considerable number of
these.

SignHicance of these Changes. — So far as the eye
is concerned, we find that glaucoma occurs very
frequently in this condition of arteriosclerosis. It
must be remembered that if acute glaucoma occurs
in an eye in which the retinal changes of arterio-
sclerosis are present, a very guarded prognosis must
be given in case of iridectomy is done. For often
the condition of the vessels is such that intraocular
hemorrhage follows operation, resulting in the loss
of the eve. But these retinal changes become very

March i6, 1907]

MEDICAL RECORD.

425

much more significant from the assistance they ren-
der us in diagnosing a serious general condition, it
may be before it has been suspected by the general
physician. It is very well understood to-day that the
diagnosis of many cases of nephritis is first made
by the oculist, often at a time when the patient may
not have shown any other evidence of the disease.
Here the renal condition is an angiosclerosis, and.
as Michel first demonstrated, the retinal changes are
also due to vascular degeneration. But it is not
alone in renal disease, but also in general arterio-
sclerosis that the ophthalmoscope gives us valuable
information, for here alone are the minute capil-
laries of the body visible. (The largest retinal ves-
sel has a diameter of not more than i-ioo of an
inch.) General arteriosclerosis affects the internal
carotid very frequently, and is very apt to involve
its principal branches, and among these the ophthal-
mic and cerebral arteries. If these degenerative
processes can be demonstrated in the retina, it is
very probable that the same disease is present in the
cerebral vessels. Of forty-four cases of Raehlmaim,
there was subsequent cerebral hemorrhage in ten.
or 21 per cent. Mr. Marcus Gunn, in a valuable
paper, reported fourteen cases of intraocular vas-
cular disease, in which cerebral hemorrhage subse-
quently occurred, and we have all of us met with
many similar cases. It is with these patients that the
responsibility of the oculist becomes very great,
for it is manifest, as de Schweinitz points out, that
he has an important duty to perform in connection
with them. For if evidence of beginning arterial
degeneration is discovered ophthalnioscopicallx'
(very often such discovery is made accidentally, it
may be, in examining a patient for glasses), the
matter should be brought to the attention of the
patient's medical adviser, so that a careful investiga-
tion of the arterial tension and of the renal condi-
tion may be made. Thus, oftentimes proper treat-
ment can be applied with the greatest benefit, and
possiblv an impending catastrophe be averted or
postponed. It cannot be too strongly emphasized
that examination of our middle-aged patients for
glasses should not be done in a perfunctory manner.
We should investigate not only the optical needs of
all such patients, but of equal, if not greater im-
portance, is it that we investigate most carefully the
condition of the retinal vessels, and ascertain
whether or not there are present any ocular evi-
dences of arteriosclerosis.

The narrowing of vessels over a short course,
possibly limited to a part of the optic nerve, is not
easily discovered, and can readily escape our notice
unless looked for very carefully. The indirect
image cannot be used, and even with the upright
image it often requires an expert observer to recog-
nize the differences in caliber, which are not infre-
quently the only evidence of the changes, and not
seldom must a mydriatic be used. As Raehlmann
says, "when sclerosis of the retinal vessels is sus-
pected, it is necessary, in order not to overlook the
changes, to carefully examine each separate vessel,
especially in its central course." If every oculist
searches for these changes in all his patients he will
find some of these in an increasing percentage of his
cases.

In conclusion, we may say, with Mr. Gunn, that
"ophthalmoscopic examination is one of the most
ready means for the early detection of important
arterial changes." The method of examination is
infinitely more delicate than palpation of the radial
or temporal arteries through the skin. We are
thus able to diagnose with great probability bv the

ophthalmoscope a vascular disease which is at the
bottom of many cerebral disease processes, often
threatening the patient's life. Inasmuch as the vas-
cular change very frequently is limited to the inter-
nal carotid and its branches, we are therefore some-
times able to diagnose the dangerous affection of
the cerebral vessels with the ophthalmoscope when
the rest of the vascular system does not show the

disease.

LITERATURE.

1. Hirschberg: Centralbl. f'r prakt. Augenh., 1882, p.
329; 1890, p. 322.

2. Raehlmann: Zeitschrift f. klin. Med., 1899, p. 606;
Zeitschrift f. Augenh., 1902, p. 425.

3. Geo. Coats : "Intraocular Vascular Disease," Ophthal-
moscope, 1906, p. 605.

4. Hertel : Beitrage ziir Kenntniss der Angiosklerose der
Centralgefasse des Auges. Arch. f. Ophthal, LII, p. 191.

5. Preston and Friedenwald : Jour. Am. Med. Asso.,
May 21, 1891.

6. Friedenwald: Ibid.. 1896.

7. Idem: Archives of Ophthalmology, XXV, No. 2.

8. Idem: Centbl. f. prakt. Augenh, 1896, Februarj-.

9. Marcus Gunn: Transac. Oph. Soc'y, United Kingdom,
1898, p. 356.

10. Bull : Medical Record, December 5. 1903.

11. Idem: A)ina\s of Ophthalmology, January, 1904.

12. .A.lleman: Amcr. Medicine. February 20, 1904. p. 304.

304.

87

13. Idem: Annals of Ophthalmology, January, 1904.

14. de Schweinitz : Trans. Amer. Oph. Society, 1906, p.

15. Thoma: Virchow's Archiv, Vol CIV, etc.

16. Wagenmann: Arch. f. Ophthal, XLIV, p. 219.

SOME REMARKS ON THE R.ADICAL MAS-
TOID OPERATION FOR THE CURE
OF CHRONIC SUPPURATION
OF THE MIDDLE EAR.*

By SEY.MOUR OPPENHEIMER, M.D.,

NEW YORK.

OTOLOGIST TO GOUVERNEUR HOSPITAL, LARYNGOLOGIST AND OTOLOGIST
TO THE SYDENHAM HOSPITAL AND TO MT. SINAI HOSPITAL DISPEN-
SARY; FELLOW OP THE AMERICAN LARYNGOLOGICAL, RHINO-
LOGICAL, AND OTOLOGICAL SOCIETY, FELLOW OP THE NEW
YORK ACADEMY OP MEDICINE.

To determine when a radical operation should be
performed for the cure of a suppurating middle
ear which has continued for a longer or shorter
period, is undoubtedly one of the most serious prob-
lems with which the otologist is confronted, for not
onlv is the question complicated in many ways, but
the difficulty of convincing the patient that such
an operation is essential, when he is conscious of
possibly only a slight aural discharge, not infre-
quently results in failure and serious if not fatal
complications may ensue.

In the selection of cases for the radical operation,
it has well been said that a large experience, rather
than any rigid rules, is the best safeguard against
the risk of delay, or of performing an unnecessary
operation. That this statement is essentially true
may be admitted, for while general indications may
be formulated, yet each case must be judged upon
its individual merits and the particular treatment
in that case carried out accordingly. The radical
operation, therefore, must be accepted or rejected
upon the merits of the individual case, based neces-
sarily upon broad general rules that bear a more or
less close application to ever>- case of chronic sup-
purative otitis, but it may be safely said_ that it
should be resorted to in almost all cases which can-
not be cured by measures less radical in nature.

While formerly intratympanic operations of va-
rious sorts were much in vogue for the treatment

*Read at a meeting of the Harlem Medical Association,
T.iniiary 2, 1907.

426

MEDICAL RECORD.

[March i6, 1907

of this condition and yet have a definite field of
applicabihty, it is undoubtedly more and more be-
ing recognized that in many cases such measures
must fail on account of the inability to remove in
this way all the morbid tissue and the remaining
nidus of disease is a further focus of infection
keeping up the suppuration. While in this con-
dition, therefore, the various intratympanic pro-
cedures formerly vaunted have steadily lost ground
as curative measures, yet in probably the majority
of cases of chronic tympanic suppuration they are
undoubtedly indicated and even to the most ardent
advocate of the radical operation it must not be
lost sight of that not infrequently in suitable cases
local antiseptic and surgical treatment, such as the
removal of granulation tissue, polypi, circumscribed
areas or carious or necrotic bone and the extrac-
tion of the carious malleus and incus, produce a
cessation of the suppuration.

Many instances of this aural affection are encoun-
tered in which, except for an irregular amount of
purulent discharge from the ear, pursue a practi-
cally symptomless course for many years, and yet
when such cases have been operated on for various
reasons, after the course of years, it has been found
almost without exception that the tvmpanic cavity
is not alone afifected, but that even more serious
morbid changes have taken place in the antrum and
mastoid cells, and that these changes, including de-
struction of large bony areas, have been progress-
ing without the patient or even the physician hav-
ing the least knowledge that such was the case. In
other instances the discharge disappears after a
longer or shorter period of treatment through the
auditory canal and may remain absent for a very
long time, to again return following infection
through the Eustachian tube from a coryza, or often
the recurrence cannot be traced at the time to any
direct source. It is in these recurrent cases, with
temporary cessation of purulent discharge, that one
is most apt to be deceived as to the measures to be
adopted, and also as to the pathological changes
that are taking place, for in many instances of this
type the patient believes that his disease is cured
when the discharge disappears, while as an actual
fact the condition is only temporarily in abeyance
and active morbid changes are apt to become promi-
nent at any moment.

The question as to the necessity of performing
a radical operation for the cure of aural suppura-
tion in the absence of active complicating symp-
toms is more and more becoming answered in the
affirmative, as this operation is undoubtedly the
safest and most efficient method of eradicating such
a condition and with proper aseptic precautions and
technique it is not dangerous to life, and in the ma-
jority of cases operated upon the results are entirely
satisfactory. The more the pathology of aural
suppuration is appreciated the more will active, rad-
ical measures be instituted early and necessarily the
less will cases of so-called incurable chronic tym-
panic suppuration be encountered. And for the
same reasons experience has shown that with a
greater number of cases operated upon the more
clearly difYerentiated becomes the indications and
the more clearly is shown its practical value.

In order to obtain the desired result from this
operation certain objects must be attained, the most
important being that all diseased tissue of whatever
nature, w-hether osseous or otherwise, be thoroughly
removed, for unless this is done a recurrence may be
always expected. .\ most important object, and one
which intratympanic operative procedures do not as

a rule accomplish, is the securing of free and per-
manent drainage. Of less importance, but still of
sufficient gravity to the patient, is the retention of
such hearing as may remain, and while this is but
a subsidiary object, yet in most instances the radical
operation conserves or even improves the auditory
perception. In addition one should always bear
in mind the great indications for the radical opera-
tion is the relief of a serious menace, not only to the
health of the individual but also to his life. To ob-
tain successful results, therefore, with certain and
rapid healing, it is essential that the diseased areas
be eliminated and that the tympanum, antrum, and
mastoid cells be converted into a single cavity, with
smooth walls, in which there are no recesses, so that
every part is readily accessible from the enlarged
auditory canal.

The advantages of this operation over other pro-
cedures in chronic tympanic suppuration cannot be
overestimated, as in the larger proportion of cases
it admits of the complete and permanent cure of the
aural disease, while in such cases where for various
reasons success has not been complete at least all
th^ parts are exposed to view and full opportunity
offered to locate and later eradicate any diseased
areas which might have escaped observation at the
time of the primary operation, or which have de-
veloped subsequently. The conditions are made
such that asepsis can also be maintained to a much
greater degree than would be possible in any other
manner, and as the result of the removal of pyo-
genic tissues from the vicinity of dangerous points
the healthy osseous tissue remaining forms an ef-
ficient barrier against any danger of an extension
of the infection to the intracranial structures.

While in general the indications for the radical
operation are sufficiently clear, it is impossible to
lay down guiding rules for all cases ; yet by care-
fuj differentiation the advisability of operation can
usually be determined, and it is desired here to in-
dicate as far as possible such rules as may be of
value for this purpose. Undoubtedly the indications
as_ enunciated by Politzer form the basis of this
subject at the present time, and these may be di-
vided into two main groups, the objective and the
subjective. Of the former which indicate operative
procedures in order to cure the suppurative process
present, marked caries of the tympanic w-alls,
the recurrence of granulation tissue and polypi after
its removal in the vicinitv of the aditus. the presence
of fistula in the mastoid cortex and marked chole-
steatomata are to be cited, while hyperostosis of the
external auditory canal, facial paralysis or paresis,
and well marked symptoms of acute mastoiditis, are
also not compatible with local treatment through
the canal. In addition, also indicating operation,
are those cases with prolonged fetid suppuration
resisting less radical measures, and especially is this
called for if there is a perforation in the superior
segment of the membrana tympani, or if the rem-
nants of the membrana are adherent to the inner
tympanic wall, and still more is operation indicated
if pus or epithelial masses can be draw-n from the
region of the aditus. Symptoms of intracranial
complications are. of course, of sufficient warrant
for radical operative procedures, irrespective of
other signs.

Of the subjective symptoms indicating operation
associated with more or less of the former manifes-
tations the following may be considered in this con-
nection : Persistent pain in the ear or in the mas-
toid region, especially if increased by percussion
and if involving the occipital or parietal regions;

Marcii !<■). 1907'

MEDICAL RECORD.

427

permanent or intermittent vertigo and cerebral
symptoms such as headaciie, torpor, etc.

In many p>atients with clironic otorrhea the ques-
tion of immediate operation, or the advisabihty of
delay for a shorter or longer time, will often prove
most puzzling, but in those cases where there is a
reinfection, or the chronic suppuration undergoes a
period of activity with more or less rapid extension
of the pathological process, then it is necessary that
the radical operation be promptly performed. In
the presence of any of the usual grave complica-
tions, one should never delay removing the focus
of the disease and at the same time the measures
adopted should be of sufficient extent as to remove
the possibility of further suppuration. Debatable
and open to question as regards the performance
of an immediate operation are those cases where the
patient suffers little or no pain and when no symp-
toms of mastoid changes are apparent, but even in
such individuals it must be recognized that serious
changes may be in progress and yet not be appar-
ent, so that if the osseus lesion is at all extensive it
is always proper to err on the side of safety and re-
move all the diseased tissue by a radical operation,
rather than adopt tentative and so-called conserva-
tive measures which in no wise will eradicate the
disease. In this connection it must always be re-
membered that the attic, aditus. and antrum, which
in many instances bear the brunt of the purulent in-
flammation, are an essential portion of the tympanic
cavity and as a result of their anatomic relationship
bear a large share in all the infectious changes that
take place in the latter.

Stetter believes that the radical operation is in-
dicated when there is marked dizziness, with dis-
turbance of gait, and when there is nausea and
vomiting, while as far as local symptoms are in-
dicative of such a procedure the duration of the dis-
ease should be seriously considered, as should also
the condition of the posterior aural region, the fre-
quency of attacks of pain, the presence or absence
of facial paralysis, and the nature and quantity of
the purulent discharge. Jackson advocates this pro-
cedure in the absence of mastoid symptoms, when
the suppuration has failed to yield in three months
after ossiculectomy, followed by the so-called wick
treatment, Milligan believing that operation should
be performed when the suppuration has persisted
for one year, and when for at least three months
careful and rational local treatment has been em-
ployed without infliiencing the course of the sup-
puration. This difficult problem is elucidated by
Macewen in a satisfactory manner, when he states
that when a pyogenic lesion exists in the middle ear
or in adnexa, which is either not accessible, or can-
not be effectually eradicated through the external
auditory canal, the mastoid cells and antrum ought
to be opened.

While operation is undoubtedly necessary when
symptoms of septicemia have commenced, or where
there is dead or carious bone in the tympanic cavity
in whatever location that may be and accompanied
by repeated attacks of serious symptoms, or when
there is evidence of involvement of the mastoid
structure either of long or short duration, vet there
is a large class of cases of aural suppuration in
which these symptoms are absent, but in which I
believe this operation is also indicated in order to
obtain a complete cessation of the purulent dis-
charge. In this group belong those cases in which
one obtains certain evidence of the presence of dead
or seriously diseased bone in the attic or other
portions of the middle ear. hut is unable to obtain

a clear history of symptoms that would indicate se-
rious outbreaks in the past. While in the other
class, which comprises those with persistent otor-
rhea, but in whom manipulation through the canal
does not furnish satisfactory evidence of osseous
lesions and one obtains a fairly clear history of the
absence of any intercurrent exacerbations, it may be
difficult to always decide that the indications war-
rant radical operation, but as a rule in selected cases
of this class a permanent cessation of the discharge
cannot be obtained in any other manner.

When the symptoms are but slight, whether ob-
jective, or subjective, or combined, one must not
only be guided in solving this question by the aural
symptoms alone, but it is always the wisest plan
to carefully study and weigh the general condition
of the individual and also his social relations. In
individuals in whom the aural suppuration gives
evidences of a tuberculous basis, or in those in
whom the otorrhea pursues an asthenic course al-
most from its inception, prolonged local treatment
through the canal, or delay in waiting for active
symptoms to arise so that clear indications for oper-
ation may be obtained, is always advisable; these
cases are especially liable to have extensive osseous
lesions, and it is always the best policy to operate
early, not only to cure the suppuration, but also to
avoid the development of serious complications.

^^'hen the secretion from the middle ear contains
cholesteatomatous masses and from time to time
these block the perforation in the membrana tym-
pani, or produce symptoms of pus retention higher
up in the aditus or antrum, it is clearly established
that little success can be obtained by measures, oper-
ative or otherwise, carried out through the external
canal, as the morbid changes are either too extensive
or the pathogenic areas are inaccessible portions. It
has been repeatedly shown that the proliferating
epithelial masses are not only derived from the cov-
ering of the osseous surfaces, but that thev prolifer-
ate and penetrate for some distance into the structure
of the bone and can only be completely eradi-
cated by removing this upper layer of osseous tissue,
so that the radical operation alone can be relied
upon to give complete access to all diseased parts.

In the absence of symptoms other than that of a
persistent otorrhea associated with more or less
foul odor, one must be guided in deciding upon
operation by the fact that continuous treatment has
not diminished or abolished the discharge, and not
by the nature of the discharge, its quality, or quan-
tity, or by the odor, it being a well-known fact that
the virulency of an otorrhea cannot always be
judged by the amount of the discharge or its odor,
although in the presence of a profuse, continuous
discharge one is warranted in opening the mastoid.
In those cases where the odor is persistent and
not at all, or but little, altered by treatment through
the canal, radical operation is undoubtedly war-
ranted, as the continuous presence of such an odor
implies that there is decomposing pus being re-
tained in inaccessible parts, or that carious bone is
present.

There are certain exceptions to the perform-
ance of the radical operation when otherwise indi-
cated for the cure of a suppurating otitis in the
absence of marked symptoms which should always
be heeded and the treatment of the diseased ear
conducted accordingly. It is absolutely contraindi-
cated in advanced cases of pulmonary tuberculosis,
or when other serious organic diseases are present,
while in the very aged individual, where the dis-
charge has lasted for a long time without apparent

420

MEDICAL RECORD.

[March i6. 1907

inconvenience, it is perfectly reasonable that such
surgical intervention should not be considered.

That the operation is not without danger, even
in the otherwise healthy individual, cannot be gain-
said in all instances, as it is a trying surgical pro-
cedure. It incapacitates the individual often for
long periods of time ; there can be no surety that
the hearing will improve following it, and even with
the operation apparently carefully performed the
purulent discharge may still continue owing to a
progressive osteomyelitic process taking place. A
negative danger may be mentioned and that of not
having all the diseased tissue thoroughly removed,
or the operation being incompletely performed.
Paralysis may follow injury to the facial nerve, or
the semicircular canal may be injured, with its train
of serious consequences. One should guard against
unavoidably opening the lateral sinus, or exposing
the middle cerebral fossa, and particularly against
injury or removal of the stapes and thus exposing
the internal ear to the dangers of serious infection.
With all this, however, the danger is not as great
to the patient as the presence of a continual focus
of suppuration in the temporal bone, and one is per-
fectly justified in saying that the "danger lies not
in the operation, but rather in its neglect."

That failure is unavoidable in some cases must
be granted from the nature of the pathological
changes present, but even if a small proportion are
not completely relieved of the discharge, and the
operation fails to produce a permanently dry and
epidermized cavity, the patient undoubtedly is in
a much safer position than before, as all foci and
recesses where purulent material may develop have
been eradicated. The concealed parts, which be-
fore operation were not accessible, or were in part
difificult of access, have been fully exposed and are
rendered capable of being accurately treated under
the sight of the otologist.

In the absence of acute symptoms or complica-
tions where the radical operation is advised for the
cure of the persistent suppuration, the question of
the effect upon the hearing will strongly influence
the action of the patient. Where tests show that
the hearing is already seriously impaired and the
labyrinth is involved, nothing will be gained as far
as the hearing is concerned by this operation, but
where the inner ear is normal and the patient can
hear ordinary conversation fairlv well, the majority
of cases operated upon show no further impairment
of auditory acuity, but rather an improvement. A
small number of individuals will, however, suffer
from still greater impairment following the opera-
tion, but practically this should receive little con-
sideration, as the elimination of the suppuration and
of the dangers to health and life which exist even in
the uncomplicated case far outweigh the further im-
pairment of what is in the majority of such cases an
already impaired hearing.

While it is not desired here to discuss the opera-
tive procedure- itself in any way, yet certain tech-
nical difficulties present themselves that must be
overcome before successful results can be obtained,
and it will be well to briefly mention these. The
most important of these is the difficulty of cleansing
the newlv formed cavity of all diseased tissue, for
unless this is done thoroughly the future outcome is
seriously jeopardized, so that in performing this
operation one should be especiallv careful to elim-
inate all suspected areas of caries or necrosis, rather
than to take the chance of a recurrence by allow-
ing a suspicious area to remain. Of these particu-
lar areas where carious tissue is apt to be over-

looked, it is important to see that the outer wall
of the attic is thoroughly removed, as at this point
a carious process of the osseous tissue is very fre-
quently found. Not only must the tympanic cavity,
aditus, antrum, and mastoid cells be converted into
one chamber, but the posterior and superior walls
of the external auditory canal must be removed to
accomplish this thoroughly, and in addition the rem-
nants of the tympanic membrane, with the malleus
and incus if still present, must be entirely taken
away. In some cases it is especially important to
open up and remove groups of pneumatic cells sit-
uated in various locations not usually considered to
be involved, and of these the posterior group of
mastoid cells should be especially explored. It is
also highly important that the cell, or group of
cells, at the tip of the mastoid process be eliminated,
as in many cases of chronic suppurative otitis with-
out mastoid symptoms at any time it will be found
on operation that a focus of diseased tissue, or
confined pus, exists at this location.

Thus will the operative field depend entirely
upon the condition of the mastoid tissues, as in
practically every case of long standing otorrhea the
mastoid will be found involved to a greater or
lesser degree, and to this point, therefore, should
the operation be primarily directed. As a result
of constantly carrying out an extremely radical
principle in operating it has been found time and
again, in the absence of serious local symptoms,
and often when the patient is apparently in perfect
health, that grave and extensive destruction has
been going on in the osseous interior, even to the
extent of exposing the intracranial structures, so
that the operation has clearly shown that one does
not always appreciate the danger in which these pa-
tients stand until the parts are exposed to view.

45 East Sixtieth Street.

THE ABORTIVE TREATMENT OF PNEU-
MONIA.

By G. LENOX CURTIS. .M.D..

KEW YORK.

.MEMBER OP THE AMERICAN MEDICAL ASSOCIATION ; AMERICAN ELEC-
TROTHERAPEUTIC ASSOCIATION; AMERICAN ASSOCIATION FOR THE
'ADVANCEMENT OF SCIENCE; NEW YORK STATE MEDICAL AS-
SOCIATION; MEDICAL ASSOCIATION OF THE GREATER CITY
OF NEW YORK; HARLEM MEDICAL ASSOCIATION, THE
SOCIETY OF SOCIAL AND MORAL PROPHYLAXIS.

For the reason that, in the language of another, "the
divisions of the various diseases of the lungs have
not been finally settled," and because, for the sake
of diagnostic accuracy, many different forms of
pneumonia are recognized and described, I wish it to
be understood that the statements contained in this
-paper refer to and include anv pneumonic disease,
either acute or chronic, which is characterized by
exudation into the alveoli and bronchioles, and which
results in consolidation and uselessness of the af-
fected area.

Like every other disease, pneumonia is the result
of two kinds of causes : the exciting or accidental,
as exposure to changes of temperature or to at-
mospheric conditions ; and the predisposing, essen-
tial, or specific which consists of vitiated secretions,
with their accompanying germs and defective elim-
ination. Von Jiirgensen, in speaking of croupous
pneumonia, says, "It is a general and not a local dis-
ease, the inflammation of the lungs being the prin-
cipal symptom."

Another authority, who evidently believes the
specific cause to be a germ or its secretions, says :
"If it were possible to prevent the entrance of the
pneumococci into the alveoli of the lungs, pneumonia

March i6, 1907]

MEDICAL RECORD.

4-'9

would be impossible," and regretfully states that any
method of preventing such an occurrence is un-
known.

To combat and remove this latter class of causes is
the chief therapeutic problem, and the success which
attends this effort is the measure of the physician's
skill and usefulness. That, taking the profession as
a whole, our failures equal if they do not exceed
our successes, is a sad commentary upon prevailing
methods of treatment. The mortality of pneumonia
under any mode of treatment which, to-day, is up-
held by the sanction of authority, is appalling ; but,
to me, no more so than the satisfied indifference
with which the majority of the profession pursue,
year after year, lines of treatment which statistics
prove to be, at best, but little better than pure ex-
pectancy.

Why are these unworthy and unreliable methods
complacentlv persisted in when it is so painfully
evident that they are wrong, and that greater success
is impossible unless means of a radically different
character are employed ? In no other line of en-
deavor, professional or otherwise, is such indiffer-
ence to success exhibited or tolerated. What lawyer,
teacher, minister, or dentist is there who would not
consider himself disqualified for his position if over
50 per cent, of his undertakings continually proved
to be flat failures?

The ordinary physician, however, is not discon-
certed by so small a matter. Like the brook he
goes on forever, continually treating pneumonia in
the same old way, in spite of his confessed inability
to do no more in the way of assisting nature to over-
come this scourge of civilized humanity.

Although they do not excuse it, there are two
reasons for this professional apathy. One is that,
in the therapeutic department of medicine, the phy-
sician has always been taught to accept as proper
whatever form of treatment tradition and authority
have decided to be best, and that any deviation from
methods thus prescribed constitutes a species of
heresy, the punishment of which is professional
ostracism. Because of this fact, original thinking
and individual investigation are hindered and the
professional conscience blunted. The other is that
the acknowledged leaders of medical thought and
practice are so intensely jealous of their ideas and
reputation that, with very few exceptions, they can-
not be induced either to accept any modification of
the methods they advocated or to investigate without
prejudice the merits of any system of practice which
radically differs from their own.

The following personal experience^one of many
— serves both to illustrate and corroborate the state-
ment just made. In talking with a well-known phy-
sician of this city — one who is both an author of
distinction and a professor in one of our medical col-
leges— about the possibility of reestablishing activity
in a consolidated lung in tuberculous cases, he not
only spurned the idea that such a thing could be
done, but when I offered to demonstrate the fact
to_ his entire satisfaction, coolly and unblushingly
said : "Rather than acknowledge that what I have
taught and written is wrong, I would retire from
the practice of medicine." When such narrowness
and bigotry exist in the minds of medical teachers,
is it any wonder that so many physicians, young in
practice, meet with so little success in their efforts
to cure the sick ?

With regard to pneumonia, I have been waiting
for years for some eminent general practitioner and
teacher to come boldly forward with some definite
and scientific plan of treatment bv which the num-

ber of cures will, at least, equal the number of fail-
ures, but, so far, I have waited in vain.

In presenting my own methods of treatment, I
do not wish to censure too severely the older mem-
bers of the profession for what seems to me to be,
upon their part, a lack of careful study of the nature
and cause of this serious malady, or to reprove them
for adhering to lines of treatment which result in
such a high death rate. I do desire, however, to
urge the younger members of the profession either
to adopt the therapeutic methods I have found so
successful, or, by research and experiment, to dis-
cover and formulate a better one.

There are two circumstances which account, in
a great measure, for the high percentage of mortality
which attends the treatment of pneumonia by pre-
vailing methods. The first is the frequent failure to
recognize the fact that, in the form in which it
usually presents itself, pneumonia is, as Von Jiir-
gensen has stated, a general as well as a local dis-
ease, and therefore remedies addressed to the lungs
alone, no matter how appropriate and reliable they
may be, must often fail to effect a cure. The second
is the lack, which has heretofore existed, of a safe
and reliable remedy for the removal of congestion.
Congestion implies not only stagnation, but chemical
deterioration of all of the fluids in the affected area,
of the interstitial fluids as well as of those within the
capillary vessels. The successful remedy, therefore,
must be one which is able, speedily, to remove both
of these morbid conditions.

Until recently drugs have been almost the only
means available for this purpose, but now more effi-
cient measures are at command. The chief of these,
according to my experience, is the ozone-producing,
electric current. This remedy, with its method of ap-
plication, was fully described in a paper entitled,
"The Influence of Electroozonation upon Disease,"
which I read before the New York Academy of
Medicine, and which appeared in the New York
Medical Journal in the issues of January 25 and
February i, 1902.

For the benefit of those who have not seen this
article, the following brief outline description of the
apparatus bv which ozone is generated must suffice :

The machine consists, practically, of an ozone
generator fed by a high-tension coil which multi-
plies the voltage of the commercial current a million
or more times and practically eliminates all am-
perage. To the generator are attached brushes or
corrugated wires from which ozone is given off in
large quantities, and also connected with it, by
means of a wire cord, is a Geisler vacuum tube
through which ozone is forced into and through the
body, thereby oxidizing all pathogenic products and
reestablishing nutrition and vitality. Connected with
this apparatus is an electric cabinet which generates
light and heat coupled with ozone. Thus, the most
important elements which enter into the problem
of life are supplied in a form to be utilized.

I find ozonation to be an ideal remedy for all
stages and degrees of congestion. Being the re-
sult of very rapid vibration, it possesses both physical
and chemical qualities in the highest degree of
efficiency. By virtue of its vibratory quality it
penetrates to. and mechanically acts upon, every
cell of the affected region. By urging forward the
sluggish contents of the capillaries it equalizes and
restores the capillary circulation ; bu stimulating
osmosis, it compels excessive accumulations, of
whatever nature, to reenter the circulatory vessels
and once more become a part of the active, systemic
circulation, and, by contracting and strengthen-
ing the muscular walls of the relaxed and distended

430

MEDICAL RECORD.

[March i6, 1907

capillaries, it enables them to maintain their circula-
tory function in a more perfect manner.

At the same time these mechanical effects are
takins; place, others of a chemical nature, resulting
from ozonation — the most active and most efiective
form of oxidation — are occurring. Not only are the
abnormal accumulations which have been deposited
at the seat of congestion o.xidized and destroyed, but
the morbific elements in the blood which constitute
the specific cause are similarly dealt with.

Ever since I fully appreciated the remedial value
of this form of ozone, it has been my chief reliance
in the treatment of pneumonia. My experience with
it comprises over sixty cases, taken as they came, at
any stage of the disease, and covering all degrees of
severity, with complete recovery in every instance.
Several of the cases were in well developed tuber-
culous patients ; some had organic disease of the
heart, and one, a case of septic pneumonia, occurred
in a patient ill with puerperal fever complicated with
a oelvic abscess. One patient, considered hopeless
when 1 was called, was taking a combination of
thirteen different drugs and only a teaspoon ful of
whiskey every two or three hours. In spite of this
there was complete recovery. Resolution was estab-
lished in twenty-four hours ; the lungs were free and
the heart action normal. The patient was up and out
in two weeks.

In another case of double pneumonia, compli-
cated with tuberculosis in the primary stage, the
patient recovered and went back to business in
two weeks. In regard to age, several of my pa-
tients were over seventy-five and one was ninety.

As further evidence of the efficacy of ozonation
in this disease, I will cite, in detail, its results in a
very severe tvpical case to which I was called when
the patient, who was eighty-nine years old, was sup-
posed to be dying. She had been under treatment
for six weeks, confined all of the time to her bed.
She was thoroughlv exhausted, and, when first seen,
w-as unconscious. The lungs were fairly clear,
respiration 32,- pulse weak, fluttering, and intermit-
ting everv second beat. There was great restlessness
with muttering delirium and involuntary discharges .
from both the bowels and bladder.

Within half an hour from the beginnig of treat-
ment bv ozonation, the pulse intermitted only every
seventh beat. Within an hour, the involuntarv
action of the bowels and bladder ceased. Half an
hour later, the nulse beat at qo, with no intermission,
and the patient fell into a quiet, restful sleep, for an
hour and a half, from which she awoke conscious
?nd askine for nourishment.

She received but two treatments daily, but made
a complete and uninterrupted recoverv. So rapidly
did her strength and vitality return that, at the ex-
piration of a month, she was able to take a long
journey by rail without the slightest unfavorable
result. Her health, since recovery, has been better
than for years before the illness occurred. She is
now in her ninety-second year, hale and hearty. Her
physician remarked that the treatment she received
at that time "seemed immediately to bring into ac-
tivity all conditions favorable to the reproduction
of life and vitality."

In acute cases, recovery is more rapid ; complete
restoration being effected generally within five or six
days. Even in those frequently occurring, serious
cases of tardv and incomplete resolution, in which,
on account of the low vitalitv, the solidification that
has occurred fails to be absorbed and remains a con-
stant menace to the life of the patient, ozonation will
establish resolution in a few days, the entire area
affected becoming free and clear.

The case of Dr. Robertson, the principal features
of which are mentioned in my paper upon "The
Influence of Electroozonation Upon Disease"
above referred to, illustrates its action in this class
of cases. On account of his low vitality, the doctor's
recovery from a severe attack of pneumonia was in-
complete, the middle lobe of the right lung remain-
ing consolidated. Several weeks after he was able
to leave his bed, his pulse was 100, temperature
99.1°, respiration 24. There w'as an irritable cough
with scanty e.xpectoration laden with pus. His phy-
sicians believed he was going into a decline, and ad-
vised him to give up practice and spend the re-
mainder of his life in tlie South — a step which he
had made preparations to take.

At this juncture, he was brought to me for treat-
ment by his physician who, however, doubted that
ozonation could be of any benefit to him. On April
iQ, 1901, within twenty-four hours after the first
treatment, the temperature rose to 105°, accom-
panied with all of the pneumonic symptoms attend-
ing such a high degree of fever. This was followed
by abundant e.xpectoration to such an e.xtent that,
within the next twenty-four hours, he had thrown
oflf over a quart of offensive, "prune-juice" mucus,
and all consolidation had disappeared. Within five
days from the first treatment, all rales had disap-
peared, and not even the slightest roughness could be
heard. Strange as it may seem, on April 23, only
four days after the first treatment, the doctor re-
placed his sign in the window, unpacked his furni-
ture, and resumed practice. His health was com-
pletely restored by fifteen treatments.

The high temperature which appeared in this
case so soon after the first treatment, always occurs
in a greater or less degree in cases of this class. It
is not caused by an aggravation or encroachment
of the disease, as might be supposed. It is, rather,
an indication of the increased vitality which ozona-
tion has conferred upon the system, and is due to the
successful effort made to establish resolution and to
get rid of the consolidation ; the intensity of the
effort being determined by the degree of vitalitv
w^hich has been acquired and the character an;!
amount of the consolidation to be removed.

This clinical record, comprising over si.xty-nine
cases of pneumonia treated, with 100 per cent, of
recoveries, w-ould seem to be sufficient to establish
the fact that there is a rational and successful method
of treating this heretofore unconquered disease ; so
that, now, instead of dreading it, as w'as formerly
the case, on account of its rapid development and
frequently fatal termination, I consider it one of the
easiest diseases to cure.

It is frequently stated that pneumonia cannot bf
aborted ; that it must always "run its course." While
this is probably the case, without exception, in the
practice of those who make this statement, I can
assure you that such an opinion is erroneous. I
have repeatedly demonstrated that, bv the proper
application of ozonation, pneumonia can be aborted
at any stage, resolution becoming established within
forty-eight hours from the beginning of treatment.
I desire to add. parenthetically, that in my opinion
there is no reason, but incompetent treatment, for
allowing any acute disease to get well by limitation.
.Any form of treatment w'hich cannot largelv dis-
count nature's unaided eflforts. is neither rational nor
scientific ; it is decidedlv worse than no treatment
at all.

Ozonation should be applied from half an hour
to two hours at a time, and repeated several times
daily, according to the severity of the case, but
never so frequentlv as to interfere with a proper

March i6, 1907]

MEDICAL RECORD.

431

amount of sleep. It should be appHed over the
head, spine, and abdomen, as well as over the con-
gested area ; over the cerebrum and medulla, be-
cause it clears the mental faculties and stimulates the
nerve centers which control both respiration and
motion ; over the abdomen, because it augments the
activity of the eliminative organs ; and over the con-
gested lung area which can be accurately outlined
by the painful sensation caused bv passing the elec-
trode over it, because it oxidizes and removes the
inflammatory deposits.

In treating pneumonia, I do not rely entirely upon
any single remedy, however efficient. I give my pa-
tients the benefit of anything which I have found
can be safelv depended upon to remove congestion,
reestablish normal circulation in the affected organs,
and eliminate effete matter from every part of the
system.

As pneumonia is uSually precipitated by a chill to
the surface of the body, causing congestion of in-
ternal parts, artificial heat is an auxiliary remedy of
too much importance to be neglected. .\ profuse
and prolonged sweat, at the appearance of the first
symptoms, often proves sufficient to bring the dis-
ease process to a sudden and favorable termination.
Maintain the heat bv any practical means ; keep the
patient's room, which should always be well venti-
lated and ozonized, at a tropical temperature (100°
or more of Fahrenheit). The patient should be kept
constantly in a mild state of perspiration until reso-
lution is fullv established.

There are many ways of doing this. If the patient
is able to sit up, a vapor bath may be given. When
unable to assume an upright position, the same re-
sults may be obtained by burning a few ounces of
alcohol under the bed clothing in a shallow cup or
saucer whicli is allowed to float in a deep, narrow
vessel partly filled with water to prevent the vessel
from breaking. Care must be taken that the bed-
clothes are raised and supported a foot or more over
the patient and so arranged that only the head is
exposed and the heated air surrounding the pa-
tient's body is not allowed to escape. A cool, damp
cloth should be kept constantl}- on the forehead to
prevent headache or an uncomfortable sensation of
fullness which might otherwise occur.

Bottles or rubber bags filled with hot water,
placed close to the legs and body of the patient, are
very serviceable ; hot tub baths may be used, with
great benefit, in the incipient stage. When available,
the electric-light bath is the most natural, efifective,
and grateful means of applying external heat, as
the patient at the same time receives the benefit
of powerful light coupled with ozone.

External heat, as a means of inducing perspira-
tion, is to be preferred to drugs ; the latter always
produce additional effects which it is better to avoid.
In fact, the fewer the drugs that are employed in
the treatment of this or anv other disease, in order
to secure desirable results, the better it is for the pa-
tient. His vitalitv is not wasted in maintaining activi-
ties which have no direct remedial bearing upon the
disease. Encourage sleep. .Kvoid evervthing that
has a tendencv to startle or shock the patient, as
noise, unnecessarv conversation, touching him with
cold hands : and see to it that his chest is not op-
pressed bv heavy coverings or bv weight or pressure
from anv cause, such as poultices.

Just here I desire to utter an emphatic protest
against the u.se of verv cold applications, especially
inthe form of ice, over the lungs. Instead of dim-
mishing the internal congestion, a= it is supposed to
do, by drawine the excess of blood into the circula-
tion, a very different result, according to Dr. Hensel,

is produced. "Owing to the attempt to diminish the
heat by ice, the congested blood," he says, "is by no
means drawn into the general circulation, but be-
cause of the mechanical constriction of the capil-
laries, through cold, it is merelv driven into the cap-
illaries at a little distance from where the ice is
placed. While the cold operates and the paralyzing
action of the ice on the nerves continues, no evii
effects are perceived, but as soon as the ice is re-
moved the congested blood begins to decompose and
poisons the rest of the blood in the body. Then we
read in the papers: 'In spite of the fact that ice
compresses were applied with frequenc}-, the dis-
ease was, nevertheless, not overcome, and all the
skill ( ?) of the physicians proved in vain.' The
proper way of expressing this, he adds, would be
"the inflammation of the lungs passed into putrefac-
tion because the pedant of a doctor made the mis-
take of keeping the inflamed blood fixed in one
Iilace, by the application of ice, instead of conducting
it towards the skin and so distributing it through
the system.'"

.\nother very important adjunct of ozonation, and
in some measure a substitute for it, is oxygen. How
many physicians are there who use oxygen in the
first stage of pneumonia? Yet, this is the very
period in which it is capable of doing the most good.
.\t this stage, o.xidation of the morbid contents of the
air-cells is more rapidly accomplished and normal
circulation more readily reestablished than later,
when solidification has occurred.

Elimination must be looked after. Keep all of the
eliminative organs active. If the bowels are consti-
pated, give a saline cathartic followed bv olive oil as
a lubricant and nutrient, and keep them open by at
least two enemas daily. No more effete matter
should be allowed in the colon than is absolutely
unavoidable, so that danger from the absorption of
toxins will be reduced to a minimum.

In the use of drugs my favorite prescriptions for
an adult are : Tincture of aconite root, J/2 to i drop,
with tincture of veratrum viride, i to 2 drops, in
water, every half hour or hour, until perspiration is
well established ; and asafetida, 5 to 10 grains, in
capsule every four hours. The aconite opens the
peripheral capillaries, and the veratrum gives the
heart power to force the blood through them and
also opens the larger vessels, thereby depleting the
congestion in the lungs. This prescription should
be discontinued when the crisis is reached, and
strychnine, in small doses (i-ioo to 1-60 grain),
should be given three or four times a day, as the
pulse may indicate. I seldom find the strychnine
necessary when ozone is administered, because the
latter is of itself a powerful stimulant.

The asafetida is a pulmonary and nerve stimu-
lant, and the number of doses should be diminished
to one or two daily, as soon as the lungs become
free and clear. Parenthetically, I desire to state that
I find asafetida. in large doses, to be of the greatest
assistance in the treatment of all congestions and
particularly of the lungs. It is a mild cathartic and
diuretic and exerts a marked germicidal influence.
Physicians who cannot avail themselves of ozona-
tion will find it. as prescribed above, of paramount
importance in all cases of pneumonia.

The patient should be well nourished in order
that his strength mav not wane. Maintain nutrition
by all the appropriate food he can bear. Delicate
persons with weak digestive power require food
which is readilv digested, such as milk and e^f^s.
in small amounts, frequently repeated. After the
crisis I often allow beef juice and hearty food.
It IS here, in the role of improving nutrition, that

432

MEDICAL RECORD.

[March i6, 1907

ozonation plays such an important part. It seems
to stimulate all of the nutritive processes through-
out the entire digestive tract. Under its influence
foods are digested and assimilated which otherwise
the system could neither tolerate nor utilize. Stimu-
lants are seldom needed when ozonation is em-
ployed. Otherwise, it is necessary to give them
liberally, especially in the form of whiskey, when
there is delirium or when the heart's action is weak.

After the lungs are clear, do not keep your pa-
tient constantly in bed, under the impression that
the recumbent position will conserve his strength ;
too much inactivity always results in weakness. Let
him sit up, more or less, the first day after the
crisis. Unless he has organic heart disease, I have
found nothing but the best results to follow this
practice. Of course, if the patient has become ex-
hausted by a prolonged illness before this specific
treatment is resorted to. the recumbent position
should be insisted upon ; but as a general rule the
more the patient is kept in bed the longer will be
the period of his convalescence.

With the exception of ozonation, the different
features comprised in the method I am advocating
are neither new nor untried. They have been suc-
cessfully employed by me for many years. But
since I have been using ozonation my success has
been phenomenal.

One word, in conclusion, concerning the advan-
tages afforded by this method. In addition to the
greatly lessened mortality, which is its best recom-
mendation as well as a source of great comfort to
the patient, it is highly appreciated by business men
and those occupying positions of trust and responsi-
bility on account of the speedy recovery it insures.

Aloreover, because of the rapid and thorough
elimination of the disease, owing to the invigorating
methods employed, not only are many complications
and sequelse avoided, but chronic, minor affections
from which the patient may have suffered often
permanently disappear.

Preventive medicine is the ideal goal of medical
science, and the more successful the phvsician is in
preventing disease or curtailing its course the great-
er service does he render to humanity.

7 West Fifty-eighth Street.

PRIMARY CARCINOMA OF THE INFER-
IOR TURBINATE, WITH REPORT
OF A CASE.

By WILLIAM WESLEY CARTER, A.M., M.D..

NEW YORK.
ASSISTANT SURGEON MANHATTAN EYE, EAR, AND THROAT HOSPITAL. "

Probably no more serious or important duty ever
comes to the rhinologist than that of making an early
diagnosis in cases of suspected malignant disease of
the nose. The disease is insidious in its develop-
ment, and experience here, as in other parts of the
body concealed from direct inspection, shows that
the diagnosis is seldom made early enough to eradi-
cate the disease by operation, for the mortality is
practically 100 per cent., which includes both oper-
ative and non-operative cases.

Malignant disease of the nose is very rare and
usually occurs in the ethmoidal or sphenoidal region ;
the case that I present, therefore, is one of the rarest
clinical developments of intranasal malignancy, for
the disease is primary and in the lower part of the
nose.

Mary C, aged thirty-eieht. married, applied for
treatment in the Manhattan Eye, Ear, and Throat
Hospital early in October.

Her family history is good. She has always lived
under fair hveienic conditions. Appetite and di-
gestion are good, and the bowels are regular. She
is a moderate tea and coffee drinker and takes beer
occasionally.

Her menstruation began at sixteen, was regular
until several years ago, since this time it occurs
sometimes as often as every two weeks. She does
not remember ever being sick except after miscar-
riage six years af^o.

Her present illness began five months ago with a
tickling sensation in the right nostril, and a constant
desire to blow the nose. In a short time this was
followed by spontaneous hemorrhages from this nos-
tril; in four weeks the hemorrhages had greatly in-
creased in frequency and the nostril was occluded.
In the meanwhile she suffered continuallv with head-
ache. At this stage she applied for treatment at a
dispensary, where a growth was removed from the
right nostril. This relieved the stenosis and other
symptoms for the time. In four weeks all of the
original symptoms had reappeared. She then went
to a private phvsician, who removed the growth and
examined it under the microscope. He found that
it was cancerous and advised her to go to the hos-
pital for more radical treatment.

I saw the patient three weeks after the last re-
moval of the growth. The woman was well nour-
ished, showed no signs of cachexia, and except for
being extremely nervous seemed to be in good physi-
cal condition.

Examination of the nose showed a cauliflower-
looking mass attached to the anterior extremity of
the right inferior turbinate, and almost filling the
nasal cavity ; it evidently extended back some dis-
tance, but just how far could not be determined by
anterior examination, and it could not be seen by
posterior rhinoscopy. There was a serous, odorless
discharge from the nostril and this, where it filled
the sulci between the coarse granulations that cov-
ered the growth, had a milky appearance. Other-
wise the nose and its accessory cavities seemed nor-
mal.

A large piece of the growth was removed with
the snare for microscopical examination ; this opera-
tion was followed by considerable hemorrhage. The
tissue was very friable, offering no appreciable re-
sistance to the snare. The specimen was examined
by Dr. Jonathan Wright, who promptly stated that
it was a tynical columnar celled epithelioma. An
immediate operation was advised. Believing that
a cancer of five months' standing or longer must
have so seriously involved the adjacent tissues and
especially the antrum, that an excision of the su-
nerior maxilla would be necessary, the case was re-
ferred to a general surgeon.

On October 4 Dr. Andrew J. McCosh performed
the following operation at the Presbyterian Hos-
pital, the writer being present :

FergTjsson's incision, reaching from the inner can-
thus of the right eye down by the side of the nose
and through the middle of the upper lip, was made.
All the tissues were elevated from the anterior wall
of the antrum, and the soft tissues of the nose from
the margin of the nasal cavity. The nose was then
pulled toward the left, giving a good view of the
operative field. It was then seen that the growth
was confined to the inferior turbinate, and an open-
ing into the antrum showed this cavity to be nor-
mal. The whole of the external wall of the nasal
cavity down to and including a portion of the floor
was removed, together with the inferior and middle
turbinates and a large p)ortion of the anterior wall

March i6, 1907]

MEDICAL RECORD.

433

of the antrum. From an examination of the speci-
mens removed the patholog-ist of the Presbyterian
Hospital confirmed the diagnosis of cancer.

Though the growth involved only the anterior
two-thirds of the inferior turbinate, the operation
was extended far into the normal tissue, as was after-
ward shown by the microscopical examination of nu-
merous specimens. We believe that every particle
of malignant tissue was removed locally, for the op-
eration extended far beyond the limits of probable
invasion by contiguity.

The external wound was closed and drainage was
effected through the nose. Primary union took
place and the patient was discharged from the hos-
pital on October 19, fifteen days after the opera-
tion.

She was put on tonic treatment and at present,
nearly three months after the operation, she seems
in better condition than when I first saw her. There
are at present no signs of recurrence. A later report
upon this point, however, will be of more value.
Points of special interest in this case are :
I — The extreme rarity of primary cancer of the
nose, and especially of the inferior turbinate.

2 — The early age at which the growth appeared
(it being almost unheard of before the forty-fifth
vear).

3 — The age, location, and extent of the growth
seemingly being favorable, we have here a fair op-
portunity to test the efficiency of the radical opera-
tion to cure malignant disease of the nose.

The first case of primary cancer of the nose was
reported by Robin in 1852. However, as late as
1869 no less accurate observers than Finder, and
Cornil and Ranvier denied that malignant disease
ever originated in the nose ; and though this as-
sumption has been proved to be incorrect, we may
still state that its occurrence in the nose is very
infrequent compared with other parts of the body.

Dreyfus, who considers only those cases in which
there has been confirmation by the microscope, states
that out of 9,554 malignant tumors of the entire
body there were only 19 of the nose; of these 15
were sarcomata and 4 carcinomata.

In 28,000 patients seen by Herzfeld during a pe-
riod of ten years, only one case of carcinoma of
the nose was observed.

In Frankel's clinic Finder observed 10 sarcomata
and 4 carcinomata among 28,000 patients.

Maljutin states that out of 125 malignant tumors
of the nose collected by him only 17 were carcino-
mata.

In IQO? Darnall stated that the total number of re-
ported cases of primary carcinoma of the nose and
its accessory cavities was 79. All of these, however,
were not confirmed by the microscope. A search of
the literature since this time enables me to add to
this number 19 cases, making the total number up
to date 98. It seems almost necessary, if we con-
sider these statistics, to classify primary malignant
disease of the nasal cavities with that of the acces-
sory sinuses, as many of the cases were seen only
after the involvement of so much tissue that it was
impossible to tell exactly where the growth orig-
inated. It is generally admitted, however, that pri-
mary malignant disease of the accessory sinuses is
much more common than of the nose, and it is highly
probable that a great majority of these 98 cases or-
iginated in the accessor}- cavities.

A review of the cases shows that sex has no ap-
preciable influence in the etiology of the disease.

Carcinoma of the nose occurs only in later life,
hardly ever before the fortv-fifth vear. Here car-

cinoma stands in strong contrast to sarcoma, which
may occur at any. age, but especially in tlie young;
Schneigelw reports a case of chondrosarcoma of
the nose in a child two years old.

By some, trauma is considered an etiological fac-
tor, but tliese men base their belief on such uncer-
tain evidence as the statements of the patients as to
when the trouble began, as in a case mentioned by
Becker, whose patient attributed the disease to a
fall on the back of the head. Irritated areas in the
nose from which polypi have been removed have
been spoken of as the seat of carcinoma. Cases dem-
onstrating this origin have been mentioned by
Trautman and Frick.

As to the origin of carcinoma from polypi, there
has been much discussion. As yet, however, no
stronger evidence has been brought forward to sup-
port this view than that of association. The fact
that carcinoma most frequently occurs in the upper
part of the nose in the region of the sphenoid and
ethmoid, the area usually afifected by polypi, cer-
tainly suggests some relation between the two. If,
however, we take into consideration the frequency
with which polypi are found, their occasional oc-
currence w'ith carcinoma is to be expected. Heyman
found that polypi constituted about 10 per cent, of
all his nasal cases ; and Zukerkandl found polypi in
the nose in one out of every ten autopsies. At the
same time we are not in a position to say that the
irritating presence of polypi does not favor the
development of carcinoma. In fact, long continued
irritation in the nose, as in other parts of the body,
seems to be a strong factor in the etiology. The
polypi accompanying the cancer and sometimes com-
bining with it, forming a mixed growth, may be ac-
counted for by the irritation of the cancer and its
necrotic products.

There is evidence that cancer may be developed
from such benign growths as adenomata and papillo-
mata after the cancerous age has been reached, and
when they have been subjected to long-continued
irritation. Kiimmel. who made a microscopical
study of the epithelial cancers of the nose, says that
they all remind one of adenoma, and he believes
this to be the chief origin of cancer. Cordes re-
ported a case that seemed to be developed from
adenoma. Polyak observed a pure papilloma for
two and a half years that later showed cancerous
metaplasia under the microscope. Citelli and Cal-
amida also found microscopically that a papilloma
that had been subjected to many irritations became
cancerous. On the other hand, Sir Felix Semon
savs that he has not seen such transformation occur
in 10,000 cases.

The disease is so insidious in its development
that it may be far advanced before the symptoms
are sufficiently pronounced to send the patient to
the physician.

Nasal obstruction and headache are probably the
earliest symptoms. Reneated hemorrhages may be
mentioned as one of the earliest and most sugges-
tive signs of malignancy ; they may be spontaneous
or induced by slight traumatism. In my case nasal
stenosis, headache, and hemorrhage were the only
subjective symptoms. Pain, at first neuralgic, later
deep and boring in character, is a late symptom ; it
is present early if the growth is in the upper part
of the nose.

The discharge may be serous, bloody, or purulent,
and if the disease is advanced it has a necrotic,
fetid odor. When the sinuses are involved, the
earlv symptoms are those of empyema of these cav-
ities.

434

MEDICAL RECORD.

[March i6, 1907

Infiltration in carcinoma of the nose does not
seem to be as rapid as in some other parts of the
body. There is a tendency for the disease to ex-
tend upwards along the lymph channels that com-
municate with the subdural and subarachnoid spaces,
many of the cases terminated from cerebral in-
volvement. It also extends backward toward the
choanse and ptarygoid fossae. Recurrence is very
rapid after incomplete removal. In my case the
growth had fullv returned within four weeks on
both occasions when it was removed to relieve
stenosis.

There is little or no tendency to metastatic de-
posits in other organs. Glandular involvement does
not occur so often, nor as early, as in malignant
disease in other parts of the body. The lymph
stream of the nose runs to the back of the choana
and is collected in the side walls of the pharynx ;
here it communicates with one or two glands situ-
ated near the Eustachian tube. It then divides, one
part courses downward and outward, joins the ves-
sels from the tonsils and arches of the gums and
communicates with the deep cervical glands, one
part goes to one or two glands situated near the
greater cornu of the hyoid bone. The second di-
vision passes backward and communicates with a
gland situated in front of the axis vertebra. In
only two of the recorded cases were the glands of
the neck involved.

From an anatomical point of view the lateral
pharyngeal gland, the gland in front of the axis,
and the glands near the greater cornu of the hyoid
would be the first involved in carcinoma of the
nose.

Cachexia is one of the late symptoms : it was not
present in my case.

In making the diagnosis we must dififerentiate
from sarcoma, benign tumors, tuberculosis, and
syphilis, also from chronic inflammatory conditions.
The writer once saw a granular mass on the right
middle turbinate of a man who had been accus-
tomed to take snufif through his right nostril for
many years. From its appearance it could have
been mistaken for a malio-nant growth ; it proved to
be an overgrowth of tissue due to the irritation of
the snufif.

Sarcoma differs from carcinoma in that it may
occur in the very young: it is usually bluish-red in
color and has considerably more consistency, in some
cases being quite hard. It produces its deformity
bv pressure and displacement of normal structures
rather than by ulceration, as in carcinoma, and it
is not as a rule accompanied by cachexia.

Benign tumors usually have pedicles, while malig-
nant ones are sessile.

There should be immediate cooperation between
clinician and pathologist in suspicious cases, for
an early diagnosis offers the only chance for suc-
cessful operative interference. Where a diagnosis
of cancer is made, the radical operation should be
performed as soon as possible after the. removal
of the specimen for microscopical examination, lest
this procedure should accelerate the disease. We
must remember that this traumatism may not only
liberate the cells of the cancer, which are verv loosely
bound together, but it may open up blood-vessels
and lymphatics to take them up and disseminate
them beyond the intended operative field. Cells
thus taken up have been seen in the lymph channels
under the microscope by several pathologists. That
the fatal termination is greatly hastened by every
inadequate operative procedure is borne out by the
experience of every writer on this subject.

The prognosis is bad ; only recently Bloodgood
has stated that not one of the 18 patients with malig-
nant disease of the nose operated upon at the Johns
Hopkins Hospital recovered. There is no authentic
case on record where recurrence has not taken place
after the operation, and often this recurrence has
taken place before the patient was able to leave the
hospital.

The duration of the disease depends upon the
age of the patient and the nature and location of
the growth. The disease progresses more rapidly
in the aged, and when it is located in the upper part
of the nose. The medullary and adenocarcinomata
are the least malignant and last the longest. The
average duration of the disease is from one to three
years. But Heurteux reported a case that lasted
fourteen years, Bosworth one that lasted nine
months, and Darnall and Gibb each reported one
that lasted only seven months.

But one variety offers any ground for a favor-
able prognosis, and that is the so-called cvlindroma
of Billroth. However, there still remains among
pathologists some doubt as to the malignancy of
this growth.

Operative treatment alone is to be considered in
dealing with these cases. If the site and e.xtent of
the lesion are favorable to complete removal, a
radical operation should be done, otherwise all
writers agree that a fatal issue is much hastened
by interference. If, however, palliative measures
are demanded for the comfort of the patient in in-
operable cases, portions of the growth should be re-
moved with the galvanocautery. The dangers of
the operation are hemorrhage, pneumonia, erysip-
elas, sepsis, and meningitis.

The choice of operation should be made accord-
ing to the location and extent of the growth, and
with a view to giving access to the greatest amount
of nasal tissue. Intranasal operations are useful only
as palliative measures.

In some cases a modified Jansen's operation may
be efifective. but where the growth is in the upper
part of the nose, and both sides are involved,
perhaps OlHer's operation gives the best view of
the field ; this consists in sawing through the nasal
bones and turning the nose forward on the face.
When the antrum is involved, excision of the su-
perior maxilla is the onlv operation to be consid-
ered.

60 West Fiftieth Stree'.

EMBOLISM.

By JOSEPH N. STUDY, M.D.,

CAMBRIDGE CITV. IND.

The name embolus applies to any foreign body
floating in a blood-vessel. Before becoming de-
tached these bodies are known as thrombi. One
of the very frequent sources of embolism is a patho-
logical condition of the inner coats of arteries, veins,
and the cavities of the heart. An altered condition
of the blood, in which its viscosity is possibly in-
creased, following disease or other conditions, may
at times have something to do in the formation of
emboli. L^pon either an acute or chronic phlebitis
bacteria of various sorts and other matter may col-
lect to form these bodies. It is not improbable that
many cases of embolism occur from the direct en-
trance into the blood stream of elements capable
of producing this condition.

An embolism may be septic or aseptic. The em-

March i6, 1907]

MEDICAL RECORD.

435

boli may be small enough to pass through the
smaller blood-vessels, or sufficiently large to com-
pletely obstruct the larger arteries, or even a cavity
of the heart. A fat embolism sometimes follows
trauma to the soft parts, where there exists adipose
tissue, as well as in fractures where bone marrow is
exposed, the fat globules finding their way into the
circulation. Fat embolism has been detected in the
brain and spinal cord. It has been thought that a
fat globule, by being rapidly propelled against the
sides of an artery, may be broken into smaller par-
ticles, reaching the floor of the fourth ventricle,
where the cardiac and respiratory nerve centers are
located, in this way causing sudden cessation of
one or both of these organs. It is not improbable
that many sudden deaths following diphtheria, pneu-
monia, and various other conditions, and usually at-
tributed to heart failure, are due to infected septic
emboli finding their way to the cardiac nerve cen-
ters.

All recognized authorities have in the past taught
and emphasized the matter in no uncertain way of
the danger of air enterine a blood-vessel, and its
liability to produce embolism. More recent experi-
ments upon horses and the smaller animals teach
that it is only when large quantities of air enter
the circulation under considerable pressure that any
serious symptoms arise. Then that air may enter
a blood-vessel, either from a surgical operation or
trauma, to a vessel in sufficient quantities to produce
■death, is rather improbable. It does seem very prob-
able that metastatic abscesses in various organs and
local inflammation, as well as ulcerated conditions,
do at times owe their origin to infected emboli. Em-
bolism has complicated and followed various patho-
logical conditions. It has followed and complicated
typhoid fever, pneumonia, diphtheria, childbirth. It
is said very frequently to follow surgical operations,
■more especially within the pelvic cavity.

In the differential diagnosis of embolism, where
trauma precedes this condition, there are three
things to consider. Shock usuallv occurs within
three hours, fat embolism three davs, pulmonary em-
"bolism three weeks. Seventy per cent, nf all emboli
probably enter the pulmonary arter\-. As these
bodies most usually originate in a vein, they enter
the right side of the heart, consequently the pul-
monary artery is a favorable site for their migra-
tion. The clinical history of many cases of em-
bolism would indicate that this condition frequently
occurs simultaneously with, or following some
b)odily movements, or excitement, as walking, laugh-
ing, or other muscular movements, which seem to
aid in liberating these bodies : and when once de-
tached evidently they soon reach their final destina-
tion. Embolism mav terminate in one of three ways
— in instant death, in delayed death, or in recovery.
When the pulmonary artery is completelv closed
•death must necessarily soon occur.

It is said that recovery has followed the complete
obstruction of one of the primary branches of the
■Dulmonary artery. .A.n embolism is at all times a
■dangerous quantity to deal with, and as such must
so be considered. However, even in the lungs emboli
do not always produce death. The lung tissue be-
in'- nourished by a separate set of vessels, the bron-
chial arteries, its nutrition need not necessarily suf-
fer. Local inflammation that writers have de-
scribed so often and termed as embolic pneumonia
■: very liable to follow the migration of an embolus
into the lungs. Such a condition may terminate in
various wavs.

I desire to report two cases of pulmonary em-
bolism.

Case I.- — Mrs. W— — , age thirty-one, American,
married two years, was never pregnant ; menstrua-
tion was regular but attended with some unusual
pain at times. Her previous health had been good.
She presented a most excellent physique, weighing
about 140 pounds. She was taken with some pain,
not severe, about the left ovary, and was having
some little increase of temperature, not exceeding
100.5°. At the end of four days she had a normal
temperature and was free from pain, and profes-
sional visits were then discontinued. The following
afternoon she was up about the room and some
neighboring ladies had called to see her, when she
expressed herself as feeling quite comfortable. Soon
after, she was in the act of walking across the room,
when she experienced great difficulty in breathing,
was assisted to a couch, and some thirty minutes
later died. Through the courtesy of her physician.
Dr. J. E. Wright, I was permitted to assist in
making an autopsy, and was accorded the privilege
of reporting the case. The pulmonary artery con-
tained a spindle-shaped embolus one inch long, com-
pletely obstrucing the vessel, which was of a dark
red color and of a friable consistence, easily break-
ing when manipulated between the fingers. The left
Fallopian tube contained about one dram of a sero-
purulent fluid. No other pathological condition was
observed.

Case II. — Mr. S., age forty, American, farmer by
occupation, previous health good, sustained a frac-
ture of the left patella, the lower fragment being
broken into two pieces of about equal size. There
was considerable ecchymosis over the knee, as well
as swelling. The fracture was dressed in the ex-
tended position, and the patient had made satisfac-
tory progress until the twenty-first day after re-
ceiving the injury. The man had eaten his break-
fast and had read the morning papers, directed his
hired man about his work, and expressed himself as
feeling well. . One hour later he was placed upon
the commode for his bowels to move, and when be-
ing replaced upon the bed he experienced much dif-
ficulty in breathing. He was soon visited by his
physician. Dr. A. E. Ehle, and his breathing and
heart's action were so alarming that strychnine and
one pint of normal saline solution, subcutaneously,
were administered. The strychnine was repeated at
intervals of two hours. Six hours after the begin-
ning of the attack I visited the patient and noted
the following conditions : Respirations 48, pulse
150, temperature in axilla io,v5° : skin somewhat
cvanosed and perspiring freely : neither pain nor
cough was present, but the patient complained of
want of air. The stethosco'^e revealed air in normal
quantities entering both lungs. The following fore-
noon I again examined the patient, when his respira-
tions were 44, pulse 140, temperature 102.5°. No
pain was complained of, but an occasional dry
cough. Auscultation indicated that air in normal
quantities was entering both lungs, and still he felt
the need of more air. Four days later I examined
the patient, when his respirations were 34, pulse 125,
temperature 102°. Auscultation revealed partial
solidification of the lower portion of the left lung.
At no time was pain complained of. neither was
there any expectoration. At the end of four weeks
the man was permitted to sit up. Two months later
the patient appeared at my office, the injured limb
yet swollen up to the groin, supported by a rubber
bandage. His lungs seemed to have fully recovered
from the embolic obstruction.

436.

MEDICAL RECORD.

[^Tarch i6, 1907

REPORT OF A CASE OF INOPERABLE

ROUND-CELLED SARCOMA OF

THE OVARY;

SUCCESSFULLY TREATED BY THE MIXED TOXINS OF
ERYSIPELAS AND BACILLUS PRODIGIOSUS, COM-
BINED LATER WITH OPER.\TION.

By HENRY C. COE. M.D.. and WILLI.^I B. COLEY, M.D.,

NEW YORK.

Mrs. E., aged thirty -two, wife of a lieutenant of the
U. S. Army, was referred to Dr. Coe by Dr. H.
Eugene Stafford of the Philippine Civil Hospital of
Manila on December 29, 1904, under whose care
she had previously been. Her previous history, as
given by Dr. Stafford, is as follows:

Early in November, 1904. Dr. Bailey of the U.S.A.
was called in to see the patient, and he treated her
for two weeks for what he supposed was an inflam-
mation of the left ovary, when a tumor developed
and he referred her to Dr. Stafford for operation.
Dr. Stafford saw her in consultation with Major E.
C. Carter of the U.S..\. Examination revealed
a large, immovable mass filling the pelvis. The
uterus was crowded down almost to the external
genitals. There was considerable tenderness of the
lower abdomen, which did not permit of much pal-
pation, and the abdominal muscles were rigid. She
was prepared for operation and upon becoming an-
esthetized the abdominal muscles rela.xed and the
tumor was seen to have grown up to, and a little
above, the umbilicus to the right side. Upon open-
ing the abdomen the mesentery was found adherent
to the outer surface of the tumor. This being dis-
sected free and a portion incised, the tumor was seen
to be nodulated in character, of a dark bluish-
white color, and, upon passing the hand down its
anterior surface to the pelvis, the greater portion
was found adherent. Upon pulling the tumor for-
ward enormous blood-vessels were seen, covering the
back of it and springing from and above the poster-
ior brim of the pelvis. From the general appear-
ance, its rapid growth, and extreme vascularity, we
decided it was a malignant growth, probably sarco-
matous. On endeavoring to free the tumor from
the blood-vessels, we found it was not adherent, but
was growing apparently from the whole of the pel-
vic wall, and its bleeding so freelv convinced us that
it would be wisest to abandon further interference,
particularly as her husband desired her to reach
home to see her parents before dying. The incision
was closed and the patient was more comfortable.
A portion of the tumor was tied off and excised and
sent to the Government laboratory. The pathologi-
cal report, which convinces me that the patient
will hardly live to reach New York, reads as fol-
lows: "An apparently rapidly growing and infil-
trating, very cellular growth of probably perithelial
origin ; perithelial hemangiosarcoma."

The patient entered the General Memorial Hos-
pital on Feb'ruan,' 20, 1905. At that time the physi-
cal examination revealed practically the same con-
ditions as just described by Dr. Stafford. Her gen-
eral health was steadily deteriorating and she was
losing weight. Since the operation she had menstru-
ated every twenty-eight days, the flow continuing for
seven days, moderate in quantity. Heart and lungs
normal. Inasmuch as the tumor was firmlv fi.xed
and clearly inoperable. Dr. Coe turned the case over
to Dr. Coley for treatment with the mixed tox-
ins, which was begun on February 24, 1905, the
first dose being J^i minim, which was injected into
the abdominal wall. The injections were continued

three to four times a week, in gradually increasing
doses up to the point of producing a moderate re-
action, a temperature of 101° to 102°. The pa-
tient's general condition was not such as to permit
of giving her very large doses, and often a temper-
ature of 102° was followed by a good deal of depres-
sion ; the highest dose reached was 7 minims and the
highest temperature 104.8°, which occurred on
March 30, following an injection of 6 minims. Most
of the reactions were much less severe, the temper-
ature usually not rising beyond 101°. She received
in all forty-seven injections, the last being given
May 31. The .v-ray was given in combination with
the toxins, though much less frequently, the patient
receiving all told twenty-two exposures of an aver-
age duration of ten minutes. There was a very
slow diminution in the size of the tumor during the
period of treatment and marked increase in its mo-
bility. Her general condition showed no improve-
ment— in fact, it seemed there was slight deteriora-
tion. It was clearly evident that her condition would
not permit of giving large enough doses to produce
complete absorption of the tumor, and in view of
the marked increase of mobility we decided, after
careful examination, that there was a possibility of
removing the tumor by operation.

On June 12, 1905, operation was performed by Dr.
Coe, assisted by Dr. Coley. A tumor, about the size
of a child's head, was found, originating in the right
ovary-, markedly pedunculated and almost entirely
free from adhesions. No metastases were present in
the other organs. The pedicle was tied off and the
tumor was easily and rapidly removed, the entire
operation taking not more than fifteen minutes.

The effects of the toxin treatment upon the tumor
were most remarkable, as shown by Dr. Martha
Tracy's report, confirmed by Dr. James Ewing :
"The tumor within was very much degenerated, the
contents being almost of a puriform consistence.
Therefore, it was difficult to fix and stain, and the
diagnosis is not clear. Dr. Ewing is unwilling to say
whether it is sarcoma, endothelioma, or carcinoma,
though of the malignancy there is no doubt." The
report of a less degenerated portion of the tumor by
Dr. Clark, the pathologist to the General Memorial
Hospital, was round-celled sarcoma.

The patient made an uninterrupted recovery,
gained twenty-eight pounds in weight during the
next six weeks, and returned to her home in per-
fect health. Within the next six months she con-
ceived and gave birth to a healthy child in the sum-
mer of 1906. She remained well up to the latter
part of January, 1907, when she contractect pneu-
monia and died within a few days.

The case is interesting from several standpoints.
First, because sarcoma of the ovary is an exceed-
ingly malignant neoplasm. We have never yet seen
a case cured by operation. Second, because the
tumor, though clearly absolutely inoperable at the
start, became operable by the preliminary treatment
with the toxins, possibly assisted by the .r-rays, al-
though we have never had an abdominal sarcoma
show much improvement from the .r-rays alone.

While sufficient time had not elapsed to warrant
us in classing the case as cured, the complete restor-
ation to health and prolongation of life for nearly
two years, when it was cut short by an attack of
pneumonia, make the case of sufficient interest to
merit reporting.

Note:. — From a recent letter received since the
above went to press, there seems a possibility that
there was metastases in the lung instead of a typical
pneumonia.

March i6, 1907]

MEDICAL RECORD.

437

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, AM., M.D., Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, March \6, 1907.

ESPERANTO.

Among the countless attempts that have been made
to construct an international language to serve as a
common means of communication for all the peoples
of the earth, Esperanto stands out as the most suc-
cessful. Volapiik seemed at one time about to con-
quer the world, but the movement went to pieces by
reason of certain fatal defects in construction and
of the obstinacy of the creator of the language in
refusing to accept any amendments looking to the
correction of these faults. Dr. Zamenhof, the origi-
nator of Esperanto, is, however, a different sort of
man, whose modesty and whose love for the creature
of his brain forbid that he should destroy this by re-
fusing to listen to proposals for its betterment, if
such might be found necessary. But, so perfect
is the instrument his genius has created, that there
is apparently no room for any but the most trivial
changes. It is unnecessary, even if space permitted,
to describe the mode of construction of the language,
for those interested can readily obtain authorized
grammars which can be mastered in a few days of
careful study. It is a language of root-words, most
of which are already familiar to anyone with a read-
ing knowledge of the three principal tongues of
Europe. From these roots, by means of prefixes
and suffixes, is built up a vocabulary which seems to
meet every verbal need of man, whether for ordi-
nary conversation or for scientific discussion. Any-
one of average intelligence can master these rules
of construction thoroughly in one week by giving
an hour a day to their study. Then, if already
familiar with Latin and Teutonic roots, he will be
able to read almost at sight any Esperanto text,
using a dictionary only to learn the meaning of the
few Slavonic roots that Dr. Zamenhof, himself a
native of Bielystok, Russia, has incorporated in the
language. The ability to write or speak the lan-
guage would, of course, demand more practice, but
the diligent student would in a month find himself
able to communicate with ease with Esperantists
in any part of the world — at least, so the Esperanto
enthusiasts claim.

It will surprise those who have not had their at-
tention turned to the subject to learn what a posi-
tion this new language has already acquired in the
few years it has been in existence. Mr. Joseph
Rhodes, vice-president of the British Espeianto
Association, says (we quote from the North Ameri-
can Revieiv of February 15, 1907) : "Statistically
considered, up to June, 1906, Esperanto was known
to have penetrated to 31 countries, and 377 societies

or groups were at work, Europe being credited with
349, America with 16 — the United States having-
then 10 societies in 7 centers — Asia with 7, Africa
with 3, and Oceanica with 2. To give a census of
Esperantists is impossible, but a recent moderate
guess at their number is 300,000. There are also 31
professional societies or organizations using Esper-
anto for special objects, 28 Esperanto magazines, in
which the national langfuage appears side by side
with the international, and 8 national periodicals
containing a regular Esperanto column. Europe is,
so far, the center of gravity, and here the societies
are distributed : France, 94 ; Great Britain, 64 ; Ger-
many, 35; Austria-Hungary, 28; Switzerland, 22;
Russia and Spain, 21 each; Bulgaria and Sweden,
15 each; Belgium, 14; Holland, 7; Denmark and
Malta, 3 each; and Monaco, i."

Any movement, whether linguistic, socialistic, re-
ligious, or scientific, which has acquired such a
momentum in a single lustrum (Dr. Zamenhof 's
first pamphlet was put forth in 1887, but, though a
few enthusiastic recruits were obtained almost
immediately, the language has really been
launched but little more than five years) is
worthy the respectful attention of thinking
men. It is already receiving practical recog-
nition in many of the countries of Europe.
The governments of France and Belgium are con-
sidering the advisability of teaching Esperanto in
the public schools ; the London County Council has
authorized the study in some of its schools; it is
being taught unofficially in the French Army; the
London Chamber of Commerce has placed it among
the official subjects of examination ; the children
of many of the royal families of Europe are learning
It ; and in Germany there are two publishing houses
making a specialty of Esperanto publications. Med-
ical men, especially in France, but not a few in this
country, are enthusiastic students and propagandists
of the language, and there is already in existence
one Esperanto medical journal.

The need of an international language for scien-
tists and physicians is self-evident, and the Medical
Record has repeatedly called attention to this, espe-
cially in relation to the Triennial International Med-
ical Congress, in which the babel of tongues is so
manifestly a bar to intelligent discussion. The im-
mense advantage that there would be in the use of a
single language, understood and spoken .by all in
these congresses, is universally acknowledged,
but unfortunately international jealousies stand
in the way of the adoption of English, French,
or German as the sole official language. The Med-
ical Record has from time to time urged the adop-
tion of modern Greek (a language as easy to learn
as French or German) as one which all might accept,
without wound to national pride, and we still main-
tain, for many reasons which we cannot here repeat,
that this would solve the problem satisfactorily, at
the same time promoting sound scholarship. But,
needless to say, the suggestion has failed of accept-
ance, and we frankly despair of ever hearing the me-
lodious phrases of Hippocrates or Galen resound in
the meeting hall of any international medical con-
gress. It remains to ask whether Esperanto will
supplv this want of a means of international commu-
nication among medical men. It may, and we dotibt
not the question will be seriously considered at the

438

MEDICAL RECORD.

[March i6. 1(507

fortlicoming Budapest Congress. Except as a com-
promise, we cannot imagine any scientific body
adopting as its official tongue a Frankenstein crea-
tion— perfect indeed in form, but soulless, such as is
Esperanto. Nevertheless, the need of some common
means of communication is imperative, and the ac-
ceptance of any single language, even an artificial
one, as the official tongue of those taking part in the
discussions at international congresses would be of
incalculalile service to scientific progress.

SEQUESTRATION ANEMIA IN SURGICAL

OPERATIONS ON THE BRAIN AND

SKULL.

Hemorrh.age must be regarded as the chief source
of shock in operative work, and the efforts to check
the same have always constituted one of the princi-
ple aims of surgical technique. The hemostatic
clamp and ligature have been found wantmg in
many respects, and in certain operations, as on the
limbs, the blood has been kept from freely circu-
lating in the member by the application of an
appropriate tourniquet. The value of this procedure
is undoubted, for not only is the operative field kept
clear, but the blood is stored away in other parts
for use as a preventive of shock. But what surgeon,
asks Dr. Dawbarn, in an article in the Annals of
Surgery for February. 1907, when about to
operate on however vascular a field of the head,
the neck, or the body, ever applies this same princi-
ple, and, to avoid hemorrhage, accumulates blood
in the extremities? The suggestion seems reason-
able enough, and if it is advisable in one instance it is
obviously so in the other. Naturally the extremi-
ties can be made more bloodless than other portions
of the body, but Dawbarn claims that experience
has shown that we can with entire safety withdraw
into .the limbs some quarts of the whole bulk of the
blood, which constitutes one-thirteenth of the indi-
vidual's weight. This temporary bleeding into the
patient's own vessels can be controlled to a degree
by carefully watching the pulse, and the sequestra-
tion can be continued until there is a noticeable
softening and decrease in the tension, at which
point the operation may be begun. In the cases in
which the procedure has been applied the writer has
obsen,-ed not only a lessened degree of hemorrhage
but also a diminished amount of surgical shock.

It would seem that the suggestion in question
might with greatest advantage be applied in surgical
operations on the brain or the skull, and Dawbarn
has used the method in seven cases of this character.
This has afforded a limited though sufficient experi-
ence to permit of drawing some conclusions as to its
advantages and disadvantages, for it is by no means
universally safe or applicable. To begin with, shock
is apparently not threatened by sequestration ane-
mia, although the brain and heart may temporarily
be deprived of a considerable part of its blood. The
vasotonic centers are still sufficiently supplied with
the circulating medium, and the partial anemia is
well borne compared with the loss of considerable
blood, and so constitutes the lesser of two evils.
Thrombosis and embolism are the two accidents to
be most guarded against, and the causes which might
operate to produce clotting of the comparatively

quiescent blood are three : changes in the blood itself,
in the vessel walls, and in the speed of the current.
Normal blood will not coagulate even when the cur-
rent is markedly slowed, as is evidenced by Bier's
method of treatment, but if either the blood or the
vessels are unhealthy, the predisposing cause is
present which makes clotting possible and seques-
tration dangerous because of venous thrombosis and
possible subsequent pulmonary embolism. Among
the conditions which would serve as contraindica-
tions on this account are the recent occurrence of
typhoid fever or puerperal sepsis, chlorosis or severe
anemias of any kind, and the presence of lime salts
in excess or atheroma of the vessel walls.

Among the chief advantages claimed for this
method of sequestration anemia in brain and skull
surgery, as summarized by Dawbarn, are the follow-
ing : Ease of control of hemorrhage during the
operation because of the lessened vascular tension ;
a shortened operation because of a dryer field ; a
lessened danger of sudden death from pressure on
the respiratory center during work on a brain tumor
or similar condition, because there is an accumula-
tion of blood elsewhere, and finally more space be-
tween brain and skull for working, which permits
the removal of old clots or the separation of adhe-
sions without the risk of lacerating the surface of
the brain. One feature about this procedure which
needs comment is the fact that should any adverse
indications appear during the course of the opera-
tion, such as irregular or rapid pulse, it is a simple
matter to deal with it by slowly releasing one or
more tourniquets, so that an increased supply of
blood is afforded to the heart. Weighing the advan-
tages and disadvantages of this procedure against
the production of shock and hemorrhage, it would
appear that the suggestion is a most valuable one if
used with the due and proper precautions enumer-
ated in the writer's paper.

THE EFFECT OF A SALT-FREE DIET IN
BRADYCARDIA.

It has been observed in a number of instances that
the complete withdrawal of salt from the food re-
sulted in a return to the normal of a permanently
slow pulse. Notwithstanding this fact, the knowl-
edge has rarely been applied, because the condition
of bradycardia has usually been attributed to some
disturbance in the innervation of the heart or to a
myocarditis, and treated accordingly, whereas in
reality a chronic nephritis is almost always the cause
of the trouble. Enriquez and Ambard (Semaine
Medicalc, No. 4. 1907). who have made a practical
study of the subject, report one case in which the
pulse increased from 32 to 72 beats within a period
of seven weeks without any measures other than the
withdrawal of salt from the food. At the same
time there was a well-marked increase in the body
weight. In seeking for a cause for bradycardia, the
writers contend that as in a true case the contrac-
tions of the ventricle alone are diminished while
those of the auricle remain normal in frequency,
the innervation of the organ is not at fault, for mus-
cular exertion will affect the contractions of both
chambers. The other theory is based on the assump-
tion that the motor impulse in a cardiac contraction
afifects the mvocardiuni without the medium of t'ae

March i6. 1907]

MEDICAL RECORD.

439

intracardiac nerves. The connection between auri-
cles and ventricles is represented by a muscle bundle
which extends from the right auricle through the
septum to the papillary muscles of the ventricles.
Division of this bundle leads at once to a disturb-
ance of the synchronism between auricles and ven-
tricles. In the animals used for the experiments the
procedure also produced the picture of a perma-
nent bradycardia, and a compression of the bundle
referred to resulted in the production of the well-
known Stokes-Adams symptom complex.

Thus far eight autopsies have been recorded in
cases of bradycardia in which the muscle bundle
known by His" name has been found to be the seat
of lesions, and this fact may be taken to constitute
an important support for the myogenous theory
of the disease. The reason why the withdrawal of
sodium chloride is effective in such cases, therefore,
becomes plain, for a chronic nephritis is usually
present, together with retention of the chlorides,
and the myocardium is therefore constantly bathed
in a hypertonic solution which interferes with its
proper functions. By withdrawing the salt, the
correct physiological tone of the muscle is restored.
An important point, however, is that a salt-free
diet must be persisted in for a long period of time
before any effect can be noted.

is affected and weakened by the toxemia nf nn -1-
monia — not merely its right auricle and ventricle
because of the pulmonary obstruction.

Cardiac Dilatation in Pneumonia.

The sudden death in this city not long since of a
man prominent in the theatrical world called atten-
tion to the danger of a dilated heart in pneumonia.
He had been ill for several days with pneumonia, but
the attack was light, and recovery would doubtless
have occurred had not acute dilatation of the heart
occurred. That this is one of the most frequent
causes of death in this disease has long been recog-
nized, and not a few clinicians have believed that
herein lies the sole danger of pneumonia, and have
based their treatment of the disease upon this theory,
their efforts being directed from the beginning of the
attack to support of the heart. In the American
Journal of the Medical Sciences for February,
Beverlev Robinson devotes a considerable part of an
interesting article on "Acute Cardiac Dilatation" to
the dilatation of the right side of the heart occurring
in the course of pneumonia. He refers to the rec-
ommendation by A. H. Smith of immediate recourse
to the vasodilators in such cases, since the indication
is to shift the mass of blood from the veins when it
is stagnating to the arteries and the left side of the
heart. Robinson, however, believes that local blood-
letting by leeches or wet cups is of greater efficacy,
and he prefers this even to venesection. He believes
the good effect is to be explained, not by the amount
of blood taken from the patient, but by the reflex
started locally in the right ventricle that is trans-
mitted to the respiratory center, and from there
becomes additionally stimulating to the heart. It is
also true, as noted by Lees, that the vasomotor
nerves are called into action through this reflex, and
afford relief through dilatation of the peripheral
arteries. We should beware of the use of digitalis
instead of the vasodilators in these cases, though
Robinson says that, after distention of the right
heart has been relieved by leeches or venesection,
digitalis may become very serviceable in giving
strength to cardiac beats when the pulse is weak,
rapid, and intermittent. Digitalis is also sometimes
useful, in his judgment, when the heart as a whole

A Method uf Identifying Tuberculous Pus.

About a vear ago Miiller and Jochmann described
a method for determining the proteolytic power of
specimens of pus by estimating the degree of diges-
tion of coagulated blood serum caused by the pres-
ence of small amounts of the material to be tested.
In order to do this, by means of a platinum loop
or a glass rod, small drops of the pus are transferred
to the surface of a Petrie dish containing Loffler's
blood serum. The dish is then kept for a consider-
able length of time, preferably twenty-four hours,
in an incubator maintained at the temperature of
50°-55° C. The occurrence of proteolytic ferment
action is then shown by the formation of minute
saucer-shaped depressions, of which the pus droplet
forms the center. If no ferment is present in the
pus the drop simply dries without causing any
change in the surface of the medium. The proteo-
lytic "action was ascribed by the authors to the set-
ting free of a ferment from the polynuclear leu-
cocytes, and as one of their conclusions they sug-
gested that it might be found possible to make use
of this method in differentiating tuberculous pus
from that produced through the agency of other
microorganisms, owing to the fact that under the
conditions stated proteolysis was not, as a -rule, pro-
duced by tuberculous pus. This idea has been tested
in a large number of tuberculous and nontuberculous
cases bv Kolaczek and Miiller (Deufsche medizin-
ische I'Vochenschrift. February 15, 1907)- These
authors have found that in dealing with pus coming
from untreated, closed, purely tuberculous proc-
esses no proteolytic action on the blood serum was
obtained, while, on the other hand, pus taken from
other infections of the most varied nature never
failed to give the characteristic digestion of the
serum medium. It therefore appears that if a given
specimen of pus does not exhibit any proteolytic
powers the case is one of tuberculous nature,
whereas if there is well marked digestion of the
medium the process is probably one of an acute
inflammatory character. The test is not, however,
in its practical application as simple as this might
seem to indicate, for in cases in which there is a
mixed infection, or in which the condition has under-
gone treatment, particularly if this has taken the
form of injections of iodoform, proteolytic powers
of considerable activity may be present in the pus.
Like many diagnostic tests the method, therefore,
has a much greater negative than positive value, but
it is quite possible that in the hands of those wlw
have become familiar with its limitations it may
prove of service.

The Treatment of Gonorrhea.

The multiplication of the remedies available in the
treatment of specific urethritis has led to what is
perhaps an exaggerated idea of the part played by
local applications in the management of the disease.
At anv rate, Zieler (Miluchener medisinische Wo-
chens'chrift. February 12, 1907) is of the opinion
that in considering ' the therapeutic problems of
gonorrhea one important factor is often lost sight
of. or at least is not accorded the importance^ it
deserves. This is the beneficial action of the in-
flammatory process itself, by means of which the
bacteria in the deeper layers of the mucous mem-

440

MEDICAL RECORD.

[March i6, 1907

brane, where they are more or less out of reach of
even those urethral medicaments that have the great-
est penetrating power, partly are destroyed by the
bactericidal properties of the serum, and partly are
brought up to the surface with the exudate. It is
largely the virtue of the modern silver preparations
that they encourage this favorable condition of local
hyperemia and exudation without any attending
damage to the tissues, while at the same time,
through their antiseptic power, they destroy the
gonococci that have been brought to the surface
of the mucosa, and which would otherwise be able
to proliferate actively in the exudate. While there
is nothing essentially new in this doctrine it empha-
sizes a phase of the phenomena going on in the
course of an acute urethral infection that is often
disregarded, but which, in view of the modern ten-
dency to attach more and more importance to the
inflammatory reactions as salutary processes, must
not be overlooked.

An Aid in Eliciting the Knee Jerk.

Clinicians not infrequently encounter difficulty in
testing the knee jerks owing to the inability of the
patient to relax properly the musculature of the leg
under investigation. It was to facilitate the exami-
nation in such cases that Jendrassik devised his
simple maneuver for diverting the attention of the
patient, and thereby eliminating all stimuli that
might interfere with the completion of the reflex
arc. As is well known, this maneuver consists in
having the patient pull, with the flexed fingers of the
one hand against those of the other, at the same
time looking upward. Kronig (Berliner kUnische
Wochenschrift, October 29, 1906) says that while
this procedure is usually successful, it is sometimes
difficult to induce patients of a low grade of intelli-
gence, or children, to carry it out properly. He
suggests in such cases resort to the following
method : The patient is directed, at the word of
command, as quickly as possible to take a forcible
inspiration, at the same time looking upward. The
patellar tendon is tapped while the patient is carry-
ing out the prescribed act, and it is stated that the
diversion of attention thus produced is sufficient to
abolish all inhibitory stimuli. Kronig says that the
measure is so simple that no difficulty is experienced
in having patients of any sort put it into execution,
and, after trying it in some hundreds of cases, he
avers that it is just as effective as the Jendrassik
maneuver, and is superior to this in its universal
applicability. The method would seem to have the
drawback of requiring considerable attention on the
part of the examiner in order to time the percussion
stroke properly, and we presume that in most cases
the Jendrassik method will continue to be generally
used. When difficulty is experienced with this it is
possible that recourse to Kronig's suggestion may
prove of service.

AUT0INT0XIC.\TI0N FOLLOWING LAPAROTOMY.

Intestinal paralysis after abdominal section oc-
curs so frequently that it is accepted by many as a
natural accompaniment of an operative invasion of
the peritoneal cavity. Various causes have been
assigned to account for this corriplication, among
which damage to the gut by handling or exposure,
sepsis, and peritonitis have been accepted as the
most common and likely. Within two or three days
after operation evidences of intestinal obstruction
appear, such as meteorism, absolute constipation,

nausea, vomiting, small rapid pulse, and a subnormal
or slightly elevated temperature — a clinical picture
familiar to most surgeons. If the patient dies the
autopsy may fail to disclose evidences of either sepsis
Or peritonitis and nothing is apparently found to
account for the often unexpected fatal ending. Dr.
Keller of Berlin, writing in the Zeitschrift fiir Geb-
nrtshilfe und Gynakologie, Vol. 55, No. 2, suggests
that this form of intestinal paralysis may possibly be
due to an autointoxication and reports two instances
in which this seems to have been proven. In neither
did the intestine receive any injury during the opera-
tion, and yet . all the usual clinical symptoms of
intestinal paralysis were present. The foul stools
which followed the administration of a cathartic
brought about a relief from the symptoms and the
urine showed a large amount of indican. As a
previous history of marked constipation was elicited
in both of these patients it would be the part of
wisdom, in every case intended for abdominal sec-
tion, carefully to correct this faulty condition. Aside
from the anteoperative prophylaxis it is advisable
in every doubtful case to stimulate peristaltic action
after operation by appropriate means, among which
diet and the omission of opium are important factors.

Amyl Nitrite in Hemoptysis.

In the Lancet of January 19, 1907, Dr. Francis
Hare refers to the recent publication of Abrams
of San Francisco relative to the latter's statement
that nitrite of amyl promotes hemostasis of the
lung largely through reflex action. Commenting
on this statement Hare maintains that the only phy-
siological action of the remedy which rests on any
secure foundation is the sudden production of vaso-
dilatation, or in other words, the sudden inhibition
of vascular tone, in wide areas, if not generally ; this
being of necessity associated with a fall of blood
pressure and a compensatory acceleration of the
heart beat. All other actions ascribed to the drug
vould appear to depend on mere inference from pre-
■ronceived theories. For example, from the relief
sometimes afforded by it in the asthmatic paroxysm,
amyl nitrite is inferred to have the power of relax-
ing the bronchial muscles. But the inference is un-
justifiable because the view that asthma depends on
bronchial constriction remains an unverified hypoth-
esis. The only view of the mechanism of the asth-
matic paroxysm which is consistent with the known
physiological action of amyl nitrite is the vasomotor
hypothesis ; amyl nitrite relieves asthma by relaxing
the peripheral vasoconstriction, which is an essential
factor in the bronchial vascular distention respon-
sible for the obstruction to respiration.

Nma at % Wnk.

The Evil Spirit of Paternalism in Medical
Organizations. — In his presidential address to the
Medical Society of the State of New York, at its
recent annual meeting, Dr. Joseph D. Bryant, now
president-elect of the American Medical Associa-
tion, said : "It would be sadly amiss, indeed, were I
not to admonish you at the opening of a united
career of the grave perils begotten by the spirit of
paternalism which, not infrequently, is a pernicious
by-product of organized power. The seductive and
oppressive influence of this spirit often usurps, and
may inhibit that nobler, more enduring, and benefi-
cent one. characteristic of common manhood and
of professional brotherhood. In this relation it

March i6, 1907]

MEDICAL RECORD.

441

should not be forgotten that the greater and more
extended is the membership of a fraternal body, the
greater and more extended its constituent paternal
desires are apt to be."

New York Skin and Cancer Hospital. — The
governors of the New York Skin and Cancer Hos-
pital, Second avenue, corner Nineteenth street, an-
nounce that Dr. L. Duncan Bulkley will close his
clinical course with four special lectures as follows :
March 27, "Practical Points in the Diagnosis and
Treatment of Diseases of the Skin ;" April 3,
"Errors in Diagnosis and Treatment : Donts in Der-
matology ;" April 10, "Danger Signals from the
Skin;" April 17, "The Significance and Treatment
of Itching." They also announce a lecture by Dr.
William Seaman Bainbridge on .'\pril 24 on "Some
Phases of the Cancer Problem." The lectures,
which are free to the medical! profession, will be held
in the Out-Patient Hall of the hospital at 4:15
o'clock.

Magazine for the Blind. — The first number of
the Matilda Ziegler Magazine for the Blind, which
has been established by Mrs. Matilda Ziegler, ap-
peared last week. The magazine contains 96 pages
and measures 14X12.X2 inches. An edition of 7,000
was prepared, and nearly all the numbers have been
sent out free, though the nominal price of the maga-
zine is ten cents a copy. The luimber is made up
of articles on a wide range of subjects, and a map
of the West Indies and Central America, showing
the situation of Kingston and of the Panama Canal,
is included. The magazine is printed partly in New
York point and partly in Braille point. The secre-
tary of the New York Association for the Blind,
Miss Winifred Holt, has announced that the associ-
ation is in need of funds for running expenses, and
that it is impossible on this account to give assist-
ance to the large numbers of blind persons who are
anxious to learn of some way of supporting them-
selves. The treasurer of the organization is Mr.
Herbert S. Barnes, of 35 Wall street.

Hudson River Ice. — The report of the chemist
employed by the Merchants' Association of this city
to e.xamine the quality of the ice being harvested
from the Hudson shows that there was considerable
evidence of sewage pollution in the samples an-
alyzed. Of twenty-five specimens examined eleven
are reported as "good," ten as "contaminated," and
four as "bad." It must be remembered, however,
that while it is undoubtedly highly undesirable that
ice intended for domestic uses should be taken from
sources open to suspicion or worse, if these analyses
had been made in samples taken from ice that had
been in storage for some months, as far as the bac-
teria are concerned, the results would probably have
been much less unfavorable.

Compulsory Vaccination. — A bill has been in-
troduced into the Pennsylvania Legislature requir-
ing all children to be vaccinated before they are two
years old, and also providing that persons taking up
their residence in the State shall be vaccinated
within one month or produce a physician's certificate
that they have been vaccinated or have already had
smallpox. It is further provided that any child or
person required to be vaccinated under the pro-
visions of this act, but suffering from any affection
or condition that would as a result of vaccination
become dangerous to life or health, mav be excused
from the enforcement of the law for a period of one
year on presentation of a written certificate to this
effect signed by a regularlv licensed physician and
indorsed by a phvsician appointed by the Depart-
ment of Public Health or by any local Board of
Health of the Commonwealth.

Illinois State University Medical School. — In

1897 the State University of Illinois organized a
medical school as one of its departments. Not
owning suitable buildings, it rented the premises of
the College of Physicians and Surgeons, making an
agreement with the college that the e.xpenses of the
new department, including rent, were not to exceed
the fees received from the students. This agreement
has been kept until the present, and the State has
not contributed a dollar to the school, which has
been supported by fees from its students. The de-
velopment of the University has reached the stage
where the ownership of its medical department
buildings is necessary. The bill now before the
legislature, while asking for an appropriation of
$386,000, states that it is for the purpose of acquir-
ing suitable buildings and equipment for tlie con-
duct of the medical department, and that in case
the trustees should see fit to purchase the property
of the College of Physicians and Surgeons, they
shall not pay a sum to exceed the actual value of
the tangible property.

Health Matters in Chicago. — Up to the close of
February a total of 48.155 children in attendance on
the public schools had been examined. Of these,
7,205, or nearly 15 in every 100, were either suffer-
ing, or convalescent, from a contagious disease, and
capable of spreading contagion among other
scholars. There were found 2,049 cases of diph-
theria and tonsillitis, 695 cases of mumps, 686 of
scarlet fever, 537 of measles, 228 of whooping-
cough, 198 of chickenpo.x. and 2,812 cases of puru-
lent oplithalmia, impetigo contagiosa, scabies,
pediculosis, etc. Nearly one-third of the total exclu-
sions were on account of diphtheria and tonsillitis,
and nearly one-tenth were on account of scarlet
fever. The Health Department asks, Is it any won-
der that these diseases have been epidemic? Had
medical school inspection been established and con-
tinued, as repeatedly prayed for by the Department,
it might not have wholly prevented the scarlet fever
epidemic, since the growing infrequency of this dis-
ease since 1902 had resulted in the accumulation of
an enormous crop of children susceptible to its infec-
tion. An epidemic among these was inevitable
whenever the specific contagion, whatever it may
be, should be introduced. But there is no question
among sanitarians and students of preventive medi-
cine that its ravages could have been greatly re-
duced and its spread effectually checked had the
early cases been promptly recognized and measures
of restriction duly enforced.

The Inspection of School Children. — The Com-
mittee on Public Health and Legislation of the St.
Louis Medical Society appeared before the Sanitary
Committee of the City Council on February 26.
together with representatives of other organized
medical bodies, and argued in favor of the passage
of a bill for the medical inspection of public school
children. They report that the passage of the bill
is practically assured.

Spectacles for School Children. — The managers
of the New York Throat, Nose, and Lung Hospital
have issued a circular addressed to school principals
in Manhattan and the Bronx announcing that the
hospital will hereafter supply spectacles free to
school children whose parents are too poor to buy
. them, and also calling attention to the dental clinic
of the hospital, where the teeth of school children
will be treated free of charge. The dental clinic
was established in October, 1905.

Throat Affections in School Children.— The
school physicians of South Manchester, Conn., re-

442

MEDICAL RECORD.

[March i6. 1907

cently found that 200 out of 1,000 pubHc school
children in that city were suffering from enlarged
tonsils or adenoids to a degree that made operation
advisable.

The St. Louis Medical Society has built a new
auditorium and created fresh enthusiasm in its mem-
bers. Many new members are being elected at each
meeting, and the average attendance at the weekly
meetings for the first two months of the year has
been 129.

The Cincinnati Academy of Medicine cele-
brated its semicentennial at the Hotel Sinton on
March 5 with a banquet, at which 350 medical men
sat down. Dr. J. E. Greiwe, the retiring president,
was toastmaster, and speeches were made by Drs.
Byron Stanton, the onlv charter member present;
Dr. A. G. Drurv, Dr. N. P. Dandridge, Dr. P. S.
Connor, Dr. B. P. Good, Dr. S. Nickles, Dr. C. D.
Palmer, and Governor Bradley of Kentucky. The
election of officers for the following year resulted
as follows : President, Dr. F. W. Langdon ; First
I'ice-Prcsideiit. Dr. Wm. Gillespie; Second Vice-
President, Dr. John Oliver ; Secretary, Dr. Mary
K. Isham ; Treasurer, Dr. A. G. Drury.

Berlin's Municipal Physicians. — The assistant
physicians in the various municipal hospitals of Ber-
lin have agreed to hand in their resignations on
April I. This is in order to express their dissatis-
faction at the reply to a petition handed to the au-
thorities over eight months ago. The petitioners
asked that the salary of the official assistant hospital
physicians be raised from 100 to 120 marks a month,
that a yearly vacation of four weeks be grantea. and
that they be received into the Government accident
insurance system. After eight months of delay a
negative decision was rendered. Each assistant
physician has seventy or more patients under his
care and is on duty from 9 a.m. to 7 p.m. In the
evening he has to write up the case histories. It is
expected that the contemplated move of the physi-
cians will cause the authorities to reconsider their
decision.

Information Bureau in Berlin. — In the Kaiserin
Friedrich-Haus an informatiisn bureau has been
opened for the benefit of foreign medical students
and physicians. It is the object of the bureau to
supplv free of charge information in regard to
courses, hospitals, collections, and other matters of
interest to visiting medical men.

Plague in Russia. — Dr. Schreiber, the worker
in the Alexander Laboratory in Kronstadt, who con-
tracted plague from cultures with which he was
experimenting, has died, and one of his colleagues is
reported to be suffering from a suspicious infection.

Smallpox is reported to be epidemic at Dunkirk,
France, and also in Lille.

The Fourteenth International Congress for
Hygiene and Demography will be held in Berlin.
Germany, September 23 to 29 of the current year.
The secretary-general of the congress is Dr. Niet-
ner, Eichhornstrasse 9, Berlin W., to whom all com-
munications with reference to the congress should
be addressed.

Congress of the German Urological Society. —
The first congress of this organization is to be held
in Vienna, October 2 to 5, 1907. The principal
theories for discussion will be the diagnosis and
treatment of renal tumors, the diagnosis and treat-
ment of nephrolithiasis and alburhinuria. One of
the features of the congress will be an exhibition of
specimens and instruments pertaining to genitouri-
nary surgery. Non-members of the society who

wish to take part in the proceedings are requested to
communicate with Dr. Kapsammer, IX. Maria The-
resienstrasse 3, Vienna.

International Congress of Psychiatry, Neurol-
ogy, and the Care of the Insane. — A congress for
those interested in these matters is being organized
under the auspices of the Dutch Society of Psychi-
atry and Neurology, to be held at Amsterdam from
September 2 to 9, 1907. Those w'ho have been in-
vited to be American members of the committee of
arrangements are : Dr. G. Alden Blumer of Provi-
dence; Drs. Charles K. Mills, John K. Mitchell and
S. Weir Mitchell, of Philadelphia, and Dr. R. G.
Rabinovitch, of New York City.

Seventh International Congress of Physiology.
— This will be held this year at Heidelberg from
.•August 13 to 16, under the presidency of Professor
August Kossel. In corinection with the congress
there will be an exhibition of scientific apparatus.
.Announcements of communications should be sent
to the Physiological Institute, Heidelberg, before
June 15.

State Medical College for Oklahoma City. — .\
charter has been granted to a new regular medical
college in Oklahoma City with the title of the Okla-
homa State Medical College. The incorporators
include Dr. W. J. Darnell of Mountain View, Okla.,
who has been made President of the school ; Dr.
West Moreland, Atlanta. Ga. : Dr. H. H. Baty of
Rome, Ga. ; Dr. J. R. Phelan of Oklahoma City,
-Secretary of the corporation, and J. P. Eckers of
(Jklahoma City.

City Hospital Buildings. — Plans have been filed
for a group of new administration buildings to be
erected on Blackwell's Island as annexes to the
present City Hospital. The group includes two one-
story reception houses for patients to cost S25.000
each, an operating pavilion to cost $25,000, a three-
story kitchen and service building to cost Si 2,000,
a three-story and attic residence for the medical
staff to cost $54,000 and to be called Janeway Hall,
and a two-story and attic residence for the hospital
superintendent to cost $20,000. Plans have also
been filed for two new recreation pavilions to be
built on the island for the inmates of the City Home
for the Aged and Infirm.

For Poor Tuberculous Patients. — A bill has
been introduced into the Pennsylvania Legislature
appropriating the sum of $600,000 for two years,
and providing for the establishment and mainte-
nance under the charge of the State Department of
Public Health of one or more sanatoria for the free
care of indigent persons suffering from tubercu-
losis.

Stony Wold Sanatorium. — The managers of
this organization, which was incorporated for the
purpose of taking care of consumptive working-
women and children, succeeded in raising before
March i the sum of $75,000 necessary to obtain a
large donation made contingent in this stipulation,
and the sanatorium is now entirely free from debt.

Contagious Diseases Hospital for Brooklyn. —

By a decision of the Court of Appeals, rendered last
week. New York City may proceed with the erection
of a contagious diseases hospital in Hawthorne
street, between Kingston and Albany avenues,
Brooklyn. A person who objected to the plan to
place such a hospital in this situation obtained a
judgment at Special Term enjoining the citv from
the erection of the hospital. The .Appellate Division
reversed the judgment, and now the Court of Ap-
peals upholds that decision.

MarcM I'l. 1907]

MEDICAL RECORD.

443

St. John's Guild. — The fortieth annual report of
this organization shows that the total number of
children and mothers who last summer received the
benefits of the Guild's floating hospital was 40,983.

Dr. J. R. Whiting has resigned as chief of the
genitourinary clinic of Columbia University and as
assistant attending genitourinary surgeon to the
first surgical division of Bellevue Hospital. Dr. W.
S. Reynolds succeeds him at the College of Physi-
cians and Surgeons, and Dr. T. F. McCarthy at
Bellevue.

Dr. C. G. Handler has been promoted to the
position of adjunct assistant attending genitourinary
surgeon to the first surgical division of Bellevue
Hospital and chief of the genitourinary clinic of the
Out-Patient Department of Bellevue Hospital.

Dr. H. M. Archer of this city has been ap-
pointed honorary medical officer of city fire depart-
ment, with the rank of chief of battalion.

The Pasteurization Bill at Albany. — The Reece
pasteurization bill had a hearing before the Cities
Committee in the Assembly of the New York Legis-
lature on Tuesday of this week. Assemblyman
Reece, speaking for his bill, said that infant mortal-
ity on Randall's Island dropped from 42 per cent, to
16 per cent, in a few years, following the introduc-
tion of pasteurization there. Health Commissioner
Darlington opposed the bill because it involved
mandatory legislation. He admitted that pasteuri-
zation was desirable under certain conditions.

Women Physicians in Europe. — Hungary is
said to have only twenty-seven women physicians.
The figures of the French Bureau of Education
show that in 1906 there were. 2, 264 female students
in the French universities, of which numljer 454
were studying medicine.

Postage Stamps costing 50 per cent, more than
the regular issues are now on sale in Holland. The
additional amount received is to be used by the gov-
ernment in the combat against tuberculosis.

The Jewish Maternity Hospital has opened its
out-door department at 270 East Broadway, and
applicants are received daily, except Sundays, be-
tween three and five p.m.

Obituary Notes. — Dr. Charles Reed of Brook-
lyn died on March 3. He was born in Ossining,
N. Y.. in 1856, and was graduated from the College
of Physicians and Surgeons in 1879.

Dr. Tho.mas a. Skillman of New Brunswick,
N. J., died on March 6 at the home of his daughter,
Mrs. Ellis Warren, in Princeton, where he had gone
to recuperate. He was injured in a trolley accident
some time ago, which compelled him to give up
active practice. He was graduated from the New
York Universitv Medical School with the class of
1878.

Dr. Clifton Scott of Des IMoines, la., died on
February 27, at the age of fifty-four years. He
was born in Como, 111., and in 1883 was graduated
from the Louisville College of Physicians and Sur-
geons, .^fter post-graduate work in Rush Medical
College he began practice in Dickson, 111., but has
been a resident of Des Moines for the past seventeen
years.

Dr. .'\lexander MacIntosh of Flalifax, N. S.,
died on February 28. in his seventy-sixth year, after
an illness of several weeks. He was born in South
River, .^ntigonish County, and received his medical
education from the LTniversity of Pennsylvania Med-
ical College, from which he was graduated in 1858.
He had practised in Antigonish for over thirty
years, although for the last fifteen years he had
retired from active w-ork.

Dr. J. M. Willis of Temple, Tex., died on Febru-
ary 24, at the age of eighty-five years. He was a
native of Barnesville, Ga., and had practised in
Waco since 1865. He retired from practice some
years ago.

Dr. Lyman W. Bliss of Saginaw, Mich., died in
San Antonio, Tex., on February 20, at the age of
seventy-one years. He was born in Smithfield,
N. Y., and served in the Civil War as surgeon of
the Tenth New York Cavalry. He had practised
in Saginaw since 1866, and in 1891 was elected
president of the State Medical Society.

Dr. Robert Provan of South Brookline, Mass.,
died on February 24. He was born in New Bruns-
wick, and received his medical degree from Harvard
College in i860. He had practised for many years
in South Boston.

Dr. John Barker of Woodbridge, Conn., died on
February 16, at the age of seventy-two years. He
was graduated from the Yale Aledical School in
i860, and, after practising for a time in New Haven,
removed to Westville about twenty-five years ago,
I'ive or six years ago he retired from active practice,
although he continued to act as medical examiner
in Woodbridge.

Dr. J. W. Parker of Kansas City, Mo., died on
March 2, at the age of eighty-five years. He was
born in Lexington, Ky., and, after receiving his
medical education in that city, in 1853 began practice
in Kansas City, at that time a village of 3,000 people.
He continued in active practice until six years ago,
when compelled to retire on account of failing eye-
sight.

Dr. George T. Church of Brooklyn died sud-
denly of heart disease on March 10, at the age of
forty-nine years. He was a native of Waterville,
N. Y., his father being the well-known Justice
Charles Church. He was graduated from Hamilton
College in the class of 1880, and, after some years
spent in various teaching positions, studied medi-
cine at the Albany Medical College and at Dart--
mouth. He practised for a time in Saratoga,
Springs, but some years ago removed to Brooklyn,
He w-as one of the examiners of the Civil Service
Board.

Dr. William B. Grain of Richfield Springs,,
N. Y., died of heart disease on March 9. at the age
of seventy years. He was graduated from the Uni-
versity of Pennsylvania at the beginning of the Civil
War and was assigned to take charge of the United;
States Military Hospital at Wa.shington, D. C.
Later he was assigned to the United States Hospital
at New Creek, Va. He served with the rank of
Major in the Maryland cavalry until the close of the
war, and was at Antietam and other battles. From
1866 until his death he was a successful practitioner
at Richfield Springs.

Dr. J. K. Cassel died at Philadelphia on March 2
at the age of seventy-two years. He was graduated
from Pennsylvania Medical College in the class of
1861, and he served during the Civil War with the
Fifty-seventh Regiment. Pennsylvania Volunteers.

Dr. Fred Suesserott died at Chambersburg, Pa.,
on March 2, at the age of fiftv years. He was grad-
uated from the Medical Department of tlie Uni-
versity of Pennsylvania in the class of 1871.

Dr. Wm. J. Butler died at Wilkesbarre, Pa., on
March 4 as the result of injuries received in a rail-
way accident. He was graduated from the Pennsyl-
vania Medical College in the class of 1885.

Dr. J. Ward Steele died at Dover, Del, oiij
March -|, at the age of tliirty-tliree years.

444

MEDICAL RECORD.

[March i6, 1907

RULE AS TO NEGLIGENCE IN X-RAY
TREATMENT.

In February of this year a case was brought to trial
before Judge Brady and a jury in the Supreme Court
in this city, in which a well-known physician was
charged with negligence, in that he "unskillfully,
carelessly, and negligently administered to the plain-
tiff what is commonly called or known as .f-ray
treatment, whereby the hair on the left side of plain-
tiff's head was burned off, and her face and neck on
the same side were greatly burned, hurt, and in-
jured." The plaintiff, a waitress, alleged special
damage in loss of wages and demanded judgment
for $10,000. The case was left to the jury, who
found a verdict for the defendant. In the absence
of any reported case on this subject in any court in
this State, the rules of law stated in the Judge's
charge to the jury are of interest. Before consider-
ing them, however, the facts as they appeared in evi-
dence should be considered.

Tlie Facts. — The plaintiff, about thirty-five years
of age, had had an operation for tuberculous glands
on the right side of her neck. A large scar, with
considerable loss of tissue, marked this operation.
Subsequently, the glands on the left side of her neck
were similarly affected, and she applied at a hospital
for treatment, but refused an operation. She was
then advised that .r-ray treatment for this malady
was often successful, and in the spring of 1903 she
applied to a physician for that treatment. After
several applications, he noticed on one occasion
when she visited his office that she had developed a
slight dermatitis. He then suspended treatment for
about two weeks. Shortly after, and while still
under treatment by this physician, she applied to the
defendant for .r-ray treatment, and during May,
1903, tlie two physicians treated her contemporane-
ously, each remaining in ignorance of the other's
treatment.

In the fall of 1903 she had three treatments from
the defendant at intervals of about ten days. A 16-
plate Waite & Bartlett machine was used with a
5-inch General Electric tube. The surface of the
tube was not less than 8 inches from the plaintiff's
neck, and the exposure on each occasion lasted 8
minutes. Her head and shoulder w-ere protected by
sheets of lead foil, with an aggregate thickness of
about i/i2-inch. Four or five days after the third
treatment a dermatitis of the second degree began to
develop, extending from the bottom of the neck to
above the ear, and embracing the whole left cheek.
She called on the defendant, who prescribed an anti-
septic dressing and urged her to call again in a day
or two. He saw her only once more, about ten days
later, when the w-ound was purulent and dirty, and
the hair about the ear had fallen.

At the time of the trial she had a network of
telangiectases over the glands in her neck and ex-
tending into her cheek, and a slight sclerosis behind
the ear. Her hair had grown again. The glands
were still slightly enlarged on both sides of the neck.
She had been examined in October, 1904, after suit
began, and it appeared that the telangiectases had
increased considerably since that time. She had had
further .r-ray treatment from a third physician in
the interval.

The Expert Ezndence. — The evidence of experts
on both sides was that the duration of the treatment
and the distance of the tube from the neck w-ere re-
garded as safe, that the static machine was deemed
safer than a coil, that the quantity and quality of the
;r-ray continuallv varied, not merely from day to
day but in the course of a single application, that

the protection by a lead sheath was the best known
to science, and that no means was known to science
of accurately measuring either the quantity or qual-
ity of the .r-ray.

The Laiv. — On this state of facts, the Judge
charged the jury upon the question of the physi-
cian's duty according to the familiar rule. {Pike v.
Honsinger, 155 N. Y. 201). First, he mu.st possess
"only that reasonable degree of learning and skill
relating to x-ray treatment commonly belonging to
a physician and surgeon using that treatment in the
city of New York in November, 1903." Second, he
must use "only reasonable care and diligence in the
e.xercise of his skill and the application of his' learn-
ing in the treatment by .^■-ray." Third, he was
bound to treat the plaintiff "according to his best
judgment." The Judge pointed out that the de-
fendant was here charged with negligence or breach
of duty only in the actual treatmt-nt, the second
branch of the duty imposed on him by law, as above
defined. The possession of adequate skill and learn-
ing, and the exercise of best judgment were thus not
in the case. Reasonable care and diligence in the
treatment meant "such ordinary care and diligence
as is usually given by a physician in good standing.
It does not mean the highest possible care and dili-
gence, or such care and diligence as might have been
used by some other physician, or even by the de-
fendant himself." The physician is not an insurei
or guarantor, and "in .r-ray he does not insure the
patient against a burn."

The part of the charge of chief significance, how-
ever, was that in which the Judge dealt with the
doctrine known as res ipsa loquitur. Briefly stated,
that doctrine means that the accident and the sur-
rounding circumstances speak for themselves, and
afford prima facie proof of negligence. A common
instance of the application of the doctrine is found
in a railroad collision between two trains. The
Court knows, and everybody knows, that when
trains are operated with ordinary and reasonable
care they do not collide, and the mere fact of a col-
lision, therefore, affords evidence of negligence; the
accident speaks for itself. But the Court here holds
that the mere happening of an .r-ray burn is not evi-
dence of negligence, and it reached that conclusion
doubtless in view of the evidence of the uncertain
state of .r-ray science and bv analogy to cases of
bursting flywheel of an electric machine, bursting oil
tank. etc. iPiehl v. Albany R. R., 30 App. Div.
166. affirmed 162 N. Y. 617; Losee v. Buchanan,
51 N. Y. jG-.Cosulich z'. Standard Oil Co., 122 N. Y.
118; Reiss z: N. Y. Steam Co., 128 N. Y. 103). In
cases of this kind the accident does not speak for
itself, because it may happen notwithstanding the
use of reasonable and ordinary care. In the case of
the bursting flywheel, Judge Landon. afterwards of
the Court of Appeals, said that the doctrine res ipsa
loquitur did not apply : "Because such are the limi-
tations upon human foresight that every reasonable
care does not always prevent accidents, and that
such is the nature of steam and electricity, and the
engines by or upon which they operate, that when
such an explosion as this occurs our experience, or
even expert experience, is not sufficiently uniform to
justify us in presuming that negligence is the cause.
The explosion does not in fact speak for itself and
tell us its cause."

If this is true of steam and electricity a fortiori it
is true of the much more uncertain science of .r-ray.
L'pon this subject the Judge charged as follows:
"If the jury find tliat the plaintiff received the bum
of which she complains in consequence of the treat-

March i6, 1907]

MEDICAL RECORD.

445

ment by the defendant, they cannot infer that the
defendant was neghgent merely because the plaintiff
afterwards suffered from x-ray burn, for the cause
of the burn may be beyond human knowledge, and
even expert experience may not be sufficiently uni-
form to indicate a sure means of preventing it.
Owing to the limitations of human knowledge, the
exercise of every reasonable care does not always
prevent accidents, and this is especially true in deal-
ing with such comparatively little known forces as
electricity and .t'-rays. The jury cannot find the de-
fendant guiltv of the negligence alleged in the com-
plaint unless it can find in the proofs some particular
act of negligence which caused the burn. To punish
the defendant because he cannot explain the cause
of the burn is not necessarily to punish him because
he has done wrong, but may be to punish him
because he does not know something which science
cannot find out, or has thus far been unable to find
out. That would be manifestly unfair, and the law
will not do it."

This charge is the only judicial expression of the
law of this State upon this subject so far as the
reports show. It appears to be logically deduced
from the analogies above referred to.

The attorneys were Black, Olcott, Gruber, and
Bonynge for the plaintiff, and Charles Stewart
Davison for the defendant. The counsel who tried
the case were Irving L. Ernst, for the plaintiff, and
Henry Winthrop Hardon. for the defendant.

OUR LOXDON LETTER.

(From Our Special Correspondent.)

ER.\SMUS WILSON LECTURE — LEUCODERMA — CONDITION OF
BLOOD-VESSELS IN SHOCK — SEQUEL TO ABDOMINAL SECTION
FOR DILATED BOWEL — PERICARDITIS AND PLEURISY IN TY-
PHOID— AMALGAMATION OF SOCIETIES — THE EPIDEMIC —
OBITUARY.

London. February 22, 1907.

An Erasmus Wilson lecture at the Royal College of Sur-
geons has at last been delivered on a dermatological sub-
ject. When the lectureship was founded by Sir E. Wilson
it was intended that this should always be the case,
though later Sir Erasmus yielded to the wish of the Col-
lege Council to extend the scope of the foundation. Since
then nearly thirty years have elapsed since a dermatologi-
cal subject has been taken up by the Erasmus Wilson lec-
turer of the year. At length, however, dermatology has
come to its own, and Dr. Willmott H. Evans on the 4th
inst. took for his subject Leucoderma. In dealing with it
and analogous changes in the pigmentation of the skin he
took up a position in direct opposition to the leading
authorities and textbooks. He maintains with confidence
from very careful examination of the facts that in no
way does the nervous system have any part in the pro-
duction or localization of the patches of leucoderma. He
thinks the action of some toxin derived from the alimen-
tary canal may probably be the cause, this being aided by
the action of light and sometimes by local injurv. The
mechanism by which the effect is produced he attributes to
the vital action of peripatetic cells. That the familiar
facts lend themselves to the first conclusion is obvious.
The "tanning" which we see in summer and which so
soon fades suggests that differences in color are physio-
logical, and the same may be said as to the color of the
different races of men. The tint of the skin in the white
races is mainly due to the color of the superficial fat and
blood-vessels, modified somewhat by the epidermal pig-
ment which in darker races obscures the other factors.
With regard to the common opinion as to a nervous origin
it has been said that symmetry indicates this, but Dr.
Evans maintains that symmetrical distribution is no sign
whatever of connection with the nervous system, and,
moreover, leucoderma is rarely symmetrical. He appealed
to herpes roster as to which there is no disputing the ner-
vous origin and that it affects only one side. TTe sliowed
views of nerve areas, root and peripheral, and bv means
of numerous lantern slides proved that leucodermic patches
do not occupy nerve areas. The association of leucoderma

with some cases of nervous diseases sometimes spoken of
he found so rare as to be mere coincidences. In drug
pigmentation Dr. Evans ranged himself with those who
consider it the effect of local action, the drug being found
where the eruption exists — from which it also appeared
that a poison circulating in the blood may be deposited in
certain places and not generally. As stated. Dr. Evans
considers a toxin from the alimentary canal the cause of
leucoderma, as he does also of some analogous diseases.
A morbid intestinal condition he found often preceded.
The localizing factors he held were mechanical or chemi-
cal— trauma and light. The actual mechanism of de-
pigmentation he compared with that of bleaching of the
hair in old age which ^letchnikoff showed was due to the
action of macrophages which swallow the pigment and
carry it away. He considered the superactivity of these
macrophages was caused by the toxin — their activity wax-
ing and waning according to the varying amount of toxin
or of the local adjuvants. It was seldom that these pec-
cant macrophages can be induced to retrace their steps
and redeposit the pigment. Should they do so the
whitened patches would resume their natural color, but
the area affected usually remained free from pigment
to the end of life.

The condition of the blood-vessels during shock was
the subject of a paper by Mr. J. D. Malcolm at the last
meeting of the Medico-Chi. He holds a view opposed to
that of Dr. G. W. Crile which was founded on experiment
and has been widely accented, and which attributes shock
to a paralysis of the vasomotor center and the consequent
relaxation of the vessels throughout the body. Mr. Mal-
colm repeated the view he has previously proposed, that
shock is due to a paralysis of the vessels in the splanchnic
area. He said Dr. Crile's theory fails to account for the
pallor and other facts, e.g. that the first effect of vaso-
dilatation is to increase the volume of blood in the arteries ;
that fluids cannot tnter the veins during extreme shock, or,
if they did, would pass into the tissues; that the blood-
pressure in the portal vein was raised ; that the specific
gravity of the blood of animals during shock was raised
as shown by Corbett and Roy. These difficulties disap-
pear if we accept Mr. Malcolm's contention that the ar-
teries are contracted. He added that the most successful
treatment is in harmony with his views. Stimulating
vasodilatation and the apnlication of warmth were the im-
portant indications.

Dr. Lockhart Mummery took up the cudgels on behalf
of Dr. Crile's theory and asserted from his own expe-
rience that the arteries were not contracted, but were
relaxed during shock. The capillaries, he said, were
empty, but that was because the arterial pressure did not
suffice to fill them and the pallor depended on this fact.
Fluids entered the circulation easily enough in shock. The
blood-pressure in the portal vein rose a little, but never
higher than that of the arteries. Loss of heat beyond
that caused by diminished metabolism was a doubtful
matter.

Dr. Leonard Williams followed on the same side but
said exhaustion of the medulla was only partial, so that
relaxation was not complete during life.

Dr. .\. Morison said the main thing in shock was cardio-
vascular paralysis, which occurred in different degrees.
In the absence of pressure the elasticity of the arteries
naturally diminished their caliber. Heat stimulated
through the central nervous system.

Dr. Sheen concluded from his personal observation that
the arteries were neither contracted nor dilated. In severe
injuries the patient at first seemed to have little the
matter which could be ascribed to rising pressure. Ac-
cumulation of blood in the abdominal veins soon followed.

Dr. Beddard said the first thing to explain was the fall
in the .general blood-pressure. The main factor was
peripheral resistance and this depended on the condition
of the microscopic arterioles. Pallor was due to accumu-
lation of blood in the abdominal veins. Even the volume
of a limb might be diminished in shock, but the chief
point was diminution of resistance in the splanchnic area.
The muscular tone was reduced and so the chief source
of heat was lost. Hence the application of heat was of the
highest importance, for the patient had become, so to say,
a cold-blooded animal for the time. Nevertheless shock
was not to be considered solely a vascular phenomenon.

The sequel to a case of extreme "dilatation of the rec-
tum and colon as far as the hepatic flexure," for which
abdominal section was performed in November, 1Q04, was
related by Drs. Morley Fletcher and Betham Robinson
at the last meeting of the Clinical Society. The dilated
bowel contained many pounds of dark feces. This matter
was snueezed out of the anus by pressure above. There
was great hvnertrophv of the bowel wall but no sign of
peritonitis, no large glands, no abdominal band. The pa-
tient, a boy of twelve, did well and was exhibited at the

4^6

MEDICAL RECORD.

[March i6, 1907

Society in April, 1905. The boy remained in good health
until Jul-- when he was seized with abdominal pain and
diarrhea and readmitted to the hospital in a comatose
state and died next day. The post mortem showed that the
dilatation had sreatly lessened, the mucous membrane was
healthy and no cause for the dilatation could be found.
The points chiefly submitted by the authors were ( i ) ab-
sence of symploiHs in carlv life; (2) suddenness of onset;
reat improvement after completely emptying the gui.
followed by careful dieting, etc.; (.1) duration of the im-
provement, and (5) the sudden termination with coma —
possibly due to ingestion of some toxic substance or to
some infection. In the absence of any condition that could
cause obstruction the case might be called by the unsatis-
factory term con.genital or idiopathic. Some discussion
followed as to the origin of such cases. The treatment
was approved. It was remarked that the sphincter mu'icle
sometimes showed changes, especially fibrosis, but Dr.
Fletcher was able to sav that in this case it was quite nor-
mal. He added that the circumference of the gut dimin-
ished by as much as five inches from the time of operation
to that of the autopsy.

A somewhat obscure case was related by Dr. Hawkins
of Reading, who had diagnosed it as tvphoid fever with the
very rare complications of pericarditis and hemorrhagic
pleurisy. The patient was a "irl of twenty and her first
complaint was of sore throat and stiffness of her legs.
Five days later she had a rigor followed by diarrhea. No
spots appeared but during her illness the abdomen was
distended and the bowels moved from twice to seven times
a day. VVidal's reaction was tested once with positive
result. Early in the third week there was a systolic mur-
mur at the apex and blood-stained expectoration w'hich
two days later was typically rusty, the physical signs indi-
cating consolidation of left base. In the fifth week the
condition seemed critical, respirations 42, pulse 128. Pa-
racentesis was done and 142 ounces of hemorrhagic fluid
withdrawn. Improvement followed, but temperature did
not become normal until the seventh week. In the dis-
cussion doubts as to the case were expressed. One sug-
gestion was that pneumococcal infection would account for
the course of the disease and the temperature chart shown
was not like typhoid. Another was rheumatic infection,
as to which Dr. Hawkins said salicylates had been given
for two days with a fall of temperature which rose again.
The chief treatment had been hydrochloric acid whicli he
thought the best antiseptic a* a routine measure in typhoid.
.\nother step has been taken this week towards the
amalgamation of our medical societies. .A.t a meeting at
the College of Physicians on Tuesday those interested in
the scheme agreed upon the name of the united body,
which is to be the Royal Society of Medicine.

Four fresh cases of cerebrospinal fever were admitted
in Belfast yesterday and there were three deaths there,
making a total for the week of 103 cases with fifty-seven
deaths. The Health Committee decided to close the school
which four children who had contracted the disease at-
tended. A case in Hull admitted on Wednesday has
proved fatal. Some other cases, sporadic they are as-
sumed to be, have occurred in other districts. Eight cases
were notified last week in Edinburgh, of which six died,
but it was shown that two were not cercbrosninal fever.
At Paisley the totals are eleven cases and six deaths.
More cases have been reported in Dublin and other towns.
The Irish Local Board has recommended local authorities
to adopt notification. The M. O. H. of Cork says in that
city this has remained in force ever since the outbreak
of 1000.

Surgeon-General Sir John M. Donnelly. K.C.B.. died
on iMonday at the a.ge of seventy-six. He joined the
Madras Army in 1856 and served in Burma from 1859 to
1874, filling various offices. In 1885 he became Deputy
Surgeon-General and was in medical charge of the Burmese
Expedition and for his service made C.B. He remained
P.M.O. in Burma until 1800, when he was in the Chin
Lushai Expedition, promoted to Surgeon-General and then
retired. Last Tune he was advanced to K.C.B. He grad-
uated M.D., R.U.I. , i8,,5.

Deputy Inspector General VVm. Campbell Seaman, M.D.,
died last Fridav at the ripe age of eighty-nine. The de-
ceased otTicer, after distinguished service, had retired from
the army many years and enjoyed a healthy old age. He
was walking out last summer, but the severe winter proved
fatal to him. He graduated M.D.Edin., in iS.to, and the
next year took the L.R.C.S. Ed.

The Abortion of Specific Diseases.— In a well-rea-
soned article in the Boston Medical and Surgical Journal
of January 31, 1907. Dr. J. M, French protests against t^e
pessimism which denies the possibility of aborting" a specific
disease. If diphtheria can be aborted, he says, why not
other infectious diseases, if the proper remedy be found?

OUR PARIS LETTER.

(From Our Special Correspondent.)

MORTALITY I.Nf PARIS — THE TREATMENT OF PHARYNGEAL
CA.NCER — IMPALEMENT THROUGH THE RECTUM — SUTURE OF
THE HEART— THE COUNTRY PRACTITIONER — ELECTRIC MEDI-
CATION— .NECROLOGY.

Paris, January, 30, 1907.

.•\n interesting study on the mortality in Paris during the
nineteenth century was presented before the Academic de
Medecine by Bertillon. The speaker pointed out the con-
siderable reduction in the death rate in Paris that had takeiv
place during the past hundred years, for, whereas at the
beginning of the past century the figure was thirty-two to-
thirty-three per thousand inhabitants, at present it was only
nineteen per thousand. This remarkable improvement was
due especially to the reduction in infantile mortality. The
causes of death that have contributed the most to the low
death rate of to-day were the infectious fevers, principally
typhoid fever and diphtheria. In addition to many diseases,
the mortality of which had remained stationary, it was
necessary to mention two which were more frequently
fatal — cancer and nephritis.

In the Societe de Chirurgie, Faure read a noteworthy
paper on the treatment of malignant disease of the
pharynx. He had found that the inverted position was
useful in operating in these cases, and he did not resort
to preliminary tracheotomy, as he considered that this in-
creased the gravity of the prognosis. He had also given up
preliminary intubation. The speaker then outlined the
different surgical routes through which the disease might
be attacked, which were, of course, different according tcv
the situation of the new growth. For tumors limited to
the tonsils he had found that a transverse incision below
the angle of the jaw% with or without additional lateral
branches, was the most useful. Through this incision it
was easy to dissect the entire region, and, after excision
of the ascending ramus of the jaw, to remove all the dis-
eased portions of the pharynx, the tonsil, the base of the
tongue, and the soft palate. However, the temporary or
permanent resection of the ramus of the jaw was a serious
mutilation that should not be resorted to when it could
possibly be avoided. Operations of this sort, although
admirable from the technical standpoint, were unfortunately
very severe, and had a mortality of from 30 to 50 per cent.
The results obtained also w'ere only mediocre, and Faure
had not been able to obtain a single permanent cure among
his patients. In most instances the recurrence had taken
place promptly, and only in one case did an interval as
long as three years elapse. In summing up, he said that
malignant disease of the pharyn.x was undoubtedly the
most serious of the cancers amenable to operation. The
surgical procedure was always a very severe one, but if
carried out in time, while the lesion was still localized, it
was possible to obtain, if not absolute cure, at least en-
couraging results, and under these conditions surgical
measures in spite of their gravity should always be re-
sorted to.

Baudet reported an interesting case of impalement of the
rectum and perineum. The patient was a child of ten years,
who, in climbing over a fence constructed of iron pickets
with sharp points, lost his balance and was impaled on one
of the spikes. The iron penetrated directly into the anui
and emerged through the perineum a little behind the
scrotum. In addition to a profuse hemorrhage, the little
patient presented disquieting symptoms that suggested the
possibility of a peritoneal injury. The peritoneum and the
abdominal wall as high as the umbilicus were the seat of
an enormous ecchymosis, and a small amount of blood
escaped from the anus. Nevertheless, the urinary system
was intact, for clear urine w-as withdrawn by catheter.
Baudet. in order to avoid any risk of causing a possible
peritoneal infection, did not make a digital examination of
the rectum, but examined it by means of a bivalve specu-
lum. In this way he discovered a longitudinal wound on
the anterior wall of the rectum, beginning several centi-
meters above the anus and .^ or 6 cm. in length, but not
reaching up to the peritoneal cul-de-sac. Baudet sutured
this wound, as well as that of the perineum, and an uncom-
plicated recovery resulted in the course of a month. Bau-
det also reported another equally interesting case. This
was a wound 01 the heart caused by a thrust with a foil,
and successfully treated by suture. The patient was a man
twenty-three years old, w^ho, while fencing, received a
thrust' in the fifth left intercostal space and became uncon-
scious shortly after the accident. The pulse was hardly
perceptible, and an hour later Baudet reached the patient
and exposed the pericardium by making a large, hinged
flap. He then discovered the pericardial wound, from
which a little blood was oozing. At this time the heart
was almost motionless, and the wound, which involved
the heart muscle itself, was easily sutured. Bv direct mas-

March i6, 1907]

MEDICAL RECORD.

447

sage the heart was induced to beat again, and it was found
that the hemorrhage was controlled by the sutures. The
thoracic flap was replaced and sutured without drainage of
the pleural cavity. The patient left the hospital at the end
of twelve days, and when seen two months later was free
from all symptoms.

The differences in the careers of country and city physi-
cians were discussed by Reymond before the Societe de
ITnternat de Paris. He stated that the country physician
usually had a most difficult and most important role to play,
and ordinarily he exemplified the highest moral qualities,
while his life was rendered arduous through the inadequacy
of the remuneration he could receive from the peasants
living in villages or on detached farms. The country phy-
sician theoretically should be a universal specialist, for he
had only his own resources to count on, and frequently was
unable to summon any colleagues to his aid. It was to be
desired that in the interest of his patients the country physi-
cian should have had some experience in surgery and a
grounding in several specialties, but unfortunately this was
not always the case, and, for example, strangulated hernia,
which ordinarily did not have a severe prognosis was fre-
quently neglected until operation had been too long deferred
because the practitioner did not have the skill to carry out
the procedure necessary to relieve his patient. For this
reason Reymond was interested in the question of estab-
lishing district hospitals, which would be useful not only
from the standpoint of the patient, but which would also
provide practitioners with a valuable source of instruction.
The action of electricity in causing remedial agents to
penetrate the skin was discussed before the Societe de
Biologic by Tuffier and Maute. They had experimented
with trypan red, silver, and salicylic acid, and had found
that these substances, by means of the continuous current,
could be made to pass through the healthy skin. When
brought into the tissues in this way they seemed to form
different combinations with the cellular protoplasm than
was the case when they were introduced by subcutaneous
injection. The penetration of the substances used was
always very superficial, however.

In the death of Prof. Pierre Budin, French obstetric art
has lost one of its chief ornaments. His scientific labors
were very diversified, and his busy life was devoted to two
main ends. As a philanthropist, he had been struck by the
ravages that ignorance of the laws of hygiene among the
poor caused among their infants. He therefore started a
crusade against this evil and founded the League for the
Prevention of Infantile Mortality, which has for its object
the education of mothers. As a teacher, Budin was able
to systematize in admirable fashion clinical instruction in
obstetrics, and it is largely through his offices that the stu-
dents at present are enabled to receive the practical instruc-
tion they do in the maternity hospitals. He died, so to
speak, on the field of battle, in the course of a journey
through France, undertaken for the purpose of dissemi-
nating throughout the country an understanding of the
importance of the combat against infantile mortality.

Emile Javal. one of the most illustrious French ophthal-
mologists, a member of the .\cademie de Medecine, has
died. His name is well known in connection with the work
he did on the subjects of astigmatism and strabismus. He
himself became completely blind as the result of glaucoma,
but in spite of his infinnity he was still able to work and
lead a useful life. It was then that he wrote his book,
"Entre .\veugles." which has been translated into most
European languages.

OUR LETTER FROM COPENHAGEN.

(From Our Special Correspondent )

R,\DIUM-EM.a.NATION IN MINER.\L WATERS — A NEW OPERATION
FOR GLAUCO.MA — THE CAUSE OF BOTHRIOCEPHALUS ANEMIA
— INDICATION FOR MASTOIDECTOMY IN THE SPECIFIC GR.WITY
OF THE PUS.

CopENH.\GBN, February 23. iqo7.

In the Medical Society of Christiania Prof. E. Poulsson
read a paper on radium and its therapeutical effects. He
drew tlie attention particularly to the fact that manv of the
usual mineral waters, e.g. the waters of Gastein. Baden-
Baden, Karlsbad. Marienbad, Wiesbaden, Kreuznach, Bath,
etc., contained rather large quantities of radium efnanation
and therefore possessed a relatively pronounced radioactiv-
ity. Perhaps this circumstance explained the fact that these
waters appeared to act better when drank at the springs
than when exported, because the water became destitute
of the emanation when kept for a long time before being
drank. The explanation might be expected to obtain, es-
pecially for those waters the composition of which ap-
proached very nearly to that of ordinary drinking water.
e.g. Gastein, which latter spring has nevertheless enjoyed
for centuries a reputation of healing powers. He also men-
tioned the experiments of Bergell and Bickell. that fresh

water from the Kochbrunnen at Wiesbaden, added to hu-
man gastric juice, accelerated the digestion, or, in other
words, that the radium emanation had an activating influ-
ence on ferments or enzymes, a quality well deserving of
notice, as many mineral waters were famous for cure of
affections of the digestive organs. In order to help those
who could not afford to travel to the springs, it would be
necessary, he said, to produce mineral waters artificially
supplied with radium emanation. Experiments in this di-
rection are now being made at the Pharmacological Insti-
tute of the University of Christiania.

In the same society Dr. S. Holth read a paper on a new
operation which he had devised for the treatment of chronic
glaucoma, and which he proposed to call "iridencleisis anti-
glaucomatosa." On these new principles he had operated
upon forty-one glaucomatous eyes with very good results.
When he reviewed the cases of chronic glaucoma operated
on by him after the classic method of iridectomy, he was
obliged to confess that the results were on the whole far
from satisfactory. But in certain cases the results were
good, and in all these it was seen that casually a little of
the periphery of the iris had healed into the incision and
formed a subconjunctival fistula, while the conjunctiva bulbi
formed a flat bulla over one or both of the ends of the
sclerocorneal cicatrix. Thereby he became convinced that
though these operations, when judged after the rules of the
classical inethod, were to be considered faulty, in reality
they indicated tlie true way to a rational treatment, because
instead of the failing physiological drainage they provided a
new one of similar anatomical nature. In suitable cases of
chronic glaucoma Holth therefore recommends that iriden-
cleisis antiglaucomatosa be performed by drawing the iris
out through the sclerocorneal incision and covering this by
a conjunctival flap. When the operation succeeds, a sub-
conjunctival bulla or localized edema forms itself under
the conjunctival flap as a testimony of the recovered drain-
age, the fluid circulating through the eye now being led
back through the subconjunctival lymph vessels. In one
case an operated e^-e could later on be microscopically ex-
amined and showed that the iris was incarcerated in the
sclerocorneal cicatrix and formed a fistula, the walls of
which were covered by black pigmented epithelium. This
finding supports the explanation given bv Dr. Holth of the
efficiency of the proposed operation. Prof. H. Schiotz and
Dr. Kolstad congratulated Dr. Holth upon the good results
of the operation as shown by the demonstrated patients.

In the Serum Institute of the State of Denmark T. W.
Tallqvist, from Helsingfors, has carried out some interest-
ing investigations into the pathogeny of - -rnicious anemia,
especially the bothriocephalus anemia. In the proglottides
of Bothiioccl'halus latus he has found, in addition to other
substances, a fatty matter (lipoid), with strongly hemolytic
qualities. He has shown by experiments on rabbits that
this lipoid causes anemia, not only when i"-f»cted under
the skin or into the peritoneal cavity, but also when intro-
duced into the intestinal tract. The experimental anemia
produced in this way has a certain likeness to the pernicious
anemia of man in respect to the hemoglobin value, the
unaltered number of the leucocytes and the remittent course
of the disease. This experijnental influence discloses itself
in an increased erythrolysis, as shown by the increased ac-
curnulation of iron pigment in the liver and in the spleen.
It is highly probable that it is this lipoid substance that
constitutes the blood-destroying poison in the bothrio-
cephalus anemia of man, a resorption of the substance
from the gut in certain cases causing the disease to develop.
To obtain this result it is. however, necessarv that a de-
struction of the proglottides sets in. as otherwise the active
substance does not become free in the gut. Clinical experi-
ence shows that in reality in a considerable number of cases
of anemia the parasite undergoes some alteration. Sub-
stances, in all respects similar to the lipoid of Bothrio-
cephalus latus are found normally in the mucous membrane
of the intestinal tract (and in some of the organs) of higher
animals. These substances are also strongly hemolytic. As
it is known that the so-called cryptogenetic form of per-
nicious anemia is nearly always accompanied by pathological
processes in the digestive organs (the mucous membrane of
the stomach), it is an obvious conclusion that the blood-
intoxication is caused also in these cases bv the lipoid sub-
stances originating in the diseased mucous membrane of
the stomach. A lipoid substance similar to those men-
tioned above has finally been isolated by Tallqvist from
carcinomatous tissues. This substance is also a pronounced
hemolytic; perhaps, therefore, the anemia sometimes to be
found in cases of cancer can be explained by a passage of
lipoid substance from the new growth to the blood.

.\t a meeting of the Danish Otolaryngological Associa-
tion Dr. P. Tetens Hahl read a paper on the fixin.g of in-
dications for the operative opening of the mastoid in cases
of acute suppurative otitis media by means of the estima-
tion of the specific gravity of the pus found in the external

448

MEDICAL RECORD.

[March i6, 1907

auditory canal. Dr. af Forselles of Hekingborg had previ-
ously tried to establish that when the specilic gravity of the
pus exceeded 1,046 this was an infalliMe sign of empyema
of the mastoid and indicated a mastoidectomy. Now, Dr.
Hald showed that af Forselles had not paid due attention
to the errors connected with the method employed for es-
timation of the specific gravity, so that at any rate the
numerical value 1,046 was highly erroneous. But he
showed further that, even if correct methods for the esti-
mation of the specific gravity of the pus were used, it
was exceedingly improbable that we might in this way get
any help to establish with greater certainty the indication
for mastoidectomy. Prof. Schmiegelow and Dr. Gronbech
said that they had entertained considerable doubt as to the
value of the method of af Forselles and congratulated Dr.
Hald upon his having shown the fallacies of it.

AROMATIC SULPHURIC ACID IN TOXEMIA.

To THE Editor of the Medical Record :

Sir: — Your editorial reference to the use of formic acid
in the treatment of toxemia following diphtheria (Febru-
ary 2, 1907) has led me to give my experience with aro-
matic sulphuric acid. About twenty-five years ago I began
using the acid in the treatment of boils, with very success-
ful results. In fact, given in five-drop doses (in one tea-
spoonful of water) every two or three hours, it will cure
boils. Later I had the same results with its use in car-
buncle. In case of carbuncle, however, as in some other
allied conditions, I have found it necessary sometimes to
add quinine. My experience with boils and carbuncles led
to the use of the acid in all forms of toxemia and blood-
poisoning generally. I even use it in cases in which suppu-
ration has already occurred. Aromatic sulphuric acid will
arrest suppurative action. It will, if given in time, prevent
suppurative action. I use the acid wkh opium in appendi-
citis. My results have been so uniformly good that I pre-
scribe the remedy in all forms of toxemia. I have used
it in the acute forms of nephritis complicated by preg-
nancy. In all cases of blood-poisoning my experience with
over two hundred cases shows the acid to be a specific in
case of chronic ulcer and sloughing ulcer. I give the aro-
matic acid internally and use carbolic acid externally. The
simple dilute acid will not give the same results as the
aromatic acid. In this connection I would add to my pre-
vious notes on carbolic acid that I have this winter in-
jected two tuberculous tumors of the neck with pure car-
bolic acid (liquefied crystals), in each case efifecting a cure
and leaving only very small scars. I have also injected a
cancer of the breast with the acid— carbolic— and have so
far brought about a considerable reduct'ion of the size of
the tumor. Robert Mason, M.D.

Exeter. N. H.

prngrrss nf iK^^tral ^rirurp.

A'l-w York Medical Journal. March 2. igo".

Accessory Nasal Sinuses, from the Rhinological
btandpoint.— C. A. Richardson gives a summary of the
symptoms of and methods of diagnosis in inflammation
of the nasal accessory sinuses. He calls attention to the
variable factor of pain, both as to its presence and location
Ihe x-ray promises much in the elucidation of doubtful
cases, except that it affords no clue to the condition of
the sphenoid sinus, but it is of value in determining the
condition of the ethmoid cells.

The Accessory Sinuses from the Ophthalmological
Standpoint.— W. C. Posey considers it bevond dispute
that sphenoiditis and ethmoiditis mav e.xcite retrobulbar
inflammation of the optic nerve of 'varying degrees of
intensity as well as paresis and palsies of the ocular mus-
cles Orbital abscess with resulting displacement of the
globus occurs frequently. Apparentlv simple muscles of
the lacrymal sac have proven at operation to have arisen
m the lacrymo-ethmoidal cells. Sinus disease may also
cause edema of the eyelids. This symptom is regarded
as of great importance by the author. The conjunctiva
has been turgid and studded with follicles in other cases,
where the nasal disease seemed to have involved the
nasopharynx rather than the sinuses: dendriform ulcer
of the cornea appeared to be dependent upon an ethmoiditis
m one instance, and change in the refraction of the
eye, occasioned either directly bv the pressure exerted
upon the globe by the wall of a dilated sinus, or perhaps
indirectly as a consequence of congestion and spasm of
the ciliary muscle, has been obser\'ed not verv infrequently.
The author states that he has not been able to satisfy
himself that ocular conditions other than these were
actually dependent upon a sinusitis.

Shreds in the Urine in Their Relation to Prognosis
and Diagnosis. — Dc S. Saxe makes a careful study of
this subject. He finds that the shreds are best studied
after proper fixation in stained specimens according to
the methods outlined, Unna's polychrome stain being
the preferred reagent for routine work and Gram's stain
when gonococci are to be demonstrated. Urethral shreds
proper may be divided into four varieties : Pus shreds,
mucopus shreds, mucus shreds, and epithelial shreds,
each of which have special naked eye and microscopic char-
acteristics. Several varieties of altered epithelia are found
in urethral shreds. Those undergoing hyaline changes
may be identified not only by the iodophile reaction, but
by a peculiar degeneration as shown by their staining
qualities with polychrome methylene blue. Shreds com-
posed of pure epithelia consisting of flat pavement cells
with small nuclei are shed spontaneously, or after instru-
mentation, in the stage of the disease in which the super-
ficial layers of the urethra become lined with squamous
cells under the influence of subjacent, submucous lesions.
Shreds from the prostate and vesicle include several spe-
cial varieties which can be recognized under the micro-
scope, but cannot be identified with the naked eye. The
so-called comma shreds in reality may be one of two
varieties of structures. The true comma shred of Fur-
brin.ger consists of booklets of stratified epithelia, de-
rived from the prostatic duct. A false variety of comma
shreds is composed of bits of mucopus shreds which roll
up into a lump at one end. The frequency of gonococci
in urethral shreds is directly as the proportion of pus
cells, and inversely as the proportion of mucus and epi-
thelia in the specimens. This rule does not apply to pros-
tatovesicular shreds. The study of shreds is not of
great value in the localization of the afifection in the
anterior or the posterior urethra. The presence of pros-
tatic or vesicular shreds which can be recognized micro-
scopically is an aid to the localization of the process. The
study of urethral shreds is most valuable in determining
the stage of the process, the order of appearance being,
with certain reservations, as follows : Pus shreds ; mu-
copus shreds; mucus shreds; and epithelial shreds. In
the prognosis the variety of urethral shreds present can
have but a limited use. The fewer the shreds and the
fewer the pus cells therein the better the prognosis. The
larger the number of gonococci and of pus cells the worse
the prognosis is as a rule. Marriage should not be sanc-
tioned unless the terminal shred or shreds contain no
pus cells for months, even after provocative measures,
such as the drinkin.g of beer.

Trypsin in Cancer. — W. S. Bainbridge says that the
report by Morton, in the Medical Record of December
6, 1906, of benefit following the use of trypsin for cancer
was premature. He says the specimen examined, upon
which was based the pathological report seeming to dem-
onstrate curative action of trypsin, was taken from near
the nipple and not from the periphery of the growth.
After this operation Bainbridge gave trypsin in much
larger dose and alternated it with amylopsin. Twenty-four
days after the operation referred to a third operation
was undertaken to remove some enlarged nodules and
secondary deposits in the skin which had appeared after
the second operation. The pathological reports on these
secondary growths showed the presence of malignant
cells, which, from the abundance of mitotic figures, would
seem to have been in an active state.

Journal of the American Medical Association , March 9,
1907.

Laminectomy. — H. M. Sherman reports a case in
which he attempted to make an osteoplastic laminectomy
of the cervical vertebra in the removal of a growth pro-
ducing pressure symptoms in that region. The difficulties
of the operation are detailed, and he concludes from the
results that a simple laminectomy in this case would have
been the better operation, saving time and tissue. The
operation which would be the better one in the kv'photic
dorsal region is not so satisfactory in the lordotic cer\'ical
spine, where the preser\'ation of the laminje is not essential
for the saving of the function of the extensor muscles. The
impossibility of an accurate anatomic suture of the mus-
cles that are divided in making the flap and the possi-
bility of* seriously interfering w-ith their inner\'ation are
matters also to be considered. The surgeons with whom
he corresponded were all in favor of the simple laminec-
tomy in this region. He still thinks, however, that an
osteoplastic operation may have its place in case of verte-
bral tuberculosis in which the angular deformitj' is prac-
tically a right angle; here the sawing of the bone
would prevent undue compression of the cord, otherwise
unprotected, by the muscles.

Multiple Neuritis Simulating Progressive Muscular
Atrophy. — Three cases, one of alcoholic polyneuritis,

March i6, 1907]

MEDICAL RECORD.

449

one of lead paralysis, and one of progressive muscular
atrophy, illustrating the futility of attempting to differ-
entiate these conditions by objective symptoms alone,
without study of the etiology and course of the disease
are reported by J. Grinker, who holds, nevertheless, to
the advisability of clinically separating the cornual from
the peripheral lower neuron disorders. His conclusions
are given as follows: I. Clinically, multiple neuritis may
simulate a spinal atrophy as regrards distribution of paraly-
sis, absence of sensory symptoms, and protracted course.
2. Progressive spinal muscular atrophy may resemble neu-
ritis in the presence of pain, remission of symptoms, and
subacute course. 3. Etiology and course are still the
best guides in the clinical diagnosis of the various muscle
atrophies.

Tumors in the Inguinal Canal. — W. L. Peple reports
three cases of this condition in young married women, all
of whom had had children. In two, the growth sprang from
periosteum or fascia covering the inner face of the ilium,
while one lay encapsulated in the inguinal canal, attached
only to its coverings. All were of comparatively rapid
growth, the average from the first time of observation to
operation being twenty-two months. In one case, preg-
nancy seemed to accelerate the growth. All the growths
were apparently fibromata that had undergone myxoma-
tous degeneration, and, while two were distinctly benign
in appearance, the other was somewhat suggestive of
sarcoma, though not identified as such. He considers the
cases somewhat unique, both as regards the growths and
the microscopic findings.

The Ripening Operation for Immature Senile Cata-
ract.— The difference of opinion in regard to the im-
portant question as to use of the ripening operation for
immature senile cataract is remarked by F. C. Todd, and
to secure the most recent opinion on the subject he ad-
dressed letters to a number of leading ophthalmologists
and received sixty-nine replies, which he analyzes and
discusses. He believes himself that the ripening operation
is imperative in some cases for humane reasons, and re-
ports a case which he thinks illustrates this. The opera-
tion is contraindicated in cases complicated with high
myopia, choroiditis, or other inflammatory conditions in
cases predisposed to glaucoma or where adhesion to the
iris is present. It is also not needed when a cataract
is nearly mature or in patients over sixty, when the
cortex is of such consistency that it can be removed
without much difficulty. Nor would it seem needed in the
case of well-behaved patients, when irrigation can be used
by an operator skilled in his practice. .A.dmitting the
advantages of irrigation, he concludes that the ripening
operation is indicated: i. In case of immature cataract (not
contraindicated as mentioned above), in which a pre-
liminary iridectomy is to be performed. 2. In those
patients who would not be likely to behave well during
the extraction, thus preventing the operator from per-
forming much toilet or from practising irrigation. If
irrigation be not practised, trituration of the lens would
be indicated in all patients with immature senile cataract
under sixty, in whom, for special reasons, relief is re-
quired.

Turnip-Top Treatment of Chronic Diarrhea and
Dysentery. — C. Wilson and H. E. Pressly report six
cases, four of chronic diarrhea and two of amebic dysen-
tery, microscopically diagnosed, which were successfully
treated with a diet of "greens" composed of turnip tops.
One of these patients, on going where the diet was not
to be had, suffered a relapse and died, the others con-
tinued well. Other vegetables, such a'; mustard. Phytolacca,
and spinach are also mentioned as having been used to
some extent. The attention of the authors was first called
to the remedy by the recovery of an apparently hopeless
case on "poke salad" (Phytolacca) after leaving their
care. Of the two cases of amebic dysentery, one patient
had tried all the ordinary remedies and was ready to
undergo an appendicostoniy or an enterostoniv if it would
relieve him, as his condition was extreme. The other was
not so bad. but had given up his work and never expected
to be able to take it up. Both made good recoveries under
the "turnip greens" diet. Wilson and Pressly have also
tried it in two cases of well-defined gastric ulcer, in one
successfully. The other patient was nearly moribund,
and while he was able to take the diet better than any-
thing else, it failed to save him. The method of cooking
is important, as it is very unpalatable if not properly
prepared. As prepared as a domestic dish in the South,
ordinary bacon is used, boiled half an hour, and then
the turnip tops, spinach, mustard, or Phytolacca tops are
added and allowed to boil from one to two hours.

The Lancet, February 23, 1907,
Cellulitis of the Spermatic Cord. — F. C. Madden re-
ports a series of cases presenting symptoms of strangulated

hernia, but which on operation have shown an empty hernial
sac in the center of the swollen inflamed tissues described
below. The clinical features of the cases are summarized
as follows : The patients generally complain of severe
pain in the scrotum and around the lower part of the
abdomen on the affected side, with constipation and some
vomiting, which, however, is not usually a prominent symp-
tom and is generally remarked only at the first onset.
The temperature is raised and the general condition
may be decidedly bad. On examination the side of the
scrotum appears to be filled with a large rounded swelling
which runs right into the region of the external ring —
in fact, presents all the appearances of an irreducible in-
guinal hernia. On palpation, it will be noted that the
skin is edematous and the swelling is hard, but doughy
on firm pressure, runs well down into the scrotum, and
cannot be reduced. There is no impulse on coughing
and the whole mass is dull on percussion. The general
impression in such cases is that it is impossible to be
sure whether we have to deal with strangulated hernia
or not, but in any case immediate operation is the proper
treatment. An incision is then made over the lower part
of the abdomen and the neck of the scrotum, through a
markedly edematous skin, and several layers of thickened
infiltrated edematous structures are divided, but still no
gut is found nor even clear fluid within a sac. Finally,
after separating off all the different layers, which are
firmly glued together bv lymph, a thick inflamed rope-
like structure is met with which runs distinctly up into
the abdomen through the internal ring. On removing this
cord between ligatures, the upper one as high up as pos-
sible, it is seen that it consists of a much infiltrated sper-
matic cord, the veins in which are all thrombosed and
filled with purulent clot, while the rest of the structure
is thickly studded with small abscesses, or rather collec-
tions of pus scattered throughout a kind of spongy tissue
in its whole length. On the removal of this portion of
the cord an elongated hernial sac of thickened inflamed
peritoneum, its serous surfaces adherent w-ith lymph, may
sometimes be found and ligatured oft' at the level of the
internal ring. On the completion of the operation a gutter
is left, formed by the opening up of the inflamed cover-
ings of the cord and scrotum, and this is packed with
sauze and the whole wound is allowed to granulate up
from the bottom. The testicles are not affected as a rule,
but, as their functions must be quite abolished by the
block in the cord, they are usually removed, a procedure
which materially simplifies the subsequent course of treat-
ment of the case. After running a modified septic course
the patients usually do very well. One case has resulted
fatally from extension of suppuration along the retro-
peritoneal tissues leading to diffuse septic cellulitis. Mad-
den suggests that the condition may be a primary phlebitis
with septic thrombosis of the veins of the spermatic cord,
though he is at a loss to explain such a lesion without
some original septic infection which the cases in question
have not presented.

Infective Endocarditis Cured by the Inoculation of a
Vaccine Prepared from Organisms Found in the Pa-
tient's Blood. — A case is detailed by J. Barr, W. B. Bell,
and S. R. Douglas, the inoculations being regulated
by the examination of the opsonic power of the patient's
serum. The patient was a woman of tvv-enty-five years,
who began with a sore throat followed by a large, soft
swelling behind the angle of the left jaw. This disap-
peared in three days. About a week later a continuous
high temperature was noted. Antistreptococcus serum was
injected without appreciable result. In about a fortnight
from the beginning of the case evidences of endocarditis
of the right ventricle were present. A small abscess ap-
peared in the foot and a streptococcus was isolated. Later
a pure culture of streptococcus was isolated from the
blood and a vaccine was made therefrom, according to
the method of Wright. The treatment was thereafter
carried on along the lines indicated in the title of the
paper, and the patient made a complete recovery. The
authors say that the problem in these septicemic cases is
whether the presence of an area containing living and
multiplying bacteria, w'hich from time to time have free
access to the blood stream, is at all favorable for the
manufacture of antibacterial substances by the infected
organism or whether a more efficient production would
take place if the bacterial products were brought into
actual contact with the cellular tissues and had to pass
through the lymph stream before reaching the general
circulation.

Condition of the Blood-Vessels During Shock.— J. D.
Malcolm takes exception to the idea expressed by Crile
th.at in a state of shock the blood-vessels are paralyzed
throughout the body and that this is due to an exhaustion
or breaking down of the vasomotor centers. He claims
that the superficial capillaries are not dilated during shock,

45°

MEDICAL RECORD.

[March i6, 1907

and no evidence has been advanced to show why it is that
their distention does not occur as a consequence of the
paralysis of tlie muscular coats of the blood-vessels which
is said to exist. Crile claimed that the fall of blood
pressure which he invariably found during shock must
result as an exhaustion of eitlier the cardiac muscle, car-
diac centers, l.ilood-vessels. and vasomotor centers. He
excluded the first three and fell back on the fourth. This
argimient is based on the assertion that a lowering of
pressure in the carotids must depend on a relaxation of
some part of tlie vascular system. This statement Mal-
colm considers as an untenable proposition. It appears,
says he, to be founded on the idea that a contraction
of the arteries causes a rise of blood pressure and a relaxa-
tion causes a fall. But this is a very incomplete and
inexact statement of the well-recognized law that the
small arteries exercise a regulating or stopcock action
on the flow of blood to the tissues. \\'hen fully set forth
an essential part of the stopcock mechanism is that a
contraction raises the pressure in the large vessels, but
at the same time lowers the pressure in the smaller ones,
in those beyond the point where the stopcock is supposed
to act. Hence, if any vessel has its lumen sufficiently
contracted the blood pressure in it will be lowered. Mal-
colm believes that in this fact we have the true explana-
tion of the fall of blood pressure in shock. The author
is convinced from clinical observation that the larger
internal vessels, arteries as well as veins, spout more
forcibly if divided when the patient approaches a condi-
tion of shock than they do if the operation is not severe.
He has noted this particularly in the cystic branch of
the hepatic artery, renal arteries, and larger mestenteric
arteries, and believes it due to the fact that these large
central vessels, both arteries and veins, are unusually full.
A rise of blood pressure in the large vascular trunks of
the internal areas is fully accounted for if the vessels
throughout the body contract and if the superficial vessels
are more tensely contracted than the central ones. A
difference between the superficial and the central areas in
this respect ought to exist, for a low temperature acts
powerfully in contracting the vessels and the superficial
temperature falls markedly in the state of shock. More-
over, the smaller vessels have comparatively a much
greater muscular power than the larger. Thus all the
conditions tend to collect the blood towards the center
of the body if his view is correct. But there is no evi-
dence of paralysis of the vessels anywhere. Concerning
the effect of adrenalin in shock, he says that the admin-
istration of this remedy here is not free from risk. During
recover}' from shock if, as he believes, the vessels are
relaxing, saline injections should be useful. And at this
stage fluid enters the vessels from the rectum almost as
quickly as by direct injection. Theoretically, and he
thinks practically, injections into the cellular tissue are
to be preferred to those into a vein, if some such treat-
ment is considered desirable during shock, because if the
fluid does not find its way into the vessels from the cellu-
lar tissue an attempt to force it into a vein is likely to
be not only futile, but also harmful. He regards the
usefulness of injections with a view to increasing the
bulk of the bicod as very limited in cases of uncom-
plicated shock.

British Medical Journal, February 23, 1907.

Antistaphylococcic Serum in Furunculosis. — R. T.

Thorne refers to the case of a woman of forty-five years
with furunculosis of the face and body, lasting over a
period of three years. Various remedies failed to give
any permanent relief. He therefore made si.x injections
of a vaccine prepared from the pus of a mature furuncle,
commencing with 0.5 c.c. and increasing up to 2 c.c,
leaving ten days between each injection. These caused
no discomfort whatever, and from the date of the first
injection to the present time (six months) no fresh furun-
cles have appeared and the patient is in perfect health.

Acute Intussusception. — A case is reported by W. G.
Williams whose patient was a boy of three years, who
fell down some steps and complained at once of some
severe umbilical pain, which disappeared, but soon re-
turned. Seen half an hour later he presented a condition
of partial collapse with frequent pains, but no vomiting.
There was a distinct swelling in the right iliac fossa,
and extending rather higher up than the usual ileocecal
variety, and this was more pronounced during the attacks
of pain. Vomiting cotnmenced in about an hour after
the accident happened. The patient was at once placed
under the influence of morphine, and three hours after
the accident an injection of sterilized warm water was
given by means of a catheter connected with an iiidia-
Tubber tube and funnel. After injecting about a pint
into the bowel the author placed his right hand over
the swelling, while with his left hand he grasped the

abdominal wall and small intestine and pulled gently
downwards and towards the left side ; suddenly, to his
satisfaction, the swelling disappeared from under his right
hand. He regards' it as of the utmost importance in
acute intussuscejition .that the patient should be seen and
diagnosed early, and at once put under the influence of
morphine. An attempt at reduction should also be made
as soon as possible, as in this way a good many lives can
be saved. In this particular case an injection only was
not sufficient, iut a little traction applied worked ad-
mirably.

Rupture of Dilated Aorta Leakage Bruit. — F. B. Sker-
rctt was called to see a man of seventy-one years who
had collat)sed while at stool. He found him pale, uncon-
scious, with pupils widely dilated, and lips blue. The
pulse was not perceptible at the wrists, and he was only
taking short breaths at intervals. On auscultation over
the precordial region the cardiac sounds could be heard
feebly, but distinct from a continuous adventitious sound
which may lie described as ''gurgling" or "lapping," as of
a cat lapping milk. The bruit, which altered in char-
acter, the successive laps becoming more rapid and finally
lost, was quite different from any sounds I have ever
heard in the chest, and suggested at once the leakage of
blood. It was thought the man had ruptured his heart
muscle. He rapidlv succumbed. At the post-mortem
examination the pericardium was greatly distended with
dark fluid and clotted blood. The heart was hypertrophied,
but no rent in it could be found. In the external wall
of the aorta were seen large dark-bluish areas almost
encircling the vessel. They looked like gangrenous patches,
but were really blood-clot infiltrations. The first part
of the aorta was somewhat dilated and very atheromatous
in parts, and in the inner coats of the wall near to the
pulmonary artery was an irregular longitudinal valvular
slit quite one and one-half inches in length, through
which the blood had leaked. From this it had traveled
in the coats of the vessel, and escaped into the pericardium
posteriorly. The valves of the heart were in good con-
dition. The rectum was found loaded. The man had
not had any symptoms, his only trouble being a chronic
bronchitis. A point to remark about the briiit heart was
its total independence of the cardiac sounds. Presumably
in rupture of the ventricle the sound of leakage, if ever
heard, would be intimately related to the cardiac systole.

Merycism or Rumination in Man. — .A.n elaborate
study of this symptom is made by E. M. Brockbank, who
gives the histories of a considerable number of personal
cases. He refers to the medical history of the trouble,
and then takes up the questions of mode of onset, power
of combat, general health, etiology, age, sex, chemistrj',
varieties. patholnp-\-. mechanism, diagnosis, and treatment.
He notes that in children imitation plays an important
role. In his own experience the affection has come on in
very early life, more often below the tenth year. The
sexes have been equally involved. It may develop after
an infectious fever or follow a blow on the stomach.
Disorders of the latter organ frequently precede it, and_
constipation is a frequent coincident symptom. Many of
the cases are very neurotic. As far as known, no chemi-
cal defect in the stomach has any causative relation to
the attacks. As to treatment, the author says that in
many cases, especially in the poorer classes, it is probably
useless trying to control the ruminating act when the
phenomenon may be called physiological. In the more
intelligent classes, by practice, an expiratory effort, at
the time of the development of the negative pressure in
the thorax, might have some good effect, and cases have
been published in which by an act of will the proces3_
could be brought on or warded off. The subjects of
rumination should be advised to eat their meals slowly,
taking considerable pains to chew the solid food well
before it is swallowed, and to avoid all specially predis-
posing foods. They should also take very little fluid with
their meals. Xo simple stomachic drugs have been of
any use in controlling the rumination. Smoking acts as
a deterrent in some instances. Where there are any con-
comitant dyspeptic symptoms these should be relieved,
and should they have been the exciting cause of the rumi-
nation, their relief would probably benefit the merycismus.
If the subjects of rumination feel ill after suppression
of what is to them a natural process, they must on no
account interfere with Nature's demands.

Berliner kh'iiischc IVochenschrift. February 25. 1907.

Magnet Operations on the Eye. — Hirschberg says
that during the twenty-seven years that have elapsed since
he first removed a fragment of iron from the depths of
the eye by means of the electromagnet he has repeated
the operation 347 times. He considers that it is ill-advised
to refrain from attempts to remove a foreign body from
the eye on the ground that it may become harmless through

March i6, 1907]

MEDICAL RECORD.

451

encapsulation, and expresses his conviction that sooner
or later the visual power of such an eye will be seriously
impaired or totally destroyed. For diagnostic purposes
both the j--ray and his own instrument, the sideroscopc,
should be made use of. It is a mistake to believe that the
magnet itself can be used to establish the presence or ab-
sence of an iron particle in the eye, for the belief that if
on approaching the instrument no pain is caused no foreign
body can be present has been proved to be erroneous by
many cases in his own experience. The author describes
two of his most recent cases in which the successful re-
moval of the foreign body by means of the magnet was of
especial importance since the eye in question was the only
one with which the patient was able to see. In the one case
the injury was recent, and a splinter measuring 3.75 by
1.75 by 2 mm. was removed. In the other case the foreign
body had entered the eye over a year and a half previously,
but was also removed without complications, although the
patient's visual power had already beeun to show serious
impairment.

Observations on the Importance of Mother's Milk
During the First Period of Infancy. — Salge says that
the importance to the infant of receiving mother's milk
during the first period of its existence cannot be sufficiently
emphasized, and that no physician should permit artificial
food to be used if it can possibly be avoided. In analyzing
fresh milk the mistake is frequently made of taking a
sample for examination before the child has begun to
nurse. Such a sample will always have a low fat con-
tent, because the amount of fat in the milk increases
steadily during each of the infant's meals. To obtain a
proper sample it is necessary to take some of tlie milk at
the beginning and also at the end of each nursing for
twenty-four hours, and then make the determination on
the mixture of all these. If artificial nourishment is abso-
lutely necessary overfeeding must be carefully avoided, and
the author's rule is never to have the intervals between
meals less than three hours. At the most, six to seven
meals a day should be given, and during the fisrt week
the total amount of nourishment should not exceed 250-
300 c.c. daily, gradually increasin"- to 600 c.c. in the course
of the first four weeks.

Pciitsclu- incdicinischc IVochcuschrift, January 31 and
February 14, 1907.
Calomel as an Antiseptic, — Theopold speaks highly
of the value of calomel as an antiseptic for general surgical
use and especially in obstetric practice. It has been em-
ployed under his direction in from 4,000 to 5,000 confine-
ments conducted mainly under the care of midwives and
the results have been extremely satisfactory. The agent
owes its safety to its insolubility in water and watery
fluids, while its antiseptic property appears to depend on its
capacity to produce coagulation of albuminous substances
when brought into close contact with them. Experiments
w-ith pathogenic bacteria have shown that its antiseptic
value is quite high, and that when applied to a given
surface it is perfectly capable of preventing infection by
small amounts of bacteria. If it is applied together with
iodoform a mutual decomposition results with the forma-
tion of the iodide of mercury, and the antiseptic action
produced is much greater than that of either agent by
itself. As ordinarily used there appears to be no danger
of causing intoxication by the application of calomel for
these purposes, and the author warmly coniinends it as a
dusting powder to be applied to the hands after these have
been sterilized in the usual way before performing any
obstetric manipulations.

Observations on Hay Fever. — Wolfif-Eisner dwells
upon the necessity for making an accurate dia.gnosis in
cases suspected to be true hay fever in order to distinguish
them from nervous coryza, nervous asthma, etc. In order
to do this it may sometimes be advisable to resort to
the use of a diagnostic pollen extract. This can be pre-
pared by triturating in a mortar pollens of the different
varieties encountered in the locality in question, adding
salt solution or plain water, centrifuging, and using the
clear fluid. He speaks highly of the use of nose filters
and protective eyeglasses with padded rims as prophylactic
measures, but does not consider that Dunbar's serum is a
true antitoxin. In order to prove a point denied by many,
namely, that the conjunctiva alone may in some cases be
susceptible to the irritating properties of the pollen, he
describes his own case. Ever since being exposed to the
pollen of rye, while collecting this in the fields for experi-
mental purposes, he has suffered from a very marked
idiosyncrasy to the influence of pollen, but this has always
manifested itself only through conjunctival symptoms and
there has never been any involvement of the nasal mucosa.
Hemorrhagic Complications of Scarlatina. — Klose, in
discussing these complications as well as hemorrhagic con-
ditions in children in general, states that he has found the

treatment by the injection of gelatin solutinns the most
satisfactory. He usually employs a toper cent, solution and
adminislers 20 c.c. at a time For the site of injection he
recommends the axillary region midway between the an-
terior and posterior axillary lines, which he says is also
very well suited for the injection of diphtheria antitoxin.
The skin in this situation is freely movable, and overlies a
satisfactory cushion of fat and connective tissue, while
lymphatic glands for absorption are close at hand. If the
gelatin solution is carefully prepared the much dreaded
danger of tetanus need not be apprehended.
Mnnchciu-r mcdiziniscUc li'tHhenschrift. February 12. 1907.
The Etiology of Erythema Nodosum. — Hildebrandt
reviews the reports of a number of authors which appear
to indicate that erythema nodosum is not infrequently
associated with tuberculosis and describes a case of his
own which he considers lends color to the view that there
may be an intimate relationship between the two con-
ditions. His patient w^as a young woman of twenty-four
vears, who had had enlarged cervical glands in childhood
and came under observation with an acute angina and
stomatitis. Ten or twelve days later she developed ery-
thema nodosum, and during the acute period of the affec-
tion, while new eruptions were still appearincr. the urine
gave a positive diazo reaction. On injecting some of
the patient's blood into two guinea pigs both animals de-
veloped tuberculosis, while no other organisms could be
discovered in the blood. Somewhat later, first a right-
sided and then a left-sided pleurisy followed by pericarditis
developed and an infiltration at the right apex could be
defected, so that these were all regarded as manifesta-
tions of a tuberculous process. Therefore at the time
when the ervthema nodosum apneared virulent tubercle
bacilli were circulating in the blood. The author is of
the opinion that while erythema nodosum occurring in a
tuberculous patient does not necessarily depend on the
tuberculous infection, it may be possible, though it has not
yet been proven, that tubercle bacilli may give rise to a
disease process that cannot be distinguished from the ordi-
nary erythema nodosum.

French and Italian Journals.
Genesis of Pulmonary Anthracosis. — Francesco Feli-
ciani gives the results of experiments on animals to ascer-
tain the origin of pulmonary anthracosis. '1 he animals
were fed with materials containing coloring matters with
a view to find out whether these substances would appear
ill the lungs or other organs. His conclusions are given
thus: Experimental ingestion of carbon or carmine iii
powder does not produce a corresponding pigmentation of
the lungs. Those powders ingested do not traverse the
intestinal mucosa and do not appear in the liver or mesen-
teric glands. Injection of powder into the peritoneal cavity
does not produce anthracosis in the lungs. Since the
biology of germs varies from that of inert powders we
cannot say that the same is the case with bacteria, such
as the Koch bacillus.—// PolicUnieo, December, 1906.

Regeneration of Nerve Fibers.— Aldo Perroncito con-
cludes his researches on the reo^eneration of nerve fibers
thus: At the central nerve stump there is a rapid new
formation of nerve fibers in continuous lines. The axis-
cylinder degenerates, but is regenerated by lateral germs
or division of the old axis cylinder near its cut extremity.
The fibers penetrate the cicatrix and reach the peripheral
fragment, anastomosing in its substance. Suture of the
nerve assists regeneration bv bringing the fragments to-
gether, and directing the course of the new nerve fibers-
to the peripheral stump. Some fibers of the peripheral
fragment degenerate ; others become club shaped at the
ends. The new fibers surround the degenerated ones. The
process of repair is not always the same in similar lesions.
The return of function is Jiot always proportional to the
amount of repair. Electrical conduction in a nerve begins
first in the peripheral fragment. No functional activity
can be demonstrated in nerves that do not show repair
ch.inges. Suture facilitates repair and reestablishnient of
function.— /Jrf/ij'tn'o per le Science Mediche, 'Vol. X\X,
Part 5.

Svohilitic Arthropathies.- Guide Marino reports two
undoubted cases of syphilitic joint affection because there
has been much doubt thrown on the existence of true
svphilitic joint lesions. There are two types of syphilitic
joint affections. Gummatous infiltration begins in the peri-
svnovial tissues. In another type the lesion is primarily
of the bones. The synovial membrane remains intact or
is involved secondarily. The efifusion that takes place is-
onlv a reaction at a distance from the periarticular m-
fiamniation. There is articular motion that is relatively
pronounced and little pain in movement. These facts showr
the normal condition of the synovial membranes,—// Foh-
clinieo. January, 1907.

452

MEDICAL RECORD.

[March i6, 1907

Sook i&PtrUnts.

The Practitioner's Medical Dictionary. An Illustrated
Dictionary of Medicine and Allied Subjects, including all
the Words and Phrases Generally Used in Medicine,
with Their Proper Pronunciation, Derivation, and Defi-
nition. By George M. Gould, A.M., M.D., Author of
"An Illustrated Dictionary of Medicine, Biology, and
Allied Sciences," "The Student's Medical Dictionary,"
"30,000 Medical Words Pronounced and Defined," "Bio-
graphic Clinics," "The Meaning and Method of Life,"
"Borderland Studies," etc.; Editor of American Medi-
cine. Philadelphia : P. Blakiston's Son & Co., 1907.
This is a new dictionary (not a revision) similar in style
and in get-up to Dr. Gould's other dictionaries with which
the profession of this country is already so familiar. In
the matter of completeness, as regards the number of
titles, it seems to be between the large "Illustrated Dic-
tionary" and the "Student's Dictionary" of the same author.
It is of very convenient size and weight, with flexible
cover, and bound so as to lie flat on the table wherever
opened.

Among the new features in which this dictionary differs
from the others by the same author is the distribution of
the eponymic terms throughout the book in their alpha-
betical order instead of their grouping in a table under the
one head, "disease." The same nrinciple might profitably,
we think, have been extended by breaking up the other
tables of signs, symptoms, tests, etc., and distributing their
single titles alphabetically. The Basle system of anatomi-
cal nomenclature [BNA] has been introduced. In the
definitions of drugs the dosage has been given in the
metric as well as the apothecaries' system, and the defi-
nitions have been changed, where needed, to conform to
the directions of the new Pharmacopoeia ; in the spelling of
the alkaloids and chemical terms, however, the dictionary
departs from this authority, which we cannot but regard as
unfortunate, since the Pharmacopceia is the standard, and
if its authority is accepted in the matter of names and
preparations it should be also in that of spelling of
ofiicial drugs. However, the dictionary will not be con-
sulted much for its spelling but for its definitions, and in
this respect and in the number of new terms defined the
work is one of surpassing excellence. We have failed
to find very few of a test list of new words, and those
only the latest coined which have really not yet won an
assured place in medical nomenclature. One curious omis-
sion is that of "eyestrain," a term which is surely worthy
of a scientific definition. The work is especially rich
in eponymic terms — a most commendable feature, since
it is possibly these terms that drive the reader of modern
medical books and journals to the dictionary. The il-
lustrations, chiefly anatomical, are not too numerous, and
are well executed ; the only criticism we would offer is
that many of them are too large, one picture taking up
sometimes nearly an entire page when it would lose noth-
ing in clearness if reduced at least one-half.

We have tried to point out the defects in the work
rather than the excellences, since the latter are assumed
to be present in every new book and new edition brought
out under the guidance of this veteran medical lexico-
grapher. The good points are numerous and striking, and
they will doubtless serve to secure for this new work the
same measure of popularity that the dictinnaries which have
preceded it have enjoyed. Taken all in all— size, weight.
binding, illustrations, definitions, and number of new terms
—the Practitioner's Metlical Dictionary is extremelv sat-
isfactory.

Diet in He.\lth and Disease. . By Julius Friedenwald,
M.D., Clinical Professor of the Diseases of the Stomach
in the College of Physicians and Surgeons, Baltimore,
and John Ruhr.\h. M.D.. Oinical Professor of Diseases
of Children in the College of Physicians and Surgeons,
Baltimore. Second Edition. Thoroughlv Revised and
Enlarged. Philadelphia and London: W. B. Saunders
Co., 1906.

In this second edition of their work, the authors have added
some valuable material, notably in the chapters on "Salts,"
Klemperer's work on "Oxaluria," "Diet at Water Cures,"
and Prochownick's "Diet in Pregnancy and Pelvic Contrac-
tion." They have noted Chittenden's work and have added
a revised list of recipes for ready reference. It is perhaps
unfortunate that in making these timely additions to their
work, the authors fail to relieve the book of much that is
cumbersome and unessential in the text of the first edition.
This would especially apply, for instance, to such chap-
ters as that_ devoted to the diet in diabetes and that upon
diet in phthisis. In the former considerable space is given
to dietaries which, while applicible in Germany, are by no
means so in England and .\merica, and the space thus taken
might, with considerable advantage to .\merican readers.

have been devoted to a more exhaustive consideration of
the works of Chittenden and Folin, which tend to demon-
strate that the old accepted standards of Voit, Von Noorden,
and others, of the proteid requirements of a healthy indi-
vidual, are probably considerably overestimated. The sec-
tion on "Infant Feeding" and '"Diet in Early Childhood"
might also with advantage have been condensed. On the
whole, however, this second edition will no doubt, like the
first, fill a certain need, especially in training schools and as
a ready reference book for the general practitioner.

Gesammelte Beitr.\ge aus DEM Gebiete der Physiologie
Pathologie und Therapie der Verdauung. Von Dr. I.
Boas und Seinen Schulern. 1886- 1906. Herausgegeben
von Dr. I Boas. Specialarzt fiir Magen and Darmkrank-
heiten in Berlin. Zwei Bande. Mit zahlreichen Textabbil-
dungen, Tabellen und 4 Tafeln. Band I. Band II. Ber-
lin ; Verlag von S'. Karger, 1906.
The one hundred and twenty-six separate articles on sub-
jects connected with the physiology, pathology, and treat-
ment of the digestive functions, comprised in these two vol-
umes of over 700 pages each, represent the research work
done by Boas and his pupils in the twenty years that the
former's private polyclinic in Berlin has been in existence.
Now that the stress of other work has forced him to give
up active work in the clinic. Boas presents these contribu-
tions in collected form, because, he says, it appears to him
to be a duty to give an accounting of what he and his as-
sistants have accomplished during this time. It is indeed a
series of records of intelligently directed effort well worthy
of those who took part in it, and of the guiding mind that
super\-ised the work. More than one-half of the articles
are by Boas himself, and of the other authors many have
attained prominence in the field of gastrointestinal medi-
cine. The subjects dealt with naturally are most varied,
and there is scarcely a phase of the subject in general that
has not been made the object of research by this diligent
coterie of workers, so that the two volumes form a work
of reference whose importance can hardly be exaggerated.
Its utility would have been greatly increased, however, if
an inde.x had been supplied.

A Text-Book of Histology. By Frederick R. Bailey,
A.M., M.D. .\djunct Professor of Normal Histology,
College of Physicians and Surgeons, Medical Department,
Columbia L^niversity, New York City. New York:
William Wood & Co., 1906.
But few departures have been made in this volume from
the plan of its first edition. The book has been improved
in a general way by changes in some of the drawings and
by the addition of several new diagrams. The short sec-
tions on Special Technique apnended to each chapter, the
semi-diagrammatic character of most of the illustrations,
and a happy accentuation of important elements in the text
give it numerous practical advantages over other books of
this kind. .\s in the first edition the elaborate section on
the nervous system remains the chief feature of the work,
which, with some revision and the embodiment of the more
recent advances, contributes more than any other of its
parts to make the book a useful one. The plan of this sec-
tion is systematic and particularly adapted to teaching pur-
poses. The author has been successful in simplifying by
his treatment this difficult subject, noticeably in those
chapters dealing with the fiber tracts of the cord. In this
lies one of the chief merits of the book.

Tumors, Innocent and Malignant; Their Clinical Char-
acteristics and -Appropriate Treatment By J. Bland-
Sutton. F.R.C.S. Fourth Edition. Chicago: W. T.
Keener & Co., 1907.

This book is based on the nrimary fact that the diagnostic
power is greatlv increased by a combination of pathologi-
cal and clinical knowledge, and this' should be drawn
not only from human, but from comparative sources, for in
in many instances it is impossible to appreciate correctly
the meaning of certain neoplasms without such informa-
tion. Our views of tumors have so changed within re-
cent years that numerous changes were rendered necessary
in the text to bring the book up to date, and this has
required the addition of many extra pages. Attention is
called to the unsatisfactory classification of tumors which
has hitherto prevailed and that adopted bv the author,
although capable of criticism, seems to fill the desired
want. He divides neoplasms into six groups, those of the
connective tissues, of the teeth, epithelium, and fetal mem-
branes, teratomata. and cysts. The distinction between
innocent and malignant growths is also well put — "the
baneful effects of innocent tumors depend entirely on their
environment but malignant tumors destroy life, whatever
their situation." The book is entertainingly written and
constitutes a verv desirable presentation, of the clinical
characters of neoplasms with general indications as to
their treatment.

March i6, 1907]

MEDICAL RECORD.

453

^nirirtji afpnrta.

THE MEDICAL ASSOCIATION OF THE GREATER
CITY OF NEW YORK.

Annual Meeting, January 21, 1907.

The President, Dr. Thomas E. Satterthwaite, in the
Chair.

Report of the Committee on the Death of Dr. Glover
C. Arnold. — Dr. Andrew H. Smith, Chairman.

Report of the Committee on the Death of Dr.
Alfred W. Gardner. — Dr. Robert Coleman Kemp, Chair-
man.

Report of the Committee on the Death of Dr. Alex-
ander E. MacDonald. — Dr. .\dolf Meyer, Chairman.

Experimental Studies in Arteriosclerosis. — Dr. Oskar
Klotz of Montreal, Canada, presented this paper, which
was read by Dr. Adolf Meyer. The author stated
that our conception of the pathology of arteriosclerosis
had recently been so altered that much confusion existed
at the present time as to what form or forms of arterial
disease should be considered under that term. There
were many who would limit the term to a single kind of
lesion, while others were more liberal and used the appel-
lation to include the great mass of arterial diseases which
eventually led to a thickening of the vessel walls. The
author of the term leaned towards using the word "arteri-
osclerosis" for all conditions of hardening of the arteries,
and with that interpretation the older anatomists had
agreed, reserving, however, the term "atheroma" for
another distinct lesion. However, Virchow's description of
endarteritis chronica deformans, as the commonest type of
arteriosclerosis, had led to the adoption of these expressions
interchangeably, and his views had recently found the most
favor. In his own studies, Dr. Klotz said, he had given the
wider use of the word, and had included under arteri-
osclerosis, as was formerly the case, all hardening of the
arterial coats. The experimental production of arterio-
sclerosis in animals was of fairly recent origin. The first
experiments undertaken were by direct injury, as crushing
of an artery. In this way the experimenters had hoped to
bring about sufficient change in the vessel walls to lead to
aneurysm. They were disappointed in this, but instead of
an aneurysm they found that certain local inflammatory
changes with endothelial proliferation were produced. It
had since been shown that in all cases where an artery was
disturbed in its natural bed, thereby affecting^ the vasa
vasorum, an inflammatory reaction was the result. Since
the above mechanical experiments were made several other
ways had been found to bring about the same results. The
chronic endarteritis had been brought about by the intra-
venous inoculation of bacteria of low virulence. Thus,
Dr. Klotz said, he had been successful in producing an en-
darteritis chronica deformans in the arch of the aorta, and
sometimes in the abdominal portion by the injection of old
laboratory stocks of the streptococcus or Bacillus typhosus.
A true inflammation of the media (a mesarteritis) he had
not succeeded in obtaining, except when the injury had
been induced close to the vessel itself. In that case the
inflammation of the surrounding tissue spread into the
arterial wall.

The experimental endarteritis chronica deformans had
histological characters quite similar to those in the human
arteries. The lesion was composed of a heaping up, layer
by layer, of the endothelial cells, while the connective tissue
underneath the endothelium was also undergoing a prolif-
eration. The result was that a white pearly plaque was
produced, under which degenerative changes of a fatty
character might develop in the deeper part of the intima.
Pathological changes in the arteries had also been pro-
duced experimentally by the use of adrenalin, digitalin,
nicotine, and barium chloride. In these cases it had been
shown that the muscle cells in the middle zone of the media

were primarily attacked, and, according to the intensity of
the intoxication by these drugs, the cells either underwent
a fatty degeneration or complete destruction. Along with
the death of the muscle cells, the elastic fibers in the media
were also affected, and, like the former, they either became
fatty, or, with more severe intoxication, underwent ne-
crosis. In each instance, the muscle fibers were primarily
affected. This type of arterial disease, in which the media
was first destroyed, was spoken of as Moenckeberg's
arteriosclerosis. Not alone was the medial degeneration,
witli calcification, produced by means of certain drugs, but
Dr. Klotz said he had also obtained it by the inoculation
of the diphtheria toxin. This was important in demon-
strating that the effects of diphtheria were not confined to
nervous tissue and heart muscle, but that the muscular
elements of the vascular walls were also attacked.

Some Diagnostic Features of Arteriosclerosis in
Clinical Medicine. — Dr. Louis Faugeres Bishop, in this
paper, said that the importance of arteriosclerosis must
be judged by the symptoms which accompanied it. In it-
self a moderate degree of arteriosclerosis was of no im-
portance to the individual. It was important only when
considered in relation to its causes, and the possibility
that their continuance might bring about serious functional
and structural degeneration of blood-vessels which would
endanger the functions of certain structures. To trace the
steps in the process of development of arteriosclerosis and
its symptoms it was necessary to begin with the physiology
of the circulation. The organs of the circulation were
composed of the heart, arteries, and veins, which consisted
of soft, expansible vessels, capable, when relaxed, of hold-
ing three times as much blood as was ordinarily found in
the body. For the proper circulation of this blood, the
organs of the circulation were maintained in a uniform
state of tension, which was altered in one place or another
to vary the blood supply to meet the demands of the body.
This general tonicity of the vessels was maintained by a
central nervous influence that was constantly active. When
for any reason this central influence was in excess, we
had the hypertonicity of the blood-vessels. This imme-
diately complicated the circulation by demanding a higher
blood pressure, and tending to a hypertrophy of the heart.
Under such circumstances, arteriosclerosis developed either
as a conservative measure analogous to the hypertrophy
of the heart, or perhaps also in a measure as a trophic
change of central origin. The symptoms of arteriosclero-
sis were, therefore, the symptoms of hypertonia vasorum,
with its irregularity of blood-vessel control, excepting in
the case of very gross lesions, where there might be purely
mechanical local results due to the blocking or rupture of a
blood-vessel. This conception of arteriosclerosis. Dr.
Bishop said, seemed to him to explain the local and gen-
eral symptoms better than any theory that had regard
only to the pathological anatomy. The influence of the
nervous system in originating and maintaining a vicious
tension in the circulation was second only in importance
to the results of degenerative kidney disease, and of late
years it had seemed to him that the cases of nervous origin
were becoming even more frequent than those primarily
of nephritic origin. Much was said about the strain of
modern life, and it seemed that here was a point where
we could put a finger upon a definite result of a too stren-
uous existence. Constant strain and worry brought about
changes in the circulatory system which apparently led
eventually to structural changes, to hypertrophy of the
heart, and the subsequent secondary degeneration. The
condition was found in women as well as in men, although
men were more subject to the causes. Dr. Bishop said he
had lately come to use the term chronic vascular overtone
to describe a disease that had attracted the attention of the
students of medicine for many years, and the true nature
of which had always been a matter of speculation. It was
ordinarily spoken of as high blood pressure, but in the
light of his experience he thought that chronic arterial
overtone would be a better name. Opposed to vascular

454

MEDICAL RECORD.

[March 16, 1907

overtone, there was a corresponding condition of vascular
undertone, which he had described in several papers under
the name of constitutional low arterial tension. The recog-
nition of the physiological fact of the existence of this
constantly acting force between the nervous system and
the vascular system would explain very beautifully many
of the disorders of circulation found in functional and
organic disease of the nervous system, and would point the
way to the interpretation and treatment of many circulatory
disorders hitherto misunderstood and considered incurable.

Visceral Arteriosclerosis. — Dr. H.\rlo\v Brooks, in
this paper, stated that the visceral arteries were those of
the "medium" class, as classified by the histologists, and
were the trunks which had a thick and well-developed
muscle coat. This heavy media w'as physiologically neces-
sary, since the blood supply to these organs w-as alternately
increased by the rela.xation of the muscle, and decreased
during the physiological resting stage by the local contrac-
tion of this coat. As a result of this delicately balanced
function, even relatively slight changes in any of the walls
of these very active vessels hindered or limited the possi-
bilities in these directions. Thus, an alteration in the
intima, even if it did not, as in most cases, also extend to
the media coat, caused an appreciable alteration in the cal-
iber of the vessel when it contracted or expandea. Most .
important of all, when the media or muscle coat became
even slightly diseased, either by degenerative muscular
alterations, by encroachments of interstitial hyperplasia, or
by true inflammatory exudate, the physiological relaxation
and contraction and the entire control of the nutritive vas-
cular supply was interfered with, and the organ might, as
a result, become chronically congested, or perhaps habitu-
ally anemic. In either case, the viscus became permanently
damaged, and was no longer able to maintain properly. its
functions and its physiological balance in the interreactions
of the body. A disturbance of this equilibrium led first to
secondary changes in the immediately dependent organ,
and perhaps finally to lesions of the general viscera. Fur-
thermore, disease of the arterial walls in vessels of this
class tended to alterations in the general blood pressure,
probably in an attempt on the part of the body by an in-
crease in pressure to balance the blood distribution, or to
furnish a normal, requisite amount of blood for the func-
tional activity of the diseased organ, especially if it be of
great vital importance, as was the case with the heart or
kidney. Elevation of the blood pressure, due apparently
to local arterial disease, was particularly well illustrated in
cases of arteriosclerosis or small contracted kidney, where
the blood pressure was almost uniformly elevated, a fact
for the full recognition of which we were chiefly indebted
to Janeway. In concluding his paper, Dr. Brooks empha-
sized the following points : i. The great frequency of
visceral arteriosclerosis and its importance, particularly in
internal medicine. 2. That it could be diagnosed in many
cases, partly by exclusion, partly by its direct signs and
symptoms, and partly by the results attending treatment.
3. That treatment was attended with great benefit in a very
considerable number of cases, but it must first be based on
a close study of the special etiology, on a thorough appre-
ciation of the physiology of the diseased organs, and of
the special idiosyncrasies of each instance ; and, finally, on
a correct diagnosis.

Arteriosclerosis in Diseases of the Eye. — By Dr.
Wilbur B. M.sirple. (See page 421.)

Dr. Reynold Webb Wilcox said the subject under dis-
cussion was one of the most important that was before the
student of internal medicine to-day. A good deal of work
had been done in the line of experimental arteriosclerosis,
as had been pointed out in the paper sent by Dr. Klotz.
and some extremely valuable contributions to this subject
had been made by Pierce of .Albany. Although this work
was still in an experimental stage, it could be assumed
with a fair degree of safety that the changes that were
thus produced in the walls of the arteries corresponded

\i.ry clcsely to those that were observed clinically in the
human subject. We knew that when an artery was injured,
followed by secondary changes in the media, precisely the
same changes took place as followed the administration of
adrenalin or barium chloride. The alterations in the arterial
walls were similar in both instances. In regard to the
changes induced by pathogenic bacteria, that question was
not yet accurately determined, and probably would require
further experimentation. In reference to Dr. Marple's
paper, the speaker said there was at least one point that
could not be too strongly emphasized ; namely, the im-
portance of the ophthalmoscope as a diagnostic aid to the
general practitioner. In speaking of so-called albuminuric
retinitis. Dr. Wilcox referred to the inaccuracy of the
term, as this form of so-called retinitis might occur without
the presence of albumin in the urine, and vice versa there
might be albuminuria without the occurrence of retinitis.
In speaking of hypertonicity, which Dr. Bishop had empha-
sized in his paper in its relation to the question of arterial
sclerosis, the speaker said that this question was not of re-
cent origin, as high blood pressure had been recognized
almost as long ago as the small red kidney of Bright.
On the other hand, Dr. Bishop's presentation of the sub-
ject was worthy of our most careful consideration because
of its great practical importance. In the light of our pres-
ent knowledge, a more appropriate name for this form of
kidney lesion would be chronic arterial nephritis, which it
really was. It simply represented one feature of a general
arterial sclerosis, and in dealing with the condition, re-
moval of the kidney capsule, as had been recommended in
some quarters, could not possibly do any good, however
much might be claimed for the procedure in other condi-
tions.

Dr. Robert C. Myles, in speaking of the nasal manifesta-
tions of arteriosclerosis, said that for many years he had
occasionally met with a certain class of patients who gave
a history of recurrent nosebleed, evidenced by very small
clots, which, upon examination, were traced, not to ero-
sions of the cartilaginous-septum, as was usually the case,
but to the rupture of small blood-vessels on the turbinals
or higher up in the nasal tract. At times, these small
hemorrhagic extravasations became mixed with muco pus
and degenerated, and gave rise to an offensive odor. The
condition was usually seen in men who were high livers
and of great nervous activity. It was invariably asso-
ciated with evidences of a general high blood pressure, and
at times was the forerunner of a fatal issue from arterial
disease.

Dr. Adolf Meyer, in discussing arteriosclerosis of the
nervous system, said that neurologists, instead of limiting
themselves to the end results of arterial disorders, as they
had long done, had at last reached the point where such
disorders were studied during the process of their forma-
tion, or at least before the onset of the final results. In
this field the work done by Fisher, Adler, Janeway, Brooks,
Collins, and others might well be a matter of pride with
the members of the profession in this city. It was scarcely
a decade ago when apoplexy and senile dementia were
practically the only neurological conditions thought of in
connection with arteriosclerosis, but the more widespread
influence of circulatory disorders upon the nervous system
was now much more fully appreciated. In the timely
recognition of these conditions, the easy methods for meas-
uring the blood pressure had become a valuable routine,
and the help of the ophthalmoscope would prove very val-
uable as the most direct means of inspection of a local
vascular net.

Dr. Bishop, in closing, said it was only by recognizing
hypertonia vasorum and its relation to the physiological tone
of the voluntary muscles that we could in any way under-
stand the K-neficial effects of exercise, particularly the re-
sistance exercises as advocated by Schott in the treatment
of certain cardiac conditions dependent upon peripheral dis-
ease The speaker said that when Schott's method was first

March i6, 1907]

MEDICAL RECORD.

455

brought to his attention, he could not understand how the
resistant movements had any particular value, and it was
not until he had worked out the connection between the
tone-maintaining influence of the voluntary muscles and
the tone-maintaining influence of the circulatory system
that it became clear to him. By these resistance exercises
and by moderately severe out-of-door exercise the blood
pressure was regulated. This fact he had frequently veri-
fied by clinical observation. Whether or not the structural
changes in the blood-vessels could be removed he knew
by actual observation that prolonged regulation of the cir-
culation broke up the high pressure habit and led to a
practical cure of hypertonia vasorum.

Dr. Marple, in reply to Dr. Wilcox, said that the term
retinitis albuminurica was not used much by opthalmolo-
gists to-day. It was a term that had been introduced many
decades ago, and had survived its usefulness. It had been
well understood for a long time that it was really due to
a vascular degeneration. Not infrequently we saw exquisite
pictures of arteriosclerosis in the retina, and no albumin
was found in the urine, yet time showed that we were
dealing with a contracted kidney. In the retina we had a
retinal sclerosis ; in the kidnev a renal sclerosis.

NEW YORK AC.'^DEMY OF MEDICINE.

SECTION ON PEDI.\TRICS.

Stated Meeting, Held February 14, 1907.

Dr. Godfrey R. Pisek in the Ch.mr.

A Case of Complete Alopecia Areata. — Dr. Henry E.
Hale presented a girl, fourteen years old, who noticed
three years ago that the hair was falling out from the
top of her head. This bald spot spread peripherally until
the hair had all disappeared within four months. One
month after the hair had disappeared from the scalp her
eyebrows and eyelashes disappeared. These latter came and
went a number of times Last November she noticed a
return of her hair, which was very light and fuzzy, and
was now com.'ng back, althouf;a very slowly. There was
no family hi.'-lory of syphilis, tuberculosis, or wasting dis-
eases.

Dr. Henry W. Frauenthal believed congenital lues to
be an enological factor in this case.

A Case of Little's Disease. — Dr. Walter B. Jennings
presented a boy, six years old, with a condition the mother
believed to be due to a difficult and protracted labor. When
four years old he had an attack of spinal meningitis. He
had been treated in Roosevelt Hospital for rachitis. He
cried a great deal during the first year of life. The speaker
had seen the child but once, and therefore the history ob-
tained was very incomplete as yet.

Dr. John Howland believed the case to be, not one of
Little's disease, but one of cranial hemorrhage occurring
at birth. This same child had been presented to a medical
society two years ago and then appeared as he now did.
The mother had stated that after birth the child breathed
badly, and artificial respiration had to be resorted to. He
could not hold his head up when eight months old, and
when eighteen months old he could not sit up without as-
sistance. There was a free sensorium. The prognosis as
regards the physical condition was bad, although bis men-
tal condition would always be good.

Dr. L. E. La Fetra had seen the child when he had
spinal meningitis, and at that time a great deal more
attention was paid to the meningitis than to the previous
history.

Dr. Godfrey R. Pisek said that the diagnosis of Little's
disease could be thrown out in this case and without
doubt the condition was due to a hemorrhage into the
brain which occurred as the result of a prolonged and
difficult labor.

A Case of Multiple Bone Tumors (Exostoses). — Dr.

Henry W. Frauenthal presented a young girl who had
a number of bone tumors scattered over the body, mostly
affecting the flat and long bones, but not the skull.

Dr. Samuel Lloyd reported the case of a four-year-old
child who fell upon both outstretched hands and devel-
oped what he then supposed to be a tuberculous dactylitis,
starting in the metacarpal bones of the little finger on
both sides. A few weeks later he was surprised to find
both olecranons involved, and shortly after these tumors
developed in other parts of the body ; she had at least half
a dozen of these exostoses. She finally died of sarcoma-
tosis, with the characteristic cracked-eggshell tumors. They
were not the characteristic osteosarcomata, but they spread
and involved the different tissues. Many of these cases,
such as presented by Dr. Frauenthal, he believed could be
traced back to parentage.

A Case of Mycotic Carditis with Multiple Emboli and
Extensive Gangrene of the Lower Extremities. — Dr. K.
H. Golustone reported this case, which was mainly of in-
terest on account of the severity or malignancy of the
process, of its comparative rarity in childhood, and of its
being somewhat atypical. The child was two and a half
years old. The family history was negative. Since last
May, when he had a second attack of pneumonia, he had
not been well ; he coughed, was pale, but the weight re-
mained stationary. In November he suffered an attack
of diphtheria, and since then the child was always ailing;
his cough grew worse, the pallor increased, he played less
but did not lose weight. Dr. Goldstone first saw the boy
December 27 last. He liad been acutely ill two days
prior with cough, dyspnea, fever, and sweating. On ex-
amination he found a normal sized child, but pale, with
an emphysematous chest, craniotabes, but without any
marked bone lesions. There were sibilant and sonor-
ous rales all over the chest; tubular breathing over
the left apex and left lower lobe behind. There was em-
physematous breathing. The heart was normal. The ab-
domen was slightly protuberant and soft. The liver and
spleen were not felt. The temperature was 100.5°, pulse
no and respiration 30. The skin was clean. The fingers
were not clubbed. The throat was clear, the gums pale,
and the child's demeanor was anxious. He believed the
child to be suffering from a chronic or persistent broncho-
pneumonia, and for such treated him. On December 31
he found a purplish discoloration encircling both ankles,
about three inches in width, not in separate spots, but one
large area of staining. There was no swelling, but the
joints were painful to the touch. There were no other
spots of ecchymosis noted. The lungs then were clear, e.x-
cept for bronchial breathing behind. The heart was ir-
regular, but there were no murmurs. The temperature
was 101.5°, pulse 20 and respirations 30. On January I
the ecchymoses had extended to middle of the leg and
covered half the foot ; these areas were swollen, exqui-
sitely tender, but hard and cold. Heart was irregular, but
there were no murmurs. On January 2 the ecchymoses
had extended to the knees and covered the whole of the
foot. The limbs were greatly swollen, cold and almost
black. The scrotum and penis were swollen, purple and
cold. On January 3 the child was semicomatose. The
gangrene had extended half way up both thighs, which
were black, cold and three or four times the size of a
normal limb, with here and there blebs and areas of
broken integument. Petechial spots about the size of a
penny appeared over both cheeks. The scrotum was
greatly enlarged, black and cold. The abdomen was re-
laxed The temperature was 100.5°. pulse 160. respira-
tions do. The dyspnea was extreme. No urine had been
passed for thirty-six hours, and the last specimen showed
albumin and blood casts, but no free blood. On January 4
the condition remained about the same until 3 p.m., when
the child went into a deep coma. There was no radial
pulse. The breathing was of the Cheyne-Stokes type and,
for the first time, a faint systolic murmur was heard at

456

MEDICAL RECORD.

[March i6, 1907

the apex. The heart's action was irregular. Moist rales
were heard over both chests. The mucous membranes were
blanched, and petechial spots appeared on the eyelids. At 5
P.M. the child died peacefully. No autopsy was obtained
and no bacteriological findings recorded, because of the
objection of the family to permit even puncturing the
skin.

Pigmented Spots in the Sacral Region of White and
Negro Infants. — Dr. Chas. Herrman read this paper.
He said that these spots occurred in the dark-skinned
races and had interested anthropologists for a very long
time.- In Japan, where 90 per cent, of the infants showed
these spots, these macroscopical appearances were discov-
ered over one hundred years ago. The first histological
examinations of sections from the skin were made by
Baetz in 1885. In 1903 Adachi published an exhaustive
paper, in which the histological findings were very fully
described. The conclusions were based upon the exam-
ination of a very large series of sections from Japanese
infants and from apes. From his earlier investigations
he came to the conclusion that the characteristic pigment
cells which were found in the deeper layers of the corium
in these cases, would be found also in white infants, even
though they presented no visible spots. He therefore ex-
amined a series of sections from twenty-four white in-
fants and found the characteristic pigment cells in ten.
Upon the basis of these findings, he suggested that a care-
ful examination of a large series of white infants would
probably reveal the presence of visible spots in a few. Act-
ing on this suggestion, a friend, Fujisawa, then attached
to the clinic for diseases of children at Munich, found the
spots in the fiftieth infant examined. In this he was for-
tunate, for the spots really occur in about i in 400. In
1906 Ebstein of Prague published a paper in which he
stated that the spots had attracted his attention for many
years. It was unfortunate that he had given to his paper the
title "The Blue Spots in the Sacral Region and Other Mon-
golian Peculiarities in European Infants," for the peculiar-
ities described were those of Mongolian imbecility. The
sacral spots were to a certain degree characteristic of the
Mongolian race insofar as they occurred in a very large
percentage of their infants. The Mongolian imbeciles
were so called by English writers from a certain super-
ficial resemblance of their features to the Mongolian type.
But they were not in the true sense of the word Mon-
golian. In this country, Ashmead, in 1905, published a
paper on the spots as they occurred in dark-skinned races,
but made no mention of their appearance in white in-
fants. The spots occurred in a number of widely sep-
arated races in Japan and China, Java, Malay Peninsula,
Hawaii, Greenland, etc., and were probably present in all
dark-skinned races. They were also present in apes, and
in them were of much larger size. During the last
eighteen months Dr. Herrman had examined about 1,800
infants. The spots were present in five — that was, about
I in 400. In all these the hair and iris were dark. In a
series of negro infants examined in Dr. La Fetra's service
at the Vanderbilt Clinic, the spots were present in 30 per
cent, and were more distinct in those cases in which
the parents were entirely dark skinned. The spots were
most frequently found in the sacral, lumbar, and gluteal
regions, and occasionally on the upper part of the back,
shoulders, or the anterior surfaces of the extremities, but
very rarely on the face ; in one case they were found on
the inner surface of the thigh. According to one author,
they appeared as early as the fourth months of embryonal
life. They were present at birth and sometimes became
more distinct during the first few weeks ; after that they
grew fainter and disappeared at the end of the second
year, and occasionally, when in an unusual situation, they
persisted for a longer time. In white infants there was
commonly a single spot; in negro infants several. Their
size varied from a dime to the palm of the hand. They

were circular, elliptical, or irregular in outline. In white
infants they were of a grayish blue color, not unlike a
tattoo mark ; in negro infants there was often a more
greenish tinge. They were not raised above the level of
the skin, did not change in appearance on pressure, and
the outline could sometimes be made more distinct by put-
ting the skin on the stretch. There was no growth of
hair on the surface and no indication of blood-vessels. On
microscopical examination of the skin the coloring was
found to be due to the presence in the deeper layers of
the corium of large spindle or star shaped cells filled with
dark brown pigment granules, not unlike those in the
choroid. These cells were present in small numbers in
about 40 per cent, of white infants, but only in one case
in 400 were they in sufficiently large numbers and suf-
ficiently closely grouped to produce a visible spot upon the
skin. The spots were easily differentiated from hemor-
rhages and vascular or pigmented nevi by their char-
acteristic situations, color, absence of hair, or blood-vessel
formation, and by the fact that they were not raised above
the surface, did not change on pressure, and tended to
disappear at the end of the second year. The last point
was worth noting, for as they occasionally occurred on
the face the question of surgical removal might come up.
Why the spots should occur with so much greater fre-
quency in the sacral region was not known, but it was
worth mentioning that this region was to a certain extent
a point of least resistance, as was shown by the occurrence
of developmental anomalies, spina bifida, dermoid cysts,
and the other tumors. The fact that the spots were pres-
ent in the infants of a large number of widely separated
races, and the fact that the characteristic pigment cells
were present on microscopical examinations in about 40
per cent, of white infants, would speak rather against
their being a racial characteristic. The evidence in favor
of their being considered stigmata of degeneration was
also insufficient.

Dr. Herma.v Schwarz and Dr. Godfrey R. Pisek dis-
cussed the paper.

Dr. Charles Herrman closed the discussion.

The Surgical Treatment of Empyema. — Dr. Samuel
Llo\T) read this paper. It was now generally conceded
that there was but one treatment for the cure of a puru-
lent pleurisy, the immediate evacuation of the puj by
some surgical procedure. It was a just criticism that
these cases were not recognized earlier and not subjected
to a more radical treatment as soon as the diagnosis was
made, and this was frequently due to neglect of some of
the diagnostic aids now available. Whenever a medical
man had a case of pneumonia which did not resolve in
the usual way, and particularly if there were evidences
of pleuritic involvement, he should suspect a localized
empyema, and he should take every possible means of de-
termining whether or not pus w-as present and respon-
sible for the continuance of the symptoms. Another
condition for which these localized symptoms were mis-
taken was tuberculosis, and Dr. Lloyd had had fourteen
or fifteen cases where the physicians had made the diag-
nosis of tuberculosis. Unless one had all the data neces-
sary to make such a diagnosis definite, the question of
empyema should be considered. One of the difficulties
noticed was that clinicians depended upon needles of too
small caliber to determine the presence or absence of pus
in the pleura! cavity. The pus in such a case was some-
times thick, filled with fibrin flakes, and would clog any
needle except one of considerable size. The needle should
be longer than the one usually emploj'ed. The syringe
should be of considerable size, or, better yet, an aspirator
should be employed. The .r-ray was of value in making
a diagnosis, and they had recently had two cases of in-
terlobar pneumonia, and one of abscess of the lung, in
which the diagnosis was made by means of the x-ray. He
emphasized the fact that a fluid which macroscopically

March i6, 1907]

MEDICAL RECORD.

457

might appear to be simply serous, microscopically might
show the presence of a large number of pyogenic micro-
organisms, and these cases were just as much empyemas
as those from which they withdrew the usual creamy
pus, and should be operated upon as soon as the diagnosis
was made. As to whether one should, at the time of
making the exploratory puncture, take out more of the
fluid than was necessary for pathological examination, or
whether one should take out as much of the fluid as was
possible, this to a certain extent depended upon the con-
dition of the patient; experience and surgical judgment
should be the controlling factors in determining whether
an aspiration should be performed, or whether the oper-
ator should proceed at once to a more radical measure.
In his series of cases he had but eighteen aspirations. Of
these, two were cured and sixteen died. Dr. Lloyd said
he favored the early aspiration of the pleural cavity. So
soon as the physician was convinced or had a suspicion
of fluid in the pleural cavity, if it was showing signs of
becoming purulent, or if there was an unresolved pneu-
monia or tuberculosis, he would introduce a large sized
exploring needle and withdraw a sufficient amount of
fluid to submit to microscopical examination, and stain-
ing, for the presence of micrococci. If these were present,
an aspirating syringe should be attached to the needle and
all of the fluid withdrawn. Should severe attacks of
coughing ensue, the withdrawal of the fluid should stop,
and tile opening be sealed. In doing this the whole chest
should be prepared as though one intended doing a cap-
ital operation. If, in the course of the aspiration, it was
determined that the lung was coming down and expand-
ing to fill the chest cavity, the operator might be satisfied
with the simple removal of the fluid. If, on the other
hand, the lung did not expand, a more radical operation
was indicated. In cases of emphysema, thoracotomy
should be performed. In simple aspiration the best re-
sults were obtained in those cases where the pneumococcus
was the cause. Thoracotomy should be performed in all
cases where it was demonstrated that the fluid was puru-
lent and the lung still capable of expansion. The ques-
tion of resection of a rib must be determined, to a certain
extent, by the condition of the fluid. If the micro-
organisms were not particularly virulent, and the ad-
hesions of the lung were recent and not too dense to pre-
vent expansion, and the intercostal space was sufficiently
wide to allow the insertion of the drainage tube without
compression, the probabilities were that the simple in-
cision between the ribs would suffice. But, on the other
hand, if these conditions did not e.xist, resection of the rib
was essential. Dr. Lloyd had used incision and drainage
only nineteen times: of these patients six were cured, two
improved, and eleven died. Simple resection of the ribs had
been performed forty-five times, with twelve patients cured,
eighteen improved, and fifteen deaths. The problem was not
simply one of the evacuation of the pus. but also of oblit-
eration of the suppurating cavity. Dr. Lloyd's experience
had convinced him that decortication of the lung as a
method of closing old cavities, as suggested by Fowler and
Delorme in 1803. had a comparativeh' small application.
He had operated upon twenty cases by this method, in
which seven were cured, five died, and five were not im-
proved, and in three the operation had to be suspended
because of hemorrhage. He had operated by the Schede-
Estlander method five times, .with one cure, three patients
improved and one death. Dr. Lloyd believed that it was
invariably better to make an elastic organ fill up the cavity
which it should occupy tiian to attempt to make the in-
elastic wall fall in against the collapsed lung. Then fol-
lowed a description of his method of operating : this will
appear in the March Annals of Surgery. The anesthetic,
in his opinion, should be ether, and the success of the
operation depended very largely upon the proper regula-
tion of the anesthetic. The patient should be completely
anesthetized until the rihs had been resected and the oper-

ator was ready to incise the pleura. Then it was his rule
to order that all anesthesia should cease at once, and be-
fore the pleura was opened. One reason for this was be-
cause occasionally they found that the fluid was evacu-
ated very rapidly in spite of all attempts to control it, the
intrapleural pressure being so great that it burst through
the pleura as soon as the soft parts and the ribs had been
removed ; in these cases if the adhesions were recent the
lung broke away from them, filled the pleural cavity, and
at the same time a large amount of the anesthetic was
inhaled. A more important reason for stopping the an-
esthetic was to allow the patient to recover gradually dur-
ing the remainder of the manipulation. Sweeping the
finger over the pleura caused the partially anesthetized pa-
tient to cough, and with each forced expiration the col-
lapsed lung was seen to expand. This should be con-
tinued until the full expansion of the lung was obtained.
Frequently it would be pushed out of the wound. Un-
less the patient was pretty well over the effects of the
anesthesia, this procedure could not be carried out. There
would be no response to pleural irritation under complete
anesthesia, and consequently no cough. This was an es-
sential part of 'the operation. The number of cases upon
which his paper was based was 400. Of this number
17-1 were cured, 114 improved, and 115 died.

Dr. L. E. La Fetra did not agree with Dr. Lloyd in
his statement that the empyema should be operated upon
as soon as diagnosed. It had always seemed to him that
the children did better if the operation was not done at
the time of the beginning of the fever which started the
empyema; it would be better to wait two or three days,
wlien the temperature would be less. A small num-
ber of cases could be cured by aspiration alone, but this
fact should not lead them to adopt this as a regular
method of treatment for empyema. He thought that Dr.
Lloyd's method of administering the anesthetic was a
great advance in the management of these cases.

Dr. Herman Schwarz agreed with Dr. La Fetra in
regard to the time for operating; not only did the em-
pyema cause the temperature, but the presence of an ac-
tive pneumonia as well, and children did not do so well
in that phase of the disease. In Dr. Koplik's wards a
rule they adhered to pretty closely was that a child under
the age of two years did not require resection of a rib.
They incised the intercostal space and drained the pus.
They gave as little anesthetic as possible; in fact, after
the skin and muscles were incised, the anesthetic was
stopped. When the pleura was incised the child was prac-
tically out of the anesthetic.

Dr. Edward W. Peterson corroborated all that Dr. Lloyd
had stated in his paper. The age of the child was an
important prognostic factor. In children under the age
of one year 75 per cent, recovered, no matter what treat-
ment was adopted. The nature of the infection was an-
other prognostic factor. If it was a pneumococcic infec-
tion, a large proportion of the cases would recover in re-
cent cases by simple incision. The whole problem was in
making the lung fit the cavity of the chest, or else making
the chest cavity collapse to fit the lung.

Dr. Lloyd, in answer to Dr. La Fetra's criticism, said
that one did not. as a rule, diagnose empyema quite so
early, and when diagnosed the case had already passed
the acute stage. He said he would not operate during the
first two or three days of the disease. In some cases of
empyema there would be present a pneumonia ; if the case
was left alone septic intoxication would rapidly become
the prevailing symptom. It had been noticed that when
such cases died it was from the empyema and not from
the pneumonia. Consequently in his opinion it was more
important to stop the intoxication than to increase the
pneumonia by any manipulation of the lung, or the ad-
ministration of an anesthetic. As a rule, the pneumonia
met with was a resolving one. In many infants, because
of the larger intercostal spaces, they drained better when

458

MEDICAL RECORD.

[March i6. 1907

a simple thoracotomy was done ; it was often not neces-
sary to resect a rib. One of the superstitions in surgery
was the insensibihty of the pleura, and the reason why
the pleurn was supposed to be insensitive was because the
patients were under the influence of an anesthetic. Let
the patient be partially under an anesthetic, or completely
out of it, then sweep your finger across the pleural sur-
face, and there would result a cough, or a series of
coughs. It had been demonstrated by Dr. Lloyd that a
lung did not collapse, in spite of the fact that the open-
ing in the chest wall was greater than the main bronchus.
He related an experience he had in operating for an
abscess in the lung, caused by a small tack being inhaled.
H* carried out the operation according to the rules he
employed in operating for empyema, with the result that
when the patient came out of the anesthetic, instead of
a collapsed lung there followed an expanded one, and he
could not then find the small abscess. In order to get ex-
pansion of the lung, the adhesions must first be broken up ;
then the pleura should be irritated in the partially an-
esthetized patient, who would begin to cough ; with this
cough there would be an attempt to force a way through
a partially closed glottis. With each expiration, but not
with each inspiration, the lung would come down. The
point he wished particularly to emphasize was the me-
chanical part of this expansion of the lung.

Maaks ^tmvth.

IVhile the I\Iedic.\l Record is pkascd to receive all new
publications u-hich may be sent to it, and an acknowledg-
ment will be promptly made of their receipt under this
heading, it must be zvith the distinct understanding that its
necessities are such that it cannot be considered under
obligation to notice or review any publication received by it
which in the judgment of its editor icill not be of interest
to its readers.

Te.\t-Bo<.ik of Ax.\tomy for Xurses. By Eliz.vbeth R.
BiNDV. M.D. 8vo. 252 pages, illustrated, muslin. P. Blakis-
ton's Son & Co., Philadelphia. Price. $1.75.

Woman. By Myer Solis-Cohen, A.B., M.D. 8vo, 469
pages, illustrated, muslin. The John C. Winston Co.. Phil-
adelphia.

The Practic.vl Medicine Series. Under editorial charge
of Gustavus P. Head, M.D. Volume X, Series igo6, i2mo,
250 pages, illustrated, muslin. The Year Book Publishers.
Chicago.

Practical Dietetics. By .\lida Frances Pattee. Fourth
edition. i2mo. 339 pages, illustrated, muslin. ,\. F. Pattee,
Publisher.

Plaster of Paris and How to Use It. By Martin W.
\\'are. M.D, 8vo, 88 pages, illustrated, muslin. Surgerv
Publishing Co.

The Chemical Investigation of Gastric and Intes-
tinal Diseases. . By Vaughax Harley, M.D., Edin., and
Francis W. Goodbody, M.D., Dubl. Bvo, 261 pages, muslin.
Longmans. Green & Co., New York.

Organic and Functional Nervous Diseases. By M
Allen S'farr. M.D.. Ph.D.. LL.D.. Sc.D. Second ed'ition.
thoroughly revised. 8vo. 816 pages, illustrated, muslin. Lea
Rrotliers & Co.. New York.

The Practice of Obstetrics. By .American .Authors. 8vo,
1.807 pages, illustrated, muslin. Lea Brothers & Co., New
York.

Transactions of the .American Ophthalmolocical So-
ciety. Forty-second annual meeting. Vol. XI, Part I. 8vo,
247 pages, illustrated, paper. Published bv the Society,
Hartford.

Diagnose und Therapie der An.Xmien. Bearbeitet von
Dr. Joseph .^rneth. 4to, 208 pages, paper. .-V Stuber's
Verlag, Wurzburg.

Experimental "Zoology. By Thomas Hunt Morgan.
8vo. 4S4 pages, illustrated, muslin. The Macmillan Co.,
New York. Price. $2.75 net.

International Clinics. Edited bv A. O. T. Kelly. .A.M.,
M.D. 8vo. 322 pages, illustrated, m'uslin. Volume IV, l6th
Series. 1906. J. B. Lippincott Co.. Philadelphia.

Transactions of the .\merican Surgical Associ.\tion.
Volume XXIV. Edited bv Richard H. H.\rte. M.D. 8vo.
Sgi pages, illustrated, muslin. William J. Dornan. Phila-
delphia.

Manuel de Gynecologie Pratique. Par. J. Barozzi.
i2nio. 813 pages, illustrated, muslin. \'igot Freres. Editeurs.
Paris.

Injuries About the Elbow? Joint.— When the .t-ray i;
not available the following plan of procedure, suggested
by Gerster and described by Dawbarn, may prove of
service in facilitating the diagnosis of injuries about the
elbow joint when there is much swelling: The patient
having been anesthetized, an Esmarch elastic bandage
is slowly and firmly applied from the hand up the fore-
arm and over the elbow to the arm-pit. This is left on
for about fifteen minutes and then removed from below
upward, the final turns upon the upper arm being al-
lowed to rernain. The removal of the edema in this
manner permits of the recognition of a fracture or dis-
location, and this having been accomplished, the upper
turns of the bandage are removed. — International Jour-
nal of Surgery.

Writers' Cramp. — The following plan was success-
fully used by Hartenberg to cure a case of writers'
cramp: The patient, who had suffered from the con-
dition for about fifteen years, was instructed to apply
a rubber tube firmly around the biceps for twenty min-
utes at a time every morning and evening. .\t the end
of a few weeks the patient had almost entirely recov-
ered.— Archives de Xeurologie.

Indications for Tracheotomy. — James Berrygives the
following advice in regard to determining whether or
not tracheotomy is necessary. Two points that guide
in the decision are the cyanosis and the recession of the
chest-walls. Cyanosis alone is not sufficient indication
for the operation. It may be due not so much to laryn-
geal obstruction as to obstruction within the chest
itself. In diphtheria, for example, there may be much
blueness of the face from pneumonia even though the
larynx be quite free from obstruction. Tracheotomy in
such a case as this would be worse than useless. Re-
cession of the chest-wall is a very valuable indication
for the operation. When you see the supraclavicular
fossK receding deeply at every attempted inspiration,
when the lower ribs and the epigastrium are sucked vio-
lently inwards each time the child tries to breathe, then
the dyspnea is due to an obstruction in or near the
larynx, and relief to the dyspnea is urgently demanded.
The dyspnea being severe and progressive, dyspnea
and the recession of the chest-walls indicating laryn-
.geal obstruction, tracheotomy is indicated, if intubation
cannot be performed. — The Clinical Journal.

Rectal Feeding. — Becker proceeds in this way: The
number of meals in twenty-four hours should not ex-
ceed two, one meal in the morning and one late at
night. One hour before the morning meal a sup-
pository of opium and belladonna is introduced, and
then an hour later the rectum is carefully cleansed with
lukewarm water to which some salt is added — it need
not be physiological salt solution. The temperature of
the cleansing water should range — like the other things
introduced into the rectum — from 42 to 45 degrees centi-
grade. It should be introduced into the rectum with
moderate force in moderate quantities, say 130 c.c. at a
time, and the tube should remain in the rectum for the
return of the soiled water. .A good sized rectal tube
should be used for the cleansing, and the tube should
have a rather wide lumen, and should not be too flabby.
The introductinn and the letting out of the water are
repeated until the water returns absolutely clean. Then
the tube is turned and pushed in and out several times
to ascertain and insure that all the water, or at least
as much as possible, has left the colon and rectum.
Now^ the patient is given a short time of rest, sav fifteen
or twentv minutes, after which the rectal meal is intro-
duced. The same rectal tube is used and is introduced
about 15 cm., and then the meal. 200 c.c. at most 230
c.c, is slowly introduced at a temperature of from 42°
to 45°. — IViscnnsin Medical Journal.

Poison Ivy. — Since there is apparently much doubt as
to the best method of treatment of the dermatitis of rhus
poisoning, the information may be of interest that in the
powdered crude sulnhur of the stores we possess a remedy
everywhere obtainable and usually oromntly successful. Its
application is best made bv mixing it with a little water, and
perhaps a few- drops of glycerin, this to be rubbed over the
afifected area two or three times a day. Next best is its use
mixed with iust sufficient lard to bind it. .\s to the time
of activity of the poison I remember a patient who infected
himself in earlv spring before anoearance of the leaves by
ten ring out roots in a clearing for garden culture.

C. G. .Amende. M.D.

March i6, 1907]

MEDICAL RECORD.

459

NfUJ Snstnmtfuti

A THERMESTHESIOMETER AND A
POCKET ESTHESIOMETER

By FREDERICK PETERSON, M.D..

NEW YORK.

The temperature sense is ,s;-eiierally tested by the
appHcation of test tubes containing hot and cold
water, and such a method is, as a ruie, sufficiently
accurate for the practical and g-ross determination

A Therniesthesicmetcr.

of the loss of this sense in, for instance, a case of
svrino-omvelia. But I have long felt that some more
precise instrument should be used for this purpose,
since the more we studv the skin and its innervation

measurements of the temperature sense may be
made, I have devised the thermesthesiometer shown
in the illustration. It consists of two metal test
tubes with covers, united at one end by a hinge, so
'that it may be opened like a compass when in use, in
order to insulate each tube from the other, and closed
when replaced in its case. Each tube has attached
to it a thermometer inclosed in wood, but in contact
with the metal of the tube on one side, so that the
temperature of each may be accurately known at
any time. The instrument has been constructed in
the best manner with carefully tested thermometers
by M. Sendtner, maker of instruments of precision,
Schillerstrasse 22, Munich, Germany, whose Ameri-
can agent is Eimer & Amend, New York.

In addition to the thermesthesiometer, Sendtner
has constructed for me the convenient pocket esthesi-
ometer shown in the accompanying illustration, with
a needle, blunt point, and camel's hair brush which
slide back into the handle on the principle of some
of the metal lead-pencils.

a W l>T Fiftieth Stkee:

Sore Nipples. — These may be painted with a 4 per
cent, solution of sih-er nitrate, or an ointment having the
following composition may be applied :

IJ Bals. Peruvian 3i

Ungt. tq. rosse.

Lanolini • aa 5ss

Epidemic Influenza. —

I)t Phenacetine gr. iii

Quin. sulphat '■ gr. iv

Pulv. ipecac et opii gr. ss

Ext. aconiti gr- Vi

M. et ft. pil. No. I. S. : One pill four times a day.
Migraine. — Carron de la Carriere recommends pills
of extract of Indian hemp, each containing O.015 of the
drug. These are given every night for thirty days, at the
end of which time, if no improvement has resulted, the
dose is increased to two pills. The remedy may be used
over long periods without danger. During acute attacks
the forehead is rubbed witli the following:

mmmmmm.

m

Fig. 2. — Pocket Estbesit.meter.

the more impurtant does it become from the neuro-
logical standpoint. I need onl\- allude to the fact that
at one time we spoke of general sensibility as one
of the five senses, whereas now we know that there
are four or five, perhaps more, skin-senses, such as
touch, heat, cold, pain, not to speak of other fonns
of general sensation, like pressure, muscle-sense,
space-sense, tickling, etc. Now we have, too, a new
and wonderful relation of the skin to psychic proc-
esses, as revealed by the electric psychometer ; and
we have the new studies of Head, Rivers, and Sher-
ren on the various avenues by which the epicritic and
protopathic systems of sensory fibers reach the cen-
tral nervous system. In studying the temperature
sense it is found that certain points on the skin feel
cold and others warm impressions, that these points
are separate, and that they are unequally distributed
over the surface of the body. For instance, on the
legs one finds areas of several square centimeters
where neither cold nor heat is perceived. Further-
more, cold points are in general more numerous
over the body than warm points, .\nother interest-
ing phenomenon is that if a cold point be touched by
an object heated above 4;° C. a sensation of cold
is produced. Tn the end. therefore, that more exact

5 Menthol S-O

Chloroform 5-0

Methyl salicylate S-O

Lanolin 30-0

— Presse Mcdicale.

Scabies. —

IJ Sodii carbonat 5i,

Sulphuris 5'ii

Glycerini 5vi

Gum. tragacanth gr. xv

The patient rubs himself with ordinary soap for half an
hour, then takes a bath, followed by brisk friction with
the above mixture. The following day and for two or
three days afterward the patient takes a starch bath (one
pound of starch for each bath), and powders himself with
the same substance. — Medical Press.

Opium Habit. — For the mental and physical depres-
sion Ringer recommends:

K Tr. capsici 3iv

Pot. bromid 3iv

Spt. amnion, aromat Siiiss

.\q. camphors 5vi

Sig. : A dessertspoonful several times daily as required.
Menorrhagia. —

IJ .^cid. gallici 3ss

.Vcid. sulphnrici dil.

Tr. opii deod 33 01

Infus. rosre comp o'v

Sig.: h tablespoonful evcrv four hours.

— B.^RTHOLOW.

460

iMEDICAL RECORD.

[March 16, 1907

^tate ilfbural Utrf naing Inarha. .

STATE BOARD EXAMINATION QUESTIONS.

University of the State ok New York.

January 2g-Febntaiy i, 1907.

The candidate is required to anszi'cr any 10 of the ques-
tions on each paper, but no more.

1. Locate and define (,a) odontoblasts, (b) the ductus
venosus, (c) the vcsiculx seniinales.

2. Describe the arrangement of the bones of the ear.

3. Mention and describe the various forms of epithelial
cells.

4. Dfscril-.e microscopically (a) bone, (b) cartilage.

5. What is unstriped muscular fiber and where in the
body is it found?

6. Describe the popliteal artery and give its branche?.

7. What are ductless glands? Name the important
ductless glands.

8. Describe a spinal nerve.

9. Give the minute anatomy of the skin.

ID. Describe the appendix vermiformis and give its
topography.

11. Give the origin, insertion, action and nerve supply
of one of the following muscles: pectoralis major, levator
ani, internal oblique.

12. Describe the superior petrosal sinus.

13. Give the gross anatomy of the tongue.

14. Describe the ovaries and give their relations.

15. What anatomic parts are normally found in the left
hypochondriac region?

PHYSIOLOtiV AND HYGIENE.

1. Describe bones as to varieties and functions. Give
the general structure of bone.

2. What constitutes the lymphatic system and what
forces are concerned in the circulation of the lymph?

3. Describe the controlling forces that regulate the
circulation of the blood in (a) the arteries, (b) the capil-
laries, (c) the veins.

4. State the functions of the medulla oblongata.

5. Give the physiological mechanism of the valves of the
heart.

6. Compare e.xpired air with inspired air. What is (a)
external respiration, (b) internal respiration?

7. Describe micturition. What mechanism serves to
keep the urine in the bladder until it is voluntarily voided?

8. State where in the body each of the following sub-
stances is found and mention the special purpose served by
each: (a) ptyalin, (b) pepsin, (c) glycogen, (d) trypsin.

9. Give all the causes of (a) contraction of the pupil,
(b) dilatation of the pupil.

10. Mention the functions of the facial nerve and
state the effects of its complete paralysis.

11. What kinds of contamination does the presence of
each, of the following substances in drinking water indicate :
(a) nitrites and nitrates, (b) excess of chlorin? Give the
causes of hardness of water.

12. Describe the best method of constructing a house
drain.

13. What special measures of prophylaxis may be best
employed against (a) typhoid fever, (b) yellow fever, (c)
malarial fevers, (d) rabies?

14. Describe the best method of heating and ventilating
a hospital ward.

15. How may milk be adulterated and how may it be
contaminated with infectious elements?

chemistry.

1. Define destructive distillation, smelting, normal salts.

2. Name tivo monads, tivo dyads and two triads. Illus-
trate each in a graphic formula.

•It is proposed in this department to publish from time to
time the examination papers of the various State Boards,
In order that a candidate may become familiar with the
character of the examination and so in some measure free
himself in advance from the nervousness and dread which
the unknown inspires. In furtherance of the same object
answers to some of the questions will be published in order
to show the candidate what the examiners expect of him.
Not all the questions of all the papers will be so treated,
for the answers to manv. especially in the anatomical papers,
are obvious or can be found In the index of any text-
oook on the subject; the answers to other questions, especially
In the surgical papers, must sometimes be omitted because of
the space they would demand. The candidate for a medical
license will not find In these answers a short and easy road to
success in the examination, for he is not likely to meet the
same questions in the papers placed before him by the
examiners. The object of publishing the questions and
answers is onlv. as noted above, to acquaint the candidate
with the general character of these examinations and to
inspire him with confidence In the result of his trial.

3. Describe the metric system of weights and meas-
ures and give the practical equivalent of each unit in Troy
weight.

4. Give the uses and the chemical properties of phos-
phorus and mention any peculiarity of phosphorus in its
relation to oxygen.

5. What constitutes hard water? How may the pres-
ence of albuminoid matter in water be recognized?

6. Give the chemical properties of ozone.

7. Name 10 principal elements chiefly concerned in the
chemical changes taking place in life and describe the
preparation of one of them.

8. Describe the preparation and give the properties of
chlorin. On what important chemical feature does the
useful application of chlorin depend ?

9. Give the percentage composition of normal urine
as to water, urea, uric acid, organic matter, and sodium
chlorid.

10. What is electrolysis? State the ionic theory.

11. Give the chemical features of disinfection.

12. Mention the general properties of organic com-
pounds.

13. What are hydrocarbons? Give the name and the
formula of one important hydrocarbon.

14. Describe a method (laboratory or otherwise) of
making alcohol (ethyl). What is the percentage of alcohol
in (a) porter, (b) port wine, (c) champagne?

15. Describe the preparation and state the uses of cyan-
oiren.

1. Give the symptoms and the treatment of actinomy-
cosis.

2. Mention the most common sites cf epitheliomata.

3. Mention three operations on the stornach. Describe
one of these operations and give the indications for its
performance.

4. Give a classification of complete frpcture .iccording
to (a) line of separation, (b) mode of production, (c)
number of fractures present.

5. What are the immediate and the remote effect.-: of
a fracture-dislocation in the lower dorsal region?

6. What tumors occur in bone?

7. Give the treatment of hip joint disease in children.

8. Give the predisposing and the exciting causes of
aneurysm.

g. What operative measures are applicable in the treat-
ment of stone in the female bladder?

10. What is meant by secondary suppurative inflamma-
tion? Give the most frequent sources of secondary sup-
purative inflammation of the abdominal wall.

11. Give the treatment of an injury of the rectum in-
volving the peritoneum.

12. What are the specific diseases of the vulva? De-
scribe one of these diseases and give treatment.

13. Describe convergent strabismus and give its sur-
gical treatment.

14. Give the symptoms of syphilitic rhinitis in the new-
born.

15. Describe the pediculus pubis and mention the symp-
toms to which it gives rise. Give treatment.

obstetrics.

1. Give a brief description of the physiology of reproduc-
tion.

2. Describe the liquor amnii and stite its functions.

3. What pathological conditions of the internal organs
of generation are liable to cause abortion? Give reasons.

4. Give the causes and the treatment of umbilical hemor-
rhage in the newborn.

5. Give the prognosis and the management of a face
presentation.

6. Describe the effects of syphilitic infection on child-
bearing.

7. i^Iention the factors that affirmatively determine
pregnancy between the third and the fourth month.

8. What is understood h.' premature artificial delivery?
Mention the conditions that justify this procedure.

9. Give the treatment of retrodeviation of the uterus
when it complicates pregnancy.

10. Give the technique of catheterization of the female.

11. Make a diagnosis of tubal pregnancy. State the
dangers of tubal pregnancy.

12. Describe phlegmasia alba dolens and give the treat-
ment.

13. Give the symptoms of pelvic abscess. Through what
channels may pelvic abscesses drain ?

14. Define vaginismus. Give the etiolog>' and the treat-
ment of vaginismus.

15. Give a technical description of the operation of
craniotomy.

March i6, 1907]

MEDICAL RECORD.

461

PATHOLOGY AND DIAGNOSIS.

1. What pathological changes occur in (a) tmnefaction,
(b) hypertrophy, (c) induration, (d) calcification?

2. Describe the bacillus of tuberculosis and give a
method of demonstrating the same.

3. Mention some of the structural tissue changes caused
by pyrexia.

4. What changes occur in the red blood corpuscles in
progressive pernicious anemia?

5. Describe a method of making a bacteriological diag-
nosis in diphtheritis.

6. Under what pathological conditions may casts' be
found in the urine? Describe hvo varieties of casts.

7. Give the macroscopic and the microscopic appear-
ance of pus.

8. Describe the skin lesions occurring in psoriasis.

9. Mention the pathological conditions that may arise
from the presence of calculi in the gall-bladder.

10. Mention the changes that may occur in the nervous
system as a result of syphilis.

11. What muscles are involved in the paralysis follow-
ing lesions of the musculospiral nerve?

12. Describe a test meal and give the method of its
use.

13. Describe the onset and the course i.f ophthalmia
neonatorum.

14. Give the incubation period of (a) scarlatina, (b)
measles, (c) variola, (d) varicella, (e) rotheln. Give the
clinical history of one of these diseases.

15. Mention tlvree pathological conditions the ]ocal
symptoms of which are manifested in the epigastric region.

THERAPEUTICS, PRACTICE, AND MATERIA MEDICA.

Questions prepared by the Board of Examiners repre-
senting the Medical Society of the State of Nezv York:

1. Give the therapeutic uses of lobelia.

2. Give the physical signs of aortic obstructive lesions
of the heart.

3., Give the physiological action of digitalis on the heart
and on the kidneys.

4. Define and describe iodism.

5. Give the treatment of acute lobar pneumonitis.

6. Mention the official preparation of strophanthus.
State the dose of this preparation and describe its physio-
logical effects.

7. Give the therapeutic uses of sanguinaria.

8. Give the diagnosis and the treatment of gonorrheal
rheumatism.

9. Mention fiz'e official preparations of senna and state
the dose of each.

10. Describe the therapeutic uses of sulphur.

11. State the period of incubation in hydrophobia. De-
scribe the prophyla.xis in hydrophobia.

12. What preparation of apomorphin is used medicin-
ally? Mention the doses of this preparation and state for
what it is employed.

13. Mention the class of acids administered to acidify
alkaline urine.

14. Give the signs and the symptoms of intestinal per-
foration in typhoid fever.

IS- State the dose of (a) liquor potassii arsenitis, (b)
liquor sodii arsenatis.

ANSWERS TO ST.\TE BOARD EXAMINING QUES-
TIONS.

University of the State of New York.

January 29 to February i, 1907.

PHYSIOLOGY AND HYGIENE.

1. Bones are described as: (i) Long bones, consisting
of a shaft (which is hollow), and two extremities; exam-
ples, humerus, tibia, metacarpals. (2) Short bones, which
are compressed, short and spongy in structure, except on
their surfaces : examples, the bones of the carpus and tarsus.

(3) Flat bones, consisting of broad, flat plates of bone in-
closing some cancellous tissue; examples, parietal, scapula.

(4) Irregular bones, consisting of compact tissue externally,
and cancellous tissue internally, are such as cannot be
grouped under one of the preceding divisions ; examples,
vertebrae, ethmoid.

The functions of bones are: (l) for protection (chiefly
the flat bones) ; (2) for muscular attachments (chiefly the
long bones) ; (3) for support of the body (chiefly the long
bones) ; (4) for locomotion and motion (chiefly the long
bones) ; (5) for strength (chiefly the short bones) ; (6)
to maintain the shape and outline of the body.

2. The lymphatic system consists of : lymphatic glands,
lymph vessels, perivascular lymph spaces, the lymph canal-

icular system, the pericardial, pleural, peritoneal, and syno-
vial cavities, and the lacteals.

The forces concerned in the circulation of the lymph are :
(l) The pressure of the blood in the blood-vessels; (2)
thoracic aspiration; (3) muscular contractions of the vol-
untary muscles; (4) contractions of the intestine; (5) the
action of the valves in the lacteals and lymphatics.

3. The circulation of the blood is regulated in (a) the
arteries, by: (i) the elasticity and tone of the arteries, (2)
the force and frequency of the cardiac contractions, (3) the
resistance in the capillaries; (b) in the capillaries it is reg-
ulated by: (l) the action of the heart, (2) the action of
the arteries; (c) in the veins it is regulated by: (l) the
action of the heart, (2) aspiration of the thorax, (3) the
contraction of the muscles, and (4) slightly by the valves
in the veins.

4. The functions of the medulla oblongata are: (l) It
is a conductor of nervous impulses or impressions from the
cord to the cerebrum, from the brain to the spinal cord,
also of coordinating impulses from the cerebellum to the
cord; (2) it contains collections of gray matter which serve
as special nerve centers for the following functions or ac-
tions : respiration, salivary secretion, mastication, sucking,
deglutition, speech production, facial expression ; it also
contains the cardiac and vasomotor centers.

6.

Oxygen

Nitrogen

Carbon dioxide
Other gases. . . .
Watery vapor. .
Temperature. ..

Volume

Bacteria

Dust

Expired .'\ir.

16.6 per cent.
70 per cent.
4.4 per cent.
Often present.
Saturated.
I'hat of body.
Diminished.
None.
None.

Inspired Air.

21 per cent.
79 per cent.
0.04 per cent.
Rare.
Variable.
Variable.
Varies.

Always present.
Always present.

(a) External respiration is the interchange that takes
place between the blood and the gases in the lungs ; (b)
internal respiration is the interchange that takes place
between the blood and the tissues of the body.

7. The urine is kept in the bladder by the sphincter
vesicae and by the muscular and elastic fibers of the urethra.

8. (a) Ptyalin is found in the saliva; it changes starch
into dextrin and sugar; (b) pepsin is found in the gastric
juice; it changes proteids into proteoses and peptones in an
acid medium; (c) glycogen is found chiefly in the liver and
the muscles, also in the white blood corpuscles, and in the
placenta; (d) trypsin is found in the pancreatic juice; it
changes proteids into proteoses and peptones, and after-
wards decomposes them into leucin and tyrosin ; it acts in
an alkaline medium.

9. (a) The pupil contracts: (i) when stimulated by
light; (2) on stimulation of the third nerve; (3) on paraly-
sis of the cervical sympathetic; (4) when the eye is accom-
modated for near objects; (s) during sleep; (6) through
the action of certain drugs, called myotics, such as opium,
and the local influence of physostigmine; (7) when the eye-
ball is turned inwards, (b) The pupil dilates: (l) on re-
moval of the stimulus of light; (2) on paralysis of the
third nerve; (3) on stimulation of the cervical sympathetic;
(4) when the eye accommodates for distant objects; (5)
in deep chloroform narcosis; (6) in dyspnea; (7) under
the influence of certain drugs, called mydriatics, as atro-
pine; (8) under the influence of pain, or fear.

10. The facial nerve is the motor nerve of the muscles
of expression, also of the platysma and the buccinator; it
also supplies the muscles of the external ear, the stylohyoid,
and the posterior belly of the digastric. Through the chorda
tvinpani it is a nerve of taste and a vasodilator of the ves-
sels of the submaxillary and sublingual glands.

"When it is paralyzed, the muscles of the face being
all powerless, the countenance acquires on the par-
alyzed side a characteristic, vacant look, from the ab-
sence of all expression ; the angle of the mouth is lower,
and the paralyzed half of the mouth looks longer than
that on the other side; the eye has an unmeaning
stare, owing to the paralysis of the orbicularis palpebrarum.
.Ml these peculiarities increase the longer the paralysis lasts,
and their appearance is exaggerated when at any time the
muscles of the opposite side of the face are made active in
any expression, or in any of their ordinary functions. In
an' attempt to blow or whistle, one side of the mouth and
cheeks acts properly, but the other side is motionless, or
flaps loosely at the impulse of the expired air ; so, in trying
to suck, one side only of the mouth acts ; in feeding, the lips
and cheek are powerless, and, on account of paralysis of
the buccinator muscle, food lodges between the cheek and
guni^." (Kirkes' Physiology.)

462

MEDICAL RECORD.

[March 16, 1907

II. (a) The presence of nitrates and nitrites denotes
contamination from nitrogenous organic matter of animal
origin ; (b) the presence of excess of chlorin denotes
organic impurity of aniinal origin.

Hardness of w.itcr is caused by the salts of calcium and
magnesium ; usually the bicarbonate or sulphate, but some-
times the chloride, phosphate, or nitrate.

15. Milk may be adulterated by the addition of water
(clean or dirty), by skimming, by the addition of coloring
matters or preservatives, and by the addition of solid sub-
stances, such as sugar, flour, etc.

Milk may be contaminated with infectious elements by
being obtained from infected cows, by being diluted with
water containing disease germs, by the cans, containers,
vessels, etc., being contaminated with dirty water; through
carelessness in handling by persons who are infected.

CHEMISTRY.

1. Destructive distillation is a process of decomposition
of nonvolatile organic matter by the agency of heat, and
with exclusion of air.

Smelting is a method of obtaining a metal from its ore
by the process of fusion.

Normal salts are salts in which all of the replaceable
hydrogen of the acid has been replaced.

2. Two iiioiiads: hvdrogen and sodium: two dyads:
oxygen and sulphur; two triads: nitrogen and boron.

H-Cl ;

Hydrochloric acid;
H

/

S

\

H

Na-Cl ; H— 0-H

Sodium chloride . Water

OH H

/ /

E— OH A— H.

\ \

OH H

Sulpnuretted nydrogEi ; Boric acid. Ammonia

4. The chief uses of phosphorus are in making matches,
rat paste, and phosphor bronze. It is also used in medicine
in cases of osteomalacia, rickets, and as a nerve tonic.

The chemical properties of phosphorus are: chiefly its
readiness to enter into combination with o.xygen ; it is a re-
ducing agent; it is not acted on by HCl or by cold HiSO.;
it is o.xidized by hot H:SO<, and by HNO3.

5. Hard water is a water containing an excess of cal-
careous salt. (See above, Physiology, II.)

6. Ozone is a strong oxidizing agent; it oxidizes nearly
all metals in the presence of moisture ; it decolorizes indigo
and other pigments of organic nature ; it is but slightly sol-
uble in water.

7. Carbon, hydrogen, nitrogen, oxygen, iron, chlorine,
sodium, potassium, calcium, sulphur.

Hydrogen is prepared by the action of zinc on dilute sul-
phuric acid :

Zn-fH,SOir=ZnSO.-fH,

8. Chlorine is prepared by the action of hydrochloric
acid on manganese dioxide :

4HCl-fMnO:=MnCl:+2HjO+Cl,
It is an active disinfecting and bleaching agent in the
presence of moisture. It acts by decomposing the water,
the nascent oxygen thus liberated attacks the odorous or
coloring substance. Chlorine will not bleach a dry sub-
stance.

9. Water, 95.00 per cent. ; urea, 2.80 per cent. ; uric acid,
o.ob per cent. ; organic matter, 3.75 per cent. ; sodium
chloride, 0.80 per cent.

10. Electrolysis is the process of electrical conduction
accompanied by the separation of the constituents of the
electrolyte : or the decomposition of a chemical compound
by passing an electric current through it. The primary
products of electrolysis are called ions ; those which sep-
arate at the positive electrode or anode are called anions ;
those which separate at the negative electrode or cathode
are called cations. A solution of sodium chloride contains
NaCl, but it also contains the cation Na and the anion CI ;
and the action of the electric current is to separate these
ions (which are already liberated) at the respective elec-
trodes. It is supposed that the hydrogen and metallic ions
are charged with positive electricity, and the hydroxyl and
acid-residue ions are charged with negative electricity ;
hence the former are attracted to the cathode and the latter
to the anode.

11. Chemical disinfectants act in virtue of their power
to form definite chemical compounds with the bacteria
which are responsible for the infection. The bacteria are
thus rendered harmless. In order to accomplish this the
disinfectant must come in direct contact with the bacteria,
and in the combination thus effected both bacteria and dis-
infectant change their chemical properties.

12. Organic compounds may be either gases, liquids, or
solids (either crystalline or amorphous) ; may be either vol-
atile or nonvolatile ; may be either colorless, tasteless, odor-

less, or have any variety of these qualities; they are
changed by heat and chemical reagents with a readiness
which is directly proportionate to their complexity.

13. Hydrocarbons are chemical compounds consisting of
carbon and hydrogen only. Example, Methane, CHj.

14. Ethyl alcohol can be formed synthetically from cal-
cium carbide, water, and hydrogen. Thus (i) calcium car-
bide and water form acetylene :

CaC,+2HjO=CaHjO=+CjH,

(2) Acetylene vapor and water form aldehyde:

C=H.+ H,0 = CH3.CH0.

(3) Aldehyde and nascent hydrogen form alcohol:

CH3.CHO-fH,=CH3.CH,OH
(a) Porter, 4 to 6 per cent.; (b) port wine, 19 to 25 per
cent.; (c) champagne, 8 to 12 per cent.

15. Cyanogen is prepared by heating mercuric cyanid :

2 Hg (CN)= = 2 Hg + 2 (CN),

2. On the skin, mucous membranes, or at the junction of
skin and mucous surfaces ; lip, ala of nose, glans penis, cer-
vix uteri, eyelid. The cylindrical celled epithelioma is more
likely to occur in the stomach, the rectum, and uterus.

3. Gastrotomy, gastrostomy, gastrorrhaphy.

The indications for gastrotomy are: In the removal of
foreign bodies from the stomach, for exploration, for the
treatment of various conditions existing in the stomach,
pylorus, or lower end of the esophagus (such as ulcer,
stricture, etc.).

4. (a) Transverse, oblique, spiral, longitudinal, dentate,
T-shaped, V-shaped, and comminuted, (b) By external
violence, either direct or indirect ; by muscular contrac-
tion; spontaneous, (c) Single and multiple; this latter
may be double, triple, or quadruple, etc.

5. "Paraplegia below the part injured is present in
most cases, and with it some amount of general shock.
When the cord is disintegrated or divided, symptoms of
spinal myelitis rapidly follow, and a fatal issue often occurs
at an early date from toxemia following septic cystitis or
sloughing of the nates. The special phenomena of paraple-
gia in the region referred to are : — complete paralysis of
the muscles of both limbs, including those passing to them
from the trunk ; total anesthesia of the legs, gluteal and
perineal regions, and possibly the lower part of the abdo-
men ; whilst, if the vesical centers are destroyed, there is
total paralysis of the bladder, with relaxation of the sphinc-
ter, dribbling of urine, which early becomes ammoniacal,
and cystitis, due to trophic changes ; if the centers escape,
retention with overflow is the usual result ; the rectum
and sphincter ani are paralyzed, causing incontinence of
feces, the passage of which is unrecognized from the
anesthetic condition of the anus." — (Rose and Carless'
Manual of Surgery.)

6. Sarcomata, chondromata, osteomata, carcinomata,
fibromata, myxomata, angiomata, myelomata.

8. Predisposing causes : atheroma, syphilis, old age,
intemperance, undue exertion, embolism. Exciting causes:
injury to an artery, increased blood pressure (either from
increased heart action or from obstruction beyond the
aneurysm), blows", strains, sudden exertion.

9. Litholapaxy, suprapubic lithomy, vaginal lithotomy,
lithotrity (and extraction with forceps or by mere manipu-
lation).

II. Laparotomy should be performed at once, the ab-
dominal cavity must be thoroughly cleansed out, and par-
ticular attention be paid to asepsis, disinfection, and
drainage.

14. Coryza or "snufHes," with a thin, watery discharge
which does not readily respond to treatment, and which
causes excoriation ; fissured lips, "rhagades," and a hoarse
cry.

15. The pediculi pubis are the shortest of the pediculi,
but are broader and flatter than the pediculi capitis. The
head is fiddle-shaped, and they bear a general resemblance
to a miniature tortoise or crab. They have six legs ; the
two front pairs are used for walking, and with the claspers
on the hinder legs they stick tight to the pubic hair, and
generally have the head buried in the follicular orifice.
The nits are situated quite near the base of the hairs.

The symptoms are : itching in the pubic and perineal re-
gions, excoriations from scratching, hemorrhagic puncta
cr papules.

Treatment : The pubic region should be shaved, washed
with soap and water twice a day, either mercurial ointment
should be rubbed in, or lotion of corrosive sublimate should
be applied.

OBSTETRICS.

2. The liquor amnii is the fluid contained in the amniotic
sac; it is alkaline in reaction, has a specific gravity of about
i.ooi to 1.008, its quantity is variable, but is generally about
two pints. It consists chiefly of water, but contains small

March i6, 1907]

MEDICAL RECORD.

463

amounts of albumin, epithelial cells, urea, phosphates,
chlorides, etc. Its source is unsettled.

Functions: (a) During Pregnancy: (l) As a protection
to the fetus against pressure and shocks from without.
(2) As a protection to the uterus from excessive fetal
movements. (3) It distends the uterus, and thus allows
for the growth and movements of the fetus. (4) It re-
ceives the excretions of the fetus. (5) It surrounds the
fetus with a medium of equable temperature, and serves
to prevent loss of heat. (6) It prevents the formation of
adhesions between the fetus and the walls of the amniotic
sac. (7) It has been supposed, by some, to afford some
slight nutrition to the fetus.

(b) During Labor: it acts as a fluid wedge, and dilates
the OS uteri and the cervix ; it also slightly lubricates the
parts.

3. Malformations, and displaceinents of the uterus
(chiefly retroversion, and prolapse) ; inflammations of the
uterus or appendages (metritis, endometritis, salpingitis,
ovaritis),; adherent uterus with perimetritis ; undue rigidity
of the uterine muscles; extreme laceration, erosion, or
ulceration of the cervix ; tumors of the uterus ; pelvic
congestion, acute or chronic.

4. If primary, it is due to slipping of the ligature or
injury to the cord; and the cord should be re-ligate^l in a
proper manner. Secondary hemorrhage is due to either :
hemorrhagic diathesis, deficient coagulability of the blood,
or loosening or tearing of the norma! coagulum from the
hypogastric arteiies. Treatment : compression with hare-
lip pins, and application around these of a figure-of-eight
ligature.

9. The patient (the bowels and bladder having been
emptied) should be placed in the knee-chest position, and
the uterus replaced by manual pressure. If this proves un-
successful, a repositor may be used; and the procedure may
be facilitated by drawing down the cervix with a volsellum
forceps. If the uterus is bound down by adhesions, tam-
pons soaked in ichthyol and glycerin should be placed in
the posterior cul-dc-sac. After reposition, the uterus should
be kept in place by a pessary or tampons.

In case the uterus becomes incarcerated, in addition to
the above procedures, anesthesia may be necessary ; and if
reposition is not possible, the advisability of inducing abor-
' tion or of performing a hysterectomy may have to be con-
sidered.

13. Fever, chills, pulse weak and rapid, pain in lower
abdomen and thighs, anorexia, pelvic tenderness, prostra-
tion ; there may be painful urination and defecation.

Drainage may take place through the vagina, or through
the abdominal wall.

14. Vaginismus is a condition of painful and spasmodic
contraction of the vaginal orifice, which renders coitus
either painful or altogether impossible. Its causes are irri-
table hymen, ulcer, or fissure anywhere in the immediate
vicinity, urethral caruncle, carunculre myrtiforrnes, a long
perineum with vaginal orifice placed too anteriorly. The
treatment consists in removing the cause when possible,
tonics and general constitutional treatment; dilatation of
the vaginal orifice may be necesary ; local application of a
S per cent, solution of cocaine will relieve the hyperesthesia
and allow of coitus.

rATHOI.OCY.

3. Cloudy swelling, fatty degeneration, coagulation
necrosis; these occur principally in the muscles, the liver,
kidneys, and the heart.

9. Impaction in the gall duct, causing biliary colic;
dilatation and inflammation of the gall-bladder ; hypertrophy
and cirrhosis of the liver ; carcinoma of the gall-bladder.

10. Formation of gummata ; meningitis, myelitis, and
degenerative changes in the nerve tissues ; hemorrhages ;
encephalitis. As a result there may follow : mania, melan-
cholia, paretic dementia, pseudoparesis, myelitis, paraplegia,
hemiplegia, locomotor ataxia, general paresis, neurasthenia,
hysteria, epilepsy, and neuralgia.

11. Triceps, anconeus, supinator longus, extensor carpi
radialis longior, brachialis anticus, supinator brevis, ex-
tensor carpi radialis brevior, extensor carpi ulnaris, exten-
sor communis digitorum, extensor indicis, extensor minimi
digiti, extensor pollicis longus, extensor pollicis brevis,
abducto; pollicis.

12. Ewald's test breakfast consists of one or two dry
rolls, or one or two slices of drv bread ; and about two-
thirds of a pint of water or weak tea. This is taken in the
morning, no food having been taken since the previous
evening. The contents of the stomach are withdrawn
about an hour to an hour and a half after the test meal, and
examined.

15. Cancer of the stomach, cancer of the pancreas,
aneurysm.

THERAPEUTICS, PRACTICE, AND MATERIA MEDICA.

I. It is used internally in asthma, bronchitis, and con-
stipation; locally for the eruption in poisoning by rhus
toxicodendron.

3. It slows the heart, increases the force of the systole,
and prolongs the diastole. It also causes a rise in blood
pressure. On the kidneys it exerts more or less of a
diuretic aceion.

4. lodism is the name applied to the condition resulting
from the prolonged use of iodin or the iodides.

The symptoms of iodism are : Severe coryza, sore throat,
conjunctivitis, headache, nausea, anorexia, metallic taste
in the mouth, increased flow of saliva, eruption on the
skin which may go on to suppuration.

6. Tinctura strophanthi. Dose llBviii. It paralyzes the
muscles, first causing stiffness, and later, loss of voluntary
movement; the heart is particularly influenced. In small
doses it has the same effect as digitalis, increasing the
force of the systole, prolonging the diastole, stimulating the
cardiac contractions, and causing increased blood pressure.
It is also a diuretic.

7. It is used as an expectorant in bronchitis, and as a
gastric and hepatic stimulant.

9. (i) Confectio sennas; dose, 5j. (2) Fluidextractum
sennx; dose, TT^xxx. (3) Infusum sennse composituni ;
dose, 5iv. (4) Syrupus sennas; dose, 3j. (5) Pulvis
glycvrrhizs compositus ; dose, 5j.

12. The hydrochloride. As an expectorant, gr. 1/30; as
an emetic, gr. i/io.

13. Benzoic acid.

14. Severe, sudden, abdominal pain ; collapse ; small,
rapid pulse; the abdomen is distended and tender; the
legs are drawn up and the thighs flexed; there may be
nausea and vomiting; blood examination shows the presence
of leucocytosis. .

15. (a) Liquor potassii arsentis, llBnj. (b) Liquor sodii
arsenatis, Tl^iij.

BULLETl.N' OF APPROACHING EXAMINATIONS.t

STATE.

16

s

8

\-AME AND ADDRESS OP PLACE AND DATE OP

SErRETARV. NEXT EXAMINATION

Alabama* W. H, Sanders, Montgomery. .Montgomery. .April i-6

.\rizona* Ancil Martin, Phoenix Phoenix. . April l

Arkansas* F. T. Murphy, Brinkley Little Rock. . .Apn 9

Cahfomia Chas. I., Tisdale, Alameda. . . .San Francisco. April

Colorado S. D. Van Meter, 1723 Tre-

mont Street, Denver Denver April

Connecticut*.. Chas. A. Tuttle, New Haven. .New Haven. . .July 9

Delaware T. H. Wilson, Dover. .... Dover. ..... .June

Dis of Col'bia. .W.C.Woodward, Washington. Washington. . .April
Florida* . T. D. Fernandez, lacksonville.Jacksonville.. .May is

Georgia E R Anthony, Griffin Atlanta Apri —

Idaho J. L Conant, Ir, Genesee Boise Apn 2

Illinois J. A. Egan. Springfield Chicago -.April 17

Indiana W. T. Gott, i 20 State House,

Indianapolis IndianapoUs. . Mav

Iowa J F. Kennedy. Des Moines... .Des Moines ...March 19

Kansas T. E. Raines. Concordia Topeka June 11

Kentucky* J. N.»McCormack, Bowhng . .

Green Louisville Aprd 23

Louisiana F. A. La Rue, 211 Camp St.,

New Orleans New Orleans. . . Ma> 9

Maine Wm. J. Mayburv, Saco Augusta July 9

Maryland J. McP. Scott, Hagerstown.. - .Baltimore June

Massachusetts* E. B. Harvev. State House,

Boston Boston Mav 14

Michigan B. D. Hanson, ^os Whitney

Building, Detroit Ann Arbor June 11

Minnesota W. S Fullerton. St. Paul St. Paid April 2

Mississippi J. F. Hunter, Jackson Jackson.. . . . . May 14

Missouri J. A. B. Adcock. Warrensburg | Kansas City / ^^"^ '*

Montana* Wm. C. Riddell. Helena Helena April —

Nebraska Geo, H. Brash, Beatrice Lincoln..

Nevada S, L. Lee, Carson City Carson City ... May 6

N. Hamp're*. - .Henry C. Morrison, State Li-

brarv. Concord Concord July 9

New Jersey J. W Bennett, Long Branch. .Trenton June 18

New Mexico.. . B. D. Black, Las Vegas Santa Fe June 3

( New York, J
New York ., C,F."Wheelock Univ.of State J Albany,

of New York, Albany. . . . ) Syracuse.
( Buffalo.

N Carolina*.. . .G. T. Sikes. Grissom Morehead City.May —

N Dakota H. M. Wheeler. Grand Forks. .Grand Forks.. .April 2

Ohio .Geo. H. Matson, Columbus... .Columbus J""*^, ''

Oklahoma*. . . .J. W. Baker, Enid Guthrie March 26

Oregon* B.E.Miller, Portland Portland. . . .April —

Pennsylvania. .'N.^C. Schaeffer. Hamsburg. { pji'tsbu'g. '^ } J'^"" ~

RhodeIslana...G.T.Swarts, Providence Providence... .April 4

S Carolina W. M. Lester, Columbia Columbia June —

S DakoU H. E. McNutt, Aberdeen Sioux Falls.. ..July 10

f Memphis. |

Tennessee* T. J. Happel, Trenton {Nashville. May —

I Knoxville, J

Texas .. . T. T. Jackson, San Antonio. . .Austin April 30

Utah* R. W. Fisher, Salt Lake City. .Salt Lake City.Apnl i

Vermont W Scott Nay, Underbill Buriinfton. . .July 9

Virginia R. S. Martin. Stuart Lynchburg... June 18

Washington*. . . C. W. Sharpies, Seattle $'«;•"",'; l^"-', ^

W Virginia*. . .H. A. Barbee, Point Pleasant.. Wbeeling April 9

Wisconsin... . .J.V.Stevens, Tefterson Madison..

Wyoming S. B. Miller. Laramie Cheyenne.

*No reciprocity recognized by these States. f 1 , ^.

tApplicants should in every case write to the secretary for latest
details regarding the^examination in any particular htate.

Mav

..July

464

MEDICAL RECORD.

[March 16, 1907

illp^iral iltms.

Contagious Diseases — Weekly Statement. — Report ot

cases and deaths from contagious disease reported to the
Sanitary Bureau, Health Department, New York City, for
the week ending March 9, 1907 :

Tuberculosis Pulmonalis .

Diphtheria

Measles.

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis.
Malarial Fever

Totals

Cases Deaths

494

278
416
320

90
44
59
24

1725

225
29
14
12

24

316

Rhinopharyngitis Mutilans (Destructive Ulcerous
Rhinopharyngitis) : a Problem in Tropical Pathology.

— James Farquharson Leys states that it may help the
European reader to realize the extensive and striking
prevalence of this rhinopharyngitis in the few limited
regions from which it is reported, if he will apply the
figures representing its prevalence in Guam (one to one
and five-tenths per cent.) or in the Dominica district (three
per cent.) to some populations with which he is familiar.
A single case of this kind in Europe would probably be
attributed to tuberculosis or tertiary syphilis. The disease
appears to be of an infectious nature. It seems to be local,
not constitutional, and this suggests, according to the
writer, that its cause may be of a fungoid nature. The
destructive and mutilating serpiginous ulceration of the
nasopharynx is usually self-limited, and has little or no
effect upon the general health. The disease begins in the
soft parts, but later attacks the bone of the palate and nasal
septum, and finally destroys these entirely. At this stage
the disease usually arrests itself, leaving the victim with
no septum, the nasal cartilage and skin fallen in, and the
nose and mouth one large cavity. The writer believes that
this disease is not a late manifestation of yaws or of any
other constitutional disease, but that it is more probably
a peculiar, independent, local afifection caused not improb-
ably by the local invasion of some infecting organism.
He declares, however, that he does not wish to advocate
any mere hypothesis as to its etiology. — The Journal of
Tropical Medicine.

Barlow's Disease in the Island of Cuba. — Joaquin L.
Duefias says that infantile scurvy exists in tlie Island of
Cuba, under the same forms and identical features assigned
to it in other countries. Its frequency is apparently less
than in other parts of the world, but the writer believes
that it will increase as the disease becomes better known.
The disease was developed in children fed upon boiled
cow's milk, sterilized cow's milk, condensed milk, and
maternal milk ; and for some reason the employment of
each of these modes of feeding was disadvantageous to
the health of the child. As the immense majority of chil-
dren reared upon the same kind of nourishment do not
suffer from scurvy, it would seem that the true cause of
the disease must be traced either to the presence of some
noxious element contained previously in the milk, or in
its subsequent development in the intestine by virtue of a
defective elaboration of the ingested material. It must be
admitted, too, that some organic or functional deficiency in
the individual is a causative factor of great importance.
In the writer's opinion the toxic agent which produces the
scorbutic anemia of the child and the hemorrhagic syn-
drome which characterizes it, is of a chemical, and not of

an infectious, nature. Barlow's disease differs from rickets.
Of the author's seven cases, three offered no signs of
rickets, neither did they present osseous symptoms, nor the
premonitory signs described by Comby, at the level of the
stomach, intestine, liver, spleen, and lymphatic glands.
The writer concludes that he can add nothing new to what
is already known with regard to the diagnosis, prognosis,
and treatment of infantile scurvy. — Archives of Pediatrics.

Health Reports.— The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital
Service, during the week ended March 8, 1907 :

SMALLPOX I'.S'ITEU STATES.

California, Los .Angeles Feb.

Florida, Jacksonville Feb.

Georgia, .'\ugusta Feb.

I ndiana, Indianapolis Feb.

La Fayette.. Feb.

Iowa, Cedar Rapids Feb

Davenport Feb.

Des Moines Nov.

North English Dec.

Louisiana, New Orleans Feb

Michigan, Detroit Jan.

■• Feb.

Missouri, St. Joseph Feb.

St. Louis Jan.

N"ew York. New York Feb.

North Dakota, General Sept.

Oct.

Ohio. Cincinnati Feb.

Oregon, Milton Jan

Pennsylvania, Homestead Feb.

South Dakota, Sioux Falls Feb

Washington, Spokane Feb.

Tacoma Feb.

Wisconsin, La Crosse Feb.

Milwaukee Feb.

16-23

16-23

19-26

17-24

18-25

1-28

14-28

2 2 — Feb. 2 2

i-Feb. 10.

15-22

26-Feb. 2. .

9-23

16-23

26-Feb. 2 . .
16-23

1-30

1-3 I

2 2-Mar. 1 . .
lo-Feb. 23 .

14-28

16-23

16-23

2-9

16-23

16-23

SMALLPOX FOREIGN".

Africa, Cape Town Jan. 12-19.

.\rgentina, Buenos Aires Jan- 5-12.

Brazil, Rio de Janeiro Jan. 13-20.

Canada, Nova Scotia. DigbyCo. . . .Feb. 23. . . .

Halifax Feb. 16-23.

Toronto Feb.

Yarmouth Co. Feb.

Chile. Coquimbo Feb.

Iquique Feb.

China, Hongkong Jan

Ecuador, Guayaquil Jan.

Jan.

France, Paris Feb.

Great Britain, Bristol Feb.

Cardiff Feb.

Liverpool Feb.

Manchester .Feb.

Southampton Feb.

Italy. General Jan.

Luxemburg. Canton Remich Jan

Maderira, Funchal Feb.

Mexico, .Aguas Calientes Feb.

Netherlands. Flushing Feb.

Persia, Gilan Province Nov.

Kermanshah Nov.

Mash-Had Dec.

Tourbat i-Haidari Oct

Russia, Odessa Feb.

St. Petersburg Jan.

Spain, Seville Jan.

16-23.
23

12-19

1-31

26-Feb. 0 . .

2-9

2-9

^9

2-9

2-9

2-9

31-Feb. 7..
26-Feb. 9 . .
10-17

9-16

9-16

1-30

1-30

i-Nov. 20.,

2-9

26-Feb. 2. .
1-3 1

YELLOW FEVER.

Ecuador, Bucay Feb. 13

Duran Feb. 14

G uayaguil Jan. 1-3 1

Jan. 26-Feb. 9.

Huigra Feb. 8

India, Bombay Jan. 22-29.

Cochin Jan. 14-22.

Madras Jan. 19-25

Rangoon Jan. 12-10

Brazil, Rio de Janeiro. .^n.

Chile, .Antofagasta Feb.

Taltal Jan

Eg>Tt, Alexandria Feb. 4-6. . .

Ismailia Jan. 28—29 - -

Suez Feb. 5

Assiout Province -Jan. 29-Feb-

India, Bombay Jan- 22-29. .

Rangoon Jan. 12-19. .

Japan. Formosa Dec. 1-31. .

Mauritius Dec. 6-20. .

Peru, Callao Jan 14

Catacaos Jan. 14

Chiclayo Jan. 14

Lima Jan

MoUendo Jan.

- ~ -Ja

Pascasmayo and San Pedro- Jan. 14- - • -

Paita Jan. 14. - - -

Trujillo. - Jan- 14. . - -

Turkey in Asia, Dieddah Jan. 11-20.

CASES. DBA'

3
16

75
8

13
25

4
14

7

i „ 1

Present
ilmp.onS.S.
Pomer'n
2

. . -y. Present
2S i'*V •• 1 1

Present
3 2

23
3

Present
Present
Present

S6
19

Present

Epidemic

1S4
28

16
3

3
12
16

Medical Record

A IVcckly Journal of Medicine and Surgery

Vol. 71, No. 12.
Whole No. J898.

New York, March 23, 1907.

$5.00 Per Annum.
Single Copies, lOc

FRACTURE DISLOCATION OF THE
SPINE.*

Bv SAMUEL LLOYD, M.D..

NEW YORK,

PROFESSOR OP SURGERY, NEW YORK POST-GRADUATE MEDICAL SCHOOi.

ATTENDING SURGEON, NEW YORK POST-GRADUATE HOSPITAL AND

babies' wards; attending surgeon ST. FRANCIS HOSPITAL

According to the statement made by Keen/ 60 per
cent, of the fractures of the spine are fracture dislo-
cations, while 20 per cent, are simple fractures, and
the remaining 20 per cent, simple dislocations.
Kocher- has classified the injuries of the vertebral
column, and Von Bergmann presents this classifica-
tion with a few practical modifications as follows :

Partial injuries: (i) Distortion; (2) single dis-
location of the lateral joints; (3) contusion; (4)
isolated fractures of the vertebral column (pressure
fractures) ; (5) isolated fractures of the arches and
spinous processes. Complete dislocations with frac-
ture : (6) Complete dislocation (dislocation of the
lateral joint and displacement in the region of the
intervertebral disk) ; (/) dislocations with fractures
due to pressure dislocation of one or both lateral
joints and pressure fracture of the body; (8) com-
plete dislocation with fracture, dislocations with
diagonal fractures, dislocation of the lateral joints,
and dislocation in the region of the vertebras.

Distortion may be produced by a fall on the head
with a bending forward or backward of the body.
Kocher says: "As long as the continuity of the
bodies of the vertebras and their ligaments is pre-
served, overextension may simply produce distor-
tion. If extension is associated with torsion, the
joint is more afifected on the side to which the face
is turned. With fle.xion and rotation, on the other
hand, the opposite joint suffers most damage.
Sometimes several vertebra are affected at the same
time. The fourth, fifth, and sixth cervical vertebrae
are most commonly alTected."

The symptoms of this condition are those result-
ing from pain. The head is held stiff, the ear drawn
down toward the shoulder of the affected side, and
the face turned toward the healthy side. All motion
is avoided, and pressure — whether upon the head or
the lateral joints or spinous processes, or upon the
neighboring vertebras — causes pain. Occasionally
there are symptoms of injury to the cord present in
these cases. This is usually due to hematomj'elia
(Wagner-Stolper''). The cord is rarely if ever
crushed. Fixation and extension constitute the best
treatment. Recovery occurs usually in from three
to four weeks, although the patient should be kept
under observation for a longer period of time.

"There may be isolated bilateral dislocation." The
rare cases of bilateral dislocation, without injury to
the cord, are considered as isolated dislocations. In
an isolated dislocation the intervertebral disk re-

*Read before the Medical Society of the County of New
York, February 25, 1907.

mains intact. A blow upon the nape of the neck, or
a fall backward on the head, will sometimes produce
a unilateral dislocation of the lateral joints. The x-
rays usually will show the displacement of the bone,
and the position of the head — drawn down toward
the healthy side — will usually enable one to make the
diagnosis. The cord is not apt to be affected,
although hematomyelia may be present. In these
cases reduction should be effected under an anes-
thetic, and then fixation and extension should be con-
tinued. Isolated fractures of the bodies of the verte-
brre are always pressure fractures, and are usually
caused by a fall upon the head or neck, or upon the
sacrum or feet. They are most common in the dor-
sal and upper lumbar regions, but rare in the cer-
vical. In these cases a certain amount of antero-
posterior deformity is noticeable, although this may
be so slight as to be overlooked. The deformity may
disappear, too, as soon as the patient is in a recum-
bent position, but may become patent when the erect
position is assumed. The symptoms may be so
slight as to be completely overlooked.

Fractures of the sternum should lead one to sus-
pect an injury to the vertebral column. Sometimes
the cord is completely destroyed, at other times it is
simply pressed upon by the displaced vertebral
bodies.

Chipault^ has suggested wiring the spinous proc-
esses in these cases in order to prevent slipping, but
often they can be treated by a plaster jacket with
extension and countere-xtension, and should remain
in a recumbent position. In case the cord has not
been injured this would be the better method of
treatment, but with the appearance of pressure upon
the cord at any time, operation should be under-
taken. This pressure may be due to hematorachis,
hematomyelia, or — when it comes on later — to the
formation of callus, decreasing the size of the spinal
canal and making pressure upon the cord.

The fractures involving the posterior portion of
the spine, spinous processes, and arches may fre-
quently be treated simply by rest. When, however,
a fracture of the spine or laminre, or both, is accom-
panied by symptoms referable to the cord, operation
should be undertaken at once, for the probabilities
in these cases are that the arch has been driven in
and is compressing the cord, or spicula of bone have
penetrated it. One must also remember, in this
condition, as in the former, that a gradually increas-
ing paralysis, coming on at any time after the
injury, is indicative of pressure upon the cord, and
should call for immediate operative interference.

The fracture dislocations, on the other hand, pre-
sent a much more difficult problem. Most authors
agree with the statement that they are produced by a
bending of the body either forward or backward,
causing a crush and dislocation of the body or bod-
ies of the vertebras, and usually accompanied by
very marked destruction of the spinal cord itself.
Occasionally these conditions are produced by very
powerful muscular action, according to Cheyne.*
Usuallv thev are caused bv indirect violence, as when

466

MEDICAL RECORD.

[March 23, 1907

the body is bent forcibI\' downward by the caving
in of an embankment or the falhng of some heavy
weight. In these cases the spine, after it has been
bent over, jumps back again, so that little or no de-
formity may be noticeable at the time of injury.
Thorburn" believes this to be a frequent cause of the
condition, and in the cervical region considers that
they are twice as common as those in which the dis-
placement is permanent.

Chipault, on the other hand, after a consideration
of a very considerable number of cases, does not
believe that this temporary displacement occurs.
The majority of observers, however, have consid-
ered that this was the usual cause of the condition,
and it seems to explain much better the extensive
lacerations of the cord which are usually found in
this class of cases.

In my paper, reviewing 103 cases of spinal
surgery, published in 1891,° I quoted Hutchinson's"
conclusions based upon twenty post-mortem exami-
nations. He says: "Permanent compression of the
cord or of any part of it is very rare — not more than
one in ten— and as most fractures in this region are
due to bends, fractures of the laminse are of littlt
consequence and never cause compression. In-
stances of great displacement sometimes occur, and
can rarely be benefited by operation, while cases in
which during life there is the greatest displacement
are not always the most serious." In considering
this question, I found that in 35 cases in which the
cause of compression was given, 11 were due to
temporary, and 13 to continued bony displacement,
thus controverting the statement made by Hutchin-
son, and showing that continued depression of the
bone was the most frequent cause of the compression
of the cord.

The cases in which the cord is found crushed, but
not compressed (at operation or post mortem), are
probably explained by the springing back of the
spinal column into position when the patient is
straightened up and laid in a horizontal position.
They may spring back so nearly into normal posi-
tion that it is almost impossible to recognize any
deformity. Sutton* has reported an interesting case
of intrauterine fracture of the spine caused by a fall
of the mother at the fifth month of gestation. This
child was born at the eighth month, and, while che
upper part of the body was fully developed, all below
the umbilicus corresponded to the development of a
five-month fetus.

These cases of fracture dislocation of the .".pine
resolve themselves, therefore, into two classes : ( i )
those in which the spinal cord is not injured, and
(2) those in which there is more or less interference
with the functions of the cord itself. In the first set
of cases operative treatment would not be indicated
in the beginning. The only symptoms directly due
to the fracture are, first, those common to all other
fractures, such as deformity, increased mobility,
crepitus, etc. The patient, however, in a case of
fracture of the spine, is unable to walk, is markedly
shocked, and even though the examiner does not
succeed in eliciting crepitus or false point of motion,
which would probably be very dangerous symptoms
to look for in these cases, he will readily make out
a point of marked tenderness along the spine. Local
signs are usually unsatisfactory. Either no irregu-
larity can be detected, or an irregularity that is so
slight as to be of little consequence — sometimes a
prominence of the vertebra may be noticeable, or
there may be a depression along the line of the spi-
nous processes, or we may be able to make out a
lateral displacement. When these signs are present,
thev are a great aid in diagnosis, and would be

almost conclusive evidence of the location of a frac-
ture if associated with marked tenderness on pres-
sure, localized pain — increased materially whenever
the position of the patient is altered — or with a
fracture of the sternum. Extravasation of blood,
too, may occur early, and by the time the patient is
examined it may be possible to recognize a distinct
infiltration of the surrounding tissues.

In making the examination, the greatest care is
essential, for the slightest twisting of the patient
may displace the injured vertebra; and cause com-
pression or laceration, or even complete destruction
of the cord. Lathrop" says that with the aid of the
Roentgen ray the fracture can be definitely seen and
splinters of bone can be located ; but it is impossible
in many of these cases, in my opinion, to get a satis-
factory ;r-ray plate, nor is it advisable to manipulate
the patient any more than is absolutely essential to
remove him from the place of the accident and to
institute the proper treatment.

I do not myself favor the application of plaster-of-
Paris unless there is marked mobility of the frag-
ments, but think that the patient is better if placed
in a horizontal position on his back, on a springless
bed, and with sufficient extension and counterexten-
sion to compel him to remain in the dorsal position.
In those cases in which there is marked mobility of
the fragments, and where it is difficult to restrain
the patient and keep him quiet, a plaster jacket
should be applied.

A much more complicated picture is presented
when the spinal cord is involved. If it were not for
some of the recent articles that have been published,
referring to the possible regeneration of the spinal
cord, I should feel that the last word had been said
on that subject in the articles I read before the
American Medical Association, Section on Surgery,
in June, 1900,^" and before the Surgical Section of
the Rochester Academy of Medicine, May, 1901.**
The question, then, is the one asked by Burrell :'^
'Ts the spinal cord irremediably damaged, and can
we tell whether a spinal cord is irremediably dam-
aged, or not?" To this must be added another:
Does regeneration of the spinal cord take place, and,
if so, what must be done in order to put it in the
proper position for regeneration ?

The svmptoms in these cases are those due to the
compression or destruction of the cord itself, and we
owe to Thorburn much of the accuracy of our
knowledge of the symptomatology- of this class of
injuries. At the time that he published his brochure
(i88g)^^ he said that surgeons would probably in
the near future open the spinal canal with as little
danger and as little hesitation as they now operate
upon the cavity of the cranium. This prophecy has
been abundantly fulfilled.

BurrelP- recognizes three types of cases: (i)
those in which the cord is crushed ; (2) those in
which doubt exists as to whether the cord is irre-
mediably damaged, and (3) those in which it is fair
to assume that the cord is not irremediably damaged.
The first forms by far the largest class of spinal
injuries. There is one other condition that has been
found in a certain number of these cases, and that is
compression by blood-clot. Four of these cases were
reported in my first paper, and Keen's case of spinal
hemorrhage is reported in full in my paper read
before the Rochester Academy. At this time I also
reported a case of my own of the same character.

Walton'^ asks whether we really have reliable
symptoms establishing, except through their persist-
ence, irremediable crush of the cord, for, if we have
not, are we doing justice to the patient when we rely
on the time-honored dictum that the damage was

IMarch 23, 1907]

MEDICAL RECORD.

467

done at the moment of impact, that the pressure of
fragments has been spontaneously relieved, and that
nothing can be accomplished b}' operation He says
that fracture of the spine with complete transverse
lesion of the cord is accompanied by immediate re-
laxed motor paralysis involving the parts below the
level of the lesion. There is entire absence of rigid-
ity, of spasm, convulsive movement, or other irrita-
tive sign in the motor sphere. The statement that
signs of motor irritation may appear at the level of
the lesion seems based rather upon theoretical con-
siderations than upon actual observation. Partial
injury to the cord, including the results of hemor-
rhage, may be indicated by a slower onset of paraly-
sis,, by unilateral or irregular distribution ( affecting
for example, the arms more than the legs), by the
preservation, or comparative preservation of re-
flexes, and by the rapid improvement. In diagnosti-
cating the level of the lesion by studying the muscles
involved in the paralysis, the tables of Thorburn,
based on clinical rather than on anatomical or ex-
perimental observations, have stood the test of prac-
tical application. It would appear that the motor
symptoms may reach a much higher level than the
sensory — at least in case of lesion of the lumbar
enlargement.

Ill fracture with total transverse lesion the area
of anesthesia is generally sharply marked, and at a
level corresponding to the segment crushed — that is,
at a level materially below the seat of the lesion.
Most authorities agree that the upper roots of the
brachial plexus supply the cap of the shoulder and
the radial side of the arm and hand, while the lower
roots supply a strip down the ulnar side of the arm
and hand. The seventh dorsal segment supplies the
ensiform region ; the eleventh dorsal, the umbilicus,
and the luinbar, the front and outer and inner
aspects of the thigh to the groin, and the inner
aspect of the leg. The sacral supplies the region
below the knee in front on the outer aspect, as well
as the whole or greater part of the foot. It supplies
also the back of the leg and a strip in the middle of
the posterior surface of the thigh, and the saddle-
shaped area, the perineum, scrotum, and penis. The
fourth cervical seginent furnishes sensation down to
a line below the clavicle adjoining the distribution of
the second dorsal. The absence of representation
on the trunk of the intervening segments is ex-
' plained by the fact that in the budding and growth
of the upper extremity, the areas supplied by the
fifth, sixth, seventh, and eighth cervical, and the
first dorsal are carried down the arm. For a similar
reason the twelfth dorsal closely approximates the
third sacral on the buttocks. It is probable that
complete anesthesia in any area implies loss of the
segments above and below the one which suppHes
that area, as each part of the body receives sensory
fibers from these segments (Sherrington). It should
not be forgotten that in case the roots are crushed
at the same level as the cord the anesthesia will'
reach to the level of the lesion. Below the well-
known strip of hyperesthesia which surmounts the
anesthesia and points to root irritation, is apt to
appear a strip of thermal anesthesia and of analge-
sia (Kocher).

Incomplete anesthesia points to incomplete lesion
of the cord. The same is generally, but not in-
variably, true of anesthesia of limited or of unilateral
distribution. It is generally true of anesthesia lim-
ited to regions far below the level of the lesion, and
in general the varying modification of the different
forms of anesthesia at different levels points to in-
complete lesion. Injur}- to nerve roots alone some-
times appears in the cervical region after stretching

and bruising- — perhaps with temporary displacement
of vertebrje and rupture of ligaments (distortion).
In this lesion the sensory symptoms, like the motor,
are apt to be limited to the arms.

Retention, rather than incontinence of urine, is the
rule in all varieties of spinal fracture with injury tO'
the cord, even when the lesion involves the lumbar
region. There may be either retention or inconti-
nence of feces, more often the former. The sensa-
tion in the rectum and bladder may be preserved in
incomplete lesions, even though voluntary evacua-
tion is impossible. The symptoms referable to vaso-
motor disturbance are variable and baffling. The
most common observation is a rise in the superficial:
temperature of the lower extremities, which may be
replaced later by coolness of the extremities, and
sometimes — though not usually — by marked cold-
ness. The skin is generally dry. Sweating is-,
absent.

The knee jerk is lost in case of complete destruc-
tion of the cord. The superficial reflexes are also
generally lost or diminished in these cases — prob-
ably alwa}'s lost in complete lesions. This may not
necessarily be limited to the reflexes below the le-
sion, but may involve those higher up. The Ba-
binski reflex may appear when no other reflex is
present.

With these data at hand we can form some fairly
definite conclusions with regard to the condition of
the cord — whether there is a complete or an incom-
plete destruction. In one of my other papers I said
that in the former case it is useless to operate ; in
the latter it becomes necessary to consider at what
time the operation can best be performed.

If operation is undertaken at once there is danger
of interference where a spontaneous cure would re-
sult if the patient were left alone, or where a com-
plete destruction of the cord renders operative
interference useless. If, however, operation be
delayed too long, and a compression be allowed to
continue, a degeneration may result which would
be as serious as though the functions of the cord
had been destroyed by the original injury. Horsley
insisted that operation should be undertaken early,
and this was my own opinion as expressed at that
time, provided the symptoms present indicated inter-
ference with the functions of the cord. In other
cases I should wait until the shock following the
injury had been overcome, watching the patient's
condition carefully, however, and at the slightest in-
dication of any symptoms pointing to an extension
of the interference with the action of the spinal cord,
whether that interference be due to hemorrhage or
to compression from depression, callus, or to the
exudation of lymph, I should operate at once.

■ In this connection, however, it is important to take
into account the general results following fractures
of the spine treated without operation, and the same
statistics that I used in my former paper will illus-
trate this point. Thus, Gurlt reported 217 deaths
out of 270 fractures, or over 80 per cent. ; while
Burrell, from the tables of the Boston City Hos-
pital, cited 82 cases with 64 deaths, or 79 per cent.,
and of the 22 per cent, of recoveries only 1 1 per cent,
were satisfactory, the other 11 per cent, being com-
pletely disabled. Burrell has published a series of
244 cases in his paper already quoted, but as he does
not say whether this last series includes both opera-
tive and nonoperative cases, we have thought best
not to include it here. These statistics also show
that in the fatal cases the greater number of deaths
occurred within a few da\-s. It is. therefore, evident
that if we operate immediatelv after the injury we
will have failures that should not be charged against

468

MEDICAL RECORD.

[March 23, 1907

the operation itself, and if possible we should wait
before operating until the question can be settled
whether the patient will overcome the shock or suc-
cumb directly to the effects of the injury.

There is another objection to immediate operation.
In so-called concussion of the spine there may be a
certain amount of anesthesia and paralysis. The
recovery, however, will be complete, or at least so
nearly so that no appreciable lesion can be made out.
Immediate operations in these cases would be unnec-
sary, as they would have recovered spontaneously
had they been left alone for a sufficient length of
time. It is impossible, too, in the first few hours to
determine with any degree of certainty how severe
the injury really is, nor can we absolutely localize
the injury to the cord. In my opinion, therefore,
we should wait until this period of shock has passed
and until it is evident that there will be no spon-
taneous recovery complete enough to render life
bearable. If after this period has passed the patient
still continues to improve, no operative interference
should be considered, but as soon as the symptoms
begin to show retrograde phenomena, or seem to
have reached the end of the improvement, operation
should be undertaken.

In those cases where no improvement follows the
recovery from the shock, and yet the suspicion re-
mains that a complete crush of the cord has not
occurred, we should operate immediately. This
divides the cases, therefore, as follows : ( i ) those
that evidently have complete destruction of the cord ;
(2) those where, following the recovery from the
shock, it is evident that the lesion of the cord has
not been completely destructive and yet no improve-
ment is noted. Operation here should be done as
soon as these facts are determined; (3) those where
the lesion of the cord is incomplete and where the
symptoms of compression are extending as evi-
denced by increasing paralysis and the enlarged
area of anesthesia ; here operation should be under-
taken immediately, as there is a hemorrhage, an in-
flammatorv thickening, or some acute process pres-
ent that threatens the destruction of the cord unless
it is controlled; (4) those in which improvement is
noted at first but is arrested later ; operation in these
should be done as soon as it is settled that the
improvement has ceased ; (5) those who made a full
recovery, or almost so, under the usual conservative
methods, where the paraplegia or other symptoms
develop at a later date ; this is probably due to com-
pression from callus, and the operation should not
be delayed any longer than is essential to establish
the fact that there has been a loss of function.

Regional statistics are important in determining
the result of operations. Thus we find out of 27
affected in the cervical region, operated on imnie-
diately, 21 died, while out of 10 operated on at a later
period only 2 died ; in the dorsal region, out of 49
operated on immediately, 23 died, while of those who
were operated on later, only 5 died, from a total of
63. Even in the lumbar region the same dispropor-
tion exists ; thus, from 6 immediate operations, 4
died, while from 22 done at a later period, only 4
were fatal.

The following table shows the results better than
any description I can w-rite ;

Immediate Later
Ccr\-ical Region. Operation. Operation.

Deaths 21 2

Recovery o 2

Improved 2 i

Not improved o 4

Subsequent death 4 3

27

12

Immediate Later

Dorsal Region. Operation. Operation.

Deaths 23 5

Recovery 4 10

Improved 9 18

Xot improved 6 16

Subsequent death 7 16

49 6s

Immediate Later

Lumbar Region, Operation. Operation.

Deaths 4 4

Recovery I 6

Improvement i 6

No improvement o 4

Subsequent death o 2

6 22

Immediate Later

Sacral Region. Operation. Operation.

Deaths o 0

Recovery o I

Improved o 3

Not improved o o

Subsequent death o o

o 4

This emphasizes the fact, which is already recog-
nized, that the cervical is the most dangerous region
for operation, and at the same time the least satisfac-
tory in its ultimate result. The results in the dorsal
region have improved since the earlier statistics, due
probably to the improvement in technique, the
greater rapidity with which the operation is done,
and the fact that operations are done earlier than
was formerly the case. The lumbar region shows
a surprisingly small number of surgical interven-
tions when it is taken into account that the safety
of the operation in this region and the decided
improvement following it was emphasized in all the
earlier papers on this subject. I cannot but feel that
some of the incomplete recoveries recorded have
been due to incomplete relief of the compression.
Unless the operator has had considerable experience
in spinal surgery, it is a very easy matter to overlook
a compressing point. It is essential, in order to
make the operation perfectly successful (i) to re-
move enough laminse to absolutely settle the fact
that there is no remaining compression of the cord ;
(2) to chisel off any projecting bone, whedier it be
a portion of a vertebral body or bodies, or one or
more articular processes; (3) to remove all blood
clots, even though laminae of imaffected vertebrae-
have to be removed to get beyond the hemorrhagic
area ; (4) to look out for thickening and compression
resulting from inflammatory processes or injuries
of the structures within the vertebral canal. It is
sometimes difficult to be absolutely certain whether
all compression has been done away with, but one
usually recognizes the fact that the cord is smaller
in the exposed area than it should be, and that its
pulsation is not complete, not as full as in a normal
cord. Care should be taken, therefore, that the cord
dilates to its full extent, and that the pulsation re-
turns. This can happen only where the cord has
not been completelv destroyed. And if the operator
cannot be sure of this fact without opening the dura,
he had better make an incision and definitely deter-
mine whether the integrity of the cord has been pre-
served. He will also sometimes recognize the fact
that the dura is discolored, looks as though there
has been an intradural hemorrhage, and while this
accident, if it has occurred, has probably produced
more or less disintegration of the cord itself, the
dura should be opened and this blood clot removed,
for one may look for a certain amount of regenera-
tion in the cord provided it is relieved from the com-
pression at a sufficiently early period, and provided
it has not been completely destroyed.

March 23, 1907]

MEDICAL RECORD.

469

After commenting on the former statistics of the
operation, Keen said: "With such statistics before
us it is impossible to draw any other conclusion than
that operation is advisable in case extension directly
after the accident fails to reduce the deformity. Of
course, the limitations arising from the time that
has elapsed since the accident, the region involved,
and the severity of the lesion must be given due
weight in reaching a conclusion in any given case.
In an instance, therefore, of such gravity, followed
by such an immense percentage of deaths, if no oper-
ation be done, it would seem to be advisable, with
our present experience, in all suitable cases, to give
the patients the real, though often desperate chance
that operation offers, and that the operation should
be done at a much earlier period than has hitherto
been the rule." If this was the conclusion reached
after a careful weighing of all the data presented up
to that time, how much more emphatically may we
advise operation at the present time.

This brings us, then, to a consideration of the
question of regeneration of the cord after complete
injury. In view of what has been said by several
recent writers on the subject, and also of the experi-
mental work that has been done along this line, is it
possible that in our former papers we were mistaken
in saying that complete destructive lesions of the
cord could not be improved by operative measures,
and therefore should not be operated upon? Bol-
ton'^ says: "Many observers have studied the proc-
esses of repair of injuries of the cord in many classes
of vertebrates, and while there is complete regenera-
tion after division in some of the lower orders, in
mammals there is practically none. In the imme-
diate neighborhood of the lesion degenerative
changes occur in the ganglion cells and fibers cut off
from their trophic centers ; while in those in which
the connection is preserved there is a feeble and
never-completed attempt at regeneration only. The
lesion is repaired by the growth of ordinary cicatri-
cial tissue from the connective tissue cells of the
blood-vessels and the Pia mater."

In 1892 Leckie^" suggested the feasibility of
removing a sufficient amount of the spinal column,
in cases of destruction of a small portion of the cord
after fracture, to permit of the appro.ximation of the
separated ends by stitches. Chipault and Maydl had
both discussed this question of suture of the spinal
cord, and dismissed it as impossible owing to the
inelasticity of the cord itself and the resistance of
the ligaments. Leckie proposed to shorten the spinal
column in order to overcome these difficulties, and
to permit of the divided ends of the cord being-
placed in apposition and the suturing of the mem-
branes. There should be no insuperable difficulty,
he says, in the removal of a part or the whole of a
vertebra, or even portions of two adjacent verte-
brae.

Mixter and Chase'" report a very suggestive case,
which is summed up as follows : "High fracture of
the spine — sixth cervical vertebra — in which all the
classical symptoms were present, upon which au-
thorities have previously based their opinion that
operation was contraindicated. because it suggested
total transverse lesion with a crush of the co'-d
beyond repair. The patient was operated upon
within twenty-four hours, and lived eleven and a
half months, during which time there was marked
and steady improvement. From a condition of total
paralysis involving all of the body excepting the
anterior surfaces of the arms and the right liand,
and the shoulders and scapular regions and head,
the patient regained nearly normal use of his hands
and arms, and such improvement in the condition of

his body and legs as to lead one to believe that if an
unfortunate complication had not arisen further im-
provement might have been e.xpected. From a con-
dition of total anesthesia over the area above referred
to there was practically complete recovery by the
ordinary tests. A series of cross sections of the
spinal cord from the pons to the coccyx made it
possible to study the paths of degeneration following
a crush at an unusual length of time after injury.
Pathological anatomy of the spinal cord showed
that descending degeneration of all injured axons
occurs in motor tracts below the level of the lesion,
and of the common tract, which is composed of short,
descending sensory collaterals from injured sensory
neurons. It shows the occurrence of ascending
degeneration of all sensory axons involved in the
lesion. The sections demonstrate that normal sens-
ory and motor a.xons e.xist at the seat of the lesion,
though their functions were interrupted at the time
of the injury, which suggested total destruction of
the cord. The operation showed fracture and de-
pression of the spinous processes and laminas
apparently lying against the cord with a blood clot
under the laminre, but none under the dura. The
condition of the bodies of the vertebrae not known."
It should be noted that no sign of regeneration was
found.

The question is pertinent — \\ hat is the value of
operation in injuries to the spinal cord? (i) It
removes depressed fragments of bone apparently
lying against the cord. (2) It removes blood clots.
(3) It allows the escape of exudate and makes room
for inflammatory thickening. (4) If extensive hem-
orrhage is present, either extra- or intradural, it
relieves pressure from the cord. It has been shown
that degeneration from pressure appears within four
days. If a cord is injured by crush and not totally
destroyed, the continued pressure of a blood clot
may succeed in completing total destruction. (5)
Traumatic spinal edema may be of such extent as to
demand greater space for enlargement of the cord
to avoid further destruction of fibers. (6) There
is absolutely no method by which one can early diag-
nosticate slight or great pressure of a fragment of
bone, the pressure of a small or a large hematoma,
whether there is a momentary pinch of the cord or
slight pressure. (7) The fact that the cord looked
normal in these cases does not preclude the possibil-
ity that pressure had existed, nor prove that a con-
dition had existed in which drainage and relief of
pressure were not distinctly beneficial. (8) The
I^atients did not suffer from any ill effect of the
operation per sc. The dangers of operation are very
slight compared to the possible benefit, and the fur-
ther satisfaction is obtained that the surgeon knozvs
that continued pressure does not exist. Typical
svmptrims of a complete transverse lesion are not
infallible, in which case the surgeon is not doing all
in his power to relieve the patient's condition imles-
he operates.

As a rule, operation in most if not all of the cases
can be delayed a few hours until a greater stability
of the nervous system is regained ; a few cases might
impress one with the immediate necessity of opera-
tion. It seems reasonable, then, to assume that even
with the appearance of total destruction we have to
do with a condition which for a time has interrupted
the registration of sensation and motion on the cere-
brum over certain neurons which after regaining
equilibrium will resume their functions. Though
fiber degeneration persisted through the year follow-
ing the operation, and no signs of regeneration were
made out in the microscopical examination, the sug-
gestion seems pertinent that the steady improvement

470

MEDICAL RECORD.

[March 23, 1907

indicated an increased transmission of impulses
through the remaining scattered fibers, the analogue
of which is found in the increase of functions occur-
ring in the kidney after unilateral nephrectomy,
showing the power of nature to accommodate her-
self to adverse conditions.

Thomas^" has examined the cord microscopically
in several cases dying within a few days of the acci-
dent, and he emphasizes the fact that hemorrhagic
conditions exist as well as marked degenerative
changes of the cord itself, for a considerable distance
beyond the actual crush. He calls attention to the
fact that sensory and paralytic symptoms are of the
greatest value for the diagnosis and the location of
the injury to the cord, hut that the injury is apt to
be even higher than the symptoms would indicate.
This bears out a suggestion that I made in a former
paper with regard to the necessity for the surgeon
to carry his exploration farther than the involved
segment, and it also suggests the possibility of a
marked improvement in the symptoms, with an ab-
sorption of these minute hemorrhagic areas, as T
suggested in a discussion before the New York
Academy of Medicine last year.

Weissman's dictum that nerve cells once destroyed
are never replaced seems to be true, although some
observations, notably those of Worcester and the
reports of several operators on the spine, would
seem to prove the contrary. Barker-" says : "Re-
generation of severed nerve fibers within the spinal
cord and brain is unfortunately very much less com-
plete than in the peripheral regions." Oliver^^ says
that "sufficient regeneration of nervous tissue to
carrv on the functions of the spinal cord does not
occur, and no method is at present known by which
these functions may be restored.

Dr. L. Pierce Clark-- concludes that animal ex-
periments fail to provide conclusive data that cen-
tral tracts of the nervous system ever regenerate so
that the former function is restored. In warm-
blooded animals, and in the human species in par-
ticular, an abortive attempt on the part of the cord
to regenerate, is largely, if not solely confined to
fibers of undoubted peripheral type. Histological
analvsis of cases of hemisection, compression para-
plegia, myelitis, and other like destructive lesions
of the cord, fail to show positive evidence that actual
structural regeneration of axis cylinders ever occurs
in the central nerve tracts of the human spinal cord.
In case of complete division of the brain and spinal
tracts, there is simply degeneration followed by
sclerosis. A most acceptable reason for nonregener-
ation of such tracts was shown in the fact that the
component nerve fibers did not possess a neurilemma
sheath from which nerve regeneration mainly if not
solelv occurs. This lack in cord and brain tracts in
contrast to the regenerating peripheral nerves was
due possibly to a difference of embryological origin
for the two structures of the nervous system. The
seven cases cited by Stewart and Hart of cord
regeneration being merely hemisections, either do
not fulfill the conditions of test, or lack definite and
convincing evidence of regeneration. In cases of
complete transverse division of the cord, from either
experimental or clinical data, there is not sufficient
justification to warrant suture of the spinal cord in
an attempt to cure the defect.

None of the cases that have been reported up to
the present time as cases of regeneration of the
spinal cord have demonstrated to my mind the
slightest sign of actual regeneration. Although all
of them are reported as complete transverse lesions
of the cord, in none of them has that been proven,
and it is more than likelv that there have been nerve

fibers that were not destroyed and that have recov-
ered their function, allowing for a more or less con-
siderable improvement in the patient's condition.
My own experience in this condition relates simply
to two cases. In both of them there was apparently
a complete transverse section of the cord, and in
both the whole of the pulpy mass was removed, and
a suture applied bringing the severed ends of the
cord in apposition. One patient lived but three
weeks and showed no signs of regeneration. The
other lived for ten months, died of the usual kidney
complications, and showed absolutely no recovery
of function below the removed segment. Up to the
present time it seems to me that we are obliged to
confess that spinal regeneration in the human spe-
cies has not been proven, and that it is fallacious
to hold out this hope to the patient. But from a con-
sideration of the cases that we have studied we
must agree that our previous statement in regard
to complete transverse lesions of the cord is probably
too drastic, and that some of these cases would prob-
ably be improved if they were operated upon. We
should therefore suggest that in the future, ana until
we have a sufficient number from which to draw
conclusions, all of these cases should be submitted
to the surgeon for operation. At the same time, as
it will not increase the dangers to the patient's life,
we should advocate that the plan of approximating
the cord, as suggested by Haynes.-' should be car-
ried out. but would warn operators against making
a complete section of the apparently dcstroyca areas,
for fear of cutting out nerve fibers that are not
involved in the destructive process and that may
resume their normal functions. .A long series of
histological examinations of these cords will have to
be made before the question of regeneration can be
definitely settled.

I have now performed laminectomy thirty-two
times, and while some of my cases have improved
to a marked degree, a very considerable number
have shown absolutely no benefit from the opera-
tion. In none can I attribute the improvement to
regeneration, but rather to the conditions already
suggested. If regeneration of the cord does occur,
we should have had more improvement in some of
the cases that were not benefited.
REFEREN'CES,

I. Dennis: Surgery, Vol. II, p. 811.

2 Von Bergmann: Bull's System of Practical Surgery,
Vol. 11, p. 664.

3. Chipault: fitudes de Chir. Medull, pp. 79-81.

4. Clicyne: Manual of Surgical Treatment, Vol. IV, p.
.76.

5. Thorbum : Brit. Med. Journal. Oct. 27, 1894.

6. Lloyd: Am. Jour, of the Med. Sciences, July, 1889.

7. Hutchinson: Clinical Record and Reports of the Lon-
don Hospital.

8. Sutton : General Pathol., p. 85.

g. Lathrop: Annals of Surgery, Vol. 32. 1900, p. 834.
10. Lloyd : Jour. Am. Medical Ass'n., April 13 and 20, and
May 4, 1901.

II. Llo'-d: Phil. Med. Journal, Feb. 8, 1902.

12. Burrell : Annals of Surgery, Vol. XLII, p. 481.

i,^. Thorburn : A Contribution to the Surgery of the
Spinal Cord, 1889.

14. Walton : Jour, of Neri-ous and Mental Diseases, Vol.
29. 1902, p. I.

13. Boltrn: Annals of Surgcrv, Vol. XXX, 1899, p. 172.
ifS. T eckie: Brit. .Med. Jour.. Oct.. 1892. p "86.

17. Mixtcr-Cbaso : .Iniials of Surgery, Vol. XXXTX. 1904.

P- 405.

18, Wagner and Stolper : Deutsche Chirurgie. Lf. 40,
1S08, p. 3.44-

iq. Thomas: Medical and Surgical Reports of the Boston
City Hospital, nth scries, Boston. 1900, p. i.

20. Barker : The Xcr\-ou5 System, p. 246.

21. Oliver: .hinals of Surgerv. Vol. 37, 1903, p. 239.

22. Clark : Medical Record. Sept. 8. 1906, p. 575.
23: Haynes: .V. V. Med. Jour.. Sept. 22, 1906, p. 583.
12 West Fiftieth Street

March 23, 1907]

MEDICAL RECORD.

471

PATHOLOGICAL CHANGES IN FRACTURE-
DISLOCATIONS OF THE SPINE.*

By PEARCE bailey. M.D.,

NEW YORK,

The pathology of the bone conditions in fracture-
dislocation of the spine is essentially surgical, and
my remarks on it must be brief, if, in the limited
time, sufficient space is to be devoted to the lesions
in the nervous system.

Permit me, then, to dismiss the bone lesions with
saying that m one-third of the lesions of the spinal
column the cord escapes all injury. This is especially
apt to be the case in the cervical region, where the
canal is larger and there is greater freedom of move-
ment in the bones. It is also more apt to be the case
in children than in adults.

Of the regions affected by fracture-dislocations,
the cervical region and lumbar region contain about
one-half the cases ; the dorsal region the other half.
Most of the dorsal fracture-dislocations involve the
eleventh or twelfth dorsal vertebra. These produce
the lumbar type of paralysis, and so should by right
be classed with the lumbar fractures.

Thus, neurologically considered, the great ma-
jority of the cases of traumatic spinal paralysis are
either of the cervical type (including the first dorsal
segment of the cord) or of the lumbo-sacral type,
including, of course, the cauda equina. Surgical
statistics show a great preponderance of the latter
over the former. Possibly some clinical cases, in
which the bone lesions are not recognizable and the
cord symptoms are slight and inconspicuous, escape
identification in surgical wards. If they do, the
actual number of cervical and lumbar cases would
tend to be more equal.

Isolated fractures of the spinous and transverse
processes of the laminae occur chiefly in the cervical
region. Fracture of the spinous process occurs in
about 8 per cent, of the cases, and in about 4 per
cent, as an isolated condition. Only in the rarest
cases does it constitute a menace to life, and then by
being thrust forward by muscular violence to com-
press the cord.

Fractures of the lamince as isolated conditions
also occur in the cervical region. These are some-
times recognizable by digital examination.

Late results of injuries to the bones consist in
osteomyelitis, which is very rare, in tuberculosis, and
in traumatic spondylitis or Kummell's disease,
which afifects most frequently the third and seventh
dorsal vertebra;.

While the injuries to the bones are. of course, of
great surgical interest, the whole importance of this
subject centers about the injury which they produce
in the cord, and all clinical expressions should be in
terms of cord rather than bone. As far as the mem-
branes of the cord are concerned, they are practi-
cally never injured alone. They may be lacerated,
and the lacerations cause extensive bleeding within
the spinal canal, either inside or outside the dura.
In my opinion, however, this never occurs as an
isolated condition ; that is, it never occurs without
there being an extensive contusion of the cord asso-
ciated with the bleeding. This condition, known
under the term of hsematorrhachis. has played quite
an important role in the clinical history of spinal
cord injuries. A special symptomatology has been
constructed for it — notably, shooting pains. The
surgeon is on the alert for it, with the idea of re-
lieving pressure and, as a consequence, of relieving
symptoms.

*Read at a meeting of the Medical Society of the County
of New York, February 25, 1907.

But if, as autopsy records seem to show, and as a
careful examination of the literature seems to show,
hxmatorrhachis never occurs by itself, but only as a
part and parcel of a general spinal-cord injury, there
is very little use of operating for it, as the hemor-
rhage will be rapidly absorbed. I have been on the
lookout for this condition for a great many years,
and have never yet seen a case of pure hamator-
rhachis.

The cord itself may be contused, lacerated, or cut
in two. Its external appearance may show the effect
of this by dents, punctate hemorrhages, or disloca-
tions; or else the cord, even when severely injured
internally, mav show nothing abnormal on its ex-
ternal appearance, the extent of the damage becom-
ing apparent only wdien it is sectioned. Thus it
cannot be said that a cord is normal because at oper-
ation its external appearances are normal.

\\'hen the cases have not been quickly fatal, and
come to operation or autopsy a long time after the
injury, the cord is bound down by adhesions to the
dura, and the dura by adhesions to the bony canal.
The cord is shriveled, oftentimes to one-third of its
original size. When removed from the canal and
sectioned, it shows to the naked eye a disarrange-
ment of the constituent parts, of which dislocation
of the gray matter, fissures, discolorations, and
hemorrhages are the common pictures.

In recent cases the cord may be so soft that it
oozes out when cut into.

Microscopical examination shows the picture
which is described as traumatic degeneration, viz.,
disintegration of spinal-cord elements, large round
cells, myelin drops, blood cells and blood pigment,
nerve cells and nerve fibers in various stages of de-
generation : in old cases the whole is obscured by an
overgrowth of new connective tissue. Properly
stained, there will also be foci of ascending and
descending degeneration : with a Marchi stain this
can be demonstrated five days after the injury.

The hemorrhage in spinal-cord injuries has a pre-
dilection for the gray matter. It often occurs as a
focus of bleeding at a single point, from which focus
columns of blood ascend and descend the cord, in the
gray matter. As the blood is absorbed cavities are
left in the cord, a condition to which Van Guison
gave the name of hjematomyelopore. This focal
hwmomyelia may occur in any region of the cord
as part of the lesions secondary to fracture-disloca-
tion. It mav also occur as a primary condition,
without demonstrable injury to the bone. It is then
found only in the cervical region, and results from
stretching of the cord in sudden fle.xions of the neck,
e.g. diving in shallow water. This condition, which
I have called primary focal ha;matomyelia, has a
rather unique clinical symptomatology and course,
and its prognosis is relatively good.

Finally, small blood extravasations may occur up
and down the cord with or without spinal fracture.

The extent of a traumatic lesion in the spinal cord
varies from the case where the cord is only lightly
contused or pressed upon, causing a few elective,
slight, and temporary symptoms, to where it is re-
duced to a pulp, or even cut in two.

Partial lesions are particularly frequent in injuries
to the cervical region and to the lower segments
of the cord.

In fractures in the dorsal region the bone dis-
placement is usually extreme and the cord lesion
consequently severe. Few dorsal lesions of the cord,
therefore, are partial. .-Xs a result, the outlook in
dorsal cases, as a class, is less favorable than in
cervical cases, as a class, in spite of the fact that a

472

MEDICAL RECORD.

[March 23, 1907

severe cervical lesion is more quickly fatal than a
severe dorsal lesion.

By a partial lesion is understood a lesion in which
one or more of the spinal functions, e.g. paralysis,
sensibility, sphincter control, is not included in the
paralysis.

Many cases have the appearance, from the pres-
ence of all symptoms in pronounced degree, imme-
diately after the accident, of being total transverse
lesions ; yet such cases in the course of weeks or
months may show, by recovery, that the cord could
not have been injured even in one-half its extent.

For many years clinicians have endeavored to
determine from the clinical symptoms the extent of
the damage done to the cord itself, and it has gen-
erally been accepted as a guiding rule for operation
that total abolition of the reflexes, especially in the
cervical region, indicated a total lesion.

This rule is not reliable, as, for several days after
the accident, the knee jerks may be absent, then
I eturn and become exaggerated ; or, in some cervical
cases, knee jerks, once exaggerated, may later dis-
appear altogether.

Regarding the question of repair after spinal cord
injuries, there are much confusion and hazmess ol
ideas — and also intelligent disagreement on well-
defined issues.

The question of repair and recovery after frac-
ture-dislocation i^re^ents itself to my mind as fol-
lows :

The injury to the cord takes place at the time of
the trauma. The cord is bruised or lacerated, or
compressed, as the case may be. As a result, there
ensue more or less softening and shrinking of the
cord. The true damage, therefore, is a result of
the initial and brief violence — the secondary and
long-continued pressure which may result from a
narrowing of the canal having little or no effect.
It is as though a banana were in a tube and the tube
were suddenly narrowed to half its size — all the
injury to the banana would have occurred at the
time of compression. So with the spinal cord. It
is neither firm enough nor elastic enough, nor tough
enough to offer any substantial resistance to com-
pression.

Furthermore, long-continued pressure of the
spinal cord seems improbable for the reason that
from the moment of the initial compression onward
the cord undergoes softening, with a constant reduc-
tion in its volume, thus making more room in the
canal and less opportunity for the so-called perma-
nent compression. This explanation leaves out of
account two conditions — one in which splinters of
bone have pierced the cord, and the other in which
there is compression of the cauda equina. The first,
though rare, undoubtedly occurs, and when in the
cervical region constitutes a cause for operation.
In the second case the relief of pressure is as
strongly indicated and is as successful as it is in the
peripheral nerves.

The question of regeneration is the most impor-
tant one in spinal-cord pathology. If the cord regen-
erates, the field for operative procedure is ver}' ex-
tensive. Does the spinal cord regenerate?

It is well known that intramedullary fibers can be
bruised and contused, and yet the symptoms which
accompanied the original injury pass away almost
entirelv. But this, it is unnecessary to say, does not
prove regeneration. It is a recovery from the origi-
nal shock of the injury, and occurs, in my opinion,
quite as often without as with the surgical relief of
pressure.

The question of regeneration is this — Do nerve
fibers of the spinal cord, which have once been ac-

tually severed in their continuity, regenerate? In
no experiment on a cold-blooded animal has it been
passible to divide the spinal cord completely and then
secure a restitution of conducting function.
Schtnaus has shown that a divided spinal cord can
be reunited by nerve fibers in case some of the blood-
vessel-carrying tissue is left — that it is along this
tissue that the new fibers push their way. But such
fibers are few in number, embryonic in character,
and form no connecting link of function between
the two ends.

I am loath to go into a discussion of the recently
reported cases of suture of the human spinal cord
— they have in no instance been accepted by neurolo-
gists as proving regeneration, and I think the early
enthusiasm of surgeons in regard to them has some-
what lessened of late. The neurological opinion,
therefore, is mainly unanimous that regeneration of
divided ends does not take place in the central nerv-
ous system.

s 2 West Fifty-third Street.

THE TREATMENT OF FRACTURE DISLO-
C.\TIONS OF THE SPINE.*

By IRVING S. HAYNES. PH.B., M.D.,

NEW YORK

Fracture of the vertebrae may occur independently
of dislocation, and a dislocation without a fracture ;
yet the two are so often associated, and it is usually
so difficult to diagnose one condition independently
of the other, that it is found more convenient and
practical to group these injuries of the spine under
a comprehensive term. This is especially useful,
as the treatment is similar in both conditions.

In practice we are confronted then with cases in
which the spine has been damaged, with or without
a concomitant injury to the spinal cord. If the in-
jury is one to the spine alone, the treatment becomes
much simpler than where there is associated with
it a lesion of the cord.

We may deal with all such uncomplicated cases
on the expectant plan : that is, by extension and im-
mobilization in a plaster jacket. Should there be
unmistakable evidences of a fracture-dislocation
without cord involvement in any region of the spine,
excepting the thoracic, the setting or reduction of
such a fracture-dislocation may be attempted under
general anesthesia without a cutting operation :
bearing in mind, however, the imperative need there
is of preventing a further displacement, due to mov-
ing the patient, with a resulting injurv to the cord.

In the majority of these cases it will be found
that, even with general anesthesia, reduction cannot
be obtained without exposing the lesion through a
free incision, and assisting the efforts at reduction
bv prying the articular processes into position, or
by resecting the lower ones which oppose such re-
duction.

In the thoracic region, it is practically impossible
to reduce the deformity through manipulation alone,
and, therefore, it is better, if there are no cord symp-
toms, to treat the case by plaster jacket.

There is greater need of the application of an
immobilizing dressing in the case of the injured
spine than in fractures or dislocations in general,
because, even if the cord is not involved at first,
we never know when it may become so through a
slipping of the injured vertebrae. Cases of sudden
death are recorded where such a fatal termination
has followed the voluntary or passive movement of

*Contributed to a symposium upon fracture-dislocations
of the spine, at a meeting of the Medical Societ>- of the
Countv of New York. February 25. 1907.

March 23, 1907J

MEDICAL RECORD.

473

the patient in bed. I had such a termination fol-
low in a case of dislocation of the fifth cervical ver-
tebra upon the sixth. Under ether anesthesia, by
e.xtension, coimtere.xtension. and manipulation, the
dislocation was reduced and a plaster collar, m-
cluding the chest and head, applied. This became
so uncomfortable after twenty-four hours, and the
patient was in such evident distress, that the cast
was cut open along the front, but not removed. The
man, who was much relieved, attempted to move his
head, and died almost immediately.

It is quite a problem how to apply a plaster jacket
in these cases of fracture-dislocations without sub-
jectinsi the patient to too many risks. The plan I
have used in some cases is this : In cervical injuries,
either during or without general anesthe.sia, the
patient's head and shoulders are brought bevond
the edge of the table, and firm extension is made
in a horizontal plane, maintained by a broad bandage
behind the occiput and beneath the chin, fastened
so it cannot slip and long enough to pass over one
shoulder, across the back, and under the arm of a
strong assistant, who is seated high enough to bring
his shoulders a little above the level of the patient.
The assistant braces his feet against the table on
which the patient lies, and can maintain extension
in such a position without fatigue for half an hour.
For lower regions of the spine I have found the
hammock support very satisfactory. With an ordi-
nary hospital iron bedstead, where the crosspieces
at the head and foot are about on a level, a sling
can be improvised by passing several turns of a
strong body bandage from one to the other, forming
a support eighteen inches wide. The patient is
placed on this face downward and steadied by as-
sistants holding his arms upward and legs down-
ward. The sagging of the support produces ex-
tension in the spine, and the support is included in
the jacket from which it can be removed later.

If we do not wish to move the patient sufficient for
the use of the above method, a safer plan is to make
a wide Scultetus' bandage composed of thick canton
flannel, well rubbed up with plaster mud. This is
laid on the bed alongside of the patient, who is
carefully rolled over, face downward, on to the ban-
dage, and the ends of the bandage are care full v ad-
justed without disturbing the patient.

\Vhile there are many cases on record of fracture-
dislocations of the spine without cord involvement,
there are so many more in which this structure is
damaged that in dealing with these conditions of
the spine we must first consider the nature of the
cord injury, and be guided by that more than by any
other factor in the treatment we shall institute.

Even at the present day, valuable time is fre-
quently lost in w^aiting to arrive at an opinion as
to the exact nature and extent of the damage to the
cord, and the dictum is quite universally accepted
that, if the cord is completely severed by the scis-
sor action of the vertebrs, then no operation is to
be undertaken.

However, competent observers are quite unani-
mous in also declaring that it is often impossible
to predict the exact nature or extent of the cord
injury within a reasonable time. Being then "at
sea" regarding the exact pathological state present
it seems to me it is our duty to act at once. I mean
by that as soon as shock has been recovered from,
or the associated injuries, if any, have received ade-
quate treatment.

The following conditions, in themselves, are rec-
ognized as justifying the operation of laminectomy,
independent of whether the operation will or will not
benefit the primary lesion in the spine :

( 1 ) To remove pressure from bone, whether the
posterior arch of a vertebra or only spiculas of bone.

(2) To arrest hemorrhage, remove blood clots,
and arrest an advancing paralysis.

(3) To allow oozing in traumatic edema of the
cord.

( 4 ) To provide drainage in septic conditions in-
volving the cord.

The cord is such a fragile structure that contact
with any foreign body, as serous exudate, blood
clot, pent-up pus, or bony spiculse or masses, speedily
induces such grave pathological changes that its
restoration to normal is impossible, unless such sub-
stances are removed at once and pressure is relieved.
Without wastmg precious time, then, in debating
whether the patient before us has or has not a
severed cord, I wish to urge immediate operation
in every case of fracture-discoloration of the spine
presenting symptoms of cord involvement, even if
the severity of the symptoms seems to point to com-
plete destruction of the cord. Mistakes in diagnosis
are easy to make here ; we cannot be sure of the
extent of the injury to the cord for several days,
and meantime the period has passed within which
surgical interference might have obtained striking
results.

Early operation will allow of the removal of the
laminae, or pieces of bone which are constricting
or pressing into the cord, will furnish an oppor-
tunity to arrest hemorrhage, and so prevent pressure
from a blood clot, and will provide an outlet for
the edema, which often follows spinal injury.

The operation of laminectomy is not a difficult
one, and not many instruments and assistants are
needed. Let the incision be in the median line four to
six inches long. Expose the spinous processes and
laminx for at least five vertebra, the center one
being the seat of the injury. With Rongeur for-
ceps bite ofif the spinous processes at their bases,
and open the spinal canal first in the middle line and
then laterally, removing the lamina and intervening
ligaments. Do not waste time with any of the
methods for plastic work in the removal of the
spinous processes and laminae, as they consume valu-
able time and their removal does not weaken the
spine to any perceptible degree. Having exposed the
cord, remove any projecting piece of bone pressing
upon the cord, arrest hemorrhage by hot compresses
or by ligature. Do not stop here ; open the dura in
the middle line and inspect the cord. If there be
oozing of blood or serum, the first needs to be ar-
rested by fine ligatures passed by a short, round, full-
curved needle, the second to be provided for by
drainage of the subdural space. Suppose the cord
is severed ; then opens a new phase of the treatment
of spinal injuries. Many writers, but, I am glad
to say, not all, advise us that in case the cord is
severed operation is hopeless, because regeneration
of a severed cord is impossible. I am not here to-
night to debate the question. My reasons for ad-
vocating surgical treatment, even in such desperate
cases, have been given at length in a previous pub-
lication, and I shall not bore you by repeating them
to-night.

I resjject the opinion of the men who assert that
no operation is justifiable upon a severed cord be-
cause no regeneration is possible in its conducting
paths after such a lesion. They know more about the
histologv, pathologv, and reparative processes of the
spinal cord than I 'do, but I will say this, and say
it emphatically, that whether their kind of regenera-
tion is possible or not. Nature has in a few cases
of sutured cords effected some sort of union of the
manv severed fibers. \Mien the cord has been

474

MEDICAL RECORD.

[March 23, 1907

severed, and no attempt made to unite it, death has
followed in every case in less than a year. In the
few cases on record, five in all, where the spinal
cord was sutured, and the ends brought together,
one patient died in ten days as a result of the in-
jury, the other four lived and were improving at
the date of the report; one two and one-half years,
and one over four years since the injury; and all
of them showed unmistakable evidence of a less or
greater restoration of functions between the sutured
segments of the cord.

Having attended to the damaged spinal canal
and its contents, the fractured or dislocated verte-
brae have to be considered. Loose pieces of bone
are removed, but those firmly adhered to ligaments
and not encroaching on the spinal canal are not dis-
turbed ; a dislocated vertebra may be reduced by re-
moving the locking articular processes as before
indicated. The wound is then closed for primary
union over a drain of several strips of rubber tissue
or strands of silk-worm gut, and a plaster cast is
applied as described above. The drainage should
be removed in twenty-four to forty-eight hours.
Treatment does not cease here, however, for if
paralytic symptoms are present, then must massage,
electricitv, and passive motion he instituted and
maintained for an indefinite period, depending alto-
gether upon the condition of the patient.

Bedsores must he given careful consideration in
prophylaxis and treatment. They are unquestion-
ably due to pressure necrosis, and can be prevented
by using a water bed and close attention to reliev-
ing pressure over the various bony prominences.
Cystitis is a serious complication, often followed by
a fatal pyelitis. Sterile catheterization with sys-
tematic irrigation of the bladder must be instituted'
early and maintained as long as necessary.

After three to four weeks of treatment in bed, if
the patient's condition allows it. a new plaster jacket
should be applied with a Sayre's extension tripod,
or after the horizontal hammock plan, and this
should be worn, changed as often as necessary, for
several months ; or if a less rigid support is permis-
sible, the Taylor spinal brace can be adjusted. Such
support should be worn for at least a year after a
laminectomv for a fracture-dislocation.

1 125 Madiso.v Avenue.

PHOTOTHERAPY IN NER\'OUS DISEASE.*

By a. D. ROCKWELL. A.M.. M.D..

NEUROLOGIST AND ELECTROTHERAPEUTIST TO THE FLUSHING HOSPIT.^L —

FORMERLY PROFESSOR OF ELECTROTHERAPEUTICS IN THE NEW YORK

POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. E.\-ELEC-

TROTHERAPEUTIST TO THE WOMAN'S HOSPITAL IN THE

STATE OF NEW YORK. ETC.

W'liEN invited some time ago to take part in this
symposium and present a short paper upon some
topic that was especially interesting me in the do-
main of neurologv or psychology, I at once fixed
upon the subject of phototherapy. Not that I had
any very large or notably valuable experience along
this line, but it so happened that I had recently
installed in mv office an incandescent light appa-
ratus of considerable power, and. like the child with
the new toy, it was superseding in immediate interest
other and more familiar physical method. I shall
not attempt to emulate the too common tendency in
the exploitation of physical methods of treatment, by
claiming for light thera])y exraordinary and uni-
formly successful results. Nevertheless there is
much truth in the alliterative phrase — light and
life, darkness and death — and in the artificial in-

*Read before the Medical Association of the Greater City
of New York, February 18, 1907.

candescent electric light we have a method of utiliz-
ing powerful luminous and calorific effects, and to
a less extent actinic effects as well, second only to
the source of all light and heat — the sun. It is well
to have a definite conception as to what phototherapy
means. It means light treatment. For practical
purposes the rate of vibration is all-important in
classifying the different forms of vibratory energy.

The slower rates which influence the auditory-
nerve and are translated into sound are unavailable
for therapeutic use. .As the rates increase in fre-
quency we get the perception on the thermic sense
as heat, and still further increase gives us light —
the visible spectrum. Beyond the visible into the
invisible regiou of the spectrum we get the ultra
violet and the .f-rays. \Vhile there are no sharply
defined lines between these different rates of energy,
we are nevertheless able to comprehend the actual
difference between sound, heat, light, and electricity
by our senses and the ultra-violet and .t'-rays by
chemical means.

In the earlier experiments by Finsen and his fol-
lowers, the term phototherapy came to be used to
include as much or more of the invisible rates as
the visible, notwithstanding the fact that what is
invisible can hardly be called light.

Strictly speaking, then, this term should be used
to include the visible spectrum only. In thera-
peutics, light is utilized by three methods : Sunlight,
the arc light, and the incandescent electric light.
Light is essentially the same from whatever source
obtained, but as a matter of convenience it is im-
portant as to how and where we get it. The com-
bined luminous, calorific, and actinic rays of sunlight
are more powerful than from any artificial source,
but the obstacles in the way of its general utilization
are obvious. It is with the incandescent {sometimes
called leucodescent) lamp light, with its powerful
heat and light rays, that I have to do in this paper.
The ultra-violet ray to be sure is a part of the in-
candescent light, but it is unavailable for use in the
mechanism of the incandescent light apparatus be-
cause of its inability to penetrate glass. And yet
the incandescent light is bv no means devoid of
chemical power, for it is sufficiently rich in the blue,
indigo, and violet frequencies, to the passage of
which glass is no hindrance. The arc light more
nearly approaches concentrated sunlight in its ac-
tinic and luminous power, but is deficient in heat
rays, and its chief value lies in its localized and
superficial action, which in certain conditions, as
Finsen so ably demonstrated, is powerfully curative.
The incandescent light therefore is manifestly in-
ferior in some respects to either sunlight as used
l)y the Finsen method, or to the arc light. It is
weaker in chemical effects, and its luminous power is
also inferior to the other two. but the heat emitted
is far greater, and in my experience this combina-
tion of calorific and light effects renders it far
more valuable than the arc light in its general con-
stitutional influence, and in the relief of local painful
conditions. That the higher rates of vibration (the
ultra violet) are useless for the production of con-
stitutional effect is due to the fact that they pene-
trate the body only under pressure or other methods
of producing dehematization of the skin, and then
but slightly, while the combined rays act efficiently
to a great depth, even passing completely through
the tissues, as evidenced by their action on a sensi-
tized plate placed on the opposite side of the body.
The incandescent light bath differs in its heat, to say
nothing of its light effects, from the ordinary hot air
bath, in that in the former the heat is communicated
to the bodv throuarh the transmission of radiant

March ^3. 1907]

MEDICAL RECORD.

475

energy — which leaves the surrounding air but
slightly affected. This is easily demonstrated by
interposing an opaque substance between the source
of light and heat and the body, when all sensation
of heat ceases. The radiant energy penetrates the
body and as it meets with the resistance of the
more or less dense bodily structures is converted into
heat. In the hot air bath, on the contrary, the heat
is derived from the air, and while more depressing
in its effects is far less penetrating than radiant
heat, and is inferior in its physiological and thera-
peutic effects.

The superior physiological effects of radiated
heat, as compared with heated air, would seem to
consist in its more powerful rubefacient effect upon
the skin with accompanying dilatation of the super-
ficial vessels. This relaxation of the superficial ves-
sels being unaccompanied by any appreciable heating
of the surrounding air can be maintained for a long
time without discomfort, and is followed bv interest-
ing alterative and reconstructive effects through its
influence upon metabolism. Perspiration is induced
more quickly by radiant heat than by most other
methods. In the Turkish hot-air bath, some twenty
minutes are necessary to excite active sweating,
while exposure to a bearable degree of radiant heat
stimulates the skin to the point of perspiration in
five minutes or less. This more rapid result is
accounted for by the stimulating effects of the light
rays upon the peripheral nerve endings.

But one of the most interesting evidences of the
increased oxidation and tissue changes induced by
this form of radiant energy is the increase in the
elimination of carbon dioxide. As compared with
the hot air bath it has been found that the increase
of the natural oxidation of the body as indicated by
the elimination of carbon dioxide was four times
greater in the light bath.

Light acts on the blood, increasing the hemo-
globin-carrying power of the red corpuscles, and is
decidedly bactericidal, although this destructive in-
fluence upon microorganisms must be attributed in
far greater measure to the action of the ultra violet
— the invisible rays. As the nervous system is the
only route through which sensations are conveyed,
it follows that light and heat effects should be
classed as a nerve stimulant or a nerve sedative
according as the degree of their intensity results
in an increase or reduction of energy.

The function of the nerve endings becomes either
more keenly alive or their perceptive powers are
dulled according to the kind, and the duration and
intensity of the physical agent employed. An in-
crease, decrease, modification or destruction of the
nervous influence are demonstrable changes in in-
nervation that follow thermic and chemical stimula-
tion, and it is by this inhibition or modification of
nerve conduction that the combined thermic, lumi-
nous, and chemical effects of light influence the
hyperesthesias, the anesthesias, and pain in general.
Since the nervous system stimulates and regulates
the functional processes, the reflex effects of local
peripheral stimulation are often seen in remote parts.

All physical therapeutic agencies are, in fact,
primarily irritants. Indeed life, with its vital proc-
esses, depends on constant irritation and physical
forces applied to the body can be believed to be
transformed into vital cell energy. At all events
it is well understood that deprivation of irritation
so that the normal functional activity is restricted
and held in abeyance results in functional weakness,
while, on the other hand, local or general physical
irritants stimulates and strengthens, or depresses

and weakens, according as they are applied in
rcoderation and adequately, or in e.xcess.

In entitling this paper "Phototherapy in Nervous
Diseases," I would by no means thus limit it, al-
though the condition of the nervous system is largely
responsible for many a disease that is not classed as
nervous.

'J'he principles on which is based the therapeutics
of light and heat are fundamentally very much the
same as govern in the application of other physical
methods of treatment. They unquestionably influ-
ence metabolism and necessarily the processes of
excretion and secretion.

The circulation is, of course, profoundly influ-
enced, and when we consider the intimate circula-
tory relationships between the skin and the various
internal organs of the body, it is no very difficult
matter to appreciate in how many ways benefit may
be derived from the play of these energies upon
the periphery. If the vessels of the skin when dis-
tended are capable of holding, as is asserted, one-
half the whole amount of blood, it is evident that
this distention must greatly relieve congested parts,
with which they are in immediate connection.

It relieves nerve pressure and pain by exciting
the activity of the circulation through congesied
areas, resulting in a sort of circulatory drainage, as
it were.

This is the primary and perhaps most important
effect of the application of light and radiant heat.
More prolonged and intense applications are still
effective in the dissipation of local hyperemias, but
not so much it is believed through an increased ac-
tivity of circulation as by inducing a secondary con-
traction of the arterioles.

To enumerate the many pathological conditions
for which the li.t^ht treatment has been found to be
of service would make a long list, and it is beyond
the scope of this paper to detail cases, although
many of a most interesting and convincing charac-
ter might be related.

But this much may be said. As a rule, whenever
and wherever pain exists, whether in the form ot the
neuralgias or neuritis, or pain of the rheumatic or
gouty type, a judicious application of the light bath
is pretty certain to give temporary relief, and suc-
cessive applications in a large proportion of cases
are followed by permanent relief. \\'ith tuberculosis
I have had no experience, but much has been claimed
for it, and I am not prepared to dispute the claim
that in chronic localized tuberculosis much good may
result. Some little experience I have had in the
application of these powerful concentrated light and
heat rays as a general tonic and an aid to nutrition,
especially in children convalescing from acute dis-
ease or with a poor inheritance of vitality.

In the toxemias and the to.xic neuroses, the thera-
peutic value of light energy is beyond question.

This I can affirm, both from mv own experience
and the observed results of Dr. T. Crothers in a
series of a thousand treatments given to patients in
his sanatorium. In the toxic neuroses and the pal-
sies thev were found to be of the greatest benefit —
far preferable to hot air and vapor baths. In my
own cases I have found that the benefit derived
from the light bath was often greatly enhanced by
supplementary physical methods, such as static elec-
tric high-frequency currents and general faradiza-
tion.

In conclusion it may be said that the basis of the
action of the light bath in disease would seem to
be these four :

I. Its bactericidal power.

47

76

MEDICAL RECORD.

I March 23, 1907

2. As a promoter of tissue metabolism.

3. Its influence in increasing the hemoglobin-car-
rying' power of the red corpuscles.

4. Its analgesic properties, due to its power to re-
lieve blood pressure through induced congestion of
superficial vessels, and to its infinitely rapid vibratory
action on the nerve units of the body.

The Sydenham, M.^rnsoN .\ven'UE and Fifty-eighth Street.

THE EARLY MOBILIZATION OF PATIENTS

AFTER MAJOR GYNECOLOGICAL

OPERATIONS.*

By ABRAJI BROTHERS, B.S., M.D.,

NEW YORK.

ADJUNCT PROFESSOR GYNECOLOGY NEW YORK POST-GRADUATE SCHOOL:
VISITING GYNECOLOGIST BETH ISRAEL HOSPITAL.

New methods which aim at overthrowing customs
established for centuries must expect to encounter
obstacles of such magnitude that the voice of a single
individual counts for little and may well be likened
to the solitary voice in the desert. The plea must
rather be for a dispassionate hearing, and, if con-
verts are to be made, the solitary voice must be
backed by logic in its argument and a sufficiently
large number of experiences to give the foundation-
stones of the argument the strength and firmness of
granite.

In the Journal of the American Medical Associa-
tion for August. i8q9 (xxxiii., pp. 454), Ries of
Chicago, in a short article, announced that, after
giving the method a trial of four years, he now
placed little or no restrictions in the movements or
diet of his patients after vaginal celiotomy or ab-
dominal section. They were permitted to turn
around and sit up in bed and out of bed as soon as
they were fairly able. In the discussion, Manley,
Wiggin, and Schaefer agreed in the main with the
new ideas set forth, but Bonifield insisted that 'the
experience of ages was not to be thrust aside in a
minute. No attention apparently was given to this
communication, and probably the majority of sur-
geons regarded the proposition as absurd, if not
insane or criminal. Fifteen years ago Boldt was
ordering his vaginal celiotomy cases out of bed in
twenty-four hours, but only two and one-half years
ago did he take up the question in connection with
abdominal work, and. after a fairlv large experience
with it, announced his confidence therein at the
Birmingham meeting of the Southern Surgical and
Gynecological .Association ; and later, at a meeting
held a year ago, of the New York Obstetrical So-
ciety. At a subsequent meeting a strong paper at-
tacking this method was written in a cleverly sar-
castic vein by one of the Fellows, Dr. Franz Foers-
ter, on which occasion, in spite of insisting on the
correctness of his position as based on his experi-
ences, the feeling of the meeting seemed to be very
strongly against Boldt. One of the Fellows re-
marked that Boldt's position was untenable, if an
accident occurred, in case of a malpractice suit, as no
colleague could be found who could conscientiously
support him in his contention that such early mobil-
ization was proper after abdominal section.

The writer confesses that nobody regarded this
proposition of early mobilization after major opera-
tions with greater suspicion and scepticism than
himself. A certain thrill of horror unconsciously
passed through his frame at the thought of a lapar-
otomized patient being taken in the arms and sat

* Presented, by special invitation, at the meeting of the
Southern Surgical and Gynecological .Association, held on
December 11, 1906.

upright in a chair within twelve hours after opera-
tion. There seemed to be an element of unjustifia-
ble brutality in the procedure. But watching the
cases of my friend. Dr. Boldt, and noting the im-
proved morale which set in almost from the moment
the patient emerged from the anesthetic, and the
rapidity with which convalescence progressed, I felt
that I owed it to myself and to my patients to "'ive
the method a cautious trial. I beg to state right
here that I have never yet had the courage, nor have
I seen the necessity, for getting my patients out of
bed before forty-eight hours, and the larger number
of my patients were not allowed out of bed until
the fifth, seventh, or eighth day. This agrees with
the plan adopted bv Ries, who does not permit any
of his patients to leave the bed until at least three
days after operation, and others not until after re-
moval of the stitches on the sixth to the eighth day ;
but all are permitted to move about in bed as soon as
they want to. Even this, however, anticipates the
convalescence by at least one or two weeks, and is in
itself, from my point of view, a vast stride in ad-
vance over the method generally in vogue, by which
patients are kept in bed from fourteen to twenty-
one days.

On what basis is the method of early mobilization
to be granted a fair and dispassionate hearing ? The
statistics of Ries. Boldt, Chanler, and myself now
easily cover 1,000 laparotomies; and in no case has
an accident occurred which can be fairly attributed
to the early mobilization of the patient.* In the paper
of Ries. above alluded to, he claims to have had only
one death in 100 vaginal celiotomies (a septic case),
of which 60 were hysterectomies, and to have had
no case of vaginal hernia or hemorrhage. The Mayo
brothers, I understand, place their patients in an up-
right posifion after operations on the stomach and
gall-bladder, as soon as the patient emerges from the
anesthetic. [Movnahan. in his work just published
on ""Abdominal Operations," advises the same pro-
cedure "'after all operations upon the stomach and
after some upon the gall-bladder." This writer
adds : "T find that it is a general custom to keep
all patients in bed much longer than is necessary. If
all is goin" well, the sooner the patient is up the
better." He permits an appendectomy patient to be
out of bed in six or seven days, and to return to
light work in a fortnight. A medical man was see-
ing patients on the fifteenth day, after a gastro-
enterestomy and cholecystotomy, and no ill effects
followed. In the Medical Record of November 24,
1906. Marshall and Quick, reportinp- 100 laparo-
tomies with two deaths, write: ""In all simple
laparotomv cases with small incisions, and in which
extensive work is not done upon the viscera, the pa-
tients are placed in a sitting posture upon the third
or fourth day, and permitted to be up unon the sixth
dav. usuallv leaving the hospital before the tenth
day."

It is a good rule that combatants look their op-
ponents squarely in the face in order to meet prop-
erlv and victoriously every variety of thrust or blow.
Let us. then, seriously and in cold reason look over
the ground and consider the objections to the early
mobilization of patients after major abdominal oper-
ations. \\'hat are the dangers after laparotomy ?

Among the immediate dangers, that of post-opera-
tive shock or collapse easily ranks first. As a matter
of fact, many cases reported formerly as shock were
simplv cases of secondary hemorrhage. I have
known even a cigarette drain in the abdominal
wound to fail to direct blood to the exterior, after

*' Since the above was written I have learned of one case
in which the laparotomy-wound reopened. This was attrib-
uted to the poor qualin- of the adhesive plaster used.

March 23, 1907]

MEDICAL RECORD.

477

extensive secondary hemorrhas^e. and this case was
treated for a time as one of primary shock due to
the traumatism of operation. On the other hand,
debility resulting from protracted invalidism, exces-
sive hemorrhage during operation, prolonged anes-
thesia, and traumatism, or excessive handling of the
intraabdominal viscera, may lead to true shock. Such
cases of shock are excluded from the category of
those in which early mobilization is to be thought
of. Dn the other hand, early mobilization does not
tend to develop shock according to the experience,
up to the present, of those best in position to know.

Hemorrhage is not to be feared in the hands of
competent surgeons. Our knowledge of ligature
materials and technique is to-day so precise that
bleeding from loosening of such ligatures is hardly
to be expected after the lapse of twelve hours — un-
less other complications, such as cough or vomiting
of a severe type, are present. As a matter of fact,
no cases of hemorrhage have been noted in the
thousand cases referred to, and the operator need
have no fear from this score.

Reopening of the abdominal wound with more or
less evisceration, I have met with three or four times
during former years. Patients who are delirious or
maniacal may tear away dressings, and with the
finger-nails reopen laparotomy wounds. This hap-
pened once, I recall, after a cesarean section fol-
lowed by complete hysterectomy, which I did on
an Italian woman who entered my service in an ad-
vanced stage of sepsis, with a large cervical fibroid
blocking the pelvic outlet, the gangrenous cord being
prolapsed several inches and presenting at the vulvar
orifice. This woman, in her maniacal state, tore
open her wound, and the intestines lay on the sur-
face of the abdomen. After carefully washing them
and returning them to the interior of the abdomen,
the laparotomy wound was again sutured, and the
woman made a good recovery. Other cases of re-
opening of the abdominal wound with more or less
evisceration occurred as the result of e-xcessive vom-
iting or associated with severe bronchitis or pneu-
monia. I do not recommend taking such patients out
of bed. Beyond the raising of the patient in bed
during a pneumonia or bronchitis, no further efforts
at mobilization should be made. As a matter of fact,
it will be shown later that immobilization on the
back is distinctly bad treatment when bronchial se-
cretions are in danger of accumulating in the air-
tubes or alveoli. As regards the risk of reopening
of the abdominal wound in the absence of these
complications, most operators who close such
wounds in three or four layers have learned to ignore
it. In the early mobilization of patients, Ries is
wrong when he allows his patients to move about
and sit up unbandaged, even if he does use strips
of adhesive plaster in order to approximate the
edges of suppurating wounds with the object, inci-
dentally, of reinforcing the abdominal wall. The po-
sition of Boldt is far more logical, in that he im-
mobilizes the abdomen by means of a bandage of
adhesive plaster surrounding the whole body, which
holds it in a vise-like grip, before he permits his
patients to be moved about. I have adopted Boldt's
method and regard his plaster as a most important
safeguard against any possibility of reopening of the
laparotomy wound. After a vaginal hysterectomy
I have known of one fatal case in the hands of a
colleague, in which early mobilization seemed to be
partlv responsible for adhesions and angulation of
the intestines. In this case the house surgeon re-
moved the vaginal drain without consulting the
operator at the end of twenty-four hours. My own
experiences, however, with vaginal celiotomy, in-

cluding hysterectomy, have been free from accidents.

Vomiting, distention, and inability to move the
bowels, are not necessarily contraindications to the
early mobilization of patients. Indeed, some of us
are convinced that moving the patients and getting
them early in an upright position in a chair even aids
intestinal peristalsis, and the early removal of gases
and intestinal contents with relief of belching and
vomiting. Indeed. Ries says that not only is intes-
tinal peristalsis assisted by early mobilization and
early feeding, but that adhesions are prevented from
forming, and that the easy and spontaneous move-
ment of the bowels is thereby assisted. In a case
recently operated on by the writer, the indication for
the laparotomy was the breaking up of old adhesions
left after a previous operation for ectopic gestation.
This woman left her bed in forty-eight hours and
began to walk about. She left the hospital free from
the old pains.* Of course, conditions of anemia
of the brain, great debility, etc., would induce the
careful surgeon to weigh all of the circumstances
and act slowly before getting such patients up.

Interference with the primary union of the lapar-
otomy wound is not a result of early mobilization.
If suppuration of the wound occurs, the fault lies
with the operation or the ligature materials. Drained
wounds are not proper cases for early mobilization
until at least a week has elapsed and the drain has
completelv or nearly been dispensed with. Other-
wise, there is risk of hernia. A rapid pulse, even
without elevation of temperature, may indicate
wound suppuration, and is a contraindication to
early mobilization.

Thrombosis and embolism constitute the greatest
and most serious of the more remote risks followinp-
laparotomy, and ofifer the gravest objection to those
wild are most earnestly opposed to the idea of early
post-operative mobilization. From the excellent
chapter by Frazier, in the first volume of Keene's
"Surgerv," just published, I abstract the following
facts and statistics.

A thrombus is defined to be a mass, the com-
ponent parts of which are derived from the blood,
formed in the heart or peripheral vessels. Infection
is the predominant factor in the majority of cases of
thrombosis which come under the surgeon's care.
Retardation of the blood current is a predisposing
or contributing cause. Unless in cooperation with
some other condition, as a lesion of the vessel wall,
or the presence of organisms, it cannot give rise to
thrombosis. Arterial thrombosis is more common
in the lower extremities, is due to embolism or
traumatism, or is associated with disease^ of the
arterial walls (endarteritis or arteriosclerosis), and
when present is usually the result of infection or
chronic disease. In some instances, both arterial
and venous thrombosis exist at the same time. The
femoral vein is almost invariably the seat of venous
thrombosis, and the majority of cases occur on the
left side.

.\lbans alludes to four etiological factors : ( i ) Dis-
turbances before operation (such as heart lesions,
varicose veins, exhaustive, prolonged decubitus,
presence of abdominal tumors") : (2) disturbances at
time of operation (such as chilling and exposing of
abdominal contents, traumatism of vessel walls) ;
(3) effect of anesthetic on the heart: (4) topo-
graphical relations of the vessels (thus an over-
loaded sigmoid might press on the left iliac vein or
the iliac artery might press on the iliac vein).

Clark attributes such a thrombophlebitis to the

* I liave since then operated in a second case for this
indication and had the patient sitting in a chair after forty-
eight hours.

4/8

MEDICAL RECORD.

[March 23, 1907

effect of traumatism exerted upon the deep epigastric
vessels during the course of a laparotomy, as a re-
sult of traction on the edges of the wound. He
thinks that the primary thrombosis may start in the
deep epigastric vein and be slowly propagated along
the line of the vessel until it reaches the external
iliac vein, whence it gives rise to a retrogressive
thrombus in the femoral vein.

In Sonneburg's clinic thrombosis was met twenty
times in 1,000 operations for appendicitis. Fourteen
of these occurred in interval operations, which are
ordinarily nonsuppurative conditions. In 3,000 lapar-
otomies Clark found records of only thirty-five cases
of thrombosis. Schenck in 7,130 gynecological op-
erations found that twenty-five cases of thrombosis
occurred after hysterectomy, and nine after ovari-
otomy. Albans notes fifty-three cases of thrombosis
in 1,140 laparotomies and twenty-six occurred after
"clean" operations. In the service of W. K. Polk
at Bellevue Hospital, between the years 1895-1902,
there was not a single record of thrombosis or
embolism in 103 abdominal or vaginal hysterec-
tomies. At the Beth Israel Hospital, from October
I, 1905, until October i, 1906, in nearly 350 ab-
dominal sections, we had four cases of femoral
thrombosis. In three of these cases the operations
were done for suppurative appendicitis and, in the
fourth, for a broad ligament abscess. None of these
patients at Beth Israel Hospital, and none of those
referred to in the foregoing statistics, to my knowl-
edge, was submitted to early mobilization. On the
other hand, the thousand cases treated by early
mobilization present only two cases (one of Boldt
and one of Ries). or possibly three, in which a
thrombosis occurred. -Xs I saw Boklt's case, I have
my doubts as to whether the mild phlebitic condition
had really anything to do with the post-operative
mobilization — occurring as it did three weeks after
the operation in a very active young lady.

In Sonneburg's 1,000 cases of appendicitis three
cases of embolism are noted with two other fatal
cases, in which embolic pneumonia was supposed to
have been present. Pulmonary embolism is said
to occur much more commonly after gynecological
than after general surgical operations. Albans, in
1,140 abdominal operations, found twenty-three
cases of pulmonary embolism. Lotheisen, in sixty-
six cases of pulmonary embolism, found forty to be
secondary to phlebitis and thrombosis of the veins
of the lower extremities : next in frequency come
those which start from thrombosis in the pelvic
veins in the puerperium, or after operations upon the
pelvic organs. In 236 operations for uterine fibroid,
according to Burkhard, twelve cases of embolism oc-
curred. Of the fifty cases of abdominal section
which were subjected to early mobilization, in my
services at the Beth Israel Hospital, Post-Graduate
Hospital, and elsewhere, all the patients recovered.
I met no cases of embolism or thrombosis, and only
one pneumonia (with pneumococci in the sputum).
Neither Reis nor Boldt met with accidents of this
kind in their 885 cases, and in my case the patient
was distinctly exposed on a very cold night to a
draught from a window, which could not be closed,
at the head of her bed.

^lanv surgeons have a grave fear of late or de-
delaved shock, and oppose earlv mobilization for
this reason. During the past year I met two such'
cases in my hospital work in which the patients
were confined to their bed. In the first case a
purulent collection was found in Douglas' sac after
an apparently spontaneous abortion. This was in-
cised and drained in the usual manner on December
25. Excepting a rapid pulse, everything was doing

nicely, with temperature (formerly 103° F.) at the
normal, when on January 2, with the patient still in
bed, she went into sudden collapse without any evi-
dence of pain. Vomiting set in, temperature dropped
to 94° F., and the pulse became imperceptible. After
free stimulation, including intravenous infusion of
saline solution, she gradually emerged from the
shock and went on to a spontaneous and complete
recovery. The second case occurred forty-eight
hours after a radical abdominal operation for sup-
purating adnexa, in which vaginal drainage was in-
stituted. Without having been moved in bed, be-
cause of a rapid pulse, the woman passed suddenly
into a condition of profound shock and was brought
back to life only by vigorous stimulation and an in-
travenous saline infusion. I consider the possibility
of secondary or delayed shock as one of serious im-
portance, and one which should be borne in mind in
the cases in which we are urging early mobilization.
I have always regarded a rapid pulse after lapar-
otomy, even in the absence of a distinct febrile
movement, with suspicion. Both of these patients
were not disturbed on that account, and perhaps the
fortunate outcome in both may have depended on
that circumstance.

Up to a recent period of time post-operative pneu-
monia was thought to be the result of the anesthetic.
Moynahan accounts for its occurrence in five differ-
ent ways. He claims, first, that the immobilization
resulting from the unconscious protection of the
wound area by the patient results in the accumulation
of bronchial secretions in the lung. Deep breaths are
avoided and the air-passages are not cleared by the
act of coughing. This results in irritation and
waterlogging of the lungs by retained secretions.
The second cause is chilling of the patient's body
during or shortly after operation. The third cause
is the inhalation of septic matter'into the lungs. The
fourth cause he attributes to septic emboli derived
from the field of operation. The fifth cause he at-
tributes to a long continuance of the Trendelenburg
position. What argument could be more potent and
favorable to early mobilization than the first reason
which Jiloynahan above gives as a predisposing
cause to post-operative pneumonia? It has long
been recognized by medical men that the sitting
position in bed conduces, in great measure, toward a
favorable result in cases of pneumonia. Why not
apply the same principle, in appropriate cases, to the
avoidance of this complication after operation ?

\\hile early mobilization is possible, and, accord-
ing to my conviction, beneficial in a large number
of cases after laparotomy, I believe that the exact
limitations of the method have not as vet been
drawn. As I do not pretent to be an extremist, I
have laid down for my own guidance the following
contraindications to the early mobilization of these
patients : ( i ) Shock or collapse preceding, during,
or subsequent to operation; (2) organic lesions of
the heart, kidneys, or blood-vessels; (7) debilitated
or senile patients ; (4) rapid heart action after oper-
ation, with or without rise of temperature; (5) per-
sistent elevation of temperature, after operation,
from any cause; (6) signs of peritonitis; (7) hernia
opeiations; (8) complications like pneumonia, diar-
rhea, dysentery, etc. ; (9) after suspension, fixation,
and prolapsus operations ; ( 10) in vaginal plastic op-
erations (especially on the perineum) associated
with laparotomy; (11) in drained and suppurating
abdominal wounds.

I believe in early, gradual, and rational mobiliza-
tion. To place a patient after a laparotomy in a
chair twelve hours after the operation, seems to me
to be one extreme ; to keep the same patient on her

March 23, 1907]

MEDICAL RECORD.

479

back in bed during three weeks, with no reaction
present, seems to me to be the opposite extreme.
That patients recover under both methods does not
prove that either is the one to be g-enerally followed.
Nor do I regard successful results after early mobil-
ization in the light of surgical curiosities, or even as
experiments. My own plan is to let the patient
severely alone during the first twenty-four hours —
the nurse merely is allowed to place the pillows
comfortably under the patient's head and shoulders.
If all goes well on the second or third day, the pa-
tient may be sat upright in bed for a few minutes,
supported on the nurse's arm ; later by a few hours
she may be propped up by pillows in a sitting posi-
tion during a quarter of an hour. The following
day she may be in this sitting posture in bed for an
hour in the forenoon and an hour in the afternoon.
After that she can be gently placed in a chair for a
reasonable period of time during each succeeding
day. While these movements are being carried out
under the orders of the physician, the nurse must
keep a close watch on the patient's pulse. With the
first evidence of faintncss or rapid pulse the patient
is returned to bed and no further efforts at mobiliza-
tion are made for several days. While I have been
obliged to desist from and postpone active mobiliza-
tion in a number of my cases, because of wound dis-
turbances, I have had no fatal complications, and 1
have been satisfied that wound suppuration, when it
did occur, was independent of the movements and
dependent solely on infection from purulent matter
soiling the wound edges at the time of operation, or
from ligature material.

Early mobilization is possible when the plaster
binder of Boldt is on the patient. This plaster sur-
rounds the body of the patient, and the serrated
ribbons so overlap each other in front, that the ab-
domen is supported from below upwards and held
in a vise-like grip. From the onset these patients
are allowed to drink freely of water, albumin water,
peptonized milk, beef extracts, and orange juice.
Moynahan says : "It seems to me not improbable
that death took place in some of my early cases
literally frofn starvation." After twenty-four hours
Ries and Boldt give their patients meat, bread, and
vegetables, insisting, however, on thorough mastica-
tion.

To sum up, early mobilization, from the writer's
point of view and experience, tends to overcome
ordinary vomiting, accumulation of intestinal flatus,
and bronchial irritation from retained secretions in
the air-passages. Instead of contributing additional
risks to the possibilities of thrombosis and embolism,
he thinks that, in the absence of septic infection, the
early moving about of these patients actually tends to
reduce these risks. The morale of these patients is
always wonderfully improved, and a tendency to
debilitv, hysteria, and mental states of depression
and anxiety correspondingly diminished. The total
result, therefore, is an earlier and more pleasant
convalescence. According to Ries, the method pre-
vents muscular atrophy, conduces to a rapid re-
covery of strength, and permits of the discharge of
these patients from the hospital in about twelve
days.

To prove that neither the character nor the magni-
tude of an operation necessarily debars earlv mobili-
zation— the objectionable conditions referred to
being absent — I append a few cases selected at
random from my notes.

Case I. — Patient of Dr. Charles L. Antony. Pa-
tient in a chronic pyemic condition from a suppurat-
ing fibroid tumor reaching up to the level of the
umbilicus. She had lost some thirty or forty pounds
in weight, and was in a debilitated condition at the

time of operation. Abdominal hysterectomy done
at Beth Israel Hospital on November 20, 1905.
Patient was out of bed on the seventh day and made
a progressive and uneventful recovery.

Case II.^ — Patient of Dr. Martin Goldberger. Case
of bilateral gonorrheal pyosalpinx. Both pus sacs
with purulent ovaries, removed with ventrofixation,
at a private sanatorium on July 10, 1905. Little sup-
puration in lower angle of wound. Patient out of
bed at end of a week. Got married later and was
well when last heard from.

Case HI. — Patient of Dr. I. A. Lehman. Lapar-
otomy for ruptured ectopic gestation at St. Mark's
Hospital on January 3, 1906. Out of bed on the
eighth day. and at home on the tenth day. Seen six
months later at my office with scar in ideal condition.

Case IV. — Patient of Dr. Max Ghertler. Lapar-
otomy at St. Mark's Hospital on February 2, 1906.
Appendectomy and right oophorectomy. Out of
bed on the fourth day. Sent home on the thirteenth
day. Scar perfect nine months later.

Case V. — Patient of Dr. Joel Grosner. Lapar-
otomy at St. Mark's Hospital for bilateral pyosalpinx
with right-sided ovarian abscess. Removal of pus
sacs complete. Out of bed on fifth day. Sent home
on the tenth day. Called at my office on the thir-
teenth day the picture of perfect health.

Case \T. — Patient of Dr. H. O. Carrington. On
June 19, igo6, at Post-Graduate Hospital, supra-
vaginal hysterectomy for large fibroid tumor of the
uterus. Out of bed on the fifth day. Sent home on
the tenth day.

Case VII. — Service case at Post-Graduate Hos-
pital. Admitted in a cyanosed condition with high
temperature and rapid heart action. Ruptured ab-
scess suspected and operated a few hours after ad-
mission. Large double tuboovarian abscesses found
on abdominal section done June 30, igo6. Rupture
during operation. Cigarette drain gradually re-
moved during six days. Out of bed eighth day. Sent
home on fourteenth day. Examined four months
later and scar found to be perfect.

Case VIIL— Case of Dr. M. Cisin. Total ab-
dominal hysterectomy for large fibroid uterus with
elongated cervix at Beth Israel Hospital on July 3,
iqo6. Out of bed on eighth day and sent home
at end of two weeks.

Case IX. — Service case at Post-Graduate Hos-
pital, operated July 27, 1906. Laparotomy for rup-
tured extrauterine pregnancy. Wound closed with-
out drainage. Patient out of bed on the fourth day,
and sent home on the tenth day.

Case X. — Service case at Post-Graduate Hospital.
Had had laparotomy done five months previously.
Second laparotomy, August 2, 1906. Removal of
right adnexal inflammatory mass. Exsection of
thickened and adherent omentum. Separation of
fxtensive adhesions to abdominal wall and elsewhere.
Exsection of blood cyst from left ovary, amputa-
tion of outer third of this tube and suture of ovary
to stump. (Dut of bed on seventh day. Presented
perfect scar two months later.

Case XI. — Service case at Post-Graduate Hospi-
tal. Woman with six months' baby at the breast.
Laparotomy on August 18, 1906, removing a large
left-sided nmltilocular ovarian cyst. Partial oo|)ho-
rectomv of left-sided cystic ovary. Ventrosuspen-
sion. Resumed nursing forty-eight hours after the
operation. Out of bed on the eighth day. Three
months later presented ideal abdominal scar.

Case XII.— Case of Dr. Aaron A. Mendel. Vag-
inal hysterectomy for carcinoma uteri at Post-Grad-
uate Hospital on September 7, 1906. Out of bed on
the seventh day. Left for home on the tenth day.

112 East Sixty-first Street.

48o

MEDICAL RECORD.

[March 23, 1907

THE PROGNOSTIC VALUE OF THE DIAZO
REACTION IN TUBERCULOSIS;

WITH INTERESTING OBSERVATIONS AS TO RACIAL DIF-
FERENCES IN WHITES AND BLACKS.*
By JOHN ROY WILLIAMS, M.D.,

Gr.BENSBORO, N. C.

LATE BACTERIOLOGIST. PATHOI OGIST AMD ASSISTANT HOUSE PHYSICIAN,

WINTAH SANATORIUM, ASHRVILLE, N. C. ; MEMBER GUILFORn COUNTY

MEDICAL SOCIETY, NORTH CAROLINA MEDICAL SOCIETY, AMERICAN

MEDICAL association; HONORARY VICE-PRESIDENT AMERICAN

INTERNATIONAL CONGRESS ON TUBERCULOSIS; LECTURE

STAPP, TRAINING SCHOOL FOR NURSES, ST. LEO's

HOSPITAL, GREENSBORO, N. C.

The value of the diazo reaction as a prognostic
sign in tuberculosis is no longer a disputed ques-
tion. For the past ten years it has been subjected
to the most critical observation, until now it is
generally accepted as a fact that the persistent pres-
ence of a marked diazo reaction in tuberculosis
means an early fatal termination. There has been
much literature published on this subject in the
last eight years, from which I gather the consensus
of opinion is that it is a bad prognostic sign.

In 1899, Michaelis' reported his observations in
106 cases of tuberculosis, as to the value of the diazo
reaction as a prognostic sign. Of these 106 cases,
the diazo reaction was found in 75, and was absent
in 31. Of those patients -giving the reaction. 89 per
cent, either died or grew worse while under his ob-
servation. Of those not giving the reaction, 87 per
cent, gave good results with treatment.

Karl von Ruck- does not give a hopeless prog-
nosis in every case where the diazo reaction is
present. He has seen a weak reaction disappear
permanently upon the administration of hot water
internally along with mild diuretics.

Wood,^ of St. Luke's Hosjvtal, New York, re-
ports 230 cases of tuberculosis. Fifty-two of these
died in the hospital. Of these 32 cases, 90 per cent,
gave a persistent, strong diazo reaction.

Upson* reports that his experience goes to show
that the persistence of the diazo reaction in a known
case of tuberculosis is of considerable value as an
unfavorable prognostic sign.

I wish to add (o the above opinions my own,
which has been formed after the observation of
100 cases of tuberculosis which have come under
my care. L-ntil I came to Greensboro, my experi-
ence in tuberculosis work had been confined to the
observation of cases which were under the care of
my father. Dr. John Hey Williams of Asheville,
N. C, and of Dr. Karl von Ruck of the Winyah
Sanatorium, .\sheville, X. C. .Since neither of
these men treat the disease in the negro race, I
never had the opportunitv to observe the disease
in the blacks. Since coming to (ireensboro I have
made no distinction in my practice as to race, and
have observed tuberculosis in its various stages in
both whites and blacks.

It is my custom to make a careful and complete
urinary analysis in every case, and the diazo reac-
tion is one thing in particular that I always look
for, believing its presence or absence a valuable
prognostic sign. My experience along this line
has been such as to confirm the opinions of those
above quoted, that is in the white race. As to the
negro race, my observations are peculiarly interest-
ing, especially in that I have never seen any report
bearing upon the diazo reaction in the urine of the
tuberculous negro.

Of the 100 cases which have come under my care,
73 have been in the white race. Of these, 38 were
advanced cases, with 23 giving a diazo reaction.

* Read at Medical Congress, 8th District, North Carolina,
Winston-Salem, N. C, January 7, 1907.

Uf those giving a diazo reaction, the diazo disap-
peared in 5 cases, upon the application of hot water
and salol internally. All of these gave a weak
reaction at the start. Of these 5 cases, the diazo
reappeared in 3, persisted, and the disease grew
worse. The two patients in whom it did not recur
improved under treatment, are still living, and there
is an apparent arrest of the disease. The other 18
patients continued to give a marked and persistent
diazo ; all of them either died or grew worse.

In my second stage cases, I had one which, upon
admission to treatment, gave no diazo reaction.
During the first five months of treatment, improve-
ment was rapid. This patient interrupted treat-
ment for one week, going to her home in Georgia.
During her absence, she contracted a very severe
cold, which lighted up her trouble to the extent
of marked severity, a caseous pneumonia develop-
ing, and a marked diazo reaction appearing, which
remained persistent. She rapidly grew worse, and
within six months from the time the diazo ap-
peared she died.

On admission, one of my first stage cases gave a
weak diazo. This patient gave a history of typhoid
fever just two months previous to my seeing him.
He left Greensboro, going tn the mountains of
Virginia. Upon his return, a urinary analysis
showed an absence of the diazo reaction. There
was not enough tuberculous trouble, and it had not
progressed to the stage necessary to produce a
diazo, and I believe that the reaction in this case
was due to a persistence from the typhoid fever.

So, of my white patients I<got a diazo in 23 of
an advanced stage, 21 of whom either died or
grew worse. One patient in the second stage de-
veloped a diazo at the fifth month, grew worse
and died. One first stage case presented a diazo
on admission, which I believe to have been due to
persistence from typhoid fever, and which disap-
peared without treatment. Eliminating this last
case, I got a diazo reaction in 24 white patients, 22
of whom either died or grew worse. So in 88.5 per
cent, of my cases giving a diazo, the prognosis was
bad; while in 11.5 per cent, the prognosis was good.
I wish to emphasize the fact, however, that in the
1 1.5 per cent, of cases giving the diazo, the reaction
was a weak one. promptly disappeared on treatment,
and did not recur. Of 40 advanced stage cases in the
white race. I got a diazo reaction in 24, or 60
per cent., 88.5 per cent, of which either died or
grew worse. The 16 advanced cases which did not
give a diazo, either improved or the disease was
arrested.

From this observation,' the logical deduction is
that, in the white race, the presence of a persistent
diazo reacticn is of an unfavorable prognosis; while
the absence of the diazo reaction in the white race
is of a favorable prognosis.

Of mv 100 cases. 27 were in the negro race. Of
these. It were patients in an advanced stage, 8 of
whom died, while 3 grew worse ; the rest recov-
ered or improved. There were five negro cases in
the second stage, all of which either improved or
recovered. There were 7 in the first stage of the
disease, S of which took treatment, making an ap-
parent recovery. Of the 2 not taking treatment, I
have heard nothing further. In all of my negro
cases, of all stages, never once have I found a
diazo reaction. Those patients who died, lived
from three days to ten months after I first saw
them.

It is peculiarly striking that in as large a num-
ber of cases as 27, 13 of which were advanced

March J3, 1907]

MEDICAL RECORD.

481

stage cases, I should find an absence of the diazo
reaction in every one. I have seen the diazo in
the negro race in cases of typhoid fever, which goes
to show that the diazo is a possibihty in the blacks.
It does, however, lead me to believe that possibly
the chemical substance in the urine which produces
a diazo reaction may be different in tuberculosis
and tvphoid fever. Also, that the chemical sub-
stance which produces the diazo in tuberculosis is
not found in the urine of the negro suffering from
this disease. This I frankly confess to be solely
theoretical. It may be that, in the future, 1 shall
find the diazo reaction present in the negro tuber-
culous urine, and that the cases which I have already
observed are not sufficient in numbers to give ac-
curate conclusions. It is strange to me, however,
that out of 40 advanced cases in the white race, I
should find a diazo present in 24, while in 15 ad-
vanced cases in the negro race, I should find it
absent in every one of them. I feel that it is a
point which is entitled to further and careful in-
vestigation.

My method of application of the diazo test is as
follows : A specimen of urine, taken from the first
passed in the morning, is selected. As soon as
possible after its passage I make the test. If my
first test is negative, I allow the urine to stand for
twenty-four hours and again test it. I do this for
the reason that on three different occasions, when
associated with the W'inyah Sanatorium at Ashe-
ville, N. C, I applied the test to specimens of urine
which were still warm from the body heat, and
failed to get a diazo reaction ; yet, allowing the
specimens to stand for twenty-four hours, testing
again, in each instance I obtained a diazo reaction,
winch shows that a single test is not reliable.

The reagents which I use are three in number:
Sulphanilic acid solution, sodium nitrite solution,
and ammonia solution. To make the first, or sul-
phanilic acid solution, I dissoh-e crystallized sulpha-
nilic acid in 3 per cent, hydrochloric acid to 1 per.
cent. The second, or sodium nitrite solution, 1
make by disolving sodium nitrite in distilled water
to 0.5 per cent. The third, or ammonia solution, is
ID per cent, aqua ammonia.

To atiply the test, I put 5 c.c. of the sulphanilic
solution in a test tube, to which I add from a pipet
three drops of the sodium nitrite solution. This
I thoroughly shake. I then add an equal volume
of the urine to be examined and thoroughly mix.
To this I add about i c.c. of the ammonia solution.
If the diazo reaction is present, upon thoroughly
shaking the foam will have a pink to a cherry-red
color; and if allowed to stand for twenty-four hours,
a dark green precipitate forms. The fluid will
sometimes have a marked cherry-red color, yet
the foam will be a pure white or a lemon-yellow
color. This is not a diazo reaction. Occasionally,
however, a specimen will give a white or yellow
foam, and if allowed to stand for twenty-four hours,
will give a greenish deposit. This is a diazo reac-
tion.

It is therefore imperative, in order to determine
the presence or absence of a diazo reaction, that
we examine not only the fresh specimen, but also
one which has stood for twenty-four hours. Also
having made the test, we should allow the test
tube, with the mixture in it, to stand for twenty-
four hours, should we fail to get the coloration of
the foam, so as to observe whether or no a greenish
precipitate forms.

The conclusions which I deduct from these ob-
servations are :

( 1 ) That for accuracy, should the fresh speci-
men fail to give the diazo reaction, we should allow
the urine to stand for twenty-four hours and ex-
amine again.

(2) Having made the test, the foam failing to
show the reaction, the mixture should be allowed
to stand for twenty-four hours to see if there is
or is not formed a greenish precipitate.

(3) That the absence of a diazo reaction in white
tuberculous cases is of a favorable prognosis, as a
rule.

(4) That the presence of a diazo reaction in
white tubercular cases is of an tmfavorable prog-
nostic value.

(5) That the absence of the diazo reaction in the
tuberculous negro is of no prognostic value.

(6) That there is possibly a racial difference be-
tween the whites and blacks which accounts for
the absence of the diazo reaction in the urine of
the tuberculous negro, and the presence of the
diazo reaction in the urine of the white tuberculous
in the advanced stage.

REFERENCES.

1. Jountal oj Tnbcrciilosu, Vol. i, p. 219.

2. Jbid.. Vol. 2, p. 468.

3. Meiiu.'vl Record. April 10, 1901.

4. Journal of Tuberculosis. Vol. 4, p. 366.

Intestinal Antisepsis in Fevers. — William F. Waugli
declares that in every febrile disease, specific or otlier-
wise, there is necessarily intestinal decomposition, toxin
formation and absorption, and toxemia. He believes that
about one-third of the fever and other symptoms may be
credited to this cause, since the illness decreases in about
this proportion after the bowels have been cleaned out
and disinfected. The various symptoms are relieved to
a much greater degree. These considerations apply to all
fevers equally. When the deadly infectious nature of a
typhoid stool is taken into account, it cannot be considered
as a fit dressing for an ulcer. Cleanliness and asepsis are
as desirable here as elsewhere. The writer expresses his
preference in the choice of antiseptics for the use of the
sulphocarbolates, following a complete eVnptying of the
alimentary canal by doses of calomel, salines, and colonic
flushings. These drugs are perfectly safe and never cause
hemolysis or hematinuria. They are efficient and inexpen-
sive. There is little taste when they are taken in hot
water solution. When chemically pure, they are far more
apt to settle an irritated stomach than to cause irrita-
tion. Toxic effects are not to be apprehended from over-
dosage.— The American Journal of Clinical Medicine.

Alcoholism, Speed Mania, and Objectless Activities.
— 'William Lee Howard discusses the effects of the luirry
and unrest of modern life. Explosions of physical and
psychical energ)' are continually taking place in the normal
individual. They are disastrous or otherwise, according
to their direction and the conditions coexistent with them.
The writer believes that it is the study and supervision
of these psychical explosions that will ultimately result in
the thorough understanding and control of the effects of
alcohol and those of its congeners, morphine and cocaine.
He calls attention to the speed mania which so often
attacks automobilists as one evidence of these increasing
explosions of psychical energy. It is an objective symptom
of the hi.gh nervous tension characteristic of the present
day. He calls it a sociologic toxin. Relaxation, both
mental and physical, is its antidota. That which is often
called courage by the unthinking is in reality a psychic
blindness to reason. Alcohol as well as the toxins of
excitement can produce this. The writer believes that the
automobile offers a wholesome vent for the reckless cour-
age which otherwise would ao to disorder and riotous
excess.— r/jf Quarterly Journal of Inebriety.

482

MEDICAL RECORD.

[March 23, 1907

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN. AM., M.D., Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, March 23, 1907.

LOWERED BIRTH-RATE AMONG
PROSPEROUS NATIONS.

THE

A LOWERED birth-rate would seem to go pari passu
with an increase of material prosperity and with a
high degree of mental culture. France is the most
conspicuous example of the truth of this proposition.
On the whole, she is perhaps the most prosperous
nation on earth, in that property there is divided
upon a fairly equal basis. There are not such num-
bers of immensely rich individuals as in America
and in Great P)ritain, but neither are there so many
l^eople in extreme poverty, in many instances verg-
ing on starvation, as there are in Great Britain. In
a word, property is more equally divided in France
than in any of the great countries of the world. As
to mental culture, surely no race on earth can sur-
pass the French. But the birth-rate of France is tlie
lowest of any nation, nor is this a coincidence.
America is now the richest country on the globe ;
Iier prosperity increases by leaps and bounds.
Again, mental culture among all classes of native
Americans has reached a very high standard. In-
deed, native-born Americans are probably the best
educated people on the face of the earth. Literature
and science in Ajnerica has made and is making
great strides. But the birth-rate among native-bom
Americans has now for some years showed a steady
and progressive decline. In place of the large fami-
lies which used to distinguish Americans of native
birth, one finds now families of two, and at the
utmost three children.

Great Britain is very rich, and possesses a very
highly-cultured section of its population, including
many of the most brilliant representatives of litera-
ture and science in the world. The birth-rate of
Great Britain, however, is falling lamentably, is
exciting alarm, and giving rise to much discussion
among thoughtful persons. W'ith the exception of
France, the birth-rate of Great Britain is the lowest
of all the European countries. The annual report
of the Registrar-General of England for 1905 has
been issued recently, and a large portion of this
report is given over to a consideration of the lowered
fertility of English women and its effect on the birth-
rate. According to the report, during the past
thirty-five years the English birth-rate has fallen to
the extent of 23 per cent. Basing the calculation
on the proportion of births to possible mothers —
women living at child-bearing ages — the decrease in
the birth-rate for the period mentioned amounted to
29 per cent. In round numbers, 17 per cent, of this
decline in the past thirty-five years is to be ascribed

to the decrease in the proportion of married women
of child-bearing age, and 10 per cent., perhaps, to
the decrease of illegitimacy. The greater part of
the remaining 73 per cent, of decrease is believed to
be due to deliberate restriction of child-bearing by
the people themselves. In 1876 the English birth-
rate reached its high-water mark, 36.3 per 1,000
living; in the year 1905 it had dropped to 27.2 per
cent.

With the advance of prosperity the birth-rate of
Germany, although it still exceeds by far that of
France and England, is nevertheless falling, and it
is only more or less primitive countries like Russia
that continue to add to their population at a rapid
rate. Riches and sophisticated ways do not go hand
in hand with increase of population.

As to whether it is well that races should increase
and multiply freely is a point regarding which much
may be said on either side. President Roosevelt is
of the opinion that the larger the family the better it
is for the country. This is very questionable, and
especially in a country of limited area and with an
overflowing population, like Great Britain, the sub-
ject for economic reasons at least is a debatable one,
although, of course, restriction of child-bearing by
artificial means is to be condemned.

THE FERMENTATION TEST FOR DRINK-
ING WATER.

The presence in water of ammonia, nitrates, and
nitrites, together with considerable quantities of
nitrogenous organic substances, indicates contami-
nation with house drainage, and the simultaneous
occurrence of large quantities of chlorine com-
pounds indicates the presence of urine. Water can-
not be regarded as sufficiently pure for drinking if
it contains more than a trace of ammonia or more
than 3 parts of chlorine, or 1.5 parts of nitric and
nitrous acids in 100,000 parts. Serious epidemics,
however, are occasionally produced by water which
has successfully passed this chemical test and is also
unobjectionable in taste and smell. This is due to
the presence of pathogenic bacteria. Now, most
specimens of water, like tlie air and the soil, contain
bacteria in greater or smaller numbers. If a meas-
ured quantity of the suspected water is added to a
mixture of bouillon and gelatin, and the mixture is
allowed to congeal, each bacterium forms the nu-
cleus of a colony which soon becomes large enough
to be seen with the naked eye. Consequently, the
number of organisms in the water can be deter-
mined by counting the colonies in the jelly. But
this apparently simple method is open to several ob-
jections. It makes no distinction between harmless
bacteria and disease germs, and, furthermore, the
colonies grow slowly, occupying several days in
becoming large enough to be counted. The gelatin
culture method is suitable only for the regular and
repeated examination of water of which the bacterial
content is approximately known. A sudden large
increase in the number of colonies then indicates a
new contamination, but gives no information con-
cerning its character.

Quite recently a new method has been introduced
which is both simpler and more reliable. The im-
purities which render water dangerous to health are
derived almost exclusively from human excretions,

March 23, 1907'

MEDICAL RECORD.

483

and principally from feces, which appear to be the
sole source of infection in cholera and dysentery,
while urine also plays a part in the dissemination
of typhoid fever. Now, all human feces contain
immense numbers of Bacillus coli. while the germs
of typhoid fever, cholera, and dysentery are present,
if at all, in much smaller numbers. Hence it is
easier to detect the Bacillus coli than the organisms
above mentioned, and its detection is further facili-
tated by two properties which it possesses. It is one
of the many microorganisms which cause sugar to
ferment and evolve carbon dioxide, and it thrives
when heated to a temperature which is fatal to most
pathogenic organisms.

Surgeon-General Hammerschmidt, writing in Die
Umschau of January 12, 1907, says .that Eijkmann
has utilized these properties of the Bacillus coli in
the examination of water. The water, mixed with
small quantities of glucose, peptone, and common
salt, is placed in a J-shaped or barometer tube of
glass and exposed to a temperature of 115° F. The
short, open branch of the tube is provided with a
bulbous expansion for the reception of the liquid
forced by the gases of fermentation out of the long,
closed branch, which at first is completely filled with
the water under examination. The mouth of the
short branch is stopped by a pledget of cotton wool
to exclude dirt and atmospheric organisms. When
water containing coli bacilli was subjected to this
test, Eijkmann found that the liquid became turbid
throughout, and there was more or less evidence of
the formation of gas. With pure water, on the other
hand, no gas is ever found, the only change being
an occasional turbidity in the open branch of the
tube after the experiment has continued forty-eight
hours.

This simple test has been proved reliable by a long
continued series of experiments. Unpolluted water
taken from good city services, clean wells, springs,
and woodland ponds, even very muddy water from
marshy pools, if entirely free from human e.xcre-
tions, produced no fermentation, but river water at
all contaminated with sewage fermented at once.
The rapidity of the development of gas and turbid-
ity depends upon the number of coli bacilli, but the
test is so delicate that in several instances ]iositive
indications were obtained from pure water to which
coli bacilli had been purposely added in a proportion
as small as one bacillus in from 10 to 20 c.c.

SULPHUR IN THE TREATMENT OF
MALARIA.

Although quinine must be acknowledged to be the
most important factor in the treatment of malaria,
it should by no means be regarded as the only one,
for there are abundant proofs that, particularly in
some of the chronic forms, the administration of
quinine alone is altogether insufficient to accom-
plish the desired result. In a recent communication
in the Archiv fiir Schiffs- und Tropcn-Hygiene,
Vol. X., No. 16, Diesing, who has had considerable
personal experience with tropical diseases, calls
attention to the value of sulphur as a prophylactic
and curative measure in malarial infections. He
found that among the natives of some of the South
African countries, sulphur fumigations were com-

monly practised, the patient shutting himself or her-
self in a tightly closed hut and inhaling as long
as possible the dioxide which resulted from the
burning of the sulphur. In other instances the
substance was given in the form of po-
tassium sulphate dissolved in water. In the
cases which he describes the fever disappeared
within twenty-four hours, and a systematic exami-
nation of the blood showed the absence of the char-
acteristic parasites. As the treatment indicated
was combined w'ith measures productive of extreme
diaphoresis, Diesing was inclined to believe that the
latter had an important bearing on the disappearance
of the malaria, for it has often been observed that
the natives could overcome the attacks by this
means.

It is possible, however, to advance a very plausi-
ble theoretical explanation of the efficiency of sul-
phur preparations in malaria. It is well known that
pigment constitutes an important factor in the de-
velopment of the specific parasite, and is absorbed
in large quantities from the red blood cells
of the patient. The more firmly the hem-
oglobin is united to the red cells, however, the less
the amount which can be taken up by the malarial
organism. It has been found that sulphur, particu-
larly when it is absorbed through the lungs in the
form of sulphureted hydrogen or sulphur dioxide,
unites with the hemoglobin to form sulphomethemo-
globin. The latter is exceedingly stable, and it may
be assumed that the resistance which it offers to the
action of the oxygen of the air is similarly exerted
against the disintegrating properties of the malarial
parasites. \\'e may then suppose that the develop-
ment of generations of malarial organisms is inter-
fered with because the necessary amount of the es-
sential pigment is not at hand. The writer was so
impressed by these facts that he employed a sulphur
cure in his own case, and found that the parasites
were promptly eradicated from the blood picture.
Not only must these sulphur treatments be regarded
as curative, but they also apparently possess a
prophylactic value, for patients treated in this man-
ner have been found to withstand the onslaughts of
malaria on their return to the infected districts with-
out a resort to quinine.

The observations noted are of extreme interest,
and although not confirmed by the test of time or
practice, ought to stimulate further research in this
field. Sulphur baths, such as recommended by the
author, are not difficult to obtain, and if they con-
tinue to meet with the good success in other hands
which was achieved in the cases under Diesing's
observation, the fact must be accounted a signal
advance in the treatment of the dread malarial poi-
soning.

THE CAUSE OF DEATH IN ACUTE DIS-
EASES OF THE PANCREAS.

Until a comparatively short time ago but little was
known of acute pancreatic disease or the causes
which lead to the rapidly fatal issue in many of the
cases. Our knowledge of the subject is by no
means complete, yet it has advanced sufficiently
lo permit of considerable progress in the treatment
of the condition. In some experiments recently
made, Guleke has found that bv the production of
an artificial embolus or the injection of various

484

MEDICAL RECORD.

[March 23, 1907

fluids into the principal excretory duct of the pan-
creatic .a:Iand of an animal it is possible to produce
a condition which in its clinical as well as pathologi-
cal features closelv resembles the acute hemorrhagic
pancreatitis of the human subject. Guleke con-
cludes, as the results of his experiments, that the
pancreas itself as it undergoes necrosis in the body
elaborates a toxic substance which is capable of
causing death. It seems immaterial whether the
]iancreas of the experimental animal itself or one
from another animal which has been introduced into
the abdominal cavity undergoes necrosis, the result
is the same. Guleke's observations therefore point
to an acute intoxication from pancreatic necrosis as
the cause of the fatal issue in these cases.

Further experiments have been made along these
lines by v. Bergmann (Zeitschrift fiir experimeii-
telle Patboloz'c iind Therapie. Vol. 3. No. 2), who
worked in conjunction with Guleke in an effort
to determine the active agent which underlay this
process. It was evident that the toxin developed
in the normal as well as in the diseased pancreas
and its secretions, but what seems most interesting
is the fact that an almost perfect degree of immunitv
could be secured in dogs by the previous injection
of trypsin in cases in which an artificial pancreatitis
was produced or the gland from another animal
had been implanted in the abdominal cavity. Acute
pancreatitis seems to be a true autointoxication, and
a more complete trial of the procedure indicated in
this paper may lead to the adoption of some means
by which the development of this fatal condition
mav be inhibited.

Retention of the Pl.\cent.-\.

It is generally considered good practice in the man-
agement of the third stage of labor to instruct the
attending nurse or midwife to keep her hand pretty
constantly on the fundus of the uterus, and to knead
this vigorously if any relaxation of the organ takes
place. This is done in order that concealed hemor-
rhage may not occur, and that any tendency to
gaping of the uterine sinuses may be forestalled by
the prompt induction of uterine contraction through
the mechanical stimulation. Durlacher (Miinchener
medisinische Wochcnschrift, February 19, 1907)
expresses an opinion which is somewhat at variance
with these rules. From an analysis of seventy-eight
cases in which he has found it necessarv in private
practice to perform manual extraction of the pla-
centa, he draws the conclusion that undue manipula-
tion of the fundus is a very fruitful cause of imper-
fect separation of the placenta, and therefore of re-
tention of the afterbirth. He ventures the opinion
that the best prophylactic against retention of the
placenta lies in not touching either the uterus or the
abdominal walls after the birth of the child. This
mode of procedure would involve such skillful ob-
sen^ation of the patient's general condition, inspec-
tion of the abdomen, etc.. as not to be feasible except
in hospital practice, where plenty of highly trained
assistance is available, and Durlacher therefore sug-
gests that the following instructions be given to mid-
wives : After the birth of the child the mother must
be kept under constant careful observation. If it is
not possible to perceive the position of the fundus by
inspection of the abdomen, the hand should be gently
applied to the abdominal wall and the position of the
uterus determined. As the uterus alternately con-
tracts and relaxes in the third stage as well as before.

if the fundus should appear soft, in case tliere is no
noteworthy hemorrhage, the hand should be kept
quietly in position until the organ contracts again of
its own accord. If the placenta has not been ex-
pelled at the expiration of an hour after the birth
of the child, the position of the fundus should be
ascertained as indicated. If it is below the umbilicus
this is a sign that the afterbirth has not been de-
tached and will probably not be spontaneously
expelled, so that a physician should be called in. If,
on the other hand, the fundus is above the umbilicus,
the midwife may endeavor to express the placenta
during a uterine contraction. If a hemorrhage of
importance takes place the midwife should immedi-
ately have a physician summoned, and in the mean-
while should continue to massage and knead the
fundus as long as the bleeding continues. We
fancy, however-, that a great deal of corroborative
evidence of the value of such a mode of procedure
will be necessary before obstetricians, as a class,
abandon a doctrine whose practical application has
so far seemed productive only of the best results.

Exophthalmic Goiter.

Gre,\t interest has been shown in the study of this
subject by the medical profession for some years.
Various theories have been propounded by dif-
ferent authorities and many treatises have been writ-
ten to uphold these theories. Among the leading
theories is that of Buschan, who believes that ex-
ophthalmic goiter is due to disturbed innervation.
Other investigators believe that the seat of the dis-
ease is to be found in the medulla oblongata. Still
others advocate the theory that this fonn of goiter
is due to an affection of the sympathetic nerves. It
has been said that this affection is a disease of the
central nervous system, with a coexistent chronic
intoxication. The theory embraced by Mobius is
that exophthalmic goiter is due primarily to "hyper-
thyroidation," that is, to a disturbance of the func-
tion of the thyroid. This condition is directly op-
posed to the failure of thyroid function. Clinical
evidence seems amply to support this theory. In
the Rez'ue de Mcdecine, December 10, 1906, Jean
Lepine refers to the discussion of this subject at
the Congres des Alienistes et Neurologistes. which
met at Bordeaux in 1895. At this time two theories
were proposed to explain the obscure pathogenesis
of exophthalmic goitre. The first considered this
disease a neurosis : the second considered it a dis-
turbance of thyroid functions. The writer then
discusses the methods tending to produce anti-
thyroid immunity and describes his own personal in-
vestigations, as well as those of other authorities.
Thyrotoxic serums prepared from the thyroid bod-
ies of animals have been found to be comparatively
inactive in relation to exophthalmic goiter in man.
\\'hen, however, human glands were used, the ex-
periments met with success. Lepine then refers to
the report of Rogers, which was given to the New
York Academv of Medicine on January 18. 1906.
\"arious cytotoxins were prepared by Beebe for this
work. The results of this first work showed that
in a general manner these patients derived more
advantage from the serum prepared from the dis-
eased gland than from that prepared from the nor-
mal thyroid body. These authorities insisted upon
the necessitv of a long course of treatment. The
writer believes that although serum therapy will
probably be of aid in the treatment of Graves' dis-
ease, too much enthusiasm should be guarded against
in relation to this method. In order to cure ex-

March 23. \()Oj]

MEDICAL RECORD.

485

ophthalmic q;oiter it is necessary neither to suppress
nor to restrain the thyroid function, but an effort
ought to be made to do away with the effects which
the reciprocal actions of vitiated secretions, both
thyroid and others, have upon the nervous system.
The vicious circle must be destroyed. It may be
useful in this attempt to combat the general state
of intoxication by specific antitoxins. This is the
role of serum therapy.

Hydatid Cysts of the Kidney and of the Spleen.

It has been learned from the compilation of sta-
tistics that the genitourinary system ranks second
as the seat of hydatid disease, although in compari-
son with the liver this location is rare. In some
cases the kidney is converted into a huge cyst which
resembles hydronephrosis. In an interesting article
on hydatid cyst of the spleen in the Gazette dcs Hop-
itaiix, October 27, 1906, Andre Martin declares that
the beginning of a hydatid cyst of the spleen may
present variable symptoms. Often at the beginning
the evolution is insidious and the swelling is recog-
nized only by chance. In other cases pain develops
months or years before the appearance of the cyst ;
in still other patients there exists a profound anemia,
the cause of which cannot be determined, while at
more or less regular intervals painful crises in the
epigastrium and the left hypochrondrium occur. An
important symptom is cardiac pain and especially
the impossibility of the patient to assume the left
lateral decubitus. Osier says that a diagnosis of hy-
datid cyst of the kidney is possible only by puncture
and by examination of the fluid. The cyst sometimes
perforates into the pelvis of the kidney and parts
of the cyst may be discharged with the urine, giving
rise to renal colic. A case is reported in which
the patient for many months passed at intervals
numbers of small cysts in the urine. Nevertheless
the general health was hardlv disturbed, aside from
the attacks of colic, which occurred while the para-
sites were being voided. In the cyst of the spleen of
the type of ascending evolution a differential diag-
nosis must be made from affections of the pleura
and the lungs. In the case of cysts with descending
evolution mesenteric cysts must be eliminated. The
symptoms are the same, constipation, vomiting, dys-
peptic disturbances ; but the tumor of the mesentery
is medium, while the splenic tumor is a little to
the left. In the cyst of the spleen of posterior evo-
lution especial care must be made to differentiate
this from affections of the kidney with which it
can easily be confused. In the cyst of the spleen
with anterior evolution the diagnosis appears to be
more easy. As to the treatment of echinococcus
disease medicines are of no benefit. Martin declares
that the most simple method of treatment is punc-
ture, but this is not exempt from danger. Splenec-
toniv when the spleen is affected assures rapid and
radical cure.

of keen critical discussion, while the advantage to be
derived from acquiring a scientific basis for quaran-
tine and prophylaxis in these diseases is so great
that this investigation must interest everyone con-
cerned in the problems of hygiene and public health.
The second theme, "Tropical Diseases of the Skin,"
while not of so much general importance, still is
particularly apposite now that our attention is so
frequently turned to the medical conditions of lands
near the equator, and that we are apt to encounter
tropical diseases or their sequelae in the persons of
those returning from our island possessions. The
third theme, "The Possibility of Immunization
.-\gainst Syphilis" and "The Present State of Our
Knowledge of the Parasitology of Syphilis," takes
up a subject in which until three years ago all ad-
vance seemed blocked by the impossibility of ex-
periment, due to the lack of a susceptible animal.
Metchnikoff's demonstration that the chimpanzee,
when inoculated with human virus, will develop not
only a chancre but also, as a rule, tyjiical secondary
lesions on the skin and mucous membranes, was the
starting point of hundreds of animal inoculations
which have revolutionized our knowledge of this
disease, and whose significance is as yet not fully
appreciated. Whatever our interpretation of the
presence of the Spirochwta pallida — and the convic-
tion that it is indeed the long-sought causative or-
ganism is steadily gaining ground — the investiga-
tions of the last three years have solved many long-
debated problems, and give promise of yet greater
advances in the near future.

The Dermatological Luxgress in Xfw Vork.

As we have previously noted, the Sixth Interna-
tional Dermatological Congress will be held in this
city, September 9 to 14 of this year. The program
arranged is an attractive one, and it is expecially
noteworthy that the subjects chosen for general
discussion are not of exclusive dermatological inter-
est, but appeal to the general practitioner as well.
The first theme, "The Etiological Relationship of
Organisms Found in the Skin in Exanthemata,"
gives promise, not only of able presentation, but also

The Treatment of V,.\ricose \'eins.

Nearly half a century ago Desgranges employed
for the treatment of varicose veins a method that
had been suggested "bv Pravaz for use in cases of
aneurysm. It consisted in causing thrombosis in
the vessels in question by the injection of a few
drops of concentrated solution of ferric chloride.
Although Desgranges is said to have had a certain
amount of success with the method, its disadvan-
tages are so obvious that it is not astonishing that it
never became popular. Trendelenburg's oi>eration
of ligating the saphenous vein high up was founded
on correct principles, and has been widely used,
giving according to Tavel ( Berliner klinisclie IVo-
clienschrift, February 18, iQOj) about 75 per cent,
of permanent cures. This author has attempted, by
means of a combination of the old idea of Pravaz
and Desgranges with that of Trendelenburg, to
obtain better results, and states that he has now
applied his procedure with success in twenty-seven
cases. Briefly stated, the operation is performed as
follows : With the patient standing, so as to cause
the veins to become prominent, the varicosities and
the course of the saphenous vein are indicated on the
skin by means of fuchsin. The saphenous vein is
then ligated in the upper portion of its length, and
preferably a short section is excised in order to
avoid any possibility of regeneration. The next day
the process of inducing thrombosis in the varicosities
is begun bv injecting into the dilated vessels small
amounts of 5 per cent, carbolic acid solution. This
eft'ects a local reaction of the vessel wall, which leads
to thrombosis, and the injections are repeated at
intervals of a few days until the entire area has
become thrombosed. 'Ultimately the thrombi be-
come organized and the veins are converted into
fibrous cords. The treatment is somewhat painful,
is often accompanied by elevations of temperature,
and more or less time must usually be spent in bed,
so that its advantages seem rather questionable.

486

MEDICAL RECORD.

[March 23, 1907

Offensiveness of Dictatorial Methods in Editing
Official Journals. — Since "every rose has its
thorn." it should not be overlooked at this time
that the flowery probabilities of mutual scientific
medical journalism might easily be inhibited,
and even destroyed, by the thorny possibilities of
selfish time-serving desires. In any event, com-
mon justice demands that all questions of mutual
material interest, and others of general interest to
the profession of the State, should find free and
impartial utterance through the pages of its own
journal. The presence of a spirit which contem-
plates that the entire membership of the profes-
sion of this State be not made familiar by its
own servants with the facts relating to the re-
spective dilTerences in all matters of common im-
portance is offensive to the principles of Ameri-
can institutions, and to those of fair dealing in all
lines of manly action. — From the presidential ad-
dress before the Medical Society of the State of
New York by Dr. Joseph D. Bryant, President-
elect of the American Medical Association.

Ray Brook Tuberculosis Sanatorium. — The
Board of Trustees of the New York State Hos-
pital for Incipient Tuberculosis at Ray Brook
makes an appeal to physicians for greater efforts
to recognize cases of pulmonary tuberculosis in
its earliest stages, and states that the institution
still suffers under the difficulty of securing pa-
tients whose lesions are slight. In the hos-
pital there are now' over thirty' vacant beds, and
this is said to be due to the fact that suitable cases
for treatment, and for which the hospital was
built, cannot be secured. Out of 940 applications
for admission to the hospital last year, 220 pa-
tients were, following examination, received for
treatment, the remaining 720 being too far ad-
vanced to be accepted. Of the 220 received, 65
per cent, only were actually incipient cases; the
balance on admission were found to be suffering
from more advanced disease, and were reclassified
at the hospital. In the last annual report of this
hospital it is shown that 85 per cent, of incipient
cases were discharged apparently recovered.
This class constituted 65 per cent, of all cases
under treatment. Of the moderately advanced
cases 23 per cent, were discharged apparently re-
covered, and of the advanced cases none
were so discharged. The possibility of obtaining
good results is plainly seen, therefore, to depend
in the main upon the amount of tuberculosis pres-
ent when the patient is placed under treatment.
The definition of an incipient case, as adopted by
the National Society for the .Study and Preven-
tion of Tuberculosis, is as follows: "Slight ini-
tial lesion in the form of infiltration limited to the
apex or a small part of one lobe : no tuberculous
complications : slight or no constitutional symp-
toms (particularly including gastric or intestinal
disturbance or rapid loss of w-eight) ; slight or no
elevation of temperature or acceleration of pulse
at any time during the twenty-four hours, es-
pecially after rest ; expectoration usually small in
amount or absent ; tubercle bacilli may be present
or absent."' It is desired to receive patients of this
type to the full capacity of the Ray Brook institu-
tion.

The Milk Question. — At a meeting of the mem-
bers of the Department of Health held last week
resolutions were adopted requiring farmers and
others producing and handling milk to exercise
greater care than has been the case in the past to
prevent contact with the dairy products by per-

sons suffering from infectious diseases. One reso-
lution provides that after .April i everj'- creamery
or milk station which ships milk or cream, or both
to the city of New York, shall be required through
its agents to furnish to the Department of Health
on Monday of each week a report stating the ex-
istence or nonexistence of either typhoid fever,
tuberculosis, diphtheria, scarlet fever, dysentery,
or any other infectious disease in the households
of all persons employed in the collection or han-
dling of milk, either at the creamery or at the
farms or dairies supplying it. Another resolu-
tion requires the farmers and dairymen to make
similar reports to the creameries every Saturday.
-Such reports are to be kept on file in the creamer-
ies for si.x months, and shall be open at all times
to the inspection of the Health Board. Should
one of these diseases break out in the family of
any employee the latter shall be excluded from
duty in connection with the handling of milk until
a physician certifies that there is no longer danger
of carrying the infection. Another resolution reg-
ulates the use of water in cleaning milking uten-
sils near a place where typhoid fever or dysentery is
known to exist. Failure to comply with these re-
quirements may be sufficient to exclude milk or
cream from the offending milk stations or cream-
eries. It will no doubt be easy to induce the per-
sons interested to make out these reports and
hand them in, but the reliability of the data fur-
nished in this way can hardly be above suspicion.

A Question of Proprietorship. — \\'hether the
spoils of an operation belong to the victor or the
victim is a question that comes up perennially. A
recent instance is attracting interest in Germany,
in which a patient, relieved of a bladder stone,
has refused to pay the surgeon's bill unless the
calculus is handed over to him. The stone is
being retained by the operator, because it has
especial interest, as its nucleus consists of a
broken-oft' catheter tip. It is expected that the
matter will go into the courts. No doubt it would
be better to make a stipulation in regard to the
disposal of such trophies before the operation,
as patients would be more likely to be willing to
resign all claim to objects of this sort before their
removal than afterwards.

The Medical Society of the County of West-
chester had its annual dinner at the Hotel Aster
on March 19. The society dates from 1797, and
claims to be the oldest organization of the kind in
the United States. Dr. H. Beattie Brown of
Yonkers presided. Dr. E. M. Hermance of Yon-
kers read a paper on "Pelvic Inflammation" and
a discussion by the members followed. There
were 123 members present.

Antitoxin from Convicts. — At a recent mfeeting
of the Baltimore County Medical .Association, Dr.
H. Burton Stevenson said that antitoxins would
be more eft'ective if they were prepared in the
human body, because only a few animals are sus-
ceptible to the diseases of man. He suggested
that such antitoxin could readily be produced by
using criminals for the production of serums. A
law could be enacted making the punishment for
certain crimes optional with the convict, impris-
onment on the one hand, inoculation with certain
disease germs on the other.

A Bill to Prevent Procreation of Certain Crimi-
nals.— A bill now before the Indiana Senate pro-
vides for the sterilization of confirmed criminals,
idiots, imbeciles, and those guilty of the crime of
rape. The bill has already been passed by the •
House. According to the bill, each institution in

March 23, 1907]

MEDICAL RECORD.

487

the State intrusted with the care of confirmed crim-
inals, idiots, rapists, and imbeciles, is to appoint upon
its staff two surgeons, whose duty it shall be,
-in conjunction with the chief physician of the insti-
tution, to examine the mental and physical condition
of such inmates as are recommended by the institu-
tional physician and board of managers. If, in the
judgment of this committee of experts and the board
of managers, procreation is inadvisable, and there
is no probability of improvement of the mental con-
dition of the inmate, it shall be lawful for the sur-
geons to perform such operation for the prevention
of procreation, as shall be decided safest and most
effective. It is established that the consultation fee
to the experts shall not exceed three dollars in any
one case.

Health Defence League Incorporated. — The
Public Health Defence League of Xew York City
was incorporated at Albany on March 15. The
directors include Austen G. Fox, Ernst J. Lederle,
Thomas R. Slicer, and Thomas Darlington of
New York, Howard J. Rogers of Albany, Robert

E. Belcher of Boston, and Henry W. Cattell of
Philadelphia. The organization has for its ob-
jects to work against practices and conditions of
every kind that are dangerous to the public health
and morals and to assist in the enforcement of
laws against quackery and charlatanism, and the
prevention of adulteration of drugs and food suli-
stances, and the sale of narcotics, alcohol, and
dangerous substances.

Food-Testing Laboratory for Boston. — At a
meeting of the executive committee of the Car-
negie Institution held in Washington, D. C, on
March 11, it was decided to establish in Boston,
Mass., a laboratory for the purpose of conducting
experiments in nutrition. An appropriation of
$100,000 was allotted for the erection of a build--
ing, and the balance is to be devoted to the scien-
tific investigations of the nutritive value of vari-
ous foodstuff's during the present year. Prof.

F. G. Benedict of Wesleyan University was se-
lected as director of the new laborator_v.

Women Medical Students in Germany. — .Ac-
cording to the Miiiuiicncr nicdicinischc irochcn-
schrift there are at present in the seven universi-
ties of Freiburg, Heidelberg, Tubingen, Munich.
Erlangen, Wiirzburg, and Leipzig, which admit
women, 254 female students, a notable increase
over previous years. Of these, 116 are studying
medicine, 92 philosophy, history, and languages,
28 mathematics and natural sciences, and the re-
mainder are dispersed among various other sub-
jects. Medicine is losing in popularity, and phi-
losophy, languages, and history are gaining more
adherents.

Medical Fees in Germany. — Following the ex-
ample of the physicians of Berlin and \'ienna, the
members of the \\'iesbaden branch of Leipziger \'er-
band have decided to announce to the public an
increase of 25 per cent, in medical fees, the change
to take eft'ect from January i, 1907. A minimum
has been established of two marks for a visit and
one and a half marks fcjr an office consultation.

The New German Reichstag, like its predeces-
sor, has among its members eight phvsicians.

Christian Science in Delaware. — The Delaware
Senate has passed a bill opposed to the practice
of Christian Science and faith treatment in that
State. The bill had passed the House two weeks
before, and, after a final open debate between rep-
resentatives of Christian Science and the medical
profession, was passed by the Senate by an over-
whelming vote.

Naturopath Held for Trial. — .\ self-termed

"naturopath" was brought before the Yorkville
Court last week charged with practising medicine
without a license. An agent of the County Med-
ical Society testified that he had prescribed a
dietary regime and hot-air baths for a stiff neck
which she consulted him about, and had charged
her two dollars for the advice. He was held in .$500
Ijail for trial, as was also a Second avenue drug-
gist, who was accused of prescribing.

Osteopathy Bill. — The Assembly Committee on
I'ublic Health has reported a compromise Oste-
opathy bill which provides that all osteopaths
now in the State who are graduates of some oste-
opathic school are to be recognized by the State,
but in future osteopaths must conform to certain
regulations concerning their medical education.

Health Statistics in Montreal. — A report just
issued by the Health 1 )epartnient of Montreal
shows that the death rate of Montreal is larger
than that of any other important city of the conti-
nent. The rate during the last year was just a'
fraction less than 22 per 1,000. an increase of 2 per
cent, over 1905. At the same time the birth rate is
shown to be the highest of any large city on the
continent.

New Journals. — A new journal devoted to the
.subjects of orthopedics, medical gymnastics, and
massage appears under the title of Zentralblatt fiir
Chirnrgischc iind mechaiiischc Orthoplidie. It is a
monthly, and is published in Berlin under the edi-
torship of Prof. O. Vulpius of Heidelberg, together
with a long list of co-editors comprising many of
the best known European orthopedists. Like the
other so-called Zcntralblattcr, it consists of several
short original articles and a large number of ab-
stracts of the literature relating to the subjects in
question. The British Journal of Tuberculosis is a
quarterly publication of which the first number has
been issued. It is published in London and is edited
by Dr. T. N. Kelynack.

Journals Consolidated. — The proprietors of the
Medical Era have acquired the Medical Mirror, and
in future the combined journals will be issued under
the name of the Medical Era. The .-April issue of
the Medical Era will be the first number of the con-
solidated journals. The editors will remain as be-
fore. Drs. S. C. Martin and Clarence Martin.

Brooklyn Home for Aged Men. — An endow-
ment of over $150,000 has been made to the annex
of the Brooklyn Home for .Aged Men in Classon
avenue and Park place by Mrs. Edward S. Hark-
ness in memory of her father, Thomas E. Stillman,
who died in September last. The annex was erected
three years ago b\' Mr. .Stillman in memory of his
wife, and is known as the Elizabeth Greenman-Still-
man Memorial.

Legacy for Yale Medical School. — By the will
of the late (^len. Samuel E. Marwin, whicli has been
filed in the Probate Court, $5,000 is set aside for the
Yale Medical School and $25,000 for the New
Haven Hospital.

Katonah Typhoid Cases. — A report made by
Dr. D. D. Jackson, chief chemist of the Water
Department of this city, states that the water
su]iply from the Croton watershed shows no evi-
dence of contamination by the recent cases of
tvphoid fever occurring in Katonah.
' The Webster County (Mo.) Medical Society
was organizetl in Marshficld mi February 27 by
T)v. T. .A. Coffelt of Springfield district, councillor
for the twentv-fifth district. The following officers
were elected :' President, Dr. M. Highfiell, Marsh-
field: I 'ice-President. Dr. J. .A. Rabenau, Fordland ;
.S><T,'/(7rv, Dr. W. R. Beatie, Rogersville ; Treasurer,
Dr v.. M. Bailev. Elkland : Censor.^. Dr. D. A. Will-

488

MEDICAL RECORD.

[March 23, 1907

iams, Xiangua ; Drs. W. H. llallinger and Eli Trim-
ble. Seymour.

Ontagamie County (Wis.) Medical Society. —
At the annual meeting of this society held m Apple-
ton on March 6, officers were elected as follows :
President, Dr. W. N. Nolan, Kaukauna; Vice-Presi-
dent, Dr. H. W. Abraham, Appleton ; Secretary and
Treasurer, Dr. M. J. Sandborn, Appleton.

Obituary Notes. — Dr. Edward W. McDonald
of Waterbury. Conn., died suddenly of heart fail-
ure on March 13, at the age of sixty-seven years.
He was born in Limerick, Ireland, but was educated
ill this country, and received his degree from the
I'niversity Medical School. He had practised in
Waterbury nearly forty years.

Dr. \ViLLi.-\M Lame, a retired physician living in
this city, died suddenly on March 13 at the age of
seventy-four years. He had practised in St. Catha-
rines, bnt.. in Lockport, N. Y., and in Swarthmore.
Pa.

Dr. Uronhy.mekha of Toronto, Can., died on
March 3 in Savannah. Ga., of heart disease and dia-
betes. He w^as a fullblooded Mohawk, and was born
on the Six Nations reservation near Brantford,
Ont., in 1841. He received his medical education in
Toronto University and also at Oxford, Eng. He
commenced practice in Frankford. Ont., but in 1875
removed to London, Ont., where he remained until
1 889, when he took up his residence in Toronto.

Dr. Henry Clay Smith of Kent, Wash., died on
March 2, at the age of fifty years. He received hi>
medical degree from the University of ^\nn Arbor
in 1883, and had practised in Portland. Tacoma. and
Kent.

Dr. Joseph C. B. Ray of Denver died of pneumo-
nia on March 5, at the age of fifty-one years. He
was a native of Kentucky, and for fifteen years prac-
tised in Owensboro in that State. He had been a
resident of Denver for about six years.

Dr. J. E. LoTHROP of Dover, N. H., died of heart
disease on March 6. He was born in 1826 in
Rochester, and received his medical education in
Jefferson Medical College. He was prominent in
public affairs and was twice Mayor of Dover.

Dr. Charles ^l. Fexn of San Diego, Cal. the
oldest physician in the city, died on March 7 of
nephritis. He was born in Hamilton, O., in 1835,
and was graduated from the medical school of the
University of Cahfornia in 1865. He practised for
three rears in San Francisco and then removed to
San Diego. He had held many official positions in
San Diego, and for a number of years was Army
post surgeon.

Dr. Columbus Hlxon of Kansas City, Mo., died
on March 7, at the age of eighty years. He was one
of the founders of the Kansas City Medical Col-
lege, and was said to have been the first surgeon in
that part of the country to perform a successful
cataract extraction.

Mr. James R. Lathrop, for over twenty-three
vears superintendent of Roosevelt Hospital, died of
apoplexy at that institution on ]\Iarch 13. He was
born in Poughkeepsie in 1847, a""^- after serving in
the Civil War for two years, he was made chief clerk
in the Lincoln General Hospital at Washington.
For several vears he was in mercantile life, and
finally became super\isor at the Bloomingdale Asy-
lum in New York. In September, 1883, he assumed
charge of the Roosevelt Hospital, where he had since
remained. On account of failing health, he ten-
dered his resignation, to take effect March i. Mr.
I^throp"s executive ability, sterling character, and
gracious manner gained for the institution and for
himself manv friends.

THE TENTH HARVEY SOCIETY LECTURE.

The last lecture of the present series given under
the auspices of the Harvey Society was delivered at
the Academy of Medicine on Saturday, March 9,
in the presence of a large audience. The speaker
was Prof. Friedrich Miiller of Munich, Germany,
and the topic was "Some Neuroses of the Heart."
In introducing the speaker, the chairman. Prof.
Graham Lusk described the Friedrich Miiller Clinic
as really typifying the clinic of modern (jermany.
It consisted of a hospital with 220 beds, looked after
by two resident physicians who had been with Prof.
Miiller for over five years. The clinic also em-
braced physiological, chemical, and pathological lab-
oratories with the necessary workers. The results
of the laboratory were at once applicable to the clin-
ical treatment- of the patient, and the w-hole was
coordinated as probably in no other clinic in the
world. In opening his lecture. Prof. Miiller stated
that he believed that observations at the bedside
were just as scientific as those of the experimental
laboratory. In the study of the heart, however, we
had been slow to apply experimental methods ; we
were only beginning to avail ourselves of experi-
mental pathology in this field.

The speaker then discussed the heart in its physi-
ological aspects. It was only part of the circulatory
svstem, and in the closest relation with the other
parts. .\s was well known, the heart of many ani-
mals could be cut out and would continue to beat
for some time. This showed, of course, that the
nerves to the heart did not originate the movements ;
they merely controlled them. The blood was not
only a lubricant to the heart, but also a stimulus.
Ringer's solution had the same effect, and the ex-
periments of Howell had shown it was mainly the
calcium ions to which the stimulation was due. Prof.
Miiller then described in detail the innervation of
the heart and the other elements that played an
important role in the action of the organ. .Among
the latter was the bundle of His. a structure only
recently adequately studied. It consisted of pecu-
liarly-shaped muscle cells described by Purkinje,
and lay mostly in the interventricular septum. A
considerable part of the bundle was broken up and
distributed in the tissues of the apex. It had been
found that permanent injury to the bundle led to an
irregularitv of the heart's action, so that the ven-
tricular contraction no longer followed regularly on
that of the auricles. This was met with in a num-
ber of clinical conditions, permanent bradycardia
among others, and these were, therefore, no longer
to be regarded as neuroses of the heart. He out-
lined the origin and distribution of the vagus and
described its two sets of fibers, and also discussed
the functions of the sympathetic innervation. The
former was probably the more important clinically.
It reriuced the work of the heart to that degree
which was sufficient for the body tissues at that par-
ticular time. In considering the innervation of the
heart, one had also to bear in mind the vasomotor
dilator and constrictor nerves, which were really a
l)art of the cardiac mechanism. The entire regula-
torv mechanism was of paramount importance, since
it responded to all kinds of stimuli.

The speaker then passed on to the subject proper,
the various so-called neuroses of the heart. W' e had
come back to believe that there was such a condition
as nervousness, though now we called it neurasthe-
nia. In individuals suffering from this condition,
there was a low vitality of the mind and of the cere-
bral centers. The centers were often highly irri-
table, so that a slight stimulus, instead of remaining
more or less confined to one center as it would do

March 23. ujo;

MEDICAL RECORD.

489

in a normal individual, spread its effects over a wide
area of nerve tissue. The symptoms usually asso-
ciated by clinicians with this condition were altera-
tions in the pulse rate, in its rhythm, palpitation of
the heart, fluctuations in blood pressure.

Taking up these various points. Prof. Aliiller said
that alteration of the pulse rate was one of the most
common cardiac changes associated with nervous-
ness. The rate of the pulse was often increased, but
the increase was seldom permanent. In neurasthenia
periods of regular pulse alternated with those of
rapid or of slow pulse. If the increased rate were
permanent, other lesions should be thought of.
\^■ith excessive muscular work, as for example in
hill climbing, if the condition were due to neurasthe-
nia there would be no dyspnea. If dyspnea were
present, or if there were evidences of a defective
circulation one should not diagnose a "nervous
heart."

.■\rvthmia was seen in nervous heart, but it was
not a common condition. There was the so-called
"changing pulse." in which only the duration of the
diastole was concerned. This was really an e.xag-
gerated reflex by way of the vagus. The "pulsus
alternans" was never a symptom of nervotis heart :
it was always associated with some myocardial
lesion. Extra systoles constituted one of the most
frequent of pulse irregularities. Did this too occur
in nervous heart? Prof. Miiller thought it did not.
This irregularity was always encountered when the
amount of work to be done was out of proportion
to the heart muscle. So, if there w^as any damage
to the heart muscle one would always find a marked
increase in the extra systoles. Perhaps occasionally,
with only a little extra systolic irregularity, there
was no diseased myocardium, but on the whole this
symptom indicated a lesion which would show itself
in other ways perhaps several years later.

In discussing palpitation of the heart, the speaker
warned against confounding it with high frequencv.
In true palpitation the shock with the beats was so
forcible that the patient should be able to count them
without holding the hand to the heart. The physi-
cian should control the counts bv noting the pulse.
Tracings of the apex were apt to throw some light
on the cause of the palpitation. In nervous heart
the curve rose very suddenly, whereas in the normal
heart the ascent on the tracing was more gradual.
This would indicate that in the former the systolic
contraction reached its maximum very quickly. The
first sound in this condition in nervous heart was
louder and more accentuated. If the muscles con-
tracted very slowly, as for instance in aortic sten-
osis, one would miss the first sound entirely. Ra-
dial sphygmographic, manometric tracings were
also of considerable value in these conditions. The
speaker illustrated this by tracings of two kinds of
cases.

The blood pressure normally varied within very
narrow limits. In nervous heart, on the other hand,
there was a liability to great fluctuations. Clinically,
the cases then showed liabilit\' to flushings of the
head, to attacks of fainting, migraine, sudden per-
spiration, cold hands and feet. The palpating finger
could often appreciate the changes in the blood
pressure. If the pressure stood permanently high,
one would not go wrong in diagnosing a beginnmg
arteriosclerosis. In nervous heart the size of the
organ showed no change, although perhaps in cases
of long standing there would occasionally he found
an enlargement, but this was not at all common.

Feelings as of imjiending death and painful sensa-
tions about the heart were often noted. Occasionally
these had their origin in the thoracic wall rather than

in the heart. .Attacks of angina pectoris, or rather
something like that condition, were sometimes en-
countered. In nervous heart, however, the pain was
not really severe. Prof. Miiller, in fact, doubted
whether pseudoangina pectoris really occurred in
nervous heart. If angina pectoris occurred there
was probablv a real lesion, such as coronary arteri-
tis.

There were a number of cardiac affections for-
nierlv regarded as of nervous origin which now were
known not to be such. An example of this was the
heart in goiter. In Southern Germany many cases of
supposed nervous heart were really cases of incom-
plete hyperthyroidism. Such a heart could be dis-
tinguished from the true nervous heart by the fact
that the increase in the heart rate was permanent,
and the acceleration in general was not as high as in
nervous heart. It might be 120 to 140 per minute,
whereas the nervous heart often had much faster
periods. The presence of tremors, the loss of flesh, a
slight soft swelling of the thyroid, these all helped in
the diagnosis. The administration of even small
doses of thvroidin often established the diagnosis,
for it made the hyperthyroid heart worse.

The excessive use of coffee, tea, or tobacco also
gave symptoms that simulated a nervous heart. The
speaker said tobacco and not nicotine advisedly — for
recent work had shown that the nicotine was not
the factor involved. Tobacco produced a distinct
increase in blood pressure in nervous hearts ;
sometimes it caused symptoms of a pseudoanginal
character, .\lcoholic drinks also produced the symp-
toms of a nervous heart. The worst form was beer.
In women and young people even small quantities
often produced marked disturbances.

Injured and feeble hearts, such as were met with
after acute infectious diseases, also simulated a
nervous heart. The poisons of the tubercle bacilli
could bring about a similar condition. The cardiac
disturbances associated with affections of the sexual
organs, e.g. arythmia in pregnancy or in disease of
the ovaries or uterus, were not referable to a nervous
heart. Thev were more or less obscure intoxica-
tions.

Finally, the speaker alluded briefly to paroxysmal
tachycardia, a condition often setting in suddenly
witli a heart rate of 140 to 160, and, after lasting sev-
eral days, as suddenly ceasing. This would sometimes
be found to be closely related to migraine or occa-
sionally to epilepsy. The more thoroughly a physi-
cian examined his case, the less often would he
make the diagnosis "nervous heart." It should only
be made after everything else had been excluded.

Therapeutically, the nervous heart should be
treated by attention to the general health of the
patient, removing him from overwork, excitement,
and worry. A change of environment was excellent.
These patients did well in high altitudes. The
crowded places, especially the various baths, should
be avoided. Above all. no medication directed to
the heart should be given.

The Death of Professor Berthelot. — The emi-
nent French chemist. Pierre Eugene Alarcellin
Berthelot, died suddenly on March 18, at the age
of eightv vears. He was watching at the bedside
of his dying wife, and when told that her life was
extinct he rose from his chair, threw up his arms,
and fell dead. He had been professor of chem-
istry at the College de France since 1865. He
was a member of the Institute and in i88g was
made perpetual secretary of the .\cademy of
Sciences, .\mong his notable discoveries were
smokeless powder and acet}'lene gas.

490

MEDICAL RECORD.

[March 23, 1907

OUR LONDON LETTER.

(From Our Special Correspondent)

KALA-AZAK — CEREBRAL TUMORS — THE PARATHYROIDS — GYNE-
COLOGY NOW AND FIFTY YEARS AGO — PROPOSED MEMORIAL —
HOSPITAL MEETINGS — THE EPIDEMIC.

LoNDO.N', March i, 1907.
The Milroy Lectures this year have been entrusted to
Dr. Leonard Rogers, Professor of Patholo<^- Calcutta, and
those interested in tropical discourses will be pleased that
he has devoted them to kala-azar, which has spread
slowly for the last thirty years up the Assam Valley. The
disease is endemic in some districts of India and in its
epidemic form seems to be identical with Burdwan fever,
and sporadic cases seem to be just the same as the "malar-
ial cachexia," so well known to Indian medical oihcers and
characterized by persistent fever, of an alternating remit-
tent and intermittent type, often mistaken for typhoid, but
rapidly leading to a cachectic condition, with great en-
largement of the spleen and later of the liver, and extreme
wasting. The fever may last months or years. The mor-
tality is from 98 per cent, at the height of an epidemic to
75 per cent, towards the end. The cause is almost certainly
a protozoal parasite discovered and described by Leishman
and Donovan and which has been said to be one stage of a
flagellated parasite, and there are good reasons for think-
ing that a biting insect is the carrier of the infection.
Dr. Rogers dealt in his first lecture with the epidemio-
logical aspect of the disease. Public attention was first at-
tracted to kala-azar in 1882 when Dr. Clarke's report
contained notes on 120 cases. It had, however, been known
from 1871 to 1876, and Dr. Rogers gave full details of its
spread in Assam with a map, charts, and diagrams. The
lecturer was selected in l8g6 to investigate the disease, and
after a year's study came to the conclusion that it was an
intense form of malarial fever, an opinion endorsed by
Ronald Ross after a personal investigation in 1899. Earlier
views, such as attributed the disease to ankylostomias or to
epidemic Malta fever, are therefore superseded. Burdwan
fever, mentioned above, named after a district it affected
in Bengal, must, it seems, be considered the same as kala-
azar, of which Dr. Rogers has lately found the parasites
in some sporadic cases from Burdwan. Another epidemic
in 1898 of the same nature was called kala-dukh. In 1904
Dr. Rogers on visiting the district where it had prevailed
found a few chronic cases remaining, and also a number
of sporadic cases. In some of these he discovered the
kala-azar parasite, so the identity with kala-azar may be
regarded as established.

In his second lecture Dr. Rogers described the disease
itself — its course, complications, and terminations. He
showed that it was not one whit less terrible when con-
sidered individually than collectively, as it killed by inches
after most prolonged sufferings which we were powerless to
effectually check. He showed a number of lantern slides
of groups of cases and pointed out their salient features,
the most marked perhaps being the tumid bellies, due to
enlargement of the spleen and sometimes also the liver,
in striking contrast with the wasted face, chest, and limbs.
Some slides showed the frequency of cases in children,
the incidence decreasing in later decades; others the ex-
treme wasting in the last stages and the dropsical and
ascitic form produced by a peculiar intracellular cirrhosis
of the liver. The incidence in family, age, sex, race, season
having been considered, tlie type of fever, the blood
changes, condition of liver and spleen, and complications
were carefully dealt with. Then came treatment, and on
this the lecturer emphasized his well known method with
massive doses of quinine. If it will not cure, it will often
delay the progress so much as to make the patient com-
fortable for long periods. In view of occasional recoveries
from hopeless conditions. Dr. Rogers hopes for the dis-
covery of a better remedy, but in the meantime he gives
quinine in massive doses — 60 or even 00 grains a day, and
savs these amounts may be persisted in for months to-
gether. The good effect of such doses was shown by a
nine months' chart of a child of eight who took 50 grains
a day for seven weeks, her weight steadily rising all the
time and no ill effect being produced.

In the second Lettsomian lecture Dr. C. E. Beever pro-
ceeded to describe six cases of tumor involving the second
or middle frontal convolution. In them all there were at-
tacks varying according to the precise position of the
tumor. In all the mental condition was dull. slow, or inat-
tentive, and the memory bad, but in none were the sphinc-
ters affected. Sensation was not affected or slight anes-
thesia to slight touch was only temporary and after the fits.
In four out of the six fine tremor of the fingers on the same

side as the tumor was detected. It appeared then that
fits, f.-iints, or attacks beginning with spasms of conjugate
movement of the eyes, or of the hand or face, followed by
weakness but not permanent anesthesia, mental dullness and
fine tremor on the side opposite to the one affected by the
fits, indicated tumor of the outer surface of the frontal
lobe anterior to the ascending convolution. Dr. Beevor
then related cases in the interior of the lobe, the difficulties
of their diagnosis being pointed out, especially before hemi-
plegia appeared from extension of the growth backwards.
Severe headache, vomiting, double optic neuritis, mental
obtuseness, incontinence of urine, gradual hemiplegia with-
out anesthesia, increase of deep reflexes with decrease of
superficial ones, and extensive plantar responses on the
paralyzed side were the chief indications. In three of the
cases there was rapid, fine tremor of the hand on the same
side as the tumor, and this was the most significant symp-
tom.

The Pathological Society had two papers before it on the
19th concerning the parathyroid glands. The first, by Dr.
David Forsyth, dealt with their anatomy. Usually he found
tW'O on each side, but the total might reach twelve. They
never lay on the superficial aspect of the muscles, and might
occur within the thyroid itself. The microscope was neces-
sary to identify them. With their tissue might be bound
up thymus or accessory thyroidal. In infancy they were
smaller but greater in number, while accessory thyroids
were more numerous in adults, suggesting that one might
be transformed into the other. The colloid in parathyroids
and thyroids seemed the same and was oxyphile as a rule.
In infancy the cells were in a resting stage and colloid ap-
peared later.

The second paper was by Mr. W. L. Harnett, who de-
scribed the appearances in various periods of life and
thought that the tissue began activity early, increased as
age advanced, and attained its height late in life. From
examinations of subjects dead from various diseases he
found nothing different from normal glands at the cor-
responding age. There were no grounds for supposing
parathyroids were affected in Graves's disease or in
tetany. Dr. H. Bayon did not believe that colloid was
formed in true parathyroid tissue ; if seen it would only
be an isolated lobule of the thyroid proper. He exhibited
a section through a goiter showing the parathyroid in
which was no trace of colloid.

The new President of the Gynecological Society is Mr.
\V. D. Spanton, Consulting Surgeon to the North Stafford-
shire Infirmary. He delivered his address on February 14,
devoting it to the gynecology of to-day and fifty years
ago. Having referred to the opposition at first to ovariot-
omy and to the radical cure for hernia offered by London
teachers w-hose knowledge of anatomy and surgery should
have prevented their attitude, he went on to consider their
position in reference to affections of women. His first
example was excision of the cervix uteri for various forms
of cancer which w-as condemned by Churchill, Montgom-
ery, and Robert Lee. But Simpson had then operated on
eight cases and only one died. It was not to be wondered
at that the operation was regarded as so grave considering
the mode of its performance then. It was only w-hen the
true principles of clean surgery were adopted that real
success was attained, and no one now expects a fatal re-
sult from this operation. Extirpation of the whole uterus
at that date was even more rigorously proscribed. The
immediate results are now less grave, though how far it is
curative for malignant disease is an open question. 'Vag-
inal hysterectomy had been practised for prolapsus asso-
ciated with various conditions, but removal of the organ
when in sitti for tumors had only just beeun. Of nineteen
cases sixteen had died, only one surviving to the fourteenth
day. This fatality was so alarming that Clay of Manchester
and Koberle of Strasburg ventured on abdominal hyster-
ectomy. Dr. Blundell with his usual sagacity had suggested
that it might be done, but Simpson pronounced it unjusti-
fiable in i860. Modern improvements have enabled us to
advise such operations. Abscess of ovaries, salpingitis, and
other points were discussed and the president remarked
that most of the pioneer work had been done by Conti-
nental obstetricians and surgeons, the British generally fol-
lowing rather than leading. The provincial surgeons have
kept rather ahead of the London schools and Mr. Spanton
thought the time had now arrived when the scientific teach-
ing of gynecology so long w-ell carried out in the provinces
should be adopted in a whole-hearted way in the metro-
politan hospital schools. He hoped the time would come
when more liberal ideas would prevail and the proper place
of extramural practice and teaching be recognized by ex-
aminin.g boards.

A memorial to the late Dr. Schorstein of the London
Hospital is bein.g raised in connection with the Medical
School. It is proposed to found a lectureship in advanced
clinical medicine, not as a part of the ordinary curriculum.

March 23, 1907]

MEDICAL RECORD.

491

but rather on the lines of the endowed lectureship at the
Royal Colleges, three or four lectures by a physician to
be elected on each occasion by the governing body, due
notice being given to afford time for the lecturers to pre-
pare a discourse worthy of the subject and of the late Dr.
Schorstein. At present the governing body is the College
Board, representing two interests, the hospital managers
and the staff. A more suitable body for selecting the
lecturer might well be chosen.

Mr. Henry Morris, P.R.C.S., presided at the annual meet-
ing of the Middlese.x Hospital yesterday. The report of
the Clinical and Bacteriological Laboratories testified to
the excellence of the work carried on in them and indicated
that the facilities afforded by the clinical investigation de-
partment were greatly appreciated by practitioners. The
financial statement was satisfactory as hospital reports go.
There was a slight increase in the patients admitted to the
cancer wards during the year. The report was adopted and
after the formal business a testimonial to one of the hospital
nurses was presented. It appeared that Nurse Cross was
in Jamaica when the earthquake took place and assisted
Dr. Arthur J. Evans on board the Port Kingston for
nearly forty hours consecutively in rendering surgical aid to
over 200 injured persons. Her conduct had been brought
before the Board and the framed testimonial was pre-
sented setting forth that "her fortitude and noble devotion
signally redound to the honor of the nursing profession
and of British womanhood."

.•\t the annual meeting of the Royal National Orthopedic
Hospital on Wednesday it was stated that the amalgama-
tion scheme was working well and that when the new
building is erected it will be the most complete hospital
of the kind in the world. It is hoped that the foundation
stone will be laid within a few months. In the meantime
three vacant wards at Charing Cross Hospital have been
rented and some property adjoining the old hospital pur-
chased to utilize during the rebuilding.

•At the meeting of the Cancer Hospital held Wednesday
it was reported that a deputation of the staff attended the
Congress at Heidelberg and visited many institutions in
Germany, 'Denmark, and the Netherlands to study the
methods of treatment. There had been a considerable in-
crease in the research and pathological department during
the year. In the report of the Medical Committee special
attention was drawn to an instruction issued to patients
advising early recourse to medical advice, as cancer often
begins as a small, painless lump.

The meeting of King's College Hospital was also held
yesterday, the Hon. W. F. D. Smith in the chair. The
ordinary expenditure for the year had been £22,315, an in-
crease of £827 over the preceding year. This was due, ac-
cording to the report, to the reassessment of the premises
at a considerably higher figure which had increased the
amount of rates and taxes by £216, and to exceptional
allowances on retirement. The ordinary income was ii6,-
081, as against £16,200 in 1905. There had been a further
decrease of work in the out-patient department, the change
in the neighborhood accounting for this — a result, I may
add, which is by no means to be regretted.

Cerebrospinal fever still seems spreading. Three or
four cases have been received in London hospitals. Com-
pulsory notification has been adopted in most places where
it appears. The Scotch and Irish cases continue to increase.

OUR BERLIN LETTER.

(From Our Special Correspont'.ent )

TRYPANOSOMIASIS — INJURIES THROUGH ELECTRICITY — INFANT
FEEDING — THE PROFESSION IN GERMANY.

Berlin", February 17. IQ07.

On February 14 an event of more than usual interest oc-
curred in the history of the Berlin Medical Society. Every
seat in the large auditorium of the Society was occupied
and the audience listened with the greatest attention to a
discourse by Paul Ehrlich of Frankfurt in which he de-
scribed his experimental studies on sleeping sickness. The
speaker took the occasion to dwell especially on the method
of experimental therapy, which he so warmlv advocates.
In all diseases it should be the object to seek to discover
remedial agents which shall be directly hostile to the causa-
tive agent and combine with it. Such substances are called
bactcriotropic or etiotropic by Ehrlich. If they are also
taken up bv the tissues of the body they may be termed
organotropic. .After it had been discovered that the mani-
festations of trypanosomiasis in animals were very similar
to those in man, hundreds of remedies were tested and two
particularly potent bactcriotropic substances were discov-
ered. One of these is a dye called trypan red. For most
of the experiments the trypanosoines used were those caus-

ing the South -American nial dc cadcras. The strain under
observation killed mice in four to five days, but if trypan
red was injected into the animals the day after the inocu-
lation they remained healthy. If, however, a few of the
organisms escaped the action of the drug, a fatal termina-
tion ensued in the course of a few weeks. There were
soine strains of trypanosomes that were not affected by
the trypan red but which were found by Laveran to he
susceptible to a combination of trypan red with arsenic.
Malachite green and brilliant green, two aniline colors,
were found also to possess toxic properties for the try-
parosome, but owing to their irritating nature these agents
were not available for practical use. Apparently the ,sim
pier the chemical composition of a dye stuff, the less irri-
tating was it likely to be. The speaker had lound that
the experiment mice exhibited considerable variations in
their powers of resistance to the parasites ; each rnouse, so
to speak, had its own titer of susceptibility. The biology of
the trypanosomes has so far not received much aftcntiou
from the therapeutic standpoint. By giving fuchsin to
n.ice Ehrlich found that the immunity produced became of
shorter and shorter duration, showing that the parasites
became habituated to the poison. In this manner it was
found possible to produce a strain which was resistant to
fuchsin. and also strains that were refractory to trypan
red and trypan blue. The tediousness of these experiments
was evident from the fact that sorne of the strains were
already in their one hundred and eightieth transfer. The
variations in the therapeutic results obtained by observers
in dififerent countries could be explained on the ground that
the various types of the parasite encountered might be
more or less resistant. It w-as therefore necessan- ft)r lab-
oratorv workers to determine the powers of resistance of
their cultures and in cases in which the arsenic treatment
was found inadequate to combine it with the administration
of trypan red. .\s it was found that trypan blue was just
as effective as trypan red, search was made for the active
component present in each and it was discovered in a
sulphur radical common to both.

Another address by a stranger was that delivered by
Jellineck of Vienna before the Society of Internal Medicine
on the pathology, prophylaxis, and treatment of accidents
bv electricity. He first called attention to the fact that
unipolar contact was sufficient to close an electrical cir-
cuit owin.g to the constant presence of electric currents in
the ground. In dealing with atmospheric shocks, true and
false lightning strokes were to be distinguished. The effect
of the lightning discharge was the result of a combination
of the actual electric current itself and of the destructive
action on the surrounding objects struck. It might also
be conveyed to a distance through such agencies as tele-
phone or tele.graph circuits. The electric discharge began
to be dangerous even at a tension below 100 volts and the
continuous current was more hazardous than the alternating
current, because the first was drawn directly from the power
house without the intermediation of a transformer. Indi-
vidual differences in resistance might also play a part in
different persons, and the resistance also varied in different
parts of the body. The character of the flooring was of im-
portance, a stone paved floor offering the greatest resistance,
.^n interesting case was one that occurred in Vienna in
which a young girl was killed through catching hold of an
incandescent light while in the bath tub. In this instance
through leakage in the wiring the circuit was closed through
the bodv of the girl, the bath tub, and the floor. The ex-
perimental observation that anesthetized animals were
aroused bv a certain current but that the same current
sufficed to' kill animals in the waking condition held good
for human beings also. Sleeping persons undergoing pow-
erful electric shocks were simply aroused, but waking indi-
viduals were killed. The speaker had seen seventy-five
cases of lightning stroke and one hundred and fifty-seven
accidents from the electric current, and he related several
interesting case histories. Lumbar puncture has been found
useful in dealing with severe cases of electrical injury.

.\ dissertation of practical importance that was also in-
teresting on account of the side light thrown on social con-
ditions in Berlin was presented by Neumann before the
Berlin Medical Society on January .30. His subject was
the natural feeding of infants in medical practice. He ad-
mitted that many healthy children did well on artificial
feeding but that in dealing with prematurelv born or
weakly infants breast feeding was necessary in order to
avoid' intestinal disturbances. If rachitis existed in the
familv, onlv through breast feeding was it possible to pre-
vent 'the le'sions caused by this disease. Children born in
the sccoml six months of the calendar year ran the greater
risk of becoming rachitic. In Berlin in the year i^ only
30 per cent, of nursing mothers were found in families
that occupied homes consisting of more than four roonis,
but it was determined that from 70 to 80 per cent, of the
mothers were phvsicallv able to nurse their children. Arti-
ficial feeding was resorted to chiefly because the mothers

492

MEDICAL RECORD.

[March 23, 1907

did not realize the dangers of it. and therefore the medical
profession shonld make greater efltorts to disseminate
knowledge on this subject. The greatest danger, both in
artificial and natural feeding, lay in overfeeding, and in
some cases the common practice of feeding by the clock
was too schematic.

Statistics of interest in regard to the medical profession
in Germany have been collected by Dr. Prinzing. The total
number of physicians is now 30.931. The absolute number
has become larger, but on accoimt of the great growth in
population the relative proportion has diininished. so that
apparently the increase in the number of physicians ob-
served during the last twenty years has been checked. In
Prussia and some other German states, three to seven physi-
cians are found for each 10.000 in'- litants. but in the large
cities, there are seven to twerty In 1901 there were 2,786
physicians in Berlin and in lyoo there were 3,196. but the
relative number has remained about the same, that is.
i2.i_per 10.000 inhabitants. The number of specialists
has increased greatly and now from a third to one-half of
all the physicians in Berlin, Munich. Dresden, and Frank-
furt are specialists. Among the specialties gynecology is
the most followed, except in Rerliii. where g^'uitourinary
specialists take the lead. Even the smaller towns are filled
with specialists and it seems advisable to warn young
physicians against attempting to devote themselves to a
single subject.

OUR VIENNA LETTER.

(From Our Special Correspondent.)

A NEW TRE.\TMF.XT OF DEFORMITIES OF THE LOWER E.XTREMI-
TIES — 0BSERV.\TI0NS OX PERLSUCHT — TEMPERATURE DETER-
MINATIONS BY MEANS OF THE URINE — ECHINOCOCCUS Of
THE LUNG — FOREIGN BODY IN THE ESOPHAGUS.

Vienna, February 15, igo;.
.\ NEW and very ingenious method for the treatment of
f^at foot, club foot, knock knees, and bow legs was recently
described by Semeleder before the Medical Association. He
presented a number of patients who exhibited the aston-
ishingly good results to be obtained by this method. The
speaker pointed out that the customary procedures were
painful and time-consuming and that the results obtained
were no better than those promptly secured by the painless
use of his appliance. The apparatus was not visible while
in use, since it was contained in a shoe that did not differ
in appearance from an ordinary one. Semeleder had the
following to say in regard to the way in which he came to
devise his appliance: The well-known fact that continuous
standing and walking tended to aggravate a condition of
flat foot, whereas the opposite of flat foot, the club foot,
was increased in the same way. led the speaker to con-
sider whether the pressure which ordinarily had a dele-
terious action might not be transformed in its eft'ect so
that in flat foot it might tend toward the production of
club foot, and vice versa. If the process of correction
were arrested at the right moment, that is, when the oppo-
site deformity had been half produced, a normal foot
might be secured from either one. After experiments had
been carried on for years a simple appliance had been de-
vised by means of which simple walking was made more
cfifective than the most carefid massage. The function of
the shoe was to perform auto-massage through the altera-
tion in the direction of action of the pressure while walk-
ing. The most valuable feature of this massage was that it
was self-regulating, since it was controlled by the patient's
weight, the weight of his step, and the amount he walked.
Under all these conditions the correcting forces always
corresponded exactly to the demand, since no force was
brought into action except the pressure of the step, the
direction of which force had simply been properly altered.
Observations on Ptvlsuclit have been continued by J. Bar-
tel in Prof. Weichselbaum's laboratory. If Perlsucht
bacilli are injected into rabbits and the animals are killed
and portions of their organs inoculated into other rabbits,
these animals die of tuberculosis and their organs are found
ful of tubercles. The same thing occurs if the bits of tissue
are preserved for some time in blood serum. On the other
hand, if the material to be inoculated is kept for some
time in the incubator before the inoculation is done no
tuberculosis appears in the experiment animals. Rabbits
that had been intraperitoneally inoculated with PcrUuchI
bacilli died some time later of generalized tuberculosis,
and advanced tuberculous changes were found in their in-
ternal organs. Rabbits, however, that had been treated for
several months previously with attenuated tubercle bacilli
did not become tuberculous on inoctdation in the same way.
The experiments showed that not every infection with
tubercle bacilli is necessarily followed by tuberculosis, be-
cause the body may have previously acquired a general

or local innnunity through the entry into the body of atten-
uated tubercle bacilli.

In order to determine bodily temperature Englander
takes the temperature of the urine while being voided.
To do this he has the patient urinate into a funnel made
of strong filter paper and having its point cut off. The
thermometer is placed in this funnel and is kept in position
by cutting a suitable supporting slip from the paper. The
advantage of the method lies in its simplicity, as the de-
termination may be made in a few seconds and accurate re-
sults are obtained both at room temperature and at very
low temperatures. Owing to the short time necessary for
the determination and the poor conducting power of the
paper funnel, the urine undergoes only a practically im-
perceptible cooling. Comparisons of results obtained by
this method with those gained by the ordinary procedures
showed that there was perfect correspondence between the
urine temperature and the rectal temperature, whereas
the axillary temperature was sometimes as much as one
degree lower. Determinations of the urine temperature
demonstrated the daily physiological fluctuations in tem-
perature, that is, a rise toward the afternoon followed by
a fall lasting until the morning hours, as well as the eleva-
tion of temperature produced by muscular work. The
method is especially suitable in dealing with patients who
are up and about and for scientific purposes.

A case of primary echinococcus of the lung has been
cured by Herczel by resorting to pneumonotomy. The pa-
tient was a boy of nine years who fifteen months greviously
had had pneumonia and three months later had suffered
from pleurisy. A quarter of a year after this, severe
attacks of coughing ensued accompanied by profuse expec-
toration without tubercle bacilli and moderate elevations
of temperature. An exploratory puncture gave a negative
result, though it was followed by fever and night sweats.
It was then noticed that the left side of the child's thorax
was larger than the right and dullness was discovered below
the angle of the left scapula. It was supposed that the
case was one of encapsulated empyema and the Roentgen
ray revealed a sharply circumscribed shadow\ It was
decided to operate and portions of the seventh and eighth
ribs 9 cm. in length were resected. Clear fluid was ob-
tained from the lung on puncture and it was evident that
an echinococcus cyst was present. The cyst was incised
and its wall was found adherent to the parietal pleura.
By careful manipulation the production of pneumonthorax
was avoided and on further investigation it was found
that the mother-cyst communicated with a bronchus. The
large cavity was packed with gauze and the skin flap su-
tured in position. Seven days later severe urticaria ap-
peared which persisted for three weeks in spite of all treat-
ment. At the end of the seventh week only a small sinus
remained which closed completely a month later. A recent
radiograph showed normal conditions.

Much interest has been aroused by an operation per-
formed in Prof. Chiari's clinic. A man of thirty-eight
years applied for treatment, saying that about a month
before he had swallowed his artificial teeth while asleep.
At first he had suffered from severe dyspnea, but this soon
subsided again. At present he was able to take only fluid
food, but he had no actual pain. On examination an ob-
struction was found in the esophagus and radiographs made
in Prof, von Eiselsberg's clinic showed a shadow resembling
the false teeth at the level of the first dorsal vertebra. The
attempt was then made to extract the foreign body without
opening the esophagus and by ingenious manipulations
with various tubes the operators succeeded in withdrawing
the plate without using undue force. This was all the
more remarkable as the plate was one of five teeth and
measured 4.5 cm. by 2.5 cm. At present the patient is
perfectly well.

OUR LETTER FROM THE PHILIPPINES.

(From Our Special Correspondent.)

DECLINE IN THE NUMBER OF LEPERS — CARE OF LEPERS IN THE
PHILIPPINES — (..\XGOS.\. OR RHINOPH.\RYNGITIS MUTIL.\NS —
COLD WEATHER IN THE PHILIPPINES — MEDIC.-\L INSPECTION
OF THE PUBLIC SCHOOLS — RESIGNATION OF DR. DE MEV.

M.\NILA. P. I.. Fetiruary i, rpo?.

An analysis of the tables prepared by the Bureau of Health
of the number of lepers in the Philippines, shows that there
has been a steady decline in the number of lepers reported.
For the year ended .\ugust 31, 1904, there were 3.623; for
the year ended August 31. 1905, there were 3,580; for the
year ended .August 31, 1906. there were 3.494; for the
quarter ended September 30. 1906. there were 3,473, and
for the quarter ended December 31, 1906, there were 3,225.
The decline has been most noticeable during the last six

March 23. 1907 J

MEDICAL RECORD.

493

months of 1906. It is believed tliat tiic reduction in the
actual number is really greater than the figures show, be-
cause the sanitary organization in the Philippines is under-
going constant improvement, so tliat many cases that would
have escaped attention entirely a few years ago, now find
their way into the official records. From a casual examina-
tion of the figures it is, of course, impossible to say whether
the reduction is due to the improved sanitary methods now
being gradually and steadily extended by the American
Government, or whether it is due to some cause not yet
well understood. On account of the reduction having been
so marked during the last six months of 1906, it would
appear that the decrease can at least be attriljuted in part
to the many centers of infection which were obliterated
during that period. It will be remembered that effective
segregation and isolation of lepers in the Philippines did
not begin until May, 1906, and it is only from that date on,
that the beginning of the 'solution of this problem can be
counted.

For the past several hundred years, the care of those who
were unfortunate enough to contract leprosy, has received
considerable attention in the Philippines, but a careful re-
view of the history shows that it was more or less of a
charitable nature, and not carried out in such a way that
the final disappearance of the disease could be hoped for. It
was the practice to admit to leper hospitals those lepers
who were unable to earn a living, or who had no one to
provide for them. This left many lepers at large who
managed to make a living by begging or by the charity of
kindlv disposed individuals. Thus, the few hundred lepers
who were actually confined to an institution had very little
effect upon reducing the number of infected foci upon the
outside. The real solution of the problem must, therefore,
date from the time of the American occupation, and more
especially from the time the Civil Government set aside
an island for this purpose and began the construction of
suitable buildings and quarters for their isolation.

The first person in the Philippine Islands definitely known
to have been afflicted with gangosa, or rhinopharyngitis
mutilans, which is the name suggested for the disease by
the Navy medical ofiicers, died at the St. Paul's Hospital,
this city, last week. Cases may have occurred in the past,
but thev have escaped recognition, and extensive inquiry
among Filipino and Spanish physicians who have been in
the islands for many years, tends to show that while cases
of a disease with similar symptoms have been observed, yet,
they were generally regarded as leprosy, and no distinct
separation was ever made.

In the description given by Surgeon J. F. Leys, United
States Navy, which appeared in the annual report of the
Surgeon General of the Navv for 1905, it is stated that
gangosa is an infectious, painful, repulsive, and disfiguring
disease, the cause of which is not known, and which pre-
vails extensively in the Island of Guam. The nose and
upper part of the face arc destroyed by slow ulceration,
while the tongue is never affected. Cases have been ob-
served in persons from three to eighty years of age. The
disease sometimes lasts from several months to a number of
years, and even during this period, in its active stage, there
is no reduction in the flesh or strength. The mortality of
the disease is low. Tlie disease is not very amenable to
treatment, although antiseptic methods appear to retard
the extension of the ulceration. It is estimated that there
are about 200 persons on the Island of Guam who are
afflicted with gangosa.

The Philippines, during the month of January, have en-
joyed an unusual amount of cool weather. The Weather
Bureau has reported that this has been the coldest January
since 1857. In the mountains of Benguet, near the Benguet
Sanitarium, and the place where the summer capital of
the Government is located, the Weather Bureau reported
that the thermometer actually registered 28° F., and ice to
the thickness of one-quarter of an inch formed in exposed
places.

A few weeks ago the systematic medical inspection of
the public schools of Manila was commenced. It is yet too
early to state what the result of this inspection will be, but
from the preliminary reports received, it appears that much
the same conditions exist among the Filipino school chil-
dren as are found among American school children in the
larger cities of the United States.

Dr. C. F. de Mey, who has been the chief of the Culion
Leper Colony Division of the Bureau of Health for the
past few years, and who was in direct charge of the con-
struction of the colony, has resigned his position and will
soon proceed to France, where he expects to practice his
profession.

An Edict Against Corsets. — The Bulgarian Minister
of Public Instruction has prohibited the wearing of corsets
by the pupils in the girls' schools of the principality. The
penalty is expulsion from school.

Nnc York Medical Journal, March 9, 1907.

Clinical Observation on the Use of Cotarnine Phtha-
late. — The use of this remedy as a uterine hemostatic
IS highly commended by C. A. von Ratpdohr. Cotar-
nine is a derivative of narcotine from opium. The new
salt is a yellowish crystalline powder freely soluble
in water. It may be given in coated tablets in doses
of three-quarters of a grain, from 3 to 9 tablets being
the daily limit. It acts on the vasomotor uterine nerves.
So far no toxic effects have followed the maximum
dosage above indicated. It is not indicated in cases
calling for hurried uterine contraction. The author
has found it superior to ergot and cotton-wood. Brief
histories of its results in six cases are given.

A Case of Cancer Treated by Trypsin.— W. J. Mor-
ton reports the case of a woman of forty-five years
with a lump in the breast, .v-ray treatment, radioactive
water, and fluorescin reduced it one-third in size, and
still later to a mass the size of the end of the thumb.
This was removed under cocaine and proved to be
a highly fibrous scirrhus carcinoma. Later two new
nodules appeared, one below the clavicle, near the
shoulder tip, and one under the chin. Trypsin and
amylopsin injections were used with success, and some
twenty months later the patient was reported as doing
well.

Indigestion; Its Significance and Diagnosis. — H. F.
Stolt refers to the various causes which may produce
gastric symptoms, although the stomach is not the
organ primarily at fault. Our errors in diagnosis may
be due to (l) incomplete history of the case; (2)
failure to make a complete examination; (3) stopping
our search for the cancer with the discovery of the
first lesion, and (4) the omission of special tests. The
author calls attention to the necessity of method, sys-
tem, and coinpleteness in our search for the cause, and
then takes up the diagnosis of some of the more com-
mon gastric maladies, as, cctasy ulcer, cancer, gastric
hyperesthesia, and nervous dyspepsia. He notes that
there is probably no class .of patients in whorn less
attempt is made at an accurate diagnosis than in the
dyspeptics. They enter the office with a tale of woe
concerning their indigestion and they are given^ a
prescription for some much advertised preparation
which "cures all kinds of indigestion," when an inspec-
tion of the mouth might have revealed a few scattered
teeth, or the passage of the stomach tube have demon-
strated the food of former days. Rational therapeutics
can only follow careful diagnosis.

Value of Differential Leucocyte Counts in Medicine.
— I. S. Wile summarizes the definite knowledge at our
command as to the value of the leucocyte count in
disease. Nothing new is brought forward. He believes
that it affords more suggestive information than any
other procedure in blood analysis. He also discusses
the prognostic value of eosinophiles, noting that in
nii'St infectious diseases accompanied by neutrophilic
leucocytosis there is a diminution of eosinophiles. The
return of eosinophiles to the circulation after a primary
decrease or absence is of good prognosis. The reap-
pearance of the eosinophiles foretells approaching con-
valescence. On the other hand, a sudden fall of the
erisinophiles during the course of an infectious disease
where they were previously present suggests some
complication which is interrupting convalescence. This
prognostic value of the eosinophiles holds true in pneu-
monia, typhoid fever, appendicitis, and septic processes.
Generally speaking, when mentioning leucocytosis we
refer to the condition of the blood where there is a
relative or absolute increase of the neutrophilic leu-
cocytes. The author calls attention also to the neces-
sity of taking the age of the patient into account in
interpreting our diflferential findings. The percentages
nf the various types of leucocytes do not approximate
the percentages normal in adults before the ninth year.
.At one year the lymphocytes average about 54 per cent.,
the nentrophiles' only 35 per cent. In adult life the
ncutrophiles form 60 per cent., and the lymphocytes
35 per cent, of the total leucocytes. Hence, 65 per
cent, nentrophiles in a child, six months old. may
represent a pronounced leucocyto.sis, whereas it would
be perfectly normal in an adult.

Journal of the American Medical Association. March
16, 1907.

Quinine Injections and Tetanus.— Having had his at-
tention called recently to a severe case of tetanus
following an injection of quinine hydrochlorate, E. F.

494

MEDICAL RECORD.

[March 23, 1907

]\IcCampbell reundertook a series of experiments pre-
viously performed by him to test the conclusions of
Vincent that the injection of quinine had a favoring
action on the development of tetanus. His earlier re-
sults were entirely negative and he therefore carefully
followed up Vincent's claim and here reports the re-
sults of two carefully conducted series of experiments.
He finds that the salts of quinine have a feebly anti-
septic action on the spores of tetanus, that of the
hydrochlorate being the greatest. The lethal dose of
neutral hydrochlorate of quinine is from 1/3500 to
1/4000 of the weight of the guinea pig and from 1/4000
to i/sooo of the w'cight of the rabbit. The dose varies
with the age, young animals being most susceptible.
Hydrochlorate of quinine has a paralyzing effect, vary-
ing in different animals, which McCampbell attributes
to the coagulating action on the protoplasm of the
peripheral nerves, .'\trophy of the extremities results
after long doses. In cases of tetanus in experimental
animals which had been injected with hydrochlorate
of quinine the disease resulted only in those cases in
which there was a mixed infection. The quinine may
have aided by its corrosive action in favoring this sec-
ondary infection, and it is possible that it may have
acted as an additional irritant to the nervous system,
rendering it less resistant, but any other mild corrosive
substance could act the same way. In cases in which
tetanus did not result after injections and there was
no secondarj- infection, the spores had evidently under-
gone phagocytosis by the leucocytes or tissues, as none
of them were ever found. Hydrochlorate of quinine is
unable to favor a tetanus infection other than in the
above indirect way. It has not the power to awaken
an infection when injected at the same time with the
tetanus spores or at other times. It causes a slight
leucocj'tosis and has a slight paralyzing efifect on the
leucocytes. If this were so extensive as to involve
the majority of the leucocytes of the body, it is possi-
ble that the spores of tetanus might develop unhin-
dered, as is the case when lactic acid is injected; but
in that case the toxic effects of the quinine itself would
be manifested and would probably cause the death
of the animal. McCampbell believes that in most of
the cases in which tetanus has followed quinine injec-
tions it can be traced to some fault of surgical tech-
nique or to some contamination of the quinine solution.
The tissue necrosis from the quinine injection would
favor infection by tetanus germs as well as bj' other
bacteria. He does not think that there is sufficient
proof that the tetanus spores can be transported from
point to point according as the quinine is injected,
nor that it is possible for the healthy living spores of
tetanus to be present in the bodv and to develop a
severe and fatal infection on the advent of an injection
of hydrochlorate of quinine.

Malaria. — W. Krauss says that no region should be
uninhabitable on account of malaria and that much of
the so-called malaria is something else. He asserts
that he has seen tuberculosis, sepsis, gall-bladder dis-
ease, liver abscess, dysentery-, uncinariasis, chronic
nephritis, and visceral malignant disease, in persons
who come to him, all w-ith the same story of "malaria
in the system." Nething is more amenable to proper
treatment than malaria! fever, he says, and a recent
infection is almost never anything but a fever. Malaria
in the beginning is an infection by one or more groups
of one or more varieties of blood parasites whose life
function in the body is the destruction of hemoglobin.
The segmentation of these parasites starts the well-
known symptoms. \ resistance is developed and the
so-called chronic malaria is, as Krauss believes, a state
of relative immunity in which repeated infections pro-
duce comparatively slight reactions, a state of sym-
biosis in which the immunizing contest between the
parasite and the blood-making organs is in a state of
equilibrium. So long as the patient remains in a
malarial climate the condition may become acute
through reinfection, especiallv when assisted by outside
influences. The merozoites resulting from segmenta-
tion, according to this theory, do not invade new cells,
but hibernate somewhere in the organism and become
active when reinforced by a new infection, or die when
the patient removes to a non-malarial climate, but they
do not, per se, he declares, produce any paroxysms.
Krauss holds that in these cases of chronic malaria
without paroxysms or marked cachexia, quinine, as well
as other factors disturbing the symbiosis, may produce
symptoms of intoxication, including hemoglobinuria.
The only time to give quinine is when developing para-
sites are found in the peripheral blood, provided also
that the infection is fresh, as shown by a characteristic
fever curve. It is his practice in the autumn to give

two or three 10 or 15 grain doses of sodium thio-
^ulphate at desirable intervals until the bowels are
freely emptied. Pernicious cases must of course be
treated more expeditiously. He advocates especially
frequent blood examinations of persons living in ma-
larial districts, even if well. His conclusions are given
as follows: "l. There is not the shadow of an excuse
for failure to make an exact diagnosis in all fever
cases. 2. The blood of residents of malarial localities
should be examined at frequent intervals. This does
not constitute an encroachment on personal liberty that
can weigh a feather's weight as compared with vac-
cination. 3. Fever cases should be treated in accord-
ance with the findings of a thorough blood examination,
with special reference to time of dosage and to the
complete immunization of the individual for the sake
of his neighbors. 4. Quinine judiciously used in ac-
cordance with findings of a h\ood examination very
rarely does harm; its prohibition on the ground of pos-
sibly producing a hemoglobinuria is unpardonable;
its administration during hemoglobinuria is very dan-
gerous and usually unnecessary; a blood examination
will save such patients from almost certain death. 5. The
screening of houses and the destruction of breeding
places of anopheles should be encouraged so far as
possible, but the prophylaxis of malaria and its defi-
nite local eradication depends on the destruction of the
parasite within its alternative host, man."

The Pretuberculous Stage of Consumption.— C. F.
Beeson calls attention to the earliest symptoms of pul-
monary tuberculosis before the physical and rational
symptoms have become fullv manifest. After noticing
the usually recognized characteristics of the phthisical
predisposition, he mentions as the signs of incipient
consumption an over brightness of the eyes, with possi-
bly slight inequality of the pupils due to reflex of
the ciliary nerve from apical irritation, brittleness of
tlie hair, variable and uncertain appetite, fluctuations
in body weight, quick fatigue, subnormal morning tem-
peratures slowly reached by the thermometer, chest
pains, frequent clearing of the throat, and husky ex-
piratory cough; there may be a bluish tinge to the lips
or an unusual redness of the gum margins. Careful
inspection mav reveal deficient expansion of one or
the other apex, or the Litten shadow may not fall as
it should. A prolonged expiratory sound may be heard
at or near an apex, and there is sometimes also a fine
laryngeal crepitus to be heard by placing the ear near
the open mouth of the patient. Sooner or later a slight
hemorrhage or a prolonged "cold" will startle the pa-
tient and be what he. and too often his physician, con-
siders the starting point of pulmonary tuberculosis.

Passage of Methylene Blue from the Mother to the
Fetus. — S. H. Corrigan reports the observation of a
healthy new-born infant whose urine for the first eighty
hours after birth left a blue stain on the diapers, the
color gradually disappearing. The mother had been
taking methylene blue during a large part of her preg.-
nancy for chronic cystitis. There was no evidence of
the drug in the liquor amnii nor any trace of it on
the sheets or pads used during labor. From these facts
he assumes that methylene blue passes from the ma-
ternal to the fetal circulation, and. there being no eN-i-
dcnce of it in the liquor amnii, the fetus does not
evacuate the bladder before birth, and its kidneys do
not excrete it beyond the amount contained in the
bladder at the time of birth.

The Lancet, March 2, 1907.

Streptococcus Wound of the Finger. — W. P. Cowes
reports the case of a man of forty-four years who,
^\hile sparring with a fellow workman, struck the back
of the right index finger against his opponent's tooth,
making an incised wound. He w'as seen four hours
later. Examination showed a wound on the index fin-
ger just posterior to the first knuckle; this was seared
over. There was no other wound found nor were
there evidences of any septic places around the hand.
On opening the wound pus was seen. A cover-glass
preparation was made and a culture was taken. The
wound was douched, very slightly enlarged, touched
with carbolic acid and alcohol, and drained. The finger
did well and the man was soon discharged. The cover
glass showed numbers of streptococcus and the culture
was a pure one of that germ. The interest in the case
lies in the unusually short period of incubation — ^name-
ly. four hours.

Rupture of the Aorta and Rupture of the Left Ven-
tricle.— R. .\. Forster's tirst patient was a woman of
seventy-nine years, slightly demented and confined to
bed three weeks with bronchitis. Death came on sud-
denly without apparent cause, .\utopsy showed pul-

March 23, 1907]

MEDICAL RECORD.

495

inonary emphysema, pericardial sac full of serum and
■clot, and a large rent in the lower and posterior walls
of the aortic arch, measuruig three inches in length
and extending round three-quarters of the circum-
ference of the vessel. The blood had evidently broken
through the inner and middle coats of the aorta, dissect-
ed its way down into the tissues between the aorta and
pulmonary artery, and finally at the origin of the latter
vessel from the heart had burst into the pericardial
sac. The walls of the aorta were thinned and showed
some small atheromatous patches, though there were
no marked signs of degenerative changes. The valves
of the heart were healthy and competent. His sec-
ond patient was a man of fifty-nine, also demented,
with atheromatous vessels, dying suddenly. Autopsy
showed left lung collapsed, and clot and serum on the
-pericardium. A rupture, measuring half an inch in
length, was present in the anterior wall of the left
ventricle, close to the intraventricular septum and mid-
way between the apex and base of the ventricle. The
edges of the rupture were ragged and the hole through
the ventricular wall was cone-shaped, the base of the
cone being the external opening. The heart muscle
was flabby, but there was no naked-eye appearance
of fatty degeneration. The aorta was atheromatous
and numerous calcified plates were seen in its walls.
The descending branch of the left coronary artery was
almost completely occluded at its origin by atheroma-
tous degeneration of its walls, and at this point the
vessel was of a stone-like hardness. This branch was
traced down to the site of rupture and evidently the
myocardium, deprived of its blood supply by the
atheromatous obstruction, had undergone the necrosis
spoken of by Zicgler as myomalacia cordis. The wall
of the ventricle thus weakened by the necrosis had
given way.

Intestinal Obstruction in Children. — Two cases are
reported by E, P. Bauman. Case i was one of acute
intussusception, reduced by manipulation, and Case 2
one of subacute intussusception simulating dysentery.
The first case completely recovered, while the second
called for surgical intervention, and abdominal incision
■was made. The patient had gone into collapse at
the time and died in two hours. The features of the
second case, which, in the author's view, are note-
worthy, were, first, the comparative rarity of these
cases of incomplete intussusception in which the oc-
clusion of the bowel is incomplete and the passage of
feces continues unimpeded, while there is little or no
vomiting. These cases may last for weeks or become
chronic and exist for months or years, death in most
instances being due to exhaustion. Secondly, there
was a considerable amount of hemorrhage from the
bowel. Usually, in subacute or chronic intussuscep-
tion, the catarrhal changes at the neck of the invo-
lution are comparatively slight and the stools are char-
acterized onlv by small hemorrhages. Thirdly, there
was the similaritv to a case of dysentery — superficial,
it is true, yet sufficiently exact to obscure the diag-
nosis. Fourthly, there were the disappearance and re-
appearance at intervals of the abdominal tumor. Ac-
<:ording to Treves a tumor is felt on abdominal ex-
amination in only fifty per cent, and rectally in only
thirty-two per cent, of these cases, and in the .paper
already quoted the author calls attention to the recog-
nized fact that the tumor, once it has been felt, may
disappear from time to time. For this reason it is
essential that the examination of the abdomen should
be undertaken both thoroughly and repeatedly. Fifthly,
the fact that another child of the same family should
also, and at about the same time, have pissed blood-
stained motions was perhaps the most perplexing factor
of this difiicult case.

Bi-ilisit Mrdira! Journal. March 2. nw;.

Two Cases of Cystin Calculi. — F. A. Southam pre-
sents histories of two cases of this rare occurrence.
In the first patient, a man of thirty-two years, the
stone which gave the usual svmptoms and was easily
detected by sounding the bladder was removed by
suprapubic lithotomy' and the patient made a good
recovery. The stone had the shape of a mushroom,
one and three-quarters inches by one and a quarter
in measurement, and was of a pale color, with an ir-
regular crystalline surface. Cystin crystals had inter-
mittently appeared with urine. In the second patient.
a girl of twenty-two years, the stone had been passed
per urethra. It was of a pear-shape, one-third of an
inch in length.

Influenza Commencing with Sudden Unconscious-
ness and Excessive Dyspnea. — The patient of VV. Har-
ris was a man of thirty-eight years, plasterer, admitted

to hospital, who had fallen unconscious while at his
work and had sli.ght convulsions. He recovered in
about twenty minutes, so as to speak, and came to
the hospital in a cab. He presented a moderate fever,
slow pulse, legs were somewhat stiff, while respirations
were very frequent — about sixty per minute. He also
complained of severe frontal headache and of pain in
his back in the lumbar region, and he was able to tell
us that he had had two similar attacks, one four years
and the other fifteen years previously. Examination of
the chest showed him to be perspiring freely; both sides
of the chest moved well, but on percussion the note
over the whole of the ri.ght front was distinctly high-
pitched, and there were numerous sticky rales to be
lieard over the right upper lobe. The arteries were
somewhat thick-walled and hard, but the urine was
of good specific gravity, and contained no albumin.
The optic discs and retins were normal, and examina-
tion of the nervous system showed no abnormal physi-
cal signs. Tentative dia.gnosis were epilepsy, cerebral
tumor, hemorrhage, or thrombosis, uremia, and pneu-
monia. The author details the reasons which led him
to reject all these and come to the conclusion that
the man had influenza, attaching great value to the
slow pulse (56) with a temperature of 99.6°. Look,
ing at the case from this point of view, the other
symptoms — the frontal headache and lumbar pain,
pyrexia, sticky rales, and cough — all clearly pointed to
this disease. Only the curious mode of onset with
sudden unconsciousness remained to be e.xplained, but,
being familiar with the literature of the disease, par-
ticularly of the epidemic of the early nineties, the au-
thor was aware of several cases having been recorded
which started suddenlv in this wav. The after-course
of his case proved this diagnosis to be correct.

Idiopathic Dilatation of the Colon. — H. P. Hawkins
makes a study of a scries of cases collected mainly from the
records of St. Thomas' Hospital. The main features of the
cases have grouped themselves as follows: (i) A history
of constipation from birth or from the earliest recollection,
which is compatible, however, with fairly good health,
until the final stage is at hand, the first sign of failure being
often a loss of weight. (2) A constipation which
often alternates with diarrhea, and which at its worst is
unlike that of obstruction, inasmuch as flatus is often
passed and fecal matter may be drained away through a
rigid rectal tube. (3) Abcjominal eidargenient, variable
or constant, often asymmetrical, with prominence in the left
iliac region, the abdomen, though distended, being seldom
tense and often surprisingly flaccid, and rarely presenting
any impairment of resonance. (4) Slow alterations in
shape, especially in the left iliac region, observable only
with patience, quite unlike the tense peristalsis seen in real
obstruction. (5) The absence or rarity of pain and vomit-
ing. Neither with real intestinal obstruction nor with sim-
ple nondilating constipation shoidd there be any confusion
when this condition is far advanced. The difficulty lies in
distin.guishing its early stage from a simple constipation,
and in recognizing the point at which the case must pass
from physician to surgeon. The author then goes on to
consider the origin of the condition, finding both an ana-
tomical and a nervous factor in its production, and studies
the anatomical morbid conditions found in the various por-
tions of the gastroenteric tract. He closes with summar-
ized accounts of the various cases on record.

Berliner klinisctu- W'ochcnschrifl. l-cbntary iS, 1007.

The Treatment of Subcutaneous Injuries of the Pan-
creas.— Karewski says that severe, isi dated, subcutane-
ous injuries of the pancreas are among the rarest of ab-
dominal lesions. Garre in 1905 was able to collect records
of about thirty subcutaneous tears of the gland, of which
only three were uncomplicated. To these, three others may
be added which have been reported since that time, and out
of this total of eleven only three patients were saved, in
each case through prompt laparotomy. The author de-
scribes a case of his own which also terminated in recov-
ery. The patient was a boy of fifteen years who received
a blow in the abdomen from a wagon pole while riding a
bicycle. He was able to walk home, but soon after went
into collapse. At the operation the head of the pancreas
was found in a crushed condition, and there was a moderate
subperitoneal hemorrhage. The pancreatic injury was
packed and the incision partly sutured. The boy made a
good recovery except for the persistence of a sinus, which
discharged pure pancreatic juice, and did not close for
nearly three months. In the after treatment careful ob-
servations were made on the influence of diet on the char-
acter of the discharge from the sinus, and it was found that,
by resorting to a diet rich in meat and fat but poor m car-
l)ohvdrates,'the juice became concentrated and very scanty.
P.v 'continuing what was practically a strict diabetic diet

^c/)

MEDICAL RECORD.

March 23, 1907

the closure of the sinus was finally secured, and the author
recommends this plan as an important feature in the man-
agement of such cases.

Miinchener mcdicinischc Wochcnschrijl, February ig, 1907.

The Operative Treatment of Laryngeal Stenosis. —

W'cndel saj's that fractures of the laryn.x, while compara-
tively rare, are serious injuries which ta.x the ability of the
surgeon, partly on account of their immediate dangers, and
partly on account of the risk of permanent impairment of
the functions of the larynx. Of seventy-five cases reported
by Fischer, the mortality was 79 per cent. Durham found
a mortality of 77 per cent, in si.Kty-nine cases, but the more
recent figures of Hopmann show a mortality of 37 per
cent, out of seventy cases. The author describes a case of
his own in which a young man fell against the edge of a
box and sustained a fracture of the thyroid cartilage. The
immediate consequences were severe, but were successfully
combated by a tracheotomy, but in the process of repair
a serious degree of stenosis of the laryn.x resulted. This
was partly due to adhesions between the posterior halves
of the two vocal cords, but on incising these it was discov-
ered that a dense cicatricial band just below was the chief
factor in the constriction. .-X laryngotomy was accordingly
done, and it was seen that there had been some displace-
ment of the fragments, so that in the course of their union
an oblique distortion of the larynx was produced. The
author describes the rather complicated method in which
the defect caused bv the excision of the cicatricial tissue
was covered in with mucous membrane, and states that the
patient recovered completely with a well-functionating
larynx, though slight hoarseness persisted.

Specific Solubility and Its Applicability in Forensic
Blood Tests. — Dehne points out the possibility of
practically making use of a property of homologous blood
sera in connection with antisera. This phenomenon, which
was first noted by Michaelis, consists in the fact that spe-
cific precipitins formed as the result of the union of anti-
serum and antigen are soluble in an excess of the latter.
Dehne describes observations made in order to test the va-
lidity of the principle laid down by Michaelis, and arrives
at the conclusion that the solubility of the precipitin in the
antigen is a specific phenomenon, for which he suggests the
term "'specific solubility." He proposes that advantage be
taken of it in order to secure corroborative evidence in
forensic blood identification work, as when positive it serves
to prove the specificity of the reaction obtained. When
dealing with very small amounts of the material to be
tested, it may also be of value in enabling the specific diag-
nosis to be made with greater certainty than would be the
case if only the ordinary precipitin reaction were available.

Deutsche incdiciiiiscltc IVoclicnsclirift, February 21, 1907.

The Treatment of Hemorrhoids by Means of Injec-
tions of Carbolic Acid. — Franck is of the opinion that
this operation has a sphere of usefulness in the work of the
general practitioner in dealing with selected cases in which
there is no local contraindication and in which general
anesthesia is undesirable. He suggests the following modi-
fications of the usual technique: The fluid injected is a 50
per cent, solution of carbolic acid in alcohol, but, before
throwing it into the hemorrhoid, this is rendered tense by
the application of a wire snare around its base. The loop
of the instrument is tightened gradually, so as to cause the
tumor to become congested slowly, and the needle is
plunged directly into the center of the mass, and several
drops of the carbolic acid are injected. The snare is not
removed until the entire mass has undergone thrombosis.
Each tumor is treated in this way, and a local dressing of
drying powder is applied. On the fourth day a dose of
castor oil is given, and by the seventh or eighth day the
necrotic tissue has usually sloughed off. Complete healing
requires from three to four weeks. The existence of deep
fissures or large size of the hemorrhoidal masses constitute
contraindications to the injection operation. The author
lays especial stress on the use of the snare in order to pro-
duce congestion of the tumor and to restrict the amount
of thrombosis, and on the employment of an alcoholic solu-
tion of the acid.

Diverticulum of the Esophagus. — Meisenburg states
that, thanks to the introduction of the use of the esophago-
scope, it is now possible to make the diagnosis of esopha-
geal diverticulum with considerable accuracy. Starck, in
his monograph, was able to collect records of ninety-three
cases reported up to 1900, but since then the number of
cases has been very largely increased. Lotheisen has de-
scribed a special form of esophagoscope for use in such
cases which is provided with a special lateral mirror in-
tended to serve the purpose of affording a view of the open-
ing into the pouch, but Meisenburg does not consider that
this is necessary in order to recognize the condition. He
gives the historv of a case in which the presence of a di-

verticulum the size of a walnut was established simply by
means of the ordinary gastric bougie, the operator finding
it possible by suitable manipulation of the handle of the
instrument to cause it to enter either the diverticulum or
the lumen of the esophagus at will. The diagnosis was
later confirmed, both by esopbagoscopy and by radiography,
and the author calls attention to the necessity for care in the
use of the former method by describing a rather serious
subcutaneous emphysema that was caused at one session
with the patient through a slight laceration of the pharyn-
geal mucosa produced through a sudden change in the
patient's position while the tube was being introduced.
French and Italian Journals.

Scleroderma Cured by Mercurial Treatment. — Pietro
Chirone discusses the etiology and treatment of sclero-
derma, describing a case observed by him that was cured
by mercurial treatment, the skin becoming soft and supple
after having been for some years hard and contracted.
The etiology is only incompletely known ; it has seemed to
result in some cases from rapid cooling of the body after
extreme heat; from a prolonged sojourn in a damp place;
from traumatism or violent emotions; from morbid condi-
tions of the genital organs, and from disturbances of the
menstrual function. It occurs most frequently between the
ages of 25 and 38. There are three prmcipal varieties :
edematous scleroderma, scleroderma in plaques, and sclero-
derma of the extremities. These forms are not entirely
independent of each other ; they may be associated with one
another, or with other similar affections, especially Rey-
naud's disease, symmetrical gangrene of the extremities,
erithromelalgia, facial hemiatrophy, and vitiligo. Sclero-
derma begins in the skin and subcutaneous cellular tissue,
after a period of indefinite symptoms, by a hypertrophy of
the tissues accompanied by induration and increase or
diminution of pigment. To this succeeds a cure of the con-
dition, or a complete atrophy of the skin, which may extend
to the periosteum and the bones. There are several theories
as to the nature of the disease : the nervous theory, which
admits a neuropathic condition and trophic alterations in
the skin ; the arterial, which depends on primary alterations
of the vessels, that is, arteriosclerosis due to alcohol and
syphilis; the dyscrasic theory, scrofula, syphilis, or chronic
rheumatism being the determining cause, and the phlogistic
theory, according to which it is essentially a chronic inter-
stitial inflammation of the skin. According to others it is
related to pathological alterations of the thyroid gland.
Histologically it is found that the corneous layer of the
skin is intact, the reticulum of Malpighi is the subject of an
increase of pigment, and the derma and subcutaneous tis-
sues show a hypertrophy of the connective tissues. There
is an accumulation of lymphoid cells along the vessels and
in the lymphatic spaces. The best remedy is mercurial
treatment, with frictions of the ointment externally, and
iodide of potassium internally.— Gi'oriia/c internazionale
dclle Science Mediche, November 30. 1906.

Physiological Pulmonary Anthracosis of Intestinal
Origin.— .According to Calmette. ^'ansteenberghe, and
Grevser. in spite of opinions to the contrary which have
been held, it must be admitted that colored dust is absorbed
by the digestive tube and can be carried by means of
the Ivmph through the mesenteric ganglia to the lungs.
It must also be admitted that the existence of a physiologi-
cal, pulmonary anthracosis of intestinal origin cannot be
contested ; and it must also be admitted that this form
nf anthracosis is absolutely identical with that which is
observed in smokers and in miners and should not be
confusc<l \vith anthracosis which is purely mechanical and
of aerial orisin.— Gazette des Hopitaux, Civils et Mili-
taircs. December 18, igo6.

Permanence of Spirochaeta Pallida in a Pigmentary
Macule Left After a Syphilitic Papule.— .\.Pisani tells
of a case of hereditary syphilis in a baby of two and a
half vears of a-^e. in which mercurial treatment had been
carefully carried out. which had a macular lesion left
after the atrophy of a syphilitic papule that had appeared
a few months after birth. The child had on only two
occasions given any s\Tnptom of syphilis, and had died
of tuberculosis of the lungs, there being no syphilitic
manifestations at the time of death. There were no
microorganisms found in the internal organs, but the
atrophied tissues in the left leg contained many spiro-
chetes, while there were no traces left of the infiltration
that had formerly existed. The spirochetes were diffused
irregularlv in the tissues: some were intracellular, some
intercellular, some well preserved, others degenerated.
The author concludes that in a oatient properly treated by
mercurials spirochetes are permanent in the atrophic resi-
dua of the specific papules even two years after apparent
cure, and that in the latent periods of syphilis the spiro-
chetes remain localized in the tissues which were the seat
of previous manifestations. — La Riforma Medico, Janu-
ary 12. 1007.

March

u)o-_

MEDICAL RECORD.

497

Maak ^nxsvaa.

American Pkactice of Surgery, A Complete System of
tlie Science and Art of Surgery by Representative Sur-
geons of the United States and Canada. Editors : Jo-
seph D. Bryant, M.D., Albert H. Buck, IM.D., of New
York City. Complete in eight volumes. Profusely illus-
trated. Volume II. New York : William Wood & Com-
pany, 1907.
The second volume of this system of surgery emphasizes
the promise of the first volume that the completed work will
make a surgical treatise without a superior in the literature
of the world. The plan of the work conlines the list of
contributors to men of North America. Whether that is
the best possible plan and one that offers a guarantee that
nothing better could have been written is an open question.
But it can be said without laying ourselves open to the
charge of chauvinism, that, taken as a body, the surgeons
of America are surpassed by none in the world, ^lany
of the great and life-saving operations have originated in
this country, and though the techninue of certain pro-
cedures may have been refined by workers in other coun-
tries, American surgery to-day has no peer, at least no
superior, anywhere in the world. -A national work, fur-
thermore, has the advantage of presenting the science of
which it treats in the form recognized and followed by the
leaders in one's own country; it is in accordance with the
teachings of the country, and the views it inculcates are
those held by the mass of practitioners. The contributors
to this volume are all men who have proved themselves
by their works and have won a national if not all an in-
ternational reputation, Thev are : W. C. Borden of the
U. S. Army, C. R. Darnall of the U. S. .Army, C. N. Dowd
of New York, V. P. Gibney of New York, A. F. Jonas of
Omaha. E. L. Keves, Jr., of New Y'ork, J. F. Leys of the
U. S. Navy, W. McD. Mastin of Mobile. D. W. Montgom-
ery of San Francisco, P. M. Pilcher of Brooklyn, J. C.
Stewart of Minneapolis, B. T. Tilton of New York, D. F.
Willard of Philadelphia, and .\. C. Wood of Philadelphia.
The subjects treated of in this volume are: "Diseases
Which Belong in Varying Degrees to the Domain of Sur-
gery (Leprosy, Plague, Glanders, Scurvy, etc.)," "Tuber-
culosis and Syphilis in Their Relation to Surgical Work,"
"Surgical Diseases of Widely Distributed Structures of
the Bodv." "Surgical Diseases Caused by Heat, Cold, and
the Electric Current," and "Simple and Complicated
Wounds." Each one of these chapters deserves a special
review, but the limits of the present notice forbid. The
reviewer, if space permitted, would criticise some of the
sections of some of these chapters as possibly lacking in
the completeness looked for in an encyclopedic treatise,
but he has no fault to find with the teaching, which is emi-
nently orthodox. The get-up of the volume is all that
could be desired. The book is heavy, indeed, but entyclo-
pedias are not manuals and are not gotten out in pocket
editions. The illustrations are umiierous and explana-
tory, and we commend the vvi.-ido.n of th; publishers in not
sacrificing the te.xt to them. Where half-tone pictures have
demanded it, moderately calendered paper has been used,
but for the most part the paper is of a dull finish, which
does not try the eyes, and the man with normal vision or
one which has been made normal by glasses, will not pay
for his study of the work, even by artificial light, with a
racking heaaaclie.

Biographic Cllxics. Volume IV. Essays Concerning the
Influence of Visual Function, Pathologic and Physiologic,
LTpon the Health of Patients. By George M. Gould.
M.D., Editor of American Medicine: Author of ".^n
Illustrated Dictionary of Medicine," "The Practitioner's
Medical Dictionary," "Borderland Studies," "The Mean-
ing and Method of Life." etc. Philadelphia: P. Blakis-
ton's Son & Co., 1906.
In this volume Dr. Gould review's the life histories of
Balzac, Tchaikovsky, Flaubert, Lafcadio Hearn, and Ber-
lioz, extracting from their bioeraphies and letters many
references to morbid symptoms which the experience of
many modern ophthalmologists teaches were due to eye-
strain. The symptoms were similar to those of Carlyle and
his wife, Huxley, Darwin, Snencer. Parker. Wagner,
Nietzsche, and others, whose troubles were recounted in
earlier volumes of this remarkable series — headache, vertigo,
nausea, indigestion, abdominal pain, mental distress, wretch-
edness, in monotonous iteration, all due to, or at least ex-
plicable by, reflex disturbances from ocular defects, and all
probably preventable by properly fitted spectacles. If Gould
is right, and no one who has experienced the relief from
recurring headaches and vertigo following the correction of
visual defects by glasses can doubt that he is in the main
correct, even if one hesitates to follow him to the limit of
his contention, the tardiness which has characterized and
still characterizes the acceptance of this truth cannot but

be deplored and wondered at. The paper on Lafcadio Hearn
is the most interesting of the series, though less instruc-
tive, since this writer's ocular defects were apparently ir-
remediable. The interest of the chapter lies in the fact that
the author and his subject enjoyed an intimate personal ac-
quaintance, and Gould points out most entertainingly the
influence upon Hearn's personal character and literary pe-
culiarities of the extreme myopia and monocular vision from
which this gifted creature suft'ered.

There are several other essays in this volume, not "bio-
graphic clinics," but bearing upon the question of eye-
strain and its enormous importance in the etiology of func-
tional disease. The first chapter is entitled "Progress" and
deals with the evidence of the gradual acceptance of the
doctrine of eyestrain by men of prominence in all branches
of medical practice. Other essays are "The Cause, Nature,
and Consequences of Eyestrain," "The Etiology of Astig-
matism," "A Study of Failures in Ophthalmic Practice,"
"The 'Exaggeration' and Hobby-Riding of the Eyestrain
Theorist." and "The Eyestrain (Origin of Epilepsy." These
articles are polemic, some of them extremely polemic, in
tone and not calculated to convince those suft'ering from
the theological disease of "invincible ignorance," es-
pecially those personally attacked. Dr. Gould is in discus-
sion a hard hitter and he hits hard in these essays. It is
a question, we think, whether the method he has chosen is
the one which will win the most converts to his views; it
certainly will not convert his active opponents — but prob-
ably nothing would. Those who are already half convinced
and those who are open to conviction will read the book
with interest, and if not converted will at least feel that
they have been repaid for the time they have given to the
reading.

Rhyth.motherapy. .a Discussion of the Physiologic Basis
and Therapeutic Potency of Mechano-Vital Vibrations,
etc. By Samuel S. Wallian, A.M.. M.D., etc. Chi-
cago : The Ouellette Press, 1906.
This is another form of treatment which is to be added
to the large aggregation of physiological methods now
in vogue, but it is apparently only a modification of what
we have known for some time as "vibration." It is not to
be denied that in this, as well as in many other methods of
a similar character, there may be some value, but unfortu-
nately the faith of the sensible reader must be shaken when
in a book of this kind by an enthusiastic advocate of some
particular "school" every disease in the calendar is brought
under the benign and beneficent influence of the method ex-
ploited. Alopecia, anuria, appendicitis, ataxia, blenor-
rhea, bronchitis, and so on through the entire alphabetical
list of diseases down to venereal affections and warts, are
all cured or benefited by "rhythmotherapeutic" procedures,
although in a number of these the writer acknowledges
the value of other means of treatment. It may be that
some day these methods will come to their own, but that
day will be indefinitely prolonged unless the subjects are
presented in a more rational manner.

Essentials of Ht.max Physiology. Bv D Noel Pa ton
M.D., B.Sc. F.R.C.P Ed. Superintendent of the Re-
search Laboratory of the Royal College of Phvsicians of
Edinburgh. Lecturer on Physiology. School of Medicine
of the Royal Colleges, Edinburgh. Examiner in Physi-
ology in the University of Glasgow and for the Royal
College of Physicians. Edinburgh; and Late Examiner in
the L'niversity of Edinburgh. Second Edition. Revised
and Enlarged. Chicago : \V. T. Keener & Co. ; Edin-
burgh and London : William Green & Son, 1905.
This handy volume contains all the physiology that is actu-
ally needed for the average student or practitioner of medi-
cine who_ does not care to take up this branch as a special
study. The author has kept the needs of the medical man
in view. ,ind has dwelt especially on the parts which have
a direct bearing on he practice of medicine, relegating
those of purely scientific interest to the background and
treating of them only in so far as is necessary to a general
comprehension of the subject. In the first part of the work
the author treats of protoplasm, the cell, and the tissues, the
latter being divided into the vegetative and the master
(muscle and nerve) tissues. Following this are sections
devoted to the senses and the nervous system. Part Second
deals with the nutrition of the tissues, with subsections on
the blood and Ivmnh. the circulatory system, respiration,
food and its digestion and utilization, interna! secretions
and immunity, and excretion. Reproduction is studied in
Part Third. The author's style is clear and easy, making
pleasant reading Upwards of two hundred illustrations,
mostly diagrammatic, serve to elucidate'the text. The book
is attractively gotten up. of convenient size and weight, and
is completed with a very satisfactory index. .A.ltogether the
work can be confidently recommended to the student as
well as to the practitioner who wishes to refresh his memory
and to keep abreast of the advances in this interesting
science

498

MEDICAL RECORD.

[^[arch 23. 1907

^nrirty sports.

MEDICAL SOCIETY OF THE COUNTY OF NEW
YORK.

Stated Meeting, Held February 25, 1907.

The President^ Dr. Walter Lester Carr, in the Chair.

The evening was devotud to a symposium on Fracture-
Dislocations of the Spine.

Fracture-Dislocation of the Spine, Causation, Symp-
toms, and Diagnosis. — Dr. Samuel Lloyd read this pa-
paper. (See page 4O5.)

Pathological Changes. — Dr. Pearce Bailey read this
paper. (See page 471.)

Surgical Treatment. — Dr. Ikvixg S. Haynes read this
paper. (See page 472.)

Dr. Joseph A. Blake saiil tliat he was more interested
in the treatment of fracture-dislocations of the spine than
in the diagnosis and the other features that had been
presented by the readers of the papers. They were talking,
of course, of fracture-dislocation of tlie spine, not the
result of bullet wounds, or other fracture-dislocations
which were apt to be associated with extensive cord lesions.
In regard to the treatment he had taken rather a con-
servative ground. At Roosevelt Hospital they had a large
number of cord injuries, but most of them were trans-
ferred. For the last two years he had taken the ground
that operation should not be denied these patients ; they
should be given the opportunity of any benefit which might
accrue from operation. Partial or complete lesions of the
cord were always serious. In regard to fracture-dislo-
cations of the spinal column without evidences of cord
lesion, it seemed to him that it would be better to operate,
to open up the canal, especially if the injury was in the
upper part of the spinal column, and try manipulation and
extension. The open operation, in his opinion, was better.
.'\11 who had attempted the reduction of the fracture-
dislocation without operation could appreciate how difficult
reduction was, and how dangerous it was if the cord was
not exposed and protected from injury. In complete
division of the cord operation was not indicated. In
partial lesion of the cord it could be divided into different
categories ; if there was a partial division with deformity,
it was better to operate. \\'hen tlie patient presented evi-
dences of compression it was better to operate. With
regard to the time for operating operation should be per-
formed before degenerative changes could take place, within
the first day or two if possible. The time for operating
was when the shock had subsided. Laminectomy per se
was not a dangerous operation and did 'not injure the
spinal column to any great extent, the integrity of the
column being preserved.

Dr. Joseph B. Bissell confined liis remarks to the treat-
ment of fracture-dislocations of the spine. He said it had
been his good luck to have seen many acute fractures,
mostly confined to the dorsal vertebrae, most of them
having been elevator accidents, and he had not seen one
case in which he did not think an exploratory laminectomy
was indicated. Operation never did harm, and it might
do good. L^nfortunately his experience had not been large
enough for him to draw any strong statements from the
results. In all the cases that he had treated he said
he would have been afraid to attempt restitution by manipu-
lation; it was better by far to operate. If the cord was
absolutely compressed or cut off, he advised that they
should always prepare such patients for 'future troubles,
that was. the occurrence of the persistent cystitis, and
therefore do a suprapubic cystotomy and place in drain-
age.

Dr. William B. Pritchard emphasized the importance
of the last remarks of Dr. Bissell regarding the prepara-
tion of patients for troubles which were to come. The
subject was not one which permitted a very extensive

experience for any of them, but there were one or two
impressions that had been deeply fixed in his mind. One
was the extreme difficulty attending the making of an
accurate diagnosis upon which to base a decision whether
operative interference was indicated. The other question
was one of prognosis. He believed the indications for
operation were chiefly negative. The final outcome in the
great majority of the cases, if operated upon, was ex-
tremely unsatisfactory ; in cases of spontaneous repair,
almost total disability resulted from fracture-dislocation of
the spine with injury to the cord. When to operate could
not be arbitrarily determined by any set rules. This was
the matter of two factors, the personal equation, plus
the experience of the specialized specialist in this particu-
lar field of medicine. It was on negative lines rather than
on positive that cures had been accomplished.

Dr. WiSNER R. TowNSEND said that certain points had
struck him in the handling of these cases of fracture-
dislocations of the spine. In the first place there was the
futility of any attempt at reduction by manipulation. It
seemed to him unwise to attempt to reduce these cases, with
or without an anesthetic, where one did not know how much
compression there was. If any attempt was made it should
be by the open operation. He had never attempted to re-
duce the deformity. He spoke of a patient seen in the hospi-
tal with a fracture-dislocation, and who was very comfort-
able in plaster. It was thought better to place some other
form of dressing on. The dressing was applied, but not in
the same way. When the patient sat up he became
cyanosed and serious symptoms set in. It seemed to Dr.
Townsend, in watching the work done in applying
plaster-of- Paris, that not eno.igh assistants were em-
ployed. The shoulder and body should be held, while other
assistants hold the head. Dr. Townsend recalled a case
of fracture-dislocation in the lower spine with symptoms
of paralysis in which the jacket was placed on in a ham-
mock, a safer method than by suspension. These jackets
should be left on for a year or more.

Dr. William M. Leszynsky' said that his experience in
fracture-dislocations was limited to the patients in the hos-
pital and seen within a few- hours, or within thirty-six
iiours. The most fatal cases were those that showed all
the signs of complete injury to the cord and where the
fracture-dislocation occured in the lumbar vertebrx. When
the injury was in this region there was paraplegia, paralysis
of the bladder, and rectum, and they were the most
unfavorable cases. Yet when one considered the element
of operation in these cases, and that laminectomy, par-
ticularly in the dorsal region, did not interfere with the
integrity of the spinal column, the patient should be given
the benefit of the doubt. He agreed with the statement
that one could not determine positively within twenty-four
or thirty-six hours that there was a complete severance
of the cord. He saw a patient one year ago within two
days after the injury. There were no positive findings of
fracture-dislocation, yet there were evidences of compres-
sion of the cord, a hemi-lesion of the cord. At least there
was a paralysis of motion on one side and of sensation
on the other of the Brown-Sequard type. The canal was
opened and a spicule of bone was found projecting from
the body of the vertebra into the cord itself. This was
rongeured off. the canal closed, but no improvement oc-
curred in a week. There was a long-continued subsidence
of the symptoms, but the paralysis remained the same at
the end of six or seven weeks. When the patient left
the hospital he was no worse. With his limited experience
he had come to the belief that, where the abdominal mus-
cles were involved, the cases resulted most unfavorably.

Dr. Reginald H. Saytje said he would like to draw
the attention of the members to the necessity of keeping
patients with fractured spines protected for a longer time
than in fractures of other bones of the body. He had had
two cases under observation where the diagnosis of frac-
ture had been made in a different hospital ; these patients

March J,^ I'joj]

MEDICAL RECORD.

499

had been kept in bed for a time and then disnnssed after
the subsidence of the symptoms. Later on, as soon as
they got on their feet again for any length of time, symp-
toms of paralysis in the upper extremities in both cases
came on. Both of these were cases of fracture of the cer-
vical spine, in one case, total; in the other, partial. The
symptoms subsided after placing on support to the head
and neck, which was continued for many months. The
skiagraph confirmed the diagnosis of fracture through the
body of the vertebra with anterior displacement in one of
the fourth upon the fifth. The other case referred to was
before the days of the radiograph, and, therefore, the diag-
nosis was not confirmed by the .v-ray.

Dr. Samuel Lloyd agreed fully witii the statement made
regarding attempts at reduction in fracture-dislocation of
the spine by means of manipulation; one was very liable
to do much damage.

MEDICAL .\SSOCL\TIOX OF THE GRE.\TER CITY
OF NEW YORK.

Slalcd Mi-rliiii;, Fcbrunry l8. 1907.

The Pkesiuen't, Dr. Thom.\s E. S-^ttkkthw.mte, in
THE Cn.MK.

Bill for the Creation of a Single Examining and Li-
censing Board for Medical Practitioners in New York
State. — Dr. Revnold Webb Wilcu.x introduced the follow-
mg resolutions, which were unanimously adopted :

Rcsohftl. That the Medical Association of the Greater
City of New York, at its stated meeting, held in New York
City, February 18. 1907, declares that it earnestly favors New
York State Senate bill No. 154 and Assembly bill No. 160,
inasmuch as they provide for the creation of a single exam-
ining and licensing board for medical practitioners, thus
obviating on the part of the State all distinctions between
the several existing schools of medicine.

Resolved, That this association is opposed to the bill
that has been introduced into the present Legislature, pro-
posing to create a special ''School of Osteopathy" ; further,
that it is opposed to the legislative creation of any special
so-called "Schools of Medicine," believing that such legis-
lation is of no advantage to the public.

Resolved, That the corresponding secretary is hereby di-
rected to send copies of these resolutions to our State Sen-
ators and .\sseniblymen, to the Speaker of the House and
to the chairman of the legislative committee of the Med-
ical Society of the State of New York.

Mental and Functional Nervous Disease in General
Practice. — Dr. Willi.am B. Noves read this paper. He
said that a discussion of mental and nervous disease from
the more technical point of view started with eliminating
those cases of purely nervous and hysterical people whose
cases did not deserve a separate diagnosis, as tlieir trouble
was merely temperamental and symptomatic. Yet the gen-
eral practitioner had to take some responsibility for these
cases, even though he realized that self-control and com-
mon sense would cure them without a physician. The
trend of recent medical literature emphasized that cases of
pure neurasthenia and pure hysteria were being nuich more
sharply defined, and as a matter of fact were much rarer
than they were formerly considered. This was obvious to
anyone who examined the records of his clinic or private
practice of recent years. The reason was the cutting away
of the relatively unimportant cases on the one hand and
considering other cases, formerly classed as hysteria and
neurasthenia, as psychoses. Just as modern internal med-
icine had made its greatest strides when working hand in
hand with the chemist, and operative surgery when bor-
rowing mechanical methods and principles from the work-
shop, and general pathology when it had learned to use
the methods and researches of the biologist, so if one
desired to get a clear and reasonable basis for the study

of nir\i.r.s and mental disease he must turn to the facts,
the methods and the theories of normal psychology. The
human mind might best be understood if wc compared
it to a boat, or to a man swinmiing in water. Wc saw part
of the vessel or of the swimmer, and wliat we saw was
the part above w'ater. Then came the water line, and below
was the submerged part. In the case of the human mind,
what we termed the part above the water line was the
conscious or objective mind. The part below the water
line, which the individual himself and the superficial ob-
server ignored, was what psychologists termed the uncon-
scious, or subconscious, or subjective mind. A healthy
average mind in a healthy body, especially in the years of
maturity, managed to keep its water line in about the
same place. Hereditary instincts, reflexes, habits, mem-
ories, and various organic sensations that seemed to be
forgotten were below the water line, below the threshold
of consciousness, and for the casual observer nonexistent.
In contrast to these normal personalities, whose water line
of consciousness did not vary to any great extent, there
was a class of individuals who possessed what was popu-
larly known as an "unstable nervous system." We might
speak of them as a class in which the water line of con-
sciousness was variable to a marked degree. In such in-
dividuals, if some definite physical condition like a tox-
emia, a strain, or a shock arose, the very personality seemed
to change. The swimmer was half out of water ; he was
obviously fatiguing himself with every stroke. He suf-
fered from innumerable disagreeable sensations that a
healthy man was unconscious of. Our education from
earliest infancy was directed toward making us ignore
thousands of sense impressions until in our adult normal
state we were completely oblivious and unconscious of
ihem. These cropped out again in the class of indi-
viduals under discussion, in wdiom the mental activity
and inhibition were rela.xed, and as a result fatigue symp-
toms were sure to appear. The balance or poise of the
personality was changed, and normal mental and physical
life was hampered by the appearance of various new and
usually unpleasant phases of personality and physical sen-
sations. The strain could easily become too great to bear,
and a complete physical breakdown might be the result.
All these persons developed the habit of introspection and
devoted themselves to a study of their new symptoms. Yet
most of these symptoms, if analyzed, were merely a part
of the subconscious mental and physical life. The fatigue
symptoms were new, but their appearance was to be ex-
pected under the circumstances. This condition we called
neurasthenia, or nervous prostration.

In the rest of his paper, and along these same lines,
Dr. Noyes discussed hysteria and the type of cases in
which the subconscious mind developed fixed ideas. Of
these the obsessions or idees fixes on the one hand, mental
ties in perfectly sane people, and paranoia on the other,
with persistent delusions and failure of reason and judg-
ment, were contrasted. Also another type of cases, not
unusual in general practice, was that where the patients,
after suffering from what one might easily call neuras-
thenia or hysteria, seemed to pass into a silly, half de-
mented or confused condition. Cases of this class were
labeled dementia prcecox. A few years ago this seemed
to be a fairly clean-cut diagnosis, and was supposed to in-
dicate a condition of permanent insanity. The diagnosis
was at present confusing, because the time limit had been
rcmowil; many of the patients improved, and little was left
but till neffati\ i>m and the primary demented condition.

The Early Diagnosis of Insanity.— By Dr. Arthur
CoNKMN BuusH of Brooklyn, N. Y. The author stated
that although some marked phase or violent outbreak on
the part of the patient was usually regarded by the friends
as the beginning of an insanity, careful inquiry would re-
veal the fact that in the majority of cases the bursting of
the storm had been preceded by a prodromal period last-
ing for mouths or years, and during which the importance

500

MEDICAL RECORD.

March 23, 1907

of the changes in the mental life of the patient had passed
unrecognized. Thus the opportunity of correcting the ab-
normal mental tendencies or guarding against their conse-
(luenccs was lost. The 'early diagnosis of insanity was
rendered difificult by the fact that there was no abstract dif-
ference between the sane and the insane mind ; that there
were no elements found in in.'^anity which were not present
in sanity ; that there was no sharp dividing line between
the two. and that our knowledge of insanity, with one ex-
ception, was purely clinical and rested on no substantial
basis. .As there was no abstract difference between the
sane and the insane mind, the recognition of the latter was
nuisl easily made by a study of the former, and the changes
in the healthy mechanism which formed the insane state.
One must be able to exclude entirely the doctrine that
the mind or soul was something apart from the body, and
be able to regard the mind as simply the product of cere-
bral activity. The psychic development of man formed his
personality or ego, and depended much on his age, educa-
tion, station in life and environment, but not wholly so. for
we inherited mental peculiarities just as we did physical
ones, for the reason already cited, that the mind was the
product of our physical brain. It was the derangement
of this wonderful mechanism which constituted an insan-
ity, for by insanity we meant a disease of the mind, and
not a simple loss of the same. In the prodromal period
the picture presented was often one of cerebral weakness,
such as was found in ordinary neurasthenia. At first the
patient often recognized his condition, and complained that
he did not sleep well ; that he was depressed and irritable ;
that he became easily fatigued mentally and was worried
about himself. But soon this recognition of his condition
was lost, and one difference was soon apparent which widely
separated neurasthenia from an insanity, and that was that
the neurasthenic recognized his true condition, while the
insane patient did not. That fact had long been recognized
and formed the basis of all our law relating to the ques-
tions concerning insanity. .-Xn insanity, from its onset,
showed itself by a disturbance of the wdiole psychic mech-
anism, although it might be most marked and remain so in
certain functions of the mind. While there was nothing
found in insanity which was not found in sanity, and while
all the changes described could and did occur at times to
a slight degree in the normal mind, it was their perma-
nency and exaggeration to a point which rendered the pa-
tient unable to jude as to the nature, quality, and conse-
quences of his acts, and thus unable to adapt himself to
his environment, which divided the sane from the insane
mind.

Aural Affections in Relation to Mental Disturbances.
— Dr. W. SuHiEK Bkv.\xt said that with respect to mental
affections, aural diseases might be divided into six cate-
gories: I. Cases of aural derangement which bore no re-
lationship whatever to mental disturbances. 2. Cases of
aural disease causing mental irritation and leading to psy-
chical affections usually colored by tlie ear symptoms.

3. Disturbances of the ear, which acted as causes of gen-
eral exhaustion and hastened the psychic symptoms.

4. Diseases of the ear, wdiich progressed to loss of hearing,
destroying the connection with the outside world and thus
upsetting the mental equilibrium. 5. Hallucinations of
hearing, which were the result of the combination of an
ear affection with a psychopathic condition, and which
w'ere caused by the subjective sensation of a disturbed or-
gan of hearing falling upon deranged higher centers. 6. Af-
fections of the ear. w'hich were secondary to the mental
disturbance. The first group occurred alone. The remain-
ing five groups might be found variously combined in any
given case. After discussing in detail these various aural
derangements and their possible bearing upon mental af-
fections. Dr. Bryant said the result of his experience in
the examination of the ears of the insane had convinced
him that ear disease was much more prevalent among the
insane than among the sane. Tn f.ict, it was the exception

not to have some demonstrable functional disturbance of
the ear. The author found it present in 90 per cent, of
the insane examined. In many of these cases a history
could be obtained which showed that the ear disease was
in existence before the insanity appeared, and in others
the condition of the ears was such that it must have
antedated the mental disturbance. His summary of the
subject was as follows: i. Insanity was usually found in
conjunction with aural diseases; in the majority the two
affections were mutually dependent. 2. Hallucinations of
hearing arose from tinnitus through the misinterpretation
of aural stimuli under psychopathic conditions. 3. Cessa-
tion of the tinnitus could be expected to relieve the audi-
tory hallucinations.

In connection with his paper. Dr. Bryant presented a
patient who was subject to distinct auditory hallucinations.
The ear condition in this case was a moderate tinnitus, as-
sociated with slight deafness and catarrhal otitis, and a
very marked degree of engorgement of the nasal mucous
membrane.

Phototherapy in Nervous Diseases. — By Dr. A. D.
KocK'.\ ELL. ( See page 474. 1

Dr. William M. Leszynskv said that while most of the
speakers had given quite a clear conception of certain
nervous diseases in a general way as they appeared from
the standpoint of the neurologist, very little had been said
as to how such cases were to be managed. What could the
general practitioner do for this class of patients after he
had recognized them?' How was he to manage a case of
neurasthenia, or hysteria, or incipient or more advanced
insanity? One of the first and most essential features in
the treatment of such cases was change of environment.
This was a difficult problem to face in dealing with pa-
tients who could not stand the expense, although steps had
recently been taken in this city to provide a free hospital
for nervous diseases.

Dr. Noyes, in closing, said that while there was ample
provision in this city for the care of general medical or
surgical cases, Bellevue Hospital and the Montefiore Home
were the only institutions that took care of patients suf-
fering from chronic nervous affections. The latter was a
model institution and there was room for at least half a
dozen similar ones in this city for the care of chronic ner-
vous disease and incipient mental disorders. It is not
impossible that private charities and church organizations
did less satisfactory work in their hospitals for acute dis-
eases than large municipal hospitals might do, but there
was an enormous field for them in caring for chronic dis-
eases, especially nervous and the less serious mental dis-
orders.

Dr. Brush, in closing, said Dr. Bryant had sounded the
keynote which he hoped would be followed in the treat-
ment of the insane. Under the old method, the treatment
(It the insane consisted essentially in shutting them out
from the world, but we now recognized the fact that these
so-called hallucinations of the insane were really illusions
resulting from faulty organ? of the body, and one of these
was the ear. If we could remove the cause of the in-
sanity before the mind was hopelessly broken down, we
would do much toward restoring the patient to a normal
mental state.

XRW YORK AC.\DEMY OF MEDICINE.

SECTION ox PUBLIC HE.\LTH.

Staled Meeting. Held Mareli 12, igoj.

Dr. Johx S. Billings. Jr., in the Ch.mr.

Milk as a Carrier of Infection. — Dr. Ch.arles Harring-
ton, secretary of the Massachusetts State Board of Health,
discussed the transmission of the nonbovine diseases es-
pecially. These were chiefly typhoid fever, diphtheria, a
group of diarrheal diseases w-hich we usually called cholera
infantum, and scarlet fever. Tn Massachusetts he had had

March 23, 1907]

MEDICAL RECORD,

501

occasion to study eighteen small epidemics of typhoid fever,
in fourteen of which the probable vehicle of infection was
the milk ; in three it was private or semi-public water sup-
ply, and in one instance it was unknown. Out of the four-
teen traced to milk, they had been able in eleven instances
to obtain a history of typhoid fever at the place of the
milk production. Typhoid infection of the milk was rela-
tively easily brought about. Out of 1,500 cases studied all
over the world, investigators had found typhoid bacilli in
the urine in about 25 per cent. About 4 per cent, of typhoid
cases became chronic bacilli carriers. The speaker enumer-
ated a number of instances in which these bacilli carriers
were the cause of infections long afterward. It certainly
was out of the question at present to examine the people
having to do with milk supplies so carefully that such
bacilli carriers would be excluded. In addition to this
there was the danger of infection by way of infected water
supplies. It had been found that extremely diluted water
could be drunk by some individuals without any harm what-
ever. They were immune. Hence the consumers of milk
infected in this way could become infected and yet no
typhoid fever be discoverable at the source of the milk sup-
ply. The speaker had seen a case of this kind in which the
water was grossly contaminated from a nearby privy vault.
Milkborne diphtheria was much less prevalent. The
bacilli were not, of course, excreted by the urine or feces,
and the disease was not waterborne.

Milkborne scarlet fever was still open to question. Epi-
demics of this character had been described, but the evi-
dence was far from convincing. He had himself observed
such an epidemic recently. On one day in January there
were 63 cases of scarlet fever reported in Boston and vicin-
ity in a population of about 800,000. In the next live days
there were 485 cases, so that the total epidemic when it
had run its course embraced 717 cases. On investigation it
was found that 84 per cent, of the cases were in families
supplied by a single large milk company doing both a
wholesale and a retail business. The milk came from 200
farms and all these were investigated, with negative re-
sults. So, also, were all the drivers and others. Finally
the infection was traced to a man tending the huge mixing
tanks, whose duty it was to taste all the milk to see whether
it was sweet or not. For this purpose an ordinary spoon
was dipped into can after can and never washed between
the tastings. The man had a suspicious tongue and sore
throat, and his sister was found at home with peeling of
the skin.

But all of the above cases of milkborne disease were as
nothing compared to the diseases in general due to the
usual dirtiness of the milk. Dr. Harrington referred par-
ticularly to the diarrheal diseases of infancy. During the
year 1905 the following deaths were recorded for the Ger-
man cities having a population of over 15,000: In March
there were 1,500 deaths, in April 1,600, in July 15,000, in
August 16,000. This was the regular picture everywhere.
The purchasing public held the key to the situation; it
should be willing to pay a little more. And yet this had
been found practically an insurmountable obstacle. It was
unfair to the clean dairyman to allow dirty milk to be
sold. There should be State and municipal regulation of
dairies and kindred institutions.

Pasteurization: the Advantages and Disadvantages
to the Consumer. — Dr. Rowland G. Freeman of New
York City began by defining pasteurization, and at once
distinguished between real pasteurization and commercial
pasteurization. It certainly was difficult to obtain good
raw milk ; hence it was necessary to pasteurize it for in-
fants' use. He claimed that the thermal death point of
tubercle bacilli should be the minimum that could be re-
garded as safe. What the thermal death point was was
still a matter of debate. He read a long list of authorities
and the degree of heat given by each. These differed con-
siderably. As a safe average he regarded 155° F. for

twenty minutes sufficient. Commercial pasteurization was
only 158° F. for fifteen seconds. This was worse than use-
less, for he had known milks to have a higher bacterial
content after this "pasteurization" than before. The pur-
pose of commercial pasteurization was only to enable the
milk dealer to market an otherwise unsalable milk. He was
opposed to commercial pasteurization, but believed strongly
in the efficiency and applicability of home pasteurization.

Pasteurization: the Advantages and Disadvantages
to the Municipality. — Dr. Joseph Roby, Deputy Health
Officer of Rochester, N. Y., said that there was one phase
of the subject that he would merely mention without en-
tering into any discussion, namely, the advisability of mu-
nicipal ownership of the pasteurizing plant. It was a
political question and not suited for a debate of this kind.
The so-called commercial pasteurization, i.e., 155° for a
few seconds, he was absolutely against. True, pasteuriza-
tion deserved some consideration. It would not in any
way reduce the cost of inspection to the city. In fact, the
milk supply should have more and more expert supervision.
He did not believe in standardizing a milk by mixing it all
together and so getting a 4 per cent, cream. It would be
better to be satisfied with it as it ran, some days high, some
days low. The newspapers and others should be taught
to discriminate between "adulteration" of milk and a milk
merely below standard. He did not think that the milk-
borne diseases amounted to much. The epidemics were
quite rare. Intelligent supervision could do a great deal
here. The farmer should be instructed as to the danger to
the milk supply from any diphtheria, scarlet fever, typhoid
and the like on his premises. The significance of a sore
throat should be pointed out to him. Pasteurization, he
thought, would tend to make the milkmen careless. They
would use any old milk. The heating also caused changes
in the milk which made it less digestible. He had de-
scribed a scheme some time ago which would largely do
away with the evils complained of. It wa3 merely the
substitution of a modified can for the milking pail. The
can held twenty q\iarts, was supplied with a slit through
which the farmer milked (through cheese cloth), and the
whole outfit was sterilized at the central creamery or dairy
and delivered sterile to the farmer. The latter milked into
it without any previous rinsing. If such a can of milk were
quickly cooled and then shipped — preferably without stand-
ardizing the milk by mi.xing in a vat — it would have a very
low bacterial content by the time it reached the consumer.
He believed that if pasteurization were adopted it should
be of such a character that tubercle bacilli were killed.
The best remedy of this tuberculosis problem he saw in
the immunization of cows as practised by von Behring, In
this way, with the milk given raw, the infants would be fed
with a milk rich in antibodies against tuberculosis.

Current Misstatements and Fallacies Regarding the
Milk and Milk Supply of New York City. — Dr. Willl^^m
H. P.-\RK of New York City began by calling attention to a
number of misstatements and inaccuracies which appeared
chiefly in the lay press, but also in some of the medical jour-
nals. Many of the writers seemed to think it was thoroughly
justifiable to exaggerate, so long as they were doing it
in a good cause. According to some, all of the contagious
diseases were to be largely wiped out. As a matter of fact,
we should not expect any such thing. Only a very small
proportion of these were milkborne. Then, too, it should
be remembered that the diphtheria bacillus does not in-
crease in the milk at the ordinary temperature at which
milk is handled. The tubercle bacillus does not grow in
milk at all — at any temperature. And yet many authors
spoke as though these bacilli were commonly found and in-
creased enormously in milk. It had been stated that a
large number of the cows in New York State were tuber-
culous. This was probably true, though the figures are per-
haps nearer 10 per cent. It had also been stated that the
milk sold in New York City was full of tubercle bacilli.

502

MEDICAL RECORD.

[March 23, 1907

This was decidedly not true. Careful experiments both
here and abroad had shown that in cows free from mani-
fest tuberculosis, but reacting to tuberculin, the milk from
the udders did not contain tubercle bacilli. It might be-
come infected if the animal or another in the stall had
clinical lesions, for then the bacilli were often abundantly
discharged in the feces. In the case of cows having tuber-
culosis of the udder the milk of course was usually in-
fected. But only about i per cent., or even less, of the
cows had udder tuberculosis. Finally, it was still a moot
point whether much tuberculosis is due to bovine infection.
Certainly everything tended to show that direct infection,
from person to person, was by far the more common
method. Of the various disease germs which did get into
milk, the typhoid bacillus was the one which would grow.
Even this, however, grew but slowly at the temperature at
which milk was ordinarily kept. This germ was easily
killed by pasteurization.

Dr. Park then discussed commercial pasteurization. It
was not a fraud, as some had said. We had no right to
limit this term to five to fifteen seconds' heating. But
he felt sure most of the opponents of this method had
not made actual bacteriological tests, for it was surprising
to see how great a destruction was effected by even very
short exposures to 140° or 150° F. He had had set up in
the Research Laboratory a pasteurizing apparatus of the
type used commercially and had tested numerous samples
of milk at various temperatures. A thirty-second exposure
at a temperature of about 150° would kill most bacteria.
It had been contended that in a pasteurized milk the
germs developed more readily than in an unheated milk.
The facts did not bear this statement out. Thus he had
heated some milk containing 300,000 bacteria per c.c. for
thirty seconds to 140° F. Tests made after heating showed
only about 2,500 germs per c.c. After cooling, the milk
had been kept in the icebox for twenty-four hours. Plates
then made showed only 2,600 germs per c.c. In other
words, no change had taken place. Several specimens had
been infected with typhoid germs. Thus before heating
the milk contained 1,500,000 typhoid bacilli ; it was then heated
to 140° F. for thirty seconds; result, 36,000 per c.c. In
one minute there were only 9,000 per c.c. and in two min-
utes no germs at all. \Mien a temperature of 150° F. was
used all the typhoid germs were killed in thirty seconds.
Experiments with diphtheria bacilli showed complete de-
struction in half a minute at 140° F. The speaker knew, of
course, that this would not kill all tubercle bacilli. Many of
these were killed, however, and experiments Had shown
that the others were injured. It certainly was worth some-
thing to kill all the typhoid, diphtheria, dysentery, and
other similar disease germs and kill a large per-
centage of the tubercle bacilli. Practical results had
always to be borne in mind. It was not necessary to
heat the milk so that every tubercle bacillus possible in
the fluid would positively be killed. Proper commercial
pasteurization had distinct advantages in certain directions.
He certainly did not think all milk should be pasteur-
ized.

Dr. L. Emmett Holt, in discussing the papers, empha-
sized the fact that milk was not the largest source of
contagious diseases in childhood. He believed that but
little tuberculosis was brought about in that way. He be-
lieved in pasteurization, but warned against expecting too
much from its adoption. Most mothers in the tenements al-
ready knew of the advantage of heating iriilk for mfant
feeding.

Dr. LixDSLEV R. Willi.vms cited Japan as having just as
much tuberculosis as we have in this country, and yet they
use but very little milk there. We should educate the peo-
ple to appreciate what a pure milk is really worth. Too
much should not be attempted by legislation. Many of our
laws were dead letters. We could not do everything by pas-
teurization alone, nor by inspection alone. Both would
probably aid us in our work of preventing disease.

Dr. SiMo.N B.ARLCH said that nineteen years ago he had
jiresented to the Pediatric Section of the Academy "A Clin-
ical .Study on the Etiology and Treatment of the Summer
Diarrhea of Infants," in which the statement was made that
sterilization of cows' milk must and would be a valuable
preventive of summer diarrhea of infants. A retrospect of
forty years enabled him to compare the fatality of the first
half of that period, during which nearly every weaned baby
fell victim to diarrhea in the summer — most of them suc-
cumbing, with the last half, during which he had never
been called upon as a family physician to sign a single
death certificate for infantile diarrhea, although infants
formed a large part of his clientele. Scrupulous steriliza-
tion of milk had wrought the magic change. This was his
warrant for raising a note of warning against a return to
raw milk as a food for infants. The portentous difference
between human milk and cows' milk was that in the one
case the milk passed directly from its source to the mouth
of the infant, while in the other the milk was liable not
only to generate its own bacterium lactis, which was so
fatal to infants, but to become infected with other patho-
genic bacteria on its more or less prolonged way from the
udder to the consumer's mouth. Sterlization or pasteuriza-
tion of milk was absolutely inefficient unless it were done
in well stoppered bottles, to which no aerial contamina-
tion could have access. Sterilization in bulk of the milk
supply of a city must prove fallacious and impracticable,
and equally fallacious was the idea that the milk supply
could be kept pure by official insnection. While the speaker
regarded official milk inspection as a distinct advance in
sanitation, he nevertheless held that all milk for infants
should be pasteurized and all milk for adults should be
boiled, unless its source was an officially certified, dairy.

The Williamsburg Medical Society.

.■\t a stated meeting, held February 13, 1907, Dr. Joseph
?iIerzbach read a paper on the "Early Diagnosis of Car-
cinoma of the Stomadi." He referred to four reasons
which made cancer of the stomach occupy the most im-
portant position among the malignant diseases of the gastro-
intestinal organs. Cancer of the stomach comprised 41 per
cent, of all cases of malignant disease. It destroyed life
more rapidly than any other tumor, excepting cancer of
the esophagus, on account of its own destructive effects and
its deleterious influence on digestion. It readily produced
metastasis. Its diagnosis was difficult and its surgical re-
moval involved technical difficulties. The diagnosis de-
pended on the history, subjective signs and objective find-
ings. A sudden beginning of digestive difficulties in an in-
dividual advanced in life whose digestion had been pre-
viously good suggested the possibility of malignant growth
and imposed care in subsequent examination. Suspicion
was further justified if the appetite progressively decreased
and was uninfluenced by proper treatment. Preservation of
the normal appetite was obser\-ed only in instances in which
the malignant process developed on the basis of a former
ulcef. Sensations of fullness and pressure after eating had
nothing characteristic, but eructations having the taste of
food taken some time before and of a foul odor were signs
of more weight. Pain was of little diagnostic importance
unless it occurred spontaneously in a location where ulcers
were not as a rule found, or if it was closely connected
with or followed deglutition and was localized at the
end of the sternum, suggesting cancer of the cardiac 3'i-
fice. Vomiting of food long since ingested was an impor-
tant symptom, taken in connection with others. Also im-
portant were small hemorrhages, but the characteristic
coffee-ground material could not be expected for an early
diagnosis. The speaker referred to the value of Falk's
benzidin test, which could detect blood in the stomach
washings even if present in a dilution of 1-200,000. Of the
objective signs, anemia had a stronger claim for recog-
nition among the early signs than cachexia. Enlargement

March 23, 1907]

MEDICAL RECORD.

503

of the left supraclavicular glands was found in a small
percentage of cases. Palpation revealed the seat of ten-
derness on pressure and the presence of a tumor, which,
however, was not to be included among the early signs of
this affliction. A tumor that could be palpated had already
passed the stage when the radical operation was feasible.
Pain on percussion at the ensiform cartilage indicated the
possibility of some pathological condition at the cardiac
orifice of the stomach. The test meal was the most im-
portant step in the objective examination. Since impaired
motility and stagnation were comparatively early signs of
carcinoma, except in the fundus, an empty stomach on the
morning following a substantial meal argued against the
existence of a malignant growth. The presence of pus,
blood, or mucus collectively or individually, were very sug-
gestive. This was particularly true of pus. In the exam-
ination of the test meal the points of great importance, when
considered collectively, were absence of free HCl, decrease
or disappearance of pepsin and rennet ferment, presence of
lactic acid bacilli in angular configuration, the presence of
amebas and spores. The speaker alluded to the method
devised by Solomon for the e.xamination of the stomach
contents for albumin. Another recent method was Holz-
knecht's radiographic examination of the stomach.

Dr. John Osborn Pal.\k read a paper on "The Treat-
ment of Inevitable and Incomplete Abortion." He dis-
cussed three cases of abortion occurring before the be-
ginning of the fourth month. The signs of inevitable abor-
tion were rhythmical uterine pains, associated with sac-
ralgia and pelvic tenesmus, chilliness or chills, nausea or
occasional vomiting, and vaginal hemorrhage. By means
of pelvic examination it was necessary to exclude ectopic
pregnancy. Examination revealed increasing uterine con-
tractions, the uterus was hard or alternately hard and soft,
and the cervix was soft, open, or dilating, and the ovum
protruding. During the first three months the ovum was
usually expelled as a whole or broken up, with more or
less hemorrhage. The management of inevitable abortion
included the control of hemorrhage, the avoidance of sep-
sis, the complete evacuation of the uterus, and its proper
retraction and involution. The speaker followed the plan of
administering a quarter of a grain of morphine hypoder-
matically, and after thorough cleansing of the parts about
the vagina, packing the cervix and vagina, with the patient
in tlie Sims, or knee-chest position. This controlled the
hemorrhage and completed the separation of the ovum. The
tampon was left in position for at least twelve hours, after
which it was to be removed and the uterine contents evac-
uated by the forceps, finger, or curette. Before the third
month the curette was best ; after the third month the
aseptic finger was best. The uterus was never to be
packed after it had been emptied, except for hemorrhage.
A firm vaginal tampon was left in for twenty-four hours,
An incomplete abortion was recognized by the bloody dis-
charge, sepsis or failure of involution, as instanced by
the soft, buggy uterus, the patulous cervix, and the detection
of fragments of the ovum. The treatment was prompt
aseptic emptying of the uterus, in order to avoid hemor-
rhage, sepsis, and adnexal inflammations. If the cervix ad-
mitted the fingdr, the patient was placed in the dorsal po-
sition, and after thorough disinfection of the parts the pa-
tient being anesthetized, the operator explored the uterus
with the finger and any portion of retained placenta or other
fetal remains was loosened and removed. The instrumental
evacuation was safer in the hands of the skilled pelvic sur-
geon and in hospital practice. If the cervix did not ad-
mit the finger, it had to be dilated, and the uterus was
then explored with the dull curette, and the contents washed
out with sterile salt solution. If pieces of adherent pla-
centa or membranes could not be removed with the finger,
forceps, or curette, it was necessary to pack the uterus
with strips of iodoform gauze, to administer ergot, and
after twenty-four hours to remove the packing and the de-
tached placenta. The after-treatment of abortions was im-

portant. It took longer to complete involution than after
labor at term. Rest in bed for ten or twelve days was im-
perative. Douches were not to be given before the end
of the first week, and then a douche of sterile water at 120°
F. twice daily, preferably with a Davidson syringe. Fol-
lowing the douche the patient was to assume the knee-
elbow position, to allow the uterus to rise out of the pelvis
and to deplete the venous plexuses of the broad ligament.
If present, a retrodeviation had to be corrected.

Chicago Surgical Society.

.•\t a meeting held February i, 1907, Dr. Edward H. Ochs-
NER reported two cases of multiple exostosis, one of which
was an exostosis the size of a filbert, springing from the
anterior surface of the right lamina of the second cervical
vertebra and making pressure on the cord. He also re-
ported one case of severe acne varioliformis of the face,
arms, and neck, which had greatly improved by the use
of a vaccine made from the bacilli and cocci found in
the pustules, according to the directions laid down by
Wright. Dr. Thor. Rothstein spoke of the symptoms
the man with exostosis showed before he was operated
on. Dr. Frederick A. Besley read a paper entitled "Rup-
ture of the Urinary Bladder," in which he reported twenty-
three cases and detailed some experiments. In the dis-
cussion of this paper. Dr. D. N. Eisendrath said his ex-
perience was limited to two cases, one of which Dr. Besley
had reported. There was one point in connection with
that case, a child, three years of age, which, he believed,
substantiated a theory advanced as to the mechanism of
rupture of the urinary bladder. The mechanism of rup-
ture of the urinary bladder in children had been but little
referred to in the literature. The child of three was
brought into the hospital one week after the injury with
an infiltration extending from the median line back to
about the level of the axilla, and from the pubes to the
costal arch. A dia,gnosis of retroperitoneal rupture was
made by exclusion, as he thought there could be no
other possibility of any subcutaneous infection having
arisen after a fall of this kind. He did a laparotomy and
found an extraperitoneal tear, but one which did not go
through the mucous coat, so that there was a slow onset
of symptoms, which could be explained by the mechanism
of the rupture ; that is, tmdoubtedly the muscular coat
must have torn first and left the mucous coat intact. He
doubted whether this could be the case until he had re-
called reporting a similar experience. Dr. Eisendrath made
some further remarks on fractures of the pelvis compli-
cated by rupture of the urinary bladder. Dr. L. L. Mc-
Arthur said the essayist stated that between seventeen
and eighteen pounds was required to rupture a bladder.
That might lead to error if the statement was not made
more clearly and specifically. He asked him if he meant
pounds to the square inch or not? A column of water,
six feet high, by gravity, makes a pressure of 2.4 pounds
to the square inch approximately. It had been his peculiar
fortune to see a bladder rupture while the irrigator with
which the bladder was being distended was held up at
arm's length on one of the stands that would hold the
irrigator probably at a height of about six feet. It was
during an operation that Dr. Danforth of Chicago was
making, and Dr. AIcArthur assisting. The bladder, on
being exposed by suprapubic incision, was found so low
as not to be reached readily. Desiring to raise tlie fundus
of the bladder, the viscus was distended with sterile water.
While he was waiting for the fundus of tlie bladder to
come up into the wound, there was a sudden spurt of
water ; he stuck his finger down and checked the stream
until the irrigator could be lowered, when it was found
that a rupture of the bladder had occurred just at the
point desired to be opened, so that without any difficulty
his finger went into the bladder through the perforation.
He mentioned a Vienna surgeon who succeeded in rup-

504

MEDICAL RECORD.

[March 23, 1907

luring the Ijladder with twelve ounces of urine. Dr. Bay-
ard Holmes had operated upon four cases of rupture of
the urinary bladder, and only one lived. Dr. John E.
Owens recalled a case of rupture of the urinary bladder
from a fracture of the pelvis. The rupture was e-xtra-
peritoneal in an otherwise healthy man. Cases of rupture
of the urinary bladder were, in his judgment, rare. He
had seen many cases of fracture of the pelvis, but this was
the only case of rupture of the bladder he had seen. Dr.
Beslcy, in closing the discussion, said there was a differ-
ence of opinion as to which coat was torn first in a rupture
of the urinary bladder, whether the mucous or serous coat.
He found in watching tears occur experimentally, as he
did in cadavers, it was not always the same coat which
was torn first. The relation was changeable. Occasionally
the mucous coat would give way first, then the muscular,
then the serous coat. In some cases the order would
be the serous coat, the muscular, and then the mucous
coat. As to the point brought out by Dr. McArthur con-
cerning the amount of pressure necessary to rupture the
bladder, he would say that the measuring apparatus used
was the ordinary steam gauge, which measured pounds to
the square inch, and it was on this basis the estimations
were made. Dr. Bayard Holmes reported three cases :
Syphilitic tumor of the testicle, syphilis of the liver, and
tumor of the colon. Dr. L. L. McArthur reported a
case of adenocarcinoma of the uterus in which he did a
hysterectomy, the patient making a good recovery. He also
presented a specimen of osteosarcoma of the lower ex-
tremity of the femur. In the discussion Dr. Carl Wagner
reported a case of osteosarcoma similar in many respects
to the one narrated by Dr. McArthur. Amputation at
the hip joint was done ; the man recovered from the
operation and was well to-day. Dr. A, J. Ochsner reported
a case of sarcoma which involved the lower end of the
femur.

At a recent clinical meeting, held at Cook County Hospital,
Chicago, Dr. Jacob Frank presented two cases showing
DoUinger's method of extirpating the glands of the neck.
He also reported a case of an old ununited intracapuslar
fracture of the neck of the femur, which he treated without
nailing or wiring, with subsequent excision. Dr. Thomas
A. Davis showed a case of gunshot wound of the spinal
column. He exhibited a man upon whom he did a modified
Kraske operation, resecting the rectum after doing a col-
ostomy. He showed a woman, seven months pregnant,
who received a gunshot wound of the thorax. She aborted
on the fifth day, but was now well. Dr. B. Brindley Eads
exhibited two cases, one of rupture of the spleen upon
which he had operated successfully, and one of exstrophy
of the bladder in a child, five years of age. Dr. William
E. S'chroeder showed a case of fracture of the second and
third lumbar vertebrae. He exhibited a patient who sus-
tained a fracture of the patella twenty-three years ago,
and who now had enormous exostoses developing from
the periphery of the cartilaginous portion of tl-ke femur.
The joint was full of fluid and had to be aspirated. Mi-
croscopic examination was negative. He showed a patient
upon whom he operated for a sarcoma of the back about
two years ago. Two months ago the tumor returned, and
had now reached an enormous size. The tumor was of
the small round-cell variety. Dr. A. E. Halstead ex-
hibited a case of hypernephroma in which the initial symp-
tom was a pathological fracture of the left femur. He
showed a patient with a large fascial sarcoma of the left
thigh; exhibited two cases of tabetic joint disease, and a
case of arthritis deformans of the polyarticular recurrent
type. He showed a case of Hodgkin's disease, and spoke
of the differential diagnosis between that disease, lympho-
sarcoma, and tuberculous adenitis. Dr. C. E. Humiston
exhibited a boy, nine years old, who fell, striking his
knee, but not producing any abrasion of the skin. Later
a pyemic abscess developed on the knee, which was opened.

and the joint was drained by the Fenger method. Dr. D.
N. EiSENDRATH showcd a patient who had three epigastric
hernias and one femoral hernia. He reported and showed
cases of retrocecal appendicitis, intussusception, sarcoma
of the humerus following an injury, and ununited fracture
of the humerus, as well as cases of ascites and venous
angioma. Dr. M. L. Harris exhibited a man who a year
ago sustained a comminuted depressed fracture of the skull.
He likewise showed a case of properitoneal lipoma.

Health Reports.— The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital
Service, during the week ended March 15, 1907:

SMALLPOX — UNITED STATES.

CASES. DEATHS.

Florida, Anthony Feb. i a- 24

Jacksonville Feb. 24-March 2 .

Tampa March 2-9

Georgia, Augusta March 5-12

Illinois, Belleville Feb. 22-March j .

Chicago March 2-0

Galesburg. Feb. 23-March 9 .

Springfield Feb. 21-28

Indiana. Elkhart March 2-0

La Fayette Feb. 25-March 1 1

Michigan City Feb. 1-28

South Bend Feb, 23-March 9 ,

Iowa, Burlington Feb. 1-28

Kansas, Kansas City March 2-0

Louisiana, New Orleans Feb. 23-&Iarch 9.40 cases, & i d'th;

1 1 cases imp't'd

Massachusetts, Chelsea March 2-0 1

Michigan, Kalamazoo Feb. 23-March 9 .

Mississippi, Natchez March 2-^

Missouri, Jefferson City J*^"-

St. Joseph Feb.

St. Louis Feb.

New York, New York Feb.

North Carolina, Charlotte Feb.

Ohio. Columbus Feb,

South Dakota, Sioux Falls Feb.

Texas, Galveston March 1-8

Hunt County Jan. i-March 8.

^A'■ashington, Spokane Feb. 23-March 2.

Wisconsin, La Crosse Feb. 23-March 2.

Milwaukee Feb. 23-March 2 .

Imported

I 2-0 . .

20-March 4 .
23-March 2 .
23-March 9 ,
Z3-March 2.
23-March 2.

1-2S

23-March g.

46

35

8

SMALLPOX — INSULAR.

Philippine Islands, Manila Jan. 12-19.

SMALLPOX FOREIGN.

Mild

Algeria, Algiers Feb.

Belgium, Brussels Feb.

Ecuador, Guayaquil.. Feb.

Egypt, Cairo Jan.

France, Paris Feb.

Great Britain, Bristol Feb.

Cardiff ■: Feb.

Dundee Feb.

Glasgow Feb.

Manchester Feb.

India, Bombay Jan.

Calcutta Jan.

Madras Feb.

Mexico, Aguas Calientes Feb.

Monteroy Feb.

Nogales Feb.

Veracruz Feb.

Russia, Moscow Feb.

Odessa Feb.

St. Petersburg Feb.

Spain, Madrid Jan.

16-23

9-16

9-16

14-2S

9-15

9-16-23. . .

16-23

16-23

22-March I.

16-23

29 -Feb. 12.
19-26

2-9

16-March 2.

17-24

23-March 2.

9-23

2-9

9-16

2-9

1-31

3
13

3
25

3
4
17

VELLOW FEVER.

Brazil. Rio de Janeiro Jan. 27-Feb.

Ecuador. Guayaqxul Feb. 9-16. .

CHOLERA INSULAR

Philippine Islands, ProWnces —

Capiz and Negros Occidental . . . .Jan. 1 2-19.

CHOLERA — FOREIGN.

India, Bombay Jan. 29-Feb. 5. .

Calcutta Jan. 19-26

Madras Jan. 26-Feb. 8. .

Rangoon Jan. 19-Feb. 2 . .

Present

361
4

Australia, Sydney Jan.

Brazil, Rio de Janeiro Jan.

Chile, Antofagasta Feb.

China, Hongkong Jan.

India, Bombay Jan.

Calcutta Jan.

Rangoon Jan.

Peru, Catacaos Jan.

Chiclayo Jan.

Lima Jan.

MaJabrigo Jan.

Paessmayo and San Pedro. .Jan.

Trujillo Jan.

Vim Jan.

5-12- •

20-Feb.

2-9. . .

Ig-26 . .

29-Feh.

19-26- .

19-Feb.

27

27

27

27

27

27

27

30

3

Medical Record

A Weekly fourual of Media' ve and Surgery

Vol. 71, No. J3.
Whole No. J899.

New York, March 30, 1907.

$5,00 Per Annum.
Sing:le Copies, tOc

^nQinal Arttrlrs.

A NEW METHOD OF OPERATION FOR
EPISPADIAS.*

By carl beck. M.D..

.NEW YORK.

PROFESSOR OF SURGERY IN* THE .NEW YORK POST-GR.\DUATE MEDICAL

SCHOOL AND HOSPITAL; VISITING SURGEO.N TO THE ST. MARR'S

HOSPITAL AND THE GER-MAN POLIKLINIK.

While the technical difficulties of changing an epis-
padiac furrow into a urethral canal are moderate
in the balanic type, the restoration in complete epis-
padias has always formed one of the most delicate
problems of plastic surgery. The usual methods,
among which Thiersch's is certainly the most bril-
liant in its conception, all show one great drawback,
namelv, the persistence of the incontinence of urine.

Fig I.

This fact is not astonishing, if it is considered
that practically the aim of these well known pro-
cedures is to cover the furrow with a skin flap. The
new arrangement looks like a canal then, but it does
not exercise a function of its own, nor does the
operation provide for a lining consisting of mucous
membrane.

In a recent case I have succeeded in avoiding
these drawbacks by an operation performed in the
following manner :

The patient, a bov of four years, suffered from
incontinence, so that his clothes were constantly
soiled with urine. On September 28. when I had
the first chance to examine him. he showed an im-

*Case presented to the Surgical Section of the New York
Academy of Medicine, November 2, 1906.

perforate, cherry-like glans, which, by being slightly
curved upwards, opposed itself against a projecting
abdominal fold above. When the glans was pulled
forward or downward, a short penis appeared, the
upper iX)rtion of which showed total absence of a
urethral canal. Instead, there was a broad furrow,

Fig. 2.

lined with a thin mucous membrane, whicli contin-
ued into a large funnel-like orifice that permitted of
the introduction of a finger into the bladder
(Fig. I). From this orifice slightly decomposed
urine dribbled in short intervals. When the penis

i:^**''*

I...

r Fig 3

was left to itself the glans covered this opening like
the cork on a bottle.

The funnel-like appearance of tiie orifice suggested
to me to dissect the surrounding walls, including
the whole urethral gutter, just the same as a hernial
sac including the cord is liberated and mobilized in

5o6

MEDICAL RECORD.

.March 30, 1907

the radical operation for inguinal hernia. This plan
was carried out by making- a continuous incision
around the funnel as well as the outer marg;ins of
the urethral .gutter, the aim being then to shell out
a coherent canal, which was meant to be the new
urethra.

the wall over the finger as if trying to put on a
glove, and then gradually freeing it from the sur-
rounding tissues. The finger served as a guide
during dissection, and at the same time drawing the
funnel-wall over it caused enough pressure to pre-
vent hemorrhage. Although the wall was naturally

*

-"■

#

•X

i

Fig.

First Step. — To secure sufficient material at the
upper portion of this improvised tube, the skin in-
cision was carried far up over the projecting ab-
dominal fold (Fig. 2). The cicatri.x-like outlines
of the fold can be recognized in Fig. 3. In Fig. 4
the outlines of the roof of the new canal are indi-
cated, the forceps on each side of the funnel lifting
the slightlv dissected wound-margins. The interior
of the funnel being lined with a thin mucous mem-

^/■X.'-

.\

fSp-"

V

\

\'''

Fig. 5-

brane makes it especially useful for the purpose. To
increase the size of the funnel, however, a small por-
tion of skin was left at its upper portion like a brim.
(Fig. 5-)

Now, further dissection was done cautiously by
introducing the index finger into the orifice, pulling

thin, it appeared to be firm, and, by holding the cut-
ting edge of the scalpel more toward the outer tis-
sues than to the wall, I avoided injuring any part
of the funnel-wall. As soon as the upper portion of
the funnel showed two inches in length, further
dissection was stopped.

Second Step. — Now a transverse incision was
made behind the glans which combined the two lon-
gitudinal incisions made alongside the urethral gut-

r

i 1 /

J : /.

\

•^

?/

\

Fig. 7.

ter at the beginning of the operation. Thus a flap
containing the urethral gutter was created, which
remained in close connection with the funnel, and
]iractically formed an integral part of it after being
freed as far as the interior of the original orifice.
There was. in fact, now a new movable hollow

March 30, 1907

MEDICAL RECORD.

507

organ appearing like a hernial sac, at the bottom
of which the neck of tlie bladder could be made out.
(Fig. 6.)

To transform this wide tube into a urethral canal
I folded its walls into several ]>ortions, pleating it
like a shirt-frill.

Third Step. — Now, by perforating the glans with
a bistouri I secured an opening which was wide
enough to permit of pulling the upper portion of the
sac through it, so that its ruffled margins could now
be fastened to the tip of the glans after the principle
of the purse-string suture (Fig. 7). They were
supported by four silk sutures, one being applied
anteriorly, another posteriorly, and another on each
side.

In order to elongate the penis somewhat, I in-
serted a small triangular skin-flap between abdomen
and penis, taking the material from the redundant
foreskin.

The loss of blood during the operation was mod-
erate. During the dissection of the funnel there was
no hemorrhage to speak of. Only the mobilization
of the urethral groove was followed bv moderate

Flc. s.

oozing, which was checked by hot irrigation and
temporary pressure.

Recovery was uninterru[)ted. The patient com-
plained of very little pain. During the first week
he had no control of his urine. On the eighth day
he could retain it for an hour, and in the third week
for two to three hours. A few days ago he retained
it for fully four hours. Now he can always pass
some water on command. The fact that there is a
stream of six inches in length after such a short
period lets me hope that in the future more power
will be developed.

It is true that the penis is still short. But it
appears longer than it was, and it is brought into a
normal position and direction (Fig. 8) instead of
leaning against the abdominal wall as before the
operation.

37 Hast Thirtv-first Street.

The application of dry hot air to the thorax has been
foiinrl very iHcfiil in cases of emphysema, chronic bron-
chitis, and bronchial asthma. The good effects are due
to actively induced hyperemia of the chest-wall and coinci-
dent depletion of the lungs. The method is contraindicated
in cases of advanced tuberculosis and cardiac insufficiency.
— Ititcntational Journal of Tlierapy.

PNEUMONIA, WITH ESPECIAL REFER-
ENCE TO THE USE OF FRESH AIR
AND A SALINE SOLUTION, AND
THE ABUSE OF ALCOHOL,
OITU.M. AND OTHER DRUGS
IN ITS TREATMENT.

Bv STEPHE.X S.MITH BURT, .A. M , M D.

XEW YORK,
pROFESSuR tJF MEDICIN'E. NEW YORK POST-GRADV ATE MEDlCAt. RL noQL.

SixcE pneumonia continues to be one of the chief
causes of mortality, and diversity of opinion still
e.xists among physicians in regard to its treatment,
repeated discussion of the subject should require
no further justification. Those giving serious
thought to the matter must perceive that, to find the
source of an infection and the means for its preven-
tion, is infinitely of more value to the human race
than any system of medication. Limited numbers
of individuals are restored to health by therapeutic
measures ; entire communities are saved from dis-
ease by wise sanitation. Pneumonia to a consider-
able extent is preventable, but so much depends
upon personal initiative for its prevention that
immediate prospects in this direction are not en-
couraging. Hence, we must persist in our endeav-
ors to discover the best means of caring for who-
ever is visited by this Nemesis of indoor^ sedentarv,
modern existence. It is a self-limited disease of
short but variable duration — that is to say, a specific
infection which, from the liability of its bacteria to
])erish, soon becomes exhausted — and ignorance of
this fact leads to many therapeutic vagaries ; disre-
gard of it to endless differences about what are the
effective remedies. The type of the disease, and
likewise the outcome, largely depend upon the extent
of the infection and the history of the patient. A
majority of those with pneumonia in early life, and,
indeed, at any time before the advent of degenera-
tive changes, fortunately recover, whatever the
method of treatment.

The best course to pursue with this aflfection, in
my opinion, is to secure for the patient repose of
mind and body, a simple regimen, and plenty of sun-
light and outdoor air. \\"e should maintain the
strength, alleviate symptoms, and avert complica-
tions as far as possible, and, withal, promote the in-
trinsic capacity of the fluids and cellular elements of
the body to overcome the virulence of the infection.
Meanwhile, however, let us attempt nothing above
all things that in any manner can injure this natural
immunity. In a laudable desire to expedite recov-
ery we are apt to lose sight of the evil results of
over-medication. The recognition of symptoms and
of complications, and the w^ell-calculated giving or
withholding of remedies will tax to their utmost the
perspicacity and judgment of the attending physi-
cian. While many persons with pneumonia may
recover without the use of drugs, a certain number
will die, owing to various causes beyond our con-
trol, despite the most skillful management; but be-
tween these extremes there are numerous examples
wherein the life of the patient depends upon the skill
and resources of the medical attendant.

First in importance, according to my view, is an
unlimited supply of fresh air to everyone, with few
exceptions, suffering from this affection. The ex-
ceptions comprise a certain proportion of those with
a terminal or a secondarv pneumonia, and possibly
some instances of idiosyncrasy, at least during in-
clement weather, where, perchance, there is not
enough vitality to endure what, as a rule, is both
bearable and beneficial. Reasoning from the eood

5o8

MEDICAL RECORD.

[March 30, 1907

effects of the outdoor care of pidmonar}-, as well as
other kinds of tuberculosis, 1 came to the conclusion
that for pneumonia a similar course had a like appli-
cation. This has been my teaching for the past
three or more years at the New York Post-Graduate
]\Iedical School, and likewise my practice whenever
and wherever practicable. My conclusion, more-
over, also was based upon tlie classic experiment of
Alonzo Clark with typhus fever, which suggested its
value in other infections. At one time, it is related,
he had 250 cases of this disease in the w-ards of
Bellevue Hospital. There were as many more and
with a great mortality under the care of his col-
leagues. Though it was winter, the windows were
removed, stoves v^ere placed before the openings to
warm the incoming air, and, except for some stimu-
lants, no other medicine was given. Not one of Dr.
Clark's 250 patients died, and in two weeks they
were convalescent. Another such experience is
recounted by Austin Flint,^ wdiich occurred as long
ago as 1853 in the practice of Dr. John H. Gris-
com. Eighty-two patients with typhus fever were
taken ashore from an emigrant ship at Perth
Amboy, N. J. As there were no hospitals or other
places of refuge, two shanties were built, boarded
on three sides, over which old sails were stretched.
Of these patients thus sheltered there were twelve
insensible at the time of removal. The medical
treatment consisted mainly of vegetable acids and
bitters, and a liberal supply of cold water and of
fresh air. All of the 82 recovered. In these open
windows and half-closed shanties, allowing fresh
air without stint, there was a lesson which it has
taken us a long time to learn. We slowly have come
to understand, however, that the outdoor air is a
vital element in the treatment of tuberculosis, and
it is my belief that, with little further delay regard-
ing pneumonia, we may reach a like understanding.
Meantime, an inborn prejudice in many of the laity,
and in some of our profession, against this pro-
cedure will have to be overcome. Nearly every
such innovation, however useful, has to fight its
way into general recognition. No person in health
takes cold while sleeping at night with w^ide open
windows, whatever the temperature, if the head and
the rest of the body are well protected. And, what
is more, those who habitually sleep under these con-
ditions store up enough energy during the night to
enable them better to withstand the infections of the
dav to which they are commonly exposed in the de-
vitalized air of the usually ill-ventilated, overheated
places in which they congregate. The widespread
fear of the outside night air probably was founded
on a former ignorance of the manner in which it is
now known malaria is acquired. It is the indoor
air, day or night, too often shorn by the steam
radiator of its life-sustaining properties, if not pol-
luted by animal exhalations, that helps to undermine
the constitution. \\'e daily subject the face, and in
breathing the lungs, to outdoor, air at all seasons,
and, if otherwise well protected, we do so ordinarily
with impunitv. Indeed, the entire surface can be
made to bear, what our faces endure now, wintry
weather practically unclothed. For instance, the
savage Fuegians manage to survive, according to
Darwin, in a cold, wretched climate almost entirely
naked, and with little shelter of any description. At
all events, during an illness like pneumonia, there is
no danger of catching cold from simply breathing
cold, fresh air. As a matter of fact, we do not catch
colds ; we catch infections : and there is much less
likelihood of being infected out of doors than in-
doors. In the Arctic regions it is said, by the way,
there are none of these diseases of the respiratory
organs.

Let us place a patient, then, with this affection in
a large, sunny room with wide open windows, if
not actually upon a roof or a veranda, and thus con-
tinually supply the extra need of air caused by the
toxemia and the consolidation. If the weather is
cold so much the better, for cold air, especially w'hen
dry, excites res])iration and thereby promotes oxi-
dation. Moreover, it is more concentrated than
warm air, and therefore contains more oxygen to a
given inhalation. In some instances there may be
an open grate fire, or any customary form of heat,
to temper the air when there is small power of re-
action. The patient must be kept comfortable by
extra bed- and other clothing. Hot water bottles
if necessarv can be placed in the bed, and screens
can be utilized for shelter from direct drafts. Two
layers of coarse wire netting, between which are
thin sheets of absorbent cotton, in the open windows,
such as are in use in the .\nnex for the treatment of
tuberculosis of the New York Post-Graduate Hos-
pital, will filter the dust-laden air of a large city
without hindering the desired ventilation. For toilet
or other purposes that require the removal of cover-
ing, a person treated in this manner can be returned
to a warm room, or the windows can be closed and
the heat turned on temporarily. These conditions,
in my opinion, aft'ord the best means for ultimate
convalescence. Pure cold air, especially when free
from humidity, is soothing to a feverish and a deliri-
ous patient, and conducive to healthful rest and
sleep : it promotes tlie appetite and impro\-es diges-
tion : it increases the strength of the heart and the
tone of the arteries ; it lessens the intensity of the
fever and the frequency of the breathing; it adds to
the bactericidal properties of the fluids of the body
and of the cellular elements, and it stimulates elimi-
nation. The fresh air treatment of pneumonia has
been tried with marked benefit in a hospital for chil-
dren in England by a physician whose name unfor-
tunately has escaped me, but who was, so far as I
know, one of the first persons to publish his experi-
ences. Nor am I alone in our country in my esti-
mate of the value of this, with respect to the disease
in question, somewhat recent departure. Northrup-
says : "Fresh air stimulates the heart, reddens the
blood, quiets restlessness, favors sleep, improves
secretion and digestion ; in short, meets mos^ of the
indications for treatment of pneumonia in infants."
And what he so truly declares in the case of infants
equally applies to adults. Likewise, Anders,^ in his
interesting article on the fresh air treatment of acute
respiratory diseases, speaking of pneumonia, re-
marks that "Naturally, then, pure air is primarily
an eft'ective prophylactic agent against the immense
majority of both acute and chronic respiratory affec-
tions," And in another paragraph he observes : "A
personal acquaintance with the fresh air method,
although somewhat limited, justifies the statement
and belief that pneumonia patients are in no danger
of contracting a cold from the perfloration of the
sick room witli fresh air, and that the mere breath-
ing of fresh air or the flowing of cool air over the
face while the patient is confined to Ued is practicallv
unattended with risk in this respect," In concluding
a valuable contribution upon this subject. Anders
remarks, among other things, that the beneficial
eff'ects of the constant breathing of cool or cold fresh
air are a lessened severity of the cough, and of the
toxemia, and. withal, a better general condition than
in cases treated by the more usual methods. In an
article recently published by Thompson,* which
everv phvsician should read and consider, he says
in regard to this subject : "The most striking bene-
fit of the uncooked air treatment is shown in case-
of pneumonia. Delirious alcoholic patients, with

March 30, 1907]

MEDICAL RECORD.

509

profound cyanosis, when taken out of the general
ward and placed at windows open day and night,
became much less nervous and restless, and dis-
tinctly less cyanosed. I formerly gave such patients
oxygen, sedatives, whiskey, and other stimulants. In
the open air they, of course, receive no oxygen and
require far less of stimulants and sedatives. During
1906 we treated in all, at the Presbyterian Hospital,
128 cases of acute lobar pneumonia. Of these
patients, 47, or 36 7/10 per cent., received absolutely
no drugs whatever — no stimulants, no narcotics, no
inhalations, no specifics, nothing except the occa-
sional laxative, which any one in bed with fever
may require, and they all recovered, in the usual
way, when the time came. Some defervesced by
crisis, some by lysis, some in five days, some in
twelve days, or other intervals. A large proportion
of these patients received the uncooked air treat-
ment and enjoyed it."

With regard to the diet, there is more danger
of overfeeding than of any lack of nourishment.
Considering that the gastrointestinal functions are
deranged, it is only hurtful to add to the system
extra burdens of digestion and assimilation. Small
quantities of pure milk, either plain, diluted with
vichy, or predigested, every two hours, possibly
fortified now and then by the yolk of an egg, alter-
nating with beef tea and various broths, such as
barley broth in particular, is a regimen that has
proved satisfactory. When a patient happens to be
sleeping naturally, by the by, rather than disturb
him, his food should be for the time being withheld.
Water must not only be freely allowed, but also
frequently urged upon the patient, for it should be
kept in mind that milk is food, though fluid, and is
adequate neither to quench thirst nor effectually to
flush the system, an important proceeding when
there is an additional poison in the body to be ex-
pelled.

A predisposing cause of pneumonia, it seems to
me, is the intestinal autoinfection which prevails so
extensively among the many overfed, poorly reno-
vated, subjects of suboxidation. When the added
toxemia of the diplococci has to be cared for by the
natural filter of the body, the liver, as e.xplained by
Hutchinson," this organ is in danger of giving out.
Failure of this hepatic function in order of time
precedes heart failure, and is almost of as serious
moment. This increased load upon the liver should
be relieved by diluents, diuretics, laxatives, and,
may be, diaphoretics, and not by attempting a direct
action upon that organ by the so-called cholagogues.

Without much doubt the fluids of the body, such
as the serum and plasma of the blood, aside from
the wandering cells, contain a substance capable of
decreasing, if not destroying, the potency of patho-
genic bacteria. Whether or not this substance,
which has been christened "opsonin" by Wright"
and Douglas (a word derived from opsono, I pre-
pare the food for), and is considered by them an
independent entity, is merely the product of the
various phagocytes as held by Metchnikofif,' is some-
what immaterial. Upon the theory that this ingre-
dient of the animal fluids aids phagocytosis, by a
chemical union with the invading bacteria wliich
inhibits their activity, Wright is making inoculations
with special toxins manufactured from disease-
producing germs designed to increase the immunity
of human serum against infections. The method
of arriving at the so-termed opsonic index of an
individual, in order to regulate the strength of a
dose, is rather complicated, and scarcely feasible
beyond the reach of a well-equipped laboratory.
However promising and interesting this, what is

called opsonic therapy, may be, concerning pneu-
monia it requires further development.

Meantime, resistance to pathogenic microbes may
be enhanced by injections, among other materials,
of a physiological saline solution. Animals, such as
guinea-pigs, thus treated, as shown by various ob-
servers, will resist doses of virus that always kill
those used as a control. An infection like the one
under consideration consumes the alkaline salts of
the blood, and augments its density to a degree that
impairs the functional activity of the living cells,
and, meanwhile, the supply of these alkaline salts, if
not the much-needed fluid, frequently is cut off by
customary dietary restrictions. Hence the sugges-
tion, first made by Henry,* of injecting a physiologi-
cal saline solution in a patient with pneumonia to
restore cellular, and also renal activity, has proved
invaluable. In fact, the introducing of this solu-
tion under the skin, a procedure known as hypo-
dermoclysis, has rescued a number of patients in
my practice, as well as in that of many others, from
impending dissolution. Care should be observed, it
must be remembered, not to inject more than one
dram of the solution to each pound of the body
weight in each quarter of an hour, lest the tissues
become injured by inundation. Such a procedure
without doubt would be useful from the beginning
in pneumonia. The administration by the mouth,
however, of alkaline salts consisting of 10 grains of
sodium chloride, 5 grains of potassium bicarbonate,
and I dram of lemon juice, to 8 ounces of pure water
every two hours, as recommended by Todd" in his
instructive article on this subject, is constituted to
accomplish, and with less trouble to all concerned.
everything, except in certain emergencies, claimed
for hypodermoclysis. It stimulates the function of
the cellular elements, diminishes the density of the
blood as shown by the decrease in the specific grav-
ity of the urine, lessens the fever, and promotes
elimination.

If pneumonia is attended by expectoration, which
is not always the case, without fail the sputa should
be destroyed, and, further, since the germs of the
disease are voided by way of the bladder and the
intestines, the urine and feces also should be de-
stroyed.

An urgent symptom at the beginning of this dis-
ease is the pleuritic pain, though fortunately it is
not always in evidence, and the remedy most fre-
quently employed for its relief is a hypodermic
injection of morphine. In truth, many physicians
consider anywhere from an eighth to a half grain
of this drug for that purpose useful and harmless,
if not indispensable. To be sure, it is not likely to
do so much harm at this stage, while the patient still
has considerable power of resistance, as when the
illness is more advanced, but any preparation of
opium is always more or less baneful in its effects,
if not dangerous, especially in old persons, young
children, and those suiTering from secondary pneu-
monia. Whence, inasmuch as this affection yet re-
mains one of the chief causes of death in this part
of the world, it would appear worth while to con-
sider whether certain conventional ways of
treatment may not contribute to this excessive mor-
tality. It has been established by experiment that
the ingestion of morbific bacteria by the living cells
of the body is one, if not the only, means of deliver-
ance froni an infection. Therefore, this cellular
function should be conserved if not promoted; cer-
tainlv not injured or destroved. Now, Metchni-
koff' relates that Cantacuzene caused the death of
some guinea-pigs, highly immunized with the chol-
era vibrio, by previously injecting them with small

510

MEDICAL RECORD.

[March 30, 1907

quantities of the tincture of opium, vvliich, as he was
able to show, paralyzed the activity of the white
blood corpuscles. i\Ietchnikoff i-emarks, apropos of
this experiment, that the phagocytes, although
. among the most resistant elements of the body, are
not entirely proof against poisons, and that opiates
and the like, which weaken phagocytic action, should
carefully be avoided. Moreover, opium with its
congeners, except in the minutest dose, depresses
and linally paralyzes the breathing centers, and also
checks every secretion save that of the integument.
We know that tlie existence of a patient with pneu-
monia in great measure depends upon maintaining
as far as possible respiration and elimination.
Breathing 40 instead of 20 times a minute, the suf-
ferer is trying by frequency to make up what is
lacking in fullness of respiration. The kidneys,
w hich are the chief means of excreting poisons from
tlie system, to say the least are sluggish in pneu-
monia. Consequently, a drug that adds to the inac-
tivity of these organs, and that tends to paralyze the
living cells and the centers of respiration, in a
malady such as this, must be injurious, if not ac-
tually hazardous.

If the pleuritic pain cannot he alleviated by such
simple expedients as an ice bag. or a hot poultice, or
else by strapping the affected side, the application of
leeches, or. still better, of dry cups, will almost in-
variably prove efficacious. But dry cupping must
be done tlioroughly. Although it is desirable to
relieve these pains, the means of relief never should
be at the expense of a patient's power of resistance.
Rather than imperil ultimate recovery, it would be
better, if otherwise without remedy, to endure for a
while some discomfort, or even suffering. Thus,
only after all other resources have failed, and the
distress is unbearable, should opium be used, even
at this early stage of the disease. The one possible
-exception to this rule is when the patient is a vic-
tim of the opium liabit. for then it may have to be
allowed, though a forlorn hope, as an essential fac-
tor of the treatment. Preparations of opium like-
wise sometimes are given to arrest or to lessen the
cough, which if annoving is not especially harmful.
In fact, the average cough of pneumonia with ex-
pectoration, for obvious reasons, rather should be
■encouraged than suppressed. Further, these drugs
are now and then prescribed in this disease to quiet
restlessness, and nearly always, in my belief, to the
patient's detriment, however comforting to his
family and friends, for restlessness at this time is
vastly preferable to a narcotic tranquility. A sim-
ple remedy such as sodium bromide, and even mod-
erate doses of alcohol, are better than opiates for
this condition. Cough and loss of rest and sleep,
however, as previously stated, are not prominent
features of the fresh-air treatment. That I am sup-
ported by good authority in my opinion of such
remedies in this affection is shown by a small part
of what Sir \Vm. T. Gairdner.'" formerly Profes-
sor of Medicine in the I'niversity of Glasgow, has
to say in this connection, namely: "I regard opium
as a drug of extreme danger in pneumonia. I am
aware that men of great eminence have taught
otherwise. But in so representing the case I am
not advocating any theory, but rather am dealing
with facts which I know to be true, and which, if
true, are such as ought to be in the mind of every
practitioner. 1 have repeatedly seen what can only
be regarded as poisonous effects from very moderate
doses of opium in certain stages of pneumonia ; and
(especially towards tlie crisis) have learned to dread
it more than almost any other drug." Morgan'^
states that he has a great repugnance to the use

of opium in pneumonia, and he is inclined to be-
lieve that many of his fatal cases owed their fatality
to its injudicious employment. Finally, with ex-
perimental proof that even small doses of opium
paralyze the activity of the white blood corpuscles,
and clinical evidence that it is harmful in other
specified ways, I feel warranted in saying that phy-
sicians should think seriously before resorting in
this disease to its administration.

The rise of temperature, such as occurs in pneu-
monia, is not only an index and measure of the in-
fection, but one of the ways in which nature checks
its progress. In the minds of some physicians fever
should be lowered at all hazards ; whereas, short of
well defined hyperpyrexia, which is exceptional, it
should be let alone, since it is not harmful, but
advantageous. High fever may tell of an extensive
infection, also it reveals an efficient jx>wer of re-
action. Moderate fever indicates either a slight in-
fection, or else a deficient power of reaction, as
often seen in secondary and terminal pneumonias.
Lenhartz'- teaches that pathogenic bacteria, such as
the pneumococci. thrive best at the normal human
bodily heat, and that they decrease in vigor with
the onset of fever, and finally die, or at least lose
their toxic properties. Bouchard'^ observes that
certain microbes are known to perish at tempera-
tures which human beings readily withstand. For
example, the bacteria of malignant pustule are un-
able to exist above 104° F., and thus cannot infect
birds whose normal heat exceeds this limit. In an
interesting experiment, by the way, Pasteur," hav-
ing reduced the temperature of a bird artificially,
was able to destroy this immunity. Increase of
heat above 98.6° F. creates a physical medium that
is inimical, if not destructive, to infectious organ-
isms. Experiments show that what are high tem-
peratures in man do not produce in animals ex-
tensive fatty degeneration, for Naunyan and
Rosenthal (Bouchard^^) were able to keep rabbits
alive for weeks with temperatures ranging between
105.8° F. and 109.4° F. without serious conse-
quences. Therefore, if the action of heat is the
same on the human heart as upon that of a lower
animal under like conditions, there cannot be much
danger in the short-lived fever itself in pneumonia.
Krehl" remarks that very high temperatures may
be haiTTiful in the same manner that a heat stroke is,
but that in fevers they are uncommon. It is pos-
sible, he also says, that a rise of temperature may
diminish the growth or the virulence of the mi-
crobes, and, so long as the elevation remains within
bounds it is relatively harmless. The rapid pulse
and respiration, the loss of appetite, and the possi-
ble degeneration of the organs, in so far as they
are directly caused by the temperature, are not in
themselves dangerous. Finally, an experiment of
Riess, quoted by Bouchard, ^^ shows that the lower-
ing of the temperature to the normal, in animals
with fever from infection, neither stays the disease
nor prevents a fatal termination. The cold sponge
bath generally is helpful in case of restlessness, and,
at the same time, somewhat of a stimulant, but, as a
rule, it is not so effective in pneumonia as in typhoid
fever, or so often necessary, especially during the
cold fresh-air treatment. At all events, none of the
antipvretic drugs, synthetic or otherwise, should be
given in this affection, for they are superfluous, if
not deleterious. Quinine in particular should not
be used in large doses, for its action on the white
blood corpuscles, as related by Metchnikoff,' has
been found, like opium, distinctly detrimental.

The condition of the heart is one of the vital ques-
tions in pneumonia. Cloudy swelling, due in great

March 30, 1907]

MEDICAL RECORD.

5"

part to the toxemia, is prone to disable this organ.
Dilatation, too, may occur, especially of the right
side, witli stasis in the veins and edema of the
lungs. If considerable these are serious complica-
tions. As stated by Todd," the blood, gradually
having been reduced in fluidity and deprived of
alkaline salts, tends to precipitate its fibrin, owing
to an increase of specific gravity. This and the
accumulation, meantime, of toxins in the circulation
finally bring on cardiac paralysis.

Pulmonary edema calls for energetic dry cupping
as well as for thorough stimulation. Ammonia,
strychnine, digitalis, and caffeine are valuable for
this purpose, but, at least in large doses, they should
be reserved for such emergencies, and not ordered
as a matter of routine. Strychnine and digitalis
are most effective hypodermically.

The integrity of the heart is best conserved in the
end by not goading it from the beginning with
stimulants simply because the patient has pneumonia.
The stronger preparations of alcohol, such as brandy
and whiskey, are seldom needed in this affection,
even as sedatives and depressants, which they are
in fact instead of stimulants. It is now pretty well
established that alcohol produces little, if any, real
stimulation. A popular belief prevails that alcohol
increases muscular and nervous energy, whereas it
simply benumbs the nerves and impairs muscular co-
ordination. Patients with a previous history of
chronic alcoholism' are known to be deficient in re-
cuperative power, and almost invariably to succumb
to pneumonia. But it is not so well known that
alcohol directly inhibits and finally destroys the
activity of the phagocytes. Deleard'-^ of the Pasteur
Institute of Lille (Metchnikoff') proved by a series
of experiments that absorption of alcohol beyond
question greatly interferes with the production of
immunity against hydrophobia. Also, he found that
rabbits which were given alcohol while being im-
munized against anthrax died of the disease, and
that control animals, which were not given alcohol,
without difficulty could be immunized. Moreover,
these laboratory tests were confirmed by Abbot,' who
showed that animals, if brought under the influence
of alcohol, became more subject to the harmful ef-
fects of several microbes, such as the bacterium coli,
the streptococci, and the staphylococci. Subse-
quently, Laitinen' performed numerous experiments
of a like nature and with similar results. For ex-
ample, sundry rabbits were given alcohol for several
days in succession, and then each was injected
through the skin with a small dose of the first vac-
cine of anthrax. Six of these so treated died after
a more or less extended illness, and they all were
found to have anthrax bacilli in their blood and
organs; whereas of four control rabbits which re-
ceived this same vaccine and no alcohol, but one
died ; the other three remained in perfect health. It
is thought by some observers, however, that a single
dose of alcohol by the mouth or hypodermically will
increase the quantity of the antibodies and tempo-
rarily the bacteriolytic power of the blood. Still, in
spite of this, alcohol ultimately has a harmful action
on the phagocytes, which are the chief means of
defence against infective microbes, as well as upon
the nerves and the rest of the tissues, and should
not be used to any great extent in the treatment of
infectious diseases, and especially in pneumonia.
Possibly the one exception to this rule may be a
case of chronic alcoholism. Burney Yeo" says that
the routine giving of alcohol in pneumonia, espe-
cially in the early stages, with the idea of preventing
cardiac failure later, in his opinion, is a serious
error. "Alcohol," he also says, "produces vaso-

motor paresis and causes dilatation of the vessels,
and it must therefore aggravate or induce tendencies
to vascular engorgement." Hay's^" account of the
influence of alcohol on the circulation, quoted from
a report by Professor Sherrington, is as follows :
"Its primary action is on the mucous membrane of
the mouth, esophagus, and stomach, and in virtue
of this action it undoubtedly acts reflexly as a car-
diac stimulant. This stimulation is neither pro-
longed nor powerful. After the absorption alcohol
exerts a specific action dilating the peripheral blood-
vessels and lowering the blood pressure, thus tend-
ing to empty the arteries and to fill the veins. On
the heart itself, directly, alcohol seems to have no
effect at all ; in large doses it enfeebles it." Also
Hay says, "Alcohol has a toxic effect upon the
protoplasm of the muscles of the heart in addition
to that of the pyrexia and toxemia." In conclusion,
he remarks, "The total action of alcohol on the
heart being depressant it is futile to give it in cases
of commencing cardiac failure with the idea that you
are combating that failure by giving a specific car-
diac stimulant."

Carbonate of creosote in pneumonia has many
advocates, and among them Smith,'" who writes of
the benefits of the drug with enthusiasm. This
remedy in doses varying from 10 to 40 minims every
two hours, is prescribed with the idea that, if begun
soon enough, it will render the exudation in the air
cells a poor culture medium for diplococci. Claim is
made that it will lessen the severity of the attack,
cause the disease to end by lysis instead of by crisis,
and decrease the mortality. Meantime, the smoky
urine which it produces is of little matter, and there
are no symptoms which are harmful or disagreeable.
It is held, too, that this remedy prevents gastro-
intestinal fermentation ; always a troublesome com-
plication. The inhalation of vaporized creosote is
recommended also by Smith,'* as well as by Robin-
son,'*' on the theory that it will have a direct local
effect inimical to the parasite. It seems to me, not-
withstanding, that unlimited fresh, and, if possible,
cold air is what is most needed in the lungs during
the entire course of the infection. The short, sharp
struggle which takes place between the invading
germs and the phagocytes at the innermost threshold
of the body leaves in its wake a more or less ex-
tensive exudation, but the most serious result of
this encounter is the subsequent toxemia caused by
the entrance of the prevailing diplococci into the
systemic circulation. Here the contest continues
and the chief reliance of the patient is upon the
living cells, the serum and plasma of the blood, and
the emunctories. All these are best stimulated and
kept in activity by the constant breathing of cold,
fresh air, and the taking of the alkaline salt solution.

Oxygen by inhalation may be of benefit if well
diluted and given early in the attack, but, as a
last resort, though it lessens the cyanosis and dis-
tress of the patient, it fails to keep him alive. How-
ever, this gas is seldom required during the open-
air treatment. Chloroform is used likewise by a
number of physicians, and favorable results are re-
ported, but I am not one of its advocates.

Local applications to the chest in pneumonia, such
as hot poultices of whatever composition, or flannel
and oil silk jackets, are valueless so far as the dis-
ease itself is concerned. Cold, wet cloths, on the
other hand, or preferably ice bags, are considered
serviceable by many practitioners.

With respect to the use of the lancet in this af-
fection little can be said as a result of experience
by the medical men of this generation. Its former
abuse gave rise to a reaction that possibly may have

512

MEDICAL RECORD.

[March 30, 1907

gone too far in the opposite direction. While there
are some instances of obstruction to the right side
of the heart possibly requiring venesection, the chief
danger to this organ is more often a parenchymatous
degeneration which requires stimulation. How-
ever, with an extensive lesion of this nature there
will not be much reserve power in the heart left for
stimulation. In these days bleeding sometimes may
be of advantage, but, as a rule, the average city
patient needs all the blood in his body for future
contingencies.

When arterial pressure is high in the beginning
it should, in my judgment, be left alone if not low-
ered by some simple remedy, such as a laxative or
perhaps a little alcohol. Aconite, veratrum viride,
tartar emetic, and the like, are worse than useless;
they are actually harmful ; they depress the action
of the heart, and thereby produce one of the things
we desire to avoid, namely, internal capillary stag-
nation. If there is high arterial tension associated
with arteriosclerosis, nitroglycerin is the remedy, but
it is permissible only under these circumstances.
Low arterial pressure with fairly normal heart
sounds is mistaken now and then by a novice for
cardiac weakness. The vasomotor centers of ani-
mals infected by the diplococci are paralyzed from
the first in varying degrees, as shown by Krehl;^*
meantime, excited action of the heart for awhile
overcomes tlie initial tendency to a fall in arterial
pressure which, however, eventually takes place.
There may be a sudden failure of circulation, due
to dilatation of the large abdominal vessels without
previous warning. When these splanchnic vessels
are involved the resulting collapse needs prompt and
energetic treatment. It is much like what happens
in surgical shock, and the intravenous injection of
one ortwo drams of the i :iooo solution of adrenalin
in a pint of physiological saline solution, as sug-
gested by Hare=" for such a happening, may chance
to avert immediate dissolution under these analogous
conditions.

With the loss of vasomotor tone chiefly in the
smaller arteries, and weakness of the first sound
of the heart at the apex, and of the second sound
at the aortic cartilage, besides accentuation of the
pulmonary second sound, a giving out of the en-
tire heart is threatened, if not imminent, and stimu-
lants are indicated. Aromatic spirit of ammonia,
Hoffman's anodyne, ergot, caffeine, digitalis may
be taken by the mouth, or, in still more pronounced
symptoms, strychnine alone or with atropine in
large doses hypodermically. Should marked cya-
nosis with distention of the veins, dyspnea, labored
action of the heart, and weakness of the pulse super-
vene, together with signs of pulmonary edema, the
manifest engorgement of the right side of the heart
possibly may be relieved by venesection, but at this
juncture a critical moment commonly has been
reached where much is done in desperation and little
accomplished.

REFEREK'CES.

1. Flint, Austin : "A Treatise on the Principles and Prac-
tice of Medicine," 5th Ed., 1884.

2. Northrup, W. P.: "Pneumonia in Infants; Early Diag-
nosis and Fresh Air Treatment," A^ Albany M. Herald,

1905. 23.

3. Anders, James M. : "The Fresh Air Treatment of
Acste Respiratory Diseases with Especial Reference to
Pneumonia," Medical Record, July 7, 1906.

4. Thompson, W. Oilman: "Fresh Air Treatment in
Hospital Wards," Medical Record, February 9, I907-.

5. Hutchinson, Woods : "The Liver as a Toxin Filter,"
The Practitioner, 1906, Vol. 77, No. 5.

6. Potter. Nathaniel Bowditch, Ditman, Norman E..
Bradlev, Ernest B. : "The Opsonic Index in Medicine,"

Journal of the American Medical Association, November
24, 1906, and December i, 1906.

Aaron, C. D. : "A Clinician's Observation of Opsonic
Therapy," New York Medical Journal, December
I, 1906; also,
Weinstein, E. : "The Basis and Amplication of
Wright's Opsonin Theory," Berliner klinische
Wochcnschrift, 1906, No. 30.

7. Metchnikoff, Elie : "The Hygiene of the Tissues,"
Journal of Preventive Medicine, June, 1906.

8. Henry, F. P. : "Hypodermoclysis in Pneumonia," In-
ternational Clinics, Vol. 4.

9. Todd, John B. : "Alkaline Beverages in the Treat-
ment of Pneumonia," N. Y. Medical Journal, May 20, 1905.

10. Gairdner, Sir Wm. T. : "The Extreme Danger of
Opium in Pneumonia," Glasgow Medical Journal, April,
1902.

11. Morgan, Dudley: "When to Use Medicine in Pneu-
monia," Medical Record, November 17, 1906.

12. Lenhartz, Hermann : "Manual of Clinical Micro-
scopy," by Prof. Herman Lenhartz, translated by Henry
T. Brooks, 1904.

13. Bouchard, Ch. : "Lectures on Autointoxication in
Disease," translated by Thomas Oliver, 1894.

14. Krehl, Ludolf: "The Principles of Clinical Patholo-
gy," 1905, translated by Albion Walter Hewlett.

15. Yeo, I. Burney : "Manual of Medical Treatment,"
Vol. I,

16. Hay, John : "Two Hundred Cases of Acute Lobar
Pneumonia," The Lancet, June 11, 1904.

17. Smith, Andrew H. : "Creosotal in Pneumonia," The
American Therapist, New York, January 15, 1905, No. 7.

18. Smith, Andrew H. : "Essential Nature of Croupous
Pneumonia," 1896.

19. Robinson, Beverley: "Some Points for Discussion
Relating to the Prevention and Treatment of Pneumonia."
Medical Record, April 7, 1906.

20. Hare, Hobart Amory : "A Text Book of Practical
Therapeutics," Tenth Edition.

ON LOCALIZATION IN MULTIPLE INTES-
TINAL OBSTRUCTION, WITH
ILLUSTR.^TIVE CASE.*

By G. A. FRIEDMAN, M.D.,

NEW YORK.

ASSOCIATE TO THE MT. SINAI HOSPITAL DISPENSARY; VISITING PHYSICIAN
TO THE METROPOLITAN HOSPITAL A.N'D DISPENSARY.

Every clinician knows how difficult it is at times to
determine whether or not a given case is one of
obstruction of the intestines. It is universally rec-
ognized that the diagnosis of obstruction belongs
to the most difficult in the pathology of internal dis-
eases. How often has laparotomy, performed for
symptoms of obstruction, led to disappointing find-
ings at the time of the operation. As an example,
we can point to the symptoms of obstruction simu-
lated by hysteria or to a condition of paralytic ileus.
On the other hand, a condition of obstruction is
often revealed during an operation or on the autopsy
table, when such was not in the least suspected
before the operation or during the life of the patient.

In case a positive diagnosis of obstruction has
been made, we are still by far not ready for a thera-
peutic interference with the condition, granting, of
course, that we are not willing to act blindly or to
force upon the surgeon an exploratory laparotomy,
for it is clear that by the term "occlusion" or "ob-
struction" we have named only a symptom. It is
accordingly necessan*- to designate the seat of such
occlusion or obstruction, which of course may not
always be possible if one does not count self-evident
cases with classical symptoms. And when we have
made a positive diagnosis of occlusion or obstruc-
tion naming as its seat the large or small intestine,
there may yet arise the question whether a second
part of tlie gut may not be affected bv a similar con-
dition, the answer to which is of the utmost impor-
tance to the operating surgeon. Cases have already
been recorded in which the symptoms of obstruc-
tion persisted after a laparotomy, so that a second

*Read before the Eastern Medical Society of New York.

March 30, 1907]

MEDICAL RECORD.

S13

operation was made necessary for the detection of
the additional seat of obstruction. Even when
these difificulties have been overcome there still re-
mains the third question of the exact pathological
condition leading to the symptoms of obstruction,
and finally the problem of how to deal with any
given case, whether to treat the patient medically in
a conservative manner, or to resort immediately to
surgical interference. The latter, moreover, is
easier to decide in acute cases than in those that
run a subacute or chronic course.

Our case is especially interesting because all the
conditions for an exact diagnosis appeared one by
one during the time of observation ; the obstructions
at two places were pointed out, the pathological con-
ditions were precisely named, and surgical inter-
ference was insisted upon. The surgeon will be in
position to communicate to you how useless would
have been further palliative treatment which might
have led to irreparable and disastrous consequences ;
the adhesions would have only increased in number,
the intestinal coils would have become more closely
pasted together, thus lengthening the time of a later
laparotomy and narcosis, and reducing very much
the chances for recovery of the little patient. More-
over, a subacute ileus could suddenly have developed
into an acute condition, and thus led to a most
deplorable result.

Boas, with reference to the difficulty of making
the diagnosis in such cases, states the following:
"Of all varieties of occlusion of the intestines this
particular variety is the most interesting from the
scientific, most frequent from the practical stand-
point, yet most unsatisfactory from the standpoint
of diagnosis." He continues in another place : "One
is exposed to vuiavoidable mistakes in those rarer
cases of simultaneous obstruction of the small and
the large intestine, which Treves has described in
his monograph, and to which Hochenegg has called
attention more recently. In these cases of "combina-
tion ileus" one must be prepared to find multiple
invaginations, cicatricial strictures, peritoneal ad-
hesions, conditions of volvulus, all of which even-
tualities are of course beyond the possibility of diag-
nosis.*

Before we enter any further upon the reasons
which enabled us to arrive at the diagnosis in our
case, we want to state the patient's history.

David Fuchs, two years and ten months old, was
brought to my office by his father on October 28,
1906. The father stated that the child was in per-
fect health until September 22 ; on that day it
was struck by an express wagon, but was not run
over. The patient was much frightened and was
brought home fully conscious. That night it vom-
ited once, the vomitus consisting of undigested
food that had no fecal odor whatever. For the
eight days following the child was perfectly nor-
mal. On September 30 violent pain set in in the ab-
dominal cavity, as well as vomiting and constipa-
tion, yet without a trace of fever. In a few days
a marked swelling of the abdomen was super-
imposed upon these symptoms. After ten days (on
October 8), completely normal stools were reestab-
lished, the swelling of the abdomen receded par-
tially, yet the continuous pain and the vomiting
showed no tendency to cease. Upon the advice of
the attending physician the child was taken on the
eleventh day of his illness to a hospital. According
to the father, the child, during his stay in the hos-
pital, did not vomit at all, had no pain, no constipa-
tion, and was therefore discharged after twelve
days. For the six days following the child felt per-

*Boas: Krankheiten des Darms, 1901, page 442.

fectly well, but in the three days preceding our first
examination he had violent pain with and without
vomiting each evening. Constipation and fever
were absent. The father could not attribute tlie
aggravation of the trouble at home to any gross in-
discretion in diet, the old symptoms reappearing
although the same semisolid diet was continued.
The child was said to have lost much weight since
September 22, having been a well nourished, robust
child before the accident ; he was said to have begun
walking at eleven months and had not passed
through any acute infectious disease in his infancy.
Syphilis was likewise denied.

Status Prassens: — First Examination (October
28). The patient possessed a well developd bony
frame, ratlier weak muscles, and a much reduced
panniculus adiposus. The visible mucous mem-
branes were quite anemic, the belly was very much
swollen, and the abdominal veins very prominent
in the shape of a caput medusre. Palpation from
the umbilicus to the various abdominal regions dis-
closed no tenderness on superficial or deep pressure.
The child continued to moan just as before the ex-
amination, apparently from fright. The lower bor-
der of the liver and the spleen were not palpable
nor could a sensation of resistance be disclosed any-
where in the belly by a most thorough palpation.
The existence of freely movable fluid in the de-
pendent parts of the cavity was easily perceived.
Percussion gave loud tympanitic sound all over,
showing the existence of diff^use meteorism. Liver
dullness could not be found because of this condi-
tion. Auscultation revealed the presence of widely
distributed gurgling sounds and borborygmi. Ex-
amination with reference to a possible appendicitis
was negative — McBurney's point not tender — rectal
examination also was negative. There was no evi-
dence of hernia ; both testicles could be felt in the
scrotum, and the rectal temperature was 98°. The
organs of respiration and circulation were normal,
the pulse was 100, easily compressible but regular.
The examination of the urine gave the following
data : The color was light yellow, reaction strongly
acid, no albumin, no sugar, diazo test negative, no
casts, and only a few squamous epithelial cells. In-
dican was in excess.

The child was kept in the office for one hour,
with abdomen bared, in the hope that an attack of
pain might intervene. This, however, did not occur.
What could have been the diagnosis on this examina-
tion and what advice could we offer to the child's
father? If we summarize the data obtained we have
the following:

A. History:— (i) Trauma. (2) Vomiting —
nonfecal — once in the night following injury. (3)
Absence of any symptoms for eight days with abso-
lute good health. (4) An illness of ten days' dura-
tion with continual violent pain, frequent nonfecal
vomiting (four or five times per day), obstinate
constipation. (5) Again cessation of all symptoms
for eighteen days (twelve days in the hospital and
six days at home). (6) Paroxysmal pain of
three days' duration with and without vomiting.
(7) Absence of fever throughout.

B. Physical Examination: — (i) Absence of ten-
derness in the abdomen. (2) Freely movable fluid
in the peritoneal cavity absolutely shown. (3)
Diffuse meteorism. (4) Well distributed bor-
borvgmi, and (5) Excess of indican in the urine.

The first thing suggested by the above symptoms
was peritonitis, for the existence of which as the
sole condition spoke the following facts: (i)_The
initial trauma. (2) Continuous pain and vomiting.
(3) Persistent constipation. (4) Freely movable

514

MEDICAL RECORD.

[March 30, 1907

fluid in the peritoneal cavity. (5) Diffuse meteor-
ism, and (6) The excess of 'indican in the urine.
The absence of tenderness and of fever, as is well
known, do not in the least exclude the existence of
peritonitis. If we were to consider the above com-
bination of symptoms without reference to the
history v.'e could not but diagnose the case as trau-
matic nonseptic peritonitis.

But was this the sole cause of the above condi-
tion of afifairs? No, for it would have been diffi-
cult to accept the existence of peritonitis as the sole
pathological condition. What kind of a peritonitis
could it have been that, having begun with such
violent symptoms, continued for ten days, then dis-
appeared for eighteen, only to reappear again with
somewhat less intense manifestations? Accordingly,
peritonitis could not be accepted as the one and only
cause of the above complex of symptoms. Intes-
tinal dyspepsia could not be thought of, because
vomiting is very rare in that condition, and the his-
tory of the case showed no symptoms whatever, that
should have preceded such a condition. Moreover,
the onset after injury did not speak for this diag-
nosis. The paroxysmal attacks of pain with and
without vomiting, in the three days before our ex-
amination, even in the absence of constipation, of
necessity directed the attention to the possibility of
obstruction or partial occlusion, caused by condi-
tions in or outside of the gut. But it is well known
that symptoms of occlusion can appear without the
existence of the condition itself, for example, in
cases of spastic ileus of hysteria or the paralytic
ileus with or without peritonitis. Hysteria could
not be thought of in this case. For the existence
of paralytic ileus spoke the history of injury, the
well marked diffuse meteorism, the pain, and vomit-
ing. But could such a paralytic ileus disappear en-
tirely in order to reappear again after eighteen days ?
Moreover, the well distributed gurgling sounds
could not allow the acceptance of such a diagnosis :
in paralysis of the gut, as is well known, there reigns
a dead stillness in the abdominal cavity.

The critical consideration of these possibilities
compelled us to accept the existence of true mechan-
ical obstruction as responsible for the symptoms.
Now, did we have to deal with a stenosis caused by
scars in the interior of the gut? This could be ex-
cluded, for the history of the case mentioned no ill-
ness whatever that could have led to such a condition
— no dysentery — no syphilis — no tuberculosis — no
typhoid fever. The existence of a new growth could
also not be considered : there was no sensation of re-
sistance— tumors are not usually caused by injury —
and the time, moreover, was too short to allow the
development of a tumor, while the patient's condi-
tion showed no cachexia, but only a well marked
anemia.

There remained only, among the rarer affections
of the intestinal canal, thrombosis or emboli of the
mesenteric vessels which may lead to a similar com-
bination of symptoms. This, however, was easily
excluded by the absence of any heart or vascular
disease. The partial occlusion, then, could be caused
by volvulus, by strangulating bands and adhesions,
or by intussusception. Volvulus could be excluded
on many grounds ; it occurs more usually in the sig-
moid flexure, there is usually a history of long con-
tinued constipation, it is a disease of advanced age,
the characteristic stool of stenosis is seldom missed,
as well as the localized meteorism (W'ahl). Now, it
remained for us to decide whether the symptoms
of the case, with the light thrown upon them by the
history, were caused by intussusception or by stran-
gulating bands and adhesions. We could not, how-

ever, accept the existence of the latter condition
as yet, because in the first place we failed com-
pletely to elicit any sensation of resistance in pal-
pating the abdomen, and secondly, because a very
important symptom, that of visible peristalsis, had
been absent throughout. Had we at that time made
a diagnosis of strangulating bands and adhesions,
which we were enabled to do later by the appear-
ance of further symptoms, then it would have been
a simple guess on our part. Therefore, we were
compelled to make the provisional diagnosis of in-
tussusception.

But even here there lacked an important objective
sign, that of the existence of the sausage-shaped
tumor of invagination. Yet we had a plausible ex-
cuse for the lack of that sign — the tumor may have
remained undetected because of the pronounced dis-
tention of the intestines. The free fluid in the ab-
dominal cavity, even had we completely given up the
diagnosis of peritonitis, did not at all exclude the
existence of intussusception. It is self-evident that
a bit of the mesentery could have been inclosed in
the process, producing stasis in the mesenteric cir-
culation and thus leading to the transudation of
free fluid into the peritoneal cavity. The general
meteorism spoke somewhat against intussusception;
that, however, only caused us to suspect the exist-
ence of a second spot affected in the same fashion.

The history of injury and the age of the patient
confirmed the above diagnosis. We transferred the
supposed seat of the invagination to the small intes-
tine because of the excess of indican in the urine.
Such excess alone does not at all indicate that the
seat of the affection is in the small intestine, be-
cause a pronounced and long continued fecal stasis
in the large gut could likewise be responsible for it.
In our case, however, the excess of indican sf)oke
for putrefaction in the small intestine only, because
constipation and accordingly fecal stasis did not ex-
ist for twenty-one days. In explanation of the in-
tussusception we could fall back either upon the
spasmodic theory of Nothnagel or the paralytic
theory of Leichtenstern.

According to the first theory we could completely
ignore the initial local peritonitis. The injury may
have caused a ring-like tetanic contraction in one
part of the intestines ; this acted as the invaginating
element over which the part of the gut below the
place of contraction was thrown. If you follow
the paralytic theory, then we are compelled to as-
sume the existence of primary local peritonitis. A
certain portion of the intestine may have been par-
alyzed and this invaginated into the active non-
damaged gut immediately below by becoming
everted into the latter's lumen.

The final diagnosis, then, was : Invaginatio par-
tialis enterica, and the father was advised to have
the child operated upon.

On the next day we had an opportunity to demon-
strate the patient to a number of physicians. The
following diagnoses were made : Traumatic peri-
tonitis, Tuberculous peritonitis, Colica flatulenta.
Paralytic ileus with and without peritonitis. Dr.
Sturmdorf, who was asked especially for surgical
advice, was of the opinion that, while a stenosis of
the intestinal canal could not be excluded, still the
absence of man}- symptoms prevented him from
making that diagnosis, and the seriousness of the
op>eration made him hesitate to recommend an ex-
ploratory incision at that time.

Ex concilio, it was decided to place the child in
the Metropolitan Hospital, put him on a semisolid
diet, wash his stomach, and give high rectal irriga-
tions. The child remained in the hospital for eight

March 30, 1907]

MEDICAL RECORD.

51S

days till November 5, during which time it was
carefully observed. No pains or vomiting oc-
curred during this time and the stools were one or
two per day of a normal character. The meteorism
disappeared almost entirely. The child played,
took nourishment with relish, and show'ed no dis-
turbance of the gastrointestinal tract.

Now the objections against our diagnosis were
put before us with renewed emphasis. We were
told that the child was not in any serious condition,
and that most likely he was suffering from intes-
tinal dyspepsia. This condition would of course be-
come worse at the home of the patient, because a
strict diet would not be adhered to. Notwithstand-
ing the striking results of the hospital treatment we
continued to insist upon the absolute indication of
a laparotomy. In this we w'ere not prompted by a
mere curiosity to see the patient's "insides," but
because there was one element, the excessive amount
of indican in the urine. We reasoned as follows :
The child's intestinal tract was thoroughly cleaned
out, per OS and per rectum ; where then existed this
putrefaction as shown by the persistence of the
excessive amount of indican? The nondisappear-
ance of indican could be explained only by a tem-
porary occlusion in the gastrointestinal canal. How-
ever, at the request of the father, the child was
discharged from the hospital on November 5.

In the evening of the 9th, we again demonstrated
the patient to a number of physicians. Fortunately,
an attack of pain occurred during the discussion.
Two parallel peristaltic waves were observed be-
tween the epigastric region and the umbilicus. Now
the existence of an obstruction was evident to all
present; yet the consensus of opinion was that the
case did not at all call for surgical interference. Nat-
urally the high mortality of operations with the nec-
essary search for the place of occlusion was men-
tioned, since the place of affection designated by us
was not considered proved. Upon our insistence,
however, the child was placed in the surgical divi-
sion of the Metropolitan Hospital under the care
of Dr. Sturmdorf. We now took pains to make
our diagnosis more exact. The provisional diag-
nosis of intussusception was of course excluded by
the occurrence of visible peristalsis. The diffuse
meteorism had already given us cause to suspect,
as we have mentioned before, that perhaps another
part of the gut was involved by the occlusion. The
two waves of peristalsis now strengthened our pre-
vious suspicion. The very moment we had given
up peritonitis as the sole cause of the above symp-
toms and accepted occlusion of the gut as the prob-
able diagnosis, the diffuse meteorism could be as-
cribed almost exclusively to the latter condition.
Yet a single occluded part could not produce such
a high degree of meteorism and its excess could be
due only to a second site of obstruction.

The next few days the child's stomach was
washed each morning before breakfast and after
the last evening meal. In no instance could bile or
pancreatic ferments be discovered in the washings.
This absolutely excluded a stenosis of the gut below
the entrance of the common bile duct. High seated
duodenal stenosis was not to be considered, since
we had no symptoms, referable to the stomach.
There was no stagnation in the stomach, moreover,
and consequently no pyloric obstruction. As is
well known, the symptoms of the latter coincide
with those of tlie high seated duodenal obstruction,
so that this also could surely be excluded.

The thorough daily palpation revealed to us one
day a cord-like resistance in the peritoneal cavity ;
this extended from the region of the ileum to the

left toward the descending colon. In this fashion
we could locate more exactly the second suspected
place of occlusion ; the "X" being discovered we
could now easily determine the second unknown
quantity. The indican content could have been
caused only by an occlusion at a higher level and .
this, in accordance with the above considerations,
could only be the jejunum. Autopsies and laparato-
mies have shown before that strangulating bands
about the jejunum are very common, and accordingly
our complete diagnosis was : Subacute partial ileus
caused by a strangulating band around the jejunum
and adhesions between ileum and the descending
colon. Palliative treatment we considered useless,
and we tlierefore surrendered the case to Dr. Sturm-
dorf for a laparatomy.

Now, what was our explanation of the course of
affairs in this case ? Because of trauma, there
gradually developed a local circumscribed peri-
tonitis, which having run its course without tem-
perature, was not of a bacterial nature. This peri-
tonitis existed as the only pathological condition
for either ten days (vomiting, pain, constipation),
or for eighteen days, if we do not ascribe the vomit-
ing on the night following injury to shock. Patho-
logically the peritonitis was of the plastic exudative
type. The free fluid in the abdominal cavity was
due only to the peritonitis, while the adhesions re-
sulted because of the plastic character of the in-
flammation. The period of eighteen days, during
which the child felt perfectly well, was necessary
to afford the time for the formation of adhesions
and of the strangulating band around the jejunum.
As soon as the adhesions and this band reached a
sufficient degree of development there intervened
of necessity the first symptoms of obstruction, such
as the paroxysmal attacks of pain for the three
days preceding our first examination. The ad-
hesions could not be palpated at that time, nor for
some time following, because they were forming
while the patient was under observation. This case
shows therefore how quickly adhesions follow a
peritonitis of short duration.

We have presented this case so extensively be-
cause it differs markedly from the ordinary run of
cases ; there were present really only fragments of
symptoms, out of which there was to be constructed
the whole diagnostic edifice.

In conclusion, I avail myself of this occasion to
thank Dr. Sturmdorf for the skillfully performed
laparatomy, the more so, as we were under special
responsibilities to the child's parents, who allowed
the operation only because of our insistence upon
the same. Dr. Sturmdorf will communicate the
surgical aspect of the case.

123 East Ninety-fifth Street.

BUTTERMILK AS AN INFANT FOOD.

By AUGUST STRAUCH. M.D.,

CHICAGO, ILL.

Dr. Ballot of Holland in 1865 called the attention
of the medical profession to buttermilk as an infant
food, which had long been used for that purpose
among the peasants of Holland and Thessaly. But
it was not until the recommendation of de Jager in
1895 and the classic publication of Teixeira de Mat-
tos in igo2 on this method of infant feeding that the
use of buttermilk became popular among the physi-
cians of Germany and Holland. Within a short time
this method of feeding healthy infants, and especially
those afflicted with gastrointestinal disturbances, has
found its way into nun-crous clinics and polyclinics

5i6

MEDICAL RECORD.

[March 30, 1907

of Germany. Authorities hke Baginsky, Heubner,
Caro, Soltmann, Escherich, Salge, and others, have
recorded very favorable resuhs. Also in France,
Roumania, Greece, and South America buttermilk
has recently been tried as infant food with equally
'encouraging results.

As the temi buttermilk is employed to designate
various dairy products, it is necessary to confine this
term exclusively to churned milk, which may be
made by the following methods : ( i ) Sweet cream,
the product of centrifugation, or of milk that has
simply stood for hours in a cool place, is churned,
whereby the milk-fat globules, after the disruption
of their haptogen membrane, form the butter. This
buttermilk is almost identical with sweet, skimmed
milk. (2) Since a slight acidity of the milk renders
the churning more profitable, milk or cream are
used which have soured by spontaneous fermenta-
tion, or after inoculation with sour milk, or with
pure cultures of Bacillus acidi lactici. The degree
of acidity nearly corresponds to the neutralizing
capacity of 5 to 7 c.c. of normal NaOH solution per
100 grams of milk. This buttermilk differs from
the aforementioned one by its acidity (due mostly to
lactic acid), and by the fact that the casein is coagu-
lated and suspended in the serum in very minute
particles.

While the physical, chemical, and biological differ-
ences between cow's and human milk correspond to
those between a calf's and an infant's stomach, sour
buttermilk deviates still more from human milk.
The former shows an acid reaction, the latter an
amphoteric or slightly alkaline reaction to litmus
paper. Human milk is abundant in fat, scanty m
albumin, its casein is dissolved and combined with
calcium, and coagulable by rennet. Buttermilk is
scanty in fat, abundant in albumin, the casein is sep-
arated from the lime, and therefore coagulated, and
incapable of farther coagulation by rennet. In
human milk the calcium salts are mostly suspended
as insoluble phosphates ; in sour buttermilk we find
the calcium partly united with lactic acid ; the insol-
uble di- and tri-calcium-phosphates are converted
into soluble mono-calcium-phosphates. Human milk
is almost sterile, buttermilk in its unboiled state
abounds in bacteria, in saccharomyces species, and
the products of their metabolism.

These great differences justified the scepticism
and reserve in regard to the use of buttermilk in
infant feeding until experiments and very favorable
experiences removed every doubt as to its great
usefulness in certain conditions. Buttermilk, in fact,
has been proven to be one of the best dietetic reme-
dies for gastrointestinal diseases of children, ac-
cording to the medical literature of Germany.
Sour buttermilk, however, is not to be administered
in its raw primary state, but modified more or less
in accordance to Teixeira's formula in the following
manner: one liter (quart) of fresh buttermilk is
mixed with one or two tablespoonfuls of rice — or
wheat — flour, the milk being added gradually at the
beginning, to prevent the formation of lumps. While
being constantly stirred, it is heated slowly for fif-
teen to twenty minutes to the boiling point, and
finally, after adding 50-70 grams of sugar, it is
cooled and hermetically bottled. The addition of
sugar makes up for the lack of fat and the resulting
deficiency in calories, and so does the flour, which,
besides, prevents the formation of coarse, tough co-
agula during boiling. The formation of these coagula
does not occur, however, if the buttermilk is boiled
very slowly, so that the boiling point is not reached
before thirty minutes. The caloric value of the but-
termilk has by this process been increased from

about 260 to 600 or 700 units pro liter, thus ap-
proaching that of human milk. It contains a high
number of caloridynamic units in a small quantity
of fluid. The prepared buttermilk is a yellowish
fluid, which, after standing, separates into two lay-
ers, the upper one consisting of the milk serum, the
lower one containing the casein coagulated and sus-
pended in very fine particles. By this fine division
it resembles the fine coagula of human milk in the
infant's stomach.

The excellent results obtained with buttermilk
feeding in Germany induced us to try this method
at the Caroline Children's Hospital in Vienna (Di-
rector, Dr. Knoepfelmacher), with a result which I
consider worthy of reporting on account of its very
encouraging features (1903).

In preparing buttermilk, we followed Teixeira's
prescription, and administered it in separate bottles
of from 50 to 100 grams. The daily quantity
amounted in its calorimetric value to 80, 100, 120
units, i.e. 120 to 200 grams of milk pro kilogram
of the infant's body weight. In acute cases of intes-
tinal disturbance after a period of from one to two
days under rice-water feeding, buttermilk was ad-
ministered gradually in increasing quantities. After
improvement had set in, the quantity was increased,
not only according to the actual weight, but also to
the a^e of the child.

Our own experience includes more than twenty
cases, mostly of malnutrition, resulting from chronic
gastrointestinal disturbances, with occasional acute
exacerbations up to the intensity of cholera infan-
tum; then some cases of alaitcment mixte, one case
of habitual vomiting (pylorospasmus), one prema-
turely-born child, and one case of icterus catarrhalis.
Some of these cases had not responded to other
methods of feeding and treatment.

I may be permitted to report in this place a few
examples for all, reporting especially the increase of
weight of the infants as the most significant indicator
of improvement.

I. — Emil Z., two months old, weight 2,000 grams ;
chronic enteric catarrh, spasms. \Veekly increase :
250, 450, and 400 grams.

2. — Rose Z., age two months, weight 3,250 grams ;
chronic gastroenteric catarrh. Increase of v/eight
in two weeks : 550 grams.

3. — Bruno Sch., age four and a half months,
weight 4,600 grams ; rachitis, chronic enteric ca-
tarrh. Weekly increase in weight : 300, 300 grams,
afterwards skimmed milk, which is less well borne.

4. — ^^'alter F., age three months, 4,400 grams;
chronic gastroenteric catarrh with acute exacerba-
tion. Weekly increase: 190 and 140 grams.

5. — Julius M., six weeks old; chronic gastro-
entero catarrh, acute exacerbation. \\'eeklv increase
of weight : 260, 300. 400, 400 grams. During the
subsequent three weeks bronchitis, with only 200
grams, later on in five days with 300 grams increase.
Change to skimmed milk is followed by diarrhea.

6. — Rudolf St., sixteen days old, weight 2,300
grams : prematurely born child ; too weak for nurs-
ing. Increase of weight in seven days : 240 grams.
The following week exclusively breast feeding, with
a loss of 90 grams in weight.

7. — Anne K., five weeks old, 3,000 grams, breast
child ; weak movements in suckling ; dystroph_v ;
mother's milk abundant. During feeding with but-
termilk, besides breast, weekly increase : 400, 300,
250, 100, 200 grams. Within the ten next days, 200
grams ; the following week, 300 grams. Exclusive
breast feeding, with weekly increase of weight of 50
to 100 grams.

8. — Anna Dr., two months old. weight 1,900

March 30, 1907]

MEDICAL RECORD.

517

grams ; chronic intestinal catarrh with acute exacer-
bations, atropliy. Rice-water diet ; calomel ; then but-
termilk. Increase of weight in six days, 150 grams,
the following ten days 250, the next week 200 grams.

9. — Karl H., live months old, 3,900, breast child ;
dyspepsia, eczema universale. The latter disappeared
after a short time of buttermilk feeding. In the be-
ginning buttermilk was not well borne. First loss,
but soon increase of weight 200 and 350 grams
weekly.

ID. — Anna F., three months and twenty days old,
weight 4.400 grams ; habitual vomiting ( pyloro-
spasm) ; breast child; excessive vomiting after each
breast feeding, also when fed with diluted cow's
milk and with rice water, given in teaspoonful doses ;
irrigation of stomach without result; buttermilk (at
first in teaspoonful doses) checks the vomiting at
once. In the first week 100 grams increase of
weight.

II. — Hans Z., three months old, weight 2,650
grams ; catarrhal icterus, with tendency to constipa-
tion ; milk-sugar, artificial Carlsbad salt, and butter-
milk feeding. The icterus disappeared soon. Weekly
increase of weight : 200, 250, and 150 grams.

12. — Josephine K., three months old, weight 3,500
grams ; chronic dyspepsia, eczema ; buttermilk feed-
ing. Increase of weight the first week : 230 grams ;
the next four days 120 grams. The child became ill
with pneumonia, and, in spite of this, gained 70
grams during the following five days and 130 grams
the following week. Without buttermilk the baby
gained within the next two weeks only 50 grams, but
after reestablishment of buttermilk feeding, 250
grams the first week, and 1,700 grams during the
two following months. The eczema disappeared
very soon.

13. — This case shows the danger of a sudden
change from buttermilk to another food. Karl U.,
ten months old, 6,600 grams ; chronic entero catarrh.
Various methods of treatment had been tried with-
out result. While the child was fed with buttermilk
the weight increased in four days 200 grams; the
following twelve days 300 grams. Then the
mother, without our consent, fed the baby with cow's
milk and noodle soup. Soon incontrollable vomiting
and diarrhea set in. followed by convulsions and
exitus letalis.

A failure was the following case :

14. — Anna T., 4.300 grams weight ; cholera in-
fantum, resulting in chronic enteritis. We tried
besides buttermilk feeding other methods, but all in
vain, and the child died after four weeks of treat-
ment under the symptoms of hydrocephaloid.

The increase of weight during butternnlk feeding
is accompanied by a general improvement. The
babies become quiet and good-natured, they sleep
well, and have a good appetite. Vomiting ceases,
or becomes less frequent ; the frequency of the stools
lessens, although they may occur oftener than in
normal breast-fed babies. The stools are usually
yellow, homogeneous, pasty, and of a neutral or alka-
line reaction. But even in cases where the quality
of the stools did not satisfy our expectation, and
where we had to dilute the prepared buttermilk with
small quantities of rice water, we observed a good
increase of bodv weight. All the babies liked the
buttermilk, even as an addition to breast feeding.

Our encouraging experiences being limited to a
comparatively small number of cases, I will briefly
review the results of others, based on a larger ex-
perience, to show how excellent a remedy and food
buttermilk has been proved to be. The excellent
e.xperiences of Teixeira are so numerous that they
have been the principal inducements for similar
experiments in Germany. His six years' experience

covered many hundreds of cases which not infre-
quently manifested a weekly increase in weight of
from 500, 600, to 700 grams. Baginski's observa-
tions range over 182 cases in the medical wards of
the Emperor and Empress Frederick Hospital of
Berlin. In 150 the results were excellent, in the re-
mainder the improvement was less pronounced ; in
32 chilih-cn the feeding was unsuccessful. In the
entire hospital he had fed 300 children with butter-
milk with similar results. A few children were
taken directly from the breast and given buttermilk
because the mothers could not visit the hospital to
nourish their children.

Salge reports 85 cases with very satisfactory re-
sults out of 119 babies, who were fed with butter-
milk for dyspepsia, chronic entero catarrh, atrophia,
and in allaitouent mixte. In the remaining cases
buttermilk failed, but so did also other methods,
including human milk.

Jean Cardametic (Greece), Rensburg, Leschziner,
Escherich (Vienna) had similar experiences, and
Dr. Riether, primarius of the foundling institution
of Vienna, stated that atrophic babies thrived excel-
lently on buttermilk after other foods had been tried
in vain. He found the remarkable fact that breast-
fed babies, who had been dystrophic without deter-
minable cause, showed a remarkable increase in
weight and improvement if small quantities (one
teaspoonful to one tablespoonful) of buttermilk were
administered before each breast feeding. He sup-
poses this to be due to the digestion-promoting ac-
tion of lactic acid, which perhaps may also account
for the good results obtained from buttermilk feed-
ing in aUaitement mixte of healthy babies.

Teixeira's original method of preparing butter-
milk has often been modified to meet special indica-
tions. For instance, the flour has been partly or en-
tirely replaced by various dextrinized flours (Kinder-
mehle) for babies in the first w-eeks of life, or for
babies whose feces showed upon microscopical ex-
amination, or with the iodine test, starch in a
greater amount, indicating insufficiency of starch
digestion.

In extreme intolerance of carbohydrates the flour
can be dispensed with entirely, and even the sugar
may be replaced for a short time by some other
sweetening substance (saccharine). The low per-
centage of fat in buttermilk has been increased with
the best results (Rommel, Rensburg, Schlossmann,
Heubner) by the admixture of cream or sesame oil,
when buttermilk alone did not give satisfactory re-
sults, and an increased amount of fat was needed.
For it is evident that fat cannot be replaced by car-
bohydrates, even isodynamically, for an indefinite
period of time, since the principle of isodynamic sub-
stitution is not applicable arbitrarily or without
limit; indeed, in some cases the poverty of fat in
buttermilk may be a drawback.

Considering the almost paradox composition of an
infant food of such approved, undoubted value in
various intestinal disturbances which so often ac-
company artificial feeding, attempts at explaining
these facts become very interesting. The unexpect-
edly good results obtained from this food which is
so rich in albumin have been explained by the rela-
tive lack of fat; but experiments with simple
skimmed milk (Knoepfelmacher) and the fact that
the addition of cream aids the good results obtamed
in manv cases do not support this sunnosition._ The
easy d'igestibilitv of the casein of buttermilk is
almost universallv admitted; it is probablv due to
the distribution of the former in extremely fine floc-
cules as a result of the mechanical process of churn-
ing. In addition, the acid reaction, the abundance of
carbohvdrates, with their acid products of fermen-

518

MEDICAL RECORD.

[March 30, 1907

tation within the intestinal tract, may perhaps pro-
tect the albumin from more intense putrefaction
and influence the reaction of the soil of the intestinal
bacterial flora.

According to Rubinstein's investigation, patho-
genic bacteria (of diphtheria, typhoid, tuberculosis,
Bacillus pyocyancus), as a rule, gradually perish
spontaneously in buttermilk, both on account of the
increasing acidity and the presence of the Bacillus
acidi lactici, or they are easily destroyed by boiling
for only one, two, to three minutes. We further
know that the acidity of the food promotes tryptic
digestion, as the acidity of the stomach contents
energetically stimulates (Pawlow) the secretion of
trypsin. The digestibility of the nitrogenous sub-
stances of buttermilk lessens the work (Heubner)
of the glands of the stomach and the intestines ; the
amount of energy thus spared is beneficial to the or-
ganism of the baby.

As to the indications for the use of buttermilk, no
absolute rules can be formed, nor is any strict classi-
fication of the various intestinal disorders unani-
mously accepted. Buttermilk has been used with
best results in insufficiency of fat — and of albumin —
digestion ; in atrophia infantum, dependent on
chronic entero catarrh ; in dystrophia infantum with-
out determinable causes; in allaitement mixte, and
in cases of sudden weaning. The high calorimetric
value of the buttermilk renders it fit for feeding
prematurely-born babies who are not able to nurse,
or if no wet nurse can be promptly secured. Many
babies with intestinal diseases digest only butter-
milk ; others digest other foods as well. As a rule,
acute intestinal disorders, and those chronic disturb-
ances due to prolonged starch feeding, should be
excluded. In case of intolerance for carbohydrates,
buttermilk without flour, or even without sugar,
may be tried for a short time.

The objections against a buttermilk regime are
due to the fact that buttermilk of standard quality,
which is indispensable for success, can be obtained
only with great difficulty in large cities. The com-
mon commercial so-called buttermilk is indeed too
often unfit for infant feeding on account of its con-
taminations, its unhygienic manipulation, and its
ureliability v^'ith reference to acidity.

To meet these objections, pure conserves of but-
termilk are prepared in Germany, and have been
tried with success in clinics under the supervision
of leading pediatrists. They are worthy of a trial
wherever genuine buttermilk cannot be secured.
REFERENCES.

Teixeira de Mattos : Jahrbuch fiir Kinderheilkunde, 1902.

Salge : Ibid., 1902.

Koeppe : Ibid., 1906.

Rubinstein : Archiv fiir Kinderheilkunde, 1904.

Leschziner: Ibid., 1904.

Caro : Ibid., 1902.

Baginsky : British Medical Jounial, 1002.

Setter : Deutsche mcdizinische Wochenschrift, 1903.

Riether : Mittheilungen der Gesellschaft fiir innere Med-
izin und Kinderheilkunde in Wien, No. 6.

Cardamatis : Archives de Medccine des Er.fants, 1904.

Morgnios: Rivista de la Sociedad Medica Argentina,
No. 12.

1455 N. Forty-first Court.

Hydrastis. — J. M. French says that he be-
lieves that hydrastis is a valuable drug. As a sto-
machic and general tonic, the crude drug and its ga-
lenic preparations may be employed. To produce
contraction of muscular and connective tissue, ber-
berine is the preferred agent. To cause contraction
of the arterioles, hydrastine and hydrastinine are
effective, and of these hydrastinine is especially su-
perior as a uterine hemostatic. — American Journal
of Clinical Medicine.

THE RELATIONSHIP OF CLINICAL SYMP-
TOMS TO MICROSCOPICAL FIND-
INGS IN CASES OF CARCINOMA
OF THE UTERUS.

By C. O. THIE.NHAUS, M.D..

MILWAUKEE, WIS.

Of all scourges which since the early existence of
humanity have devastated and terrorized mankind,
none up to the present time has been able to resist
the penetrating searchlight of microscopy, bacte-
riology, and chemistry so obstinately and, unfor-
tunately, so successfully, as carcinoma. In the
same manner as during the time of Hippocrates
and Aulus Cornelius Celsus, the physician and sur-
geon of to-day is forced to battle with cancer as
an enemy of whose origin, mode of living, and
strength he knows but little, if anything, and with
full justification his position then, as now, can be
compared to that of a general who is compelled to
accept battle without sufficient reconnoitering
against an enemy, whose quality and quantity is
unknown to him, and who is sheltered by the dark-
ness of night and entrenched in a seemingly im-
penetrable position.

However, time and scientific progress have been
grinding slowly but surely, and have destroyed
gradually a few outlying forts of the enemy's
fortress, and although all efiforts of detecting the
"fons et origio" of cancer have been unavailing
and many elegant hypotheses have proven to be
nothing but chateaux en Espagne and have had
to disappear from the horizon of scientific truth
like the fata morgana, still our clinical results,
achieved in this combat, show a decided gain, and
surgery of to-day can claim to have reduced the
mortality of cancer from almost 100 per cent., as
existing during the time of Hippocrates, to a mor-
tality of about 60 per cent. In other words, at the
present time surgery is enabled to save, according
to circumstances which will be illustrated later, from
25 to 50 per cent., conservatively speaking, of all
carcinoma patients.

The reasons for this wonderful success and
changed state of affairs are, as known to all of us,
twofold : First, the phenomenal advancement of sur-
gical technique, based upon the epoch-making dis-
covery of Lister; an advancement of technique
which, in regard to carcinoma operations at the
present time, has been pushed to the utmost degree
of perfection and seems almost to have reached
the limit of human possibility; second, the advance-
ment of clinical diagnosis and microscopic pathology.
Thus we are enabled first to demonstrate conclu-
sively that carcinoma in the incipient stages of its
development is a local disease, and, based upon this
fundamental dogma, second, to make our diagnosis
in its early stages, at which time our now perfected
surgical technique can be employed most effectively,
and can reap its just reward : Sanatio complete.
To achieve this purpose fully, however, and to make
the diagnosis of carcinoma in its earliest stages pos-
sible, it is absolutely essential that the study of
clinical symptoms go hand in hand and be inter-
woven, so to speak, with the study of microscopical
pathology. That they are inseparable from each
other, and that in each individual case the patho-
logical examination by the microscope has to speak
the last and decisive word in regard to diagnosis
of carcinoma ; in fact, that without it such a diag-
nosis has hardly any merit from a scientific stand-
point, can best be demonstrated by a study of the
relationship of clinical symptoms to microscopical

March 30, 1907]

MEDICAL RECORD.

519

findings in cases of cancer of the uterus, with which
this paper has to deal.

It is hardly possible within the limits of one article
to go into minute details, and as this paper is ad-
dressed to the general practitioner, and not to the
specialist, such details are not necessary. Its scope
will be held within the boundaries of a general
survey, emphasizing chiefly those points which are
essential for the purpose of recapitulating, and, if
possible, of advancing the knowledge of the general
practitioner to the early diagnosis of carcinoma
uteri.

What are the clinical symptoms pointing to a
possibility of a malignancy of the uterus in the in-
dividual case — symptoms which must make it neces-
sary for the general practitioner to make imme-
diately a thorough clinical examination of the female
genital organs of the patient ?

A. When a woman over fifty j^ears of age has
entered the climacterium, and after some months
of cessation of the menstrual flow, notices a bloody
discharge or even a watery sanguineous discharge
from the vagina, there exists strong suspicion of
carcinoma of the uterus, and an immediate physical
examination of the generative organs is imperative.
The vulva and vagina should be examined thor-
oughly and the cerv-ix uteri inspected. If it is found
that no growth or ulcerative or catarrhal process is
present in these organs to explain the symptoms,
and that bimanual examination does not reveal the
presence of a tumor of the uterus or adjacent organs
as a remotely possible source of the bloody discharge,
then it is necessary that a thorough currettement
of the body and of the cervix uteri be made. All
scrapings obtained by this curettement, performed
in a most thorough manner, so as not to overlook
a beginning carcinomatous growth in the tubal
cornua of the uterus, should be saved and preserved
in a 4-10 per cent, formaldehyde solution for micro-
scopical examination, either by the practitioner him-
self, if he is competent for this specialistic work,
or by a competent g\'necologist or pathologist. If
during the curettage we find that the inside of the
uterus is uneven or rugged, or if large masses of
tissue easily gave way during curetting, our sus-
picion of carcinoma of the body of the uterus re-
ceives further confirmation and is clinically almost
a certainty, but the accurate scientific diagnosis only
the microscope is able to reveal, as tlie same clinical
symptoms may be found in cases of submucous and
interstitial fibroid of the uterus which has under-
gone necrotic or sarcomatous degeneration, or in
cases of sarcoma of the corpus uteri ; mucous
and fibroid polypi originating from the cer-
vical canal or the cavity of the uterus ;
glandular endometritis, and very rarely tu-
berculosis of the corpus uteri. However, we all
know in cases of myoma of the uterus the climacteric
very seldom begins before the fiftieth year, but
usually much later, and that in cases of submucous
fibroid the patient usually gives a history of menor-
rhagia and metrorrhagia occurring before the age
of fifty. That such menorrhagia and metrorrhagia
between the age of thirty and fifty is furthermore
oftentimes the first clinical symptom of cancer of the
portio and the cervix uteri, will be considered later.

Cancer of the body of the uterus usually occurs
between the ages of fifty and sixty, and in the pre-
dilection for this age it resembles sarcoma of the
corpus uteri. It is furthermore well known and
proven by statistics that of all cases of cancer of the
uterus, carcinoma of the corpus gives the best sur-
gical results, because its virulency (so-called) or its
tendency to produce metastasis, and to spread to the

broad ligament and adjacent organs, is less pro-
nounced than in cases of cancer of the cervix. As
an illustration, I will here only briefly mention the
operative results in cases of cancer of the uterus
from Chrobak's clinic, Vienna. According to his
statistics, published recently by Blau {Beitrdge zur
Gebiirtschiilfe nnd Gyndcologie, Bd. 10, Heft. 3),
he performed from January, 1890, to October, 1903,
309 vaginal hysterectomies for cancer of the uterus.
Of these, 87.7 per cent, were cases of cancer of the
cervix uteri, and 11.5 per cent, cases of cancer of
the corpus uteri. Seventy-five per cent, of the cases
of cancer of the corpus were permanently cured,
that is, there was no recurrence after three years;
from the cases of cancer of the cervix only 40 per
cent, were cured. Because of this great possibility
of permanent cures of cancer of the corpus uteri, it
is extremely deplorable when such cases come too
late to the surgeon, in a state, for instance, when
the carcinomatous growth has penetrated the entire
thickness of the wall of the uterus, and has pro-
duced metastasis within the peritoneal cavity. About
three years ago I had the misfortune of observing
such a case, which gave the following history : Mrs.
K., from M., Mich., fifty-four years of age, states
that she ceased to menstruate at the age of fifty.
Two years later a bloody discharge made its ap-
pearance, which she believed was nothing extraor-
dinary, but merely a nenewal of her old menstrua-
tion. The discharge became more copious later on,
and was at times of a foul smelling character. This,

Fig. I. — .-Adenocarcinoma of the corpus uteri.

together with some pain in the lower portion of her
abdomen, was the incentive (two years after the
appearance of the first symptoms) to consult a
physician, Dr. Y., who called me in consultation.
Bimanual examination revealed no abnormalities
in the vagina or cervix. The body of the uterus
was enlarged to double its normal size, and was
painful to pressure ; a bloody, foul discharge exuded
from the external os. The microscopical examina-
tion of some scrapings kindly made by Dr. Beflfel,
the microscopical drawing of whicn (made by Dr.
Ruhland) is herewith reproduced on Plate No. i,
showed that we had to deal with an adenocarcinoma
of the corpus uteri. During the operation, per-
formed by the combined vaginoabdominal method,
it was found that metastatic growths had already
formed within the peritoneal cavity. One of these,
as large as a walnut, was removed, and plate No. 2
reproduces a microscopical picture of this metastatic
growth. The woman recovered from the operation,
gained in strength for one-half year, and died one
and one-half years later, a victim of her own igno-
rance and superstition. According to the excellent
results, which, as already pointed out, surgery can
achieve in cases of cancer of the body of the uterus,
this woman's life could almost certainly have been
saved if immediately following or within half a year
following the beginning of her clinical symptoms
hysterectomy had been performed.

520

MEDICAL RECORD.

[March 30, 1907

In case that during an examination a polypus is
encountered as the underlying cause of the metror-
rhagia, this polypus must be removed thoroughly at
the base of its insertion to the cervical or uterine
wall, the uterus curetted, and polypus and scrapings
subjected to a microscopical examination. Although
most polypi are of a mucous or fibrous nature, they
sometimes undergo carcinomatous degeneration. It
is furthermore advisable to keep all patients from
whom uterine polypi have been removed, under
strict observation for the next one or two years,
because of the possibility of the recurrence of the

even crumbling from manipulation, then the diagno-
sis of carcinoma is, from a clinical standpoint, almost
a certainty. In such cases a piece of portio contain-
ing both healthy and diseased tissue should be ex-
cised under antiseptic precautions and examined
microscopically. It is well known that the findings
and symptoms above referred to — such as bleeding
during coitus, friability, etc. — which point so
strongly toward the diagnosis of cancroid or cauli-
flower carcinoma of the cervix, may also be found in
cases of simple erosion of the portio vaginalis.
The two patients from whom were taken the tis-

FlG. 2. — Metastatic growth in the peritoneal cavity. A case of adeno-
carcinoma of the corpus uteri.

polypi and the future development of malignancy.
The following observation of my own will illustrate
this point. Mrs. E. M., from M., Wis., forty-
eight years old, complained that for six months she
had been suffering from menorrhagia and metror-
rhagia. The examination revealed a polypus pro-
truding out of the external os. The uterus was
curetted and the polypus removed. The microscop-
ical examination, as shown in plate No. 3, showed
that there was no malignancy present. One and
one-half years later the menorrhagia returned and
another polypus of benign character had to be
removed. No further disturbances since this time.
In case a tumor of the adnexa is encountered as
underlying cause of the menorrhagia, a laparotomy
has to be performed, and if the tumor proves to be.
a malignant growth, it is necessary to remove the
uterus and the adnexa on the other side of it, because
a metastatic growth may have already developed or
may develop later on in the body of the uterus or the
ovarv. I observed one case in which a benign tumor

Fig. 3. — Polypus cervicis uteri.

of the left ovary, a fibroma the size of a man's fist,
was the underlying cause of excessive post-climac-
teric menorrhagia and metrorrhagia. These sub-
sided promptly after the removal of the fibroma
ovarii.

B. — ^^ hen a woman from thirtv to fift\' years
of age complains of frequent menorrhagia and
metrorrhagia, and furthermore points out that
bloody discharges, intermingled with leucorrhea, oc-
cur during or following coitus or vaginal douching,
there again exists strong suspicion of carcinoma —
the probability being that the portio vaginalis uteri
is the seat of the disease. If, during examination
of the patient, we detect a growth or ulcerative
process on the portio vaginalis, easily bleeding or

Fig. 4. — Cancroid of the cervix uten, showing areas of hyaline de-
generation.

sues illustrated in plates Xos. 4 and 5, demonstrate
this point very clearly. In both these cases the diag-
nosis of carcinoma of the cervix uteri had been made
by several physicians on the basis of the clinical
symptoms and physical findings. In the first case
(plate Xo. 4), the microscope confirmed the diag-
nosis, and showed that we had to deal with a can-
croid of the portio vaginalis, hyaline degeneration
being present in some places. In the second case,
as shown in plate No. 5, the microscope showed
that the process was a purely inflammatory one.
Curettage and partial excision of the cervix was
advised and performed in this case three years ago,
and the patient has enjoyed perfect health ever since.
At this point I would like to sound a warning
against the indiscriminate cauterization of what ap-
pears to be simple erosions of the cervix, without
first confirming the diagnosis with the microscope.
Many cases are cited in the literature (and naturally
many more are never reported at all for obvious
reasons) in which during the delay from cauteriz-

t-^^-'-^-^.

:i

Fig. 5. — Erosion of the cer\n.x uteri, showing round-celled infiltiation.

ing, what was supposed to be a simple erosion of
the cerv'i.x, an unsuspected carcinoma is allowed to
pass the stage of surgical operability. On the other
hand, it is hardly necessary to point out once more
that statistics of surgeons who claim to have cured
so many cases of cancer of the cervix uteri are
absolutely worthless without the confirmation by
microscopic examination in every case.

The greatest obstacles to early clinical diagnosis
are encountered in those cases of carcinoma of the
cervix uteri which originate from the epithelium
of the mucous membrane above the external os, or
from the epithelium of the deeper glands of the
same region. In such cases the clinical symptoms
of menorrhagia and metrorrhagia occur so late

IMarch 30, 1907]

MEDICAL RECORD.

521

that the patient seldom consults her physician for
relief until all hope of radical cure has vanished.
In the examination of such cases the physician is
apt to find that, while the external os may be of its
natural size and appearance, immediately above it a
crater-like cavity, lined with friable tissue, is en-
countered. In addition to this, hard nodules or in-
filtrations may be found on one or both sides of the
uterus — the result of extension of the carcinoma
into the broad ligament.

C. — If, during an abortion, an hydatid mole is en-
countered, and if after a lapse of some weeks hem-
orrhages occur in spite of the previous thorough
emptying of the uterus, either by curettement or
digital ablation, there is again suspicion that one of
the most malignant forms of carcinoma may have
developed on the basis of the mole, namely, chorion-
epithelioma or deciduoma malignum. This form of
carcinoma may, though rarely, follow a simple abor-
tion. If, therefore, hemorrhages persist after
thorough and possibly repeated curettement of an
abortion case, such a possibility must be borne in
mind. If during the examination of a case such
as just referred to a soft tumor is found within the
vaginal wall, this tumor should be carefully ex-
amined microscopically, for cases are on record
where, following the expulsion of a hydatid mole,
or even after simple abortion, primary chorion-
epithelioma has developed in the vaginal wall with-
out the presence of any similar growth in the uterus
at all. Some authors even go so far as to advocate
hysterectomy in every case of hydatid mole, believ-
ing that a hydatid mole per se is the beginning of a
malignant process. This advise, it seems to me,
is a little too radical.

In summing up, if we ask ourselves why is it that
in cases of cancer of the uterus women consult the
physician usually at a period when radical cure by
surgical means is out of the question, we must at-
tribute this to two causes — first, to gross ignorance
on the part of the public in regard to cancer in
general and especially its early symptoms, and
second, to the insidious character of the disease. I
have already referred to the prevalent belief that,
when after the climacterium has set in, hemor-
rhages occur, these hemorrhages are nothing more
than the reappearance of the natural menstrual flow,
or a natural rejuvenation. ,\nother erroneous be-
lief, strongly prevalent among the public, is, that
hemorrhages from the uterus without pain cannot
be cancerous in origin. We all know that pain in
any case of cancer of the uterus, in the absence of
any inflammatory process, almost invariably indi-
cates that the neoplasm has extended beyond the
limits of the uterus itself, and that our prognosis,
as far as a radical cure by operation is concerned,
must be valdc dubia ant pcssima. This ignorance
on the part of the public must be overcome before
we can ever hope for any material improvement in
our surgical results. In this matter every physician
should consider it his duty to help dispel the dense
ignorance of the masses by education. Great prog-
ress has already been made in this respect in Ger-
many by such gynecologists as Winter, Duehrs-
sen, and others, who by public lectures, magazine
articles, and circular letters of instruction to mid-
wives, are meeting with great success in reducing
the mortality from uterine carcinoma by education
of the masses.

To combat successfully the insidiousness of carci-
noma, it is imperative for the practitioner to make
careful and conscientious clinical, and, if necessary,
as above illustrated, microscopical examinations in
dubious cases, and it is better for him in case of

doubt to share the responsibility with the specialist,
than to resort to dilatory and experimental tliera-
peutics.

At the same time we sincerely hope and trust that
the great efforts now being made in the various
cancer laboratories of the world to determine the
genesis and nature of the scourge may be crowned
with success in the near future, and that the dark-
ness of the pestilence may soon be dispelled by
"melir Licht."

Post Graduate Hospital.

ILLUSTRATIONS FOR MEDICAL JOUR-
NALS.

By a. J. MARTIN,

PATHOLOGICAL ARTIST.
NEW YORK.

Among the medical journals of the world, those of
the United States are far away ahead in the com-
paratively new departure of illustrations. In this
age of hustling and competition the ever-busy med-
ical practitioner who glances at his journal in what
spare time he can afford, expects as a matter of
course to find fully illustrated articles. The illus-
trated medical journal has become a necessity ; it
has come and come to stay.

Fig. I — I-ine drawing: from a case of fun^ating sarcoma, showing
the type ol illustration best suited to journal work.

Now a word, in brief, as to the adaptability of the
different methods adopted in illustrating medical
articles. It is a not uncommon fallacy to suppose
that an etcher can produce a good block out of any-
thing. Let him be supplied with as good an original
as is procurable.

Without doubt, line — pen and ink — drawings
stand preeminent. They are in most cases suffi-
ciently comprehensive, and reproduce better and
more cheaply than half-tones made from wash draw-
ings and photographs. And nothing is more_ pleas-
ing than a well-executed line drawing. This fact
is indeed particularly true in journal work when
one remembers that the paper used is uncalendered
and the printing done very rapidly.

Photography'' is to-day playing a great part in il-

-322

MEDICAL RECORD.

[March 30, 1907

lustrating our journals. Some men prefer it be-
cause they say the camera cannot lie. But I aver
that, with comparatively few exceptions, photo-
graphs that have not been "touched up" and trans-
formed literally into drawings, do not furnish good

Fig. 2. — From an untouched pnoiograph oi a case ol mediastinai
umor, with swelling of tlie glands of the neck on the left side and
edema of the upper lid of the right eye; numerous dilated veins were
present in the skin covering the thoracic swelling.

material for a successful reproduction. Figs. 2 and
3 well illustrate this point.

Wash drawings, possessing strong contrast of
light and shade, make beautiful half-tone reproduc-

As to color work little need be said. There is a
wreath of laurels awaiting the man who will devise
a method of reproduction in natural colors suffi-
ciently cheap to enable our editors to delight their
readers with this form of illustration. But this is
an age of rapid progression, and I confidently be-
lieve that the time is not far distant when our med-
ical journals will be much more interesting pic-
torially than they are at the present day.

Fig. 3. — From the same photograph as Fig. 2. after retouching to
bring out the salient points.

tions, and are in great favor at the present day.
But, to my mind, this class of illustration is more
suited to works in book form than to the journals,
where expense in reproduction is a more serious
matter.

The Opsonic Index in Relation to Tuberculous Peri-
tonitis.— .Arthur H. White calls attention to the surgi-
cal cures of certain cases of tuberculous peritonitis by the
flushing of the peritoneal cavity. In relation to this well
known fact the author speaks of the recent work of Wright,
who has shown that there is present in the blood a pro-
tective substance hitherto unknown, which he calls opsonin.
To the presence of this substance phagocytosis is largely
due. This investigator has also shown that in cases of
local tuberculosis the blood contains less opsonin than
that of normal individuals. The opsonic index may be
raised by the inoculation of a tubercle vaccine. He has
proved that in raising the opsonic index and keeping it
steadily at the normal, or higher than normal by means
of inoculation, ultimate complete cure of local tuberculosis
will result. The writer believes that operations should still
be performed in these cases, because they furnish the only
or the best means of getting rid of the fluid poor in opso-
nin and of promoting the necessary exchange which occuri
between the blood and the locally infected area. It will
be well also to raise the opsonic index before operation
by inoculation. The after-treatment should include blood
examinations from time to time to determine the degree
of the opsonic index. — The Dublin Journal of Medical
Science.

Torsion of a Hydrosalpinx. — Some fifty cases of this
condition are already on record and renewed interest in
the subject has been aroused by the report of a recent case
by Dr. Albert Martin, which is editorially reviewed in the
British Medical Journal of January 19, 1907. The patient,
thirty-four years old, not pregnant, supposed herself
threatened with a miscarriage. Nine years previously
she had suffered from a violent attack of pain in the hypo-
gastrium, chiefly towards the right side, with abdominal
distention. She kept her bed for a month, and recovered
spontaneously ; no diagnosis being made. The illness which
led her to consult Dr. Martin was a return of the ab-
dominal distention, with diminution of the catamenial flow.
On this occasion the acute attack followed instead of pre-
ceding the distention. It came on when the patient was
finishing her lunch, and was very severe, chiefly in the right
iliac fossa, radiating down the lower extremity. As she had
suspected pregnancy, the acute attack was taken by the
patient for threatened abortion. On examining the pelvis
Martin detected a tender swelling in the right fornix,
reaching into Douglas' pouch. It suggested torsion of the
pedicle of a small ovarian cyst Abdominal section was
performed, and a large hydrosalpinx of the right tube was
discovered. It resembled superficially a coil of distended
strangulated intestine, and was twisted two turns on its
pedicle. It is significant that there were no adhesions, and
as dilated tube is very common but not often twisted, yet
usually more or less adherent to adjacent structures, the
cause of the relative rarity of torsion is clear. Ovarian
cysts often rotate on their pedicles, but they are much
heavier than tubes and therefore not so readily fixed by
adhesions. An instructive discussion followed the reading
of Dr. JSIartin's monograph. Siredey related a case where
a lady was attacked suddenly with "enteritis" when at a
watering place A tumor was detected; it proved to be a
large hydrosalpinx with twisted pedicle.

March 30, 1907]

MEDICAL RECORD.

523

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, AM., M.D., Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, March 30, 1907.

THE EVIL OF EXAMINATIONS IN :\IEDI-
CAL EDUCATION.

We are constantly hearing so much about education
in all its aspects that the mention of the subject is a
suggestion of boredom. We think it must have
required some courage to announce an address on
the "true aim of medical education and the evil of
the examination fetich" as a commemoration of
John Hunter. This course was adopted, however,
by Dr. Lauriston Shaw, physician to Guy's Hos-
pital, London, who delivered the oration at the
Hunterian Society on February 15, and succeeded
in imparting to his discourse a degree of novelty
which was as unusual as the lesson he inculcated
was important. It came as a surprise at the outset
that Hunter's defective preliminary education, with
his later extraordinary mental development, and
even his tragic sudden death, should be cited in sup-
port of the theme. Not that it was suggested that
his amazing work and development were to be con-
sidered due to the fact that he could not have passe^l
the equivalent for his day of one of our
preliminary examinations when he began his
life work. But it was an open question whether
a school and college course might not have pro-
duced a merely successful practitioner instead of
one of our most brilliant thinkers. Possiblv his
protest against the requirement of preliminary in-
struction, in the excitement of which he expired,
was occasioned by the recognition that such barriers
would have shut him out from the career in which
he must have known that he had attained remark-
able success. Dr. Shaw referred to Hunter's
crabbed style as due to his defective early education,
and commented on the rarity of the two-fold power
of searching out the hidden facts of nature, und
telling in clear language the truths one has found ;
but a facile pen might have drawn him from the
bench to the writing table, and, after all, "if hz
could have told us more fluently what he saw, would
he have seen so much ?"

The lecturer proceeded to show the blighting in-
fluence of the examination system on both teachers
and pupils. He maintained that the fetich of exam-
ination is gaining a hold year by year, that its In-
fluence is wholly detrimental, and its eflfects demor-
alizing. Yet it would be easier for medicine than
for some other studies to free itself from this evil.
The ideal examination of those who worship the
fetich is conducted by one who knows the candidate
only as a number. How can he test the powers of
the mind ? One point he can try, that which is com-

monly spoken of as "the knack of passing," the
ability to keep a store of facts on the surface and
pour them out rapidly in presence of a stranger —
a power essentially depended on by the crammer —
"a mixture indeed of memory and cheek." Dr.
Shaw admitted this power was an attribute of mind,
just as bulk is of muscle, but said to worry a man
who wants to develop his mind with continual inves-
tigations of his memory was as senseless as periodi-
cally to test the lifting powers of a man who was
learning the violin. As in one case, the subtle power
of coordination would be lessened, so in the other
case would cramming deteriorate the higher intel-
lectual faculties. No sooner does the medical stu-
dent become acquainted with his teachers than the
chilling specter of the examiner comes between, and
both are handicapped at every step by the question,
"Will this pay at exams ?" Dr. Shaw admitted that
after his twenty years' teaching, he knew too wel'
what would pay in this way, and he knew, too, that
many a student's desire for knowledge, power of
observation, capacity for reflection, judgment, and
reasoning faculties have been crushed by the domi-
nation of the examination fetich. In no calling are
the highest faculties more necessary than in ours.
It is useless to develop only a power to collect facts
in a man destined to practise. A man primed with
a knowledge of the possible beliefs of his examiners
may be incapable of exercising a sound judgment of
such beliefs. No mass of facts in his memory will
serve in diagnosis the man who has not trained his
eyes, ears, and fingers as well as his brain.

Dr. Shaw would have inspection replace some of
the examinations, and records of work done allowed
to count toward marks for qualification. He would
have bedside work and that done in the post-mortem
room and in the laboratories given their proper
value. Tangible results of a student's work could
be judged by his clinical records, his charts, his bac-
teriological, chemical, and hematological reports,
together with duly attested microscopic slides, heart
and pulse tracings, photographs, drawings, and so
on, to be kept available for surprise visits of the in-
spector. Much better would such a record be "-han
examination tips by the crammer. Dr. Shaw be-
lieved that such inspection would ultimately be
acclaimed as a means of "overthrowing the exami-
nation fetich and allowing us to attain the true aim
of medical examination." The author of this ad-
dress from which we have quoted is to be congratu-
lated on his courage in stating his views, and still
more perhaps on his own escape from the evils of the
fetich of which his university (the London) was
so long the high altar.

RELATION OF ENDOTHELIOMA TO CAN-
CER RESEARCH WORK.

A DISCUSSION of this question was recently held be-
fore the Glasgow Medico-Chirurgical Society, the
paper of the session being presented by Dr. W, S.
Lazarus Barlow {Lancet, March 9, 1907). After a
description of the various forms of endothelial cells,
the essayist indicated the distinguishing histological
features between the endotheliomata on the one
hand and angiosarcomata and certain varieties of
spheroidal and squamous-cell carcinomata on the

5-'4

MEDICAL RECORD.

[March 30, 1907

Other. He believed that a considerable number of
the growths found in the breast and in the cervix
uteri, which were described as spheroidal-cell carci-
noma and squamous-cell carcinoma respectively,
were in reality examples of lymphatic perithelioma.
The cases to which he was referring^ were these in
which masses of cells were present with a central
degenerated material. It had been usually consid-
ered that this degenerated material had arisen from
a necrosis of the central portion of a formerly com-
pletely solid mass of cells, but he pointed out tiat
under such conditions there should be a gradation
between the outermost and undegenerated cells and
the central degenerated mass. On the contrary, in
the cases under consideration there was a sharp dif-
ferentiation between the cellular portion and the
debris, and in addition a definite endothelial lining,
such as one was accustomed to meet with in the ordi-
nary blood-vessel or lymphatic, often bounded the
proliferated cells on their internal aspect and com-
pletely shut them off from the central debris. He
urged further that these cases were identical in his-
tological appearance whether they were derived
from the breast or the cervix and were best ex-
plained on the view that they were lymphatic peri-
thelioma ta.

The greatest difficulty in differentiation lay be-
tween the endotheliomata and those carcinomata
containing the so-called Malpighian and the pure
prickle cells. In examining the sections from cases
in a certain hospital for a period of six years or
more, he had found that about 10 per cent, of svio-
posed breast cancers and the same number of uterine
cancers should, on the ground of his own researches,
be considered as endotheliomata. There was evi-
dence that the endotheliomata were amongst the
most malignant of new growths. On the other hand
"parotid tumors"' and certain tumors of the cere-
bral meninges showed that growths which were his-
tologically identical with those that had been de-
scribed might be non-malignant in respect of the fact
that they did not tend to recur after removal. It
was clear, therefore, that endotheliomata might be
intensely malignant or non-malignant, and the im-
portant question at the present time, bearing in mind
the amount of work that was being done on the sub-
ject of mouse cancer, was to determine in what
class of growths this latter should be included. A
recognition of the true character of mouse tumors
was necessary for determining whether work on
these growths was attacking the cancer question at
its very heart, which would be the case if they were
carcinomata, or whether it concerned a relatively
uncommon form of new growth — namely, the endo-
theliomata. Moreover, supposing that tlie majority
of mouse tumors were ultimately considered to be
endotheliomata there remained the question as to
whether they belonged to the intensely malignant or
to the non-malignant variety.

THE MILK SUPPLY OF NEW YORK.

An interesting symposium on the milk supph of
large cities was held at the Academy of Medicine
two weeks ago, a report of which was published in
the Medic.\l Record for March 23. .\t the present
day the proper supervision of the milk supply is

recognized by all as being a matter of paramount
importance, and all the best authorities are agreed
that the public health boards should be allowed con-
siderable power in dealing with the subject; it is
interesting, however, to see the difference of opinion
among the experts as to the direction this control
should take. That it is possible to supply an ex-
tremely pure raw milk has been shown by the dairy-
farms certified by the Milk Commission of the
County Medical Society. But the measures neces-
sary to produce such a milk place it beyond the reach
of the ordinary individual, for it is absolutely impos-
sible to sell certified milk in New York for less than
twelve cents a quart, and there is but little for sale
under fifteen cents.

What, then, can be done? The answer to this
must be governed largely by our knowledge as to
the prevalence of diseases traceable to milk. So far
as tuberculosis is concerned, the recent careful re-
searches of Ostertag show that cows reacting to
tuberculin, but presenting no clinical evidences of tu-
berculosis, rarely excrete tubercle bacilli in the milk.
On the other hand, with cows showing manifest
signs of, for example, tuberculosis of the lung, there
is often an enormous excretion of tubercle bacilli in
the feces, and these are readily carried into the
milk. The clinical evidence as to the frequency of
infection through milk must also be considered, and
while most pathologists here are agreed that this
mode of infection obtains in only a small percentage
of cases, it nevertheless does quite certainly occur
occasionally. One of the speakers at the meeting
to which we have referred described an extensive
outbreak of scarlet fever traced to infected milk in
Boston, and the literature contains reports of a num-
ber of smaller epidemics thus originating. Epidem-
ics of typhoid fever have quite often been caused by
an infected milk supply, and now and then diphtheria
infection has been carried in this way. On the
whole, however, such occurrences are not very fre-
quent. There still remain to be considered the large
number of cases and deaths from diarrheal disease in
infants. How many of these can fairly be charged
to a high bacterial content of the milk? Dr. Har-
rington thought a large percentage should be so
charged, but Dr. Holt, who has given special atten-
tion to this phase of the subject, thought that by far
the larger percentage should be charged to un-
hygienic surroundings, bad air, improper clothmg,
excessive hot weather, and the improper modification
of cow's milk, for in this city most infants receive
heated milk in summer, so that the diarrheas due to
raw milk have already been largely eliminated. The
extensive researches of Park and Holt showed that
pasteurized polluted milk did not give as good re-
sults as pure raw milk, and that the latter gave
about equally good results when raw as when pas-
teurized.

In discussing the question of pasteurization sev-
eral of the speakers expressed entire disbelief in the
efficacy of so<alled "commercial pasteurization."
This consists in passing the milk through heated
coils, the temperature usually being about 160° F.,
and the time of passage varying from 15 to 30 sec-
onds. It was claimed that pasteurization, in order
to be of benefit, should kill all the tubercle bacilli
that might possibly be present. This would require

March 30, 1907]

MEDICAL RECORD.

525

a heating of at least twenty minutes to 145°, and
anything short of this would be incomplete and use-
less. A critical examination of all the data, how-
ever, tends to show that this view is hardly tenable.
As was well pointed out by Park, an exposure of
thirty seconds to 160° F. does kill a large percentage
of non-spore bearing bacteria. In a series of experi-
ments now being carried on with a "commercial"
pasteurizer at the health department laboratory,
neither typhoid nor diphtheria bacilli withstood this
degree of heat. Furthermore, certain European
observers have found that even tubercle bacilli are
injured by this heat, for infected milk thus heated
usually did not infect guinea-pigs in feeding experi-
ments, but only when injected. It has been claimed"
that pasteurized milk when kept for twenty- four
hours usually shows a higher bacterial content than
unheated milk, because of heated milk being a better
soil for growth of bacteria. Park's experiments
showed that ordinary milk really heated for thirty
seconds to 160° F., and then kept in the ice-box for
twenty-four hours, has less than ten per cent, of the
number of bacteria which would have been present
if the milk had been unheated and kept under the
same conditions.

Following largely on the researches of Spolvcrini,
there has been considerable discussion as to the im-
portance and the functions of the ferments found in
milk. Raudnitz, probably the foremost authoritv on
the chemistry of milk, believes that the presence of
the ferments is to be looked upon as in the nature
of an excretion and of no particular significance. In
the suppression of tuberculosis, as developed by
von Behring, one of the main points is the produc-
tion of a tuberculosis-immune milk for infant feed-
ing. Such a milk cannot be pasteurized without at
least partiallv destroying the protective substances.
So far as the digestibility of raw and pasteurized
milk is concerned, there is also still considerable dif-
ference of opinion.

Repeating the recommendations we made in a pre-
vious issue, we believe it would be feasible for the
health authorities to license a considerable percent-
age of farms to supply raw milk, provided all the
cattle were subjected to the tuberculin test twice a
year and to a physical examination by a competent
veterinarian every three months. The animals that
react to tuberculin and others found diseased would
have to be removed. Furthermore, such farms
should be held very strictly to requirements as to
cleanliness, cooling of milk, freedom from conta-
gion, etc., violation of which would be punishable
by the exclusion of the milk from the city or by
compulsory thorough pasteurization. Of course, a
large staff of inspectors would be necessary to see
that the farmers lived up to these requirements. So
far as the milk supplied by farmers unwill-
ing or unable to comply with such restric-
tions is concerned, we believe that pasteuri-
zation under the supervision of the health
authorities should be insisted on. In orc'er to
insure efficient pasteurization a maximum bac-
terial content and a minimum heating should be
established. Furthermore, every bottle of pasteur-
ized milk should be plainly so marked, and the de-
gree of heat, length of e.xposure, and date of treat-
ment should also be stated.

ENDURANCE AND DIET.

The claim is always made by vegetarians — the
sober-minded among them as well as the fanatics —
that the man who eschews flesh food is "fitter" than
the meat-eater, but there has not been much evidence
of this beyond the statements of the former regard-
ing their subjective feelings. The carnivore has
maintained that this was no proof, for the Eddyite
made the same claim while eating anything in sight
and despising every hygienic law. As a matter of
fact, however, we may remark in parenthesis, the
member of the Church of Christ Scientist, while
pretending to ignore the laws of health, is a pretty
fair hygienist, and takes very good care of her body,
as a rule — especially if she aspires to the role and
emoluments of a "reader." Vegetarians, too — at
least the professionals — are not neglectful of hy-
gienic laws in addition to the practice of their pecu-
liar tenet. They avoid not only meat but also all the
stimulating or exciting products of the vegetable
kingdom, such as spices, coffee, and alcohol, and are
given to an open-air life, deep breathing, and sensi-
ble clothing. The meat eaters with whom they con-
trast themselves are, moreover, usually the intem-
perate of their class, the heavy eaters and those who
fill themselves to repletion with animal food three
times a day. Nearly everyone admits that excessive
consumption of meat is injurious, and a comparison
of the strict vegetarian with the intemperate meat
eater is manifestly unfair. It is as inconclusive as to
compare the total abstainer from alcohol with the
drunkard, rather than with the temperate wine
drinker.

A comparative test of the respective powers of
endurance of meat eaters and vegetarians, which
eliminated some, though not all, of the unfairness of
such comparisons, was recently made by Professor
Irving Fisher of Yale University (Yale Medical
Journal, March, 1907). The results obtained were
interesting and worthy of consideration. The tests
of endurance were three in number: holding the
arms horizontally, deep knee bending, and leg rais-
ing. The subjects of the test were divided into
three groups : athletes accustomed to a high-proteid
and full-flesh dietary, athletes accustomed to a low-
proteid and non-flesh dietary, and sedentary persons
accustomed to a low-proteid and non-flesh dietary.
The vegetarians had, with few exceptions, abstained
from flesh food for periods varying from 4 to 20
years, and some had never eaten meat. The flesh
eaters had, with few e.xceptions, been accustomed
to take meat two or three times daily, so that they
could not be called temperate meat eaters, and the
test was therefore not quite fair from the point of
view of the advocates of a moderate flesh dietary.
The results were all in favor of the vegetarians, as
shown by the following table :

ArmHoi dixg

Deep Knee
Ben'ding

Leg Raising

No. of
Persons

AveraRc

Record

Minutes

0 S

Average

Record

Times

1/5

6 i

Avcnigf

Record

Times

Flesh eaters, athletes
Abstainers, athletes
Abstainers, sedentary

15
13

10

11

9

16

5

383
027
535

6
6

T

279

288

74

A study of this table, though demonstrating the
superior endurance of the vegetarians, brings out

;26

MEDICAL RECORD.

[March 30, 1907

some curious facts. In the matter of leg raising,
excluding the one sedentary abstainer, the superi-
ority of the abstaining athletes over the meat eaters
of the same class was slight, but in knee bending it
was more marked, even the sedentary abstainers
Seating the meat-eating athletes. In the arm-hold-
mg contest, not only did the abstainers far outstrip
the meat eaters, but the sedentary abstainers were
nearly twice as capable as the athletes of their own
diet class. Manifestly one must look to something
else than the diet to account for this greater mus-
cular endurance on the part of those of sedentary
pursuits.

Professor Fisher's experiments are interesting
and the results are suggestive; though they are not
conclusive as to the comparative merits of total ab-
stinence from meat and of moderate indulgence.
The tests would also have been more satisfactory
had he included among his subjects a group of sed-
entary meat eaters, ^^'e have seen that the seden-
tary abstainers were superior to the athletic abstain-
ers in the arm-holding test, and it would be interest-
ing to know whether they would also be superior to
meat eaters of their own class. That they would
win in a contest with immoderate (three meals a
day) meat eaters we think probable, but that either
they or the abstaining athletes would prove better
in the matter of endurance than open-air lovers, of
temperate habits, who eat meat in moderation, has
not been demonstrated. Comparison between ex-
tremists is of interest, but it is of little value to the
average man. It simply indicates that total absti-
nence is better than overindulgence in what is 1
poison when taken in excess, but which the experi-
ence of mankind has demonstrated is a life-sustain-
ing food when eaten in moderation.

The Desmoid Test Ag.'^in.

During the past year or so the merits and demerits
of Sahli's so-called desmoid test for determining the
functional efficiency of the stomach have been dis-
cussed with considerable thoroughness by workers
in the field of gastrointestinal diseases. Sahli has
in so many ways shown himself a reliable guide
that it would be unwise to arrive at an unfavorable
conclusion in regard to this method unless those
criticising it had a good deal of evidence on their
side, but it must be conceded that as the case now
stands it appears that the desmoid test is not des-
tined to occupy the important position in clinical
diagnosis that its originator hoped for. Lewinski,
writing on the subject in the Miinchcner medizin-
ische Wochenschrift of February 26, 1907, suggests
that, as the conditions under which the desmoid test
and the ordinary test meal are carried out are so
different, some of the contradictions between the
results obtained by the two methods may be ex-
plained in this way. He endeavored to make a fairer
series of observations by resorting to Schmidt's test
diet and comparing the result of the desmoid test
with the amount of connective tissue from the meal
found undigested in the stool. Out of thirty-two
comparative tests made in this way on dififerent pa-
tients, conflicting results were obtained in fifteen, or
nearly one-half the number. Several suggestions
are made by the author to account for this discrep-
ancy, among others that different specimens of cat-
gut, owing to the mode of manufacture of the raw
material, may easily vary in their resistance to diges-

tion, and the still more important observation that
tests of various sorts in vitro showed that catgut
may be digested in intestinal juice or in gastric juice
apparently free from peptic ferment. While it will
be a disappointment if the ingenious and simple
method, proposed by Sahli as a substitute for the
test meal with its many disagreeable features, turns
out to be unsuitable for ordinary use, there is much
in favor of Lewinski's recommendation that infor-
mation of a similar nature be sought for by examin-
ing the stools after placing the patient on Schmidt's
regime in order to ascertain the ability of the
stomach to digest the connective tissue of the
chopped meat forming part of this diet.

Industrial Diseases.

In a communication to the Lancet of March 9, 1907,
in reference to the relation of industrial diseases to
the Workmen's Compensation Act, Dr. A. J. Greene
points out that unless this class of affections is very
limited in number employers will be compelled, in
order to protect themselves against damage suits, to
have all their workmen medically examined before
they are engaged, and declares that such a course
would lead to the rejection of many who are now
able to earn good wages. The economic outcome
would be that the rejected ones would perforce
become objects of charity, while those accepted
would be able to demand higher wages, as their
labor would be at a premium. Prices would go up
and foreign competition would be increased. Offi-
cial inquiries have been made with reference to
chronic carbon monoxide poisoning, pulmonary
fibrosis and chronic pneumonia, miner's nystag-
mus, miner's knee, and cardiac dilatation. The
author shows that the symptoms of some of
these conditions are extremely indefinite, and that it
might be very difficult to determine whether a low-
ered vitality in a given case was due to any one of
the foregoing causes or to some error of living or
vicious habit with which the occupation itself had
absolutely nothing to do. Many diseases to which
the name of some occupation is attached are by no
means confined to those who follow that particular
calling.

The Presence of the Meningococcus in the
Circulating Blood.

It is only within recent years that the meningococ-
cus has been definitelv demonstrated in the circulat-
ing blood and the possibility of a hematogenous
origin in cerebrospinal meningitis acknowledged.
The number of cases is, however, still limited so
that every additional demonstration is of value. In
a report made by Marcovich in the Wiener klinlsche
Wochenschrift, No. 44, 1906, mention is made of
a case in which the ordinary clinical features of
epidemic cerebrospinal meningitis were absent and
the presence of a peculiar skin eruption led to a
diagnosis of typhus fever. There was no increase of
temperature and no stiffness in the neck. The pa-
tient died within a few days after being taken sick,
and the autopsy revealed the presence of a purulent
meningitis along the convexity and the base of the
brain. The ventricles were quite empty and the
cerebrospinal fluid clear. The case is of particular
bacteriological interest, because the blood obtained
from a vein showed the meningococcus of Weichsel-
baum in pure culture. It is probable, therefore, that
in this instance a meningococcus sepsis was the pri-
mary lesion and this was followed by a localization
of the infectious process in the meninges.

March 30, 1907]

MEDICAL RECORD.

527

Dangers Associated with the Starvation Cure.

In certain forms of gastric ulcer, a so-called starva-
tion cure has been largely employed without much
thought as to its general effects aside from those
on the local process. Reichmann, however, writ-
ing in the Archiv fi'ir Verdauungskrankheiten, Vol.
II, No. 2, states as the result of an extended experi-
ence that the method of treatment known by this
name may be the cause of numerous complications.
In the first place we have to deal with the results of
the diminished nutrition, weakness, vertigo, dis-
turbances of the heart, etc., which may be developed
to such an extent that the treatment must be stopped
for a time at least if not altogether. The writer has
also noted in a number of instances the production of
a suppurative parotitis which he believes can be
ascribed to the increased number of pyogenic bac-
teria which collect in the oral cavity and the duct
of Steno as the result of an insufficient cleansing of
the mucous membrane by the act of chewing and
of a diminished flow of saliva. In order to protect
the patient against these serious complications the
oral cavity and particularly the mucous membrane
of the cheeks should be kept as clean as possible
with appropriate antiseptic solutions, among which
Reichmann has found a four per cent, solution of
boric acid among the most satisfactory.

Cancer Par.'Ksites.

Although the ranks of those who regard the cancer
question from the standpoint of parasitology have
been growing rather thinner of late, there seems to
be no doubt in the minds of the believers in this doc-
trine that ultimately it will prevail. Schiiller is one
of the most assertive of the parasitologists, and in a
recent number of the Berliner klinische IVoehen-
schrift (March 4, 1907) he announces the forth-
coming publication of a book in which he has ex-
plained the methods to be employed for the demon-
stration of his particular microorganism. He be-
lieves that the active proliferation of the cells in car-
cinoma and sarcoma depends on the local stimula-
tion caused by the intracellular parasites, and gives
in his article drawings reproduced from photo-
graphs, and intended to show the action of the in-
vading organisms in inciting division of the nuclei.
He closes by expressing the conviction that it may
be regarded as absolutely certain that the develop-
ment and growth of carcinoma and sarcoma in the
human body are dependent on the parasites he has
discovered.

How the Earnings of the "Journal" Should be
Expended. — In his presidential address before
the Medical Society of the State of New York, in
January of this year. Dr. Joseph D. Bryant, presi-
dent-elect of the American Medical Association,
referring to the prospective profits of the Journal,
said: "I am, however, clearly of the opinion that
the net earnings of the Journal should be utilized for
its betterment, and for the purpose of extending,
when feasible, publication courtesies to such of
those as contribute to its pages important and origi-
nal articles. It should not be the policy of this
Society, in my judgment, to accumulate worldly
belongings, but instead to increase the wealth of
good fellowship and professional advance, by a wise
adjustment relating thereto, of its business man-
agement."

Resolutions Regarding the Milk Supply. — The
Section on Public Health of the New York .•\cad-
emy of Medicine passed the following resolution at
its meeting of March 12, and this resolution was
adopted by the Academy at its meeting on March 21 :

Resolved: (i) That the Section on Public
Health of the New York Academy of Medicine does
not believe in the necessity of the compulsory pas-
teurization of all of the milk supply of New York
City, but recommends for the present to all those
whose milk supply cannot be proven to be thor-
oughly inspected and wholesome, and mainly the
milk destined for the feeding of infants unless it
is "certified," to boil their milk when delivered in
the morning for three minutes. (2) That the health
of the City of New York demands a persistence in
the policy of supervision of farms, dairies, and
creameries, supervision of the milk during transit
and on delivery in the city, and supervision at the
points of distribution in the city to the consumer,
whether the milk that is distributed has been pas-
teurized or not. (3) That local and State health
authorities and the Bureau of .\nimal Industry ot
the United States Department of Agriculture should
cooperate with milk producers to prevent the oc-
currence of communicable disease in cattle and their
caretakers. (4) That the Section on Public Health
recommends that the New York Academy of IVedi-
cine adopt the above resolutions, and that a copy
be sent to the members of the Committee on Pub-
lic Health of the Board of Aldermen, to the Com-
mittee of the New York State Legislature having
under consideration the Reece bill, and to the med-
ical and the lay press.

Police to Aid in Suppression of Noise. — As the

result of an appeal from Mrs. Isaac L. Rice, presi-
dent of the Society for the Suppression of Un-
necessary Noises, Police Commissioner Bingham
has issued an order instructing every captain and
commanding officer in the greater city to have all
unnecessary noises stopped in the neighborhood of
hospitals. The order calls attention to the fact
that in the summer time, when it is necessary to
keep hospital windows open, loud and boisterous
talk on the adjacent streets disturbs the patients.
Street vendors of all kinds, including lusty youths
who yell "u.xtry !" and sell late editions of the
newspapers, are among the worst offenders. The
small boy and the tin can make a combination
that racks the nerves of sick people. Patrolmen
are directed to insist that these unnecessary noises
stop, particularly near hospitals, and, when neces-
sary, to make arrests and explain to the Magis-
trates the necessity for so doing. Embodied in
the order are sections of the Penal Code and the
city ordinances relating to noises.

The Fight Against Tuberculosis in Chicago. —

Efforts of the Chicago Tuberculosis Institute this
year to reduce the death rate from this disease in
Chicago will require $25,000, according to the
estimates of its officials. Plans of the Institute
include the establishment of a dispensary and a
day camp, a comprehensive investigation of con-
ditions in homes, workshops, stores, schools, pub-
lic conveyances, traveling exhibits, and lectures
and conferences. A successful camp sanatorium
for women and girls in early stages of tuberculo-
sis is being maintained at Dunning, Illinois. It
is known as Camp Norwood. It cost only $2,000
to establish it, and it accommodates twenty pa-
tients.

Emergency Hospital, Chicago. — The Iroquois
Memorial Emergency Hospital Association has

528

MEDICAL RECORD.

[March 30, 1907

made an offer to construct an emergency hos-
pital at a cost of not less than $25,000, near the
loop downtown, provided a site can be had, and
if the maintenance of the institution is under-
taken.

Chicago Medical Colleges to be Inspected. —
Arrangements were completed at a meeting of
the State Board of Health, held March 15, for
the inspection annually of the medical colleges of
Chicago and Cook county. To find out whether
or not all the provisions under which these col-
leges operate under the State law are being ob-
served, these examinations are to be held by the
Board.

The Biological Station of the University of
California, at La Jolla, a suburb of San Diego,
promises soon to become one of the most thor-
oughly equipped institutions of the kind. By
recent enactments of the State legislature and the
city council, a park has been set aside to the use
of the station, and money has been contributed
for putting up a suitable building. Work of a
high order has been carried on for several years,
and furnishes a basis for further undertakings.
The station has been located at this point on
account of the great variety of sea-life found in
the vicinity.

Mosquito Extermination in New Jersey. — The
Jersey City Board of Health has under considera-
tion plans for exterminating mosquitos in the
Hackensack meadows by a system of drainage
ditches twenty miles in length. The main
trenches emptying into the Hackensack river will
be thirty inches deep, varying from two to four
feet in width. The lateral ditches will be ten
inches wide. The ditches will be dug by means
of an excavating machine, and it is estimated
that the cost of the work will not exceed $2,500.

Dr. Hermann Grad has been appointed assist-
ant surgeon of the Woman's Hospital of this city.

Dr. Charles F. Millar, chief surgeon at the Cen-
tral Emergency Hospital of San Francisco, has
resigned from the service on account of ill-health.
He has been connected with the health depart-
ment for the past seven j'ears, and displayed re-
markable ability at all times, but especially in the
trying times following the earthquake of a year
ago.

Measles in the Navy. — An epidemic of measles
has broken out on the battleship Georgia, now at
Hampton Roads. A month ago about thirty of
the seamen on the vessel suffered from the dis-
ease, and for a time it seemed that the epidemic
had subsided, but new cases are occurring again,
and orders for the future movements of the ship
have been cancelled.

Alleged Attacks on Insane Patients. — Six for-
mer or present attendants of the State Hospital
for the Insane in Cleveland have been indicteil
by the Grand Jury on the charge of having used
undue violence toward patients in their care.
One of these attendants has nine separate indict-
ments against him.

To Prevent Seasickness. — The value of Dr.
Schlick's g}TOScopic apparatus, intended to reduce
the motion of vessels at sea. has been attested bv
Sir William H. White, F.R.S., a British authority
in maritime construction. At a meeting of the In-
stitution of Naval Architects he said that from per-
sonal observation he could certify to the remark-
able steadying effect on a vessel of the g>TOScopic
apparatus. In all cases its effect was to extinguish

the rolling motion of the ship almost immediately.
The vessel on which he had observed the working
of the apparatus was practically deprived by it of
rolling motion as she lay broadside to the sea. Sir
William expressed the opinion that the apparatus
would have great utility attached to Channel and
coasting passenger steamers. Gyroscopes could also
be designed which would have a steadying effect on
the largest ocean liners.

Dr. C. E. Ruth, for many years Professor of
Surgery in the Keokuk Medical College was guest
of honor at a dinner given in Burlington, la., by
his professional friends as a farewell on the occasion
of Dr. Ruth's impending removal to Colorado.

McGill University Medical School. — The medi-
cal course at McGill University, Montreal, has been
lengthened by a year, and five years of study are now
requisite to obtain the degree of M.D. from that
faculty.

Standardized Sausage. — The Lancet, which has
already made suggestions in regard to the standard-
ization of Christmas puddings and the height of the
steps in staircases, now advocates the adoption of a
■'legal authoritative definition of a sausage." It is
admitted that sausages, as a whole, are nowadays
usually composed of wholesome ingredients, though
this useful comestible is a common subject of jest,
since it is so often regarded as a convenient vehicle
for materials which when undisguised certainly do
not appeal to us as being suitable or even wholesome
for purposes of food. One particular abuse to which
the Lancet objects is the addition of bread or broken
waste biscuit with the object of cheapening the
product. This is a palpable fraud, as the sausage
is looked upon as a meaty and not a farinaceous
food, and, moreover, the price is approximately
that of meat.

Prof. Behring Recovered. — Cable despatches
announce that \'on Behring, who was lately said
to have been suffering from a mental breakdown,
has entirely recovered again and will not be
obliged to give up work for the present.

Paris Morgue Closed to Visitors. — The munici-
pal authorities have decided that the Paris
morgue is no longer to be open to sightseers, and
that in future no persons shall be admitted to
inspect the bodies unless they can convince the
registrar that they come for the purpose of iden-
tifying a corpse.

Absinthe to be Tabooed in France. — The com-
mission on hygiene of the French Chamber of
Deputies has reported in favor of the total pro-
hibition of the distillation, importation, traffic in,
and sale of absinthe. The commission proposes
that the manufacture of absinthe shall cease in
one year, and that after two years its sale shall
become illegal.

Smallpox. — The sporadic occurrence of a few
cases of smallpo.x in Paris and various other
French cities is said to have caused much popular
apprehension in Paris, and great numbers of
people of all classes are being vaccinated. The
Parisian cases are supposed to have been im-
ported from Tunis and Tripoli, and were of a
severe type. The transatlantic liner Pennsylvania
was detained at Quarantine last week owing to
the presence on board of a case of the disease.
The patient, a child, was removed to the Brooklyn
Hospital and the steamer was fumigated. Those
of the passengers who had been more directly
exposed were sent to Hoffman Island for observa-
tion.

March 30, 1907]

MEDICAL RECORD.

529

Prof. Karl Hess of Wurzburg, a prominent
ophthalmologist, sails for this country on April 9
to give lectures on subjects relating to his spe-
cialty in various cities.

Hospital Appropriations. — The Legislature of
California recently made the following appropria-
tions : For improvements at the Southern Cali-
fornia State Hospital, $45,000; for improvements
at the Home for the Care of Feeble-minded Chil-
dren, $100,000; for the State Hospital at Napa,
$63,000; for additional building at the Stockton
State Hospital, $78,000.

Bequests to Public Institutions. — By the will
of the late Francis P. Furnald, Columbia Univer-
sity will inherit $300,000 on the death of the wife
of the testator, Mrs. Sarah E. Furnald, to whom
all his estate is left in trust for her life. The trus-
tees of the Presbyterian Hospital will receive on
Mrs. Furnald's death $100,000, to be spent in
maintaining beds for worthy applicants, and the
Bethany Day Nursery and the Manhattan Work-
ing Girls' Society will also receive $100,000 each
to create funds in memory of Mrs. Furnald.

Bequests to Hospitals. — By the will of the late
Samuel Elkin of Philadelphia the sum of $5,000
is bequeathed to the Jewish Hospital in the name
of his mother. Eve Elkin; $3,000 to the Jewish
Foster Home, also in the name of his mother;
$3,000 to the operating department of Jefferson
Hospital ; $5,000 to the Episcopal Hospital ; $5,000
to the Presbyterian Hospital ; $5,000 to St. Agnes'
Hospital, and $10,000 to the Home for Crippled
Children.

Sanatorium Gabriels. — Those in charge of this
institution, which is intended for the care of
patients in the earlier stage of tuberculosis, state
that it is handicapped seriously by lack of funds.
The sanatorium is situated at Paul Smith's in the
Adirondacks, and was begun in 1895. The sum
of $135,000 has been spent on buildings and equip-
ment and $50,000 has been expended on interest.
The debt is now $65,000, of which $18,461 must
be met before May 24.

Roane County (Tenn.) Medical Association. —
At the last meeting of this society, officers for the
ensuing year were elected as follows : President,
Dr. J. J. Waller of Oliver Springs ; J 'ice-President,
Dr. John Roberts of Kingston ; Secretary, Dr. G. C.
G. Givan of Harriman, reelected; Treasurer, Dr.
C. W. Green of Harriman, reelected.

Western Massachusetts Homeopathic Associa-
tion.— At the annual meeting of this society held
in Springfield on March 21, officers were elected as
follows for the ensuing year : President, Dr. H. C.
Cheney of Palmer ; First Vice-President, Dr. E. W.
Capen of Monson ; Second Vice-President, Dr. S. A.
Lewis of Springfield ; Secretary and Treasurer, Dr.
James B. Comins of Springfield.

Saline County (Ark.) Medical Society. — The

following officers were elected at a recent meeting
of this organization held in Benton : President, Dr.
J. W. Melton ; Vice-President, Dr. Charles Prickett;
Secretary and Treasurer, Dr. Charles Steed.

Massachusetts General Hospital Alumni Asso-
ciation.— More than 160 members of this associ-
ation were present at the second annual banquet
held in Boston on March 16. The officers elected
for the ensuing year are: President, Dr. Ellery
Stedman of Boston ; Vice-Presidents, Dr. Dudley
P. Allen of Cleveland, Dr. John Brannan of New
York, and Dr. W. N. Swift of New Bedford ; Sec-
retary, Dr. F. A. Washburn, Jr., reelected.

Professor von Bergmann of Berlin, the well-
known German surgeon, died of appendicitis at
Wiesbaden on Monday of this week. He was
operated upon the day before his death. Last
summer he presided over a series of three meet-
ings of the Berlin Medical Society devoted to a
discussion of appendicitis, and voiced an emphatic
opinion in favor of early operation, as a necessary
preliminary to which was early diagnosis. He was
born in Livonia, December 16, 1836, and studied
medicine at the Universities of Dorpat, Berlin,
and Vienna. During the Austro-Prussian war
of 1866 Prof, von Bergmann was at the
head of the military hospital at Koenigin-
hoft', Bohemia, and during the Franco-Prussian
war he directed the military hospitals at
Mannheim and at Carlsruhe. He was appointed
professor of surgery at Dorpat in 1875 and
remained there until the outbreak of the
Turko-Russian war, when he was attached to the
Russian army of the Danube as consulting sur-
geon. In 1878 he became chief surgeon of the
hospital at Wurzburg and was called in 1882 to
succeed Prof, von Langenbeck in the chair of
surgery at the University of Berlin and in the di-
rection of the surgical clinic of that city. He oper-
ated upon the Emperor, Frederick HI., and main-
tained, in opposition to Morell Mackenzie and Vir-
chow, that the growth was cancerous.

In Memory of Dr. Fowler. — On Easter Sunday
the Society of Ex-Internes of the Seney Hospital
will unveil a bronze tablet in memory of the late
Dr. George R. Fowler. The tablet bears the fol-
lowing inscription, and will be placed in the main
hall of the hospital : "In memory of Dr. George
Ryerson Fowler, surgeon in the Methodist Epis-
copal Hospital, 1887-1906. This tablet is erected
by the Society of Ex-Internes in grateful recogni-
tion of him as teacher, counsellor, friend."

Obituary Notes. — Dr. John H. Brinton died
at Philadelphia on March 18, at the age of seventy-
five years. He was graduated from Jefferson Med-
ical College in the class of 1852, and subsequently
spent a year in foreign study. In 1853 he gave a
course of demonstrations in operative surgery at the
anatomical rooms in College avenue. In 1859 he
was elected surgeon to St. Joseph's Hospital, and
he was consulting surgeon to this hospital at the
time of his death. In 1861 he was commissioned by
President Lincoln brigade-surgeon of Volunteers,
and he was assigned to the oiifice of the Medical
Director of the District of Cairo, where he assumed
the duties of Acting Medical Director on the staff of
General Grant. He subsequently acted as Medical
Director of the Army of the Tennessee, with the
rank of Major. In 1862 Dr. Brinton was assigned
by Surgeon-General Hammond to the oiifice of the
Surgeon-General, where he was ordered to prepare
a "Surgical History of the Rebellion." A short
time later he was assigned to the founding of the
Army Medical Museum. At a later period he was
assigned to duty in the Department of Missouri,
and he served as Medical Director in the field during
the Missouri campaign. Still later lie served as
Superintendent and Director of General Hospitals at
Nashville, and afterward as Acting Medical Director
of the Army of the Cumberland. On his return to
Philadelphia at the close of the war Dr. Brinton was
appointed lecturer on operative surgery in the sum-
mer course at Jefferson Medical College, and a few
years later was made one of the surgeons to the
Philadelphia Hospital. In 1877 he was elected sur-
geon to Jefferson Hospital, and in 1882 Professor

530

MEDICAL RECORD.

[March 30, 1907

of Surgery and of Clinical Surgery in Jefferson
Medical College. This last position he resigned a
year ago when he was elected Emeritus Professor.
Major William J. Wakemax, Surgeon U.S.A.,
died on March 20 at Fort Monroe, \"a. He was
born in Connecticut in 1845. After receiving his
degrees in arts and medicine from Yale University
he was made assistant surgeon in the army in
1882. He served through the Spanish war as sur-
geon of Volunteers, and in 1900 received the rank
of Major.

Dr. Rodney C. F. Combes of Brooklyn died on
March 18 of typhoid fever which he had contracted
while on a trip through Mexico. He was born in
East Rockaway, L. I., fifty-one years ago.

Dr. William B. Thomas of Ionia, Mich., died on
March 5, at the age of seventy-six years. He was
born in ilonroe County, N. Y., and after being grad-
uated from Genesee College, the University of Buf-
falo, and the University of Michigan, he began prac-
tice in Ionia in 1859. He served in the Civil War,
and in 1866 was appointed United States Marshal.
In 1871 he was Superintendent of Schools of Ionia
countv, and in the same vear was admitted to the
Bar. '

Dr. James Utley of Newton, Mass., died on
March 15 at the age of sixty-eight years. He was
born in Chatham, N. Y., and received his medical
education in the Bowdoin Medical College and the
Hahnemann Medical College of Philadelphia. He
settled in Taunton early in the sixties, but some
years later removed to Newton, where he had since
resided.

Dr. J. J. Hopkins of Upper Tract, W. Va., died
suddenly on March 14, at the age of sixty-four years.
He was graduated from the New York University
Medical College in 1874.

Dr. W. J. Sneed of Nashville, Tenn., died on
March 17, at the age of seventy-two years. He was
born in Brentwood, Tenn., and was graduated in
medicine from the Vanderbilt ^Medical College, in
which institution he was afterward professor of
anatomy. He served as surgeon in the Confederate.
Army and had practised in Nashville for over forty
years.

Dr. Albert M. Warner of Waukesha, Wis., died
on March 15, at the age of ninety-one years. He
was born in Andover, Vt., and was graduated from
the Vermont Medical College at Woodstock in
1842. After practising a short time in New York,
he removing to Waukesha, where he had resided
ever since.

Dr. J. L. Edgar of Clearwater, Fla., died sud-
denly of apoplexy on March 13. He was a native of
Missouri, and had practised in Florida for over
twenty-five years.

Dr. David H. Shenk died at Lancaster, Pa., on
March 11, at the age of fifty-five years. He was
graduated from Long Island College Hospital in
the class of 1874.

Dr. Leander P. Jones of Greenwich, Conn., died
on March 18 at Bellaire, Fla. Dr. Jones was born
in 1845 in southern Vermont. He was graduated
in 1874 from the New York College of Homeop-
athy. After practising for a time in Hartford, he
went to Greenwich in 1876. In 1894 he was elected
State Senator, and at the close of his term was asked
to take the nomination for Governor, but declined.
He was for many years fleet surgeon of the Indian
Harbor Yacht Club, and had just been reappointed
to that office. He had held numerous public offices,
and at the time of his death he was medical exam-
iner for Greenwich.
Dr. Robert Stewart MacGregor of this citv died

of pneumonia on March 23, at the age of thirty-
eight years. Dr. MacGregor was born in St. An-
drews, Province of Quebec. At an early age he
moved to this State. In 1894 he was graduated
with honors from Brown University, and three years
later he finished the medical course at New York
University. Since that time he has practised medi-
cine in this city with the exception of one year
which he spent in a hospital at Yonkers.

®bUuari|.

GEORGE G. WHEELOCK, M.D.

NEW YORK.

Dr. George G. Wheelock of this city died on
March 22, at the age of sixty-eight years. He was
born in Boston in 1838, and took his bachelor's
degree at Harvard College in i860, and his master's
degree in 1864. In that year he also took the degree
of Doctor of ^ledicine at the College of Physicians
and Surgeons of this city. He entered the Govern-
ment medical military service, and was for a year
in charge of the General Hospital at Savannah," Ga.
He later served as house surgeon in the New York
Hospital, and, after some time spent in study abroad,
began practice in New York. He soon received
the position of Assistant Demonstrator of Anatomy
and Lecturer on Physical Diagnosis in the College
of Physicians and Surgeons, becoming later a Trus-
tee of the college, and Registrar of its Board of
Trustees, and serving for many years as Treasurer
of the Association of the Alumni. He was also ap-
pointed attending physician to St. Luke's Hospital,
and to the Nursery and Child's Hospital. In 1891
Dr. Wheelock was elected a Trustee of Columbia,
and became a manager of the Vanderbilt Clinic and
of the Sloane Maternity Hospital, ail of which of-
fices he held at his death, being President of the last-
named institution. Dr. Wheelock retired from the
practice of medicine in 1891, and since then had
given his time to the service of the various public
works in which he was interested.

OUR LONDON LETTER.

(From Our Special Correspondent.)

HUMAX AND BOVINE TUBERCULOSIS — TROPIC.-U. S.\NITATION" —
CEREBROSPINAL FEVEK — A CLERIC DENOUNCES ROBBING THE
DOCTOR — OBITUARY.

London*. March 8, X907.

At the iledico-Chirurgical on the 26th ult. Dr. Nathan Raw
read a paper on Human and Bovine Tuberculosis, having
special reference to treatment by corresponding varieties of
tuberculin. He held that infection of the human body
may be by either bacillus, the two being varieties of the
same species, but giving rise, according to the method of
infection, to quite different and distinct lesions. The
cultural differences were sufficient, when typical, to dif-
ferentiate them, but the microscopic appearances were not.
Basing his conclusions on 4,000 cases of phthisis, includ-
ing 700 post-mortem examinations as well as on animal
inoculation, Dr. Raw divided the lesions in the human
species into two groups: (i) Lesions caused by the T. B.,
typus humanus; phthisis pulmonalis, secondary intestinal
ulceration, tuberculous laryngitis ; (2) caused by the typus
hovinus (conveyed by meat, milk, etc.. or by direct infec-
tion), acute miliarj- tuberculosis, primary' intestinal and
mesenteric disease (tabes, peritonitis, pelvic tubercle),
tuberculous hmphatic glands, tuberculous joints and bones,
lupus, tuberculous meningitis and tuberculous ulcerations
of the cornea. Human and bovine tuberculosis were antag-
onistic and one could confer immunit}- from the other.
Dr. Raw had had a new tuberculin prepared based on
these obsen-ations.
Dr. David Lawson remarked on the rarity of surgical

March 30, 1907]

MEDICAL RECORD.

531

tuberculosis in pulmonary phthisis. Out of 600 or 700
consecutive cases none had lupus, only three bone disease
and only five gland affection. The frequency of miliary
tuberculosis as a termination of phthisis required explana-
tion. There were some good results in phthisis from T. R.
tuberculin as checked by the opsonic index, though not
so striking as in surgical tuberculosis.

Mr. J. P. Lord asked whether the two groups could be
distinguished in milk.

Dr. C. Calvert said the Royal Commission had reported
both bacilli found in cervical glands. He thought the two
were varieties — not types.

Dr. Tooth inquired as to the precautions which had
been adopted in regard to injections.

Dr. Sandwith said all forms of tuberculosis were com-
mon in Egypt except meningitis. He found injections gave
bad results in surgical cases. He had not seen lupus in a
phthisical case. The women in Egypt suckled their chil-
dren even for two years and all other milk was generally
boiled and tubercle among cattle was rare. Nevertheless
tuberculosis was frequent.

Professor Ronald Ross gave a lecture last Friday at
the Sanitary Institute on "Points of Interest Connected with
Tropical Sanitation." The Duke of Northumberland,
president, paid a well-merited tribute to the indefatiga-
ble labors of Dr. Ross in the field of tropical medicine, and
at the close proposed a vote of thanks to the professor for
his instructive lecture. Dr. Ross showed a number of
lantern slides to illustrate the history and progress of
sleeping sickness, yellow fever and malaria, and said we
now know as much about the anatomy of the tsetse fly,
which carries the sleeping sickness parasite, as we do of
the anatomy of the human body. It was not possible to
get rid of the larvs of the tsetse fly, so the only way to
prevent the spread of the disease is to cure it in the
patients. It is depopulating whole districts in Africa and
many almost despair of combating it. Quarantining trade
routes is one of the latest proposals. The lecturer then
gave an account of the discovery that yellow fever is
caused by the bite of the tiger mosquito, but the parasite
it introduces has not yet been discovered. Dealing with
malaria, he insisted on the importance of draining the soil,
and referred to the effort about to be made to clear the
valleys of Greece of this devastating disease.

I have received from the County Council a copy of an
order making cerebrospinal fever notifiable in the admin-
istrative county of London for six months from Tuesday
next. The council has also sent with the notice extracts
from a memorandum dated July, 1905, by Mr. Power,
M.O.H. of the Local Government Board. This board has
issued a report by Dr. M. H. Gordon, dealing with the
micrococcus especially in reference to its identification in
the upper respiratory tract. He finds the agglutination test
of little value for distinguishing the meningococcus from
normal cocci of the mouth and throat.

The Surrey Medical Officers of Health held a meeting
last Friday to discuss preventive measures. Cases have
been reported in various districts, but some are probably
not cerebrospinal. One or two have occurred in the suburbs
of London ; yesterday an inquest on a child resulted in a
verdict that death was due to the disease. In Ireland and
Scotland the epidemic has continued.

The clergy are generally so little appreciative of the
profession that a recent word by Father Vaughn deserves
notice. He has been giving a series of sermons on the
'"Sins of Society," which he expressly directs to the "smart
set." Last Sunday he addressed them on Truth, telling them
that as Pilate had no place for it in practical politics, so
it was in their "grab for riches, push for place, and rush
for honors." To-day, he said, men and women did not
pause to reckon with truth but indulged in forms of speech
which "were lies as black as the 'father of lies' himself."
For instance, society women made themselves out poor
when it suited them, as in one case under his notice when
a famous oculist had been robbed of his fee for an opera-
tion by a pretense of poverty. Now that woman, said the
preacher, not only defrauded the oculist but she also de-
frauded some poor sister of a free operation, because there
was a limit to the number of cases which, even one of the
most generous class of men, physicians and surgeons, could
undertake without fee.

Dr. Allan Macfadyen died on Friday last at the early age
of 46. Educated at Edinburgh University, he afterwards
studied in London, Berne, and Munich. From 1889 to 1892
he held the Sanitary Research Scholarship founded by the
Grocer's Company. He was connected later with the
Jenner Institute (now the Lister), and was Professor of
Physiology at the Royal institution. His bacteriological
work is well known. To the Local Government Board
Reports, 1889, he contributed an important paper on the
"Chemical Action of Bacteria on Albumins and Peptones."

A number of papers from his pen detail his researches as to
the possibility of immunizing animals against typhoid,
cholera, plague, and other diseases, ^vere regarded as of high
value, and it seems sad that he should not have lived to
complete his work. It would require a bacteriologist to do
justice to his investigations.

Lt.-Col. G. M. McKee of the Indian Medical Service died
on the 27th ult., aged 52. He entered as assistant surgeon in
1880 to the 83rd light infantry, served in the Burmese Expe-
dition, 1885-7, and obtained the medal and clasp. He became
Lt.-Col. in October, 1900.

Lt.-Col. E. Fitz-Stubbs, late Army Medical Service, died
on the 28th ult., at the age of 60. He entered tlie army in
1871 and retired in 1896. He had the Ashunti medal (1873-
4) and the Egyptian medal and bronze star (1882).

A HEALTHFUL SPORT.

To THE Editor of the Medical Record :

Sir: — Rifle shooting as a means of relaxation does not
receive the attention it should. It trains the eye to see
accurately, the mind to judge correctly, and exercises the
powers of coordination, while the strict attention it re-
quires takes the mind clear of business cares and all the
other worries and irritations of modern life. It is the
sport par excellence for the neurasthenic, for he is obliged
to forget himself, and introspection for the time becomes
impossible when every faculty is centered on a target
maybe five hundred yards away.

While it can be indulged in during the winter or in bad
weather in some indoor gallery, its perfection as a sport
and change for the busy professional man or merchant is
found out on the range under the blue sky, where fresh
air, good company, and attention to the business in hand
cause all cares to "fold their tents like the Arabs and
silently steal away." Add to these advantages the fact
that it is in itself an act of patriotism, qualifying a man to
fulfill one of the highest duties of citizenship, the defense
of his country in time of need.

The time was when the country was new that we were
a nation of riflemen, but that is no longer the case, and
special efforts must now be made to have a sufficient supply
of marksmen. Therefore, every man should lend his
encouragement to this sport which is clean, healthful, and
patriotic You or I may feel that we never would be called
upon to use that skill directly; but by example and sup-
port we may excite enthusiasm in others and use what
skill we may obtain in helping to train others.

In a short time there will be scarcely a town of any con-
siderable size which will not have a branch of the National
Rifle Association. The United States Government is as-
sisting these clubs in every way, and if the physicians of
the country would take an active part they would derive
great physical benefit themselves, do their duty by their
country, and help make popular a sport which all could
take part in, as it does not require severe physical exertion,
nor does it, like other field sports, tempt its devotees to
overtax their strength.

Long range shooting especially cultivates the powers of
observation, mathematical reasoning, and logical deduc-
tion to a degree unknown to any other sport, while, at the
same time, it is free from envy, spite, and the littleness of
many other forms of personal competition. Many doctors
realize this, and a very large proportion of the expert
shots of this countr>' are doctors — notably Dr. VV. G.
Hudson, to whose work in perfecting the modern high
power bullet the United States Government owes a large
debt of gratitude. William C. Wood, M.D.

Gloversville, N. Y.

SULPHATE OF COPPER IN TYPHOID FEVER.

To THE Editor of the Medical Record:

Sir: — Hare says in his Practice of Medicine: "Very
recently it has been shown in the United States Govern-
ment Laboratories at Washington, and in the City Labo-
ratory at Philadelphia, that so small an amount of sulphate
of copper as I :i,ooo,cioo or even i :4,ooo,ooo, will destroy the
typhoid bacillus in a few hours." When so high an au-
thority makes such a statement it may well give us pause.
If this attenuated dilution (almost Hahnemannian) will
destroy the bacillus typhosus in tanks and reservoirs, why
not within the human body? The proportion of 1:1,000,000
is approximately one grain to sixteen gallons of water.
The average human body contains perhaps sixteen gallons
water. To immunize the average person from typhoid
fever it is therefore necessary to incorporate with it one
grain of sulphate of copper. The salts of copper being
diffusible substances quickly enter the blood and are
eliminated by the liver, intestinal canal, salivary glands,

532

MEDICAL RECORD.

[March 30, 1907

and kidneys. In the blood, as is the case with other metal-
lic poisons, copper probably exists in the form of an
albuminate in close relation with the red blood globules.
It would seem that copper in any form is fatal to the
typhoid germs. How it acts is not known. It has also
been stated that if water containing typhoid bacilli is placed
in burnished copper vessels for a few hours most of the
typhoid germs are destroyed.

If our premise is correct the conclusion follows : Given
one grain of sulphate of copper, say every four hours for
possibly three days, all the typhoid germs will have been
destroyed and the disease aborted. If given after necrotic
changes have taken place in the intestinal glands, conva-
lescence would be delayed until sufficient time for repair,
perhaps one week, or at most ten days or a fortnight.

When one has a case of typhoid fever, let him follow
these suggestions. It will not interfere with other treat-
ment, which it may be well to add should not be neglected
— at least not for the present. J. L. Gilbert, M.D.

Kendallville, Ind.

Nnt.' York Medical Jourmil, March 16, 1907.

General Infection by the Colon Bacillus with Rapidly
Fatal Septicemia and Hemoglobinemia — The patient
of A. D. Blackader and B. D. Gillies was a young
woman of twenty-seven years, apparently in good con-
dition, who was stricken down and died within forty-
eight hours, developing an extreme hemolysis before
death. There had evidently been an abortion between
the second and third months of pregnancy and this
had been followed by the usual toxic symptoms, which
in turn were succeeded by a colon bacillus infection
of the uterus, as shown by smears and cultures. Later
severe septicemia developed and finally a rapid destruc-
tion of the blood cells. A full history is given with
autopsy findings. The authors consider that the rapid
hemolysis is the most interesting feature in the case,
and they refer to the literature of the special lysins,
the products of various bacteria, such as the B. pyocya-
netis. B. typhosus, B. coli communis, B. Staphylococcus
albus. and aureus and Streptococcus pyogenes. The de-
velopment of these lysins is in the main extrabacillary.
It begins on the second or third day and increases rapidly
to a maximum on the sixth or seventh, after which it
slowly decreases. The authors quote freely from Abbott
with reference to this class of substances. So far as they
know, no previous case on record has brought to light
any such severe .grade of hemoglobinemia.

Trachoma, Clinically and Socially Considered.— A
general description of the disease is given by H. F.
Hansel, who also alludes to the national regulations
bearing on the subject. The article traverses familiar
ground and nothing new is brought out. The author
believes that immigrants who have reached the cicatri-
cial stage of the malady, with eyes otherwise in good
condition, may be allowed to land.

Rhinoscleroma Treated writh the X-Ray.— After a
brief allusion to the nature of the disease and its
geographical distribution, M. J. Ballin relates one
personal case occurring in a Russian woman of fifty-
three years. Photographs are shown in the paper
by which the progress of the case can be traced. The
note\vorthy features of the case are: first, its long
duration, viz. sixteen years; second, the complete free-
dom of the larynx: third, the extremely large size of
the nasal organ, and fourth, the surprisingly good effect
of the -f-rays in treatment. At the time of the report
the case was not absolutely cured, but a vast improve-
inent had been made, although there w^as some obstruc-
tion inside the nares. Removal of pieces of afl^ected
tissue to allow of a greater air space are generally
followed by increased activity of the pathological proc-
ess. It is hoped bv the author that the use of very
small tubes for the .v-ray within the nose will result
in a full restoration of their patency, or at least lead to
satisfactory cicatrization. It is thought that the reduc-
tion of size of the nose has been due not to a breaking
down of the tissue, but to a gradual absorption brought
about by some chemical change.

The Significance of Bladder Symptoms in Relation
to Some Spinal Cord Lesions. — Five cases are detailed
by J-. B. Squier. who speaks of the necessity for closer
discrimination between urinary symptoms arising from
de.generative changes in the motor or sensory centers
in the cord and those due whollv to organic conditions
in the bladder and its adnexa. Concerning the bladder
symptoms in tabes the author says that it is of the

utmost importance to seek out and treat, if they be pres-
ent, any lesions of the urethra which may add pe-
ripheral irritation to the already degenerated cord cen-
ters. The treatment of vesical conditions due to spinal
cord lesions is more or less identical to that of the
organic lecal disease by which they are similarly pro-
duced. The spasm of the irritable stricture can It
relieved by the passage of a sound, and in like manner
the vesical spasm of tabes may be relieved by the
same procedure. The treatment of these cases fre-
quently gives results far beyond that which one would
be led to expect, in consideration of their causative
factor. The utmost of persistence and perseverance
is required, and nowhere in the realm of medicine is
the carrying out of the details of treatment more neces-
sary. A tabetic bladder should never be allowed to
become overdistended. If it becomes necessary to
place the catheter in the patient's hands the most
rigorous instruction in the technique of aseptic catheter-
ization is imperative. Trophic disturbances are com-
mon to the disease, and on this account the patients
are especially prone to infection, and a tabetic bladder
once infected is no easy matter to restore to a state
of asepsis. Further, the smallest source of irritation
should not be overlooked. Sometimes the mere di-
vision of an abnormally small meatus will do much
towards relief of a vesical spasm. Mitchell. Frenkel,
and others have accomplished considerable for the
ataxia of tabetic patients by motor reeducation. In
like manner a certain amount can be gained in relieving
the weakened viscus by educating the abdominal mus-
cles to aid the vesical detrusor. Of the drugs, bella-
donna administered internally is the most efficient to
relax vesical spasm. For toning up the bladder and
preventing inflammation, solutions of silver nitrate act
better than the newer silver salts.

Journal of the Amcriran Medical Association, March 23,
190;.

Simple Ulcer of the Bladder. — G. Walker gives a

report of two personal observations of this compara-
tively infrequent condition, which he defines as a single
non-inflammatory ulcer of the mucous membrane of
the bladder, occasionally penetrating the entire wall,
and due probably to local disturbance in, or complete
blocking of the terminal or by an interference with
the trophic nerves, and never produced by infection of
the bladder, though in its second and third stages it
becomes infected with the ordinary pyogenic organ-
isms. Two types are recognized; the simple chronic
form leading to cystitis, and the acute perforating ulcer.
The early symptoms of the chronic type are those
of irritation; increased frequency of micturition, scald-
ing, pain, etc., and later cystitis with aggravation of
all the symptoms, finally, bladder paresis and the pa-
tient, unless relieved by operation, succumbs to ex-
haustion or ascending infection. In case of the acute
perforating ulcer there are no symptoms whatever
until perforation occurs. In the earlier stages the
cystoscope affords the only means of diagnosis, and
shows a simple ulcer with cleancut and slightly in-
durated edges surrounded by normal mucosa. It is
distinguished from tuberculous ulcer by its clean, not
undermined edges, the appearance of its base, the ab-
sence of surrounding tubercle, and of tuberculosis else-
where. Only in this early stage can it be distinguished
from the ulceration of the various forms of cystitis,
and Walker believes that many cases of diagnosed
healed tuberculosis cystitis were primarily this disease.
The prognosis of simple ulcer in the early stage is
good if proper treatment is given. In the second stage,
when lime salts have been deposited and the ulcerations
are exaggerated, curetting and drainage will generally
effect a cure. In the third stage, when there is great
interstitial change, the prognosis is grave, and the
acute perforating ulcer is usually fatal, practically
always so when the peritoneum is involved. One very
early recognized case is reported by Harrison, in
which the patient was cured by operation. Silver nitrate
irrigations, from i to 10.000 up to I to 5,000, every
second day will usually cure in the first stage. In the
second stage, curetting and cauterization with prolonged
suprapubic drainage are generally necessary. In the
third stage, drainage, irrigation, and gradual bladder
distention are all that can be done.

The Nasal Accessory Sinus and Eye Diseases. — F. E.
Brawley calls attention to what he considers a prac-
tically unrecognized condition, rarely attributed to the
nose and almost always to the eyes, and the fact that
glasses will sometimes give temporary relief tends to
confirm the error. The origin of the trouble generally
dates back to an attack of grip or a hard cold, and the

March 30, 1907]

MEDICAL RECORD.

533

headache when it first appears is often unilateral, though
later becoming general. It occurs both by night and
day, often beginning and ending at regular hours. Dur-
ing the attacks the use of the eyes is almost impossi-
ble, as it intensifies the symptoms; insufficiency, both
of accommodation and convergence, is usual, and dis-
tant vision may be reduced. There is often unilateral
lacrymation with local pain and swelling about the
eyes. Stooping over especially aggravates it, and it is
aflfected by jarring, circulatory disturbances of any kind,
excesses in eating, etc. As a rule, there is no history of
nasal disease. A close examination will reveal a swol-
len, boggy turbinal or one so closely applied to the
lateral nasal wall as to press on the hiatus semilunaris
and to interfere with the interchange of air and exit
of normal secretions from the frontal and anterior
ethmoidal cells. If the use of suprarenalin and cocaine
to the middle turbinal and infundibulum relieves the
attack, a resection of the hypertrophied anterior end of
the middle turbinal is indicated to restore normal
conditions of air interchange and exit of secretions.
The point specially emphasized in his paper is the
absence of all definite nasal symptoms and the ap-
parently normal nose. There may be more serious con-
ditions, however, such as acute suppuration of the sinus
producing these symptoms. It is in the milder non-
suppurative case that the real cause of the condition
is likely to be overlooked.

Eyestrain as the Cause of Chronic Headache.— Bas-
ing himself on his records of nearly 1,300 eye examina-
tions, S. W. S. Toms claims that ninety per cent, of all
those suffering from reflex or neuralgic headache have
ocular defects. Over six hundred of the patients ex-
amined were altogether unaware of their defect. Fully
half the cases were of only slight refractive errors or
muscular imbalance, and it is in these cases in which
ciliary spasm is the direct factor in causing headache in
persons whose occupation calls for near vision, that
accommodative asthenopia results. While there were
occasional complications, only five per cent, of the
patients had discoverable organic lesions that possibly
intensified or were partly to blame for the head pain.
Of those who were relieved of their headaches seventy-
five per cent, had no other treatment than properly
adjusted glasses or appropriate treatment for their mus-
cular anomalies. The types most frequently met are the
occipito-cervical, fronto-temporal and the hemicranias.
There is no apparent relation between the severity of
the headache and the degree of the ocular defect, and
nothing especially characteristic except, perhaps, the
patient's non-suspicion of the cause. Sickness or health
impairment may be the first inciting factor in some
patient with considerable ocular defects which gave
no trouble before. In this connection, the author
mentions as an ocular condition that does not receive
the attention it deserves in young subjects, subnormal
accommodation, or premature presbyopia, which may
be the cause of alarming symptoms of headache and
insomnia. Such patients often have a very acute vision
for distance, with a slight muscular trouble of exophoria
or esophoria, which is a misleading condition. They
refuse all distance lenses or prisms, but find immediate
relief when a presbyopia correction is made.

Examination of Students' Eyes. — W. C. Posey and
R. T. McKenzie describe the methods and results of
the examination of the ej'es of 883 students of the
University of Pennsylvania during the college year of
1905-06. So far as known, the University of Penn-
sylvania is the only degree-conferring institution in
which such examinations are systematically made. Of
the total number examined, 640 were students in the
college department, 108 in the medical, 81 in the dental,
51 in the law, and 3 in the veterinary department. Of
this total 14.70 were found myopic, the remainder being
either hypermetropic or emmetropic. As regards the
evidence of the influence of age and study, it is stated
that among over 600 students in the two lower classes,
87.25 per cent, were hypermetropic and 12.75 per
cent, myopic; while of 261 in the upper classes. 80.25
per cent, were hypermetropic and 19.7S per cent, were
myopic. Five per cent, more of myopia was found in
the professional departments in scholars of similar age
than in the college department, which is accounted for
by the larger number in the former from the rural dis-
tricts, where the care of the eye is more apt to be
neglected. The average age of all students was 21.4
years, and the statistics showed an increase of about
2.5 per cent, of myopia for each of the four years of
college life. Of the students examined, 609 had full
visual acuity of both eyes, 94 had it in but one eye,
while 180 had subnormal vision in both eyes. These
latter were decidedly at a disadvantage in certain

forms of classroom work, irrespective of effects of
uncorrected strain, while those with only one eye with
normal vision were handicapped in the proper use of
scientific instruments. Three hundred and three stu-
dents wore glasses, 217 were hypermetropic, and 86
myopic. Eighty-seven complained of headache, 47 01
these wore glasses. Of those with headache only, 7.59
per cent, had subnormal vision; the remainder were
normal and therefore did not credit it to their eyes.
Fifty-eight of the total number had scoliosis, or 6.68
per cent., 48 were hypernietropes, and 10 myopes. In 13.79
per cent, of the spinal curvature cases the vision of
one eye was perceptibly lower than that of the other,
supporting the inference of some ophthalmologists that
ocular errors may cause this abnormality. The au-
thors think that these figures, which are only a few
out of the many compiled from the examinations, suffi-
ciently indicate the importance of careful ocular tests
as a part of the physical examination of every student
and the importance' of correcting existing errors.^

Insanity in Women.— VV. O. Henry reviews the litera-
ture of the subject, quoting the opinions of various
authorities and criticising some of them who have
minimized the value of gynecologic operations for the
cure of insanity in women. He gives very brief reports
of 28 cases, in which he operated on such patients; of
this number he claims that 16 recovered from their
mental disorders. 3 of them having remained well
nine, ten, and eleven years, respectively. He thinks
that there is a vast amount of undiscovered pelvic
disease in insane women, the relief of which by opera-
tive methods would be possible. He insists on the
necessity of radical work in these cases so as to leave
no possible source of irritation that might perpetuate
the insanity.

Till- Lancet. March 9, IQO/.
Dislocation of the Semilunar Bone Complicating
Fracture of the Styloid Process of the Radius.— P. R.
Wrigley reports a case of this injury, his patient being
a painter, thirty-five years old. who fell thirty feet from
a ladder, dropping on his feet and then on his out-
stretched hand. The injury was at first supposed to be
a Colles' fracture. The author who saw the case some
days later found a transverse lacerated w^Dund one inch
long in front of the inner side of the wrist swollen,
but permitting the recognition of the radial fracture.
Later a rounded projection of bone was noted on
the front of the wrist to the inner side of the palmaris
longus tendon. An .r-ray picture revealed a forward
and upward dislocation of the semilunar bone, which
lay just in front of the articulation between the radius
and ulnar, the condition being complicated by a vertical
fracture of the radius severing the styloid process from
the rest of the radius. As the dislocated bone seemed
too firmly fixed for reduction and the wound was sup-
purating freely, rendering excision inadvisable, it was
judged best to await events. The wound healed in
about a fortnight when splints were discarded and
massage and active movements were commenced. This
treatment was carried out for about a month with
a gradually increasing range of movement of the wrist
and fingers, but the patient began to complain of a feel-
ing of^numbness and tingling in his ring and little
fingers. This was followed by characteristic ulnar
paralysis affecting these fingers and in a minor degree
the adductors of the thumb. It was obvious that if
permanent injury to the ulnar nerve was to be avoided
the offending bone must be removed. Ten weeks after
the accident the semilunar bone was removed through
a vertical incision. It was firmly imbedded in fibrous
tissue, the ulnar vessels and nerves being displaced
outwards. Healing resulted by first intention and mas-
sage was begun. In five weeks the ulnar paralysis
had almost disappeared, there being only slight flexion
at the interphalangeal joints of the little finger; the
movements of the wrist were good and daily increas-
ing in strength and range, so that the patient has now
begun to do light work.

Operative Treatment of Traumatic Psychosis.--.A
case report is made by B. Hollander, whose patient
was a physician of thirty-nine years, who had been
kicked on' the right side of the chin by a horse and
who a year later had a bicycle accident, falling on
the right side of his head. There were no visible signs
of injury, but the accident was followed by hemicrania
of great severity, preventing any intellectual work, and
by definite character changes. He became emotional,
anxious, very depressed, accused himself of unpardon-
able sins, developed suicidal ideas, grew suspicious,
easily offended, irritable and profane, erotic, and subject
to uncontrollable fits of sexual excess. He suffered
also from obstinate constipation, persistent insomnia,

534

iMEDICAL RECORD.

[March 30, 1907

and had sensory disturbances in the left arm. He
sought relief in changes of scene by traveling, but to
no effect, and his strange conduct frequently led him
into difficulties. In the spring of 1905 (six years after
the bicycle accident) he had symptoms of word blind-
ness and a transient attack of paralysis of the right
side of the face and left half of the body. The depres-
sion and headache increased and all medical treatment
failed to cure him. Believing in the possibility of
localization of mental functions, and hoping that if his
symptoms were localizable operation would show path-
ological changes and give relief, he came to London.
On examination on October .■^. 1905, he appeared de-
pressed, emotional, showed strong suicidal tendency,
and complained of intense headache on the right side
and a burning sensation just posterior to the right
parietal eminence. It was ajudged that there was a
lesion originally limited to the neighborhood of the
supramarginal and angular convolutions, later spread-
ing downwards over the posterior temporal region.
When the head was shaved preparatory to operation a
scar appeared two inches behind the right ear and two
inches long, commencing behind the parietal eminence
in the situation of the angular gyrus and extending
vertically downwards, corresponding to the posterior
part of the temporal convolutions. A semicircular flap
was made, extending from the tip of the ear to the
occipital protuberance. The scar tissues were found
firmly adherent to the bone and had to be forcibly
detached. Two trephine openings were made, one
one inch in diameter, and the other ii-i6ths of an
inch just below and a little behind the other and
joined together. The bone over the angular gyrus was
found thickened and hardened, with scarcely any diploe
and the dura mater was adherent to it. When the bone
was demoved the dura mater bulged into the opening,
but showed no signs of pulsation, although the pulse
of the patient at the time was quite strong. On cross
incision of the dura mater a stream of clear fluid es-
caped. The membrane was opaque and thickened, but
the brain appeared normal and on examination the
neighboring parts revealed no pathological changes.
The dura mater was stitched together and the perios-
teum over it. the portion of bone not being replaced.
A drainage tube was kept in the scalp wound for
three weeks. The patient during this period had still
occasional attacks of depression and irritability, head-
ache, and trigeminal neuralgia, but with the closing
of the wound all symptoms disappeared. Five weeks
later the wound had quite healed. The trephine open-
ings were felt through the scalp. The brain was felt
pulsating beneath, but there was no protrusion. There
was no tenderness of the surrounding nerves. The gen-
eral condition was quite good. Three months later the
patient reported himself as absolutely well. There had
been no return of the insomnia, the headache, neuralgic
pains, or the sensory disturbances in the left hand
and arm. The obstinate constipation of the bowels that
obtained throughout the case prior to the operation
one and a half years ago had entirely disappeared.
Mentally, he had lost completely his morbid suspicion
and all suicidal thoughts. The attacks of mental de-
pression, the erotic feelings and morbid sexual symp
toms had likewise entirely disappeared. He had re-
sumed interest in all the affairs of life. Surgically the
head was perfect in appearance and there was no
tenderness anywhere.

British Medical Journal, March 9, 1907.

Deafness or Myxedema. — J. W. King refers to a
case of myxedema extending with intermissions
throughout a period of four years, but always yielding
to thyroid treatment. The patient, a man of fifty-six
years, had unimpaired hearing previous to the initial at-
tack four years ago, but on each subsequent attack
he has invariably tjecome so deaf as to hear only loud
shouting.

Influenza and Epistaxis. — Case histories are given
by J. Pugh Jones and T. E. Turnly, both cases present-
ing the usual febrile manifestations and intercurrent
nose bleed. In one instance sodium salicylate had been
given, and the author was unable to decide whether
the epistaxis was due to the effects of this drug or was
an accompaniment of an ordinary nasal sinus suppura-
tion due to the influenza bacillus.

The Staining of Animal Parasites. — I. W. Hall gives
the following directions, (i) Prepare a film of the
blood, feces, or sediment of the secretion. Fix: by
heat, or, less preferably, by formalin vapor. (2) Treat
the film with the following solution, one-half to two
minutes: Watery methylene blue, one per cent., 100
c.cm.: glacial acetic acid, 5 c.cm. (Neisser's methylene

blue solution may be equally well used if at hand.
Methyl violet, Nile blue, etc., are not so good). (3)
Wash in water. (4) Cover the film with saturated alco-
holic eosin solution. Allow to stain for five or ten
minutes, or (following Muir's excellent method de-
scribed in the Journal of Pathology, 1906) heat over the
flame, blowing out the alcohol each time it catches
fire, until the film is almost dry. (5) Wash in water.
(6) Fix in potash alum solution, one-half to two min-
utes. (7) Decolorize in ninety per cent, alcohol until
a uniformly pink color obtains. (8) Wash in water;
allow to dry; mount in Canada balsam. It is the treat-
ment with acetic acid which affects the outer coverings
of the ova, embryos, and parasites, and allows the
stain to permeate the entire structure. The paper closes
with the applications of the foregoing method to feces,
sediments from secretions and cyst contents, filaria,
adult parasites, and spores. Concerning adult parasites
the author states that by this method the internal struc-
tures, particularly the reproductive organs and the ova,
are well brought out. It is best to allow the parasites
or the segments to remain in the acid solution for about
one hour, and in the eosin solution over a night. After
thorough drying with absorbent paper they are cleared
in clove oil or xylol for twenty-four hours and then
mounted in balsam.

The Treatment of Incipient and Borderland Cases
of Insanity in General Practice. — The various forms
of mental disease considered by the author are grouped
under the headings of backward or deficient cases, the
epileptic, the nervous, the moral imbecile, the incipient
melancholic and maniacal, the borderland delusional,
and the premature dement. Forms met with in adult
life are incipient mania and melancholia, borderland
delusional insanity, incipient general paresis of the in-
sane, borderland alcoholic insanity, and associated men-
tal unsoundness. In old age we have incipient senile
mania and melancholia, borderland paralytic insanity,
and incipient senile dementia. Under each of these
headings are grouped the respective hygienic and medi-
cal measures the author has found most beneficial, such
groupings following a summary of symptoms. The
author claims that the chronic borderland insane cases
are neglected at the present time, and that the volun-
tary boarder system which exists in England for reg-
istered hospitals and licensed houses must be extended
to county and borough asylums receiving paying pa-
tients, to be used for patients of this class. Thus
additional means will be obtained for skilled treatment
in the early sta.ges of mental disease. Since contact
with certified insane persons undoubtedly has a de-
moralizing and injurious effect upon many of the in-
cipient insane, individual treatment in single care, un-
certified, with all the surroundings and comforts of
home, is much to be commended. The tendency very
rightly is at the present time to this decentralization
and segregation, and he believes the best results will
be obtained thereby.

Berliner kUnische Wochenschrift, March 4, 1907.

The Connection of Lactic Acid with the Convulsions
of Puerperal Eiclampsia. — Donath considers the theories
of Zweifel and his coworkers who ascribe to sarcolactic
acid an important role in regard to the convulsive seizures
in puerperal eclampsia. In order to investigate the power
of this agent to evoke convulsions he first studied the
cerebrospinal fluid of epileptics, usually obtained shortly
after an attack, and in another set of experiments intro-
duced considerable quantities of it into the circulation of
.inimals. The fluid obtained by lumbar puncture from nine
epileptics was examined but it was never possible to demon-
strate the presence of any lactic acid. On injecting from
one to one and one-half grams per kilo of neutral sodium
lactate into dogs no symptoms of any importance were
caused. The author therefore concludes that in eclampsia,
as well as in epilepsy, the muscular action attending the
convulsions induces the formation in the muscles of sarco-
lactic acid. This is then rapidly oxidized in the blood, and
only a small portion of it is excreted unchanged in the
urine. It is accordingly not to be regarded as having any-
thing to do with the causation of the convulsions in
eclampsia, and is simply a secondary manifestation of the
muscular activity.

Munchener medicinischc Wochenschrift, February 30, 1907.

The Effect of Narcosis on the Blood. — Mulzer studied
the effect of ether and chloroform on the blood by
subjecting animals to prolonged and very profound
narcosis with these agents. He found that sections
of the organs of these animals gave evidence of a
noteworthy change in the character of the blood in
the vessels. Alterations in the appearance of the red

March 30, 1907]

MEDICAL RECORD.

535

blood cells led him to believe that these undergo serious
damage, and structures were also discovered which
he considered as being granules and strands of fibrin.
These lesions were most pronounced in the vessels of
the lung, and numerous control observations seenied
to show that they were the direct result of the action
of the anesthetic agents. Chloroform appeared to
have a somewhat greater power to produce the changes
than ether. The coagulability of the blood was slightly
increased after narcosis and the hemoglobin was re-
duced. The number of erythrocytes was still diminished
to a very considerable degree, and the abnormalities in
the shape of the cells indicated the destructive action
of the anesthetics.

Scopolamine-Morphine-Chloro£orm Narcosis. — Kreu-
ter reports on one hundred cases of chloroform an-
esthesia preceded by two injections of scopolamine and
morphine carried out in the Erlangen University Hos-
pital. In eighty-six per cent, of the cases the results
were satisfactory, while in the others little or no effect
seemed to be produced by the preliminary injections.
The general conclusion reached is very much in favor
of the method, which is characterized as the ideal from
the patient's standpoint, though an uncomfortable
sequel is the trying sensation of thirst that commonly
persists during the first twenty-four hours. This repre-
sents, however, one of the valuable features of the
method, since it is due to the general inhibition of se-
cretion that is caused by the alkaloids, and this, accord-
ing to the author, is an important prophylactic against
postoperative pneumonia. He considers that when
the a!I<aloids are used in small amounts the method is
free from danger, and it appears that a much smaller
quantity of ether or chloroform is required. The dis-
advantages of the method lie in the uncertainty of
action of the alkaloids and in the thirst that follows
the operation. The method is contraindicated in opera-
tions about the face, mouth, or respiratory passages in
which there is danger of aspiration, and expectoration
is desired, but it may safely be resorted to even for
long operations on weak patients. For details as to the
technique employed in the Erlangen clinic reference
must be made to the original.

Deutsche mcdizinische Wochenschrift, February 28, 1907.

Differential Stains for Distinguishing Tubercle from
Perlsucht Bacilli. — Spengler says that in about sixty
per cent, of the cases of phthisis the tubercle bacillus
and the perlsucht bacillus are present in a condition of
symbiosis. In order to assist in the recognition of such
■cases he suggests several staining methods. One of
these is a capsule stain performed as follows: The
smear is rendered alkaline with one per cent, solution
of sodium or potassium hydrate and is dried without
resorting to more than the least possible degree of
heat in order to avoid injury to the extremely sus-
ceptible capsule of the perlsucht bacillus. Loffler's
methylene blue is poured over the preparation, which
is then washed with water. The preparation is next
treated with carbol fuchsin solution heated gently until
it steams, and is washed with water. Finally the prepa-
ration is stained for a few seconds with methylene
blue, to which one or two drops of fifteen per cent,
nitric acid have been added, is rinsed with water and
is carefully dried. Perlsucht bacilli will be found to
be very much larger than tubercle bacilli; in fact, they
appear gigantic, accordin.g to the author, and the dis-
tinction between the tvi'o is easy. Another method con-
sists in staining with carbol fuchsin and then treating
the smear several times with a solution of picric acid
acidulated with three or four drops of fifteen per cent,
nitric acid. The picric acid solution consists of equal
parts of a saturated aqueous solution of picric acid or of
Esbach's solution, and absolute alcohol. The smear is
then treated with fifteen per cent, nitric acid until it
has a pale yellow color, is rinsed with alcohol, and
is again stained with the picric acid solution. For
the details of these and other methods reference must
be made to the original.

Pathology of the Heart Beat. — Bonniger contributes
an article on this subject in which he says that simultane-
ous contraction of the auricles and ventricles as evidenced
by systolic venous pulse is a not infrequent condition.
Systolic venous pulsation is seen in cases of tricuspid in-
sufficiency, but the condition described by the author i>
independent of any leakage of this sort. The customary
concomitants of tricuspid incompetence such as early and
severe edema, dilatation of the veins, and pulsating liver,
are absent, though the cardiac action is likely to be very
irregular. It is possible to recognize the condition by
observation of the heart with the fluoroscope. and the
absence of the congestive and other accompaniments of

tricuspid lesions is characteristic. The significance of the
phenomenon lies not so much in its effect on the circula-
tion, since this often seems to be but slightly affected, but
in the province of treatment, as the use of digitalis appears
to be undesirable and often serves only to increase the ir-
regularity and tachycardia.

French and Italian Journals.
Treatment of Angiomata and Naevi.— Zimmern in
speaking of the treatment of these blemishes says that
electrolysis bv the method of electropuncture is sometimes
used, in na:vi with visible telangiectasis this treatment at
the end of a period sometimes long, sometimes short, pro-
duces very satisfactory esthetic results, according to Brocq.
Negative monopolar electrolysis is used. Recently Bergo-
nie has proposed to treat smooth vascular nsevi by high-
frequency currents. Brocq considers that in the case of
prominent vascular tumors, that is, erectile tumors, elec-
trolysis constitutes a wonderful treatment. Electrolysis in
the treatment of angiomata is a definite operation, sure and
applicable to all varieties of cavernous angiomata, small,
grave, circumscribed, diffuse, or those invading neighbor-
ing tissues. The writer then describes with illustrations
the technique of the treatment for these lesions.— /owrKa/
de Medccine dc Paris, December 27, 1906.

Scopolamine in Surgery and in Obstetrics.— Albert
Laurendeau in a recent work on this subject advises a
dose of 1.50 grains of the hydrobromate of scopolamine
combined with i/S of a grain of morphine to be given to
adults by means of hypodermic injections in the lower ex-
tremities. This injection may be given if necessary three
times in all at hour and a half intervals. This medication
is not meant to replace chloroform absolutely. The toxic
coefficient of scopolamine-morphine is less than that of
chloroform. Its manipulation is more easy, and its method
of administration is more definite. It may be employed in
cases of tuberculosis, of heart lesion, and of cachexia.
These drugs are advised in the case of patients who are
subject to vomiting, in cases in which the intervention is
of long duration, in cases in which surgical intervention is
followed by severe pain, in first aid work, and in obstetrics.
One dose suffices to abolish all consciousness and memory
for several hours. — Le Journal de Medecine ct de Chirurgie,
Montreal. Canada, December 29, 1906.

Transparence of the Cranial Bones to X-Rays.— C.
Luraschi began in 1904 a study of the results to diagnosis
and prognosis of the application of the .r-ray to the bones
of the skull. He finds that it is of value in locating dis-
ease of the various sinuses, as the frontal, mastoid, and
the antrum, and in detecting tumors of the brain. The
rays are of more value in the examination of thin bones,
such as those of children. It is possible to distinguish the
layers of skin, skull, and dura mater by photography.
By radiography one can distinguish the thickness of various
parts of bones, and localize foreign bodies, such as pro-
jectiles. Thev are of the greatest use to the rhinologist
and the AtnX\k.—Giornale di Elettricita Medica, September
and October, 1906.

Experimental Pancreatectomy in the Dog.— -At the
meeting of the Biological Society, November 24, 1906,
Sauve showed a dog on which he had practised fifteen
days previously a duodeno-gastro-pancreatectomy. From
the results of experiments which this investigator _ has
made on a series of ten dogs, he concludes that it is
impossible to remove the entire pancreas of the dog with-
out removing the duodenum also. If the duodenum is
not removed it will slough. Gastro-duodeno-pancreatec-
tomy in the dog may be practised at one sitting, at the
same time with the complementary operations for reestab-
lishing the course of the chyme and of the bile. The
question of glycosuria which, after pancreatectomy, lasts
till death, is still, in spite of current opinion, unsolved.
The negative experiments of Pflueger and a case of total
pancreatectomy in a man corroborate the reports of the
author.— La Presse Medicale. December i, 1906.

Aberrant Goitre. — Reynier reports two observations
of tumors, the one located under the angle of the jaw
in the submaxillary region; the other adherent to the
external surface of the vessels over the sternomastoid and
which projected into the subclavicular triangle. Careful
histological examination of these cases left no doubt as to
the thyroid origin of these tumors. It showed conclusively
that the thyroid origin of certain branchial tumors can
no longer be denied; and it also supported certain recent
embrvological data in the explanation of their development.
According to Delbet, it is an important fact that epitheho-
mata of the neck develop from epithelial debris which
have existed since the embryonic period. Histological vari-
ation matters little since it is now known how closely
connected are the branchial clefts, the lateral thyroid in-
vaginations, and the thymic invaginations.— J?£'J'm<? de Chi-
rurgie. December 10, 1906.

536

MEDICAL RECORD.

[March 30, 1907

Snok Sf tiirma.

The International Medical Annual: A Yearbook of
Treatment and Practitioner's Index. Twenty-fifth Year.
New York : E. B. Treat & Company, 1907.
We find a number of subjects comparatively new in medi-
cal science, and for the most part not yet admitted to
the te.xt-books, treated fully and intelligently in this ex-
cellent review of the year's progress. Among the titles of
the chapters, giving an indication of their contents, are :
"Serum-therapeutics," "Opsonins and Vaccine Inocula-
tions." "Cancer," "Diseases of the Ductless Glands," "Chem-
ical Pathology of Gout," "Bier's Treatment," "Spinal Sur-
gery," "Colored Urines Tested by the Spectroscope," "Dic-
tionary of Treatment," "Examination of the Blood," "Elec-
trotherapeutics and Radiotherapeutics," "Syphilis," and
"Diseases of the Sinuses." The two last named are excel-
lently illustrated, four plates, two colored, being devoted
to the illustration of the spirochete of syphilis. Indeed,
the illustrations throughout the work are very good ; there
are 28 plates and 60 pictures in the text. The contribu-
tions number thirty-five. The reader of medical periodical
literature, in other words the educated and progressive
physician, will find what he has read and studied from
week to week through the year admirably summarized in
this volume and put in a form where it is easily accessible
for review or occasional reference.

The New Hygiene. Three Lectures on the Prevention of
Infectious Diseases By Elie Metchnikoff, Author of
"The Nature of Man." with Preface by E. Ray Lan-
kester. Chicago : W. T. Keener & Co., 1906.
These are the three Harben lectures delivered by Dr.
Metchnikoff before the Royal Institute of Public Health
in London last year. In the first lecture, "The Hygiene of
the Tissues," the protective influence of the phagocytes
is discussed in the light of the new impetus given to the
humoral theory of immunity by the opsonic doctrine, and
the conclusion is reached that, whatever may be the value
of the opsonins in preparing microorganisms for destruction
by the leucocytes, it is, after all, the latter which are
the active and essential agents in the defense of the organ-
ism against the invasion by disease germs. The lesson of
this is the importance of strengthening the phagocytes in
their struggle against the host of pathogenic bacteria.

The second lecture, "The Hygiene of the Alimentary
Canal," treats of the entrance of pathogenic bacteria into
the blood by way of the digestive tract after their introduc-
tion therein with food. The lesson of this is that food
should not be eaten raw, since in this way disease germs,
but especially the ova of intestinal parasites, may be intro-
duced. These helminths, though perhaps harmless in them-
selves, facilitate the passage of bacteria into the blood by
wounding the intestinal mucous membrane.

The third lecture, "Hygienic Measures Against Syphilis,"
recounts the efforts that have been made, and are still be-
ing made, with the hope of ultimate success, to arrest
syphilitic infection after inoculation with the virus of the
disease.

M. Metchnikoff is not only a scientist and an original
thinker of the first order, but also possesses the gift of
a pleasing literary style, by which he is enabled to impart
to others the knowledge he has gained by exnerimentation.
These lectures will be found of absorbing interest not only
by medical men but by those of the laity as well who have
more than an elementary knowledge of physiology.

Practical and Theoretical Esperanto. A Handy Text-
book for Beginners and Advanced Students, for Self-
Instruction and Teaching Purposes. Containing Elemen-
tary Grammar, Formation of Words, Complete Syntax
and Exercises. By Dr. Max Talmey. New York and
Boston: Universal Language Publishing Co., 1906.
This is, so far as we know, the pioneer instruction book
for Esperanto written by an American. The author must
have had considerable experience in language teaching, for
he presents his subject in a way which shows that he knows
the needs of the student. The exposition of the formation
of the language is simple and most intelligible and the very
questions which would naturally arise in the mind of the
beginner are all answered clearly and distinctly. In a lan-
guage which has not the authority of cultivated speakers,
using their native tongues to support it, the question of
pronunciation is perhaps the most difficult. Without abso-
lutely fixed rules, illustrated, in the grammars for the use
of different nations, by references to the established laws
of pronunciation in the respective vernaculars, a confusion
fatal to the employment of the language as a means of oral
communication must arise. The author has recognized this
necessity and has made the section on pronunciation very
complete and explicit. Unfortunately, however, no two
authorities which we have consulted, and we have compared

for this purpose six or eight grammars by English, French
and German authors, agree on this point. Even in the
series of articles on Esperanto now running in the North
American Review, the two sections devoted to the pronun-
ciation are mutually contradictory on various points. Dr.
Talmey also shows, in his discussion on the subject, that
very marked differences exist, and the authority of even the
creator of the language. Dr. Zamenhof, is rejected by him.
If such a lack of uniformity in pronunciation e.xists at the
beginning, what must the confusion become as Esperanto
spreads among different nations, each with its own tra-
dition of the value of the various letters. The next Con-
gress of Esperantists should devote itself to the adoption
of some absolute and immutable standard of pronunciation
if they would save their language from meeting the fate of
Volapiik.

Diseases of the Stomach and Intestines. By Board-
man Reed, M.D. Second Edition. New York: E, B.
Treat & Co., 1907.

The whole digestive tract practically being one organ.
Reed thought best to describe the diseases of the stomach
and intestines in one volume. The writer greatly enhances
what is of value to the practitioner and is thereby guided
by his own large experience. The physical methods of
treatment are discussed at great length. According to
Reed massage acts beneficially in conditions accompanied
by a diminution of gastric secretion, while it is harmful
in hyperchlorhydria. Reed says : "Considering the seri-
ous and often disastrous results to health that may come
from hyperchlorhydria with its train of intestinal and
nervous symptoms, and the readiness with which it can
be greatly increased by massage of the abdomen, this
powerful remedy should be prescribed with great careful-
ness and with more exact dosage than is now customary;
and it needs to be remembered that in many neurasthenic
patients with a tendency to excessive secretion of the
gastric glands, even very moderate massage over the
abdomen can set up this troublesome condition with a
resulting aggravation of the constipation, as well as of
the insomnia and all the nervous symptoms."

Rest treatment the writer recommends in the following
words : "By rest patients are not only given the absolute
rest in bed which is grateful to many of them, but, what is
far more important, are thereby removed at once from
numerous actual or possible disturbing causes — from men-
tal strain, overexcitement or overe.xertion of any kind,
nagging cares and worries, the temptations of dietetic
indiscretions as to food or drink, late hours, with insuffi-
cient sleep and dissipation of whatever form, whether
downright vicious and under the ban or fashionable and
approved by society, no matter how unhygienic. All such
dangers, known and unknown, are cut off at one blow by
the rest treatment, and many of them are particularly
efficient causes of hyperchlorhydria.

The illustrations accompanying the text are numerous
and excellent. As a whole the nresent book can be highly
recommended.

The Chemical In\-estigation of Gastric and Intestinal
Diseases by the Aid of Test Meals. By Vaughan
Harley. M.D.. Edin., M.R.C.P., F.C.S. Professor of
Pathological Chemistry, University College, London, and
Francis W. Goodbody, M.D.. Dubl., M.R.C.P. Assistant
Professor of Pathological Chemistrj', University Col-
lege, London. London : Edward Arnold. New York :
Longmans, Green & Co., 1906.
The diagnosis of diseases of the alimentary tract is now
so largely founded on the purely objective results ob-
tained by means of chemical and microscopical examina-
tions of material obtained from the stomach or intestine
that it is not astonishing to find a work of 250 odd pages
devoted purely to the former of these modes of inves-
tigation. The first eighty-eight pages contain a thorough-
going discussion of the methods of gastric analysis and
the remainder of the volume is given up to the subject
of intestinal disorders. How important the laboratory
methods have become in dealing with cases of this sort
is evidenced by the fact that the description of the chemical
examination of the feces alone covers nearlv a quarter of
the book. The use of test diets in the investigation of
the feces is described and suitable diets are suggested.
The microscopical and bacteriological aspects of the sub-
jects under discussion are not taken up, as they have not
been especially studied by the authors ; but although the
work is not primarily a clinical one. this phase has re-
ceived sufficient consideration to make the text full of
interest to the practitioner as well as to the laboratory
worker. The one subject that seems to have been rather
inadequately handled is that of occult hemorrhages, and
some of the more recent tests for blood in the stools or
stomach contents are not mentioned. The book is distinct-
ly an interesting and useful one.

March 30, 1907]

MEDICAL RECORD.

537

NEW YORK ACADEMY OF MEDICINE.

Regular Meeting, Held February 21, 1907.
First Vice-President, Dr. Robert Abbe, in the Chair.

This meeting was held under the auspices of the Section
of Medicine.

Nitrogenous Metabolism in Typhoid Fever. — Dr.
James Ewing read this, the opening paper of the sympo-
sium on typhoid fever. He said it had long been known
that typhoid fever, rather more than other continued fever,
was marked by a very high urinary nitrogen excretion, but
the partition of this nitrogen and the bearing of variation
in the forms of nitrogenous compounds excreted in the
urine upon the pathology of this disease had received very
scant attention. The total nitrogen excretion in urine
and feces in typhoid had recently been studied in de-
tail. The fecal excretion had been found to be relatively
small, forming only 10 per cent, of the total nitrogen elim-
ination. During the active febrile period and sometimes
continuing into convalescence there was a pronounced loss
of nitrogen, excretion exceeding ingestion by as much as
10 grams daily, the loss diminishing as the fever subsided.
Since they were able to limit this loss to some extent by
supplying nitrogen-free diet, they argued at length that
the excessive nitrogen elimination of typhoid fever was not
evidence of toxic destruction of cell proteids, but a result
of simply hyperactivity of the metabolic functions. The
present study was undertaken in 1905 as a control for the
interpretation of results obtained by Wolf and himself
in the investigations of the urinary nitrogen in the tox-
emia of pregnancy. It was also suggested that typhoid
fever, especially in the later stages, was largely an auto-
intoxication. It was pursued also in the hope of finding
some correlation between changes in the urinary nitrogen
and histological changes in the liver. The results were
not without interest. The analytic methods employed
were those described in a recent article by Dr.
Wolf and the writer. Appended were reports of the an-
alyses of seventeen cases, and the most obvious interest
was in the relation of the urinary nitrogen and its par-
tition to the clinical symptoms. The records showed a to-
tal urinary nitrogen excretion reaching 27.40 grams on
the thirteenth day of a moderately severe case, but aver-
aging considerably below 20 grams. With a restricted
milk diet of these patients, this large percentage of nitro-
gen must signify consumption of tissue proteids and a
marked loss of nitrogen on balance. The total nitrogen
varied with the temperature, diminished in defervescence,
when nitrogen retention began. The more favorable the
condition the higher was the percentage of urea nitrogen.
In severe stages it usually ran below 80 per cent., when 12
to 20 grams of N. were excreted ; while in some cases
which recovered it was found below 70 per cent., and even
as low as 60 per cent. A ratio below 70 per cent, seemed
to indicate a grave condition. Sharp increases in this ratio
were very favorable signs ; a rapid decrease, 82 per cent, to
67 per cent., and 80 per cent, to 60 per cent., was shortly
followed by the death of the patients. In some instances the
urea ratio seemed to be a better index of the patient's
condition than was the temperature or the pulse. In two
fatal cases the ammonia ratio reached 9 per cent, and 10
per cent, and in one fleshy woman severely ill it was
found at 11 per cent. The present indications did not
indicate that acidosis was a prominent feature of typhoid
fever. Even the highest figures observed indicated only
moderate grades of acidosis, especially for patients on a
restricted milk diet. Brugsch had claimed that one of the
chief causes of acidosis, when the system was unpro-
tected by food, was the burning of the body fats, and the
comparatively low ammonia excretion in typhoid fever

when there was extensive consumption of tissue proteids
was consistent with this view. In typhoid fever the total
ammonia did not e.xceed the figure established by Folin,
about .7 grams. The acetone bodies were not estimated
in this series. A fall in the urea nitrogen was regularly
accompanied by a corresponding rise in the rest-nitrogen.
In severe stages of the disease the rest-nitrogen ran be-
tween IS per cent, and 20 per cent, and in three fatal
cases it rose above 20 per cent., once to 41 per cent. In
two cases a sudden rise in the rest-nitrogen with a fall
in the urea preceded the appearance of albuminuria. The
following points of clinical interest appeared. Urea ratios
below 70 per cent, and rest-nitrogen above 15 per cent, be-
longed to the severer stages and types of the disease. Rapid
falls in urea with rises in rest-nitrogen occurred at un-
favorable times in the disease. The ammonia nitrogen
tended to run comparatively low, but in fatty subjects,
or severe cases, or before death, it might rise to 10 per
cent, or more of the total nitrogen. The character of the
nitrogen partition in typhoid fever seemed to show some
dependence upon, or relation to the lesion in the liver. In
typhoid fever the liver, as a rule, showed some intense
granular degeneration and usually focal necroses. Fatty
degeneration was not prominent. If the final synthesis
of urea was largely a function of the liver, the severe dam-
age to the liver might be expected to yield for a time
a low percentage of urea in a high total nitrogen output.
The absence of extreme acidosis in typhoid fever accorded
with the usual condition of the typhoid liver. The changes
in the urine in fatal typhoid fever were very similar to
those in acute yellow atrophy, and the occurrence of acute
yellow atrophy as a termination of typhoid fever was not
extremely rare. The results showed that the disturbance
of nitrogenous metabolism was very similar to that of
other infections and in some intoxications which were not
of bacterial origin. Since this disturbance of metabolism
was of a type which seemed never to occur without ab-
normal symptoms, there was reason to believe that it was
partly responsible for these symptoms. Hence the con-
clusion was reached that in typhoid fever and other in-
fectious diseases an important part of the morbid process
consisted in a disturbance of nitrogenous metabolism which
was very similar in type to that seen in pure autointoxica-
tions, and which therefore was not directly connected with
the toxins of the invading bacteria. The excessive nitro-
genous metabolism of typhoid fever was not the specific
effect of the action of the endotoxins of the typhoid bacilli,
but represented hyperactivity of a normal type associated
with the fever. Wolf had pointed out that bacterial endo-
toxins were much alike in their actions and affected chiefly
the nervous system. The central phenomena expressed
i)f the disease resulted from the course which the metab-
olic activities of the organism took in reaching an equi-
librium and effecting a cure. What they saw of typhoid
fever was not merely the entrance and destructive effect of
the typhoid endoto.xins, but the burning of 30 pounds of
tissue proteid in three weeks. Hence in studying the nitro-
genous metabolism they were obtaining information about
one of the fundamental processes going on in the dis-
eased organism.

Dr. C. G. L. Wolf said that Dr. Ewing, in presenting
the results of the investigations of typhoid fever, had
endeavored to show the practical results which had been
obtained, and the work suffered from its fragmentary char-
acter, as Dr. Ewing had remarked. Work of this kind, to
be of the greatest value, must at first be done under ex-
ceptionally favorable conditions. The analytical technique
should be as perfect as possible, and by that he meant
the entire exclusion of the so-called clinical methods, such
as the h.vpobromite method for urea, and the various purin-
ometers, uricometers, and instruments of that sort. These
various contrivances were not to be relied upon, any more
than methods depending upon the centrifuge were of any
value in the quantitative estimation of albumin, chlorides.

538

MEDICAL RECORD.

[March 30, 1907

sulphates, and phosphates. But even with perfect technique,
the task was not half completed. The importance which
attached to the complete collection of a 24-hour specimen of
urine could not be too strongly insisted upon. Further-
more, he said he was convinced that the patient should be
placed on an accurate standard diet, of which the nitro-
gen content and the calorific value were accurately known.
The diet should preferably be free from purin compounds.
It was not in the least difficult to choose a diet of this sort,
which would be suitable for almost any disease. He said
he could speak with a certain amount of authority on this
point, for in the work which Dr. Alexander Lambert and
he had done in the metabolism in pneumonia they had ob-
tained what they were inclined to believe were important
data, which could not have been procured had the patient
been allowed a diet which varied from day to day. It also
seemed to him that a very careful clinical daily report
would help to clear up many of the metabolic vagaries
which were encountered in the examination of urines of
this type. He trusted that the time would come when as
a result of the accurate study of metabolism they
should be able to substitute simpler methods, which might
be used by clinicians, independent of the chemical labora-
tory; but the time had not yet come, and appeared to be
at some distance. He thought he might safely say that
anyone who would take up a single affection, such as
those of the kidney, the liver, the anemias, and the various
infectious diseases, and work out a few carefully selected
cases on the lines which Dr. Ewing had laid down,
would obtain results of distinctly permanent value.

The Manageinent of the Intestinal Tract in Typhoid
Fever. — Dr. Walter B. J.ames read this paper, in which
he considered briefly the feeding, the nursing, the general
management, and the treatment of complications. He con-
fined his remarks to the consideration of a few principles
underlying the general treatment of the digestive system
in typhoid fever.

Dr. George L. Peabody called attention to one difficult
part of the problem, the management of the stomach. It
had happened to him to have patients brought under his
care who had been under no medical care at all, but
under the care of relatives or friends, and their stomachs
had been rendered irritable by bad feeding, obstinate vomit-
ing being the early symptom. Even in the best managed
cases obstinate vomiting occurred early in the disease. In
this connection the first thing to do was to give the stom-
ach a rest, and postpone introducing anything in it for
twelve or more hours. He applied counter-irritation to the
epigastrium, such as strong mustard paste. If the vom-
iting persisted, he advised against temporizing longer, but
resorting to lavage. When he began feeding he used the
utmost caution. If the vomiting was not checked within
twent}--four hours, he used lavage. He said that Dr.
James had referred to the unsatisfactory efforts made to
regulate the amount of food taken by the number of calor-
ies we knew the patient should require. We could tell the
number of calories required in health, but when there
was such an altered metabolism as occurred in fevers, it
was hard to say how many should be had. A patient
weighing 120 pounds should receive 1,925 calories a day
during health. But when there was an increased activity,
and, therefore, increased metabolism, the patient should
receive more. If milk alone was given, five or six pints
would be required. Therefore, he agreed with Dr. James
in his statement that milk alone was not a suitable diet
for these patients. The number of calories could be
greatly increased by giving alcohol in any form. Eggs
helped materially. There were various modifications of
milk that he was in the habit of using, such as koumiss,
or matzoon. Clear soups were given throughout the dis-
ease ; they stimulated the heart and the appetite, were
agreeable and palatable. Water should be given in abund-
ance. Beef juice was highly acceptable to the patient.

For many years he had been in the habit of
feeding the patients solid food if they became hungry. He
was particularly fond of giving ice-cream in all stages of
the disease. Constipation was best met by giving enemata.
The presence of constipation was no evidence of the
absence of ulceration, nor was diarrhea an evidence of the
presence of ulceration ; the latter was evidence only of a
catarrhal condition. He had never known of a case of per-
foration caused by the use of cathartics. He never treated
the diarrhea at all, unless there were more than three
or four movements a day. If the patients had more than
that number a day, it exhausted them ; then he usually gave
bismuth or opium, especially the aqueous extract. Meteor-
ism was a serious symptom ; when due to gas in the large
intestine it was best relieved by the rectal tube, but not a
large one. A catheter the size of a lead pencil was large
enough. He believed still in the value of turpentine for the
treatment of meteorism. administering 10 minims every
three hours; this will often soften the abdomen and lessen
the tension by reducing the amount of gas. Occasionally
turpentine stupes would aid, but not often. There was
not much to do for intestinal hemorrhage; place the bleed-
ing part at rest by placing the patient at rest. Surgery
was of no avail in intestinal hemorrhage. But in cases
of intestinal perforation, nothing but surgery would avail,
and only with promptness.

Dr. W. Gn-MAN Thompson wondered what had become
of the "gurgling and tenderness in the right iliac fossa," so
much spoken of in the earlier text-books on medicine. He
could not recall a case presenting gurgling and tenderness
in the right iliac fossa, in cases of typhoid fever. He had
not even seen those symptoms in late years ; it w-as a
striking fact that this pair of symptoms had practically
gone out of date, probably owing to better methods of feed-
ing. He did not believe that there was any disease in
which so much routine treatment was recommended as in
tj-phoid fever, and the more he saw of t>'phoid fever the
more convinced ^vas he that one could allow a great deal
of latitude in treating the different types of the dis-
ease. When the soldiers came back from Santiago, turned
loose on furloughs, with high temperatures and typhoidal
stools scattered all over the country, from the 200 cases of
typhoid fever then seen he had learned how much such
patients could stand ; it was surprising how many got well
Of course, they were all young and in fair health, but there
was a high toleration of the human system for that dis-
ease. Of late years he had been treating typhoid fever
patients more liberally in regard to diet. He gave a milk
diet so long as it agreed. When the tongue became coated
and there was a distaste for milk, he believed something
else should be given. He gave liberally of beef and orange
juice, etc. The great danger from meteorism was from
stretching the gut and so causing perforation. When the
gut was distended with gas the lesions could not heal. He
was not accustomed to withhold food as Dr. James did
in those cases. He believed there was a field for the use
of drugs in cases of tympanites. There was nothing in
the name ''intestinal antiseptics," but there was some-
thing in intestinal antifermentatives. He gave salol and
creosote in coated pills which did not dissolve in the stom-
ach ; they were dissolved in the intestine only and aided
in keeping down meteorism. When the stools became foul
and offensive, and there was diarrhea, and a tendency to
tympanites, there should be proper attention to the regula-
tion of the diet and cleansing the lower part of the boweL
Vv'hen the stools were fetid, the absorption of food stuffs
was added to the toxemia of the typhoid fever. He be-
lieved in giving turpentine internally, as well as externally.
One should endeavor to keep down the tympanites, which
was more to be dreaded than hemorrhage. It was well
to feed typhoid fever patients early in convalescence with
some solid food. If a relapse occurred the patient then
would be better able to bear the disease again than if

March 30, 1907]

MEDICAL RECORD.

539

he had been on an exclusive diet. He never had seen a
relapse due to the giving of food. Ten per cent, of typhoid
patients would have relapses no matter what the diet
was.

The Treatment of Typhoid Spine. — Dr. Virgil P. Gib-
NEY read this paper. He said that the term "typhoid
spine" was first suggested in 1889, when it was distinctly
stated that it carried with it no pathological commitment.
A suggestion was made, based upon seemingly good foun-
dation, that a periosteal lesion, inflammatory in character
and caused by the presence of the typhoid bacillus, was in
all probability a lesion that could be accepted. Soon after,
other reporters recorded cases that presented a fixed de-
formity, and the term "spondylitis" was employed to des-
ignate a destructive lesion in the bodies of the vertebrae
resulting in deformity, such as one got in Pott's disease
of the spine. Again, the term "neurosis" was invoked
as explaining cases where no deformity existed. An
osteoarthritis, posttyphoidal and involving the transverse
processes and lateral masses, as well as the articular borders
of the vertebrre, was believed by some to be the prevail-
ing pathological condition. He referred to Thomas Mc-
Crea's paper on "Typhoid and Paratyphoid Spondylitis
with Bony Changes in the Vertebrae," read before the As-
sociation of American Physicians in Washington, May,
1906 (see Medical Record, Vol. LXIX, page 897). A
periostitis of the vertebrK naturally suggested involve-
ment of the articular borders and the foramina of exit
of the nerv-es, and the many cases already on record of
bony enlargement were confirmatory of the theory first
advanced as the primary pathological lesion. McCrea's
conclusions were: "l. In certain instances of typhoid
spondylitis there are certain definite bony changes in
the vertebras. 2. The general features of the condition
suggest the probability of organic changes in the spine
being a usual occurrence. 3. The similarity of the
changes found in typical spondylitis and those found in
spondylitis of other infections, especially arthritis de-
formans, suggest that the latter may be due to various
infectious agents.'' It seemed pretty well established
by a number of cases already on record that trauma played
a very important part as a factor in the etiology. Dr.
Gibney claimed to have had fairly good results in a rea-
sonable length of time by resorting to fixation of the col-
umn, the avoidance of trauma, the free use of the Pa-
quelin cautery, and the subsequent employment of well-
directed massage and graded exercises. The value of the
cautery as a counter-irritant had proved so valuable in
his hands that he felt justified in recommending it above
all others. The plaster-of-Paris jacket or corset had
not proved so valuable an agent as had the simple Knight
spinal brace or the posterior spinal assistant of Taylor.
The crisscross strapping with Z-0 plaster had been a val-
uable adjunct, especially in the milder forms of the dis-
ease. Where deformity existed it was necessary to wear
apparatus for longer periods. He emphasized the import-
ance of a clean-cut diagnosis made by a careful examina-
tion of the parts, by interpretation of the pains in an hon-
est endeavor to determine whether the pains were radiat-
ing and due to pressure on a nerve, or whether they
were boring pains of surfaces rubbed together, and after
having made the diagnosis adopt methods of treatment
that might be regarded as rational. In spinal lesions it
was important to immobilize not only the parts involved
but those contiguous thereto, above and below, and to get
an accurate adjustment of the immobilizing apparatus.
The Paquelin cautery was insisted upon as a regular line
of treatment as long as tenderness and pain on move-
ment existed.

Dr. T. Halsted Myers said that he had looked up the
medical histories at St. Luke's Hospital and found that
there had been 500 cases of typhoid fever in five years,
and there was not one single case recorded of typhoid
spine. There were some cases of periostitis, but in other

locations than the spine. He urged the importance of
diagnosis.

Dr. Leonard W. Ely said that the name "tj-phoid
spine" seemed to be the best. While there might be a
spondylitis present, and probably was, yet one never got
abscesses, and the disease always terminated in an abso-
lute recovery. All these cases got well. He invariably
told his patients that, dating from the beginning of the
trouble, they should be well in one year or eighteen months.
Nobody agreed with Dr. Osier's statement that the dis-
ease was a neurosis. There was almost always a history of
trauma. The use of the Paquelin cautery was of value
in the convalescent stages, as well as in the active when
there was the acute pain. The pain in the acute stage
was sometimes terrible, and sometimes in these acute
paroxysms morphine or anesthetics were required. Rest
in bed, counterirritation, and later on the jacket or brace,
was the treatment.

Stated Meeting, Held March 7, 1907.

The President, Dr. John A. Wyeth, in the Chair.

A New Section. — It was moved, seconded, and unani-
mously carried that a Section on Materia Medica and
Therapeutics be organized in the New York Academy of
Medicine.

The Typhoid Epidemic in Berwick, Pa.— Dr. J. H.
Bowman of Berwick presented this paper, which was read
by Dr. Charles F. Adams. He said that for two winters
in succession Berwick had been visited by epidemics of
typhoid fever. The epidemic of 1906-7 began in October,
the first case having been reported on the isth of that
month ; new cases continued to be reported until January
I, 1907. The total number of cases to March I was 114
and the mortality 9. It was noticed that by far the greater
number of cases occurred in the rolling mill department of
the local industrial plant, where on account of the great
heat an abundance of water was drunk. It was also ob-
served that in the last epidemic a greater number of women
and children were ill than in the former. Berwick and its
immediate vicinity had a population of 15,000 and was de-
pendent for its water supply on several mountain streams
and on the Susquehanna river. It was situated 41 miles
below Scranton. The sewage of both these cities as well
as that of Wilkesbarre and Pittston emptied into this river.
Soon after the outbreak in the fall the water from the
river was turned off and was not turned on again until Feb-
ruary 15. The State inspectors examined the water from
all sources but said that the presence of the typhoid bacillus
could not be demonstrated. The water sheds were inspected
but no source of infection was found. The dairies were
also inspected, but failed to reveal any cause for the out-
break. With all these negative results the fact remained
that the infection was so general and widespread that the
cause, whatever it was, was conveyed by some general
commodity, such as drinking water. The conclusions
reached w^ere that polluted water was the cause of the
wide distribution of the typhoid germs. In all probability
the first case resulted from the use of Susquehanna river
water, drawing as it did a large volume of sewage from
Scranton. These cases distributed over the general area
of Berwick and its suburbs carried the infection into the
mountain streams, so that although the river water was
cut off the other supply had become infected. A concurrent
epidemic of influenza which attacked a greater number of
patients than in any year since the memorable epidemic
of 1889-1890, diminished the normal resistance in these
cases and made the subjects more susceptible to the typhoid
infection.

The Typhoid Epidemic in Pittsburg.— Dr. J. F. Ed-
wards, Superintendent of the Bureau of Health, Pittsburg,
Pa., presented this paper, which was read by Dr. John A.
Wyeth. He said that it must be borne in mind in the

540

MEDICAL RECORD.

[March 30, 1907

study of this epidemic that typhoid fever had been prevalent
continuously during the period of available statistics, or
since 1873. Certain years or groups of years showed a
high percentage as compared with others, but in no year
had the mortality been low as compared with other Amer-
ican cities. The average mortality from 1880 to 1906 per
100,000 of the population was 107. The lowest rate was
55 per 100,000 in 1894, and the highest 158 in 1882. With
the exception of these two years the highest rate was 141
per 100,000 in 1900. It was evident that a predominating
etiological factor was at work continuously but with vary-
ing intensity for the past 36 vL-ars, and probably for a much
longer period. The present high rate period began in 1899 as
was shown by the following: 1899, 112; 1900, 141; 1901, 124;
1902, 130; 1903, 135; 1904, 140; 190S, 100; 1906, 130. These
figures showed that the causative factor had acted continu-
ously during the past eight years and to a greater degree
than in any like period in the history of the city. The pre-
dominant cause was an infected water supply. It was fair
to assume that other conditions at work elsewhere in con-
veying the disease were also at work here. The general
water supply of the city was drawn from two intakes in the
Monongahela river and two from the Allegheny river.
The water was pumped directly into reservoirs, from
whence it was distributed to consumers. Several wards
in the city were supplied by corporations, one having its
intake about one mile further up than that of the city.
There is said to be some filtration here by means of a crib
in the river bed. One ward was supplied by a corporation
with water taken from the Monongahela from an intake
above the others and last year instituted a filtration plant.
It was the only ward supplied with filtered water and was
at present practically free from tj-phoid. Both rivers had a
large population in towns situated near the water's edge.
The towns on the Monongahela were larger than those on
the Allegheny and one would expect more typhoid in those
portions supplied by that river, but such did not seem to
be the case. In the past two years the rate per thousand
had been about one-half as great in those wards supplied by
the Monongahela as in those supplied by the Allegheny.
The Monongahela had a very slight fall and a slow cur-
rent and in low-water stages was said to be pumped out
and put back five or six times during its course. One of
these times it must run back through the sewers of the
town. Both mines and mills introduced mineral acids into
the water in sufficient quantities to make the water of the
river acid during low water. In a laboratory experiment
he had found that s parts of free sulphuric acid per 100,000
killed typhoid germs in one and one-half hours. It was
said that the river reached 7 per 100,000 at times and near
works might go lOO and more. The objection to the acid
theory was that the river was alkaline during a good part
of the year and typhoid fever was quite high on the South
Side in .\ugust. when the water was low. Another corrigent
of the Monongahela was the heating of the water by the
works along its banks. Four large establishments pumped
178.000,000 gallons per day, five and three-quarter million
gallons was to a certainty heated to the sterilizing point.
Plants further up the river discharged proportionate vol-
umes of sterilized water. The total was very large. During
the winter of 1905- 1906 typhoid prevailed in a number of
boroughs above the city on the Allegheny river. The
March thaw probably accounted for the grave increase in
the number of cases reported in April. During the year
a special effort was made to determine the influence of
the milk supply. It could not be shown that any consid-
erable number of cases could be traced to the milk supply.
Since July of 1905 there had been a progressive increase
both in cases and deaths which culminated in the sharp rise
of April, 1906, when 820 cases with 78 deaths were re-
ported. During the whole year there were 5,729 cases with
508 deaths. The ratio of deaths to reported cases was
lower than in any other year and it was believed that this

was partly due to the fact that more cases were reported
than at any previous time. In general it might be stated
that typhoid fever was more prevalent, all other things
being equal, in districts where the standard of living was
lowest. The incidence of cases during the last year ex-
emplified this. Many people of the better classes did not
drink raw city water. In congested districts there were
greater opportunities for contact infection. A large per-
centage of cases occurred among immigrants from Austria,'
Hungary, Russia, and Italy. In conclusion, he stated that
there was every prospect that Pittsburg's long and unenvi-
able history as a typhoid city would soon close as a mu-
nicipal filtration plant was nearing completion and it was
hoped that this would greatly diminish the ravages of this
disease, which destroyed on an average 300 of the most pro-
ductive part of the population every year. Another promise
of relief came from the State, which was looking toward
the prevention of the further pollution of the streams
throughout the State.

The Typhoid Epidemic at Scranton in the Winter of
1906-1907. — Dr. J. M. Wainwright, Chief Surgeon of the
Moses Taylor Hospital, Scranton, Pa., read this paper. In
regard to typhoid in Scranton previous to this epidemic
he said that reliable morbidity reports were not at hand,
but from the death reports it appeared that, while the dis-
ease had been constantly present, the total had not been
very great as American cities went. The number of deaths
was 21, 20, II, and 25 respectively for the years 1902 to
1905. Estimating the mortality at 10 per cent., there had
been during the past four years 200 cases. Reckoning the
population at 75,000 to 150,000, Scranton had been hereto-
fore comparatively free from this disease. Studying the
conditions for the months previous to the outbreak, one saw
that the fall rise in Scranton was not nearly as sharp as
in other cities. So far as his hospital experience went, he
did not notice the ordinary diarrheas which some authors
had noted as precursors to typhoid epidemics. The epi-
demic broke from a clear sky and must have been due to
a sudden and very large pollution of the water. It was
interesting to note that in Philadelphia and Pittsburg,
where typhoid was epidemic at all times, there was no fall
rise. He described the Scranton water supply and pre-
sented a map showing that the larger part of the city was
supplied by the Elmhurst reservoir. The principal tribu-
tary of this reservoir was Roaring Brook, which a few
miles above ran through Moscow, a village of six to eight
hundred inhabitants. This brook also ran through a ham-
let of about 200 inhabitants. The Elmhurst water in pre-
vious years had been delivered over a spillway and allowed
to run several miles into a storage reservoir. The distance
from the inlet to the outlet in this reservoir was about
2,000 feet and the water displaced itself in from two to four
days. For a number of miles a railroad ran near the brook
and the railroad also ran close to the Elmhurst reservoir
and another railroad actually crossed a small set bank. In
October, 1906, this system was changed and the water was
piped directly from the Elmhurst reservoir, cutting out the
storage reservoir and taking the water from the bottom of
the reservoir instead of over the spillway. According to
Dr. Parke, from two to four times as many bacteria would
be delivered in the water taken from the bottom of the
reservoir as could be delivered over the spillway. About
50 per cent, of the bacteria would have died out in the
passage of the water over the 2,000 feet of the storage
reservoir. In October 20 cases were reported and in No-
vember 18. During the first week in December 11 cases
were reported. This time suggested close connection with
a heavy snowstorm on November 15, followed by warm
rains, so that it was probable that a fecal accumulation of
some time was washed into the reservoir suddenly at this
time. It was a lamentable fact that the earlier cases were
not reported and that proper action by the Board of Health
was delayed for some days. The active period of the epi-

March 30, 1907

MEDICAL RECORD.

541

demic was from December 10 to January 10. Cases de-
veloping after that time were few and a number of
secondary cases were due to direct communication, which
could be easily traced. Considering the epidemic to have
extended over December, January, and February, there was
a total of 1,15s cases reported and iii deaths; estimating
the population at 115,000, one person was sick to each 100 of
the population. A study of the map of the city showed
very strikingly the distribution of the cases with reference
to the Elmhurst water supply. The cases were very
thickly grouped. In portions of the city having another
water supply there were only 28 cases, and these were
frequent visitors to that part supplied by the Elmhurst
reservoir. He had been greatly impressed by the direct
communicability of the disease. In 54 families there were
two cases of the disease, in 22 of these the second person
had been the attendant of the first case. In seven families
there were three cases and in nine families four cases.
Among these 16 families, in eight the attendant had been
one of the secondary cases. It was interesting that in an
unusual number of cases the secondary case was a child.
The chief of the visiting nurses, Miss O'Halloran, who
spent her time going from place to place fighting typhoid
epidemics, considered that secondary infections were fre-
quently due to other members of the family eating the
portions of unusual delicacies which the patients left un-
finished. It had been a great disappointment that, after a
most painstaking search of the entire watershed by both
city and State authorities, it was probable that the very
multiplicity of possibilities had in itself been important in
letting the exact cause escape unnoticed. The methods
employed by city and State oflScials in fighting the epidemic
did not involve anything new to sanitary officers. Close
inspection was kept on the milk and no bottles were deliv-
ered to families. The spread of the disease from individual
cases was combated by the visits of nurses under Miss
O'Halloran. Circulars of instruction were sent to every
house from which a case was reported and specific direc-
tions were given for the use of lime. He thought that the
conclusions which they could draw from their lessons were:
I. All cases of typhoid ought to be promptly reported.
When this was neglected grave danger signs would pass
unnoticed. In going over statistics he had found a number
of cities who had 20 to 25 per cent, mortality from typhoid
on the face of reported cases. Health Boards, as well as
physicians, were to blame for this laxity. 2. The advan-
tages of municipal ownership. Under this system one at
least eliminated the harm a private corporation might do
during an epidemic in its efforts to safeguard the capital
stock at the expense of further disaster to the people. 3.
The numerous nuisances that had been maintained for years
on this watershed showed the necessity of a rigid police
inspection of the entire watershed by inspectors employed
by and for the people and not by the water company. 4.
Another safeguard which had been shown to be decidedly
valuable was the frequent bacteriological and chemical ex-
amination of the water. The city laboratory of Scranton
had not been equipped for such a purpose but soon would
be. According to an authentic newspaper report there was
a chemical analysis made by a private chemist early last
fall which showed undoubted sewage pollution, and, if
made by the city, intelligent people could have been warned
that the water was unfit to drink. 5. In times of epidemic
the water supply should be changed if possible. Hammer at
the people the need of boiling water and milk and use all
possible precaution to protect the milk supply. Prevent the
spread of individual cases by visiting nurses, circulars of
instruction, and the free distribution of one antiseptic. 6.
Typhoid was to a very distinctly appreciable degree a
directly communicable disease. 7. Physicians and sanitari-
ans must recover from their habit of speaking of a certain
amount of typhoid fever as "normal." Typhoid was a filth
disease caused by imbibing more or less directly the feces

of a sick man. The only normal amount for a civilized
conmuuiity was none at all.

The Bacteriology of the Blood in Typhoid Fever,
Based on an Analysis of 1,600 Cases. — Dr. Warren
Coleman read this paper, which was the result of his own
and Dr. B. H. Buxton's investigations. He said that in
1904 they had published an analysis of 604 cases of typhoid
fever whose blood had been examined bacteriologically and
75 per cent, of those cases had shown the presence of the
typhoid bacillus. In their earlier experiments they had
used broth flasks, putting 2 or 3 c.c. of blood into each
100 c.c. of broth. Since Aug^ist, 1906, they had used ox-bile,
which not only prevented coagulation, but inhibited the
bactericidal action of drawn blood. Their tests had con-
firmed the observations of Conradi, Kayser, and others. Their
method was to take 90 c.c. of o.x-bile, 10 c.c. of glycerin,
and 2 grams of peptone. The mixture was distributed in
small flasks containing 20 c.c. each and sterilized. Three
of these flasks were used for each examination, about 3 c.c.
of blood being run into each. The flasks were then incu-
bated and the next morning streaks were made from each
over the surface of litmus-lactose-agar plate. If the micro-
organisms were present they might be observed in five or
six hours. If the growth did not redden the medium, and
was found to be a bacillus resembling typhoid, it was
tested for the Widal reaction with immune serum. In this
way one could determine whether the case was one of
typhoid fever within twenty-four hours from the time of
drawing blood. Results showed that of the 1,602 cases
1,197, or 75 per cent., gave positive results. Since using
the ox-bile method a much larger percentage of positive
results went to show that the bacillus was present in the
blood in practically all cases of typhoid fever. An analysis
of the cases by weeks showed that of 224 examinations in
the first week of the disease, 200, or 89 per cent., were
positive. The earliest positive result was reported by
Widal, who found the bacillus on the second day. Of 484
examinations made in the second week, 353, or 73 per cent.,
were positive. Of 268 examinations made in the third week
of the disease, 178, or 60 per cent., were positive. Of 103
examinations made in the fourth week, exclusive of re-
lapses, 15, or 26 per cent., were positive. The percentage
of positive results was greatest, therefore, in the first
week and steadily declined thereafter. Since using the
bile method their results had been practically as successful
as those of Busquet and others who had recovered bacillus
from the blood of practically 100 per cent, of their cases.
The various series of cases giving practically 100 per cent,
of positive bacteriological results were too numerous to
be accidental and compelled the conclusion that the typhoid
bacillus was present in every case of typhoid fever and that
failure to recover it was due to faulty technique. The
diminishing percentage during the latter weeks of the dis-
ease did not indicate that the bacillus had disappeared from
the blood in negative cases but pointed to a diminishing
number of bacilli, whose presence imperfect methods failed
to reveal. .'Ml investigators were agreed that the bacillus
disappeared from the blood at or about the time that the
temperature fell to normal. It was probable that the bacillus
was present throughout the course of the disease, or at least
within a day or two of defervescence. It seemed that in
order to produce typhoid fever the bacillus must not have
been present in the body and growing, but must grow in a
situation whence it had free access to the blood. From
work done on the absorption of the typhoid bacillus from
the peritoneum and from the fact that in typhoid fever
the lymph nodes and spleen contained such enormous
numbers of bacilli, they concluded that in typhoid fever the
bacillus first found its way from the alimentary tract to
the lymphopoietic system, including the spleen, where it
developed chiefly and from which it invaded the blood
stream. They thought it doubtful if the bacillus multiplied
in the blood, but believed that its presence there repre-

542

MEDICAL RECORD.

[March 30, 1907

sented simply an overflow from the lymph organs. Hence
the presence of the bacillus in the blood did not constitute
a true septicemia. Absorption experiments showed that
the destruction of the bacilli proceeded most rapidly in
the blood. Hence they thought the disease was caused by
the destruction of vast numbers of bacilli in the blood with
the liberation of their endoto.xins. The idea that the course
of typhoid fever could be influenced by intestinal anti-
septics was irrational because, after the invasion of the
body proper by the bacillus, the battle ground shifted from
the intestine to the blood. There appeared to be a definite
relation in the evolution of typhoid fever between the symp-
toms and the bacillemia. The increased intensity of the
symptoms in the earlier stages of the disease corresponded
to the active growth of the bacilli. They invaded the
blood stream in increasing numbers and were there de-
stroyed. Then came the stationary period, when the ratio
of growth and destruction appeared to be uniform. The
steep curve period corresponded to a diminishing bacil-
lemia, and defervescence to complete disappearance of the
bacilli from the blood. They maintained that exclusive
of convalescence, which was regarded as a period of re-
pair, degenerative changes occurred only in the presence
of active growth and destruction of bacilli. While bacilli
disappeared from the blood at or just before defervescence,
it was improbable that all the bacilli in the body had been
destroyed, or relapses and post-typhoid inflammatory le-
sions would be impossible. The bacillemia apparently bore
no relation to the type or severity of the disease except in
so far as regarded number of bacilli. The bacillus was
found in the blood equally, but not with the same persist-
ence, in the mild as in the severe cases, and in the cases
of short as well as of long duration. The importance of
the definite establishment of the nature of these short dura-
tion cases could scarcely be overestimated from the epi-
demiological standpoint. The blood had been examined
bacteriologically in thirty-three relapses, the typhoid bacil-
lus having been recovered in thirty, or 90 per cent, of the
cases. They now thought that a relapse was not due to re-
infection with the typhoid bacillus from the intestine as
the result of inestinal trauma brought about by dietary ir-
regularities. He would not have it understood, however,
that they were advocating a liberal diet in typhoid fever.
They reiterated their former conclusion that the typhoid
bacillus was always present in the blood before the serum
reaction developed, for the reason that endotoxins must
be liberated before the agglutinins could be formed. For
the complete diagnosis of obscure cases by the serum
reaction the tests must be made daily.

Dr. MoRWS M.^NGES, speaking on the question of direct
infection raised by Dr. Wainvvright, asked if there could
not be a direct infection from the sufferer to another
rather than by the intake of polluted water. He referred
to the case of a woman baker in Germany and all who
used her bread developed typhoid fever. The typhoid
bacilli were found in her feces; inasmuch as she prepared
the food, and used the same toilet, the source of the infec-
tion was not hard to find. He recalled another case of a
woman who had some intestinal complaint and fed only
on a beef diet. The cook had a slight diarrhea, but the
feces contained numbers of spirilla, thus showing the source
of infection. Dr. Manges said that the work before Dr.
Wainwright in Scranton was not an easy one if he wanted
to find where the local focus was after the epidemic had
passed away. In the Pittsburg epidemic the acidity of the
river water was stated to have been 7 to 100,000, and yet
the bacilli c 'i,J not live for any length of time, it was
stated, where the acidity exceeded 5. That showed Dr.
Manges how fallacious the antiseptic action of the gastric
juice on the typhoid bacillus was. He called attention to
the unreliability of the number of cases reported, especially
in villages, and recalled an instance where the Board of
Health made an investigation and found that where but 8

cases of typhoid fever had been reported by physicians 72
cases had not been reported, and of these 53 occurred in
children. In other words, there were nine times as many
cases of typhoid fever as had been actually reported. With
regard to river pollution in relation to the ice supply, Dr.
Manges said that the ice companies were doing a gfreat
service ; they were showing the enormous amount of pollu-
tion of the rivers, and when complaint was made to them
they replied, "Why do you pollute the water where we
get the ice?"

Dr. Sedgewick said that "food, fingers, and flies" was
the summary of infection.

Dr. LiBMAN discussed the paper read by Dr. Coleman.

Drs. Wainwright and Coleman closed the discussion.

MEDICAL SOCIETY OF THE COUNTY OF KINGS.

Stated Meeting, Held February 19, 1907.

Dr. Glentworth R. Butler in the Chair.

Medicine, Education, and Social Work; Their Neces-
sary Relations. — Dr. Rich.\rd C. Cabot of Boston, Mass.,
read this paper. He alluded to the fact that at the exer-
cises celebrating the opening of the new Harvard Medical
School, President Eliot and Dr. Welch had summed up
the achievements of medicine in the past and the directions
of its future development. They had referred to the neces-
sity of the study of animal diseases and to the importance
of comparative pathology. The increased importance of
the study of insects had also been alluded to. They had
referred to the growth of preventive medicine and to the
achievements of health officers. The pride of the Hsteners
had been excited, yet the speaker, who had been one of
them, had wondered whether the audience realized how
small a proportion of sickness would be removed even if
all infectious diseases were abolished. In the twenty-five
years that had elapsed since Koch discovered the tubercle
bacillus, the tendency had been to think of infectious dis-
ease as coextensive with disease in general. Prof. A. E.
Wright had shown somewhat this same tendency. It was
a fallacy that the bacteria were the cause of all disease,
although all the recent medical heroes had won their vic-
tories in the treatment of infectious diseases. It had to be
realized that there was a large residuum of diseases, con-
stituting one-half of all disease, which would remain after
all infectious disease had been abolished. The speaker had
tabulated the 10,000 cases that had been treated in the out-
patient service of the Massachusetts General Hospital dur-
ing the past year, and found that from 30 to 40 per cent
of all these cases were functional in character. They in-
cluded constipation, neurasthenia, insomnia, obesity, alco-
holism, etc. It was probable that in private practice the
proportion of functional disease was still greater, probably
one-half of the whole. These cases were certainly not to
be treated by means of antitoxins. They were to be com-
bated rather by building up good habits and improving
the environment of the patients. It was hence to be real-
ized that medicine was necessarily bound up with educa-
tion. By means of the latter were to be inculcated good
habits of eating, sleeping, working, eta This was to be
accomplished through the agency of demonstrations, ex-
planations, public lectures, reading, and other channels. The
cooperation of schools, institutions, and sanatoria had to
be enlisted. It was necessary to investigate the finances
of the patient. It was sometimes necessary to take him
out of his family or improve the family surroundings.
This was properly the sphere of the social worker, but it
was rightly also the sphere of the physician. It did not
mean that the latter was to become a jack-of-all-trades.
Drugs were not the only remedies for disease. Faulty
habits and faulty environment were causes that had to be
eradicated. In former years the prescription was the main
thing handed out to the dispensary patient. Later on this

March 30, 1907]

MEDICAL RECORD.

543

was supplemented by the list of printed directions and
warnings. But it was common knowledge that the latter
were rarely effective. One year ago the speaker had or-
ganized in the Massachusetts General Hospital a depart-
ment of social work. He had become tired of seeing pa-
tient after patient who could not be reached by means of
medicine and surgery. One of the first things done was to
follow up these patients. The victims of tuberculosis were
instructed how to build their platform and put up their
tent on the roof, or if the latter was not available, how to
sleep in the yard. It was frequently necessary to advise
the patient to take a vacation, but no inquiry was made as
to his means of doing so. If a father, he had his family
to support; if a mother, she had the household to look
after. The response of the patient to this advice was usu-
ally, "But I can't, doctor," and the latter responded by call-
ing out, "Next patient." The department of social work
thus served to fill the wide gap between good intentions and
their fulfillment. Social work and education were there-
fore necessary factors if the physician was to do any real
good to his patients. One-fifth of the patients in the dis-
pensary and in private practice needed simply proper in-
struction in hygiene. The simple life which suited the
needs of one patient would drive another to drink. There
was also organized a hygiene class which was presided over
by a graduate nurse. Another nurse was employed who
gave her whole time to following up cases of infant feed-
ing to their homes, and to instruct and direct mothers in
the proper preparation of their infants' foods. Wherever
was found a good physician there was found one who
was actively engaged in some kind of educational work.
Medical men wrote more than any other professional
class. This was not merely for advertising purposes. There
was a natural kinship between medical writing and teach-
ing. The colleges, public schools, and lecture platform
were the means through which the physician could reach
the individual and the family. Public medical lectures had
been established at the Har\'ard Medical School and were
delivered every Saturday and Sunday. As an educator the
physician had long been recognized ; as a social worker he
was only beginning to e.xercise his opportunity and priv-
ilege. There were two other fields through which the
physician was to e.xercise his influence, namely, psycho-
therapeutics and public health. The speaker did not pretend
to do more than to refer to these subjects in a synoptical
way. In psychotherapeutics one dealt with the patient from
his sociological aspects. There was the need of studying
each patient's work, with the view of determining its ef-
fect upon him ; whether it produced worry, internal fric-
tion, restlessness. Was it suited to his capacities or tastes?
It was also necessary to consider the domestic and se.xual
relations of the patient. Was the patient stoical, cynical,
complacent, fatalistic, reckless, etc.? The physician also
had to reckon with his inheritance. The relation of the
physician to his patient through the medium of the public
health was a subject that had grown so fast in the past
decade that it was a source of wonder whether there would
be any private practitioners in the future. The medical
inspection of schools was a recent development. In the
schools the physician had put his hands upon disease in
the most critical period of life. His advice guided the
construction of public playgrounds, school houses, and
the solution of problems of ventilation. Through depart-
ments of health the physician sought the prevention of
malaria, diphtheria, etc. The free distribution of quinine
and antitoxin was a natural corollary of the State's inter-
vention. The foundation of free sanatoria, the regulation
of dangerous trades, the enforced renovation of filthy
slaughter houses, the abolition of dangerous house con-
ditions, the control of venereal diseases, were all evidences
of the public character of modern medical endeavor. One
could not think of a single nameless profession of which
medicine, social work and education were not branches.
This trinity formed a striking contrast to the professions

of conquest, namely, war, business, and athletics. War
was usually business, and business was usually war. In
medicine the aim was development. It was to heal by teach-
ing and to teach by healing. Whenever medical work
was good work it merged with that of the educator and
the social worker.

Treatment of Chronic Heart Diseases. — Dr. Theodor
ScHOTT of Nauheim, Germany, read this paper. He said
that twenty-five years had elapsed since the time when,
apart from hygiene, there were only two means of dealing
with chronic heart disease, namely, the enforcement of
rest and the administration of digitalis. Particular atten-
tion had been paid to pathological anatomy and diagnosis,
but treatment was neglected. During this quarter of a
century three methods of physiological therapeutics had
been developed. They were the Swedish gymnastics,
Oertel's treatment, and the Schott treatment. For the sake
of completeness the speaker next discussed the role of
drugs in heart disease. There was a remarkable increase
in the number of remedial agents. Digitalis was used
either with or without digitonin or digito.xin. Sometimes
its cumulative effect necessitated a resort to strophanthus.
In the presence of a relaxation of the heart muscle, strych-
nine elicited strong contractions, but it soon elicited ab-
normal irritability, followed by a depression of the heart's
action. Erythrol tetranitrate and nitroglycerine were val-
uable chiefly for tlieir effects on the arteries. The salts
of inercury, as calomel, were not strictly heart remedies.
They influenced the heart indirectly through tlieir diuretic
action. Morphine failed to tone up the heart, but it was
not to be discarded in the case of cardiac pain and oppres-
sion, in which a strong dose might be administered. The
speaker next discussed the physiological methods of treat-
ment. It was the Dublin physician, Stokes, who first
favored mountain climbing in the treatment of heart
disease. His views were forgotten until twenty-five years
later, when Oertel took them up, with the addition of a
restriction in the amount of liquids allowed to the patient.
The principle of this restriction was that by means of
it the circulation was facilitated. The Schott treatment
granted that the heart was strengthened by climbing; but
diet was an important accessory. On the other hand, dimi-
nution in the supply of liquids was not necessary. The
composition of the blood was constant, irrespective of the
amount of liquid that the patient took. The diet selected
was that best adapted to maintain the nutrition of the pa-
tient. It was desirable to prevent the accumulation of fat
and to cause an increase in the amount of muscle tissue.
E.xperience showed that a rapid diminution in the weight
caused bad effects. The mechanical part of tlie treatment
aimed at a development of cardiac strength by means of
an increased action of the muscles. The original treat-
ment had been devised for fatty heart. The theories that
had been advanced in favor of the Oertel treatment were
for the most part erroneous. Instead of a low diet, the
patient often required an abundance of food. Climbing
was resorted to only after the heart had been strengthened
by other treatment. Oertel gave an erroneous interpreta-
tion to the mechanical treatment. The use of Swedish
movements had no scientific basis. The exercises devised
by Zander were carried out independent of the position
of the patient's body. They caused an increase in the
musculature and an acceleration of the circulation. They
required continual supervision, and a regulation of the re-
sistance. Failures were frequent, for an exact determina-
tion of the resistance was difficult. The expense of the
apparatus was another drawback. Tlie speaker next dis-
cussed the method of physiological gymnastics. It was
first introduced in 1872. It was then found that mineral
baths were effective in rheumatism complicated with car-
diac disease. The speaker's late brother had found that
the physiological cure by means of mountain climbing had
produced the best results. They had both found that the
regulated haths had the same effect as the mountain climb-

544

MEDICAL RECORD.

[March 30, 1907

ing — in toning up a weak heart. In this condition one dealt
with the inadequacy of tlie heart to nnpel blood, which
usually led to a dilatation of the heart. But not every
dilatation caused a failure of compensation. Only the
former kind of dilatation required treatment. If the dilata-
tion was due to inability of the heart to contract, or to a
valvular lesion, there was caused a congestion of the
heart itself. By means of batlis and gymnastics tlie heart
was rendered better able to contract. There resulted hy-
perkincsis and hypertrophy, and an increased pressure in
the arterial system. 'I'he heart was relieved of the over-
pressure due to excessive filling. The heart was made to
beat more slowly and vigorously. These results were con-
firmed by others, and also by means of animal experiments.
Some observers explained the action of the baths on the
basis of a derivation of blood to the surface. In the speak-
er's opinion this view was not correct. Comparing the ef-
fects of the baths with those due to tlie mountain climb-
ing, it was found that those due to the baths were not as
strong, but were more enduring, while those due to the
gymnastics were more marked, but were less persistent.
They both caused a decrease in congestion and cyanosis, a
reduction in the pulse, an increased diastole. In suitable
cases, arrhythmia disappeared. The speaker cited the case
of a patient fifty-two years of age, suffering from mitral
insufficiency, associated with myocarditis and pulmonary
emphysema. He had had two attacks of embolism of the
lung and had congestion of the limbs. His condition was
wonderfully improved by the combined balneological and
gymnastic treatment. Percussion revealed the good effects
upon the heart. This reduction in size was also shown by
means of changes in heart tracings and by means of skia-
grams. The defect in skiagrams was due to the impos-
sibility of getting the patient into the same position each
time. On auscultation there was a change in the cardiac
sounds ; weak sounds became more audible, and hitherto
inaudible murmurs became audible. Diuresis became more
potent through balneological treatment. The whole organ-
ism gained strength, venous congestion was diminished,
and there was a greater volume of blood in the arterial
sj'stem. Owing to the larger amount of blood in the
coronary arteries, the nutrition of the heart muscle was
improved. There was an increase in the amount of hemo-
globin. The balneolopfical part of the Schott treatment had
been described by many observers, including Osier, Bab-
cock, Anders, etc., and it was impossible to give more than
the general rules for its application. It was an agent of
great power and had to be practised with great caution and
with frequent observation of the patient, for the clinical
picture often changed. As the treatment progressed it was
necessary to lower the temperature of the water. It was
often advisable to observe the patient before, during, and
after tlie bath. It was necessary to begin with brine con-
taining 2 to 3 per cent, of sodium chloride, and the same
percentage of calcium chloride. The bath was given at a
temperature of 93° and lasted ten minutes. The tempera-
ture was not to be lowered during the first week. In the
anemic patient it was prudent to give the bath at 95°. This
temperature was not to be exceeded even with the combina-
tion of rheumatism and heart disease. In such cases cooler
and shorter baths were more desirable. If the patient was
quiet, he first experienced chilliness and then comfort,
which was due partly to the heating and partly to the
composition of the water. If the reaction did not occur
within one minute, it was necessary to have the temper-
ature of the water higher and kept so tliroughout the en-
tire bath. Sometimes a second chilliness occurred. This
was avoided by shortening the duration of the bath. If
the baths were well borne, the sodium chloride, and particu-
larly the calcium chloride, were increased. Later carbon
dioxide was added. At first the percentage of this was
weak. It was supplied from large underground basins con-
taining 1. 000 cc. of free carbon dioxide to each liter of
water. Later the baths contained from 1.200 to 1,500 cc.

of CO2 to each liter of water. Still later there were ad-
ministered effervescent running baths, the water flowing
with a pressure of from I 1-2 to 2 atmospheres and at a
temperature of 96°, also containing 2,00O cc. of COj to each
liter. This was the strongest form of bath given. Most
patients required an intermission in the treatment. The
bath rarely exceeded twenty minutes in duration and was
followed by a brisk rub. The patient then went to bed for
one hour. Later baths were given cooler and were more
prolonged. They also contained mother-lye, which consists
of 40 per cent, chlorate of lime. It was supposed that the
movable molecules of CO2 penetrated the skin. The cure
was best administered in the summer, and for mild cases it
lasted from four to six weeks, and was followed by a
short stay in a locality of moderate altitude. Severe cases
required a treatment lasting several months. The winter
cures were given in a warm southern climate. The Nau-
heim baths could be made artificially, either with the aid of
the Nauheim bath salts, or with the aid of NaCl and CaClj
in proper proportions. The CO2 is prepared by means of
the interaction of HCl and NaHCOs, the quantity of the
last being at first lOO grams per bath, and later increased
to 500 grams. The HCl had to be pure and evenly dis-
tributed, and the CO2 was to be developed slowly, its evolu-
tion lasting one-half hour. The artificial Nauheim baths
had come into general use. It was an erroneous view that
only the CO- was the active ingredient. Good results were
obtained by the gradual increase of all the ingredients. It
was observed that unsatisfactory results were obtained with
many patients ow'ing to the inability to properly regulate
the bath. Long experience was necessary to do this. It
was important also that the patient should be relieved from
family and business cares, and should be on a proper diet.
Besides, the strongest baths could not be made artificially.
The baths wielded their influence through the sensory
nerves, while the graduated gymnastics acted through the
motor nerves. The latter brought the antagonistic muscles
into action. Each exercise was developed slowly and the
resistance so adjusted as to permit freedom of respiration.
The various muscles were alternately brought into use, and
when the series were completed the exercises were gone
over again. The movements comprised a great variety, in-
volving the movements of flexion, extension, adduction,
abduction, and rotation. It was not difficult to teach a
person of intelligence to become a gymnastic director. It
was an advantage to train a member of the patient's fam-
ily for this work. One of the rules was not to grasp or
impede any part of the patient's body. .Another was that
no new exercises were to be begun until the pulse became
slower and the breathing more easy. Later on mountain
climbing w-as to be resorted to. Its contraindications were
aneurysm of the heart or of the larger arteries, arterio-
sclerosis, apoplexy, and embolism. In cases of cardiac ex-
citation, tranquillity was secured in a short time by means
of tapottement. Vibratory massage was also useful. Ice-
bags were also eft'ective in quieting the heart. For this pur-
pose also electricity, more recently the sinusoidal currents,
were employed. The diet was to be a mixed one, with the
avoidance of stimulating beverages, and with precautions
against a distended stomach. The use of tobacco was either
restricted or entirely prohibited. The physician had to take
account of the question of social stress, CKCupation, and
marriage. In the face of the Schott treatment, scepticism
had in large measure vanished.

Bleeding Hemorrhoids.-

ommended by Boas as a
Every morning after the
a 10 per cent, solution of
rectum and retained for a
to hemorrhage is pronoun
be made at night. If the
may produce burning, p
der Gegemvart.

— Chloride of calcium is rec-
hemostatic in this condition,
bowels have moved 20 cc. of
this agent is injected into the
little while. If the tendency
ced, a second injection should
drug is not chemically pure it
ain, and tenesmus.— T/wrapi*

March 30, lyoj

MEDICAL RECORD.

545

STATE BOARD EXAMINATION QUESTIONS.

Medical Board of Examiners of the State of Penn-
sylvania.

December 4 to 7, igo6.

anatomy.

1. Name the arteries through which blood would pass
from the heart to the thumb and the veins through which
it would return from the thumb to the heart.

2. Describe the formation of the palmar arterial arches,
and give anatomical landmarks for location of the same.

3. Describe the bony relationships and landmarks of the
elbow joint.

4. Describe the anatomical structure of the female
perineum.

5. Describe the structure and anatomical relationships
of the female mammary gland.

6. Describe the anatomical structures entering into the
formation of (a) the internal and (b) the external abdomi-
nal rings.

7. What muscles are attached to the great trochanter
of the femur?

8. Describe the appendix verraiformis; give its relations
and the external landmarks of its location.

9. Describe the superior maxillary bone.

10. Describe the uterus and give its relations and nerve
supply.

PHYSIOLOGY.

1. Define metabolism. Cite an example.

2. Enumerate four conditions to be observed in taking
the pulse, and describe what each signifies.

3. Over what functions of the body does the cerebellum
preside?

4. Describe the thermal and chemical changes in muscle,
as the result of exercise.

5. How is respiration influenced by the nervous system?

CHEMISTRY.

1. What is hemoglobin : name- some of its properties
and give a chemical test for it.

2. What chemical reaction takes place when hydrogen
dioxid is applied to sloughing wounds?

3. Describe a reliable test for the detection of free
hydrochloric acid in gastric contents.

4. When testing for albumin in urine, how do you
determine between it and other coagulable proteids?

5. When testing for glycosuria with Fehling's solution,
how do you determine whether the reaction is that of
sugar or some other reducing agent ?

MATERIA MEDICA.

1. Classify electricity as a remedial agent, (b) and name
the different forms useful in the treatment of morbid
conditions, (c) describe how they are applied.

2. Name five vegetable and three mineral astringents,
describing method of administration and dose in each
instance.

3. Name and describe three antiseptics useful in interna!
medication.

4. Describe and classify the important active principle
of each of the following drugs ; Hydrastis canadensis,
veratrum viride. and humulus.

5. Write a complete prescription for a child of three
years suffering witPi pertussis, (or) Discuss ergota, stat-
ing to what alkaloid or active principle it owes its thera-
peutic activity.

PATHOLOGY.

1. Describe the cardiac changes that occur in mitral
stenosis.

2. Describe the alterations that occur in the respective
coats of an artery which is the seat of endarteritis ob-
literans.

3. Describe two methods of wound repair.

4. Describe the pathological changes occurring in dry
gangrene.

5. Describe the various forms of acute salpingitis.

diagnosis.

1. Give a practical method of differentiating gas-
troptosis and gastrcctasis.

2. Differentiate chronic parenchymatous nephritis and
chronic interstitial nephritis.

3. Describe a case of tabes dorsalis and differentiate
the condition from multiple sclerosis.

4. State the diagnostic symptoms of progressive per-
nicious anemia, and what changes in the blood aid in
the diagnosis.

5. Differentiate acute synovitis and acute articular rheu-
matism.

therapeutics and practice of medicine.

1. What are the symptoms of exophthalmic goiter, and
what are some of the measures employed in its treatment?

2. What are the symptoms of abscess of the lung?

3. Describe the treatment of a case of sunstroke.

4. What are the symptoms of a typical case of acute
lobar pneumonia?

5. Describe the treatment of a case of diphtheria.

6. Describe the symptoms and treatment of a case of
acute tonsillitis.

7. Describe the symptoms of a case of chronic lead
poisoning and outline a method of treatment.

8. What are the symptoms of poisoning by belladonna,
and how would you treat such a case?

9. Name some of the indications and contraindications
of ergot.

10. Name some of the most important uses of the prepa-
rations of opium.

obstetrics.

1. Give the maternal causes of dystocia, and methods of
treatment.

2. Give the most frequent causes of puerperal mammary
inflammation and give treatment.

3. How would you deliver a child when face is present-
ing with chin posterior?

4. Describe the various methods of preventing infection
during childbirth.

5. Give symptoms and treatment of placenta praevia.

6. Give the indications for version, and detail the opera-
tion.

7. Give the methods of resuscitation in the apparently
still-born.

8. What symptoms would lead you to suspect threatened
miscarriage?

9. Name the cause and give the diagnosis of pelvic
hematocele.

10. To prevent laceration of the perineum, describe the
proper method of delivering the head.

surgery.

1. Give the diagnosis and treatment of transverse frac-
ture of the patella.

2. Describe the symptoms and give the treatment of the
several forms of gangrene.

3. Define surgical shock and give treatment.

4. What are the symptoms of "Colics' fracture," and
give treatment.

5. Describe a backward dislocation of the hip joint,
and give treatment.

6. Describe the objective anJ subjective symptoms of
strangulated inguinal hernia, and an operation for the
relief of the same.

7. Give the symptoms and treatment of fracture of
the vertebral column with compression of the spinal cord.

8. Enumerate the recognized degrees of burns, and de-
scribe the treatment for the second degree.

9. Describe surgical methods for treatment of stricture
of the male urethra, with respective indications.

10. Give a minute description for the proper adminis-
■ tration of ether for general anesthesia.

HYGIENE.

1. Name three diseases due to animal parasites, and tell
how their introduction into the human system may be
prevented.

2. What are the relative effects on health of altitude, sea
air. humidity and sunshine.

3. What diseases are communicated by stools and
sputum, and what are the best methods of prevention of
communication?

4. Name three exanthematous fevers and describe a
rational effective method of quarantine, giving the proper
duration thereof.

^. Give the disadvantages and dangers of cold storage
foods.

ANSWT'RS TO STATE BOARD EXAMINATION
QUESTIONS.

Medical Board of Examiners of the State of Penn-
sylvania.

December 4 to 7, 1906.

ANATOMY.

I. The arteries through which blood would pass from
the heart to the thumb, are :— Aorta, innominate (on
right side onlv^i subclavian, axillary, brachial, radial, and
princeps poUicis or dorsalis pollicis. The reins through
which it would return to the heart are arranged in two
sets:— (l) Stipcrfieicl 7'ciiis:— venous plexuses, superficial
radial, cephalic, axillary, subclavian, innominate and su-

546

MEDICAL RECORD.

[March 30, 1907

perior vena cava. And (2) Deep veins: — The venae comites
of the radial or deep radial, brachial, axillary, subclavian,
innominate, and superior vena cava.

3. If the forearm is extended, the internal condyle of the
humerus, the tip of the olecranon, and the external condyle
will all be found on the same transverse line. In extreme
extension the tip of the olecranon is slightly above the level
of the condyles. If the forearm is He.xed to a right angle,
the tip of the olecranon is immediately below the condyles.

PHYSIOLOGY.

1. Metabolism is a name given to the entire series of
changes that occur in a cell or organism during the
processes of nutrition. It is of two kinds: — (i) anabolic,
or constructive, and (2) catabolic, or destructive. The
changes produced in the cells by the oxygen or nutrition
conveyed by the blood, come under the class of anabolic
changes.

2. (i) Its frequencv: this gives the rate of the heart
beats. (2) its compressibility : this denotes the force with
which the heart is beating. (3) Its tension: this denotes
the peripheral resistance, and also the state of the arterial
walls. (4) Its regularity or rhythm: this denotes the reg-
ularity (or otherwise) of the heart's action in force or
rhythm.

3. Muscular coordination, and equilibrium.

4. There is an increase in heat production, and conse-
quently a rise of temperature. The muscle becomes acid
in reaction, due to the development of sarcolactic acid ; at
the same time there is an increased consumption of oxygen,
and rnore carbon dio.xide is set free.

CHEMISTRY.

1. Hemoglobin is the coloring matter of the blood. It
exists in the blood in two forms, as hemoglobin and as
oxyhemoglobin. Chemically it is a protein ; its molecule is
very complex, and consists of the elements carbon, hydro-
gen, oxygen, nitrogen, iron, and sulnhur. It is a crystalline
solid, and is not diffusible. Hemoglobin is the means by
which the oxygen is carried by the blood to the tissues. It
readily enters into combination with other gases such as
carbon monoxide, nitrogen dio.xide, and hydrocyanic acid.
It is soluble in water, insoluble in alcohol and ether.

Test. Mix some of the suspected liquid with a few drops
of a saturated solution of sodium chloride, evaporate to
dryness on a microscopic slide, add a drop or two of glacial
acetic acid and gently warm ; crystals or hemin or hematin
will form on cooling, and may be seen under the micro-
scope.

2. O.xygen is liberated and effervescence occurs. It
acts as an antiseptic.

3. The phloroglucin-vanillin test: — The reagent is made
by dissolving two grams of phloroglucin and one gram of
vanillin in 100 cc. of alcohol. The test is made by taking
a few drops of the filtered gastric contents and an equal
quantity of the freshly-prepared reagent ; these are then
mi.xed in a porcelain dish, and evaporated over a water
bath ; in the presence of free hydrochloric acid a brilliant
red color is produced, beginning at the upper border.

4. By using the four tests, as mentioned in the follow-
ing table (compiled from Croftaii ) :

The

The

The Potassium

The

Boiling

Nitric Acid

Ferrocyanide

Biuret

Test

Test

Test

Reaction

Serum Albumin. ..

Positive. .

Positive

Positive

Positive

Serum Globulin. ..

Positive. -

Positive

Positive.

On the addi-
tion of acetic
acid there is a
p re c i pitate
which is re-
dissolved on

Positive

the addition

' of more acid.

Nucleo-albumin. .

Negative .

Positive Positive

Positive

On the addi-

tion of acetic

acid there is

p r e c i pitate

which does

not re-dis-

solve on the

addition 0 f

more acid.

Albumoses

Negative .

Positive. Positive.

The precipi- The precipi-
tates formed' tates formed
in the cold in the cold
disappear on disappear on
heating, but heating, but
re-appear on re-appear on
cooling. cooling.

Positive

Peptones

Negative .

iiegative

Negative

Positive

MATERIA MEDICA.

1. Bartholow classifies electricity among the agents used
to excite the functional activity of the spinal cord and the
sympathetic.

{b) Static or frictional, magnetism, galvanism, faradism.

2. Five vegetable astringents : — Hammamelis, dose of
the fluid extract, TlBxxx. Gambir, dose, gr. xv. Kino, dose,
gr. vijss. Hematoxylon, dose of the extract, gr. xv.
Tannic acid, dose, gr. vijss.

Three mineral astringents: — Alum, dose, gr. vijss. Cop-
per sulphate, dose, gr. 1/5. Silver nitrate, dose, gr. 1/5.
Of the above silver nitrate is only applied locally as an as-
tringent; all the others can be used internally or locally.

3. Phenol, creosote, and phenyl salicylate (salol).

4. Hydrastis canadensis: berberine and hydrastine, both
alkaloids. Vcratrum viride : jervine and veratrine, both
alkaloids. WiojiM/ifcr :lupuline, an alkaloid.

5. 5' Tincturae belladonns 5j

Extract! cannabis indica; gr. jss

Glycerini 3J

Tincturae aurantii amari Sijss

Aqux destillatae q. s. ad 3iv. Misce.
Signa : — Two teaspoonfuls every four hours.
The composition of ergot is indefinite ; the chief con-
stituents are : — Ergotine, ergotinine, ecboline, sphacelic
acid, ergotinic acid, cornutine. tannic acid, and other sub-
stances. Most of these ingredients contract the blood ves-
sels ; the cornutine, in addition, is credited with the chief
part in contracting the uterus.

DIAGNOSIS.

1. The stomach should be inflated; the diagnosis is then
made by outlining the stomach. In both conditions the
lower border of the stomach is depressed below the umbili-
cus. But in Gastroptosis, the upper border and pyloric end
are also depressed, and the stomach assumes a vertical
position ; whereas in Gastrectasis, the upper border and
pyloric end are but slightly depressed.

2. The following table is from Millard's work on
Bright's Disease :

CHRONIC PARENCHYMATOUS
NEPHRITIS.

5. On getting a positive result with Fehling's solution,
a further examination should be made by the fermentation
test. If fermentation occurs, it indicates the presence of
sugar. The phenylhydrazine test may also be applied ; it
does not react with reducing agents other than sugar.

The urine is always albu-
minous.

Urine usually scanty.

Dropsy and edema almost
always occur.

Hypertrophy of the heart
seldom exists.

Specific gravity of urine
usually higher than the nor-
mal. Urine darker and with
less of a soapy appearance.

Uremic symptoms less
frequent.

Epistaxis and cerebral
hemorrhages rare.

Occurs most frequently
before the age of forty.

Blood cornuscles and con-
nective tissue shreds more
frequently found.

Casts more numerous and
in greater variety : waxy,
granular, fatty, and hyaline
casts occurring.

Enithelia from the kidney
and pus corpuscles more nu-
merous.

Urates and phosphates
predominate : oxalates rare.

.Mbuminous retinitis rare.

Gangrenous erysipelas an<l
phlegmonous swellings more
common; also dyspepsia and

CHRONIC INTERSTITIAL NE-
PHRITIS.

Urine not constantly al-
buminous.

Urine usually abundant.

Dropsy seldom or never
present ; sometimes slight
edema.

Some hypertrophy of
heart, with increased arte-
rial tension, almost always
present.

Urine generally of a light
color and low specific grav-
ity.

Uremic symptoms are met
with in their most pro-
nounced form, and in severe
cases usually occur.

Epista.xis and cerebral
hemorrhages frequent.

Occurs most frequently
after forty.

Absent.

Develooment more grad-
ual, the health of patient
often less impaired, and
duration longer.

Casts rare, the hyaline
varietv- being most frequent-
ly met with.

Kidney epithelia and pus
corpuscles scantv. and oc-
cisionally absent.

Oxalate of lime almost
always occurs.

.\lbuminous retinitis com-

anemia.

Visceral complications not

Visceral

complications

uncommon.

rare.

.Atheroma of arteries rare.

Atheroma

common.

March 30, 1907]

MEDICAL RECORD.

547

3. In multiple sclerosis there will be found increased
reflexes, a greater loss of muscular power, volitional tre-
mor, nystagmus. .

In locomotor ataxia, there are: lightnmg pams, loss of
knee jerk, ataxia, but not much loss of muscular power,
Argyll-Robertson pupil.

4. Pallor, indisposition to e.\ertion, palpitation of heart,
flabbiness of muscles, poor appetite, languor, edema, de-
bility, hemic murmurs, water-hammer pulse, dyspepsia,
diarrhea. The blood changes are :— great diminution in the
number of red corpuscles, hemoglobin is relatively in-
creased, the red cells vary considerably in size and shape,
and there are present nucleated red corpuscles of all sizes
and in varying numbers. The white corpuscles are either
unchanged or slightly diminished in number.

THER.^PEUTICS AND PR.\CTICE OF MEDICINE.

1. Tachycardia, enlargement of the thyroid gland, ex-
ophthalmos, and tremor are the cardinal symptoms. Other
symptoms are :— pigmentation of the skin, edema and mois-
ture of the skin, impaired nutrition, anemia, and mental
irritability and depression.

Among the measures employed in its treatment are :—
iron, digitalis, ergot, the bromides, rest in bed with appli-
cation of ice bag over the heart or thyroid gland, electricity,
thyroid or thymus extract, iodine, opium, section of the
cervical sympathetic nerve, and partial thyroidectomy.

2. Chills, high fever, signs of a cavity or of general
pyemia; the sputum is offensive and yellowish or greenish
in color, and contains elastic fibers or fragments of lung
tissue.

3. The first thing is to lower the body temperature. The
patient should be put into a cold bath, rubbed with ice,
and given a hypodermic of some active antipyretic ; he
should be wrapped in a wet sheet, and if necessary may re-
ceive ice water enemata. Further symptoms may be treated
as they arise ; for heart failure, digitalis and strychnine
may be given liypodcrmatically ; for convulsions, chloral or
chloroform.

7. Symptoms : — colic, chiefly round the umbilicus ;
cramps in the flexor muscles, muscular paralysis (wrist
drop); pain in some of the joints; blue line on the gums
at the border of contact with the teeth; anemia; consti-
pation; eclampsia and nervous symptoms may also be
present.

Treatment: — The patient should be removed from the
source of harm, personal cleanliness in every way must be
enforced, a hypodermic of morphine (gr. J4) may be
given for the pain, then hot baths, Epsom salts, diuretics,
electricity, iron, and strychnine are all useful.

8. Symptoms of belladonna poisoning: — In the first
stage, that of delirium, there are dryness of the throat,
thirst, difficulty of deglutition and spasms upon swallowing
liquids, face at first pale, afterwards highly reddened, pulse
extremely rapid, eyes prominent, brilliant, with widely-
dilated pupils, complete paralysis of accommodation, dis-
turbances of vision, attacks of giddiness and vertigo, with
severe headache, followed by delirium, occasionally silent
or muttering, but usually violent, noisy, and destructive,
accompanied by the most fantastic delusions and hallucina-
tions. Usually the urine is retained, and the body tem-
perature is above the normal. The delirium gradually
subsides, and the second stage, that of coma, is established,
with slow, stertorous respiration, and gradually failing
pulse, until death occurs from respiratory or cardiac
paralysis, or sometimes in an attack of syncope during
apparent amelioration. (Witthaus.)

Treatment: — The stomach should be washed out; pilo-
carpin may be given hypodermatically ; mornhine may be
given cautiously during the period of violent excitement;
cold applications to the head and artificial respiration are
useful. There is no chemical antidote.

9. Indications: — To promote uterine contractions dur-
ing third stage of labor; fibroids, menorrhagia. post-partum
hemorrhage. Some forms of amenorrhea and dysmenorrhea,
dysentery, arterial hemorrhage, congestive headaches, laxity
of sphincters of bladder or rectum, hemorrhoids, aneurysm,
diabetes, urinary incontinence, direct paraly;is nf the
sphincter vesica?, atonic spermatorrhea.

Contraindications : — In labor if the birth canal is not
free, and the os uteri is not dilated.

HYGIENE.

I. (i") Malaria. (2) Trichinosis, and (3) Tapeworms.

(1) In the case of Malaria: — the destruction of all
mosquitoes, or the prevention of inoculation.

(2) In the case of Trichinosis : — the meat (of the pig)
should be thoroughly cooked ; mere curing or smoking will
not do. Further, there should be systematic inspection of
the meat sold, and the animals should not be fed with the
refuse of slaughter-houses.

(3) In the case of Tapeivorms: — all meat should be

thoroughly cooked, and vegetables should be thoroughly

cleansed. t- i. -j r

3. Diseases communicated by the 5foo« :— Typhoid fe-
ver, dysentery, cholera, intestinal tuberculosis. To pre-
vent communication of these diseases, the stools should be
received in vessels containing a disinfectant solution in
greater quantity than the expected discharge. The whole
should be thoroughly mixed and allowed to stand for at
least one hour before final disposition.

Diseases communicated by the 5'/'i(/Hm :— Pulmonary tu-
berculosis and pneumonia. To prevent communication of
these diseases, the sputum should be received in vessels
containing disinfectant solution, and kept covered when not
in use. The contents of the vessel should be burnt, and the
vessel washed with disinfectant solution. The patient
should not wear either beard or mustache.

BULLETIN OF APPROACHING EXAMINATIONS.!

STATE NAME AND ADDRESS OP PLACE AND DATE OP

SECRETARY. NE.XT EXAMINATION

Alabama* W. H. Sanders, Montgomery. . Montgomery . . April i-6

Arizona* Ancil Martin, Phoenix fl'Of"',?- ■," ' ' ■^P''., '

Arkansas* F. T. Murphy. Brinkley Little Rock. . .April 9

California Chas. L.Tisdale, Alameda. . . San Francisco. AprU 16

Colorado S. D. Van Meter. 1723 Tre-

mont Street. Denver Denver Apnl 2

Connecticut*.. .Chas. A.Tuttle, New Haven. .New Haven. . .July 9

Delaware J. H. Wilson. Dover Dover June 18

Dis of Corbia. .W.C.Woodward, Washington. Washington.. .April 11

Florida* J. D. Fernandez. Jacksonville. Jacksonville. .May 15

J .- I Atlanta April 30

Georgia E R. Anthony. Gnflin ( AuHusta May 2

Idaho J. L. Conant, .Ir.. Genesee Boise April 2

lUinois LA. Egan. Springfield Chicago Apnl J7

Indiana W. T. Gott. 1 20 State House.

Indianapolis Indianapolis. . Mav 28

Iowa Louis A. Thomas. Des Moines.. Des Moines... June —

Kansas T. E. Raines. Concordia Topeka June 11

Kentucky* J. N. McCormack. Bowling .

' -^ Green Louisville Apnl 23

Louisiana F. A. La Rue. 211 Camp St.,

New Orleans New Orleans... Ma> 9

Maine Wm. J. Mayburv. Saco Augusta. . July 9

Maryland J. McP. Scott, Hagerstown. . .Baltimore June —

Massachusetts* E. B. Harvey. State House,

Boston Boston May 14

Michigan B. D. Harison. 205 Whitney

Building. Detroit Ann Arbor June 11

Minnesota W. S Fullerton. St. Paul. .. .St. Paul Apnl 2

Mississippi J. F. Hunter. Jackson Ja_ckson^.^. . . .May 14

Missouri J. A. B.Adcock.Warrensburgl Kansas City } ^P"''^ '*

MonUna* Wm. C. Riddell. Helena Helena AprU 2

Nebraska : .Geo. H. Brash. Beatrice Lincoln..

Nevada S. L. Lee. Carson City .Carson City. . .May 6

N. Hamp' re*... Henry C. Morrison. State Li-

brary. Concord Concord July 9

New Jersey J. W. Bennett, Long Branch. .Trenton Tune 18

NewMexico....B.D. Black, Las Vegas Santa Fe. June 3

t New York, j
New York .. .C.F.Wheelock Univ.of State J Albany,

of New York. Albany 1 Syracuse.

>■ Mav

. Buffalo.

N. Carolina*.. . .G. T. Sikes. Grissom Morehead City.May —

N Dakota H. M. Wheeler. Grand Forks. .Grand Forks... AprU 2

Ohio Geo. H . Matson. Columbus.. . . Columbus June 1 1

Oklahoma* J. W. Baker. Enid S"''!"'^i ■J^"'^ ~^

Oregon* B. E. MiUer. Portland Portland. . .May 8

Pennsylvania. .' N.:C. Schaeffer, Harrisburg. { pittsburg, '^ } J"°^ ~

Rhode Island. , .G. T. Swarts. Providence Providence... .April 4

S Carolina W. .M. Lester. Columbia Columbia June —

S Dakota H. E. McNutt, Aberdeen Sioux Falls. ... July 10

f Memphis. ]

Tennessee* T. J. Happel. Trenton { Nashville, May —

\ KnoxviUe. J

Texas . . T. T. Jackson. San Antonio. . . Austin AprU 30

Utah* R. W. Fisher. Salt Lake City. .Salt LakelCity.Apnl i

Vermont W Scott Nay. Underhill Burlinston. . . . July 9

Vircinia . .R. S. Martin. Stuart Lynchburg. .. .June 18

Washington*.. .C. W, Sharpies. Seattle Seattle July 3

W Virginia*. . .H. A. Barbee. Point Pleasant. Wbeeling AprU 9

Wisconsin J. V. Stevens. Jefferson Madison.. . . .July 9

Wyoming S. B. Miller. Laramie Cheyenne

*No reciprocity recognized by these States.

t.'^pplicants should in every case write to the secretary for latest
details regarding the "examination in any aprticular State.

California.— In order to obtain a duplicate certificate
to practise medicine in this State, it will be necessary
for physicians whose certificates were destroyed m the
San Francisco fire to present to the Secretary of the
Board an aftidavit as to the loss of the original certifi-
cate. The applicant will also have to be identified.
The fee for such certificate will be $1.00.

New York. — During the year ending July 31, 1906,
the total number of candidates examined by all three
boards was 1.035. Of those examined by the Regular
Board: (i) 379 took the whole examination; of these
292 passed, "and 87. or 22.9 per cent., were rejected.
(2) 262 took the first half; of these 258 passed, and 4.
or i.t; per cent., were rejected. (3) 276 took the final
half;'of these 264 passed, and 12, or 4.3 per cent., were
rejected. The rejections per topic for the academic year
were as follows: Anatomy. 43; Physiology and Hy-
giene. 44; Chemistry, 27; Surgery. 41; Obstetrics. 46;
Pathology and Diagnosis, 40; Therapeutics Practice
and Materia Medica. 10: .Average rejection per topic,
.36. Honor men for the year: State Board, 9; Homeo-
pathic Board. 3; Eclectic Board, o.

548

MEDICAL RECORD.

[March 30, 1907

OJliwajieuttr l^intH.

Flatulence. —

]ji Mag. carbonat.

Sacchar. alb aa lo.o

Bismuthi subsalicylat.

Salolis.

Fruct. cari aa 5.0

M. ft. pulv. Sig. : A tcaspoonful after eating.

— Kantorowicz.

Lead and Opium Wash. — A simple and cheap method
of prescribing this valuable lotion is as follows:
Tr. Opii

Liq. Plumb! Subacetat aa 5ss

— IVisconsin Medical Journal.
M. Sig.: Add entire contents of bottle to one pint of
water and apply locally.
Pyemia. —
1^ Syr. ferri hypophosphitis.

Liq. hydrogen peroxide 10 vol

Glycerinae aa 15.0

Aquae q-s. ad. 180.0

M. Sig.: Tablespoonful three times a day.

— GuiTERAS, Medical Review of Reviews.

Scarlet Fever. — Early in the disease Wiest begins to
give the following:

51 Tr. digitalis (fresh) 3ss

Liq. ammon. acetat. (fresh) 3 iss

Spt. aether, nit 3_ii

Syr. tolu 5 ss

Aquae cari 5 ss

M. Sig.: Teaspoonful every 3 hours.

For the itching Shollenberger uses an ointment hav-
ing this composition:

R Menthol gr. x

Ung. zinci oxidi 5_ss

Lanolini q.s. ad. jss

M. Sig.: Apply tocally.

— Denver Medical Times.

Pruritus Ani. — Drueck says that when the pruritus is
due to proctitis, hemorrhoids, fissure, ulceration, fistula,
prolapse, or polypus, and the patient refuses to submit
to surgical treatment, or in senile, debilitated, or hem-
orrhagic subjects, much relief may be given by the use
of the following:

R Calomel gr. 30

Menthol gr. 10 to 20

Vaseline .'1 1

Sign. — .A.pply after each bowel movement, bathing the
surface carefully, and sopping it dry.
For eczema of the anus he employs :

R Picis liquidae Siy

Ung. belladonnae 3ii

Ac. carbolici hEx

Adeps lanae 3ii

Bathe the parts repeatedly in water as hot as can be
borne, and in green soap, to remove the thickened scales,
and to deplete the local circulation. In exaggerated cases,
a solution of caustic potash, five grains to the ounce, may
be used. \ cloth may be used to sop the hot water on the
parts, but do not allow any rubbing.

— Chicago Medical Recorder.

Chordee. — W, J. Robinson states that the following
are useful prescriptions:

1^ Codeins phosph gr. 1-3

Heroini hydrochlor gr. 1-12

Camphors monobrom grs. 2

Lupulini optimi grs. 3

Ext. rhamni purshianae grs. 2

M. Ft. caps. No. i. Sig.: Take one capsule before re-
tiring.

Sometimes suppositories prove the most efficient, and the
following is an excellent comb'nation :

It Codeinse phosph gr. 1-2

.Atropinae sulph gr. 1-120

Antipyrinae gr. 5

01. tiieobromae gr. 15

M. Ft. suppos. No. I. Dentur tales doses No. 12. Sig. :
Insert one before going to bed; another one may be used
during the night.

To relieve the actual attack, the patient should wrap a
cloth or towel wrung out of ice water about the member,
or put it in hot water, as hot as cin be borne. If the desire
to urinate is present at the same time with the chordee, the
patient should urinate in the water. Swallowing pieces of
ice has relieved many patients, but whether suggestion plays
a part here or not is hard to determine.

— American Journal of Clinical Medicine.

iHflJiral 31tpms.

Contagious Diseases — Weekly Statement. — Report of

cases and deaths from contagious disease reported to the
Sanitary Bureau, Health Department, New York City, for
the week ending March l5 and 23, 1907 :

Tuberculosis Pulmonalis . . .

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis . . .
Malarial Fever

Totals

Week of Mar. i6
Cases Deaths

435
256
429
365

106

55
45
21

1712

2og
37
13
25

313

Week of Mar. 23
Cases Death*

410
318
444
375
3
99

lOI

61
21

169
34
13
19

17
12

18

1832!

I

282

Health Reports. -The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital

Service, during the week ended March 22, 1907:

SMALLPOX UNITED STATES.

California. San Francisco Mar. 2-9

Illinois. Chicago Mar. 9-16

Indiana. Indianapolis Feb. 24-Mar. 10

Iowa. Davenport Mar. i-is

Kansas, Lawrence Feb. 1—28

Topeka Mar. 2-9

Louisiana. Shreveport Feb. 23-Mar. 2.

Ohio, Cincinnati Mar. 8-15

Cleveland Mar. 8-15

Pennsylvania, Homestead Feb. 28-Niar. 7.

Tennessee, Nashville Mar. 9-16

Wisconsin, Milwaukee Mar. 2-9

CASES. DEATHS.

SMALLPOX — INSULAR

Philippine Islands. Mariveles Quar-
antine Jan. 26-Feb. 2. On S.S. Pioneer

SMALLPOX-

Africa. Cape Town

.\rgentina, Buenos Aires

Brazil. Bahia

Para

Pemambuco

Rio de Janeiro

Canada. Digby County, N. S

Chile. Coquimbo

China. Shanghai

Columbia. Cartagena

Ecuador. Guayaquil

Egypt, Cairo

France. Marseille

Great Britain. Cardiff

Hull

New Castle on Tyne

India. Calcutta

Italy, General

Mexico. A^uas Cahentes

Netherlands. Rotterdam

Russia, Odessa

Siberia. Vladivostok

Spain, Malaga

Turkey, Constantinople

Jan.
Jan.
Jan.
Feb.
Jan.
Feb.
Feb.
Feb.
Jan.

FOREIGN'.

26-Feb. 2 . .

12-26

I2-Feb. 16.

2-9

15-31

2-9

2-9

6

6-1.?

Feb. 24-Mar. 3. .

Feb. 16-23

Feb. 18-25

Feb. 2o-ilar. 6. .
Feb. 23-Mar. 2.

Feb. 16-23

Feb. 16-23

Feb. 2-9

Feb. 1-28

Mar. 2-9

Feb. 23-Mar. 2. .

Feb. 16-23

Jan. 21-28

Feb. 16-23

Feb. 17-Mar. 3. .

26

36

28

Epidemic

YELLOW FEVER — UNITED STATES.

Texas, Galveston Mar. 1 7

(From S. S. Basil from Para.

YELLOW FEVER FOREIGN".

Brazil, Para Feb. 2-23 . .

Rio de Janeiro Feb. 2-9...

Ecuador. Guayaquil Feb. 16-23 . .

CHOLERA — INSULAR.

Philippine Islands. Provinces Jan. 6-12

CHOLERA — FOREIGN.

Ceylon. Colombo Jan. 26 — Feb. 2.

India. Calcutta Feb. 2-9

PLAGUE.

•Argentina. Buenos .Aires Jan.

.Australia. Brisbane Jan.

Brazil Bahia Jan.

Para Feb.

Chile. Antofagasta Feb.

Santiago Feb.

China. Niuchwang Jan.

Egypt, ProWnces — Beni Souef Feb.

Guerga Feb.

Kena Feb.

Kouss Feb.

Minieh Feb.

India. General Jan.

Calcutta Feb

Peru. Callao Feb.

Chiclavo Feb.

Ferrenafe Feb.

Lima Feb.

MoUendo Feb.

Pacasmayo Feb.

Pueblo Xuevo Feb.

TrujiUo Feb.

12-26. .
12—19. .
1 2-Feb.

2-23. .

6

j6.

23-30.
15

6

9

6

Present

36

19-21 .
26-Feb.

20.262 20,706

8-i6.

Medical Record

A Weekly Jonriial of Medicine and Surgery

Vol. 71, No. J4.
Whole No. 1900.

New York, April 6, 1907.

$5.00 Per Annum.
Single Copies, lOc.

©rtgutal Artirlra.

GASTROSCOPY.*

Bv CHEVALIER JACKSON, M.D.,

PITTSBURG. PA.

LARYNGOLOGIST AND RftlNOLOGIST TO THE WESTERN PENNSYLVANIA

HOSPITAL, THE EYE AND EAR HOSPITAL. AND THE MONTEFIORE

HOSPITAL.

When, in these days of limited fields of work, a
man feels it incumbent upon him to write upon the
examination of an organ to which he has not devoted
a lifetime of study, some apology is necessary.

During the course of his esophageal work, from
time to time, the writer has looked into the stomach.
He has found that an elongated model of hisesophag-
oscope makes a very satisfactory gastroscope. The
results obtained have been so brilliant that he feels
it his duty to call the attention of those interested
in the stomach to the feasibility of gastroscopy.
The cases herewith reported were not examined
with test meals and the other aids of the gastro-
enterologist, as every opportunity was immediately
taken advantage of to test the possibilities of gastros-
copy. Delay to get complete chemical and clinical
data would have resulted in missing some examina-
tions. It is not intended to compare the results of
gastroscopy with those of other diagnostic and
therapeutic aids. I am utterly incompetent by lack
of training and inclination to examine a stomach
case in any other way than gastroscopically, and it
has been my purpose only to demonstrate the feasi-
bility of this way and to call the attention of the
gastroenterologist to it. It remains for him to de-
cide whether he needs to see the organ he is treat-
ing.

The writer's training and instincts are rhino-
laryngological, so that it is natural to look upon
every disease from an anatomical viewpoint, and
to feel that to treat any organ without seeing it is
but groping in the dark. Yet reflection enables him
to realize that the internist and the gastroenterologist
of to-dav wish to know the perversion of physiologi-
cal function, as well as the anatomical basis of dis-
ease. A simple gastroscope that can be used in
practicallv ever\' case where needed, is offered
modestly as an addition to the armamentarium of
the physician and surgeon. The views are so clear
and satisfactory that the writer believes that the
end of the next decade will see the internist and the
gastroenterologist passing the gastroscope as fre-
quently as the g^'necologist of to-day passes the
cystoscope. The gastroenterologist will not see all
of the ventricular mucosa, any more than the rhinol-
ogist sees all of the nasal mucosa.

History. — When I first obtained good endoscopic
views of the stomach I thought it had never been
attempted before. But a search of the literature
brought to light several previous attempts.

The first recorded attempt to construct a gastro-
scope was by Mr. Leiter and Dr. Nitze, whose names

*Read by invitation before the New York Academy of
Medicine, Section on Laryngology, January 23, 1907

are inseparably connected with the cystoscope. Both
before and after this time attempts to construct
flexible and jointed instruments containing optical
apparatus had failed in the mechanical stage.

Trouve, in 1873, perfected a polyscope, with which
Collin of France demonstrated endoscopically the
functions of the stomach of a bull, and with which
Ledentu and Raynaud diagnosticated a cicatricial
stricture of tlie esophagus near the cardia.

Mikulicz in 1881 started on the basis that a
gastroscope must be rigid, but after repeated trials
lie came to the conclusion that a straight, rigid in-
strument could not be passed into the stomach on
account of the physiological curve of the vertebral
column, to accommodate his instrument to which he
gave the instrument an angle of 150° at the junc-
tion of the ventral and middle thirds. This angle
prevented a rotation of more than 180° within the
stomach, so that two complete instruments were
necessary with windows opening in opposite direc-
tions. To touch the gastric walls meant to fog the
window and dim the image.

Mikulicz arrived at the conclusion that a straight
instrument was absolutely impracticable ; that it
could be passed as far as the cardia, which he be-
lieved to be located at the eighth or ninth vertebra,
where it encountered an insurpassable obstruction
in the subjacent vertebra. His straight experimental
staff never really reached the cardia at all. What
he encountered was the constriction, anatomic and
spasmodic, at tlie hiatus diaphragmatis and the sub-
jacent esophageal curve.

Mikulicz' examinations were mostly on healthy
persons, as he thought the normal was to be studied
first, and he seemed to doubt the safety of examin-
ing the stomach in serious disease of this organ.
With one exception he did not record the appear-
ance of any lesion within the stomach, and his de-
scription of the normal is very meager and un-
illustrated.

After 18S3 no account of the use of gastros-
copy appears in literature for twelve years, and the
procedure was evidently abandoned by its originator.

Rosenheim, in 1896, reported experiments with
a gastroscope 12 mm. in diameter, 68 cm. in length.
It was made up of three concentric tubes, the inner
being a terrestrial telescope of 60°, with the addi-
tion of a prism below the objective, a different prism
to be substituted to inspect different areas, the optic
tube being withdrawn for the purpose.

External to the optic tube is the intermediate or
illuminating tube in the walls of which four canals
run ; two for water circulation to cool the lamp
(water at 40° C. to prevent condensation on the
glass surfaces being required) ; a third canal for
conducting wires ; and a fourth canal for the pur-
pose of inflating the stomach with air.

In addition to the straight gastroscope, Rosen-
heim states that in some cases the spiral twist of the
lower esophagus required an instrument bent at an
angle of 160° at a point 7 cm. from its distal ex-
tremitv. He also used a straight rigid staff of the

550

MEDICAL RECORD.

[April 6, 1907

size of the gastroscope to ascertain if it were pos-
sible to pass his gastroscope in the particular case,
and if passable to measure the distance that the gas-
troscope will have to be introduced. He also used a
straight sound to overcome the refle.x e.xcitability in
difficult cases. This straight sound could be intro-
duced in only about 70 per cent, of his cases. He
found that various bends and curves
were necessary, and in some instances
he used a corkscrew-like twist, throw-
ing the longitudinal axes of parts of
the instrument above and below the
bend out of the same plane. A very
significant fact is that after the beak
of the instrument entered the stomach the straight
part followed readily. His whole trouble in intro-
duction was that his instrument was not designed
to be passed by sight. He used cocaine anesthesia,
applied with an esophageal syringe.

.•\s to results, Rosenheim states that gastroscopy
is impossible in tumor of the stomach, and that it
is contraindicated in ulcer.

Rewidzof in 1899 reported results with a modi-
fied Rosenheim gastroscope which he passed through
a previously introduced flexible rubber
tube.

None of these early workers has left
us any drawing of what he saw, and the
written descriptions are hopelessly
meager. The procedure has been en-
tirely abandoned. The cause for the
failure and abandonment of gastros-
copy may be summed up in two words :
Impractical instruments.

At the door of the Nitze cystoscope
must be laid the blame of the practical
failure of gastroscopy up until the pres-
ent day. The attempt to adapt the
cystoscopic principles to the totally dif-
ferent conditions in the stomach re-
sulted in the misdirection of the earnest,
able, scientific efforts of Mikulicz,
Rosenheim, and Rewidzof. The instru-
ments were difficult of introduction.
The optic apparatus absorbed light and
yielded a feeble image, which soon dis-
appeared altogether from soiling of the
window every time it touched the mu-
cosa. For the same reason the appa-
ratus could not be greased for intro-
duction. The optic apparatus, furthermore, pre-
vented the passage of the instruments by sight, it
prevented the wiping away of secretions and the
probing of suspected areas, without which little or
nothing can be learned. The stomach had to be
empty, which it never is. All failed to recognize
the mistake of trying to see a large field in a dilated
stomach. The field must be traversed in the col-
lapsed state of the stomach, fold by fold. These
things are not said in criticism, for, while the work
of these pioneers was of no help to me, as mine
was done before I learned of their labors, yet they
have rendered great aid in determining that cysto-
scopic methods are not adapted to gastroscopic work.
This would certainly have been tried by others, and
much time and thought consumed by some one.
Mikulicz himself recognized the complexity of his
apparatus. He said : "There remains no doubt but
that tlie instruments, as well as the method, furnish
ample room for improvement and simplification.''
The simplification I think has now been reached,
though of course there is still ample room for im-
provement.

The steps in the development of gastroscopy are

these :

Mikulicz determined one p<Dint, namely, that a
gastroscope must be rigid, but he gave it a bend.
Rosenheim went a step farther, and said it must
not only be rigid, but should be straight, though he
failed at times to introduce it without a bend. Now,
I think, we are readv to add four more dicta:

Fig. I. — The author's gastroscope.

1. (Jptic apparatus must be abandoned.

2. The tube must be passed by sig'ht.

3. The stomach must be examined in a collapsed
state, to permit of mopping, palpation with the in-
strument, probing, and combined endoscopy and
external palpation.

4. General anesthesia is indispensable to prevent
retching, during which the diaphragin clamps the
tube, rendering exploration impossible.

In a recent article"' '- I described my ga.stroscope

Fig

Positions of assistants.

nurses, operator and patient during the introduction
of the gastroscope.

and gave the technique of its use, together with a
report of six cases in which I had obtained positive
results from gastroscopy. I described the normal
gastroscopic appearances.

The stomach is examined in the collapsed state,
that is, after a twelve-hour fast. Fig. 3 gives a fair
conception of one of the thousands of forms in
which the stomach folds present themselves before
the end of the gastroscope during the examination.
There is one point upon which I did not lay suffi-
cient stress, and that is the importance of proper
gagging.

I have had more trouble in getting an assistant
who can manage the gag and the patient's head than
in any other part of the technique. The mouth
must be gagged to the extreme limit : it must be held
so, and the gag must never be allowed to slip. If it
does, the tube will be damaged and its introduction
interfered w-ith.

The second assistant kneels or sits (Fig. 2) with
the right arm around the patient's neck, his right
hand holding the gag. which is tightened if the jaws
separate wider, and his left hand controls the pa-
tient's head. He vields the head to the slightest

April 6, 1907]

MEDICAL RECORD.

551

^"■^ %•

Fig. 3. — Gastro-
scopic view. Nor-
mal stomach. Col-
lapsed state. Case
VII.

movement of the tube by the operator. The shoul-
ders of the patient are at the edge of the table, and
the head and neck are suspended in the air under
the control of the second assistant with the gag.

The gag should always be inserted in the left side
of the patient's mouth, not farther back than the
canine teeth. For this I have found the Ferguson
gag best, as it has sufficient spread to
be used on the lateral incisors. If
placed farther back, any gag is apt
to slip ; yet many gags have not
spread enough to be used forward.

Dangers. — In my former paper I
discussed the possibility of harm
from gastroscopy. but a few words
may here be added on the subject.
In careful hands there are no dangers
other than those of ether anesthesia.
In general, it may be stated that the stomach is a
ver)- much less sensitive organ than the esophagus ;
not only less sensitive in the strict meaning of sen-
sation, but in the matter of efferent impulses for the
production of reflexes, and of congestion and in-
flammatory reactions to local irritations.

As the real question of importance is as to shock
incident to tlie passing of a rigid instrument through
the entire length of the esophagus (which, a priori,
would seem the only question of importance, as the
stomach is quite insensitive), a number of sphyg-
momanometric observations upon my cases were
made. The following is an analysis by Dr. John W.
Boyce of the charts made by himself, Dr. Helen F.
Upham, and Dr. Joseph H. Barach :
"A notable fall of blood pressure
has been noted in some instances of
operative interferences with the
esophagus, and observations have
been made with some care to ascer-
tain if there is anything analogous
during the passage of the gastro-
scope.

"The charts in the Margaret S.
and Sarah McG. cases show absolutely no change
that can be attributed to this manipulation of the
esophagus. In the case of Henry H. a very slight
(10 mm.) fall occurred while the tube was passing
down the esophagus. This may have been acci-
dental. Tlie chart shows a slow rise to the original
level while the tube was iti situ and the inspection
being made.

"In a fourth case, that of Henry A., however,
the pressure fell steadily from the time the tube was
inserted, and rose again when it was withdrawn, and
fell a second time while the tube was in the stomach,
and the mass being manipulated to bring it within
the field of vision. Each time the fall aggregated
40 mm. or more, carrying the pressure down from
between 120 and 130 (w^hich seemed to be the normal
for this case while under anesthesia)
to below 90. Gastroscopy is apt to
lie done under very shallow anesthe-
sia, and the pressure cur\-e is partic-
ularly likely to be distorted by acci-
dental circumstances, but in the four
cases observed the readings were
Fig..;.— Pylorus fairly uniform, and it seemed safe to
Case IX, gj^y ^j^^j ^hej-e is ordinarily no appre-

ciable disturbance of the circulation, but that in an
occasional case the characteristic esophageal fall
will occur from the passage of a rigid instrument
of this length. In these cases, however, the pressure
does not remain at the low point, but starts to rise
at once, and reaches the original level while gastro-
scopic search is in progress."

IJ

F1G.4.-

Case IX.

-Pylorus

Gastroscopy certainly is not as dangerous as pass-
ing a sound or tube, for all diseased spots are seen
and pressure upon them avoided. Thus, in malig-
nant disease of the cervical esophagus, the natural
constriction at the introitus is increased, and care-
lessness might force a stomach tube through, but •
with the rigid gastroscope passed by sight the

growth at once is discovered. As I

have stated, I start the tube with my
finger, and rely upon a previou
laryngoscopic examination to exckuk-
disease of the introitus, and in two
suspicious cases I found disease of
tlie upper esophagus witli the laryn- fig.o-— uiccro;
geal speculum. Dysphagia with re- ^tomacii. Case x
gurgitation is usual in disease of the
upper esophagus ; so that in dysphagia with regurgi-
tation we may safely conclude that the disease is far
enough within the esophagus to allow the tube to be
started by the sense of touch without reaching the
diseased tissue.

^Mikulicz doubted the safety of examining cases
of suspected malignancy, and doubtless he was cor-
rect, with his instrument with its bend which had to
be swung with necessarily im{>erfect control, and,
most important of all, without seeing what the end
was doing. With a perfectly controllable straight
instrument unobscured and unweighted with a tele-
scopic optic apparatus, the touch is gentle, certain,
and under full control.

Suspicious spots can be seen and pressure upon
them avoided. Disease of the abdominal esophagus,
which makes a more or less sharp
turn ( relative to the advancing
tube), would be particularly danger-
ous with an instrument passed blindly.
-As to the danger of taking a speci-
men, I have done so in two cases
without any ill result. They were
both cases associated with fungation.
I do not believe this to be fraught
with any danger, because in the five
malignant cases that I have examined there was no
hemorrhage from contact of the tube or from wiping
with the little gauze sponges. Yet, because a single
accident might prevent or delay the adoption of
what promises to be so useful a procedure, I should
hesitate to remove a specimen from the edge of any
flat ulceration, as there might be some risk of per-
foration.

The foregoing statement of dangers is based upon
the utmost gentleness of manipulation under the re-
laxation of deep anesthesia : the passage of the gas-
troscope by sight ; the withdrawal of it within the
esophagus, should retching supervene, and upon
the strict observance of all the minor details alreadv
alluded to.

I herewith report eight additional cases in which
positive results have been obtained.
C.-\SE VH. — Stomach lesion nega-
tived by gastroscopy; Cardiospasm.
Miss Sarah McG., age 19, sent to me
by Dr. Ewing W. Day. Patient com-
plained of difficulty in "'getting
things down," often requiring a pint
of water to wash down a small mor-
sel of food. Occasional nausea and
vomiting, also regurgitation. Lost twenty pounds
in weight.

Assi.-ted by Dr. Ellen J. Patter.son, witii Dr.
Helen F. Upham admini,stering the ether, and witli
Dr. Joseph H. Barach at the sphyginomanometer,
I passed the gastroscope. The patient being fully
relaxed, the gastroscope slid readily down into the

Fig.
spasm.

7. — Cardo
Case XI.

Fig. S.— Ulcer of
stomach. Case XI.

552

MEDICAL RECORD.

[April 6, 1907

L m

stomach without resistance. The esophagus was
perfectly normal. The gastric mucosa was of the
most beautiful delicate pink color. Fold after- fold
was explored (Fig. 3) but nothing abnormal was
found. Here and there a fold was drained of its
fluid, which, to the naked eye, seemed normal in
consistency and of a pale olive color as it ran from
the tube.

The tube was withdrawn to the
bifurcation level, and reinserted as
the patient began to come out of the
anesthesia. The cardia opened and
closed spasmodically.

We had here an anatomically nor-
FiG. 9— Scar, mal esophagus and stomach, and an
Luetic. Case XI. ggophageal neurosis. The case was
referred to Dr. J. A. Lichty, who reported, after
tests, a functionally normal stomach. Under his
skilful care the neuropathic basis was so far bene-
fited that the symptoms entirely disappeared.

Case YIII.— Gastric Syphilis. Michael V., age
28, admitted to the Western Pennsylvania Hospital
in the service of Dr. John W. Boyce. History of
syphilis and of alcoholism. Complained of epigas-
tric pain, worse after eating, anorexia and constipa-
tion of one or two months' duration. Vomited three
times during preceding week, the vomitus containing
"coffee grounds" flakes. A small mass was palpable
in the epigastric region.

With the assistance of Dr. Ellen J. Patterson,
Dr. J. J. Schoenig. and Dr. R. A. Brundage_, I
passed the gastroscope with some difficulty, owing
to a defective mouth gag and an incomplete anesthe-
sia. When the tube entered the
stomach a bleeding granular mass
was found somewhere near the car-
dia. Owing to continued bleeding
and to defective aspirating and swab-
bing apparatus at that time at hand,
1 was unable to locate the mass or to
o-et a satisfactory view of it. The

" , ' J J J 1. i cinoma near py-

mucosa seemed reddened, but even lonis. CaseXiii.
of this I could not be certain. While
the bleeding was enough with my then imperfect
apparatus to obscure the view, it was of no moment,
the amount of blood being not over a few drams.
Dr. Boyce made a diagnosis of gastric syphilis and
put the patient upon specific treatment, under whicli
he made an entire and complete recovery, the mass
disappearing entirely.

Case IX. — Gastroptosis, neurasthenia, esophagis-
mus ("globus hystericus") : Inspection of the nor-
mal pylorus. Margaret S., age 33, was brought by
Dr. A. A. Dranga to me for esophagoscopy and gas-
troscopy on account of difficulty in swallowing, dis-
tress after eating. Patient was able to take food in
very small morsels, finely masticated.
The patient was a neurasthenic, and
feared cancer, of which her mother
had died.

Dr. Dranga anesthetized the pa-
tient with chloroform, and with the
assistance of Drs. Patterson, Upham,
Fig. II.— Near and L. L. Schwartz, with Dr. Boyce
pylorus, inffltra- ^t: the Sphygmomanometer, I passed

tion (to left). Case ., i ■ i \ • *„ tU

XIII. the gastroscope, which went into the

stomach without meeting the slight-
est obstruction. The esophagus was absolutely nor-
mal.

The gastric mucosa was very pale, of the most
delicate pink tint, and of the smoothest appearance.
Considerable quantities of chloroform vapor were
forced out into my eye by the respiratory movements
of the stomach, so that' a good deal of chloroform

Fig.

-Car-

cinoma of pylorus
Left edge ot tumor.

Fig.

-Car-

must have been present in the stomach, either from
swallowing or by elimination, yet the gastric mucosa
retained its pale tint.

The gastroscope passed on down until the distal
end was 71 cm. from the upper teeth. At this dis-
tance the pylorus was reached. The pylorus was
for a moment funnel-shaped, with a rounded cen-
tral opening surrounded by folds par-
allel with the axis of the tube. The
depths beyond could not be seen at
first. Gradually, by a movement
which was so slow, and so blended
with the respiratory movement that
it seemed a part thereof, the rounded
opening changed to a slit (Fig. 4).
This slit gradually became wider in
the center, ■ formed an oval, beyond
which the duodenal folds were visible, then became
surrounded by a rosette of folds at right angles to
the axis of the tube. Suddenly the duodenal folds
rolled in tovrard the tube (Fig. 5) and a small quan-
tity of dark-looking fluid was exuded. The patient
was now partially out of anesthesia and began to
vomit, and the gastroscope was withdrawn within
the esophagus. After deep anesthesia was agairi
produced, and the pylorus was approached, it was
found hidden behind a series of folds at right angles
to the tube.

There were now only respiratory movements, pos-
sibly because of the depth of the anesthesia. A half-
hour longer, making a total of about an hour, was
consumed in exploring fold after fold of the stom-
ach. Because of the gastroptosis, this stomach
could be explored over almost its
entire mucosal surface.

Drs. Dranga, Patterson, Boyce,
and Schwartz each examined the
stomach for a few moments, and
commented on the clear views ob-
tained. After the patient began to
regain consciousness the gastroscope
w^as again introduced as far as the
cardia, but was interfered witli and
clasped by the spasmodic contrac-
tions of the esophagus at every level.
Remarks. — Tliis is the second case in which I suc-
ceeded in seeing the pylorus, and it was utterly
unlike the first, which was seen only for a few mc^-
ments, and was surrounded by annular mucosal
folds. It will require, probably, hundreds of ob-
servations to determine what is the average appear-
ance of the pylorus. The vertical position of the
stomach greatly facilitated examination, which was
so thoroughly made that I felt justified in assuring
the patient that she had no disease of the stomach,
and that the spasm of the esophagus was the cause
of her symptoms. Practically all of the interior cf
the stomach was explored. Under
Dr. Dranga "s skilful care these s>Tnp-
toms are rapidly subsiding.

Sphygmomanometiic charts of the
four foregoing cases, and also of
Case XIV., are analyzed under "Dan-
gers."

Case X. — Gastric ulcer in a pa-
tient complaining of a foreign body.
Mrs. Matirt O., age 26, sent by Dr.
M. H. Moss of Homestead. Patient complained of
pain on swallowing, later becoming constant, and
attributed to a chicken bone swallowed four days
previously. A radiograph by Dr. R. H. Boggs
negatived a foreign body, but the patient insisted
there was something there, pointing to the epigas-
trium. Gastroscopy^ assisted by Drs. Geraent Jones,

Fig. 13. — Car-
cinoma of pylorus.
Infiltration under
normal but un-
'.vrinWled mucosa.
Right of picture-
Case XIV.

Fig. 14. — An-
other view of Case
XIV.

April 6, 1907]

MEDICAL RECORD.

553

Ellen J. Patterson, J. M. Hamilton, and M. H. Moss,
Dr. H. F. Upham giving ether. A small ulcer was
found above the cardia and another on the posterior
wall of the stomach (Fig. 6). The ventricular ulcer
was seen by Drs. Jones, Hamilton, and Moss. An
explanation of the foreign body history in this case
was suggested by Dr. Clement Jone.s. namely, that
attention was first called to the epigastric sensations
by the swallowing of a very large bolus of food.
Under Dr. Moss' studious care the patient is stead-
ily improving.

Case XI. — Peptic ulcer of the stomach and esoph-
agus, cicatrix on gastric mucosa, ulcer of abdominal
esophagus, cardiospasm, esophagisinns, chronic gas-
tritis. Referred to me for gastroscopy by Dr. Milton
I. Goldsmith. Henry H., age 59, family history and
personal specific history negative, uses alcohol regu-
larly, formerly e.xcessively. Vomits everything he
eats e.xcept raw eggs, and very small, well-chewed
morsels of dry bread. Retains a small portion of
milk swallowed, most of it being regurgitated.
Duration si.x months. Symptoms attributed by
patient to the drinking of large quantities of ice
water. Under ether administered by Dr. Helen F.
Upham, and with the assistance of Drs. Ellen J.
Patterson and Milton I. Goldsmith, with Dr. Barach
at the sphygmomanometer, I introduced the gastro-
scope. When the hiatus was passed, an ulcer di-
rectly ahead of the tube was noticed on the right
wall of the esophagus. It was oval, surrounded by
an inflammatory areola, though the edges were not
infiltrated.

In endeavoring carefully to pass
the ulcer, it was noticed that as soon
as the tube mouth touched the ulcer
there was an immediate sudden spas-
modic closure of the esophagus just
below, at the cardia (Fig. 7). The
patient had come partially out of
anesthesia. To test the matter the
tube was twice withdrawn above the
ulcer and reintroduced, and each time
the same cardiospasmodic phenomenon occurred.
Upon pushing the ether to deep anesthesia the spasm
disappeared completely and the gastroscope slid
easily into the stomach. An ulcer about i cm. in
diameter was found upon the posterior wall, to the
right, in the region of the greater curvature (Fig.
8). This was plainly seen by Dr. Goldsmith and
Dr. Patterson. The mucosa, deep pink in color,
was covered with thick, tenacious mucus, with
patches of adherent secretion that looked like an
exudate in a number of locations.

Upon the greater curvature with the tube mouth
pressed flatly upon the mucosa, a white, roughly
quadrangular area, surrounded by a slightly pig-
mented ( ?) area of irregular outline (Fig. 9). The
entire area was stiff enough to tilt and shift as one
piece when moved by the tube.

Remarks.- — The spot just referred to I took to be
a scar. The spasmodic closure of the lower end of
the esophagus, when the ulcer was touched, was, in
my opinion, an esophagismiis similar to sphincteric
spasm in anal ulcer, though of course we do see
cardiospasm and esophagismus where no ulceration
exists. Again, it is possible that the ulceration may
have been secondary. The ulcerations 1 deemed
benign, because one had healed, and because they
were multiple, with healthy, intervening mucosa.
The gastroscope decided beyond doubt that the
dysphagia and regurgitation were due to a spas-
modic, not an anatomical stenosis, and that there
were precancerous conditions warranting gastro-
enterostomv. This is a case of the kind in which

Fig. 15. — -An-
other view of Case
XIV.

the gastroscope can save the patient's life by furnish-
ing an exact knowledge of the lesions present, thus
giving the physician, or perhaps still more the sur-
geon, a chance to cure ere it is too late. These
remarks must be qualified by the reservation that I
have no knowledge of gastric medicine or surgery.

Attention should be called to the danger in this
case of passing a tube blindly, and not by sight.
The normal curve to the left of the abdominal
esophagus presented the ulcer precisely where the
point of the tube would strike it, the danger being
increased by the spasm below and the absence of
anesthesia. Under anesthesia, and by guiding the
tube past the ulcer, with tlie aid of sight, rendered
the procedure safe. Sphygmomanometric readings
taken by Dr. Joseph H. Barach in this case are
analyzed under "Dangers."

C.\SE XII. — Carcinoma of the cardia diagnosti-
cated gastroscopically. Referred by Dr. J. M. Jack-
son. Mrs. A. L., age 60. Family history negative.
Three weeks before had noticed, for the first, pain
back of sternum on swallowing, gradually increas-
ing, and associated for two weeks with increasing
difficulty in getting food down. Now only liquids
can be swallowed. Some vomiting complained of,
which may really have been regurgitation. It con-
tained no blood, fresh or old. Had been under the
care of a noted physician, who had cured the trouble
completely, but it had recurred. Patient claimed she
had lost no weight. Ether being administered by
Dr. J. M. Jackson, with the assistance of Dr. Pat-
terson and Dr. Boyce, I passed the gastroscope. The
entire cardia was found filled with a fungating cauli-
flower-like growth, which extended up the esoph-
agus to a point 42 cm. from the upper teeth. A
slight infiltration, with narrowing, was present in
the esophageal wall just above this at 38 cm., but it
was not ulcerated. The fungating portion was seen
plainly through the gastroscope by Drs. J. M. Jack-
son, Patterson, and Boyce. A large specimen was
removed from near the cardia. No bleeding fol-
lowed. The specimen was reported by Dr. Joseph
H. Barach as squamous-celled epithelioma.

Remarks. — This case is interesting for the follow-
ing points : The history- of only three weeks' dura-
tion ; the history of apparent cure ; a large extent of
disease with a history of no emaciation ; the absence
of signs of blood in the vomitus.

Of course, I am aware that these points would
not necessarily have misled a careful diagnostician ;'
yet they were certainly unusual. The absence of
hemorrhage after the taking of so large a specimen
is worthy of note.

Case XIII. — Carcinoma of the pylorus, with ec-
tasia, diagnosticated gastroscopically. Gastrosco-
pized at the request of Dr. E. S. Montgomery, who
gave me the following notes of the case, from which
matters irrelevant to the stomach are omitted : "Mrs.
W. E. D., age 26. Complained of sharp pains
through back and right side, at first intermittent,
later constant. Also had deep-seated pain and ten-
derness one inch to the right of the median line and
one and one-half inches below costal region. X
small mass could be felt at this point. Family his-
tory negative."

At the Passavant Hospital, Dr. I\Iontgomer\- an-
chored the right kidney and asked me to pass the
gastroscope during the same anesthesia prior to his
operation. With the assistance of Dr. Patterson. I
explored gastroscopically. Dr. E. S. Montgomery
looking through the tube from time to time.

The gastric mucosa was iiale. of whitish pink
color. Upon approaching the pylorus there sud-
denly came into view a dark, purplish, nodular sur-

554

MEDICAL RECORD.

[April 6, 1907

face (Fig. 10). Beyond this mass the mucosa was
of normal color, but under it hartl infiltration could
be felt (Fig. 11) on the left. The pyloric opening
appeared somewhat triangular behind folds, one of
which (Fig. II, slightly to right of center) had a
dark slit parallel witli the ridge (vertical curve).
Whether this was an ulcer or not I could not be cer-
tain. It was not infiltrated, and I could not turn the
fold to look into the depth of the slit. Through the
triangular pyloric opening poured about two ounces
of cloudy, whey-like fluid, in which floated thickly,
dark-brownish flakes about the size and color of
coffee grounds.

The pylorus in this case was reached at 72 cm.,
but this was not its usual location. The whole
pyloric end was quite movable, and was displaced
downward into the right iliac fossa (as indicated by
paralleling the tube externally with its obturator).
The greater curvature was encountered when the
tube reached 60 cm. The examination was not pro-
longed, because of the operation to follow.

Two specimens taken were reported upon nega-
tively. Notwithstanding this, and also the age (26)
of the patient, I pronounced the growth malignant
on the strength of the gastroscopic findings alone.

Case XIV. — Carcinoma of the pylorus, diagnosti-
cated gastroscopically. Referred to me for gastros-
copy by Dr. L. S. Walton, who has given me the
relevant portion of his history as follows: "Henry
A., age 46; family history unknown; personal his-
tory negative; moderate drinker. Catarrhal jaun-
dice twelve years ago; asthma for past si.x years."
Three months ago first noticed mass in umbilical
region, coincident with development of acid eructa-
tions, occasional sharp pains in upper abdomen, nau-
sea, and vomiting. These symptoins gradually in-
creased in severity, the vomiting occurring daily,
usually about an hour after eating, the vomitus
being occasionally of a brown color. Mass increased
in size. Slight loss of weight and strength. Appe-
tite remained good for meats and all his accustomed
foods. Mass roughly measuring 3 inches in width
by about 4 inches in height in right epigastric and
umbilical regions. Percussion flatly tympanitic
over mass, which is movable, and is depressed three-
quarters of an inch on deep inspiration. No indica-
tions of cachexia.

At the Eye and Ear Hospital ether was given by
Dr. Walton, and a gastroscopic examination was
made by Dr. Clement Jones and myself. Sphygmo-
manometric readings by Dr. Barach. After explor-
ing the anterior and posterior walls and greater
curvature as far toward the pylorus as possible.
Dr. Jones, with his ri,ght hand, grasped the stomach
end of the gastroscope through the abdominal wall,
while with his left hand he moved the tumor mass
over in front of the tube.

Observing through the gastroscope. I saw a por-
tion of the tumor surface of dark red color, spotted
with brownish discolorations (Fig. 12). In one
portion the nonnal, but un wrinkled mucosa, under-
laid with a hard mass I Fig. 13} showed part of the
tumor to be outside of the stomach wall. It seemed
to occupy about two-thirds of the periphery of the
pyloric third, extending over at one point to the
middle third. Fig. 14 shows one point at which a
zone of dilated capillaries was visible, and Fig. 15
an overhanging, dark, mulberry-like fungating
nodule. There was not the slightest hemorrhage.

Owing to unavoidable circumstances, this patient
was gastroscopized three hours after eating stew^ed
chicken and drinlcing a glass of whisKey. A large
portion of this food was in the stomach. Several
pieces of the chicken tissues were removed w^th

forceps. Some of these were as large as a peanut
kernel. These were in the left third of the stomach.
When the pyloric third was approached the fluid
contents poured out in a steady stream, over a pint
in total quantity.

What influence the posture and the anesthetic had
on this distribution I do not know. This case was
afterward skilfully operated upon by Dr. James
McClelland, who found the location and character
of the growth exactly as demonstrated by the gastro-
scope.

Conclusions. — i. History. The attempts made
in the past to examine the stomach gastroscopically
were abandoned because no practical instrument was
devised.

2. Usefulness. Gastroscopy is not simply a feat.
It has a field of usefulness that will increase as our
skill and knowledge increases. Gastroscopy, in my
opinion, is useful for the detection and removal of
foreign bodies, the diagnosis of many pathological
conditions, as inflarmnation, ulceration, scars, neo-
plasms, dilated vessels, and the treatment of at least
one of these conditions, namely, benign ulcer. When
the gastroscope shall have gained its deserved recog-
nition, malignant disease of the stomach will be
diagnosticated in many instances sufficiently early to
give the abdominal surgeon a fair chance. Better
still, a positive diagnosis of precancerous conditions
will be made sufficiently early to enable him to save
lives that are now being lost through reluctance of
the patient to submit to an exploratory celiotomy.
Gastroscopy is not offered as a substitute for an ex-
ploratory operation in everv- instance, but only in
those cases in which the patient declines to submit,
or in which the surgeon or the physician considers
a simple procedure almost free from risk preferable
to operative exploration.

Gastroscopy is the only method known to-day that
yields ocular information as to the condition of the
gastric mucosa. Other methods give information
only by inference from the disturbance of function.
Thus gastroscopy becomes an auxiliary.

3. Results. — With the gastroscope I have made a
diagnosis of chronic gastritis in two cases ; gastrop-
tosis in two cases ; malignant disease of the cardia
in two cases, and of the pylorus in tliree cases; in
two of these cases a specimen was taken. I have
made diagnosis of peptic ulcer in five cases, one of
which was cured by direct applications. In one case
negative results of value were obtained. I have
removed one foreign body from the stomach, being
a forceps jaw lost therein by myself. In one case
the gastroscopic findings enabled a diagnosis of gas-
tric syphilis.

4. Limitations. Negative results from gastros-
copy are of limited value, because we cannot be
certain that no lesion exists in the unexplorable area.
But with greater perfection and skill this unexplor-
able area will be very much diminished.

5. Anesthesia by ether is preferable. Chloroform
is unsafe alone, though it may be added as needed
for relaxation. Cocaine, though an adequate anal-
gesic, does not stop the retching which will interrupt
so constantly.

6. The e.vplorable area, wuth a stomach of the
classic shape and position is the middle third. More
than a third of the greater curvature is readily seen.
likewise of the anterior and posterior w-alls at their
inferior portions, the lateral extent of the field di-
minishing upward toward the esophageal orifice.
The fundus and the pyloric ends can be brought
within range of the gastroscope by the external as-
sistance of an expert abdominal manipulator, the
tube being withdrawn w-ithin tlie esophagus until

April 6, 1907]

MEDICAL RECORD.

555

the new field is in place. In vertical and gastrop-
totic stomachs, the lesser curvature and the pyloric
third are reatlily explored with little or no external
manipulation, and in some instances the pylorus can
be seen.

8. Dangers. — In a patient with a normal esopha-
gus and stomach, the only danger is that of ether
anesthesia. An ulcer of the esophagus or stomach
constitutes an exceedingly slight risk, unless the
ulcer bed be so thin that it w-ould perforate within a
few days by erosion or by the normal spontaneous
movements of the stomach. In chronic inflam-
matory states of the stomach no risks are incurred.
In malignant disease a specimen may be taken with
little risk in fungating conditions, but in flat ulcera-
tions suspected of malignancy, the biting out of the
edge of the ulcer, though very easy of accomplish-
ment, is unjustifiable. The danger of hemorrhage
in gastroscopy is nil in the normal stomach ; in the
diseased stomach it exists only in cases which are
about to bleed, anyway, and none such were en-
countered in this series. There was no bleeding fol-
lowing the taking of a specimen in two instances.

The foregoing statement of dangers is based upon
gentle manipulations, and the observance of certain
rules, the most important of which is the immediate
withdrawal of the gastroscope within the esophagus
should retching super\'ene, waiting for the readvent
of deep anesthesia before again pushing the tube
downward.

9. Anv physician can learn to examine the stom-
ach with the gastroscope.

10. As to the future of gastroscopy : Will even.'
physician have a gastroscope? No. No more than
every physician has an ophthalmoscope.

BIBLIOGRAPHY.

1. Mikulicz : Ueber Gastroskopie und Oesophagoskopie.
Wiener med. Presse, 1881, XXII, No. 45.

2. Mikulicz: Centralblatt f. Chirurgie, No. 43, October
29, 1881.

3. Mikulicz: Wiener klin. IVochenschriff, 1183, Vol.
33, Nos. 23-24.

4. Rosenheim : Ueber die Besichtigung der Cardia nebst
Bemerkungen iiber Gastroskopie, Deutsche med. Woch.,

1895, No. 45 ; Rosenheim, Gastroskopie, Berl. klin. Woch.,

1896, No. 13 to 15.

5. Oser: Ueber Gastroskopie, Wein. Med. Bl., 1881,
Vol. 4, p. 1598.

6. Rewidzof, P. : Noch Einige Worte iiber mein Gumme-
Gastroskope, Achiv f. Verdatiungskr., Berlin, 1899, Vol.
5. p. 484.

7. Zur Teknik der Gastroskopie (Modification des
Rosenheim's chen Gastroskope), Cong. International Med.,
p. 214; Cong. Mosc, 1899, III, Section 5. p. 214.

8. Baratoux, J. : De I'Oesophagoscopie et de la Gastro-
scope. Revue mens, de laryngol, etc., Paris, 1882, Vol. 2,
p. 107.

9. Kelling, G. : Endoscopy of the Esophagus and Stom-
ach, Lancet. April 28. igoo.

10. Leading Article, Esophagoscopy and Gnstroscopv,
Medical Times. May 5, 1883.

11. Chevalier Jackson: Annals of Otology. Rhinology
and Laryngology (Frankel Festschrift), December, 1906.

12. Chevalier Jackson: Archives Internationales de
Laryngologie. Rhinologie et Otologic. January-February,
1907.

Sterilization of Catgut.— Stich speaks highly of cat-
gut prepared according to the following method. The
catgut is wound on glass plates and is then iinmersed
for a quarter to one-half hour in the dark in a I per
cent, alcoholic ammoniacal solution of silver nitrate, is
then washed in alcohol, and is exposed to the sunlight
in a sterile container. The silver salt which has pene-
trated to the interior of the strand of catgut is decom-
posed by the light, and the material may then be pre-
served for use in a mixture of absolute alcohol and 10
per cent, of glycerin. Tests showed that catgut pre-
pared in this way was perfectly sterile and was stronger
then the raw material. — Zentralblatt fiir Chirurgie.

HARMFUL INVOLUTION OF THE APPEN-
DIX.*

By ROBERT T. MORRIS. iM.D.,

NEW YORK.

PROFESSOR OF SCRCERY l.N THE NEW YORK POST-I'.RADUATE MEDICAL
SCHOOL AND HOSPITAL.

My effort to catch this stibject in the screw thread
of professional interest two years ago did not suc-
ceed, because of the title of the published article,
"Normal Involution of the Appendix." No one
seems to be much interested in anything normal
associated with the appendix.

Senn and Ribbert first called attention to the fact
that the appendix vermiformis normally undergoes
an involution process, with replacement of the lym-
phoid, mucous, and submucous coats by connectivs
tissues. They attached no clinical significance to a
condition which sends many thousands of patients
to the doctor every year. A study of the subject
brought out the fact that nerve filaments persist
longer than other structures in a disappearing ap-
pendix. Contraction of the hyperplastic connective
tissue irritates these nerve filaments in the appendix

!

1 s

■i '.
( ■■ ■

ll

■' ■ 1

'

w^.

Fig

-Symmetrical Involution -

just as it does in any sort of scar tissue elsewhere
in the body. The observation pressed a button that
suddenly turned on the light in a dark part of the
abdomen.

Irritation of persisting nerve filaments in the in-
voluting appendi.x gives us a cleanly diagnosticable
class of cases that go the rounds of the profession
with intestinal dvsoepsia. Very often these patients
go from physician to physician, without having the
part of Hamlet observed in the play. In other
cases the appendix takes the form of a question
mark, and the patient goes from surgeon to surgeon.
Like Marguerite with the petals the question runs :
"He will operate ; he will not operate ; he will oper-
ate ; he will not operate."

Whether the appendix is eventually removed 01
not will depend upon the personality of the last
speaker in the case. Patients do not go to bed
with their involuting appendices. The process is an
irritative one, and is not an infective one. Further
than that the involution process seems actually to
guard patients against infective processes in the ap-
pendi.x, although these patients are quite as apt
as any others to ask to have the appendix looked
after. Many a surgeon has operated in these cases,

*A paper read before the meeting of the Southern Sur-
gical and Gynecological .Association, December 13, 1906.

556

MEDICAL RECORD.

April 6, 1907

and has removed \\iiat he feared was a normal ap-
pendix. It went into the waste basket instead of
to the patholos;ist. The surgeon regretted that he
had made a mistake in diagnosis, but the patient
gained forty pounds in weight, and paid his bill.
That does not satisfy a conscientious surgeon, but
it sets him at thinking. The pathologist can give
him an object lesson. He can show that the inner
coats of the appendix are undergoing replacement

Fig. 2. — Xodular involution.

by connective tissue ; that nerve filaments persist
abundantly, and that the nerve filaments are sui-
rounded by such groups of new cells that the irri-
tation feature stands out in colors upon the map.

Normal involution of the appendix may begin in
the early years of life, but most of the patients
whom we see with this condition are past twenty-
five years of age.

Connective tissue replacement of the appendix
may, and usuallv does, progress evenly from the
distal extremitv.

Fig. I shows an appendix from which all normal
structures, excepting peritoneum, nerve filaments,
and capillaries, had disappeared. The lumen wa~;
obliterated whollv in this case. The patient had
suffered from "intestinal dvspepsia" for about ten
years. She was immediately cured on removal of
the appendix.

Fig. 2 shows an appendix of a rather rare type.
in which involution was progressing in the form
of nodes. The bulging parts in the cut represent
internodes of mucosa and lymphoid tissue, while
the constricted parts represent nodes of connective
tissue replacement of such structures. No lumen
was left patent at the nodes. This patient had suf-
fered for some vears with intestinal dyspepsia, and
with rather more than ordinary discomfort in the
appendix region. He was cured at once by removal
of the appendix.

In most of the cases we find the proximal portion
of the appendix still patent and carrving a thin lavcr
of mucosa, with involution changes most marked
toward the distal extremitv.

Fig. 3 shows a cross section of the appendix of
■ Fig. I. The circular line of cleavage between former
tissue planes differentiates the appendix that is
undergoing an involution process from the scarred
appendix which is found after an infective' appen-
dicitis.

The symptoms of normal involution of the ap-
pendix begin graduallv. and are usually given the
dignity of the diagnostic entity of "intestinal dys-
pepsia." The appendix is sometimes included as
a possible causative factor, but is usually left out.

What are the symptoms of normal involution of
the appendix ? They may be divided into two groups.

First, the group of the endless chain of symptoms
running out of the hawse hole of autointoxication.

Next, four links of the chain which suffice to hold
us short up to the diagnosis. These are the four
links: (i) Intestinal dyspepsia; (2) a sensation of
discomfort in the aonendix region; (3) an appendix
that feels narrow and hard on palpation; (4) hyper-
esthesia of the right lumbar plexus of nerves.

Now let us elaborate a bit.

(i) What are the characteristics of intestinal
dyspepsia of involution appendix origin ? Persist-
ent distention of the cecum and ascending colon
with gas. Irritation of the entrapped nerve fila-
ments of the appendix irritates the intimate ganglia
of the bowel wall (.\uerbach's and Meissner's
plexuses) and apparently causes the greatest degree
of disturbance in that part of the bowel which is
nearest to the original point of irritation.

(2) The sensation of discomfort in the appendix
region is characteristic. The patient has a tendency
to press upon the abdomen at that point with his

Fig. 3. — Transverse section of the appendix, showing replacement of
the inner coats by connective tissue.

hand, or to lean against a table occasionally. The
sensation may pass awav for a few hours, or even
for a few days at a time, but it is soon back again,
and it lasts for years. Formerly I told patients
that their discomfort was caused by the presence
of gas in the cecum and ascending colon. I was
wrong about that. Now when I hear other physi-
cians tell patients the same thing 1 know that they
are as wronsr as I used to be.

April 6, 1907]

MEDICAL RECORD.

557

(3) The appendix that is undergoing invokition
changes feels harder on palpation than a normal
one. So does an Edebohls' appendix ("Congestion
caused by the pressure of a loose kidney upon the
superior mesenteric vein"). So also does a scar
appendix. All three appendices cause symptom No.
4 (hyperesthesia of right lumbar plexus).

How are we to separate the three types of appen-
dix?

The scar appendix goes with a history of previous
infective invasion. Edebohls' appendix feels plump
on palpation — the plumpness of interstitial exuda-
tion. It is often tender on pressure, and a loose
right kidney is found with it.

The appendix which I describe feels narrow and
hard on palpation — the hardness of hyperplastic con-
nective tissue. It has no history of infective in-
vasion, and there are times when it is not at all
tender on pressure. Further, the scar appendix
may be the seat of acute or chronic infective invasion
at any time if lymphoid tissue and mucosa remain.
Edebohls' appendix may be the seat of acute or
chronic infection at any time, although it usually
gets up protection. The appendix which I describe
is not at any time the seat of acute or chronic infec-
tion, so far as I am able to learn.

(4) In the scar appendix, in Edebohls" appendix,
and in the appendix which I describe, there is one
constant diagnostic sign in hyperesthesia of the right
lumbar nerve plexus. Press upon the abdomen at a
point about one inch to the right and to the left
of the navel, carrying the finger points well down
toward each side of the spinal column. This will
make pressure upon the right and left lumbar plex-
uses. The natient will tell the rest of the story.

From what other causes are we to differentiate
the intestinal dyspepsia that goes with involution
of the appendix ?*

(a) From scar appendix and from Edebohls' ap-
pendix, by the features already described ; (b) from
bile-tract adhesions, "gall-spider cases," by the pre-
dominance of gastric dyspepsia, and by tenderness
and muscle protection of the gall-bladder region ;
(c) from eyestrain cases, by the predominance of
gastric dyspepsia in the latter, and by having the
possible eyestrain factor worked out by an ophthal-
mologist who reports upon muscular imbalance
rather than upon "the sight;" (rf) from visceral
ptoses, by the ptoses in evidence.

It is not necessary to .go into further details,
because bile-tract adhesions, eyestrain, visceral
ptoses, and appendices undergoing involution cause
such a large proportion of all dyspepsias that one
who is in the habit of eliminating these causes in
a diagnostic way will have his own methods for
follovying up other dyspepsias.

What are we to say to patients who come for
advice about appendices that are undergoing harm-
ful involution? My own custom is to tell them
that it is not necessary to have the appendix re-
moved, so far as securing safety is concerned. It
is merely a matter of expediency. Before I under-
stood the subject I sometimes told patients that the
appendices which were always .growling might bet-
ter be removed in order to avert possible e.xplosions
in the future. This advice was given upon a wrong
basis. Now I tell the patients that if their physicians
can keep them comfortable and maintain a .good

*Blake described, in the Annals -of Surgery for Scpiein-
ber, 1905, similar symptoms, caused by faulty mesenteric
attachment of the appendix, and some years ago I ascribed
such symptoms to "torsion of the appendix." At that time
the appendices had not been examined microscopically,
and they may have been appendices undergoing involution
changes.

.general health standard, there is no need for opera-
tion— even though the operation is rather unimpor-
tant as surgical operations .go. The patients leave
the office relieved of their apprehensions, but a good
many of them will turn up a.gain in about a year
and say that they are tired of makin.g it a business
to keep well. They have too many other things to
do. They .get along pretty well under medical treat-
ment, but they weary of keeping it up. Friends get
after them and persuade them to obtain a remnant
lot of advice, good, bad, and indifferent.

In my first published contribution to the subject
of the appendix that is undergoing normal involution
changes, reasons were given for dissuading physi-
cians from adoptin.g the nomenclature which had
been adopted by some of my assistants and by some
of the physicians who for convenience' sake and for
brevity had .given this type of appendix my name.
The nomenclature went wrong and .got to stand for
normal appendices. That will not do at all. I have
never at any time, in speaking or in writing, advo-
cated removal of the normal appendix, even when
it appears in the field conveniently durin.g the course
of some other operation. Mv dictum has previously
been, leave the appendix alone until it is infected,
and then lose no time in having it inspected.

Of late I have had to make a change, and now re-
move uninfected appendices that are undergoing
normal involution changes, provided that the pa-
tients and their ph\sicians are agreed upon making
the request. It is a different attitude from the one
that the surgeon is bound to take, on moral .grounds,
when a case of infective appendicitis comes under his
care and responsibility.

It is a pity that the nomenclature for the appendix
that is undergoing involution changes went wrong
in two instances : when the title of normal involution
of the appendix failed to engage professional in-
terest, and when such an appendix called by my
name got to stand for a normal appendix. Mr.
Cleveland has said that in social and in political
economics nothing is more dangerous than phrases.
In inedical economics nothin.g is more dangerous
than nomenclature. The term "wood alcohol" has
caused deaths and blindness because few people are
scared by wood, and fewer still are afraid of alco-
hol. The term ".gonorrheal rheumatism" has led to
giving patients antirheumatic treatment when that
sort of treatment was exactly what they could not
bear. Increasing the natural physiological resist-
ance of the patients would have been found to be
the keynote to successful treatment of the cases if
the word "septicemia" had appeared in place of
"rheumatism." The appellation of "catarrhal ap-
pendicitis" has caused endless deaths and disaster,
because it was the sand in which so many advisors
hid their heads when gangrene and perforation of
the appendix were impending. I have operated
in very many cases of appendicitis that had been
diagnosticated as "catarrhal." and have seen only
one or two that could properly and safely have
been classified under that title.

Let us .get right on the nomenclature of normal
involution of the appendix, and if it is called by
any more brief term, let us not under any circum-
stances have it stand for the normal apjiendix. The
subject is as important as any other subject with
which the physician has to deal re,gularly in his daiiy
routine of work, for there are few cases of any
one sort which one will see more often than cases
in which the appendix is undergoin.g harmful involu-
tion changes, and causing intestinal dyspepsia.

616 Madison Avexup.

558

MEDICAL RECORD.

[April 6, 1907

THE CAUSE AND CURE OF CANCER:

AN HYPOTHIiSrS AND A PRACTICAL SUGGESTION BASED
THEREON.

By ARTHUR C. J.A.COBSON. .M.D..

BROOKLYN, NEW YORK.

In the light of the hypothesis which I wish to sub-
mit, it would seem that a new line of procedure in
dealing- with cancer is susceptible of definition, which
it is barely possible may be found to involve a meas-
ure of efficacy, if such practical ipplication be
thought worth while.

Our ignorance of the real etiology if cancer being
so great, and our knowledge practi- dly confined to
studies of its ravages, one is certa..ily at liberty to
speculate, so long as one's intellectual excursions
into unknown seas are not chartless, reason and
common sense minding the helm. Moreover, the
disease is becoming more prevalent, challenging
more and more our much boasted medical science to
prove its abilty to cope with the fell scourge. In
1900 a fevv less than 33,000 died in the United
States alone, appealing to medicine in vain. In
England the death-rate from cancer is about 902
per million. In Germany, in the twenty years end-
ing in 1898, the death-rate from cancer doubled.

Here I wish to say that some of the physiology
in this paper may not seem orthodox ; in fact, to
some it may sound esoteric rather than scientific.
But let us for once, in this matter of which we know
little or nothing, follow Socrates' advice, concede
our ignorance, put aside for a little while the au-
thority of the schools, and begin all over again —
divorce ourselves from mere tradition and prejudice,
as Spencer did when he wrote the Synthetic Philoso-
phy. It is not alone the scheme of spiritual salva-
tion which may be served by thus becoming as little
children — in science also this has served its purposes.

If Cohnheim could assume, hypothetically, an
aberrant embryonal cell, which no one has ever dem-
onstrated, and which, in the nature of things, is
inadmissible of demonstration, then the writer feels
that he can, no less properly, break new ground in
the predication of principles.

Before proceeding directly to the subject proper,
let us for a moment consider the present attitude of
the profession toward this problem. The theory of
parasitism is still somewhat to the fore, although the
Harvard Commission discredits it and tlie Imperial
Cancer Research Fund rejects all known theories
and advances no new one. Those which have chiefly
engrossed the attention of the profession have been
Hansemann's theory of asymmetric cell division
(karyokinesis) ; the parasitic theory of Podvyssotski
and others, in which have figured the coccidium, the
psorosperm, Hoffman's parasite, and the gregarina;
the theory of Adamkiewicz, which affirmed that the
cancer cells were themselves the parasites, merelv
resembling epithelial cells, and producing cancroin,
which caused the cachexia : and the theory of Klebs,
which alleged a fructification of epithelial cells by
leucocytes. All are familiar with the theory of
Beard, recently advanced.*

Here the writer would say that it is his belief that
parasites may be concerned in the etiology of can-
cer in so far as they may constitute causes of local
irritation, but he regards the feverish search of in-
vestigators for a tangible, specific cause, of parasitic
nature, as futile. This subject of parasitism will be
touched upon again. We shall now take up our
hypothesis.

If we may conceive of the carcinomatous process
as a manifestation of perverted grozvth, in other

*Medical Record, February 2. 1907.

words, of perverted physiological energy (the can-
cer tissue, from a broad viewpoint, being not in
itself histologically foreign to the organism), then
may we not, without concerning ourselves too inti-
mately with the rationale of such perversion (whic'n
in the nature of things is hardly possible of exact
and scientific formulation, anyway) seek to utilize
this perverted energy in vicarious channels ; that is
to say, divert it to sane physiological uses? We do
not know what electricity is, yet we can harness it
for practical purposes.

At that degenerative period of life which is so
closely related to the occurrence of cancer, when ces-
sation of the se-xual functions and atrophy of the
sexual organs supervene, may there not be a quota
of that dynamic element that we shall call, for want
of a more definitive term, physiological enero-v.
which finds itself at a loss, as it were, for lawful
occupation in the economy? What more "natural"
than that, being at liberty, so to speak, it should
expend its force in ways biological but mischievous.
As Nature abhors a vacuum, so she abhors unused
energies.

As youth is the developmental, constructive period
of life, so age is the disintegrative period — disinte-
grative as regards the "vital forces" not less than the
somatic fabric. This is a trite saying, but a truth
which will bear restatement in this connection.

We are accustomed to think, and there is a basis
of fact for the belief, that the races other than the
white are physically inferior to the Caucasian type.
The negro is certainly so, the yellow man somewhat
less so. The Eskimo is a diminutive, fat, short-lived
animal. The people of Burmah, Persia, Borneo, and
India are certainly not characterized by surplus
energy. In brief, may we not find here a partial
light thrown upon the less frequent occurrence of
cancer among these peoples because of a lesser sum-
total of energ}', which is consequently less liable to
sufifer mischievous diversions in some individuals at
certain biological epochs, by reason perhaps of ex-
ternal irritations in the form of trauma, or mternal
influences in the form of excessive meat eating?
Here even the possible presence and potential ar-
rangement of the embryonic cell, which Senn postu-
lates, becomes less operative, because less charged
with a biological impulse both excessive and per-
verted and pregnant with mischievous possibilities.

Coley's occasional results in the treatment of the
cancer group may depend essentially upon the
cytophagous reaction which ensues after the injec-
tion of the toxins used, and which must involve the
diversion and engagement of considerable energ_\-.
But tlie effect is ordinarily too evanescent. The set-
ting up of an actual erysipelas when possible, or of
a number of consecutive attacks of erysipelas, has
been more efficacious because of the prolonged and
persistent demand on the forces concerned in a very
active phagocytosis and in local repair. Coley's
work takes us to the very threshold of the secret and
gives us a peep through the mist which veils the
noumena of carcinoma and sarcoma.

Again, in the influence of oophorectomy over
mammary growtlis may we not find another guiding
thought? Alay not the physiological utilization of
that "body force," which operates when called upon
as the inciting cause of the process of repair in a
laparotomy wound and in tlie pelvic tissues which
have been divided, account in a vicarious sense for
the phenomena of retrogression in, or disappearance
of, the growth ?

Senger and IMohr have reported cases in which
incomplete removal has been followed by cure. Lin-
dner, Hahn, Kroenlein, Alsberg, Baer, and Steudel

April 6, 1907]

MEDICAL RECORD.

559

have reported cures of gastric cancer following sim-
ple gastroenterostomy. It would not seem that such
results — stupendous when we consider the malignant
nature of cancer — are explainable on the mere
ground of removal of irritation and relief of hyper-
emia.

Might not analogous and perhaps curative results
be obtained by the removal from time to time of cer-
tain epithelial structures {e.g. skin, as in grafting
operation), as well as extirpation of the growth
itself (a sine qua non), thus affording vicarious
avenues for the operation of forces which otherwise
will expend themselves in other quarters with dis-
astrous results? The establishment of setons and
issues would hardly be consonant with modern sur-
gical principles.

From the foregoing it will be seen that our
hypothesis takes account both of Cohnheim's theory
and, in a sense, of parasitism. For the etiology of a
benign growth we postulate Cohnheim's theory, the
type of growth being determined by what type of
embryonic cell is operative, plus perhaps trauma,
inducing a locus minoris resistcntice. Here, again,
we may conceive, theoretically, of parasites furnish-
ing the source of irritation no less than in the case of
malignant growths — an incidental factor in both in-
stances. We may also conceive of a misplaced
embryonic cell as constituting per se a competent
source of irritation, without introducing assumptions
of additional factors in traimiatism, due to cytolergy
of some sort not necessarily related to traumatism
in the conventional sense.

For the etiology of malignant growths we nuist
postulate a further factor — perverted energy. We
must also postulate a selective affinity of this per-
verted energy for epithelial tissues, they constituting
the media for the appearance of cancer in tangible
form for the reason that they are most exposed
to cytolytic damage and most wanting in resistance
because of their high slate of differentiation.

Castration is said to have no hastening influence
on the time of the occurrence of the disease. This
may be due to the mutilation involved, operating in
like manner to oophorectomy.

Cancer has been known to undergo spontaneous
disappearance. Here we may invoke the probable
occurrence of some readjustment of the economy's
energy. Some infection, say of la grippe, erysipelas,
or malaria — which Dahlgetty thinks may account in
some way for the relative imnumity of the women
of Hindoostan — may account for the phenomenon.
Phagocytosis incidental to the breaking down of
involved tissue may, if intense, occasionally suffice,
though a local phagocytosis would not be as effica-
cious as a general cytophagous participation, as in
erysipelas. It is essentially a question of adequate
vicarious utilization of perverted energy.

Two things are commonly put forward in support
of the parasitic theory of cancer. First is the ten-
dency of cancer to form colonies or foci, and second,
the tendency to lymphatic dissemination. We may
regard these as simply two degrees of parasitic met-
astasis from the parasitic point of view, but it is pos-
sible, in the light of our hypothesis, to view them
from a totally different standpoint. These metas-
tases may be only apparently parasitic. Autoinocu-
lations, which we have successfully produced, are
essentially primary growths. So also some of these
apparent metastases may really be primary in nature,
just as much so as the original growth. After the
original growth has led to lowered vitality and mal-
nutrition, recognized factors in inducing that which
our postulates included as a locus minor resistcnticc,
we can see how such autoinoculations, impossible in

the normal subject, become possible in the diseased.
Whereas originally only one embryonic cell may
have played its part in Nature's laboratory, now we
are introducing many. All the postulates are satis-
fied and there is no need of invoking the agency of
parasites. These living cells of the embryonal type,
vicariously endowed with a potentiality for life and
growth, are, under the special conditions, invested
with powers not inferior to those of any parasite.
These transposed or transplanted cells still exhibit
the phenomenon of lawless growth, not because of
any inherent faculty or the influence of a specific
germ, but by reason of the repeated conditions
already postulated. Here we must assume a sur-
plus in the organism of perverted energy.

It is altogether likely that what we know as col-
onies and metastases are usually due to lymphatic
dissemination, not of parasites, but of cancer cells
alone. They may also be primary in some instances.
It has been noted by many observers that there is
a lesser tendency to metastasis in the cases occurring
early in life. This is probably because all the factors
are relatively less operative. Young and healthy
individuals cannot be inoculated simply because the
fundamental factor is wanting.

If cancer is an infectious disease, why is it that
the negro, more susceptible to tuberculosis than the
white man, is vastly less susceptible to cancer? The
explanation lies deeper than the bacteriological
domain.

Another argument against the swallowing whole
of the theory of parasitism is the relative fewness
of such parasites as have been found when com-
pared to the number of cancer cells. But, of course,
nobody now believes that the parasites aforesaid
have any specific relation to cancer.

W'lt have also to consider the metamorphosis of
benign into malignant growths. In this case the
tumor merely plays the part of a local irritation,
the epochal occurrence in the organism of perverted
energy furnishing the essential factor.

Here we may call attention to the fact that, after
the menopause, the degenerating, atrophying female
sexual organs themselves constitute, in a sense,
foreign bodies, and are therefore especially liable to
attack, provided a histological basis is present in the
form of an errant embryonic cell of the epithelial_ or
connective-tissue type, latent, but capable of being
charged with the requisite potentiality, and awaiting
only the other factors in the malignant equation.*

We know from sad experience that radical extir-
pation is not usually enough. Something is lacking.
What this is we have attempted to analyze. Mere
extirpation of the growth does not extirpate the
fundamental factor. The operation exercises a salu-
tary effect temporarily, but the cancer recurs in or
near the scar when the process of repair is corn-
plete, or shortly subsequent thereto. We must in
some wav continue to harness the force concerned
until such time as it shall cease to operate. The
occasional successes of surgery depend upon the
degree of potentiality of the force concerned, and.
if we may so say, its "quantity." Degrees of malig-
nancy are thereby determined.

Etiologically, cancer is of intangible, dynamic
nature, which' explains the baffling of investigators.
They are all looking for something tangible. The
tangible things they find are all secondary.

tlie part played by heredity is a relatively un-

*In tlie louninl of the American Medical Association of
February 16, iq07 (p. 625), there is an interesting query as
to the nossible influence of office treatments in exciting
cancerous growth. We "irritate the uterus every day or
every few days for a month or a year with chemicals and
foreign substances."

i6o

MEDICAL RECORD.

[April 6, 1907

important one. It probably signifies merely a trans-
mission of poor resisting- powers, only one factor in
pathogenesis.

Cancer in the very young must also be reckoned
with. About I per cent, of 26,574 cases collected
by Burger, De la Camp, Borst, Glaser, and Lubarsch
were in persons under 30 years of age. Hofmann,
Muth. ^'lalibert, Leopold, Beigel, Eckhardt, Gurlt,
Czerny, Billroth, Port, Kiistner, Andouard, Briick-
ner, Pierre, Adam, Kelly, and McBurney have re-
ported instances in persons ranging in age from 30
down to 13 years. In 15.134 autopsies after death
from cancer collected by Burger, none of the sub-
jects was under 15. Congenital cancer has been de-
scribed, and instances have been reported in those
under the age of 13, concerning which the author
has no statistics immediately available. Suffice it to
say that the occurrence of cancer in very early life
is occasionally observed.

The maximum incidence, in all the vertebrates,
coincides with the decline of reproductive activity.
It is altogether likely, therefore, that its occurrence
in the young is due to sexual anomalies, the nature
of which we can only conjecture, but which deter-
mine maladjustments of energy.

With respect to the alleged infectiousness of
cancer, we may conceive of such being possible with-
out invalidating our hypothesis. We do not have to
assume a specific parasite. It can, of course, be
infectious only to those satisfying all the postulates.

Our hypotheses ought to be not merely satisfying
from the scientific standpoint; they ought also to
point the way to practical possibilities. "The art of
healing as practised by Hippocrates and Sydenham
w^as founded upon the nature of things and on the
limits of human ability." ^^'e must to-day approach
the baffling problem of cancer with our science no
less than our art similarlv founded upon these things.

IIS Johnson Street.

OBSERVATIONS ON THE DIAGNOSTIC
AND PROGNOSTIC VALUE OF THE
EOSINOPHILES IN THE CIRCU-
LATING BLOOD;

TOGETHER WITH A CASE OF RECT.A.L INFECTION BY

SCHISTOSOMA HEM.\TOBIUM.

By LEONARD BLUMGART. .M,D.,

NEW YORK.
FORMERLY HOUSE PHYSICIAN ANIJ HOUSE SURGEON. GERMAN HOSPITAL.

Among the various forms of leucocytes, the eosino-
phils have ahvays been regarded with a marked
degree of interest, and at present are claiming
more and more attention by reason of their diag-
nostic and prognostic worth. Rindfleisch^ was the
first to describe them as "Kornchenzellen," but it
remained for Ehrlich" to designate them as "eosino-
phile Zellen." Their practical value as a means
of diagnosis has been proven, especially in three
groups of diseases, viz., certain diseases of the
skin, the acute infectious diseases, and some of the
animal parasitic affections, particularly those of the
gastrointestinal tract. Neusser" was the first to call
attention to their increase in certain skin diseases,
Turk^ pointed out their importance in the acute
infectious diseases, Rieder" first emphasized their
absence in typhoid fever, while Brown'^ and Thayer'
were the first to observe their enormous increase in
trichinosis.

The object of this paper is to direct attention to
the diagnostic and prognostic worth of the eosinor
philcs in some parasitic and infectious diseases and

to emphasize their prognostic value in typhoid fever.
The cases which follow occurred in the medical
division of the German Hosnital, service of Dr. I.
Adler.

Case I. — Male, age forty-two years, German,
book agent traveling in Long Island. The family
and previous history bear no relation to the pres-
ent condition of the patient. Two weeks previous
to admission he began to lose his appetite, feel tired,
and have pain in his legs, arms, and back. This
general malaise gradually increased in severity, and,
feeling verv ill, he left Long Island and returned
to New York. The week previous to admission he
had headache, vertigo, slight dvspnea, two attacks
of epistaxis, and a few chilly sensations. The pains
in his limbs increased in severity, so much so that
walking, dressing, and, in fact, any exertion, was
painful. He consulted two physicians, both of whom
diagnosed typhoid fever. The night before admis-
sion to the hospital he had a slight chill, followed
by fever and sweating. He had no cough. His
bow-els were constipated.

The physical examination showed the patient to
be well developed and fairlv well nourished. His
mental condition was clear. The face w-as flushed,
very slightly cyanotic, and the expression apathetic.
The tongue was dry with a central coating of thick
brown fur, and there was a marked tremor on
protruding it. Except for the base of the left lung
behind, where there was a slight dullness with harsh
breathing, also a few moist rales, the lungs were
normal. The pulmonic second sound was slightly
accentuated ; otherwise the heart was normal. The
abdomen was flat and slightly rigid ; there was no
localized tenderness, mass, or tympanites. The
skin of the abdomen showed about six maculo-
papular, rose-colored spots. The liver e.xtended
in the midclavicular line from the sixth rib to
iust below the costal margin, and its edge could
be felt as smooth, round, and firm. The spleen
was just palnable on deep inspiration. The ex-
tremities were held in a rigid, extended position
and showed on their flexor aspects a few maculo-
papular spots. There w-as no edema of the eyelids
or extremities. The axillary and inguinal glands
were not enlarged. Pulse 132, temperature 104.6°
P., respiration 32.

The patient was put under typhoid precautions
because of the history, temperature, enlarged spleen,
rose-colored spots, and general appearance. The next
day a full laboratory examination was made, with the
following results : Hemoglobin, 60 per cent. ; red
blood cells, 3,424,000; white blood cells, 15,300.
Differential leucocyte count (500 cells) : Poly-
nuclears, 49.4 per cent.; lymphocytes. 5.6; large
mononuclears, 5.2; eosinophiles, 39.8; basophiles,
0.0.

The examination for plasmodia was negative,
also the Gruber-Widal reaction for typhoid and
paratyphoid bacilli. The feces were exan-iined for
blood by the aloin test, but with negative result.
No parasites were seen. The urine was acid, amber,
clear ; specific gravity 1022 ; no albumin nor
sugar. The diazo reaction was positive. The dif-
ferential leucocyte count of 39.8 per cent, eosino-
philes in 15.300 leucocytes at once suggested trichi-
nosis and the exclusion of tvphoid fever. Careful
inquiry into the patient's history now revealed the
fact that five weeks before admission he had par-
taken of canned pork-tenderloin, which he described
as being only partially smoked. The second day
the patient also complained of severe pain in the
deltoids, glutei, and extensors of the thigh. Sections

April 6, 1907]

MEDICAL RECORD.

=;6i

from these muscles showed Trichina spiralis in
laro'e numbers. Two davs later the patient for
the first time presented slight edema around the
ankles ; at no time was there any facial or other
edema.

The patient was in the hospital for seven weeks,
and during; the first two weeks the temperature,
general condition, and eosinophilia fluctuated syn-
chronously. Each rise in temperature and increase
of muscular pain was accompanied by a correspond-
ing increase in the eosinophiles, which at one time
reached 48i< per cent. The diazo reaction remained
positive for two weeks. Repeated examinations of
the blood bv the Gruber-Widal test for typhoid and
paratyphoid and of the feces with the Conradi-
Drigalski media were negative.

No attempt was made to treat the trichinosis, ex-
cept by good nursing and rectal irrigations of thymol
1-10,000, and a little stimulation with whiskey and
strychnine. Recovery was very slow, the patient
gaining his streneth so slowly that when he Jeft
the hospital he was just able to walk without aid ;
on the day of discharge from the hospital he still
had thirteen per cent, of eosinophiles. The patient
has just recently (1906) reported his complete cure
and the total disappearance of muscular symptoms.

In this case the general appearance, history,
spleen, skin, and diazo reaction all suggested typhoid
fever, the studv of the blood alone leading to
the correct diaenosis. Tn December, 1905, and
January, 1906, there occurred in the German Hos-
pital eight cases of trichinosis in which the diag-
nosis was suggested bv the eosinophilia. These
cases will be reported later.

Peculiar interest attaches to our next case :

Case II. — Male, thirty-seven years old, German,
manufacturer, admitted December, 1904. For the
past ten years the patient had lived in various parts
of South .\merica, chiefly in Brazil. Seven years
ago while there he contracted typhoid fever, which
kept him in the hospital for two months ; one month
later while recuperating in a small inland town he
had an attack of acute gastroenteritis \vith general
abdominal pain and diarrhea. He improved except
for the diarrhea, which, with an occasional intermis-
sion of one to two months, had persisted up to the
day of admission. The patient had five to seven
defecations a dav, preceded bv slight colicky pains ;
he described the stools as being very soft, but not
fluid, containing at times blood and mucus. During
the last two months the diarrhea and pain had in-
creased and he had suffered a considerable loss in
weight and strength.

The physical examination showed the patient to
be poorly nourished, anemic, and emaciated. The
lungs and heart were normal. The abdomen was
soft and there was neither mass, tympanites, nor
tenderness. The liver extended in the midclavicular
line from the fifth rib to four cm. below the costal
margin, the edge being felt as firm, round, and
smooth. The spleen was not enlarged or palpable.
The colon appeared distinctly thickened and could
be traced throughout its entire extent. A digital
examination of the rectum showed nothing abnor-
mal. The urine contained a trace of albumin and a
moderate number of hvaline casts.

Blood Examination: Hemoglobin, 62 per cent.;
red blood cells, 4,448,000; white blood cells, 5,300.
Differential leucocyte count (500 cells) : Poly-
nuclears, "^ per cent.; lymphocytes, 16.2; large
mononuclears. 2.8; eo.sinophiles. 23.0; basophiles,
i.o.

The low leucocyte count and the hi^tf)rv, togetlier

with the absence of muscular symptoms, edefna, and
fever, tended to e.xclude trichinosis. The diarrhea
which had persisted for years, the bloody char-
acter of the stools, and the increased eosinophilia all
pointed strongly to a parasitic infection of some
part of the intestinal tract. This was corroborated
by a careful examination of the feces. The feces
were a light brown, alkaline, semifluid, homogene-
ous mass, odor not abnormally offensive. Macro-
scopically there were blood-stained mucus and mi-
nute clots of pure blood. The microscope showed
blood, mucus, epithelial and pus cells, triple phos-
phate crystals, bile pigment, and the usual enormous
number of bacteria. The most important result
of the examination of the feces was the discovery
of two varieties of nematodes — Stroni^yloidcs in-
testinalis and Tricocephalus trichiurus, and one
variety of trematode, Bilharcia haniatobia, or Schis-
tosoma hamatobiitm , which were abundantly pres-
ent in every stool that was examined. Adult speci-
mens of Strons;yloides intestiualis were not seen,
neither were the eggs seen, but an abundance of
rhabditiform larvje were observed in every stool.
They measured apnroximately 65 by 35 microns
and were actively motile for hours after being
passed.

Infection by the Stron^^vloides intestiualis is very
common in Cochin China, where it produces the
disease known as "Cochin China diarrhea." In-
fections have been observed in the United States.
Thaver** reported the first three cases in 1901, and
since then others" have described five additional
cases. In the discussion following the reading of
papers on the subject, physicians from the lower
Southern States reported having seen a number of
cases, so that it is very probable that the disease
is more widespread than is generally believed.

The second variety of nematode found was the
rather common Tricocephalus trichiurus, or Trico-
cephalus dispar. Only the eggs were seen with
their characteristic bipolar, light-yellow projections.

The most interesting; of this trio of parasites was
the rather rare trematode Bilharda hcvniatobia. or
Schistosoma hccmatobinm, for the recognition of
which I am indebted to Dr. Charles Wardell Stiles.
Chief of the Division of Zoolog^^ of the United
States Public Health and Marine Hospital Service.
While investigating the diseases of Egypt, Bilharz'"
discovered the schistosoma in the urine of persons
suffering from hematuria. Since then its presence
has been shown to be almost universal in Africa. In
the Transvaal it is so common an infection that no
Boer boy is thought healthy unless he passes bloody
urine (Brock^M. Cases are being reported in in-
creasing number from South America, and it has
recently been observed in Porto Rico and the Philip-
pines. It is also prevalent in Japan, where Toyama
and Tsuchiya^- report cases.

The infection is now considered to take place in
either of two ways. Sonsino" claims that the in-
fection occurs through the gastrointestinal tract by
means of infected food or water, while Brock'^ con-
siders that the mode of entrance is through the
skin while bathing in infected streams. This he
bases on the fact that the hundreds of cases seen
bv him in the Transvaal were nearly all in boys
of from ten to twenty-one years, which is the bathing
I-ieriod of the Boer boy. The adult worm finds its
way into a small vein of the portal system, becomes
encysted there, and lavs its eggs : these burst the
wall of the vessel and so escape into the neighboring
tissues and vessels. The organs most frequently
involved arc the bladder, ureters, pelvis of the kid-

S62

MEDICAL RECORD.

[April 6, 1907

ney, seminal vesicles, mesenteric .e;lands, and rectum.
Thev have been found in the liver, kidney, and
prostate by Kartulis" and in the lungs by Mackie^'
and others, and even in the left ventricle by Greisin-
ger." The usual site of miJture is in the bladder.
When the encysted worm ruptures hemorrhage oc-
curs and when this takes place into the bladder
hematuria results.

The pathological results are induration, ulcera-
tion, and polypoid vegetations. It is only in the
rectum, however, that the vegetative and ulcerative
changes take place. The onh' symptoms which seem
to be constantlv produced are diarrhea and pain.
In our case the eggs were found in everj^ stool ex-
amined. They were quite typical, being 0.16 mm.
long and 0.06 mm. wide; the spine of the egg was
placed laterally in our case, instead of terminally,
which seems to be the rule in rectal infections.
The cause of this difference in the location of the
spine is not at present known, but the trend of
thought seems to be toward the opinion that there
are two different species. A proctoscopic examina-
tion revealed many small ulcers, but no polypoid
vegetations were seen.

The disease is rare in the United States, only
seven cases having been reported. The first case
was seen bv Booth'' in 1882, the second by Curtis"
in 1896, the third by Porter'** in i8q7. Porter's case
was referred to by Brooks-" and Sondern.-' The
fourth case was reported by Walker-- in 1900 and
again observed by the Raffertys"' in 1904. The fifth
case was seen by PooP* in 1903. the sixth case by
O'Xeik'^ in 1904, and the seventh case by Anders
and Callahan-" in 1905. Smith"' reports seven cases
occurring among Boers who came to this country
for exhibition purposes after the Boer war. All
these were urinary infections, while ours, I believe,
is the first case of rectal infection reported in the
United States.

In connection with the hypoleucocytosis, almost
cc^nstantly observed in typhoid fever, is the extraor-
dinary diminution of the eosinophiles, and in the
great majority of cases their disanpearance, which
usually occurs in the very beginning of the infec-
tion. Reider-* in ten consecutive cases could not
find a single eosinophile in a thousand cells, while
one mild infection showed 0.3 per cent, of eosino-
philes. Tez,-" Turk,-''" Za^nert," and others have
since confirmed this observation. This is true to
such an extent that in a doubtful case the diagnosis
may almost he made by the presence or absence of
the eosinophiles. In fact, Niigeli.''- in view of his
experience in an epidemic of typhoid fever, excludes
typhoid in every case in which the characteristic ab-
sence or diminution of the eosinophiles is not demon-
strable. The cause of this disappearance, according to
Metchnikofif, is the inhibitory action of the typhoid
toxin on the bone marrow. From all this it would
seem probable that the behavior of the eosinophiles
in tvphoid fever would afford valuable clues as to
the course of the disease. In accordance with this
view 500-cen, differential leucocyte counts have been
made dailv in all cases of tvphoid fever at the Ger-
man Hospital ; in all, over forty cases have been
observed both in the public and private wards. Cases
which retained from 0.2 per cent, of eosinophiles
ran a very mild course ; in the moderate and severe
cases every eosinophile disappeared absolutely. In
the moderate cases the eosinophiles began to re-
appear at the beg-inning of the fourth week, at first
only in small numbers, from 0.2 to 0.5 per cent.;
subsequently there occurs what has been called an
eosinophile crisis, when they increase in number
from these small percentages to from two to five

per cent, within twenty-four hours. When this
eosinophilia sets in and remains more or less con-
stant, convalescence is well advanced and relapse
is highly improbable. We have, however, never
seen one occur under these conditions. If no eosino-
philia occurs when the patient is apparently well on
the way to recovery, or if having been observed
the eosinophiles again disappear, it may be taken as
a reliable sign that the pathological process is still
active and a relapse almost certain, even though the
temperature and all other conditions have appar-
ently been normal for many days. The import-
ance of this fact for prognosis and general manage-
ment is obvious. It is our observation that until
a patient has eosinophiles in his blood his condi-
tion is such that he cannot be discharged from
the hospital, and we have also learned that to
discharge a patient without an eosinophilia is dan-
gerous. One patient this fall (1905) was dis-
charged at her own request. Although her tem-
perature and general condition had been nor-
mal for fourteen days, she had no eosinophiles ;
in three days she was back with a severe relapse.
.Another patient, who at the end of the fourth week
had an eosinophile count of 23^ per cent., sud-
denly lost this, began to run an elevated temper-
ature, and was afterwards proven at autopsy to
have had a fresh infection resulting in a colo-
typhoid with tremendous hemorrhages. In all the
fatal cases the lost eosinophiles were never recovered.
One patient during convalescence had an eosino-
pliilia of 3.4 per cent. ; he then had a relapse, but
twenty-four hours before the onset of the fever
the eosinophiles disappeared. Two patients, after
their temperature had been normal for two weeks,
did not recover their strength, although tonics, food,
fresh air, and sunshine were tried. Finally, after
having been ill for nine weeks, the eosinophiles
and strength returned simultaneously.

In conclusion, a few remarks based upon the
foregoing observations might be made:

1. It is of importance not only to count the
leucocytes, but to make a careful differential count
and to repeat it frequentlv throu<^hout the course
of the disease, until in fact the patient is dis-
missed.

2. The entire disappearance or very marked dimi-
nution of the eosinophiles, together with a distinct
leukopenia, goes far to, establish the diagnosis of
typhoid fever in doubtful cases.

3. A normal or increased percentage of eosino-
philes, other thino-s being equal, speaks against ty-
phoid. This holds good, of course, only for the
febrile course of the disease.

4. In cases of undoubted typhoid, the presence
of eosinophiles, even in small numbers, during the
first week is a favorable sign and speaks for a prob-
able mild type.

5. No typhoid fever patient should be consid-
ered cured or dismissed from observation before
he has regained permanentlv. at least, a normal
percentage of eosinophiles.

For the suggestions leading to this paper and the
help in preparing it I wish to thank Dr. I. Adler.
REFERENCES.

1. Rindfleiscli : Experimentalstudien u. die Histologic
(Jcs Blutes. Leipzig, 1863.

2. Ehrlich : ^Iethodolog. Beitrage z. Physiologic u. Pa-
thologie d. verscheid. Formen d. Leucocytcn. Zeitschr. f.
klinisclie Medic. Bd. I S., 553.

3. Neusser: Klin, haemat. Mitteil. IVieit klin. IVochen-
sfJir.. 1892, 3, 4.

4. Turk : Klin. Untersuchungen iiber d. Verhalten d.
Elutes b. acut. Infections. Krankh. Wien u. Leipzig, 1898.

5. Rieder : Uber Vorkommen und klin. Bedeutung der
Eosinophil. Zellen. Miinchcner tiied. Wochcnschrift, 1891,
Xo. 14.

April 6. 1907]

MEDICAL RECORD.

563

6. Brown: Studies on Trichinosis. Johns Hopkins Hos-
pilal Bulletin, 1897.

7. Thayer: On the increase of eosinophilic cells in the
circulating blood in Trichinosis. The Lancet. No. 3865,
September 25, 1897.

8. Thayer: Journal of Experimental Medicine. Novem-
ber, 190;.

9. (0) S'trong: Johns Hopkins Hospital Records, 1901 ;
Vol. 10, p. 91-

{b) Price: Joitrn. Am. Med. Assoc, Vol. 41, 1903,
pp. 651 and 713.

(c) Ward: Ibid. p. 713.

(d) Wainwright and Nichols: Medical Neivs, 1904,

p. 785.
((t) Brown: Boston Med. and Sur^. Journ.. 1903, p.

583.
(/) Moore: American Medicine, M?Ly y>. 1903.

10. Bilharz: Zeitschrift fiir Wissenschaft, Zooloi^ie, Bd.

4. 1851.

11. Brock: Journ. of Path, and Bad., London and Edin-
burgh, 1894, Vol. 2, p. 54.

12. Toyama and Tsuchiya : Medical Soc. of Tokio Report
in the Deutsche medicin. JVochen., No. 43, 1905, pp. 1739-41.

13. Sonsino : Ricerche sulla Sviluppo della Bilharzia ;
Giornale della R. Academei di Medicinadi Torino, August,
1884.

14. Kartulis : Virchow's Archiv, 1885, bd. 95.

15. Mackie: The Lancet, October I, 1887. p. 659.

16. Greisinger : Klin. u. anat. Beobachtung uber die
Krankheiten von Egypt. Archiv fiir Heilkunde, 1856, 12
Jahr., S'. I, p. 561.

17. Booth : Western Medical Reporter, Chicago, 1882,
Vol. 4, pp. 81-84.

18. Curtis: Annals of Surgery, 1896, Vol. 23. pp. 56-58.

19. Porter: Internat. Clin. Phila., 1897, Vol. 3, pp. 123-
127.

20. Brooks : Medical Record, April 3, 1897.

21. Sondern : Medical Nczcs. May i, 1897.

22. Walker : Journ. Am. Med. Assoc, February 17, 1900.

23. Rafferty: Medical Record, 1904, Vol. 65, p. 918.

24. Pool: Proc. N. Y. Path. Soc, 1903-1904, n.s., Vol.
3, pp. 83-87.

25. O'Neil : Boston Med. and Surg. Journ., 1904, Vol.
15:, pp. 453-457-

26. -Andrews and Callahan : Medicine, Detroit, 1905, Vol.
9, pp. 509-519-

27. Smith : Seven Cases of Bilharzia Hematobium.
American Medicine, October 14, 1905.

28. Rieder : Ueber Vorkommen und klin. Bedeutung
der eosinoph. Zellen ; Miinchener med. IVoclienschrift, 1891,
No. 14.

29. jez : Die Leucocytose bei Infections-Krankli. insbes.
bei Typhus abdom. (Polish) ; Pr::cglad. lekarski, 1895, cit
b. Turk.

30. Turk : Op Cit.

31. Zappert : Ueber das vorkommen der eosinophilen
Zellen itn menschl. Blute ; Zeitschrift fiir klinischc Medicin,
Bd. -3. 1893.

32. Nageli : (a) L'eber die Typhus Epidemic, in Obcrlipp.
Correspondbl. fiir Schu-ci::er Aercte, Bd. 29, 1899. (b)
Die Leucocyten b. Typhus /Xbdominalis \Deutsches Archiv
fiir klin. Medicin, Bd. 67, 1900.

A REPORT OF FOUR LUETIC CASES UN-
ASSOCIATED WITH OBSERVABLE
SECONDARY MANIFESTATIONS.

By GEORGE M. M.^C KEE, M.D..

NEW YORK.

INSTRUCTOR OF DERMATOLOGY .IT THE UNIVERSITY AND BELLEVVK
HOSPITAL MEDICAL COLLEGE.

The followiii"' histories are from cases treated in
private practice, the patients having sufficient intel-
ligence to appreciate the character of the disease in
question as well as the necessity for a positive diag-
nosis. They aided me in every possible way in
my observations, and I never hacl any reason to
doubt their veracitv.

Case I. — Mr. .\., twenty-two vears of age, single,
employed as a clerk in a large wholesale house. First
came under observation .'^eptember. Tgo2. present-
ing a small nonindurated ulcer lying in the sulcus on
left side of freiuun. It was impossible to estimate
the incubation period because of frequent inter-
course. The ulcer had been present three davs and
no treatment of any kind had been applied previous

to the first visit. Although a diagnosis of chan-
croidal or herpetic ulceration was made, the possibil-
ity of syphilitic infection was explained, expectant
treatment advised, and the patient placed under ob-
servation, making three visits to the office each week
for a period of three months. The ulcer, which be-
came slightly indurated, persisted for three weeks
when it healed without leaving a cicatrix, although
the induration remained for a week or more. He
also had a mild bilateral inguinal adenitis which en-
tirely disappeared four weeks after the ulcer healed.
Si.x weeks after the first consultation, enlargement
of the axillary and cervical glands was observed,
but when the patient stated that he was sub-
ject to mild attacks of adenitis, no importance was
attached to the discovery. Throughout the entire
three months he remained in excellent general
health, had no fever, no eruption, alopecia, throat
or mouth symptoms, nor, in fact, any manifestation
of secondary syphilis, and was therefore told that
although the danger could possibly extend over an-
other month he could discontinue his office visits.

On May 10, 1906, he again consulted me regard-
ing a livid red infiltrated nonpruritic circinate
patch covered with a few tenacious epidermic flakes
on the palm of the left hand at the base of the
thumb. The chain of glands along the radial side
of the flexor surface of the forearm were the seat of
gummatous degeneration, and the overlying epider-
mis was stained a deep copper color. The pharyn-
gofaucial and nasal mucous membranes were exten-
sively infiltrated. The patient also complained of
severe headaches and rheumatic pains. This state
of affairs had existed for about three months, the
symptoms gradually increasing in severity. Six
grains of the salicylate of mercury were given in
divided doses by means of deep muscular injections,
one grain being administered each week. As a
result of this treatment the lesions promptly disap-
peared. Although having been advised to report
again in two weeks for further treatment he has
thus far failed to follow instructions. This patient
absolutely denies any primary, secondary, or terti-
ary manifestations excepting those above mentioned.
In this case one must consider the possibility of the
secondary eruption occurring after the ninety-day
limit and being so mild as to escape his attention in
spite of the fact that he had been warned of its
possible occurrence. It is also possible that primary
and secondary lesions existed before or after my
first series of observations, and either escaped his
attention or were wrongly diagnosed. Finally he
may have for some unknown reason given false
answers to questions relative to his history.

C.\SE II. — Mr. H.,* twenty-two years of age,
waiter by occupation, unmarried and presenting a
history of several attacks of herpes progenitalis.
On October 26, 1903, three days after sexual inter-
course, he developed a group of herpetiform
vesicles situated in the sulcus one-half inch from
the frcnum, which soon ulcerated and uniting de-
velnpc<l a discharging ulcer about one-half inch in
diameter involving the frenum and glans. Several
small idcers formed on the glans and mucous surface
of the prepuce. Cleanliness was difficult in this
case because of the excessive purulent discharge and
a somewhat redundant foreskin. Beginning on De-
cember 23, the lesions were sparked for five mimites
every second day with the current derived from the

*Tht- history of this patient was given in an article
entitled "The Treatment of Chancroidal, Herpetic, and
Varicose Ulcerations by the High-Frequency Spark." Pub-
lished in the Journal of Cutaneous Diseases. December,
1905.

564

MEDICAL RECORD.

[April 6, 1907

secondary coil of the I'lffard hyperstatic transfor-
mer, a static niacliine being employed as the genera-
tor. After seventeen days of such treatment the
sores had entirely healed. On November 24, 1906,
he presented a scaly papular syphilide on the palmar
surface of the left hand, a circinate papular syphi-
lide on the dorsal surface of both hands, and two
circinate papular slightly eroded patches on the
glans penis. On the left shin there was a large hy-
pertrophied papule covered with psoriatic scales.
On the outer aspect of the right foreleg there were
several infiltrated patches of the papulosquamous
type. These lesions had existed about six or eight
weeks, but responded at once to mixed treatment.
At the present writing nothing remains but the char-
acteristic pigmentation. This patient positively de-
clares that he never had any cutaneous lesions with
which I am not acquainted, excepting an occasional
attack of herpes, which were never severe enough
to merit attention. He was married in the fall of
1904, and so far as can be determined his wife has
never developed any signs of the disease. Inasmuch
as the patie,nt was only under personal observation
for a period of seventeen days, coupled with the fact
that no direct attention was given to the possibility
of syphilitic infection, mild secondary manifestations
could readily have been overlooked.

Case III. — Mrs. W., twenty vears of age and mar-
ried about one year. The first consultation was on
August 8, 1904, at which time she presented a large
ulcer on the right labium majora with a smaller one
on the left side. Both labia were edematous and in-
durated. The ulcers had been present about two or
three weeks. Both chains of inguinal glands were
involved, but there was no adenitis elsewhere at the
time, nor did any develop subsequently. A careful
inspection of the entire body failed to demonstrate
any other lesions of the skin or mucous membranes,
excepting a very slight sore throat which only
lasted three days. She was quite certain that no
other eruption had existed prior to her first visit.
The possible nature of the disease was explained to
both the patient and her husband, who positivelv de-
nied any syphilitic history, and they promised to
note any suspicious symptoms. The ulcers had
entirely healed by August 22, and up to September
15 not a single secondary manifestation had been
observed. On this date, however, the patient gave
birth to a male child of about seven and one-half
or eight months' gestation. The child, which only
lived a few minutes, was poorly nourished and al-
though not having definite lesions, presented the
general features of a syphilitic infant. The placenta
also showed signs of degeneration. One year later
another premature labor occurred at about the sev-
enth month. This time, according to the statement
of the .girl's brother, the infant was covered with
sores, poorly nourished and lived but a few hours.
In the interval of time elapsing between the two
•confinements there had been no other manifesta-
tions of the disease nor had antisyphilitic treattnent
"been administered. In September, 1906, an appar-
ently healthy, full term child was born. The hus-
band failed to contract the disease and they both
•consider my fears groundless, but it will be of no
little interest to watch for future developments in
this interesting family. The fact that the husband
failed to become infected naturallv suggests the
possible source of the patient's inoculation. In this
connection I recall a young woman who was married
in June. 1902, and who developed a genital chancre
in July of the same year, which was followed in
six weeks by secondary symptoms. Her husband

positively denied having had the disease, nor could
I discover any manifestations of the same upon his
body. Although failing to take any special prophy-
lactic measures, he has to this time failed to con-
tract the disease.

C.\SE IV. — Mr. J., twenty-seven years of age, sin-
gle, employed as a bookkeeper in a publishing house.
This patient developed a severe attack of .gon-
orrhea on January 17, 1903, nine days after cohabi-
tation. Thirteen days later he developed a slightly
indurated penile ulcer, which persisted for three
months, leaving a cicatrix after healing. His gon-
orrhea, which was complicated with prostatic in-
volvement, necessitated daily treatments for a pe-
riod of four months, during which time I made daily
examinations of his entire body for the secondary
eruption which was certainly expected. The in-
guinal glands were involved, but at no time was
any general adenitis, alopecia, sore throat, nor any
manifestations of the suspected disease observed.
Yet this patient on March 12, 1906, presented un-
mistakable signs of neglected syphilis. There was
an ulcerating lesion of the left shin, accompanied
with characteristic pigmentary changes, which had
begun, according to the patient's observation, some
weeks previously as a bruise, the result of an in-
jury. The ulcer failed to improve under local ap-
plications, but promptly responded to mixed treat-
ment. He states positively that he never had
cutaneous lesions other than those recorded above.
The other histories may be defective, but surely
if this patient had secondary symptoms they must
indeed have been slight. Whenever a patient con-
sults me regarding a possible primary lesion of
syphilis I have always depended upon the develop-
ment of the secondaries for a positive diagnosis and
always supposed myself safe in so doing. I can
distinctly recall many cases of young men having
suspicious sores several years ago who subsequently
failed to develop secondaries and who were told they
need not worry longer.

In all probability the diagnosis of chancroid or
ulcerated herpes in these cases was correct. For
their sake at least it is to be hoped so. I spe-
cifically recall one young gentleman who contracted
a sore having an incubation period of two weeks
from a young woman who at the time was under
treatment for secondary syphilis. This patient was
placed under strict observation. The sore required
several weeks to heal. At one time there appeared
to be a slight macular eruption on the thorax under
the arms, at the same time he became anemic and
developed acne pustules upon the back. A consulta-
tion was held with an eminent syphilographer, who
decided against specific infection. Under tonic treat-
ment the patient soon regained his usual good
health and has retained the same to the present
writing.

Now the following question naturally arises : Upon
what features can a safe diagnosis of early syphilis
be made, and when should constitutional treatment
be instituted ? This question has been discussed
in text books, in papers and at societ}' meetings,
vet the opinion of the medical profession remains
divided. Fournier,' who is of the same opinion
;i.s Ricord," starts constitutional treatment as
soon as the primary lesion presents the features
of the .syphilitic chancre. By so doing he believes
an ultimate cure is more likely to be effected. At
the same time he advises extreme caution and
whenever the slightest doubt exists he awaits the
appearance of the secondaries. Van Buren and
Keves.' Lvdston,* \\"ild,°. and in fact the major-

April 6. 1907]

MEDICAL RECORD.

56=

ity of writers concur in this opinion. Dumesnil,"
Taylor,' and others, on the other hand, ow-
ing to the fact that nonsyphilitic sores may simu-
late the typical chancre and znce versa, consider
the difficulties of a diagnosis in this stage so great
as to make the giving of mercury unjustifiable, no
matter how plainly marked the case may be. The
only advantage in employing constitutional treat-
ment in the primary stage is in the possible pre-
vention of severe secondary symptoms and to attack
the disease before it becomes deeply seated. Now as
a matter of fact the secondaries will appear as a
rule whether mercury has been given or not. The
fact that they sometimes do not occur when mer-
cury has been given is certainly a poor criterion
inasmuch as they may fail to appear in cases which
have not been so treated. Regarding the efifect of
early treatment upon the rernote course of the dis-
ease there is no good reason to believe that this
method has any advantage, at any rate the evidence
is as strong one way as it is the other. If ener-
getic treatment be given immediately upon the ap-
pearance of the secondaries these symptoms will
usually be very mild indeed. We must also con-
sider the moral efifect of the secondary manifesta-
tions. If during the primary period of the disease
the patient receives proper instruction and is told
that the diagnosis rests upon the appearance of sec-
ondary symptoms, he will naturally be impressed
with the nature of the disease when these symp-
toms develop. On the other hand, if early treatment
has been given and the secondaries fail to follow,
the patient will, after a few months, unless he has
unlimited confidence in his physician, doubt the di-
agnosis and become indifferent to the treatment.
It not infrequently happens that this feeling of doubt
is also shared by the physician.

A positive, diagnosis can of course be made when
the secondaries develop and appropriate treatment
immediately begun. But when the secondaries
do not follow a suspicious sore, can one without
awaiting further evidence positively say that syphilis
does not exist? All authors with whose writings I
am familiar, although admitting that the secondary
symptoms may be so mild as to be overlooked or
ignored bv the patient, believe they always do occur
and can always be demonstrated by careful observa-
tion. It is no uncommon occurrence, especially in
"dispensary practice, to have patients present ter-
tiary lesions and have no knowledge of primary or
secondary svmptoms. This happens most frequently
in women, who often have a uterine chancre and
who very often overlook the subsequent inguinal
adenitis and superficial eruptions. Again the erup-
tions of the secondary period may be modified by
being associated with other skin affections, and the
true character of the disease not recognized.

The first three cases mentioned in this paper may
or may not have had secondarv symptoms. The
fourth case did not develop them unless they ap-
peared after one hundred and twenty days. It is
of course possible that this patient may have had a
neglected infection prior to my observations. Con-
sidering that the case is truly represented, it is prob-
able that such cases are of rare occurrence, and as
a rule it is safe to base a diagnosis upon the appear-
ance or nonappearance of the secondary manifes-
tations. It should, however, be borne in mind that
these symptoms may not only be mild but entirely
absent. In this connection the organism of Shau-
dinn and Hoffmann should receive consideration.
Although the majority of investigators feel cer-
tain that this organism is the etiological factor of

syphilis, there are many dissenters, and until abso-
lute ])roof is forthcoming one may not be entirely
exempt from criticism if the diagnosis be based upon
the finding of the Spiroclucta pallida alone. So far
as I am aware, all patients having a sore in which
these organisms were found have later developed
secondaries, while on the other hand cases in which
the pallida could not be demonstrated failed to
develop secondary manifestations. P reported
several such cases last spring. W. B. Trimble,^
at the ninety-seventh regular meeting of the New
York Society of Dermatology and Genitourinary
Diseases, reported the case of a man thirty-four
years of age, presenting a lesion of the upper lip
having all the features of an initial sclerosis. This-
patient was seen by several eminent; dermatologists,
who unhesitatingly made a diagnosis of chancre. A
careful search for the Spirochccta pallida resulted
negatively. This patient was under observation for
four or five months, at which time the ulcer, al-
though reduced in size, was still present, but sec-
ondary lesions had failed to develop. It is safe
to state that in all probability there would be con-
siderable difference of opinion regarding the ad-
visability of starting mecurial treatment in this case.
Dr. Trimble preferred to keep this patient under
prolonged observation rather than make a positive
diagnosis upon the evidence as presented. Many
physicians will agree, while others will disagree
with this method. I am still in accord with such
procedure in spite of experience with cases as re-
corded in the beginning of this article. Regarding
the association of the Spirochccta pallida with the
primary and secondary lesions of syphilis, it must
he remembered that they often can not be found
after the process of repair sets in. They are also
difficult to demonstrate upon the surface of such
lesions. The search should therefore be made as
early as possible and in every case it is advisable
to obtain a specimen after a fairly deep curettage.
In doubtful cases the chancre may be excised and
microscopical sections studied. The diagnostic se-
rum devised by Wassermann, Neisser and Bruck^**'
may be employed if the necessary material is at hand.
Conclusion. — The physician must recognize and
assume the responsibility of a positive diagnosis of
sviihilis before advising the recognized course of
constitutional treatment. He may consider the
features (if a given ca^e ■-nfticie'-it to make a diagno-
sis in the primary period, but the establishment of a
diagnosis in this period is attended with consider-
able difficulty and inasmuch as the early use of
mercury may modify the secondary symptoms to
such an extent as to produce an hiatus in the pa-
tient's history, one certainly assumes a tremendous
responsibility by this method. Although one can
not absolutely depend upon the development of
secondary symptoms in every case, it is undoubtedly
a verv rare occurrence for them to be overlooked by
a physician who e.xpects to see them appear. It
would seem preferable, therefore, to accept this
slight chance of ignoring a case rather than risk
the possibility of condemning many, or even one
innocent patient, to a life of mental misery and un-
necessarily giving him several years of antisvphilitic
treatment'. .A careful search for the Spirochccta
pallida should be made in the primary and second-
arv lesions of every case, for if they are demon-
strated one will add considerable strength to the
diagnosis. The time is probably not far distant
when a diagnosis of chancre can be based upon
a diagnostic serum or by the microscopical examin-
ation of a smear preparation and the constitutional

566

MEDICAL RECORD.

I April 6, 1907

treatniciit at once inslilutcd. It is not beyond rea-
sonable expectation to anticipate the development
of an antihietic serum, doinsj away with the time-
honored mercury.

REFERENCES.

1. Fournier ; Prophylaxis and Ireatment of Syphilis.

2. Ricord: Lemons sur Ic Chancre.

3. Van Buren and Keyes, Genitourinary Diseases, with
Syphilis.

4. Lydston : Genitourinary, Venereal, and Sexual Dis-
eases.

5. Wild : British Journal of Dermatology, May, 1906.

6. Dumesnil : St. Louis Medical and Surgical Journal,
August, 1883.

7. Taylor: (leMitourinary and Venereal Diseases.

8. MacKee; American Journal of Dermatology, St.
Louis, Vol. 10, No. 4.

9. Trimble : Journal of Cutaneous Diseases, October,
1906.

ID. Wassermann, Neisser, and Bruck: Deutsche medi-
cinische Wochenschrift, May 10, 1906.
6i6 Madison* Avenue.

AN EARLY CASE OF FORMAL OPERATION

FOR THE SEPARATION OF JOINED

TWINS (XIPHOPAGUS).

By major CHARLES F. KIEFFER,

SURGBON UNITED STATES ARMY. FORT D. A. RUSSELL, WYOMIN'G, ON
DETACHED SERVICE WITH THE ARMY OF CUBAN PACIFICATION
AT SANTIAGO DE CUBA, CUBA.

The case here reported is of great interest for two
reasons. First, the illustration is an unusually good
one of an extensive keloid growth. Second, the ex-
treme interest of the history the patient gives. This
patient is now in the General Hospital at Santiago
de Cuba, where I saw him while making an inspec-
tion of the institution. On questioning him as to
the length of time during which he suffered from
keloid and the origin of the growth, the following
curious history was developed. The man is very
intelligent, and gives the story with abundant de-
tails. Some of these details I have been able to
verify by old residents of the city. Personally I
am satisfied that the history as given is substantially
correct. It is well worth a place in surgical history.
\enerado Rivero ; negro ; age 66 years. In the
spring of 1840 the African village in which his
mother lived was captured by slave traders and
those of the unfortunate negroes who were not slain
were driven to the coast as slaves over one of those
routes drenched with the blood and tears of the
myriad victims of this hideous traffic. He has never
heard or known the name or exact location of this
village further tlian that it was in the Congo River
District. In the summer of the same year these
people were herded aboard a slaver for export to
America. He does not know the name of the ship,
neither does he know her nationality.

While in midocean his mother fell in labor and
suffered nine days without being delivered. On the
eighth day of her trial the slaver (or "negrero," as
he calls it) was pursued and captured by a Spanish
corvette. La Numancia. On the following day the
wretched woman's condition was discovered. The
Naval surgeon on board La Numancia immediately
performed a Cesarean section and removed a xipho-
pagtis monster. Both were well formed males, and
both were living. The mother died that same day.
On the day of their birth the surgeon of the cor-
vette separated the two children. Venerado is now
living at the age of sixty-six years. His brother
survived the operation three days. One of the
slave women took charge of him and raised him.
The party was landed in Cuba ; worked for a time
as contract laborers or peons, and then became free.
This party is well known in Cuba as the first
emancipados. Venerado's history was perfectly well

known among them, and he has remembered all of
the details as given him by his foster mother and
others of the human cargo of the "negrero." They
have even been able to preserve the name of the
surgeon : Jose Brito y Boin.

The keloid began in the scar over the sternum,
marking the location of the fusion with his mate.
When he was eight years old, in 1848, it had grown
to such proportions that an operation for its re-
moval was made in Havana. The keloid reappeared
in this location, hut never grew to be very thick;
but he remeinbers that at that time he had very
small lesions at the locations of the present keloidal
masses which have slowly increased with his years
until they have developed into the condition as
shown in the picture. He does not remember that
he had any other injuries or scars at these points.

The large mass over the right temple and parietal
region was removed a few years ago, but the tumor
speedily grew again. The white patches under the
iaw mark points of breaking down and ulceration
which began about a year ago. The gross appear-
ance at these points strongly suggests a malignant
transformation of the keloid.

Certainly this case is at least as interesting as
the famous and well-advertised Radica and Doodica
operation, and the percentage of success was the
same. Think of the different circumstances under
which these operations were done! The one in a
perfectly appointed amphitheatre, with the ready
l>ress to carry the news over the world. The other
on the deck or in the hold of a pestilential slave ship.
Remember, too, please, that in this earlier case there
was no anesthesia, no asepsis or antisepsis, and
that it was sixty-six years ago ! I make my homage
to the shade of Jose Brito y Boin. He was evidently
a good deal of a surgeon, as well as a good deal of
a man.

April 6, 1907]

MEDICAL RECORD.

567

Medical Record.

A Weekly "Journal of Medicine and Surgery.

THOMAS L. STEDMAN, AM., M.D., Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, April 6, 1907.

THE CURABILITY OF PARANOIA.

Paranoia has long stood as a bete noir of psychi-
atry. Krafift-Ebing in his fourth edition (i8go)
gave out as a dictum that he had never seen a patient
suffering from paranoia recover. His definition,
however, almost precluded the possibility of any
other standpoint, and as his writings obtained a wide
vogue we find the same standpoint reflected among
many English and American writers, most of whom
have slavishly followed Krafft-Ebing. Within the
past fifteen years, however, it has been becoming
evident that paranoia, in the sense in which Krafft-
Ebing used the word, is not one disease, but a num-
ber, and newer investigations have thrown into high
relief the fact that one is compelled to adopt Wer-
nicke's comprehensive even if less definite term of
the paranoid states, if one is to avoid the discomfort
of finding one's incurable paranoiacs turn out to be
curable something else. This has happened to
almost all practising alienists, especially those im-
bued with Kraft't-Ebing's ideas, although asylum
physicians, who are less liable to have acute and mild
paranoid conditions come before them, are less often
called upon to revise their opinions.

Modern French authors — notably Anglade, in
Ballet's Traite de Pathologic mentale — have at-
tempted a comparative study of the terms used to
define the paranoid states with a marked degree of
satisfaction. The most marked group of these states
constitutes the systematized delusional or primary
paranoias, under which heading one finds the acute
simple and hallucinatory forms, as well as the
chronic systematized delusional ones. In the former,
the prognosis, if we follow Mendel, may be cure,
cure with remissions, episodic and recurrent attacks,
and chronic forms. It is not certain that the recur-
rent cases are not referable to Kraepelin's manic de-
pressive group, although Ziehen and his followers
maintain the occurrence of a periodic paranoia with
a good prognosis. As for the chronic systematized
forms, the prognosis is bad. It should not be over-
looked, however, that Bartels, Freyberg, Ilberg, and
a number of other observers have described recover-
ies with fair or complete insight even in this group,
and that both Wernicke and Kraepelin admit the
curability of this form at times.

The old delusional manias and melancholias of
our American asylums are grouped by Anglade with
the secondary paranoias. These are of frequent
occurrence in other psychoses following infectious
diseases, and are particularly frequent in many in-
■ toxications, notably alcoholic. In this latter form

delusions of jealousy, as well as persecutory delu-
sions, are extremely common. Delusions of persecu-
tion in morphinists and cocainists are not unknown.
The great group of the paranoid dements is to be
classed here. The prognosis in this group is in gen-
eral good, depending on the nature of the primary
affection. Even the paranoid dements sometimes
gain insight.

A third group of Anglade's is perhaps the most
interesting from the medicolegal point of view. Here
are the many half fools, half geniuses of the world —
the long-haired reformers, the unsuccessful but
never-daunted inventors, the erotics, and perhaps
many of the perverts. Those suffering from pho-
bias, obsessions, fixed ideas, etc., all meet in this
common ground of defectives of a mild grade.
Those in whom the stamp of persecutory delusions
comes out with any degree of force are the subjects
of the rudimentary or abortive paranoias of Mor-
selli, Westphal, and others, or of the isolated mono-
manias, a term which has done so much to cloud the
real nature of the defects of judgment in these indi-
viduals. In many of these the prognosis is good,
especially if neurasthenic overtaxation is responsible
for the efflorescence of the psychotic state.

Thus it may be seen from this short review that
"die paranoische Frage," as our German friends call
it, is not by any means a simple matter. With Wer-
nicke at one side laying much emphasis on the dif-
ferent paranoid states, and Kraepelin on the other
storing away the same patients in one or other
pigeon holes of his category, until few real "para-
noias" in his restricted sense remain, one has ample
ground for much disputation.

THE COURSE OF LYMPHATIC INFEC-
TIONS.

Some years ago Weleminsky reported a series of
experiments he had made on guinea-pigs in order
to determine the lymphatic channels traversed by
infectious agents entering the body through different
portals. For this purpose he infected about 1,000
animals in different parts of the body with tubercle
bacilli and then killed them at definite intervals.
The result was that no matter what the site of the
original infection had been, whether subcutaneous,
under the chin, at the angle of the jaw, in the axilla,
or in the groin, intraperitoneally, or even directly
in the intestine by enema, in every case first the
local lymph glands, then those lying along the route
to the bronchial glands, and finally the bronchial
glands themselves were invaded by the infectious
process. Not until the bronchial glands had become
involved did the blood stream become contaminated,
that is to say, the lungs were ahvays attacked after
the bronchial glands. Weleminsky, therefore, re-
garded the bronchial glands as a center for the entire
lymphatic system, a lymph heart, so to speak, toward
which infectious streams from the periphery con-
verge and from which infections of the blood take
place.

These conclusions have recently been assailed bv
Beitzke on the ground that the bronchial glands
might also be infected from above through inhala-
tion or through the animal's swallowing tubercle
bacilli set free through the rupture of the abscesses

568

MEDICAL RECORD.

[April 6, 1907

formed in consequence of the subcutaneous inocula-
tion. He also asserts that the possibility that tuber-
cle bacilli may gain access to the bronchial glands
from the blood stream has not been sufificiently con-
sidered by Weleminsky. The latter author in the
Berliner klinische IVochensclirift, March 11, 1907,
publishes a rebuttal of these criticisms, and offers
further evidence confirmatory of his original stand-
point. To discuss his statements in detail would
require too much space, but, while there is undoubt-
edly much to be said on both sides, there appears to
be good reason to believe that in future the bronchial
glands must be accorded even greater importance in
the mechanism of pulmonary infection than has
hitherto been the case.

EXPERIMENTAL ARTERIOSCLEROSIS.

Hand in hand with the increasing realization of the
importance clinically of the changes in blood pres-
sure and other accompaniments of arteriosclerosis,
have gone the attempts to obtain a deeper insight
into the nature of the lesions of the vessel walls by
endeavoring to counterfeit them experimentally. A
considerable literature on the subject has already
accumulated, and it seems settled that at least two
substances, nicotine and adrenalin, when injected
into the vessels of rabbits during considerable
periods of time, in a large proportion of the cases
occasion changes in the aorta which simulate the
lesions of human arteriosclerosis more or less
closely. Sceptics are not lacking, however, and not
very long ago so good a judge of such matters as
Kaiserling expressed the view that the experi-
menters in this field had not yet proved their point,
and that an attitude of reserve in regard to their
results was still advisable. He called attention
especially to the fact that sufficient consideration
had not been given to the condition of the blood
vessels in untreated rabbits, and suggested that
some one should investigate this matter in, say, a
thousand animals, in order that satisfactory control
statistics might be made available.

While such an attitude is perhaps unduly con-
servative, it is certain that some of the earlier com-
munications on the subject were published before
the results had been checked up with the necessary
care. For example, Koranyi. who was one of the
first to report that the adrenalin lesions could be
diminished or prevented by the simultaneous injec-
tion of iodides, has recently {Deutsche medizinischc
IVochensclirift, January 31, 1907) admitted that he
was mistaken in his conclusions. The iodine prep-
aration he used has an oily base, and control experi-
ments made by injecting oil of sesame without
iodine showed that it was the oil and not the iodine
that had been the effective agent. Biland even
believes that the simultaneous injection of potassium
iodide together with the adrenalin intensifies the
damage wrought by the latter, so that the attractive
supposition that an explanation had been offered
of the manner in which potassium iodide exerts its
beneficent action in certain cases of vascular dis-
order appears untenable.

Lately, Loeb and Fleischer (Deutsche medizin-
ische Woclicnschrift, March 7, 1907) have reported
on an extensive series of experiments undertaken

in order to investigate this question. They express
the opinion that it is not possible by means of injec-
tions of iodine preparations to prevent the develop-
ment of the adrenalin lesions in the rabbits aorta,
and state that they were not able to observe any
beneficial results from the procedure. On the con-
trary, when large amounts of the iodides were used
the effect appeared to be distinctly injurious, and the
adrenalin lesions were increased in intensity instead
of being diminished. Injections of small or of rela-
tively large amounts of potassium sulphocyanate did
not intensify the action of the adrenalin, and there
seems a possibility that this substance may tend to
prevent it. The authors consider, however, that
their experiments are not conclusive as yet, and that
further observations on larger series of animals are
necessarv before a definite statement is justifiable.

THE DIAGNOSIS OF BONE TUMORS BY AN
EXAMINATION OF THE BLOOD.

.-\ttextiox has been called during recent years to
the peculiar picture presented by the blood in the
presence of malignant metastatic deposits in the mar-
row of the longbones. This closelyresem.blesasevere
pernicious anemia and myelocytes are present in
large numbers. The condition is believed to be due
to the encroachment upon the normal boundaries of
the cavity by the growth. It has been claimed
that this particular blood picture, which can be
definitely distinguished from an essential pernicious
anemia as well, as from the various leukemias,
may serve as a means of diagnosis even when
the original neoplasm cannot be located with cer-
tainty. The validity of this claim is apparently
demonstrated in three cases reported by Schleip in
the Zeitschrift fiir klinische Medidii, Vol. 59, Nos.
2 and 3, in all of which the blood changes referred
to were present and at autopsy a more or less
extensive infiltration of a malignant character was
tound to be distributed throughout the marrow of
certain of the long bones.

These cases are of considerable intere.-t xrom the
diagnostic standpoint. In the first there uas pres-
ent a primary carcinoma of the stomach which
gave rise to practically no symptoms, but to a num-
ber of metastatic bone deposits. The only svmptom
:eferable to the latter was a transitory pain over
the tibiae. An examination of the blood shoved
nucleated red cells, numerous myelocytes, and cer-
tain abnormal cell forms which were found post
mortem to be identical with the cells of the metasta-
ses in the bones. In the second case the patient
was the subject of a profound anemia and presented
the general characteristics of Hodgkin's disease,
and the suspicion of a malignant neoplasm partial'y
confirmed bv the blood picture was fuliy demcu-
strated later by the finding of a primary carcinoma
of the verm.iform appendix with numerous metasta-
tic growths in the bones. In the third case the
writer found certain cells which were more than
half as numerous as the leucocytes. The increase
in these cells was accompanied bv an absolute as
well as a relative decrease in the number of normal
Ivmphocytes. These abnormal cells were at first
reg-arded as bone-marrow cells, as initial stages of

April 6, 1907]

MEDICAL RECORD.

569

the myelocytes, but a more careful exsaiiuatioii
showed that they were entirely d't^ferent iu char-
acter, and the autopsy disclosed a diffuse sarcoma-
ous infiltration of the marrow of most of the bones
together with an involvement of tlie lymphatic
glands.

These findings are of particular interest, as a
knowledge of the fact that the blood picture may
afford some clue to the correct diagnosis in obscure
instances of malignant disease may aid in confirming
a suspicion as to the true nature of the case which
could not otherwise be supported.

The Benzidin Test.

The value of Adler's benzidin test for blood has
already been attested by numerous observers. In-
deed, the most serious drawback that has been
alleged against it is that of being too delicate, and
Schumm has even expressed the opinion that ow-ng'
to this excessive sensitiveness it is not suitable for
ordinary use in testing feces. Schlesinger and Hohf
{Mi'mchcncr medidiiischc IVoclicnschrift. March 5,
1907), however, describe a method by means of
which they consider that all the advantages of tlie
reagent are retained, and it is made available for
routine use. The patient should refrain from meat
for three, or better four, days and from the mixed
stool of a single evacuation a portion the size of a
pea is shaken up with a small quantity of water
in a test tube, and the mixture boiled for a few min-
utes. -A. few drops of this fluid are added to the
reagent in another test tube. and. if blood is present,
a green or blue color, depending on the amount
of blood, will appear. The reagent consists of a
freshly prepared, saturated alcoholic solution of ben-
zidin acidulated with glacial acetic acid. To one-half
c.c. of this two to three c.c. of 3 per cent, peroxide
of hvdrogen solution is added. That the test per-
formed in this way is not misleadingly delicate is
shown by the fact that in a series of one hundred
and fifty stools from patients supposed to have gas-
trointestinal ulceration or carcinoma, negative re-
sults were obtained in about one-third of the tests
The authors also recommend it highly for the pur-
pose of detecting minimal amounts of blood in urine,
and suggest the following mode of procedure. To
ten c.c. of urine in a test tube one-half to one c.c. of
acetic acid is added, and, after shaking, one-third of
the volume of sulphuric ether is added. The whole
IS well shaken, and the ether extract is caused to
separate completely by dropping in five or ten drops
of absolute alcohol. This clear ether extract is then
tested with the benzidin reagent in the manner indi-
cated above. It was found that, performed in this
way, the benzidin test was twenty times as delicate
as Heller's test, and five times as delicate as the
aruaiac and aloin tests.

chcnsclmft, 1907, Xo. 2) that the diagnosis in sus-
pected cases be aided by an examination of the
urine. The test for the presence of a toxin is made
by boiling a small quantity of the latter and then
adding a few drops of fluid nitrate of mercury. If
there are no intestinal parasites present the urine, it
is claimed, becomes milky and a white precipitate
is finally thrown down, otherwise it turns a gray or
black color. From a large number of observations
it has been found that the latter reaction is always
constant when intestinal parasites are present, al-
though there are several sources of error which
must be guarded against. For two days previous
to the test the patient must not be given any medi-
cine, as there are a number of drugs which give
rise to a similar urine reaction. This is particularly
true of sodium bicarbonate as well as all other
alkalies, of substances containing lead and sul-
phur, and of certain salts of iron. The salicylates,
morphine, carbolic acid, zinc and copper salts,
quinine, and antipyrin fail to give rise to either a
gray or a black discoloration. The presence of al-
bumin, sugar, or indican in no wise influences the
test, although pus may. A positive result does not
give any clue as to the variety of parasite present,
although it is claimed that the reaction is much
less marked with round than with flat worms. It
is also stated that a microscopical examination will
afford more detailed information as to the specific
infection present. If a few drops of the suspected
urine are evaporated on a glass slide, the finding
of numerous small granular crystals is claimed by
Jefimow to point to the presence of tapeworms,
"while a similar deposit of cruciform crystals de-
notes infection with the nematodes.

The Diagnosis of Helminthiasis.

It is often a very difficult matter to diagnose the
presence of intestinal worms because they fre-
quently lead to symptoms which are not likely
to be attributed to this cause. An examination
of the stools is not always reliable, for the organ-
isms may be extruded at irregular intervals, and
even frequent attempts may lead to negative re-
sults. In the belief that intestinal worms, similar
to other parasitic organisms, excrete a toxin which
circulates through the body of the host, it is sug-
gested by Jefimow {Kliiiisch-fherapciitischc IJ'o-

Pseudostenosis of the Mitral Valve.

The differentiation of the physical signs associated
with organic heart disease and those of purely
iuncl'ona! disturbances, constitutes one of the most
difficult problems in cardiac pathology. A well
marked presystolic murmur is often found in young
individuals, and this in the presence of dyspnea on
exertion and cardiac palpitation is accepted as evi-
dence of mitral stenosis. Later examination may
fail, however, to confirm this fact and the apparently
well marked murmur is no longer present. In such
cases we usually find symptoms of chlorosis present
and the functional disturbances of the heart are of
little clinical importance, their practical interest
merely residing in the possibility of confusion with
those produced by organic cardiac lesions. Two
factors are associated in the production of these
functional murmurs — the condition of the blood and
the slowing of the blood stream, particularly during
the presystolic phase. There may also be present
some change in the manner of the auricular con-
tractions under the influence of the increased irrita-
bility of the cardiovascular apparatus. The dif-
ferential diagnosis between true mitral stenosis and
the functional pseudomitral stenosis must be based
entirely on the palpatory and auscultatory signs.
Bard, writing in La Semainc Mcdicale. No. 30,
1906, divides the physical phenomena of mitral
stenosis into two categories — those due to the pas-
sage of the blood through a narrowed ostium and
those dependent upon a rigidity of the valves. The
trcniivr on palpation and the sounds heard on auscul-
t;ition ;nay be included in the former, but neither
is sufiicieiitly characteristic of cither type to permit
it to be used as a basis for a differential diagnosis.
A phenomenon of the second type is the short, sharp

.1/^

MEDICAL RECORD.

[April 6, 1907

vibration which closely follows the tremor already
referred to. This sign is considered by Bard to
be quite characteristic of organic mitral stenosis
and is absent in the false form. In a case of pseudo-
stenosis it is not possible moreover to determine by
[Palpation whctlier this fremitus is systolic or pre-
systolic, and it is only by auscultation that we be-
come aware of the presystolic character of the sound,
which is also much softer and weaker than the
fremitus evident to the iiand.

The Action of S.\line Infusions in B.\ctekial

I'OXEMI.'K.

The good results attained in the treatment of
to.xemias of bacterial origin by the infusion of
physiological salt solution has been ascribed to the
e.xcretion of the diluted to.xins following an increase
in heart action and blood pressure and the resultant
diuresis. In other words, the process may be de-
scribed as a lavage of the blood. This view of the
question is contradicted, however, by Berend and
Deutsch {Centralblatt fiir die Grensgebiete dcr Med-
ium tind Chinirgie, Vol. IX., No. 19), who have
made a series of experiments on animals poisoned
by bacterial toxins of various kinds and found that
the "lavage" either with or without venesection is
l>ractically without effect, as a rapid union between
the cells and the toxins always takes place which it
is impossible to break up by the method mentioned.
The favorable effects of saline infusions which have
been a matter of clinical record must therefore be
ascribed to a stimulation of the cardiac function and
the increased blood pressure rather than to a diluent
action, according to the observations of these writers.
.'\n exception is granted, however, in uremic condi-
tions where the affinity between the cells and the
toxins is less marked, and here the infusion com-
bined with venesection is more truly a washing out
of the system through the blood channels.

The Present Status of Ethyl Chloride as an
Anesthetic.

An interesting discussion on the value of ethyl
chloride was recently held before the Society of
Anesthetists — as reported in the Lancet for March
16. Dr. Mennell stated his reasons for having prac-
tically discontinued the use of this anesthetic, his
action being based upon a number of cases at St.
Thomas' Hospital. He showed that ethyl chloride
increased the coagulability of the blood, and that in
consequence of this pulmonary embolism occurred
after the use of the ethyl chloride-ether sequence
more frequently than when ether was preceded by
nitrous oxide. In the discussion that followed ex-
ception was taken to the alleged danger of embolism.
Dr. Llewellyn Powell had seen instances of un-
doubted embolism, but not as yet in connection with
the use of ethyl chloride. Dr. J. F. W. Silk was
accustomed to employ ethyl chloride in large doses
with free air dilution, the object being merely to
obtain a degree of insensibility sufficient to allow
for the introduction of such an anesthetic as the
A. C. E. mixture. Other speakers testified to the
value of ethyl chloride before ether in muscular and
in alcoholic individuals. Some were unable to cor-
roborate Dr. Mennell's conclusions as to the detri-
mental after-effects from ethyl chloride, and thev
thought that very likely some of the ill-eflects de-
scribed were due to the ease with which ether was
used to excess in immediate sequence to ethyl chlo-
ride.

The Tuberculous Opsonic Index.

Drs. Stewart and Ritchie described at a recent
meeting of the Edinburgh Medicochirurgical So-
ciety a method by which they thought tuberculosis
could be discovered in the very earliest stage (Brit-
ish Medical Journal, ?ilarch 16). This method con-
sisted in the injection of a minute dose of tuberculin
K, and observations of the tuberculo-opsonic index
of the blood before and after inoculation. The tu-
berculo-opsonic index alone might give very falla-
cious results, as in a large number of undoubted
tuberculous cases it might lie within a normal limit.
When 1/500 of a milligram of tuberculin R was in-
jected into nontuberculous subjects the opsonic
index rose, but when administered to tuberculous
patients it fell. If this "negative phase" appeared
after inoculation of any person, the diagnosis of
tuberculous disease was, in their opinion, established.
Their investigations were based on a total of sixty-
two cases of tuberculous disease of various forms
and on thirteen nontuberculous persons.

Npuih of tljp Mnk.

The Evil Consequences of Bossism and Oppres-
sion in Medical Organizations. — Dr. Joseph D.
Bryant, now president-elect of the American
Medical .Association, said, in his presidential ad-
dress before the Medical Society of the State of
New York : "If, on our part, a spirit of fraternal
oppression of any kind should develop as the out-
come of organized strength, then indeed will the
day of consolidation become one of mourning for
the loss in fraternal fellowship and in professional
station, instead, as it ought, a day of rejoicing
because of the great opportunity for general good,
thus brought into existence." These truths
should reach a wider audience than the compara-
tively^ few who were privileged to listen to Dr.
Bryant's eloquent and thought-inspiring address.

American Anti-Tuberculosis League. — This
society will hold its next meeting at Atlantic
City, N. J., on June i to 4, 1907, under the presi-
dency of Dr. George Brown of Atlanta, Ga. The
headquarters of the League will be at the Hotel
Holmhurst. The chairman of the Reception
Committee is Dr. Edward Guion of Atlantic City,
to whom communications from those desiring
further information may be addressed. The
League, as announced in the notice of meeting,
has been organized for the prevention of con-
sumption : to educate the people that this is a pre-
ventable disease ; to secure State aid for poor con-
sumptives : to establish hospitals in every State
in the Union. Its membership is not limited to
physicians, but is open to all men of whatever
calling to whom these objects appeal.

The State's Ice Supply. — Commissioner Porter
of the State Board of Health, in a communication
incorporated in the March issue of the bulletin of
the department, states that a bill will be introduced
in the Legislature designed to give the department
effective powers of supervision over the business of
liarvesting and distributing natural ice. The Com-
missioner says that the department now has no
authority and no funds for this purpose. The gen-
eral subject of infection through ice is also discussed,
and attention is called to the fact that the danger
from ice that has been kept in storage for anj' length
of time is comparatively remote. It has been found
in general that bacteria are reduced in number about
50 per cent, after exposure to freezing temperatures

April 6, 1907]

MEDICAL RECORD.

571

for a period of one hour. 90 per cent, after twenty-
four hours, and practicall\- 100 per cent, after ex-
posure from two to three weeks. The few that are
not killed after exposure for, say one month, have
become so attenuated as to be unable to produce
disease. On the other hand, however, Dr. Porter
speaks of the real dangers of infection due to han-
dling and distributing, to surface pollution due to
the pernicious practice of flooding ice to get a
thicker crop, to rains and melting snow washing pol-
lution from side slopes on to ice already formed,
and finally to the dangers of artificial ice when this
has been manufactured from contaminated water
and delivered to consumers before the natural proc-
ess of purification has had an opportunity to become
effective.

Antivivisection in This State. — A bill has been
introduced in the .Assembly at Albany providing for
the restriction of research by means of experiments
on living animals. The bill does not seek to abolish
vivisection altogether, but is designed to confine ex-
perimentation of this sort to certain qualified per-
sons. The bill provides that experiments on living
animals shall be attempted only under the authority
of the faculty of a college or university incorporated
under New York laws or under the authority of the
State Commissioner of Health, or a City Board of
Health. The place where the experiment is con-
ducted must be registered with the State Health
Commissioner, who shall license the holder to pur-
sue animal experimentation. Before and during the
experiment the animal must ht completely under an
anesthetic. If pain is likely when the effect of the
anesthetic has ceased, the animal must be killed im-
mediately. It is further provided that the experi-
ment must be for the advancement of knowledge
useful for saving or prolonging life or alleviating
suffering.

Eye-glasses for School Children. — The Board
of Education is considering the advisability of pro-
viding spectacles for those of the pupils m tne city's
public schools who require them. .According to a
report made by the Committee on Elementar\-
Schools, about 36,000 children in the schools, or
about 6 per cent, of the total number, are suffering
from visual defects that demand correction if the
scholars are to profit to the full by the opportunities
for study given them. The committee submitted
four resolutions intended to cope with the problem.
The first of these suggested that the Board of Esti-
mate be requested to appropriate $^0,000 for the
purpose of fitting up centers for the examination of
children whose sight is defective and to provide eye-
glasses made to prescription. The second resolution
provided that the Department of Health be requested
to furnish thirty expert oculists to examine the eyes
of all the pupils of the public schools who are re-
ferred to them bv the medical e.xaminers in the
schools. The third authorized the Committee on
Elementary Schools to invite five prominent oculists
to advise the committee as to the equipment of the
examination centers. The fourth authorized the
Committee on Supplies to secure bids for the equip-
ment of the examination centers and for the supply
of eye-glasses, in the event of the Board of Estimate
granting the appropriation asked. It is estimated
that all the spectacles necessary could be purchased
for about S6.000.

Spectacle Swindler. — A large number of
mothers in Queens and Nassau counties have been
swindled out of from $2 to $5 by a young man who
impersonated a Board of Health inspector and stated
that he had been sent to examine the children's eves.

He prescribed glasses, and said that these must be
provided before the child could be allowed to con-
tinue at school. He then oft'ered spectacles which he
said would correct the fault, and is said to have
effected a large number of sales.

Shellfish from Polluted Waters. — A report has
been made by Dr. B. R. Richards of the bacteriologi-
cal laboratory of the Boston Health Department
showing that most of the shellfish taken, from New-
England waters, at least, is likely to be contaminated
with sewage organisms. Clams collected along the
coast from Digby, N. S., to the shoulder of Cape
Cod, were tested for sewage organisms, and only
those dug at Yarmouth, Mass., were found to be free
from infection. Oysters, most of them brought from
Cape Cod, made a better showing, and in most of the
samples the evidence of contamination was insignifi-
cant. Maine lobsters were found in a satisfactory
state, except those that had come by land and had
been packed and handled carelessly. It is stated in
the report that it is a question whether shellfish
taken from sewage polluted waters are safe articles
of food, even if all infectious organisms have been
killed by cooking.

Lectures on Public Health Topics. — The Ford-
ham University Medical School announces a series
of lectures on Tuesday afternoons in April at 4
P.M. on "Public Health Problems and Hygiene"
under the auspices of the New York City Depart-
ment of Health. These lectures are to be illustrated
by lantern slides showing conditions and their ameli-
oration in New York. Memliers of the medical pro-
fession are invited to attend. The first lecture will
be given on April g by Dr. Thomas Darlington,
Commissioner of Health of New York City, on
"The City's Health." Dr. John S. Billings, Jr.,
Chief of the Division of Communicable Diseases,
will lecture on April 16 on "The City and Tubercu-
losis," and on .^pril 23 on "The City and Typhoid
Fever and Other Communicable Diseases." Dr.
John J. Cronin of the New York Department of
Health will lecture on April ^o on "The City and
School Health."

Anti-Cocaine Bill Passed. — The .\ssembly at
Albany on March 28 unanimously passed the Smith
l)ill. intended to restrict the use of cocaine. The
bill, which was opposed by the patent medicine inter-
ests, provides that cocaine shall not be sold except
on a physician's prescription, to be filled but once.
.Another bill has been introduced by Assemblyman
Smith, which prohibits the sale and manufacture of
cigarettes in this State.

New Medical Organization. — A meeting of
about fifty physicians interested in insurance exam-
inations was held in Boston last week to discuss the
organization of a society composed of workers in
this field. Addresses were made by Drs. E. M.
Green, Qiarles D. Cutting, and Francis Donoghue.
A committee was appointed to draft a constitution
and by-laws and to nominate officers.

Tulserculous Cows in New Jersey. — It is the
opinion of some of those conversant with the con-
ditions, that in the neighborhood of 40 per cent, of
the milch cows in the State of New Jersey are tuber-
culous. In order to encourage farmers to have their
stock inspected, the State Commission on Tubercu-
losis in .A.nimals is paving full value for animals
killed. Recently twenty cows out o'f a herd of forty
were found tuberculous and were condemned, the
owner receiving full compensation.

Civil Service Examinations. — The State Civil
Service Commission will hold examinations
.April 27, 1907, for the following medical posi-

0/^

MEDICAL RECORD.

[April 6, 1907

lions among others : Health Officer, Town of
Scio, Allegany County ; Medical Superintendent,
State Hospital for Tuberculosis. The last day
for filing applications for these positions is April
20. Full information and application forms may
be obtained by addressing the Chief E.xaiiiiner of
the Commission at .Mbany.

Society of Sanitary and Moral Prophylaxis. —
.\ regular meeting uf this Society will be held at
the Academy of Aledicine, Thursday, April 11, at
8:30 P.M. The following papers will be read;
(i) "How and to What Efifective Extent Can the
Health Authorities Aid in the Prophylaxis of
Venereal Diseases," by M. M. L. Coplin of Phila-
delphia; (2) "Professional Secrecy and the Obli-
gatory Notification of Venereal Diseases," by \Vm.
A. Punington ; (3) "The Medical Secret and the
Safeguarding of Alarriage from -Venereal Infec-
tion," by Edward L. Keyes and Egbert H. Gran-
din.

For a New State Hospital. — As the State's lease
of Ward's Island expires in five years, the State
Lunacy Commission is making arrangements for the
disposal of the 4,000 odd insane patients now quar-
tered there. It is the plan of the commission to
have the State purchase a site of large size suitable
for the construction of a hospital of the colony type.
It is desired to find such a site within easy access
of the city, both by rail and by water. The commis-
sion has drafted a bill for passage by the Legisla-
ture at the present session to provide for a small
appropriation for the expense of finding a suitable
site.

Commission on Problems of Nutrition. — Under
the auspices of the Cniversity of Illinois, a commis-
sion was organized at a conference held in this citv
last week for the purpose of conducting experiments
on the effect on the consumer of the preservatives
in common use in food stuffs, especially meats. The
work will be done under the direction of Prof. H. S.
Grindley of the department of physiological chem-
istry of the university, and with him on the commis-
sion are R. H. Chittenden, Professor of Physiologi-
cal Chemistry of Yale ; J. J. Abel, Professor of
Pharmacology of Johns Hopkins L'niversity, and A.
P. ^Mathews, Professor of Physiological Chemistry
of the University of Chicago. The expense of the
investigations is to be borne in part by the univer-
sity and in part by some of the beef packing houses
of Qiicago.

Chicago Ambulance Surgeons. — Under the su-
pervision of the Chicago Health Department, 915
calls were responded to during the first four
weeks of the service by the ambulance surgeons ;
S77 ill and injured w-ere removed to hospitals ,
296 individuals received first aid, and of this num-
ber 99 were taken to their homes ; 67 patients
with contagious diseases were removed to the
county and other hospitals; 49 miscellaneous
cases, including 5 insane and destitute persons,
were cared for, and 915 individual reports were
received and filed by the ^ledical Inspector. Thus
far the ambulance service has given excellent
satisfaction.

Scarlet Fever in Chicago. — In reply to circulars
of inquiry sent to physicians reporting terminated
cases of scarlet fever, answers were received from
nearly three hundred, reporting four hundred and
ninety-nine cases, of which seventy-one were de-
nominated atypical scarlet fever. There were also
reported at the County Hospital during January
thirty-seven cases of scarlet fever terminated, in
February seventv-one, and in March ninetv-three.

making a total of seven hundred cases reported in
full in answer to the circular inqui'ry. The ages of
the patients varied from four months to fifty-seven
years. The forty-four deaths occurred at the ages
of one year to forty years. Four hundred and
twenty-five of the cases were mild. Of the atypical
cases, most of them were so described on account
of the mildness of the symptoms ; others because
they lacked one or more of the classical symptoms.
In very few cases, not over twenty reported by
physicians, no peeling was observed. The County
Hospital records mention that symptom in a few
instances only. Four had had scarlet fever before.
.\s to the complications, albuminuria, adenitis,
otitis, and arthritis were most prominent in the order
named. Eighteen cases had diphtheria at the same
time, si.x had measles, fourteen varicella, and two
pertussis. .Seven had pneumonia, four endocarditis,
one pericarditis, and three purulent conjunctivitis.

Automobile Rides for Hospital Patients. —
Largely through the efforts of Magistrate Crane
and Mr. W. E. D. Stokes, several automobile deal-
ers and owners have made arrangements with vari-
ous hospitals to send their cars once a week to take
convalescent patients for an airing.

Red Cross Congress. — Aliss Mabel T. Board-
man and Surgeon-General O'Reilley of the Army
have been designated as delegates to the Interna-
tional Red Cross Congress, to open in London on
June ID. Four other delegates remain to be ap-
pointed by the State Department.

A New Journal. — Cinder the title of The Proc-
tologist, the first number of a new journal to be de-
voted to the surgery of the rectum appears in St.
Louis. It is a quarterlv. and is edited and published
by Dr. Rollin H. Barnes.

Rebellious Farmers. — At a meeting of about
300 farmers of Rhode .Island and Massachusetts
held in Swansea last week, it was decided to pro-
test against the proposed application of the tubercu-
lin test to the herds in the neighborhood of Fall
River. This action was the result of the announce-
ment of the Fall River Health Board, acting on a
suggestion of the State Board of Health, that it
would be desirable to have the dairy herds of that
section properly inspected.

Infectious Disease Among Dogs. — In Chester,
Pa., a large number of dogs have been discovered
suffering from an infectious disease alleged to be
diphtheria. To prevent its spread, all the animals
attacked are being killed, and notices have been sent
to all owners of dogs to report any evidences of sick-
ness in their live stock.

A Royal Consumptive. — According to the cable
despatches. King .\lfonso of Spain is suffering from
tuberculosis and the Spanish court is very uneasy
regarding his condition.

Meningitis at Harvard. — The death of a mem-
ber of the sophomore class at Harvard is reported
after an illness of four days from cerebrospinal men-
ingitis.

Williamsburg Hospital. — At the annual com-
petitive examination for internes in the Williams-
burg Hospital held last week, the first place was-
won by Miss Mary Crawford, a student in the Cor-
nell L^niversity Medical School. She will be the
first woman to hold such a position in a Brooklyn
hospital.

Montana State Board of Health. — The new

Montana State Board of Health, created under an
act of the Legislature replacing the old board, at its
organization meeting in Helena on March 15 elected'

April 6, 1907]

MEDICAL RECORD.

as President Dr. William J. Treacy of Helena, and
Secretary Dr. E. D. Tuttle" of Billings.

Greenwich (Conn.) Medical Society. — At the
annual meeting of this organization officers were
elected as follows : President, Dr. L. P. Jones ; Vice-
President, Dr. Frank Terry Brooks ; Secretary and
Treasurer. Dr. J. A. Clarke.

Northwest Arkansas Medical Association. — At
the meeting of this society held in Ft. Smith on
March 20 the following were elected as officers :
President, Dr. W. N. Yates of Fayetteville ; Vice-
President. Dr. T- I. Smith of Van Buren; Secretary,
Dr. J. A. Foltz of Ft. Smith; Treasurer, Dr. O. M.
Bourland of Van Buren. Fayetteville was selected
for the next annual meeting.

Western Massachusetts Homeopathic Medical
Society. — The following were elected as officers
at the annual meeting of this organization held in
Springfield on March 20 : President, Dr. H. C.
Cheney of Palmer; First Vice-President, Dr. E. W.
Capen of Munson ; Second Vice-President, Dr. S. A.
Lewis ; Secretary and Treasurer, Dr. James B.
Comins.

Memphis and Shelby County (Tenn.) Medical
Society. — At the annual meeting of this society
held in Memphis, officers were elected as follows :
President, Dr. Alexander Erskine of Memphis ;
Vice-President. Dr. George Livermore ; Secretary,
Dr. J. W. Price, reelected.

Florida Medical Association. — The thirty-
fourth annual meeting of this society will be held
at Tampa, April 17, 18, and 19, 1907, under the
presidency of Dr. John McDiarmid of Deland. The
Secretary is Dr. J. D. Fernandez of Jacksonville.

Augusta Medical College. — In order to cele-
brate the seA'enty-fifth anniversary of this institu-
tion, arrangements are being made for a reunion of
as many of its alumni as possible at the ^ipproaching
commencement.

Bequests to Hospitals. — By the will of the late
Dr. J. E. Lothrop of Dover, N. H., the following
bequests are made, payable on the death of the tes-
tator's wife: To the Dover Children's Home, the
Dover public library, and the Went worth Hospital,
§1,000 each, and to the Wentworth Home for the
Aged, $500.

Dr. Reginald M. Rowls has been appointed
Assistant Surgeon to the ^^'oman's Hospital in
this city.

Bequests to Hebrew Institutions. — By the will
of the late Adolphus Price the sum of $500 is left
to each of the following institutions : The Hebrew
Benevolent and Orphan Asylum Society, the Monte-
fiore Home for Chronic Invalids, the Hebrew Tech-
nical Institute, the Home for Aged and Infirm
Hebrews, the Hebrew Sheltering Guardian Society,
the United Hebrew Charities Association, the Mount
Sinai Hospital, and the Children's Aid Society.

Notable Deaths. — From Holyoke, Mass., is re-
ported the death of the oldest woman in the city,
from mumps at the' age of ninety-five years. A
resident of Mechanicsville, Conn., said to be the
heaviest man in New England, died last week at the
age of forty-three years. He weighed 450 pounds,
and until. si.x months ago worked as a weaver. He
died suddenly while in a Turkish bath.

Obituary Notes. — Dr. Otto Albert Weig.\nd
of Jersey City died on March 24 of tuberculosis at
the age of thirty-eight years. He was graduated
from Columbia University fourteen years ago.

Dr. Pemberton Dudley of Philadelphia died on

March 25, at the age of seventy years, as the result
of injuries received some months ago in a trolley car
accident. He had been for many years dean of the
Hahnemann Medical College.

Dr. George Warren Bartow of Three Bridges,
N. J., died on March 28, at the age of sixty-three
years. He was a member of Company A, Fifteenth
Regiment, New Jersey Volunteers, and was
wounded at the battle of Petersburg. At the close
of the war he studied medicine, and received his de-
gree from the College of Physicians and Surgeons in
this city. He had practised in Three Bridges for
thirty- four years.

Dr. Charles E. McAdams of Wichita, Kan., died
suddenly of heart disease in Kansas City on March
19. He was one of the first settlers in Wichita,
and had been a prominent figure in the development
of the city.

Dr. E. W. Slayton of Northfield, Vt., died of
cerebral hemorrhage on March 20, at the age of
sixtv-four years. He was born in Calais, and re-
ceived his early education in Hardwick and Mont-
pelier, receiving his medical degree from the Uni-
versity of Vermont. He began to practise in Albany
in 1866, but two years later removed to Warren,
where he spent the greater part of his life. He had
occupied many official positions, and in iSg8 was
elected to the State Senate.

Dr. Charles R. Browx of Lynn, Mass., died sud-
denly of heart failure on March 21, at the age of
seventy-one years. He was born in Gorham, Me.,
but had resided in Lynn' for about thirty-five years.
He was a graduate of Bowdoin College and of the
Hahnemann Medical School of Philadelphia.

Dr. A. J. Willard, a former superintendent and
resident physician of the Mary Fletcher Hospital.
Burlington, Vt., and founder of the Mary Fletcher
Hospital Training School for Nurses, is dead in his
home in Swanton.

Dr. J. W. McCoxNELL of Cornelia, Ga., died on
March 20 of pneumonia, at tbe age of forty-four
years.

Dr. Robert C. Arnett of Monticello, S. C, died
on starch 18 of nephritis. He was a member of the
Sixth South Carolina Infantry, and was a well-
known practitioner of Fairfield County.

Dr. Clement Overton Fountaine of Crystal
Hill. \'a.. died on March 16 of heart disease at
Gladys, Campbell County. He was graduated from
the \Iedical College of Virginia in 1900. Both his
father and grandfather had been well-known physi-
cians of Buckingham County.

Dr. Albert Fox of Waterbury, Conn., died on
March 20, at the age of eighty-one years. He was
born in East Hartford, Conn., and had practised in
Pawling, N. Y., and in Danbury, Conn. In iQOO
he removed to ^^'atcrbury. where he had since re-
sided.

Dr. Frances Van* Cleve Fuller of Brooklyn
died on March 2'/. at the age of fifty-seven years.
She was born in Newark, and was graduated from
the Woman's Medical College of New York in 1884.
She was one of the first women to be admitted to
membership in the Kings County Medical Society,
and had practised in "Brooklyn for over twenty
vears. Dr. Fuller was the treasurer of the
'Woman's Auxiliary of the State M.ilitia forces in
Brooklyn during the Spanish war.

Dr. Robert Parries of this city died on March 31,
at the age of forty-two vears. He was born in Dum-
fries. S'cotland, but came to this country while a
voung man, and studied medicine at the L'niversity
of Alichigan and at the Long Island Medical Col-

574

MEDICAL RECORD.

[April 6. 1907

Ico;e, being graduated from the latter institution
with the class of 1865.

Dr. Lawrence F. Pekrv, one of the resident phy-
sicians in the Philadel]ihia Hospital, died of septi-
cemia in that institution on March 28, at the age of
twenty-five years. He was born in Ripon, W. Va.,
and was graduated from Jefferson Medical College
in the class of 1905. He had served for fourteen of
the eighteen months of his term.

Dr. Samuel Clarke died at Philadelphia on
March 28. He was graduated from Jefferson Med-
ical College in the class of 1899.

Dr. Samuel D. Bickel died at Atlantic City,
N. J., on March 27. He was graduated from the
Medical Department of the University of Pennsyl-
vania in the class of 1895.

OUR LONDON LETTER.

(From Our Special Corresporuk'nt.)

KALA-AZAR — CEREBELLARi TUMORS — MEMBRANOUS DYSMENOR-
RHEA—URINE FIliRUM.\TA — HOSPITALS — CEREBROSPINAL FE-
VER ; THE ORGANISM — OBITUARY.

London. March is, 1907.

Professor Leonard Rogers devoted his third Milroy lec-
ture to the life history of the kala-azar parasite, the mode
of infection and prophylaxis. As a rule the infection is
largely a house one, and on this fact he based pro-
phylactic measures which were very successful even before
the discovery of the parasite. The organism was found
independently by more than one observer and the difficulties
of differentiating it explains why the disease was long con-
founded with other chronic fevers of malarial kind. The
discovery of the new parasite, the lecturer said, has done
more toward clearing up Indian fevers than anything since
Laveran's description of the parasites of malaria. The or-
ganism can now be found in practically every part of the
body, but is more numerous in the spleen, bone-marrow,
and liver. When Dr. Rogers discovered the flagellate form
suggestions as to its extracorporeal stages were forthcom-
ing. It was thought at first to be very rare in the periph-
eral blood, but Donovan, Christophers, and James found it
in leucocytes. Others reported the parasites in the red cor-
puscles, but this has been questioned, it being considered
that they were only on the surfaces of the red disks. It is
at any rate now clear that they are present in the circulating
blood in large numbers, in most advanced cases, and could
enter the stomach of any bloodsucking insect which might
serve as the host for future development, and this the lec-
turer's work has traced. The organism differs from all
ilagellates previously known. The cultivation must be car-
ried on with strict attention to temperature limitations,
sterility, anaerobic conditions. On considering various
facts in connection with his experiments Dr. Rogers sus-
pected that the bedbug was the carrier of the infection. In
investigating these in plague patients he had previously
found the contents of the stomach sterile — an unexpected
result. He then tested the reaction of the fluid after suck-
ing human blood and found it distinctly acid, showing the
secretion of the organ could neutralize the alkalinity of the
Mood. This led him to try the cft'ect of neutralizing or
faintly acidifying his medium with a drop or two of a sterile
citric acid solution, when he was rewarded with an abun-
dant and complete development of active flagellated forms.
The significance of this is obvious. The next step was to
feed the bugs with infected himian blood, and in this Dr.
Rogers was met with fresh difficulty, the insects refusing
the food in this form. He then mixed human blood from
the spleen with fluid from the stomachs of the insects and
succeeded in developing at suitable temperature fully flagel-
lated forms. It then only remained to find these forms in
the insects after feeding on kala-azar patients. This be-
gun, he had to discontinue on account of his eyes, but his
work was followed up by his official successor. Dr. Patton,
I. M.S., who soon after wrote to him : "I have got the com-
plete cycle of the parasite up to completely developed flagel-
lates ; there is no shadow of doubt that the bedbug trans-
mits the disease." Something yet remains to be done to
ascertain in what form the parasite is again inoculated into
the human body, for the long time during which infection
clings to houses suggests it may be transmitted through the
progeny of the first-affected insects as in the piroplasma
of dogs and cattle. Hence the lecturer said the ovaries and

salivary glands should be carefully examined in fed in-
sects for further stages of the parasite. Nevertheless, our
knowledge of the organism now suffices to make the facts
valuable for prophylaxis. In regard to this the lecturer
described some efforts to destroy insects which had been
tried with more or less success previous to the discovery
of flagellates in the stomachs of bedbugs, and he concliided
by emphasizing the fact that the advances he had described
in our knowledge of the most terrible of all tropical dis-
eases is a pleasing instance of increased interest in these
affections leading to combined work in different places by
medical men of British nationality.

In his concluding Lettsomian lecture Dr. Beevor dealt
with tumors affecting the cerebellum. He said the majority
of extraccrebellar tumors were found in the anterior part
of the posterior fossa between the cerebellum and pons
close to the petrous bone. Occasionally they grew more
posteriorly, compressing the lateral lobe. In both extra-
and intraccrebellar growths severe headache and vomiting
were present. Optic neuritis was earlier in intra- than extra-
tumors. Vertigo or giddiness appeared in Ijoth and the pa-
tient thought objects were revolving in the direction away
from the side of his lesion. In extra-cases compression
of the auditory and facial nerves was common and gave
rise to symptoms. This compression did not occur in intra-
cases. In the limbs paresis was associated with absent knee
jerk in locomotor ataxia; in cerebellar tumor it might be
combined with increase of that reflex. A healthy person
executing a movement against resistance which was sud-
denly removed could prevent the movement being carried
on by bringing into action the antagonizing muscles, but
this power appeared to be lost in cerebellar tumors. Also
when the patient closed his eyes the ataxy was in-
creased, showing its origin to be central, not peripheral
as in locomotor ataxia. The peculiar staggering gait was
likened to a landsman trying to walk on a rolling sea, but
there was a tendency to go to one side more than the other.
It was difficult to say which way he would fall ; he tended
to deviate to the side of the lesion and so might walk in
a circle; but he was conscious of this and tried to coun-
teract it by bringing forward the shoulder of the same side.
.•\nothcr test was to make the patient stand on one leg
and then on the other ; he would be more unsteadv on the
same side as the lesion. That was the walk of both forms.
In extraccrebellar tumors the knee jerk was not altered; in
intraccrebellar it might be diminished on the same side, but
this was very uncertain. As to the diagnosis from cerebral
tumors, there was to be considered absence of mental symp-
toms, sphincter troubles, and epileptiform attacks. A reel-
ing gait associated with deviation — say to the left — with
weakness of movements of the eyes to the left and paresis
of left limbs without alteration of refle.xcs. would be in
favor of intracerebellar growth in the left lateral lobe.
Deafness and left facial paralysis, with weakened eye and
limb movements of left side, and weakness and rigidity
of the right limbs with increased knee jerk and extensor
plantar reflex indicated an extraccrebellar tumor on the
left side.

Membranous dysmenorrhea was discussed at the Gyne-
cological Society last month. Dr. S. J. Aarons showed
specimens from four cases. In none of the casts was there
a cavity, though one of them showed a small opening sug-
gestive of closure by pressure. His treatment was curettage
followed by the application of nitric acid.

Dr. M. Moullin thou.ght curettage useless and no treat-
ment of much value. The cases he had seen were nearly
all in sterile women. He had sometimes seen a second
membrane passed within four days of the first, showing
the rapidity with which it may be formed.

Dr. Hey wood Smith could hardly imagine a dysmenor-
rheal membrane not to be an open sac.

Dr. Giles was interested at finding some of these casts
solid, contrary to the usual teaching. As they were formed
by exudation in the uterine cavity it was not very sur-
prising that such exudation should sometimes appear solid.
If the cavity was distended the exudation might solidify
before the surfaces came together and so a cavity result.

Dr. Macnaughton Jones did not think treatment of these
cases so hopeless as some seemed to do. He had cured
some by applications of pure carbolic acid and thought
curettage also did good. Arsenic internally he considered
valuable.

Mr. Spanton, president, said one always had the idea
the passage of these casts was part of a vicious circle.

The meeting afterwards considered the question of opera-
tions for fibroma. Dr. Dauber showed a specimen of
fibroma of the ovary removed from a patient of 77. It
had been fixed in the pelvis, causing complete extrusion
of the uterus. He said this case proved that aged patients
bore abdominal operations well. He had operated lately
at ages 70 to 80 and recovery was in each case rapid and
complete, as the case of the specimen shown also was.

April 6. 1907]

Mf:DICAL RECORD.

:>/:>

Dr. Macnaughton Jones agreed to this and said he had a
letter from a lady of 83 from whom he remo%ed the uterus
at 74.

Mr. Furneaux Jordan said a fibroid however small should
always be removed if it gave rise to symptoms.

Mr. Bowreman Jessett was for operation for all fibroids.
Many patients could be saved trouble and risk by early re-
moval.

The president, Air. Spanton, would be sorrj- for the
society to lav down the dictum that every small fibroid
should be removed.

Dr. Dauber advocated removal of every fibroid.

Dr. M. Jones protested against operations when no
symptoms were produced. The greatest operators did not
operate unless symptoms arose to justify them.

The fear of an epidemic of cerebrospinal fever still pre-
vails among the public to a certain extent, but there is no
sign of panic and the statements of the Medical Officers of
Health are for the most part reassuring. Some of the
newspapers are heedless of the effects of their statements,
though for the most part they are discouraging alarm.
Professor Osier has suffered an interview in which he said
that both from the history of the disease and from the
course of the present local outbreaks it is not likely to
become a serious epidemic. It is, he added, a singularly
localized disease, rarely spreading to any extent even from
one city where it may be prevalent to another in the vicin-
ity. This he illustrated by the New York outbreak of
IQ05-6 which was not transmitted to other cities, nor was
that of Boston. So he thought an epidemic in London very
unlikely, but that the Local Government Board was making
a wise provision in having the disease compulsorily notified
and thoroughly investigated.

Some of the papers have further published extracts from
Dr. Osier's "Practice of Medicine" on the disease, with an
elaborate account of the distinctions the learned professor
has attained.

Prof. White has shown organisms from the Dublin cases
to the Academy of Medicine. He made direct cultivations
from spinal fluid obtained by lumbar puncture. From these
he grew pure cultures of a diplococcus in tetrad form.
He continued inoculation to the fifth generation. From
animal inoculations he had only negative results. The
diplococcus resembled that described by Weichselbaum, but
difl'ered in having a capsule and forming short chains. He
felt sure the organism was a distinct entity. It might pos-
sibly be a modified pneumococcus. In a former outbreak
he had only obtained pneumococci from a large number of
cases. Prof. McWceney also told the Academy that he
had grown from fluid obtained by lumbar puncture the only
organism present, a gram staining diplococcus tending to
form tetrads, but which was not the same as that described
by Prof. White.

On Wednesday there was an influential meeting at Lord
Brassey's house in Park Lane to plead for the immediate
needs of the East London Children's Hospital. It had been
arranged to hold a bazaar in June, but that has been post-
poned because the Sundav fund collection is then made
and will not give a grant to an institution appealing at the
same time. Adeline. Duchess of Bedford, made an eloquent
speech, contrasting the smiles of the children of the rich
and those of the poor; said children's hospitals ought to
be thank offerings and memorials, every cot and every
object in such hospitals a gift or thank offering; they were
often memorials of dead children but should oftener be
thank offerings for the living. Sir William Evans-Gordon
said the hospital not only provided relief and cure but in-
structed mothers how to take care of the children, and so
tried to check infantile mortality.

The annual meeting of the Royal Sea-Bathing Hospital
was held on Wednesday. The Earl of Derby (president)
spoke of the splendid work it had done and pleaded for
£15,000 to provide extension which was needed to meet the
demands on the charity.

The death has occurred of Dr. Arthur Ernest Sansom,
Consulting Physician to the London Hospital, at the age of
sixty-eight. Educated at King's College, he graduated at
the University of London, M.B., 1859 ; M.D., 1866. He was
elected assistant physician to the London Hospital in May,
1874, became full physician in May, 1890, and on resigning
in 1902 was made consulting physician. In 1878 he was
elected a Fellow of the Royal College of Physicians. Dr.
Sansom took an active part in the teaching at the London
Hospital College and was much esteemed by his colleagues.
He had served as examiner at the two Royal Colleges, as
well as to the L'niversity of Durham and to his own Uni-
versity. He had also been president of the Medical So-
ciety, and among other appointments was consultant to the
K. E. Children's Hospital and the Royal Hospital for Dis-
eases of the Chest. He was the author of three works
on heart diseases, including his Lettsomian lectures and of
many contributions to the journals and societies on thoracic

diseases, anesthetics, antiseptics, and points in clinical medi-
cine. He contributed to Allbutt's System and the Txacntieth
Century Practice. He was largelv instrumental in intro-
ducing the use of the sulphocarbolates.

Many of your traveled readers may remember Dr. Her-
bert, late Physician to the Herbert Hospital, Paris, who
died on the 8th inst. He was an Oxford man where he
took his M.A. and then entered as a student in Paris
where he took M.D. and where he was during the siege.
He was an officer of the Legion of Honor.

Dr. William Henry Pearse died on the 7th inst. at
Plymouth where he had practised for over thirty years.
He had previously been surgeon in the Government Emi-
gration Service and wrote a work on "Health in Calcutta
and British Emigrant Ships," 1866. He was M.D., Edin.,
1851, and M.R.C.P., Edin., 1882, He contributed a number
of articles on consumption and other practical papers to
periodicals, chiefly to the Medical Press and Circular. All
Plymouth mourns the loss of her deeply regretted and es-
teemed physician.

Dr. Surgeon-General J. K. Carr, M.D., retired, died on
the 4th inst. in his eighty-seventh year, having been in the
Medical Service of the Army from 1846 to 1875.

ACUTE PERFORATIVE PERITONITIS.

To THE Editor of the Medical Record:

Sir; — In Dr. Brownson's answer, published in the Medi-
cal Record of February 16, to my criticism appearing in
your issue of January 12, 1907, exception is taken to my
fear that the readers of your journal might suffer by the
acceptance of his misjudged conclusions, on the ground
that your readers are competent to decide for themselves.
I can hardly agree to that regarding all your readers unless
both sides of the question are presented, and dependence
on their good judgment under these circumstances is my
reason for presenting the other side. Conclusions that the
experienced surgeon lays down are accepted by the gen-
eral practitioner for his guidance. He is the first attendant
of these cases, and woe to many of them if the surgeon's
assistance is called in too late by reason of said "misjudged
conclusions." The doctor, in speaking of my criticism of
his ideas as to the hopelessness of general peritonitis cases,
first misuses quotation marks and submits an argument that
at first si.ght seems to have some relation to the subject,
hut on secohd look proves to be entirely irrelevant. The
point under consideration was operation in .general peri-
tonitis, the argument against it applies to appendicitis and
not to general peritonitis. Everyone so long in practice
knows what the mortality was si.K or ei.ght years ago in
operations for peritonitis and how loth surgeons were
then to operate in this condition.

Another point, and an important one, that I spoke of
in my letter was that "perforation and peritoneal infection
with a temperature of 105° or 106° and pulse of 140 or
160 is a rare combination and does not represent the
condition in the really bad cases." This the doctor answers
by a second abuse of quotation marks, this time by omit-
ting them, and makin.g words that I quoted from him, and
so indicated by the proper marks, look as if they were
my own.

There is no practical distinction, so far as conditions
indicative of operation are concerned, between peritonitis
caused by the bursting of an abscess, which Dr. Brownson
lays so much stress on as being the class of cases he refers
to, and perforation of the appendix in the absence of
surrounding protective adhesions. The fact that so much
stress is laid on this particular cause, "the bursting of an
abscess," suggests that one of the reasons the doctor en-
counters this condition so frequently may be due to what
he terms "the more modern scientific treatment of to-day,"
which he advocates and supposedly follows in usual acute
appendicitis cases. He does not operate during the "inter-
mediary period when there is fever and distention of the
abdomen." This would correspond to the period when
most of the acute and really urgent cases come under the
surgeon's observation. Delay in operation under these
circumstances would permit the development of the usual
proportion of abscesses and so supply abundant material
where it is possible for the "bursting of an abscess" to
occur.

Tlie doctor wants to know why, if I advocate operation
in general peritonitis because nothing is lost thereby, I do
not on this principle operate on all cases of tuberculosis
of the lungs, etc. He omits to remark that I gave the
reason anci that I distinctly stated that "the fact is that
to-day a fair proportion of these patients are saved by oper-
ating on them." I have no sympathy with those who blind
themselves to their duty behind tiie cloak of "every failure
tends to discoura.ge surgery and discourage those who

5/6

MEDICAL RECORD.

[April 6, 1907

could and sliould be operated on with safety and benefit."
I cannot see the justification for refusal of his chance of
life, be it ever so sn'iall, to any individual because some-
one else misht refuse operation on that account. That I
am not alone in this stand I was pleased to see on reading
Dr. Douglas' article on this subject in the Medical Record
of February 23, 1907, p. 304. where, among other remarks
directly to the point, he says : "Suffice it to say that in pri-
vate work his (the surgeon's) highest obligation is to his
individual patient, regardless of how it may react either
upon him. you, or the community." That strikes me as
sensible.

One more statement made by Dr. Brownsou I want to
correct. He says "the technique of removal of the appen-
dix adds to the risk of the operation and is of no practical
benefit, since the process that forms the abscess removes
the portion of the appendix that is diseased." That the
remains of a gangrenous appendi.x may be removed by
natural means is a possibility, as pointed out and explained
in a previous article by me (Nc7i' York State Journal of
Medicine. August, 1906), but such disposition is decidedly
exceptional. If not removed the appendix remains to cause
recurrence of trouble in the future. This must be evident
to anyone doing extensive work in this line and familiar
with conditions encountered, and my personal experience
with the few cases where I failed to remove the appendix,
as well as with some cases of others where the appendix
was not removed, bears out the conclusion. To give
instances would take too much space here, but they are
at the disposal of anyone who inay ask for them.

Dr. Brownson quotes from "a well known and experi-
enced surgeon," and from "one of the greatest authorities
on appendicitis," but does not give their names that we
might judge of the value of their sayings. The last quota-
tion is very apt, and in its ambiguity could be applied to
any side of any question. "It is only a question of time
when all will be forced to accept this theory, as facts
will overcome prejudice and tradition."

.■\. E. Is.\.\cs, M.D.
240 E..\ST Bro-^dw.w, Xew York.

New York Medical Journal, March 23, 1907.

Auial Aflections in Relation to Mental Disturbances.

— W. S. Bryant divides aural affections with reference
to mental disturbances into the following classes: (i)
Cases of aural derangement which bear no relationship
whatever to mental disturbances; (2) cases of aural
disease causing mental irritation and leading to psychi-
cal affections, usually colored by the ear symptoms;
(3) disturbances of the ear which act as causes of gen-
eral exhaustion and hasten the psychic symptoms; (4''
diseases of the ear which progress to loss of hearing,
destroying the connection with the outside world, and
thus upsetting the mental equilibrium; (5) hallucina-
tions of hearing, which are a result of the combination
of an ear affection with a psychopathic condition and
which are caused by the subjective sensation of a dis-
turbed organ of hearin.g falling upon deranged higher
centers; and (6) affections of the ear which are second-
ary to the mental disturbance. He discusses these
various classes and arrives at the following conclusions:
(l) Insanity is usually accompanied by aural disease. In
the majority of the insane the two affections are natu-
rally dependent. (2) Hallucinations of hearing arise
from tinnitus through the misinterpretation of aural
stimuli under psychopathic conditions. (3) Cessation
of the tinnitus can be expected to relieve the auditory
hallucinations.

Pasteurization; Advantages and Disadvantages to the
Consumer. — R. G. Freeman points out the distinction
between efficient pasteurization and the ordinary com-
mercial process. The home process, in which the milk,
after sealing in nursing bottles, is kept at 168° F. for
half an hour and then rapidly cooled, the bottles being
kept sealed and used for only, a twenty-four hours'
supply, he strongly commends. Such milk is much
safer than our cleanest raw milk. Concerning milk
depot pasteurization, he notes the varying conditions
in different localities, and thinks that success is more
likely to follow the distribution in New York City of
modified milk efficiently pasteurized in milking bottles
by the supplying milk depots than by a similar distri-
bution of raw milk. He condemns commercial pas-
teurization as interfering with the crusasde for clean
milk by making dirty milk more marketable. It gives
the public a false sense of security, the public buys it,
supposing it a fairly sterile milk, freed from pathogenic

bacteria, while the milk in question is a highly con-
taminated product, wdiich continues to deteriorate much
faster than raw milk, even if kept moderately cold.
The author summarizes his views as follows: There
are two distinct processes known as pasteurization,
(l) Efficient pasteurization in nursing bottles intended
to protect the consumer of the milk from bacteria and
producing a food with few bacteria, and no living
pathogenic bacteria we fear in milk. (2) Commercial
pasteurization intended to make marketable dirty milk
which could not otherwise be kept sweet until con-
sumed, but which usually contains, on reaching the con-
sumer, a large number of living bacteria, including
possibly pathogenic bacteria and the tubercle bacillus
if it is present in the milk. Efficient pasteurization ha3
been most valuable as used in homes and milk depots.
Commercial pasteurization should be tolerated only as
a temporary means of modifying the dangers of dirty
milk.

The Use of Ammonia in Counteracting the Fumes of

Formaldehyde. — E. \'. Wilco.x found that commercial
formaldehyde mixed with aqua ammonia; undergoes
a rather rapid reaction, causing the development of heat
and the formation of a crystalline body appearing on
evaporation. This body is hexamethylenamine (CH2)«
N.4, which is practically odorless. Further experiments
showed that the fumes of formaldehyde could be com-
pletely neutralized by ammonia fumes and vice versa.
The experiment was repeated on a large scale under
the ordinary conditions of disinfecting a room. Form-
aldehyde was employed, and as soon as the room had
been sufficiently aired to allow men to work in it,
ammonia was sprinkled around and the room closed
a.gain. The odor of the original disinfectant was de-
stroyed in half an hour. In the experiment made, two
quarts of methyl alcohol were consumed in a room of
1,500 cubic feet capacity in a formaldehyde generator,
and. in addition, three pounds of commercial formalde-
hyde were exposed on the sheets. Three pints of am-
monia water w-ere then used. The method does not
seem to interfere with the effectiveness of the fumiga-
tion.

Journal of the American Medical Association, March 30,

1907.

Lymphoid Changes in Infectious Diseases. — W. T.

Councilman calls attention to the proliferative changes
followed by necrosis taking place in the lymph nodes
throughout the body in certain infectious diseases, but
specially noticeable in certain regions. The necrosis
occurs chiefly in the germinal centers, but there may
also be destruction of small scattered lymphoid cells.
The necrotic cells are taken up by phagocytes, which
are greatly increased by proliferation of the endothelial
cells of the sinuses. The new formation of cells does
not. as normally, lead to increase in the small lym-
phoid cells. The new cell formation seems to start
from cells of an indifferent character resembling those
found in the germinal centers. Some of them seem sim-
ply to grow in size. Others are converted into plasma
cells and some cannot be distinguished from myelo-
cytes. Polynuclear leucocytes are not formed. These
new cells enter into the blood, partly by means of the
efferent lymphatics, partly by migrating into the ves-
sels, and are found in blood-vessels of all tissues of the
body, but they seem less adapted to the blood move-
ment than the normal leucoc^'tes. They are found in
great numbers in the vessels of certain organs, such
as the kidney, and they pass from the vessels by active
ameboid motion into the interstitial tissues in such
numbers as sometimes treble the weight of the organ.
In the interstitial tissues the cells have a greater ten-
dency to plasma cell differentiation than elsewhere.
and foci may be found composed of typical plasma
cells. The cells have marked power of proliferation
and nuclear figures are abundant. In division, the cyto-
plasm becomes more granular and .granules are cast
off. Councilman has not been able to find a relation
between these foci and injury or degeneration of the
tissue. The interstitial foci are most frequently found
in the kidney and next in the adrenals.

Meningism as Distinguished from Meningitis. — C.
Jackson favors the use of the term meningism. intro-
duced by French writers, to designate a syndrome with ■
most of the earlier symptoms of meningitis, but with-
out lesions of the meninges and of more favorable
prognosis. Any of the symptoms of meningitis may
occur, but the erethistic. rather than the depressive,
predominate. The full development of pressure symp-
toms, paralysis or other indications of actual organic
disease, will usually exclude meningism. He recognizes

April 6, 1907]

MEDICAL RECORD.

as etiologic types the toxemic, the reflex, and the
irritative; in all three there are circulatory changes "and
in many cases direct action on the cortical cells. In
the toxemic cases the nosotoxins in the blood act simi-
larh' to toxic drug doses on the cerebrum. The readi-
ness with which the symptoms of meningism can be
quieted by small doses of morphine is remarked on by
Jackson as an important diagnostic point. These cases
are distinct from Quincke's serous meningitis inasmuch
as there is no serous involvement. Looking at the con-
dition from the otologist's point of view, the irritative
and toxemic cases, he says, when occurring in the
course of middle-ear disease, are of the utmost impor-
tance as regards diagnosis, and often call for radical
operation even if the mastoid is yet uninvolved.

The Radical Mastoid Operation. — F. Allport gives
a detailed and verv fully illustrated description of the
radical mastoid operation, which, he says, is the acme
of mastoid surgery, should only be undertaken by an
operator of special experience, and is worthy of the
continued study of the aural surgeon. He makes a long
incision so as to expose a wide operative field and uses
self-retaining retractors that check all soft tissue hemor-
rhage. Each stage of the operation is described in de-
tail and special stress is laid on the proper after-pack-
ing of the cavities, for which he uses several pieces
of gauze instead of a single one, as is done b}' some
operators. The importance of the after-treatment is
emphasized generally. He closes his paper with a
quotation from Ballance against undue conservatism as
regards this operation for the relief of intractable puru-
lent otorrhea.

Spins Bifida. — H. Greenburg pleads for the more ex-
tended use of operative methods in the treatment of
spina bifida, and reports a case, calling attention to
certain points in the technique. He employed the mus-
cle flap method of Bayer, improving on it, however, by
utilizing the aponeurosis of the latissimus dorsi. A
longitudinal incision of sufficient length to cover the
defect was made over one side of the spinous processes
above the cleft, thus freeing a section of the aponeu-
rosis at its origin on that side. .Another longer oblique
downward incision was made from the upper point of
the first, thus making a triangular flap of aponeurosis
free at all points except the apex. Using this apex as
a center, the whole flap is rotated downward until it
covers the defect of the vertebra on that side. The
same procedure is follow-ed on the other side, and
the borders of the flaps are united with chromicized
catgut directly over the defect, giving a covering next
to bone in strength and consistency. His patient, who
had been getting steadily worse, began to improve and
was nearly well in two months. The pressure on the
cord, which had lasted for sixteen years, and had
suspended the function of the cord, had not so impaired
its tissue as to prevent a speedy alleviation of symp-
toms and restoration of function.

Arseniuretted Hydrogen Poisoning. — X. W, Jones
gives the history of five cases of poisoning by ar-
seniuretted hydrogen in workers w'ith the cyanid proc-
ess of gold extraction from low-grade ores, and also
tabulates fifty-five other cases of poisoning from this
gas collected in medical literature. Considering the very
common presence of arsenic in the materials used in
this process a rather frequent occurrence of such poison-
ing might be looked for, but these cases seem to be
exceptional. It seems rather remarkable that so few
cases of this poisoning from all sources are on record
in view of the numerous possible sources in the arts
and manufactures. Jones discusses the pathology,
symptomatology, and treatment, and reviews the litera-
ture in regard to the effects on the system. The poison
acts differently from the other salts of arsenic. The
blood and kidneys are principally involved, the hemo-
globin and red cells being attacked, and the kidneys
undergoing an intense degenerative process mainly in-
volving the convoluted tubules, and the glomeruli least.
The three characteristic symptoms are pain in the re-
gion of the kidneys, hemoglobinuria, which is a constant
symptom, and jaundice, probably obstructive, though
the disturbed liver cell function, may play a part. Death
when it occurs is undoubtedly largely due to acute
urinary suppression. Some patients have shown uremic
symptoms, but the majority do not. Twenty of the
cases tabulated were fatal, death occurring in from two
to thirty days, the average being S.2 days. The chief
indications in treatment are: First, abundant fresh air
and administration of oxygen. Second, the production
of free diuresis to prevent blocking of the uriniferous
tubules with disintegrated blood cells and epithelium.
Saline enemas and warm baths may also be useful. Gen-

eral supportive treatment is of course required. .A.clive_
diuresis is a very favorable sign, as the majority of
patients with polyuria recover. The consecutive anemia
is much benefited by iron.

Inspection of the Jugular "Vein and Visual Methods
in Diagnosis of Heart-Block. — .Arthur D. Hirschfeldcr
crilicises the recent contribution on this subject by
G. W. McCaskey, Fort Wayne, Ind., who replies to the
criticism. Hirschfelder fails to see what advantage Mc-
Caskey's ocular method of diagnosing heart-block by
means of a specially devised apparatus has over simply
v.'atching the pulsation of the jugular vein while feel-
ing the pulse in the carotid with the finger. He believes
that mere inspection of the venous pulse, while some-
titnes of value, is subject to grave diagnostic error. In
his repli* McCaskey, while admitting that Hirschfelder's
criticism is partly right, believes that in a large num-
ber of cases the use of his apparatus will be of great
value in arriving at a diagnosis. He thinks there can
be no question as to the greater ease with which com-
parison can be made between the venous and arterial
pulsations by means of his apparatus as compared with
the clumsier method of inspection and palpation. He
thinks the whole question is whether these advantages
are sufficient to offset the multiplication of instruments.
The Lancet, March 16, 1907.

Aceto-Salicylic Acid in Rheumatic Endocarditis. — .\
case history is detailed by E. C. Ibotson, whose patient
was a thin anemic girl of sixteen years, presenting the
usual features of rheumatic endocarditis and being in
a condition of extreme debility. Aceto-salicylic acid
was used in fifteen grain doses, when the temperature
showed a tendency to rise. It w'as later continued in
seven grain doses thrice daily. In the author's view
the case seems to point out the superiority of this par-
ticular acid in rheumatic fever when the salicylates
have been tried without positive and permanent effect.
He does not overlook, however, the value of the opium
and blisters used in this special case. For a ferruginous
tonic following the acute symptoms hemoglobin is less
liable to produce relapse than iron salts in combating
the subsequent anemia. He has found that salicylates
aggravate epistaxis which in his experience is not by
any means an uncommon concomitant of rheumatism, and
is probably due to the accompanying anemia. It is im-
portant that the aceto-salicylic acid should not be given
in tabloid form unless the tabloids are crushed before
administration. The powder suspended in water with
a little mucilage acts well and has no unpleasant taste.
He has not found aceto-salicylic acid produce head-
ache or dyspepsia, but, he thinks, that it is contra-
indicated in chronic rheumatism occurring in the sub-
jects of organic heart disease of non-rheumatic origin.

The Medical Treatment of Congenital Pyloric Steno-
sis.— G. A. Sutherland gives detailed histories of three
cases, two recovering and one dying without apparent
cause. He then discusses in turn, the object aimed
at by treatment, the food required and feeding methods,
and gastric lavage. The aim of treatment is to keep the
stomach free from irritants, which may maintain pyloric
spasm and from anything in the food line which, di-
.gested or undigested, may excite such spasm. Signs
of progress are cessation of vomiting, regular bowel
action, less marked stomach peristalsis, cessation of
discomfort, whining, apathy, etc., on the child's part,
and improvement of nutrition. Diarrhea is a common
complication during the course of treatment. The best
plan here is to reduce the amount of food one-half and
keep it so until the diarrhea has ceased. Half a grain of
gray powder may be given twice or thrice daily. The
diarrhea is always a serious symptom and may cause
death. The author has found no results from anti-
spasmodic drugs or opium even pushed to the full de-
gree. In cases of marasmatic infants with pyloric
stenosis, with all the tissues dried up, the u?e of saline
injections both subcutaneously and per rectum has
seemed beneficial. From four to ten ounces of norma!
saline solution can be given daily and will act as a
restorative until the improvement of the pyloric function
allows of the entrance of a sufficient amount of fluid
into the system by the natural route. In cases in which
the infant is much reduced or has a subnormal tem-
perature brandy, up to half a dram daily, will be found
of service as a general tonic. The administration of cod-
liver oil by inunction, if it be of any value, would ap-
pear to be specially suited to the conditions present in
this aft'ection. The author ha^ only employed it r.nce
and in that case a skin eruption quickly followed and led
to its discontinuance.

Tertiary Syphilitic Fever and the Visceral and Other
Changes Connected with It. — The paper of F. P. Weber

57t

MEDICAL RECORD.

[April 6, 1907

opens with the history of the case of a woman of 36
years who caine under observation at various times,
there being at each time a remarkably rapid disappear-
ance of the syphilitic fever on the commencement within
two days or so of antisyphilitic treatment. Such a fever
can easily be mistaken for the pyrexia of sepsis or of
tuberculosis. It has sometiines been mistaken for ma-
laria. Other maladies requiring exclusion arc typhoid,
malignant endocarditis, and febrile cholelithiasis. The
author passes in review the literature of the subject
and refers to various cases in which local symptoms
have pointed to the involvement of some definite organ
or system, due to specific infection, the febrile movement
being a prominent symptom. Under this category are
mentioned enlarged liver with jaundice, dyspepsia,
diarrhea, etc. Authorities seem to a.gree that it is in
the cases in which the infection lodges in the portal sys-
tem that the fever is particularly constant and promi-
nent. It is often of an intermittent type and accom-
panied by shivering. One case is recorded of a man
dying from intraperitoneal hemorrhage, which the au-
topsy showed to have arisen from a perforating syphil-
itic ulcer of the stomach. It must be acknowledged
that while undoubted syphilitic gumma of the stomach
and bowels is rare, a good many cases have been veri-
fied either by the results of treatment or autopsy.

British Medical Journal. March 16, 1907.

Intestinal Worms in the Vermiform Appendix. — J. W.

Heekes refers to this subject in connection with an
operation on a pelvic case in a woman of thirty-one
years. As the appendi.x was elongated, swollen, and
coherent, it was removed, .\fter ligature of the stump
a thread-worm was seen to wriggle out from the lumen
of the appendix. On subsequently opening up the ex-
cised portion ten more were seen lying in the mucous
membrane for about iH in. of its length; some were
on the surface, one or two lay deep down in the lining
membrane, but none had pierced the other coats of the
appendi.x. On examination microscopically three were
found to be male, and the remainder female, with ova
in great numbers. The mucous membrane of the ap-
pendix was not much inflamed, but there was some con-
gestion. Probably this was due to the pelvic peritonitis
having involved the appendix and caused the adhesions.
The occurrence of the worms in the appendix was most
likely accidental, they iiaving migrated from the cecum,
for the patient had had the usual symptoms of the pres-
ence of thread-worms for about three and a half
months. The history of the case pointed to old-stand-
ing trouble in the pelvis, especially on the right side,
though at the operation the left Fallopian tube was
also found adherent and swollen, and was removed.
Three weeks before admission the patient had pain in
the right iliac region, accompanied by vomiting, and the
bowels were constipated, but there was no proof that
this attack was of appendicular origin.

Class Incidence in Cancer. — D. Heron has made
some investigations based on the English Registrar-
General's returns and tabulates his results in this
brief paper. It appears from his figures that there is
always a substantial correlation between the cancer
death-rate and social status: in other words, the evi-
dence of cancer is most heavy among the well-to-do
class. The author observes that what is badly needed
at the present time is a collection of complete family
histories of cancer cases. While such family histories
in cases of insanity and pulmonary tuberculosis have
been provided for the use of this laboratory in fair
numbers, which we hope may go on increasing, we
have, and can find, no records of any value bearing on
heredity in cancer cases. The statements "a family
history" or "no family historv"' are purely useless for
scientific discussion of inheritance, when neither the
individual relatives attacked nor the sizes of the fam-
ilies are stated.

The Relation of Diet to Thyroid Activity. — Experi-
ments have been made by .\. D. Fordyce in feeding rats
on milk alone and on bread and milk, and comparing
the thyroids removed from these two series of animals
with those of wild rats. He found that the glands of
all animals fed on bread and milk showed a constant
picture, while those from the wild rats (caught at the
same time and place), though showing somewhat wider
variations, yet in all cases displayed in a greater or
less degree the same nature of differences from both
the preceding type of gland. In the milk-fed rat gland-
sections showed large vesicles, well filled with colloid
material, while the lining cells were small with deeply-
stained nuclei. In the bread-and-milk-fed rats the vesi-
cles were seen to be very markcdlv smaller and the

amount of colloid present very considerably less.
Whereas, in the case of milk-fed rats, each vesicle con-
sisted of a large lumen surrounded by a narrow ring
of somewhat Hattened cells; here it consisted of a ring
of columnar cells enclosing a minute lumen or lying
apparently almost in contact. Examination of the
glands of wild rats showed them to be of a more or less
intermediate nature between those of milk-fed and those
of bread-and-milk-fed animals. Compared with sec-
tions from bread-and-milk-fed animals, the vesicles ap-
peared distinctly larger, they contained considerably
more colloid material, and the lining cells showed a
greater variation in shape. These glands, one and all, it
must be remembered, were removed from animals clinically
in perfect health ; and, while the thyroid gland is an
organ well known to be subject to considerable varia-
tions in structure, yet the interest in the present note
rests in the fact that the variations in the series of glands
examined corresponded with the differences in diet.

The Use of the Calcium Salts as Cardiac Tonics in
Pneumonia and Heart Disease. — Lauder Brunton states
that he was called to see a case of pneumonia, and.
fearing that the heart would fail, he thought over all
the remedies which were likely to avert such an un-
fortunate result. It then occurred to him that calcium
chloride ought to be useful. The only harm it was
likely to do was to increase the coagulability of the
blood, but any risk of this- sort was small in compari-
son to that from cardiac failure, so he prescribed it.
It is not so easy to judge of the usefulness of calcium
salts in theatencd cardiac failure as it is of the action
of oxygen and strychnine, because the results are not
so immediately apparent. As the patient for whom he
prescribed the calcium made a good recovery he was
encouraged to give it again, and has done so in a con-
siderable number of cases. In some of them a fatal
result has ensued in spite of everything that could be
done, but in a number of them the effects appear to him
so encouraging as to deserve a wider trial for the
medicine. He usually gives it in 5 to 10 gr. doses every
four hours, simply dissolved in water. As it is very
deliquescent it can only be kept in solution. It has a
very disagreeable saline taste, but this is well covered
by saccharine, one minim of the elixir of saccharine
containing one-twentieth of a grain of saccharine is
sufficient to cover the taste of 10 gr. of calcium chloride.
This mixture may be given either in water or in milk,
and it does not interfere with the use of anj' other
remedies. He has also used it in cardiac disease,
where the ventricular wall appeared to be losing power,
and here also the results have been encouraging. In
cases of pneumonia, where one wishes to get rapid
action, he thinks the chloride is the best salt of calcium,
but in cardiac disease other salts may be employed,
such as the lactophosphate or the glycerophosphate. It is
quite possible that the great benefit one frequently ob-
serves from a milk diet in cases of heart disease may be
due. in part at least, to the large quantitj- of calcium
salts which the milk contains.

Berliner klinische Jl'ochenschrift, March 11, 1907.

Retropharyngeal Growths. — Litthauer reviews the
literature of tumors in this situation and says that so
.far thirtj'-four such cases have been reported. He con-
tributes to this number two of his own. One of these was
a gumma which promptly subsided under the adminis-
tration of potassiutn iodide, while the other was a
fibrosarcoma measuring 0 cm. by 6.5 cm. b3' 5 cm. It
occurred in a woman of thirty-five years and was re-
moved through an incision running parallel to the left
lower jaw and extending from the mastoid process to
the hyoid bone. The patient made a good recovery
though certain paretic symptoms such as weakness of
the soft palate, dysphagia, etc., persisted. Among
these symptoms the so-called Horner's symptom com-
plex was conspicuous; this depends on paralysis of the
sympathetic and comprises contraction of the pupil,
narrow'ing of the palpebral opening and enophthalmos.
From a consideration of the reported cases Litthauer
concludes that the incision he made use of is the most
advantageous and that attempts to remove retropharyn-
geal growths through the mouth or through a subhyoid
pharyngotomy are ill-advised.

African Sleeping Sickness. — Kutscher contributes an
account of what is known in regard to this infection.
Formerly considered to be more or less confined to
the western coast of .A.frica. Cook in igoi discovered a
new area of infection in British Uganda, on the shores
of the Yictoria-Nyanza, which since that time has been
spreading rapidly in spite of all efforts made to restrict
it. Clinically four stages of the disease may be dis-

April (j, 1907]

MEDICAL RECORD.

579

tinguished. In the first, which extends from the date
of infection with the trypanosomes to the onset of
fever and the appearance of the eruption, no symptoms
occur. Sometimes during this period it is possible
to demonstrate the presence of trypanosomes in the
blood or in the swollen cervical glands. This stage is
of uncertain duration and is followed by the so-called
trypanosome fever. This is characterized by irregular
attacks of fever which are usually accompanied by se-
vere headache and are often taken for malaria. To-
gether with the fever transitory edema, erythema, and
urticaria of the face and legs frequently develop. The
heart rate and respiratioci are increased, and swelling
of the spleen may be noted. The lymph nodes, espe-
cially tlie cervical glands, are swollen. This stage grad-
ually merges into the third phase, the true sleeping sick-
ness. The patients evince a tendency to fatigue, irri-
tability, and neglect of the person; gradually the ten-
dency to somnolence increases, it is difficult to persuade
the patient to take the necessary amount of nourish-
ment, and finally the fourth stage sets in, in the course
of which a terminal secondary diplococcus infection of
the cerebral membranes frequently takes place. It has
been established that the infection occurs through the
hitc of a tsetse fly, the Glossina palfalis. and attempts
at prophylaxis must be directed towards the extermina-
tion of this insect. The prognosis of sleeping sickness
is extremely bad, although certain arsenic combinations
and trypan red may be found to be satisfactory thera-
peutic agents.

Miinchencr medizinischc IVochcnschrift, March 5, 1907.

The Prophylaxis of Ophthalmia in the Nevyborn. —

Seefeldcr speaks highly of the value of silver acetate
as a substitute for silver nitrate as a prophylactic
against ophthalmia in infants. The efficiency of this
agent is as great as that of the nitrate, while it seems
to have no disadvantages. In a series of 500 infants
the author applied the acetate to one eye and the nitrate
to the other and found that in no case were any evi-
dences of irritation caused by the acetate. There was
also no demonstrable damage to the corneal epithelium
and the conjunctiva did not offer any indications of
undue stimulation. He therefore considers that silver
acetate is not inferior to the nitrate in its action, while
it possesses the advantage that its solutions do not be-
come more concentrated through evaporation, whereas,
with silver nitrate, a change of this nature may lead to
serious consequences.

The Effect of Cholin and of the X-Rays on the
Course of Pregnancy. — Hippel and Pagenstecher re-
view the literature of this subject which has now be-
come quite laree and also describe the results of some
experimental observations of their own. They found
on exposing pregnant rabbits to the ;r-rays that three
sessions of fifteen minutes each were usually sufficient
to destroy entirely or in great part the product of con-
ception, but that individual variations in susceptibility
in this respect were very great. It was also found that
on covering the abdomen of the animal subjected to the
action of the rays with a lead plate, the destruction of
the embryos took place just about as when the rays
were allowed to impinge directly on the unprotected
abdomen. Fourteen animals were given injections of
cholin; in ten of these sterility resulted, and in two
others some of the embryos were destroyed. Only two
of the animals were delivered normally, and both of
these had received only small amounts of the substance.
The authors state that apparently a daily injection of
10 c.c. of a one per cent, solution of cholin given for
eight days, beginning with the sixth or seventh day
after impregnation, almost always prevents the progress
of the pregnancy. This result may also be obtained,
however, even if the treatment is not given until much
later. They consider it likely that the action of the
.f-rays produces in the body some toxic substance simi-
lar to cholin or to the derivative of the latter formed
in the body which passes from the maternal body to
that of the embryo and destroys the vitality of the
latter's cells. The dead embryo then undergoes absorp-
tion and the changes in the uterine wall attending the
pregnancy gradually retrograde. Cholin itself, if pure,
appears to have no toxic effect on the maternal animal
in the doses employed.

Deutsche medicinische Wochenschrift, March 7, IQ07.

The Successful Inoculation of Calves with Bacilli
from Human Pulmonary Tuberculosis. — Eber. who as-
sumes the standpoint that human and bovine tubercu-
Iosis_ are due to the same etiological factor, describes
two instances in which he was able to inoculate success-
fully calves with material obtained from cases of human

pulmonary infection. In the one instance a portion of
a phthisical lung was used and in the other a portion
of the pia from a patient with pulmonary tuberculosis
and tuberculous meningitis. These tissues were inocu-
lated into guinea pigs and portions of the organs of
the animals were used for the inoculation of the calves.
Eber believes that these experiments do not prove that
the two patients in question were suffering from a
bovine infection and he expresses his disagreement
with the alleged view of Koch and his pupils that all
tuberculous lesions in man, which, on inoculation into
the cattle prove to be virulent for these animals, were
originally due to a bovine infection. The author's con-
clusions are assailed in another article by Weber, who
discusses Eber's experiments and views and comes to
rather different conclusions. The details of the con-
troversy cannot be reproduced in brief.

French and Italian Journals.

Rupture of the Heart. — Leenhardt reports this case.
The patient was a woman sixty-eight years old, and
obese. She was attacked suddenly by intense pain
over the whole left side of the thorax and by e.xtrcme
dyspnea. No pathological antecedent could be dis-
covered. The patient presented a condition of extrenle
asphyxia and great distress; the face was congested, the
eyes bulged forward, the lips were cyanosed, and there
was very violent pain in the precordial region, which
the patient pressed with both hands; the pulse was
very rapid and irregular. Auscultation of the heart was
useless on account of the rapidity and irregularity of
its action. Two hours later all of these symptoms
diminished, and on the following day there was no sign
of what had passed except a pulse which was a little
more rapid than normal, beating 92 to the minute. The
pain and dj'spnea had completely disappeared. For
three days this condition persisted and then suddenly
more than seventy hours after the onset of the symp-
toms the patient sat up in bed, uttered a cry, and fell
back dead. At autopsy the heart was found to be large
and completely infiltrated with fatty tissue. The peri-
cardium was distended by blood and clots. On the
anterior surface of the left ventricle was a fissure com-
municating with the ventricles. The rupture of the
heart was found to have been caused by an infarct. —
Bulletin et Mhnoires de la Societc Anatomique de Paris,
July, 1906.

Testicular Atrophy. — Achard and Demanche had a
man sixty-eight years old under their care. The patient
suffered from mitral insufficiency. There existed atrophy
of the testicles, which had developed after a violent trau-
matism at the age of twenty-five years. This accident
had been followed by a diminution of muscular activity
and by a falling of hair. The patient's face was almost
smooth, his hair of the head was extremely thin, and the
hairs over the entire body were almost wholly lacking.
The visage was pale and wan. The cheeks were pendent
and the fascies recalled that of an old woman suffering
from my.xedema. After studying the case the writers sug-
,gest the possibility of a relation between testicular insuffi-
ciency and thyroid insufficiency. — Gaccttc dcs Hopitaux
Civils et Militaires. December 27, 1906.

Ferments in the Urine of the Child. — Angiola Bur-
rino has made examinations of the urine of healthy chil-
dren from a few days old to twelve years of age to deter-
mine whether the ferments of the gastrointestinal system,
pepsin, and trypsin are to be found in the urine. Both are
known to be found in the urine of adults. The author
finds that a ferment analogous to pepsin is found in the
urine of children of all ages, while a ferment analogous
to trypsin seems to be absent. Uropepsin is found in
nursing babies and the newborn. Other authors have found
it in the stomach of the fetus. — Rivista di Clinica Pedinlrica.
December, 1906.

Primary Sarcoma of the Tendon Sheaths. — V. Gau-
diana says that up to 1880 it was thought that sarcomata
never occurred on tendons or their sheaths. It is now
known that such tumors do occur, and the author describes
one in a child of twelve years, occurring on the tendons
of the long and short extensors over the first metatarsal
bone of the left foot, the course of which was very malig-
nant. These tumors occur at any age, on any tendon, and
arc in general rather small, lobulated, and soft, or hard,
according to the type of sarcoma present. Both the skin
over the tumor and the tumor itself are movable, and the
function of the part is not interfered with. The glaniK
are not involved early, and metastases occur late in thi-
disease. — // Policlinico, December, 1906.

Traumatic Ruptures of the Perineal Urethra.— Opera-
tive Results. — Savariaud has practised three interven-
tions for trnunuitic rupture of tlie perineal ureter. In the

;8o

MEDICAL RECORD.

[April 6, 1907

first patient he found the corpus sponp'iosuni ruptured and
the ureteral mucosa opened in a small area of its inferior
surface. He practised suture of the ureter of the corpus
spongiosum and completely closed the perineum. Healing
took place by first intention, and when the patient left
the hospital tlie caliber of the ureter was sufficient for the
passage of a sound number forty-eight. Three years later
the ureter admitted only a bougie number twenty-one. In
the second case immediate suture was not successful and
several vvccUs later a new intervention was performed.
The result is not known on account of the disappearance
of the patient. In the third case a suture of the ureter
was impossible on account of the condition of the ruptured
extremities, the borders of which were slashed, consequently
Savariaud attached the ruptured extremities to the skin
and placed a sound in position for a few days. Bougies
were then passed. The patient urinates with comfort, but
in the perineum there is cicatricial block which is noticed
when the smallest bougies are inserted. — Revue de Chi-
rwie, December 10, 1906.

Pubiotomy. — Gigli believes that we have arrived at a
new era in obstetrics owing to the important and precious
discovery of pubiotomy. He thinks that he has reached
the method of cutting the pelvic ring that gives the best
jjossible prognosis, because it involves separation at the
most favorable point of the pelvis, that point which results
in the least danger of infection, the quickest healing, and
the firmest union. He hopes to be able to convince
his colleagues that svmnhyseotomy, exposing the' woman to
grave dangers of infection and of inability to walk as it
does, has no right to exist, and that they will all desist
from performing it and use his method. He reports a
series of 300 cases of pubiotomy with a mortality of three
per cent., and the cases that were fatal were all infected
before the, operation. If we leave out these cases we have
a mortality that is reduced to zero. — La Rifurina Mcdica.
December 8, igo6.

Temporomaxillary Actinomycosis Cured by lodo-
Gelatine. — Francesco Putzu published the history of a
case of actinomycosis of the temporo-maxillary articulation
and side of the jaw, occurring in a woman of twenty-eight
3'ears of age. The swelling was of woody hardness, and
examination of the pus from softened areas showed the
presence of actinomyces and the absence of any other pus
germs. They were in abundance in all pus examined dur-
ing the second year of the disease. Each granule consisted
of a central mass of filaments and a peripheral mass of
rays. Cultures in animals showed foci of actinomycosis.
The neighboring elands showed a characteristic hyperplasia
with foci of detritus similar to cheesy matter. The patient
was treated with iodide of potassium internally and with in-
jections of the iodo-gelatinc of Sclavo. The result was a
complete disappearance of the growth and of all symptoms
e.xcept an ankylosis of the jaw due to a large amount
of cicatricial tissue in the articulation. This was removed
by operation and the patient recovered the use of the ar-
ticulation.— Rivista Critica di CUtiica Mcdica. December
I, 1906.

Hypodermic Injections of Sea Water. — P. Schivardi
describes the use of injections of sea water for scrofula,
tuberculosis, and similar conditions, which has been at-
tempted since 1904. As used at present the water is ob-
tained in the deep sea, far from any river, and will keep
pure for some days. It must be sterilized before use and
diluted with freshly prepared distilled water. One part of
sea water is used to three parts of distilled water. It has
been found better to use small injections daily rather than
larger ones at longer intervals. The temperature of the
injections should be that of the body, and syringes of metal
or rubber should not be used. Five or ten centigrams
of isotonic marine serum are injected at once. There is
no reaction, but thirst is produced which produces diuresis.
The best place for injections is the anterolateral region of
the abdomen. Aseptic precautions are observed, and local
massage follows. The results of such treatment have been
most encouraging. — Ga::ct!(! Mcdica di Rome, November,
1906.

Treatment of Heart Disease by Removal of Chlorides.

— R. Massalongo and G. Zambelli have made use of a diet
that limits the ingestion of chlorides in cases of heart
diseases for several years with gratifying results. They
conclude that the chloride of sodium is a regulator of th.e
isotonia of the humors, of osmotic pressure, of the dehy-
dration of the tissues, and of arterial pressure, but at the
same time is a factor in asystolic phenomena and dropsy
in cardiac diseases. In the period lack of compensation
there is a constant retention of the chlorides and hydration
of the tissues, and a diminution of the chlorides ingested
soon restores the equilibrium and puts an end to the
unfavorable symptoms. Diagnostic and prognostic infor-
mation can be gained by experimenting w'ith the diet in

this direction. The use of a diet poor in chlorides must
often be supplemented by the use of diuretics or heart
tonics which accelerate the cure. The diet is diuretic and
regulates the circulation because the removal of edema
lessens the obstacles to the heart action, and indirectly in-
creases the energy of the heart. It has an important sus-
pensive action, preventing asystolia, and it has not only a
regulating and dishydrating action, but an energetic disin-
toxicating effect, retarding uremic symptoms. — La Riforma
Medica, December 8, 1906.

Uilifrappultr l^inla.

Acne Rosacea. —

IJ Lac sulphur 5 i

Camphor gr. x

Tragacanth gr. x

Rose water J iv

M. et Sig. : .\pply night and morning.

— J. E. LocKRiDGE, Medical Times and Hospital Gazette.

Diarrhea. —

I^ Tinct. kino TTExxx

Tinct. opii TTJlv

Tinct. zingib njjxv

Mist. cretJe q.s. ad. ji

Sig.: To be taken every four hours.

— Be.azely.

Scabies. —

IJ Xaphthol 5iv

Saponis viridis ■ 3iss

Pul v. cretffi gr. xl

.A.dipis 5viii

Ft. ungt. Sig. : Apply locally, dust with starch, and
wrap in linen. — K.\POSI.

Tonsillitis. — The following is recommended as a prophj--
lactic for use by persons prone to tonsillitis:

IJ 01. menth. pip gtt. viii

Acid, carbolic! oi

Spt, vini rect 3ii

M. S : Ten drops added to a cup of cold water and
used as a gargle night and morning.

— The Hospital

Creosote in Phthisis. — For success in the use of creosote
in phthisis pulmonalis it is essential (i) that the creosote
should be absolutely pure; (2) that it be taken im-
mediately after meals. The creosote should be given
in gelatin capsules, each containing one minim. Begin
with one capsule thrice daily, and gradually increase
the dose until the patient is taking 15 minims of pure
creosote thrice dailv.

Sir Felix Semon.

Acute Rheumatism. — Bourget uses the following:

]J -A-cid salicyl i . o

Lanolin i . o

01. terebinth, rect .^ i ■ o

Adipis 10. o

M. S.: Apply without rubbing and then bandage
the joint with flannel.

Influenza. — To prevent nasal and aural complica--
tions, a small amount of the following may be intro-
duced into the nares night and morning:

IJ Resorcin gr. xv

Menthol gr. ii

Petrolati 5vi

If there is a dry cough, expectoration may be en-
couraged by the following:

5 Sodii benzoat oi

.\mmon. acetat oii

Spt. ifither. comp lipxxx

Syr. aurant. flor 3i

Codein gr. iv

.\qu3e 3v.

M. S.: Three to four tablespoonfuls daily. The
following mav be used as an inhalation:

R Menthol 5;

Tr. eucalypt 5i

.\q. colon 5Jv

M. S. : A tablespoonful in a bowl of boiling water,
inhaled by means of a funnel.
\/, 1, t- ' — Medical Press.

Neuralgia. — Durand uses locally two to eight drops of a
I per cent, solution of veratrine in equal parts of diluted
alcohol and distilled water (caution against getting
it in the eyes), or:

R Veratrina? o . i

Morph. hydrochlor o . i

Ungt. aq. rosEe 0.5

M. ft. Ungt.: Apply a very small portion to the pain-
ful area with slight friction once or twice a day

— Journal de Midecine.

April 6, 1907]

MEDICAL RECORD.

vSi

lack ErutfuiB.

Treatise on Orthopedic Surgerv. By Roval Whitman,
M.D. Third Edition. Revised and Enlarged. Phila-
delphia and New York: Lea Brothers & Co., 1907.
Dr. Whitman's book has met with a very appreciative
reception, as shown by the succession of editions withi.n
a comparatively few years. The subject is presented, as
far as possible, in an objective manner, and the space
allotted to each individual topic has been determined
primarily by its relative importance in the actual work
of orthopedic clinics. Particular attention has also been
given to methods of examination, to symptoms, and to
the causes and effects of disease and disability, so as to
indicate in natural sequence the principles of treatment.
The book is in many respects a personal record of the
writer's experience, particularly as regards treatment.
The illustrations, which are of uniform excellence, are
also taken largely from the material at the author's clinics
and hospital service and constitute a very important addi-
tion to the text. The good opinion expressed with regard
to the worth of previous editions may be repeated here
and the work labeled as a thoroughly up-to-date treatise
on a most important subject, a proper knowledge of which
is essential to every practitioner of medicine.

Clinical Lectures on Enlargement of the Prost.\te,
With a Description of the .\uthor's Operation of Total
Enucleation of the Organ. By P. J. Freyer. M.A.,
M.D., M.Ch. Third Edition. New York : William Wood
& Co., 1906.
These lectures constitute a portion of the work which
the author intends to publish at a later date on the
"Surgical Diseases of the LVinary Organs." The most
important part of the book is taken up with a description
of the writer's operation for total enucleation with which
his name has been closely associated and which he had
done in over three hundred cases up to the date of publi-
cation. Of the 312 cases 290 were successful to the extent
that the patient was able to retain or pass urine without
the aid of a catheter. The mortality in this series was
about seven per cent. In the concluding chapter is pre-
sented a brief discussion of the claims of the writer in
opposition to those for a similar operative procedure made
by Fuller of New York, which is shown, however, to be
totally different. The book presents the subject of prostatic
hypertrophy and its treatment by local enucleation in a
very clear and systematic manner, and constitutes a valu-
able guide to a procedure which has gained greatly in
favor since its introduction.

Minor Maladies and their Treatment. By Leonard
Williams. M.D., M.R.C.P. Physician to the French
Hospital, etc., London. New York : William Wood &
Co., igo6.
The subject matter of this book consists of a series of
lectures delivered at the Medical Graduates' College and
Polyclinic in London by the author, and the object in
publishing them in the present form has been to supply
in an accessible shape detailed information on topics with
which the ordinary text-book deals only in a cursory man-
ner. The book is very comprehensive in scope, dealing
with the maladies which are liable to be of every-day oc-
currence, with numerous hints as to their differential
diagnosis and the treatment. In a chapter entitled "Change
of Air," there are reviewed the principles of climatologv'
and spa treatment, and another chapter presents the main
principles of domestic and personal sanitation. There is
also an excellent concluding chapter on the subject of
insanity, in which are given the practical and legal aspects
of the matter. Taken as a whole, the work is a very
efficient little manual, although the detailed references to
certain forms of medication and treatment will not always
appeal to the -•\merican practitioner. There is an excellent
and complete index.

On Retroperitoneal Hernia; Being the ".\rris and Gale"
Lectures on the Anatomy and Surgery of the Peritoneal
Fossae, delivered at the Roval College of Surgeons of
England in 189; by B. G. A. Moynihan, M.S.. F.R.C.S.
Second Edition. Revised, and in part rewritten bv the
author and J. F. Dobson. M.S.. F.R.C.S. New "i'ork:
William Wood & Co., 1906.
The advances which have Iieen made in the anatomy of
retroperitoneal hernia since the first publication of these
lectures in 1899 have made imperative certain changes
of opinion, and this has necessitated a number of impor-
tant changes in the present edition. Within less than two
hundred pases is aiven a very comprehensive idea of a
subject which received comparatively little attention until
within recert vears. After descrilv.ng the development of
the intestinal canal and peritoneum, a knowledge of which

is most essential to the understanding of the subject, the
writers take up the various herni.'e which may occur in
the duodenal folds and fossae, the folds and pouches in
the neighborhood of the cecum and vermiform appendix,
the intersigmoid fossa, and the lesser peritoneal sac. ,\
number of illustrative cases of the various types of hernia
referred to are appended.

.\nalyse des Uri.nes. Consideree comme un des elements
de diagnostic. Par le Dr. Ern. Gerard, Professeur a
la Faculte de Medecine et de Pharmacie dtf Lille.
Deuxieme edition revue et augmentee. Paris : 'Vigot
Freres, 1906.
The title of this book fullv indicates its nature. The
author has endeavored to create a work which should
fill a want which does really exist. To students not fa-
miliar with the French as distinguished from the German
view of some of the questions discussed, perhaps the book
will appear somewhat peculiar ; but as the modern English
and American pathology is so distinctly German, an ac-
quaintance with other views may be of value. Really
original work in this department of study is hardly pos-
sible, yet a careful study of this book may have its reward.

.\tlas and Te.xtbook of Human ."Anatomy. By Dr. Jo-
hannes Sobotta, Professor of Anatomy in the University
of Wiirzburg. Edited, with additions, by J. Playfair
McMurrich, A.m., Ph.D., Professor of Anatomy in the
University of Michigan. 'Vol. I, Bones, Ligaments, Joints,
and Muscles. Vol. II, the Viscera, Including the Heart.
Philadelphia and London : W. B. Saunders Company,
1906.

This is a translation, with notes and additions, of Professor
Sobotta's well-known and valued anatomical atlas. It dif-
fers from the original, however, in that the atlas has been
combined with the text, instead of the two constituting
separate parts. We question the wisdom of this, for the
work was intended chiefly for consultation, and not as a
textbook for the undergraduate, who has better works for
his purpose in Cunningham and Gray. In the original the
atlas first contained the illustrations with only the abso-
lutely essential descriptive matter. The text might, indeed,
almost as well have been omitted as far as the utility of the
work to the majority of those who will use it goes. This
does not mean that the text is not good, but it is in the way
of the man who wants only to sharpen the lines of his men-
tal picture of a certain anatomical region which may have
faded a little since his dissecting days. The inclusion of a
description of the heart among the viscera in this second
volume is perhaps anatomically justifiable, but we think it
would have been better to follow the usual custom of de-
scribing the heart with the rest of the circulatory system,
which will presumably form part of the subject matter of
the third volume of the work. The illustrations, of which
there are 320 in the first volume and 214 in the second, are
exquisitely beautiful and of photographic accuracy, those of
the bones especially being extremely well done. They are
mostly lithographs printed in colors. In the pictures of the
bones of the skull the plan has been adopted of giving each
of the bones a color of its own, so that in the topographical
views of the cranium one distinguishes the different bones
with ease. The Basle anatomical nomenclature [BNA] has
been employed for the most part, though many of the terms
(except those in the section on myology) have been angli-
cized. The translation has been well done by Dr. W. Henry
Thomas.

Progressive Medicine. A Quarterly Digest of Advances,
Discoveries, and Improvements in the Medical and Sur-
gical Sciences. Edited by Hobart .'\mory Hare. M.D,,
Professor of Theraneutics and Materia Medica in the
Jefferson Medical Collesre. Philadelphia. Assisted by
H. R. M. Landis, M.D., Assistant Physician to the Out-
Patient Medical Department of the Jefferson Medical
College Hospital. December I. 1906. ' Philadelphia and
New York: Lea Brothers & Co., 1906.
The December number of this nuarterlv digest is on the
same plan as heretofore, and it is also up to its own high
standard of excellence. In the present volume Dr. Steele
considers diseases of the digestive tract and allied organs,
the liver, pancreas, and peritoneum : Dr. Belfield con-
tributes the section on genitourinary diseases: Dr. Brad-
ford writes on the diseases of the kidneys ; Dr. Blood-
cood devotes one hundred pages to the consideratinn of
anesthetics, fractures, dislocations, amputations, surgery
of the extremities, and orthopedics: and. finally. Dr. Landis
supplies a therapeutic referendum. All of these con-
tributions are useful, and the busy practitioner can here
find whatever is of value in the periodical literature of
the past year or more. Further, the judicious work of
the editors of the various sections saves the bu.sy reader
the trouble of sifting the wheat from the chaff: only
the former is here presented.

5^2

MEDICAL RECORD.

[April 6, 1907

NEW YORK ACADEMY OF MEDICINE.

SECTION ON SURGERY.

Slated Meeting, Held Mareh i, 1907.

Ok. John F. F.rdm.\n in the Chair.

Hernia of the Bladder.— Dr. W.m. A. Duwnes presented
a man. fifty-four years old, who had had a hernia for a
number of years, and who was admitted to the hospital
December 24 and operated on December ,^ii. His liernia
had not given him trouble until one or two years ago, when
he had to get up six or seven times at night to empty the
bladder. During the day he had no such trouble. The
sac was opened on the upper and outer side ; in so doing
the lower and inner portion showed the usual characteris-
tic; of bladder hernias, a great deal of peritoneal fat. In
stripping off tliis fat he tore a three or four inch hole in the
top of the bladder. He introduced his finger and found at
least two-thirds of the bladder in the hernial sac. The
finger went to the trigone, and it was evident that the
greater portion of the bladder was in the hernia right
along. A cigarette drain was introduced and a catheter
passed through the urethra into the bladder; this latter
was kept in five days. The patient was discharged in three
or four weeks without trouble, and without any leakage.
There was a prompt healing of the wound. Dr. Downes
believed that hernia of the bladder was more common
than generally supposed. In three years he had had no
adult hernias; four of these were of the bladder. One was
in a femoral hernia, the other three in a direct inguinal
hernia.

Case of Bilateral Goiter.— Dr. John F. Erd.man pre-
sented this patient for Dr. Frauenthal. The patient was
twenty-four years old. He started general anesthesia and
at the first whiff of the laughing gas she went into com-
plete asphyxia. The operation was done then without any
anesthetic, the patient feeling absolutely no pain whatever.
When he removed the left lobe he found the trachea was
angulated and he then removed the right lateral lobe. Evi-
dently the parathyroids were not removed, for the patient
had not suffered from myxedema at all. She also had a
large fluctuating vascular growth upon the right thigh.

Dr. Torek said that it was interesting to hear that the
asphyxia was noticed before the operation. The cases in
which asphyxia happened during anesthesia were usually
the ones that presented asphy.xia before operation. He re-
called a disagreeable experience he once had in a case of
carcinoma of the thyroid on which he wanted to operate.
The narcosis had just begun when the patient died from
asphyxia. The operation was to be done to relieve the
asphyxia. Since that experience he had been heating
again and again of cases in which asphyxia in goiter cases
occurred before and with the administration of the an-
esthetic; the inference was that if a patient with goiter had
asphyxia an anesthetic should not be given.

Amputation of the Leg by Bier's Method. — Dr. A. V.
MoscncowiTZ presented a man whose leg had been am-
putated by Bier's method for Raynaud's disease, with
absolutely bad results, violating every rule both of com-
mission and of omission, calling for a perfect result. The
scar was upon the end of the stump and was made up of
granulation and cicatricial tissue. The flaps had been made
large enough, but they sloughed. The scar was adherent
to the bone. The stump was absolutely painless. .Y-ray
pictures of the stump were shown.

Myxofibroma of the Duodenum; Pylorectomy with
Partial Atypical Duodenectomy. — Dr. A. A. Berg
presented a man, thirty-seven years old, who had been
referred to him by Dr. Basch, with a history of ulcer and
with the physical signs of ulcer at the pyloric end of the
stomach or first portion of the duodenum. Dr. Basch was

inclined to the latter view. Inasmuch as extensive internal
treatment had not yielded satisfactory results in the relief
of the symptoms. Dr. Basch had proposed that operative
therapy be carried out. The patient was sent to Mt. Sinai
Hospital, where Dr. Berg opened the abdomen and found
the pyloric end of the stomach, the first and second portion
of the duodenum, the gall-bladder and under surface of the
liver and head of the pancreas fused into one mass about
half again as large as a hen's egg. There were numerous
adhesions surrounding the gall-bladder, first and second po-
sitions of the duodenum and stomach. Some glands in
the gastrohepatic omentum were infiltrated. The case
promised to be a very difficult one because of the dense
adhesions. The adhesions between the gall-bladder and
first and second portions of the duodenum were first di-
vided. In trying to separate the adhesions here it was
necessary to separate the portal vein and common bile duct
from the tumor. With sharp dissection he was able to get
to and ligate the gastric and the left gastroepiploic artery,
thus making it easy to approach the posterior aspect of
the tumor from the gastric rather than from the duodenal
side. The tumor mass was finally exposed and removed.
On macroscopical examination it apparently was a car-
cinoma. A gastrojejunostomy was performed. The an-
esthesia was not well taken and the patient developed a
capillary bronchitis, thus prolonging convalescence. The
histological examination of the mass showed it to be a
myxofibroma and probably was secondary to ulcer of the
duodenum.

Dr. Basch said that this case illustrated the difficulties
of diagnosis and rather impressed upon the internist the
necessity for early operation. Dr Basch then gave the
medical history of the case.

Pyloric Tumor, with Acute Dilatation of the Stomach;
Pylorectomy. — Dr. A. A. Berg presented a man, thirty-
si.x years old, a painter by occupation, who had been ad-
mitted to Mt. Sinai Hospital six weeks before. For two
years previous to the present illness he had had occasional
attacks of abdominal cramps, with loose movements of the
bowels due to lead poisoning. There was no loss of
weight, no history of syphilis or of gonorrhea. His pres-
ent illness came on three weeks before his admission. The
initial symptoms were intermittent burning pains across
the upper portion of the abdomen. They lasted one week,
and during this week there was no vomiting. The bowels
were moved by enemata. After the first week vomiting set
in and the bowels became constipated. The pains continued
to be severe, but were relieved by vomiting or when the
stomach was washed out. During the last week of illness
prior to admission to the hospital the bowels had not moved
and no gas was expelled. He vomited a yellowish-green
fluid. On admission he was given ox gall, with the result
that he passed some gas, but no fecal matter. The physical
examination made by Dr. Moschcowitz showed that there
was a large central prominence in the abdomen surroimded
by a depressed area in the perhiphery. There was a wave
and splashing sound. The stomach tube introduced pro-
duced two gallons of this yellowish-green fluid. When this
fluid was removed the tumor could be felt in the epigastric
region. A diagnosis was made of a pyloric tumor constrict-
ing the pylorus and giving rise to an acute dilatation of
the stomach. Five days after admission operation was
performed. There was found a hard nodular tumor,
occupying the pyloric region of the stomach and the first
portion of the duodenum. There was an extensive gland-
ular involvement. The excision of the mass was com-
paratively easy. -A gastrojejunostomy was performed with
Murphy's button. The middle colic artery was often in-
jured in these operations, and, if there were adhesions
present, it was hard to avoid it.

Case of Fracture of the Upper End of the Radius. —
Dr. Carter S. Cole presented this patient to illustrate his
paper. The patient was a man, a 'cello player and teacher.

April 6, 1907]

MEDICAL RECORD.

583

who came to him with a condition beautifully bhown by
excellent plates and prints made by Dr. Caldwell, showing
the head of the radius broken into several pieces, and with
a quadrilateral fracture in the ulna. The only thing that
could be defined by the first examination immediately after
the injury was that there was a fracture of the head of
the radius, a fracture of the ulna, a displacement of both
bones backwards, and considerable extravasation about the
joint. His first course was to restore the parts as nearly
as possible to their proper position, put on abundant ab-
sorbent cotton, with a firm compression bandage, and over
this a plaster-of-Paris bandage, the forearm being at a
right angle and slightly pronated. His anxiety about the
ulna, his fear of losing both flexion and extension, as well
as pronation and supination, if any operative measure was
taken, made him conclude that he would do nothing ex-
cept to keep the parts in best possible position until the
ulnar fracture had united ; and if he then found that flex-
ion and extension were prevented by the fragments of the
radial head, he would remove the latter. Following his
usual custom, he waited for six weeks, changing the plaster
from time to time as the effusion got less and the splint
became loose, and then, under an anesthetic, he tried flex-
ion and extension. The adhesions yielded with very little
effort and he satisfied himself that this function in time
would be perfect. The accident occurred in May. In Au-
gust he had already begun to play his 'cello with his or-
chestra, and from October until the present time he had
played from four to seven hours daily. The splendid func-
tion was demonstrated by his playing the instrument before
the Section.

The Adequacy of Local Anesthesia in Inguinal Hernia
Operations. — Dr. John A. Bodixe read this paper. He
said that modern surgery advised a patient with inguinal
hernia to submit to operation for cure and in lieu of this
curative advice the patient accepted his hernia and a truss.
The surgical proposition of 90 per cent, cured, with short
detention from business and small danger to life, would
seem attractive for the relief of such a condition to per-
sons who were suffering a 15 to 50 per cent, loss of earn-
ing capacity and were exposed to the danger of potential
death, yet the number of trusses worn attested the uni-
versal rejection of this proposition. General narcosis, with
its small but certain danger to life and its disagreeable
features, presented a deterrent factor to accepting a surgi-
cal cure of hernia. If they eliminated the danger, the dread
and the disagreeableness of general narcosis, they might
turn a conspicuous surgical defeat into a colossal victory.
In the earlier operations an effort was made to cocainize
the ilioinguinal, the iliohypogastric, and the genitocrural,
but it had been found that cocainization of the ilioinguinal
alone, with infiltration into certain sensitive areas, suf-
ficed for a painless dissection. The technique had been
explained in previous papers. If the skin and subcutaneous
tissue were properly infiltrated by a i to 500 warm cocaine
solution, the incision down to and through the CNternal
oblique aponeurosis was totally devoid of pain. But few
blood-vessels and nerve filaments were encountered in the
incision to and through the external oblique, if the in-
cision was not carried to-or 'below the level of the external
ring. At this latter point the ilioinguinal nerve expanded
into many filaments and the bleeding points were numer-
ous. It was, therefore, essential to find and cocainize the
ilioinguinal trunk before incision into this level. After
cocainizing the ilioinguinal at the upper limit of the hernia
incision the operation in simple cases could be completed
without additional analgesia and with little or no complaint
of pain. Infiltration was necessary into the internal oblique
around the arching fibers of the internal ring and around
the sac neck during its dissection in the margin of the
opening. Not one of the patients he had operated upon
had given any evidence of either acute or moderate pain.
None had grumbled or complained during the operation.

Patients were often willing and even desirous of having
the second side operated upon at one sitting. To each and
every one of the double cases general narcosis was offered
as a test at the second operation and refused. As the pa-
tient was flaccid, quiet and uncomplaining, there was no
temptation to shorten or curtail the operation. That a
solution of cocaine, amounting in sum total to any frac-
tional part of a grain intermittently injected during an
hour of time, was less dangerous than cerebral narcosis
for the same time was obvious, and that it was entirely
without danger to the patient was probably a fact. There
was at times a set of symptoms once regarded as toxic
manifestations of cocaine, sweating, pallor, and sighing,
but they were purely psychic and in no way toxic. Fat
presented the principal limitation to the method. The chief
difficulty was in the necessary retraction for excision in a
wound so deep. Age and lesions of the kidney and of the
heart offered no barrier. In strangulated hernia local an-
algesia rose almost to the dignity of an imperative method.
The added shock of an hour under cerebral narcosis, the
danger from drowning in fecal vomit and the hurried de-
cision as to whether a loop of .gut should be excised or not,
accentuated the advantage of a method that did not shock,
which permitted the patient to control the vomit, and
gave any quantity of time to decide on the circulation
in the gut. There were certain advantages associated with
local analgesia. It imposed upon the surgeon respect for
tissues, gentleness of manipulation amounting to dainti-
ness. Blunt dissection, tearing or rubbing the sac from
the cord with gauze pads was impossible. Clean-cut dis-
section was necessary from beginning to end. The signal
advantage of this method was the preservation of the
structural integrity of the nerves in this area. Thinning,
atrophy and paralysis followed division of a nerve trunk
as an inexorable law, and this must to a greater or less
extent follow injury to the ilioinguinal or hypogastric.
This thinning or atrophy invited recurrences. A personal
experience of over 400 operations for the radical cure of
inguinal hernia with local cocaine analgesia formed the
basis of his remarks. Since his first operation of this
series no case of inguinal hernia had been operated upon
under any other kind or method of analgesia. Conse-
quently his experience embraced nearly all variations of
the simple hernial protrusion and nearly, if not all, the
different types of patients. In conclusion he believed that
local analgesia was entirely adequate for the radical cure
of inguinal hernia. In his 400 cases he had not had one in-
stance of suppuration.

Dr. Brooks H. Wells, Dr. Schley, Dr. Foot, Dr. Berg,
Dr. MoscHcowiTZ, Dr. Dozane, and Dr. Douglas discussed
the paper.

Dr. Bodine closed the discussion.

Fracture of the Upper End of the Radius; Some Per-
sonal Experiences with Radiographs and Plates. — Dr.
C.VRTER S. Cole read this paper. For ten or twelve years
he said he had been taught, read, and believed that frac-
tures of the head of the radius were exceedingly rare, and
that fractures of the neck of the radius were hardly pos-
sibilities. But he admitted that with the added means
of diagnosis, the .r-ray, a different conclusion could have
been reached in some of the cases that passed under his ob-
servation. During his interne service at Chambers street
(of sixteen months) no such fracture was recognized by
any one, and a service of more than two years at
Hudson street failed to bring to his notice any injury of
this kind. A practically continuous service at the Post-
Graduate Hospital for fourteen years did not furnish the
desired and Iimg-sought-for lesion until about three years
ago; and then within a short time the several cases re-
ported came under his obser\-ation. Dr. Cole believed that
without .v-ray examination the best they could do in the
matter of diagnosis was to say that they had a fracture;
to that they might add whatever seemed to be the prob-

584

MEDICAL RECORD.

April 6, 1907

able variety. Tlieir diagnosis was made on pain and
crepitus upon rotation of the radius, together with pain
on pressure about tlie radiouhiar articulation, and in in-
dividual cases there might be slight deformity. There
was at first very little limitation to rotation, and there
might be or not distinct crepitus or simply a click; the
limitation to extcn.sion or flexion might not be worthy of
consideration ; but later the loss of rotation was consider-
able if not complete and was necessary to a diagnosis if
neither a fluoroscopic examination nor an .r-ray picture
was available for that purpose. His conclusions were as
follows: (i) In fractures of the head of the radius treat-
ment by plaster-of-Paris circular bandage, the forearm
flexed to a right angle and carried just a little beyond mid-
pronation in the direction of pronation, the elbow joint hav-
ing first been liberally surrounded by absorbent cotton held
in place by a firm muslin bandage. Later, if sufficient inter-
ference be caused by any fixation sufficient to justify opera-
tive measures, removal of the fragments, and an efltort to
restore the function of the joint might be made. (2) In
fracture of the neck immediate removal of the fragments,
as fixation and loss of function must follow under any
form of treatment. The same treatment was all the more
imperative if fracture of the neck was complicated by frac-
ture of the head. (3) If the ulna was fractured at the
same time, avoid any open operative interference until a
sufficiently long time had elapsed to show what permanent
loss of function had been sustained and what probable
improvement could be obtained without operation.

Dr. Foot, Dr. Bissell, Dr. G.\ll.\nt, Dr. Morehead, and
Dr. Frauenthal discussed the paper.

Dr. Cole closed the discussion.

.A New X-Ray Table.— Dr. M. L. Kakels presented
this. (See page 586.)

THE WILLIAMSBURG MEDICAL SOCIETY.
Stated Meeting, Held March 11, 1907.

"Some Middle Ear Dent's for the General Practitioner."

—Dr. John E. Sheppakd read this paper. Although the
subject was an elementary one, it was frequently necessary
to recall to one's mind some of the things already well
known. Ear-drops of all kinds, from sweet oil and lauda-
num to solutions of cocaine, were to be avoided. Flax-
seed poultices usually did harm. The best household
remedy for earache was dry heat. If more heat was re-
quired, it was obtained by filling the external auditory
canal with hot sterile water (112° to 120°) and placing
the hot water bag on top of it. A patient was not to be
allowed to suffer from an unrelieved earache any longer
than was absolutely necessary. Early incision of the drum
was the best preventive for mastoiditis, and was the most
likely means to insure a speedy return to the normal
hearing. A few hours after the ear began to run, pain
should cease, and almost always did cease, unless the
mastoid was inflamed. When the pain continued, it was
necessary to investigate the mastoid for tenderness, and
if this was found, the question of operation was not to be
postponed too long. The late symptoms of mastoiditis
(edema and redness behind the ear) were not to be waited
for, as they indicated that the infection had already made
its way through the .external mastoid cortex, and that
there was a beginning subperiosteal abscess. Waiting for
the perforation of the external cortex gave equal oppor-
tunity for the perforation of the internal cortex, with the
resultant intracranial complications. The occurrence of a
mastoiditis without discharge from the ear was not infre-
quent. The appearance of pyemic symptoms in the course
nf, or following, a middle-ear suppuration probably signi-
fied a lateral sinus infection. It was not to be overlooked
that an otherwise unexplained high temperature in infants,
or a sudden increase of fever in various diseases, might in-
dicate middle-ear involvement. The significance of mouth-

breathing in relation to middle-ear conditions was not to be
forgotten. It was in itself a symptom, not a habit. In
adults it meant adenoids, deflected septum, hypertrophied
turbinates, etc. In children it almost always indicated
adenoids, and these were, undoubtedly the cause of the
majority of the ear troubles of childhood. They were
also the cause of most of the cases of incurable middle-ear
catarrhal deafness of later life. The remark was not to be
sanctioned that the removal of adenoids was a fad. It
was profitable to solve the problem of how to prevent
their occurrence. Probably the lack of humidity in the
atmosphere of the average living room was the cause of
the development of adenoids. The use of the nasal douche
in any of its forms was not to be countenanced.

Catarrh of the Upper Respiratory Tract. — Dr.
Charles W, Stickle read this paper. He dwelt particu-
larly on the suppurative conditions of the nasal accessory
sinuses. Patients complaining of symptoms of hawking
and spitting from a continual dropping in the throat, of
difficulty of breathing through the nose, of hoarseness, deaf-
ness, of headache or other neuralgias, and of other dis-
agreeable symptoms, were frequently treated to no avail
for catarrh, and merely advised to use the nasal douche, or
spray, or given astringent drugs, or sent to a high, dry
climate. Their condition grew worse and worse, until
they died from some sequela of an original infected mucous
membrane in one or all of their accessory sinuses. Owing
to the fact that in infants these sinuses were not developed,
any purulent nasal or pharyngeal discharge was in the
majority of cases directly due to the presence of pharyngeal
adenoids. Xinety-eight per cent, of the benign purulent in-
flammations of the nose were summed up in the words
"sinus empyema." It was the modern opinion of the ma-
jority of rhinologists that any discharge of pus, whether
in the form of ozena or of ordinary pus streaks, was
symptomatic of nasal accessory sinus necrosis, unless it
was due to tuberculous or syphilitic ulceration of the nasal
septum or lateral sinus. The pus issuing from the nasal
sinuses was capable by direct contact or by means of sys-
temic absorption, or local degeneration, of causing,
first, the vasomotor inflammations in the nose it-
self, appearing most frequently under the form of
frequent or continuous attacks of coryza, middle-ear ab-
scess and its sequelx, gastrointestinal derangements from
the absorption of pus, thickening of the posterior wall of
the larynx causing hoarseness, with subacute inflamma-
tion of the surrounding tissues, merging into a tracheitis,
bronchitis, or bronchiectasis. Eye symptoms almost always
accompanied sinus inflammation. What was to be ex-
pected when the pus was pent up in the accessory sinuses?
First, and most to be feared, was meningitis. Epilepsy
had been reported as due in some cases to sinus suppura-
tion, with malformations and pressure of the nasal septum
and turbinates. The etiology of sinus disease was clear;
it resulted from the extension from the mucous membrane
of the nose during the course of a simple corj'za, of pneu-
mococcic staphlycoccic. or streptococcic infections. The
treatment was operative.

Early Diagnosis of Carcinoma of the Breast. — Dr.
.\dolph Boxxer. in this papfr, said that the importance of
early diagnosis was seen in the fact that late surgical in-
terference had negative results, and that 75 per cent, of
neoplasms of the breast were carcinomatous. Tumefaction
was the first evidence of carcinoma, which most frequently
involved the upper outer quadrant. The tumor was hard,
its border ill-defined and immovable in the surrounding
tissues. Pitting of the skin and retraction of the nipples
were early signs. Radiating and lancinating pains were
sometimes early symptoms, but were never likely to occur
when the tumor had acquired some size. Fibroma was
found earlier in life, and though hard was well defined and
movable in the surrounding tissues. The skin was not
adherent. The pain was intermittent in character and
aggravated at the menstrual period. Adenoma occurred at

April 6, 1907]

MEDICAL RECORD.

585

the age of functional activity of the breast, and tlie tumor
was well defined and lobulated, and the skin over it freely
movable. Lipomata, chondromata. and echinococcus were
rare. Diffuse hypertrophy was found early in life and
associated with pregnancy. Gummata were rare, but when
found were superficial, with early discoloration and ulcera-
tion of the overlying skin. Deep gummata underwent early
breaking down and ulceration and were not well defined
nor movable in the surrounding tissues. In the test of
treatment it was to be remembered that iodides and mer-
cury caused a transitory arrest in the growth of carcinoma.
Tuberculous mastitis was rarely primary. In chronic mas-
titis the tumor was irregular and immovable, and never
involved the glands. Its chronicity and the tendency to
retract the nipple made it hard to differentiate between
chronic mastitis and scirrhus carcinoma. Methodical
physical examination included a determination of the rela-
tive size of the breasts ; color of the skin, and its character,
whether smooth, nodular, dimpled, drawn, or ulcerated ;
character of the nipples, whether on the same level, promi-
nent or retracted, or offering the same resistance on trac-
tion. In palpation the breast was immobilized with one
hand and the tumor moved in the direction of the fibers of
the pectoralis major with the other, in order to determine
the question of its attachment or not. At the same time
consistency, size, and shape were determined. With the
patient's arm adducted, the glands at the lower outer
border of the pectoralis major muscle were ne.\t e.xamined,
the physician's finger tips pressing with an upward and
downward motion into the a.xilla. Suspicion of carcinoma
justified early incision.

Joint Meeting of the Chicago Medical axd Chicago
Pediatric Societies.

At a joint meeting of these societies, held February 27,
1907, there was a symposium on "Scarlet Fever," Dr. Lud-
wiG Hektoen discussed the etiology and pathology of the
disease, and from the facts he presented we are justified
in concluding (i) that the predominant feature of the
bacteriology of the throat in scarlet fever is the constant
presence of large numbers of Streptococcus pyogenes. (2)
That the overwhelming majority of the so-called compli-
cations and of the deaths in scarlet fever is due to invasion
of the tissues and the blood by this microbe. (3) That in
scarlet fever, even when mild, the organism gives evidence
of systemic reaction to streptococci by variations in the
streptococcus opsonic index, and probably also by the forma-
tion of streptococcus agglutinins. There is, therefore, noes-
cape from the conclusion that Streptococcus pyogenes or
some form thereof plays a most significant part in the
scarlatinal process, but the author did not think that
we were ready to take the final step and conclude that
scarlet fever was wholly a streptococcus disease. Dr.
Heman Spaldi.vg discussed the prophylaxis of scarlet
fever, and said that in considering preventive measures
it should be borne in mind that scarlet fever is not so
generally infectious as measles or smallpox. In a com-
munity of susceptibles — those never having had the dis-
ease— about ,^8 per cent, will contract the disease when
exposed to it, whereas in a like community about 90 per
cent, would contract smallpox or measles if exposed to
those diseases. As to the manner of transmission, the
proof is strong that the infection can be conveyed through
the milk supply. Fruit and vegetables peddled from a
house where scarlet fever exists can be the means of
spreading the disease. The prophylaxis of scarlet fever
consists in separating the sick from the well and destroy-
ing all infection emanating from the scarlet fever patient.
He emphasized strongly the point that after scarlet fever
the entire house should be disinfected. Dr. John M,
DoDSON, in discussing the clinical history and diagnosis,

presented a summary of the course and symptoms of scar-
let fever as presented in 300 cases treated at the Memorial
Institute for Infectious Diseases. He described the course
of the usual type of moderate severity, and then noted
the distinctive features of the more severe forms of the
disease. Dr. M. P. Hatfield, in speaking of atypical cases
of scarlet fever, said that he was distrustful of vomiting
as a pathognomonic symptom of the disease. One should
not rely too much on the thermometer in making a diag-
nosis of scarlet fever. There is a class of cases in which
there is a reversal of the ordinary temperatures noted in
scarlet fever, namely, the temperature is higher in the
morning and declines towards the evening; whereas one
expects lo find the reverse in a typical case of the disease.
One symptom to which he pins most of his faith is the
characteristic angina. As to erythema, there are more va-
riations in this than any single symptom found in the
course of the disease. As to desquamation, a few years ago
he saw a case in which there was a sloughing off of a cast
of the whole upper lip. There was one form of atypical
scarlatina which the physician dreaded, namely, scarlatina
fulrainans, which killed patients by the intensity of the
toxins before the physician was able to make a diagnosis.
He cited one such case. Dr. Alfred C. Cotton said that
in the treatment of scarlet fever the main indications are
to support Hie patient and to aid in the elimination of the
toxins. Dr. H. Manning Fish said that one serious ocular
complication following scarlet fever is disease of the optic
nerve. Dr. William L, Baum said he had searched high
and low for a case of Duke's disease during the recent
epidemic of scarlet fever, yet he had been unable to find
a single instance which tallied with the description of that
disease as described by Duke in the London Lancet. In
all cases of doubt as to diagnosis they relied on examina-
tions of the blood at the Cook County Hospital. Dr. H. B.
Hemenwav referred to the epidemic of scarlet fever in
Evanston, He furnished unmistakable evidence of the epi-
demic in that city being due to an infected milk supply.
Dr, H. W, Cheney spoke of Moser's serum in the treat-
ment of scarlet fever. The eft'ect begins to manifest itself
in from ei.ght to twelve hours after injection, and is char-
acterized Ijy a marked fall in the temperature, oftentimes
the temperature dropping to normal within twenty-four
hours, and continuing there, or nearly so. The pulse shows
much the same change. The rash, when the injection of
the scrum is given early, either does not develop or fades
away more rapidly than usual. A most notable change is a
marked betterment in the general condition of the pa-
tient. The workers in Vienna in the Kinderkrankenhaus
are convinced of the value of this serum. One hundred
cases have been treated with the serum. Only the severest
cases are injected with it. The serum has been used there
since 1900, Before that time the mortality from scarlet fever
at this hospital was 15 per cent.: since then it has averaged
less than 9 per cent. The mortality in other hospitals in
Vienna, where the serum was not used durine the period
since 1900, has averased 13 per cent. Dr. O. Tydings said
the successful treatment of scarlet fever rests principally
upon treating the comnlications which arise during the dis-
ease. Dr, H, G. Vaughan referred to an epidemic of
scarlet fever in Oak Park, 111. He thinks that epidemics
of the disease can be caused by infected milk. They have
had approximately no cases of the disease in that suburb,
the cases running much the same course as those in Evans-
ton and elsewhere, with suspicion resting upon a company
that furnished infected milk. After thorough investigation,
however, the members of the Health Department were un-
able to draw any definite conclusions implicating this milk
company. Dr. A. H. Burr of Rogers Park spoke of an
epidemic in that city, saying the disease appeared simul-
taneously with the epidemic in Evanston, and could without
doubt be traced to infected milk supplied by one company
of milk dealers.

586

MEDICAL RECORD.

[April 6, 1907

Nfui Snatruuipiita.

A NEW A'-RAY TAI5LE.*

By M. S. KAKELS. M IJ,.

NKW YORK.
ADJUNCT SURGEON', LEBANON HOSPITAL.

Appreciating the desirability of transmitting tlic .r-
ray from below tlirousjh a jKiticnt while lying in a
horizontal position for thioroscop)-, radiography, or
radiotherapy, 1 have devised for that purpose a table
which I present for your inspection this evening.
The practicability of this table overcomes the in-

radiograjjhy or radiotherapy. The other great ad-
vantage is a protected Crooks tube carrier, which
plays beneath the top of the table, moving either
forward, backward, or lengthwise by simply turning
the knobs on the side. One can readily appreciate
what a distinct advantage this is for the examiner
who wishes the aid of the Roentgen ray passing
through any part of the body from below.

Of great importance also for the surgeon is this
arrangement by which surgical procedures can take
place while the tube is in operation without any
deleterious influence whatsoever to the operator
arising from the ray.

conveniences experienced in examining patients
who, owing to the nature of their condition, are
unable to stand, and in whom it is absolutely neces-
sary either to fluoroscope or radiograph for diagnos-
tic purposes. In surgical practice such cases fre-
quently arise, and the methods heretofore used in
examining by the Roentgen ray were impracticable
and very limited.

The table is constructed of a strong wooden
frame 6 feet 4 inches long by 26 inches wide and
30 inches high. The top consists of two covers.
The upi^er one easily removed is made of wood Ij4
inches thick and separated from the lower one by a
space of 23-2 inches, which is plentv wide enough to
admit the compression apparatus, which is fixed on
a platform to ea^ilv rn!! from one end to the other,

In its construction, one of the advantages it pos-
sesses is that it has combined with it a detachable
compression apparatus, which can be readily moved
to any position without disturbing the patient, so
that any portion of the body may be compressed for

*Presented and described before the surgical section of
Academy of Medicine, March i. igo/.

on the two rails which arc fastened to the sides of
the framework.

The compression apparatus can thus be easily
moved to any position over tlie whole length of the
table while the patient is lying on the top cover
witliout disturbing him in the least, and when not
required may be readily rolled of?.

April 6, 1907]

MEDICAL RECORD.

587

For radiographic work, the movable top has been
made of wood, because it offers a firm support when
the compression apparatus is employed. The lower
cover or top consists of a rectangular frame, over
which is tightly stretched a layer of canvas heavy
enough to hold a patient of any weight. I have used
canvas, as it has practically no resistance to the
Roentgen ray. It also has an advantage over fiber
wood in that the latter contains impurities and warps
in damp weather.

The canvas top is fastened by two hinges to one
side of the table, so that, when the upper wooden
cover and compression apparatus are removed, it
can be easily opened and kept open by stays, for the
placing and adjusting the .r-ray tube in the car
which runs underneath it.

The car, containing the Crooks tube, is a wooden
box 26 inches long by 14 inches wide and 12 inches
deep, large enough to hold an 80 cm. tube. It is
lined with a layer of special opaque material and
reinforced by a layer of lead glass, which makes a
most efficient method for preventing the penetration
of the .I'-ray. It is mounted on a truck which moves
lengthwise by rack and pinion, while the car itself
moves forward and backward on this truck by a
cord and pulley arrangement. These movements
are controlled and regulated by the two knobs mov-
ing with the truck, which extend from the sides of
the table. This double movement makes it feasible
to center the tube at any spot on the patient while he
is lying on the table by simply turning the knobs one
way or the other, that is, either to the right or to the
left. An opening on the bottom of the box. which
is covered by a sheet of lead glass, permits the light
to be reflected from a mirror fitted beneath, thus
affording the examiner to view the condition of the
tube. This mirror is automatically adjusted so that
the tube is constantly in sight, no matter where the
box may be. The top or cover of the tube-carr\-ing
box can be removed for the insertion of a tube of
any length. It has a circular opening 4 inches in
diameter sufficiently large for admitting the .r-ray
to the part to be examined.

An adjustment on either end of the box consists
of a hollow metal tube, containing a spring, which
clasps the ends of the Crooks tube, and, besides
forming the connecting pieces for the electrical con-
nection to the coil, afford the simplest support for it.
When held thus the center of the tube is about 6
inches from the top of the canvas cover. There are
many occasions and opportunities which prove the
practicability of this table. A patient can easily be
carried on a stretcher from his bed, and with it laid
directly on the canvas or wooden top for fluoro-
scopy or radiography. While setting a fracture of
the lower extremity, it can be fluoroscoped while the
patient is on the table and immediately reexamined
and compared with the other healthy limb by sim-
ply turning the knobs and rolling the car, holding
the Crooks tube under either of them.

I need not dilate upon the immense advantage
thus afforded in seeing any errors in malposition
and thus facilitating timely correction.

This is but one of the many instances for which
this table may be used.

Another practical use for which it may be em-
ployed is that by it we have a means for operating
in many instances for a foreign body by the Roent-
gen ray while the operator is absolutely shielded
from its influence. Foreign bodies such as bullets,
etc., mav be located in such parts of the body where
on account of the nature of the traumatism inflicted
patients are unable to stand.

For practicability it seems to me this table meets

all the requirements for which it has been devised.
I am indebted to ]\Iessrs. Wapper and Bro. for
valuable suggestions in the construction of the me-
chanical parts of the table.

Maaks Stmuri.

While the Medic.\l Record is pleased to receive all new
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Traite des Urines. Par le Dr. E. Gerard. i2mo, 550
pages, illustrated, muslin. Vigot Freres, Editeurs, Paris.

Manuel Pratique de Massage. Par J. E. Marfort.
i2mo. 3iq pages, illustrated, muslin. Vigot Freres, Editeurs,
Paris.

La Sterilite Chez la Femme. Par le Dr. E. Hugon.
i2ino. 0,^ pages, paper. Vigot Freres, Editeurs. P ni^

Notions Slementaires de Prophylaxie des Maladies
Tropicales. Par R. Wurtz. 8vo, 30 pages, paper. Vigot
Freres, Editeurs, Paris.

Twentieth Annual Report of the St.\te Board of
He.^lth of the State of Ohio for the year ending Decem-
ber 31, 1905. 8vo. 501 pages, paper. Springfield Publishing
Co., Springfield, 0.

On the Synthesis of Protein Through the .Action of
Trypsin. By .Alonzo Exglebert Taylor. The University
of California Press. Berkeley.

Dictionnaire de Medecine et de Therapeutique. Sep-
tieme edition, 4to, 1,575 pages, illustrated, paper. Felix
.A.lcan. Editeur, Paris.

The Diagnosis and Treatment of Intussception. By
Charles P. B. Clubbe. 8vo, 92 pages, muslin. Young J.
Pentland, London.

Modern Medicin..\l Preparations. i2nio, 92 pages, mus-
lin. Victor Koechl & Co.. New York.

Traite d'Hy'giene. Public en Fascicules. 8vo, 317 pages
paper. Librarie J. B. Bailliere et Fils, Paris.

The Muscles of the Eye.. By Lucien Howe, ^LA.,
M.D. 2 volumes, Bvo, 455 pages, illustrated, muslin. G. P.
Putnam's Sons. New York.

.■\merican Practice of Surgery. Volume 2. 4to, 778
pages, illustrated, muslin. William Wood & Co., New
York.

The Practitioner's Medical Diction.\rv. By George
^L Gould, .'\.M., M.D. 8vo, 1.043 pages, illustrated, flex-
ible leather. P. Blakiston's Son & Co., Philadelphia.
Price, $5.

The British Tourn.\l of Tuberculosis. Edited by T. N.
Kelynack, M.D'., M.R.C.P. Vol. I. No. i. 102 pages, illus-
trated, paper. Bailliere, Tindall & Co.x, London.

Burdett's Hospit.-\ls .^nd Ch.arities. IQ07. By Sir
Henry Burdett, K.C.B. i2mo, 963 pages, muslin. The
Scientific Press, Ltd., London.

Medical Diagnosis. Fifth edition. By J. J. Gr.\ham
Brown and W. T. Ritchie. i2mo, 50S pages, illustrated,
muslin. Imperial Publishing Co., New York.

Manu.\l of Clinical Chemistry-. By A. E. Austin,
A.B., j\LD. i2mo, 278 pages, illustrated, muslin. D. C.
Heath & Co., Boston.

Biographic Clinics Vol. IV. By George M. Gould.
M.D. l2mo, 375 pages, muslin. P. Blakiston's Son & Co.,
Philadelphia. Price, $1 net.

Biographic Clinics. Vol. V. By George M. Gould.
M.D. i2mo. 390 pages, muslin. P. Blakiston's Son & Co.,
Philadelphia. Price, $1 net.

Zentr.^lbl.\tt fur Chirurgische und Mechanische
Orthop.Kdie. 8vo, 48 pages, illustrated, paper. Redigiert
von Prof. Dr. O. Vulpius in Heidelberg.

Beitr.\ge zur Diagnostik und Ther.\pie der Gesch-
wulste. Von Prof. Dr. H. Oppenheim in Berlin. 196
pages, 8vo, illustrated, paper. Berlin. 1907. Verlag von S.
Karger.

NiERENCHiRURGiE. Ein Handbuch fur Praktiker. Von
Prof. Dr. C. Garre und Dr. O. Ehrhardt. 4to, 348 pages,
illustrated, paper. Berlin, 1907. Verlag von S. Karger.

Newspaper Directory and Advertisers' Manu.il. 1907.
i6mo, 655 pages, flexible leather. Geo. M. Savage Adver-
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Race Culture, or Race Suicide' By Robert Reid Ren-
TOUL, M.D. 8vo, 182 pages, muslin. The Walter Scott
Publishing Co.. Ltd.. New York.

A Manu.\l of Prescription Writing. By Matthew D.
M.\XN. .'\.M.. ^I.D. i6mo. sixth revised edition. 232 pages,
muslin. G. P. Putnam's Son=. New York.

588

MEDICAL RECORD.

[April 6, 1907

iHriitral Mnna.

Contagious Diseases — Weekly Statement. — Report of

cases and deaths from contagious disease reported to the
Sanitary Bureau, Heahh Department, New York City, for
the week ending March 30, ux>7 :

Tuberculosis Pulmonalis.

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis.
Malarial Fever

Totals

Cases Deaths

Somatic and Psychic Electrotraumata. — Anacleto
Romano calls our attention to the manifestations of epi-
lepsy following injuries by currents of low tension and
from his studies of the condition concludes that inter-
mittent currents of low tension penetrate the brain and
produce a suspension of the functions of the hemisphere;
such currents traversing the brain produce epilepsy with
the three phases of tonic and clonic convulsions followed
by coma. The development of this condition is modified
by medication introduced into the circulation as well as
by the functional and chemical conditions of the brain.
Apoplectiform attacks may also be produced by electric
currents interrupted and increasing in intensity. They di-
rectly afifect the circulation of the brain, or indirectly they
paralyze nerves or segments of nerves, such as the vagus.
These electrotraumata produce psychical symptoms that
are very marked : among others a "true form of dementia!
paralytica, preceded by disturbances of the mental facul-
ties. All the neuroses and psychoses may result from elec-
trotraurna. They either predispose to neurotic and psy-
chopathic conditions, or directly determine them. In
Vienna has been established a clinic for the treatment of
conditions due to the electrical atmosphere and results of
the industrial trades in which it is used. The remedies
to be used, after an accident by electricity, are such as
lower the blood pressure, stimulate the respiration, and
quiet the cerebrum. Preventive measures in the line of
perfect insulation should be carried out by all companies
installing electrical apparatus. — AHiiali di Elcttrkita Medi-
ca c Terapia Fisica.

The Etiology of the Punctiform Hemorrhages in the
Mucous Membrane of the Appendix. — Bayer recounts
the theoretical and practical considerations which lead him
to regard the minute extravasations of blood frequently
seen in the mucous membrane of appendices removed dur-
ing the interval as artefacts produced in the course of the
removal of the organ. It is his theory that in tying off the
blood supply of the appendix the veins are usually in-
cluded in the ligature, but the artery often escapes and
has to be secured separately later on. In consequence of
this there is a tremendous rise in pressure in the capillary
network, which results in minute ruptures and hemor-
rhagic spots. Such lesions may be observed in appendices
that have been removed in the most careful manner pos-
sible, so that it seems out of the question to consider any
mechanical injury responsible for them. — Centralblatt fiir
Chirurgie.

Health Reports.— The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital
Service, during the week ended March 20. 1007:

SM.ALLPO.X — VN'ITED STATES.

CASES. DEATHS.

Georgia. .A.ugusta Mar. 12-26 11

Illinois. Chicago Mar. 16-2,^ • p i

Galesbiirg Mar. 9-23 9

Springfield .Mar. 7-14 i

Danvnlle - . Mar. 13—27 3

Stark County To Mar. 13 27.^

Indiana. Culver Jan. 21-Mar. 5 - - - . 6

Elkhart Mar. 16-2? 4

Indianapolis Mar. 10-24 o

Iowa. Dubuque Mar. 18 63

Peoria Feb. 2— Mar. 23 ... . 63

Spencer Jan. 8-Mar. 14 ... . s;

Kansas. General Jan. 1-31

Louisiana. \ew Orleans Mar. 9-23

126

Shreveport Mar.

Massachtasetts. Boston. Mar.

Michigan. Center\-ille Feb.

Detroit Feb.

0-16. .
16-23.

7 cases imported

.Minnesota, General Jan. 2S-Mar. i"! . . .

Winona 1 .Mar. 9

J .\lar. 16-23

.Mississippi. Natchez Feb. 2-Mar. 16....

Missouri, St. Joseph Mar. 16-23

St. Louis Mar. 16-23

Xew Jersey. Newark ^Ia^. 16-23

New York, Binghanaton .Mar. 16-23

.Vew York Mar. 16-23

North Carohna. Charlotte Mar. 9-23

Greensboro Mar. 9-16

Ohio, Cleveland Mar. 15-22

Hamilton Feb. 9-16

South Dakota. Sioux Falls Mar. 9-23

Texas. Galveston Mar 15-22

Wilhamson Co.. George-
town included Dec. -Mar. 23

Virginia, Richmond Mar. 9-23

Washington, Spokane Mar. 2-16

Wisconsin, Milwaukee Mar. 9-23

Wasau ^Iar. 9-16

13
■5

- (Toul 3

SMALLPOX I.NSCLAR.

Philippine Islands, Manila Feb. 2-9.. . .

On S. S. Ban Yek

SMALLPOX — FOREIGN.

.Africa, .^giers Feb.

Brazil. Para Mar.

Rio de Janeiro F'eb.

Chile, Coquimbo Feb.

Iquique Feb.

China. Hongkong Jan.

Colombia. Cartagena Mar.

Equador. Guayaquil Feb.

Egypt, Cairo Feb.

France. Marseilles Feb.

Paris Feb.

Germany, Bremen Mar.

Gibraltar Feb.

Great Britain, Bristol Feb.

Cardiff Mar.

. Bombay Feb.

Calcutta Feb.

Madras Feb.

Naples Mar.

Madeira. Funchal Feb.

Mexico. Aguas Calientes Mar.

Jalapa Mar.

Indi;

Italy.

Mexico .

Dec.

.Mi

Netherlands. Rotterdam NIar.

Portugal. Lisbon Feb.

Russia. Moscow Feb.

Odessa Feb.

^^'^ {Sar.

Warsaw Feb.

Sal\'ador, San Salvador Feb.

Spain. Barcelona Feb.

Cadiz Feb.

Seville Feb.

Valencia. . Feb.

1-28

2-9

24-Mar. 3 . .

S5

25

26-Feb. 2, . .

2-9

23-Mar. 2. .

25— Mar. 4 . .

1-2S

23-Mar. 9 . .

2-9

25-Mar. 10.

23-Mar. 2 . .

2-9

12—26

9-16

16-22

g-i6

24-Mar. 10.

9-16

8-15.

26..

16.,

2-9

23-Mar. 9.
g-Mar. 2. .
25-Mar. 2.

1-31

2-9

2-9

9-16

i8-Mar. 10

1-2S

1-28

23-Mar. 2.

4
24

Present

6

Present

4

I

230

29- Jan.
27-Feb.

43
16

6

7
6

28

YELLOW FEVER — UNITED STATES.

Louisiana, Mississippi. River Quar-
antine Mar. 20 1

On. S. S. Cayosoto, from Cuban and Mexican ports

Texas, Galveston Quarantine Mar. 22 3

On S. S. Basil from Para

YELLOW FEVER — KOREIG.N.

Brazil. Nichtheroy Feb. 16 i

Rio de Janeiro Feb. 24-Mar. 3 . . . . 2 2

Ecuador. Guayaquil Feb. 23-Mar. 2 7

Mexico. Paraje Xuevo Mar. 3-8 i i

Peru. Callao Feb. 17-19- ■ -

CHOLERA.

India, Bombay Feb. 12-26..

Calcutta Feb. 9-16..

Madras Feb. 9-22,.

Rangoon Feb. 2-16..

On S. S. PaUna.

3
58
19
23

Australia, New South Wales —

Kempsey

Sydney

Queensland —

Brisbane

Port Douglas

Brazil. Para

Rio de Janeiro ,

Chile. Antofagasta

Egypt. Assiout ProWnce . . .

Baliana Province

Beni Souef Province

Ismailia

Girgeh ProWnce

Keneh Province

Minieh Province

Formosa. General

India. General

Bombay

Calcutta

Rangoon

Mauritius

Chepen

Chiclayo

Choiseca

Lambayeque

Lima

Pacasmayo and San Pedro. .

Tru jillo

Vim

Russia, Cronstadt

Peru.

Philippine Islands. Manila.

-Jan. 29 I

.Jan. 19-Feb. 2 12

.Jan. 19-Feb. 2 9

.Jan. 19-26 31

. Feb. 23— Mar. 9 . . . . 11

.Feb. lo-Mar. 3. . . . 9

. Feb. 25 10

-Feb. 7-25 12

. Feb. 23-2" 20

.Feb. 23-24 2

-Feb. 25—26 2

Feb. 8-27 7

. Feb. 26 2

.Feb. 25-27 3

Jan. 1-3 1 165

.Feb. 9-26 27,384

-Feb. 12-26

. Feb. 9-16

. Feb. 2-16

.Jan. 24-Feb. 14- ■■ 27

-Feb. 14 I

Feb. 14 «; 4

Feb. 14 13 6

Feb 14 3 I

Feb. 14 2

Feb. 14 3 3

Feb. 14. I

Feb. 14 3 3

Mar. 5 i i

(Laboratory Plague.)

INSULAR.

Feb. 2-9 10 5

16

141
23.411

384
17

105

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 71, No. 15.
Whole No. 1 90 J.

New York, April 13, 1907.

$5.00 Per Annum.
Single Copies, JOc.

®riginal Artirlrs.

TREATMENT OF ACUTE CARDIAC AFFEC-
TIONS IN CHILDHOOD.

Bv ADOLF BAGINSKY. M.D..

BERLIN.

EXTRAORDINARY PROFESSOR OF PBDIATRICS IN THE UNIVERSITY OF

BERLIN. DIRECTOR OF THE KAISER AND KAISERIN PRIEDRICH

HOSPITAL FOR CHILDREN.

The great importance of cardiac diseases in child-
hood is evident to every practitioner, and under this
term must be included not only affections of the peri-
cardium and endocardium, but also those of the
myocardium. By the physician engaged in private
practice, however, the subject does not always meet
with the attention it deserves, because his opportuni-
ties for observing the condition must necessarily be
limited, his cases being sporadic only. But in the
eyes of the hospital physician the disease assumes a
much more important and serious aspect, for he

diac complications, so that the total amounts to 66,
or 2.6 per cent. And this does not include the car-
diac complications occurring as sequelae of diph-
theria or scarlet fever. All in all, we find here an
imposing array of cases which, on account of the
immediate danger as well as of the possibility of per-
manent harmful after-effects, merit more serious
attention than has been accorded to them. And this
is the experience of but one hospital. Variations
will undoubtedly occur because the development of
articular rheumatism and chorea depends, although
probably not so intimately as was formerly believed,
to a considerable degree on temperature and cli-
matic variations, humidity, and rainfall. The figures
stated may be taken, notwithstanding these excep-
tions, as a fair average of the proportion of cardiac
affections to the other diseases of childhood, if we
exclude here the infectious diseases referred to
above.

This experience has led me to pay particular

F:g.

-Erich Karp; cardiac area, November 2K. 1907-

FiG. 2. — Erich Karp; cardiac area, January 8, 1907.

meets not only with the acute cases, but also those
in which there have been repeated attacks, the pa-
tients being brought to the hospital in an almost
helpless state with extreme dyspnea, dropsy, and
total cardiac insufificiency. Then, notwithstanding
an occasional almost phenomenal improvement, the
patient will sooner or later succumb to the incurable
malady. That at least has been the experience in
Germany.

The prevalence of the disease in early years may
be indicated by the statistics furnished by the Kaiser
and Kaiserin Friedrich Hospital during the admin-
istrative year from April i, 1905, to April i, IQ06.
A total of 2,328 children were under treatment in
this institution during the period in question, and of
these 2.^, or 0.9 per cent., were admitted for the
treatment of acute or chronic cardiac disease. This
does not seem like a large number, but we must add
28 cases of acute articular rheumatism, in which
without exception the heart was involved, as well as
15 cases of chorea in which there were likewise car-

attention to the condition under discussion, and as a
result a number of papers on polyarthritis, pericar-
ditis, and endocarditis have been published, partly
by myself and partly by my assistant, Lachmanski.*

In the present paper I have no intention of taking
up the discussion of the extensive field of the thera-
peutics of cardiac diseases, but will confine myself
to a description of the course and the treatment of
the acute form of the disease, my remarks being
based mainh- on a number of noteworthy cases in
which pericarditis and endocarditis developed as
complicating features of a polyarthritis.

Case I. — Erich Karp, age seven, was admitted to
the hospital on November 27, 1906. The boy had
pneumonia in early childhood, from which he made
a good recovery. When three and a half years of
age he had his first attack of articular rheumatism
with cardiac complications. ,\bout eight days pre-

*Baginsky: Berliner klinische IVochenselin'ft, N. 48.
1898, and No. 49, 1904. Lachmanski: Arehiv fiir Kinder-
heilkunde, Vol. 28, 1900.

S90

MEDICAL RECORD.

[April 13, 1907

vious to admission the boy began to complain of
vague pains and headache, and developed a tender
swelling of the right knee. There was also pain in
the chest and insomnia. E.xamination at the time
of admission showed a pale and poorlv developed
boy, with considerable dyspnea and occasional
marked cyanosis. The right knee was swollen and
tender, and the leg was held in a slightly flexed

Fig. 3. — A\ex Schledermann; cardiac area. November 29. 1006.

position. The remaining joints were free. Tem-
perature 38° C, pulse 80, regular, with normal ten-
sion. The pulmonary percussion note was normal,
with the exception of a circumscribed area at the
left apex, where it was slightly tympanitic. The
respiratory murmur was vesicular, but slightly accel-
erated. The area of cardiac dullness extended
beyond the right edge of the sternum and merged
with the upper border of the liver dullness. Above
it reached to the level of the second rib and curved
down to the left to the anterior axillary line at the
sixth rib. The heart sounds could not be distin-
guished over this area of cardiac dullness, and dur-
ing the systolic and diastolic periods two loud
friction sounds were audible with a ma.ximum in-
tensity over the sternum and at the level of the third
and fourth ribs. The ape.x beat could not be deter-
mined. Pulse 100 to 130, regular, not intermittent;
temperature 39.5° C. The liver dullness extended
about 3 cm. above the costal arch. The area of
splenic dullness was not increased. The urine con-
tained a small amount of albumin and a few hvaline
and granular casts. The diagnosis was broncho-
pneumonia, pericarditis with effusion, and nephri-
tis ( ?). The treatment consisted of an ice bag over
the cardiac region with ichthyol ointment and the
application of a salicylic acid preparation to the knee
joint. Acetylsalioilic acid was given in 0.5 gram
doses three times daily. Some improvement
took place during the next two days, the
pains diminished, and the temperature varied
from T,/° to 39.5° C. The dyspnea was not
marked, but still noteworthy, and the heart action
was moderately strong, pulse from 90 to 120. On
the other hand, the dullness extended over the lower
portions of the thora.x in the back to the lower angles
of the scapulre, and there was a diminished res-
piratory murmur with loss of vocal fremitus.

There seemed to be in addition an increase rather
than a diminution in the area of cardiac dullness,
and the urine amounted to only 350 to 400 c.c. pro
die. The acetylsalicylic acid was stopped and
soluble digitoxin given internally twice daily
in doses of JX c.c. Inunction with mer-
curial ointment w-as also practised, i gram
three times daily. The ice bag was contin-
ued. The boy did not apparently improve much ;
he continued pale and weak, there was more or less
dyspnea, and the temperature varied between 38°

and 39.5°, being usually about 39° C. The digi-
toxin seemed to have little effect on the pulse, which
remained around 1 10 to 120, and of the same general
character. On December i the digitalis preijaration
was stopped and potassium iodide solution (3:100)
given three to four times daily in teasp(X>nful doses.
tJn the next day the temperature dropped to
37.25° C. and there occurred a marked ciiange in
the general appearance and condition. The dyspnea
diminished, although the areas of cardiac and pul-
monary dullness were not affected, and the rasping
systolic and diastolic murmurs continued unchanged.
1 he eu]ihoria and defervescence continued during
the administration of the potassium iodide and the
mercurial inunctions, and during the following days
the temperature sometimes fell below the normal.
By the loth of December it was possible to make
out not only a diminution in the area of cardiac dull-
ness, but also an entire absence of the murmurs. At
the ape.x a blowing endocardial murmur could now
be heard. The thoracic dullness behind was also
markedly reduced. The urine contained only traces
of albumin and isolated casts. The improvement
continued, and on January 9 the area of cardiac dull-
ness had reached practically its normal boundaries,
and only a weak systolic murmur was heard at the
apex. The urine was now free from albumin. The
respiratory murmur and percussion note were nor-
mal, the pulse was 96 and regular. The boy"s gen-
eral condition was excellent, and he had gained 2.5
kilos in weight. He was dismissed as practically
cured with only a remnant of endocardial disturb-
ance.

C.\Sif; II. — Alex. Schledermann, age thirteen and
a half years, w-as stated to have had a weak heart
since his sixth year. The boy was admitted on
October 31, 1906, with swollen and painful joints.
He was poorly nourished and anemic, weak, and
apathetic. The administration of acetylsalicylic
acid relieved the pain and swelling of the
joints. Then, on the 29th of November,
the boy became suddenly feverish, and his
appearance indicated collapse. Examination dis-
closed a marked increase in the area of cardiac
dullness, which extended to the second rib above and
beyond the right border of the sternum to the e.xtent
of 4 cm. At the level of the si.xth rib this dullness
merged with that from the liver. The apex beat was
])alpalile in the fifth interspace about 2 cm. to the

F:g. 4. — .\Iex- Schledermann. cardiac area. January 7, 1907

left of the mammary line. A systolic murmur could
be heard at the apex and over the mitral area. Over
the lower third of the sternum could be detected a
post-systolic and diastolic friction sound. There
was severe pain over the entire cardiac region ; the
pulse was 120 to 130, with considerable tension.
The urine contained hyaline casts, red blood cells.

April 13. 1907]

MEDIC\L RECORD.

591

leucocytes, and granular epithelium, the total quan-
tity being 800 c.c, with a sp. gr. of 1,015. The liver
dullness extended about 4 or 5 cm. above the costal
border. Dullness and diminished respiratory mur-
mur were evident over the entire left side of the
thorax posteriorly to the angle of the scapula. A
teaspoonful of potassium iodide solution (3:100)
was given every three hours and inunctions with i
gram of mercurial ointment three times daily. The
patient's general condition did not undergo any
appreciable change during the next few days. He
remained very pale and seemed exhausted. In addi-
tion to the other medication he was then given
'■■2 c.c. of the digitalis preparation used in the former
case three times daily, which gradually effected a
diminution in the frequency of the pulse rate (100
to no). Iron was also administered, and after a
time, with the treatment noted, the more serious
symptoms subsided, and the condition of apathy
and collapse disappeared. By December 18 the area
of cardiac dullness had undergone considerable dim-
inution, particularlv on the right side, and at the
ape.K a saw-like murmur could still be heard. .\t
the base a systolic murmur was evident and the
second pulmonary sound remained accentuated. The
improvement from now on was rapid, the cardiac
dullness as well as that over the posterior aspect of
the thorax gradually subsiding. On December 29
the boy. who had become bright and cheerful, was
allowed to leave his bed. The apex murmur could
still be plainly heard. On January 9 the patient
was dismissed as practically cured, with the evi-
dences of a slight mitral insufficiency and an area
of cardiac dullness about normal in extent. Tliere
were adhesions present in all probability between
the heart and the pericardium, as shown by the
physical signs obtained on changing the position of
the patient.

These two cases are not, of course, particularly
noteworthv, and agree in their main features with
those of articular rheumatism complicated by acute
cardiac lesions. Their instructive character is de-
pendent entirely upon the therapeutic aspects.

In the first case the pericarditis dominated the
clinical picture. The friction sounds showed that
in addition to an exudate we had to deal with the
formation of adhesions between the heart and peri-
cardium. The administration of acetylsalicylic acid
seemed effective in controlling the polyarthri-
tis, but was entirely without effect on the
endo- and pericarditis. The application of an
ice bag, although agreeable enough to the
patient, seemed to have as little effect in
reducing the inflammatory symptoms as the
ichthyol ointment or digitalis. The patient in fact
was placed in mortal danger by the dyspnea and the
threatened cardiac collapse. A certain and rapid
improvement did not take place until the combined
administration of mercurial inunctions, and potas-
sium iodide was instituted. This is a combination
which was formerly rather in disfavor, and even
feared on account of its possible chemical incompati-
bilitv, but has been show-n by actual experience to
be perfectly harmless in its application. Of all the
remedies which I have hitherto employed in the
treatment of acute inflammatory diseases of the
heart, the pericardium, the pleura, and even of the
lungs. I am compelled to acknowledge potassium
iodide as the most efficient. Its effects in pericardi-
tis seem to be increased by the combination with
mercurial ointment, and in the condition of com-
plete helplessness which the practitioner is often
compelled to acknowledge in the presence of the
rheumatic cardiac diseases, this method of treatment
mav safelv be commended. The endocarditis which

manifests itself in these cases by very stormy symp-
toms may be effectively combated by the ice bag and
the internal administration of digitalis. Of course
these methods are only of value in overcoming the
immediate danger, and thus far I cannot say with
certainty whether they are able to prevent the pro-
duction of a chronic endocarditis or chronic valvular
disease.

The second case has led practically to the same
results as the first. Here we had to deal with in-
herent cardiac weakness, to which there was added
during a recurrent attack of polyarthritis an endo-
carditis and pericarditis. Although mild at first, the
pericarditis, with an effusion added to that from the
pleura, constituted a serious menace to the life of a
boy already in a very weakened condition. In this
instance also the combined use of mercury and
potassium iodide showed itself a most efficient rem-
edy. The administration of digitalis was indicated
by the endocardial condition, and its efficacy ap-
peared to be undoubted. The action of the potas-
sium iodide is worthy of particular attention, for the
surprisingly rapid absorption of the serous exu-
dates can hardly be regarded as spontaneous, and
must in all probability be attributed to the effect of
the iodide.

There are tw'o questions which must be consid-
ered in regard to this subject, (i) Should any
resort be had to venesection at the height of the
disease in these cases; and (2) Is early puncture
with the needle indicated where an extreme degree
of pericardial effusion is present? Venesection, for-
merly in great favor but later abandoned, has ro-
centlv been revived by some English authors as a
therapeutic procedure. I have used the method in
two cases, one of acute endocarditis complicated
with pericarditis, the other of acute cardiac dilata-
tion with violent heart action, with some success as
regards the pain and overactivity. The disease itself
did not seem to be in any way aft'ected, and the i^ain
and dyspnea returned. The second case ended
fatally. On account of this experience I feel that I
can scarcely recommend the abstraction of blood in
these cardiac cases as a safe or efficient procedure,
for, aside from the difficulty of controlling subse-
quent hemorrhage, there is also the danger of septic
infection from the woimd caused by the leech bite.
Exploratory puncture of the pericardial sac is
undoubtedly indicated in certain cases where the
diagnosis of a large pericardial effusion can be made
with accuracy. This, however, is sometimes a very
difficult matter, particularly in children, where the
condition may be confused with acute cardiac dila-
tation. W'hen the dyspnea is extreme, the pulse
small, frequent, and irregular, the value of asjiini-
tion is uncloubted. In the second one of our cases I
would certainly have resorted to this procedure' if
the exudate had not been so quickly absorbed under
the influence of the potassium iodide. In those cases
where the pericardial exudate is combined with ar;
even larger one of the pleural cavity, it is advisable
to combat the dyspnea by doing a paracentesis of
the chest before that of the pericardium is attempted.
It w-i!l often be found that the dyspnea disappears,
and then puncture of the pericardium is rendered
unnecessary.

.A.nother remedy which has lately been revived hy
the French writers is the application of vesicant;
over the cardiac area. I do not desire to recom-
mend this procedure, which is not only_ cruelly
annoving and distressing for children, but is ineffi-
cient' there is also a danger to life in using this
method, for the wounds caused may become the site
of a diphtheritic infection, as has been shown in a

592

MEDICAL RECORD.

[April 13. 1907

number of instances. The suggestion should thcic-
fore be abandoned.

Both of our patients showed evidences of renal
irritation — albumin, blood, and casts in the urine.
A proper degree of diuresis should therefore be pro-
vided for, which ma)- be accomplished by the admin-
istration of the alkaline mineral waters without the
use of stronger diuretic measures. The latter may
be reserved for certain extreme cases. Cases of
chronic heart disease furnish entirely different indi-
cations and demand the application of cardiac tonics
(digitalis, caffeine, strophanthus, valerian) in com-
bination with diuretics. I have included only those
acute conditions in which the pericarditis occupied
the foreground of the clinical picture, and shall dis-
cuss the chronic cardiac diseases of children at
another time.

LOCAL THERMOTHERAPY.*

Bv W. (;iLM.-\X THOMPSCX. M,D .

XE'.V YORK.

The topical apphcation of heat and cold in the treat-
ment of disease processes is one of the oldest known
therapeutic measures, but owing to the progress of
physiolog}-, pathology, and the surgery of localized
pyogenic inflammations, there has been, of recent
years considerable modification of the views regard-
ing its efficiency. Thus it may be stated in general
that while the development of peripheral local ther-
motherapy has been greatly advanced by improved
technique in combined methods of douching with
massage and by the so-called "baking" processes,
etc., there is, on the other hand, increasing scepti-
cism as to the possibility of modifying deep-seated
visceral congestions, inflammations, or hemorrhages
by means of any external local thermic applications.
Is there any use in attempting to control the hemor-
rhage of typhoid fever by an abdominal cold coil,
to control pulmonary hemorrhage by an ice bag, to
modify, the course of a pneumonia by poultices or
cold compresses, or the course of appendicitis, or an
otitis media, or a quinsy, by the laying on of cold?
Can the function of the kidneys be stimulated by
lumbar poultices, or the course of meningitis be
influenced by an ice cap at the head or neck? Is
there an)- real value in any of these measures other
than the fact that they sometimes, though by no
means invariably, contribute to the comfort of the
patient. And if, on the contrary, they annoy him.
should their use be nevertheless continued ? Being
unable to find any satisfactory experiments determi-
ning the penetrating power of heat and cold locally
applied to the surface of the body, I undertook such
a series of experiments upon animals some vears
ago while working in a physiological laboratory. I
have never published them in full, as thev were
made primarily for my own guidance, but I have
supplemented them from time to time by further
researches upon the human body, and believe that
they possess considerable interest as well as prac-
tical imfwrtance in connection with the present dis-
cussion.

In conducting the experiments 1 used special ther-
mometers, similar to those employed in thermostats,
and used also by beer brewers. These thermome-
ters are about ten inches long, with slender stems
and small bulbs, a little larger than those of the ordi-
nary clinical thermometer. They possess a wide
range of index, and are not self-registering, so that
fluctuations alternating both above and below the
normal body temperature are promptlv observable.
*A paper read before the Practitioners' Society, March
I. 1907-

As the bulbs are small, they are quickly influenced,
and as the stems are long they may be deeply
inserted into cavities in an animal or the human
body. In experimenting with poultices three ther-
inometers were simultaneously used, one inserted in
the poultice itself, one placed between the poultice
and the skin, and one in some cavity of the body
immediately beneath the poultice. In anesthetized
animals, punctures were made into various cavities
of the body, and thermometers inserted at various
depths beneath the site of ai>i:)lication of the poul-
tice. In the living human subject thermometers
were inserted in the buccal cavity, in the bladder, in
the rectum high up, and deeply into the thorax in
several cases of post-operative empyema with long
sinuses. In the human cadaver punctures were
made in the abdominal wall and thorax, and ther-
mometers inserted and held against the inner sur-
face of the wall, while poultices, ice bags, ice, coils,
etc., were applied in alternation immediately exter-
nal to the thermometer bulbs. The results were in
all cases most striking, and proved that so long as
the normal peripheral circulation is maintained,
neither extremes of local heat or cold possess pene-
trating power of any practical importance whatso-
ever. In other words, the thin layer of blood in
the cutaneous or subcutaneous circulation passes
along with such rapidity as to constantly remove
any thennal units, so to speak, and prevent deeper
penetration. As soon as an animal is killed, how-
ever, and the circulation ceases, or if the experi-
ment be tried upon the human cadaver, extremes of
both heat and cold acquire considerable penetrating
effect. So promptly does the peripheral circulation
act in dissipating or neutralizing external local heat
or cold that the thermometer placed between the
skin and the poultice or ice bag shows much less
change than might be expected. (In all the experi-
ments herein recorded the Fahrenheit scale was
employed.) A poultice made by adding boiling
water to flaxseed meal usually cools down to about
i40°-i45° before it can be applied to the patient. If
the mixing bowl be previously heated, and the meal
itself be warmed, a poultice can be made as hot as
160° or 165° or more. Patients vary much in their
abilitv to tolerate external local heat, and there is,
moreover, much difference on the various parts of
the body. L^sually a hotter poultice can be borne
over the face than elsewhere, and here a temperature
of 150° may be endured, but most persons find
a heat much above 140° uncomfortable, and some
cannot endure more than 123° or 130° on the
thorax. Poultices made of Indian meal or boiled
mashed potatoes retain their heat somewhat longer
than flaxseed. As ordinarily applied by trained
nurses, a flaxseed poultice loses about 20° of heat
in the first half hour, starting at 140°, and the other
varieties mentioned lose about 15°. The addition
of sweet oil keeps the poultice pliable, but does not
materially aft'ect its heat radiation. The ice water
coils, which are referred to in these experiments,
were made with about 11 feet of nibber tubing fed
from a pail of iced water. After running through
such a tube, the water temperature is usually about
38°. A thermometer placed between the skin and
the coiled rubber tubing registers on an average
58°, or between the skin and poultice 103.5°. -^^
the normal body temperature the total heat units,
contained in a human being weighing 140 pounds,
would be nearly 14.000 as compared with those of a
flaxseed poultice weighing one pound at 140°. which
would contain only 140 units. Hence, the total
heat of the poultice is inappreciable compared with
that of the human bodv.

April 13, 1907]

MEDICAL RECORD.

593

111 an anesthetized dog a thermometer was pushed
into the lung and a poultice at 146° was placed over
it on the outer surface of the shaved chest wall. At
the end of 25 minutes no effect whatever was pro-
duced on the internal temperature. In another ani-
mal a hotter poultice at 160° was applied, but the
lung temperature was raised only 0.6°. When an
ice water coil was substituted for the poultice, the
lung temperature was made to fall 1.8° in 25 mm-
utes. When the dogs were killed, however, the lung
temperature was made to rise 5° with the poultice,
and to fall 15° with the coil. Similar results were
obtained by placing the thermometer within a dog's
abdomen and making thermic applications over it
on the outside. In all the experiments of this
nature it will be observed that the topical applica-
tion of cold produced a relatively greater effect than
that of heat. This is doubtless due to the fact that
the source of heat, the poultice, is steadily and rap-
idly cooling oft", whereas the source of cold, the ice
water, remains constant. These experiments were
made in 1890 before the days of the electric heating
pads, now so commonly used, in which the source
of heat supply remains a constant quantity.

Prolonged ether inhalation is apt to lower the
general body temperature in dogs. In one animal,
after an hour's continuous ether inhalation, the
intraabdominal temperature fell from 101° to 97°.
A poultice at 150° was then applied over the thin
abdominal wall (which was not more than 1-3 inch
thick). .\ thermometer inserted in the abdomen
and pressed close beneath the poultice showed
a rise of 5.5° F. in temperature, but held one-half
inch deeper, i.e. away from the abdominal wall, it
only recorded an elevation of one degree. The in-
testinal capillaries were carefully studied during the
experiments, but neither very hot poultices (150'^)
or very cold coils produced the slightest appreciable
eft'ect upon their color or caliber. A single excep-
tion occurred in the case of a dog with a very thin
abdominal wall. The hair was shaved over the
abdomen, and, after application of a poultice at 168°,
considerable congestion was apparent in a coil of
intestine immediately beneath the poultice. This
degree of temperature, however, could not be en-
dured by man, and could only be tolerated by a dog
when anesthetized. In the same animal prolonged
application of an ice-water coil produced no visible
effect on the intestine.

In an anesthetized dog a portion of the trachea
was exposed to view, while, in alternation, poultices
and ice bags were applied over the animal's neck
and also over the thorax, but there was no visible
evidence of either congestion or of blanching of the
capillaries of the tracheal mucosa.

In another anesthetized dog a small glass window-
was inserted in the thora.x in an aperture made by
excising a portion of two ribs. The window was
made with a double flange, which held it in place,
when the skin was hermetically closed around it.
The air which entered the pleural cavity was as-
pirated out. and the lung then expanded against the
window. The dog's lung is of a delicate pink color,
easily showing variations in tint depending upon
fluctuations in blood supply. Through the glass win-
dow it was possible to observe the lung under prac-
tically normal respiratory conditions while hot poul-
tices and ice coils were applied in alternation to the
overlying thoracic surface. No changes of any
kind were perceptible in the appearance of the lung,
even when rai)i<l alternation in extremes of external
temperature were made, or when a jioultice was
placed on one side of the chest and an ice coil on
the other. Variations in the rate of brcathinc: were

sometimes observed, due to the reflex stimulation in-
duced by sudden changes in temperature. The coloi"
of the lung surface was considerably modified, how-
ever, by varying the quantity of ether inhaled.
These experiments were repeated upon several ani-
mals with uniform results, and they make it difficult
to believe that cold applications to the thorax can
ever materially influence pulmonary hemorrhage.

To determine the transmission of heat through
the cheek, as when a poultice is applied over an
inflamed gum. the following experiments were
made :

I. — Temperature inside of cheek, 97". A poultice
at 152° was applied for 15 minutes, when the tem-
perature of the inner surface of the cheek rose 1.7°.

II. — Temperature inside the cheek, 97.8°. Poultice
at 160° applied 15 minutes; internal temperature
rose 0.6°. During both these experiments the tem-
perature of the poultice fell 30° in 13 minutes,
although it was well protected by towels.

III. — Temperature inside the cheek, 98.6°. Poul-
tice at 150° applied for half an hour; temperature
rose in mouth 0.5°. A thermometer placed between
the poultice and the outer surface of the cheek
recorded only 105.6°, although the thermometer in
the center of the poultice registered 150°. The
gum appeared slightly reddened beneath the poul-
tice on the affected side. A poultice at 160° applied
<in the outside of the neck for some minutes pro-
duced no appreciable effect upon the color of the
mucous membranes of the larynx or pharynx, but
when ice was applied directly afterwards, decided
jiallor of the mucosa of the posterior pharyngeal wall
and base of the uvula was apparent. An immedi-
ate reapplication of the poultice produced no fur-
ther change, the mucous membrane remaining pale
for a considerable period.

In a patient having a deep, straight empvema
sinus, I was enabled to insert a thermometer' bulb
eight and a half inches into the thorax. The ther-
mometer registered 99.8°. After 15 minutes' appli-
cation of a poultice of 140° over the adjacent tho-
racic wall, the lung temperature rose onlv 0.4°. An
ice poultice, made of pounded ice mixed with flax-
seed_ meal to prevent too rapid melting, was then
applied. After 15 minutes the lung temperature
was absolutely unaffected.

In a second case of post-operative empvema, a
thermometer was inserted through the sinus one
and a half inches into the thorax. A poultice at
144° applied externally raised the temperature only
o.C^" after 20 minutes.

Several years ago I happened to have three
women patients in hospital, who for various reasons
had worn large cold coils over the abdomen and
pelvis for several days almost continuously. Each
one developed a marked cystitis, although neither
one had been catheterized or had gonorrhea. I
was led to wonder whether this occurrence was a
mere coincidence or whether the cold had in any
manner reduced the resisting power of .the bladder. T
therefore inserted thermometers in the bladders of
several female patients and applied externally both
poultices and ice coils scriathii. In one case an
hour's application of the coil over the pelvis reduced
the internal bladder temperature only 0.6°. In a
second case there was a variation of only 0.2°,
which, moreover, proved to be wholly independent
of all external applications. It does not seem pos-
sible, therefore, to dii'ectly transmit either heat .or
cold to the bladder by the means above mentioned.
In the bladder there is not alone the circulation in
the vesical wall, but the constant entrance of warm:

594

MEDICAL RECORD.

[April 13, 1907

urine to be reckoned with as factors in neutralizing
external local thermic applications.

In seven women wlio were given vaginal douches
at a temperature of 114° to 1 16° the maximum rec-
tal temperature was 3° higher immediately after
the douche than before, but the average elevation
was only 1.6°, showing that even as thin a layer
of tissues as the rectovaginal wall suffices, owing to
its high degree of vascularity, to prevent local heat
accumulation in any marked degree.

The question to what extent the heart may be
influenced by local external thermic applications
is of considerable importance. If a neu-
rotic patient with palpitation be told to place an ice
bag almost anywhere on the body and lie down and
keep quiet, the heart action will be slowed, and it is
not well to attribute too much importance to the ice
bag, which may have a purely psychic effect. There
are cases, however, of true angina pectoris in which
the pain is mitigated by placing a hot poultice over
the precordium, and there are cases of tachycardia
and of pericarditis in which undoubted relief, both
of pain and rapid heart action, seems to be pro-
duced by the continued application of cold to the
precordium, but there are also many cases of tachy-
cardia in which cold seems to produce no effect. If
such applications prove of use clinically, they are
certainly harmless, and are desirable, no matter
what may be the theory of their mode of action.
It is nevertheless interesting to speculate upon this
matter, and it is not my belief that local heat or cold
is ever made to reach the heart, or even pericar-
dium directly, but only to exert indirect reflex nerve
excitation or inhibition through the cutaneous
nerves.

Experiments were made to determine to what ex-
tent the stomach is chilled bv drinking ice water.
In one patient who swallowed a tumblerful of iced
water at 37°, the water, after being recovered with
a stomach tube in 5 minutes, was found to have a
temperature of 76°. In another patient water at 36°
was allowed to remain in the stomach for 10 min-
utes, when, upon withdrawal by syphonage, the tem-
perature registered 90°. In a third case water swal-
lowed at 35° was recovered in 2' j minutes at 70°.

In marked contrast with the failure to modify the
deep internal temperature of organs in the living
body are the results of the same topical applications
to the cadaver. .^ thermometer was inserted be-
neath the abdominal wall in a cadaver, and a poul-
tice applied externally over it. Although the poul-
tice used was not very hot — only 114° — within half
an hour the intraabdominal thermometer showed a
rise of 14°. When a cold coil was applied under
similar conditions, using water at 36.5°, the intra-
abdominal temperature fell 13° in the same period,
and continued falling for some time thereafter. No
other result would of course be expected, but it is
instructive to note the relativelv rapid rate of heat
transmission through dead tissues in distinction
from the living.

The chief interest of these experiments concerns
the common employment of topical cold for sup-
posed influence in arresting deep internal hemor-
rhage, from the lungs, the stomach, or the intestine,
as in typhoid fever. Clinically, I have never been
convinced that the use of ice bags, ice poultices
made with flaxseed, cold wet compresses, ice coils,
etc., was of any value whatever, beyond the fact
that they may be somewhat soothing to the surface,
and to balance them in position the patient must lie
quiet upon the back. Rest, and possibly the mor-
phine commonly given in such cases, are the real
factors, and from experimental observation I am

convinced that topical applications of cold can never
modify the caliber of deep-seated vessels sufficiently
to exert any astringent effect. In the great major-
ity of these cases the hemorrhage ceases spontane-
ously when the blood pressure falls sufficiently low,
or the blood stream is retarded. Theoretically, the
depletion of peripheral blood-vessels by cold would
tend to raise internal blood i)ressure, and thus favor
the hemorrhage, but practically this also is an in-
significant factor. Similarly the swallowing of
cracked ice, for control of hemoptysis or hemate-
mesis is useless, for the ice is melted in the mouth,
and the ice water, in its slow passage through the
esophagus, is warmed by the blood-vessels long
before it reaches the stomach. It may serve to
allay somewhat the patient's anxiety if he shares the
popular faith in its efiicacy, but it is without scien-
tific reason. In situations where heat can be directly
applied to the bleeding surface, as, for example,
the nasal mucosa, it is well known that to pro-
duce any astringent effect a temperature of at least
110° or 112° must be employed, lesser degrees of
heat tending to favor contiiuiance of the bleeding.
Similarly, to successfully control oozing of blood
from the surface of the skin or mucous mem-
branes, moderate degrees of cold are of little value,
but ice itself must be employed.

In all the foregoing experiments it has been shown
that a deviation of onehalf to one degree from the
normal is all that can be obtained under most favor-
able conditions, when deep-seated vessels are ex-
pected to be influenced by external local thermo-
therapy. Such trifling temperature reactions cannot
be believed to influence the caliber of capillaries, or
the coagulation of blood. Hemorrhage from the
uterus presents of course an entirely different propo-
sition, for the hemostatic effect of hot water or of ice
within this organ depends chiefly on the stimulation
to the uterine muscle to contract.

\Mth regard to the common practice of poulticing
the lumbar region to relieve congestion of the kid-
neys and favor diuresis, it may be similarly argued
that these organs lie too remote from the surface
to be affected by any degree of heat penetration.
Clinically. I have never seen results from such treat-
ment which were not to l)e traced to some other
factor.

As regards pneumonia, the articles claiming
"cures" by either continued jioulticing or local re-
frigeration, which were so common in medical liter-
ature fifteen or twenty years ago, have well nigh
ceased to appear altogether, doubtless owing to a
broader conception of the pathology of the disease.
In cases with severe pleuritic pain, they unquestion-
ably often give much relief to the patient, and in
such cases their use is desirable. Although they pos-
sess some reflex effect in alleviation of pain, they
are absolutely without influence in modifving the
course of the disease.

The use of heat or cold to accelerate or abort deep-
seated pus formation is now generallv regarded as
of much less importance than formerly. An ice bag
may relieve the pain of appendicitis, and aid in
quieting the patient, but it is not to be regarded as
a factor worthy of any consideration in checking a
suppurative process, and to make use of it to tem-
porize, may prove highly dangerous for the patient.
The same is to be said of the former practice of
applying poultices to draw deep-seated pus to an
outward focus, while the patient is becoming daily
more septic.

In depreciating the value of topical thermother-
apv for deep-seated hemorrhages, congestions and
inflammations, it is bv no means intended to reflect

April 13, 1907]

MEDICAL RECORD.

595

upon the value of such treatment for the relief of
visceral pains. To do so would be to oppose uni-
versal experience. Most certainly the pain of pleu-
risy is relieved by local hot or cold applications, as
the case may be, just as gastralgia and enteralgia
and the various abdominal colics are relieved and
often cured by a poultice or hot water bag. But
such relief is quite apart from any question of vaso-
motor influences, through direct caloric transmission,
and is explainable rather upon the obscure reflex
relationship between the cutaneous nerves and the
nerves of the viscera most nearly related to them
topographically.

I have stated that while the modern view of local
thermotherapy tends to lessen its importance in the
treatment of certain deep-seated visceral diseases
and disorders, it is rapidly gaining importance in
the treatment of peripheral lesions. Here the con-
ditions are altogether difterent, for not only may
the cutaneous sensory nerves be affected, but the
underlying vasomotor nerves, the caliber of the ves-
sels, the local temperature of the blood, the sweat
glands, and the muscles and ligaments, are all within
the immediate reach of direct thermic influences,
which are known to modify local innervation, nutri-
tion, and functional activity to a phenomenal de-
gree, ^loreover, this peripheral treatment is greatly
reinforced by such adjuncts as local massage and the
mechanical stimulus of pressure, as when the alter-
nating hot and cold douche is given with scientifi-
cally adjusted force and combined with mechanical
manipulations.

It is a matter of astonishment and regret that so
few of our large general hospitals have thus far
made any provision for methods of treatment, which
are proving of increasing usefulness as they are
better understood. In many a hospital in this city
the sole bathing outfit for a large general ward
consists of a small tub placed against the wall,
usually in a water-closet — an arrangement as in-
adequate as it is unhygienic and unesthetic ! A
very large class of patients can receive no satisfac-
tory treatment in the general hospital ward, such as
cases of chronic and subacute rheumatism, arthritis
deformans, local neuritis, chronic gout, gonorrheal
arthritis, a variety of muscular atrophies and dys-
trophies, sciatica, lumbago, neuralgias, hemiplegias,
besides a variety of surgical injuries, etc., because
what they really need is not to be put to bed and
given potassium iodide, but a thorough course of
local thermotherapy combined with or rather includ-
ing hydrotherapy, massage, and other manipulations,
together with good fresh air and all-round hygiene.
The strongest stimulation of peripheral nerves is
often best obtained through the rapid alternation of
extremes of temperature, combined with mechanical
shock such as that communicated by a stream of
water under carefully graded pressure. To accom-
plish such treatment special apparatus is needed
wherewith the temperature of the water used may be
rapidly changed and accurately measured, at the
same time that the douche stream may be modified
in form, as well as in force.

No modern foreign general hospital is now re-
garded as complete without a large establishment
comprising a series of rooms fitted with every kind
of apparatus for douching under modified pressures
and temperatures, applying local and general hot-air
baths, electric light baths, steaming, local sand baths,
massage, and vibration, etc., all under the manipula-
tion of well-trained atfendants. Anyone who is fa-
miliar with the results which such methods are
capable of yielding cannot but regret that our own
facilities in this direction are so meager.

In conclusion it may be stated :

1. That the topical application of thermotherapy
is of little if any value in controlling deep-seated
visceral hemorrhages, congestions, or inflammations.

2. That experiments demonstrate that the ordi-
nary means of applying local heat and cold to the
surface completely fail to affect the temperature of
structures lying beneath the skin to any practical
extent, so long as the peripheral circulation remains
active.

3. That thermotherapy as applied to the periph-
eral structures of the body is of so much importance
that more adequate facilities should be provided for
its employment.

34 E.\ST Thirty-first Street.

ANEURYSM OF THE ARCH OF THE
AORTA

WHICH RUPTURED INTO THE ESOPH.AGUS IN A YOUNG

WOM.\N WITHOUT EXTERN.\L EVIDENCE OF

SYPHILIS.*

By GEORGE L. PEABODY. M.D.,

NEW YORK.

The aorta and adjacent viscera, which I present to
you this evening, are chiefly of interest as throwing
light on a somewhat obscure question of diagnosis,
and also as suggesting caution in the use of the
stomach tube in cases of dysphagia.

The patient was a healthy-looking woman, thirty-
three years of age, who appeared much younger.
She came under observation early in January of
the present year, and died just eleven days later.
She told us that her father had died at the
age of 48 of some unknown disease, and that her
mother had died at the age of 35 of cancer of the
rectum. She knew of no other disease in the fam-
ily. Although always of nervous temperament her-
self she had never been ill since she had measles in
early childhood ; she had never suffered from heart
symptoms, and had never had any manifestations of
syphilis. She had borne several healthy children,
who were alive and well, and had had no abortions
or miscarriages. She was accustomed to drinking
four or five cups of coff'ee a day and two or three
glasses of beer before retiring at night.

Five weeks before admission she had first noticed
a feeling as if her food was arrested in its passage
to the stomach at the level of the ensiform cartilage.
This seemed to cause a sharp, stabbing pain at this
point, which radiated to either side in what she
called a "band-like" manner, circling the body, and
meeting behind in the lower dorsal region. There,
at times, she experienced a sensation as of a severe
burning, which passed through the body like a knife
to the starting point of all her pain underneath the
ensiform cartilage. This pain had become almost
constant and interfered with sleep. To gain relief
she had become accustomed to taking morphine.
Associated with this was a well-described globus
hystericus. Her physician — a man of experience —
had first passed a stomach-tube two weeks previ-
ously, and had, he thought, encountered a slight ob-
struction ten inches from the teeth, beyond which
the tube had readily passed. The stomach was
always found empty. The passage of the tube was
not painful, but it had given her no relief.

One week before admission she thought that solid
food was more difficult for her to swallow than
fluid. Occasionally the withdrawal of the tube had

*Presented at a meetino; of the Practitioners' Society of
New York, Friday, March i, 1907.

596

MEDICAL RFXORD.

[April 13, 1907

been followed by a little bloody mucus — not more
than frequently follows its use in gastric cases. Of
late the dysphagia had been less marked and less
constant, and all of her symptoms had been improv-
ing.

She was a little hoarse, and very nervous and
anxious, and, although well nourished, said she had
lost twenty-five pounds in weight. Her conjunctival
reflexes were absent and her pharynx entirely an-
esthetic to palpation. Her pupils, heart, superficial
arteries, and radial pulses were normal, as were also
her lungs. Percussion and auscultation of the chest
revealed nothing abnormal.

There were no scars upon the surface of the body
and there were no enlarged lymphatics. Thus, it

Lavage showed a slight amount of mucus m the
stomach-washings — nothing more. Occasionally a
little bloody mucus adhered to the tube on its with-
drawal. For some days she was fed once daily
through the stomach tube. The passing of the tube
was not difficult, although about ten inches from the
teeth it always encountered some resistance.

She slept badly on account of the pain, and con-
tinued to lose weight, and as her symptom.s did not
yield to the usual methods of treating hysterical
dyspliagia, it was deemed wise to have an ;tr-ray
piiotograph of her thorax, the negative of which I
show you here. This established the diagnosis of
aneurysm of the descending aortic arch and showed
clearly its displacement of the esophagus. Before

^SSi.

will be observ'ed, there were present many of the
typical stigmata of hysteria, and there was a com-
plete absence of all the physical signs of thoracic
aneurysm, together with both of the etiological fac-
tors that go to justify that diagnosis. Her age and
sex, too, were factors rather in favor of hysteria
than of aneurysm, and when you add the well-
described globus hystericus, and the corneal and
pharyngeal anesthesia, I feel that an error in diag-
nosis is at least explained, if not justified.

For a few days she was put upon milk diet, cold
pack, faradism in site of pain, laxatives, and seda-
tives at night.

She continued to complain of pain, to vomit, and
to have the same and an increasing difficulty in swal-
lowing.

the photograph was taken the patient swallowed
some bismuth subnitrate, whose presence demon-
strates in the photograph the distention of the
esophagus above the site of its constriction by pres-
sure of the aneurysm.

Rectal feeding was then resorted to. Naturally
she continued to do badly. In a few' days more she
suddenly vomited about ten ounces of blood and be-
came pulseless and cyanotic, and in a few minutes
died.

The autopsy showed a small, false aneurysm of
the descending aortic arch which communicated with
the esophagus through a large, ragged opening. Her
stomach was full of blood. In the arch of the aorta
were several raised patches of that kind of aortititis
without calcareous change which is commonly re-

April 13, 1907]

MEDICAL RECORD.

597

garded as of syphilitic origin. Sections taken from
these patches, as well as from the wall of the an-
eurysm, show the areas of atrophy of elastic fibers,
which are also regarded as diagnostic of syphilis.

The specimen in gross I will demonstrate to the
Society, and will also show the sections under the
microscope to those who are interested in looking at
them.

DIAGNOSIS OF EARLY PREGNANCY WITH
REFERENCE TO A PARTICULAR SIGN.^'

By LOUIS J. LADINSKI, A.B..

M.D..

NEW YORK.

r

5*i.-S!',,

/DJUNCT PROFESSOR OP GYNECOLOGY. N. Y. POLYCLINIC MEDICAL SCHOOL

AND HOSPITAL; VISITING GYNECOLOGIST. BETH ISRAEL HOSPITAL;

VISITING SURGEON, GOUVERNEUR HOSPITAL; CONSULTING

GYNECOLOGIST, JEWISH HOSPITAL FOR DEFORMITIES

AND JOINT DISEASES.

The fact that the question of pregnancy sooner or
later solves itself is probably one of the main rea-
sons for the comparatively little attention that has
been given to the study of the
signs of early pregnancy.

Not only are there innumer-
able instances where it is ex-
tremely desirable that a diag-
nosis of early pregnancy be i
made, either in the interest of
the patients or as a test of the
diagnostic skill of the physi-
cian ; but the knowledge of the '^'^^ -r--^:.
presence or absence of preg- ' .',<;
nancy is often of the greatest ■
importance to the life of the
patient from a medical and '
surgical standpoint.

As a material aid in differ- ^
ential diagnosis it is of espe- '
cial value in a number of very
important gynecological con-
ditions, among which may be
mentioned : Extrauterine preg-
nancy ; tumors, including myo- i
mata and hematometra, inflam-
matory conditions of the
uterus ; cysts of the ovaries
and tubes; ovarian cysts com-
plicating pregnancy ; and spu-
rious pregnancy. j

The teaching on this sub- ^ti^

ject, as e.xpressed in the best
te.xt-books on obstetrics and
gynecology of the present
day, are in my opinion mis-
leading and erroneous, as, for example, Will-
iams in his book on Obstetrics makes the
following assertion (p. 157) : "Mistakes in
diagnosis are most frequently made in the
first months of pregnancy"; and again he says:
"It is often a matter of considerable importance that
a diagnosis be made in the early months of preg-
nancy, but unfortunately it is just at this point that
our diagnostic ability is most restricted." On page
119 of Edgar's book is the following statement:
"A number of symptoms and signs taken together
give certain evidence of the presence of pregnancy ;
and single signs, especially in the latter part of
pregnancy, render the diagnosis probable or even
positive."

My observations in this field, extending over a
period of about fifteen years, and based on verified

*Read at a meeting of the Section of Obstetrics and
Gynecology of the New York Academy of Medicine, Feb-
ruary 28, 1907.

results obtained from the examination of a very
large number of patients in dispensaries and clinics
and in private practice, are entirely at variance with
the above doctrine, which represents the generally
accepted views of the present day. My experience
has convinced me, and this opinion is shared in by
my clinical associates, that a diagnosis of "early
uterine pregnancy" can be made or excluded in
nearly every instance with almost absolute certainty.

The textbooks give the following classification
of the signs and symptoms of early pregnancy:
They are divided into: (i) Presumptive; (2)
probable; (3) positive.

The presumptive signs are mainly subjective, and
are to be considered in the early months of preg-
nancy. They consist of: (i) Amenorrhea, (2)
changes in the breast, (3) morning sickness, (4)
urinary disturbances, (5) discoloration of the va-
gina.

The probable signs refer also to the early months
of pregnancy, when the following can be obtained :

Fig. 1. — Position of the two hands in the bimanual examination for the diagnosis of pregnancy
(Edgar); Hegar's sign is obtained by piessing the external hand deep down into the abdomen and
grasping the lower uterine segment between the two hands.

(i) Changes in the shape and consistency of the
body of uterus, (2) changes in the cervix. (3) in-
crease in size of uterus, (4) intermittent contractions
of uterus.

The positive signs are : (i) Fetal heart beat, (2)
passive and active movement of the fetus, (3) out-
line of the fetus.

From this classification it will be noticed that the
signs given as positive refer entirely to the fetiis,
and are to be looked for only in advanced preg-
nancy, and do not therefore apply to the period
under discussion.

Of the presumptive signs the changes in the
breast and discoloration of the vagina do not. as a
rule, appear in the early months of pregnancy, and
we must depend on the patients for the other pre-
sumptive symptoms, namely, morning sickness, uri-
nary disturbances, and amenorrhea.

Morning sickness may occur at the beginning of
the fifth week, and last several or more months, but

598

MEDICAL RECORD.

[April 13, 1907

it is found only, according to various observers, in
from 15 to 50 per cent, of cases of pregnancy, and
it may also be the result of nervousness, anxiety to
conceive, or fear of an illegitimate pregnancy.

Bladder symptoms are so unreliable as to be abso-
lutely valueless.

As for amenorrhea, we know that pregnancy may
take place during an interval of the cessation of men-
struation as the result of other diseases, or because
of lactation. Frequently a false history of amenor-
rhea is given by patients who purposely wish to
deceive the physician, and occasionally a period may
be missed because of fear of conception; and there
are cases on record of menstruation during the first
months of pregnancy.

The signs therefore of pregnancy in the early
months, and these are considered only as probable
signs, are : ( i ) Changes in the shape and consist-
ency of the body of the uterus, (2) increase in size
of uterus, (3) changes in the cervix, (4) intermit-
tent contractions of uterus. Of these signs the last

Fig. 2. — Position of the two hands in the bimanual palpation of the uterus for the detec-
tion of the elastic area of precnancy; the external hand used only for counter pressure; the
arrow indicating tlie site of the elastic area in the 5th or 6th week of pregnancy.

two, namely, changes in the cervix and intermittent
contractions of the uterus, can be looked upon only
as corroborative signs.

I have found, however, that the change in the con-
sistency of the uterus is an invariably constant and
positive sign of early pregnancy ; and furthermore
that this change can be detected frequently as early
as the fifth week, but always in the sixth week of
pregnancv. As an indication of pregnancy it is in
my opinion equally as reliable as any of the positive
signs of advanced pregnancy.

Numerous observers have noticed a peculiar
change in the consistency of the uterus in the early
months of pregnancy, and have offered it as an im-
portant indication of pregnancy, but in their descrip-
tions and interpretations of the changes observed
they have differed materially from one another. As,
for instance :

\'on Braun describes the change to consist of "a
more or less longitudinal furrow, dividing the ute-
rus into two halves, one of which, usually the left,
is softer than the other." Landau finds compres-
sible points at the uterine cornua. Lohlein and

Gardner call the changes "A cystic softening of the
uterus." Dickinson considers "A bellying or bulg-
ing of the fundus and elasticity of the body of the
uterus" as pathognomonic of pregnancy.

Hegar's sign was first described by Rheinl, in
1884, and is obtained by bimanual palpation, with
one hand upon the abdomen and one or two fingers
in the vagina ; the firm, hard cervix and the elastic
body of the uterus is felt by the palpating fingers,
while between the body and the cervix a soft com-
pressible area, involving the lower segment of the
uterus throughout its entire thickness is felt. Hegar's
sign is now universally accepted ; it has undoubtedly
suggested the various other descriptions of the
change in consistency subsequently advanced by
various investigators.

It was while looking for tlie Hegar sign for early
pregnancy, many years ago, that I succeeded in de-
tecting and developing the sign of early pregnancy
which I have taught and employed ever since, and
have found to be almost infallible.

I do not know with what constancy
and uniformity the changes in the con-
sistency of the body of the uterus, as
described by the other observers, can
be obtained. I certainly have not de-
tected them to any great extent in the
study of my cases while searching for
the sign I depend on ; I do know, how-
ever, that Hegar's sign cannot be
obtained in a very large percentage of
the cases of early pregnancy (Dickin-
son claims that it cannot be detected
in 40 per cent, of cases), and further-
more that it is present in other condi-
tions, namely, retrodisplacement of the
uterus ; in the puerperal state ; and
especially in subinvolution following
delivery or abortion.

The change in the consistency in the
body of the uterus I desire to call
attention to is as follows: Frequently
as early as the fifth week, but always
in the sixth week, there can be felt in
the median line in the anterior wall
of the body of the uterus just above
the junction of the body and cervix,
in other words in the isthmus of the
uterus, a circular area the size of the
tip of the finger, which presents to the
palpating finger the sensation of an
elastic fluctuation.

As pregnancy advances this area increases in size
in a crescentic manner, until between the third and
fourth month, when nearly the entire anterior body,
with the exception of the upper crescent of the fun-
dus, partakes of this change, and gives the cystic
fluctuating feel to the examining finger. The
change appears in the anterior wall of the uterus
when the uterus is in the normal position or slightly
anteverted, but in extremely retroverted or retro-
flexed uteri the elastic area appears in the posterior
wall, but instead of being perceptible in the fifth
or sixth week of pregnancy, is usually felt in the
sixth or seventh week.

In incomplete abortion or subinvolution there is
a change in the consistency of a similar area of the
uterine wall, but while in pregnancy the feel of this
area is distinctly elastic or cystic, the sensation ob-
tained in subinvolution and incomplete abortion is
verv soft and doughy. The two conditions can very
readily be differentiated.

It will thus be seen that a familiarity with this
sign of pregnancy will also enable one to determine

April 13, 1907]

MEDICAL RECORD.

599

with a fair degree of certainty whether an abortion
is threatened, inevitable, or incomplete. Here again
my experience differs from the views generally ac-
cepted— that a diagnosis of the death of the ovum
in the early months offers considerable difficulty,
and can only be made after repeated examination
of the uterus proves that it remains stationary in
size.

In cases of early pregnancy with symptoms of
threatened abortion tlie area above referred to re-
mains cystic and elastic so long as the ovum is
viable, but becomes soft, doughy, and compressible
when the ovum dies, and the abortion is inevitable.
I have repeatedly advised against a proposed curet-
tage which seemed justified in cases of prolonged
bleeding during early pregnancy, when I found the
spot in the anterior wall of the uterus to be elastic,
and have had the satisfaction of seeing many of
the cases I had the opportunity to follow delivered
at term. When the area is soft and doughy to
the touch, a diagnosis of "blighted ovum" can be
made with certainty.

There is another condition which presents a dif-
ference in the consistency of the upper and lower
portions of the body of the uterus, and that is when
a small, symmetrical fibroid is situated in the an-
terior wall of the uterus, near the fundus. In that
case the lower portion is softer than the upper por-
tion of the body of the uterus, but it must be remem-
bered that it is only comparatively so, for while the
fundus and body present the hard characteristic feel
of a fibroid, the isthmus has the consistency of the
normal uterine wall.

However, when a soft myoma, or cystic fibroid,
is situated in the anterior wall of the uterus, the
cystic or elastic feel elicited in the uterine wall is
identical with that of pregnancy, and this is the one
condition in which this sign is not of diagnostic
value; especially when the soft myoma is associated
with amenorrhea, which was present in several cases
that came under my observation.

As to the manner of obtaining this sign, it is
absolutely essential that bimanual palpation be em-
ployed : While the e.xternal hand fixes the uterus
by cotmterpressure, and the anterior wall of the
uterus from the cervix to the fundus is palpated with
the internal finger or fingers, the elastic area in the
body of the uterus, immediately above the cervix,
will be readily made out ; the size of the area will
correspond with the duration of pregnancy. I de-
sire to emphasize the fact that the recognition of this
elastic area does not require any special skill or
dexterity ; the ordinary technique and tactile sense
requisite for a bimanual examination, combined
with a correct interpretation of the change noted in
the wall of the uterus, will enable the general prac-
titioner to make a diagnosis with the same ease as
the specialist.

Again, the absence of this sign is an absolute
indication for the exclusion of uterine pregnancy.
In the absence of this change in the uterine wall,
pregnancy of more than five or six weeks can be
positively eliminated, even in the presence of other
presumptive or probable signs.

I will not enter into a full discussion of the dif-
ferential dia.gnosis of early pregnancy with regard
to the various conditions with which it may be con-
founded, except that of extrauterine pregnancy,
which I propose to consider somewhat in detail.

In every case of suspected ectopic pregnancy the
most important aid to a correct diagnosis is the de-
termination of the presence or absence of uterine
pregnancy. That becomes apparent when we realize
that in all supposed cases of ectopic pregnancy, in

addition to the other various signs and symptoms
to be taken into consideration, some or all of the
presumptive and probable signs and symptoms of
pregnancy are invariably present, and the first ques-
tion to be decided is whether the case is one of
uterine pregnancy. With a sign at our disposal
which enables us to make a positive diagnosis of
the presence or absence of uterine pregnancy, we
have eliminated one of the most prolific sources of
error in the diagnosis of ectopic pregnancy.

It must be remembered, however, that this sign
cannot be depended upon for a differential diagnosis
before the fifth and occasionally sixth week of ec-
topic pregnancy, but fortunately patients requiring
attention at so early a stage are comparatively rare.

I have no hesitancy in saying that my ability to
exclude uterine pregnancy by this sign has mate-
rially assisted me in arriving at a correct diagnosis
of ectopic pregnancy in a large number of other-
wise doubtful cases, and is largely responsible for
my belief that the diagnosis of extrauterine preg-
nancy can be made with as much certainty as any
other pathological condition of the pelvis. In sev-
eral of my list of cases of extrauterine pregnancy
the absence of uterine pregnancy was the only abso-
lute positive indication on which a diagnosis was
based and found to be correct.

Fig. 3. — Diagramatic representation of the approximate size and
shape of the elastic area in tne various weeks of pregnancy.

I will take tlie liberty of citing one case which
illustrates this fact most forcibly :

Last summer a lady about 36 years old, who
was stopping at a summer hotel in Fleischmanns,
Catskill Mountains, and who had previously en-
joyed the ver)' best health, after a period of amen-
orrhea of seven weeks was suddenly seized one
morning with severe pain in the left ovarian region,
with nausea and vomiting. She had fainting spells,
grew extremely pale, her respirations were frequent
and shallow, and the pulse became very rapid and
feeble ; in short, she presented a clear case of internal
hemorrhage. Tv.o colleagues, Drs. Ludwig Kohn
and I. M. Rottenberg, who were attending her, made
a diagnosis of "ruptured tubal pregnancy," and tele-
phoned to me in the city to come up prepared to do a
laparotomy.

After heroic hypodermic stimulation and the ad-
ministration of large quantities of champagne, the
patient gradually improved in condition and appear-
ance, so that I found her, late that same afternoon,
with an absolutely normal pulse, with good color,
and free from pain. The physicians in attendance,
both men of large experience and very able diag-
nosticians, began to doubt the correctness of their
diagnosis, and I was asked for a decision.

Examination revealed a slightly distended abdo-

6oo

MEDICAL RECORD.

[April 13, 1907

men, but owing to the extreme obesity of the
patient, the signs of free fluid in the peritoneal cav-
ity could not be made out with any degree of cer-
tainty.

Vaginally, the uterus was found normal in posi-
tion and slightly enlarged, but with no elastic area
in the anterior wall. TThere was no enlargement of
either tube to justify a diagnosis of tubal pregnancy.
There was but slight evidence of free fluid in the
pelvis. The patient's last child was seven years old,
and she had been regular in her menstruation since,
except that she had her last ])eriod seven weeks pre-
viously.

Had this patient been in a hospital, or in her home
in the city, I confess I would have been tempted to
keep her under observation before deciding to oper-
ate ; but in view of the fact that she was in a coun-
try hotel, and that if her condition became urgent
during the night the necessary aid could probably
not reach her, an exploratory laparotomy was indi-
cated. To complicate matters, the husband of the
patient insisted on a positive diagnosis before he
would consent to an operation.

Now here we had a case presenting absolutely
no positive signs of tubal pregnancy, and the only
symptom to guide us was the amenorrhea. The
sudden attack of vomiting and abdominal pain and
the shock could also be explained by the fact that
after an enema she had had several large evacua-
tions containing mucus and a quantity of undigested
material. The fact that I was able positively to
exclude uterine pregnancy in this case was the most
important factor that led me to confirm and adhere
to the diagnosis of ectopic pregnancy.

The operation proved the case to be one of rup-
tured tubal pregnancy, and the reason for my failure
to feel the characteristic distention of the tube, and
the marked improvement in her condition subse-
quent to her collapse, will be found in the specimen,
which presents a rupture of a cornual pregnancv of
early duration.

As for the cause of this change in the wall of the
pregnant uterus, I do not share the opinion of those
who claim that it is due to the presence of the ovum
and its attachment to the uterine wall. It is gen-
erally conceded that the enlargement of the uterus
in pregnancy is the result of physiological and not
mechanical causes, and that the changes in the organ
are reflex in character and begin with impregnation,
as evidenced by the enlargement of the uterus in
extrauterine pregnancy, and. furthermore, that the
hypertrophic process involves not only the muscular
fibers and connective tissue, but all the vessels. The
branches of the uterine vessels that supply the body
of the uterus enter the uterus on a level with the
elastic area of pregnancy, and form a loose, dilated,
and tortuous plexus, which is probably the first of
the important changes that take place in the uterus
as the result of pregnancy.

I believe, therefore, that the peculiar elasticity
found in early pregnancy is in all probability due to
the extreme vascularity of that particular portion of
the uterine wall, and to no other cause ; but later,
however, the fluctuating feel of the body of the
uterus is no doubt due also to the presence of the
gravid sac.

In emphasizing the fact that the change found by
me differs materially from the other signs advanced,
and especially from Hegar's, with which it must not
be confounded, it is not my intention to detract in
the least from the work done in this direction by
other obser\^ers : that there is a unanimity of opinion
that a change in the consistency of the uterus does
take place as the result of pregnancy, whatever the

interpretation may be, is the best possible proof of
its diagnostic value.

The sign I advocate possesses the great advantage
that it can be elicited more readily by the general
practitioner and the specialist than the other signs,
which require especial skill in bimanual palpation
for their recognition, and above all because it is uni-
form and constant in its appearance.

In offering this sign to the general practitioner
and specialist, I am doing so, fully convinced that
when it is put to a fair test its reliability and value
as a means for diagnosis will soon be established.

■ i38q Madison' AvENt'E.

SYMPTOMLESS MASTOIDITIS, FOL-
LOWED BY MENINGITIS AND
DEATH.*

By A. B. BENNETT. M.D.,

WASHINGTON, D. C.

A VERY unusual case has recently come under my
care, and in view of the very misleading symptoms I
beg leave to report its history. Mr. H., male, white,
married, age fifty-four, clerk. Family history un-
known. Previous history : He said he had never
been ill a day in his life ; that he had had one child
which had water on its brain, its head was very
large, and was tapped and operated upon several
times, but it died at an early age. Present illness:
The last of October he contracted grippe, which was
accompanied by severe earache on both sides and
almost absolute deafness. He was treated by his
family physician until November 10, 1906, when he
came under my care. He then complained of severe
earache, alternating from side to side, and especially
severe at night, causing him much loss of rest. He
was also very deaf, not being able to hear the street
noises going on about him, and only catching a few
words when I fairly shouted into his ear. On exam-
ination, his nose, nasopharynx, pharynx, and larynx
were very free from inflammation, there being no
secretion in the nose, nasopharynx or accessory sin-
uses. The right membrana tympani was congested in
Schrapnel's membrane and along the long process
of the malleus. The left membrana tympani was en-
tirely congested and slightly swollen in its superior
posterior quadrant. There was no tenderness on
severe pressure over either mastoid. With the Eu-
stachian catheter I found the right tube fairly dry,
but the left tube contained a great amount of puru-
lent fluid, which was easily aspirated with the cath-
eter, affording the patient immediate though tem-
porary relief and improvement in hearing. At home
he douched his ears with hot water ever}- two hours.
This treatment I continued for several days, the
pain becoming less ; and in my records under date of
November 17, one week from my first examination,
I have this note, "Much better, no pain, and in-
creased hearing." The congestion of the right mem-
brana tympani soon disappeared, leaving evidence
of a chronic catarrhal otitis media of long standing.
The congestion of the left membrana tympani also
greatlv decreased, confining itself almost entirely
to Schrapnel's membrane and along the long proc-
ess of the malleus. From this time on the patient
made slow and steady improvement. His general
health and p-'-'^tite improved; he went about on his
bicycle and his hearing improved so he could hear
distinctly ordinary conversational tones and could
hear his clock tick at home. However, he continued
to suffer with tinnitus and a "rumbling in his head."

*Reported before the Society- of Ophthalmologists and
Otologists of Washington. D. C. January- t8, 1907.

April 13, 1907]

MEDICAL RECORD.

601

Repeated examinations of both mastoids failed to re-
veal anv tenderness. During this time he was com-
ing to mv office about three times a week for treat-
ment, and his Ijst visit was on Saturday, December
29, 1906.

The following Thursday evening I received a let-
ter from his wife, stating that Mr. H. had been very
ill with headache, vertigo, nausea, and vomiting.
Suspecting something serious, I wrote her to bring
him to the hospital the next day, which she did.
There was a marked change in the appearance of
the patient : he looked septic and reeled when walk-
ing so that he had to be supported. His tempera-
ture was 97.4°, pulse jz. There was no change in
the appearance of either membrana tympani, and
there was no mastoid tenderness on either side. Feel-
ing that there were no indications for operation, I
had the natient put to bed on a liquid diet. The next
day, Saturday, January 5, 1907, again the local con-
ditions were imchanged. The patient's temperature
ranged between 07.4° and 98° and he seemed better,
having had no nausea and but little vertigo. Sun-
day, January 6, 1907. his temperature was between
97.8° and 98.4° and he was very bright and cheer-
ful, laughing and joking with his relatives. About
noon on Monday, Januarv 7, he had an attack of
nausea, explosive vomiting, vertigo, and a rise in
temperature to 101° at 6 p.m. These symptoms con-
tinued, the patient tossing about verv restlessly,
moaning and groaning. At 10 p.m. his temperature
had fallen to 98.6°. At 11 o'clock I operated on
both mastoids, doing tlie left side first and finding
a tremendous amoimt of carious bone which was
readily curetted from the dura. The dura was in-
cised, evacuating a small amount of serum. The
lateral sinus was exposed and found normal. The
right mastoid was less diseased than the left, and
neither the dura nor the lateral sinus w'as exposed.
The wounds were packed with gauze. The patient's
temperature was then 102°, reaching 104° by 8 a.m.,
105° by 2 p. M., where it remained until 10 p.m.
Shortly thereafter the patient died, never having
regained consciousness. Dr. R. S. Lamb performed
the autopsy, and the following is his report :

"Post mortem in the case of W. H., male white,
age fifty-four. Admitted to hospital January 4.
Died January 8, 1907. Height, 5 feet 10; weight,
150 pounds ; bodv well nourished ; color, light
saffron ; eyes, blue. Double mastoidectomy evident.
On removing the calvarium the longitudinal sinus
was found immensely engorged, as were also the
vessels of the dura mater. The removal of the
dura exposed a markedly congested pia mater cov-
ered w-ith purulent Ivmph — a diffuse leptomeningitis.
The removal of the brain and cutting the spinal
cord was attended by the outf^ow^ of blood and
pus in large quantities, the brain being literally
bathed in pus. In the left lateral sinus was found
a large, soft, dark clot, in the torcular Herophili a
similar clot, and in the right lateral sinus a white
disintegrating clot (thrombosis). The base of the
skull interiorly was normal, except an absence of
the left tesmen tympani. The brain showed a diffuse
leptomeningitis over the entire cerebrum and cere-
bellum with pus in the lateral ventricles. The
examination of the other organs of the body showed
normal lungs, heart, and kidneys, with congested
liver : other organs normal. In conclusion it would
appear that the leptomeningitis was of otic origin,
via a thrombosed right lateral sinus, as the dura
over the absent teemen tympani showed no pachv-
menineitis externa." Signed, R. S. Lamb, M.D.

It cannot be possible that this amount of disease

came on suddenly, and just when and how the infec-
tion took place is surmise. Of the meninges of this
brain the parts apparently least affected were those
parts just over the ear in the middle fossae. The
engorged vessels of the dura with the lymph de-
posits on the pia and the presence of pus in the
lateral ventricles are similar to the pathology of
cerebrospinal meningitis, and many of the symp-
toms were similar also, but the absence of hyper-
esthesia, anesthesia, signs of motor irritation, and
the cutaneous changes, with the presence of the
otitis media and lateral sinus thrombosis certainly
warrant the opinion that the cerebral changes were
of otic origin. Mavbe I have detailed this history
somewhat unnecessarilv, but it is a'^'^alling to me to
think that for two months I saw this patient every
few days and that the apparently good results from
the treatment so completely deceived me as to what
was actually going on ; and it is my wish to em-
phasize these few points in closing:

First, that I sincerely reeret not making a lumbar
puncture before the operation, and that the leucocyte
count was not worked up.

Secondly, in regard to the history, to repeat that
during the entire attack he never had fever to
my knowledge until four hours before the operation ;
at no time was there any mastoid tenderness ; the
membrana tympani never perforated or discharged,
but the conditions steadily improved, as also did his
hearing, and the svmptoms of meningitis were the
first svmptoms that pointed tow'ard operative inter-
ference.

The Farragut.

PROLAPSE OF THE RECTUM:

REPORT OF AN OPERATION FOR THE RELIEF OF THE
CONDITION IN A DEMENT.

By JAMES K. HALL. M.D.,

MORGANTON, .V. C.
ASSISTANT PHYSICIAN NORTH CAROLINA STATE HOSPITAL.

The comparative frequency with which prolapse of
the rectum occurs in all classes of society, and the
noticeable infrequency in current medical literature
of reports of measures successfully adopted for the
relief of this distressing and repulsive condition,
prompt me to submit the following report of an
operation on a young dement who had been suffer-
ing for several years from rectal prolapse.

Clinical No. 1753. — G. A., male, white, aged 36,
was admitted to the State Hospital at Morganton in
1895. There had been very marked mental dis-
turbance for two years before admission, and his
mental development had never been normal. His
father, as well as a sister, were epileptics. Before
admission the patient had delusions of fear and sus-
picion, was violent and destructive, and gave his
family much concern.

Since admission, mental deterioration has been
gradual but progressive. In this article, however, a
detailed psychic history of the case, interesting
though it might be, would not be in place. Let it
suffice to say that for several years after admission
the patient enjoyed periods of comparative mental
lucidity, during which he was tractable and worked
with considerable intelligence. For the past five or
six years, however, the periods of depression have
been much more frequent and pronounced than for-
merly, and at such times there has been present
always an uncontrollable impulse to take his own
life. Five years ago, for instance, the patient ate a
quantity of Paris green, but by prompt treatment

6o2

MEDICAL RECORD.

[April 13, 1907

was saved from death. Only a short time before
this he had attempted to cut his throat with an old
piece of steel which he had sharpened by rubbing
against a brick wall. Having failed with the poison,
he soon made another attempt to cut his throat, but
the instrument was too dull. He even tried to throw
himself into a rapidly revolving engine wheel, and,
at another time, in front of a moving wagon. Less
than a month before the operation, which will be
described, hemorrhage from a self-inflicted wound
on the neck all but had the result he hoped for.
Because of this strong suicidal tendency, confine-
ment in the ward and close watching had been neces-
sary for several years. As a result of the confine-
ment, tlie depression, and the many attempts at self-
destruction, his physical health was not robust.

It is impossible to say definitely when the condi-
tion began. But it is certain that five years ago a
prolapse of such size had taken place that the
patient was forced to replace the tumor digitally
after each stool. Sphincter power was so strong,
however, that recurrence came only with a bowel
movement. But as time went by more and more of
the rectal tissue descended at each stool, and its
reduction became more painful. Finally, the condi-
tion became so bad that the patient spent the greater
portion of each afternoon in the closet.

The accompanying illustration, made from a
kodak taken the day of the operation, will furnish
some idea of the size of the mass. It was pear-
shaped, quite firm, about eight inches in the long
axis, and six transversely. There were on it numer-
ous small abraded and bleeding spots, caused by
unskilful methods of reduction. Replacement must
have been attended by the most atrocious pain, for
the agonized groans of the patient could be heard
throughout the ward. .And lacking in all the finer
feelings though he was, the condition was so re-
pulsive, even to the patient himself, that he sought
seclusion in the closet, and refused all aid. Eflforts
at reduction, although accompanied with difficulty
and always attended by great pain, were invariably
successful. In the intervals between stools, the
sphincters retained the rectum within the pelvis, and
there seemed to be no discomfort, even though he
spent mucli of his time on his feet.

About the middle of September the patient made
a long gash on the right side of the neck, completely
severing the external jugular vein and bringing into
view the deeper vessels. Hemorrhage from this
wound was severe, and from the time of the acci-
dent until the operation the patient was too weak to
be up. The heart and lungs seemed to be normal,

and nothing was found in the urine to forbid the
administration of ether.

Of the many operative measures suggested for the
relief of this condition, that one was selected which
has for its purpose fixation of the colon, just above
the sigmoid, to the anterior abdominal wall. Oper-
ation was scheduled for October 16. On the morn-
ing of the 15th magnesium sulphate was given in
2 dram doses every hour until the bowels were thor-
oughly emptied. The abdomen was carefully
cleansed in the afternoon, and covered with a weak
bichloride dressing. The diet was restricted to milk
in small quantities. On the day of operation an
ether breakfast was given, i.e. a glass of milk and a
slice of bread. The bowels were again thoroughly
emptied by soapsuds enemata, and the lower bowel
was irrigated with liberal quantities of physiological
saline solution.

The patient was put on the table at 4:30 p.m.
The abdomen was again cleansed with soap and
water, ether, alcohol, and a strong solution of mer-
curic chloride. An incision was made through the
abdominal wall on the left side about two inches
above Poupart's ligament, parallel with the ligament,
and four inches in lengdi. The incision terminated
medially at the deep epigastric artery. The rectum
was found to be much thickened and indurated, and
to the palpating hand it gave the impression of a
cone with the apex pointing upward. Other viscera
that could be felt seemed to be normal and in their
proper positions. The parietal peritoneum for half
an inch around the margin of the incision, was sep-
arated from the overlying tissue. The colon was
then drawn upward and made rather tense. At the
upper angle of the incision a strong silk suture was
entered just beneath the skin, was passed through
the wall tO' tlie peritoneum, through the longitudinal
band of fibers in the colon, in like manner through
the abdominal wall on the opposite side, and firmly
tied. This suture, which later became buried, served
the double purpose of keeping the rectum and sig-
moid on the stretch and the longitudinal bundle of
colon fibers in the long axis of the incision. Begin-
ning at the lower angle of the wound, the parietal
peritoneum was sutured to the colon. Fine silk was
used in a small, curved needle, and the continuous
suture was employed. At the lower end of the
incision the attachment of the parietal peritoneum
to the colon began on the anterior bundle of longi-
tudinal fibers ; further up the attachment was about
a half inch from the bundle of fibers, and at the
upper angle it again approached them. The attach-
ment of the parietal peritoneum to the front and
each side of the colon thus formed a kind of dia-
mond-shaped figure, about four inches in the longer
axis and an inch and a half at the widest point. The
peritoneal cavity was in this way closed. At the
lower angle of the incision an interrupted suture
was introduced on one side, just beneath the skin,
passed downward to the parietal peritoneum, made
to catch firmly the anterior longitudinal band of
fibers in the colon, and brought through the same
constituents of the abdominal wall on the opposite
side. Sutures were introduced in like manner about
a half inch apart along the entire length of the
incision, and were of catgut and silk alternately.
They were held by hemostats. and were temporarily
left untied. Interrupted sutures of good-sized silk-
worm gut were now introduced through the abdom-
inal wall, excluding only the peritoneum, and not
catching the colon. They were placed half an inch
apart. The interrupted sutures of silk and catgut,
which had been put through the abdominal wall and
also through the band of the colon, were now re-

April 13, 1907]

MEDICAL RECORD.

603

leased from the heniostats and tied. These became
buried sutures, and their purpose was to bring about
a third of the circumference of the peritoneal coat
of the intestines for a length of four inches into close
and firm contact with the raw surface of the abdom-
inal wall — the transversalis fascia — in the hope that
strong adhesions might result. The interrupted
silkworm gut sutures were now tied, closing the
abdominal incision. A dry dressing was applied to
the wound, and held in place by adhesive strips and
a scultetus. The buttocks were kept in close appo-
sition by adhesive strips applied transversely, thus
furnishing some support to the rectum from below.
Strychnine, gr. 1-30, was given on the table, and the
patient was removed from the operating room at
6:30, in good condition.

It was thought advisable to keep the bowels con-
fined for several days, and to keep the patient abso-
lutely quiet. For this purpose morphine was given
frequently. At 9 p.m. on the day of operation
gr. 1-6 of morphine was given hypodermically, pro-
ducing sleep for several hours. At i a.m. the next
day, to allay restlessness, 1-8 of a grain was again
given in the same manner. At this hour the temper-
ature was 101.3°, snd the pulse 105. Urine was
voided freely, but there was no desire to move the
bowels. At noon on the day following operation a
teaspoonful of hot water, to be given every hour,
was begun, but resulting nausea soon necessitated its
discontinuance and the administration of morphine
in small doses late in the day. The second night was
passed in comfort; urine was voided and flatus ex-
pelled. On the second day milk was given every two
hours in tablespoonful quantities, but at night there
was nausea and vomiting, and morphia was admin-
istered. On the third day the temperature did not
rise above 101° ; the administration of morphine was
not resorted to, and liquids — milk, lemonade, and
cracked ice in small quantities — were retained. The
condition on the fourth day was quite satisfactory.
The temperature had fallen to 100° ; liquid nourish-
ment was retained, and there was no discomfort.
Restlessness and slight nausea were allayed on the
next day by morphine, 1-8 of a grain in the forenoon,
and a small dose at night. On the sixth day calomel
was given hourly in ^A grain doses for six hours in
the forenoon. Soon after the last dose there was in-
clination to bowel movement, and an oil enema was
given, resulting in a small stool. Soon afterwards a
Seidlitz powder was taken, and within an hour there
was a copious stool, unaccompanied by pain or a re-
currence of the prolapse. One week after the oper-
ation liquids were being taken freely and there was
no discomfort whatever. The condition during the
three following days, however, was far from satis-
factory, and at one time was a source of considerable
anxiety. Nausea recurred, there was abdominal dis-
comfort, the pulse became weak, the vitality was
lowered, and the patient became restless. Strych-
nine, gr. 1-30, was ordered given every three hours
by hypodermic injection. On the ninth day there
was a slight voluntary bowel movement, and vomit-
ing occurred several times. An enema was given on
the tenth day, and immediately a very large scyba-
lous mass was e.xpelled, and its removal was at-
tended by great effort and pain.

After this improvement was rapid. Nausea
ceased, the appetite improved, and the bowels moved
without pain every day. The stitches were removed
at the end of two weeks. There were one or two small
stitch abscesses, but union was firm. For three
weeks after operation the patient was kept under
constant watch day and night, and was scarcely
allowed to raise his head. During this time the bed

pan was used when bowel movements occurred.
At the end of three weeks the patient was propped
up in bed a few minutes daily. After the fourth
week he was allowed to sit up and to walk around
a little each day. The bed pan was dispensed with.
Several of the buried sutures worked out.

The patient is now, more than four months after
the operation, in better physical condition than he
has been in for several years. He does not suffer
the slightest discomfort at stool, and there has been
no sign of a recurrence of the prolapse. Although
little improvement was looked for in the mental con-
dition, it is evident that he takes a much more cheer-
ful view of life than formerly. How much the con-
dition had to do in impelling him to self-destruction
one cannot say, but one can readily understand how
such a condition could make life unendurable, even
to an insane man. It is too much to expect the sui-
cidal tendency to disappear, but the pain has been
relieved, and its cause removed.

I have no idea of the frequency with which rectal
prolapse occurs. An estimate based on the number
of cases in this institution would put its occurrence
at I in every 200 or 300. I have no doubt that tlie
condition exists much more frequently than we
think. If every physician were to examine every
case of "protruding piles" which he treats without
seeing with some kind of ointment, he would doubt-
less discover many cases of incipient prolapse of the
rectum.

My thanks are due the superintendent of the hos-
pital, Dr. P. L. Murphy, for permission to report
this case.

ASPIRATION IN OTITIS MEDIA ACUTA.

By PERCY R. WOOD. M.D..

MARSIIALLTOWK, IOWA.

.\cuTE middle-ear suppuration frequently runs a
protracted course, convalesces tediously, and
leaves in its wake most serious conditions. This
arises from failure promptly to control suppura-
tion and limit the zone of infection. While these
diseases frequently attack the neurotic and poorly
nourished, following exanthematous fevers or in-
fluenza, the largest number of cases occur in chil-
dren suffering from unsuspected adenoids.

Ninety per cent, of middle-ear suppurations
arise from pathological conditions in the naso-
pharynx. The unsatisfactory results so fre-
quently obtained in treatment arise largely
through ignorance of these conditions and their
relation to this disease. This region should be
carefully examined in every instance, not alone
with the mirror, but especially with the tip of
the index finger, since the eye here does not al-
ways furnish complete data. Severe inflammations
dependent upon systemic or local irritants might
be easily recognized, but the bursa might be
filled with hj'pertrophied lymphoid tissue, or
small tufts surround and even encroach upon the
Eustachian orifices and the vault still appear
healthy, especially to the inexperienced.

These apparently slight departures from normal
play major roles in the production of middle-ear
diseases, favoring inflammatory action and in-
terfering with tympanic drainage and aeration,
while their glandular character enables them to
retain and transmit pathogenic microorganisms to
the middle ear and adjacent structures. The
following case is an apt illustratidn. Johnny B.
of Marshalltown, eleven months old, had been suf-
fering six weeks with middle-ear suppuration, none

604

MEDICAL RECORD.

[April 13, 1907

of the characteristic signs of adenoids being
present. Examination disclosed a slight bulging
of the bursa and a few tufts of lymphoid tissue
overlapping the orifice of the right tube. After
their removal and aspiration of the middle ear by
means of an original device to be later described,
suppuration ceased the third day under appro-
priate treatment, and complete recovery followed
in less than two weeks.

A crisis is established at every onset of an
acute otitis media. Infection is invariably a
factor, and purulency and chronicity ever-present
possibilities. The pathogenic secretions in al-
most every instance, by traveling paths of least
resistance enter the mastoid, and pathological
changes here may go on for years without ex-
citing suspicion.

The writer performed an operation this winter
entailing entire evisceration of the middle ear and
mastoid process with exposure of the brain cover-
ings and venous channels. There was a history
of acute suppuration twenty years previously,
yet symptoms necessitating active measures ap-
peared but a few weeks before.

In these acute cases, custom prescribes seda-
tives, anodynes, leeches, counterirritants, and
antiseptic medication, coupled with the advice to
wait. In the meantime infection is spreading; dis-
integrating changes taking place in tympanic and
mucous membranes, and even if acute symptoms do
subside with or without tympanic rupture and reso-

JluMirr fll/itng

^i/'A-r ^yii-t/

Middle-ear Aspirator.

lution does seem to obtain, not infrequently
function has been permanently impaired, while the
patient, lured to a false sense of security, may be
awakened months or years later with chronic middle-
ear disease. It is better therefore rather to
anticipate and prevent than attempt to cure these
conditions. Hence the necessity of some treatment
calculated to control inflammation promptly and
limit the spread of infection, and so provide
against immediate injury* and subsequent chronicity.

An early paracentesis meets these indications
by protecting structures from mechanical and
pathological action of the secretions, and by re-
lief of tension lessening the chances of mastoid
involvement. The wound heals in from three
to five days, with no permanent impairment of
audition. A solution of equal parts of menthol,
cocaine, and carbolic acid applied on an inserted
pledget of cotton and retained five minutes ren-
ders the operation painless. A large opening is
not necessary unless the secretions are exceed-
ingly tenacious, but should be placed right and ex-
tend to the floor of the canal.

After drainage is established, removal of the
pathogenic exudates is really the paramount issue
upon which hinges ultimate success or failure.
Merely liberating these does not insure the de-
sired results. They not infrequently have already
involved the mastoid, and inspissated particles
containing colonies of various cocci invariably
cling to the ossicular articulations and the walls

and roof of the attics, to the recess of the round
window, around the foot of the stapes, and to
other sequestered points known to be chosen
seats of caries, and there they form pathological
foci which develop later. Proof abounds in the
chronic cases which are numerous where the
tympanic membrane is totally or partially want-
ing, the ossicles necrosed or absent, and their
places occupied by connective tissue bands — all
the legitimate fruitage of inadequate treatment.

The writer once enjoyed the privilege of listen-
ing to Prof. Politzer on this subject, when he
stated that acute middle-ear suppurations usually
left traces in the mastoid which remained a con-
stant menace to function, if not to life.

In order to carry out the technique as above
suggested an instrument has been specially de-
vised by the writer and called "the middle-ear
aspirator." It is manufactured by F. .\. Hardy
& Co., of Chicago.

It consists of a glass tube three inches long
with a reservoir for exudates. The aural ex-
tremity tapers and is tipped with rubber, and to
the other is attached a syringe with a good
sized air chamber. When in place the rubber
tipped end seals the opening, the piston is drawn
out gently and retained until the reservoir fills,
or until no further exudates, blood, or serum
escape. By this means these cavities are relieved
of vast quantities of pathological secretions which
would never entirely drain away or be absorbed,
but remain throughout life to threaten the in-
tegrity of the parts. While this procedure does not
exactly sterilize these parts, by the removal of vast
quantities of microorganisms their preponderance
over the living tissues is destroyed. Another feature
not to be ignored is the favorable influence e.xerted
by the blood-letting principle applied by the instru-
ment. It relieves congestion, soothes pain, and
hastens convalescence.

When the inaccessibleness of these regions and
their vulnerability to necrotic action is consid-
ered, as well as the large percentage of cases
which for these reasons become chronic, the prac-
ticability of this procedure is beyond question.

When through aspirating the auditory canal is
sterilized, a current of warm camphorated vapor is
sent through from the Eustachian side, the parts
are dusted with boracic acid powder and packed
loosely with iodoform gauze, and the pharynx is
swabbed with a 2 per cent, solution of silver ni-
trate. This dressing and treatment should be
renewed daily at first. Permanent recovery with
reestablished normal function usually ensues
within ten davs.

ARRESTED MENTAL DEVELOPMENT.

Bv HUBERT RICH.\RDSON, M.D..

BALTIMORE. MD.

LATE PATHOLOGIST TO MOVXT HOPE RETREAT; LECTURER OX N'EUROLOGT

A.VD PSVrHOLOGY AND ON PHYSIOLOGICAL CHEMISTRY, UNIVERSITY

OF MARYLAND: P.ATHOLOGIST TO THE MARYLAND ASYLUM

AND TRAI.NING SCHOOL FOR FEEBLE-MINDED CHILDREN.

.•\rrested mental development is a misfortune to
both parent and child, calling for the physician
to put forth all his efforts to discover the cause
and if possible remedy the condition. It is prob-
able that, notwithstanding the statistics, a very
large proportion of our feeble-minded children are
not heirs to the sins of omission and commission
of their parents, but that the etiological factor
of their defective mentality is of postnatal origin.
.Acute diseases in the first three vears of life

April 13, 1907]

MEDICAL RECORD.

605

are often the cause of lesions which permanently
affect both the mental and the physical develop-
ment of the child. It has been a matter of com-
mon observation that after a severe attack of the
acute diseases of childhood, such as measles,
scarlet fever, whooping cough, etc., there has oc-
curred a gradual decrease in mental growth ; the
child may not be stupid or apathetic, but his men-
tality remains behind for his years, described as
weakness of character or childishness, he hav-
ing the normal mentality of a child much younger
in years : puberty is delayed, and as he grows older it
is true his mind also grows, but he never arrives at
true mental maturity. In other cases the child de-
teriorates, becoming imbecile or even idiotic ; in
which case it is more than probable that during
the acute disease from which he has suffered his
thyroid has become infected, resulting in a cir-
rhotic condition of the gland, and consequent
insufficiency; at puberty, when extra demands are
thrown upon the thyroid, the symptoms become
accentuated, a myxedematous condition com-
mencing which, unless treated, will proceed to a
cretinic condition from which there is little or
no hope of recovc}-.

Another cause of arrested mentality is found in
defects of assimilation and metabolism. Cases
occur in which, from some acute disease, the gas-
tric juice fails to contain either hydrochloric acid
or the ferments ; the exciting factor to the intes-
tinal secretions not being present, the digestive
process is deranged, and both physical and mental
development are arrested for lack of nutrition.
These patients usually have an uncontrollable
diarrhea, with poor assimilation of fat.

■Still another cause is to be found in circulatory
defects. The cardiac energy may have been af-
fected, and on taking the erect position there is
not sufificient force to drive the blood to the brain.
These children are usually well developed in the
lower trunk and limbs, but the head and expres-
sion give the observer the impression of feeble de-
velopment. The quantity of blood required by
every organ can be divided into three portions,
the first required for food, the second for func-
tioning, and the third for growth. While the
child remains recumbent the circulation is about
equal all over the body, but on his taking the erect
position the heart is unable to force the blood to
the vertex, and though it may send enough for
nutrition, yet not enough for perfect functioning
and growth ; in cases of angioplasia when the
arteries are reduced in caliber this condition
exists.

Acute disease may have affected the special
senses, the child does not commence to walk
or talk till long after the usual age, his limbs
may be well nourished, but he lacks the nervous
force from the cerebral centers ; when he does
commence to talk there are defects of speech
which may be due to structural irregularities in
the peripheral organs of speech, the tongue, pal-
ate, lips, teeth, nostrils, or pharynx, or in their
nerve supply. The intellectual centers of the
brain are in close connection with the central or
cerebral speech mechanism, language and thought
are inseparable ; to think is to speak low, to speak
is to think aloud. It is impossible to learn to
speak without calling into requisition the sense
of hearing, and the child cannot talk or think
if its hearing is defective, which is often due to
infection of the auditory apparatus. Those chil-
dren whose hearing is defective may appear

bright in certain lines, they may be able to make
their every want understood by pantomime, but
their mental development is permanently retarded
unless the auditory defects can be remedied.
Many children can be found in every asylum
whose enfeebled mentality is due to ear disease,
the result of postnatal infection. Defective sight,
owing to the strain upon the eyes, often arrests
the mental development of the child, and in a few
cases produces epilepsy which in its turn increases
the mental hebetude. There is every probability
that insufficiency of the suprarenal glands is also
a cause of arrested development, and absence of
the testicular secretion has also a pathological
effect upon both body and mind.

Intestinal parasites are often a cause of stunted
growth, owing probably to the fact that they pro-
duce an antibody which destroys enterokinase,
the ferment whose function it is to convert the
inactive trypsinogen of the pancreatic secretion
into active trypsin, thus striking at the very
foundation of intestinal protein digestion.

Much can be done for those whose development
has been retarded by antenatal conditions pro-
duced by disease of the mother during pregnancy.
As the fetal liver is the organ which receives
the maternal toxins, it is the organ requiring the
postnatal attention of the physician. The right
side of the heart during fetal life is the principal
factor in the circulation, and antenatal valvular
lesions are almost invariably in the tricuspid
valve. In every case attention to the digestive
tract is of the first importance, as without nu-
trition, no matter what other lesions mav exist,
development, either mental or phvsical. is im-
possible.

SiQ P.ARK Avenue.

Operations During Typhoid Fever. — .At a recent
meeting of the Liverpool Medic.il Institution (Lancet,
January 12. 1907). Dr. W. T. Thomas reported two cases
of operations during typhoid fever, one for perforation,
the other for appendicitis, in both of which recovery took
place. He called attention to the fatal character of per-
foration unless surgically treated, when the recovery rate
was 30 per cent, or more. .Although in many cases the
diagnosis was uncertain, it would be wiser to explore (un-
der local anesthesia) than to wait until general septic
peritonitis had set in. The treatment of the perforation by
quick suture or the formation of a fecal fistula appeared
to be the two alternatives — fancy work such as enterectomy
with end-to-end anastomosis was not to be recommended ;
enterostomy had the further advantage of draining the ty-
phoid intestine and keeping it at rest. Dr. F. T. Paul re-
ferred to a case in which a perforation twelve inches from
the cecum occurred three months after the onset of ty-
phoid fever. In this case the ulceration was so extensive
that the perforation could be closed only by excising it
and the patient died nine days after the operation. Dr. T.
C. Jones mentioned a case in which he had operated
successfully last July. A Lascar boy was taken to the
Liverpool Infirmary at the end of the second day after per-
foration of a typhoid ulcer. Simple suture of the ulcer
was performed and the abdomen was cleaned of intestinal
contents. The boy was transferred to his ship three weeks
afterwards. Perforation was rare in Hindus and the in-
fection was comparatively slight. Dr. R. W. Murray said
that better results from operative interference would prob-
ably be obtained if, as a general rule, the bowel at the point
of perforation w-as brought to the surface and a fecal fistula
temporarily established. Such an operation could be
quickly performed and would have the great advantage of
permitting the inflamed bowel to rest.

6o6

MEDICAL RECORD.

[April 13, 190?

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A M., M.D., Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, April 13, J907.

THE EFFECTS OF MATERNAL GONOR-
RHEA ON THE OFFSPRING.

It is a matter of quite widespread popular belief
that gonorrhea in the mother has no deleterious
effect on the offsprino; be3-ond a possible ophthalmia.
This, of course, is serious enough, although it may
ordinarily be avoided by prophylgctic means, but a
recent investigation by Lobenstine and Harrar, re-
ported in the Bulletin of the Lying-in Hospital,
December, 1906, shows that in addition to the pro-
duction of an ophthalmia, the general nutrition of
the infant is likely- to fail when the pregnant
woman is suffering from gonorrhea. The inves-
tigation in question was conducted at one of the
large maternity hospitals, where an extensive ma-
terial was available for the purpose. The work is
based upon comparisons made between fifty babies
of gonorrheal mothers, one hundred and fifty babies
of normal mothers, and fifty babies of non-gonor-
rheal mothers who presented more or less marked
elevations of temperature. The babies in this series
of cases were all breast-fed and the period of ob-
servation extended over the first ten days of infant
life. The gonococcus was demonstrated in the geni-
tal tract of each of the mothers alleged to be suf?er-
;:i"- from gonorrhea.

A detailed study of the results presented by the
authors of the paper shows conclusively that the
disease process referred to e.xerts a well marked
deleterious influence on the nutrition of the fetus.
The average birth weight of the babies of gonorrheal
mothers was found to be 297 grams less than those
of normal mothers and the average initial loss in
weight was also more pronounced in the former
than in the latter. Another important fact was that
the amount of the loss which was regained by the
tenth day was much less in the gonorrheal than in
the normal babies. The former also suffered more
from fever and intestinal disturbances than the
latter. Gonorrhea in the mother is evidently also
a frequent cause of premature births, for in this
series of cases it amounted to about twenty-two per
cent., whereas under normal conditions it occurs
only in somewhat over two per cent. Fever in
the mother, no matter what its cause, always exerts
an unfortunate effect on the child, and we find that
the loss in weight which the latter experiences is
always very slowly regained.

The writers do not think, however, that the in-
terference with the infant's nutrition is due to any
.•specific toxins excreted by the milk of the gonorrheal
mother, but rather that it is due to local effects of

the disease, which vitiates the normal nutrition of
the fetus, and also to the presence of elevated tem-
perature during the puerperium of the mother.
These results are of considerable practical interest
as demonstrating the extreme care which .should be
exercised in treating any gonorrheal inflammation
which may be present in the mother during her
pregnancy, for the effects of this disease have
been shown to exert a general as well as a local
effect on the offspring. A knowledge of these facts
needs general diffusion, and the deleterious effects
of the venereal diseases not only upon those im-
mediately afflicted, but on their offspring, is a sub-
ject which demands increased attention from the
laity as well as from the medical profession.

THE DERMATITIS CAUSED BY THE
BROWN-TAIL MOTH.

Derm.^tologists, and more especially entomolo-
gists, have long recognized that contact with the
larvae of certain of the lepidopterous insects is
capable of inducing a more or less annoying form
of dermatitis, but, in this country at least, the species
that possess this property are not very well repre-
sented, and until recently the subject has not at-
tracted a great deal of attention. Of late years, how-
ever, one of the worst offenders in this respect, the
so-called brown-tail moth, Porthesia or Euproctis or
Liparis clirysorrhwa, has become so common in cer-
tain parts of New England, and appears to evince
so decided a propensity to enlarge its habitat that
the subject seems well worthy of consideration.

Among the first to point out the part played by the
caterpillar of this moth in the production of a pe-
culiar urticarial type of dermatitis frequently seen
in the districts infected, were Drs. J. C. White and
E. R. Meek, who presented communications to this
effect in the Boston Medical and Surgical Journal
in 1901. It was suggested that it was the hairs of
the caterpillar, which are very brittle and easily
detached, that were the source of the irritation, and
the question arose as to whether the dermatitis was
simply the result of the mechanical action of the
hairs or was due to a poisonous substance conveyed
by them into the skin. Fernald and Kirkland, the
authors of the Massachusetts State Board of Agri-
culture bulletin on the brown-tail moth, as the result
of an examination of the hairs, cocoons, and molted
skins of the insects made by Mr. F. J. Smith, chem-
ist of the Gipsy Moth Committee, inclined to the
view that the effect was purely a mechanical one.
As the result of a very thorough investigation of
the subject by E. E. Tyzzer {Journctl of Medical
Research, March, 1907), this belief appears
untenable, however. He agrees with the preceding
observers that the dermatitis is produced by a spe-
cialized form of short, barbed spines termed "nettling
hairs," but demonstrates that the actual morbific
agent is a toxic substance which greatly aggravates
the irritation produced by the penetration of the
hairs. The nettling hairs are straight, tapering,
needle-pointed shafts, provided with numerous re-
current barbs and measuring on the average o.i
millimeter in length and 0.005 millimeter in thick-
ness at the larger extremity. No pore is visible in
the hairs, but their behavior in regard to staining

April 13, 1907]

MEDICAL RECORD.

607

fluids, and other considerations, make it seem likely
that the poisonous substance is contained in a cavity
in their interior. They develop in the caterpillar,
and are present even in very young specimens. In
the process of manufacturing the cocoon the hairs
are rubbed ofiE the caterpillar and enter into the
structure of the cocoon, and are also found mingled
with the long hairs of the brown tuft on the tail of
the moth, though it is probable that they simply
become entangled in the scales of the moth as it
works its way out through the cocoon, and are thus
all primarily derived from the caterpillar. They also
occur in the egg masses and in the winter webs, and
are blown about in the air.

By control experiments with finely comminuted
glass wool and the barbed hairs of the harmless tus-
sock moth caterpillar, Tyzzer was able to show that
the mechanical irritation alone of the hairs was not
sufficient to give rise to the clinical picture of the
dermatitis, and the discovery of a peculiar reaction
caused when they were added to blood indicated
that a soluble chemical substance must be present
in them. It was found that if a number of nettling
hairs were placed in a drop of blood between a slide
and cover-glass, an immediate change took place in
the red blood corpuscles. They at once became
coarsely crenated. and the rouleaux were broken up
in the vicinity of the hair. The corpuscles decreased
in size and the coarse crenations were transformed
into slender spines which rapidly disappeared, leav-
ing the corpuscles in the form of spheres, the light
refraction of which contrasted them sharply from
the normal corpuscles. The change of form, in ad-
dition to a slight shrinkage, caused the red blood
corpuscles to appear much smaller than normal.
This reaction takes place so rapidly when the fresh,
active, nettling hairs are used that the eye cannot
follow its various stages, but by treating these hairs
in various ways, the time of this reaction may be
slowed so that all stages of transformation may be
seen. Control tests with similar minute foreign
bodies of different origin were negative.

The next step lay in the demonstration of the fact
that the hairs could be deprived of their specific
irritating properties by heating them to 115° C. for
one hour, though their structural integrity was not
impaired by baking at a much higher temperature
than this. It was further found that although this
active substance was refractory to a large number of
solvents tested, it could be extracted with distilled
water at 60° C. and by dilute alkaline solutions at
room temperature, the hairs so treated becoming
inactive. The stabile nature of the substance con-
tained in the hairs afforded an explanation of the
fact that the hairs adhering to empty cocoons retain
their irritating properties indefinitely, and that
underclothing hung to dry in the neighborhood of
infested trees and then packed away for a year has
been known to produce dermatitis when worn again.

The reaction of the human skin to the nettling
hairs of the brown-tail moth varies greatly with dif-
ferent individuals. When these hairs are rubbed
upon the skin there is immediately, with most per-
sons, considerable itching, and the inoculated area
rises up in the course of fifteen or twenty minutes
in the form of a wheal about which there is con-
siderable reddening that changes to white when the

skin is stretched. The reaction, however, is not
always so prompt to appear, and the severest process
observed by the author showed nothing for a period
of eight hours after the inoculation. The nettling
hairs, even when rubbed into the skin of other indi-
viduals, produce only slight reddening, or perhaps
very slight elevation, and practically no discomfort.
Whether or not decreased alkalinity of the blood
forms a factor in the insusceptibility of these per-
sons, is only a matter of conjecture. The dermatitis,
as it occurs naturally, is of two types, according to
the manner of acquisition. If, for instance, a cater-
pillar is felt crawling over one's neck, and is there-
upon slapped or crushed, and the part afterward
thoroughly rubbed and scratched, a marked local
dermatitis develops in which the lesions are con-
fluent. There is local reddening and thickening of
the skin with the formation of papules or vesicles,
as the case may be. A patient in this condition is
liable to seek the advice of a physician. On the
other hand, if the nettling hairs are distributed by a
breeze to underclothes as they hang drying, the der-
matitis which results from wearing these clothes is
of the nature of a scattered urticarial rash. The
lesions in such a case are in the form of small dis-
crete papules which, if not scratched, often show at
their summit a tiny vesicle filled with clear fluid.
They are generally more numerous on parts of the
body where the skin is soft. Many persons having
such rashes never consult the physician. Warm,
muggy weather aggravates the condition ; the reason
is that the epidermis is then kept moist by perspira-
tion, and becoming softer favors the penetration
of the nettling hairs. The duration of the dermatitis
is variable, but the individual lesions usually heal
in from seven to ten days. The severest forms are
seen during May and June, as it is at this time that
the caterpillars reach their maturity.

By microscopical examination of sections of in-
fected tissue from his own person and from experi-
ment animals Tyzzer was able to show that the
pathological process in the skin consists of necrosis
of the epidermal cells around the nettling hairs,
the formation of spaces or microscopic vesicles in
the epidermis at the site of injury, and inflammatory
changes about the vessels of the corium. Mice
inoculated with active nettling hairs presented le-
sions characterized by a large amount of fluid e.xu-
date, while those inoculated with inactivated nettling
hairs showed merely inflammation of the nature of
a reaction due to the mechanical injury brought
about by these elements.

These ingenious investigations of Tyzzer's throw
light on the nature and pathology of a condition
which, while not very serious, is yet most annoying,
and which is likely to become of interest to more
practitioners from year to year, as the insect extends
its area of activity. They also show that there are
more than merely economic reasons making it de-
sirable to spare no efforts to exterminate the pest.

Uniformity in Pharmacopoeias. — The Belgian Acade-
my of Medicine at a session devoted to a discussion
of the discrepancies in the official pharmacopceias in
use in the different countries adopted a resolution rec-
ommending the government to take steps toward the
formation of an international commission having for
its object the establishment of a permanent bureau to
work for greater consistency in this respect.

6o8

MEDICAL RECORD.

[April 13, 1907

STRONTIUM BROMIDE IN THE TREAT-
MENT OF EPILEPSY,

It will not be gainsaid that a careful regulation of
the entire mode of life has a most beneficent
influence upon the course of epilepsy, but, despite
the well-known objections to the use, and especially
the continued use, of the bromides in the treatment
of that disease, such a therapeutic course is often
rendered necessary for the purpose of diminishing
the frequency and lessening the severity of the
attacks.

The bromides, like other agencies potent for good,
are also capable of doing much harm, and it is the
part of the intelligent therapeutist to avail himself
of the one influence and to avoid the other. The
bromides are serviceable, especially in the treatment
of major epilepsy, and they exert little or no good
effect on the course of minor epilepsy. Even in
cases in which they do good, the bromides sometimes
lose their effect, after a time, and it has been found
that a combination of two or more bromides is at
times more useful than one alone. Moreover, a
change in the drug employed is often sufficient to
continue a good effect once begun. It is, therefore,
advantageous to have at command as large a variety
of efficacious agents as possible. Distinct advan-
tages are claimed for the several bromides with re-
spect to solubility, tolerance on the part of the
stomach, amount of combined bromine, hypnotic
effect, and influence on reflex activity. The potas-
sium-salt is, perhaps, the one most commonly em-
ploved, but the sodium salt is more soluble, less
irritating, and less depressing to the heart. These ad-
vantages of the sodium salt are shared also by the
strontium salt, which has at times proved more suc-
cessful therapeutically than the former.

For the purpose of testing the comparative use-
fulness of strontium bromide. Dr. J. M. Bennion
{Lancet, January 5, 1907, p. 19) administered this
drug in doses of thirty grains in an ounce of water
thrice daily to twelve male and ten female insane
patients suffering from epileptic seizures, all other
conditions remaining as they had been previously.
It was found that strontium bromide acted better in
controlling the number and the severity of the
attacks than the mixed bromides of potassium and
sodium. It rarely caused depression, and in no
instance was its use attended with a cutaneous exan-
them. The good effects appeared to be more
marked in females than in males. It is reasoned
that if such good results could be obtained under
the conditions of the test, certainly not less good
ones are possible in cases of less aggravated char-
acter.

The Economic Aspects of Bovine Tuberculosis.

Farmers as a class are certainly far from unintelli-
gent, and there is no doubt that when they shall
have been brought to realize the menace, not only
to public health but also to agricultural prosperity,
involved in a hostile, or even only an indifferent,
attitude toward the effort to exterminate tubercu-
losis in cattle, they will be only too willing to aid
those W'ho are trying so hard to convince them of
this necessity. We trust the time will soon come
when so misgtiided an exhibition of feeling as that
shown bv the meeting of Massachusetts farmers who

recently assembled in Swansea to protest in no
measured terms against the local Health Board's
recommendation that the dairy herds of the vicinity
be examined for the presence of tuberculous animals,
will l)e an impossibility. Self interest alone should
point out the wisdom of accepting, if necessary, some
immediate sacrifice in order to avoid the infinitely
greater future loss. While it is difficult to estimate
with any approach to accuracy the losses to the
farmers as a whole from a disease like tuberculosis,
concerning which the statistics are still so incom-
plete, the figures supplied by the Committee on the
Prevention of Tuberculosis of the Charity Organiza-
tion Society of the city of New York are very sug-
gestive. It is stated that there are now approxi-
mately 11,000 carcasses of beef and 65,000 carcasses
of hogs condemned each year by the Federal meat
inspectors on account of tuberculosis. One should
not be far wrong in estimating the loss on these car-
casses at present prices as $40 each on the beef and
$12 each on the pork, according to the United
States Department of Agriculture. We should
therefore have as the net annual loss from the con-
demnation of carcasses $440,000 for beef and $780,-
000 for pork, or a total of $1,220,000. This state-
ment, however, does not include the 647 parts of
beef carcasses and the 142,105 parts of hog carcasses
which it was necessary last year to condemn for the
same cause, and the approximate value of which
cannot be ascertained. In addition to the carcasses
condemned by Federal inspectors, there are a con-
siderable number condemned by State and munici-
pal inspectors. These are mostly carcasses of dairy
cattle killed in the work of suppressing tuberculosis,
or of cows no longer profitable in the dairy which
are sent for slaughter to the smaller abattoirs. The
aggregate number of these has not been ascer-
tained, but in some years it has amounted to several
thousand carcasses. The losses to the dairy indus-
try from tuberculosis have been enormous from
decrease in milk and depreciation and death of
animals. The dairy herds have been affected to a
greater extent than any others, and the infection as
a rule spread through the cows of a herd until 50
per cent, to 80 per cent, of the animals were affected.
In the early stages of the disease the product of the
cows is not visibly lessened, but as the tuberculous
process develops the animals often become feverish,
their milk is diminished in quantity, and they lose
flesh and are no longer profitable. The losses from
shrinkage of the milk and from the destruction of
so many cows must be tremendous, but they have
never been definitely determined.

The After-Tre.\tmext of C.\ses of Excision of
THE Rectum.

In a recent paper by Professor Hochenegg
(Deutsche Zeitschrift fur Chirurgie, vol. 85, 1906)
there are noted some particularly valuable sugges-
tions for overcoming the objections attendant upon
the operation of e.xcision of the rectum by the
sacral route. He thinks that the successful outcome
is more especially dependent upon the after-treat-
ment in this than in any other operative procedure.
His own experience with this operation extends
over a large number of cases, so that his advice may
be taken without hesitation. Among the first pre-
cautions to he taken with these patients is to keep
them on the side rather than on the back, and to
have the pelvis at a lower level than the trunk. This
prevents the intestinal contents or those of an abcess
from getting into the general peritoneal cavit\' in
case rupture takes place. Urinary retention after

April 13, 1907]

MEDICAL RECORD.

609

rectal operations is frequent, and in cases where the
rectum has been excised there is plenty of room for
the bladder to be distended backwards, so that the
condition may escape attention for a longer period.
The patients, of course, do not notice the distention
on account of the pain from the wound, or because
they are still under the influence of the anesthetic.
Even after the catheter has been introduced the
bladder will be found to contract \vith difficulty, so
that cystitis is frequent. The latter is favored,
moreover, bv the close proximity of the posterior
surface of the bladder to the operative wound. Sys-
tematic bacteriological examination of the urine in
these cases has shown that the wall of the bladder
may readily be penetrated by infectious material,
so that vesical sepsis is often found to be the cause
of death in these patients. Careful catheterization
should therefore constituteoneof the leading features
of the after-treatment. Great care must also be ex-
ercised in moving the bowels for the first few times,
but later on thorough evacuations must be secured
so that the general nutrition of the patients may be
improved. The results from this operation are at
best none too good, so that any suggestions of this
kind from so eminent an authority deserve careful
consideration.

Typhoid Ixoculation in the English Army.

A REPORT on the progress of typhoid inoculation in
the English army was recently made by Lieut. Col.
W. B. Leishman before the London I'athological
Society, as reported in the British Medical Journal
of March 23. The author stated that numerous vac-
cines had been prepared from typhoid bacteria killed
at different temperatures, by various chemical
agents, by desiccation, etc., and their effects tested
by measurement of the various protective substances
which developed in the blood of inoculated animals.
In several instances, where the results appeared
promising, similar tests were carried out on man.
The vaccine at present in use was described, and an
account given of the mode of preparation and stand-
ardization, which had been somewhat modified from
Sir A. E. Wright's methods in the light of the ex-
perimental work referred to. The bacteria were
still killed by heat, but the temperature had been
reduced to the minimum degree which would insure
death in one hour — 53° C. The deleterious effects
of higher temperatures had been clearly brought
out by some of the experimental work, and it was
suggested that the comparatively poor results ob-
tained in some instances in the past mav have been
due to overheating of the vaccine. The system
adopted for ascertaining the protective value of the
inoculations was then described, and the result of
the inoculation of one regiment was given. This
regiment, the only one which had been exposed to a
severe epidemic of typhoid fever since the modified
vaccine had been in use, had 147 officers and men
inoculated out of a strength of 509. They had 62
cases of typhoid infection, with 11 deaths. All of
these occurred among the uninoculated with the
exception of 2, both being men who had refused the
second inoculation : both of these men recovered.

Indications for Operation in the Presence or
Diabetic Gangrene.

From a study of the most recent literature, Klem-
perer (Therapie der Gegenzvart. Januarv, 1907)
concludes that the presence or absence of acidosis
constitutes the most valuable dififerential sign. Dia-
betic patients without acidosis are not subjects for

surgical interference if gangrene supervenes. An
expectant treatment is indicated, carefully restricted
diet, and patient waiting for the line of demarca-
tion to form. The latter process may perhaps be
hastened by the application of proper dressings and
by Bier's procedure. In diabetic subjects who pre-
sent no acidosis, but have a marked albuminuria or
signs of granular atrophy, a high amputation should
be undertaken as soon as possible after evidences of
gangrene appear. Where acidosis is present the
patients are likewise to be immediately operated on,
as they are otherwise sure to succumb. It is im-
material whether the acidosis was already present
or did not appear until after the introduction of a
diet free from carbohydrates and a high amputation
must be done, even when the original focus is very
small.

The Dangers of Elixirs.

Simple elixir, so called, has been adopted as a com-
mon vehicle in prescriptions intended for children,
yet it is probable that but few physicians realize
that this elixir contains a considerable proportion
of alcohol which under other circumstances they
would hesitate to administer. It remains for a.
pharmacist to call attention to this fact, and to show
that the ordinary doses of the preparation may be
productive of considerable harm in those of tender
years. Mr. E. F. Heffner, in a paper read at the
twenty-ninth annual meeting of the Pennsylvania
Pharmaceutical Association, cited a number of com-
mon prescriptions in which this might occur. Thus
sodium bromide is very often administered in the
proportion of one grain to the teaspoonful of simple
elixir, every hour or half hour, which means that
the child, often less than a year old, is getting about
a quarter of a teaspoonful of alcohol at every dose,
or the equivalent of two teaspoonfuls of wine or
over half a teaspoonful of whisky or brandy. In
older children correspondingly larger doses are
given, which are not only harmful in themselves,
but also counteract the sedative effects of the bro-
mide. Another common prescription contains chlo-
ral and bromides in simple elixir, which makes a
bright, clear, and palatable solution. But the fact
is overlooked that there is a chemical incompatabil-
ity of chloral and alkaline bromides in alcoholic
solution, for on standing the chloral alcoholate will
come to the top in a clear layer of about the same
color as the rest of the mixture. LTnless shaken,
the patient is likely to get all the chloral in one dose.
These examples need no comment, for the danger-
ous effect of alcohol in children is of common
knowledge, but as HefTner truly states, it is well
that the prescribing mind be occasionally refreshed
in cases of this kind. In order to avoid any possible
danger he advises the use of an aromatic water and
simple syrup as a vehicle in prescriptions of this
nature.

^tms of tlyp Bpfk.

The United States Civil Service Commission
announces an examination on June 13-14, 1907-
to secure eligibles from which to make certifica-
tion to fill at least five vacancies in the position
of medical interne (male), at $600 per annum
each, with maintenance, in the Government Hos-
pital for the Insane, Washington, D. C, and va-
cancies as they may occur in any branch of the
service requiring similar qualifications. The de-
partment states that it reserves the right to con-
tinue or terminate appointment at the end of one

6io

MEDICAL RECORD.

[April 13, 1907

year, or to promote the appointee at the expira-
tion of that length of service. The examination
will consist of the following subjects, weighted as
indicated : Letter-writing, 5 ; anatomy and physi-
ology, 15; chemistry, materia medica, and thera-
peutics, 10; surgery and surgical pathology, 20;
general pathology and practice, 25 ; bacteriology
and hygiene, 10; obstetrics and gynecology, 15.
Two days will be required for this examination.
Men only will be admitted. Age limit, 20 years
or over on the date of the examination ; candi-
dates must be graduates of reputable medical col-
leges. This examination is open to all citizens of
the United States who comply with the require-
ments. Intending candidates should at once apply
to the United States Civil Service Commission,
Washington. D. C, for application form 1312.

Conference of the Illinois State Board of Health
with the Officers of Medical Societies of the State
of Illinois. — This conference was held in Chicago,
April 5. Methods looking toward improvement
of the public health, the advancement of medical
education, the advancement of the interests of
legally qualified physicians in the State, were
considered. Committees on the following sub-
jects were appointed : Reciprocity, Medical Edu-
cation in Illinois, Relation of the State Board of
Health to Local Health Boards ; Examination of
Candidates and the Method Pursued in Connec-
tion with the Adininistration of the Medical Prac-
tice Act in the Case of Unlicensed Practitioners ;
To Promote Cooperation Between State Medical
Societies and the State Board of Health ; Ct)opera-
tion Between the Four Schools of ^ledicine. The
conference adjourned to meet again April 24, at
which time the chairmen of these committees
will submit their reports for discussion and rati-
fication or rejection.

Pennsylvania State Hospital for the Criminal
Insane. — Plans are under consideration for a new
State Hospital for the Insane in Pennsylvania,
and options have been obtained upon several hun-
dred acres of land adjoining the site of 600 acres
presented to the State by the Delaware and Hud-
son Railroad. The sum of $150,000 is to be ap-
propriated by the Legislature for the erection of
an administration building, which will contain
the offices and quarters for the executive officers
and accommodations for probably 100 patients. It
is the intention of the commission having the
matter in charge to btiild an institution capable of
accommodating 1,000 patients at a cost likely to
be more than $1,000,000. The New York State
Hospital for the Criminal Insane at Matteawan
is to be taken as a model, and such improvements
will be made as have been found desirable since
the building for that institution was constructed.

A New Milk Commission. — A commission con-
sisting of five members has been appointed by
!Mayor McClellan to consider the advisability of
rendering pasteurization of all or a part of the
city's milk supply compulsory. The commission
is to investigate the entire subject of the milk
supply and make recommendations in regard to
whatever measures seem necessary to insure its
purity. The commission has the following mem-
bers : Dr. Joseph D. Brj-ant, Dr. T. Mitchell
Prudden, Dr. Rowland G. Freeman, Dr. L.
Emmett Holt, Dr. Abraham Tacobi.

The XVIth International Medical Congress. —
At the last International Medical Congress held
in Lisbon, Budapest was selected as the next
place of assembly, and the preliminaries are

already in progress. His Majesty the King has
assumed the patronage of the congress, and the
State and the municipality have each contributed
the sum of 100,000 crowns to defray the expenses.
Numerous committees and subcommittees have
already been appointed, and it has been decided
to have twenty-one sections to the congress. The
date of opening has been fixed for August 29,
1909, and the sessions will be continued until
September 4. The first circular, which will con-
tain much information in regard to details, as well
as the statutes, will be ready for distribution in
the course of this year. The President of the
Congress is Professor Caiman Miiller, and the
General Secretary, Professor Emil Grosz, an-
nounces his readiness to give information to in-
quirers. His address is Budapest, Hungary, VIII.
Esterhazy-utcza 7.

Mexican Medical Congress. — The Medical So-
ciety Pedro Escobedo of Mexico is organizing its
second biennial congress to be held in Mexico
City, May 28, 29, 30, and 31. President Diaz i3
honorary president and will open the congress.
The president of the society is Dr. Lopez Her-
mosa, and the secretary is Dr. Enrique Aragon.
There will be eleven sections, each comprising
two special subjects.

The XLVth International Congress of Hygiene
and Demography. — Those in charge of this con-
gress, which is to be held in Berlin, September 23
to 29, have decided to make a special effort to
render it possible for those who take part in the
congress to see as much as possible of the various
public institutions of Berlin and its suburbs.
Accordingly, the scientific sessions will always be
over by two o'clock, in order to leave the after-
noons free for sightseeing. A list of one hundred
institutions has been prepared, which may be vis-
ited either informally or in groups under the guid-
ance of a qualified authority. A guide book in
three languages has also been composed which
contains short descriptions of all these institu-
tions.

The Xllth Congress of the German Gyneco-
logical Society. — At the congress of this Society
to be held in Dresden, May 21 to 25, the follow-
ing have been selected as topics for general dis-
cussion: I. "The Indications, Technique, and
Results of Operations Increasing the Size of the
Pelvic Outlet ;" 2. "Asepsis in Gynecological
Operations ;" 3. "The Midwife Question."

The Second International Congress of Physio-
therapy will be held in Rome, Italy, on October
13^ I4.- 15- ^nd 16, 1907, under the presidency of
Prof. Guido Baccelli. The general secretary
is Prof. Carlo Colombo, Via Plinio, i,
Rome. The officers of the American Committee
have been appointed as follows : President, Dr.
Francis B. Bishop of Washington, D. C. ; Secretary,
Dr. Wm. Benham Snow of tliis city : Treasurer, Dr.
Albert C. Geyser of this city. A special committee
has also been appointed as follows: Dr. Fred H.
Morse, mechanotherapy ; Dr. ^Margaret A. Cleaves,
phototherapy : Dr. Geo. C. Johnston, radiography ;
Dr. Wm. tames ^Morton, radiumtherapy : Dr. Mor-
ris W. Brinkman, rhythmotherapy : Dr. Chas. Deni-
son, climatology ; Dr. G. Betton Massey, massive
cataphoresis ; Dr. David E. Hogg, thermotherapy ;
Dr. Edward C. Titus, electrotherapy.

Mortality in Chicago. — According to the
weekly bulletin of the Chicago Health Depart-
ment, during the week ended March 30. 744
deaths were reported, equivalent to an annual

April 13, 1907]

MEDICAL RECORD.

611

death-rate per 1,000 of 18.40. The death-rate for
the corresponding week of 1906 was 14.80 per
1,000. Pneumonia caused 172 deaths; consump-
tion, 85 ; heart disease, 55 ; nephritis, 45 ; violence,
including suicide, 40; cancer, 34, and acute intes-
tinal diseases, 30.

Mount Sinai Hospital. — A considerable number
of adjunct physicians and surgeons will soon be
added to the visiting staff of Mount Sinai Hos-
pital. The new appointees will rank as assistants
to the present adjunct attending staff. The ap-
pointments to be made will increase the visiting
staff of the hospital by seventeen men, and will
aft'ect the following departments : general medir
cine, general surgery, gynecology, genitourinary
surgery, otology and ophthalmology, pediatrics,
neurology, and dermatology.

Osteopathy Bill. — An amendment to the oste-
opathy bill has been adopted by the Assembly at
Albany, providing that osteopaths otherwise eli-
gible under the Whitney bill shall pass an exami-
nation in surgery before being allowed to practice
surgery.

The City of Montreal, owing, it is' alleged, to
the expense, has decided to discontinue its med-
ical inspection of the pupils in the public schools.

A New System of Identification. — Dr. Prager,
an Austrian army surgeon, who has made a spe-
cial study of the physical characteristics that may
be used as means of identification, suggests a
system based on variations in the conformation of
the palate. He maintains that this method can
be used more effectively than that founded on the
finger-print principle.

Fire at McGill University. — The MacDonald
engineering building of McGill University, Mon-
treal, which was erected about fifteen years ago
at a cost of $500,000, was completely destroyed by
fire on April 5. The building was equipped with
numerous laboratories containing much expensive'
apparatus, and the loss is estimated at $750,000.
The cause of the fire has not been determined.

Porto Rico Tuberculosis Sanatorium. — The
San Juan Tuberculosis Sanatorium, the establish-
ment of which is due to the exertions of the Anti-
Tuberculosis League of Porto Rico, was dedicated
on April 5 by Governor Winthrop. The league,
which raised the money necessary to carry out
the project was organized in March of last year.
The municipality of San Juan appropriated $2,000
for the purchase of a site, and with this money
twenty acres of high ground, overlooking the sea,
near San Juan, was bought. The sanatorium was
then erected with money raised by means of enter-
tainments and private subscriptions. The insular
government will contribute $300 a month and the
city of San Juan $200 a month toward its main-
tenance, besides which a number of private dona-
tions have been promised.

Lord Lister's Birthday. — Lord Lister on April
5 celebrated his eightieth birthday and was the re-
cipient of an immense number of messages of con-
gratulation from all over the world. This is also
almost the fortieth anniversary of antisepsis, for the
first of Lister's publications on the subject appeared
in the Lancet of March 16, 1867, with the title : "On
a New Method of Treating Compound Fracture.
Abscess, etc. Observations on the Conditions of
Suppuration. By Joseph Lister, Esq., F. R. S., Pro-
fessor of Surgery in the LTniversity of Glasgow."

Christian Science in Delaware. — Governor Lea
of Delaware has signed the bill directed against the
practice of Christian Science in that State. The new

law prohibits healers of this sect from giving treat-
ment for any compensation, gift, or reward. State
Senator Dr. Thomas C. Moore of Smyrna was
largely instrumental in securing the passage of the
bill.

Nicotine-free Tobacco. — Numerous so-called
nicotine-free brands of tobacco have been offered
for sale from time to time, but these products do not
seem to have become very popular. Now the
French government, which controls as a monopoly
the manufacture of tobacco in France, has put on
the market a variety of caporal, the tobacco most
used, said to have been deprived of its nicotine. To
strengthen this assertion, it is stated that whereas
rabbits into whose ear veins infusion of ordinary
caporal was repeatedly injected, developed the le-
sions in the aorta resembling arteriosclerosis which
have already been studied by experimenters, other
rabbits treated in the same way with the nicotineless
tobacco remained alive for months, and when killed
were found to have healthy aortas.

Meningitis. — Cerebrospinal meningitis is be-
ginning to appear again in some of the Prussian
provinces and in Poland.

Foreign Physicians in France. — The regula-
tions governing the practice of medicine by for-
eigners in France have recently been modified so
that conditions are made easier for alien practi-
tioners. From now on, physicians and students
of medicine who' have qualified for the final exam-
inations in their own countries, if they intend to
become naturalized, will be accorded the French
degree of Doctor of Medicine on passing not more
than three examinations, provided that they
already possess the bachelor's degree or one
equivalent to it.

Smallpox in Africa. — It is reported that small-
pox has become epidemic in the German posses-
sions in Kameroon, and the health authorities are
making an effort to vaccinate the entire native
and foreign population.

Industrial Dusts. — The American Institute of
Social Service has received from Dr. Sommerfeld
of Berlin a valuable antitubercidosis exhibit for
the department of industrial h3'giene in its Mu-
seum of Security. There are forty-five specimens
of dift'erent kinds of dust, mineral, animal,
and vegetable, produced in various indus-
tries, and likely to be inhaled by workmen. The
same number of photographs show the microsco-
pical characteristics of these various dusts. Mod-
els in wax represent human lungs as they are
aff'ected by occupational dusts ; other models show
normal lungs for comparison, while still others
show the effects of industrial poisons on the sys-
tem. An advisory committee of the editors of the
great technical papers has been organized to
cooperate with the Institute in the work of pro-
tecting life and limb in industrial workers.

Race Suicide in Germany. — The statistics of the
German Imperial Census Bureau relating to the
births and deaths of the year 1904, which have
just been published, show that the fecundity of
married couples, which up to the year 1903 had
been gradually declining, was slowly rising
again.

The City of Diisseldorf, Germany, has granted
a building site on which a local organization of
women is to erect a building to serve as a training
school for nurses in which young women from
any part of the empire will be given free instruc-

6i-

MEDICAL RECORD.

[April 13, 1907

Gift to Syracuse Hospital. — Mrs. Russell Sage
has presented $5,000 to the Woman's Auxiliary
of the Hospital of the Good Shepherd of Syra-
cuse, X. Y., toward the $10,000 endowment fund
for a free bed in that institution.

Bequests to Charities and Hospitals. — The will
of the late William C. Egleston of this city, who
died on March 25, filed for probate last week,
contains charitable and educational bequests
amounting to $275,000, of which Yale University
and St. Luke's Hospital will each receive $100,-
000. The bequest to St. Luke's Hospital is to be
used in endowing as many free beds, both adult
and children's, as possible, these to be known as
the "William C. and Ella Egleston beds," in
memory of the testator and his wife. The other
charitable bequests include $20,000 to the Sister-
hood of St. Mary's Society of this city, to be
devoted to the uses of St. Mary's Free Hospital
for Children, in memory of the dead children of
the testator. Louise and Adelaide Egleston. The
New York Institution for the Blind will receive
$15,000 under the will, and the New York Institu-
tion for the Instruction of the Deaf and Dumb
$15,000.

Daniel Shechan, who died in St. Vincent's
Hospital on March 20 last, leaves $500 each to
Sister Benign of St. Vincent's Hospital, to the
Superior of the Little Sisters of the Poor of New
York, to the Superior of the House of the Good
Shepherd, to the Superior of the House of the
Holy Family, to the president of the Mission of
the Immaculate Virgin, to the Superior of St.
Joseph's Hospital, the Bronx ; to the Superior of
the Foundling Hospital, East Sixty-eighth street ;
to the Mother Superior of the Dominican Convent
of L'ur Lad}' of the Rosary, and to the Superior
of the Catholic Hospital for Consumptives at
Spuyten Duyvil.

Mount of Olives Hospital. — The foundation
stone of the new German hospital on the Mount
of Olives was laid April i in the presence of
the Governor of Jerusalem, the other local offi-
cials, and many spectators. The land was given
by Emperor \\'illiam, and he was officially repre-
sented at the ceremonies.

Iowa City Homeopathic Society. — On March
28 this Society was organized and Dr. Leora
Johnson elected president and Dr. T. R. Hazard
secretary.

Boston Society of Examining Physicians and
Surgeons. — At a meeting held on April 3 this
Society was organized and officers were elected as
follows : President, Dr. Francis D. Donoghue ;
First J 'ice-President, Dr. Frank E. Allard ; Second
J'icc-Prcsidciit. Dr. Edward M. Greene; Secretary,
Dr. Charles T. Cutting; Treasurer, Dr. Oiarles O.
Kepler. There will be three meetings a year, and
all physicians and surgeons in good standing who
examine regularly for some association or corpora-
tion are eligible for membership.

Hardin County (la.) Medical Association. — At
it? annual meeting held in Eldora on ]\Iarch 29 the
following officers were elected for the ensuing year :
President, Dr. J. J. Miller of Ackley ; Vice-Presi-
dent, Dr. C. O. Mabie of New Providence; Secre-
tary, Dr. W. E. Whitney of Eldora ; Treasurer, Dr.
R. Thornton of Ackley.

For a Button Memorial. — A movement is on
foot in England to collect a fund of $50,000 to
endow a Dutton Memorial Research Professorship
in tropical diseases in honor of Dr. Joseph Everett
Dutton, the discoverer of the Trypanosoma gam-

biense. He died of tick fever in Kasongo at the age
of twenty-nine years, while a member of a commis-
sion investigating this disease.

The Graduate Mediczd School of Cincinnati
opens for the first time this spring. The teaching
force is the faculty of the Medical College of Ohio,
the Medical Department of the University of Cin-
cinnati, with which it is connected.

The Late Dr. George Bingham Fowler. — At
the stated meeting of the Medical Society of the
County of New York, held Monday, March 25,
1907, the following preamble and resolution was
unanimously adopted : Whereas, Death has re-
moved from us one of our ex-presidents, Dr. George
Bingham Fowler, a distinguished and respected
member of this Society ; therefore, be it Resolved,
That we deeply regret the loss we have sustained,
not only in our individual relations to him, but also
in the various public and consulting positions which
he held, and be it further Resolved, That we extend
our deepest sympathy to the bereaved family of the
deceased, and that a copy of these resolutions be
spread in full upon the minutes of the Society and
be published in the medical papers. (Signed) Wen-
dell C. Phillips. Edward D. Fisher, Charles N.
Dowd, Committee.

Obituary Notes. — Dr. M. A. Sheffield of St.
John, N. B.. died suddenly of heart disease on
March 30. He was born in Cornwallis, N. S., in
1837, and received his medical education in the
Bellevue Hospital iMedical School. For five years
he practised in Berwick, but in 1872 removed to St.
John, where he had since resided.

Dr. J. N. Knight of Cliftondale, Mass., died on
March 30 after an illness of about a year's duration.
He was born in Salem in 1862, and was graduated
from the medical department of Boston University
in 1883. Shortly after graduating he settled in Clif-
tondale. and had practised there ever since.

Dr. William D. McCarthy of San Francisco,
Cal., died on March 14 after a long illness conse-
quent on service in the Philippines during the Span-
ish-American War. Dr. McCarthy was born in
Boston in 1861, and, after receiving his preliminary
education in St. Mary's College, was graduated from
Cooper Medical College in the class of 1885. At
the opening of the Spanish-.American War he en-
listed in the First California \^olunteers, and served
as surgeon in the Philippines until the regiment was
recalled two years later.

Dr. Edward L. C.-vrpexter of Louisville, Ky.,
died on March 24. at the age of forty-one years. He
was the son of the late Dr. L. ^I. Carpenter of
Louisville, and received his medical education in the
I'niversitv of Louisville.

Dr. Albert M. Warner of Waukesha, Wis., died
on March 16, at the age of ninety-one years. He
was born at Andover, Vt., and was graduated from
the Vermont Medical College at Woodstock in 1842.
After practising for a time in New York State, he
removed to \\'aukesha in 1845, a"d had resided there
until about three years ago, when he went to live
with a daughter in Chicago.

Dr. A. C. SiMONTON of Seattle. Wash., died on
March 27. at the age of sixty-five years, after a long
illness. He had practised for many years in Des
Moines. la., but eight years ago removed to Roslyn,
where he was one of the surgeons at the Northern
Pacific mines.

Dr. Charles Fr.^ncis Reilly of Woonsocket,
Mass., died on March 31 of heart disease. He was
born in Blackstone in 1872. and received his medical
degree from the College of Physicians and Surgeons
in Baltimore in the class of 1902. After his gradua-

April 13, 1907]

MEDICAL RECORD.

613

tion he practised for a time in Everett, Alass.,
and Millville. About a year ago he removed to
Woonsocket.

Dr. Harry E. Burdett of St. Paul, Minn., died
of heart disease on March 28 at tlie age of forty-
five years. He was a native of Belleville, Ont., but
had practised in St. Paul for over twenty years.

Dr. J. N. Taylor of Lynchburg, Tenn., died sud-
denly on March 29, at the age of seventy years. He
had served with distinction in the Confederate Arm>
and had practised for over thirty years in Lynch-
burg.

Dr. John M. Winfree of Richmond, Va., died on
March 31 at Raleigh. N. C, after a long illness. He
was graduated from the Medical College of Virginia
some years ago, and at once began to practise in
Richmond, but in 1905 was obliged to give up active
work on account of ill health.

Dr. J. P. Crawford of Davenport, la., died on
March 25, at the age of fifty-one years. He was
prominent in medical circles, and was for many
years surgeon for the Chicago, Milwaukee and St.
Paul Railroad Company.

Dr. Clarence E. A. Buckley of Halifax, N. S..
died on March 28, at the age of twenty-five years.
He was a son of Dr. H. F. Buckley of Halifax, and
was graduated from Dalhousie Medical School in
1904. He practised in Thorburn until about a year
ago, when forced to give up active work on account
of illness.

Dr. James S. O'Sullivan of Randolph, Mass.,
died on March 25 of pneumonia, at the age of forty-
two years. He was a native of ^^'orcester, gradu-
ating from Holy Cross College, and later from Har-
vard Medical School. He practised for a time in
West Quincy, but for the past eight years had been
a resident of Randolph.

Dr. Fr-IiNK Swartzlander died at Doylestown,
Pa., on March 31, at the age of sixty- four years.
He was graduated from the Medical Department of
the University of Pennsylvania in the class of 1863.
During the Civil War he was assigned to the Mili-
tary Hospital in Philadelphia, and later to the
Seventy-fourth Pennsylvania Volunteers. At the
battle of Gettysburg he was surgeon of the operating
staff of the field hospital of the Eleventh Army
Corps. Later he was assigned to join Sherman in
his march to the sea, meeting the army at Savannah,
where he was placed in charge of the auxiliary mili-
tary hospital. He remained in the hospital service
until the end of the war.

Dr. Ashbell P. Grinnell of this city died on
April 6 after a long illness, the immediate cause of
his death being septic endocarditis. Dr. Grinnell
was graduated from the Bellevue Hospital Medical
School in 1869. and was for years Dean of the ]\Ied-
ical College of the LIniversity of Vermont. Of late
years he had interested himself in forensic medicine,
and at the time of his death he was vice-president
of the Medico-Legal Society.

Dr. George R. Shepherd of Hartford, Conn.,
died on April 6. at the age of sixty-two years. He
was graduated from Yale Medical School in 1866
and was Medical Director of the Connecticut Mutual
Life Insurance Company.

Alcohol in Diabetes. — Benedikt and Torok in the
course of investigations on the role of the fats in the
formation of the acetone bodies in diabetes studied
the effect of alcohol in this disease. They found that
on adding about three ounces a day of brandy to the
dietary a marked diminution in the amount of acetone
bodies resuhed, Thev conckide that alcohol is useful
because it reduces the susar excretion and saves al-
bumin.— Zeitschrift f. klin. Medisin.

THE VENEREAL PERIL.

A POSSIBLE STEP TOWARD ITS REMOVAL.

To THE Editor of the Medical Record :

Sir: — "For the safety of the public," is a cry often heard
to-day, and truly much is being done in many directions for
the betterment of conditions generally. The various boards
of health throughout the country have accomplished a
great deal by their vigorous lighting to lessen and keep
down the spread of tuberculosis, and hope eventually to
eliminate that dread disease entirely. The same boards
have dealt admirably with many other forms of disease
and conditions that have proved a menace to the public
health, so that to-day we stand protected, or nearly so,
from many of the commoner forms of contagion and infec-
tion. There is, however, one subject that has been over-
looked, apparently, or possibly it has presented itself, or
been presented for consideration, but because of its nature,
which necessarily involves much deep thought and atten-
tion, it has been impossible for the several boards or com-
missions of public health to agree upon a suitable course to
pursue, and which, in the meantime, has been allowed to
run riot. The condition to which I refer is the venereal
peril.

When we stop to consider the awful ravages that are
continually presenting themselves as a result of infection
from gonorrhea or syphilis, the thought — How can we
prevent a furtherance of these conditions? — is very apt to
arise. The profession is only too well acquainted with the
existing state of affairs, but the laity, who know little or
nothing of the nature or manner in which these dread dis-
eases are spread — in fact, who are thoroughly ignorant of
the awful suffering extant as a result of infection by one
or the other condition — are the ones who should in some
way be enlightened and thereby better protected. The par-
ent who, because of a sense of what he or she may consider
modesty, hesitates to speak to the budding youth or maid
on a subject that seems too delicate and complex for the
presumably tender and sensitive mind to grasp, is guilty of
gross negligence and such neglect on the part of parents
who are at all aware of the existence of present conditions
15. in my mind, almost criminal. Often the parent hesi-
tates to speak on the subject because of insufficient knowl-
edge, and just here is where the public health commission
can begin a most magnificent work. But little or no atten-
tioii is given — certainly not the proper attention— and why?
Is it_ because the subject, being of the nature that it is, is
considered indecent and not fit for public discussion ?
Should modesty of speech be permitted to stand in the
way of the safety of the public health ? It is a duty that we
(the profession) owe, as protectors of the health and well-
being of the community, of the world at large, to see that
!>roper means are taken to obliterate this appalling condition
which now exists. Shall the younger generation and those
to follow continue to become the innocent recipients of
these frightful contaminations, and all simply because of
the fact that the public is not sufficiently enlightened?
Sornething rnust be done and that promptly or the untold
sufferings will continue and increase until they shall have
reached a stage where it will be almost impossible to oft'er
relief.

If the young man or young woman arriving at a time
or age when the sexual appetite begins to make demands on
the mental proclivities for satisfaction, were sufficiently well
informed and apprised of the possible dangers concomitant
with a general disregard for virtue and morality, how much
good would result. How many young women would be
saved from the tortures of an infected uterus, pus tubes,
and inflamed ovaries. How many infants would be spared
the agonies of an ophthalmia or the sufferin.g? that follow
an inherited syphilis.

.A-S a step toward obliterating all this I would suggest
and recommend a graded system of lectures to be dehvered
to the children of our public schools and institutions as a
part of the regular curriculum, beginning with children of
an age or sufficiently advanced to understand the principles
of contagion and infection. Pamphlets dealing with the
subject could also be supplied by health officers to parents
for home instruction. Special lectures could be arranged
for older boys and girls and men and women, and still
others for the unfortunates who have suffered and are now
in the throes and who, learning of the enormity of the
affair, would prove a factor in controlling the spread of
the peril. Much can be done by the health boards in pass-
ing amendments to the law, compelling the removal from
public use of the cigar cutter, drinking cup, etc., and also in

6i4

MEDICAL RECORD.

[April 13, 1907

insisting that all restaurants and hotels, even the inferior ones,
of course, boil and properly disinfect all towels, linen, nap-
kins, etc., in public use

The subject, you will admit, is an all-important one and
worthy of serious consideration. Much more can, and
doubtless will, be said on the subject, but the time is now
ripe-, and quick and strong action should be taken in an
effort to crush this death-dealing monster that pollutes the
race. W. A. Funk, M.D.,

Assistant Clinici.in, Dermatological Department or

THE New York University and Bellevue Hospital

Medical College Clinic.
East Orange, N. J.

THE FRESH AIR TREATMENT OF PNEUMONIA.

To the Editor of the Medical Record :

Sir: — Our medical papers are of late advocating a new
treatment of pneumonia, namely, the fresh or cold air treat-
ment, representing this treatment as a rather new way
of dealing with this disease. In this case, as in a good
many others, history repeats itself.

I cite Juergensen in Ziemssen's Handbook of Special
Pathology and Therapeutics, Leipsic, 1877, page 174, trans-
lated from the German edition : "A pneumonic patient
above all needs fresh air. If we can procure air without
producing a draught, so much the better ; but if we have
to choose between foul air and draught, let us choose the
draught and our patients will do well. Even if we let them
take a bath under these conditions, and their wet skin is
exposed to the draught, there is no danger. Very often
we have removed a pane of glass from a window, or even
the whole window, to let in fresh air, and we never have ob-
served complications, such as bronchitis, pleurisy, and peri-
carditis ; and we have never noticed a bad effect in the
sequels of pneumonia, such as chronic pneumonia, phthisis,
and so on. We would therefore not hesitate to expose our
patients to the air until the temperature goes down, if we
thought that the temperature should be reduced and cold
baths could not be used."

Juergensen, by the way, also recommends cold baths for
the treatment of pneumonia.

.'Vrthur Stern, M.D.

Elizabeth, N. J.

ESPERANTO.

To the Editor of the Medical Record :

Sir: — Your remarks in the Medical Record of March
30 relating to the pronunciation of Esperanto are apt to be
misunderstood and so create the impression as though
Esperanto were pronounced so diversely by the different
nations that they hardly understand one another. I would
ask you, therefore, to allow me space in your valuable
paper for a reply obviating this impression. There is no
natural language which is pronounced precisely alike every-
where in its own country. The university professor born
in Leipzig pronounces the German differently from the
professor born in Berlin, the latter differently from the one
born in Munich. The English of a Bostonian college grad-
uate sounds differently from the English of a New York
college graduate. Something similar is true of the French
language, etc. Now let me tell your readers that the dif-
ferences in pronunciation of Esperanto are much slighter
than those met with in any living natural language. I can
make this assertion from my own experience and investi-
gations, as well as from the facts brought out at the two
international congresses of Esperantists. At the Boulogne
congress in August-September, 1905, 1,200 delegates from
twenty-two different countries were assembled. Many of
them spoke Esperanto without the slightest difficulty in
understanding one another. At the second congress in
Geneva in August-September. 1906, twenty-three countries
were represented. Many of the delegates of different na-
tionalities conversed in the new language so freely and
easily and with such fluency and- even loquacity that the un-
initiated gained the impression they were speaking their
mother tongue. Differences in pronunciation noticeable at
the first congress to the trained ear of the student of the
subject of pronunciation were much less noticeable at the
second congress.

Just because the pronunciation of Esperanto is extremely
simple, the first manuals of the language paid little attention
to it, and were rather careless in its exposition. Noticing
this, I made careful observations of the existing differences
and investigated specially the pronunciation by discussion
with a European Esperantist living in the United States,

but having learned the language in Europe, and who had
known and spoken with its inventor; further, by extensive
correspondence with the most prominent European Esper-
anto authorities, including the ingenious creator of Esper-
anto, Dr. L. Zormenhof. The result of my investigations is
laid down in my text book.

Up to the present time Dr. Zamenhof is the recognized
incontcstible, official authority in everything pertaining to
Esperanto, and no author of a text book has contradicted
him m matters about which he was explicit. Neither am
I at variance with the illustrious inventor of the new lan-
guage. The passage in my book which seemed to you to
contradict Dr. Zamenhof on the contrary shows expressly
that he teaches the same pronunciation of a certain diph-
thong as I do, only that the inference which he, in one of
his letters to me, made from this pronunciation was "un-
intelligible" to me.

The differences in the pronunciation of Esperanto are
gradually disappearing, since the Esperanto authorities have
begun to pay more attention to pronunciation. But even if
they were never to disappear, they are, as stated above, of
such a slight degree that they would never disparage the
language or even cause it to undergo the same fate as
Volapiik. Dr. Max Talmf.y.

62 West I26th Street.

OUR LONDON LETTER.
(From Our Special Correspondent.)

INSANITY — CH-iXURL^ — KING EDWARd'S HOSPITAL FUND — IN-
CORPORATION OF king's college WITH UNIVEESITV —
Or;ITUARV.

London, March 2 a, igo?.
Insanity has been prominently before the profession and
the public during the last few days. The most important
contribution to the subject is the course of Lumleian lec-
tures at the Royal College of Physicians by Dr. Geo. H.
Savage. He opened with a naive confession of pride at his
selection, followed by doubt about his subject, and then
a dread of failure. But his life's work indicated to him
something connected with insanity and though the field had
been partly occupied he happily decided that he might add
something from his own special experience. He has thus
given us interesting food for thought. Admitting a con-
siderable increase of the insane, he has no dread of the
future of the race and he endeavored to show that much
insanity does not depend on material brain disease, but has
reference to the complexity of society and the numerous
social misfits which occur, many persons being treated as
insane because they are out of harmony with their sur-
roundings. He proposed no fresh classification, holding
with Hughlings Jackson that alienists are more like mar-
ket gardeners than botanists — have groups for convenience,
but no natural orders. Unsoundness of mind often oc-
curred without anything that could be called insanity aris-
ing. The medical man looked for brain change, the lawyer
for responsibility, society considered only whether a per-
son was a danger to himself or others. There could,
therefore, be no common pathological basis for the various
classes, and the lecturer maintained that there are many
cases in which there is no ground for suspecting any ma-
terial change in the nervous system. Insanity was not a
definite disease, but a negation. There was no fixed stand-
ard of sanity, and insanity was often a question of degree.
Normal feelings might pass into delusions, and Dr. Savage
did not expect to find a seat in the brain for such ideas. He
accepted what Hughlings Jackson had written in his "Fac-
tors of Insanity" as to the removal of the higher spheres
of control and letting loose the lower. Referring then to
some typical forms, the lecturer said we may have men-
tal disorder marked chiefly by loss of this higher control,
varying in degree from hysteria to acute mania ; parallel
to this, delirium from toxic agents may be noted, showing
hallucinations of the senses. Melancholia ranges from hy-
pochondriacal self-consciousness to profound stupor. This
seems increasing, as does dementia, general paralysis, and
senile disorders. Dr. Savage believes there is an increase
among the simply neurotic, that neurasthenia is also on the
increase, and such conditions are at the root of a large
number of cases of delusional insanity, chronic recurrent
insanity, and paranoiac insanity, which fill our asylums.

In his second lecture Dr. Savage dealt with heredity,
combating the common idea that insanity of all forms
was inherited. Consanguineous marriages were not dan-
gerous from merely near kinship and the old idea that the
deaf and dumb or weak minded owed their infirmity to
marriages of cousins had not been confirmed. There was
indeed a tolerably definite neurotic stock or t>"pe. but in

April 13, 1907]

MEDICAL RECORD.

615

his opinion insanity as such was not transmitted. Still, in
the insane there was a strong tendency to produce off-
spring who were unduly unstable. But insanity, like genius
and all highly specialized mental capacities, tended to extinc-
tion or to nervous instability in the following generations.
Great inventors, millionaires, and persons of exceptional
genius all ran a great risk of having degenerate children. The
general tendency of highly gifted parents was either to
have no children or to have neurotic offspring. So said Dr.
Savage, but the impressions left by reading many biog-
raphies seems a different one, though of course such im-
pressions are not to be trusted. The lecturer next remarked
that tricks or habits often reappeared in children — even
the handwriting of children frequently resembled that of
their parents, though here again I might interpolate a doubt
as to the cause assigned, for a child often learned from its
father or mother, or if not so taught might delight in
imitating a parent's rather than a tutor's writing. This imi-
tative disposition seemed to be recognized, if unconsciously,
in Dr. Savage's next point, the great danger of association
of an insane parent with a child. He had known children
living with an insane parent to develop the same or similar
delusions. The insane or highly neurotic parent tended to
pass on, if anything, special forms of insanity, which might
be called habit insanities and a tendency to break down
at certain epochs of life, making them incapable of bearing
normal physiological stress. But with that there was an
extraordinary power of recovery, so that patients of a
highly neurotic stock might have dozens of attacks of vio-
lent mania and retain till the end of a long life mental
ability. The conclusion was that there was no such thing
as transmission of any form of insanity direct, but there
was a danger of the passing on of a nervous instability
which led to mental disorder resulting from slight or even
normal physiological strain.

On Tuesday a paper was read at the Royal Statistical
Society by j\lr. Noel A. Humphreys, dealing with the "al-
leged increase of insanity." In his opinion no proof what-
ever had been advanced of such increase. He pointed
out the fallacy of regarding the number of certified and
registered cases as .x proof of increasing prevalence. There
was a reserve of mental unsoundness outside the control of
the lunacy commissioners, though that had been declining
of late owing to greater accuracy of registration and
changes in the degree of insanity for which asylum treat-
ment was deemed desirable. Moreover, people appreciated
the improvement effected by asylum treatment and were
less desirous of resuming personal care of discharged cases.
There had been a constant decline of the discharge rate (in-
cluding deaths), accounting for the accumulation of cases
in the asylums. Mr. Humphreys demanded a scientilic
definition of what constituted insanity as a necessary pre-
liminary to a solution of the question whether the preva-
lence has increased or decreased.

On Tuesday Mr. Gladstone (Home Secretary) received
a deputation from the Lancashire authorities on asylums
and the poor law to urge more economical housing of
chronic lunatics. He replied to the deputation that he
understood the general view of experts to favor a higher
standard of medical treatment, diet, housing, etc., for
curable cases. Of course special effort was desirable when-
ever there was a chance of a cure, and he was sure that
all reasonable and proper care would be given to others.
He therefore considered differential treatment was abso-
lutely justifiable and would cooperate with the deputation
in that object.

A case of chyluria in England was described by Dr. A. F.
Hertz at the Mcdico-Chirurgical in a sailor of 66, admitted in
October, 1906, with a history of milky urine for about nine
months. He had been in India twenty years previously.
The opacity was due to fat; proteid was always found,
dextrose never. The fat and proteid disappeared with a
fat-free diet if he rested after meals. But fat in food gave
rise to proteid and fat in the urine as soon as thirty-three
minutes — the maximum amount being about five hours
later, and the last traces about eight hours. Exercise or
the upright position increased the amount. At the post mortem
the thoracic duct was obstructed about 7 cm. above the dia-
phragm. The abdominal lymphatics were dilated and there
was an anastomosis between the lacteals and the lymphatics
on the right side of the bladder, inside which fibrin adhered
to the mucous membrane at a point where dilated lymph-
atics were, and which perhaps marked the spot where the
contents of the lacteals and lymphatics of the leg had pene-
trated. It was suggested that the case mip-ht be due to
an old infection by filaria: which had died out but left the
obstruction brought on. Non-filiarial cases might be due
to another parasite or to pressure on the duct by a tumor,
the most frequent being caseous glands.

The annual meeting of King Edward's Hospital Fund
was held this day week, the Prince of Wales as president
occupying the chair. The report stated that the total in-
come had amounted to £110,955 and the sum distributed to
£111,000. Donations and subscriptions showed a decrease
of over £13,900. Of this, £10,000 represents the loss of the
generous subscription of the late Mrs. Lewis-Hill, but by
her death the fund comes into the capital sum of £250,000,
besides a residue of the estate not yet ascertained. Legacies
are acknowledged from Mr. Beit, £20,000; Mr. Nicholas,
£10,000; Lord Grimthorpe, ^£5.000, and Mrs. Finnie's estate,
£6,700. The League of Mercy contributed £18,000, an ad-
vance of £3,000 on the previous year. Every eligible hos-
pital applying to the fund for a grant was inspected and
reported upon and the council expressed pleasure at no-
ticing a diminution of expenditure in several hospitals in
which the cost per bed seemed to have been excessive. The
revision of the uniform system of hospital accounts was
brought to a successful conclusion during the year 1906;
the three funds have adopted the system which is now in
force. Last year H.R.H. the president appointed a finance
committee in view of the magnitude of the fund's invested
property. He also expressed a desire to place the fund on
a defined footing, by incorporation by an act of Parliament.
With the approval of the King, steps are being taken to
seek the consent of Parliament to a bill for accomplishing
that purpose.

King's College issued its appeal on Saturday for funds
to carry out its incorporation in the University of London.
One htindred and twenty-five thousand pounds is required
and an additional £20.000 to keep up the theological faculty,
for this is necessarily separated and independent on ac-
count of the undenominational character of the university.
The council point out that during the last ten years they
have made great efforts to improve the college, have re-
duced the debt by £56,000, and secured £14,000 for the ex-
tension and equipment— most of this being provided by
private friends. They, therefore, think they may now rea-
sonably ask institutions and individuals interested in higher
education in London to help them complete the work. The
debt began with the opening of the college seventy-five
years ago and has grown with the eflfort to meet the re-
quirements. The scheme of incorporation follows on the
lines of that of University College. This, however, was
undenominational, and therefore it is only the secular side
of King's that will be completely incorporated. The facul-
ties of Arts, Law, Science, Engineering, Medicine (prelim-
inary and intermediate) and the women's department at
Kensington will be continued and governed by the Senate
through a committee or delegacy. The hospital and ad-
vanced medical school has to be under separate manage-
ment and is transferred to the new suburban premises to-
ward the building on which £170,000 has been collected
and much more is required. The separation facilitates the
incoporation, as the university cannot be connected with
the management of a hospital, nor can it be responsible for
one of the twelve advanced medical schools of London.

Surgeon-General Sir John Harry Innes, K.CB.. died at
Florence on the 12th inst.. aged 87. He graduated in 1842
and entered the Army Medical Department. He served
in the Crimea, through the Indian meeting and later in
Afghanistan; was Sanitary Commissioner in the Franco-
Prussian war, 1870, and P.M.O. in India from 1876 to 1880.
He was appointed Surgeon to Queen Victoria in 1872 and
created K.CB. in 18S7.

Dr. Samuel Barker, Consulting Physician to the Chil-
dren's Hospital at Brighton, and one of its founders, died
on the nth inst., aged 86. He was M.D., St. And.,
1858, and had retired for many years. He held some
other appointments at Brighton, where he had practised for
about fiftv vears and had the respect of all classes. He
made a number of contributions to medical literature,
chiefly on subjects connected with the health and diseases
of children.

Facial Neuralgia and Radiotherapy.— Beclere and

Harrey have reported a case of facial neuralgia in which
the pain disappeared after a course of radiotherapy. The
patient was attacked seven years ago with an epileptiform
facial neuralgia. Several surgical interventions were per-
formed, but were followed by a subsidence of a violent pain
for only a few months. Finally recourse was had to radio-
therapy. This treatment resulted in the complete dis-
apnearance of the pain after four sittings eight d.iys apart.
The rays were directed toward the interior of the mouth
against the alveolar border. The neuralgia has not re-
turned since April 25, 1905.— Lo Tribune Medicate.

6i6

MEDICAL RECORD.

[April 13, 1907

OUR VIENNA LETTER.

(From Our Special Correspondent.)

ANNIVERSARY CELEBRATIONS — INCREASE OF MEDICAL FEES —
TUBERCLES OF THE LIVER — SUBCUTANEOUS USE OF GELATIN
IN CARCINOM.\ — LEUKEMIA WITHOUT LEUCOCYTOSIS — AN
OPERATION FOR CLEFT PALATE — MORTALITY FROM TUBER-
CULOSIS AND CANCER.

Vienna, March 20. igo7.

On March 16 the Royal Institute of Operative Surgery
celebrated its centenary. This institution has as one of its
functions the education of surgical assistants who later
enter the clinics in order to perfect themselves by several
years' work under the tutelage of eminent specialists. Many
prorninent operators have received a portion of their train-
ing in the Institute; in fact, nearly all the surgeons of the
Austrian clinics of the last decades exceptin Prof. Bill-
roth, who himself during his work in Vienna was director
of the Institute. A large number of well known foreign
surgeons have also been workers in the Institute. Recep-
tions were held in the two university clinics, in conjunc-
tion with which interesting cases were presented and the
clinics were inspected. At the first clinic the guests were
received by Councilor von Eiselsberg, who in a short ad-
dress outlined the revolution in surgery that had been
effected by the development of anesthesia and of antisepsis.
He referred to the approaching eightieth birthday of Lord
Lister and said that the great English surgeon must to-
day be e.xperiencing the delightful conviction that thanks
to his discovery millions of lives had been saved that
otherwise would have been lost. Prof, von Eiselsberg then
referred to the operation of appendectomy, which he termed
the most modern of operations, and he presented a statis-
tical table of 700 cases intended to show its value. The
assemblage then passed on into the second surgical clinic,
where Councilor Hochenegg spoke on the increase in
the scope of operative surgery during the last fifty years.
In the year 1841 in this clinic 56 major operations' were
performed, in the year 1S67 120, in 1887 512, and in 1896
713- In the year 1869 no case of appendicitis came to oper-
ation, in 1899 there were 14 cases, and in 1896 128 cases.
The number of gallstone operations in 1899 was 2 and in
1906 was 20. The speaker then presented several patients
who had recovered after unusual surgical conditions. A
collation given by the chiefs of the two surgical clinics
formed the conclusion of the exercises.

All of the participants in this centenary celebration, on
the evening of the same day took part in a testimonial
meeting held in the assembly room of the medical society
in honor of Lister's eightieth birthday. The meeting was
presided over by Councilor Chrobak and the address was
delivered by Prof. Fraenkel. He said that two considera-
tions rendered the present celebration a solemn one, one of
them was the retrospect over the hundred years of activity
of the surgical Institute and the other was the entrance of
Joseph Lister, the great reformer of surgery, into the
ninth decade of his illustrious life. After pointing out
the true altruism that pervades the medical profession in
its labors for the good of the populace, he closed with
the quotation from the Roman Emperor who said, "Melius
est unum servare civem quam mille occidere hostes."

To conclude the centenary celebration the chiefs of the
university clinics, Profs, von Eiselsberg and Hochenegg,
had invited the guests to a reception in the universitv. At
9 o'clock in the evening almost all the professors, instruc-
tors, and assistants of the medical faculty, prominent mem-
bers of the three other faculties, as well as a large num-
ber of eminent physicians and former graduates of the In-
stitute from all countries assembled in the reception rooms.
The dean of the university and his suite entered the hall
m solemn procession. From the rostrum, beside which
the banner of the university had been planted, the rector
delivered an address of welcome. He expressed his pleas-
ure at seeing all the members of the medical school united
again in the university, since the separate medical insti-
tutes were situated outside of it, and emphasized the value
of the spirit of unity conferred by the universit}'. Dr.
Scholz then delivered an address of thanks to the academic
senate in the name of those who had enjoyed its hospitalitv.
Hereupon the guests formed informal groups in the ad-
joining rooms in which the supper tables had been placed,
and old classmates who had not seen each other for years
celebrated their reunion.

.•\!1 through Austria-Hungary there has been of late such
an increase in the cost of living that even the physicians
have decided not to hold back any longer and have con-
cluded to increase their lees by 50 per cent. Many circum-
stances have of late years contributed to cause a diminu-
tion in the prosperity of the medical profession, especially

overcrowding of the profession, the reduction in fees
caused by the lodges, and the foundation of charitable in-
stitutions on a large scale by wealthy persons, so that an
effort to increase the income of the physician seems fully
justified.

Dr. Schnitzler has removed by operation large solitary
tubercles of the liver from a young man. The patient, who
several years before had been operated on for tuberculous
glands of the neck, two years ago began to complain of
pain in the region of the liver. The organ was enlarged
and on palpation was found to be nodular, .\ntisyphilitic
treatment, founded on a diagnosis of hepatic gummata,
was without effect. At an exploratory laparotomy it was
seen that the right lobe of the liver contained numerous
white, hard tumors resembling gummata in appearance.
After the operation a temporary diminution in the pain
and in the size of the tumors was noted, but as the im-
provement was not of long duration laparotomy was per-
formed. From both lobes of the liver a number of hard
tumors, some of them almost as large as the fist, were re-
moved : hemorrhage from the incisions into the liver was
controlled by packing with adrenalin tampons. On micro-
scopical examination it was found that the tumors were
tubercles, the occurrence of which in such size is a great
rarity. At present the patient's condition is excellent.

Hauer has made numerous observations on the sub-
cutaneous administration of gelatin in carcinoma, and in
the course of the past two years has frequently resorted to
injections of a 10 per cent, solution of this substance in
the treatment of hemorrhage due to carcinoma of the
uterus. The general condition of these patients improved
greatly, and in some instances the cancerous process itself
was changed for the better. In order to investigate the
matter further, observations were made in thirty-eight cases
of carcinoma and two of sarcoma. The hemorrhages in
most cases ceased after one or two injections and the
greater proportion of the patients showed a considerable
increase in weight. The pain diminished, the general con-
dition improved, the cachexia was lessened and the mucous
membranes regained their color; the odor of the discharges
became much less offensive and in some cases the growth
itself gave evidence of retrogression. The ulcers became
less purulent, their size diminished and in some of the
cases clinical changes were observed that appeared to jus-
tify the opinion that the primary lesion had been cured.
The metastases were less favorably affected, though here
also the process was arrested. Gelatin is to be considered
as the best palliative remedy in carcinoma, and in inoper-
able cases is a most useful means of alleviating symp-
toms. The injections of 40 g. each are given at intervals
of one or two weeks for months. To explain the action
it is supposed that cytolysins are formed in the body, or
that the Gelatin causes thrombus formation in the arterioles
of the new growth.

A case of leukemia without leucocytosis has been ob-
served by Sluka in a nine-year-old girl. The diagnosis i>t
acute lymphatic leukemia was suggested by the general
symptom complex, consisting of pallor, puffiness of the
face, general glandular enlargement, cutaneous hemorrhages,
and the rapid onset of the condition. The blood picture
caused astonishment, therefore, for it presented a leu-
copenia with a predominance of the lymphocytic elements,
which were of the type common in acute lymphatic leu-
kemia. Apparently the number alone of the white cells
is not to be considered in the diagnosis of acute lymphatic
leukemia, but the most important feature is their morphol-
ogy. According to Turk, such cases should be termed acute
alymphemic lymphomatosis. The prognosis is bad, for in
all the cases so far observed death has resulted in less than
a vear, usually in four to six months. Roentgen ray treat-
ment would hardly be indicated in such a case, since it
would not be desirable to decrease still further the small
number of leucocrtes present.

Moszkowicz has operated on fourteen children with
congenital cleft palate by a method that was suggested
as long ago as 1824. but which has since fallen into dis-
use. It consists in the formation of a flap of mucous mem-
brane and periosteum on one side of the defect, which is
freed by two incisions running parallel to the cleft and to
the alveolar process, and is then stripped up from the
bone. The opposite edge of the cleft is freshened and
the border of the flap is sutured to this so that it covers
the gap. According to this method, it is possible to close
wide defects and if necessary a second flap may be formed
from the other side. By prolonging the flap backward
the defect in the soft palate is closed in a similar way.
Two cases which were operated on while only a few days
old ended fatally, and it therefore appears to be ad-
visable at first to correct only the harelip and to cloee

April 13, 1907]

MEDICAL RECORD.

617

the opening in the palate by means of an obturator. Later
on, but before the children begin to speak, the staphy-
lorrhaphy is done. In the other twelve cases the func-
tional result was very good. By injecting adrenalin it was
found possible to control the hemorrhage perfectly.

The municipal authorities of Vienna have issued some
interesting statistics relating to the mortality from tuber-
culosis and cancer in the year 1904. Pulmonary tubercu-
losis forms 17 per cent, of the causes of death, but in the
last fourteen years has been diminishing steadily. All ages
are attacked, but it is commonest in persons of the produc-
tive time of life, from twenty to thirty years of age, and
more men than women succumb. Persons in the humbler
walks of life suffer more from tuberculosis than those
in better circumstances. A somewhat different state of
affairs prevails in regard to carcinoma and other malig-
nant new growths. Here the mortality is greatest among
those of advanced years, and women predominate. Cancer
also is rather a disease of the better classes.

New York Medical Journal, March 30, 1907.

Hodgkin's Disease as a Type of Sarcoma.— After a

reference to the histological changes in and symptoms of
this affection, W. B. Coley presents illustrations of several
personal cases together with their clinical histories. He
states his conviction based on a study of upward of
600 cases of sarcoma, 74 of which originated in the cervical
glands, that Hod.gkin's disease is merely a special variety
of sarcoma, in containing as a rule a fairly definite clini-
cal and pathological type, but yet, in many cases, shading
off into other types that correspond most closely w.ith the
ordinary types of round celled sarcoma. The very evidence
brought forward by Reed and others in favor of the in-
fectious origin of Hodgkin's disease need not be disproved.
Most of it holds true of sarcoma, and all of it but adds
to the slowly accumulating mass of evidence in favor of
the microparasitic or infectious nature of sarcoma as well
as carcinoma. The question of retaining the name Hodg-
kin's disease is not of great importance compared with the
recognition of the true pathological condition, just as it
matters little whether we call a certain disease of the
thyroid gland exophthalmic goiter or Graves' disease. If
the malignant nature of the disease becomes generally
accepted, as the author believes it undoubtedly will, it will
be hard, he thinks, to find a better iiame for the disease
than lymphosarcoma, which Billroth applied to it many
years ago. prefixing multiple to it; or calling it lympho-
sarcomatosis to distinguish it from the type of sarcoma
confined to a single lymph gland.

The Possible Significance of the New Pyloric and
Duodenal Lesion Observed in Guinea Pigs Inoculated
Subcutaneously with Diphtheria Toxin. — The lesion
referred to by W. D. Cannon consists of sharply defined
areas of congestion, hemorrhage, or ulceration involving
the pyloric end of the stomach and sometimes the duo-
denum to the extent of half an inch. He refers to the
work of Turck. Rosenau. and Anderson who first observed
the above change, and calls attention to the possible sig-
nificance of such lesions in the general study of the induc-
tion of artificial gastric ulcer. The author further brings
up their possible relation to the familiar duodenal ulcer
occurring in the human subject after superficial burns of
large skin areas. He asks, does not the intense acute
inflammation of the subcutaneous connective tissue in the
guinea pig. with its resultant hyperplasia, edema, and
sometimes necrosis of the skin, involving from 64 to 100
c.c. of dermal tissue surrounding the site of inoculation,
constitute a skin lesion analogous to skin burns of the
first or second degree? There is probably impairment if
not total arrest of the skin functions, absorption, excre-
tion, respiration, heat radiation, sensation, and protection
in the area involved. Just which one, or combination of
arrested functions, is capable in inducing duodenal ulcer,
and later weath. has not been determined.

Pubiotomy. — R. C. Norris notes the growing popu-
larity of pubiotomy over symphyseotomy, and reports one
successful case. The degree of pelvic deformity indicating
pubiotomv is the same as that ordinarily given for the rela-
tive indication of cesarean section, i.e. a conjugata vera
to 7 cm. The majority of operations thus far have been
done for cases with contraction between 7 and 8.5 cm.
To replace embryotomy it has also been recommended
and performed in cases of impacted face or brow presen-
tation. It has been recommended to place the saw ready
for section of the bone as a prophylactic measure when
about to extract a difficult breech presentation or after

version. The increase in the diameters is as follows : A
separation of the cut ends of the bone of 3 cm. increased
the conjugata vera I cm.; the transverse 1.4 cm.; both
oblique diameters 1.3 cm. A separation of 4 cm. is
likely to damage the sacroiliac joint. One authority de-
clares the conjugata vera in the normal pelvis is increased
8 per cent, of its length ; in the rhachitic pelvis over 25
per cent. The space gained is about the same as is gained
with symphyseotomy with equal separation of the bones.
The advantage of pubiotomy lies in the fact that the sup-
ports of the bladder and urethra and the clitoris and
structures behind the symphysis are not only not cut, but
also are not so likely to be lacerated by the bilateral trac-
tion caused by the separation of the bones. Lacerations
of the vagina and unavoidable hematomata have been the
most frequent accidents thus far reported. Under aseptic
conditions these really are not serious and often may
he avoided by a proper technique of operation and by a
proper method of delivery. Tearing of the vaginal or
cervical attachments ought to be avoided by careful de-
livery after section of the bone. Reference is made to
the literature on the subject and noteworthy incidents in
various cases reported by the different authors are also
referred to.

What Stage in the Development of Cataract, Par-
ticularly Senile Cataract, Is the Most Suitable for Its
Removal by Extraction? — J. E. Weeks briefly describes
the most frequent types of senile cataract. These are:
(i) Equatorial (cortical) cataract: (a) imbibition cata-
ract; (b) cataract, always smaller than the normal lens.
(2) Cortical (chorioidal) cataract; anterior, or posterior,
or both. (3) Nuclear cataract. He adds that extraction
of the cataract in the fore.going types described, if done
vi-hen most propitious for the welfare of the patient, would
be performed in the first type as soon as liquor Morgagni
appeared between the lens capsule and the lens substance ;
in the second tvpe. at the convenience of the patient after
vision is reduced below that necessary for the ordinary
vocations of life; in the third type, when useful vision
has been abolished, and the lens is appreciably shrunken.
The author also refers to the zonular type where the
cataractous portion becomes so dense and is so large that
vision is reduced below the point which enables the patient
to follow the ordinary vocations of life (particularly when
the density of the cataract reaches this stage in adults)
and the cases in which calcareous deposits render dissipa-
tion of the cataract by needling imprudent or impossible.
Extraction in this fourth type should be made at the
convenience of the patient after vision is reduced below
that necessary for ordinary uses.

Journal of the American Medical Association, April 6, 1907.

Tuberculous Meningitis. — H. Koplik gives an analysis
of fifty-two cases of tuberculous meningitis occurring in
his hospital practice during the last six years. All the
cases utilized in his article were diagnosed clinically and
the diagnosis confirmed by post mortem, lumbar puncture,
or animal experimentation. The oldest patient was ten
years, the youngest six months, the average four years
and four months. The onset, in cases in which reliable
data could be obtained, was generally insidious, and Koplik
is inclined to question the majority of the reports of
sudden onset in this disease. Rigidity was absent in four-
teen (twenty-seven per cent.) ; hyperesthesia was lacking
in the great majority (ninety per cent.), the patient gen-
erally lying dull and giving little attention to surroundings
and reacting slowly to irritation. The Kernig symptom
was present only in twenty-two cases, and he considers
it of comparatively slight diagnostic value. The Babin-
ski reflex, on the other hand, is, he thinks, a more valu-
able evidence of the tuberculous nature of the disease, as
it is exceptional in the cerebrospinal type. Skin eruptions,
the tache cerebrate, the character of the pulse, and of
the respiration have not much value for the diagnosis ;
vomiting occurs when the ventricles are distended, but
is not a leading feature or persistent. Temperature is
important; the absence of fever, or persistently low tem-
perature with the cerebral symptoms is strong evidence
of tuberculous meningitis. Very high temperature means
either a complication or approaching death. Localized
pareses only appear toward the close of the disease and
then their evanescent character is characteristic. While
leucopenia is a presumptive evidence of a tuberculous proc-
ess the leucocyte count furnishes nothing pathognomonic
in this form of meningitis. The eyes of all the patients
were examined by experts and some change, varying
from optic neuritis to chorioidal tubercle was found pres-
ent from the beginning in sixty-six per cent. This symp-
tom sharplv distinguishes this form from other types of
meningitis, especially the cerebrospinal, in which fundamen-
tal changes are rare. Skull percussion is of the greatest value

6i8

MEDICAL RECORD.

[April 13, 1907

in the early stages of the disorder when the symptoms are
still rather equivocal. McEwen's method should be fol-
lowed ; the patient is in an upright position, the head
slightly inclined and percussed over the pterion. Koplik
found this of value in thirty-four of his fifty-two cases.
Lumbar puncture, while admittedly the most valuable
precise diagnostic method, is advised only as a confirma-
tory method after the clinical examination has rendered
the presence of tuberculous meningitis highly probable.
In other words, Koplik would use it only as a means of
confirming or excluding the presence of a disease whose
prognosis is hopeless. He believes that careful search
will reveal tubercle bacilli by this method in a majority
of cases. Although a lymphocytosis of the puncture fluid
is not pathognomonic a predominance of lymphocytes is of
considerable significance and certainly e.xcludes the diag-
nosis of certain acute purulent forms of meningitis. Sum-
ming up the diagnostic points the author says that the
diagnosis of tuberculous meningitis in its earlier stages
is possible to-day, whereas it was well-nigh impossible
formerly. The slow onset interrupted by periods of irri-
tability, etc., the irregularity of the pulse and respiration,
the low or normal temperature, the absence of hyper-
esthesia, the lack of appetite, and the discovery of hydro-
cephalus by percussiQn of the skull will all tend to estab-
lish the diagnosis. If after this we can obtain a lumbar
puncture, the examination of the fluid in the great ma-
jority of cases will put the diagnosis beyond a doubt. The
examination of the fundus of the eye is also conclusive
in many cases.

Intermittent Tick Fever. — C. F. Kieffer describes
what seems to be a new type of fever due to tick bite,
observed by him at Fort D. A. Russell, Wyo. The in-
fected region from which all cases originated, partly on
the maneuver reservation of the post, is at the head waters
of three small streams which together make up Crow
Creek. All the patients had been bitten by ticks, speci-
mens of which, sent on to Washington, were identified by
Dr. C. W. Stiles as Dcnnaccntor occidentalis, the same
species which is credited with the causation of Rocky
Mountain spotted fever. Kieffer thinks the connection
between the tick bite and the fever beyond question. The
cases generally correspond to one type. After a short
period of incubation (from three to seven days), with
brief and ill-defined prodromal symptoms, the attack is
ushered in by a chill, with nausea and vomiting and in-
tense and increasing pain in the muscles and joints. The
chill lasts two or three hours, and with it a febrile move-
ment begins, the temperature rising to 103° or 109° F.,
and remaining there as a rule for forty-eight hours, though
exceptionally it may last only twenty-four hours. Then
a remission occurs lasting about forty-eight hours, the
temperature falling nearly to the normal. The disease
consists usually of from three to seven such cycles, after
which, barring a pronounced anemia, the patient is well.
There is another type in which the fever rises ladderlike
for two or three days, and there are more marked pro-
dromes and more marked abdominal symptoms (tender-
ness and splenic enlargement), and the suggestion of
typhoid is strong. Blood examination in all cases showed
a marked decrease of the red cells and hemoglobin, and
the differential leucocj-te count gave only a very slight
leucocytosis, but a moderate (absolute as well as relative)
increase in the number of large mononuclears. Careful
search revealed no malarial parasites and nothing like
Piroplasma hominis. The VVidal reaction was always lack-
ing. Quinine, given in all the earlier cases, appeared only
to aggravate the discomfort. Kieffer is convinced, how-
ever, that arsenic, especially subcutaneously, has a con-
trolling and curative effect on the disease. The best for-
mula is Kobner's ; the solution should be sterilized and is
used in a dose of from one to two c.c. twice daily. After
the acute stage the blood deterioration is to be met by
smaller doses of arsenic or the use of the ordinary iron
preparation. Five cases are reported.

Is Scarlet Fever a Streptococcus Disease? — From a
study of the facts of scarlet fever, L. Hektoen thinks that
we are justified in concluding: (i) That the predominant
feature of the bacteriology of the throat in scarlet fever is
the constant presence of large numbers of Streptococcus
pyogenes; (2) that the overwhelming majority of the so-
called complications and of the deaths in scarlet fewer are
due to an invasion of the tissues and the blood by this
germ ; and (.•?) that in scarlet fever, even when mild, the
organism gives evidence of systemic reaction to strepto-
cocci by variations in the streptococco-opsonic inde.x and
probably also by the formation of streptococco-agglutinins.
In spite of all this and of the fact that many of the
essential symptoms of scarlet fever can be explained by
what we know of the pathogenic powers of the strepto-
coccus, there are serious difficulties in accepting the strep-

tococcal theory of the disorder. There is no analogy in
known streptococcus infections with the lasting immunity
conferred by even mild cases of scarlatina; there is the
reported lack of evidence of streptococcic invasion in
certain fulminating cases of scarlet fever; streptococci are
scarce in the skin in this disease, notwithstanding the gen-
erally accepted infectiousness of the skin lesions ; the
longevity of the scarlatinal virus, of which there are many
reported instances, is contrary to anything known of the
streptococcus. The view, therefore, that the germ of
scarlatina is yet unknown and that the streptococcus is a
concomitant or secondary invader, seems to Hektoen to
harmonize better with the facts. We may infer that the
throat conditions in scarlet fever are particularly favor-
able to the Streptococcus pyogenes, and the chief signifi-
cance of the pure scarlatinal virus would seem to be to
open the door, so to speak, to streptococci. The need
for potent antistreptococcus _remedies is as urgent as if
it were a purely streptococcus disease. Especially in view
of the fact that streptococci grow in virulence in the sus-
ceptible animal organism, it is our duty to guard against
the transfer of especial virulent strains from patient to
patient by insuring adequate measures of isolation.

Pulsus Paradoxus in Pericarditis with Effusion. —
W. J. Calvert has had the opportunity of studying two
cadavers of patients dying with pericardia! effusion. The
cadavers were injected and hardened with formalin and
then transversely sectioned in such a way as to preserve
the position of the organs at the time of death. The
conditions found are described by Calvert, and he deduces
from them the following explanation of the occurrence
of pulsus paradoxus in pericarditis with effusion. I. Peri-
cardial effusion produces stenosis of the vena cava. 2.
This stenosis is relatively compensated by a rise in venous
pressure. 3. This compensation falls when the pericardial
pressure is greater than the venous pressure. 4. Owing'
to respiratory change in venous pressure the degree of
broken compensation varies in inspiration and expiration
— greatest in inspiration, least in expiration. 5. The varia-
tion in compensation carries varying quantities of blood
to the right heart (and to general circulation) — least in
inspiration, greatest in expiration. 6. The respiratory
variation in quantity of blood passing to general circula-
tion is sufficient to explain pulsus paradoxus.

Synthetic Chemicals and the Food and Drugs Act.
— L. F. Kebler remarks that an entirely new meaning has
been given to the word "synthetic," applying it not to the
production of new chemical compounds alone, but also to
mixtures, and in some cases for the purpose of deceiving
the public, as in the well-known case of certain coal-tar
preparations. In the Food and Drugs Act the very corn-
prehensive term, "derivative and preparation of same," is
purposely employed to cover such cases, and Kebler dis-
cusses certain of the synthetic chemicals as they are affected
by this law and the changes that have been made by
manufacturers to meet the new conditions. Manufacturers
are making frequent requests to be allowed to use other
names for some of these drugs than those specifically
mentioned in the act, and substitutions of drugs less fa-
miliar to the public, such as acetphenetidin in place o£
acetanilid in headache powders, etc., are common. While
there was question about including certain chemicals and
products in the list of those to be specified on labels, at
the time of the passage of the law, the general consensus
of the best authorities seems to be at the present time that
the list was hardly large enough and that other drugs
should be included. He also remarks on some of the
food preservatives, noticing the established harmfulness of
the salicylates. While benzoic acid and benzoates are
claimed by some to be less harmful, this, he says, is yet
to be established. Saccharin is another commonly em-
ployed agent which should be specified on labels.

Tincture of Strophanthus. — R. A. Hatcher enumer-
ates the advantages possessed by strophanthus over digi-
talis and digitoxin, and notices as somewhat remarkable
the fact that it has not rivaled digitalis more in the favor
of the profession. It is prompter in its action, is said
to be less cumulative in its effects, is more soluble in
water, is less irritant, and, therefore, can be used hypo-
dermically, while at the same time it is much more active
and less expensive than digitoxin. It produces much less
vasoconstriction in the splanchnic area than digitoxin, and
while this is a disadvantage in shock, it is better for
diuresis ; according to Gottlieb and Magnus, in contrast to
digitoxin it produces no constriction of the coronary ves-
sels, which is also an important point when cardiac hyper-
trophy is desired. Of late years strophanthus has been
used with satisfactory results in Holland, Belgium, and
France, showing that a fair degree of uniformity of the
drug has been obtained. In order to test the conditions
here in this respect. Hatcher procured and tested a number

April 13, 1907]

MEDICAL RECORD.

619

of samples of tincture of strophanthus from the east
side drug stores in New York City, comparing them with
other samples carefully prepared by himself from the best
obtainable seed, as well as with specimens prepared from
seed which had been on hand for different periods of
time. The physiological test advocated by Fraenkel of de-
termining the amount required to produce systolic stand-
still of the ventricle per 100 grams of frog in one hour
was employed, which has been satisfactorily demonstrated
to be an index of therapeutic activity. Cats and dogs
were also used in the tests as well as frogs. The experi-
ments are detailed and their results prove, he thinks, that
we have a much more uniform product in the tincture
of strophanthus, even when obtained from the poorer class
of drug stores of New York, than is the case with the
digitalis preparation. It may be stated, positively, he
says, that there is no difficulty in obtaining tincture of
strophanthus in the open market of quite as nearly uniform
potency as obtains in the case of tinctures of other drugs
which are not standardized, and that the seeds do not
undergo deterioration on being kept for several years,
possessing in this respect a great advantage over digitalis
leaves, which deteriorate rapidly despite care on the part
of the pharmacist.

The Lancet, March 23, 1907.

Tests for Acetone in the Urine. — B. J. Jackson Taylor
says with reference to the sodium-nitroprusside test, which
consists in the darkening which takes place on the addition
of acetic acid to a solution of sodium-nitroprusside, urine,
and liquor potasss, that the test is rendered more simple,
delicate, and accurate by a sli"^ht modification — namely, the
substitution of stron.g ammonia for the liquor potassa;
and the elimination of the use of acetic acid. In the
ordinary test when the solution of potash is employed
there is a uniform reddening of the whole solution which
on the addition of acetic acid in the presence of acetone
becomes darker when the acid comes in contact with the
urine, the darkening passing down as the acid sinks.
Therefore, with this test the addition of liquor potassae
to the urine and sodium-nitroprusside yields a red colora-
tion whether acetone is present or not, and it is only
after the final addition of acetic acid that the presence
of acetone is recognized and then only when there is a
fair amount of the latter present. The detection of the
presence of acetone is therefore dependent on the darken-
ing of an already darkish red fluid by the final reagent,
acetic acid, and the degree of darkening, when acetone is
present only in small quantities, is not altogether easy to
determine. If, however, strong ammonia replaces the
potash solution the test for acetone is as follows: On
adding the ammonia to a solution of sodium-nitroprusside
and urine the ammonia solution remains on the top ; thus
there is a clear solution uppermost with the urine solu-
tion below. Sliould acetone be present, even in minute
quantity, a well-marked and absolutely characteristic ring
of magenta (or petunia) appears within from one to three
minutes at the junction of the two fluids and gradually
spreads upu'ards pervading the whole of the ammonia so-
lution if acetone is present in considerable amount. In
the absence of acetone usually no coloration occurs, but
sometimes an orange-red ring forms at the junction of the
urine and ammonia solution, but this bears no resemblance
to the "acetone ring" described above, hence the presence
or absence of the latter is easily ascertained by the method
which the author believes has not been generally recog-
nized. The strength of the solution of sodium-nitro-
prusside is not important, but it is important that it should
be prepared fresh and a few crystals dissolved in a test-
tube of water are sufficient.

Carcinoma Mammae in the Mouse. — E. F. Bashford
and J. A. IVIurrav describe certain anatomical and patho-
logical features of sporadic tumors occurring in the mouse'
Several illustrations are included setting forth their find-
ings in their series of animal experimentations. They
believe that these growths are epithelial in nature, are
malignant, and are identical with similar malignant new
erowths in the human subject. This being the case, they
claim that their methods have an important practical bear-
ing on the present work of cancer research. They de-
scribe the arrangement of the mammary structures in the
mouse and present a section illustrating the histolo.gy of
the normal structures. The tumors first appear as roughly
spherical swellings, usually placed asymmetrically with ref-
erence to the nipple as in the human subject. The loose-
ness and elasticity of the skin may permit growth to pro-
ceed without invasion of the chest wall, although the lungs
may be almost completely replaced by metastatic growths.
Lymphatic gl.nnds in the neighborhood may also show sec-
ondary deposits. These mammary growths frequently ap-
pear on the removal of the skin to be completely encap-
sulated by a fibrous layer of varying thickness, but this

capsule is usually invaded by strands and columns of tumor
cells. The illustrations demonstrate, the authors claim,
that they are dealing with new growths of the mammary
region of the mouse, which grow progressively (recur
after incomplete removal), infiltrate the surrounding nor-
mal tissues, and produce metastases of the same histologi-
cal type in the lungs and lymphatic glands. They lead to
the death of the animal. The conclusion is inevitable that
they are malignant new growths of the mamma.

Opsonins and Immtinity. — J. L. Bunch says that the
opsonic inde.x of a patient to a given microorganism is
simply the expression of the relative power of the patient's
opsonins to influence the taking up of the germ by phago-
cytes as compared with that of a healthy individual. In
other words, the opsonic index is a definite expression of
the patient's relative immunity. An increase of the opsonic
content of the blood in disease is brought about by the
injection of the appropriate vaccine. If the right dose
is given a short "negative phase" will be followed by a
well marked positive phase, during which the antibacterial
power of the blood is increased and the resistance of the
patient to the disease is increased. After tubercle inocu-
lations this improved power of resistance may be main-
tained for several weeks, but, as a rule, it falls back again
aften ten days or a fortnight, and a further dose of the
vaccine is necessary. Only the minimal dose must be em-
ployed which will produce a satisfactory response and
this must not be increased until it ceases to produce its
effect. The dose, moreover, must not be repeated until
the effect of the preceding dose is passing off. If it were
possible to produce a summation of positive phases it would
be advantageous to give successive doses at short inter-
vals, so as to produce a maximal favorable effect, but
such summation is not possible in the case of tubercle.
Each inoculation, therefore, produces its effect independ-
ently and it remains to take the greatest advantage possi-
ble of the increased elaboration of protective substances
which the artificial stimulus has produced.

French and Italian Journals.

Protective Function of the Liver Against Intestinal
Toxins. — G. A. Petrone and Aurelio Pagano describes
the functions of the liver as protective against the vege-
table alkaloids, many mineral poisons, foreign substances
that occasionally find their way into the intestine, such as
anmionia and the aromatic substance due to putrefaction
of albuminoids, peptones, albumins, soaps, and alcohol. Also
against saturated solutions of bicarbonate of soda, sul-
phate of soda, chloride of soda, adrenalin, sulphuric ether,
chromic acid, and phosphorus. It protects against some
microorganisms, and does not against others. It acts
against tetanus to.xin, cholera, bacillus, coli, alcoholic ex-
tracts, putrid materials, and alcohol typhoid materials.
The action against bacteria is due to phagocytosis exerted
bv the epithelium of the blood-vessels, according to some.
Others refer it to the amount of glycogen contained in
the liver. The authors have made experiments to ascer-
tain whether there is a protective action against the ordi-
nary intestinal to.xins. The toxic substances were injected
into a mesenteric vein and into a peripheral vein and the
results compared. The results lead them to conclude that
the liver exerts a marked protective action against ordinary
intestinal toxins. The first barrier against these toxins
is furnished by the walls of the gastrointestinal tube, and
many of them are thus removed. Those that are left meet
a second obstacle in the hepatic gland, with its rich circu-
Ir.tion and innumerable endothelial elements. The lung
then acts on those that have escaped the liver, and last
of all the blood by means of circulating leucocytes con-
tinues the action. — La Prcsse Medicale. February 13, 1907.

Chromatophore Cells and Langerhans Cells in the
Skin. — E. Bizzozero has made examinations of many
condylomatous growths of the skin, of elephantiasis, and
matophore cells and Langerhans cells in the skin. He
presents these conclusions : That the interepithelial chro-
molluscum fibrosum to determine the presence of chro-
matophore cells are connective tissue cells containing pig-
ment, which have immigrated from the cutis. Thai the
structure of the nuclei varies according to the conditions
of nutrition in which they existed. That the nucleus in
inflammatory processes may multiply by direct division
without any division of the protoplasm, or by indirect
division followed by division of the protoplasm. That
the chromatophore cells progressing toward the surface of
the skin may be broken up into minute detritus and the
pigment spread in the interepithelial spaces, or may be
gradually destroyed later. That in the group of Langer-
hans cell's must be included pigmented chromatophores, un-
pigniented chromatophores, and those whose granules are
only brought out by nitrate of silver ; excluded shoiild be
epithelial cells, miffratinsr cells, and nerve cells. — Archivio
fer le Scien-c Mcdiche. Vol. XXX. Part 6.

620

MEDICAL RECORD.

[April 13, 1907

?Biiok firtHnos.

NouvEAU Traite de Medecine et de Therapeutique.
Publie en Fascicules sous la direction de MM. P. Brou-
ARDEL et A. Gilbert, Professeurs a la Faculte de Medecine
de Paris. XL Into.xications. Par P. Carnot, E.
Lancereau-X, M. Letulle et R. Wurtz, Professeurs
Agreges a la Faculte de Medecine, Medecins des Hopi-
tau.x, Paris : J. B. Bailliere et Fils, 1906.
The Systern of Medicine of Brouardel and Gilbert has, in
the new edition, been made much more accessible by its
publication in small sections, each complete in itself and
separately purchasable. The volume on '"Intoxications" is
in every way an admirable contribution to the literature of
the subject. Paul Carnot, in a brief review of the chemical
and physiological mechanism underlying poisonings in gen-
eral, has written an excellent introductory chapter. While
there is a certain uniform thoroughness in the treatment of
all the following sections, by far the most satisfactory are
the one on "Lead Intoxications," by Letulle, and the truly
masterful treatise on "Alcoholism," by Lancereaux. There
have probably been no more excellent studies made of this
important subject than this one of Lancereaux, who, with-
out neglect of the purely medical aspects of the matter in
hand, deals at length with the statistical and sociological
problems involved, the subdivision on "Hereditary Alcohol-
ism" and the one on "Legislative Prophylaxis" being par-
ticularly, good. The authors have made a very thorough
use of the literature of all countries, and the book gives
the impression of bringing its subject completely up to date.
Throughout there is a literary quality and skill of treat-
ment which make its pages easy and pleasant reading, a
feature which may well be recommended to many of our
American writers of text-books.

Who's Who. 1907. An Annual Biographical Dictionary.
Fifty-ninth Year of Issue. London, Adam and Charles
Black; New York: The Macmillan Company, 1907.
This is the original of all the Who's Whos, national, mu-
nicipal, professional. It is not strictly national in its scope,
but includes biographies of some of the most prominent men
in science, letters, arts, finance, and politics in the countries
of Europe and America. Chiefly, however, it gives informa-
tion concerning residents in the United Kingdom and its
colonies. The book will be found very serviceable to all
readers of newspapers and reviews who want to know some-
thing about the men of Great Britain and Ireland who are,
without the information here given, only names to most of
us. The data about Americans mentioned in the work appear
to be in the main correct, though we notice that the name of
the late Albert Bierstadt, the artist, is retained in the book
as though he were still living.

The Toxins and Venoms and their Antibodies. Bv Em.
Pozzi-EscoT. Authorized translation by Alfred I. Cohn,
Phar. D. First Edition. New York: John Wiley &
Sons, 1906.

The first part of this book deals with generalities regard-
ing toxins and antitoxins; the second half treats of the
toxins proper — vegetable and animal toxins, microbial
toxins, and the venoms. The book is small, and only
the merest outline is given; but it will serve as a useful
introduction to the more detailed study of an important
subject. Thevalue of the book is increased by numerous
footnotes, which refer to fuller sources of information.
The Practice of Obstetrics. Designed for the use of
Students and Practitioners of Medicine. By J. Cufton
Edgar. Professor of Obstetrics and Clinical Midwifery
in the Cornell University Medical College; Visiting Ob-
stetrician to the Emereenci' Hospital of Bellevue Hos-
pital. New York City: Surgeon to the Manhattan Ma-
ternity and Dispensary; Consulting Obstetrician to the
New York Maternity Hospital. Third Edition. Revised.
With 1,279 illustrations, including five colored plates
and 38 figures printed in colors. Philadelphia: P.
Blakiston's Son & Co., 1007.
It would seem that there is no need to do more than an-
nounce the appearance of a new edition of this standard
work. Still, admirable as were the two former editions,
the present volume contains new matter that adds to its
value. There are new sections on anoendicitis complicat-
ing pregnancy, tapeworm complicating pregnancy, hematoma
of the vulva, fibroma molluscum gravidarum, lactation
atrophy of the uterus and breasts, brachial birth paralysis,
vaginal incision and drainage, new history charts for in-
stitution work. In addition the following subjects have
been more or less rewritten : The development of the ovum,
embryo, fetus, fetal membranes, and fetal structures ;
chorioepithelioma malignum; the treatment of placenta
prxvia; the toxemia of pregnancy; the etiology of eclamp-
sia ; ectopic gestation ; the treatment of pelvic deformity ;
morbidity in the puernerium ; indications for the induction

of abortion and premature labor; the forceps; cesarean
section ; vaginal cesarean section ; Porro-cesarean section ;
complete and incomplete abdominal hysterectomy. Al-
though much new matter and 140 new illustrations have
been added, the size of the present volume has been re-
duced by about one hundred pages ; this has been accom-
plished by rewriting, condensation, the omission of obso-
lete matter, and a reduction in the size of some of tha
illustrations.

Self- Propelled Vehicles. A Practical Treatise on the
Theory, Construction, Operation, Care, and Management
of All Forms of Automobiles. By James E. Homans,
A.M. S'i.xth Edition, Revised and Enlarged. With Up-
wards of 500 Illustrations and Diagrams, Giving the
Essential Details of Construction and Many Important
Points on the Successful Operation of the Various
Types of Motor Carriages Driven by S'tea.m, Gasoline,
and Electricity. New York : Theo. Audel & Co., 1907.
Thanks to the skill of designers and makers, the con-
struction of motor vehicles is each year becoming simpler
and at the same time more effective. Even the least com-
plex, however, demands of its driver a considerable degree
of technical knowledge if it is to be operated profitably,
and the present is an admirable text-book for tyros, and
work of reference for the more experienced. In accord-
ance with its practical importance the greatest amount
of space is given to the gasoline vehicle, though the ap-
plication of steam and electricity as motive powers is
adequately described. The more important structural fea-
tures of most of the well-known foreign and domestic
cars are discussed and illustrated, and much practical
information is given, both in regard to routine driving
and also concerning the unexpected happenings for which
automobiles are so notorious. The book is well indexed
and is paragraphed with side heads in such a way as to
make it convenient for reference, and it may warmly be
commended as a complete, easily comprehensible hand-
book on the anatomy, physiology, pathology, and thera-
peutics of motor vehicles.

Manuel d'Histologie Pathologique. Par V. Cornil,
Professeur a la Faculte de Medecine, et L. Ranvier,
Professeur au College de France. .Avec la Collaboration
de A. Brault, Medecin de I'Hopital Lariboisiere, et M.
Letulle. Professeur Agrege a la Faculte de Medecine.
Troisieme Edition. Tome Troisieme. Avec 388 gravures
en noir et en couleurs dans le texte. Paris : Feli.x Alcan,
fiditeur, 1907.
The first volume of this very elaborate system was de-
voted to the principles of pathology, to tumors, and to the
pathology of the bones, joints, and serous membranes.
The second volume contained the discussions of the pa-
thology of the muscles, blood, and marrow, and in the
present work the central nervous system, the cardio-
vascular system, the lymphatic system, the spleen, and
the larynx are considered. The volume is a very large
one of 1,170 pages, with 388 illustrations, many of them
in colors, and nearly all of unusual interest and excel-
lence. The first 850 pages comprise a series of e.xhaustive
articles on the pathology of the brain, cord, and peripheral
nerves by Gombault. Riche. Nageotte. and Durante. The
vascular system is treated of by Marie in 150 pages ;
Bezangon covers the lymphatic system in 100 pages more,
and the volume is closed by an article on the larynx by
Legry. This last does not seem properly to belong with
the other subjects included in this section, since it forms
the beginning of the work on the respiratory system
which is to follow in the fourth and last volume of the
system shortly to be published. The eminence of the two
editors-in-chief sufficiently guarantees the quality of the
te.xt. and the work is an important addition to the litera-
ture of pathological histology.

Mercer's Company Lectures on Recent Advances in
the Physiology of Digestion. Delivered in the Michael-
mas Term, 1905, in the Physiological Department of
Universitv College. London. By Ernest H. Starling,
M.D., F.R.S., Jodrell Professor of Physiology. With
twelve illustrations. Chica.go : \N'. T. Keener & Co.,
1006.
One of the most important of the recent advances in our
knowledge of the physiology of digestion concerns the
nature of the stimuli which evoke the gastric and pan-
creatic secretions when food or chyme enters the stomach
or duodenum. Formerly supposed to be due to reflex
nervous activity it now appears that the secretory stimulus
is largely a chemical one dependin.g on the formation of a
hormone at the seat of stimulation which then reaches
the gland in question through the blood stream. The
steps which have led up to the discovery of these gastric
and duodenal secretins are traced in detail in these lec-
tures, as well as many other phases of digestion which
have been made the subjects of recent investigation.

April 13, 1907]

MEDICAL RECORD.

621

0nriftg SfparlB.

THE PRACTITIONERS' SOCIETY OF NEW YORK.

2o8f/i Regular Meeting, Held March i, 1907.

The President, Dr. Robert Abbe, in the Chair.

A Case of Cervical Rib, with Symptoms.— Dr. Lewis

A. Conner presented a girl, seventeen years old, with bi-
lateral cervical ribs, who had been shown to the society
one year ago. At that time she complained of occasional
slight pains in her left shoulder, but it was impossible to
tell whether or not the pains were related to her super-
numerary rib. Since that time the pain had become more
constant and severe, and now was present most of the time.
It no longer was felt only in the shoulder, but frequently
radiated to the elbow. There was no evidence of muscular
atrophy on the affected side, and the left deltoid showed
only slight diminution in faradic irritability. Power in
the two arms was equal, but the left tired more easily.
The skin sensibility was not disturbed. In the light of the
developments of the past year there was now little doubt
that the symptoms were the result of pressure of the cer-
vical rib upon the nerve trunks, and if these symptoms
increased, the question of operation would have to be con-
sidered. In reply to a question, Dr. Conner said this condi-
tion of cervical rib was frequently bilateral, but not always.
The operation for the removal of the rib was regarded by
surgeons as sometimes quite a difficult one. The symptoms
associated with the condition were apt to develop during
early adult life, which was perhaps due to the elongation
or increasing rigidity of the ribs at that time.

Local Thermotherapy. — By Dr. W. Gilm.\n Thomp-
son. (See page 502.)

Dr. Beverley Robinson said that in spite of the un-
doubted accuracy and scientific value of the investigations
of Dr. Thompson along the lines indicated in his paper,
his findings were not in entire accord with clinical e.\-
perience in the use of local thermotherapy, and until the
art of medicine could be reduced to an exact science, such
discrepancies would doubtless continue to exist. For ex-
ample, the use of ergot to control pulmonary bleeding was
generally regarded as utterly unscientific ; still. Dr. Robin-
son, said, he invariably gave the drug in such cases, and
had a certain amount of faith in its efficacy.

Dr. .'\ndrew H. Smith said that very early in his medical
career he had been instructed to the effect that when heat
or cold was indicated as a local application, either one
could be selected, the choice depending on the personal
comfort of the patient and the therapeutic effect ap-
parently varying with the subjective sensations. That
general rule was still more or less observed by prac-
titioners. When theory failed we resorted to practical
results. When, in a certain case, we found that cold
aggravated the pain, while warmth apparently allayed it,
we were justified in resorting to the later, or vice versa.
The practical utility of thermotherapy could not be doubted,
whatever the scientific basis for it might be. For in-
stance, a toothache was always aggravated by cold appli-
cations, and usually eased by hot ones. The same was
true in the pain accompanying inflammations of the middle
ear.

Dr. John Winters Brannan inquired whether in Dr.
Thompson's opinion the abdominal ice coil was of use in
typhoid fever, apart from cases in which there was intes-
tinal hemorrhage. The speaker said that last autumn,
when he was endeavoring to induce the physicians of
Harlem Hospital to place their typhoid patients on the
balconies to get the benefit of the fresh air, they objected
on the ground that it interfered with the use of the ice
coil. In cases of sprained ankle. Dr. Brannan said, he
had seen the swelling and pain rapidly disappear under
the use of hot applications.

Dr. George L. Peabodv recalled Dr. Thompson's previous

work in connection with this subject, and stated that
he had long been in entire accord with the views ex-
pressed, which contained nothing antagonistic to the use
of local thermotherapy in the treattnent of certain con-
ditions. Personally, Dr. Peabody said, he confessed great
faith in hot applications for pleuritic pains. In certain
other similar conditions cold seemed more efficacious than
heat, and both seemed to accomplish the same result in
different ways. While local thermotherapy did not aflfect
the internal temperature directly, still in a reflex manner
it influenced the blood supply of the part, reducing it either
by constriction of the afferent vessels, thus preventing
the inliow of blood, or increasing the outflow of blood
by its eflfect on the efferent vessels. In both cases there
would be a diminution of the amount of blood at the site
of the inflamed part. The speaker said he had an abiding
faith in the relief of appendicular pain by the continuous
application of an ice bag, and under its use he had seen
many cases in which the acute symptoms subsided, permit-
ting a subsequent interval operation.

Dr. Francis P. Kinnicutt said that while he was un-
able to offer any scientific explanation of how heat and
cold acted, respectively, in relieving pain, their efficacy
in that regard had been borne out by clinical experience.
The pain of appendicitis for example was often materially
diminished by cold applications. The same was true of the
pain of pericarditis and even of deeply seated organs. The
explanation by Dr. Peabody of the similar results effected
either by cold or heat was of much interest. While the
laboratory tests bearing on this subject made by Dr.
Thompson were very thorough and interesting. Dr. Kin-
nicutt said he did not think they were entirely conclusive.
For example, in trying to ascertain the effect of local
thermotherapy upon the blood supply of a part, mere
visual inspection would be insufficient, as the human
eye would be incapable of recognizing slight changes
either in the caliber of the vessels or in the rapidity of
the blood current. Slight blanching or reddening of the
parts were difficult to recognize, yet slight changes in
the local circulation might suffice to relieve the pressure
on the nerve filament, to which the pain in many cases
should be ascribed.

Dr. Charles L. Dana thought Dr. Thompson had cer-
tainly established the fact that our therapeutic results from
local heat and cold were not due to any direct transmission
of the heat or cold to the internal organs. The inference
to be drawn from his investigations was that there was
a very intimate relationship between the cutaneous nerves
and the vascular condition of the internal organs. Dr.
Head had shown that variations due to acute pathological
processes in the deep viscera were reflected very quickly
upon the cutaneous organs. In chronic conditions this
relationship was less intimate, as a certain degree of equili-
brium was established. It could be legitimately inferred,
however, that external applications likewise produced defi-
nite reflex effects on internal organs, and the subject of
local thermotherapy therefore resolved itself into a study
of how much we could effect by such refle.x action. The
i!peaker recalled the time when Chapman's ice bags were
very much in vogue as a therapeutic measure, and he had
resorted to the use of long ice bags and short ice bags
on the spine in the treatment of locomotor ataxia and
spinal irritation and various other nervous affections. In
chronic conditions he had never seen any results from
the use of such applications, but in acute conditions, such
as headache and some forms of spinal pain and pares-
thesia, he had seen relief follow the use of such applica-
tions. After cerebral apoplexy it was the usual thing
to apply an ice bag to the head, and while this rendered
some of these patients more comfortable by relieving the
headache and the constricting sensations, it had no direct
effect on hemorrhage. In local pains, such as the various
tN^pes of neuritis, the application of heat or cold was often
very grateful, and in such cases the benefit was due, per-

622

MEDICAL RECORD.

[April 13, 1907

haps, partly to direct transmission and partly to reflex
action. Dr. Dana said he was in hearty accord with the
reader of the paper that intelligent local thermotherapy
should be more generally adopted and carried out in our
general hospitals.

The President, Dr. Abbe, said that from a surgical stand-
point he thought there was no doubt that local applica-
tions of heat and cold had a controlling influence on deep
inflammatory processes. For instance, in synovitis of the
knee-joint, the application of an ice bag was of undoubted
value, reducing the inflammatory process and diminishing
the size of the distended joint. In appendicitis the appli-
cation of cold was frequently followed by a rapid reduc-
tion of the engorgement of the deep-parts which were the
seat of inflammation, sometimes to such an extent that
the strictured condition of the appendix, swollen to the
point of obstruction, yielded and the attack would be over
for the time being. In looking for a possible explanation
of the beneficial effects of local thermotherapy. Dr. Abbe
said he would be inclined to ascribe them to vasomotor
influences. This was evidenced in the, at times, almost
magical effects of hot applications to the forehead or nape
of the neck in migraine, resulting, apparently, in reliev-
ing the local congestion of the vessels.

Dr. Robinson said that in certain cases where heat was
indicated, he had found the electric pad more serviceable
than the hot water bag. He also referred to the value
of the actual cauter>" in old heart cases with dilatation
and pain.

Dr. Thompson, in closing, said that in his paper he had
admitted the value of local thermotherapy in various con-
ditions of pain, but his chief contention was that it was
difficult, if not impossible, to reach deep-seated hemorrhage,
congestion, or inflammation by the ordinary methods of
applying heat or cold, and that whatever effect such
applications had in those cases, they were certainly not
due to direct thermic transmission. This, of course, did
not apply to cases of toothache, alveolar abscess, etc., where
the heat or cold came in close contact with the source of
irritation. The electric pad, to which Dr. Robinson had
referred, was superior to the hot water bottle only because
in the former the source of the heat was constant. The
heat of the thermocautery was only momentary, and its
beneficial effects were the result of its stimulating rather
than its heating properties.

He said the changes in the circulation referred to by
Dr. Kinnicutt were probably brought about by reflex action,
perhaps distantly transmitted. For example, any stimulus
applied over the precordium, in order to affect the deeper
parts, might travel through the spinal centers and from
thence be transmitted to the pleura and pericardium, and
perhaps to the heart itself. The speaker said he was
inclined to doubt that heat iself had any deep penetrating
influence. Our knowledge of cutaneous stimulation and
its effect on the internal circulation was slight. It was
a far cry from the cutaneous circulation to the renal circu-
lation, and a long distance for the nerve currents to travel.
It was curious that there was such a close relationship,
apparently, between certain cutaneous areas and some or-
gan immediately underneath with which they had no direct
physiological or nervous connection, although the clinical
relationship was undoubted.

In speaking of the use of the abdominal ice coil in
typhoid fever. Dr. Thompson said he had formerly em-
ployed it in patients who were too ill to be given tub
baths, or where a hemorrhage had occurred and it was
undesirable to disturb the patients. He had become con-
vinced, however, that the ice coil was of little practical
utility in these cases.

Dr. Dana said that the connection between the reflex
effects of local stimuli and deep-seated pains, like those
of pericarditis, was perhaps not as complicated as Dr.
Thompson had suggested. On the contrary, a very close
relationship had been shown to exist between the heart and

pericardium and segmental areas of the overlying skin,
and applications of heat or cold to the latter would in-
fluence corresponding sympathetic nerves. Dr. Dana said
that at times the simple application of methyl chloride to
the skin relieved pain which appeared to lay in one of
the internal viscera. The only explanation he had to offer
for this phenomenon was that this stimulation of the cuta-
neous nerves gave rise to inhibitory influences, thus pro-
ducing interfering currents.

Dr. Conner said that if deep visceral pain produced
definite and constant areas of skin hyperesthesia, as Head
had so clearly demonstrated, the deduction seemed per-
fectly reasonable that grateful applications of those cutane-
ous areas might tend to relieve pain located in deep-seated
organs.

Dr. Peabodv referred to the value of the alcohol poul-
tice, even in cases where the pain was deep-seated, as in
acute peritonitis. In making these applications it was
essential to have the epidermis absolutely saturated with
alcohol, which could be applied upon several thicknesses
of cheese-cloth, properly covered. The method was not
advisable in areas where the epidermis was very thin, as
in the scrotal region. He had often found it very effica-
cious in relieving the pain of phlebitis. The alcohol ap-
parently paralyzed the blood-vessels, increasing their lumen
and producing a blanching of the parts. In regard to the
electric pad, to which Dr. Robinson had referred, Dr.
Peabody said he had recently had two of these pads take
fire while in use, and in one instance the patient's bed
was set on fire. The conflagration was explained by the
manufacturer on the ground of improper voltage.

Dr. Robinson said that in some cases of deep-seated
pain he still had faith in the old-fashioned method of
drawing blood by the use of leeches, which he regarded
superior to wet cupping.

Dr. Andrew H. Smith suggested that the lymphatics
possibly played an important role in the more chronic
forms of pain that were relieved by the application of
heat or cold.

Dr. Thompson said he also had seen a conflagration of
one of the electric pads. This possible danger attending
the use of the pads should not be lost sight of.

Aneurysm of the Arch of Aorta, which Ruptured into
Esophagus in a Young Woman without External
Evidence of Syphilis. — Reported by Dr. George L. Pea-
body, with specimen. (See page 595.)

Dr. Andrew H. Smith said that in a case of aortic
aneuo'sm observed at the Presbyterian Hospital about fif-
teen years ago it was possible to detect a distinct souffle
by placing the bell of an ordinary stethoscope in the
patient's mouth, with the lips firmly closed around the
tube. In that case the souffle could not be heard by the
ordinary method of auscultation.

Dr. Abbe recalled one case of aortic aneurj-sm where the
tumor imparted a marked impulse to the stomach tube.

Tuberculosis of the Iris Cured by Tuberculin Injec-
tions.— Dr. Charles Stedman Bull reported this case.

XEW YORK ACADEMY OF MEDICINE.

SECTION ON OBSTETRICS AND GYNECOLOGY.

Stated Meeting, Held Febiuiiry 28, 1907.

Dr. Howard C. Taylor in the '"hair.

Degenerating Fibroid Complicating Pregnancy; Myo-
mectomy, with Resection of Adherent Omentum; Con-
tinuation of Pregnancy. — Dr. F. A. Dorman presented a
degenerating fibroid which he had removed from a patient
thirty years old. She had been married thirteen months.
Her childhood was healthy, her menses were regular, flow-
ing five days, normal in amount, and without pain. Within
the past year a miscarriage occurred at the third month;
this was brought about possibly by over-exertion. At the

April 13, 1907]

MEDICAL RECORD.

623

time of operation she was nearly five months pregnant. In
the early months of pregnancy there had been fairly con-
stant paint over the lower mid-abdomen, worse upon exer-
tion, but this had gradually lessened for the past two
months. A week before operation she began to have
cramping pains over the lower abdomen, so severe that
she was obliged to stay in bed part of the time. She had
some nausea and vomiting. There was no constipation, no
chills, or fever. On admission to the hospital two days
before operation, the pain had lessened, the temperature
was 99.8° F. and the pulse 98. The next day the pain was
more severe and operation was decided upon. The ab-
dominal examination showed a five months pregnant uterus,
with a protruding mass, fairly firm, about the size of a
small orange, extending forwards and near the apex of
the fundus to the left. A median abdominal incision was
made exposing the uterus, and the tumor was exposed in
the wound. It was found to be a fibroid attached to the
left side of the uterus near tlie anterior surface of the
left horn by a broad base. It was also attached quite
firmly to the omentum and to several loops of small in-
testine. The adhesions were separated and the fibroid
removed by a circular incision about its base, and shelled
out by careful enucleation. The depth of the uterine wound
was nearly that of the thickness of the uterine muscle.
The bleeding was profuse, but controlled by pad pressure,
and the wound was sewed up by layer catgut sutures. The
matted section of the omentum was removed by chain
ligature. The patient was kept quiet for two days by
morphine and until the fifth day by codeine. The conval-
escence, except for a temperature of 102.6° on the fourth
day, was normal. She was discharged on the seventeenth
day. Labor came on, following a rupture of the mem-
branes, just before the eighth month. The pains were
very insufficient and the cervix rigid. After nearly forty-
eight hours' labor, with the cervix two-thirds dilated, he
placed her under chloroform, completed the dilatation dig-
itally, and delivered her of a four-pound baby by medium
forceps. Both mother and child did well.

Dr. Brooks H. Wells said this report was interesting
on account of the condition being a rare one; ordinarily
fibroids in the fundus of tlie uterus in the pregnant woman
did not require any interference. It was unusual to find,
too, a fibroid undergoing degeneration in a uterus so well
nourished. As to the way these women stood operation,
his experience was that they continued in the pregnant
state provided the operation was done cleanly, and if the
uterine cavity was not punctured. His experience was
limited to four cases. In one the woman was about five
months pregnant, and she had a dermoid cyst of each
ovary. The ovaries and tubes were taken out close to
the uterus. She was seen with Dr. Munde and it was be-
lieved that she would abort. The baby was delivered at
full term. He then saw another case with Dr. Munde
where there was a large ovarian cyst ; this was removed
and the woman went on to full term. He had had two
other cases in his own experience; in both there was a
large cyst, which was removed during pregnancy, and
the patients went on to full term without difficulty.

Dr. S. M. Brickner said that in two years they had had
four cases at the Mount Sinai Hospital where operations
were undertaken during pregnancy and none had aborted
or miscarried. With regard to the point raised as to the
rarity of necrosis, which was the most common form of de-
generation, where the fibroid was pedunculated or twisted,
or where there was a submucous fibroid, the fibroid was
most likely to become necrosed. He recalled one case
where the woman aborted at six and a half months ;
she ran a temperature of 101° before and after the abor-
tion for some days, with tenderness and pain in the right
iliac region. An examination failed to disclose any ex-
udate or involvement of the appendages. He decided then
to examine her under an anesthetic and he was surprised

to tind a good sized submucous fibroid, which was easily
enucleated. She made a good recovery. He had seen
within the last year a rather large subperitoneal fibroid
which occupied the fundus uteri, which became necrotic
and which was removed at the fourth month of pregnancy.
The symptoms were similar to those presented in Dr.
Dornian's case.

Dr. George H. Balleray said that he never operated for
fibroids in pregnant women. He had seen several cases,
but none had degenerated. After delivery they disap-
peared within eighteen months or two years. He said he
had operated during pregnancy for the removal of ovarian
tumors in six cases, and all went on without aborting. He
had also operated for leaking pus tube in the fourth
months of pregnancy. The tube was removed and she
did not abort, but went on to the sixth month, when pre-
mature delivery occurred. He asked Dr. Dorman what
the change was that occurred in the fibroid presented by
him. He thought it was rather firm and had rather a
healthy appearance.

Dr. Dorman, in reply to Dr. Balleray, said he had not
had the pathological examination made, but the tumor
as shown differed now from what it appeared to be in the
fresh state. It was then acutely inflamed at the point
of attachment. The incision made was about one-half to
three-quarters of an inch in depth in the uterine wall.
It was a circular one, converted into a longitudinal one.
He had at present a case of double dermoid cyst in a five
months pregnant woman; both ovaries were prolapsed and
there was the irregular feeling of the dermoid ovarian cyst.
There was one twist in one of them.

Fibroid Tumor of Large Size; Operation; Continua-
tion of Pregnancy.— Dr. Edward J. Ill of Newark pre-
sented this specimen, which weighed sixteen pounds, and
was removed from a woman who was in the fifth month
of pregnancy, with no miscarriage following. In twelve
years he had had forty-five cases of uterine fibroids com-
plicating pregnancj', and in only one case was it necessary
to remove the tumor. He said he had often wondered if
the old country doctors had ever seen such cases, where
the presence of the tumors was the cause of death. One
old doctor he questioned had never seen one case in thirty-
five years' practice and he had records of over two thou-
sand cases of labor. He had often wondered what became
of these tumors and how they behaved. The specimen he
presented was of special interest. The woman was deliv-
ered one year ago in a Western State. She was thirty-
eight years old and this was her first child. Then fol-
lowed a long siege of pain and fever, which was attributed
to an autointoxication. She got perfectly well and it was
thought she was pregnant again. An examination proved
that she was not pregnant and she menstruated again.
After that the tumor appeared to become soft and, fearful
of having trouble during pregnancy, Dr. Ill agreed to re-
move the tumor for her. The indications were not well
drawn, except that the tumor was soft When he got
down to and into the tumor he found a large pocket con-
taining yellowish-gray grumous material, of which he re-
moved at least one pint. He presented the remains of the
uterine fibroids. The uterine cavity was small. She had
no temperature and no annoying symptoms. The fluid
must have been sterile because there was no temperature.
This case might have gone on to cure if it had been left
alone and if she had not again become pregnant.

Some Causes of Failure in Plastic Operations. — Dr.
Samuel M. Brickner read this paper. He asked what con-
stituted a failure in the results of a plastic operation. It
might be anatomical, functional, or symptomatic failure.
Three important elements entered into the performance of
a plastic operation, namely, the patient, the operator, and
the technique of the operation, including the after-treat-
ment. The selection of patients for a plastic operation
was the first important step. Diabetes, chronic nephritis,

624

MEDICAL RECORD.

[April 13, 1907

exophthalmic goiter, an active tuberculosis, were contra-
indications to operation, except in cases of rectal or vesical
fistula, or complex lacerations of the perineum, vi'hich
threaten the patient's life or which made her life a burden.
Aged women, who could be made comfortable with the
aid of pessaries, were better treated thus than by opera-
tive intervention. Unless a perineal laceration could be
repaired within a few hours or a few days after the birth
of the child, it was far better to wait a full eight months ;
before this period had elapsed the tissues were not only
exceedingly vascular, making hemostasis difficult, but they
were more brittle. Women who were "run down" should
first be subjected to the proper sort of tonic treatment.
Plastic operation upon the vagina should be employed only
by those thoroughly familiar with gynecological work.
Gynecologists could prepare themselves for this plastic
work only by unremitting toil and ceaseless work. The
operator should be born with, or must acquire, a "plastic
imagination." No factor contributed to failure more fre-
quently than incompleteness. To attempt to correct a
complete laceration of the perineum by the flap-splitting
method without denuding and repairing the invariable vag-
inal laceration, involved inevitable failure; and yet this
was not an uncommon blunder. Perhaps the most com-
mon error in this category was the suture of the vaginal
mucosa in either anterior or posterior colporrhaphy with-
out including the fascia in the former case and the muscles
and fascia in the latter. An operation for cystocele was
not complete unless it included pushing back the bladder
and its retention in its new position by some method of
suture. The denudation or the suture of the underlying
tissues must be so done that the suture of the mucous
membrane would lie in the median line. It was also im-
portant that like tissues be joined. Many an extensive
and well-performed plastic operation had been ruined be-
cause the patient's bowels had moved during the procedure
If the finger was to be inserted into the rectum while sutur-
ing the posterior vaginal wall, it should be protected by a
sterile finger-cot or glove ; but the tying of sutures should
then be done by an assistant. A too liberal use of anti-
septics and a too vigorous scrubbing of the vagina might
so injure the mucous membrane that it would not readily
heal. A prominent cause of necrosis of tissue following
plastic operation lay in tying the sutures too tightly, es-
pecially if they were of chromic catgut. Sutures should not
be placed too near each other. Personally he did not believe
that it made much difference what kind of suture material
was used, provided the stitches were placed at proper in-
tervals, were not tied too tightly, and, if of silk or silk-
worm gut, were removed before they had torn through, or
if they strangulate the tissues, or when they became loose.
Perfect hemostasis w-as an important desideratum in plastic
operations. A frequent source of functional failure in
plastic operations lay in the too tight closure of the vulvar
outlet ; the reverse was also true. With regard to the
after care of plastic cases, there was one blundering error
of permitting a full-sized rectal tube to be passed in cases
of complete laceration of the perineum. A suitable length
of time should pass before the bowels were permitted to
be moved. Catheterization must be rigidly aseptic, for a
woman was not cured who left their hands with chronic
cystitis. This again was a subject for scrupulous teaching
to nurses.

Dr. Brooks H. Wells said that he subscribed most heart-
ily to everything the doctor had stated, and emphasized the
fact that the patients should be properly prepared before
operation. To get the best results, the patient should be
in the hands of a well-trained gj'necologist. He emphasized
the importance of a wide separation of the bladder from
the underlying tissues in order to get the most perfect
results. He called attention to the persistent and some-
times serious hemorrhage that occurred from the veins
at the base of the bladder : this happened when the oper-

ator went a little deeper in the tissues than was necessary.
He did not like to tie vessels in plastic operations. The
smaller the number of ligatures used in plastic operations
the better the healing. In operations upon the posterior
wall it had always seemed to him that the shape of the
denudation was the least important thing; the most im-
portant thing was to recognize the nature of the injury
in that particular case and to try to overcome it. In
nearly all these cases, where the indications were clear for
operation upon the posterior wall, one would find marked
relaxation of the fibers of the levator ani muscle. In ex-
amining such a case one should insert the finger and the
muscle bundle would be found quite well up. Unless the
sutures were placed so as to bring these fibers together
good results would not follow. The fingers should be
kept out of the wound and away from the business ends
of the instruments. If gauze pads were used, they should
be used at once. One should irrigate with normal salt
solution. In complete lacerations of the perineum an im-
portant point was to make the incision above the angle
of the tear between the rectum and the vagina, a little
way up in the mucous membrane of the posterior wall,
and dissect down, turning down and making this apron
cover the rectum. This avoided sutures in the mucosa of
the rectum and the infection of the wound. In cases of
complete prolapsus the method which gave the greatest
success was a high amputation of the cervix, as Kelly
did, following it up with an operation upon the anterior
and posterior wall ; then make an incision in the median
line of the abdomen and do a ventral fixation, picking the
uterus up from the front and stitching it against the an-
terior wall.

Dr. George H. Baller-W said that it was a great mis-
take to operate too soon after delivery, when the parts
were not in proper condition for healing. That was the
fault frequently found in the cases sent to him. Prepara-
tory treatment was certainly indicated. In many of the
rebellious cases of prolapse it seemed to him better to
remove the uterus per vaginam and then to do an anterior
and posterior colporrhaphy if necessary.

Dr. L. J. L.\DiNSKi said that plastic work was imder-
rated as a rule, not only b}' men with proper training and
ability and technique, but even by those who were looked
upon as gynecologists. Such work was usually handed
over to members of the house staff. Personally he felt
that his plastic work in the gynecological department had
been more satisfactory than in others, and the patients
were more grateful. The patients were always grateful.
Whereas patients operated upon for tumors, with their
lives saved, always had some cause for complaint subse-
quently, either from loss of function or some little pelvic
trouble, going from one physician to another, and they
were not at all grateful. Sharp rather than blunt dissec-
tion should always be done ; it removed less tissue and
left a better surface behind.

Dr. Wells said that when he spoke of sharp dissection
it was in reference to the perineum.

Dr. S. JM. Brickner said in reference to the point raised
by Dr. Wells in operations for complete prolapse of the
uterus, that no operation would be a successful one un-
less one precaution was taken, viz., after amputation of the
cervix and when the sutures were taken in the continuance
of the plastic operation, as each suture was tied the cervix
should be pushed back a little. If that was not done when
the posterior colporrhaphy was done, the stump of the
cervix would become strangulated between the sutures
above it in the anterior and posterior wall and slough
away.

The Diagnosis of Early Pregnancy. — Dr. L. T. La-
DixsKi read this paper. (See page 59"-)

Dr. E. McDo.N-.^LD said that in a discussion on the early
signs of pregnancy held in Philadelphia the speakers, among
whom were Hirst, Baldy, and others, depended upon one

April 13, 1907]

MEDICAL RECORD.

625

sign for the diagnosis of early pregnancy, and this Dr. Mc-
Donald thought was a mistake. In a study he presented
there he gave the findings in 100 cases and he thought that
a resume might be of interest to the members of the Sec-
tion. This was as follows :

Week. 5 6 7 8 9 10 11 12 13

No. of Examinations 6 8 12 12 15 15 12 12 8

Enlargement Symmetrical.. . . 4 9 3 9 3 9 1' 5 — 53

Left 2 I 2 3 3 6 2.. 2—21

Right 4 3 I 6 3 6 I I 1—26

Softening Symmetrical 4 9 3 9 3 9 n 5 — S3

Left 2 I 2 3 3 6 2 .. 2—21

Right 4 2 I 6 3 6 I I I — 25

Jacquemier's, Slight 2369424 1 — 34

Marked 3.. 6 6 4 t — 23

Absent 6 6 9 3 6 5 4 4 .—43

Hegar's, Moderate 2666984J i — 45

Definite 2 i 3 6 6 7 8 9 7—49

Absent 2 i 3 — 6

Cervix, Blush 2 I 3 6 9 10 10 12 8—61

Absent 4 7 9 6 6 5 2... .—39

Cervix, Softening 2 2 6 6 S 12 10 12 8 — 66

Absent 4 6 6 6 7 3 2.. . . — 34

Intermittent Contractions.. 3 6 12 12 19 13 11 12 8 — 88

Absent 3 2 . . . . 4 2 I . . . . — 12

McDonald's, Definite 2 6 8 9 18 12 10 10 8—76

Moderate 2 2 3 3 4 3 2 2 ..—21

Absent 2 .. i — 3

Dr. Sidney D. Jacobson said there was no occurrence in
the whole life history of woman which so profoundly af-
fected her body and mind as the advent of pregnancy.
Every organ in the body was influenced directly or indi-
rectly by constructive metamorphosis which went on within
the uterus. Thus the thyroid gland enlarged, the heart
hypertrophied, the kidneys, liver, and digestive tract showed
the strain of increased metabolism. The skin became pig-
mented and both the cerebrospinal and sympathetic nervous
systems gave evidence of functional disturbance. The
blood also was altered profoundly in its character; it
became hydremic, and a leucocytosis was found. This leu-
cocytosis was progressive and reached its highest point just
before delivery of the child and then dropped below normal
for several days or weeks. Rokitansky pointed out that
during pregnancy calcareous plates were deposited upon
the inner table of the patient's skull, and he called these
puerperal osteophites. Because they were rather ele-
mentary Dr. Jacobson said that he would refrain from
describing the minute histological changes which took
place in the genital tract of the pregnant woman, but
would point to some interesting facts which perhaps were
not so well known or so constantly taught. (l) The
uterine and ovarian arteries enlarged so that at term
they were the size of a crow's quill, while the veins
became as thick as a man's little finger. (2) The un-
striped muscular fibers which composed the bulk of the
uterine musculature became elongated to ten times their
previous size, viz., 500 microns. (3) According to Levret
the surface of the virginal uterus was about 16 square
inches; at the end of pregnancy this had enlarged to 339
square inches. (4) According to Krause the capacity of
the uterus at term was 519 times as great as that of the
virgin uterus. Roughly, this would be like the difference
in size of a rowboat and an ocean steamer. (5) The
weight of a nonimpregnated normal uterus was about SO
grms. ; at term it was 1,000 grms. The lait>- could diagnose
a pregnancy in an advanced stage ; but in its beginning the
diagnosis of pregnancy was very difficult. There was a
multiplicity of signs of pregnancy, but not one of them was
decisive before the third month. Dr. Jacobson said that
he felt indebted to Dr. Ladinski for having brought for-
ward a new sign which was decisive of early pregnancy,
and if it proved such Dr. Ladinski would have earned great
merit and deserve the gratitude of the whole profession.

Dr. Brooks H. Wells said that in 1884 Dr. Collyer and
himself made the diagnosis of pregnancy by this same
sign, but they had called it by other names. These signs,
like others, were discovered, became popular, and were
then forgotten. Then they were, as it were, rediscovered.
Therefore, Dr. Wells objected to calling a sign by the
name of an individual, but preferred to give it a descriptive
name. He believed it was perfectly possible to diagnose
pregnancy in certain cases as early as the fourth, the sixth
or the eighth week. A number of cases had been positively
diagnosed in the fifth and sixth week.

Dr. Herman L. Collyer said that he believed Hegar
to be the first to discover or suggest this early sign of
pregnancy and. in this country, Dr. Grandin wrote the
first article on Hegar's sign, but he had added to that sign
what Dr. Grandin had discovered himself but without
taking the credit. Hegar's sign was merely the softening of
the cervical tissue. Dr. Collyer called it an elastic enlarge-
ment at the fundus, as though a rubber ball, had been
shoved up the uterus. Dr. Dickinson had written an ex-
cellent article on this and gave an interesting description.
In addition to the elastic enlargement, discoverable at four
weeks, there was also a softening at the tip of the cervix.
TTiere was also beginning softening of the cervical tissue,
but this was not so early as the elastic enlargement at the
fundus. If the ovum was impregnated at the cornua, the
elastic enlargement would be at that cornua of the uterus.
It seemed to him that the uterus enlarged at the site of
the ovum, where it was apt to remain. Dr. Collyer said
there was another sign equally important, but only corrob-
orative— the pulse sign of Janet of Paris: in this the pulse
beats were the same whether the patient was standing or
sitting.

Dr. Willl\m S. Stone said that at the Vanderbilt Clinic
since September every man who had examined a certain
woman said, "She is about four months pregnant." Dr.
Stone had said the same thing only yesterday (March 27).
Therefore, there was some uncertainty about this sign. He
asked if this elasticity was felt just above the internal os
and then called attention to the explanation of this soften-
ing occurring in Winter's book on "Gynecological Diag-
nosis." McDonald's sign depended upon the same ana-
tomical condition as did Hegar's sign. There was one
thing that they could rely upon, namely, the asymmetrical
uterus in the early part of pregnancy.

Dr. F. h. DoRMAN said there were cases in which every
sign would fail, and the more one examined these cases the
less willing would he be to swear absolutely that a woman
was pregnant at the sixth week. The sign ofTered by Dr.
Ladinski was a valuable one and, from the strong state-
ments made, he would study it more.

Dr. Ladinski said that he had been teaching the im-
portance of this sign for fifteen years and that he had al-
ways told his students that the sign was not original with
him. He had had a splendid opportunity to examine for
this sign at the Beth Israel Hospital, where on some days
as many as seventy or eighty women were examined, and
the sign was found without any questioning of the patient.
He believed that the sign was infallible.

SECTION ON PEDIATRICS.

Stated Meeting, Held March 14. 1907.

Dr. Godfrey* R. Pisek in the Chair.

Angioneurotic and Other Essential Edemas in Children.
— Dr. Herman Schwaez described in brief some of the
theories as to the causation of general and local edema.
The works of Weltzer and Inincke were mentioned. He
then went on to the clinical portion of this paper. The
first case was one of general edema following scarlet fever,
without albumin or casts in the urine. Tlie edema oc-
curred in the second week of the disease, during what

626

MEDICAL RECORD.

[April 13, 1907

appeared to be a normal convalescence, it lasted about two
weeks, and at no time was there albumin in the urine.
The patient made a perfect recovery. The second case
was one of giant urticaria following scarlet fever after
the exhibition of quinine. There was swelling of the
hands, face, and feet, occurring one after the other and
disappearing rapidly. The urine was and has been per-
fectly normal. The third case was one of general edema
following erysipelas neonatorum. Here the signs of the
erysipelas had almost entirely disappeared, and it was only
with the help of the previous history and the condition
of the skin (bleb-desquamation, etc.) that the cause of
this edema was discovered ; urine negative — recovery in
two weeks. Finkelstein and Hensch mention similar cases.
The fourth case was one of general edema, following
gastroenteritis. The uranalysis was negative. This case
was interesting inasmuch as the child was given a mi.x-
ture of fennel tea and barley water for three weeks. Dur-
ing this time it had no edema. Then it was put upon a
mixture of equal parts of milk and barley water — seven bot-
tles a day and a pinch (10 grs.) of salt in each bottle-
in other words, the child received 70 grains of NaCl in
24 hours. After being on this mixture for three days the
edema began to appear. Very probably the atrocious mix-
ture of fennel tea and barley water and the resulting poor
condition of the child had a great deal to do with the
edema, yet in the light of our new theories as to the con-
nection between the retention of chlorides and the appear-
ance of edema, the large amount of salt taken by the baby
might also be taken into consideration and probably be an
exciting factor in this case. The fifth and last case was one
of angioneurotic, or better, acute circumscribed edema, in a
girl of eleven years. The attacks had been coming since
her sixth year — face, hands, and feet, were involved at
different times. She had had edema of the glottis twice
during the past three years. With and without these swell-
ings there were attacks of abdominal pain and vomiting.
These attacks lasted twelve to twenty-four hours. There
was no family history. Neither diet nor drugs had had
any effect in diminishing the frequency or severity of the
attacks.

Dr. Attilio C.-\ccini reported the case of a girl, seven
years old, who was taken ill and developed general
anasarca, and died without presenting any kidney lesions so
far as the urinary findings were concerned. The examina-
tion of the blood showed 7,000,000 red cells, and 120 per
cent, hemoglobin. This was a case probably of angio-
neurotic edema. He said that he had at present a boy,
twelve years old, under observation, whose attacks came
on with the slightest disturbances, as of the tonsils or the
intestines. There was much itching, especially of the head,
neck, and chest. After two or three days lumps would
appear on his forehead, then all over the head, their size
being about that of half an orange. These lumps at times
made him appear as a monster. Another case he had seen
was that of a boy who was suddenly taken with great
dyspnea and, in spite of intubation and tracheotomy, died.
At autopsy nothing was found to account for the death
except the edema of the larynx. He related the history
of another case of a superintendent of a hospital who
complained of toothache, and who was advised to go to a
dentist. For some reason he was given phenacetin, walked
from the hospital, and in fifteen minutes dropped dead
on the sidewalk. His eyes were so swollen that he was
hardly recognizable.

Dr. Louis Curtis Ager of Brooklyn believed that in the
first two cases reported by Dr. Schwarz, the so-called angio-
neurotic edema following scarlet fever, there might have
been some kidney lesions behind to account for the edema
which had not been recognized. He called attention to
Dr. Cabot's long series of investigation in relation to the
urinarj' findings in the various forms of nephritides, and
how careful one should be to exclude nephritis because of
negaitve urinary findings, A large number of cases that

came to autopsy showed kidney lesions when there were
only negative urinary findings during life. One should bear
in mind too that all sorts of irritating conditions of the
skin were produced in children under one year of age by
slight reactions or mild infections. Again, in true angio-
neurotic edema there was apt to be an eosinophilia. Most
of these cases he thought were due to some toxic condi-
tion.

Dr. Godfrey R. Pisek recently was called to see a case
of primary edema of the lungs. Under large doses of
strychnine and adrenals by the mouth, the condition cleared
up. The child was two and a half years old.

Dr. George Dow Scott reported the case of a child with
acute bronchitis and edema of the larynx. The patient
quickly became moribund and died.

Dr. Eli Long said that many of the cases of edema
were due to nephritis, whether anything was found during
life in the urine or not. In those poorly fed, in maras-
matics, edema appeared sooner or later. Also, it was
seen in children with congenital specific disease. He
thought that angioneurotic edema should be placed in a
class by itself, where there was no etiological factor.
Dr. Long told of the case of a child fed on condensed milk;
when placed on proper food the edema cleared up and a
good recovery followed.

Dr. E. H. Bartley of Brooklyn asked for a distinction
between angioneurotic edema and giant urticaria. He
reported the failures made in attempting to cure a man,
forty years old, who had what was diagnosed as giant
urticaria or hives.

Dr. Schwarz said that he had tried to find a distinction
between giant urticaria and angioneurotic edema, but had
not been successful. Cases of urticaria, however, were
almost alwaj's associated with some form of digestive dis-
turbance. Packard had mentioned a case of urticaria asso-
ciated with asthma. Dr. Schwarz could not find any
mention of the violent attacks of colic, vomiting, or diar-
rhea in angioneurotic edema, as occurred in some forms
of urticaria. Light attacks of edema following gastro-
intestinal disturbance he believed to be quite common, and
they disappeared very rapidly on change in diet. The
cases he reported were not very common, especially that
one of erysipelas neonatorum. In the case of enteritis
the question arose whether or not the salt given might
not have had some effect in the production of a nephritis.

The Indications for and the Technique of Paracentesis
of the Drum Membrane. — Dr. John McCoy read this
paper. He first took up the anatomical considerations, be-
lieving that for the intelligent understanding of the causes
and effects of suppuration of the middle ear, it was abso-
lutely essential to have a comprehensive knowledge of the
anatomy of this region. It was of special interest to note
that the roof or vault of the tympanic or middle ear
cavity was formed by the osseous lamina of the squama
and had lying above it a portion of the brain of the middle
fossa. In infants the petrosquamous suture was still
patent, and there was an intimate relation of the blood-
vessels of the dura and of the middle ear. This explained
why so many infants manifested meningeal symptoms when
they had a suppuration in the middle ear, and why it was
so easy for them to develop a meningitis. The following
points should be looked for in a normal drum: (i) A
lustrous pearl-gray, slightly concave, membrane. (2) A
bright reflex of light at the anterior inferior quadrant of
this membrane. (3) A prominent white projection about
the size of a small pin head situated in the center of the
upper portion of the drum. (4) Two whitish bands run-
ning from this prominent white spot in a horizontal direc-
tion, one to the anterior circumference, and the other to
the posterior circumference of the drum. These- were
known as the anterior and posterior folds, and marked
the dividing line between the relaxed and the tense portion
of the drum. Aside from traumatic rupture of the drum
and infection of the middle ear from the external auditory

April 13, 1907]

MEDICAL RECORD.

627

canal, the cause which led in the great majority of cases to
a suppurative inflammation of the middle ear cavity, was
an extension of an inflammation from tlie nose or pharynx
through the Eustachian tube. Occasionally, however, the
inflammation in the middle ear was primary. It had been
demonstrated that streptococci were found in the healthy
middle ear free from all inflammation. The diseased con-
ditions which conduced to an involvement of the middle ear
through the Eustachian tube were such as occurred in any
of the exanthemata, especially scarlet fever, diphtheria, mea-
sles, pneumonia, and influenza. It frequently followed the
ordinary catarrhal cold, and it might follow the introduction
of fluids through the nose into the Eustachian tube. Fol-
lowing the changes to be seen in the drum membrane
from the inception of the inflammatory process to the time
when it became necessary to incise it, there would be seen,
first, that the drum was losing its luster ; following this
there would take place a congestion in the upper rela.xed
portion of the drum which would gradually spread
over the whole driuii. Then would be noticed ,i
slight bulging of outward, usually in the upper posterior
portion of the drum. It was then time to incise
it. In examining ,in ear for this condition it
was well to bear several points in nnnd, as follows :
(i) In infants, the auricle should be drawn downward
and backward to separate the inferior from the superior
wall of the meatus. In older children the auricle should
be drawn upward and backward. (2) One should be pre-
pared with an applicator and cotton to remove particles
either of wax or dead epithelium or medicaments, such as
oil or other substances that might have been introduced
into the canal. (.1) One should remember that instead
of seeing a red bulging drum, one might see a drum of a
dull whitish-gray color. This was due to necrosis of the
Ml epithelium of the dermal layer of the drum, and if this
R was gently swabbed it would come away and rcv^'al the
congested drum beneath. (4) It was always well to ex-
amine both ears. Many children gave no subjective symp-
toms of ear trouble. Earache was frequently produced by
decayed teeth, without any change in the ear wdiatsoever.
Fever was really the only constant symptom, and in the
absence of all other physical signs to explain it. the ears
should always be examined. Prior to a paracentesis the
external auditory canal should be sterilized by irrigation
with 1-2000 bichloride solution. The hands should be
L| sterilized and the instruments boiled. In infants it was
PI better not to give an anesthetic. For older children nitron-^
o.xid gas was safe and efficient. Beginning at the lower
posterior segment a small straight, or sickle-shaped knife
should be plunged into the membrane, and this should be
carried directly up to the superior margin of the drum
and in withdrawing the incision should be carried outward
for about one-eighth of an inch. This gave free drainage
to the whole cavity: the loss of blood and fluid relieved
the pressure and pain ; there was more rapid healing of
the cut surface than if a small opening was made or a
spontaneous perforation was allowed to take place; there
were also minimized the chances of mastoid involvement.
The dangers of paracentesis were that if too much force
was used, or if the operator did not know the direction
in which his knife was cutting, he might enter some of the
structures he had enumerated ; cases had been reported
where the jugular bulb, the carotid artery, or the internal
ear had been entered.

Dr. Louis C. Acer. Dr. Herma.x Sciiw.\rz, Dr. Eli Long,
and others discussed this paper.
Dr. McCoy closed the discussion.

gastrointestinal complications. Dr. Wm. G. Stear.xs pointed
out the complications affecting the nervous system, and
discussed their treatment. Inasmuch as the primary effect
of the influenzal toxin upon the nervous system is always
irritative, he said opium and bromides were found to be
of the greatest use. Calomel and soda, if given with
opium, would aid the diuretic and hepatic stimulation.
\\1iere the wet pack was properly used, its effect was most
benelicial. Dr. Willi.a.m Lincoln Ballenger, in discussing
the treatment of acute mastoiditis due to scarlet fever,
diphtheria, and influenza, presented the following con-
clusions: (I) The reaction of inflammation consisted of an
increased hyperemia, increased cell nutrition (increased
resistance), and an increased migration of leucocytes. (2)
The reaction of inflammation was an increased physiologi-
cal activity for the purpose of eliminating certain noxious
irritants, notably bacteria and their toxins, from the tissues.
(3) In acute inflammations the reaction of inflammation
was usually inadequate to accomplish the destruction of the
bacteria and their toxins within a short time. (4) The
reaction being inadequate, it should be promoted, and
experience had shown such promotion to be effective. (5)
In acute otitis media incision of the ear drum promoted
the reaction of inflammation in the quickest and surest
way, and thus often prevented destructive processes of
this important organ. Incision also provided for adequati*
drainage, and thus favored the elimination of the bacteria,
and raised the resistance of the tissues. In acute mas-
toiditis, leeching, in addition to incision of the ear drum,
if spontaneous perforation had not already occurred, was
the best available means of promoting the reaction of in-
flammation. Heat followed by a dash of cold water was
another effective means of promoting the reaction of in-
flammation. Dr. H. Manning Fish discussed the compli-
cations of influenza resulting from infection of the nasal
accessory sinuses. The author said that the cerebral and
ocular symptoms which either accompanied influenza or
appeared 111 :i patient with a history of influenza should
suggest a sinus disease. Certain symptoms, as vertigo,
cephalalgia, optic neuritis, and other ocular lesions that
were often attributed to circumscribed meningitis, or to a
brain tumor, might be due to a sinus disease. .\ recurrent
inflammatory condition in the eye that was aggravated by a
cold, or was worse in the winter months, suggested a
chronic sinusitis. In :ill c;ises with cerebral symptoms the
accessory sinuses should be examined as well as the
car. S'inus disease should not be excluded on account
of a negative nasal finding, or by the absence of pain,
either spontaneous or on pressure. In the discussion Dr.
Theodore Tieken said he had noticed irritable bladder in
many cases of influenza, and in these microscopic examina-
tion disclosed a catarrhal cystitis. He mentioned a young
girl, with influenza, who urinated every ten or fifteen
minutes. Dr. .\dolph Gehrmann referred to the wide
distribution of the bacillus of influenza, saying it was
relatively easy to lind on mucous surfaces and in pus
that had recently formed. Apparently this bacillus died
when the pus remained for any length of time, and we
probably had the eft'ect of the influenzal bacillus through
its toxin from disintegration. He had found this bacillus
on every mucous membrane in the boily. Dr. .\lmerix W.
Baer deprecated the frequent use of coal tar preparations
in treating cases of influenza, believin.g that nothing was
more debilitating to sick patients than tlie addition of
such drugs to their alreadv diseased condition.

Chicago Medic.\l Society.

At a regular meeting held February 20, iQo;, there was a
symposium on Influenza. Dr. Joseph L. Miller dis-
cussed the etiology, diagnosis, symptoms, and treatment.
with special reference to the cardiac, pulmonary, and

Nervous Lesions Accompanying Exophthalmic Goiter.

— Poggio describes the autopsy on a wonvn i \ ]■■'' -wv •■■■'•{
years, suffering from exophthalmic gniter. ulm diid 111
coma. Except for slight cardiac byinrlrdpliy the organs
were normal. The central nervous system w.is congested
and in the medulla, pons, the floor of tin- fourth venlricle
and in the nuclei of several of the cr:iiiial lu-rves tliere weru
degenerative changes. — Cliiiiai Mrdii-u llaliaiia.

628

MEDICAL RECORD.

[April 13, 1907

i'urijiral g'uijijriittons.

Gunpowder Marks. An ointment of beta-naphthol,
10 ; sulphur, 45 ; lard, 24 ; and green soap, enough to make '
100 pans, is useful in removnig gunpowder not too d'.H'iib
situated in the skin. It must be employed cautiously, how-
ever, to avoid a destructive dermatitis.— -'Imcnfaii Jour-
nal of Surgi-yy.

Epididymitis.— Johnson reports excellent results fol-
lowmg the application of adhesive strips, which latter are
so placed that thev form a slnig. The technique follows:
A.ftcr shaving the parts, the patient being m dorsal decu-
bitus, a strip of zinc oxide plaster two and one-half to
three inches wide is applied to the lower abdomen, from
one and one-half to two inches from the median line ; the
strip, face upward, is taken around and under the scrotum,
elevating the testicles to a level at least as high as the
penopub'ic angle, and forming, as it were, a sling; the
other end of the strip is passed upward on the opposite side
of the median line of the abdomen. A second strap is
similarly applied, and adjusted about the scrotum; a few
short straps are placed across the anterior portion of the
scrotum. Johnson emphasizes the fact that there should be
no pressure made on the inllained ns^^iioi. — i)t. Louis
Courier of Medicine.

Removal of Adenoids.— The following position of the
patient is recommended by Holmes in the Laryngoscope:
The patient, when thoroughly anesthetized, is placed on his
left side on an operating table, the foot of which is slightly
elevated. The left arm and shoulder of the patient are
drawn back, so that the former lies on the table behind the
patient, and the right shoulder is drawn back by an as-
sistant with a view to increasing the breathing space and
at the same time steadying the child. The face is brought
even with the edge of the table or slightly over the edge,
and the operator, equipped with an electric forehead mirror
and seated on a stool of medium height, performs the oper-
ation in the usual way. By this method of performing the
operation, first, the position of the patient adds nothing
to the ordinary dangers of the anesthetic ; the force of
gravitation doe's not add to the burden of the heart ; the
neck is straight ; the respiration is not embarrassed by
"embracing" the chest or "fixing" the arms or by the
pharynx filling with blood which is likely to find its way
into the windpipe. Second, the position of the head is
such that all of the hemorrhage finds its way out_ of the
nose, or out of the mouth. In this way the field of
operation is kept clear so that the operator can at all
times see the posterior pharyngeal wall or can easily clear
it with a wad of cotton on a sponge holder, and can detect
and remove any shreds that tend to make the operation
imperfect: and. third, the amount of blood lost can be
accurately appreciated. — Fort Wayne Medical Journal.

Rectal Hemorrhage. — Tilason says that when blood
is passed from the bowel it is nearly always due to some
form of internal hemorrhoids, generally of the capillary
variety. Well-formed venous tumors, when con-tricted
by the internal sphincter muscle, often bleed profusely, due
to the blood being forced out through a small opening in
the tumor wall. In either case the blood is lost at_ stool.
If the amount is small and is noticed immediately follow-
ing a bowel movement and is accompanied by pain of a
lacerating, aching character, it probably comes from a fis-
sure. If it comes on independently of a bowel movement
it may be due to a carcinoma or ulcer. If it comes on
suddenly and has not been noticed before, it may be due
to a foreign body. — American Journal of Clinical Medicine.
Ankylosis of the Elbowr. — Hoffman has successfully
transplanted a flap of periosteum from the tibia to the
freshened surfaces of the humerus and ulna in a case of
ankylosis at the elbow and in this way secured a satis-
factory result. — Arehiv fiir klinisclie Chirurgie.

Milk as a Hemostatic. — Salt states that in a number
of cases he has found that milk given by rectum served
as a hemostatic in cases of uterine, gastric, and pulmonary
hemorrhage. From eight ounces to two pints of milk,
to which a little salt had been added, were injected. Salt
explains the effect by referring to the fact that milk con-
tains a number of substances, such as calcium and iron
salts, that are ordinarily used as hemostatics, as well as
the products of the degeneration of leucocytes. When
the milk is given by mouth the digested processes interfere
with this hemostatic action. — Tbcrapeutische Monatshefte.
Retroversion of the Uterus. — The following modifica-
tion of the many similar operations for this condition is
suggested by Liepmann. The peritoneum at either side
of the median incision is buttonholed and through each
of the small openings a loop of the corresponding round
ligament is drawn and fixed by a suture passing through
the fascia of the rectus muscle. — Zcntralblatt fiir Gynako-
logie.

STATE BOARD EXAMINATION QUESTIONS.

BoAKC OF Medical Examiners ok the State of Nevada.

August 7, 8, and 9, 1905.

1. What valves guard the auriculoventricular opening
in the left side of the heart? Those in the right?

2. Between the cartilages of what ribs would you locate
the apex of the normal heart? What is the average weight
of the heart of an adult male?

3. What is the average weight of the brain in the adult
male? In the adult female?

4. Name the three principal arteries of the forearm.

5. Of what artery is the nutrient of the tibia a branch?

6. Describe a sesamoid bone, its development, and func-
tion. Name the largest in the body.

7. What muscles are attached, wholly or in part, to the
trochanter major?

8. Name the nerve that supplies the tongue with the
sense of taste: of sensation; of motion.

9. Name the three muscles of the tibiofibular region
(superficial) that form the calf of the leg.

10. Name the ligament implanted near the center of
the head of the femur.

PHYSIOLOGY.

1. Describe a cardiac cycle, and give the phenomena
attending it.

2. Describe the reflex centers.

3. Describe the phenomena of blood clot.

4. What is the function of bile?

5. What is the normal ratio of heart pulsations to res-
piration in a healthy adult?

6. Give the physiological cause of sleep.

7. What is the function of the cerebellum?

8. Give a brief description of the portal circulation.

9. Give principal events in gastric digestion.

10. Define blood pressure.

PATHOLOUV.

1. Give the pathology of arteriosclerosis.

2. What diseases are attended with ulceration of the
intestines?

3. What diseases are attended with cardiac hypertrophy?

4. Describe pus, and give its essential elements.

5. Differentiate fatty degeneration and fatty infiltration;
give cause of each.

6. Describe briefly the pathological changes taking place
in acute lobar pneumonia.

7. Describe lipoma, and give its most frequent locations.

8. State the most important sequel of diphtheria, and
describe to what extent it may occur.

0. What is the significance of hyaline casts in urine?
Of granular casts?

10. Give pathology of embolus ; of thrombus.

BACTERIOLOGY'.

1. Give Koch's rules in regard to bacterial cause of
diseases.

2. Describe the Klebs-Lofiler bacillus.

3. Name four pathogenic bacteria that do not stain by
Gram's method.

4. Describe the Widal serum reaction.

5 What is the commonest microorganism found in em-
pyema ?

MATERIA MEDICA AND THERAPEUTICS.

1. Give the adult dose of three opium preparations.
Name its principal alkaloids.

2. Name three mercurial preparations. Give dose and
use cf each.

3. Name five emetics with dose of each.

4. Name two drugs incompatible with tannic acid. Give
reasons.

5. With what preparations should the iodides 110/ be
combined ?

6. Why should pepsin and pancreatin not be used to-
gether?

7. When is turpentine contraindicated?

8. From where are the following alkaloids obtained?
Quinine, strychnine, physostigmine, hydrastin, atropine.

9. Outline treatment of a case of acute pneumonia.

10. Outline treatment of a case of typhoid fever.

CHEMISTRY .-^ND TOXICOLOGY.

1. What is a mechanical mixture? A chemical com-
pound? Give three examples of each.

2. Describe briefly the three acids most used in labora-
tory.

•April 13, 1907]

MEDICAL RECORD.

029

3. State the occurrence and properties of oxygen, hy-
drogen, and nitrogen.

4. State the occurrence and properties of arsenic, mer-
cury, and iron.

5. Describe respiration from a chemical point of view.

6. Describe the toxic etYect of carbolic acid. Outline
treatment for same.

7. Give symptoms of and antidote for arsenic poisoning.

8. Give symptoms of and outline treatment for a vege-
table poison.

9. Name antidote for nitrate of silver, opium, phos-
phorus, corrosive sublimate, wild parsnip.

10. Give inventory for contents of antidote bag.

THEORY AND PRACTICE OF MEDICINE.

1. Give the symptoms of typhoid fever in first, second,
third, and fourth weeks, and treatment of same.

2. Give diagnosis, pathological anatomy, symptoms, and
treatment of chronic parenchymatous nephritis.

3. Give symptoms and treatment of cerebrospinal men-
ingitis.

4. Give stages and symptoms of acute lobar pneumonia,
and treatment.

5. What are the symptoms, complications, and differen-
tial diagnosis of acute articular rheumatism and treatment?

6. What are the causes of, morbid anatomy, symptoms
and treatment of rickets?

7. Give difTerential diagnosis of chronic gastric catarrh,
gastric ulcer, and gastric cancer.

8. Give the forms of endocarditis, pathological anato-
my, and physical signs.

9. Give definition, etiology, symptoms, complications,
prognosis, and treatment of erysipelas.

10. Give the causes and symptoms of pneumothorax.

OBSTETRICS.

1. What is tubal pregnancy? Differentiate it from nor-
mal pregnancy. What are the three greatest dangers to
the mother in tubal pregnancy?

2. What foramen unites the right and left auricles in
the fetal heart?

3. In twin births how many placentas are there?

4. What membranes invest the fetus? Define their re-
lations to it from within outward.

5. What veins carry arterial blood in the fetus?

6. What are the two most reliable diagnostic indications
of abortion? How would you treat a case of threatened
abortion ?

7. What position does the uterus assume during the
first three months of pregnancy?

8. What is the average period of pregnancy, computed
. hy days? What were the extremes that legitimized a child

under the Code Napoleon?

9. Diagnose a placenta previa. How would you treat
such a case'

in. What are the most grave gynecological diseases to
anticipate after delivery?

GENITOURINARY DISEASES.

1. Give differential diagnosis of anterior and posterior
urethritis, complications of each, and write six prescrip-
tions for treatment, three internal and three local.

2. What are the causes of orchitis, and give treatment
of same.

3. Give treatment for gleet.

4. Describe a case of gonorrheal rheumatism, give
causes, treatment, and prognosis.

.S. Give history and description of syphilitic dermatitis.

6. Make differential diagnosis of hard and soft chancre
and treatment of each.

7. Give causes, symptoms, and treatment of organic
urethral stricture.

8. W^hat is syphilitic dactylitis, the varieties, and tissues
involved in each variety?

9. Describe the general course of syphilis, giving stages,
symptoms, and treatment of each stage.

10. Give causes, symptoms, prognosis, and treatment of
pyosalpinx.

.WSWERS TO ST.A.TE BOARD EX.\MIX.\TIOX
QUESTIONS.

Board of Medical ExAMiNr.RS of the State of Nevada.

AtigKst 7, 8. and 0. 1005.

ANATOMY.

1. The mitral or bicuspid valve, on the left side; the
tricuspid valve, on the right side.

2. Between the fifth and sixth, on the left side. .Aver-
age weight is ten to twelve ounces.

,;. Ill the male, forty-nine ounces; in the female, forty-
four ounces.

4. 1 he radial, the ulnar, and the posterior interosseous.

5. The posterior tibial.

(j. Sesamoid bones are cartilaginous in early life, but
later become osseous. They are developed in the tendons
of muscles at points where these latter are exposed to
pressure upon the parts over which they glide. Their
function is to increase tlie leverage of the muscles. The
largest sesamoid bone in the body is the patella.

7. Gluteus niedius, gluteus minimus, pyriformis, obtura-
tor externus, obturator internus, gemellus superior, gemel-
lus inferior, and quadratus femoris.

8. The tongue is supplied with the sense of tdslc by
the chorda tympani and the glossopharyngeal nerves ; of
sensation, by the lingual branch of the inferior maxillary
division of the fifth cranial nerve; of motion, by the hygo-
glossal nerve.

o. The gastrocnemius, soleus, and plantaris.
lb. The ligamentum teres.

PHYSIOLOGY.

3. When blood is withdrawn from the blood-vessels of
the living body, it first becomes viscid, then sets, and is
converted into a jelly-like mass. This is due to the forma-
tion of fibrin. The jelly contracts forming the clot; and
at the same time the serum is squeezed out from the clot.
Various circumstances and conditions will hasten or delay
the process of coagulation. In man, the blood generally
becomes viscid in from two to three minutes ; it forms
the jelly-like mass in from five to six minutes; a few min-
utes later the serum begins to appear; and the whole
process is completed in from twenty-four to thirty-six
hours. The clot then floats on the serum. The process
is thus summed up bv Halliburton : In the plasma a proteid
substance exists, called Fibrinogen. From the colorless
corpuscles a nucleo-proteid is shed out, called Prothrombin.
Bv the action of calcium salts prothrombin is converted into
fibrin ferment, or Thrombin. Thrombin acts on fibrinogen
in such a way that two new substances are formed : one of
these is unimportant and remains in solution ; the other
is important, viz.. Fibrin, which entangles the corpuscles,
and so forms the clot.

4. The functions of the bile are: (l) to assist in the
emulsification and saponification of fats; (2) to aid in
the absorption of fats: (3) to stimulate the cells of the
intestine to increased secretory activity, and so promote
peristalsis, and at the same time tend to keep the feces
moist ; (4) to eliminate waste products of metabolism, such
as lecithin and cholesterin ; (5) it has a slight action in
converting starch into sugar; (6) it neutralizes the acid
chyme from the stomach, and thus inhibits peptic digestion ;
(7) it has a very feeble antiseptic action.

5. About four or five heart pulsations to one respira-
tion.

6. "There are several hypotheses as to the causation
of sleep. It has been attributed to cerebral aneiuia: to
chemical changes in the brain cells or neurons, such as an
exhaustion of their intramolecular oxygen, or an accumu-
lation of fatigue products; to a contraction of the dendritic
processes, and a consequent break in the transmission of
nervous impulses ; to an expansion of the neuroglial cell
processes insulating the nerve cell processes, and pro-
ducing the same effect : and to a purely psychological con-
dition, namely, loss of consciousness apart from any
physical or chemical change. This last explanation is
simply a cloak for our ignorance. The most probable
hypothesis is that of an altered metabolism of the cerebral
cells dependent upon exhaustion and diminished influx of
stimuli." (Allbutt's System of Medicine.) Two new
theories have recently been promulgated : One claims that
sleep is due to an internal secretion of the pituitary gland,
v.hereas the other makes it depend upon the phenomena of
osmosis.

7. Coordination and equilibrium.

u. The principal events in gastric digestion are the con-
version of the proteids into proteoses and peptones, _which
are more soluble and diffusilile. Starches arc unaffected,
and fats are not altered chemically.

10. Blood pressure is the pressure on the blood due
to the ventricular systole, the elasticity of the walls of
the arteries, and the resistance of the capill.iries.

PATHOLOGY.

2. Typhoid fever, tuberculous enteritis, dysentery, chronjc
nephritis, extensive burns, syphilis, cancer, enteritis in
children, actinomycosis, and anthrax.

3. Chronic nephritis, emphysema, fibroid plillii^is. _aortic
stenosis, aortic rcgursitatinn. mitral regurgitation, fibrous
mvocarditis, arteriosclerosis, gout, lithemia, pericardial ad-
hesions, exophthalmic goiter, hvsteria, lead poisoning, and
syphilis.

630

MEDICAL RECORD.

[April 13, 1907

4. Pus is a thick, creamy fluid, alkaline in reaction, with
a specific gravity of abdut 1030. and containing from eighty
to ninety per cent, of water. On standing it separates into
two layers, the upper part being fluid, and consisting of
serum, a little proteid matter and liquefied tissue ; the
lower, or solid part, contains dead and living pus cor-
puscles, fatty and granular debris, and sometimes micro-
organisms, and a few red blood cells.

5. In fatty iiMtralion the tis.sues contain fat brought
from without; there is no change in the cell protoplasm,
and such damage as the tissue undergoes is due to the
mechanical pressure caused by the fat.

In fatty degeneration the cell protoplasm undergoes
change : the fat is in the cells, and not between them.

Fatty infiltration may be due to obesity, lack of exercise,
overeating, or drinking, carcinoma, diabetes, chlorosis, frac-
ture, or disease of bones, or it mav be hereditary.

Fatty degeneration may be caused by poisoning (chiefly
by phosphorus, lead, mercury, or arsenic), anemia, pro-
longed fevers, diabetes.

7. .\ lipoma is a benign tumor composed of fatty tissue.
It is roundish, soft, generally circumscribed and encapsu-
lated, and lobulatcd. On section the fat is seen to be
divided by septa of fibrous connective tissue. It is of
slow- growth, and generally appears in adult or middle
life, but mav also appear in childhood.

The most freciuent locations are the subcutaneous tissue
of the shoulders, limbs, back, and buttocks, the mammary
gland, and kidney.

8. Paralysis is the most important sequel of diphtheria.
It is due to toxic neuritis, and is found as a rule during
convalescence, and occurs in from about ten to fifteen per
cent, of all cases. It may follow either a mild or a severe
attack of diphtheria; and the pharynx, uvula, muscles of
the eves, face, one or both extremities, respiration, or
heart may be afltected.

9. "Hyaline casts are common to all diseases and dis-
turbances of the kidney, and not pathognomonic of any
one abnormal condition. 'They arc, however, predominant
in the sediment in cases of chronic interstitial, chronic dif-
fuse nephritis, amyloid infiltration, and in passive hyper-
emia; w-hile their relative proportion is much smaller _ in
comparison with the other forms of casts present in active
hyperemia, acute nephritis, and subacute glomerular ne-
phritis."

"Finely granular easts are found in every disease or
disturbance of the kidney; they, therefore, cannot be con-
sidered patho.gnomonic of any one disease or class of dis-
eases." (Ogilen, On the Urine.)

BACTERIOLOGY.

1. Koch's rules in regard to the bacterial cause of
disease are: (l) the microorganism must be found in the
tissues, blood, or secretions of a person or animal sick or
dead of the disease; (2) the microorganism must be iso-
lated and cultivated from these same sources; it must also
be .grown for several generations in artificial culture
media; (3) the pure cultures, when thus obtained, must, on
inoculation into a healthy and susceptible animal, produce
the diseases in question, and (4) the same microorganisms
must again be found in the tissues, blood, or secretions of
the inoculated animal.

2. The Klcbs-Loeftler bacillus is a short rod, about
three to six microns in length, and about a half to one
micron in breadth ; the extremities may be rounded or
clubbed. The bacilli are slightly curved, and may occur
singly, in pairs, or in .groups ; they are non-motile, have
no flagella, are aeroliic, and contain granules which take
on a deeper stain. The bacillus stains with the analine
colors, by Gram's method, and with Loeffler's alkaline
m.ethylene-bluc.

3. Bacillus cflli communis. Spirillum cholcrce asiaticce.
Friedlandcr's Bacillus fneumouia, and Obermeier's spiro-
chete of relapsin.g fever.

4. The Widai serirm reaction "depends upon the fact
that serum from the blood of one ill with typhoid fever,
mi.xed with a recent culture, will cause the typhoid bacilli
to lose their motility and gather in groups, the whole
called 'clumping.' Three drops of blood are taken from
the well-washed aseptic finger tip or lobe of the ear,
and each lies by itself on a sterile slide, passed through
a flame and cooled just before use; this slide may be
wrapped in cotton and transported for examination at
the laboratory. Here one drop is mixed with a large drop
of sterile water, to redissolve it. A drop from the summit
of this is then mixed with six drops of fresh broth culture
of the bacillus (not over twenty-four hours old) on a
sterile slide. From this a small drop of mingled culture
and blood is placed in the middle of a sterile cover-glass,
and this is inverted over a sterile hollow-ground slide
and examined. ... A positive reaction is obtained when
all the bacilli present gather in one or two masses or

clumps, and cease their rapid movement inside of twenty
minutes." (From Thayer's Pathology.)

5. The microorganisms most commonly found in em-
pyema are the Stret'tococcus pyogenes and the pncumo-
coccus ; others commonly found are the Staphylococcus
pyogenes and the tubercle bacillus.

M.-VTERIA MEDICA AND THERAPEUTICS.

1. Pulvis Ipecacuanhae et Opii, dose gr. vijss. Acetum
Opil. dose HEviij. Tinctura Opii, dose TIEviij. Vinum
Opii, dose TlEviij. The principal alkaloids are: Morphine,
codeine, thebaine, narcotine, papaverine, pseudomorphine,
and narceine.

2. Mydrargyri Chloridum Corrosivum, dose gr. 1/20;
used chiefly, externally, as an antiseptic and parasiticide.
Hydrargyrum cum Creta, dose gr. iv ; used chiefly as a
mild laxative, an alterative, and antisyphilitic. Hydrargyri
Subsulphas Flavus, dose gr. ij to iv ; used as an emetic.

3. .Xpomorphinse hydrochloriduni, dose gr. 1/16, hypo-
dcrmatically ; or gr. i/io, by mouth. Zinci Sulphas, dose gr.
XV to XXX. Cupri Sulphas, dose gr. iv. Alumen, dose a
teaspoonful. Antimonii et Potassii Tartras, dose gr. j to ij.

4. Ferric Salts and Alkaloids. With the former, ink
is formed ; with the latter, an insoluble precipitate.

i. With mineral acids, alkaloids and their salts, metallic
salts, and ammonia.

6. Because pepsin requires an acid medium in which
to exercise its powers, and pancreatin requires an alkaline
medium.

7. In diseases of the kidneys, cardiac hypertrophy,
hemorrhage, and plethora.

8. Quinine, from Cinchona. Strychnine, from Strychnos
Xux Vomica, and Strychnos Ignatia. Physostigmine, from
Physostigma (Calabar bean). Hydrastin, from Hydrastis
(Golden Seal or Yellow Puccoon). Atropine, from Atropa
Belladonna.

CHEMISTRY AND TOXICOLOGY.

1. A chemical compound is a substance made of two
or more elements, chemically united, in definite propor-
tions. Examples : water, sulphuric acid, iodoform.

.4 mechanical mi.vture is the product obtained by uniting
into a more or less homogeneous whole two or more
substances, whether elements or compounds, in any pro-
portion, and without any chemical union. Examples : air,
sugar adulterated with sand, salt in water.

2. Hydrochloric acid: when pure this is a colorless
gas with a sharp, penerating. and irritating odor ; it is very
soluble in water ; it does not support combustion nor
does it burn in air; it is very corrosive. The ordinary
hydrochloric acid is a solution of this gas in water,
and is found in three varieties : the commercial, the pure,
and the dilute acids.

Sulphuric acid is a colorless, thick, oily liquid, odorless,
very corrosive ; has a great tendency to unite with water ;
it chars organic matter.

.Xitrie acid is a colorless or faintly yellow liquid, has
a sour taste, a suffocating odor, and is very corrosive.
It is a strong oxidizing agent, and stains animal tissues
vvllow.

3. 0.rygen. Occurrence: free in the air and in com-
bination in water, rocks, minerals, etc. It is more abun-
dant than any other element, forming about forty per
cent, of the total weight of the earth. Properties: It is
a colorless, odorless, tasteless gas, heavier than air, slightly
soluble in water, has an intense affinity for other elements,
combining with almost all of them except fluorine. It
is necessary to life, and is a supporter of combustion.

Hydrogen. Occurrence: free in volcanic gases, in fire
damp, and the gases of the intestines ; and in combination
in water, all acids and in many organic compounds. Prop-
erties: A colorless, odorless, tasteless .gas, the lightest
known substance ; it has a great affinity for o.xygen ; it
supports neither combustion nor respiration ; it is a neces-
sary constituent of all acids ; the gas will burn with a
pale blue flame, giving little light, but an intense heat.

Nitrogen. Occurrence: free in the air, in combination
in nitrates, ammonia, and in many organic substances.
Properties: A colorless, odorless, tasteless gas, it neither
burns nor supports combustion nor respiration, it has no
tendency to unite with other elements.

4. Arsenic. Occurrence: free in very small quantities;
chiefly in combination with sulphur as realgar, orpiment,
and mispickel. Properties: It is a gray solid, is easily
powdered, if pure it is odorless and tasteless; it is a
good conductor of electricity, and is easily oxidized. There
are four atoms to the molecule of arsenic.

Mercury. Occurrence: Usually found in combination
with sulphur, as cinnabar. Properties: It is liquid metal,
is slightly volatile, the molecule contains only one atom ;
it unites directly with chlorine, bromine, and iodine ; it
is a necessary constituent of amalgams.

Iron. Occurrence: free, in small quantities only; in

April 1,5, 1907

MEDICAL RECORD.

631

combination as oxides, carbonates, or sulpliidcs. in hema-
tite, magnetic iron, spathic iron, pyrites, etc. Piopciiii's:
Pure iron is white and soft, and crystallizes in cnbcs or
ootahedra; it is vmaffected by dry air at ordinary tempera-
ture; in damp air it is converted into iron rust (,a hydrate
of iron) ; at red heat it is o.xidized. It is dissolved by
the strong' mineral acids.

6. Syiiifitoiiis: "Those portions of the skin and mucous
membrane which have been in contact witli the poison are
whitened and hardened. There are burning pains in the
moutli. esopliagus, and stomach, and vomiting; lowering of
the pulse and temperature, contraction of the pupils, stupor,
syncope, and collapse, terminating in death. The urine,
clear and of the normal color when voided, becomes rapi41y
greenish, and finally dark olive-green or almost black."
(Witthaus. )

Tri'almcnt: White of egg should be administered; also
sodium sulphate, and the stomach should be gently washed
out. .'\lcohol is said to be antidotal.

7. Syiiif'toms: "In acute cases the symptoms usually
begin in from twenty to forty-five minutes. Nausea and
faintness. Violent, burning pain in the stomach, which
becomes more and more intense, and increases on press-
ure. Persisting and distressing vomiting of matters, some-
times brown or gray, or streaked with blood, or green
(Paris green). Purging. More or less severe cramps in
the lower extremities."

Ill Chronic Cases: "Inflammation of the conjunctiv.Te.
with intolerance of light. Irritation of the skin, accom-
panied by an eruption (eczema arscnicale). Local paralyses.
Great weakness and emaciation. Exfoliation of the cuticle
and falling out of the hair." (Witthaus.)

The antidote is freshly prepared ferric hydroxide.

9. The antidote for nitrate of silver is salt and water;
for allium, there is no one substance which is a complete
antidote, washing out the stomach with a dilute solution
of potassium permanganate is the best treatment ; for phos-
j'Jwrus. old French oil of turpentine ; for corrosive sub-
limate, white of egg; for ',eild parsnip, emetics, lavage, and
purgatives.

10. The following is mentioned in Potter's Materia
Medico, etc. : Dialyzed iron, syrup or chloral, chloroform,
spirits of chloroform, calcined magnesia, aromatic spirits
of ammonia, oil of turpentine, acetic acid, tincture of digi-
talis, tannic acid, amyl nitrite, zinc sulphate, ipecacuanha,
potassium bromide, potassium permanganate. Also a hypo-
dermic syringe and solutions or pellets therefor of: mor-
phine sulphate, atropine sulphate, apomorphine hydro-
chlorate, pilocarpine nitrate, strychnine nitrate. To the
above should be added a stomach tube and a soft rubber
catheter.

THEORY .AND PK.MTKE OF MEDICINE.

7. Chronic !;aslric catarrh is generally caused by indis-
cretions in diet, or by mental worry, it may occur at any
time of life, and is characterized by pain in the epigastric
region which generally comes on after eating; there is
apt to be morning vomiting, the vomitus consisting of
mucus with undigested particles of food ; there is seldom
hemorrhage; the stomach may be enlarged, and examination
of the gastric contents shows free HCl diminished or
absent, and the digestive ferments diminished.

Gastric ulcer is generally caused by injury or bacteria,
is most apt to occur between the ages of twenty and forty-
five ; after eating there is pain localized in the stomach,
vomiting occurs soon after eating, hcmatemesis is common,
there is localized tenderness over the stomach, and examin-
ation of the gastric contents shows an excess of free HCl.

Gastric cancer does not usually occur before forty years
of age, is more common in males, the pain is localized and
constant, vomiting is copious and occurs some time after
eating; the vomitus contains "coffee ground" material;
heniorrha.ges are common ; a tumor may be palpated, and
examination of the eastric contents shows absence of free
HCl and presence of lactic acid; severe anemia and ca-
chexia are also present.

OBSTETRIC s.

I. Tubal pregnancy is a pregnancy in which the ovum
is arrested in the Fallopian tube and develops there in-
stead of in the uterine cavity.

In differentiating this condition from a normal pregnancy
the following signs and symptoms are of most reliance.
"When extrauterine pregnancy exists, there are: (i) The
general and reflex symptoms of pregnancy ; they have often
come On after an uncertain period of sterility. Nausea
and vomiting appear aggravated. (2) Then comes a dis-
ordered menstruation, especially n>etrorrhagia, accom-
panied with gushes of blood, and with pelvic pain coinci-
dent with the above symptoms of pregnancy. Pains are
often very severe, with marked tenderness within the pelvis.
Such symptoms are highly suggestive. (3) There is the
presence of a pelvic tumor characterized as a tense cvst.

sensitive to the touch, actively pulsating. This tumor
has a steady and progressive growth. In the lirst two
months it has the size of a pigeon's egg; in the third
month it has the size of a hen's egg ; in the fourth month
it has the size of two fists. (4) The 05 uteri is patulous;
the uterus is displaced, but is slightly enlarged and empty.
(,S) Symptoms No. 2 may be absent until the end of the
third month, when suddenly they become severe, with
spasmodic pains, followed by the general symptoms of
collapse. (6) Expulsion of the decidua, in part or whole.
Nos. I and 2 are presumptive signs: Nos. 3 and 4 are
probable signs; Nos. 5 and 6 arc positive signs." (American
Text-Book of Obstetrics.)

The three greatest dangers to the mother are : hemor-
rhage, peritonitis, and death.

2. The foramen ovale.

3. If the twins are from two ova from separate Graafian
follicles there will be two placentae ; if from two ovules
from one Graafian follicle, there will be one placenta; if
from a single ovule with two nuclei, there will be one
placenta.

4. The membranes investing the fetus are, from within
outwards, the amnion, the chorion, and the decidua.

5. The umbilical veins.

6. Hemorrhage and a dilated os.

Absolute quiet and rest in bed, with the head lowered,
and in a darkened room. Nerve sedatives should be ad-
ministered in large doses; opium is indicated, cither lauda-
num in fifteen or twenty minim doses, or the extract
of opium in suppository. After the cessation of the hemor-
rhage the patient should be kept in bed for one or two
weeks.

7. Increased anteflexion and descent.

8. About 278 to 280 days.

The extremes that legitimatized a child under the Code
Napoleon were 180 and .soo days.

10. "Tears of the perineum destroy the integrity of
the pelvic floor and result eventually in rectocele. cystocele,
hemorrhoids, and displacements of the pelvic organs. If
the tear involves the sphincter ani. incontinence also results.
Lacerations of the cervix retard or check involution of the
uterus and predispose to endometritis, menorrhagia, dis-
placements, cversion of the cervical mucous membrane, cys-
tic degeneration, and malignant disease. Deep lacerations
of the vaginal vault may open into the base of the broad
ligaments, and in the majority of instances genitourinary
fistulas are caused by traumatisms of labor. All lacerations
are immediately dangerous on account of the increased
liability to sepsis, while the remote results are generally
due to interference with involution or the pelvic circula-
tion and to the destruction of the normal supports of the
pelvis." (Ashton's Gynecology.)

(;enitoi'rin.\rv di-seases

1. "The symptoms of acute anterior urethritis are: An in-
cubation period of twenty-four hours, a tickling or an
itching sensation at the meatus, which is red, glazed, and
often colored with grayish, opaline mucus; the discharge is
scanty at first, but gradualy increases. ,'\t the end of
three or four days the redness and congestion about the
meatus increase and may cause edema, phimosis, and para-
phimosis. Lymphangitis is present. The discharge becomes
thick and purulent. Ardor urinae, chordee, and frequent
urination are now present. .\t this stage, when the urine
is passed into two glasses, in the first glass the urine will
be cloudy; in the second, clear. The symptoms just men-
tioned usually last for about four weeks, when they grad-
ually abate.

"The complications of acute anterior urethritis are
phimosis, paraphimosis, chordee, painful erections, penitis,
lyiniihangitis, adenitis, balanitis, periurethral abscess, Cow-
pentis, hemorrhage, and preputial folliculitis.

"Symptoms of acute posterior urethritis. — The discharge
decreases ; the frequency of urination increases ; vesical te-
nesmus may be present ; there is considerable pain ; he-
maturia, albuminuria, and retention of urine are also
symptoms. When the urine is passed into two glasses,
both specimens will be cloudy.

"Complications of posterior urethritis are prostatitis,
seminal vesiculitis, inflammation of the cord, epididymitis,
orchitis, cystitis, nephritis, pyelitis, abscess of the prostate,
abscess of the kidney, peritonitis, uremia, retention of
urine, gonorrheal rheumatism. The sequels arc hyypochon-
driasis. sexual neurasthenia, stricture, impotence, sterility,
hyperesthesia, spermatorrhea, and melancholia." (Gould
and Pylc's Cyclopedin of Medicine and Surgery.)

2. Causes of orchitis: — Traumatism, inflamm;ition of the
urethra, epididymitis, rheumatism, mumps.

Treatnieut : — Rest in bed. elevation of the parts, hot or
cold applications, pain is to be relieved by opiates or
leeches, lead water and laudanum should be applied, salines
or cathartics are to be administered. Sometimes strapping

632

MEDICAL RECORD.

[April 13, 1907

the testicle is of service; so too,
iclithyol and lanolin,
6.

the application of

HARD CHANCRE.

First lesion of a constitu-
tional disease, viz., syphi-
lis.

Due to syphilitic infection.

Generally a venereal infec-
tion.

May occur anywhere on the
body.

Period of incubation never
as ^hort as ten days.

Generally single.
Not autoinoculable.
Secretion slight.

Slightly or not at all painful.

As a rule only occurs once
in any patient.

Buboes are painless and sel-
dom suppurate.

SOFT CHANCRE.

A local disease.

Due to contact with secre-
tion from chancroid.
Alway.s a venereal infection.

Nearly always on genitals.

Period of incubation always
less than ten days (gen-
erallv about three).

Generally multiple.

Autoinoculable.

Secretion profuse and puru-
lent.

Generally painful.

May reoccur in same pa-
tient.

Buboes are painful, and
usually suppurate.

8. Syphilitic dactylitis is a specific gummatous mfiltration
of the tissues of the digits, occurring in the tertiary stage
of syphilis. It tends to undergo necrosis and ulceration, or
inflammation and subsequent pyogenic infection.

There are two varieties: (l) In which the subcutaneous
fibrous tissues and the ligaments are involved; and (2) in
which the periosteum and bone are specially affected.

BULLETIN OF APPROACHING EXAMINATlONS.t

STATE.

Alabama*.
Arizona*. ..
Arkansas* .
California. .
Colorado. . .

Connecticut*. .

Delaware

Dis. otCol'bia.
Florida*

Georgia

Idaho

Illinois

Indiana

lou-a

Kansas. . . .
Kentucky*..

Louisiana.. .

Maine

Maryland

Massachusetts*

Michigan ....

NAME AND ADDRESS O? PLACE AND DATE OF

SECRETARY. NEXT EXAMINATIOV

W. H. Sanders. Montgomery. Montgomery. ..May i

.A.ncil Martin. Phoenix Phoenix July

F.T. Murphy. Brinkley Little Rock. . .Julx

Chas. L.Tisdale, Alameda San Francisco. April

S. D. Van Meter. 1723 Tre-

mont Street. Denver Denver July

Chas. A.Tuttle. New Haven. .New Haven. .July

I. H. Wilson. Dover Dover June

W.C.Woodward, Washington. Washington. . .July
J. D. Fernandez, Jacksonville.Jacksonville. .May

r. t. A .u r^ -cK (Atlanta April

E R. Anthony, Gnffin •) Augusta May

J. L-Conant, In, Genesee Boise October

J. A. Egan, Springfield Chicago AprU

W T. Gott, iro State House,

Indianapolis Indianapohs. . Mav

Louis .\. Thomas. Des Moines. Des Moines June

T. E. Raines, Concordia Topeka June

J. N. McCormack. Bowling

Green Louis\-iIle .April

,F. A. La Rue, 211 Camp St.,

New Orleans New Orleans. .May

Wm. J. Mayburv, Saco Augusta July

J. McP. Scott, Hagerstown... .Baltimore June

E. B. Har^'ey, State House,

28

Minnesota. . .
Mississippi. . .

Missouri

Montana*.. . .
Nebraska. . . .

Nevada

N. Hamp're*.

New Jersey.. .
New Mexico..

Boston Boston May

.B. D. Harison, 20'; Whitney

Bxiilding, Detroit Ann .Arbor. . . . June

. W. S Fullerton. St, Paul St. Paul June

J. F. Hunter, Jackson Jackson May

St. Louis..

April

. J. A. B . Adcock, Warrensburg { Kansas City f

."Wm. C. Ridden, Helena Helena October

.Geo. H. Brash. Beatrice Lincoln

.S- L.Lee, Carson City Carson City. May

.Henry C. Morrison. State Li-
brary, Concord Concord July

.J. W Bennett, Lone Branch. .Trenton June

B. D. Black, Las Vegas Santa Fe June

New York .

N. Carolina*...

N. Dakota

Ohio

Oklahoma* . . .
Oregon*

Pennsylvania..

Rhode Island..
S. Carolina. . . .
S. Dakota

Tennessee* —

Texas

Utah*

Vermont

Virginia

Washington*..
W. Virginia*. .

Wisconsin

Wyoming

i New York,
C.F.WheelockUnivof State J Albany,
of New York, Albany ^ Syracuse.

^ ,- Mav

, Buffalo

G. T. Sikes. Grissom Morehead City.May

H. M. Wheeler. Grand Forks. .Grand Forks.. . July

Geo H. Matson, Columbus... .Columbus June

J. W.Baker, Enid Guthrie June

B. E. Miller. Portland Portland

N. C. Schaeffer. Harrisburg. { ^I'^t'sWg!''^ } J""^

G.T. Swarts. Provilence. . . . .Pro\*idence July

W. M. Lester, Columbia Columbia June

H. E. McXutt, Aberdeen Sioux Falls July

f Memphis. ]
T. J. Happel. Trenton \ Xash%-ille, } May

[ Knoxville, j

T. T. Jackson, San Antonio. . .Austin AprU

,R. W. Fisher, Salt Lake City. .Salt Lake City. Ju'.y

, W Scott Nay, Underhill Burlington... .July

R. S. Martin. Stuart Lvnchburg... .June

,C. W, Sharpies, Seattle Seattle July

H. A. Barbee. Point Pleasant. Charleston. . . .July

.J. V. Stevens. Jeflerson Madison July

, S. B. Miller, Laramie Cheyenne

Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious disease reported to the
Sanitary Bureau, Health Department, New York City, for

the week ending April 6, 1907 :

Jxine II

June —
May S

*No reciprocity recognized by these States,
t.^pplicants should in every case write to the secretary for
details regarding the examination in any aprticular State.

Tuberculosis Pulmonalis

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis
Malarial Fever

Totals

Cases Deaths

386

211

319

38

4IS

21

392

16

4

—

73

—

92

18

74

12

18

10

1773

326

Health Reports.— The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital

Service, during the week ended April 5, 1907:

SMALLPOX — UNITED STATES.

California. San Francisco Mar, 16-23 . • •

Florida. Duval Co.. Jackson\-i!le . .Mar. 23-30. . .

Hillsboro County Mar. 23-30. . .

Polk County Mar. 23-30. . .

Suwanee County Mar. 23-30. . .

Georgia. Augusta Mar. 26-Apr.

Illinois. Chicago Mar. 23-30 . . .

Galesburg Mar. 23-30 . . .

Indiana. Indianapolis Mar. 24-31- • •

Marion Mar. 1-3 1 . . .

Iowa. Clinton Mar. 16-23. • -

Kansas. Kansas City Mar. 23-30. . .

Louisiana, Xew Orleans Mar. 23-30. . .

Massachusetts. Boston Mar. 23—30. . .

Michigan. Detroit Mar. 2-9. . . .

^lissi:^sippi. Gulfport Mar. 18-25. • ■

^lissovlri. St. Joseph Mar. 2-q. . . .

St. Louis Mar. 23-30. . .

Xew Jersey. Hoboken Mar. 23-30. . ,

Newark , , . Mar. 23-30 . . .

Xorth Carolina. Charlotte Mar. 23-30. . .

Ohio, Cleveland Mar. 22—29. - ■

Texas, Houston Feb. 3-Mar.

Washington, Seattle Mar. 17-24- ■ •

Spokane Mar. 16-23. - ■

CASES. DEATHS.

I I imported

SMALLPOX FOREIGN.

II Canada: X. S.: Colchester County. .Mar.

Pictou County Mar.

23 B. C. : Vancouver Mar.

Manitoba, Winnipeg. .... Mar.

9 China. Hongkong Feb.

9 Shanghai Feb.

— Ecuador. Guayaquil Mar.

France. Dunkirk Feb.

14 Marseille Mar.

Paris Mar.

11 Germany. Bremen.. .. Mar.

4, Metz and \'icinity Mar.

14 Great Britain. Manchester . . .Mar.

.^ India. Bombay Peb.

^^ C:^:cutta Feb.

1 Madras Feb.

Italy. Turin Mar.

6 Mexico. Agiias Calientes Mar.

Mexico. Feb.

9 Portugal. Lisbon Mar.

18 Russia Odessa Mar.'

3 Riga Mar.

St. Petersburg Feb.

Warsaw Feb.

'5 ■ ■

1 6-23

16-23

2-16

g-23

2—16

6-Mar. 8.

6-13

9-16

9-16

3-16

9-16

27-Mar. 5 .

16—23

23-Mar. I .

2-9

16-23

1 6-Mar. 2.

9-16, ... .

2-0

9-16

23-Mar. 9.

9-16

76

I

18

Present
Present

X

1
27

26

12

StiU
n

i

5 imported
present

2

3
33

32

6

YELLOW FEVER.

Africa, Dahomey. Grand Pope. . . Jan. 15 ... .

Brazil, Para Mar. 2-0 - .

Ecuador. Guayaquil Mar. 2-16. .

Mexico. Vera Cruz. Paraje Xuevo. .Mar. 2-9. -

CHOLERA.

India. Calcutta Feb. 16-23.

Madras Mar. i . . . .

Rangoon Feb. 16-23 .

PLAGUE.

Hawaii. Honolulu Mar. 2-9. .

PLAGl" BEFORE ION.

9-16.

J

3

29

Present

42

3

4

1-7.

1-7.

China. Hongkong Feb.

N'iuchwang Feb.

Egypt. .Assicut Pro\Hnce Mar.

Girgeh ProWnce Mar.

Ismailia Mar. 4

Keneh Province Mar. 2-7

India. General " Feb. 16-25

Bombay Feb. 27-Mar. 5.

Calcutta Feb. ift-23

Rangoon Feb. 16-25

16

7

46

31

1

2.5

l6

<i^

2., 242

306

27

55

Medical Record

A Weekly Jo7irnal of Medichte and Surgery

Vol. 7 J, No. 16.
Whole No. 1902.

New York, April 20, 1907.

$5.00 Per Annum.
Single Copies, lOc.

©rtgutal Artirl^a.

THE REFRACTION-CHANGES DEPENDENT
UPON GLYCOSURIA.*

By GEORGE M. GOULD, XI. D.,

PHILADELPHIA.

The majority of oculists havelongbutvaguelyknown
that glycosuria produces changes in the refraction of
the healthy eye, but no one seems to have gathered
the facts to a focus or gleaned the lessons derivable
from their study. When a perfect illustration of the
condition came into my practice I was therefore
astonished to find that the few reports of cases ob-
served in the past were mostly badly reported, a
portion probably incorrectly reported, and a series
of eight absolutely irreconcilable with another series
of eight. Moreover, the theories as to the mechan-
ism of the refraction-changes were as numerous as
vague, and as irreconcilable as the reports of the
cases themselves. As I tried harder and harder, in
my first studies of these cases and theories, to under-
stand them and resolve the mysteries, I found myself
always deeper in doubt and amazement. But when
I faced a final charting of the cases, the problem
seemed to me to be suddenly resolved. The report
of my case is as follows :

Gould's Casc.f Dr. M., a busy physician
carrying on a large practice, had for many years
been a patient of mine, and by frequently repeated
examinations I had kept close watch of his refrac-
tion-errors, because the least eyestrain in so severe
a worker and student meant a vast deal for him. I
may add that this patient also took a great deal of
personal interest in the eyestrain problem, and had
learned by bitter experience, subjective and objec-
tive, that certain theories as to the ocular origin of
much systemic disease were true. He was, therefore,
admirablv fitted to help me correlate the facts to be
described. Another condition to be noted is that
the patient is now 58 years of age and myopic, so
that the chance of error from incorrectly diagnosti-
cated accommodation is quite out of the count.

In December, 1902, Dr. M. had been wearing

R. — Sph. 2.62 — Cyi. 0.75 ax. 35*' = 2o/20 +

L.— Sph. 2.62— Cyl. I.2S ay. i67° = 2o/20 +

B. E. — Sph. 0.S7 andCyls. for near work, in bifocals.

This error of refraction, although frequently
tested had not materially changed for many years.
On the i8th of the month my patient appeared with
clearly marked symptoms of eyestrain. I found a
sudden increase of myopia, measured by

R.— Sph 3.25 — Cyl. 0.75 ax. 25^=20/20 +
L. — Sph. 3. 25 — Cyl. 1.50 ax. r66°=2o/20 +
B. E.— Sph. 1. 1 2 and cylinders for near.

There was also a noteworthy limitation of the
range of accommodation. This increase of myopia
in a man of 53, in one apparently healthy, although
explainable, perhaps, in other ways, aroused my

*Read before the Ophthalmic Section of the College of
Physicians, Philadelphia. .April 16, 1907.
tHitherto unpublished report.

suspicions. Rigid questioning brought out the con-
fession of several symptonis, which made me urge
careful urine analysis. Quickly came the answer:
"The urine is loaded with sugar."

The strictest dieting was immediately carriea out,
and within a few days every trace of sugar was
eliminated from the urine. But then, as promptly,
there was again eyestrain. A reexamination of the
refraction showed that the errors had returned
almost exactly to the point of seven days before.

In the next four years the total of the myopic cor-
rections increased slowly and more in the last year,
when Dr. M.'s health began to show some instability.
I warned in vain. The sequel proved that he had
simply grown more careless as to his food, eating
sweets and starches with thoughtless indifference.
In December, 1906, the errors were demonstrated
to be

R.-Sph. 2.87-Cyl. 0.87 ax. 250=20/20 +
L. — Sph. 3.oo~Cyl. 1.50 ax. 172°= 20/20 +
B. E.— Sph. o.-TO and cylinders for near.

By February i8, 1907, symptoms of ill-health
began to grow manifest, even to the careless-of-self
mind of the patient, and he resumed the long-
neglected analyses of the urine. The first one
showed again an extremely high percentage of
sugar. He was also having eyestrain, ignored for
the time being, in his interest in other things. Of
course the rigid diet was again put into force, and
in two or three days not a sign of glycosuria could
be detected. Then the patient returned to me with
greater eyestrain than ever, and again there was the
astonishing reduction in myopia measured by

R.-Sph. 2,00-Cyl. 0.62 ax. 2O°=20/20 + l.ni,tanrp

L. -Sph. 1.87 -Cyl. I 37 ax. 170°= 20/20+ j "'S'ance
R. Cyl. alone 1 x,

L. + Sph. 0.12 and cylinder j "'^'^

These corrections brought perfect visual acuity
for distance and near, absence of all eyestrain, and
the ocular conditions, with unessential changes, will
probably remain the same so long as there is no
glycosuria.

Grimsdalc's Case,^ of a woman aged 45, who came
October 7, 1897, wearing for some years, for near
vision,

R. + Sph. i.oo+Cyl. 0.75 ax. 160°
L. +Sph. 1.75

Fourteen days previously the woman had noticed
that her refraction had suddenly changed, so that her
reading glasses were no longer needed, and distant
objects were not seen so clearly as formerly. Vis-
ion, natural, was 6/60 in each eye. Without mydri-
asis the errors were estimated as follows :

R.-Sph. 2.00 — Cyl. 0.50 ax. iSo°=2o/2o
L. — Sph. 2.00=20/20

With this correction the patient at once said, "That
is how I used to see." No mydriatic was used, nor
was the range of accommodation tested. The right
lens had scattered central opacities, the left was
clear. At this time there were 26 grains to the
ounce of sugar in the urine. Treatment was now
instituted, and in ten days the report of the oculist

was

R. 6/18 — o.<^ = 6/i2. not improved by cylinder
L. 6/6 No Hm.

634

MEDICAL RECORD.

[April 20. 1907

"She now required + Sph. 2.50 to enable her to read
0.3 Sn. at one foot." "She was on strict diet, and
the total amount of sugar had much diminished."
"The right lens presented considerable irregular
astigmatism." In a few weeks death occurred fol-
lowing diabetic coma.

De Schzveinitz's Second Case was that of a girl
20 years old, with no organic lesions except congen-
ital posterior capsular opacity in each eye. Under
cycloplegia the errors were determined

R. + Sph. 0.25 — Cyl. 0.7S ax. ijs^ — e/io
L.-Cyl. 0.61 ax. 15" = 6/7 i

Six months later the patient returned, complaining
of rapidly deteriorating vision following some pro-
longed illness. It was learned that diabetic symp-
toms came on shortly after the first visit, and that
large quantities of sugar had continued in the urine
ever since, despite treatment. No mydriatic was
now used, one judges, but a myopia of 3.00 D. in the
right eye, and 2.00 D. in the left was demonstrated,
with vision of 6/22 and 6/12 respectively. Systemic
treatment was continued, and in three months the
visual acuteness was holding its own. But edema-
tous choroid and vitreous opacities had now become
manifest. In another month the myopia of the
right remained the same, but that of the left eye
had become 5. The patient died not long after this.
Dr. de Schweinitz concludes that a diffuse edematous
afifection of the choroid is the underlying pathologi-
cal process in such cases.

Appcnzellers Case (Graefe-Saemisch) was of
a patient 43 years old, who liad i.oo D. myopia
while the glycosuria existed, but when under treat-
ment the urine was normal emmetropia again re-
turned.

Hirschberg's Case." — Hirschberg gives a brief re-
sume of the case of a man 48 years old, who had for
many years seen plainly with — Sph. 9", i.e. — Sph.
4.62 D., but who now complained of dimness of
vision. With his old lenses he could not read any
longer. There was no paralysis of the accommoda-
tion. The proper correcting lenses were now found
to be —8" Sph., — Cyl. 40" ax. 180°. Diabetes
had been present for 14 days, followed by some
(doubtful) loss of weight. The eye-grounds were
normal. The urine contained 6 '4 per cent, of sugar.

Dujardin's Case^ was of a woman 69 years of
age, applying April. 1899. There was high glyco-
suria, and despite treatment the percentage of sugar
remained between ~o and 80 grams per liter. The
media were clear and the eyes healthy. She could
no longer see well at a distance, although formerly
she had had sharp acuteness. For reading she had
required + Sph. 4. D., but could not now read with
these lenses. The pupils would not widen under
atropin. By retinoscopy about 5. D. of myopia was
made out. Homatropin was ordered as a collyrium
and belladonna given internally on the theory that
a spasmodic condition of the ciliary muscle existed.
.\ montli later conditions remained the same.

Risley's First Case.*- — A woman of 49, having had
glycosuria in the past, complained that, with the
suppression of the glycosuria, and consequent im-
provement in general health, her vision had grown
rapidly worse. She was wearing -^ Sph. 2.75. The
dimmed vision had been observed only within a few
days. Under mydriasis the errors were

R. + Sph. s.oo + Cyl. 1.25 ax. 75'' = 2o/2o
' L. + Sph. 6.00 + CyI. 0.75 ax. ios"'=2o/2o

In ten days glycosuria returned, and with it dimness
of vision again, and the correction (nonmydriatic,
one gathers) was

R. + Sph. 3,00+Cyl. 1. 25 ax. 750=20/20
L. + Sph. 3.50 + Cyl. 0.75 ax. 105°" 20/20

Fifteen days after this she chose (nonmydriatic,
probably)

R. + Sph. i.2s + Cyl. 1.25 ax. 75**"2o/2o
L. + Sph. i.so + Cyl. 0.7S ax. 105"-- 20/20

Risley's Second Case.* — A man, 74, suffering
from saccharin diabetes for at least six years, was
the subject. In August, 1896, the errors were

R. + Sph. 1.50 + Cyl. 1. 25 ax. i8o°-6/7 1/2
L. + Sph. i.2s+Cyl. 1.25 ax. i8o» = 6/io

The lenses were cataractous. In April. 1897, the
vision in each eye remained the same, presumably,
with the same errors of refraction. Fourteen days
later dimness of vision was complained of, and the
visual acuteness with his distance-glasses was with
each eye 6/30. No sugar, or but a trace, was pres-
ent, and the man now selected

R. + Sph. 2.50 + Cy!. J. 25 ax. i8o»-6/7 1/2
L. + Sph. 2.00 + Cyl. 1.25 ax. igo"'-6/io

Within three days of a month later the patient had
been compelled to return to his old glasses within a
few days, and he now chose this correction, the first
above given, with almost the same visual acuteness.
Sugar was again found — 4.20 per cent., and a spe-
cific gravity of the urine of 1,027.

Carpenter's Case* was of a woman, 51 years old;
consultation was for dimness in reading during last
six months. There was no local ocular disease. Re-
fraction (without a mydriatic) was diagnosed

R. — Sph. 0.25— Cyl. 0.50 ax. 9o''=2o/2o
L. — Cyl. 0.50 ax. 90"= 20/20
+ Sph. 1.75 added for reading. Reading glasses only ordered.

Six years later the patient returned, stating that her
reading glasses had proved comfortable until within
a few weeks. Her correction was now found to be

L.+i^h! \:ll=To^To }D-t-"-t Bifocals ordered.
With + Sph. 2. 25 added !or reading (

Four weeks before this last visit glycosuria had been
diagnosed by her physician, and treatment begun,
with great decrease of the percentage of sugar. Still
no local disease of the eyes was found. In three
weeks she returned to her original careless diet (rich
food, sugar, etc.), and convex lenses made vision
worse, but R. — Sph. 0.75, L. — Sph. 0.50 again
brought the distant acuteness to normal.

De Schzi-einits's First Case^ was of a patient, a
man of 47. The man had fairly healthy eyes, but
the report does not state whether the first refraction
was made under cycloplegia. or not. "Each eye was
hyperopic. + 1.25 D. The complaint was of failing
vision in presbyopia. One gathers that glasses were
ordered for presbyopia only. Four years later the
complaint was of dimness of vision for distance,
"scarcely one-half" what it had been four years pre-
viously, i.e. normal, and — Sph. 0.50 was now re-
quired to give normal acuteness. Glycosuria was
suspected and demonstrated. By June 14, 1895 (a
month later) sugar had been extinguished. Al-
though the static refraction does not seem to have
been determined — a matter of regret — the inference
is that the change of refraction from -f Sph. 1.25 to
— Sph. 0.50 was due to the glycosuria. As there
was no decided lesion to be discovered by the oph-
thalmoscope, etc., the inference seems justified, and
another case of displacement of the focus forward
is to be added to the list.

Neuberger's First Case.^ — A 50-year-old woman
who had been emmetropic and able to read the finest
print with -j- Sph. 2.00. came four months later, re-
duced in flesh and with a myopia of R. 1.5 D.. L.
2.00 D. Smallest print could now be read with
+ Sph. 1.5 D, and L. -f i.oo D. Weak-ness of the
accommodation was also present. The lenses were,

*Not published. MS. report kindly loaned by Dr. Car-
penter of Philadelphia.

April 20, 1907]

MEDICAL RECORD.

635

and remained clear. The urine contained 3.5 per
cent, of sugar. In about three weeks emmetropia
returned and + Sph. 2.5 D. was required to read fine
print. The myopia had thus disappeared, although
at this time the glycosuria had increased to 7 per
cent. Diabetic retinitis later appeared, but the
lenses continued clear and the refraction emme-
tropic.

Neuherger's Second Case^ was of a woman of 48,
who two years before had a hyperopia of 0.75
(-f- 1.5 for near), but now was myopic, R. i., L.
2.5 D., and no glass for reading. The lenses were
clear at first, but later became obscure. Six months
later the myopia was R. 3.00, L. 8.00 D., with cata-
ract progressing.

Alexandei-'s Case.' — -The patient was a man of 5"
years of age. who had felt a decrease of visual acute-
ness for distance during the last 14 days. A myopia
of i.oo was diagnosed. For near -f- Sph. 0.75 was
sufficient when 1.75 was before demanded. The
sugar was 5.7 per cent. In 8 days dieting brought
the urine to normality, emmetropia returned, but
this in 5 days changed to a hyperopia of 1.75 D.,
the urine continuing free from sugar. In epitomiz-
ing this history Groenouw* rightly says the original
refraction was probably hyperopia, which later
became manifest.

Groenotnv's CasC^^ — A woman of 55, sufifering
from diabetes, suddenly acquired a myopia of i. D.,
which in 3 weeks became emmetropia. The lenses
were clear. This is given by Groenouw as a case
of latent hyperopia becoming manifest.

Doyne's Casey was of a physician of 40 who con-
sulted the oculist for failing sight. The man was
sufifering from acute diabetes. Three diopters of
hyperopia were found, and this correction was or-
dered and the glasses were worn without discom-
fort. Practice was discontinued and a sea voyage
undertaken, but upon his return he complained of
dimness of vision for distance. The hyperopia had
lessened and + Sph. 2.50 each eye again gave nor-
mal vision. Soon afterwards dimness of distant ob-
jects again recurred and the strength of the glasses
had again to he reduced, "and later on, when the
sugar disappeared, under homatropin freely used,
only 0.75 of hypermetropia existed."

Horner's Case" was of a woman of 55. The hy-
peropia had rapidly increased ; it was 1/14" at the
time of the visit, but with improvement in the gen-
eral health it sank to 1/48".

Cohn's Case (Graefe-Saemisch) was one of
increase of the hyperopia in a 68-year-oId woman,
from 1.50 to 3.00 D.

Laiidolt's Case.'^" — "We have observed, among
others, a most interesting case of this kind. A lady
had a fall and became diabetic as a consequence of
this traumatism, although her general condition was
not much affected by it. -At the same time she com-
menced to no longer see well at a distance, and
found the spectacles, that she had previously worn
on account of her presbyopia, to be insufficient. The
refraction could be determined, in this case, with the
utmost accuracy, not only because the patient was
very intelligent, but because she had reached an age
at which the accommodation is almost nil. I made
out a hyperopia of 0.5 D., which certainly had not
previously existed. It increased and then dimin-
ished, according to the amount of sugar e.xcreted.
and finally disappeared entirely. So that, when this
traumatic diabetes was cured, the patient could dis-
pense with her distance-spectacles, and substitute,

*Reportcd in tlie discussion of IMr. Grimsdale's case.'
tAugenleiden bei Diabetes Mellitus, Groenouw, 1907,
p. 46.

when reading, her former spectacles for the stronger
glasses which she had been obliged to resort to. I
have seen the patient for several years, and it has
been extremely interesting to note that each little
recurrence of diabetes has announcd itself at once
by a diminution of refraction, to such a point that
the curve of hyperopia was, so to say, parallel with
that of the quantity of sugar eliminated with the
urine."

Callus' Cairt"." — A man aged 51, under treatment
for diabetes for two weeks, noticed impairment of
vision for distance. Sph. -\- 2.00 for reading had
become too weak, although he "could see well
through them into distance." Examination revealed
R. + Sph. 1.50 -f Cyl. 0.50 ax. 180°= (What?) L.
+ Sph. 2.00 + Cyl. 0.50 ax. 180°= (What?) With
+ 2. added he could read the smallest type. Under
treatment glycosuria ceased, and in two months the
hyperopia had subsided so that the patient needed
only cylinders and could read again with -f Sph.
2.00 -|- Cy. 0.50.

Lichtenstein's Case'^- occurred in a man seventeen
years old. The refraction is given as -f Sph. 1.50,
estimated without a mydriatic, but 12. D. -|-Sph.
lenses were required to enablethepatienttoreadfrom
print at 9 cm. The paralysis of the accommodation
is said to have been "complete." He had
suffered from no diseases (except glycosuria)
which would cause this paralysis. Despite
treatment his glycosuria had increased in
severity, and urinalysis now showed 4.5
per cent, of sugar present, and some six liters of
urine were voided daily. The patient was sent to a
colleague, and the next day the hyperopia was found
to be 2,5 D., with 13 D. lenses required for near.
Homatropin now showed the same 2.3 D. of hyper-
(ipia. Five days later it was 3.5 D., demonstrated by
atropinization and skiascopy. For 14 days the condi-
tions remained the same, but the young man felt bet-
ter. Now 3.5 D. was required for distance, but
only 1 1 D. for near. But this was soon reduced to
6 D., and in about two weeks from the first visit
it had fallen to 5 D. The hyperopia gradually fell
from 3 D. to 2.5 D., then to 2 D., and finally to
1.3 D., the point whence it started on March 8, 1906.
Lichtenstein says the doubt as to the latency of hy-
peropia was excluded by his atropinization. L. ex-
plains that in this case two factors united to produce
the result, paralysis of the accommodation, and
transitory hyperopia. He explains this as due to
loss of water by the contents of the globe and a re-
sultant shortening of the anteroposterior axis.

Sourdille's Case. — In an emmetropic woman, 33
years old, S. observed a hyperopia of 2.00 D. occur,
which again disappeared with the disappearance of
sugar.

Lundsgaard's Case.^' — The patient was a woman,
who in 1892 was found to have -j- Sph. 0.50; "the
ophthalmoscope showed emmetropia." In the sum-
mer of 1903 there was great thirst and polyuria, but
according to the general physician no sugar or albu-
min existed in the urine. In 1906 traces of sugar ap-
peared, and in a month the percentage was 7;^.
Dieting reduced the sugar somewhat, but sudden
dimness of vision called attention to the eyes when
a hyperopia of 2.30 and 2.00 was found. The me-
dia were clear. Accommodation accorded with the
age. The percentage of sugar was now reduced
but not extinguished, and the hyperopia fell ; finally
the sugar was eliminated entirely and on the 19th
of November. 1906, the hyperopia returned to the
figure of 1902.

These twenty-tw-o cases are not all those which,
by more rigid search or less rigid rules of exclu-

636

MEDICAL RECORD.

[April 20. 1907

sion. might possibly be included as data.* If we ar-
range them in three series we find the first, com-
posed of those in which myopia is increased by
glycosuria (or decreased by its extinction) is made
up of si.x — those of Gould, Grimsdale, de Schwein-
itz's Second, Appenzeller, Hirschberg, Dujardin.

The second series, those in which hyperopia is de-
creased by glycosuria (or increased by a return to
normality) is made up of eight — those of Risley's
Two, Carpenter, de Schweinitz's First, Neuberger's
Two, Alexander, and Groenouw.

The third series, those in which hyperopia is re-
ported as increased by glycosuria, is composed of
eight — Doyne, Horner, Cohn, Landolt, Gallus,
Lichtenstein, Sourdille, Lundsgaard.

Principles Governing the Determination of the
Refraetive Conditions. — It is of first importance that
in the report of a case the precedent static refrac-
tion must be the basis of any comparison. In all
persons under 60 years of age, except occasionally
in myopia, the accommodation, unless paralyzed,
would make a possible error rendering all compari-
sons inaccurate, and if under 50 years almost wholly
untrustworthy. The reports of glycosuric refrac-
tion change in hyperopes under 50, unless the diag-
nostic tests have each been made under cycloplegia,
are of little value, except that the physician believed
and reported his belief that the presence or absence
of sugar in a general way indicated certain refrac-
tion changes. If the presbyope is highly myopic
that gives an added element of accuracy. Still
greater precision is to be predicated in cases in
which previous accurate refractions have been made
frequently and over a long period of years. The
astigmatic error, once correctly determined, may be
discarded in speaking subsequently of the cases be-
cause this changes but slightly in cases of paralyzed
accommodation, so that the statement of the relative
myopia and hyperopia is practically all that is nec-
essary. In no case so far reported has there been
any exact mathematical relationship stated between
the varying amounts of the sugar and the degrees
of the resultant refraction-change. This valuable
aid must therefore be left out of the count. In the
reports of future cases it should be made out and
reported upon. The absence of local ocular dis-
ease that would obscure the nature of the refrac-
tion changes must also be insured. When glycosuria
has set up extensive choroidoretinitis, pronounced
cataract, etc., a new factor is added which may be
the cause of so much doubt that the report is made
suspicious. The tests, to be of the best value, must
be in cases wath acute glycosuria, in which the eyes
are so far healthy, the media sufficiently clear, the
funduses so nearly normal, the acuteness of vision
so good, etc., that the measure of refraction is not
in doubt. The shorter the period of time between
the tests of the glycosuric and the nonglycosuric re-
fraction the more valuable will be the data obtained,
and the more convincing the deductions made from
them. Lastly, the oculist must be a refractionist,
believing in the value of accurate refraction tests,
habituated to make them, and seriously aware of the
evil results of bad and slipshod refraction to eye
and general system. There is little or no possibility
of securing a trustworthy estimate of the refrac-
tion in all Europe, where the refraction is pro-
nounced alike in both eyes, astigmatism ignored,
etc., and w^henever a report comes to us wherein
the refraction has been estimated with the ophthal-
moscope, and bearing ludicrous internal evidences
of bungling, and contradicting the reports of care-

*Kako's case of developing + astigmatism, e.g. is omitted
for evident reasons.

ful and keen-witted refractionists, there may be no
delay in speedily setting it aside as worthless, or of
little scientific value.

E.vclusion of reports according to the foregoing
principles becomes easier when we notice that there
is no reported case of myopia in which glycosuria
has not had the efifect of increasing the myopia —
that is, of bringing the focus of the dioptric system
forward. .'\11 such cases are logical, one may say,
as naturally the effect of glycosuria must be to affect
the focus in that way. Whatever be the mechanism
intermediating the change it is impossible to com-
prehend how glycosuria can displace the focus f>os-
teriorly. Now, as the myopia of an eye is far more
easily and accurately measured than the hyperopia,
and without a cycloplegic, it is not surprising that
all observers, good or bad, unite, in their reports,
that glycosuria, if it changes the refraction at all,
increases the preexisting myopia.

Confirming this result we find that the reports of
eight cases of change in hyperopia also say that the
efifect of glycosuria is to advance the focus exactly
as happens in myopia. .And in this series occur the
names of such trustworthy refractionists as Risley,
Carpenter, de Schweinitz, etc.

It is simply inconceivable that the mere accidents
of the location of the retina in the path of the re-
fracted cone of light-rays should have the reverse
efifect in displacing the focus in hyperopia, from
what it does in myopia. Tlierefore when eight re-
porters find such an illogical if not impossible re-
versal of the natural consequences as testified to by
fourteen, it behooves us to doubt the accuracy of
the oculists' tests and reports rather than to indulge
a belief in the inherently improbable and impossible.
Let us briefly glance at the cases critically of those
reporting increase of hyperopia :

In Doyle's case, the patient was 40, no mydriatic
was used at first and as the only true basis of com-
parison, and the squint of the corner of the mouth
becomes visible when it is said that three diopters
of hyperopia were found! The case was pretty
plain'lv one of latent hyperopia, astigmatism, etc.,
liecoming manifest "later on,'' because of the fre-
quent eft'ect of glycosuria on the accommodation,
or because of advancing presbyopia. It should
therefore be set aside. No wonder that Mr. Doyle
had no explanation to offer.

Graefe and Saemisch explain Horner's case
and that of Cohn as due to latent hyperopia.
Schmidt-Rimpler, and Groenouw also explain simi-
lar cases in this way.

In Landolt's case there is too much vagueness
in the report and too little increase of the hyperopia
— only 0.50 D. — to make us heed the claim of "ut-
most accuracy," made in behalf of the improbable.

The patient of Gallus was 51, the acuteness of
vision was not noted, no mydriatic was used, etc.
The change was probably in the accommodation,
not in the (untested) static refraction.

Of Lichtenstein's case one doesn't know what to
say, except that the inherent absurdity of 2.5 D.
hyperopia with 13. D. required for near vision is
so great as to make us smile with incredulity. Then
it must not be forgotten that atropin in Dujardin's
case did not even widen the pupil. Until competent
refractionists report other cases similar to this one
it must remain as a single and anomalous empiric
fact in which other factors than glycosuria were
present. This is the only case reported of one so
young as I" years, a fact to be remembered.

Sourdine's case was in a patient 53 years of age,
and no mydriatic was used. Exit!

In Lundsgaard's case, "the ophthalmoscope

April 20, 1907]

MEDICAL RECORD.

637

showed emmetropia," and with that admission "the
defence may rest its case." (In speaking of his
own case Schmidt-Rimpler {Die Erkrankungen des
Auges, etc., Wien, 1905), says, "the upright image
demonstrated a hyperopia of 0.5 D.," so that case
may also go to the Jury forthwith.)

We may therefore feel no compunctions in ex-
cluding on the ground of erroneous diagnosis due to
failure to estimate correctly the static refraction
almost all of the cases so far reported in which it
is claimed that glycosuria removes the focus of the
dioptric system to a position posterior to that occu-
pied in the previous nonglycosuric period.

It would require an entire paper and a long one,
to enumerate and critically judge of the theories
advanced to explain the modus operandi of the effect
of glycosuria upon the refraction. I doubt if the
most capable mind could do much toward clarifying
the obscure subject. I had made a list of these
numerous theories, but I do not think it would be
edifying to read it. The arguments point toward a
consensus of opinion favoring increased density of
the ocular fluids, functional disturbances and paraly-
sis of the lens and ciliary muscle, etc., rather than
to changes in the corneal curves, changes in volume
of the contents of the globe, or displacement of the
macular region of the retina.

As to the significance of the phenomenon, every-
body has emphasized the importance of the recog-
nition of the refraction and accommodation changes
as warnings of the existence of the systemic dis-
ease. In the days of life insurance examinations,
of routine urinalyses by the general practitioner in
almost all cases of ill-health, of the striking evi-
dences to the patient of thirst, polyuria, etc., the
warnings seem somewhat antiquarian, at least not
of the first importance. The wideawake American
oculist would prefer to doubly emphasize the over-
looked truths : ( I ) That the eyestrain preceding
the glycosuric refraction-change may have been a
prime factor in producing the functional dietetic
and nutritional disease called glycosuria ; most sig-
nificant is the fact that the great majority of the
cases occur during the presbyopic period; (2) that
the secondary refraction-change serves as a perfect
illustration of the increase of the diseases due to
overstrain by the proverbial vicious circle, in-
creasing the irritation and nutritional abnormalism
by the secondarily induced refractional changes
caused by the glycosuria: (3) the necessity of pre-
venting quick-following ocular disease, both func-
tional and organic, by heeding the accurate warnings
given by the refraction changes consequent upon
early and curable glycosuria. But whatever the point
of view, and whatever the injuries done or threat-
ened, the accurate diagnosis of the static refraction
overtops and conditions every measure of preven-
tion and every step of progress either in science or
in therapeutics.

REFERENCES.

1. Grimsdale: Transactions of the Ophthalmological So-
ciety of the United Kingdom. Vol. XIX, 1899, p. 267.

2. Hirschberg: Deutsche medi~inische IVochenschrift,
No. 13, 1891, p. 467.

3. Dujardin: Journal des Sciences Medicates de Lille,
July, 1900.

4. Risley: Transactions of the American Ophthalmologi-
cal Society, 1897, p. 122.

5. De Schweinitz : Ophthalmic Record, December. 1897.

6. Neuberger : Plotzlich erworbene Kiirzsichtigkeit, etc.,
Miinchcncr medisinische IVochenschrift, 1901 and 1903.

7. Alexander: Klinische Monatsbldtter fiir Augeiiheil-
kunde, rgo2.

8. Groenouw : Augenleiden bei Diabetes mellitus, 1907,
p. 46.

9. Horner: Monatsblatter fiir Augcnheilkunde, 1873, p.

490; abstracted in Graefe und Saemisch, Handbuch, Lief,
37 and 38. 1902, p. 339.

10. Landolt (Culver) : The Refraction and Accommoda-
tion of the Eye, p. 419.

11. Callus: Zcitschrift fUr Angeiiheilliunde, igo6.

12. Lichtenstein : Ibid., October. 1906.

13. Lundsgaard : Ibid., February, 1907.

SOME UNUSUAL RESULTS OF INTRA-
THORACIC COMPRESSION.

By THEODORE B. B.\RRINGER. Jr.. M.D.,

NEW YORK.
INSTRUCTOR IN MEDICINB. CORNELL UNIVERSITY MEDICAL COLLEGE.

Collateral venous circulations of unusual extent,
following compression and thrombosis of the supe-
rior vena cava and of the left innominate vein re-
spectively, and an uncommon physical sign of bron-
chial compression, are the points of interest about
the three cases here reported.

Case I. — The first case is one of gradual narrow-
ing and obliteration of the superior vena cava by
probably a mass of sclerosed and caseous bronchial
glands.

The patient, male, white, sixty-two years old, a
watchman, of Irish nativity, vvas first seen in IMarch,
1906. He had had measles, whooping cough, and
gonorrhea. About twenty years ago he had noticed
a swelling of the superficial abdominal veins. The
onset was apparently gradual, and there was no his-
tory of thrombosis or phlebitis of the veins of the
face, neck, or arms. Since July, 1905, he had suf-
fered from cough, inucopurulent expectoration,
hoarseness, and loss of weight.

He was an emaciated old man, pallid and dysp-
neic. All of his superficial arteries were sclerosed.
There were slight varicosities of the veins of both
legs. The anterior portion of the chest, the front
and sides of the abdomen, and the left lumbar region
showed extraordinarily large and tortuous veins, of
which the superior and inferior epigastric were the
most prominent. The blood current in these veins
was downward. His lungs showed consolidation of
the upper right lobe and infiltration of the remain-
der of that lung and of the upper left lobe. The
lieart was slightly enlarged, intermitted occasionally,
and showed an accentuated aortic second sound and
no murmurs. His sputum contained numerous
tubercle bacilli.

The fluoroscope showed, in addition to the lung
lesions, a shadow about 4 c.c. in diameter, just at
the right of the heart shadow, and a chain of en-
larged bronchial glands at the left. The shadow
did not pulsate and was taken to be a mass of scle-
rosed bronchial glands. The enlargement of the ab-
dominal veins is shown in the illustration.

The size of the veins involved in the collateral
circulation and the downward current of blood
therein, led us to make a diagnosis of obstruction in
the superior vena cava. This history of a slow on-
set, and the absence of any history of sudden edema
and cyanosis of the arms or face, enabled us to ex-
clude a thrombosis of the cervical or arm veins,
which sometimes precedes a thrombosis of the cava
superior, and made probable a gradually increasing
compression as the cause of the obstruction. This
cause would permit the gradual and uneventful es-
tablishment of a collateral circulation which ensued
in our case. The identification by the fluoroscope of
what was probably a mass of sclerosed and caseous
glands just to the right of the heart, at the site of
the superior cava, revealed the compressing factor.

Osier has reported three cases of obliteration of
the superior vena cava,^ together with a very com-

6.^^

MEDICAL RECORD.

[April 20, 1907

plete summary of cases found in the literature up
to 1903. Eppinger- reports a case in which the
autopsy showed the superior cava changed into a
thick fibrous cord, surrounded by degenerated bron-
chial glands. Schrotler^ also reports a case of
marked narrowing of this vein by a group of scle-
rosed and caseous bronchial glands in a tuberculous
patient.

In cases of complete closure of the superior cava,
the blood regurgitates from the obstruction, through
the cava to the innominate vein, to the internal mam-
mary, to the superior epigastric, to the superficial
and the deep e])igastric, to the iliac veins, and so to
the inferior cava and the heart. Many other col-
lateral circulations may be brought into play, de-
pending somewhat on the site of the obstruction —
whether above or below the opening of the azygos
vein into the superior cava. If below, the blood
passes from the superior cava through the azygos
vein, to the lumbar and renal veins and thence to
the inferior cava. The enlargement of one of the

left lumbar veins in our case showed that the vena
azygos was concerned in the collateral circulation
and that therefore the obstruction was below the
opening of that vein.

Rapid closure of a vein is attended by marked
vascular disturbances, as edema, cyanosis, etc., and
only after a period of time are these overcome by
the formation of a collateral circulation. The grad-
ual closure of the vein in our case prevented the
appearance of any sudden circulatory incompetence.

Case II. — The second case exemplifies the effect
of sudden venous obstruction. The patient was a
mattress maker, thirty-three years old. who had
never had any serious illness. He denied syphilis,
but had always been a heavy drinker. On February
16. 1006, immediately after a paroxysm of coughing,
he felt a "snap" near the left "collar bone." That
afternoon the left shoulder felt sore, and the sore-
ness gradually extended down to the left arm and
left side of the chest. The next day he noticed
swelling of the left side of the neck just above the
clavicle, of the left side of the chest around the

nipple, and of the left arm and forearm. The swell-
ing and soreness have gradually increased. The
pain is now ( four days after the onset) most marked
over the upper inner portion of the left arm.

The patient is an obese plethoric man, who is
slightly dyspneic. The left side of the neck just
above the clavicle is distinctly swollen and cyanosed.
The upper left chest as far as the ninple, and the left
shoulder, arm, and forearm are also swollen and
cyanosed. The swelling does not pit on pressure.
There are numerous small dilated veins on the left
chest and shoulder. There are redness and tenderness
along the lower portion of the left axillary vein.
There is decided dullness over the manubrium and in
the second left intercostal space next to the sternum.
There is slight dullness over the upper left chest as
far as the third rib in front and the spine of the scap-
ula behind, and over this area the tactile fremitus,
breath, and voice sounds are decreased; also over
the left supraspinous fossa the expiration is dis-
tantly bronchial — all of which are evidences of com-
pression of the left bronchus. The heart is negative.
The left radial pulse is slightly smaller than the
right. There is slight trachial tugging. The move-
ments of the vocal cords are normal.

The fluoroscope shows a small pulsating shadow
above the heart to the left of the sternum, and a
diagnosis was made of aneurysm of the transverse
arch compressing the left brochus and the left in-
nominate vein.

The edema and cyanosis disappeared a few weeks
later. Ten months later the small veins on the chest
and shoulder observed during the first visit showed
a marked increase in size and number. The blood
current in these large veins was downward. The
fluoroscope showed that the aneurysm had increased
markedly in size, the shadow extending almost 8
cm. to the right of the sternum. There were no
evidences of bronchial compression.

In this case the aneurysm first produced a nar-
rowing, but no complete obstruction of the left in-
nominate vein. Following this narrowing numerous
small varicose veins developed on the chest and
shoulder and were obser\-ed at the time of his first
visit. These may be regarded as evidence of the
beginning collateral circulation, and had probably
been present a long time. Then a thrombosis of the
innominate vein suddenly super\-ened, as was evi-
denced by the sudden venous congestion of the arm,
chest, and neck. That the thrombosis completely
closed the vein is shown by the present extensive
collateral circulation.

The non-pitting character of the edema in these
cases is to be explained by a greater involvement of
the subfascicular rather than the subcuticular veins.

The compression of the left bronchus showed the
usual physical signs of bronchial stenosis and will
be contrasted with some imusual signs of this con-
dition obser\-ed in our third case.

Case III. — This patient was a driver, twenty-nine
years old, of American birth. His family history
was negative and he had had no infectious diseases.
When seventeen years old he had had a chancre,
but no secondary symptoms. He had smoked and
used whiskey to excess for years. In August, 1905,
he began to suffer from a "croupy cough," with
scantv expectoration, and at times slight pain under
the sternum. He also had noticed some shortness
of breath on exertion and some cardiac palpitation,
which have continued. On November 15, 1905, his
phvsical examination was as follows: A well-nour-
ished, muscular young man, somewhat dyspneic,
with a frequent, harsh, brassy cough. His heart
was of normal size, with rapid and regular action,

April 20, 1907]

MEDICAL RECORD.

639

and showed no murinurs. His pulse was 132 to the
minute, regular, of fair tension, and corresponded
in the two radials. The respirations were 32 per
minute, and the lungs, of normal size, showed every-
where many sibilant rales.

On November 22, 1905, the patient was seen
again. He was dyspneic, and examination of the
lungs showed a remarkable condition. The left lung
moved very slightly with respiration, transmitted a
very feeble fremitus over the upper lobe, gave a
markedly hyperresonant note, and was much in-
creased in size, entirely obscuring the heart dullness.
Breathing over the left apex, anterior, was heard
only during the latter half of inspiration and then
it sounded as if air were rushing through a nar-
rowed bronchus. Posteriorly the breath and voice
sounds were almost absent. There was no tracheal
tugging. The larynx was not examined.

Excepting the peculiar character of inspiration
over the left apex in front, the physical signs were
those of marked emphysema of the left lung. While
we suspected an aneurysm pressing on the left bron-
chus, these physical signs were most puzzling.

He was sent up to the hospital ward where he died
ten days later from profuse hemoptysis, losing about
a liter of bright red blood. Shortly after admission
the peculiar physical signs over the left lung disap-
peared and evidences were found of an aneurysm of
the transverse arch presenting at and to the right
of the manubrium sterni. Unfortunately, no radio-
graph was taken, nor was an autopsy secured. The
diagnosis was made of an aneurysm of the trans-
verse arch which had compressed the left bronchus
and trachea, producing the dyspnea and unusual
physical signs.

The signs of compression of a bronchus, as given
in the half-dozen books on diagnosis we have con-
sulted, are dullness, feeble or absent tactile fremitus,
and diminished or absent breath and voice sounds
over the corresponding portion of lung. These signs
were present in the preceding case, but this case
showed a hyperresonant note and a marked increase
in size of the lung, so we were obliged to conclude
that other conditions than those ordinarily found
in bronchial stenosis must have been present.

A hyperresonant or tympanitic note over an organ
can be caused by an increase in the air content of the
organ or by a relaxation of the enclosing walls,
which latter produces a decrease in the tension of
the contained air.* Relaxation of the alveolar walls
as a result of the absorption of air from the lung tis-
sue corresponding to a stenosed bronchus, might be
evinced by a hyperresonant note, but in our case the
lung was decidedly increased in size, so, following
the above law, the air content of the aflfected lung
must have been increased.

The explanation given by Hoiifman" of the ana-
tomical conditions in cases of bronchial stenosis
seems very rational and explains why there is an
increase in the air content of the corresponding
lung, producing a localized emphysema. He says:
"The gradtial iiarrozmng of a bronchus favors accu-
mulation of air and increased pressure in the periph-
eral section of the corresponding lung, and as
long as the condition remains comparatively aseptic,
emphysema is the chief result. Sudden closure of
a bronchus results in atelectasis, and if there is no
infection, atrophy and cirrhosis of the correspond-
ing lung tissue. In a gradual narrowing, the air,
during inspiration, is sucked through the stenosed
place, but the expiratory power is not sufficient to
expel it, for the driving power during expiration
is only the elasticity of the lung tissue lying below
the stenosis. The great expiratory pressure, pro-

duced by the muscles of expiration, has, in this case,
but little effect, for it can never act so uniformly
from all sides, as does the elastic tug which draws
air into the bronchus — it acts spasmodically and
presses equally on all parts of the thorax. Also,
any tough mucus present may act like a valve, per-
mitting the air to enter easier than to escape."

The condition obtaining in bronchial asthma af-
fords another illustration of Hoffman's explanation.
Here we have a stenosis of the smaller bronchi due
either to spasm or to turgescence of the mucous
membrane, and very frequently an extensive em-
physema.

Irvine'^ concludes as a result of his clinical
and post-mortem experience that (i) emphysema
follows compression of a bronchus; (2) bron-
chiectasis may be associated with this emphysema ;
(3) destructive pneumonia may further ensue; (4)
collapse of the lung may occur early in the stage of
compression. He reports four cases of aneurysmal
compression of the left bronchus, and in but one of
these were the physical signs suggestive of emphy-
sema of the left lung. Autopsy showed that in two
of these cases the left lung was enlarged and the
seat of various infective processes, that in one case
the left lung was partially collapsed and partially
emphysematous, and that in one case the left lung
was normal in size. The right lung in all of the
four cases showed a compensatory emphysema.

One would judge from the statements of these
authors that pulmonary emphysema, following
bronchial stenosis, is a very frequent occurrence,
and yet none of the leading English authorities on
physical diagnosis mention it. The percussion note
is uniformly described as normal or dull, but no
reference is made to increase in size of the lung.

The probable explanation for this is that the con-
ditions for rapid development of emphysema,
namely that degree of stenosis which will permit of
free ingress and but little egress of air, or the pres-
ence of a viscid, valve-acting secretion immediately
below the stenosis, are rarely present. The emphy-
sema generally develops slowly, and the concomitant
infectious processes obscure the emphysematous
signs. Nevertheless it should be borne in mind that
localized pulmonary emphysema, although rarely
seen, points to a bronchial stenosis.

These three cases were seen in the Second Med-
ical Division of the Bellevue Hospital, Out-patient
Department, and it is through the courtesy of Dr.
N. R. Norton. Chief of the Dispensary, that I am
enabled to report them.

REFERENCES.

1. Journal American Medical Association, June 7. 1902;
Bulletin of the Johns Hopkins Hospital, Vol. XIV'., No.
148.

2. Nothnagel's Specielle Pathologic und Therapie-Er-
krankungen der Venen, p. 486.

3. Ibid., p. 487.

4. Sahli : Klinische Untersuchungs-Methoden, pp. 154. 213.

5. Nothnagel : Specielle Pathologic und Therapic, XIII.,
Die Krank. der Bronchien, p. 174.

6. Transactions Pathological Society of London, XXX.,
p. 248.

34 West Eighty-fourth Street.

The Bier Treatment. — Too prolonged or too rapid
and vigorous use of the pump in the Bier apparatus will
frequently cause a rupture of the superficial blood-
vessels, and in many cases severe sloughing of the
superficial parts ensues, the result of the treatment
being worse than the primary cause of the trouble.
Application of the Bier cup to an abscess for four to
five minutes twice a day is more beneficial than a single
ten-minute application. — American Journal of Surgery.

640

MEDICAL RECORD.

[April 20, 1907

DERMATOLOGICAL TRANSITIONS.

By OMAR M. WILSON, M.D.. CM.,

OTTAWA, ONTARIO.
LATB BOUSE PHYSICIAN, NEW YORK SKIN AND CANCER HOSPITAL.

In the practice of medicine to-day, we are often
prone to be too specific in our diagnoses, too apt
sometimes to overlook the fact that there may be a
gradual evolution of one process or disease into an-
other— in short, a transition. In no branch of medi-
cine probably, do we find these changes occurring so
frequently, and with such marked emphasis, as in
dermatology. Broadly speaking, there are two types
of transitions encountered in the practice of cuta-
neous medicine : ( i ) The transitions of diseases ;
(2) the transitions of lesions. The former has two
main subdivisions : False and True.

False Transitions. — Under false transitions we
class certain conditions in which a new lesion or a
new chain of symptoms has been added to or grafted
upon a preexisting disease or lesion. Cases are re-
ported from time to time where, for example,
epithelioma has developed upon the site of an old
chancre or gumma ; lupus vulgaris has been followed
by epitlielioma : lupus erythematosus has assumed
an epitheliomatous tendency in its later stages,*
while cases of scabies, terminating in eczema, and
initial lesion supervening upon herpes preputialis
are of everyday occurrence.

Transitions due to Traumatism. — Many hold that
most of these changes are to be classed in the cate-
gory of "cause and efTect." The pruritus of scabies,
relieved by constant scratching, changes into eczema,
in patients predisposed to this disease — the inflamed,
thickened, weeping condition being due to the me-
chanical irritation.

Chronic eczema of the palms often changes into
keratosis palmaris from a similar cause. The small
warty papule, picked, scratched, or otherwise irri-
tated, becomes epitheliomatous. Cases have been
reported in which the primary lesion of syphilis has
developed on the site of an old scabies lesion, or in
which a herpes preputialis has been followed by a
definite indurated chancre. The report of such a
case may be of interest :

Case I. — Andrew L., age 28, born in United
States. Seen first in April, 1905, with herpes pre-
putialis. on dorsal surface of the foreskin. While
under treatment the patient became exposed to
syphilitic infection, and about three weeks later,
a typical indurated chancre developed on the site
of the treated herpes. This was followed in due
time by general adenopathy and the secondary ro-
seola. Here, then, we had the two conditions exist-
ing conjointlv, the herpetic lesion being the avenue
of entrance of the specific virus.

Psoriasis is particularly liable to have pseudo-
transitions occurring in the natural course of the
disease. The following case is a pertinent example :

Case II. — Rebecca H., age 20, native of Russia.
In September, 1902. the patient was first admitted
to clinic, suffering from an acute generalized psoria-
sis. The disease,. under dispensary treatment, im-
proved for a time, but in 1905 the condition seemed
to come to a standstill, and the patient was admitted
to the hospital. Here she has remained for two
years, with intermittent outbreaks of the disease.
Periods of quiescence, with apparent clearing up of
the symptoms, would be followed by a very acute
attack, during which hardly a square inch of the
patient's body would be free from lesions. During
one of these exacerbations, following the appear-

*Two cases reported by Pringle.

ance of large hypertrophic plaques, almost verru-
cous in nature, the patient developed an acute
exfoliative condition, which was most marked on the
back. Papery scales, the size of a dime, were thrown
off in abundance, leaving a shiny, red, florid sur-
face, similar to that seen in pityriasis rubra. Under
emollient treatment, small islands of normal skin
appeared, the florid appearance became considerably
lessened and finally cleared entirely, leaving only
the generalized psoriasis.

Here, then, we had a change, occurring in the
natural course of the disease, strongly simulating
another condition, while the clinical manifestations
of psoriasis continued as before. It could be termed
a pityriasiform psoriasis, and may possibly have
been caused by a too free or too strong application
of chrysarobin.

Cases have been reported of pemphigus foliaceus,
terminating in dermatitis exfoliativa; of ichthyosis
hystrix changing into pityriasis rubra: of lichen
planus developing into generalized exfoliative der-
matitis. These changes were probably due to over-
treatment. Too free use of mercury in lichen planus,
chrysarobin in psoriasis, or sulphur in scabies will
oftentimes produce lesions simulating pityriasis
rubra very closely.

True Transitions. — Occasionally, however, we find
cases in which true transitions have undoubtedly
taken place. By the term "true transition" we mean
a gradual evolution of one process or disease into
another, without any clearly defined boundary line
to indicate where one jirocess begins and the other
ends. This may be exemplified in a variety of con-
ditions :

1. Eczema, pemphigus, or psoriasis changing into
pityriasis rubra — the further evolution of this con-
dition into mycosis fungoides.

2. The transition of eczema seborrhoeicum into
mvcosis fungoides.

3. The change of urticaria, pruritus, or eczema
into dermatitis herpetitormis.

4. Eczema of the nipple into Paget's disease.
3. Rosacea into rhinophyma.

6. .Senile wart into epithelioma.

7. Specific glossitis or tubercular syphilide Into
carcinoma.

8. Transitory changes in xeroderma pigmentosa.

9. Transitory changes in Sailor's skin disease.

10. Transitory changes in kraurosis vulvae.
These, then, are examples of true transitions. The

eczema, psioriasis. urticaria, or rosacea continues
for a time a more or less natural course. Then there
supervenes a period of activity — the condition be-
comes more acute, and suddenly we realize that a
new condition is thrusting itself upon us : that the
original disease, although possibly still active, is
being encroached upon, replaced and gradually
eliminated by an entirely new condition, having an
entirely new chain of symptoms, and differing from
the former, both clinically and morphologically.
This can possibly be exemplified by citing a few
cases which came under my notice during my ser-
vice at the New York Skin and Cancer Hospital.

The Change of Eczema into Pityriasis Rubra of
Hebra.

Case III. — Anna D., age 60. born in Ireland. In
September, 1903, the patient first had a mild attack
of eczema, involving the back and extremities. This
later became worse, rapidly spread, and soon in-
volved the whole skin. The patient had chills, fever,
delirium, etc.. and "could not get on enough bed-
clothes, even on a hot summer's day." There were
marked intermissions, and the patient occasionally
became much improved. In May, 1905, she entered

April 20, 1907]

MEDICAL RECORD.

641

the hospital. The skin was thickened, scaly, infil-
trated, and reddened, and marked contractions
around the eyes were evident. Sometimes quan-
tities of serum would exude. Large quantities of
penny-sized scales were scattered over everything
if. the patient remained in the same position for any
appreciable time. The condition gradually became
worse, until the patient died in November, 1905, of
pulmonary edema. This case starting as a simple
eczema, grew gradually worse. A new condition
was evolved, having all the classical symptoms of
pityriasis rubra, which led to a fatal termination.

Transitions into Mycosis Fungoides : Stages :
Psoriasis (?), Eczema, Pityriasis Rubra, Mycosis
Fungoides.

C.-\SE IV. — John H., age 45, native of Germany.
In 1904 while in Germany the patient had psoriasis,
the diagnosis being made by a reputable dermatolo-
gist in Hamburg. He came to Ainerica in 1905,
and entered the hospital in March of the same year,
suffering from a generalized eczema. This rapidly
grew worse ; the skin became thickened, infiltrated,
and reddened, and two months later the patient man-
ifested intense itching, chills, and fever — all the
indications of an acute attack of pityriasis rubra.
In ]May of the same year, tumors and ulcers ap-
peared on the chest and back, and the diagnosis of
mycosis fungoides was made. This was subse-
quently confirmed by pathological examination. The
tumefaction and ulceration were held in check by
the .r-ray, the ulcers healing rapidly under its in-
fluence until August of the same year, when four
large, deep ulcers appeared on the scalp. These
yielded readily to the .i--ray treatment, however.
From this time the predominant symptom was in-
tense itching, accompanied by the usual premycotic
eczematoid condition, and marked exfoliation. The
premycotic eczema still continued with no abate-
ment of symptoms, and with the constant appear-
ance of tumors and ulcers, until the patient died of
asthenia in January, 1906.

Eczema Seborrhoeicum, Pityriasis Rubra, My-
cosis Fungoides.

Case V. — Bessie F., age 30, born in Russia. In
June, 1904, the patient was first troubled with a
falling out of the hair, accompanied apparently by
an eczema seborrhoeicum of the scalp. This con-
tinued and was soon followed by chills and fever,
which lasted for two days, after which erythematous
scaly patches appeared all over the body. These
spots continued to form, became larger and co-
alesced. Scales, large and thick, began to accumu-
late, and the skin became thickened, hard and dry,
and slightly drawn. In December, 1904, symptoms
typical of pityriasis rubra appeared. There began
a profuse exfoliation. On moving about, the pa-
tient produced a very shower of small dime-sized
scales. This exfoliation was accompanied by chills,
nausea, and delirium, while the contractions about
the eyes became more marked. The diagnosis of
pityriasis rubra was made and confirmed by a mi-
croscopical examination of a section of the diseased
skin. During this time, considerable itching and
burning was manifested, although no scratch marks
were evident. Several ulcers appeared over the
body, face, and limbs, very superficial and circum-
scribed, with borders clear cut, and covered closely
with a thick, brownish crust. The integument be-
came absolutely devoid of hair. The nails thick-
•ned, especially at their extremities, and became
increasingly brittle. This condition of affairs con-
tinued for three months, with marked intermissions.
Fresh outbreaks occurred at more frequent inter-
vals, accompanied by terrific headaches, faintness,

and general malaise. The pruritus still continued
as the dominant symptom, relieved only by long
daily exposures to the .t^-ray. In March, 1905, from
small tumefactions then appearing, the diagnosis of
mycosis fungoides was made, and this was con-
firmed at the time by examination of the patholo-
gist. Urticaria-like spots, really premycotic lesions,
constantly appeared, and were held in check and
gradually melted by the .r-ray applications alone.
Left for a week without .r-ray exposures, the pa-
tient would have a fresh outbreak of these lesions,
and these, protected from the action of the rays by
thick coverings of tinfoil, resulted in typical my-
cotic tumors. Exacerbations became increasingly
frequent, attacks of faintness, malaise and general
depressions more marked. During a period of
quiescence in June, 1906, the patient left the hos-
pital. She died three weeks later, endocarditis being
noted as the cause of death.

Eczema Seborrhoeicum — Mycosis Fungoides.

Case VI.^Lars E., age 46, born in Norway.
The patient was first seen in March, 1906, with a
typical seborrheic eczema of the scalp, chest, and
inguinal folds. Late in April, and in the early part
of May of the same year, lesions were noticed to
appear first on the genitals as tumor masses, pig-
mented spots, and infiltrated, thickened, itchy
patches. These were at this time recognized by
three different dermatologists as manifestations of
a true case of mycosis fungoides. This condition
soon became generalized, and pruritus was unmodi-
fied by any of the ordinary antipruritic remedies.
Under general dietetic and local treatment the con-
stitutional condition improved, and the tumors grad-
ually melted. The patient was discharged in an
apparently normal condition, and resumed work as a
laborer, with no recurrence as yet.

Allowing the possible inaccuracy in the diagnosis
of psoriasis in Case IV., we still have two marked
and distinct transitions — the eczema into pityriasis
rubra, and the pityriasis rubra into mycosis fun-
goides while under observation in hospital. In
Cases III., v., and VI. the changes were un-
doubted, and were verified by careful pathological
examination.

One will notice at a glance the apparent import-
ance of the -r-ray treatment in allaying the itching,
and causing a general subsidence of these conditions,
particularly in the mycotic stage. Some have stated
even that the .r-ray is almost a specific in this con-
dition. This I doubt, for, although patients have
improved considerably under its influence, although
tumors have melted, and the pruritus has been less-
ened, yet, in the later stages of Cases IV. and V., a
gradual decline in general vitality was noticed, and
the patients gradually failed from inroads of the
disease, despite long daily exposures to the .r-ray.

Urticaria and Eczema Changing into Dermatitis
Herpetiformis.

Case VII. — John R., age 14, born in United
States. As a child, the patient was brought up on
the bottle, the mother not having suflicient milk to
support the child. He was a strong, vigorous child,
and was allowed to appease his appetite at every
feeding. At the age of three months, an eczema of
the infantile type appeared first on the face, and
afterward over the body generally. This condition,
in spite of treatment, continued, became chronic,
attacks occurring intermittently throughout a period
of thirteen years. In May, 1905. the patient suffered
from eczema orbicularis, which cleared up under a
few weeks' treatment. The generalized eczema con-
tinued to break out at intervals, however, respond-
ing satisfactorily to treatment until June. 1906,

642

MEDICAL RECORD.

[April 20, 1907

when it began to disappear. The fading of the
eczema was only preliminary to the advent of
a new condition. Vesicles occurring in groups,
rising from a distinctly inflammatory base, began to
appear on the back, chest, and extremities. The
lesions were definitely herpetic in nature, and were
accompanied by an intense pruritus. There was no
involvement of the scalp or of the mucous membrane
of the mouth, and the face was comparatively free.
Blood examination revealed an eosinophilia, but
otherwise the blood condition was normal. The
condition was now recognized to be dermatitis her-
petiformis, having all the classical symptoms of that
disease, the preexisting eczema having entirely dis-
appeared.

Urticaria, as we all know, is a very common
antecedent of dermatitis herpetiformis. The lat-
ter condition is almost always subsequent to one
of that class of symptoms indicative of an autointox-
ication, e.g. graphodermia, urticaria, or erythema
multiforme. Some observers, in fact, believe these
to be merely clinical manifestations of the disease
itself, and not entities, as is generally supposed.

Paget's Disease — Carcinoma. — The surgeon and
dermatologist frequently confer regarding the con-
dition known as "Paget's Disease." The lesion is
usually found involving the nipple and areola. Con-
ciderable pruritus is experienced, necessitating some-
times constant scratching. Oftener, however, the
prtiritus is less intense ; a fissured condition presents
itself, accompanied by considerable oozing of serum,
which often forms thick crusts. On the removal of
these crusts, a red granular base is exposed, and a
definite hardness is felt around the site of the lesion.
Sooner or later we find a nodular growth in the
breast tissues truly carcinomatous in nature.

Case VIII. — Lydia R., age 48, born in Germany,
unmarried. The patient has been in America fifteen
years. There is no hereditary history of cancer and
no traumatic history. One year ago the patient no-
ticed a slight redness of the right nipple shading
faintly into the surrounding skin. A few weeks
later fissures appeared on the sides of the nipple, a
serous exudate appeared, forming thick impetige-
nous crusts. At that time the patient noticed no in-
duration around the site of the lesion, and little or
no pruritus was experienced. Seen in our dispen-
sary in March, 1905, the patient suffered from con-
siderable pruritus. On the removal of the thick
crusts around the nipple, a red granular base was
exposed, giving to the touch the "coin under a
cloth" feeling, typical of Paget's disease. Having
left the city, the patient was not seen until ten months
later, when definite carcinomatous nodules were felt
in the breast ; the skin over the tumors was reddened
and fixed, and had the typical "pig-skin" appear-
ance. Involved glands in the axilla and along the
outer border of the greater pectoral muscle, were
easily palpated. The patient refused operation and
disappeared.

C.\SE IX. — Margaret F., age 80, born in Germany,
occupation housewife. The patient has always been
healthy and was the mother of four children, all
of whom she has outlived. In March, 1902, the
patient noticed a slight redness of the left nipple an<f
areola, but experienced no pruritus. This, under
local applications, cleared up at times, but early in
May. 1906, the redness recurred. This time, too,
no pruritus was experienced. The redness and
slight induration pvroved resistant to any form of
local treatment, and when the patient presented her-
self in the dispensary in August. 1906, the lesion
was already ulcerative. It was thickly covered by
a heavy crust, and on the removal of the same, a

red granular-looking surface was exposed. Imme-
diately below, and to the outer side of the nipple, an
indurated globular tumor was made out, and this
was firmly adherent to the adjacent skin. No glands
could be palpated in the axilla. Amputation of the
breast one week later disclosed a tumor which the
pathologist reported as true cacinoma, on microscop-
ical examination.

Rosacea — Rhinophyma. — Rosacea, or acne ro-
sacea, as it is sometimes called, also presents transi-
tory changes throughout its course. Primarily is
noticed an hyperemia of the skin in some part of the
middle of the face — the forehead, nose, cheeks, or
chin. Within the inflamed area, acne-like nodules
develop, which eventually become pustular. This
continued hyperemia leads to an increased develop-
ment of fibrous tissue, which gives a feeling of thick-
ness to the involved areas. Allowed to continue,
large fibrous, pendulous masses often develop, giv-
ing to the nose an irregular potato-like appearance,
and to the other areas the leonine expression of
nodular leprosy. A case of mine, seen in practice,
is illustrative:

Case X. — Bridget M., age 58, born in Ireland,
occupation news-vendor. For eleven years the pa-
tient had suffered from a diffuse redness of the
middle part of the face, interspersed with small
lumpy protuberances. She had been subject to acute
indigestion, severe eructations of gas being the domi-
nant symptom. The patient has always been mod-
erately alcoholic until recent years, when stimulants
have been indulged in more frequently than usual.
Her occupation as news-vendor necessitated con-
stant exposure to the weather and the patient be-
lieves this to have been an etiological factor in the
production of the rhinophymatous condition present,
when first seen. Seen by me in December, 1906,
the patient presented all the indications of rhino-
phyma. The forehead, inner parts of the cheeks,
nose, and chin were thickened and reddened, evi-
dences of the preexisting rosacea. The nose was
enlarged to about twice its normal size. From the
left ala nasi protruded several tumor masses, some
pedunculated, others merely excessive thickenings
of the skin itself. Over the thickened reddened
area on the forehead were to be seen oily scales
peculiar to seborrhoea oleosa. Under local and con-
stitutional treatment slight improvement was noted.

Senile Wart — Epithelioma. — Surgeons who op-
erate cancer extensively have observed from time to
time the occurrence and development of epithelio-
mata from senile warts. On the average individual
over the age of sixty, suffering from epithelioma or
carcinoma, we find freely distributed over the ex-
posed parts, rough, warty protuberances. These are
peculiar to old people, and with or without irrita-
tion, they subsequently develop into epitheliomata.
Many individuals exhibit a definite epitheliomatous
"diathesis" in this respect.

Specific Glossitis — Carcinoma.

Case XL — Patrick O.. age 46, native of Ireland.
The patient contracted syphilis at the age of 3;, the
disease running its natural course without any vig-
orous treatment. The usual symptoms of night
headaches and pain in the bones were experienced.
The patient was first seen in the dispensary in Sep-
tember, 1906. At that time there were multiple
small specific cicatrices-on the forehead. The tongue
was indurated and tender, while numerous mucous
patches were seen in the mouth. The right sub-
maxillary and right cervical glands were consider-
ably enlarged and tender. There was also consid-
erable salivation. Over a circular area about four
inches in diameter, and located just below the lower

April 20, 1907;

MEDICAL RECORD.

643

right costal border, was seen a rupial florid-appear-
ing lesion, described by Sabouraud as the "syphilitic
bouquet." Under mixed treatment the lesions im-
proved for a time. The rupial lesion cleared up,
leaving a dull purple-colored scar. The tongue
seemed less indurated, but the cervical glands re-
mained the same. A fortnight later the condition
grew worse. The tongue became hard and sore,
being seamed with fissures peculiar to specific glossi-
tis. The cervical glands became increasingly hard,
and soon the floor of the mouth was involved, the
whole mass becoming matted together, and prac-
tically immovable. The secretion of saliva became
profuse, causing the patient no little discomfort.
In November, 1906, a biopsy specimen was taken
from the tongue and the pathologist reported car-
cinoma at once, advising immediate removal. Sur-
geons pronounced the case inoperable, advising pal-
liative measures for his few remaining days.

Case XII. — Peter S., age 52, native of Germany.
The patient contracted syphilis at the age of 28,
the disease running its regular course without medi-
cal attention. In May, 1906, the tongue first grew
hard and sore. The patient had previously had mu-
cous patches in the mouth, but no tongue involve-
ment. Marked salivation was an early symptom,
which increased and was accompanied by a putrid
odor. In this condition the patient was admitted to
the dispensary in June, 1906. Ordinary anti-
syphilitic treatment produced no results, and soon
the suspicion of a more malignant condition was
aroused. The glands of the neck became mvolved
and hardened. On the surgeon's advice the tongue
was removed (Kocher's operation), and the glands
of the neck were thoroughly cleaned out. Patho-
logical examination of the diseased tissue disclosed
the presence of true carcinoma.

Transitions in Lesions. — No more striking ex-
ample of "true transition" can be found than the
transitory changes in xeroderma pigmentosa. Unna
describes this condition as beginning as an inflam-
matory hyperemia and freckle-like collection of pro-
tective brown pigment, while shining mother-of-
pearl spots appear between the pigmented areas —
a definite sclerosis. A roughness of the skin is no-
ticed early in the disease. This is due to innu-
merable small verrucous foci, which soon develop
into definite warty protuberances, and finally become
either true or pigmented carcinomata. Here then
we have primarilv an inflammatory hyperemia. From
this there develop warty growths which finally as-
sume the form of carcinomata.

Similarly, too, Unna, in describing the condition
termed "sailor's skin disease," says : "To the first
stage of erythema, pigmentation or hyperkeratosis
there succeeds a further one. Large wart-like
growths appear, hypertrophy of sebaceous glands,
and papillary ulcerating carcinomata are the end
results." So, too. in kraurosis vulvae we primarily
have an intense pruritus. Then an eczema develops.
Later tumefaction and malignancy are the final re-
sults.

In the above group we have transitions not from
one disease into another, but from one lesion into
another, each part and parcel of the same disease.

There may also be found a series of intervening
cases, neither "true" nor "false" in transitory
change, but simply one condition may precede an-
other with such marked frequency that one might
easily consider it a true definite transition.

Bulkley, in his Boston paper before the American
Aledical Association, made the remarkable state-
ment that a very large percentage of his cases of
psoriasis in private practice were preceded by one

or more attacks of dermatitis seborrhceicum. He
does not consider this a transition, but thinks that the
soil most favorable for the development of eczema
seborrhceicum is also most suitable for the appear-
ance of psoriasis. In short, individuals predisposed
to the one condition are invariably predisposed to
the other, the seborrheic element being the first to
appear. It is remarkable how very difficult it is —
at times impossible — in border-line conditions, to sav
definitely whether lesions are to be classed as psoria-
sis or eczema seborrhceicum. The correlation is note-
worthy.

Norman Walker, on the other hand, is very em-
phatic in his belief that here we have a definite trans-
ition. He claims that no sharp line of demarcation
can be drawn, and that eczema seborrhceicum is the
natural antecendent of psoriasis in many instances.

Observers have noted from time to time the fre-
quency with which seborrheic eczema has preceded
acne rosacea. Antecedent to the hyperemic stage
one very often finds oily seborrheic scales covering
the area subsequently involved. Some dermatolo-
gists believe the seborrhea to be an etiological factor
in the production of the rosacea.

Then, too. in prurigo we find pruritus or urticaria
preceding the condition so commonly, that many
writers have come to believe that the papule of pru-
rigo is not due to the inherent disease, but to the
scratching attendant upon the severe pruritus —
purely a secondary condition.

These are but a few meager examples of dermato-
logical transitions. The changes are varied and in-
numerable, necessitating careful study and patient
observation. It is to be hoped that a more general
acceptance of the term "transition" may lead to a
fuller recognition of the correlation of skin diseases,
a more careful study of their common cause, i.e.
metabolic derangement : and last, but not least, a
simplifying of the nomenclature.

222 LvoN Street.

CRIMINAL ASPECT OF VENEREAL DIS-
EASES IX CHILDREN.*

RASED UPON THE PERSOX.\L EXAMIN.A.TION OF OVER

900 CHILDREN, THE ALLEGED VICTIMS OF

RAPE, SODOMY, INDECENT ASSAULT, ETC.

By W. TR.WIS GIBB. B.S . ^LD.,

NEW YORK.

VISITING SURGEON, ^VORKHOVSE. ALMSHOUSE AND PENITENTIARY HOS-
PITALS. BLACKWELL's island, consulting SURGEON, KINGS COUNTY
PENITENTIARY HOSPITAL; EXAMINING PHYSICIAN, NEW YORK SO-
CIETY FOR THE PREVENTION OF CRUELTY TO CHILDREN, ETC.

.Sexu.^l crimes against children of tender years are
much more prevalent in our great city than many of
our profession are aware, and no one, not intimately
connected with a great society which has in its
charge the physical and moral well-being of children,
can realize the vast amount of misery these helpless
infants are compelled to suffer through the igno-
rance, cupidity, carelessness, and brutality of men
and women, and frequently the worst of these offend-
ers are the very ones who naturally ought to protect
those who become their victims. This is a sad con-
dition of affairs, but we have in our city_ a large
cosmopolitan population, many of them coming from
foreign countries where childhood is not as sacred
as with us, or where children, maturing at an earlier
age, have the vicissitudes of adult life forced upon

*Read before the American Society of Sanitary and Moral
Prophylaxis, October 11. iC)o6. and' the Pennsylvania So-
ciety for the Study and Prevention of Social Disease, De-
cember 20, 1906.

644

MEDICAL RECORD.

[April 20. 1907

them sooner than in this country. Such people,
bringing their foreign ideas here, commit acts which
are considered criminal in this country, but which,
in their native lands, would be looked upon with
indifference.

Many of these crimes are undoubtedly committed
by sexual perverts whose vagaries are such that they
can only be regarded as emanating from an insane
mind. I have seen this exemplified in many in-
stances, one of which I may be permitted to cite :
A big. lusty Italian raped his eight-months old
infant, tearing through the perineum and recto-
vaginal septum to such a degree that an extensive
plastic operation was necessary to repair the dam-
age. His efforts were so violent that he abraded
and e.xcoriated his glans penis so that the injuries
were apparent when I examined him a number of
days after the crime. He assured me that he had
been instructed by God to commit the act in order
to save his child's soul. The man was undoubtedly
insane and was so declared by a committee and sent
to an asylum for criminal insane.

Intoxication is another cause, or rather excuse
for many of these crimes. It has been brought to
my notice many times that among certain classes,
especiallv ignorant Italians, Chinese, and Negroes,
it is an accepted belief that if a man, afflicted with
an obstinate venereal disease have intercourse with
a virgin, the latter will develop the disease and he
will be cured. This belief is responsible for many
of the cases of venereal diseases among children
which come to our notice.

A fairly large proportion of the rape cases which
I have examined occur in girls between the ages
of twelve and sixteen, where the child is the willing
victim, and in many of these cases the children are
so precocious that if the law as to the age of consent
was not perfectly explicit it would be extremely
difficult to secure the punishment of the perpetrator
of the act. If we take into consideration the moral
and physical environments under which these chil-
dren are raised it is not at all surprising that their
standards of morality are so exceedingly low. These
children are herded in crowded tenements where it
frequently happens that in addition to the family
in the small apartment, boarders or lodgers are
taken and the quarters are so cramped that there can
be no decent privacy for anyone. The boarder or
lodger in a crowded tenement apartment is a very
frequent offender in the rape cases I have seen. In
addition to this crowded condition of their homes,
the low moral standard of the parents and guardians
has much to do toward familiarizing the children
with the immoral side of life. I am reminded of a
case, and this is one of many, where three children
were removed from the home of a longshoreman
on the grounds that the children's morals were en-
dangered. The man was accustomed to cohabit
with his wife in the presence of his children when-
ever he was inclined. Is it to be expected that chil-
dren raised amid such surroundings would develop
very exalted moral ideas?

This low standard of morality affects children
even of a very tender age, and in some instances
girls of nine or ten years, and even younger, have
been found with abnormally developed sexual in-
stincts, and they often submit willingly, usually
for pay. to the man whose perverted instincts leads
him to choose a very young child for the gratifica-
tion of his sexual desires. It is horribly pathetic
to learn how far a nickel or a quarter will go toward
purchasing the virtue of these children.

It is no uncommon occurrence for the father of
a child to be charged with that most revolting and

heinous of all crimes — incest. Within the past two
weeks I examined a negro girl, eight years of age,
suft'ering from gonorrhea, whose father was ac-
cused of raping her. I know of many instances
where a father has used his daughters for his sexual
gratification one after another as they grew large
enough to permit his advances. The majority of
these cases have occurred among Germans of the
lowest class, and the defense of the accused man
was usually that he thought he had a right to do
as he pleased with his own children, and he resented
the action of the authorities in stopping the practice
and punishing him as an encroachment upon his
rights.

i have been connected with the New York Society
for the Prevention of Cruelty to Children for the
past fifteen years as examining physician, and in that
capacity have examined over eight hundred girls
upon whom it was alleged the crime of rape had
been committed, and about one hundred girls and
boys the alleged victims of sodomy, indecent as-
sault, and other sexual and unnatural crimes. These
children were from eight months to sixteen years of
age ; the latter age being the age of consent under
the old law in this State. This age of consent has
recently been raised to eighteen years, but as the
Society was organized for the protection of children
under the age of sixteen, it does not lend its aid in
the investigation and prosecution of cases where the
alleged victim is beyond the age of sixteen. The
city authorities have charge of the investigation and
prosecution of all rape cases where the complainant
is between sixteen and eighteen years of age, and
the scarcity of such cases which are brought to trial
in comparison with the number where the complain-
ants are between fourteen and sixteen, where the
investigation and prosecution are under the super-
vision of the officers of the Society for the Preven-
tion of Cruelty to Children, exemplifies to a marked
extent the efficiency of that society, for it must be
admitted that rape is more liable to occur in girls
between sixteen and eighteen than in those between
fourteen and sixteen.

In the examination of these nine hundred children
I found that in about 33 per cent, there was abso-
lutely no physical evidence that there had been any
violation of their persons. Their hymens were in-
tact, and there were no evidences of contusions,
abrasions, excoriations, or discharges upon or about
the genitalia which might have been caused by an
act of violence. .A.11 suspicious discharges are ex-
amined microscopically and if gonorrhea exists an
effort is made to secure an examination of the ac-
cused.

In 17 per cent, of the cases there were evidences
of complete and recent penetration. In other words,
the tears in the hymen or fourchette, the abrasions,
contusions, etc., of the mucous membranes and
neighboring soft parts had not had time to heal be-
tween the time of the commission of the alleged
crime and my examination.

In exactly 50 per cent, of the cases there was
evidence of complete, though not recent, penetration
of the genital organs by some blunt object. All the
injuries, tears, stretching, abrasions, and contusions
had had sufficient time to heal between the first pen-
etration and my examination, and there remained
absolutely no physical evidence to show whether the
assault had occurred ten days or ten months pre-
viously.

In view of the fact that the subject under dis-
cussion is venereal diseases as affecting children
and not sexual crimes upon children, a discussion
of the methods and results of my examinations in

April 20, 1907]

MEDICAL RECORD.

645

these cases, except where venereal diseases were
present, would be out of order.

In my examination of these nine hundred cases
of alleged sexual crimes upon children I found that
almost 13 per cent, of all the children examined, or
117 children, were suffering from venereal diseases
in some form. Of these. 81, or about 9 per cent.,
had gonorrheal vaginitis, vulvitis, or urethritis. The
macroscopical appearance in each case was verified
by finding the gonococcus in a stained specimen of
the discharge obtained at the time of the examina-
tion. Two and one-half per cent, of the children
had chancroidal ulcerations involving some portion
of the genital tract or anus. These ulcers varied in
number from one to a dozen or more. In about
I per cent, there were venereal warts. There were
three cases of gonarthritis and two of gonorrheal
■ infection of the rectum in boys.

I have been surprised at the very small number
of cases of syphilis found among the 900 children
I have examined. Not over two or three cases have
been noted in the whole list. The apparent rarity
of this ordinarily common form of venereal disease
is due in my opinion to the fact that the children are
usually examined within a very short time after the
commission of the alleged crime, and sufficient time
has not elapsed for the development of the charac-
teristic lesions of the disease. I seldom see the
children after my examination until the trial of the
accused takes place, and the cases are frequently
disposed of entirely within such a short time that
if the disease develops at all it makes its appearance
after the child has left the care of the Society.

All the children entering the Society's care are
bathed before they are allowed to mingle with the
other inmates. The bathroom attendant is trained
to note any abnormal condition and report to the
nurse in charge. All suspicious cases are at once
isolated, and a medical examination is made. Should
the child be found to have a venereal disease it is
transferred as soon as possible to a suitable hospital
for treatment. The very small children are sent
to St. Mary's Hospital for Children, where they re--
ceive the most excellent care and treatment and are
returned to the care of the Society when cured.
The older children, especially the girls, are usually
sent to the venereal wards of the City Hospital on
Blackwell's Island and occasionally to some of the
other hospitals which will receive them. It is a
deplorable condition of affairs which renders it nec-
essary to send children of tender age, suffering from
loathsome diseases, for treatment to the wards of a
public hospital where they are brought in contact
with the most abandoned and degraded members of
their sex, and whatever of wickedness and depravity
they may not have learned before, they are apt to
acquire during their stay in the hospital. The young
girls are frequently very proud of the fact that they
have been in what is popularly known as the "vagi-
nitis wards," and it is quite a mark of distinction
when they return to the Society.

There is another condition in reference to children
to which I would like to call attention. I have been
told by a number of dispensary physicians that they
treat venereal diseases in children with a fair de-
gree of frequency. While it is possible that such
diseases may be transmitted through infected
clothes, water closets, etc., the majority of them, it
must be admitted, are the results of criminal as-
saults, and the doctors' e.xaminations are frequently
the first intimation the parents or guardians may
have that such an assault has occurred. I would
strongly urge that all such suspicious cases, and also
all cases of pregnancy in unmarried girls under the

legal age of consent, be reported to the proper au-
thorities for full investigation. Where the disease
was contracted accidentally no harm would be done,
but where a crime has been committed the perpe-
trator might be unearthed and brought to justice,
when otherwise he might escape.

Recently within a single week I examined five
girls, all under eight years of age and suffering
from gonorrheal vaginitis and vulvitis. In three
of the cases the accused was a Chinaman, in another
an Italian, and in the last the child's father, a negro,
— was the accused. In all the cases permission to
examine the accused was denied.

In a number of cases in which I have found the
victim of an alleged assault sulifering from a vene-
real disease, an examination of the accused revealed
that he had absolutely no evidence of the disease.
C>f course, an investigation is always made in such
cases to ascertain whether the accused might not
have had the venereal disease in question at the
time of the alleged assault, and been cured before
the e.xamination was made. The absence of any evi-
dence that he has or has had the disease I have
always considered good proof that he did not infect
her. If, however, the accused is found to be suffer-
ing from the same venereal disease as the victim,
tlie medical evidence is very damaging.

In these 117 cases of venereal disease among the
children I have examined, the nationalities of the
accused were about as follows: Italian 29, Chinese
25, German and Hebrew 16, Irish 5, Greek 4, Polish
Hebrews 4, colored 4, United States 2, not stated 18.
The ages of the children affected with venereal
diseases varied from three to sixteen years. I found
two children three years of age suffering from gon-
orrhea of criminal origin ; fifty-eight were under ten
years of age, and thirty-six were between fifteen and
sixteen.

These nine hundred cases examined represented
something more than half the total number of ex-
aminations made for the Society in this class of cases
during the past fifteen years. There are many more
cases of alleged sexual crimes against children
brought to the notice of the Society, but the exam-
ining physicians see only those cases in which, in
the opinion of the city magistrate, there is suificient
corroborative evidence to warrant an examination.
In spite of this large number of cases which have
been brought to the attention of the Society, I am of
the opinion that they are but a small proportion
of the cases of sexual crimes against children which
actually occur in our city. In a large majority of
tlie cases the children themselves never tell what
has happened to them, and again the fear of pub-
licity, the effects of such publicity upon the children
and their future, and the dread of placing their chil-
dren in the care of the authorities are dominant
factors in deterring many parents and guardians
from making criminal charges when they find their
children the victims of such sexual crimes, espe-
cially when the injury is more moral than physical.
It is seldom that children of the better classes are
the complainants in the prosecution of these cases.
Undoubtedly these crimes occur among the well-
to-do. but the parents of these children are very
loath to endure the unpleasant notoriety which is
sure to accompany the prosecution of such a charge.
The amount of sexual crime perpetrated upon
children in our city is enormous and is largely due
to the crowded conditions under which the poorer
classes live. In addition, there is the superstition and
dense ignorance of our large foreign population, the
brutality, perversion, and intemperance of many of

646

MEDICAL RECORD.

[April 20, 1907

the alleged perpetrators, and the precocity and low
moral standard of many of the child victims.

Since this paper was written, a little more than a
month ago, I have e.xamined sixteen girls for rape,
three of whom, aged respectively eight, ten, and
eleven years, were suffering from gonorrhea. One
of these cases was particularly interesting from a
medicolegal standpoint.

On November 12, two days after the alleged
crime, I examined the eleven-year-old girl and found
her hymen intact, with an orifice 12 mm. in diam-
eter ; there were no contusions or abrasions, and not
the slightest evidence of discharge. I gave a cer-
tificate that in my opinion there was no physical
evidence that a criminal assault had been perpe-
trated upon her. The corroborating evidence was
slight and the case was disposed of in court by the
discharge of the accused, and the child left the
charge of the Societv three days after my examina-
tion. About December i, eighteen days after my
examination and twenty days after the alleged as-
sault, the mother noticed that the child's garments
were stained by some vaginal discharge. She was
taken to a dispensary for treatment and a few days
later, because the child refused to take her medicine,
the mother beat her severely with a strap, producing
a number of contusions upon her thighs and legs.
On December 8 she became very ill and was taken to
a hospital where it was found she was suffering
from severe abdominal pains and great tenderness.
Finding the child severely bruised and learning that
there had been an alleged assault, the physicians
e.xamined the vaginal discharge and found it to be
due to gonorrhea. The hospital authorities at once
notified the coroner who ordered the immediate re-
arrest of the alleged assailant. An examination of
his penis by the hospital doctors failed to reveal the
slightest evidence of gonorrhea.

I was directed to see the child and on December
10 found her to be suffering from a gonorrheal
vaginitis, together with a peritonitis involving the
entire right side of the abdomen, extending to the
free border of the ribs. The pain, tenderness, and
tension were most marked over the region of the
appendix. I e.xamined the man and failed to find
gonococci.

In this case the gonorrhea developed almost three
weeks after the alleged assault. In the meantime
the mother had beaten the child severely, the accused
man had absolutely no indication of gonorrhea, and
the child developed a condition which resembled
very closely an attack of acute appendicitis. The
child recovered, but it would be interesting to know
in the case of the child's death who would have
been held responsible.

SS West Thirty-eighth Street.

OBSER\'ATIOXS OX THE TREATMENT OF
TUBERCULOSIS IX ARIZOX.\.

By IS.A.'iC W. BREWER. M.D.,

FORT HTACHVC^, ARI70XA.

Every winter brings a host of persons with tuber-
culosis to Arizona and Xew Mexico. A consider-
able proportion of them recover or improve, while
not a few do badly, and either die or remove to some
other portion of the country, hoping to be benefited
by the change. Without doubt the climate of the
Southwest, with its low humidity, abundance of sun-
shine, and mild winters, is a most favorable factor
in the treatment of tuberculosis ; but a study of the
condition of the Indians in that region will convince
anyone that climate alone will neither cure nor pre-
vent the disease.

In this paper it is my intention to consider
what appear to be the reasons why some of the
patients sent to the Southwest fail to obtain any
benefit from a sojourn in that region, and then to
give some general information about the climate
and accommodations that are to be found in the ter-
ritories. These remarks are based upon e.xperience
with a few cases that have come under my care in
this region and upon conversations with physicians,
and with patients suffering with the disease whom I
have met in different portions of the Southwest.

One of the principal causes of failure is lack of
proper food. Physicians in the East do not appre-
ciate that very little of the food supply of the South-
west is grown in that region. As a rule, almost
everything is imported from Southern California
or the East, and, owing to the excessive freight
rates, everything is very high. The charge on a
box of fruit from Southern California to Fort Hua-
chuca generally equals, and frequently exceeds the
original cost in the Los Angeles market. Butter is
generally forty cents a pound, milk ten cents a quart.
eggs from thirty to sixty cents a dozen, and other
staples correspondingly high. The native beef is
often tough and stringy, although in some of the
large towns alfalfa beef from the Salt River Valley
can be had. This is probably the best beef in the
country. For persons with plenty of money these
figures mean nothing, but for those in moderate cir-
cumstances tliey are prohibitory. Around Phoenix
the conditions are somewhat better, as the local mar-
kets are largely supplied from the surrounding
farms.

In order to overcome the high prices it is not un-
common to find invalids economizing either by cook-
ing their own food or by taking their meals at some
cheap restaurant. In the first case their food is
badly cooked, and in the latter instance the quality
is generally poor, and the service is always bad.

My experience with boarding houses has been
limited, and my information is largely second hand.
At most of the resorts there are satisfactory accom-
' modations of this class, but the number is limited.
One great disadvantage in them is that a large num-
ber of persons are thrown together without proper
supervision, and not infrequently they become mor-
bid and despondent. Constant discussion of symp-
toms does not encourage the sufferer, especially dur-
ing the early days of his sojourn.

There are few, if any, first-class hotels in this
region. This is partly due to the difficulty in obtain-
ing competent help and partly to the cost of food
supplies. Most of the hotels do not take "consump-
tives." which means that they do not take cases that
are far advanced. I have not seen a hotel in this
region that did not have one or more persons with
tuberculosis among their permanent boarders. The
rates at the best houses are from three to five dol-
lars per day.

Lack of Congenial Society.— Dr. Xorman Bridge
of Los Angeles, speaking of the climatic treatment
of tuberculosis, says: "The patient in any climate
must be properly fed, housed, and warmed. . . .

It is just as important that he should have con-
tentment and mental peace I would

rather have a patient kept in the outskirts of an
Eastern city (or in the heart of the city), under
good hygienic management, sleeping in the best air
obtainable winter and summer, and with friends and
comforts about him. than to send him to some better
climate to shift for himself and be lonesome and
homesick." These words from a man w^ho has had
a large experience with the treatment of tuberculo-
sis should be remembered by every physician before

April 20, 1907]

MEDICAL RECORD.

647

he sends his patient among strangers to some re-
mote region to obtain the problematic benefits of
climate. Not a few persons who come here suffer
from nostalgia. Especially is this the case with city
bred men who have been used to the hurry of mod-
ern business life. They are liable to find fault with
everything and to consider their sojourn in the West
as a banishment. Such persons always do badly.
Those who cannot adapt themselves to new condi-
tions had better stay away. If your patient be de-
spondent, keep him at home.

Many consumptives come to this region having
been instructed by their home physician to leave
medicines and physicians alone and to live in the
open and "rough it." This is about as pernicious
advice as can be given. The patient's first duty is to
consult some local physician. He will thereby be
saved considerable expense and annoyance and will
start properly. The physicians in this region are
forced to pay particular attention to tuberculosis,
and, besides the usual interest that physicians take
in their patients, many of them having had the dis-
ease have a fellow feeling for the suflFerer.

Few, if any, tuberculous persons have the strength
to "rough it" when they first arrive here. The in-
creased altitude causes an e.xtra strain on the heart
and lungs, and until compensation is established
most persons suffer from more or less shortness of
breath. They should therefore be quiet until they
have become used to the climate and the altitude.

If, after becoming acclimated, one desires to try
camp life, and the local physician considers him
physically able to endure its hardships, he may pro-
cure several Munson tents, a competent guide, and
saddle and pack animals, and shift his camp from
place to place as the season advances, going north
to the region of the Black Mesa or Flagstaff in the
summer, and returning to Tucson, or the Salt River
Valley in the vicinity of Phoenix, in the winter. The
tents will rarely be used excepting in bad weather,
for during the greater part of the summer and fall
it will be possible to sleep in the open. There are
many charms to such an outing. It is devoid of
monotony, and hunting and fishing may be enjoyed
in the mountains. The region traversed is filled
with prehistoric ruins, especially the valley of the
Verde and around Flagstaff. On such a trip the
food will be necessarily confined to canned vege-
tables and fruits, and bacon will constitute a large
portion of the meat ration.

There are a number of tent colonies in Arizona,
and, if under proper medical supervision, they are
excellent. Being cheaper than other accommoda-
tions, they are available for those in moderate cir-
cumstances. Many of them unfortunately are not
properly laid out, and the tents are often close and
badly ventilated. The practice of wainscoting tents
is objectionable, as it reduces the amount of fresh
air that can be admitted.

Tents should be pitched so that they will be
shaded during a portion of the day. It is well to
have them face the east, so that they can be flooded
with sunlight as soon as vacated in the morning.
They should be provided with board floors made in
small sections that can be readily removed so as the
space beneath may be kept clean. They should never
remain on the same ground for more than five days
at a time; at the end of that time they should be
moved so that the ground may be thoroughly dis-
infected by the direct rays of the sun.

In rainy weather tents become cold and clammy,
and to obviate this a small stove is often used. Some
of the camps that have come under my notice have
been badly conducted from a sanitary point of view.

As regards exercise, many physicians have er-

roneous ideas. Being used to the overfed business
man wiio leads a sedentary life, they think all per-
sons should take as much e.xercise as possible. We
encounter many persons who have been sent here
and told to procure a horse and ride as much as
possible. Every physician who has had any e.x-
perience with tuberculosis in this region well knows
that the new comer should rest for a considerable
time after his arrival. He may then begin to do a
little walking, and later may indulge in horseback
riding if his condition warrants it. A physician in
an eastern city, who has a reputation as a specialist in
lung diseases, once told me that every patient with
tuberculosis should buy a horse as soon as he came
to the Southwest, remarking that there is a peculiar
magnetism transmitted to the rider from the horse
which greatly aids his recovery. I have looked for
this magnetism in vain, nor has it been evident to
any of my friends. I say without reservation that
the majority of persons with tuberculosis who ride
horses in this region shortly after their arrival do
themselves great harm. This is especially true of
persons with pleurisy.

Exercise, like all other forms of treatment, should
be taken only on the advice of a competent physi-
cian.

There is a lack of proper diversion in this region.
Theatrical performances are not very common, and
musical entertainments are infrequent. In this re-
spect conditions are improving. In the days when
gambling was wide open (now happily passing)
many who could not endure the monotony resorted
to the barrooms and playhouses, and, besides losing
their money, lost their health by remaining in a viti-
ated atmosphere and indulging in alcohol.

Work and Means of Support. — Do not send your
patients to Arizona unless they have sufficient funds
to cover their expenses for a year, or unless they
have assured a position that will support them.
There is little work such as persons with tubercu-
losis are able to do, and for every place there are
many applicants. There is plenty of hard work for
strong men in the mines and on the railroads, but
few consumptives are able to undertake such work.
After a residence of a year or so one's health may
be so far restored as to enable him to engage in
hard work. Many of the most successful business
men in the territory were invalids when they ar-
rived.

What Class of Cases Shall be Sent to Arizona ? —
Incipient cases do best, and the sooner they come
under the influence of this climate the better. Do
not delay until the diagnosis has been confirmed by
finding the bacilli in the sputa, but as soon as there
is a well-grounded suspicion of the disease send
them out. provided they can afford it. Such patients
nearly always recover. A certain proportion of
those who come under the influence of this climate
later in the disease also recover. When there is sec-
ondary infection, or a mixed infection, the prog-
nosis is not so favorable. .'Mthough there have been
some very encouraging reports of such cases during
the past year. I do not think it advisable to send
them to this region. They generallv are too far gone
to be benefited, and they are better left at home
among their friends.

There is an impression that laryngeal cases do not
do well here. My experience leads me to believe
that it is well founded. The dryness of the air and
the occasional dust storms tend to cause irritation
of the laryngeal and nasal tissues, and all the cases
of simple laryngitis that have come under my ob-
servation have done badly. It is therefore suggested
that such cases be sent to a more moist climate.
Organic heart disease is usually said to do badly

648

MEDICAL RECORD.

[April 20, 1907

in an elevated region, but Babcock does not hold
that opinion, and I have known of three patients
with advanced valvular disease who have improved
very much since coming to Fort Huachuca, which
has an elevation of about five thousand feet.

Where Shall the Patient be Sent? — To many Ari-
zona is the "country God forgot," and is nothing
but the dreary desert seen from the windows of the
transcontinental trains. Others think it has an ideal
climate for the treatment of tuberculosis. Neither
of these opinions is correct. There are periods when
the climate is anything but mild and sunny. In a
previous paper* it has been shown that the Indians
who live in the open air in this region are rapidly
being exterminated by tuberculosis. Much of the
territory is arid, but there are large areas of forests
and many fertile valleys.

The health resorts may be classified as follows:

Summer stations: Flagstaff and vicinity.

All-the-year-round stations: Prescott and other
points in the southern portion that have an elevation
of about five thousand feet.

Winter stations : Tucson, Phoenix, and Yuma.

Flagstafif has an elevation of seven thousand feet
and is situated on a mesa at the southern base of the
San Francisco Mountain Range. The summer cli-
mate is delightful, the days are never hot, and the
nights are always cool. Frosts occur during every
month excepting July and August. The accommo-
dations are very poor. Cottages can be had at
reasonable rates, but during the summer the demand
is greater than the supply. The cost of living is very
high. There are two hotels, the proprietors of which
profess not to take "consumptives," but there were
at the time of my visit at least two stopping at one
of them. The surrounding country is full of inter-
esting ruins, and the green pine trees, with their
fragrance, are very welcome to those who have win-
tered in southern Arizona.

Prescott has an elevation of 5,260 feet. During
the summer there are some warm days, but being in
the mountains there is always a breeze at night, and
during the hotter hours of the day there is usually
a strong wind which prevents the heat from becom-
ing oppressive. The winter nights are cold, and
those who sleep outdoors will have to be warmly
clad. The humidity is low. The precipitation
amounts to 15.6 inches. During the winter there is
considerable snow. There are during the year an
average of 228 clear days, loi partly cloudy days,
and 36 cloudy days. It is a pretty little town, and
has a pleasant society. There is a hospital in the
town, and about a mile west of the plaza Dr. Flinn
has established a tent and cottage sanitorium. The
hotels are not very good, but there are said to be
some good boarding houses. Persons in the early
stages will be able to find suitable accommodations,
but when the disease is more advanced it will be
more difficult.

Tucson has an elevation of 2,368 feet. It is dis-
tinctly a desert town, and all of its food supply is
imported, consequently the cost of living is high.
There are a number of pretty good hotels and sev-
eral cottages that take roomers. Tents and small
cottages can be rented at reasonable rates, and board
can be had at any of the hotels. The climate is
cooler than either Yuma or Phoenix, especially the
winter nights. The mean minimum temperature for
December is 37° F., and in January it is 35°. Never-
theless, many persons sleep in tents or the open air
during the entire winter. There are occasional

♦Tuberculosis among the Indians of Arizona and New-
Mexico ; New York Medical Journal, Vol. Ixxxiv, 1906,
p. g8i.

snow storms. The winter precipitation is 4.2 inches.
The humidity is about the same as at Yuma and >
Phoenix. From October to March there are on an :
average 119 clear days, 42 partly cloudy days, and ,
21 cloudy days.

Forty miles north of Tucson, in the Santa Cata-
lina Mountains, at an elevation of 4,500 feet, is
Oracle. It is from six to ten degrees cooler than
Tucson, and there are two ranches where tents and
cottages can be rented at reasonable rates.

PhcEnix has an elevation of 1,087 f^^t- ^^^ is prob-
ably the best known resort in Arizona. Being a
modern town, and distinctly a healtli resort, the
invalid will find many comforts not obtainable in
other portions of the territory. The surrounding
country is highly cultivated, and much of the prod-
uce used is raised in the immediate vicinity. The
alfalfa fed beef is the best I have ever tasted. The
mean temperature is 70° in October, and falls to
50° in January, rising to 60° in March. The aver-
age precipitation for the six months ending with
March is 4.2 inches. The humidity has a greater
range than in Yuma, being 41 per cent, in October,
rising to 52 per cent, in January, and falling to 38
per cent, in March. During the six cooler months
there are 119 clear days, 38 partly cloudy days, and
25 cloudy days. Sleeping out is possible during the
entire year. In the town are numerous boarding
houses, besides a large number of hotels. Just
beyond the city limits there are two cottage and
tent sanatoriums, where board and a tent may be
had for from $12 per week up.

Yuma is situated at the point where the Gila emp-
ties into the Colorado, and has an elevation of 14I
feet. The town is small and the accommodations
are limited. Recently the Yuma Heights Sanator-
ium has been opened and better accommodations
are assured. The sanatorium is only open during
the winter months. The mean temperature is 72°
in October, falls to 54° in January, and is 64° in
March. The humidity ranges from 44 per cent, in
October to 41 per cent, in March. The total pre-
cipitation for the period from October to March
inclusive is 2.1 inches. During the same period
there are on an average 130 clear days, 42 partly
cloudy days, and 10 cloudy days. Yuma seems to be
a desirable winter station for persons who cannot
stand the elevation of Phoenix or Tucson. When
the irrigation project now under way is completed
it will become a large farming community.

In the above I have given what appear to be some
of the more important causes why patients sent to
the Southwest do not recover from tuberculosis. An
outline has been given of the climatic conditions of
the principal stations in the territory. Those who
desire more exact information are referred to the
following papers dealing with local conditions:
Climatology of the United States, Bulletin "'Q"
United StVtes Weather Bureau, 1906. The climate
of Flagstafif, Journal of the Outdoor Life, Vol III.,
pages 195-197. The winter climate of Tucson,
Boston Medical and Surgical Journal, Vol CLV.,
1906, pages 307-309. The climate of Prescott, Coh
nadian Lancet. Vol XL., 1906, pages 206-210.

The object of this paper is not to discourage the
sending of patients to this region, but is a plea for
more care in selecting cases, and to urge upon the
profession not to send persons who have not the
funds with which to secure proper food and com-
forts.

I do not believe there is any quality of this climate
which will cure tuberculosis irrespective of good
food and proper care, but I do believe that when
patients can secure such things they stand a better

April 20, 1907]

MEDICAL RECORD.

649

chance of recovering in this than in any other region
of our country. If there be anything in the outdooc
life, then I am right. To appreciate this, one has
but to compare the conditions which obtain here
with what the patient is exposed to during the win-
ter in the East. Here the invahd can be outdoors
nearly all the time, while in other sections, owing
to bad weather, a large portion of the time must be
passed within the house. I have a patient who has
not slept in the house for over a year. His only
protection is a porch and a canvas screen to keep
off the snow and rain.

The greatest need, from a tuberculosis point of
view, is a large sanatorium conducted on the same
principle as the Adirondack Cottage Sanatorium.
The Federal Government has given millions of
acres of the public domain for educational purposes ;
why should it not devote some of its desert lands to
be used for those sick with tuberculosis ? There is
plenty of land available for this purpose. Not far
from where I write is an abandoned military reser-
vation that would answer admirably. Adjoming it
is a large forest reserve which would be an excellent
recreation ground for those who are convalescent.

THE STOMACH TUBE IN DIAGNOSIS.

By NELLIS B.^RNESIFOSTER, M.D.,

NEW YORK.

For some reason which is not clear there is a
belief among a number of medical practitioners in
this city that the use of the stomach tube in the
diagnosis of gastric disease is usually of no value,
or at best an aid only in exceptional instances.
These men, at least in part, are in the habit of
confining their attention to the acid secretion as
shown in the ordinary Ewald test breakfast. If
only one test meal is taken from a patient and no
observations are made on the material removed
other than to estimate the amounts of free and
combined hydrochloric acid, then, of course, from
these facts no conclusion whatever can be made.
But the man who uses only a part of a method
is in a poor position to condemn the whole process.
If but one observation can be made on a patient,
as frequently occurs, and the presence or absence
of HCl is the only fact desired, the desmoid test
as used by Sahli is more convenient to both physi-
cian and patient than would be a test meal. When,
however, a diagnosis is desired with anything like
accuracy, much more information can be gained by
the use of test meals and a few simple tests ap-
plied to the material removed from the stomach.

There are three things which must be considered
in diagnosis and in the treatment of abnormal gas-
tric conditions. They may be grouped under the
headings of (i) secretion; (2) motility: and (3)
the presence of abnormal materials.

While we are more conservative in drawing de-
ductions from amounts of HCl, which we find
secreted in the stomach than formerly, because
it is now believed that the normal range is wider
than it was at one time supposed to be. yet it
cannot be denied that abnormal function in the
stomach is often manifested by marked variation
in the secretion of HCl, and that a hvpo- or hyper-
acidity is important to diagnosticate, since it is so
useful a clue to treatment. However, I do not think
that one may conclude that he has to deal with
a case of hvneracidity on the evidence of a single
test meal — mental states have a marked influence on
gastric secretion, and the mental state of a nervous
patient anticipating his first ordeal with a stomach

tube cannot be described as one of equanimity. In
short, the acid findings in an initial test meal
are the least accurate of the data ascertainable.
Some idea of the motility in the stomach is one of
the easiest facts to determine, yet it is the function
most frequently neglected by diagnosticians. Sim-
ply washing out the stomach in the morning before
any food is taken sometimes gives ample evidence
of deficient motility. It is not a unique experience
to find in the sediment from such a lavage recog-
nizable elements of each of the three meals eaten
the day previously. Another method is to remove
the contents of the stomach a number of hours
after a moderate meal of meat, vegetables, and
bread. So many causes may give rise to deficient
motility besides ectasia that it is not surprising we
find it so frequently. Among these causes cicatrix
(we are prone to forget that ulcers are often latent),
resulting in partial stenosis of the pylorus, is most
frequent in my case records, next is stenosis due
to tumors, both benign and malignant, and last
stenosis due to adhesions between the duodenum
and some other viscus, such as the gall-bladder.
These adhesions produce partial stenosis by causing
kinking of the duodenum.* In conditions of this
nature it is useless to endeavor to make a diagnosis
without resorting to the repeated use of a stomach
tube. To illustrate the importance of this method
of examination one case may be mentioned :

H. C, age thirty-four. Complained of vomiting
and loss in weight. His past history is unimportant.
For a year he has been vomiting at irregular inter-
vals : during the last six months he has vomited
almost daily. His weight has fallen from 145
pounds to 119. He has no pain, but a feeling of
discomfort in his stomach region constantly. There
has never been blood in the vomitus nor have his
stools been black. He has consulted three physi-
cians, the last of whom took a test meal. He was
told that his stomach secreted no acid and was
directed to use acid after meals.

On examination the patient siiowed no evidence
of organic disease — morning lavage of the stomach
removed considerable residue in which food ma-
terial could be recognized. Ewald test meals showed
no free HCl ; mucus in excess, numerous bacteria,
and fermation in tubes. Lavage at varying
times after meals disclosed pronounced motor in-
sufiiciency, but the stomach was not dilated and its
muscle tone appeared excellent.

Believing that there existed some form of benign
stricture of the -■vlorus, operation was advised. The
condition found was a scar due to a healed ulcer
at the pylorus, this scar producing so marked a
contraction of the pyloric opening that only a small
sound could be passed through it. Finnev's opera-
tion was done and an absolute cure resulted. This
case is mentioned solely as an example of those
instances wherein a diagnosis might be made by
inspection of the stomach contents alone without
resorting to any tests whatsoever. This simple in-
spection is too frequentlv omitted.

The most important abnormal material to look
for in test meals is blood. The presence of occult
blood in the stomach content.-; is quite constant in
cases of carcinoma, and a frequent finding in ulcer
cases. It signifies little what test is employed, the
guaiac, aloin, or the various modifications of these
tests are all good.f

*The cause of stenosis in tliese case? wa.s citlier con-
firmed by or determined at operation.

tWhere ulcer or cancer is suspected tlic <iiet should be
made meat free for a couple of days, in order to permit
of examination of the feces for occult blood.

-eso

MEDICAL RECORD.

[April 20, 1907

These tests for blood are so simple and the results
are not infrequently so important that one can ill-
afford to neglect them. Blood is found in other
conditions than ulcer and carcinoma, i.e. esophageal
varices, erosions of the mucous membrane, but a
differential diagnosis is seldom difficult and the
existence of the mentioned possible origin of blood
does not detract from the value of the test when
used as a routine in gastric analysis.

Of more questionable worth is the microscopic
examination of smears of the gastric contents for
bacteria. Occasionally such large numbers of mi-
croorganisms are found that a clue is given to the
nature of the disorder, and the finding of Boas-
Oppler bacilli or sarcinse is significant. In the ma-
jority of examinations so few bacteria are pres-
ent that a fermentation test of the gastric contents
in fermentation tubes is, perhaps, a more trust-
worthy guide to the nature of the bacteria present.
The omission of the microscopic examination, how-
ever, is inadvisable.

There exists an impression, which has been shown
reoeatedly to be false, that the presence of free
hydrochloric acid in the stomach excludes the for-
mation of lactic acid. It is quite possible for lactic
acid fermentation to proceed in the presence of
HCl, and tlie former should always be looked for
in routine analysis ; especially is this true in con-
nection with the early recognition of carcinoma,
since the early differentiation of this malady is the
only hope of successful sureical aid.

The interpretation of facts disclosed by the em-
ployment of test meals is not always clear, but error
lies more often in drawing a conclusion from in-
sufficient data than it does in misinterpretation. The
presence of a normal amount of free hydrochloric
acid in the gastric secretion is not incompatible with
carcinoma, nor does the absence of free acid of
necessity indicate this malady. Other data, such as
the presence or absence of occult blood, lactic acid,
etc., are indispensable. But in no other way can
one detect cancer of the stomach at a sufficiently
earlv period to make an operation of therapeutic use.
When a tumor has developed so that it may be
felt, the time for complete removal of the growth has
gone by. In the benign gastric conditions, steno-
sis of the pylorus and marked dilatation wherein
surgical aid is being found so useful, the stomach
tube is the quickest means and most reliable for
determining^ when such aid shall be considered. The
differentiation of eastric ulcer from gastric neuroses
can hardly be made with any degree of confidence
%yithout recourse to test meals.

In conclusion it must be especially emphasized
that the determinations of the acidity of the gastric
iuice are the least dependable of the diagnostic data,
and that when this alone is done valuable aids, such
as the tests above mentioned, are ignored.

The tests I have mentioned are those which have
been most fruitful in my experience in securing
diagnostic data. I am convinced that anyone using
these methods with care will find them constantly
a help and often indispensable to diagnosis. The
surprising thing is that after the advances that have
"been made in the diagnosis of gastric disorders, par-
ticularly cancer and ulcer, any one should feel in
doubt about the utility of the special method on
Avhich these advances primarily depend.

loS Madison Avenue.

OPERATION FOR INTESTINAL OBSTRUC-
TION IN A CHILD OF FIFTY-FIVE
HOURS— DEATH IN SEVEN-
TEEN HOURS.

By HOWARD CRUTCHER, M.D.,

MEXICO, MO.

In the early hours of January 8, 1907, I was
called by Dr. M. E. Crawford of this city to see
with him a female child that had passed nothing
from its bowels since birth. The child appeared
to be perfectly developed and very vigorous, but
presented a clear-cut picture of total intestinal
obstruction. Dr. Crawford had tried mild purga-
tives without effect, and together we applied
water pressure through the rectum without good
results. There were occasional vomiting spells
and the distention was extreme. The case pre-
sented an almost hopeless outlook, but Dr. Paul
E. Coil, who had been summoned in the mean-
time, agreed with Dr. Crawford and myself that
the child was justly entitled to the only possible
chance to save its life. With this conclusion the
parents of the child agreed, not, however, with-
out receiving the usual flood of feminine lay
advice, which is always most vigorous and volum-
inous when backed by the densest ignorance.

No anesthetic was given. Through a small
incision in the right inguinal region the exploring
finger detected a collapsed colon and a highly
distended small intestine. Peritonitis was already
well advanced. A loop of ileum was drawn into
the wound and a fecal fistula established by the
usual methods. The bowel was opened at once,
and a profuse discharge of gas and fecal matter
followed. This continued at intervals during the
remaining hours of life.

The child ceased to vomit, retained some slight
nourishment, grew more quiet, but gradually
sank, and died seventeen hours after the opera-
tion, apparently from extension of the peritonitis.
The infection started no doubt from the point
of occlusion and traveled through the intestinal
vyall.

I regret that I am unable to throw any more
light upon the cause and seat of the obstruction
in this case. A prolonged or extensive operation
would have killed the patient on the table. We
did the only practicable thing and lost. Unfor-
tunately no post-mortem examination was permit-
ted. The case is reported only on account of
the tender age of the patient. I believe that every
such patient should be given tlie benefits of sur-
gery, without regard to the dark outlook ahead.
Without the blessings of modern teaching and
practice the outlook would be much darker than
it is.

A Titled Ophthalmologist. — The Emperor of .\ustria
lias conferred on Duke Karl Theodor of Bavaria the
Order for .\rt and Science in recognition of his distinc-
tion as an ophthalmologist.

Why Defective Nasal Respiration Impedes Growth
and Development.— P. Watson Williams declares that
the pernicious effects of mouth-breathing in children are
seen in the constant tendency to infective catarrhs, bron-
chia! colds, and pulmonary complaints, from which children
with adenoids and some other causes of nasal obstruction
are prone to suffer. ".■Adenoid growths" are by far the
commonest cause of defective nasal respiration in child-
hood. The absence of normal nasal respiration causes pul-
monary troubles and defective development of the chest
wall. It may be said that children who persistently fail
to expand their lungs are underfed. After abnormal con-
ditions in the nose and throat are removed the physician
should advocate the advantage of open air, cold bathing,
and appropriate respiratory exercises, in order that these
listless, partly asphy.xiated children may grow up in the
fullness of life. — The Bristol Medico-Chirurgical Journal.

April 20, 1907]

MEDICAL RECORD.

651

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A.M.. M.D., Editor.

PUBLISHERS
WM. WOOD 8l CO , 51 FIFTH AVENUE.

New York, April 20, J907.

THE RELATION OF IMMIGRATION TO
THE PREVALENCE OF INSANITY.

The constant increase in our asylum population
cannot serve otherwise than as an indication that
mental disease is on the increase. The question
naturally arises to what is this due, and the answer
is that it may be traced to several sources. One of
these was discussed at the recent New York State
Conference of Charities and Correction following
a paper by Dr. T. W. Salmon, who is in charge of
the medical inspection service at the immigrant sta-
tion on Ellis Island. In addition to the cases of
insanity which originate among what we may for
practical purposes designate as the native popula-
tion, there is a large influx to this class from among
our immigrants. New York being the chief port
of entry, it is natural that it should become the des-
tination of those immigrants of defective physical
and mental equipment whose means do not suffice
to carry them further. This tendency to remain is
fostered by the large colonies of aliens in this citv
which assure some support to a dependent country-
man. It is also a matter of statistics that, although
this State receives but thirty-one per cent, of the
entire immigration into the United States, it is the
intended destination of more than seventy per cent,
of those who are admitted to the hospitals upon
their arrival at Ellis Island, certified as being unfit
to land on account of some mental or physical
defect.

That a definite relation exists between these fig-
ures and the prevalence of insanity in this State is
a conclusion which is made very evident by Dr.
Salmon in his thoughtful paper. In 1875 the ratio
of the insane to the whole population was one in
675 ; in 1895 it was one in 294. In order to arrive
at some opinion as to the part that immigration has
played in this result, it is necessary to consider a
number of questions. First among these is the pro-
portion of foreigners in our institutions for the
insane. The reports of these hospitals show that in
1905 one in 190 of the foreign born and one in 3('i3
of the native population was in an institution for the
insane. Of all the admissions to the New York
State hospitals since 1888, 48.4 per cent, were of
foreign birth, although the foreign born never ex-
ceeded 26 per cent, of the entire population of the
State. It would appear only reasonable to suppose
that the immigration in recent years especially has
contributed very heavily and quite disproportion-
ately to the prevalence of insanity in this State.

Within the past decade the type of immigrant has
changed considerably, and where we once had a

preponderance of the northern races of Europe, we
now find the Hebrew, Slav, and Italian more
strongly represented. An attempt to compare the
ratios of insanity between the "old" and the "new"
immigration is scarcely practicable with the data at
hand, although it is quite generally admitted that
among the Hebrews certain types of mental disease
are very prevalent. Whatever doubt there mav be,
however, about the relative occurrence of insanity
between these two classes, there is no such uncer-
tainty about the proportion of idiots and other men-
tal defectives. Defectives are as great a danger to
the community as the insane, for especially those
of the lighter types are not admitted to institutions
for the insane, but are at liberty to exercise at large
their criminal instincts and deformed moral sense.
This makes them not only undesirable members of
society, but frequently public burdens in the penal
institutions. It appears from the record that many
defectives are landed at Ellis Island, but unfortu-
nately the present immigration law does not make
their deportation mandatory unless they are actually
in a condition of idiocy. The fact is that during
the past year 15 per cent, of those certified for
imbecility or other mental defects were admitted
to this country by the authorities.

Tliere are laws to prevent the landing of the
insane or to provide for deportation if they become
a public charge within two years after admission.
It seems, however, that there are numerous loop-
holes through which escape is possible. It may be
difficult to subject these errors to direct reform,
hut there are other ways in which some good can
be accomplished in preventing the entrance into this
country of undesirable individuals of this type. In-
sanity is apparently sufficiently dealt with in the
immigration laws, but the latter should be amendeil
to include in the prohibited class all mental defei.-
tives and those certified as having evidences of con-
stitutional mental inferiority or instability. With
a law of this kind all those undesirable accessions
to our population which are likely to develop crimi-
nal tendencies could also be excluded. We are
undoubtedly confronted by a serious problem as
regards the character of some of our foreign-born
population, and the question should be regarded in
a sensible light rather than in the sentimental aspect
which finds favor among a certain class of our pop-
ulation. We need the immigration, but it must be
selected, and the selection should be based on men-
tal and bodily fitness rather than on other and less
important considerations.

THE COLLEGE OF PHYSICIANS AND SUR-
GEONS.
The Columbia University Quarterly, in giving up
practically the whole of its current issue to articles
on subjects concerning the medical profession, bears
graceful witness to the prominent position of the
medical faculty in the fabric of the University. The
number commemorates the centenary of the old
College of Physicians and Surgeons, now the Med-
ical School of Columbia University, which received
its charter on March 12, 1807, and in November of
the same year opened its doors in a house on Robin-
.son street, now Park place. Six years later the new

652

MEDICAL RECORD.

[April 20, 1907

institution absorbed the alreadv languishing med
ical school of Columbia College, in i860 entered into
a nominal union with Columbia College, and in 1891
became an integral part of the University, thus
realizing what is said to have been a cherished
dream of the eminent Dr. Samuel Bard, under
whose early presidency the foundations of the insti-
tution's future prosperity were laid.

The record of the institution's development from
its modest beginning with a faculty of seven mem-
bers and a first graduating class of eight, to
its present importance, is traced in engaging fashion
by Dr. Frederic S. Lee, while an interesting side
light on the medical life of the city a century and
more ago is afforded by a sketch of the life of
Dr. Bard contributed by Dr. Walter B. James. Dr.
M. Allen Starr, in an article on medical education
in New York, rehearses the manifold advantages
of this city as a center for medical education and
the opportunities for undergraduate and advanced
workers ofifered by its seventy-four hospitals and
fifty-three dispensaries — to leave out of the count
Brooklyn's large list of medical institutions. The
teaching anatomical museum for undergraduates, a
recently elaborated feature of the equipment of the
school, is described by Dr. George S. Huntington,
and Dr. James A. Miller outlines the progress of the
antituberculosis movement in New York.

The address entitled "Medical Ideals and ]Medi-
cal Tendencies," delivered by Dr. L. Emmett Holt
at the opening of the college last fall, is reproduced,
and forms a delightful essay on the attitude of the
physician to his life work, well worthy of the consid-
eration of every medical reader. In pointing out
the undesirability of a too blind subservience to
what he terms the scientific spirit in modern medi-
cine, which tends to sacrifice to some extent the
faculty of careful bedside observation to the cult of
laboratory diagnosis. Dr. Holt touches on one of
the difficult problems of modern medical instruction,
which is discussed at length by Dr. Francis C. Wood
in an article on the department of clinical pathology
of the college. In this thoughtful paper the necessity
for a broader policy of coordination between hos-
pital laboratory and hospital ward is indicated, and
a well-rounded system of undergraduate and post-
graduate instruction in clinical pathology, which
shall be abreast of modern conditions and yet free
from one-sidedness from either the laboraton,' or
the clinical standpoint, is convincingly advocated.
In the editorial department are to be found pertinent
comments on the anniversary celebration of the
College of Physicians and Surgeons which is to be
held in June, and on the quiz system and the clinic
in medical teaching.

This commemorative number of the University
Quarterly serves but as one more illustration of the
mutual benefits that have attended the coalition of
the two institutions, and of the fact that the art of
medical pedagogics has been much advanced by their
union.

METALLIC SUTURES.

The general popularity of the absorbable suture has
led to the practical abandonment of most other ma-
terials for this purpose, particularly when they are

to be buried in the tissues. The absorbable suture,
however, has always the uncertainty connected with
it of becoming the center of growth for an infectious
process or of continuing the same when placed in its
close proximity. The truth of this has been recog-
nized in the attempts which have been made to im-
pregnate catgut, for example, with iodine and other
antiseptic agents. Certain of the metals are known
to possess the property of inhibiting the growth of
microorganisms, but sutures of these materials seem
to have found little favor except in isolated in-
stances. The main objection to them has been the
local irritation which they are said to cause, but it
has often been shown that this need not interfere
with their employment.

The antiseptic value of the metal suture has again
been studied by Leedham-Greene ( The Practitioner,
March, 1907), who examined the inhibitory proper-
ties of a number of metals when incubated with gela-
tin or agar cultures of staphylococcus aureus. In
the case of the majority of the metals, the presence
of the wire loop in the gelatin seemed to have little
or no influence on the growth of the microorgan-
isms, which flourished in all parts of the dish, as
well as in the immediate vicinity of the metal. But
it was evident that some metals exhibited a distinct
and powerful inhibitory action upon the bacterial
growth. In these cases the culture medium in the
immediate neighborhood remained free from
growth, a microscopical examination of the plates
confirming the gross appearance. Gold, platinum,
tin, aluminum, magnesium, and nickel showed prac-
tically no inhibitive power, and lead and silver only
when cultures grown at a low temperature were
employed. Iron exhibited a variable action, depend-
ing on whether oxidation was hindered or favored.

From the bactericidal standpoint, copper proved
the most powerful of the metals, and, in a less de-
gree, its alloys, bronze and brass. It would appear
that a metal possessing this power of inhibiting bac-
terial growth to a marked degree would prove suit-
able for suture material providing its ductility,
tenacity, and freedom from irritating properties
were not affected. Silver, although apparently the
most widely used, does not conform to these specifi-
cations to any marked degree ; it is costly, not as
tough or ductile as might be desirable, and its anti-
septic power is insignificant. Aluminum-bronze
wire has been largely used on the Continent to sup-
plant silver, and from the large amount of copper
present (95 per cent.), it would be likely to meet the
desired indications. The metal, being rather soft,
cannot be used in the form of screws or nails, and
Leedham-Greene suggests a true bronze, consisting
of a mixture of copper and tin, for this purpose. It
has been shown that sutures of this kind which pos-
sess a certain degree of bactericidal action are less
irritating to the tissues and less apt to be followed by
the production of sinuses than those having no anti-
septic value. Pure copper would seem to be the most
nearly ideal material for the purpose, and, although
it is generally considered to be too irritating to the
tissues, Greene finds that in his own experience this
assumption is not borne out by the facts. While
absorbable sutures will probably continue to be pre-
ferred for routine use, it is possible that Greene's
suggestions may prove practicable for certain cases.

April 20, 1907]

MEDICAL RECORD.

653

CLOTHING FOR THE TROPICS.
In his interesting work on ''The Influence of Trop-
ical Light on White Men." Major Charles E. Wood-
ruff speaks of the mistaken notion that white is the
best color for clothing in the Tropics. It is true
that white garments reflect the heat rays, but the
actinic rays pass through them readily ; hence if
they are worn it should be in conjunction with
vellow, red, or black underclothing. The negro with
a white suit is, he says, the most contented of beings
under a tropical sun, and the white man should imi-
tate him, supplying the missing pigment by black
undergarments.

Dr. Louis W. Sambon, writing in The Journal of
Tropical Medicine and Hygiene for February 15,
1907, on the subject of tropical clothing, comes to
the same conclusion. "The use of white clothing for
the Tropics," he says, "has been adopted in imita-
tion of native custom, and no doubt it is wise to fol-
low the dictates of a long experience ; but those who
borrowed this custom overlooked the all-important
fact that the native is already fully protected by a
natural armor of pigment which is impervious to
the harmful actinic rays. Having no reason to fear
the chemical rays of the sun, the native dons an
ample white robe, which, by reflecting the long heat
rays, keeps him comfortably cool." But even the
natives do not always wear white, for red, yellow,
and brown are really the predominating colors, more
especially with regard to the protection of the head
and abdomen. White is for comfort, but health
demands a lining of pigment.

To avoid the additional weight and thickness of
several layers of cloth. Dr. Sambon conceived the
idea of a fabric composed of white and colored
threads, woven in such a way as to produce a warp
or outer surface of white and a woof or inner sur-
face of black, red, or orange. For army use, where
a white tunic would be undesirable, he used threads
of yellow and blue for the warp and red for the
woof, producing a khaki effect externally with a red
color-screen for the inner surface. Such a cloth,
with a heat-reflecting outer surface and an opaque
inner layer, will, he thinks, meet all the requirements
of comfort and protection for garments for tropical
use.

The Clinic.\l Thermometer.

In view of the immense number of thermometric
determinations that are being made in medical prac-
tice, and of the important deductions drawn from
them, the subjects of the accuracy of the instruments
employed and of the physiological variations in body
temperature certainly deserve more attention than is
usually accorded them. Most practitioners prob-
ably take it for granted that the thermometers — at
least those of the medium and better grades — sup-
plied by the dealers are instruments of precision,
yet comparison with a standard thermometer will
often reveal a most astonishing degree of inac-
curacy. While the fragile nature of the instru-
ment and the vicissitudes of daily use usually pre-
clude any serious inaccuracy due to the changes
attending the so-called seasoning of the glass, if a
thermometer survives more than a year it should be
retested and the necessary corrections noted. Very
little consideration also is usually given to the sub-
ject of the normal fluctuations of temperature, which

are much wider than is commonly realized. In this
connection Myers (Yale Medical Journal, April,
1907) says that the temperature of the healthv
human body undergoes certain variations which,
when graphically expressed, take the form of a
curve, the essential characteristics of which are an
evening fall, with a minimum somewhere between
12 midnight and 6 a.m., and a marked rise in the
morning with a maximum between 4 and 6 p.m.
The temperature in the course of twenty-four hours
may vary through a range of 2° C. (3.6° F.) under
perfectly normal conditions. Thus, in observing the
late afternoon or early evening temperature, a record
might be obtained as high as 38° C. (100.4° F.),
or again, the temperature in the early morning
might be as low as 36° C. (96.8° F.) under normal
conditions, .^fter anv muscular exertion, such as a
rapid walk to the physician's office, one might expect
to observe a temperature as high as 37.5° C.
(99.5° F.) in a normal individual. A point which
should be much emphasized lies here. Unless a
distinctly febrile temperature is observed, there are
many factors which must be considered in using
body temperature as diagnostic of an abnormal
condition. It appears that each person has his own
normal body temperature and normal curve of fluc-
tuation, and these must always be taken into con-
sideration if possible in clinical temperature deter-
minations. While the causes of the fluctuations in
normal body temperature are incompletely under-
stood, it is. known that muscular work, food, and
the standing position elevate the body temperature,
while inactivity, rest, and possibly fasting, have the
reverse effect.

To Prevent Prem.\ture Buri.^l.

The problem of discovering a simple yet reliable
sign of death is one that has attracted much interest
in France, and several prizes have been offered for
its solution. One of these was some years ago
awarded to Dr. Icard of ^larseilles, who has been
a prolific experimenter and writer on the subject,
and has even succeeded in inducing the municipal
authorities of several cities to give their official
sanction to the use of his fluoresceine test. This
consists in the subcutaneous injection of a solution
of fluoresceine ; if circulation of the blood, however
sluggish, is still going on, the skin in the course of a
few hours becomes intensely yellow and the con-
junctiva green. This discoloration is only tempo-
rary in the living, and the procedure is not injurious.
A somewhat simpler, though perhaps equally dra-
matic test, is one that he has lately suggested. It
is founded on the blackening produced in solutions
of lead acetate on contact with sulphuretted hydro-
gen, and is carried out by writing a few words such
as "I am dead" with a solution of the lead salt on
a strip of paper. This apparently blank slip is to be
rolled up and placed in the nostril of the supposed
corpse. It is alleged that before any external evi-
dences of putrefaction can be detected sulphuretted
hydrogen is given off from the lungs, and the
writing, therefore, becomes visible if death has taken
place. Icard proposes that such slips of paper be
given to persons reporting deaths at which no physi-
cian has been present, with the direction to place
them in the nostrils of the deceased. The next day
the slips are to be brought back to the proper official,
after the dead person has, so to speak, made outhis
own death certificate. The conception is certainly
ingenious and has an attractive touch of the theatri-
cal, but unfortunately doubts have been cast on its
reliability. At least the Edinburgh Medical Journal

654

MEDICAL RECORD.

[April 20, 1907

states that in many cases in which the test was
applied it failed to give satisfactory results, and in
bodies that had been kept for a week or more, and
in which other evidences of putrefaction had long
appeared, the pieces of lead paper in the nostrils did
not show more than the merest trace of discolora-
tion.

conditions in this country, at least should serve as
an additional incentive to make every effort to en-
courage breast feeding.

Orthostatic Albuminuria.

In connection with Heubner's recently reported case
of orthostatic albuminuria with autopsy (Medical
Record, February 2, 1907), it is interesting to note
a communication of Langstein's in the Berliner
klinische IVochenschrift, January 28, 1907, referring
to the nature of the albuminous bodies to be found
in the urine in instances of this peculiar affection.
Langstein has found that in all specimens of albumi-
nous urine from patients with orthostatic albumi-
nuria an albuminous body which is precipitated by
acetic acid is present. Those cases in which only
this body is found are per se to be distinguished
from cases of chronic nephritis, whereas in the
chronic nephritis of children this particular albu-
minous body is either absent or is present in smaller
amounts than the ordinary albumin. For its de-
tection he suggests the following mode of pro-
cedure : Two test tubes are filled to the same
height with urine, a few drops of dilute acetic acid
are added to each, and the tubes are shaken for
several minutes. The specimens are ihen diluted
with three or four volumes of water, and to one
of them a few drops of potassium ferrocyanide solu-
tion are added. On holding the tubes against a black
background the presence or absence of the acetic
acid albumin in the one tube can be determined and
its bulk may be compared with that of the total al-
bumin in the other. The addition of water after
acidulating is necessary in order to prevent the pre-
cipitation of uric acid from a urine of high specific
gravity. The nature of this albuminous body is still
uncertain, but it appears to resemble that which von
Leube discovered in about two-thirds of a large
number of healthv soldiers after moderate exertion.

The Breast Feeding of Infants.

In spite of the efforts of pediatrists to popularize a
knowledge of the advantages of breast feeding, there
seems to be little doubt that the practice of artificial
feeding is becoming more prevalent, instead of the
reverse. It is usually assumed that resort to bottle
feeding as a matter of mere expediency is a problem
to be dealt with primarily among the better classes,
but Neumann (Deutsche medizinische IVochen-
schrift, February 21, 1907) shows that in Germany,
at least, the tendency is growing among the poorer
people as well. He estimates that artificial feeding
of infants has increased by about two-thirds in Ber-
lin since 1885 in all classes of the population. In
that year, among the families inhabiting one or two
rooms. 70 per cent, to 80 per cent, of' the mothers
could have nursed their infants, and 65 per cent.
actually did so. Now, however, about 50 per cent,
resort to bottle feeding without sufficient reason,
and among the families living in four or more
rooms, in 1900 only 30 per cent, of the mothers were
found nursing their infants. It is not necessary to
rehearse Neumann's list of the reasons that make
natural feeding preferable to artificial — they are
sufficiently well known to medical men — but the
Berlin statistics, even if not directlv apphcable to

The Cause of the Odor of Ozena.

It is quite generally acknowledged that the fetor
which accompanies ozena is out of proportion to
the extent of the lesion, and very little is known of
the immediate causes of its production. Frese,
who has recently investigated this subject {Deut-
schcs Archiv fiir klinische Medicin, Vol. 86), finds
that the odor is of a mixed origin. Chemical analy-
sis of the secretion has shown the presence of a va-
riety of substances which are always found in the
process of decomposition of albuminous materials.
Chief among these are a number of fatty acids, vola-
tile in character, which constitute the principal of-
fensive substances, and seem to arise from a direct
conversion of the neutral fats. The secretion itself
is without odor when first formed, but its peculiar
constitution renders it immediately liable to decom-
position in the presence of microorganisms. Frese
finds, however, that the so-called ozena bacillus is
unable to institute this process. It w^as also deter-
mined that the foul products arising from a tertiary
nasal syphilis are of the same general character as
those associated with true ozena.

A New Pupillary Reaction.

An interesting observation has recently been made
by Lowy {Neitrologisches Zentralblatt, 1906, No.
20), with reference to the behavior of the pupils in
the presence of local painful areas. He claims that
when the pupils are contracted by intense light, the
pain elicited by pressure on an organically diseased
region will be accompanied by a distinct relaxation
of the pupillary ring, whereas that proceeding from
a functional lesion is not distinguished by this phe-
nomenon. Lowy believes that this symptom is of
value as a differential diagnostic sign in avoiding
a confusion between pain of an organic and that of a
psychic origin, such as is associated with hysteria.
Likewise in traumatic neuroses it may serve to show
whether the tenderness elicited at the site of the
injury is due to the trauma itself or is of psychic
origin.

"^tms at tijp Hpfk.

A Chair of Hydrotherapy. — Dr. Simon Baruch
has been made Professor of Hydrotherapy in the
medical department of Columbia University, and a
hydrotherapeutic department is to be established in
the Vanderbilt Clinic. In this department students
in small sections will receive practical instruction in
hydrotherapy, the course being an obligatory one,
and the final examinations will include this subject.
It is not necessary to point out what a valuable
iimovation this will be.

Iroquois Memorial Hospital in Chicago. —
The project recently submitted to tlie County
Board for the establishment somewhere down-
town of an institution to be known by this
name was recently unanimously indorsed by
the Council of the Chicago Medical Society.
Dr. George W. Webster, President of the
Chicago Medical Society, supported the resolution
of indorsement and spoke in favor of its adoption.
In return for the use of its name, the Iroquois

April 20, 1907]

MEDICAL RECORD.

655

Memorial Association agrees to contribute a fund
of $25,000 already collected for that purpose, and
such other sums as may be raised by members of
the Association.

Results of Examinations for Internes. — Of
ninety-six students recently examined at the Cook
County Hospital, forty-four students passed the
required grade for interneship. Fifteen of the suc-
cessful applicants will be appointed internes in June.

Work of the Antismoke League. — This organ-
ization, acting in conjunction with the Health De-
partment, during the last year caused 193 arrests
for violations of Section 26 of the Sanitary Code
which provides that no smoke, cinders, or noxious
gases shall be allowed to escape from chimneys, etc.
Of the persons arrested, 132 were convicted, 36
were discharged, and at the end of the year 25 cases
were pending. The effect of this activity on the part
of the League is shown in the record of convictions
for this offense in previous years: 1902, 17 convic-
tions; 1903, 45 convictions; 1904, none; 11)05, none;
1906, 132 convictions.

Smallpox. — The Russian steamer Pelcrsbnrg.
which arrived last week from Libau and Rot-
terdam with 981 steerage passengers, was de-
tained at quarantine because of a case of smallpox
in the steerage. The patient, who had been ill eight
days, was transferred to the Kingston Avenue Hos-
pital, and 150 passengers who occupied the same
compartment were sent to Hoffman Island for
observation. The steamer was disinfected. Owing
to the occurrence of nine cases of smallpox in Chel-
sea, Mass., three of the public schools of the city
have been closed as a precautionary measure.

Yellow Fever. — In the port of Kingston. Ja-
maica, a rigid quarantine has l>een established
against vessels from Cuba and Trinidad, where yel-
low fever has apjieared.

Child Labor Bill.— The Page child labor bill
was passed by the Assembly at Albany on April 9.
Originally the bill provided that children could be
employed between the hours of 7 .a.m. and 7 p.m.,
but in the Assembly it was amended, and the bill
passed prohibits the employment of children except
between the hours of 8 a.m. and 5 p.m.

To Control Expert Testimony. — A bill has been
introduced in the Assembly at Albany which is
intended to restrict the scope of expert testimony in
regard to the mental condition of defendants in
murder trials. The bill provides that the expert
must have actually examined the person concerning
whose mental state he is to testify, and also provides
against the abuse of the hypothetical question.

Appropriations for State Institutions. — Among
bills recently signed by Governor Hughes are those
providing for appropriations for State Hospitals as
follows: Bingliamton Hospital, $50,000 for new
dining room and kitchen, $81,000 for nurses' home,
and $7,500 for water supply; Middletown Hospital,
$81,000 for nurses' home; Hudson River Hospital,
$81,000 for nurses' home; Kings Park Hospital,
$62,000 for new laundry.

New Home for Incurables. — Mrs. Henrietta M.
Parker of this city has filed the plans for the erec-
tion of the Parker Home for Incurables, at Eastern
avenue and Landing road, New Brunswick, N. J.,
which she intends to build in memory of her hus-
band, the late Francis Parker of this city. The
building will have a basement, two hospital wards,
and thirty-one rooms, which will include sun parlors,
of^ces, nurses' rooms, baths, living rooms, etc. The
building will be of brick and marble and will com-

mand a magnificent view of the Raritan and sur-
rounding country. It is expected that it will be
ready for use November i.

Professor William Keen of Philadelphia, a dele-
gate to the German Surgical Congress in Berlin, has
been elected an honorary member of the German
Surgical Society, and was one of five delegates re-
ceived at a special audience by the German Empress.

Dr. P. F. Chambers has been appointed Clinical
Professor of Gynecology in the medical department
of Columbia llniversity.

An International Congress of Psychiatry, Neu-
rology, Psychology, and the Care of the Insane is
to be held in Amsterdam on September 2 to 7, 1907.
It will differ from the preceding congresses that
have been held in Brussels, Paris, Antwerp, and
Milan, in having a section of experimental psychol-
ogy.

International Medical Association for the Sup-
pression of War. — Dr. J. Riviere, 25 Rue des Ma-
thurins, Opera, Paris, the president of this society,
invites correspondence from those interested in the
subject relative to an internati(jnal congress of phy-
sicians to be held in Paris during the year 1908.

Exhibit of Colored Physicians at Jamestown. —
In order to demonstrate the progress of the negro
race in medical education, an emergency hospital,
under the direction of colored physicians and at-
tended by colored nurses, is to form part of the
negro exhibit at the Jamestown Exposition. The
hospital building will include an exhibition room,
in which a display of hospital records and supplies,
pathological and bacteriological specimens, etc., will
lie shown. The following committee is in charge of
the medical exhibit : Dr. A. M. Curtis, Washington,
D. C. ; Dr. George C. Hall, Chicago, 111. ; Dr. R. F.
Boyd. Nashville, Tenn. ; Dr. W. A. Warfield, Wash-
ington. D. C, and Dr. Joseph j. France, Portsmouth,
Va.

Springfield (Mass.) Academy of Medicine. —
This organization received its charter on April 9,
and was formally inaugurated. Officers were elect-
ed as follows : President, Dr. W. A. Smith of
Springfield ; First Vice-President, Dr. John A. Hou-
ston of Northampton; Second Vice-President, Dr.
R. H. Seelye ; Secretary, Dr. Joel I. Butler; Treas-
urer, Dr. H. W. Van Allen. There are already
more than 200 names on the charter list, represent-
ing Vermont, New Hampshire, and Western Massa-
chusetts as far east as Worcester, and the list will be
left open for the next thirty days. It is planned
ultimately to erect a building for the academy, with
assembly hall, library, etc.

Dr. J. William White, John Rhea Barton Pro-
fessor of Surgery in the LTniversity of Pennsylva-
nia, and Senior Surgeon to the University Hos-
pital, has been appointed advisory surgeon to the
Pennsylvania Railroad Company.

Transfer of Insane Patients. — In consequence
of a fire in one of the buildings of the State Hos-
pital for the Insane at Norristown, Pa., one hundred
male patients have been transferred temporarily to
the Insane Department of the Philadelphia Hos-
pital. Plans are already under consideration for the
reconstruction of the burned building, or it may be
decided to utilize a sum of $416,000 appropriated by
the present Legislature for the purpose of erecting
an entirely new series of buildings.

For the Suppression of Cerebrospinal Menin-
gitis.-— In an effort to prevent the further spread
of cerebrospinal meningitis, a number of cases of
which have recently been observed in the city of

656

MEDICAL RECORD.

[April 20, 1907

Philadelphia, Dr. A. C. Abbott, Chief of the Health
Bureau, has ordered a house-to-house inspection in
the lower wards of the city. In addition, the co-
operation of the Department of Public Works will
be asked for the purpose of making; a thorough and
careful inspection of the streets and alleys in the
section named.

Bloodshed in Italy. — Recently published sta-
tistics show that in Italy there has been a decrease in
the number of persons killed by violence, which is
attributed mainly to the progress of surgery, how-
ever, for there has been an increase in the number
of wounded. Di:ring the year 1903, 3,106 persons
were murdered and 93,768 wounded, and it is cal-
culated that in a period of twenty-seven vears 97,000
persons met violent deaths and 2.000,000 have been
wounded. The record for criminality is held by
Sicily, where the proportion of murders reaches 42
to every 100,000 inhabitants in the province of Gir-
genti. The proportion decreases in other provinces
and falls to 25 for every 100,000 in Naples. It still
further decreases considerably in northern Italy,
where, at Bergamo, there is only one murder for
every 100.000 persons.

Women's Medical Society of New York State.—
An organization having this title was formed in
Rochester on March 11. On the occasion of the
seventy-eighth birthday of Dr. Sarah R. x^damson
Dolley of Rochester, the Blackwell Medical Society
of Rochester, The Physicians' League of Buffalo.
The Women's Medical Association of New York
City, and The Dr. Cordelia A. Greene Society of
Castile, affiliated and invited the women physicians
of the State to join them at a banquet, the new
society being then organized. The officers are as
follows : Honorary President, Dr. Elizabeth Black-
well of Hastings, England ; President, Dr. Sarah R.
Adamson Dollev of Rochester. N. Y. ; First Vice-
President, Dr. Electa B. \\hipple of Buffalo, N. Y.:
Second Vice-President. Dr. Marv H. Cotton of New
York City; Third Vice-President. Dr. Mary
Theresa Greene of Castile, N. Y. : Secretary, Dr.
Eveline P. Ballintine of Rochester, N. Y. ; Treas-
urer, Dr. ]\I. May Allen of Rochester. N. Y.

Northern Medical Association, Philadelphia. —
At the annual dinner held April 10. toasts were
responded to as follows : "The Anamolies and
Curiosities of Medicine," by Dr. Walter L. Pyle;
"Medical Legislation," by Dr. Henry Beates : "^lod-
ern Surgen,-," by Dr. John B. Deaver : '"The La-
dies," by Dr. Charles P. Noble, and "Some Remi-
niscences of Philadelphia's ^ledical Teachers and
Practitioners," by Dr. Chas. K. Mills.

Officers of Tennessee State Medical Associa-
tion.^— At the seventy-fourth annual session of
this Association held at Nashville. April g. 10. and
II, the following officers were elected for the en-
suing year: President, Dr. A. B. Cooke of Nash-
ville : Vice-Presidents. Dr. R. E. Fort of Nashville,
Dr. Chas. P. ?^IcNabb of Knoxville. Dr. R. W. Tate
of Bolivar ; Secretary, Dr. Geo. H. Price of Nash-
ville, reelected ; Treasurer, Dr. W. C. Bilbro of
Murfreesboro, reelected; Delegate to the American
Medical Association, Dr. S. W. \\''oodyard, Green-
ville ; Alternate Delegate, Dr. C. E. Ristine, Knox-
ville. Knoxville was selected as the place for hold-
ing the next annual session.

Asotin County (Wash.) Medical Association. —
At a meeting of this organization held in Clarkston
on April i, officers were elected as follows: Presi-
dent, Dr. L. W. Woodruff of Asotin ; Vice-Presi-
dent. Dr. P. W. Johnson of Clarkston ; Secretary,
Dr. I. U. Temple of Clarkston ; Treasurer, Dr. S.
D. Brazeau of Asotin.

Association of Railway Surgeons. — The sur-
geons of the T. P. and \\ . Railway met in Peoria,
111., on April i and formed a society to be known
as the T. P. and W. Railway Surgeons' Association.

Davidson County (N. H.) Medical Society. —
Officers were elected as follows at the meeting of
this society held on April 2 in Newmarket : Presi-
dent, Dr. Marvin M. Cullom ; Vice-President, Dr.
Rufus E. Fort; Secretary and Treasurer, Dr. Hol-
land M. Tigert, reelected.

New London County (Conn.) Medical Society.
— At the annual meeting of this society held in New
London on April 4, officers were elected as follows :
President. Dr. Harry M. Lee of New London ; Vice-
President. Dr. M. E. Fox of Montville ; Clerk, Dr.
E. C. Chipman of New London.

Garland County (Ark.) Medical Society. — At
the recent meeting of this society, officers were elect-
ed as follows: President. Dr. O. H. Burton; Vice-
President. Dr. F. H. Tribble ; Secretary, Dr. M. F.
Mount ; Treasurer, Dr. J. S. Horner.

Hartford County (Conn.) Medical Society. —
The one hundred and fifteenth annual meeting of
this society was held in Hartford on April 2. The
following were elected as officers for the ensuing
year: President, Dr. Edward K. Root of Hartford;
Vice-President, Dr. Charles M. Wooster of Tariff-
ville: Secretary, Dr. Frederick B. Willard of Hart-
ford.

In Honor of Dr. Hodgen. — Under the auspices
of the St. Louis Medical Society memorial exercises
will be held in that city on April 28, in commemora-
tion of the twenty-fifth anniversary of the death of
Dr. John T. Hodgen. A generation ago Dr. Hodgen
was one of the prominent figures in American medi-
cal life, and he served at different times as president
of the American Medical Association, the Missouri
State [Medical Society, and the St. Louis Medical
Society.

In Memory of Mobius. — A committee of Ger-
man physicians, of which Dr. Curt Rheinhardt of
Leipzig is the secretary, has been organized for the
purpose of collecting a fund to be used to establish
a vearly prize to be given as a memorial to the late
Dr. Paul J. Mobius of Leipzig. It is planned alter-
nately in one year to award the prize for an origfinal
paper to be published in the Psychiatrisch-N eurolo-
gische Wochenschrift, and in the next for the best
article on a psychiatric or neurological subject to
have been published in the two preceding years.

Obituary Notes. — Dr. Dicia H. Baker of Bir-
mingham. Ala., died on April 4, at the age of forty-
four years. She was a native of Tennessee and was
graduated from the Laura Memorial College of Cin-
cinnati. Dr. Baker was the first woman to be gradu-
ated in Pharmacy from the \'anderbilt University
at Nashville. She had practised in Birmingham
about eight years.

Dr. A. F. Ritchie of Duluth. Minn., died on
April I at Mt. Clemens. He was born in 1854, and
was graduated from McGill L^niversity in 1876.
After several years of post-graduate work in Eu-
rope he began practice in Duluth, where he had re-
sided ever since.

Dr. Hexry W. Spillman of Edgerton, Wis.,
died on April 2 at the age of eighty-seven years. For
the past twenty-seven years he had practised in
Edgerton.

Dr. Frank Riley of St. Joseph, Mo., died at the
age of forty-eight years, of paralysis, on April_ i,
after several years of illness. Dr. Riley was a native
of Illinois, and received his early education in the

April 20, 1907]

MEDICAL RECORD.

657

university of that State. In 1882 he was graduated
from St. Joseph Medical College, and after practis-
ing for some years in Bolckow and in .\urora he
removed to St. Joseph.

Dr. Charles B. Combe of Brownsville, Tex.,
died on March 31 at the age of seventy years. He
was born in Davis County, Ky., and received his
medical degree from Jefferson Medical College in
Philadelphia in 1858. After a year in the Charity
Hospital of New Orleans he located in Brownsville,
and served during the Civil War as surgeon on the
staff of General Magruder. At various times he
was president of the Brownsville and Matamoras
Medical Association, president of the district Medi-
cal Examination Board, and State Health Officer.

Dr. Henry P. Ev.arts of Grand Rapids, Mich.,
died on April i at the age of sixty-two years. Dr.
Evarts was born in Madison, O., and was graduated
from the Cincinnati Medical College in 1870. He
had practised in Grand Rapids for over eighteen
years.

Dr. L.-\wrence Berry of Athens, Ga., died in
Philadelphia on March 30. He was a recent gradu-
ate of the Jefferson Medical College.
■ Dr. John Edgar March of St. John, N. B., died
suddenly of cerebral hemorrhage on April 3, at the
age of forty-seven years. He was graduated from
the Bellevue Hospital Medical School and practised
for some years in Hampton, N. B. He then removed
to St. John, and in 1894 was appointed Quarantine
Officer of the Port, a position he had held since
that date.

Dr. George W. Biggers of La Grande. Ore., the
father of Dr. George L. Biggers of that city, died
on March 29 at the age of seventy-one years. He
had practised in Oregon since 1848.

Dr. W. H. Harris of Belleville, Mo., died on
April 3 at the age of sixty-five years. He was born
in Meridian, Ala., and had practised in Belleville
since 1884.

Dr. Justin L. Barnes of this city, died on April
13 at the age of forty-seven years. He was gradu-
ated from Cornell University ■ in 1881, and four
years later received his medical degree from the
New York University Medical School. He devoted
himself to ophthalmology, and for many years had
been connected with the Manhattan Eye and Ear
Hospital. He was born in Middletown, Conn.

Dr. Henry DeWitt Joy of West Brighton died
of apoplexy on April 15. Dr. Joy was born in this
city in 1841. He was graduated from Williams
College and from the College of Physicians and Sur-
geons. For many years he was chief surgeon of
the Pacific Steamship Line, and in 1900 he became
consulting physician at the Sailors' Snug Harbor on
Staten Island.

material. It was not the patient's first experience of the
sort and I have heard of other similar cases from the same
cause. This would indicate that the hairs are at least not
necessary to the conveyance of the poison, which appears
to be contained in the sap and to retain activitv after
prolonged drying.

Manley F. Gates, Surgeon. United States Navy.

(Hatrsspanlimn,

JAPANES'E LACQUER DERMATITIS.
To THE Editor of the Medical Record:

Sir: — In your issue of January 12, 1907, is an abstract
from an article in the Medical Review of Reviews by A.
Hadden on Poison Ivy. I have not access to the original,
but the abstract reads :

"The nature of this poison has not yet been clearly defined.
On the leaf and stem of this vine {Rhus toxicodendron)
there is a fine hairy formation on both the upper and
lower sides. To this is attributed the chief agency of
communication of the poison. Both flies and mosquitos
are doubtless the carriers of these small hairy particles
as well as of the sap to many sensitive skins."

Much of the Japanese black lacquer work is made with
the sap of an allied plant (Rhus vernicifera) and a case
has come under my care of severe rhus poisoning in a very
susceptible individual from handling a box made of this

OUR LONDON LETTER.
(From Our Special Correspondent.)

insanity^spikochetes of relapsing and tick fevers —
typhoid inoculation in the army — malaria and trop-
ICAL diseases — A QUASI-DIPHTHERIA BACILLUS — A TYPHOID
BACILLUS FROM A SINUS — TUBERCULOSIS OF TESTIS — HOS-
PITAL FUNDS.

London, March 29, 1907.

In his concluding Lumleian lecture Dr. Savage dealt with
alcoholism and influenza as causes of insanity. In respect
to the first his conclusions did not quite accord with the
common view, and he remarked that we have no proof
that the abolition of alcoholism would diminish insanity.
The recent increase bore no relation to the consumption of
alcohol, for people were more temperate than formerly.
.\ccording to the special report of the Irish Commission-
ers, excessive tea drinking should not be overlooked as a
possible cause, .-^t the same time he was obliged to admit
that alcohol reduces the nutrition of brain and may be
called a nerve toxin, and often thereby causes delusions,
leading in bad cases to brain degeneration and premature
senility. But a more potent factor, he held, was influenza.
Some twenty-five years ago he had pointed out that this
disease predisposed to nervous and mental disorders, but
he was then scolded at and told he saw insanity in every-
thing— even influenza. His view was now widely accepted
and he argued that influenza w-as a more active cause of
insanity than all others. It produced insomnia and neural-
gia and upset digestion, and so the nutrition of the brain
was impeded and melancholia, mania, or dementia might be
started. .-Xcute insanity sometimes was seen in the early
stage of influenza, but there was no special form of in-
fluenzal insanity, and though the disease often caused men-
tal derangement it might sometimes exercise a modifying
influence on those already insane. Dr. Savage believes
a special receiving hospital in London such as Glasgow has
would do good by sifting out acute and curable cases and
saving them from being sent to asylums.

Sir K. ^I. Mackenzie, secretary to the Lord Chancellor,
gave evidence on Wednesday before the Royal Commis-
sion on the feeble-minded. He had great confidence in the
authorities in lunacy and a very serious question had arisen
as to whether the Lunacy Commissioners were overworked.
If the present system remained unchanged, some addition
to their numbers should be made. He held that the Lunacy
Commissioners should remain, in fact and in name, an
independent body, and not become absorbed in a Govern-
ment department. Lunacy was not a matter of policy, to be
assigned to the Home Office, nor of sanitation, to pass un-
der the local Government board. If it were classified with
anything else it was more akin to the care of infants and
the wards of court. But there were objections to trans-
ferring them to chancery.

Lieutenant-Colonel \V. B. Leishman submitted some in-
teresting observations on the spirochetes of relapsing fever
and tick fever to the last meeting of the Pathological So-
ciety. His material included films from Austria, .'Vden, and
India, as well as living organisms. He studied the devel-
opment in white mice and found them equally fatal, con-
trary to the e.xperience of others. The virulence was in-
creased by passage, as shown by earlier appearance in the
blood and more rapid multiplication. He could not con-
firm Novy and Knapp's description of morphological dif-
ferences between the spirochetes of tick fever, European
relapsing fever and Indian relapsing fever. He had found
wide variations in each case, and they seemed to him due
to such factors as the vitality of the organism, stage of the
disease, method of fi.xation, etc. From the work of others
he had no doubt of the specific dift'erence between the
spirochetes of tick and relapsing fevers. But further work
seemed necessary to show if there were varieties of re-
lapsing fever. Novy and Knapp consider these spirochetes
to be true bacteria, but this view was not fully accepted by
Colonel Leishman. He had not been able to demonstrate
fiagella in either, but he had observed the structure which
Schaudinn considered was an undulating membrane in the
organism of relapsing fever. This, as well as living organ-
isms, were shown in a microscopical demonstration which
followed the paper.

658

MEDICAL RECORD.

[April 20. 1907

The progress of antityphoid inoculation in the army
since the method was resumed on tlie recommendation of
a committee appointed by the Army Coimcil to investigate
it, was described at tlie same meeting by Lieutenant-Colonel
Leishman. Lectures arc given to all drafts going on for-
eign service, and as far as possible the inoculations are
carried out before embarkation, though sometimes the sec-
ond is done on board — the vaccine being placed on every
transport. Inoculation is also being widely tried in India
and elsewhere, 20,000 doses of vaccine having been issued
from the Royal Army Medical College during the last
twelve months. Colonel Leishman and his colleagues have
also carried on research work as to the method at the
college without interruption, and he e.xplained the methods
of preparing and standardizing the vaccines. These had
been prepared from typhoid bacteria killed at different
temperatures by different chemicals, by desiccation, etc.
Their several effects were tested on animals. In some
instances where the results seemed promising similar tests
were made on man. In the light of these researches the
vaccine at present in use was obtained by a modification
of Sir A. E, Wright's process. The bacteria were still
killed by heat, but the temperature had been reduced to
the minimum which would insure death in one hour, 53° C.
The deleterious effects of higher temperatures had been
shown during the e.xperiments and it was suggested that
some comparatively inferior results may have been due
to overheating. The value of inoculation was seen in the
case of a regiment which had been e.xposed to a severe epi-
demic of enteric. Out of a strength of 509 officers and
men, 147 had been inoculated with the modified vaccine.
There were 62 cases of enteric, with 11 deaths, all among
the uninoculated, e.xcept 2, both of whom had declined in-
oculation, but both recovered.

We have had a good supply of contributions respecting
malaria lately. I gave you some notice of a lecture by
Prof. Ronald Ross in my letter of the 8th inst. and may
add further examples. Dr. Lloyd Roberts of Liverpool
read a paper to the Institute based on 124 consecutive cases
treated in his tropical wards at the Southern Hospital. A
lantern demonstration was given and the diagnosis be-
tween malaria and some other diseases dealt with. Dr. W.
Canter suggested that it was time t6 discard the word
malaria, w^hich was a relic of the superstition about bad air
He held the chief problems demanding solution were: (i)
The occurrence of attacks vears after leaving infected areas ;
(2) apparent immunity of exceptional individuals after re-
peated bites: (3) impossibility of employing quinine in
some cases. He further said persistent vomiting sometimes
rendered it necessary to give the quinine per rectum or sub-
cutaneously. For coma he found the best treatment was
blistering the shaven scalp, unless the temperature was very
high, when cold baths were required in addition. In some
chronic cachectic cases with acute exacerbations he had
found Warburg's tincture useful if quinine could not be
borne.

Major H. W. Grattan has read a paper at the Patho-
logical Society on "blackwater fever," as observed in
Sierra Leone. He said that in eight out of ten cases
quinine had been taken before the onset of blackwater.
Malarial parasites were found in the peripheral blood of
36 per cent, after the onset. The Ankylostomum duodenalc
was found in 50 per cent. The fall in hemoglobin and red
cells was very great and absolute polynuclear leucocytosis
was noted. No malarial parasites or pigment were found
in the organs after death. He held the disease to be
malarial because there was a previous historv of malaria
in every case, and the parasite was found in the blood in 36
per cent, of cases. Further, his opinion was that the dis-
ease was due to a special form of malarial parasite allied
to, but distinct from, that of malignant tertian. He showed
specimens of blood films containing parasites and charts
illustrating the destruction and regeneration of the red cells
and the hemoglobin.

The new society for promoting the study of tropical dis-
eases may^ now be considered as successfully established.
This "Society of Tropical Medicine and Hygiene" met at
the College of Physicians on the 15th and completed
its organization. The promoters hope to have an extensive
membership, and as many of the most ardent workers reside
abroad it will then be almost international in its scope.

Prof. Ronald Ross has to present in the Autumn a re-
port to the International Congress of Hygiene at Berlin on
the progress of antimalarial measures in British possessions
and. if possible, in .America. Let me ask the support on
his behalf of those engaged in this campaign. He will be
thankful for statements of the areas and districts dealt
with, the exact nature of the measures employed, and any

facts bearing on their results, addressed to him at the
University of Liverpool.

Major W. S. Harrison showed the society a bacillus
which microscopically resembled that of diphtheria. It
was isolated from an old case of chronic suppuration of
the middle ear. The organism produced involution forms
very like diphtheria bacilli in agar. The differences in cul-
tural reactions were described. Major Harrison also ex-
hibited a typhoid bacillus isolated a year after typhoid fever
from a sinus which followed a post-typhoid abscess. This
organism formed long, involuted strings, like typhoid cul-
tures on malachite green media ; it gave all the cultural
character of typhoid bacilli and was agglutinated by an
antityphoid serum. The patient's serum agglutinated other
strains of typhoid bacilli in i to 200 to i to 400, and his
own strain in I to 1,000; its phagocytic ratio was two to
four times as great for other strains and forty-six times
greater for his own than normal. It was very resistant to
phagocytosis in normal serum. It seems difficult to ac-
count for the persistence of the organism in the body of
a patient whose serum had such a high phagocytic ratio for
typhoid bacilli.

Tuberculosis of the testis is so rare in infants that you
may be interested in a paper on the subject read at the
Children's Society by Mr. Russell Howard. He found
the percentage compared with all surgical cases in the
London Hospital during ten years had been .07. In
adults the percentage was .33. The disease is primary in
the epididymis, spreading thence to the body of the testis.
The vesiculse scminales and prostate are very rarely
affected. The left testis is most often attacked, the un-
descended testis seldom. Hydrocele occurred in a third of
the cases. The diagnosis from syphilis is difficult and
chiefly rests on indirect evidence and the effects of treat-
ment. Tuberculous peritonitis is a rather frequent compli-
cation. If treatment be without effect and only one testis
affected, it may be removed without bad effect ; but if both
be involved, ablation would only be justifiable as a last
resource on account of the impairment of bodily and mental
vigor produced.

The thirty-third annual report of the Hospital Satur-
day Fund records steady progress. The income in 1906
was £26,460, as against ^25.930 in 1905. The board ap-
proved a distribution of £23,898 among 205 institutions.

The Birmingham fund is the next largest to London, for
last year its collection exceeded £19,000. and this year it is
hoped still more will be raised. The other Saturday funds
amounted to £10,981 at Leicester, £10.279 at Leeds'. £8,276
at Liverpool, £4,608 at Manchester.

OUR LETTER 'FROM THE PHILIPPINES.

(From Our Special Correspondent.)

FOURTH .ANNU.AI. MEETING OF THE PHILIPPINE ISL.\XDS
MEDICAL ASSOCIATION — A SPIROCHETE IN YAWS — CESARE.\N
SECTION UNDER DIFFICULTIES — TYPHOID FEVER — HAWAILAIf
FE\'ER — X-RAY TREATMENT OF LEPROSY — PERSONAL.

Ma-mla. p. I.. Februarj- 16. 1907.
The fourth annual meeting of the Philippine Islands Medi-
cal Association will take place in Manila from February
27 to March 2, sessions being held daily during that
period. An interesting program has been prepared.
Among the papers to be read will be "The Pathologically
Active Constituents of Some Philippine Medicinal Plants,
Arrow Poisons, and Fish Poisons." by Dr. R. F. Bacon
of the Bureau of Science. Another paper, entitled "The
Transmission of Leprosy to .\pes," by Moses T. Clegg of
the Bureau of Science. .Another, "The Fate of the Agglu-
tinins upon Filtering an Immune Serum," by Dr. R. T.
Edwards. Another, entitled "Observations on the Etiology
of Dengue Fever," by Dr. Percy M. .^shburn, .Assistant
Surgeon U. S. Army, and ist Lieut. C. F. Craig, U. S.
Army, both members of the Army Medical Board for
Tropical Diseases. It is understood that some new data
upon the transmission of this disease will be presented.
Another paper. ".\ Summarj' of Experimental Work on
Plague Immunity." by Dr. R. P. Strong.

A number of distinguished foreign guests have accepted
invitations to be present .Among these will be Dr. J. M.
Atkinson, the Honorable Principal Civil Medical Officer
of Hongkong: Dr. W. V. M. Koch, Medical Officer in
Charge of Infectious Disease Hospitals. Hongkong: Dr.
Sia Tien Pao, Delegate from His Imperial Chinese Majes-
ty's Government: Dr. Kannosuke Myajina, Delegate from
His Imperial Japanese Majesty's Government.

The regular monthly meeting of the Manila Medical
Society was held at the St. Paul's Hospital. February 4,
1907, at 8:30 P.M. Dr. .Ashburn of the .Army Board of

April 20, 1907]

MEDICAL RECORD.

659

Tropical Diseases showed a number of interesting micro-
scopical specimens. Among others were some spirochetes,
which were taken from some cases of yaws found in
Manila. From microscopical examination, the organisms
could not be distinguished from the ordinary Slyirochccta
piillida of syphilis, and they corresponded very closely to
the spirochetes described by Celli of Colombo.

A paper prepared by Dr. Frank T. Woodbury, Captain
and Assistant Surgeon U. S. Army, upon "Performing
Cesarean Section Under Difficulties" was read before the
society. It was another practical demonstration of what
may be accomplished when the rudiments of aseptic sur-
gery are observed, even though the operation is per-
formed in the interior of a sparsely inhabited tropical
island, without proper instruments or surroundings usu-
ally deemed necessary in such cases.

Within the past few weeks about ten cases of typhoid
fever have been reported in the tity of Manila, which,
upon investigation, all proved to be positive to the Widal
reaction. An investigation is now being made with the
hope of ascertaining the source from which the infection
in these cases was derived. The investigation, so far,
shows that long before the American occupation, typhoid
cases were found, from time to time, but there did not
seem to be any tendency for the disease to spread. On
account of the very few cases that occur, the water ob-
tained from the city mains can almost be dismissed from
consideration. It is hoped that this inquiry will throw
some light upon the fact as to whether typhoid does not
spread as rapidly in tropical countries as in temperate
ones, on account of some climatic condition, or whether it
is perhaps due to the fact that the means or vehicles for
the transmission of the disease are not present. This
latter view would appear tenable, especially in Manila,
where, up to a few years ago, very little fresh milk, oysters,
or other shellfish likely to become infected have been t:sed,
but both are now coming into general use, and it may
possibly be that the present increase in typhoid fever in
Manila can be attributed to that fact.

During the past few weeks there have also been a num-
ber of cases of obscure fevers observed, which in their
general symptomatology resembled somewhat the so-called
Hawaiian fever, which has been described as occurring in
those islands. The onset is much more rapid than in
typhoid fever, the prodromes lasting a w'eek or less and
are generally characterized by general malaise, pain in the
joints and limbs, which lasts about a day, no headache,
moderate pain in and behind the eyes; bronchitis often
occurs after the onset of the disease. The digestive dis-
turbances are not very marked, the appetite, in most cases,
remaining fair. The fever rises gradually for the first
w-eek to about 104, and then drops within forty-eight hours
to normal, leaving the patient in much the same exhausted
condition as found in certain forms of influenza, in the
United States. In some of the cases the disease appears
to localize itself in the larynx and the upper air passages,
causing intense congestion, and sometimes complete loss
of voice for about a week. There are no rose spots, occa-
sionally there is nose bleed ; the spleen appears not to be
enlarged. Bacteriologically the condition does not corre-
spond to para-typhoid. Careful examinations have failed
to show any malarial organisms or other blood parasites
and the Widal reaction is absent, while the diazo is pres-
ent. The occurrence of these obscure fevers again em-
phasizes in a forcible manner the necessity and advisability
of undertaking additional research work in order that the
etiology and pathologyof these unusual diseases may be
better understood. Of the twelve patients referred to herein,
two died, but it was not possible to obtain an autopsy.

One of the lepers, who has been mentioned heretofore,
from time to time, as having undergone treatment by the x-
ray at the San Lazaro Hospital, and having once been
apparently cured and remained so for a period of nine
months, after which time he again showed leper bacilli in
skin scrapings, has been under .r-ray treatment for the past
two months, and is now again, so far as can be deter-
mined by microscopical examination, entirely free from
the disease. It is the intention, this time, to continue the
treatment at intervals for at least a year or more, after
which it is proposed to treat him at intervals of three
nionths. The general principles upon which the treatment
is to be applied this time will correspond closely to the
method of treating syphilis with mercury, which is recom-
mended by many standard syphilographers.

Passed Assistant Surgeon Carroll Fox of the Public
Health and Marine Hospital Service, who has been on
duty as Quarantine Officer in the Philippine Islands for the
past four years, during three of which he was stationed
at the port of Cebu, has been relieved and returned to the
United States.

Passed Assistant Surgeon Thomas B. McClintic, and
Assistant Surgeons W. F. McKeon and Joseph Pettyjohn,
of the Public Health and Marine Hospital Service, in com-
pliance with orders of the Surgeon-General, have arrived
in the Philippines and been placed on duty as quarantine of-
ficers at ports of entry.

At';c' \'oyi; Medical Journal, April 6, 1907.

Endemic Neuritis. — In this issue J. M. Wheate con-
cludes an article on endemic neuritis, contributing some
observations hitherto unpublished, and review'ing re-
cent researches and opinions of recent investigations by
various authorities. His own observations were made
in the Philippines in connection with his army medical
service. His general conclusions are as follows: (i)
Beriberi is an acute infectious disease, transmitted by
direct infection, probably always through a skin abra-
sion upon some vulnerable part of the body. (2) The
specific organism causing the disease is an exceedingly
small bacillus, usually seen in pairs but not encapsu-
lated, ancl is found in the cerebrospinal fluid and blood
only during the acute or inflammatory stage of the
disease, after which time it rapidly disappears from
these tissues. (3) The favorite habitat is virgin soil
protected from sunlight. It is a slightly facultative
anaerobin and not very viable, being speedily killed by
exposure to sunlight as demonstrated by bacteriological
test and by clinical experience. (4) The former classi-
fication of the disease as beriberi hydrops and beriberi
atrophica is erroneous. There is but one form of beri-
beri, w'hich is characterized by three stages: First, tlie
stage of invasion: second, the stage of exudation, bo-
ginning in the cord and following by toxic motor and
sensory paralysis of varying extent, which in typical
cases proceeds to the third, or the stage of compensa-
tion, in which the disappearance of the bacilli and the
toxic stage results in the rapid (usually) disappearance
of the dropsy in cases in which softening and dilatation
have not progressed to the degree of permanent loss
of compensatory action. (5) The degenerative cord and
nerve lesion is long present in all moderately severe
cases, resembling the lesion in tabes in this particular,
and even though the heart lesion appears to have sub-
sided while the patient is leading the inactive life of a
convalescent, the damage to function is permanent.
This explains the numerous cases of sudden and un-
accountable death in patients leaving hospital appar-
ently cured, as reported by many observers with exten-
sive hospital experience. (6) That a toxin or toxalbu-
min should be isolated is the rational conclusion, and
that an antitoxin curative in the period of germ activ-
ity and before degenerative change has taken place is
the inevitable reward for properly directed effort.

Spondylose Rhizomelique. — .\ further contribution to
the study of this malady is made by A. Gordon, who
presents the clinical histories of two personal cases.
In the first case there was rigidity of the lower part of
the spine and a kyphosis at the same level. Symptoms
of involvement of the spinal cord and of the roots were
very evident. A rheumatic family or personal history
was wanting, while the general condition of the patient
had been stationary from the onset of the disease. In
the second case there was a marked rigidity of the lower
spine and an ankylosis of the large proximal joints of
the lower limbs. Pain was present in both extremities
and in the back. Cord involvement was also evident,
and in contrast with the first case in which all the re-
flexes were abolished, they were here exaggerated,
pointing to an involvement of a different tract in the
cord. Rheumatic history was wanting. The essential
pathological feature of this curious affection seems to
be an ossification of the periarticular ligaments of the
spine and hypertrophy of the articular processes which
come into immediate contact with each other after the
last vestige of the cartilages has disappeared. Accord-
ing to the author, the disease can hardly be considered
as a pathological entity. It is probably not of rheu-
matic origin. Two types of the affection have been de-
scribed. In one there is ankylosis of the cervical spine
with meningomyelitis. In the other there is spinal
ankylosis and ankylosis of the large proximal joints
of the lower extremities without cord involvement.
The author states that the idea of uniting all forms of
spondylosis in one cannot reasonably be accepted, and
the term "spondylosis" should be reserved only for the
purpose of designating the symptom, rigidity of the
spine, and the original name given by Bechterew,
Striimpell, and Marie be abandoned. Spondylosis is

66o

MEDICAL RECORD.

[April 20, 1907

only a symptom of a more complicated disease, and the
frequent involvement of the cord shows that the etio-
logical factor is of a more complicated order than one
may suppose.

Eructations in Heart Patients. — This question is con-
sidered by F. Schwyzer, who finds the condition more
common in old cardio- and arteriosclerotic patients.
The presence of gas in the stomach may be the most
troublesome symptom complained of. The gas arises
first of all from fermentation, and the impaired abdomi-
nal circulation prevents the gas from being taken up
by the blood and carried to the lungs for exhalation.
It may also be true that defective abdominal pressure
is operative in old persons whose abdominal muscles
are getting flabby. So also some of these patients seem
to swallow considerable ordinary air. Irregularities in
the intestinal circulation lead to abnormal condition of
the gastrointestinal fluids. The result of insufficient
circulation in the intestinal tract brings on a condi-
tion which we may call intestinal dyspnea. Locally
diminished blood or oxygen supply of the gastric or
intestinal wall causes peristalsis or contraction, until
the smooth muscular fibers become exhausted and relax.
Thus the stomach reacts with contraction on momen-
tary insufiiciency of its circulation, while the heart
under the same conditions causes more or less intense
pain and oppression. If the gastric circulation is seri-
ously insufficient, the stomach will react verj- soon after
a moderate quantity of food has been taken. The
patient will feel the pressure in the stomach, he will
expel some gas, and his appetite will be satisfied too
soon. If the circulation in the gastric wall is fairly
sufficient, the patient will be able to take quite a large
meal; he will eat as much as the stomach will hold,
and then when gastric fermentation sets in and begins
to distend the stomach still more, the border line of
sufficiency in the circulation will be passed and gastric
symptoms will show themselves. Still another causa-
tive factor may be exercise during the height of diges-
tion.

Journal of the American Medical Association, April 13,
1907.

Internal Hydrocephalus. — ^^". J. Spiller and .\. R.
Allen discuss the causes of internal hydrocephalus, re-
viewing the literature, and remark that while the occlu-
sion of the aqueduct of Sylvius is not infrequentlj' men-
tioned as an etiological factor in the text-books, it is
rare to find references to actual cases of such occur-
rence. They take the opportunity, therefore, to report
a case in which the condition was induced by a prob-
ably congenital, almost total occlusion of the aqueduct.
The subject was an elderly woman who was supposed
to have been born hydrocephalic, but in spite of this
and of an epilepsy that had lasted for years she had
lived to the advanced age of sixty-two, and retained
her faculties fairly well-developed. The aqueduct, while
almost entirely occluded, was well-lined throughout by
a layer of ependymal cells which would not be the case
had its occlusion been due to neuroglia proliferation, as
in a previous case reported by Spiller. This, and the
long continuance of the condition through the patient's
whole life, indicates the congenital nature of the ob-
struction.

The Pathology of Paralysis Agitans. — C. D. Camp.

after giving a review of the literature of the pathological
findings in the nervous system in paralysis agitans. reports
the results of his examination of fourteen cases, in eight
of which he was able to study the peripheral nerves
and muscles, and in two the ductless glands also. The
most constant lesion in the nerve centers was a fibrosis
of the capillary blood-vessels of the spinal cord, which
by rendering them more prominent, caused them to
appear rnore numerous. The posterior and lateral col-
umn regions seemed most involved. There was no de-
generation of nerve fibers of the cord in any case, and
in only two cases was this observed in the peripheral
nerves with the Weigert hematoxylin stain; in two
others there was a swelling of the myelin sheaths,
accompanied in one case by swelling of the axis cylin-
ders. There was considerable pigmentation of the
Betz cells in the paracentral lobule, but in only two
cases were distinctly degenerated cells observed. He
discusses the various theories of the disease, and thinks
that many of the pathological conditions found, and to
which the disorder has been attributed, are only coin-
cident senile changes. The muscular theories are also
discussed, and in nine cases in which he examined the
muscles, one of them during life, he found pathological
changes in all. There was swelling of the fibers, which
were round in cross-section instead of polygonal, mul-
tiplication of nuclei, etc., his findings agreeing in the

main with those of Schwenn, Schiefferdecker, and Idel-
sohn, indicating, he is inclined to believe, a specific
change in the muscles in paralysis agitans, though he
admits that this is not yet definitely proven. Camp, in
considering the pathogenesis of the affection, finds
most reason to believe that it is due to a toxemia, and
that this is connected with disordered parathyroid func-
tion. In the two cases in which he was able to exam-
ine the ductless glands he found the parathyroids in a
decidedly pathological condition; in both there was a
peculiar fatty infiltration, especially in relation to the
blood-vessels. Such a finding, in connection with the
experimental evidence as to the effect of parathyroi-
dectomy and the therapeutic results of Berkley in the
treatment of paralysis agitans with parathyroid extract,
furnish, he thinks, strong proof that the parathyroids
play an important part in the pathogenesis of paralysis
agitans. His conclusions are given as follows: I. Paraly-
sis agitans is not a neurosis nor is it senility. 2. The
anatomic basis of the symptoms, muscular rigidity,
tremor and the symptoms dependent on them, lies in the
affection of the muscles. 3. The disease is probably a
general toxemia, and there is evidence that it is due
to alteration in the secretion of the parathyroid glands.
Tlie case histories of the patients of which Camp made
the pathological studies are appended to his article.

Acute Otitis Media. — W. J. Leach describes acute
middle ear disease, its symptoms, course, and treat-
ment. In case palliatives fail and bulging of the drum
and pain increase after thirty-six hours' treatment, he
advises the immediate performance of myringotomy as
lessening the danger of invasion of the mastoid cells,
and after cleansing with peroxide of hydrogen and mop-
ping out with dry cotton, filling the canal one-third
full of boric acid, and inserting a cotton plug. After
the discharge has ceased he would use 10 per cent.
ichj'thol in liquid vaseline until the wound is healed,
careful attention being given to nasal and pharyngeal
conditions. The treatment should be carried on
directly by the physician, and Leach emphasizes this as
an essential. If intrusted to others it will not be well
done. The prognosis of acute otitis media is good, he
thinks, if the condition is promptly treated, but when
the mastoid cells are involved the prognosis becomes
serious. The way to success in otology is never to let
acute otitis become chronic.

Physiological Action of Alkaloidal Salts. — O. H.
Brown remarks on the common notion that different
salts of an alkaloid have a similar quantitative effect,
and says that he has long been of the opinion that the
eft'ect varies with the acid with which the alkaloid is
combined. He describes his method of experimenta-
tion, in which he tested various solutions of the easily
obtainable salts of morphine, strychnine, and quinine as
to their activity in the destruction of paramecia. A
simple unicellular organism of this kind gives more
accurate results than would a more complex oiie, and
the strength of the solution and the time required to
destroy their active movements, w^hich are always ^-isi-
ble during life, are easily observed with low power of
the microscope. The results are given in tabulated
form, and show a striking difference in the action of
different salts of the same alkaloid, and it is a rather
interesting fact that the paramecia of the sameculture
and of different cultures, varied considerably in their
susceptibility to the same solution. This was specially
noticeable with those solutions that required some time
to produce toxic effects; in the more rapidly acting ones
it was scarcely noticeable. He sums up his results as
follows: The acid with which certain alkaloids, strych-
nine, quinine, and morphine are combined alter de-
cidedly the pharmacological action of the alkaloid —
at least, in regard to their toxicity for paramecia. The
most to.xic salts of strychnine and quinine are in some
instances, at least, those which stimulate catalytic proc-
esses the most markedly. The salts of morphine with
the smallest degree of toxicity, in some instances, are
the salts of those acids, the sodium salts of which stimu-
late the catalysis the most markedly.

Holes in the Mesentery. — G, K. Dickinson reports
two operations in which intraperitoneal hernia through
holes in the mesentery was found to exist, and remarks
on the comparative rarity of the condition. He attri-
butes the occurrence of the holes to defective arterial
supply; they are usually found in the mesentery near the
cecal region where the anastomosis of the ileocolic
branch of the mesenteric artery with the intestinal
branches is sometimes so incomplete as to make it im-
possible to inject this area.

Blood Pressure in Arteriosclerosis and Bright's Dis-
ease.— h. R. Elliott reports and discusses the variations in
Sivstolic blood pressure in certain cases of arteriosclero-

April 20, 1907]

MEDICAL RECORD.

661

and chronic renal disease which had been under routine
observation for considerable periods of time. The
gauges used were Cook's modification of the Riva-
Rocci apparatus with a 9 cm. arm band and Stanton's
sphygmomanometer. The great majority of the ob-
servations were taken with the patient in the sitting
position, the exact conditions were sought to be dupli-
cated and physical repose and mental tranquillity of the
subject under observation, so far as possible, were
secured. In thirty cases of arteriosclerosis observed
in this way, in only six (20 per cent.) was there a posi-
tive hypertension. This high percentage of cases with-
out excessive tension shows that the degree of sclerosis
of superficial arteries is no criterion of the severity
of the sclerosis of visceral arteries or of the degree of
tension present. If we can exclude chronic nephritis
when high blood pressure and cardiac hypertrophy
develop, we have reason to suspect splanchnic or aortic
sclerosis. Sixty cases of chronic Bright's disease were
also observed, and the high average blood pressure in
these (190 mm.) was in marked contrast with the cases
of arteriosclerosis. No constant ratio was observed
between the degree of blood pressure and the intensity
of the albuminuria or the amount of urine excreted.
High tension in Bright's disease is in a way com-
pensatory, but it needs watching. The first indication is
to reduce, if possible, the systemic toxemia, and diet,
fluid intake, elimination and persotial hygiene generally
must be looked after. The question of special vascular
medication, however, is discussed. Before giving vas-
cular drugs, ascertain thoroughly the cardiac and cir-
culator}- conditions; high pressure does not always
require reduction by drugs. In emergencies, such as
angina pectoris, apoplexy, etc., they may be called for.
A sustained high pressure, with disquieting symptoms,
may call for vasodilator medication, but it should be
given cautiously, watching the effects. A fall of 10 or
IS per cent, is all that it is necessary or judicious to
produce. The benefit from such medication must not
be estimated by the blood pressure record, the patient's
comfort, and the pulse rate are better indications
of the effect produced. The use of vasodilators in the
late stages of Bright's disease, with cardiac dilatation,
dropsy, etc., is practically useless.

Points Regarding Opsonins. — Experiments to deter-
mine a number of points regarding opsonins were per-
formed by E. A. Knorr, who finds that the phagocytic
cells are, generally speaking, in direct proportion to the
strength of the bacterial emulsion : that both undergo a dis-
tinct increase with long exposure, the maximum being
reached in one hour. .A.fter two hours the degenerative
changes in leucocytes render accurate observations impossi-
ble. Phagocytosis does not occur at room temperature, but
an exposure of fully six hours is required to make it as
noticeable as it usually is after fifteen minutes at body tem-
perature. As re.gards the etfect of the number of persons
composing the pool, he concludes that a simple, or at
most a double-mixed pool is necessary for ordinary
purposes, a conclusion he believes Wright himself has
reached. Aging of the culture does not lead to a drop
in the phagocytic or percentage index, and boiling,
thymol, and chloroform do not appear to have any
inhibitory effect on the opsonic values, while lysol
seems to produce a decrease. His experiments show
that the serum loses one-half its opsonic power in
twenty-four hours, artd that after this there is no
apparent change for the next twenty-four hours; then
there is a rapid drop, but it does not wholly disappear
until after five days. This is with serum collected and
kept in a sterile condition. The corpuscles rapidly lose
their capacity for phagocytosis, and only fresh ones
can be used in opsonic work. Knorr's e.xperience is that
after six hours many of them are dead, and fallacious
results are obtained if such are used. With weak emul-
sions the chances of error are greater than with strong
emulsions, keeping in mind the fact that with too rich
emulsions counting becomes difficult if not impossible.
In many of his experiments the advantage of Simon's
percentage index over the bacillary index of Wright
are. i:i his opinion, very clearly shown.

Accidental Plague Inoculation. — P. C. Freer gives
an account of the accidental inoculation with plague
of a number of Philippine natives which oc-
curred in the course of a very successful series
of anticholera vaccinations. The cholera vaccine that
had been used consisted of an extract of the killed, digested
and filtered organisms, later modified to a mi.xture of such
an extract with one obtained by shaking — in a machine —
the living organisms in distilled water and then filtering.
The reaction that follows the use of this vaccine is less
severe than that frequently following smallpox vaccina-
tion, and yet a high degree of blood immunity is pro-

duced. It being thought desirable to test the method
recommended by certain German authorities of using
the whole organism and not its extracts, it was neces-
sary for this purpose to inoculate immediately with a
mixture of fresh twenty-four-hour cultures in saline
solution, and inoculations were made for several days
without accident. It is supposed that on the day that
the accident occurred some unknow-n person misplaced
a tube of virulent plague culture, which closely resem-
bled the cholera cultures, among tlie latter, as such a
tube was found missing from the incubator in which
the plague cultures were. The matter was thoroughly
investigated and these facts developed. It must be
understood that the regular anticholera vaccine had
absolutely no connection with the accident, the mixture
responsible being an altogether different thing. Its
microscopic examination revealed no plague bacilli, but
guinea-pig and monkey inoculations were followed by
the disease.

The Lancet. March 30, 1907.

Certain Acute Infective or Toxic Conditions of the
Nervous System. — In the third Goulstonian lecture,
E. F. Buzzard refers particularly to acute ascending
myelitic, Landry's paralysis, and acute toxic polyneu-
ritis. Three clinical histories are given under the third
of these classes. Here it is natural to suppose that the
poison at work is carried by the blood, and that the
parts innervated by the gray matter of the cervical and
lumbar enlargements suffer more than those in similar
connection with the dorsal region. At the same time
the whole of each lower motor neuron, including both
the ceil and its axion is exposed to the poison in the
general circulation, and in these circumstances the
particular affection of the long processes to the periph-
ery of the limbs has an explanation offering some de-
gree of probability. In one of the author's cases of
Landry's paralysis, he found cocci in the extradural
tissues, and it is quite conceivable that infection either
by [he cocci or by their toxins could take place from
those tissues into the extramedullary and intramedul-
lary lymphatics. From the absence of actual organisms
in the spinal tissues in most of these cases it is prob-
able that the toxins play the most important part in this
infection. Allowing for a moment that this theoretical
process can take place, it must be granted that an ex-
planation of the gradual, ascending, step by step,
involvement of the central nervous system is provided,
and one which makes the more progressive and even
distribution of the palsies more readily understood.
This theory does not necessarily presuppose that the
blood is free from the responsible organism nor that
the extradural tissue is its only resting place, but it
suggests that there may be places where the bacteria
may find suitable lodgm.ent for the purposes^ of multi-
plication and whence they may pour their toxin into the
spinal lymphatic system.

British Medical Journal. March 23 and 30, 1907.

Removal of Enlarged Tonsils.— R. Maclaren prefers
deep anesthesia, the patient being laid on one side. The
instruments used are a gag, straight vulsellum, blunt dis-
sector like a periosteum elevator, scissors curved on the
flat, scalpel, probe-pointed bistoury, and forceps for holding
tampons. The operation is commenced by opening the
mouth as widely as possible with the gag. The tonsil of
the side on which the patient is lying is then caught by
the vulsellum. The best grip is got by placing one blade
on the nasal and the other on the laryngeal end of the
tonsil. The tonsil is drawn inwards and forwards. If it
comes out from between the pillars no knife need be used,
but if a considerable part of it remains behind the palate
a transverse incision is made to expose the gland thor-
oughly. This is done with a sharp pointed scalpel from
within outwards through the mucous membrane. It starts
about the middle of the anterior pillar and is from half
to three-quarters of an inch long, according to the size
of the tonsil, which is made to bulge through it. At this
stage, whether the mucous membrane has been cut or
not, as much traction is put on the gland as it will bear
and the blunt dissector is pushed behind it from above.
It is then systematically teased out from its connections.
There is this distinct advantage in starting^ in this way.
that it prevents the uvula being injured, as it might be if
the gland were taken out from below. Most tonsils peel
cleanly out with a smooth and rounded back surface. Much
of the completeness and facility of the operation depends
on the consistence of the gland. If it is firm the removal
is easy, but if it is soft and bears traction badly it may be
a matter of diflficulty to get it out whole owing to the
teeth of the vulsellum tearing through. Scissors or the
blunt bistoury are very useful for a tonsil of this latter
snrt. It is first well loosened by the dissector, and then

662

MEDICAL RECORD.

[April 20, 1907

its final attaclimciits snipped or cut. When one tonsil
has been removed it is advisable to wait for a few min-
utes to allow bleeding to diminish. The second tonsil is
then dealt with in a similar way and adenoid growths and
turbinate thickening attended to if necessary.

Infiltration Anesthesia in Major and Minor Surgery.
— This method of anesthesia is strongly commended by
G. J. Arnold, who says that the resirable qualities of
solutions for this purpose are as follows: (l) The per-
centage of the active agent contained in the solution must
be sufficiently high to render the fluid efficient as an anes-
thetic, but the total quality of fluid infiltrated from be-
ginning to end of an operation must contain an amount
of the active agent insufficient to give rise to toxic results.
As a corollary, it follows that solutions of cocaine are
inadmissible unless only a small quantity of fluid be re-
quired, since it is not safe to inject more than about one-
quarter grain of this substance. (2) The solution must
be sterile, which is nearly equivalent to saving that its
active agent should be capable of being boiled without
impairment of its anesthetic properties. (.3) The third
essential of the solution on which stress must be laid con-
cerns its physical and physiological features. It must be
as nearly as possible isotonic with the tissues. The
author fully describes the technique of the process
used and states that his own list of operations
by this method included the following: Gastrostomy
(by the Ssabanajew-Frank method). Herniotomy
(three cases) ; appendectomy in a quiet interval. Laparo-
tomy for intestinal obstruction. Laparotomy with resec-
tion of small intestine and end-to-end anastomosis. -Su-
prapubic cystotomy. Closure of an artificial anus (pre-
hmmary colostomy). Radical cure of hernia. Radical
cure of varicocele. Removal of a mass of suppurating
tuberculous glands in the groin (in an old and debilitated
patient). Extirpation of the saphenous vein in the thigh and
Its tributaries in the leg for varix (many cases). Numerous
minor operations for the removal of cysts, lipomata
needles, etc.

The Calcium Salts as Heart Tonics.— W. Ewart ex-
presses the belief that so long as we continue to pre-
scribe calcium salts to favor coagulation, there would
seem to be some inconsistency in recommending them
in a disease like pneumonia, for instance, which is so
prone to clotting that one of its common fatal termi-
nations is intracardiac thrombosis. Our cardiac stimu-
lants should be sought in some other direction. As a
fact the danger special to pneumonia is not so much
a clotting in the vessels as that within the alveoli;
and the worst danger for the patient is the attitude of
expectancy w^hich watches the progress of his "consoli-
dation" as though it were a fated fulfilment, instead
ot hastening to forestall it by defibrinating treatment.
The prevailing neglect of this early and only opportu-
nity of influencing the disease accounts for the uni-
formly neutral results from various lines of medica-
tion. \vhich are all likely to be inoperative after con-
solidation has set its seal upon the case. Happily
those therapeutic and dietetic measures which are indi-
cated, whilst they are in themselves harmless, are dem-
onstrably of service, and effectual in proportion to the
early date of their adoption. Their aim is to maintain
m the congested areas as much fluidity of blood and
lymph as possible, to prevent vascular and lymphatic
obstructions, and thereby to promote a steady rate of
elimination of the infecting agents and of their toxins,
thus avoiding or lessening the possible disaster conse-
quent upon their concentration. In view of these indi-
cations calcium chloride can have no place in our treat-
ment of the early stages, but there remains the more
urgent duty of relieving local congestion by leeches, of
withholding fibrin formers from the fever diet, of
stimulating excretion in every way. including cardiac
stimulation: and. lastly, of administering freely the
citrates and iodide of potassium to reduce the viscosity
of the blood, unless we should discover some better
means of checking the deposit of fibrin and of further-
ing its reabsorption before it has become completely
solidified.

Operative Treatment of Ascites. — In a paper pre-
sented to the London Medical Society. Laurence Jones
said that the actual cause of ascites occurring with
hepatic cirrhosis was still doubtful. Both portal ob-
struction and toxemia seemed to play some part, and it
alone was unable to reproduce the effusion if the portal
vein was able to produce ascites only when a certain
grade of toxemia was present, but that the toxemia
alone was unable to produce the effusion if the portal
obstruction was relieved by the formation of fresh
portocaval anastomoses. Chronic peritonitis, althou.gh
often associated with ascites, was not necessarily the
primary cause. The patient ninst suitable for operative

treatment was one who had survived the tapping of a
fluid shown to be of mechanical rather than of inflam-
matory origin, whose liver was in the hypertrophic
stage, who was still fairly young, and whose symptoms
were more those of toxemia. The common object
of all operations was to increase the communications
between the portal and caval systems; the omentum
was the portal area usually selected, and it was sutured
to the abdominal wall outside the peritoneum, as in the
operations of Schiazzi. Bunge. Pascale, and others, or
inside the peritoneum as in the original operation of
JNIonson. The operation as devised by Monson seemed
still the best. Various additions, such as hepatopexy
and splenopexy had been made to simple fixation of
the omentum or had been performed where the latter
had failed or had been impossible. The operation cer-
tainly relieved the patient in many cases of the ascites
and thereby prolonged life in comfort for some years;
occasionally the condition of the liver itself appeared
to have improved, but that efifect was not claimed for
the operation, and it was not possible to explain any
such result. About one-third of the patients died within
one month of the operation, about one-third were defi-
nitely improved and their lives were prolonged for some
years, and about one-third were improved but slightly
or not at all. The death-rate due to the operation
should not be more than 10 per cent.

Bacterial Diagnosis of Cholera. — M. A. Ruflfer sum-
marizes an extensive series of investigations on this
subject, and describes the technical methods followed.
The investigations were carried on at Port Said, and
they justify, according to the author, the following
conclusions: (i) A certain number of vibrios, although
agglutinating to some extent with cholera serum, are
sharply differentiated morphologically from the cholera
vibrio, by the fact that they are multiciliated. (2)
Whereas some vibrios found in ship water are agglu-
tinated by very dilute solutions of cholera serum,
others are agglutinated by far stronger solutions only.
The latter form a transition stage, so to speak, between
the nonagglutinating and the highly agglutinating
vibrios. (3) -Mthough an active cholera serum agglu-
tinates all the vibrios to some extent, yet only two of
these vibrios when injected into animals produce serums
having a powerful agglutinating effect on cholera
vibrios; two serums had the same property but to a
slighter extent, and two had none. These experiments,
therefore, support the conclusion previously arrived at
— namely, that it is not advisable to trust to the agglu-
tination test only in the bacteriological diagnosis of
cholera. The test is useful but not specific.

Diagnosis of Certain Forms of Renal Disease. — In
the course of an interesting paper on this subject, J. R.
Bradford expresses the opinion that nephritis of the
parenchymatous or diffuse tubal type is by no means
uncommon in the first two years following syphilitic
infection. It often comes on at a time when the
patient feels perfectly w-ell, is not deeply modified by
the underlying dyscrasia, and hence is commonly
referred to exposure to cold. Examination may show
a few spots suggestive of syphilis or even a gumma.
This form of nephritis is characterized by very intense
albuminuria, the urine frequently becoming solid,
although the patient may not seem very sick. Conse-
quently the disease comes to light unexpectedly. Al-
buminuria also is persistent, lasting several months, but
it may entirely clear up. Nephritis may also occur
during the course of secondary syphilis and be of an
intense type. Probably all cases of renal disease are
ultimately due to toxic agents rather than directly to
exposure to cold. Syphilis may supply the toxic factor.

Berliner klinischc Wochenschrifi. March 18 and 23, 1907.

Hyperemesis Gravidarum. — Baisch finds that all these
cases can be included in one of three types as regards their
source — they are gastric, central, or uterine. That de-
pending on a nervous basis probably is the most frequent,
and among the twenty cases personally observed by the
author fifteen may be_ included in this category. In the
latter class of cases the prognosis is better than in the
others. In addition to sug^gestive and medicinal treatment,
operative procedures should always be considered in those
patients who do not respond readily to the former. The
writer thinks that the best means of deciding when the
medical treatment is to be superseded by the radical is the
weight scale. If there is a progressive loss in weight,
as show-n by weighing done twice a week, the uterus
should be immediately emptied. He claims that the die-,
turn stated by Freund, to wait for edema, convulsions,
and mental confusion, is entirely false. Abortion, when
decided on. should be carried out with the least expenditure
of the patient's energy, and the technique should be simple

April 20, 1907]

MEDICAL RECORD.

663

enough to preclude any danger from infection. The writer
prefers to introduce a laminaria tent after sufficient dilata-
tion of the cervix by graduated dilators. This produces
sufficient dilatation to permit the removal of the fetus with
the ordinary Winter's forceps. The manipulations are not
extensive and in most cases the operation may be done
without anesthesia.

A Case of Hepatic Abscess Containing Typhoid Ba-
cilli.— Venema and Griinberg report a case in which
durnig an attack of typhciid an abscess developed in the
right lobe of the liver which was evacuated with good
results. The pus from the abscess was carefully exam-
ined and the Bacillus typhosus obtained in pure culture.
Only five cases in which a definite bacteriological proof
is at hand are to be found in the literature. The prog-
nosis is very unfavorable, the mortality amounting to
about 66 per cent. The treatment can only be surgical,
and the result depends on whether we have to deal
with single or multiple abscesses. In the latter case,
where the condition is evidently the result of a pyelo-
phlebitis, surgical interference is naturally useless, but
in the former a good result may be expected.

An Epidemic of Meat Poisoning in Berlin. — Jacobson
refers to an epidemic of poisoning cases during a short
period, in which ninety persons living in a restricted
area were taken with symptoms of an acute intoxication
or infection, which was traced to the meat consuined by
these people. Two fatal cases are included in the num-
ber. The meat in question appeared to be in good
condition, and there was nothing in the odor, taste, or
consistency to give rise to any suspicion of its poison-
ous character. The symptoms came on within eight
hours after eating, and were most severe in those per-
sons who had eaten the meat raw. Examination of the
tainted beef showed that it contained the Bacillus para-
tvplwsus. This organism was later also obtained in
pure cultures from the stools of the affected individuals.
The symptoms were those associated with a para-
typhoid infection. The source of the infection of the
meat itself could not be traced with any certainty.

Miincliencr iiicdicinischc Jl'ochcnschiift, March 12 and 19,
1907.

Scopolamine Morphine Narcosis in Labor. — Bass pub-
lishes a report of 107 cases of labor conducted with this
method of anesthesia, .^s the result of his observations
he claims that the pain of the labor may in the large ma-
jority of cases be alleviated in a marked degree. For the
purpose indicated a dose of 0.0003 .?m- scopolamine and
o.oi gm. morphine was found to be sufficient, and any
increase in the size of the dose did not improve the results.
In some cases a delay in the labor occurred, but tjiis did
not appear to have any bad effect on either the mother or
the child. The uterine contractions and the placental
delivery were not apparently affected, but the abdominal
expulsive efforts were considerably inhibited. In no in-
stance were any undesirable after-effects noted as regards
the mother, but the result on the child must not be re-
garded with indifference. In one case the death of the
fetus may have been due to this procedure, and for this
reason considerable care should be exercised in adminis-
tering an otherwise valuable combination of drugs.

On the Course of Urobilinuria in Typhoid. — Rubin
reports his observations on this phenomenon in a series
of eight cases. For the purpose of making the test he
employed Schlesinger's reagent, which consists of a ten
per cent, solution of zinc acetate in alcohol. Equal parts
of urine and reagent are allowed to stand for twenty-four
hours, and after fluorescence appears the specimen is
subjected to spectroscopic examination. Rubin's results
agree in the main with those of Hildebrandt. The appear-
ance of a well marked urobilinuria at the beginning of
defervescence may be regarded as an evidence of a favor-
able outcome. If the phenomenon continues during con-
valescence in any given case, care should be taken in
increasing the patient's diet or allowing him to get up.
Not until the test is negative is it apparently safe to dis-
charge the patient.

The Indications and Technique of Extirpation of the
Lacrymal Sac— Baumler reports a aseries of 350 cases
in which this operation was done. The operation of
extirpation is indicated in all cases where the removal
of the infectious focus is necessary in order to protect
or preserve the eye, or where the presence of a chronic
dacryocystitis has resisted all other forms of treat-
ment. In doing the operation it is necessary to remove
not only the diseased sac, but also the surrounding
tissues, particularly the periosteum. In most cases the
after-treatment may be conducted as an ambulatory
one. The final results in this series of cases were
excellent, and in only a few cases did primary union of
the wound fail to take place.

Polyserositis. — Wagner calls attention to a condition
of which only a comparatively small number of in-
stances have been reported, where an e.xudation of
serum takes place into all the large serous cavities of
the body, without any apparent underlying cause. The
disease is usually chronic, and ends fatally after a longer
or shorter period. In the serous cavities we find all
the evidences of a productive inflammation — adhesions
between the pleura, accumulation of large quantities of
fluid and masses of fibrin in the peritoneum, oblitera-
tion of the pericardial cavity with its consequences.
Only a few instances of this disease have been observed
during the early stages, among them a case reported
by W'agner, where the serous exudate appeared simul-
taneously in all the serous cavities, and where a cure
resulted in a relatively short time. The patient, a young
man, was in good general health, and no cause for the
appearance of the trouble could be ascertained. It is
probable that the disease may have been caused by^ the
presence in the circulating blood of some infectious
material similar to what we find in acute articular
rheumatism. The liver also became enlarged, and traces
of biliary coloring matter appeared in the urine, so
that this organ may have been the center of some of
the circulatory disturbance. The only treatment applied
consisted of the use of the ice bag in the cardiac re-
gion, rest in bed, and a light restricted mixed diet.

Dcutsclic iin-dicinischc IVochcnschrift, March 14, 1907.

Hydrotherapy During the Climacteric— Zweig dis-
cusses the value of hydriatic procedures on the nervous
and vasomotor disturbances associated with this condition.
The employment of these measures has met with insuffi-
cient attention, although there is abundant proof at hand
to show that the improvement in the subjective symptoms
may be well marked. Just what the effect is on the
objective features it is difficult to estimate, because the
individual effects vary to such a great extent. Extreme
care must be used, however, in applying hydriatic meas-
ures because of the increased sensitiveness of the patient
to external irritants. The temperature of the water should
he such as to cause no reaction or only a slight one. In
most cases a lukewarm bath, followed by the addition
of cold water, may be taken two or three times during
the course of the week. Salt may be added to the bath
with benefit, but carbonic acid and electric baths may with
advantage iDe omitted. The method referred to applies
only to cases where the disturbance is a functional one.
Where organic disease is present modifications must be
considered. A number of cases are reported in which hy-
drotherapeutic measures were used with success. A fea-
ture of these was a loss in weight, which the author does
not consider unfavorable because a woman is apt to become
stout naturally during this period.

Experience with Oil of Chenopodium in the Treat-
ment of Ascaris in Children. — Briining has subjected
the .American oil to tests in a series of twenty cases and
found that it is very efficient in the treatment of the con-
dition noted. Depending on the age of the child, the dose
varies from 8-15 drops three times daily, followed by a
cathartic. It seems that one treatment is sufficient for
most cases. The worms are apparently not killed by
the oil, but merely narcotized, so that the administration
of the cathartic is most important. The author believes
that the efficient action of the remedy resides in an ethereal
oil of the following composition : CoHieO:. Experiments
have shown that the same effect may be obtained with the
latter as with the ordinary oil.

Action of Baths of 'White and Blue Light Upon the

Blood. — U. Masucci records experiments to ascertain
the effect of baths of blue and white light on the blood.
His conclusions are given us thus: White light produces a
slight increase of red corpuscles and diminution of white
corpuscles. There is an increase of lymphocytes, and ili;;ht
increase of nongranular mononucleated cells, and a slight
diminution of polynucleated and eosinophiles. The changes
in eosinophiles are most permanent. The effects are due
to negative phototrophismus, which has a repulsive action
on the polynucleated cells. There is a large increase of
young cells, lymphocytes and mononucleated. Blue light
produces a still greater lessening of leucocytes. The ef-
fects are more marked and more transient on all the forms
of cells. Only the diminution of eosinophiles is permanent.
These changes are due to the chemical rays. Phototrophis-
mus acts on the lymphoid tissue of the bone marrow, driv-
ing the polynucleated cells from the circulation to the
spleen. The increase of lymphocytes is due to the effect of
the rays on the glandular lymphoid tissues, which makes
the lymphatic circulation more rapid. There is a renewal
of young cells and a destruction of the old ones. — Giornale
di Elcttricita Medico.

664

MEDICAL RECORD.

[April 20, 1907

Syllabus of Lectures on Human Embryology. An
Introduction to the Study of Obstetrics and Gynecology
for Medical Students and Practitioners ; with a Glos-
sary of Embryological Terms. By Walter Porter
Manton, M.D., Professor of Clinical Gynecology and
Professor Adjunct of Obstetrics in the Detroit College
of Medicine ; Fellow of the Zoological Society of Lon-
don, of the Michigan Academy of Sciences, etc., etc.
Third Edition. Revised and Enlarged. Illustrated with
numerous outline drawings. Philadelphia: F. A. Davis
Company. 1906.
The essentials of embryology are here set forth in con-
densed form primarily for the use of students, but more
advanced readers who may wish to refresh their memo-
ries or to learn the present standpoint of workers in this
difficult subject will no doubt find it equally useful. It is
clearly written and fairly well illustrated, and seems well
adapted to its purpose.

Textbook of Anatomy for Nurses. By Elizabeth R.
BuNDY, M.D., Member of the Medical Staff of the
Woman's Hospital of Philadelphia; Gynecologist, Xew
Jersey Training School, Vineland; Late Adjunct Pro-
fessor of Anatomy and Demonstrator of Anatomy in
the Woman's Medical College of Pennsylvania ; For-
merly Superintendent of the Coimecticut Training
School for Nurses, New Haven. Philadelphia: P.
Blakiston's Son & Co., 1906.
In this well constructed book the trained nurse will find
all that is essential for her to know of the anatomy of
the human body. The descriptions are clear and concise,
and the work is judiciously illustrated with upward of
200 well executed pictures, a number of them in colors.
The book is well conceived and well e.xecuted and will be
found most useful to those for whom it is intended.
Surgery. Its Principles and Practice. By various authors.
Edited by William Williams Keen, M.D., LL.D.,
Professor of the Principles of Surgery and of Clinical
Surgery, Jefferson Medical College, Philadelphia. Vol-
ume I. Philadelphia and London : W. B. Saunders
Company. 1906.
Under the skilful direction of the accomplished editor the
contributors to the first volume of this extensive work
have produced a series of essays that promise well for the
volumes that are to follow. The present volume is de-
voted to the customary introductory and general subjects.
The chapters on surgical physiology, and wounds and con-
tusions by Dr. Geo. W. Crile contain many practical appli-
cations of experimental data obtained by the author,
among which the discussion of the nature and treatment of
shock and collapse are prominent. A section is devoted to
the subject of blood pressure determinations and their
practical value in surgery. Infection and immunity have
been made the subject of a chapter by Dr. Ludwig Hek-
toen in which the involved ramifications of these difficult
branches of modern research are set forth in simple but
adequate fashion, and Dr. J. George Adami contributes an
article on inflammation in which the author's well-known
views as to the conservative nature of this process are de-
tailed. A chapter of especial interest, not only to the
surgeon on account of the many practical considerations
involved, but also to the pathologist, owing to the large
amount of original research it represents, is that on the
processes of repair by Dr. F. C. Wood. Concerning the
introductory essay on the history of surgery by Dr. James
G. Mumford, one can but echo the writer's regret that
the exigencies of space did not permit its e.xtension to a
greater length. Indeed, the need of brevity seems to have
led him to omit mention of much of value that has been
accomplished by American surgeons, especiallv those of the
Southern States. The other articles of the volume are by
Drs. John Bland-Sutton, John C. Da Costa, John C. Da
Costa, Jr.. Charles H. Frazier, Leonard Freeman. Edward
Martin, Edward H. Nichols, and Eugene .\. Smith.

In spite of the natural defects inherent to systematic
treatises that are written by many hands, this form of
mosaic work appears to be gaining in popularity, no doubt
deservedly so. for with the ever-increasing scope of medi-
cal and surgical knowledge there can be but few men in
a generation whose leisure and experience would enable
them to produce a sufficiently comprehensive and authori-
tative gtiide for general use. The present work is, of
course, by no means free from faults: some articles must
inevitably fall below the average in excellence and some
overlapping and some omissions are sure to occur in spite
of the most careful editorial supervision. The publishers
have done their part to give the subject matter an appro-
priate setting; the type is clear and the illustrations are
excellent. "Their beauty has been gained, however, at the
expense of the reader's comfort, for the highly calendered

paper used which lends itself so well to half-tone repro-
duction is also, at least by artificial light, very trying to
the eyes. The binding also is badly done, which is a
serious defect in a work that presumably is intended to
withstand the wear and tear of frequent reference during
a period of years.

Practical Materia Medica for Nurses, with an Appen-
dix Containing Poisons and Their Antidotes, with
Poison-Emergencies ; Mineral Waters ; Weights and
Measures; Dose-List, and a Glossary of the Terms
Used in Materia Medica and Therapeutics. By Emily
A. M. Stoney, Graduate of the Training-School for
Nurses. Lawrence, Mass. ; Late Head Nurse. Mercy
Hospital. Chicago, 111. ; Late Superintendent of Train-
ing-School for Nurses, Carney Hospital, South Boston,
Mass.; Author of "Practical Points in Nursing." Third
Edition. Thoroughly Revised. Philadelphia and Lon-
don : W. B. Saunders Company, 1906.
This is a well written, intelligently condensed handbook
of materia medica adapted to the needs of nurses and
others who would familiarize themselves with the prop-
erties and doses of the drugs most commonly employed
to-day in medical practice, "rhe subjects are taken up in
alphabetical order and not according to therapeutic uses,
but their classification is presented in a table in the intro-
duction. A list of poisons and their antidotes, a dose-
table, a glossary of unfamiliar terms, and an index com-
plete the work. The book should be in every nurse's
library.

Elementary Manual of Regional Topographical Dee-
matol(x;y. By R. Sabouraud, Director of the City of
Paris Dermatological Laboratory, St. Louis Hospital.
English Translation by C. F. Marshall, Late Assistant
Surgeon to the Hospital for Diseases of the Skin, Black-
friars, London. New York: Rebman Company; Lon-
don : Rebman, Limited, 1906.

For the general practitioner, who sometimes has occasion
to treat skin diseases, this is probably the most useful
volume published. Its great and peculiar value is as a
first aid in diagnosis. The different regions of the skin
are taken up one by one, and the eruptions that occur on
each are described in fair detail. A novice, in doubt as to
the lesion before him, gets little help from the ordinary
textbook, for he does not know where to turn, but with
this volume he finds quickly a clear description of the
various diseases that may occur upon the area involved,
and then, if necessary, he may seek fuller information else-
where. The translation is generally veo' good; only oc-
casionally has the language been injured in transit, as
when the phrase "seconde enfance" is rendered by second
infancy, whereas the French locution means simply child-
hood, and has no reference to dotage. A graver fault is
the inaccuracy with which the formulas are transcribed.
Generally they approximate sufficiently to the original, but
occasionally, and probably through careless proofreading,
the proportions are made to differ radically in the French
and the English versions. There are slight condensations
in the text, but without any sacrifice of clearness. The
presswork is good, the illustrations are still as clear as
in the original, the book is lighter and easier to handle.
On the whole, it is an e.xceedingly valuable work, and if
its prescriptions are accepted with caution, it is a very
sound guide.

The Nature, Causes, Variety, and Tre-^tment ok
Bodily Deformities : In a Series of Lectures delivered
at the City Orthopedic Hospital in the year 1852, and
subsequently, by the late E. J. Chance, F.R.C.S. Eng.
With illustrations drawn on wood by the .A.uthor from
cases in his own practice, and many additional drawings
and copious notes from cases in the Editor's practice.
Edited by John Poland, F.R.C.S. Eng. Second Edition.
In two volumes : Vol. i. London : Smith, Elder & Co.,
1905-
This volume consists of six lectures delivered more than
half a century ago. Its value, therefore, is chiefly histori-
cal ; and the student of that side of medicine will find in
the introduction and notes several interesting points.
Thus, the rise of special practice and of special hospitals,
and the criticism and opposition evoked thereby ; how
men like Cheselden and .\bernethy sent cases of club-foot
to bonesetters for treatment; how the terms specialist
and quack were once svnonymous — all these make inter-
esting reading. It is also noticeable that the lectures of
fifty years ago were characterized bv fine literary style.
broad general culture, abundant knowledge of the subject
under discussion, and were evidently prepared with the
most painstaking care ; on all of which points they more
than hold their own with similar publications of later
date.

April 20, 1907]

MEDICAL RECORD.

665

NEW YORK ACADEMY OF MEDICINE.

Stated Meeting, Held March 21, 1907.

The President, Dr. John A. Wyeth, in the Chair.

This meeting was held under the auspices of the Section
on Genitourinary Diseases. The subject of discussion
was ''New Growths of the Bladder."

Pathology. — Dr. F. S. IMandlebaum opened the sym-
posium with a paper which was based chiefly on the obser-
vation and study of specimens referred to the Pathological
Department of the Mount Sinai Hospital during the past
nine years, and embraced twenty-nine cases of primary
tumor of the bladder and eight of secondary tumor. Among
these thirty-seven cases were two, inoperable in nature, in
which the specimens were obtained at autopsy. The re-
maining thirty-five cases were operated on by the attending
staff. The most satisfactory classification of these tumors
was (i) epithelial tissue group, in which were placed
papilloma, adenoma, carcinoma, and cysts; (2) connective
tissue group, comprising fibroma, my.xoma and sarcoma;
(3) a muscle tissue group, in which were placed myomata.
Statistics showed that primary bladder tumors comprised
about 0.7 per cent, of all tumors, and were quite equally
divided between males and females. Carcinoma as a rule
vi-as found between the ages of fifty and si.xty, while sar-
coma occurred more frequently in younger subjects. The
benign tumors might arise at any period. Chronic irrita-
tion was an important factor in the etiology. Calculi,
cj'stitis, the Distonia hematobiuin, the irritating effects on
the bladder in the manufacture of aniline dyes, as well as
psorosperms, had all been noted as being of etiological sig-
nificance. Secondary tumors were those arising in neigh-
boring or adjacent organs and growing into the bladder
by direct extension. These tumors frequently originated
in the prostate, uterus, vagina, or intestine. Metastatic
bladder tumors were of the greatest rarity. Dr. Mandle-
baum took up the consideration of the tumors of the differ-
ent types, illustrating each with photomicrographs. He be-
lieved that a better name for papilloma was fibroepithe-
lioma, inasmuch as both of these structures were involved
in its production, or better still, papillary fibroepithelioraa.
A papilloma might occur singly or be multiple, and
might arise from any portion of the bladder wall.
The typical form consisted of a stem or pedicle, springing
directly from the mucosa. Many tufts or villi sprang
from the pedicle, giving a shaggy appearance to the growth.
The villi usually bifurcated into innumerable branches,
varying somewhat in length. Occasionally a deposit of
phosphates might form superficially. A papilloma might
range in size from a small tumor of a few millimeters in
diameter to one nearly filling the bladder. As in all other
tumors of this organ, the growth might interfere with the
normal bladder functions, so that urination might be
disturbed or hydronephrosis be produced, depending upon
its situation. Inflammation might supervene and the tumor
become involved in the inflammatory process. The ten-
dency for papilloma to recur after removal was a well
established fact. The growth frequently reappeared as a
simple benign tumor, though in some instances it might
be distinctly malignant in character. Can a simple, benign
papilloma become malignant? The weight of evidence
to-day was confirmative, and cases had been described
which seemed to bear out such a view. In one of his cases
the change in the epithelioma from simple papilloma
to carcinoma was most striking, and the transition could
be clearly followed. The statistics of several carefully
examined series showed that the simple papilloma formed
about twenty per cent, of the cases of primary bladder
tumors. A papillary carcinoma might resemble the simple
papilloma so closely that a microscopical examination alone
could decide. In his series this variety of tumor occurred

in sixteen of the cases, or fifty-seven per cent, of all the
primary growths. All the cases were in males, and the
ages ranged from twentyrfive to eighty-two years, the
average being fifty-two. In all the bladder wall was
infiltrated; in three no involvement had occurred, and in
two it was impossible to determine this point. Ulceration
and hemorrhage were not infrequent. A papillary carcinoma
might arise from any portion of the bladder. The prostate
was not involved in any of his cases. Perforation of the
bladder wall was very rare, and metastases occurred only
in the late stages. The non-papillary forms of carcinoma
were somewhat less frequent. The flat or squamous celled
carcinoma might be found in the bladder, but also was
somewhat infrequent. In his series it occurred only in
two cases, both males. There were five cases of fibro-
carcinoma, all in males, in his series of cases, and, in
every instance, the bladder was infiltrated, and all ter-
minated fatally. These five cases were all carefully exam-
ined before operation, they were diagnosed as new growths
of the bladder, and as such were operated upon. A close
study of all the extirpated tumors, and a post-mortem
examination in two of the cases, revealed the fact that
four of these tumors were primary growths of the prostate,
with a secondary involvement of the bladder. Therefore,
he was compelled to place four of these five cases in the
class with the secondary tumors. A similar observation
was made in studying two cases of adenocarcinoma, both
in males, aged, respectively, forty-eight and sixty-seven
years. In both the prostate was primarily affected. Sim-
ple adenoma, as well as fibroadenoma, was quite rare in
the bladder. Colloid carcinoma was not common in the
bladder. Cysts might be found as the result of congenital
defects connected with the urachus, the Wolffian body, or
Gartner's duct. The connective tissue tumors were less
frequent than those already described. Fibroma was not
often met. The favorite site was at the base of the blad-
der, and was described as a hard growth, often peduncu-
lated, and containing fibrous tissue and muscle fibers.
Myxoma was not so rare a form and occurred in child-
hood often. Other forms of sarcoma other than my.xo-
sarcoma might be found in the bladder, but as a rule
they did not have any definite or uniform features. They
were sessile as a rule, but a pedunculated variety had been
described. It was interesting that about thirty per cent,
of the reported cases of sarcoma had been found in fe-
males. Myoma of the bladder was not common. Only
one case of dermoid of the bladder was known, that
described by Thompson.

Diagnosis. — Dr. Hugh Cabot of Boston read this
paper. He said the diagnosis of bladder tumors was not
as satisfactory as it might be. The failures in early
diagnosis were responsible for the failures in the treat-
ment. Failure to take advantage of the new methods now
was a serious responsibility. The real dangers from delay
were: (i) Continued growth of the tumor; (2) infection
of the bladder; (3) infection of the upper urinary tract,
and (4) damage or destruction of one kidney by pressure
upon the lower end of the ureter. An early diagnosis
might be the means of avoiding these dangers. It still
remained that the average practitioner would allow a
painless hematuria pass by undiagnosed. The cardinal
s>Tnptoms of tumor of the bladder were a painless hema-
turia and disturbance of bladder function. The hematuria
must be distinguished from disease of the kidney, ureter,
prostate, and other diseases of the bladder other than
tumor. There was great difficulty in diagnosing disturb-
ances of bladder function. Tumors of the bladder must
be differentiated from stone, from hypertrophied prostate,
etc. In attempting to differentiate bladder tumors from
disease of the prostate, there was a lack of symptoms
absolutely diagnostic. There were many suggestive symp-
toms to bear in mind in connection with tumors of the
bladder. Tumors often existed for a long time without
exact symptoms. Hematuria was the first symptom in

666

MEDICAL RECORD.

[April 20, 1907

one-half the cases, and it was always present at some
stage of the disease, but was not an early symptom. On
the other hand, a profuse and even fatal hemorrhage might
occur even from small growths. Hematuria was almost
always followed by the stage of infection. In some cases
the surface of the growth was crusted with calcium salts.
The symptoms were not at all diagnostic. There were
two methods of examination of value and which would
lead to a correct diagnosis, examination by the rectum,
and the use of the cystoscope. Dr. Cabot told of a col-
league of his who attempted to crush a stone. Upon
opening the bladder a fibromyxoma was found. The only
thorough diagnostic method at hand now he believed to
be the cystoscope. In some cases the bleeding might be
so profuse as to preclude its use; then one should do a
suprapubic cystotomy. Some time was spent in speaking
of the difficulties of cystoscopy. It was the duty of all
practitioners in the presence of a painless hematuria, or
hemorrhage accompanied by pain, or cases of disturbances
of bladder function, to make use of the cystoscope by
promptly referring the case to one who could use one.
Nothing was gained by delay.

Treatment. — Dr. Ramon Guiteras presented this com-
munication. He said before considering the treatment of
bladder tumors, one must take into consideration the
different varieties of tumors, their size, shape, and loca-
tion, the symptoms they produce, the complications that
existed or might develop, the age and general condition
of the patient, etc. Finally, after studying the individual
case carefully, and considering the different factors con-
nected with it judiciously, one should make up his mind
whether or not the patient should be operated upon ; for
it must be remembered that patients with bladder tumors
often lived many years in comfort without operation
who, if they were operated upon too radically, might not
survive the operation. So soon as hemorrhage occurred
in bladder tumor treatment should be begun by rest in
bed and a bland diet, S to 15 grains of calcium every two
or three hours, tincture of iron, ergot, and gelatin. Lo-
cally a catheter should be introduced and an attempt
made to aspirate or suck out any blood clots. If none
come away by aspiration, a small quantity of hot saline
solution should be introduced into the bladder, and the
catheter worked about carefully in an effort to break up
the blood clots without causing additional hemorrhage.
Gelatin might be used locally. Dr. Guiteras said he had
never performed suprapubic cystotomy, and he packed the
bladder in cases of hemorrhage due to tumors. Tenesmus
and spasm were treated palliatively by antispasmodics,
massage of the prostate, if associated with prostate
trouble, and stretching the bladder sphincter with a Kohl-
man dilator. In cases of bladder infection it should be
washed out with solutions of boracic acid, permanganate
of potassium, or nitrate of silver followed by a solution of
organic silver. The operative treatment of vesical tumors
consisted in removal through the dilated urethra in
women, vaginal vesical incision, perinea! cystotomy
(Thompson), removal by means of the cystoscope in-
travesical (Nitze), suprapubic cystotomy, cystectomy (re-
section), cystectomy complete (extirpation), and nephrot-
omy-nephrostomy. After considering each of these meth-
ods he concluded (i) that more attention should be paid
by cystoscopists to the intravesical work by means of the
Nitze's operating cystoscope in the radical treatment of
tumors of the bladder, as it was to-day beginning to
occupy the same position in tumor work that the litho-
trite had in the work on vesical calculi. (2) That more
attention should also be given to the use of the air cysto-
scope for increasing its usefulness in the treatment of
bladder disease. (3) That in the case of all tumors in
the front and sides of the bladder, in which there was
plenty of space to make the incision clear of the tumor
base, excision was the best operation. (4) That ne-
phrostomy would in the future be as important an operation

in cases of malignant tumors of the bladder as colostomy
was at present in cases of malignant disease of the rec-
tum. (5) That malignant tumors of the rectum situated
about the mouths of the ureters should not be excised,
nor should the bladder in these cases be extirpated, but
when through the pressure of the growth on the ureters
of one side, the kidney on that side began to develop a
renal retention, a nephrostomy should be performed. (6)
That in the treatment of bladder tumors they should be
conservative and not too radical in their operative pro-
cedures. Casper said "patients generally do better and
live longer without than with operation." Dr. Guiteras
was inclined to believe that he was right in malignant
cases.

Results of Surgical Treatment. — Dr. F. S. Watson of
Boston presented lour tables showing the operative results
of tumors of the bladder. There was an extraordinary
tendency, he said, to malignant transition. The malignant
process might begin in the minute villi in the periphery.
There might be recurrences not in situ, but elsewhere in
the bladder. There were two facts to be considered in
connection with operative results, and they both had to do
with the cause of death. There were an extraordinary
number of recurrences in benign tumors ; this was a fact
in connection with operations of partial resection involving
the transplantation of one ureter in the rectum, skin, or
elsewhere; also in all cases of double transplantation nec-
essitated by a total extirpation ; the deaths in these cases
were due, one-half to the shock producd, the other to an
ascending infection. One or two things might be done.
The growth might be bitten off and then let alone. He
advised against touching the malignant growths at all.
That was all right in small polypoid growths. He asked
how these unfortunate results could be improved upon.
He could conceive of but one way. If such a large number
of benign tumors of the bladder become malignant, it
seemed to him that they should treat all cases as
though they were malignant tumors, and treat them by
as radical measures as could be applied, namely, by taking
away the diseased area, performing a total extirpation.
The question then arose, why so great a mortality? If
one could diminish the length of time of operation and
could cut off the deaths occurring from an ascending in-
fection, the patients would have a fair chance. He ad-
vised a double bilateral simultaneous nephrostomy done
as a preliminary step. Then after a month or six weeks
removal of the bladder as well as of the prostate and
seminal vesicles if there was any question of their being
involved. One shortened the time of operation by getting
rid of the ureteral implantation. Cases of recurrent be-
nign tumors of the bladder, or recurrences following
tumors originally benign in which there was some doubt
that they might be carcinoma, called for this method of
operating; Dr. Watson employed it in all cases in which
it was proper to do a radical operation, as though it was a
carcinoma from the start. He never operated in this way
upon sarcomata; they never got well. In three cases of
bilateral simultaneous lumbar nephrostomy there was no
shock per se. One died from a continuance of the uremic
condition. Were they not going to have trouble with in-
fection of the kidney? He answered no, that the kidneys
would drain freely if they were kept clean. Was there
not an intolerable distress when a double nephrostomy
was done? He said no, that he had a patient who had
been draining for twelve years, in perfect health, and with
not a smell or odor. Nobody was aware of his condi-
tion. Dr. Watson wished to have it repeated and empha-
sized, that there was no shock per se in doing a double
lumbar nephrostomy simultaneously. The shock would
be greatly reduced by a total extirpation by first ha^ang
the whole question of urinary drainage settled at a pre-
liminary operation, having the secretion properly diverted.

Dr. Howard Lilienth.\l referred to that part of Dr.
Mandlebaum's paper in which he said that malignant

April 20, 1907]

MEDICAL RECORD.

667

growths of the bladder starting in the prostate might be
mistaken for primary growths. In other words, in secon-
dary malignant growths of the bladder 80 per cent, gave
chances that the parent growth was in tlie prostate. With
regard to the cystoscope, one could not be dead sure of
what they saw through it ; but one could be sure when
working through a suprapubic incision. He said that in-
stead of making a hole in the perineum or introducing a
cystoscope, it would be better to make this suprapubic
opening. As to Dr. Watson's suggestion, he was con-
vinced that the procedure was the most rational treatment
for cancerous disease of the bladder with one possible ex-
ception. He thought they should first make tlie suprapubic
opening and obtain a piece of the growth for diagnostic
purposes, and then subsequently doing the double nephros-
tomy. This would greatly diminish the dangers. There
was no question but that by this operation they diminished
the dangers of an ascending infection. The ureters should
be implanted into an excluded loop of intestine, preferably
the ascending colon previously excluded.

Dr. H. GoLDENBERG said that at the Mount Sinai Hospital
during the last year they had twenty-one cases of bladder
tumor, with thirteen operations, the remaining eight re-
fusing operation, or else being inoperable. Of these thirteen
cases, eight were carcinomata, four papillomata, and one
sarcoma. The results were bad in carcinoma when there
was infiltration. The time was as yet too short to report
the results in papilloma. The question arose as to whether
they should operate upon these cases so soon as the diagno-
sis was made ; it was difficult to answer. He had had a case
which he had watched for four years, a case of benign
tumor of the bladder, with intermittent hematuria. He
had had another opportunity of watching one of Casper's
cases in Berlin which had been under observation for
* eleven years, the patient having refused operation. One
should be governed by general surgical principles in these
cases.

Dr. Edward L. Iveves, Jr., spoke in reference to palliative
hemostasis where operation was refused or where it was
impossible to do operation, when at times the bleeding was
quite sharp, and said that he had found out one or two
tricks which he believed would be worth while mentioning.
Of the internal remedies, especially when there was bleed-
ing from the kidneys or the bladder, he believed the best to
be turpentine, given in capsules, 10 minims three times a
day, or 10 minims given on a lump of sugar. Another
remedy he favored was the fluid extract of senecio aureus
given in dram doses three times a day. As a local hemo-
static he believed the best remedy was alum, and the form
that he used was Squibb's camphorated alum ; a dram of
this was added to eight ounces of warm water and in-
jected into the bladder. This was far better than adrenalin.
Dr. Eugene Fuller said that in some cases there was a
tendency to diagnose a granulomatous condition met with
at the base of the bladder as tumor of the bladder. If that
was removed or scraped ofif, the patient would gradually
get well. These should not be classed, however, as bladder
tumors. If there was a malignant growth of the bladder
he thought it better to leave it alone, or do a nephrostomy.
Partial resection was not worthy a trial.

Dr. H. H. Morton of Brooklyn called attention to the
importance of diagnosis as a prognostic aid, especially the
knowledge whether the tumor was benign or malignant.
In the early stages one could see with the cystoscope the
tumor floating, but when there was bleeding this instru-
ment threw no light upon it, even when adrenalin was
used. If it were possible to take a piece with the Casper
or Nitze's cystoscope for microscopical examination, then
they would have something to go on. One could not tell
whether the tumor was benign or malignant merely by
looking at it. He had seen the operating cystoscope used
by Nitze, and it was a very difficult instrument to ma-
nipulate.
Dr. Harlow Brooks spoke of the prevention of malig-

nant disease of the bladder and said that a great many
cases of vesical carcinoma originated in the prostate;
therefore, to prevent them closer inspection and observation
of conditions in the prostate should be called for.

Dr. L. Bolton Bangs, speaking in reference to the double
nephrostomy, asked, "What is the use?" Patients who re-
quired such an undertaking as that had already reached
such a point in their malady that it was utterly hopeless,
for metastases had already taken place. The degree with
which the disease had extended from the bladder was an
utterly unknown quantity. The disease was beyond you.
The question of nephrostomy which Dr. Watson proposed
appealed strongly to him, but only in a very limited class
of cases. The question of shock did not concern them.
Dr. Bangs said that he had a patient who had been carrying
a tube for eleven years in the loins. Before undertaking
a double nephrostomy the extent of the malady should be
determined as far as was possible.

Dr. George E. Brewer said that he had a patient who
had had a double nephrostomy performed on him three
years ago; it was done for suppurative disease of both
kidneys from calculi. The man was in good condition and
not inconvenienced at all.

Reform Urged in the Board of Health Inspectors. —
Dr. A. Jacobi introduced the following resolution, which
was unanimously carried, proposed to the consideration
of the Academy by the Section on Public Health : Resolved,
That the New York Academy of Medicine urge upon the
Department of Health of New York City the following
requirement, namely, that the inspectors of the Department
of Health observe the same precautions as to clothing
and personal disinfection, when their duties bring them
into contact with communicable diseases, as are required
by the physicians in attendance at the Willard Parker
Hospital.

The Milk Supply of New York City. — Dr. Jacobi also
introduced a resolution on this subject (see page 527).

THE MEDICAL ASSOCIATION OF THE GREATER
CITY OF NEW YORK.

Stated Meeting, March 18, 1907.

The Corresponding Secretary^ Dr. Frank C. Raynor,
IN THE Chair.

The Executive Council announced that on account of the
continued illness of the late Treasurer, Dr. J. Lee Morrill,
Dr. A. Ernest Gallant had been appointed to that office.
Weak Foot and Its Treatment. — By Dr.CASL R. Kep-
PLER. Under this head, the author included: (l) The
nondeforming, painful weak foot ; (2) the deforming weak
foot, without spasm; (3) the spastic deforming weak foot
or flat foot. Before taking up the treatment of this condi-
tion, which he regarded as the most common of all painful
deforming processes the human body was subjected to, he
stated that hand in hand with the trend of civilization had
developed the distorting and so-called stylishly beautifying
feature of our footwear, and the shoemaker was confronted
with the necessity of either building the same according to
popular fancy, or losing his business. The resultant mis-
shapen leather boxes into which people now squeezed their
feet were of so many varieties that it was impossible to
describe them, and he emphasized the fact that these shoes
were one of the main causative factors in the development
of adult weak foot. As a prophylactic and curative measure
he mentioned, i. Correct shoes: In the incipient stage,
when only indefinite pain and weakness were complained of,
and before any deformity or stiffness had developed, a
well built shoe, combined with graded, corrective exer-
cises, was usually sufficient to overcome the aflliction.
A high lace boot was ordered, reaching up to and includ-
ing the ankle, not because the constriction of the latter
was a necessary adjunct to efficiency, but because it seemed

668

MEDICAL RECORD.

[April 20, 1907

to be the only kind of footwear that would fit snugly,
hold the foot evenly, and retain its shape. 2. Correc-
tion : Before fitting any corrective brace, and also after
its application, it was of the utmost importance to bring
the general tone of the foot structure, as well as of the
muscles and tissues, into as nearly a normal condition as
possible, thus to retain them and actively aid in reducing
the deformity itself. To achieve this, he emplo}'ed active
exercises, such as adduction and dorsiflexion; rising on
the toes, and board walking. As further aids, he em-
ployed manipulation, both manual and mechanical. Com-
plications had to be met and treated as they arose. Mas-
sage, electricity, and vibration were valuable aids in over-
coming muscular weakness and circulatory disturbance.
Other adjuncts that he had found of value in certain
cases were hot foot baths, medication, retention, built-up
shoes, adhesive plaster dressing, and braces. Of the latter
there were legion, but the salient feature of the brace was
to train the act of walking and force the foot structure
continually into its normal attitude, as well as to overcome
the apparent deformity. In certain severe and selected
cases, operation was justifiable, but as a general rule he
deemed it advisable to try less radical means before re-
sorting to it. In the advanced type of flat foot, in which
correction of the deformity either actively or passively
was impossible on account of the absolute rigidity and
marked tenderness, the administration of an anesthetic was
indicated. Dr. Keppler said that while the treatment he
had outlined in his paper was long and tedious, unhappily
a deformity was not a diseased spot which we could cut
away. It had to be slowly and gradually overcome. •\s
there were no two normal feet alike, so there were no
two misshapen feet alike, and individual, careful treat-
ment was therefore of prime importance.

Results in the Treatment of Congenital Dislocation
of the Hip by the Bloodless Method. — Dr. Dexter D.
.'Ashley stated that after the flood tide of popular enthu-
siasm following the memorable visit of Dr. Lorenz to this
country four years ago, which imparted a marked stimulus
to the work of the orthopedic surgeon in general and to
the study of the congenitally dislocated hip in particular,
a strong ebb tide soon set in, due to disappointments of
various kinds, and enhanced by the overexpectations of
profession and laity, through a lack of understanding of
the limits of the operation in varied hands, and of the
long and careful after-treatment that was necessary, to
which might be attributed many failures to obtain good
functional results. During the past three years, however,
the operation had regained ground in America, more oper-
ators appreciating its application and limitations, and re
porting increasingly favorable results. Dr. Ashley said
that while we should not conclude that this was the only
method to be used in all instances, recent statistics had
raised the percentage of successes over those quoted by
Lorenz and his followers in 1902. This was principally
due to the acceptance of good functional results, instead
of considering as cures only those anatomically perfect. It
was, of course, impossible to have an anatomically perfect
hip where there was deformity of the head, or a coxa vara
or valga, even if the deformed head was placed within the
acetabulum. A careful study and record of conditions
found in each case before operation would help to eliminate
those to which the method was inapplicable, and would
reduce the failures from the operation to a negligible
quantity. Where chances were taken which were not
authorized by the limitations of the operation, the results
should not enter into statistics of those cases to which
the operation was generally considered applicable. After
quoting the statistics recently collected by Dr. W. G. Stern
of Cleveland, Dr. .\shley said he had operated seventy-nine
times for congenital dislocation of the hip by the bloodless
method, with the following results : In twenty-nine an
anatomical reposition was obtained; in twenty-five there
were good functional results, and nineteen were improved.

There were six failures, although two of these considered
themselves very much improved. Five of the six failures
were beyond the age limit, and the sixth was one of his
early cases. Of the seventy-four cases suitable for statis-
tics, many were beyond the age of selection, which v,-as
from three to five years. Some had been previously oper-
ated upon, thus reducing very materially the possibilities
of success when the first operator did not succeed in
making an anatomical repositioru Many of the patients
were poor, and the parents were negligent in regard to
bringing the children for after-treatment or supplying them
with modified shoes. Others resided at a distance, and
were so situated financially as to make careful observation
impossible at the critical stage of the treatment. In spite
of these adverse conditions, he had succeeded in getting
73 per cent, of very good functional results, the patients
walking with a scarcely perceptible limp, and 98 per cent
of functional improvement. While perfection was not
attained by this, method, yet he contended that the results
were better, on an average, than with the open operation,
while danger to life during the age of selection was almost
nil. In connection with his paper, Dr. Ashley showed a
number of patients upon whom he had operated, together
with a series of skiagraphs.

Affections of the Sacroiliac Joints. — Dr. Henry Li.vg
Taylor, who presented this paper, said it was strange that
one of the largest and most important joints in the body
had attracted but little attention either from anatomists
or surgeons. Standard anatomical works were brief and
unsatisfactory in their descriptions of the form and func-
tion of these parts, and even the more elaborate treatises
differed among themselves as to the size and location and
even the e.xistence of a synovial cavity, and still more
as to the existence of motion under normal conditions,
many classing the joints at the sides of the sacrum as
fixed, others as movable or slightly movable. This was
no doubt due in part to the variations presented by differ-
ent subjects and at various ages. It seemed to be true
that these joints varied in structure in different individuals
and under different conditions rather more than most
joints. Obstetricians had been for a long time interested
in the structure and function of the pelvic joints, and
had recognized the considerable degree of mobility which
supervened in these parts during pregnancy. This occa-
sionally was of such extent as to give rise to extreme disa-
bility and entire loss of locomotion in the late months
of pregnancy or after delivery. It frequently occasioned
pains and less serious interferences with locomotion whose
cause was often unrecognized. The increased mobility
at the iliac joint in parturient women permitted a pubic
separation of several centimeters after symphyseotomy,
and this was seldom followed by permanent disability.
When the pubic separation amounted to five to seven centi-
meters, the ligaments in front of the iliac joints were
partially peeled off with the periosteum, and partially rup-
tured. The pubic joint, the joints of the spine, and probably
all the joints of the body participated in this puerperal
relaxation. Infections of the iliac joints after parturition
had also been reported, and this was briefly the state of our
knowledge when Goldthwait and Osgood of Boston pub-
lished their paper on the pelvic articulations in the Boston
Medical and Surgical Journal (May 25 and June I, 1905),
in which they showed from anatomical investigation and
clinical observation that the iliac joints were normally
movable in men and women, and that they were subject to
relaxation, strains, displacements, and infections; in short,
to the affections of which the larger joints were subject
The diagnosis of iliac affections from disease of the hip
joint was easy, as with the latter motion at the hip was
more or less restricted : in iliac disease this was not the
case, excepting when the thigh was flexed with a straight
knee. In primary sciatica there was pain in the sciatic
distribution, and tenderness over the nerve trtmk; in iliac
affections there was tenderness over the iliac joint, and

April 20, 1907]

MEDICAL RECORD.

669

usually none over the sciatic. In sciatica, raising the ex-
tended leg would cause pain in the sciatic rather than in
the iliac joint, and raising the leg of the unaffected side
would not cause pain, although it often did in iliac affec-
tions. This maneuver might also cause pain in the lower
back in rheumatoid and other affections of the lumbar
spine. Here the possibility of a complicating iliac affection
should be borne in mind, and the occasional occurrence
of sacral disease should not be forgotten. The prognosis
was good in a considerable proportion of cases under
proper treatment. A certain few were fairly obstinate,
and could be only partially relieved. The treatment for
laxity, irritation, or inflammation was pelvic strapping
with two-inch adhesive plaster just above the trochanters,
as an emergency measure; the adjustment of a pelvic belt
or girdle, the use of a special corset reinforced by shaped
steel bars, and provided with a pelvic belt, or a long plaster
jacket or corset firmly grasping the pelvis. Recumbency
was necessary in a few of the cases. All cases of obscure
pains across the sacrum, in the sacroiliac region, behind
the hip and down the legs, with more or less disability in
standing, sitting, and lying, so frequent in gynecologic,
neurologic, and general practice, should be carefully e.x-
amined for affections of the iliac joints. If this was
done, many obscure, tedious, and seemingly hopeless cases
might be transferred from the list of incurable to that of
curable affections.

Posture as an Aid in the Diagnosis of Bone Lesions,
Before the Occurrence of Deformity. — By Dr. Regin.\ld
H. Sayre, with lantern illustrations. The speaker said
it frequently happened that the child was brought to the
orthopedic surgeon with the statement that it turned its
toes in, and the request was made that it should be caused
to turn its toes out. Investigation of these cases almost
invariably showed that the pigeon-toes was a voluntary
act on the part of the child, taken in an unconscious
attempt to protect a weak arch from the strain of weight-
bearing. Knock-knees not infrequently lay behind the
pigeon-toes as a cause, the weight being brought in con-
sequence of the knock-knees much more on the inner than
on the outer border of the foot if held in the usual posi-
tion, and the child turned in its toes because it was more
comfortable in that position, and the surgeon who com-
pelled it to turn its toes out without first remedying the
knock-knees was doing more harm than good. This atti-
tude of pigeon-toes. Dr. Sayre said, was typical of a
number of so-called "bad habits" which were held respon-
sible by parents for various deformities, whereas the truth
was that the habit was only the e.Kpression of motion along
the path of least resistance, the child assuming certain
postures, or walking in a peculiar manner because certain
abnormalities of structure rendered it easier to do this
than to perform the motion in the usual way. The child
was frequently scolded for doing what it could not help
doing, and the underlying influence which produced the
habit was not investigated. Children were scolded for
being inattentive when the fact was that they were deaf.
Efforts were made to correct a forward stoop of the
shoulders by braces, when a myopia should have been re-
lieved by properly adjusted glasses, and the speaker said
he had seen the walk of Pott's disease caused by an effort
to relieve the spine from injury ascribed to a desire to imi-
tate the peculiar gait of a fat negro cook. When Andre
in 1636 described orthopedic surgery as "the art of pre-
venting and correcting deformities in children," he in-
cluded a part of the subject that had frequently been
neglected in spite of its importance. Almost all the ac-
quired deformities of the body were the result of disease
which had been present for long periods of time, and
which would have been discernible to those who knew how
to properly interpret the danger signals which nature hung
out for our information. The marked deformities only
occurred after long periods of time, and could usually
be prevented if the cause which produced them was recog-
nized earlv in the disease.

Dr. I'KED H. Albee said that some time ago, in attempt-
ing to look up the minute anatomy of the sacroiliac joint
or synchondrosis, he was much surprised to find such
a marked disagreement among the most prominent anato-
mists and gynecologists as to its histology and macroscopic
anatomy. Morris, for example, held that even the pres-
ence of synovial membrane at all was not constant, stating
that he believed it more apt to be present in the female.
Luschka believed that a small amount of synovial mem-
brane was always present, and that it increased in size
at the time of pregnancy. Cunningham believed that
hyaline articular cartilage existed usually. Testut, the
great French anatomist, mentioned certain folds of synovial
membrane occurring here and there on the margins of fibro-
cartilage. Morris denied the existence of appreciable move-
ment at this joint, while Williams and Kuttner claimed
that movement always existed. Dr. Albee said that when
we considered the mechanism of this articulation, there was
no reason to wonder at the presence of movement, sprain,
and other affections which large joints were subject to. He
had proved to his own satisfaction that it was a tnie
joint. ."Vt the Cornell Medical School he had dissected forty
sacroiliac joints, and the results were briefly as follows:
Synovial membrane was found in all cases ; the synovial
cavity was as constant in its size and relations as that of
any other large joint; distinct movement was measured in
every case excepting one, and in that instance the joint was
ankylosed from an existing osteoarthritis. The thinness
of the capsule on the internal pelvic aspect of this joint
was of importance surgically, in that the joint, when in-
fected, was so apt to drain into the pelvis, thus causing a
pelvic peritonitis.

Dr. A. Ernest G.'iI-l.-xnt, in referring to the treatment of
weak foot, said that as a pupil of Dr. John Ridlon he had
always made use of intoeing in running and dancing. He
said that last January he had a patient who suffered from
pain in her limbs in the late stages of pregnancy, and dur-
ing a forceps delivery the pubic joint was heard to crack.
-\fter delivery the patient suffered excruciating pain; there
was inability to move the legs and the same crackling noise
whenever she attempted to draw up her legs or change
from side to side. All of these symptoms were immedi-
ately relieved on tightly strapping the pelvis. The sore-
ness that patients sometimes complained of after operation.
Dr. Gallant said, he relieved by massage and change of
position as soon as the effects of the ether had passed off.

Dr. Franz J. A. Torek, in discussing Dr. Keppler's
paper, said he thought the orthopedist could rightly con-
sider it within his province to superintend the manufac-
ture of lasts upon which shoes for normal as well as for
weak or deformed feet could be properly and scientifically
iitted. Such work would be regarded in the line of prophy-
lactic treatment, and would in nowise lower the dignity of
the profession.

The discussion was closed by Drs. Keppler and Sayre.

CHic.\r,o Medical and Chicago Larv.\gological and Oto-
LOGiCAL Societies.

.\t a joint meeting of these societies, held March 20, 1907,
Dr. E. Fletcher Ingals read a paper entitled "Relation
Between Diseases of the Faucial Tonsils and Rheumatism."
He drew the following deductions: (i) He had gradually
fallen into error regarding the relation of tonsillitis and
rheumatism, and that what had appeared to him merely
casual was in fact due to an identical cause for the two
in from thirteen per cent, to possibly twenty-nine per cent,
of all cases of acute tonsillitis. (2) Forty-five per cent, of
the cases of tonsillitis had a rheumatic history, but sixteen
per cent, of other affections of the throat and chest also
had a rheumatic history, so that not more than twenty-
nine per cent, of the cases of acute tonsillitis could fairly
be attributed in any way to the rheumatic poisons, and
more than half of these were very doubtful. (3) Among

670

MEDICAL RECORD.

[April 20, 1907

liis patients only nineteen per cent, gave a history of previ-
ous attacks of articular rheumatism and eighteen per cent, a
history of muscular pains that they ascribed to rheumatism.
(4) Eight per cent, of the cases of acute tonsillitis were
attended by. or immediately followed by, articular rheu-
matism; the same number claimed to have had muscular
rheumatism, while in five per cent, the rheumatic attacks
immediately preceded the angina. (5) There was not as
yet sufficient evidence to prove that the tonsil was the
only or even the chief portal of entrance for the rheumatic
poison. Considering, however, that acute articular rheu-
matism represented a mild type of septic hematogenic infec-
tion of the joints, there was no reason why the tonsil with
its notorious facility for infection with pyogenic germs
should not, possibly even frequently, assume the role of
an infected wound leading to septic consequences of a
systemic nature. These septic conditions varied in degree
and location, and rheumatism was perhaps one of the
phenomena. (6) The evidence did not yet justify the
belief that inflammation of the tonsil might prevent or
take the place of an attack of rheumatism. (7) The
statement that the acute beginning of muscular rheumatism
was nearly always preceded by tonsillitis was not supported
by the histories of his case, as in only two per cent, did
muscular rheumatism follow tonsillitis. However, in six
per cent muscular pains that were called rheumatism at-
tended the tonsillitis, although they may have been due
to the fever attending the inflammation of the tonsil. Dr.
James T. Campbell followed with a paper in which he dis-
cussed the relation between disease of the faucial tonsils
and enlargement of the glands of the neck. Dr. Charles
M. Robertson discussed the occurrence of tuberculous dis-
eases of the tonsils. Dr. Joseph A. Capps referred to
the type of cases with acute cervical adenitis that oc-
curred, especially in children, with a sore throat. This
combination of sore throat and adenitis was important (l)
because the combination had in the last year been more
prevalent than usual: and (2) because the etiology of these
infections was interesting. He described in detail the
clinical picture of such cases. Dr. Daniel N. Eisendrath
said that cases of acute enlargement of the lymph nodes
of the neck probably corresponded to some extent with
those described by Pfeif?er in 1899 as glandular fever.
Tn the cases which he had seen the enlargement of
the lymph nodes was out of proportion to the height of
the temperature. He cited a case. There had been eleven
undoubted cases of primary tuberculosis of the tonsil
reported, the majority of them having been verified by
autopsies and by finding primary tuberculosis of the tonsil,
in which there were no other tubercle bacilli found in the
body. A surgeon in operating for tuberculous glands of the
neck should also remove the tonsils and adenoids. .A,s to
the relation between appendicitis and tonsillitis scarcely a
winter had passed during the last two or three years with-
out surgeons having seen tonsillitis in children followed by
typical attacks of appendicitis, so that clinically the asso-
ciation of the two diseases was quite well established. Dr.
Robert H. Babcock said that in a very large percentage of
cases the portal of entrance of infection was the tonsil. A
large percentage of the cases he saw were instances of
some form of heart disease, and nearly all which he had
investigated, since his attention was drawn to the subject
a good many years ago by the researches of Fritz Meyer,
had shown either chronicallv diseased tonsils, or a history
of previous sore throat, and many times a tonsillitis. The
trend of investigation was to the effect that the old notion
that acute articular rheumatism was a blood disease in the
sense of its being due to some chemical irritant must be
abandoned ; in fact, it was a specific disease, and many
observations had been made which go far to prove that
the microorganism responsible for attacks of acute articu-
lar rheumatism of the classical type was the diplococcus
rheumaticus. As to the importance played by follicular ton-
sillitis in the production of acute endocarditis. Dr. Babcock

cited the case of a young man who developed malignant
endocarditis from which he died. Autopsy substantiated
the diagnosis which was made during life. Dr. Frank S.
Churchill said that in children the pediatrician did not
see an arthritis as the most common and frequent manifes-
tation of rheumatism. He saw rather endocarditis. Other
manifestations of rheumatism were the subcutaneous en-
largements which Chcadle and other Englishmen spoke of
frequently; also erythema and pleurisy. Some English
writers spoke of attacks of appendicitis as a manifestation
of rheumatism. The speaker then went on to say that in
his opinion chorea was another manifestation of rheu-
matism. The subject was further discussed by Drs. Elmer
L. Kenyon and William L. Ballenger. The latter said
that his experience had shown him that to remove the
atrium of infection we should remove the tonsils to the
depth of the crypts, and the easiest and most certain way
to do that was to take away the tonsil with its capsule.

Chicago Surgical Society.

At a meeting held March i, 1907, Dr. Allan B. Kanavel
read a paper on "Surgical Intervention in Leontiasis
Ossea." Up to the present time the feasibility of surgical
intervention for the cure or palliation of leontiasis ossea
had not been carefully considered. The analysis of the
cases noted in the literature, with the report of one ob-
served by himself, was made for the purpose of determin-
ing whether or not such intervention was justifiable. And
in case of operation, of deciding to what extent it should
be carried, and what were the probabilities of curative
or palliative results. Thirty-five so-called typical cases
have been recorded and a careful study made of nineteen
skulls. The general division of the cases may be made
into: I. Isolated bones involved. 2. Hemihypertrophy of
the face and skull. These cases are always most marked
in the anterior portion. 3. Bilateral involvement of certain
bones. 4. Involvement of the entire face and skull. In
these cases the inferior maxilla was frequently uninvolved
or not mentioned. In relation to cerebral compression it
was noted that fourteen patients showed symptoms which
could be attributed to cerebral compression, and in at least
half of these operation would have been of benefit to the
patients. Seventeen of the thirty-five cases showed in-
volvement of the orbital cavities. The eyes were pushed
out by the increasing bony deposit, and this proptosis prac-
tically always preceded evidences of optic neuritis, and there
was every reason to believe that the blindness was due
primarily to the encroachment upon the orbital cavities.
Many of the patients lived for years after blindness inter-
vened. After adding the bibliography, the reports of the
cases, and the skulls, the article was summarized as fol-
low?: "(i) Operative procedures are justifiable in a
certain proportion of the cases. (2) No well defined opera-
tion can be suggested as a curative measure. The pituitary
body has been observed enlarged in only one case and
there microscopical examination is lacking. Further care-
ful examination should be made when opportunity pre-
sents itself. (3) Palliative operations should be done to
relieve cerebral compression, and encroachment upon the
orbital and nasal cavities. The indication for these pro-
cedures is clear; the diagnosis can be made, and relief
from symptoms with the preservation of sight and mental-
ity for years can be expected. (4) Obstruction of the
blood supply and operations for cosmetic purposes may
be considered. (5) The relationship between acromegaly,
von Recklinghausens' disease and generalized trophic
changes in bones on the one hand and so-called leontiasis
ossea on the other cannot be stated at the present time,
therefore the latter should not as yet be classified as a
pathological entity, although its clinical individuality should
be retained."

April 20. 1907]

MEDICAL RECORD.

St. Louis Medical Society of Missouri.

.•\t the weekly meeting. Saturday, February 16, Dr. John
Green, Jr., reported that the first meeting of the Ophthal-
mic Section had been yery successful. Of a total of twenty-
five members twenty were present, and there were eight
contributions to the program. Dr. Jesse S. Myer gave an
interesting demonstration of esophagoscopy on a patient
having stricture of the esophagus. He called attention to
three principal uses of the esophagoscope, viz., diagnosis,
removal of foreign bodies, and as a most valuable aid in
treatment of strictures. He emphasized the point that the
use of the esophagoscope was attended with no danger if the
obturator was removed as soon as it had passed the
cricoid cartilage, and if the instrument was passed fur-
ther under direct scrutiny of the operator. Papers on
medical education in America, Paris, London, Berlin,
other German universities, and Vienna, were read by Drs.
John Young Brown, C. G. Chaddock, Llewellyn Wil-
liamson, A. E. Meisenbach, W. C. Gavlor, and Louis
Rassieur. Dr. Ravold, discussing the question of post-
graduate study, said that America had a great deal to
offer in facilities for medical education. After a student
had finished the prescribed medical course and had spent
one or two years in a hospital or with some good clinician,
he was ready to look about to learn a specialty. America
had splendid laboratories and just as great masters in
charge as would be found anywhere. They would take
one as far as they could and push him off into original
research. We had the best surgeons the world has pro
duced. The question was, with all these advantages
should one go abroad? It took a tremendous time to learn
a new language. He had a slight knowledge of German,
but when he arrived in Germany it had all evaporated.
For the first five weeks he had difficulty in making his
wants known. For the first three months, although study-
ing German six and seven hours a day, he was unable
even to catch the drift of the lectures. During the ne.xt
three months he was able to catch sentences from the
lectures. At the end of a year he could catch the import
of most that was said and felt elated over his achieve-
ment. After eighteen months he could understand all that
was said, translate it mentally, and take notes in English,
still unable to think in German. He said he did not
believe himself duller than the average student, but that
he wanted to tell the truth about medical education abroad.
He believed, however, that it paid to study abroad, for
the great cultural advantages and for the reason that
it broadened one's views and made one capable of seeing
good in the accomplishments of men in any part of the
world.

which tended to show that the choroid plexus possessed
the properties of a secreting structure, as indicated espe-
cially by the changes in the protoplasm and in the position
of the nuclei of the cells of the plexus. Dr. G. L. Streeter
made a demonstration of models, showing the "Develop-
ment of the Corpus Callosum."

Philadelphia Neurological Society.

At a stated meeting held March 26 Drs. J. H. W. Rhein
and Herbert Fox presented a communication entitled "Ab-
scess of the Brain in a Chimpanzee." The animal had
been on exhibition in the Zoological Garden and had on
several occasions been tested with tuberculin. While under
observation the animal developed paresis of the members
of one side of the body. Sensibility appeared to be un-
involved. After death three abscesses were found in the
brain, one in one hemisphere and two in the other, and
bacteriologic examination of the contents of these disclosed
the presence of tubercle bacilli. Dr. Alfred Reginald
.^llen presented a communication entitled "Fat Crystals
in the Spinal Cord." He reported the presence of such
crystals in the posterior columns of a spinal cord that
he was studying from another point of view and he dis-
cussed the question as to whether they were artefacts or
the result of changes in the cord prior to death. Dr. H. H.
DoN,\LDS0N presented a communication entitled "Studies
of the Choroid Ple.xus." He detailed the results of work
done by several students in the University of Chicago and

Changes in the Position of the Heart with Increase
of Pressure in the Left Pleural Cavity. — M. V. Carletti
discusses the reasons for the changes in the position of
the heart when the intrathoracic pressure is increased by
the presence of fluid or air in the pleural cavity, and gives
us these conclusions : That the heart always changes posi-
tion in obedience to certain laws, and its position is inti-
mately related to the anatomical development and modifi-
cations in position of the surrounding organs. The volume
of the heart and liver, and the inclination of the diaphragm
are the principal factors which influence the position of
the heart. The heart changes position in loto toward the
right, especially if it is large and the inclination of the
diaphragm is slight. It changes position in toto, becoming
vertical and rotating on its axis, so that the left ventricle
becomes anterior and the right ventricle faces posteriorly
when there is a more marked inclination of the di.iphragui
and the heart is small. It is carried to the right when
the inclination of the diaphragm is great; the apex is near
the xiphoid appendix, and the base is in a plane much
more posterior than normal. In all three of these cases
the apex is to the left of the base. There is a rare possi-
bility that the apex may be carried to the right of the
sternum further than the base when there is little inclina-
tion of the diaphragm and the heart is very small. — //
Policlinico.

Anomalies of the Vaginal Entrance. — Leonardo
Tranchida tells us that atresia of the vagina may be either
congenital or acquired. When congenital it is the result of
an early anomaly of growth, before the twelfth week of
intrauterine life, at which time the ducts of Miiller are en-
tirely united to form the genital tract. Such anomaly may
be caused in many ways — arrest of development, circulator^'
changes due to trauma, twisting of the cord, infections, in-
toxications. Any one of these agencies may produce con-
gestion, hemorrhage, disturbances of nutrition, which af-
fect the trophic conditions of the organs, new growths or
overgrowth of the neighboring organs causing pressure on
the growing genital organs ; hyperplastic overgrowth of
the epithelium of the vagina causing the walls to adhere by
contact. Acquired atresia may be due to general infec-
tions, or local pathological processes, in the child or adult.
Such are catarrhal, croupous, diphtheritic, or phlegmonous
vaginitis, obstetrical injuries, puerperal infections, and
caustics used in medication. — // Policlinico.

Chloroform Anesthesia Preceded by an Injection of
Scopolamine. — Psaltoff concludes, from his experience,
that scopolamine injections before the administration of
chloroform are productive of calm sleep which suppresses
apprehension of operation ; that during the course of anes-
thesia the period of excitement is suppressed, as well as the
nausea and vomiting; that the respiration is always regu-
lar, and that the patient remains quietly sleeping for sev-
eral hours after the administration of the chloroform. In
certain cases late nausea and vomiting have been noted, but
in no instance has contracture, hemorrhage, or serious
symptoms of any kind been observed. This investigator,
who has anesthetized 11,000 patients with chloroform with-
out one death, believes that the addition of the scopola-
mine is advantageous and should be employed. Walther
reports success in this same line of work and advocates the
etnployment of the scopolamine with the chloroform, de-
claring that it, together with small doses of chloroform,
may be administered even to hepatic and cardiac patients. —
Le Bulletin Medical.

672

MEDICAL RECORD.

[April 20, 1907

Mfiitral Sterna.

Contagious Diseases — Weekly Statement. — Report of

cases and deaths from contagious disease reported to the
Sanitary Bureau, Health Department, New York City, for

tlie \veel< ending April 13. 1907;

Tuberculosis Pulmonalis

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis
Malarial Fever

Totals

Cases Deaths

466

200

341

39

469

6

438

I
6q

14

80

8

55

/

17

15

1936

Suppressed Gout. — Guthrie Rankin, in considering
the Routy state, adopts as a working hypothesis the fact
that the exciting cause is a toxemia probably originating
in the upper part of the gastrointestinal tract. He regards
the following characteristics as essential symptoms : gas-
tric disturbance; a history of dietetic habits of excess, or
irregularity on the part of the patient, or a record of gouty
antecedents in his family; and a more or less pronounced
and permanent degree of plus tension in the arteries. The
writer then cites the history of two cases which illustrata
different stages in the progression of this pathological
condition. Neither patient had ever suffered from true
gout. Both, however, had gouty antecedents, were beyond
the prime of life, and had undergone more than the aver-
age amount of work and worry. Gastric disturbance was
the first evidence of the trouble. Vascular tension, arterial
degeneration, and threatened cardiac failure, in order led
up to the brink of angina pectoris and Bright's disease.
Neither patient would believe the malady to be gouty. The
writer then mentions various other effects of the gouty
poison aside from those relating to the vascular system.
He speaks of pancreatitis as being sometimes not impossi-
bly a direct consequence of irregular gout. The writer con-
cludes by giving various directions concerning treatment.
He considers any form of tender meat wholesome, but it
should be taken sparingly. Vegetables, excepting rhubarb
and tomatoes, may all be taken if thoroughly cooked. He
does not see why sugar should be forbidden in cases in
which there is no glycosuria. Spices, rich sauces, and
pickles should be avoided. Fruit may be taken, ripe or
cooked. Salt should be limited in amount in the dietary
of the gouty. Constipation must be guarded against. —
The Practitioner.

Clinical Considerations with Reference to Thirty Cases

of Nephropexy. — P. I'lori says that surgical interference
is positively indicated in cases of movable kidney when
this is complicated by albuminuria, uronephrosis, cylin-
druria, hematuria, or crises of strangulation of the kidney,
as well as in grave gastrointestinal complications which
manifestly depend on the alterations dependent on the
prolapse of the kidney ; also in severe nervous disturbances
with pain dependent on nephroptosis, which are not re-
lieved by orthopedic measures. It is relatively indicated
in those cases which are benefited by orthopedic treat-
ment in which there are not anatomical changes in other
organs resulting from the position of the kidney. It is
contraindicated in splanchnoptosis unless the condition is
aggravated by intrinsic kidney changes of a nephritic
type. When associated with genital lesions treatment for
these is to be used, except when there is a blood dyscrasia
resulting from the general condition. Nephropexy is allow-
able whenever all other means of treatment have been
tried without relief and the svmptoms, especially nervous,
are increasing. Fortunately the perfection of the clinical
indications makes this a rare proceeding of last resort,
and its value is enhanced on account of the absolute harm-
lessness of the operation. — La Riforma Medica.

The Removal of Foreign Bodies from the Esophagus.

— Franke has found that it is not always necessary to
open the esophagus in order to remove foreign bodies
which cannot be extracted by instrumentation through
the mouth. The method he recommends if the foreign
body is in the upper part of the esophagus is to cut
down upon this tube in the manner prescribed for
esophagotomy, but before incising ijie esophagus to
locate the impacted object. In many cases it will be

found possible, by careful manipulation from without
with the fingers, to work it gradually upward until it
can be reached with an instrument passed through the
mouth. Franke describes one case in which he was
able to extract in this way a set of false teeth which
had been swallowed and liad become impacted in the
upper part of the esophagus, and he advises that this
simple maneuver should always be resorted to before
exposing the patient to the risks that accompany
esophagotomy. — Zentralblatt fiir Chirurgie.

Milk and Tuberculosis. — Marchand refers to the work
of various modern investigators in this subject. A num-
ber of authorities, including Calmette and Guerin of the
Pasteur Institute, have concluded that the principal portal
of entry of tuberculosis into the organism is the intestine,
and that this disease can be introduced by the ingestion of
milk taken from tuberculous animals. Every infectious
malady of the cow renders its milk dangerous to the
health of the consumer. Even the food eaten by the cow
influences the quality of its milk. But cooking the milk —
sterilization, pasteurization, or boiling — distinctb' modifies
its constitution. Such a process tends to convert the lac-
tose into caramel. A part of the albuminoid element it
makes insoluble. It affects as well various salts contained
in the milk, especially those necessary to the bony tissues
of the new-born. Even if it kills the injurious microbes,
it has, nevertheless, the disadvantage of destroying the
natural digestive ferments which the milk contains, besides
changing its taste. Recent investigations show that next
to maternal milk normal raw milk from a healthy animal,
and naturally sterile, offers the best conditions of alimen-
tation for young children. It is also the best form for pa-
tients or old people. The writer calls attention to the im-
portance of employing tuberculin in order to distinguish
diseased animals from healthy ones. The greatest care
should be taken to use the milk of healthy cows only. —
I.c Nord Medical.

Health Reports. —The following cases of smallpox.
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine- Hospital
.Service, during the week ended April 12, 1907:

SM.\LLPOX — LNITEli STATES

California. San Francisco Mar.

Kansas. Topeka Mar.

^lassachusetts. Lawrence Mar.

.Minnesota, Winona Mar.

^Iissouri. St. Joseph Mar.

CASES. DEATHS.

.\ew Jersey. Newark Mar.

wY< - " ■

Broome County }an.

Xew York. 1 1 Counties Jan.

North Carolina, Greensboro Mar.

Ohio. Canton Mar.

Mar.

South Dakota. Sioux Falls Mar.

Tennessee. Nash\'ine Mar.

Virginia, Richmond Mar.

Washington, Spokane Mar.

Wisconsin, La Casse Mar.

2f-3o. . .
16-30. ..
23-30. ■■
23-30. ..
22-29. . ■
23-30. ..

i-Mar.

i-Mar.
23-30. ..

2-9 ... .
25-31. ..
23-30. ..
23-30. ..
23-30. ..
23-30 . . .
23-30. ..

S6

Epidemic

SMALLPOX — FOREIGN.

Brazil. Bahia .Feb. 16-Mar.

Pemambuco Feb. 1-15. . .

Canada;

New Brunswick, Kent Co Mar. 23-30. . .

Nova Scotia, .\ntigonish Co Mar. 23-30. . .

Colchester Co Mar. 23-30...

Digby Co Mar. 23-30. . .

Halifax Co Mar. 23-30. . .

Pictou Co Mar. 23-30 . . .

Yarmouth Co Mar. 23-30...

China. Hongkong Feb. 16-Mar.

Ecuador. Guayaquil Feb. 16-28. . .

France. Canne Feb. 1-28. . .

Italy. General Mar. 7-21 . . .

Mexico. Guerrero. State Mar. 27

64
Present

Epidemic

SMALLPOX — INSULAR.

Philippine Islands. .Manila Feb, 23-Mar. 2.

I

VELLOW FEVER.

Brazil, Manaos Mar. 2—16.

Para Mar. 9-16.

Cuba. Habana April 5. .. .

Ecuador. Guayaquil Feb. 16-28.

Mexico. Merida Mar. 17-23.

West Indies, Trinidad, Port of

Spain Mar. 9-16.

I, origin Nuova
Paz.

13

PLAGUE — INSULAR.

Hawaii. Honolulu .April 7.

PLAGUE — FOREIGN.

Brazil. Bahia Feb. 16-Mar. 9.

Pemambuco Feb. 1-15

Peru. Chiclayo Feb. 28

Eten Feb. 28

Lamhayeque Feb. 28

San Pedro and Pacasmayo . . . Feb. 28

Truiillo Feb. 28

Medical Record

A Weekly Journal of Medici7ie and Surgery

Vol. 71, No. 17.
Whole No. 1903.

New York, April 27, 1907.

$5.00 Per Annum.
Sfng:Ie Copies, lOc.

©rigtnal ArttrlPB.

OBSERVATIONS ON ARTERIOSCLEROSIS.

By H. NEWTON HEINEMAN. M.D.,

BAD NAUHEIM. GERMANY.

Arteriosclerosis before old age is a disease of
exhaustion and of excess. The term angiosclerosis
is used because veins as well as arteries are often
affected. Atherosclerosis is suggested because
atheroma is a stage of arteriosclerosis.

The disease is increasing steadily in America, and
even Germany shows 22 per cent, in 11,000 cases of
general mortality.*

Etiology. — Pressure in ordinary physical or men-
tal daily labor with want or excess in life's acces-
sories maintained for long periods, especially in neu-
rotic subjects, acts to cause arteriosclerosis. Excess
in stimulation, whether in tea, coffee, tobacco, al-
cohol or prolonged improper diet, which alter the
alkaline blood reaction and constituents are contrib-
uting causes.

Age. — Appearing rarely in the young (shortly
after pv.berty), it is usually specific before 40 years,
occurs generally between 45 and 55 years, later gen-
erally approaching the usual senile type. Sex shows
in favor of the males, as comparatively few women
are affected. Inheritancef acts here as elsewhere
through inherent weakness. Mental worry, strain,
and neurasthenic conditions generally are of the
greatest moment.

Gout and rheumatism are noted in one-half to
one-third of all cases, and their acute form in older
persons may start the trouble.

General infections, most commonly typhoid, in-
fluenza, scarlatina, diphtheria, severe follicular ton-
sillitis, erysipelas, in about the order stated, but also
all exanthemata and infections, including malaria,
are its causes, and especially when aided by predis-
position and later exciting agencies. Local sup-
purations may in rare cases inaugurate slow vascu-
lar change.

Syphilis in from 15 per cent, (my own) to 35 per
cent., according to individual practice, accounts for
it.

Toxins. — External and internal toxins, whether
from fatigue or from the body as in certain forms
of obesity, diabetes, etc., from prolonged intestinal
autointoxication, from vicious habits of overstimula-
tion, or from atmospheric surroundings, such as
noxious vapors or any poisoned atmosphere cause it.

External injuries, such as repeated injuries to ves-
sels by work, or excessive use of certain extremities,
affect its origin and locality.

Pathology. — Normal circulation requires an un-
irritating medium, normal heart, and vessels, normal
cardiac and circulatory vasomotor centers and
nerves, and normal lymphatic conditions.

*Bahrdt : Leipzig Life Insurance Companies. Cong. f.
Inn. Med., 1904.
tHnch.ird and Frank speak of liereditary aortitis.

Arrested circulation at some point with intravas-
cular irritation are cognate active requirements for
arteriosclerosis. When, therefore, from circulating
toxins and irritation within the vessels, local con-
gestion, spasm, or other slowing of blood exists,
then physical or mental overstrain causes in even
greater degree than it does normally an aggravated
state of circulatory arrest or spasm, and both re-
quired conditions are rendered more active.

E.xperimental pathology in the hands of Josue,
Erb, jr., and others Jias produced aortic and arterial
changes in animals with the use of adrenalin injec-
tions. These changes resemble those of the senile
and work type of arteriosclerosis with its marked
calcareous degeneration, but with less or almost
no intima lesion. These results bear largely upon
our subject, but the exact function of the circulating
poison introduced, and the element of spasm cre-
ated, are still subjects for clearer definition.

The vessels in arteriosclerosis are generally dif-
fusely affected, less often with nodular thickenings.
.\\\ sizes of arteries may suffer. When veins are
involved they have generally been previously acutely
inflamed. Any set, single artery, or branch may be
extensively or slightly engaged, leaving healthy
places between. Internal arteries may be changed,
while those of the extremities are little or not so, and
the reverse. Influenced by the considered causes,
certain arteries are more frequently involved ; ana-
tomical statistics vary, but approximately the fol-
lowing is the order of sequence : renals, aorta,
splenic artery, crurals, coronaries, cerebrals, etc.

The primarv and secondary lesions worthy of
special reference here are these, among others :

Cardiac: muscle degeneration (myocarditis)
with infrequent cardiac nerve involvement.

Renal : sclerosis of vesesls and other changes
producing the characteristic small asymmetrical ir-
regularly granular kidney, with decided cortical
changes specially marked in the glomeruli. Other
varieties or hybrids of the granular, the chronic dif-
fuse, and the parenchvmatous nephritis may be
found. Atrophic suprarenal capsules exist at times.

Splenic, and less marked gastric, mesenteric, or in-
testinal arterial changes result in visceral changes
such as fibrous pyloric thickening, gastric and duo-
denal ulcer, intestinal thickening, atrophic spleen,
or pancreas and chronic peritonitis. Such a gastric
ulcer is here presented by specimen, such a duodenal
ulcer was demonstrated to ine bv Dr. Longcope
(Philadelphia).

Microscopical changes early show fat cells crowd-
ing the interspaces and fatty degeneration in the
cells of the intima. This stage or condition, common
also to anemia, etc., and therefore not characteristic,
may clear up. Next the fat globules drop out of the
changed cell bodies, cell jirolifcration occurs, new
connective and cicatricial tissue takes the place of
the intima, its few elastic fibers also suft'ering. Such
changes often escape any but the closest scrutiny.
Coincidently or subsequently other more patent

6-4

MEDICAL RECORD.

[April 27, 1907

pathological changes in the intima and media take
place, those in the latter or former ultimately pre-
dominating according to type. Finally, the process
passes from one to the other, or all of the three
coats, least to the adventitia,* involving them in vary-
ing degree. Further cell production with new elas-
tic formation, fatty degeneration, and atheroma of
varying amount, with or without calcification, consti-
tute successive changes. .Atheromaf is simply de-
generative change in the sclerotic tissue, and cannot
anatomically or clinically be differentiated. The
atheromatous degeneration often leads to erosion
and secondary thrombosis (well seen in aneurysms,
etc.)

Certain distinct types appear to present them-
selves pathologically.

The "specific type" involves the aorta generally,
and the arteries of the nervous system (cerebral and
spinal) more particularly. It advances along the
aorta by sharply defined segments. It is mostly a
media disease (mesarteritis) in the aorta, and pro-
duces cicatrices which decidedly involve the adven-
titia, also the intima, and give rise to a distinct multi-
sacculated appearance of the aofta. The media ma>
contain gummata or other specifically characteristic
tissue, but the Spirochata pallida has been found in
only a few cases. It generally leads to aneurysmal
formation.

.•\s a post-syphilitic disease arteriosclerosis occurs
not infrequently in the ordinary diffuse variety with-
out any specific characteristic lesion. A special
general arterial nodular form with specific mi-
croscopic tissue lesions, generally, however, as an
acute affection known as periarteritis nodosa, occurs,
and has been studied by Kussmaul, Bostroem,
Monckeberg, et al. Its specific character was for-
merly overlooked.

The "senile and labor type'' involves the lower
extremities most commonly, often the upper or both,
and has marked calcareous change. Infrequently it
is seen as a noncalcified type, with diffusely thick-
ened tortuous vessels of almost the entire body. The
heart is often relatively normal at times, may have
moderate coronary thickening or advanced (non-
disurbing physiological) coronary change, aside
from muscular changes.

The "renal type" is the best understood with it=
granular kidney, general arteriosclerosis, hyper-
trophied left ventricle, and frequent termination with
cerebral hemorrhage or aggravated renal trouble.

The "myocarditic type" with multiple arterioscler-
osis, small or great, in various parts, marked myo-
carditis, is often complicated by embolism, and ter-
minates from cardiac failure.

Clinical History. — Some cases of arteriosclerosis
occur in young, growing persons, and are usually
associated with a congenital or acquired (at pu-
lierty) insufficient vascular system. In a few of the
working classes the working type of arteriosclerosis
appears early in nervously disposed persons ; possi-
bly syphilis may influence this in some of them.

In adults under forty years of age syphilis is
alwavs to be thought of. and early apoplectic strokes
arouse the same suspicion.

To us it has appeared that, apart from the renal
form, most cases appear to present features in which
one of three groups of symptoms predominate be-

* Incipient adventitia change's arise from local causes, like
injnries. etc.

■'■ Two' specimens were presented, one specilic (36 years")
and the other a senile aorta (86 years), with marked
arteriosclerosis, without calcification or erosion showing
diffuse atheromatous change, as proved by the red spots >n
intima and inedia produced by proper aniline stain.

sides the generally prevailing ones. These are either
angina, anginose, or angiospasm symptoins or signs,
again myocardial, and thirdly neurasthenic.

The renal form, hitherto erroneously accepted as
the type of all, manifests itself, as is well known,
by long-continued occipital pressure and headache, a
sense of fullness of neck, eye symptoms (recog-
nizable in 36 per cent, of the cases), but which eye
sym])toms often improve later, advanced urinary
signs as persistent granular or epithelial casts, and
albumin in larger ainounts, later by apoplectic
strokes or uremic symptoms.

In all forms of arteriosclerosis, and more es-
pecially in those well established, disturbances of
digestion are not only precursors of progressing dis-
ease, but become pronounced with its advance. Gas-
tric and intestinal digestion becomes slow and im-
perfect, meals are longer in digesting, and the former
quantities are not digested. Symptoms of gastric
dilatation are not unusual, indigestion, gastric, and
intestinal catarrh, o.x^luric symptoms, and hepatic
disturbances are very common, and abdominal arteri-
osclerotic colic appears.

Autointoxication from fermentation, constipation,
or more directly from any diminished blood pro-
tective power or active bacterial increase is at all
times a threatening factor of the disease. Constipa-
tion becomes very harmful, and, if persistent, often
excites angina from autointoxication or from irrita-
tion, and nothing is more dangerous at such times
than indiscreet diet, particularly game and fermenta-
ble food. Such errors as dilution and weakening of
gastric juice by mixing quantities of liquid food with
solids, induce serious cardiac difficulty mechanically
from gastrointestinal overdistention, besides in-
creasing the danger of autointoxication.

The presence of myocardial signs and symptoms
is common to all groups. Heart signs which are
most commonly met with are intermissions, aryth-
mia, and changed character of heart sounds, with
or without murmurs.

Aside from hemic and other subsidiary murmurs,
simulated or secondary murmurs from a disturbed
valvular orifice mechanically affected by the lesion
in an adjacent orifice, are also to be reckoned with,
antral stenosis is thus infrequently simulated in old
arteriosclerotics from rigidity about the aortic
valves, just as aortic regurgitation is sometimes
simulated in severe mitral stenosis in the young.

The heart sounds are characterized by the lesions
of myocarditis or of high blood-pressure, variably
one or both. Absence of more or less muscular qual-
ity, and partial or complete hollow quality of first
sound, are common with accentuated second sound.
The more hollow the first the shorter and less clear
becomes the whole second sound, always a matter of
serious import. Intermissions longer or shorter are
frequent, and depend, as they really do in most of
their occurrences, upon reflected gastric, intestinal,
or hepatic disturbances, if not upon direct autointox-
ication. Cardiac intermissions, while never desired,
may be no indication of immediate, often not even
remote, gravity, and in cases sometimes a sign of
comparatively good import. Thus the occurrence;
of intermissions in late stages of threateningly fatal
pneumonia gives a ray of hope even, for now the
]>neumogastric is controlling conditions somewhat.

ArythiTiia is frequent, often present for years in
certain cases, and, if the irregularity be regular, less
important than usual.

Tachycardia and bradycardia are both important
and frequent, the latter less common, and both
induce more serious trouble. The former is often
met in neurasthenic or nervously disposed persons.

April 2-/, 1907]

MEDICAL RECORD.

675

Both must be considered relatively to the patient's
normal pulse rate, and may be consistent, barring
short lapses, with apparent good health for years if
kept in check.

Angina may exist in its various types, and may
occur in the mildest forms, often called false angina ;
it may present only parts of its characteristic phe-
nomena of localized pains by sensations variously
limited about the chest, neck, or arm; or the signs
of facial and pulmonary angiospasm causing flushes
with heat and dyspnea, and hurried breathing, or
congestion of serous membranes, more commonly
the pleura, of internal organs, the pulmonary, renal,
hepatic, or of pharyngeal constriction, laryngeal ob-
struction ; least serious is when swellings of the hand
or arm, of the supraclavicular fossae, or anywhere
in the integument, occur, which latter are rarely ac-
companied by the heat and redness of erythemata.
Angiospasm of the radials during angina attacks
the artery, these varying in diameter, being in the
same case alternately small and large, in others
dilated during the attack, but in all cases evidencing
high tension.

In the average case the disease may announce
itself from a clear sky with angina pectoris and pre-
cordial or poststernal oppression, together or sep-
arate, and with various heart irregularities.

Dyspnea is apt to be a marked early symptom, less
so later until complications such as aggravated
hepatic, gastric, renal, or cardiac conditions set in.

Cardiac asthma with, in early cases, slight or
abortive angina, becoming more pronounced later, i.^
a frequent decided chest symptom.

Cheyne-Stokes respiration appears during times of
intentness upon mental or physical work, when pa-
tients can be unobtrusively observed, and often in
sleep, during apparent health. It is of course well
known in serious conditions, as is also the Adams-
Stokes phenomenon most comm(_)nlv met in severe
bradycardia.

Renal symptoms, such as occasional albumin and
hyalin, with less frequent slightly granular casts,
are found in two-thirds of our persona! cases. Often
nervous, or again digestive and hepatic disturbances
from dietary errors, cause their reappearance.

The next important group is that which begins
with nervous or neurasthenic symptoms : vertigo,
irritability, and increasing difficulty in continued
work and fear of it. unsteady handwriting, slight
hesitancy in speech, especially when excited, im-
paired memory and mind, depression, emotionalism,
and lacrymoseness. most important of all insomnia,
and not infrequently melancholia and suicidal ten-
dencies of a mild type, which disappear later.

A certain number of patients, more especial)}
women, show early symptoms of bad air effects when
in overheated or badly ventilated rooms, particular]}
in public, when oi)i>ression, d\spnea, faintness. tach} -
cardia, cardiac irregularity, with generally nervous
flushings and fear supervene. The intimate relation
of neurasthenia and arteriosclerosis is especially
worth noting.

Vasomotor DisUirbances. — The importance which
abdominal arteriosclerosis assumes, the changes
which closer investigation will demonstrate in the
abdominal plexuses, just as has been demonstrated
in a moderate number of cases in the cardiac plexus,
has special significance in producing the class of
disturbances already described, and which may be
accentuated under this heading. Angina from an
apparently cloudless sky, or from varying neuras-
thenic influences, with its condition of small and
contracted arteries during the attack, succeeded in
some cases at its maximum by apparently paralyzed

or widened peripheral arteries having equal or
almost equal high pressure in both the contracted
as well as the dilated condition, and passing over to
the danger point, when the pulse becomes marketlly
(|uickened, is a condition which is significant. Con
gestions of portions of the face and mental dis-
tiu-bance replacing angina, and occasionally masking
it and calling forth hysterical manifestations or asso-
ciated nervous phenomena and the numerous angio-
spasms, are not uninteresting appearances.

Blood States. — Anemia in its various form is
common. Often pernicious anemia is simulated in
women, but the absence of macrocytes and nucleated
red corpuscles differentiates this.

Blood pressure presents high tension during a cer-
tain stage of all cases, declining to a later low ten-
sion, or varies under nervous, cardiac, renal, diges-
tive, blood, and special localized arterial conditions,
such as diminished aortic elasticity.

Only 18 per cent, of my ow^n unequivocal cases
showed normal or lower pressure. Dunin, in ex-
amining 420 cases, found 300 (71 per cent.) with
pressure above 150 mm. and 120 (29 per cent.)
with low or normal pressure. Casting aside one-
third of the 120, 80 (21 per cent.) unequivocal cases
of the latter remained.

Von Basch has divided arteriosclerosis upon a
coml)ined symptomatic and pressure basis into : true
arteriosclerosis when pressure is over 150 mm. with
more or less persistent albuminuria, latent sclerosis
with over 120 mm. and under 150 mm., and pseudo-
sclerosis with 120 mm. or under, each with certain
symptoms and signs. This division, except with the
experienced, may lead to error.

The absence of symptoms referable to the heart
condition met with not infrequently in the senile and
work type, when coronary change is suspected and
found at autopsy, is worthy of notice, and finds this
physiological explanation : that so long as some
initial impulse-giving muscular fibers about the ven-
ous sinuses remain, and a sufficiently contractile con-
tinuous muscular conductivity in the ventricle exists,
fair heart action is possible. In other words, the
sclerosis here does not menace tli£ most vital heart
portions, or else insufficiently, or, again, the gradual
coronary change may have undermined the muscle
less. .Xgain, quiet disposition may influence this
absence.

It is interesting to note the tendency in the men-
tal and city patient towards central lesions, w'hile in
the purelv senile, the labor, and country patient that
towards peripheral lesions predominates.

Limping gait, described by Charcot and Erb, is
characteristic of some cases. Carious teeth, as an
accident or incident, are often met with.

Diagnosis and Differential Diag)iosis. — The diag-
nosis is based lupon the clinical history pointing to
I lid infection of some kind, unusual persistent men-
tal or physical strain, either or both, abuse of stimu-
lant of any kind, symptoms of gradually increasing
irritability, insomnia, difficulty in ordinary mental
processes, with some cardiac and either gastrointes-
tinal or renal symptoms, or all accompanied by signs
of ilecided cardiac weakness or irregularity, or both,
with altered heart sounds, recognizable change in
pulse trace, and pressure and ophthalmoscopic
changes. Naturally, as the arteries of different por-
tions of the body are more or less greatly involved,
whether the cardiac, the gastric, the cerebral, or
others, the symptoms and signs will be more intense
in their direction, as when with aortic and cerebral
\essol change we may have neck and head rhythmic
inilsation. so do other marked symptoms and signs
occur in other combinations.

676

MEDICAL RECORD.

[April 27, 1907

In the pulse tracing care must be taken to sep-
arate the early and the postmyocardial trace. Then,
too, the venous pulse trace has value for judging the
right heart, as the radial has more particularly for
the left. I advise the use of the simple Dudgeon
(unimproved) to begin with, and later the use of
the Mackenzie or Jacquet* for two or three com-
bined traces of pulse, apex beat, or venousf impulse,
under the following precautions : ( i ) Adjust straps
properly, using a right and left arm arrangement;
avoid the tightening under the wrist, making it at
the outside. (2) Take the lowest of the most char-
acteristic traces obtainable, not the lowest trace of
any kind. (3) See that trace is in the middle of the
tracing paper. Above the middle may mean over,
and below the middle, underpressure of the instru-
ment. If a proper midway trace is impossible for
any reason, note it always. Such tracings are always
open to question. They become valuable under sim-
ilarly noted conditions of other observers. (4)
Always take every kind of trace singly, as well, s©
as to judge the correctness of each individual trace
in a combined series.

In pressure the following observations are im-
portant: (i) The time of day affects the pressure,
for it is apt to be higher after meals and in the morn-
ing in certain cases. A restless night lowers pres-
sure. Pressure varies with mental state, medica-
tion, etc., and should be repeatedly taken. It should
indicate arterial (P.A.) or capillary pressure (P.C.)
in records. Then, too, systolic and diastolic pressure
have value, and so has the differential pressure cf
these latter. (2) The instrument should be properly
tested, well understood by the observer, so that he
knows his own personal equation of error and its
relative value to other instruments. My own pre-
ferred instruments are an Oliver of the old type
besides the Boulimiet or combined Potain-Gaertner
instrument, and occasionally the Riva-Rocci im-
proved (Janeway).

Radiogram. — In seeking to decide questions of
uncertain cardiac enlargement or of sclerotic ar-
teries, I have this to say : The expert upon this
subject, Geheimrat Prof. Moritz of Giessen reported
(three years ago) that it gave him the correct right
border in 68 per cent., the correct left border in 70
per cent., both borders correctly in 50 per cent., and
both borders wrongly in 12 per cent. Despite the
fact that no adequate picture is as yet obtained
except in calcification, which in external arteries is
appreciable to the finger, it is of great value in such
aortic conditions, of confirmatory value in heart
cases, and of diagnostic value in emphysema, chest
deformities, etc., when other methods are dubious.

We must remember that Roentgen pictures are
silhouettes. The source of light, its direction and
intensity, if allowed to vary, give different results,
as does also the least variation in the patient's posi-
tion. A flat, wooden, unyielding table, marked off in
squares on the top and bottom, and a quarter-inch
metallic (lead) strip at the nipple level attached to
the table across underneath, the patient laid on the
table with shoulders, certain ribs, and other anatom-
ical points plumbed to their respective squares on
the table (and recorded), and the metallic line pro-
jected through the nipples in the photograph, give
the only satisfactory results. Sitting or semiprone
postures give doubtful pictures.

Well-marked angina pectoris, always the strongest

*The Jacquet instrument with two tracings is more prac-
tical than that with three.

tUse grooved venous pulsometer.

JFrench standard 10 or 12 equals the German and others
of 100. 120. etc.

evidence of coronary arteriosclerosis, points to prob-
able general arteriosclerosis. Persistent or oft
repeated angina within the twenty-four hours, de-
spite careful (sedentary) and regulated habit and
nitroglycerin administration, always points to coro-
nary sclerosis with marked cardiac dilatation, even
when percussion and auscultation leave a doubt.
Exceptionally in phlegmatic and well-ordered per-
sons, even marked coronary sclerosis may present
only signs of myocarditis when aortitis is absent.

In marked aortitis, of which coronary sclerosis
usually forms a part, some aortic dilatation is pres-
ent, the aorta (and the right subclavian artery) is
sometimes within reach, there is neck and head
rhythmic pulsation (Musset sign), and the greater
transverse aortic dullness can often be made ap-
parent early by first gently percussing, noting its
transverse area, then striking five or six finger blows
over the aorta, when repercussion will show a dimin-
ished area (Cherchewsky). Retrosternal pains
are more or less constant, the radials are unequal,
often show the aneurysmal trace, and a roughened
coronary artery projecting into the aorta may cause
a loud obstructive murmur.

Myocardial cases manifest the symptoms and
signs referred to, of the changed heart sounds, the
first being early, parchment like, the second compar-
atively or really reinforced. When the first is dis-
tinctly hollow or tubular and the second thin, like the
snapping of thin cord, marked dilatation exists.

A gouty history and gouty symptoms, and strong
uric acid and its related conditions, accentuate the
suspicion of arteriosclerosis.

Prognosis. — A recent authority has said: "From
a general standpoint nothing can be done (except in
syphilis) to lessen the existing influences upon the
diminished arterial resistance." To this opinion I
take decided exception. In 1895 I heard the patholo-
gist, Thoma. say, "by avoiding the causes of in-
creasing blood pressure, by proper hygiene and
regimen, serious and fatal vascular disease might be
anticipated. If it became possible to recognize
arteriosclerosis sufficiently early, it would be easy to
limit the danger of rupture of blood-vessels and
aneurysmal formation."

My labors for the past ten years along the latter
indicated lines have taught me their truth, and that
well-directed medical experience and a patient's
intelligent aid can check the increasing danger.
Readjustment of physique and work,_ not always
retirement from work, are needed on the patient's
part. Are not five, eight, and ten years' prolonga-
tion of life, with more or less working capacity and
in comparative comfort, as Nauheim has frequently
demonstrated, of value? Is not one year. even, with
clearer mind, restored mental balance, and ability
to enjoy life, as I have seen, worth a struggle? In
ten years at Nauheim, with many hundreds of such
cases, mostly serious, the mortality during treatment
has been three-fourths of one per cent., and in all
my cases the entire mortality, including those who
died at home any time after treatment to date. 2.6
per cent, (under 3 per cent). And I add here that
no patient has died at sea. The dangers are, when
landing, frotn overdoing and froin the new tempta-
tion to indulge in food and drink to excess.

Treatment. — The treatment iinplies mental and
physical adjustment of the patient to his recognized
condition, besides the physical and internal remedies
to undo or prevent further trouble. Work must be
diminished and limited for a long time to what 'is
essential, and sources of irritation removed or ig-
nored. A proper methodical life, hygienic surround-
ings, proper diet, regulated sleep and rest periods.

April 2-j, 1907]

MEDICAL RECORD.

677

and above all properly controlled method in every-
thing, constitute the only safeguard against increas-
ing disease, life with pain, or unnecessary earlier
death. Well-aired and not too warm apartments
never over 68° F., and for sleeping apartments as
much less as the patient can bear, should be our aim,
but brought about by careful graduation in the over-
heated American homes. Sleep in most cases of not
over seven hours continuously, with rests during
the day or a regular afternoon siesta, is best for
most of these patients, a rule well applicable to most
of our cardiac cases as well.

Daily exercise, as riding, driving, mild limited
gymnastics in the room, all carefully directed, ad-
justed, and varied (guarding against overuse of the
left arm and hand to prevent needless heartstrain).
walking on the level, and later up moderate ascents.
Respiratory exercises are indicated, as are also re-
sistance movements (manual for a time), then in
appropriate cases by the Herz or Zander system.
When exercise is limited from whatever cause, mas-
sage* is most necessary, which may be followed by
frictions. Dry frictions in the morning, with cool
or cold sponging before retiring (the latter induces
sleep), or reverse operations as to time. In some
cases the morning cool or cold sponging or plunge is
well replaced by warm dips.

Bath Treatment.— While fresh water baths often
disagree, salinej warm baths are general!}' well
borne. When saline baths cause discomfort, partial
body immersion, enough to cover legs or more and
douching the upper body, coincidently overcomes it.
The happy influence of the saline carbonated baths,
natural when possible, and otherwise artificial, is of
far-reaching value in this affection. The special vir-
tues of Nauheim. in relation to arteriosclerotic treat-
ment are herewith affirmed after seventeen years of
impartial observation and practice. In his recent
work, Romberg of Tiibingen corroborates another
recent utterance of a great German scientist as fol-
lows: "Among the natural carbonated baths. Bad
Nauheim, by reason of its wonderfully graduated
baths, its excellent arrangements, favorable situa-
tion, and special local influences, unquestionably
ranks first, and is to be recommended in all cardiac
insufficiencies."

Diet. — Dietarv directions constitute the most im-
portant of internal remedies, and its immediate per-
manent control in urgent cases, its gradual regula-
tion in all in the course of a few months or less,
absolute limitation in all after six months or a year,
and final permanent restriction in every instance,
are imperative. Avoid sudden revolutions, but
always limit quantity and quality. Discard hearty
meals, and in some cases give light food between.

Avoid fluids with ordinary hearty meals, giving
up soups, especially meat soups, and confining the
use of all fluids to 4 or 6 ounces at the meal. In
proper cases permit fluids between meals. When
digested, milk is best of all. Cofifee should be dis-
carded (save a few drops in milk when seemingly
needed), and replaced bv milk or freshly infused
weak tea. In habitual tea drinkers, tilleul (linden
tree flower infusion) may be substituted.

Increase vegetables and diminish meats. Use
white meats, save in those with anemic tendencies,
when red meat may occasionally be needed. Substi-
tute digestible fish for even some white meat. Ex-
clude game, save fresh white game.

*Massage must be moderate. Vigorous abdominal mas-
sage may increase blood pressure and cause intermission,
that of the back and legs often reduces the pulse.

jThrce to five pounds of common sea salt makes an arti-
ficial saline bath, to which carbonating salts or carbonated
water mav be added.

Discard sweets and starchy desserts, overseason-
ing, spices, and condiments.

Test by accepted methods the digestibility, and the
equally important assimilabilty of indicated articles
of diet in individual cases, so as to select the best.

Reduce alcohol and tobacco, finally absolutely ;
gradually but without much delay all alcohol should
be limited to small quantities of whiskey (a few
tablespoonfuls) with water for gouty subjects, for
others a glass of good claret or a not heavy but
sound Moselle, all diluted equally with water.

Occasionally for a fortnight or longer in marked
renal cases give milk diet partial or complete, espe-
cially when well borne. In all cases avoid fresh
bread, which should be well baked and stale, and
often may well be replaced by light soda biscuit,
zwieback, and the specially made toasted rusks.

Digestion aids, antifermentatives, and relief for
constipation rank first in the internal remedial
agents. Six to eight ounces of vichy three-quarters
of an hour before meals, gastric massage before
meals, the various digestive aids, muriatic acid (Ger-
man) among the rest: beta-naphthalin, creosote,
salol, etc., and laxative agents find place. The im-
portant indication of antiautointoxication treatment
is best met by food control and regular evacuations,
helped by medicines where required. In these di-
rections calomel for hepatic, intestinal, and anti-
fermentative relief is a sheet anchor in this disease.
Repeated doses at bedtime for a series of days or
else weekly administration, or both for various
lengths of time, are imperative. A combination of
calomel gr. 1-4 to gr. i, euonymin and sodium bicar-
bonate, each gr. i, well triturated, given at night, and
followed by a mild saline in the morning, is a favor-
ite remedy with me. The arteriosclerotic intestinal
colic is often relieved by horizontal rest.

Constitutional Treatment. — Iodide of potassium in
3 to 5 grain doses, continued for months or for one
or two years with interruptions, or iodide of
sodium, which is less potent and rather more of an
antispasmodic, at first giving a few grains at night
only, are universal favorites.

Trunececk serum and simlar remedies, which are
composed of potassium, sodium, and allied salt mix-
tures, tnay replace the iodides at times, and also act
as alteratives and help to diminish pressure. Ovarin
and lutein, both organic derivatives, certainly dimin-
ish pressure and are efficacious in women. Lacto-
serum derived from milk has also been used of late
years. The exact eflfect of these agents as direct
antispasmodics, and their effect upon blood ferments
and corpuscles, is variously attributed to blood
realkalinization in diminished alkaline states, to
white corpuscle increase, and to catalytic body intro-
duction.

Arterial pressure reduction is more immediately
attained by the specific agents, the nitrites, such as
nitrite of amyl, nitroglycerin, etc. Nitroglycerin in
as small doses (1-200 to i-ioo grain) as will keep
the patient comfortable, not fearing the largest doses
(gr. 1-50 to 1-20). may be maintained for months
when needed, and reduced to a minimum, or entirely,
when indications cease, when congestion, angio-
spasm, or angina ceases, or when pressure becomes
and remains not excessive. Anticipatory doses often
save large ones.

Myocardial indications are met in the usual way
by cardiac agents, as irritable, spasmodic, or re-
laxed action indicates. Recognizing how digitalis
leaves and preparations may vary, standard solu-
tions of recognized firms only should be used. A
standard fluid extract (one or two drops), the

678

MEDICAL RFXORD.

[April

1907

French Nativelle solution of one milligram of digi-
talin, or the (ierman digitoxin derivatives may
be given in small doses for long periods, or in
full doses for immediate effect (remembering that
in ordinary doses the full effect of digitalis takes
forty-eight hours). Strophanthus (European prep-
arations are two to four times stronger), spartein,
or convallaria can be given for a long time.

Anemia. — This important indication may be met
in the usual way, or else by arsenic substitutes hypo-
dermically, such as cacodylate or methylarseniate
of soda ( 0.03 on alternate days, later daily, or up
to 0.05 for two or three weeks). Oxygen in daily
inhalations, beginning with 15 to 20 liters, later 30
to 50 liters, avoiding overstinnilation, is useful.

As general aids, we have electric treatment by
current ( D'Arsonvalization, etc.), or b\- light (Fin-
sen) in individual cases. In gouty subjects the uric
acid and allied tendencies are improved by stated use
of urinary antiseptics. Insomnia, so common, is re-
lieved by always avoiding brain tension in the even-
ing and excitement by day, by light, early evening
meals, sometimes adding a biscuit, etc., when needed
before retiring, by late s]K>nging, and by bromides,
valerian tincture, etc.

Physiological salt solution by hypodermic or rectal
injections often replaces diminished water supply.

The work of Zirkel and his disciples in osmology,
and the labors of Wright in opsonology, are worthy
of our highest attention in their influence upon our
therapeutic endeavor.

MALIGNANT DISEASE AND MALARIA.

WITH REFERENCE TO THEIR SUPPOSED .\XT.\GONISM.
By Major CHARLES F. KIEFFER.

SURGEON U- S. ARMY. FORT D. A. RUSSELL. WYOMING; O.V DETACHED

SERVICE WITH THE ARMY OF CUBAN PACIFICATION AT SANTIAGO

DE CUBA. vCUBA.

Frequent comments have appeared on the apparent
relative iminunity of certain tropical peoples to ma-
lignant disease. The belief was quite widely held.

About five years ago F. Loftier advanced the idea
that the apparent immunity to malignant disease in
tro])ical countries was due to the fact that in these
countries practically the entire population had at
some time or another in their lives suffered with
severe paludic infections, and that the antagonism
between the two diseases was the underlying cause
for the absence of cancer. h'oUowing out this idea,
he made the suggestion that cancer might be com-
bated by inoculation with lualarial parasites.

I'ollowing this suggestion, numerous papers have
appeared tending to show the fallacy of the premise
on which this theory is based. Reports were made
from countries intensely malarial in which the death
rate from malignant disease reached quite a respecta-
ble figure. Thus, Kruse (Archiv fi'tr Hygiene, Bd.
XII. lift. 3, 1902) studied the cancer and malarial
statistics of Italy, and found that, despite the very
general distribution of malaria, cancer is quite as
common there as it is in Prussia, where malaria is
almost nonexistent. Also Prochnik {Wiener klin-
ische Wochenschrift), reporting from the South Sea
Islands (Dutch India), finds that malaria is of no
effect in the control of carcinoma. Malaria is so
common in these islands that there are few, if any,
of the inhabitants, foreign or native, who escape the
infection. Carcinoma is stated to be also fairly
[irevalent, and, generally speaking, is more common
among the natives than the foreigners. Indeed, the
author has observed numerous persons suffermg
from both conditions at the same time, and he has
never seen the slightest amelioration of the carci-
nomatous condition. He believes, in fact, that ma-
larial infection, far from being preventative of car-
cinoma, is the indirect cause of the large proportion
of malignant disease of the liver observed in those
islands.

On the other hand, to show that where the disease
is relatively absent in tropical countries, the diminu-
tion is not due to malaria, but to some other cause
or causes, J. Goldschmidt (Deutsche viedizinische
Wochenschrift, July 10, 1902) cites statistics from

"] ■'■

1 J: I

1-

3 1 rf I

- i ^ I ^

I I 11

1111

:;.r-h;;r_,.

^j-^l-f^

H

illUU

Chart i. — ShowinK the percenla.^e ot total mort.ilits' due to cancer and malaria in towns ol more than 20.000 inhabitants in Cntja for the

years 1004 and IQ05; the light line denotes malaria: the black line, cancer.

and indeed is still held by some, that this is especially
true of the tropical countries most severely infected
with paludism. The idea is very old that a patient
afflicted with cancer may lose his tumor after a sharp
attack of malaria, and many striking cases are on
record which lend color to the idea that there may
be some antagonism between the two diseases.

the island of Madeira. In this island malaria is
practically unknown, and at the same time the figures
show that carcinoma is also a rare disease. He
thinks it is very reasonable to suppose that if ma-
laria and carcinoma are so distinctly antagonistic,
then in the absence of the former tlie island should
show a larger proportion of cases of the latter

April 27, 1907]

MEDICAL RECORD.

679

disease. Robertson (Joiinial of Tropical Medicine,
November i, 1905) cites cases to show that malig-
nant disease is fairly prevalent in the Gilbert Islands.
A considerable and varied experience in tropical
practice has convinced me that malignant disease is
relatively less frequent in hot countries than in cold
countries, but, while in some hot countries it is ex-
tremely rare, in others it is quite a factor in the
morbidity and mortality. When the distribution of

Chart 2. — Showing the percentage of total mortality due to malaria
and cancer in the six provinces of Cuba during the year 1904. The
light column indicates malaria; the black column cancer.

malignant disease in the various countries, or better
still in the various towns and provinces of a country,
is studied, it will be found quite independent of the
distribution of paludism in the same regions. As far
as individual instances are concerned, I have fre-
quently observed carcinomatous patients suffering
from intense malaria. In two cases severe e.xplo-
sions of latent malaria were observed after opera-
tions for the removal of malignant growths, and
with no effect on the later recidive and fatal termi-
nation. Davidson reports the death of a European
from cancer of the stomach who was stated to have
suffered from frequent attacks of malarial fevers.
Prochnik (loc. cit.) observed the concurrence of the
diseases in "numerous cases." Cardamitis (Grece
Medicale, Vol VI.. No. _V) encountered cancer asso-
ciated with malaria, and consequently denies that
there can be any antagonism. He has, in fact, wit-
nessed the development of malaria in a woman with
an operable cancer after she had been bitten by
infected mosquitos. There was no demonstrable
variation of either disease process.

There is an undoubted relative racial immunity
which is not necessarily confined to tropical peoples.
Kruse, in the paper already cited, calls attention to
this fact. Cancer is more common in northern than
in southern Italy, and the ethnological differences be-
tween the inhabitants of the two different sections is
marked. He believes that the Alpine country gives
evidence of a race distinctly more prone to malignant
disease, and that this race helped to stock southern
Germany and northern Italy. For this reason the
prevalence of cancer in Continental Europe increases
in the direction of the Alps. In the tropics this rela-
tive immunity is helped out by the simpler mode of
life which the natives pursue, and particularly by
the absence of many of the forms of continued irri-
tation which we know lead to malignant disease. I
am convinced of the correctness of the observation
that improvement in native races in the way and

mode of life of civilization is followed by increase
in the rate of malignant disease. In many tropical
countries increasing civilization means a more or
less complete adoption of European modes of life,
and of these principally excessive meat eating and
increased consumption of alcohol. Both of these
are, I believe, powerful indirect factors in the pro-
duction of malignant disease. In many instances,
when the tropical native eats little meat, it is not
on account of any aversion to it as a food stuff, but
because it is usually beyond his means. Where he
has the means, then he becomes, as a rule, as ex-
cessive a meat eater as either the average European
or the average American,

In the Philippine Islands malignant disease is not
rare. In a restricted surgical practice among the
natives, I sa\y luimerous cases of skin cancer and
extirpated four cancerous breasts. I was particu-
larly impressed with the number of cases of malig-
nant disease of the penis encountered. I then
thought it a coincidence that I saw in a short time
six cases of well-developed epithelioma of the penis.
Since coming to Cuba I have seen several more, and
it will be observed in the figures from the General
Hospital at Santiago that among the operations for
malignant disease there is an unusually large pro-
portion of cases of malignant disease of the penis.
Able Cuban practitioners seemed surprised when
told that epithelioma of the penis is among the rarer
manifestations of malignant disease in the United
States. I have not been able to discover any etio-
logical factor. I have no figures bearing on the fre-
quency of malignant disease in the Philippine
Islands. My experience was, however, that I saw
about the usual proportion of these cases to other
pathological surgery. There certainly was no such
marked disprop<3rtioii either way as to call attention
to it. Since coming to Cuba I have studied the

Chart 3. — Showing the percentage of total mortality due to cancer
in the six provinces of Cuba during the year 1904, compared with that
in the six New England States in the year 1900.

question carefully and compiled all available data,
and the following interesting charts and figures are
the result.

Chart No. i shows the percentage of the total
mortality from paludism and cancer in twenty-two
cities in Cuba exceeding 20,000 population. These
figures are compiled from the monthly reports, and
embrace the years 1904 and 1905. The light line
shows the percentage of paludism and the heavy line

68o

MEDICAL RECORD.

[April 27, 1907

the percentage of cancer. The mortality from ma-
lignant disease, it will be observed, varies quite a
little in the different communities, and yet an exam-
ination of the chart shows but little relation between
this line and the fluctuations of the line for paludism.
For instance, Puerto Padre, Manzanillo, Sancti
Spiritus, and Cardenas show the greatest malignant
disease rates ; yet in the first two the paludic rate is
very high and' in the last two it is relatively low.
Consolacion has the lowest malignant disease death
rate and also one of the lowest paludic rates.

Chart No. 2 shows the percentage of the total
death rate ascribed to paludism and malignant dis-
ease grouped by provinces for the entire island of
Cuba for the year 1904. In this chart it will be
observed that the province of Habana, with the low-
est paludic death rate, and the province of Oriente,
with the highest paludic death rate, have identical
rates for malignant disease.

Chart No. 3 shows an interesting comparison be-
tween the malignant disease rate of Cuba and that
of the New England States. The figures used for
Cuba are the same provincial figures as used in the
previous chart embracing the year 1904. The fig-
ures of the six New England States correspond to
the year 1900, and were the only ones I had available
for comparison. In both of them the figures are
expressed in percentage of the total mortality.

A study of the mortality tables of the city of
Santiago de Cuba, which has a fairly large morbid-
itv and mortality rate from paludism, shows the fol-
lowing table of deaths from malignant disease and
paludism in Santiago de Cuba for a period of six-
teen months to include October, 1906:

Natives

Foreign

White

Colored

White

Colored

Paludism;

21.

60.

35-

(i, Hayti).

1 18.

Cancer, etc.

12.

35-

5-

(Martinique,
Africa. China)

ss.

Population of Santiago. — Native white i5,7ii

Foreign white 3458

Colored 26,309

45.478

The colored are not separated into native and for-
eign, because practically all those classed as foreign
are from adjacent islands like Jamaica, Antiqua, etc.,
and are all tropical residents.

Annual ratio per thousand from malignant disease. . .916
Annua! ratio per thousand from paludism 1.96

The following is a statement of the surgical work
for malignant disease done in the General Hospital
at Santiago during the eight years from 1899-1906:

All surgical operations 2,989

All major surgical operations over age 35 803

All major surgical operations for malignant disease. . 209

In the records of the hospital these patients are
not classified by nationalities, but by color. Of the
operations for malignant disease there were :

White. Mulatto. Black.

Male 21 17 32

Female 36 66 37

Total 57 83 69

In the list of 803 major surgical operations on
patients above the age 35, which has been assumed
as the cancer age for this paper, all sorts of opera-
tions are included, such as special genitourinary
operations, gynecological, and major obstetrical
operations. This should be borne in mind when the

figures are compared with other statistics where,
under the head of operations, are only classed the
usual operations of pathological surgery. In figur-
ing up this list, however, all accident surger>', what-
ever its gravity, was excluded.

The special diagnoses of malignant disease as
they appear in the records of the cases are as fol-
lows :

CASES CLASSED AS CARCINOMA.

Uterus 34

Uterus and vagina 4, 38

Breast 24

Stomach 6

Penis 5

Abdominal wall 2

Neck 2

Adenocarcinoma, Scarpa's triangle.... 2

Parotid gland i

Face I

Spermatic cord i

Liver i

Occipital region I

Tibia (encephaloid) i

Ovary i

Hand i

Kidney i

Gall-bladder i

Mesentery i

Pancreas I

Foot I

Testicle i

Carcinoma, iliac fossa i

Groin i

Vulva I

97

CASES CLASSED AS EPITHELIOMA, ETC.

Skin 17

Penis 10

Cervix 7

Mouth 6

Lip 4

Clitoris I

Anus I

Epitheliomatous degeneration of ke-
loid 2

Malignant epulis 4

52

CASES CLASSED AS SARCOMA.

Osteosarcoma of Femur 5

Lower jaw 5

Tibia 5

Humerus 3

Calcaneum 2

Foot I

Finger I

Malar bone 1-23

Uterus 2

Uterus and ovary 10, 12

Breast 5

Lymphosarcoma (not designated).... 5

Fibrosarcoma (not designated) 5

Sarcoma Scarpa's triangle 2

Mesenteric 2

Eye 2

Carotid region i

Face I

.A.uricle i

Angiosarcoma (supraclavicular) 1

62

Grand total, 209

The following conclusions seem justified :

1. There is no real antagonism between malaria
and malignant disease.

2. Malarial infection super\'ening on malignant
disease does not modify the latter.

3. Natives of tropical countries enjoy a relative
immunity to malignant disease, which, however,
varies within wide limits.

4. The progress of civilization with the adoption
of the ways of life of the white man materially di-
minish this immunitv.

April 27, 1907]

MEDICAL RECORD.

681

NOTES ON SIX THOUSAND CASES OF
NEURASTHENIA.

Bv CHARLES D. CLEGHORN, M.D..

NEW YORK.

CLINICAL ASSISTANT. DEPARTMENT NERVOUS DISEASES. VANDERBILT
CLINIC.

Neurasthenia is the bete noire of the dispensary
neurologist. This condition of affairs is easily un-
derstood. It arises from the fact that certain essen-
tial elements in the treatment of the disease are well
nigh impossible for the average dispensary patient to
undertake. Such patients cannot, as a rule, cease
their work, nor alter it; they cannot change their
surroundings ; they cannot regulate their hours of
sleep, nor can they often take rest enough, and their
diet can seldom be much improved. The treatment
of the disease by drugs is thus, to a large extent,
made necessary, though it is far from satisfactory.
In the following notes, therefore, no endeavor has
been made to draw conclusions from methods of
treatment at the clinic, but to present the facts
obtainable regarding the patient and his illness prior
to the introduction of treatment, i.e. history and
symptomatology.

Before giving any figures let us recall a few of
the classifications of neurasthenia advocated by dif-
ferent men. Nothing could well be more varied.
To begin, Beard^ divided cases into (i) cerebral,

(2) spinal, (3) digestive, (4) sexual, (5) trau-
matic, (6) hysterical, (7) hemineurasthenic. Starr-
says we can recognize cases as due to ( i ) anxiety
and worry, (2) overexertion, mental or physical,

(3) beginning degeneration of neurons, (4) toxic
cases. Again, Starr^ divides the cases anatomically
into (i) general neurasthenia, afTecting all parts of
the nervous system and (2) local, involving brain
or cord, or vasomotor system chiefly. Dana* gives
the following forms: (i) primary, (2) hysterical,
(3) acquired, (4) climacteric, (5) traumatic, (6)
spinal, (7) with fixed ideas, (8) angiopathic, and
(9) grave. Finally. Proust and Ballet^ state as
forms of neurasthenia (i) cerebrospinal, (2) neu-
rasthenia of women, (3) genital, and (4) traumatic.

Out of 37,564 patients who have applied for treat-
ment in the neurological department at Vanderbilt
Clinic during the eighteen years from October, 1888.
to November, 1906, there were found 6,000 cases of
neurasthenia. From this list are excluded cases
which had any definite symptoms recorded of hys-
teria or insanity. No cases in children under thir-
teen years of age were found which could not be
attributed to the ordinary nervousness brought on
by fright or poor environment, though some of them
might have been found to be neurasthenic had they
been followed up for a sufficient time.

Of the 6,000 cases thus remaining, 3,516, or 58.6
per cent., were male and 2,484, or 41.4 per cent,
females. These figures correspond quite closely
with those of Savill" and those of Collins and Phil-
lips,' though differing widely from those of Von
Hossling (see Table I).

TABLE I.
Showing Sex R.\tio in Neur.^sthenia.

Reported bi-

Xo.
Cases

127

828
6 ,000

Male

Per

Cent.

Fe-
male

Per
Cent.

Savin

Collins and Phillips. .

Von Hossling

Cleghorn .

77
183
604

3.516

61
5.=;

72 .0
58.6

5°

150

224

2.484

30
45

27.1
41.4

Totals

7,288' 4.380

60. q

2 ,Qo8

30-0

Proust and Ballet' and Starr^ state that the dis-
ease is more frequent in men. but thev give no
figures. Savill" says it occurs equally in the sexes.

but his figures do not bear out this statement (see
above).

The civil state of the cases in our series shows, as
would be imagined, that the percentages of married
and single patients are almost equal. Table II. gives
the findings of Collins and Phillips compared with

our own.

TABLE n.
Showing Civil State Ratio in Neurasthenia.

Reported by | Sex

Single Married

Widowed

Per Cent. Per Cent.

Per Cent

Collins and Phillips

Male

26

29

Female

14

31

Cleghorn

Male

31-3 24-2

■9

Female

14. 1

25-7

3-8

Neurasthenia occurs most frequently in the early
years of maturity, a time when the organism should
be strongest in repelling disease of mind or body, but
a time when one is subjected usually to the greatest
mental and physical strain. The part this plays as
an etiological factor will be considered later. Our
figures show a very large percentage of men affected
between the ages of 20 and 30 years. This dispro-
portion is explained by the frequency of the sexual
type in men at that period of life, about 80 per cent.
of sexual neurasthenias occurring in the third
decade. Even omitting these cases, the third decade
would remain on an equal footing with the fourth
in its production of neurasthenia. The oldest case
we found recorded was in a woman seventy-five
years of age ; the youngest, as stated above, was
thirteen, at which age three girls were recorded.
Table III. gives the numbers and percentages of our
cases by decades compared with the percentages
given by Collins and Phillips.

TABLE in.

Showing Ages of Neurasthenics by Decades.

Decade

Cleghorn

iCOLLINS &

Phillips

Male

= 0-3°

30-40

40-50

50-60

tio-70

.Wjove 70 . .

242

I .542

1 .002

481

172

55

3

Female Per Cent. Per Cent

162
822
815
370
244
60
6

6.
39-

14.2

i.g

6

39
27
16

8
2

t

*.\Ke not recorded in 24 cases.
tFirst decade not shown.

Natives of the United States, of course, predom-
inate among the applicants foi- treatment at the clin-
ics in New York. In our statistics due allowance
nuist therefore be made for this fact. Russians and
Poles are said to have a susceptibility for neurasthe-
nia, but no statistics were found referable to the dis-
ease in Russia. Natives of that country formed lo
per cent, of our series, while Collins and Phillips had
20 per cent, among their 333 cases.

TABLE lY.
Nativity Percentages.

Birthplace

Cleghorn

Collins

and
Phillips

Per Cent. Per Cent.

United States

Ireland

Russia

Germany

England and Canada.

.\ustria

Hungary

Italy

Sweden

France

Scattering

43-5
10. 2
20.7
10. 2

0.6
7.6

682

MEDICAL RECORD.

[April 27, 1907

Occupation in its relation to neurasthenia has been
the subject of much discussion. According to Starr'
the disease is more frequent among the highly edu-
cated classes than among manual workers, and this
view is borne out by Von Hossling's* report (q.v.).
This distinction, however, is not available in dis-
pensary work. Here we can compare only active
with sedentary and indoor work. We found 2,063
cases occurring among persons engaged in the prin-
cipal indoor occupations, i.e. housework, domestic
service, sewing, tailoring, factory work, machine
operating, clerking, studying, storekeeping etc. On
the other hand, the active and outdoor workers,
drivers, laborers, porters, waiters, carpenters, paint-
ers, firemen, watchmen, and railroad workers,
yielded only 1,053, or about one-half as many cases.
This would seem to be a strong piece of evidence
toward proving the sedentary occupations a pre-
disposing cause of neurasthenia. Table V. shows
occupations as we found them, omitting the unim-
portant ones. Von Hossling's' table and one from
Collins and Phillips' are also given.

TABLE V
Cleghorn.

Occupation

Housework. . . .

Clerks

Laborers

Tailors

R. R. Workers.
Factory hands.

Drivers

Domestics

Sewing

Storekeepers. . .

Operators

Carpenters

Waiters

Metal Workers..

No.

542
340

2Q7
286

188 1

'74 ;
156
142 j
137 i
136 i
117
106
103
94

Occupation | No.

Salespersons 1 92

Agents J 90

Porters ' 85

Printers 86

Tobacco Workers .. . 79

Painters j 73

Barbers 61

Plumbers 58

Peddlers ; 56

Students I 51

Watchmen > 28

Weavers j 26

Firemen 23

Teachers 19

TABLE VL

Vox HoSSLING.

Occupation-

Merchants

Clerks

Professors, Teachers

Students

Officers

Artists

No occupation

Medical men » . . .

Farmers

Clergy

Scientists

School boys

Laborers

.\o.

19S

130

68

56

38

33

19

17

17

10

6

6

6

TABLE VII.
Collins and Phillips.

Occupation

No. of
Cases

Housewives

94
37
26

Tailors

Clerks

Indoor Work

264

The etiological factors in neurasthenia are so
many and so varied that they must be classified in
some way, in order to simplify them. After divid-
ing them into the predisposing and the exciting
causes, hardly any two men use the same classifica-
tion. Starr^ gives heredity as the predisposing
cause "par excellence," and as exciting causes (i)

mental strain and worry, (2) alcoholic and sexual
excess, (3) disease, (4) shock and anxiety, (5)
sudden change in life habits, (6) genital disorders,
especially in women, (7) reflex irritation, (8) poi-
sons from imperfect metabolism, (9) injury, (10)
fright. Saviir gives as predisposing causes (l)
heredity, (2) sedentary occupation and indoor life,

(3) general malnutrition, and as exciting causes (l)
overwork, (2) alcohol, (3) masturbation, (4) long-
continued pain, (5) dyspepsia, (6) constipation, (7)
Graves' disease, (8) Glenard's disease, (9) illness,
(10) grief, (11) eyestrain, (12) trauma, (13)
drugs, (14) insomnia, (15) poor teeth.

Proust and Ballet' mention as special causes (i)
heredity and (2) defective education, and as exciting
causes (i) excessive brain work, (2) pressure in
school, (3) moral overpressure, (4) intoxications,
(5) disease, (6) trauma, (7) fright, (8) dyspepsia,
(9) genital disorders.

Beard' said the fundamental causes were (i)
mental labor and overstrain, (2) derangement of
nutrition.

Drowse^ places great stress on heredity, and says
"the fundamental cause of neurasthenia is a want
of correlative integrity between cerebrospinal and
sympathetic centers."

Abrams" gives as causes (i) overwork, (2)
worry, (3) alcohol, tea, and coffee, (4) syphiHs, (5)
illness, (6) trauma, (7) puberty, (8) genital dis-
orders. Glenard gave enteroptosis as the cause.'
Dunin'^ stated that many cases were due to consti-
pation, and Federn'- thought that most cases had
an intestinal origin. Collins and Phillips' had in
their series as causative factors (i) overwork in
27 cases, (2) masturbation in 26, (3) worry in 18,

(4) childbirth in 12, (5) sorrow in 11, (6) fright
in 10, (7) trauma in 8, (8) disease in 7, (9) alcohol
in 4.

A definite etiological factor was recorded in 1,793
cases in this series, or, if we include constipation as
a cause, in about 3,000 cases. Should we also add
to this list cases which gave dyspepsia as a most
prominent symptom (according to Savill, and Proust
and Ballet), we would have some hundreds more.
The e.xact figures, however, cannot be had, as many
patients gave constipation or dyspepsia as a symp-
tom after stating some more generally recognized
cause. The heredity of patients in our series unfor-
tunately was not obtainable, as it was recorded in
but a few instances. In the table showing etiologi-
cal factors, the list is modeled after that given by
Church and Peterson,'^ which is followed quite
closely.

TABLE VIII.
Showing Etiology in Neurasthenia.

Etiology

Male ' Female ! Total

Heredity, Neuropathic.
Heredity. Cachexias. . .
Overwork and Worry. .

Alcoholism

Tea and Coffee excess. .

Trauma

Post-operative

Illness

Toxic States

Shock

Menopause

Miscarriage

Pregnancy

30

3

90

343
29

IIS
29

58
6q

48

20

5°

7

10

119

209

87

430

192

221

61

176

52

81

7.'>

133

8

77

ISO

198

90

90

83

83

35

35

In the above table the toxic cases consist of five
cases of lead poisoning and seventy-two cases of
probable nicotine poisoning. The heading, over-
work and worry, covers both mental and physical

April

1907]

MEDICAL RECORD.

683

overstrain, also worry or anxiety over family or
business troubles. From the figures, e.xcess in al-
cohol among the men, and in tea and coffee among
the women, stand out as frequent causative factors.
Together they form 33 per cent, of the whole list.
Overwork and worry also play a prominent part,
and in this class were found many of the fifty-one
students recorded. It is of interest to note here that
Nesteroff'^ found neurasthenic symptoms present in
30 per cent, of 588 pupils examined by him, the per-
centages increasing from a minimum in the young
classes to a maximum near graduation. Illness,
finally, as remarked by most men, is one of the chief
causes of nervous exhaustion, and was a factor in
133 cases of our series.

Symptoms will be given in the order they are
named by Church and Peterson, no other list appar-
ently suiting all conditions so well. First, then, let
us consider motor disorders. Tremors were noted
in 1,087 cases and muscular twitchings in 166;
weakness was complained of by 742 patients. The
reflexes were recorded as exaggerated in 340 and
decreased in 54 cases.

Among the sensorv disturbances, headache was
the principal symptom. It occurred in 1,935 ^^'
stances (for subdivision see Table IX). Paresthe-
sias were present in 434, dizziness in 560, and back-
ache in 518. The vague sensations of indefinite
character, which could not be classified, were rather
constant, being found in 705 persons. Disorders of
sight and hearing were not common.

The alimentary tract gave rise to the symptoms
most frequently met with, as follows : Poor appe-
tite in 898 cases, constipation in 1,499, ^^id diarrhea
in 90, gastric flatulence in 387, pain in the region
of the stomach in 297.

The circulatory system showed cardiac palpitation
in 479 patients, and vasomotor disturbance in 429.

Among mental symptoms emotional irritability
was the most frequent, occurring in 550 cases. Then
followed worry in 444, various fears in 351, and
poor memory in 338. Insomnia, ne.xt to headache,
was the most constant symptom found, being com-
plained of by 1,684, almost equally divided between
males (879) and females (S05). Depression was
noted 599 times. The complete figures and approx-
imate percentages follow :

TABLE IX.
Symptoms in Neurasthenia.

Symptoms

Weakness

Tremors

Twitching

Reflexes +

Reflexes —

Paresthesia

Hyperesthesia. . . .

Fatigue

Headache. Occip.*
" Frontal. . .

Vertical. .

Temporal.

Dizziness

Heavy head

Backache

Tenderness

Vague feelings. . . .

Tired Eyes

Poor Sight

Poor Hearing

Tinnitus

No.

742

1087

166

340

54

434

8

242

860

672

295
107
560
60
S18
12

705
22

83

20

loi

Per
C't.

4
14
1 1

5
2

0
I
8

Symptoms

Lost taste, smell . .
Poor Appetite. . . .

Constipation

Diarrhea

Flatulence

Pain in Stomach. .

Palpitation

Pain in Heart

Vasomotor dis'd'r.
No capacity work.

Anemia

Secretory disorder

Poor memory

Worry

Fears

Emotional

Insomnia

Drowsiness

Depressed

Syphilis

No.

S
8g8

1499

90

387

297

475
103
429
197
529
46

338
444
351
550
1684

78
599
199

Per
C't.

15

25

I
6

5
8
2
7
3

5
7
6

9
28

I
10

3

The various symptoms, in order of frequenc^' as
we found them, compared with the lists given by
Savill" and by Collins and Phillips,'' may be of in-
terest. They are shown below :

TABLE X.
Symptoms in Order of Frequency

Collins

SaviU

and
Phillips

Cleghorn

Fatigue easilv

Insomnia

Headache

Headache

Headache

Insomnia

Insomnia

Constipation

Constipation

Restlessness

Palpitation

Tremors

Pain in back and legs

Poor appetite

Poor appetite

Emotional, Irritable

Indigestion

Weakness

Timiditv

Vertigo

Vague Sensations

Poor memory

Backache

Depression

No capacity for

Hot flashes

Dizziness

Cerebration

Epigastric pain

Emotional irrita-

Sighing and Yawning

tability

Rapid Pulse

Anemia

Vertigo

Backache

Gastric Symptoms

Palpitation

One type of neurasthenia is still to be spoken
about, namely, the sexual. This occurred in 839
cases out of 6,000, including 5 females. Loss of
sexual power was shown in only 185, while 5^5
cases gave a history of masturbation.

TABLE XI.
Sexual Neurasthenia.

Sexual excess

Loss of power

Nocturnal emissions.

Masturbation

Pain in genitals

Male

196
184
462
518
18

Female ' Total

3
13

199

185
462

525
18

* Patients whose symptoms included constipation and
headache with unrecorded location were put in Frontal
Headache class.

Were it possible to make a careful study of each
case among these 6,000, no doubt some would be
found whose symptoms were caused by a pathologi-
cal condition which was undiscovered. Some of the
records of these cases were somewhat lacking in
completeness, but they seem sufficiently definite to
warrant certain conclusions of value about the dis-
ease.

To summarize the facts most clearly brought out:

1. Neurasthenia is much more frequent in men
than in women.

2. It occurs between the ages of 20 and 40 in
two-thirds of the cases, few comparatively starting
after 40.

3. The indoor occupations furnish a large ma-
jority of all cases.

4. Among causative factors, the disturbances of
the gastrointestinal tract and the intoxications stand
out as principals, and

5. The most constantly present symptoms seem
to be headache, insomnia, and constipation.

Is this last-mentioned condition really a cause or
a result of the disease ? I wish very much that more
information on this point might be brought to light.

REFERENCES.

1. Beard and Rockwell ; "Nervous Exhaustion," N. Y.,

2. Starr: "The Toxic Origin of Neurasthenia, Medical
Record, N. Y., 1901.

3. Starr : "Nervous Diseases Organic and Functional,"
N. Y., 1907.

4. Dana: "Text Book of Nervous Diseases," 1901.

5. Proust and Ballet : "The Treatment of Neurasthenia,"
London, 1902.

6. Savill : "Clinical Lectures on Neurasthenia," Lon-
don, 1899.

684

MEDICAL RECORD.

[April 27, 1907

7. Collins and Phillips: "Etiology and Treatment of
Neurasthenia," Medical Record, N. Y., 1899.

8. Von Hossling: "Handbuch der Neurasthenie," Leip-
zig, 1893.

9. Drowse : "Neurasthenia," London, 1894.

10. Abrams : "The Blues," N. Y., 1904.

11. Dunin: "Ueber habituelle Stuhlverstopfung, deren
Ursache u. Behandlung," Berlin, 1891.

12. Federn : "Blutdruck und Darmatonie," 1894.

13. Church and Peterson : "Nervous and Jilental Dis-
eases," Philadelphia, 1904.

14. Nesteroff: "Die Aloderne Schule und die Gesundheit,"
1890.

313 West Nin'ety-third Street.

PATHOLOGY

OF GONORRHEA
WOMEN.*

H. C. COE. M.D,,

IN

XEW YORK.

I RECALL an eloquent tribute paid by my rev-
erend teacher, Dr. Oliver Wendell Holmes, to
his colleague. Dr. James Jackson, the ancient Pro-
fessor of Pathological Anatomy, who, unaided by
the microscope, had attained a knowledge of his sub-
ject far in advance of his generation. With a sim-
ilar admiration do we reread the classical paper of
Dr. Noeggerath, who thirty years ago, with an
imperfect knowledge of pelvic pathology and no
inkling of the future achievements of bacteriology-,
had what now seems to be a prophetic vision of
the results of the infection which claims out at-
tention this evening. Few of those present can recall
the incredulity with which his advanced views on
■"latent gonorrhea" were received, but all admit that
he was the pioneer in this field of investigation.
Like Sims, he sketched in outline a picture which
those who followed him have gradually filled out in
detail. In my student days gonorrhea was regarded
as a trivial local afTection, transient in its course, and
easily cured. The medical student of to-day is
taught to regard it as even more serious than syphi-
lis, especially in the female. His familiarity with its
results, as seen at the operating table, is a more
forcible object lesson than could be furnished by
any lecturer or te.xt-book.

The brief time allotted to me forbids my discuss-
ing the more elementary points in pathology, which
I assume are known to you, so that I shall devote
my attention to the more recent investigations of
the intrapelvic lesions in the female as they are seen
by the surgeon. The old views as to the site of pri-
mary infection have been considerably modified. It
was formerly held that the vagina was first infected,
but we now know that the intact mucosa of this
canal is quite resistant to the action of the gonococ-
cus, and that the germ may enter the cer-
vix at the time of the impure coitus, with
or without accompanying infection of the urethra,
Bartholinian glands, or vulva. Moreover, it is
a fact often noted that the most virulent
specific vaginitis may not extend beyond the cer-
vical canal. It has never been satisfactorily ex-
plained why such extensive changes in the tubes
should result from an infection apparently so mild
that its inception was not noticed by the patient, or
why a severe type should remain localized below
the OS internum. Doubtless the different powers of
resistance in the tissues of different individuals
accounts for this irregularity. Certain it is that gon-
orrheal infection assumes protean forms, as is known
to surgeons who have operated during all stages of
the disease.

It has been demonstrated beyond a doubt

*Read at a meeting of the Medical Societj' of the Coun-
ty of New York, March 25. 1907.

that the mere presence of Neisser's cocci in the
secretion does not account for all the tissue
changes that occur. They possess toxic properties
which are active after the microorganisms them-
selves have perished. Bacteriologists are familiar
with the frequent occurrence of mixed infection,
and it is probable that the Staphylococcus aureus
and colon bacillus remain active after the gonococci
have disappeared. "Latent gonorrhea" is observed
in the female as well as in the male, small foci of
infection again spreading under the influence of
pregnancy and the puerperium, or even in conse-
quence of the menstrual congestion. It is customary
to regard gonorrheal infection as superficial, rarely
penetrating the subepithelial layer, and extending
only by continuity to the tubal mucosa, thus offering
a sharp contrast to the more profound and far-
reaching effects of the streptococcus ; but it has
been shown conclusively that the muscular wall of
the uterus may be invaded, and that lymphatic in-
fection does occasionally occur in the specific form
of inflammation, as well as in the septic. Gonorrheal
cellulitis, like gonorrheal rheumatism, is rare in the
female, and is probably due to mixed infection.

So far as my personal observation goes, I am in-
clined to doubt that the stroma of the ovary is pri-
marily affected by way of the lymph-channels, as in
septic oophoritis, and there is no reason to believe
that the intact cortical zone is easily infected second-
ary to specific salpingitis. In my opinion, the acute
oophoritis in this connection is more often due to
mixed infection, while hyperplastic and cystic de-
generation are rather the result of interference with
tlie normal circulation in consequence of surround-
ing exudates. It is common to enucleate from a
mass of adhesions a normal ovary, which can be
safelv spared when the tube is hopelessly diseased.

The subject of diffuse gonorrheal peritoni-
tis has awakened much interest of late, several cases
having been recorded which are explained by
the theory of lymphatic infection. Most of those
have been operated upon successfully, in striking con-
trast to the virulent character of diffuse septic peri-
tonitis. Fortunately, Nature's protective power is
shown in the majority of these cases by the localized
inflammation which confines the focus of infection
to the pelvis. Intraperitoneal rupture of a pus tube
I have never observed. It must be most rare.
The opportunities for studying the various types of
gonorrheal affection in the female in Bellevue Hos-
pital are probably unsurpassed. The routine bac-
teriological examination of vaginal discharges and
of the contents of tubal and ovarian abscesses has
developed many interesting facts, the most impor-
tant practical result being the conclusion that irriga-
tion and drainage are seldom necessary. Until re-
cently abdominal surgeons prided themselves on
saving many patients by this practice. Now we see
that they recovered in spite of those measures.
Why? Because in the majority of the cases either
the pus was sterile, or the focus of infection was
entirelv removed at the time of operation.

Lack of time forbids my entering into details. It
suflfices to state that we have found in pus every va-
riety of microorganism (except the pneumococcus,
which has been found bv other observers) associated
with the gonococcus ; that in patients with an acute
gonorrheal vaginitis and urethritis the contents of dis-
eased tubes has often proved to be sterile, although
signs of a recent attack of peritonitis were present.
In other cases where there was no eviderce of
vaginal or uterine infection, such an acute infemma-
tion has been found within the pelvis and abdomen
that in several instances it could be f^Hy charac-

April 27, 1907]

MEDICAL RECORD.

685

terized as a hemorrhagic peritonitis — in fact, they
were supposed to be cases of ruptured ectopic on
account of the amount of free blood, until a careful
examination of the tubes showed that they were the
seat of an intense gonorrheal inflammation. These
facts are hard to explain, except on the sup-
position that the infection may actually skip the
vaginal and uterine mucosa; to expend its action on
the tubes.

The type of gonorrheal inflammation en-
countered by the surgeon is rarely of the
acute type. It goes without saying that the
presence of sactosalpinx, greatly thickened
tubes, and dense adhesions implies a long-standing
process. This applies even to those cases (such as
one that I encountered to-day) in which, with an
acute gonorrheal endometritis, the patient had an old
inflammatory condition of the adnexa of undoubted
specific origin. I have removed half a dozen tubes,
the seat of intense salpingitis, the anatomical ap-
pearance corresponding to the history of acute in-
fection, where Neisser's coccus was found in large
numbers in the pus squeezed from the distal ends of
the tubes. Conservative operations were performed
in most instances, and no febrile reaction followed.
The operation was not done intentionally, for I do
not feel that there is sufficient warrant to either
curette the endometrium during the acute stage of
gonorrheal infection, or to remove such tubes as I
have described.

Although so fond of the urethral glands, fortu-
nately gonorrheal infection rarely extends to the
bladder, and still more infrequent is ascending
ureteritis and specific inflammation of the renal pel-
vis. The danger of interfering with Nature's bar-
rier at the sphincter vesicae has been shown in in-
stances in which infection has occurred as the result
of endoscopic examinations and catheterization.

Attention has been called to the susceptibility of the
puerperal uterus to gonococcus infection. In a sad
case of this sort, in which impure coitus occurred a
day or two before delivery the symptoms were so
acute as to be mistaken for those of perforative
peritonitis. I operated on the fifth day, but
too late to save the patient. The appendix was
normal : both tubes were intensely congested and
filled with pus. and there was a diflfuse peritonitis.
No adhesions were present. The infant had severe
gonorrheal ophthalmia.

I have called attention in previous papers to the
frequent association of appendicitis with tubo-
ovarian disease. This is doubtless nearly always
secondary to the perisalpingitis attending gonorrheal
pyosalpinx, and not to specific infection.

All surgeons are familiar with the various forms
of adhesions and exudates found at the operating
table, especially the extensive intestinal form, which
may render the enucleation of pus tubes so formid-
able to the inexperienced.

The interesting questions suggest themselves : Do
such exudates disappear spontaneously or under pal-
liative measures and if so, why? Is a restitutio
in integrum possible in the case of a tube, the mu-
cosa of which has been destroyed by gonorrheal in-
fection? Can a pyosalpinx discharge itself into the
uterine cavity ? To what extent is a previous sal-
pingitis an etiological factor in the causation of tubal
gestation ? Is "latent gonorrhea" the principal cause
of sterility, as Noeggerath originally claimed? I
regret that I cannot discuss these at leng^th, but can
only state briefly the results of my own obserwi-
tion.

There is no question that under the influence
of rest, hot douches, and boroglyceride or ichthyol

tampons the most extensive exudates do disappear
(probably through lymphatic ab.sorption), leaving
the diseased tubes clearly outlined, where before
they were indistinguishable, and that a symptomatic
cure is obtained. I do not believe, from my experi-
ence both as a pathologist and a surgeon,
that a tube once thoroughly diseased is ever
restored to its previous normal condition.
There is no question that the mucosa may be re-
generated after exfoliation, but the ends of the tubes
are nearly always agglutinated, so that sterility is
inevitable. Clinical evidence alone does not con-
vince me to the contrary.

I have never been able to satisfy myself, either
clinically or from examinations of hundreds of pus
tubes, that their contents can be spontaneously dis-
charged into the uterus. Patients in whom this has
been said to occur I have afterward operated upon,
and have demonstrated its impossibility.

I think that too much stress has been laid upon
the importance of gonorrheal salpingitis as a cause
of arrest of the impregnated ovum in the tube, since
the distal end is usually sealed up as the result of
the disease. It is difficult to imagine a gonorrheal
inflammation that has been arrested at the inner or
middle third, leaving the outer third untouched.
The old question of the frequency of "latent gon-
orrhea" in the male, as a cause of infection of the
tubes and resulting sterility, must be answered
with some qualifications. Since it has become the
practice to pay more attention to the matter of
azoospermia in the husband before treating the wife
for sterility, we have doubtless concluded that Noeg-
gerath's percentage was rather too high, and that
occlusion of the seminal ducts, as well as of the
tubes, plays an important part in this question.

GONORRHEA IN WOMEN.*

INFECTION OF THE URETHRA, V.\GINA, AND DUCTS OF
THE GLANDS OF BARTHOLIN.

By WILLIAM S. STONE, M.D..

NEW YORK.

The frequency of gonorrheal infection in women,
and the opportunity thus afforded for every general
practitioner to observe its clinical relations, would
almost seem to render the present discussion of the
disease unnecessary. The great importance, how-
ever, of the disease to the community, and the er-
roneous impressions that are still prevalent about
some of its manifestations, may furnish the reason
for its discussion at this time. This is especially
true of the lesions of the external genital organs,
the consideration of which has, perhaps, been some-
what neglected on account of the keen attention that
has been directed toward the surgical treatment of
the results of this infection in the internal organs.
The infections of the external genitals also, repre-
senting as they usually do the early and more acute
stages of the disease, are often not observed bv the
physician because of the frequently transitory nature
of the subjective symptoms and of the erroneous
significance which the patients themselves ascribe to
their presence.

The writer's share in the evening's discussion will,
perhaps, be best performed (i) by briefly referring
to some of the features observed in his own experi-
ence, mentioning particularly some of the prevalent
impressions that seem to him to be erroneous, and
(2) by pointing out the practical value these lesions

*Read at a meeting of the Medical Society of the County
of New York, March 25, iQo;.

686

MEDICAL RECORD.

[April 27, 1907

may have for the physician in the way of diagnosis
and treatment.

The Urethra. — The common idea that the urethra
rarely escapes being involved early in the course of
the disease the writer believes to be true, although
functional disturbances of the bladder from other
causes are so frequent in women that the physician
is often not consulted until the urethritis is better or
well. On account of the shortness of tlie female
urethra, its entire length is usually involved, but
the course of the disease is usually milder and of
shorter duration than in the male. It is the experi-
ence of the writer that, with appropriate treatment,
the disease lasts only from four to six weeks, but
that without treatment the involvement of Skene's
ducts occurs in a large number of cases, thus per-
sisting as a local complication for an indefinite
period of time. On account of the early involvement
of the entire length of the canal, frequency of urina-
tion and more or less vesical tenesmus are rarely
absent, giving rise to the common expression "gon-
orrheal cystitis." Whenever the writer hears this
expression used he wonders whether it is from igno-
rance or carelessness, because the truth of the matter
is that, with the exception of a congestion at the
vesical neck, gonorrheal cystitis rarely occurs, and
the ascent of the infection to the ureters, as re-
ported by Kelly, is the rarest of all complications.
Qironic gonorrheal urethritis frequently occurs,
usually, however, as a local condition in or about
Skene's ducts. Stricture of the female urethra as
a result of this disease the writer has only observed
once in an experience of over twelve years at Van-
derbilt Clinic. Suburethral abscess, as a result, has
been noted by the writer three times. Based upon
his observation of the natural course of the disease,
the writer's treatment has consisted ( i ) in proper
instructions relative to diet and the contagiousness
of the disease; (2) in copious draughts of plain
water and such internal medication as will render
the urine bland, of which the tincture of hyoscyamus
and the bicarbonate of potassium have been as effi-
cient as any; (3) in the applications of heat to the
external genitals, preferably by means of hot sitz
baths, and (4), the most important of all, in fre-
quent cleansing of the external genitals with plain
or mildly antiseptic solutions, in order to prevent
infection of Skene's ducts and the ducts of the Bar-
tholinian glands. Injections in the acute form of
the disease the writer believes are unnecessary and
perhaps harmful. The writer's general conclusion
in regard to the disease in the female urethra, then,
is that it is usually less important than in the male,
the chief thing being the frequent involvement of
Skene's ducts whereby reinfection of other parts is
always liable to occur, and the constant danger of
the transmission of the disease to others.

The Vagina. — The most frequent misapplication
of terms is the expression "gonorrheal vaginitis," as
applied to the presence of the infection in adults.
The absence of glands and the character of the
vaginal epithelium render this part of the genital
tract comparatively invulnerable to the invasion of
the gonococcus, except in young girls before pu-
berty, in adult women during pregnancy and the
puerperium, and in elderly women at the time of the
menopause. A redness and irritation from the stag-
nation of gonorrheal discharges from the uterus
often occurs, but a few douches with a mildly anti-
septic solution quickly clears it up. The writer at
this time will only emphasize the importance of its
earlv recognition and treatment as representing the
chief lesion in young girls before puberty. It is
commonly taught that, on account of the rudimen-

tary condition of the uterus and adnexa at this period
of life, these organs are rarely involved, but the
reports of cases of obscure peritonitis in female
children are rapidly accumulating, so that this ob-
servation may not be so true as it was once thought
to be. In two cases of young women who have pre-
sented a chronic uterine discharge, with genital
organs resembling those of women at the meno-
pause, the writer was able to trace the course of the
disease directly back to a gonorrheal infection in
childhood.

In elderly women whose history shows that a
gonorrheal endometritis has existed for a long time
the atrophic changes incident to the age of the pa-
tient will be often seen associated with a very pro-
fuse and purulent discharge containing gonococci,
often also in conjunction with an acute purulent
urethritis. There is no doubt in the writer's mind
that these atrophic changes are important factors in
the lighting up of an old gonorrhea with a reinfec-
tion of the urethra. The vaginal mucosa, however,
in its normal condition, should be considered as com-
paratively invulnerable to this infection, and to act
upon the belief that treatment directed exclusively
to this part of the genital tract will eradicate the dis-
ease can only lead to grave disaster. It should also
be remembered that the taking of the vaginal dis-
charge alone for a microscopic diagnosis of the dis-
ease will often lead to error.

The Ducts of Bartholin's Gland. — The common
mistake of regarding the glands themselves as the
seat of the disease is illustrated by the printed pro-
gram for this evening, as the infection is usually
limited to the ducts, and whenever the glands are
involved it is generally regarded as a mixed infec-
tion. The infection of these ducts is considerably
less frequent than that of the urethra, and usually
occurs later in the disease. It is the result, prob-
ably, in most instances of the stagnation of gon-
orrheal discharges about the genitals, and thus is
largely preventable. The smallness of the opening
undoubtedly accounts for their escape in a certain
number of cases, for in children in which the open-
ing is very small the ducts are almost never involved.
The swelling of the duct from the retention of pus
in the closed duct is well known to all. Not infre-
quently, however, if seen early, the opening is still
patent, and pus may be pressed out, and by daily
milking its closure may be prevented until the in-
flammation has disappeared. I know of no way of
treating the inflammation in the duct itself except by
incision and drainage.

The Diagnostic J'alue of These Lesions to the
Physician. — It has been the custom of the writer for
a number of years to teach tliat as a matter of rou-
tine the external genitals should be inspected and
palpated before the vaginal examination is made,
interpreting the following as evidences of a previous
or recent gonorrhea ; the swelling of a Bartholinian
duct, the presence of a purulent discharge from the
opening, the presence of reddened patches about the
orifice (the macula gonorrhoica of Sanger). Al-
though as shown by Kronig and Menge, and others,
infection of these ducts in exceptional instances may
be due to the staphylococcus or other bacteria, the
gonococcus is the causative agent, in almost all cases.
The presence of pus in the urethra is given the same
interpretation as it is in the male. In order to detect
the presence of pus in the urethra, a certain tech-
nique in the examination must be followed. The
meatus must be first wiped perfectly clean in order
not to mistake discharges that may be present about
the vestibule for urethral pus. \\'ith one finger in
the vagina the urethra is milked from the vesical

April 27, 1907]

MEDICAL RECORD.

687

neck downwards to the meatus. The pressure
against the urethra must be continued down to the
very edge of the meatus, the latter part of the pres-
sure being made against the anterior surface of the
symphysis. It is only in this way that discharges
retained in Skene's ducts will be expressed, it fre-
quently appearing on either side of the urethra at
the very last moment. The frequency with which
pus may be expressed from these ducts may be con-
cluded from the fact that in fifty clinic cases re-
cently examined by the writer, pus or muco-pus was
present in thirty-six. In regard to the information
that the presence of these lesions may give, the
writer wishes to call attention to one particular class
of case, which is often seen in any large clinic,
namely, the patients applying for relief of sterility.
In many of these cases the uteri have been previ-
ously dilated and curetted, and among them are not
a few with symptoms that they did not have pre-
vious to their operation. The examination will dis-
close the presence of inflammatory diseases of the
adnexa which, from their history, there is every
reason to believe followed their operations. The
signs of an old gonorrhea will also be found about
the external genitals ; usually pus can be expressed
from Skene's ducts. The writer has made this
observation so many times now that he always points
out to the students the significance of these signs
about the external genitals, and teaches them that,
although the uterus may be of that type in which
operative procedures are often of value, yet with the
presence of pus in the urethra, for example, all oper-
ative measures are contraindicated.

In conclusion, the writer would call special atten-
tion to the value of these signs of gonorrhea as aids
in the diagnosis and treatment of diseases of the
female genital organs.

41 West Seventy-first Street.

GONORRHEA DURING PREGNANCY.*

Bv J, CLIFTON EDG.\R. M.D.,

NEW YORK.

The time limit of ten niituites allowed for the pres-
entation of this important subject of necessity com-
pels one to confine his remarks to the more promi-
nent facts only regarding gestational gonorrhea.

Few observations have heretofore been made on
the subject; in fact, so little work has been done
upon both pregnancy and puerperal gonorrhea that
there are some who deny the existence of a gonor-
rheal morbidity or mortality in pregnancy and the
puerperium. The difficulty in recognizing the gon-
ococcus has undoubtedly favored this belief.

It is in private practice particularly that our most
valuable and reliable information can be obtained
upon this subject, because here one often can observe
the course of the disease from infection through
pregnancy, during labor, and until the termination
of the puerperium.

The average case in a maternity hospital is seen
possibly once before confinement, and often not
until labor actually sets in. Then, again, patients
of the lower class can rarely be prevailed upon to
remain more than ten days in the hospital after con-
finement, unless actually bed-ridden, so that observa-
tions and statistics of this class of patients must
naturally be looked upon with discredit. To be sure,
the difficulty of getting patients to speak the truth
in such matters as vaginal infection applies to both
classes of patients, but this difficulty is largely

*Read at a meeting of the Medical Society of the County
of New York, March 25, 1907.

counterbalanced in private practice by reason that
the patient is more often seen, and can usually be
kept under observation from start to finish.

Even accepting, for the sake of argument, the
statement of Blaschko, claiming that every man who
does not marry until the age of thirty, has had gon-
orrhea twice, or that of Ricord, that the percentage
of males who contract gonorrhea is over eighty, or
the recent one of Erb' that about forty-nine per
cent, of men have gonorrhea before marriage, most
of them contracting it before the age of twenty-five.
Accepting these figures as within the bounds of
truth, still my observation leads me to take a rather
optimistic view of the effects of gonorrheal infection
upon the pregnant woman. By this I mean those
instances in which infection has occurred either dur-
ing pregnancy or just prior to impregnation, or
during the act of conception itself. I do not wish
to be understood as belittling the importance of the
gonococcus as a causative factor in the production
of endometritis and subsequent abortion, salpingitis,
pelvic inflammation, a storm)' or even a fatal puer-
perium, and one-child sterility, but simply that
women who contract gonorrhea during pregnancy
do not necessarily suffer as far as the pregnancy is
concerned. Indeed, it would appear that invasion
of the uterine cavity by the gonococcus during preg-
nancy is less likely to occur than in the nonpregnant
state. To be sure, the gonococcus has been demon-
strated in decidual endometritis in a limited number
of cases by Neumann, Maslovsky, Williams, and
others. Again, in a still more limited number of
instances, the gonococcus is said to obtain access to
the liquor amnii, causing antepartum gonorrheal
ophthalmia in the fetus.

Armarguac- is authority for one case of prenatal
gonorrheal ophthalmia, and Nieden' reports an in-
stance in which the fetus was born with a caul, and
when liberated from the membranes was found to
have gonorrheal conjunctivitis. Such cases could
hardly occur unless a gonorrheal endometritis or de-
ciduitis had previously existed.

Wintersteiner's analysis'* of 122 cases of actual
ophthalmia neonatorum includes two instances of
antepartum infection of the fetal eyes.

A glance at the literature of gestational gonorrhea
will readily demonstrate a wide diversity of opinion
upon the subject.

It was Sanger's belief that gonococci continue to
thrive during gestation. He has seen them in vari-
ous localities. One claim of his is that gestation
is seldom interfered with, which is controverted
by some of his colleagues.

Friihenholz also denies that the gonococcus is mil-
itant against pregnancy. For him gonorrhea in
early gestation is a reawakened focus. On the other
hand Audebers claims that gonorrhea interrupts
pregnancy in two out of three cases.

Fehling calls attention to the fact that conception
and contraction of gonorrhea are prone to occur at
the same time. He believes under such circum-
stances that the cocci may reach the tubes before
labor.

Steinbuchel studied 328 pregnancies to determine
the frequency of gonorrhea. He found the cocci
present in 70 in the secretions, but, notwithstanding,
but three cases of puerperal gonorrhea resulted.
Conversely Kronig found that of 296 cases of puer-
peral fever, 31 had antecedent gonorrheal endo-
metritis.

Bumm thinks that gonorrhea is spontaneously
healed late in pregnancy,, as far as the disappearance
of cocci from the secretions is concerned. But he
believes that the said germs persist alive in the endo-

688

MEDICAL RECORD.

[April 27, 1907

cervical g'lands, and may be roused to activity at
labor. \Vertheim's views are the same.

The fact that oronorrheal infection of pregnancy
is often apparently mild in character, and frequently
fails to attract attention by reason of the absence of
endometritis, tubal involvement, and pelvic inflam-
mation, is liable to deceive the patient and her physi-
cian, into a position of false security. Treatment of
the condition is desultory or neglected, and all too
late the true seriousness of the infection is realized
at labor and the puerperium, by reason of a gonor-
rheal ophthalmia of the infant and an extension of
tlie infection into the uterus, tubes, and pelvic peri-
toneum of the mother.

The most severe case of gonorrheal ophthalmia I
ever saw in private practice was in the instance of a
patient who married in January, and whose husband
subsequently confessed to me that he suffered from
acute gonorrhea the previous August. The pres-
ence of gonorrheal infection in this patient was un-
suspected during pregnancy, as her only symptom
was a persistent leucorrheal discharge which she at-
tributed to her pregnant condition, and for which
she did not consult her physician. In another in-
stance, gonorrheal infection of the glands of Bar-
tholin resulted during the latter part of pregnancy
in little if any systemic disturbance, but immediately
after delivery the symptoms of pelvic infection
became marked, general systemic infection followed,
and death occurred ten days post partum.

A serious sequela of gestational gonorrhea, and
one which, so far as I know, has received little if
any attention, is the effect of several months' insidi-
ous endocervicitis of gonorrheal origin upon the tis-
sues of the cervi.x and lower uterine segment. In
several of my cases in private practice I can explain
the prolonged and difficult dilatation of the os on
no other grounds.

I am of the opinion that the teaching of Bumm
and Kronig, which held that the vaginal mucus
possessed a bactericidal action, has done more harm
than good, because it has been widely misunderstood
and generally applied to gonococcus infection. The
vaginal mucus has never been proven to possess
such an antagonism to the gonococcus. If we accept
the frequency of gonorrheal infection in the male as
laid down by Blaschko, Ricord, and Erb, as only ap-
proximately correct, then it must follow that the
same infection in the female is more frequent than
is generally accepted. It certainly, in my experience,
is commonly met w-ith in private practice. And if
this be true, and moreover if it be true that gonor-
rhea in pregnancy is often overlooked by reason of
the absence of uterine and parauterine, and peri-
uterine conditions, then the tendency to consider the
pregnant vagina sterile in most instances is danger-
ous and liable to increase the morbidity of the puer-
perium, and the cases of ophthalmia neonatorum.

REFERENCES.

1. Miinchencr mcdizinischc IVochenschrift, No. 27, 1906.

2. Annales d'Ocidistiquc, 1902.

X KUnische Monatshldttcr fiir Augenhcilkunde, October,
1891.
4. Wiener klinischc Wochctischrift, No. 37, 1904.
50 East Thirty-fourth Street.

The Differential Diagnosis Between Acute Appen-
dicitis and Acute Scilpingitis. — The sudden acute onset
of abdominal pain with tenderness over the appendix
region, but with rigidity of the right rectus low down,
is very suggestive of acute salpingitis. The diagnosis
is further confirmed if there is high temperature and
extremely hgh leucocyte count (20,000-40,000; poly-
nuclears. 8o-go per cent.), even though vaginal examina-
tion be negative. — American Journal of Surgery.

THE EYE AND EAR COMPLICATIONS OF
INFLUENZA.*

By CHARLES GRAEF. M.D„

KEW YORK.

As influenza is an acute, infectious disease, one may
expect it to present eye and ear affections of a type
coimnon to other diseases of this class. .\s it is an
infectious disease with a markedly catarrhal tend-
ency, its effects are most marked on the mucous
membrane portions of these organs. When we re-
member the vast numbers of persons commonly af-
fected in any epidemic of influenza, it is proper to
add, however, that eye complications are compara-
tively infrequent. The initial coryza common with
many patients is accompanied by hyperemia of the
conjunctiva. It is hardly a complication, and should
be rather regarded as a symptom of the disease. It
is an irritation of this mucous membrane — not an
inflammation.

Conjunctivitis with mucous or mucopurulent se-
cretion, is much less common and severe cases oc-
cur but rarely. Croupous, and even diphtheritic
forms of conjunctivitis have been observed as a se-
quence of influenza, but are not properly classed as a
complication of this disease. Endemic outbreaks of
catarrhal conjunctivitis, commonly known as "pink
eye," sometimes occur with or soon after the ap-
pearance of influenza in a community. Such an out-
break is a coincidence, rather than a matter of cause
and effect. Sometimes edema of the conjunctiva
and swelling of the lids are seen, and hordeola or
styes are quite common.

Conjunctival hemorrhages occur at times in in-
fluenza patients, and are produced by purely me-
chanical means through severe spasms of cough-
ing and sneezing. This is especially likely to hap-
pen in older persons, whose vessels have brittle
walls.

Inflammations of the tear duct are caused at times
by the infection of the membrane lining this passage,
and in patients liable to such troubles, outbreaks of
dacryocystitis are easily produced.

Influenza patients suffer quite often with erup-
tions of herpes. On the lips this occurs in as many
as 25 per cent, of all cases. Similar eruptions occur
quite frequently on the lids and cornea, and break-
ing open are likely to end in ulcers of a more or less
troublesome form.

.\ching pain about the eyes, with tenderness on
pressure and on movement of the globe, is often
complained of. These pains are more often due to
inflammation and swelling of the mucous membrane
lining the frontal sinuses and other cavities about
the orbit, than to any affection of the eyes them-
selves.

More serious affections of the eyes, due to in-
fluenza occur, but it is pleasing to note that the more
serious the complication the less often it is seen.
Many of these, too, are due to embolic processes
and are caused by mixed infections — staphylococci,
streptococci, and the pneumococcus being most often
responsible (Knies). Inflammations of the iris
and of the connective tissue coats of the eye are
among the rarer occurrences, I have seen recently
several cases of iritis, in rheumatic persons, in whom
the outbreak was very evidently due to an attack of
influenza.

The occasional occurrence of acute glaucoma in
persons disposed to this serious disease, following
infection by the influenza poison, should not be for-

*Contributed to a symposium on influenza before the
Bronx Medical .Association. March 28. 1007.

April 27, 1907]

MEDICAL RECORD.

689

gotten. The severe headache of influenza easily
disguises the similar pains due to glaucoma, and the
confusion of these causes may easily end in loss of
sight. Any patient suffering from influenza and
having a persistent headache which does not yield
to the usual sedatives should prompt a careful ex-
amination of the eye, and nasal passages, for in these
the root of the difficulty will be frequently found.
Cases of optic neuritis due to influenza alone, occur
very rarely. They have been reported.

Nervous disorders of vision, weakness of accom-
modation, and twitching of the lids, are not uncom-
mon in persons who have had a severe influenza
and a protracted convalescence. Such troubles are
not infrequently aggravated by the patient's efforts
to read too soon after his acute symptoms have sub-
sided, and especially by prolonged attempts to read
in bed.

Ear affections due to influenza are much more
common. Every epidemic of this disease brings to
the aurist a large increase in the number of acute
ear cases under his care, and these cases are of a
type distinctly more virulent, as a rule, than simi-
lar infections due to other diseases in which the ears
are attacked. Many of these cases develop mas-
toiditis, and rapid destruction of this bone is fre-
quently found. It is safe to say that no other disase
is so frequently responsible for severe ear infections
in older persons as influenza.

The pronounced catarrh accompanying the disease
is of course responsible for this fact; the accessory
sinuses of the nose and the middle ear and Eusta-
chian tube being lined with a continuation of the mu-
cous membrane lining the nasal chambers proper,
inflammation and swelling of the latter, if severe,
means a similar state throughout. The aching
pains in the head and ears so commonly complained
of should. not be explained as neuralgic, in the sense
that this term is usually used ; they are due to acute
congestion and inflammation of regions that are
under our control in the majority of cases.

It is a mistake to wait for the rupture of the tym-
panic membrane to relieve the distressing earache,
for instance. This pain is nearly always due to
pressure caused by accumulated fluid in the ear
drum, and while this is sufficient in most cases to
burst its way through the macerated drumhead in
time, the infective matter has during this interval
a pronounced tendency to seek the antrum and other
cells of the mastoid bone. Many of these sufferers
make the mistake of putting such mixtures as
warmed sweet oil and laudanum into the ear to re-
lieve the pain. This is wrong, because the laudanum
does little more good than plain warm water put
into the ear would do, and the sticky mess thus made
in the ear is surgically unclean and favors the activ-
ity of the infective agents, once they have penetrated
the drum membrane.

A more logical and effective plan is that of apply-
ing to the drumhead a gauze drain, whose inner
half has been soaked in glycerine. This undoubted-
ly acts well in many cases if used early, haying a
tendency to abstract from the drum a portion of the
fluid collected in it. Three or four grains of car-
bolic acid to the ounce of glycerine does no harm,
and is believed to be of advantage not only for its
antiseptic properties, but on the ground that it acts
as a local anesthetic of some value. The glycerine
drops should be warmed before using. Heat ap-
plied to the inflamed ear by means of a hot-water
bag, or bags of salt, etc., is very comforting and
helpful. If these measures do not bring relief within
an hour or two, nothing but an opening of the drum
membrane and release of the accumulated fluid will

do so, and a free incision should be made in the
membrane for this purpose. The term "paracen-
tesis" should not be used in this connection — the
stab wound indicated by it, and even yet sometimes
depended on in practice, being of little or no value
as a therapeutic measure. A free opening made in
the drumhead relieves the pain, shortens the after-
period of discharge, and preserves the hearing, since
knife wounds heal more readilv and cleanly than
ruptures of the membrane — and, above all, greatly
lessens the danger of extension of the disease to the
mastoid bone.

A fairly large number of influenza patients have
ear troubles of a less severe form than this : Dull-
ness of hearing, a feeling of stuffiness in the head,
and noises in the ear (tinnitus) are often com-
plained of. These are cases of catarrh of the
Eustachian tube, and are, as a rule, readily cleared
up with inflations by the catheter, repeated at in-
tervals of a day or two for a week or ten days,
though some of them are very persistent even under
the most painstaking treatment.

Another form of ear trouble common in influenza
patients is the painful condition of the canal, due to
furuncles. The pain of this trouble is often intense
and cannot be distinguished from that due to middle
ear inflammations. These cases are commonly made
more tedious by the introduction of such messy
oils as I have spoken of. Nothing but a free open-
ing of these furuncles, they are nearly always mul-
tiple, will cut short the pain and deafness caused by
them.

Children suffer from influenza more generally
than is recognized. In them the systemic symptoms
are not so much complained of as in adults, but the
numerous cases of cold in the head associated with
earaches and middle-ear abscess seen in children
during these epidemics, undoubtedly owe their in-
fection to the same germs that are affecting the
older members of the family with grippe. Such
cases are, of course, most common among children
who have adenoid vegetations in the pharynx, and
correct treatment of cases of this kind should always
include a clean removal of the adenoid growths.
Lacking this the ear troubles are almost certain to
persist or to recur from time to time.

1076 Boston Road.

The Nurse's Obstetric Knowledge. — In a recent book
on midwifery for nurses some opinions are expressed by
the reviewer which are not in sympathy with the author's
statements. The latter thinks that a nurse might treat
chorea in pregnancy. The reviewer regards this as ex-
trejnely inadvisable. The author says that he thinks "a
nurse ought not to perform version in England. If she
intends to practise midwifery in some foreign country,
where doctors are few and far between, she may obtain
special instruction with the phantom and fetus, and learn
how to turn, when to turn, and when not to turn. The
doctrine that it is better for a patient to run the risk of
dying of hemorrhage than to have version performed by a
nurse sounds a hard one, but the ordinary training of a
nurse does not develop sufficient manipulative skill for her
to perform version with safety, and unless she were given
much more training than is at present considered neces-
sary she would be very likely to do her patient grievous
bodily harm." With this, as applied to version in pla-
centa prssvia, or to version early in labor, the reviewer en-
tirely agrees, but he thinks it may reasonably be said that
if a nurse when called to a case finds tlie membranes un-
ruptured, the OS uteri fully dilated, the child lying trans-
versely and freely movable, she does better if she takes
hold of a foot and delivers than if she sends for a doctor
and runs the risk that the membranes may rupture, the
liquor amnii escape, and the uterus contract round the child
before he comes. In such cases there is hardly any risk in
version, the risk being to the child in extraction, and ex-
traction in breech cases is recognized as part of a mid-
wife's duty.

690

MEDICAL RECORD.

[April 27, 1907

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A.M.. M.D., Editor.

PUBLISHERS
WM. WOOD tL CO . 51 FIFTH AVENUE.

New York, April 27, J907.

INFANT MORTALITY IN LARGE CITIES.

The death rate of infants in all the large cities of
the civilized world is far greater than it should be.
This excessive mortality is ascribed to a variety of
causes. In New York the chief reasons that infants
die prematurely are overcrowding in the tenement
districts, injudicious feeding, the impo.ssibility or
rather the great difficulty of procuring unpolluted
milk at a moderate price, and the fact that many
women of the working class labor themselves, either
at home or in factories, thereby neglecting their in-
fants. However, the situation here, so far as infant
mortality is concerned, is hardly so bad as in Lon-
don. In the British metropolis the death rate among
the young and the great increase of degeneracy are
exciting much concern, and of late the matter has
been discussed from all points of view and by all
sorts and conditions of men.

The most lamentable feature as regards London,
and it must be said to a lesser extent as regards all
large British cities, is the ever-increasing habit of
women drinking at the bars of saloons. This in
itself must react disastrously upon the offspring.
But the worst phase of the matter is that not only
do women of the lower classes frequent saloons,
thev also take with them their infants in arms, to
whom they give beer or strong spirits. The ques-
tion has become recently a public scandal in London,
and one of the most brilliant journalists of that city
has been writing a series of graphic articles nar-
rating all the facts of the case.

So great an impression has been caused by the
publication of these articles that on March 4 a large
conference was called to discuss the matter, at which
were present eminent men of all professions, the
medical profession being especially well represented.
The chair was taken by Sir Thomas Barlow, and
speeches were made by Sir Victor Horsley, Sir
Lauder Brunton, and Professor Sims Woodhead.
Sir Thomas Barlow pointed out that the birth rate of
Great Britain was going down in every division of
society, and at the same time, so far as the children
of the town were concerned, infant mortality was not
lessening. In his opinion the panacea for the evil
lay in the improvement of education and in the
teaching of hygiene and temperance in the schools.
As to the immediate peril of women drinking in
saloons and teaching infants to drink also, protec-
tion should be afiforded the infants in some way.
The problem was to devise legislation, short, simple,
definite, and direct, to meet the peril.

Sir Lauder Brunton spoke to the same effect, say-

ing that it must be quite evident that the custom of
giving infants gin or gin and water was a process
of slow poisoning which destroyed the child one
would say body and mind, were it not that very
often the body was destroyed before the mind had
had time to develop. Other speakers urged the
necessity of legislation to stop as quickly as possible
the custom of women taking infants in arms to
saloons and giving them strong drink, as the re-
sults must be disastrous in the extreme.

While New York does not suffer to any extent
in its mortality rate from the custom of women
drinking and teaching children to do the same, yet
in one respect, as concerns the influence on the death
rate, the conditions in New York and London are
very similar. The state of the milk supply is re-
referred to. In London this, according to all ac-
counts, is much worse than in New York. The
Lancet has had recently special articles treating of
the way in which milk is retailed in small general
provision shops. It appears that in London some-
thing like 80 per cent, of the shops in which milk
is sold are of this character. The sanitary state of
these .shops leaves much to be desired, and indeed
from all points of view the milk supply of London
is susceptible of great improvement. However, the
physicians of London and to a lesser extent the pop-
ulation generally seem to be awakening to a realiza-
tion of this fact, and no doubt, as is the custom in
Great Britain, reforms will be introduced slowly
but surely. The British people are not quick to
move, but when they do move they usually do things
thoroug:hlv.

THE RIGHT UPPER ABDOMINAL QUAD-
RANT.

It is not so many years ago that the interest of the
medical profession was centered in the lower right
abdominal quadrant. But now we find that the ap-
pendix and the right ovary, having been thoroughlv
exploited, must bow to the upward march of prog-
ress and retire in favor of that group of organs and
structures situated in the corresponding upner quad-
rant of the abdomen. Here may be included the
gall-bladder and its ducts, the pylorus and first part
of the duodenum, the head of the pancreas, and the
right kidney, which together offer to the surgeon
many varied opportunities for differential diagnoses
and operative procedures. Thus an attack of pain
in the region referred to may be due to stones in
the gall-bladder or the common duct, to cholecys-
titis, stricture of the pylorus, ulcers or perforations,
pancreatitis, and a number of other conditions. The
differential diagnosis of these various disturbances
is surrounded by many difficulties, and only too
often must the surgeon wait for an exploratory
laparotomy to reveal the true state of affairs. The
question is very ably discussed in a recent paper
by F. B. Lund (Boston Medical and Surgical Jour-
nal, March 21, 1907). who refers to the upper ab-
domen as the borderland not only of surgery, but
also of medicine. The surgeon by early operation
in cases of gallstones and gastric ulcer has given us
our present knowledge of the pathologj' of these
diseases in their early and curable stages. This fact

April 27, 1907]

MEDICAL RECORD.

691

is of great importance to the general practitioner of
medicine, who may acquire a greater skill in the
diagnosis of these conditions if he attend the opera-
tion itself rather than gain his knowledge from the
autopsy table. There a diagnosis may be confirmed
or disproved and on a subsequent occasion he will
be in a position to profit by the combination of clini-
cal observation and that of the operating table.

As the diagnosis of pathological conditions in the
upper abdominal quadrants is so often in doubt, the
surgeon must be prepared to deal with whatever
lesions may present themselves. Thus, where a case
is supposed to be one of cholecystitis, the operator
must be ready to change his opinion as soon as the
abdominal cavity is opened and to nerform a gastro-
enterostomy or other operative procedure in case
there is present an ulcer of the duodenum or py-
lorus. The early surgery of these conditions has
been proved by experience to be perfectly safe in
competent hands, and it is only in the late or neg-
lected cases that the mortality is high. It is only
by stimulating the interest in this comparatively
new field that we can hope for better results in the
surgical treatment of lesions of this portion of the
abdominal cavity, for such interest means that the
possibility of these various lesions will be borne in
mind when the physical signs and symptoms in any
given case point to some trouble in this section.

THE PROPHYLAXIS OF MENINGITIS.

The question of the prevention of epidemic cerebro-
spinal meningitis is a subject which is of the
most vital interest to the whole civilized world
and especially at the present time to the medical
men of New York. Since the cessation of the
actual epidemic, which was at its height in 1904 and
1905, cases have occurred endemically in numbers
sufficient to keep the subject alarmingly before the
minds of those most conscious of our comparatively
helpless condition to prevent them.

The prevention of any infectious disease, of
course, is directly dependent upon the detailed
knowledge we may be able to gain as to the organ-
ism which causes it, its vitality, its favorite haunts,
its most common roads of invasion. The diplococcus
of Weichselbaum is now pretty well understood as
to its biological functions, but there is still a great
deal of work to be done. The difficulties of its cul-
tivation, we believe, have generally been much over-
estimated. The German observers, especially, lay
much stress upon its delicate reaction to tempera-
tures and the necessity of great richness in the con-
stitution of the media — while several observers here
in America appear to have been able to cultivate the
organism with much greater ease and have shown
with sufficient certainty that the organism is unfor-
tunately not as delicate as had been supposed. Its
resistance to external environment when not kept
upon artificial media — that is to say, just as the or-
ganism would be cast off by the infected patient —
has been variously determined. Sunlight will kill
the meningococcus, according to Bettencourt and
Francas, in two hours ; according to v. Lingelsheim,
in six hours. Complete drying will kill it — certainly
in the space of twenty-four hours.

These observations, added to the fact that, so

far, it has not been possible to isolate definitely iden-
tified meningococci from dust, furniture, and other
objects in the rooms of patients, seem to indicate
rather strongly that few if any of the new cases
are traceable to an infection.

The investigations into the nasal and pharyngeal
secretions of individuals in direct contact with pa-
tients have yielded rather more significant results.
During the meningitis epidemic in Silesia the diplo-
coccus w^as found — often in pure culture — in the
throats of many perfectly healthy people. Of those
in contact with patients, as many as 75 per cent,
were found to harbor the organism in their noses
and throats, and this, not for a short period, but for
weeks and months.

Kutscher, in a thoughtful article in the Medizin-
ischc Klinik, 1907, No. 12, concludes that it is in the
infection by agency of these indirect carriers that we
must look for most of the propagation of the dis-
ease, and that in these persons we have the factor
at present most reasonably offering hope for suc-
cessful prophylaxis.

The difficulties of formulating a practicable plan
on the basis of such knowledge are, of course, tre-
mendous, but at any rate until our knowledge be-
comes more complete there can be no question that
isolation, with all the usual precautions, is at least
advisable for these cases, including their exclusion
from the general wards of hosnitals and the utmost
care of disinfection of nose and throat of those in
contact with the natients before they mingle with
other and possibly more susceptible individuals.

ACUTE SUPRARENAL INSUFFICIENCY.

This condition is believed by Sergent and Bernard
to be responsible in many cases for sudden death
where no other cause is apparent. Two functions
may be associated with the suprarenal gland, one
an antitoxic, the other an angiotonic. The former
becomes active against the various toxic substances
which are developed as the result of muscular exer-
tion as well as those due to other endogenous
sources. The angiotonic effect is manifested by the
phenomenon of vasoconstriction. Among the con-
ditions which lead to this type of glandular insuffi-
ciency are tuberculosis, hemorrhages, neoplasms,
and inflammatory processes, and the affection may
run an acute, a subacute, or a chronic course. In
the acute cases which run their course in a few
days, the alarming symptoms come on very suddenly
and death follows rapidly. There may be no other
previous evidence of trouble, and the subjects are
often apparently healthy young men. Otherwise the
condition is marked by an attack of extremely severe
pain in the lumbar region accompanied by anorexia,
vomiting, diarrhea, headache, prostration, and a
small and weak pulse, with a tendency to collapse.
The general symptom complex would le.id one to
suspect acute poisoning, cholera, typhoid fever, or
some acute abdominal condition. Sudden death from
this affection of the suprarenals during apparently
good health assumes, therefore, considerable im.-
portance from the forensic standpoint, for it might
be assumed that certain direct causes, such as
trauma, slight infections, inflammations of the ap-
pendix or the adnexa, pregnancy, malaria, or vari-

692

MEDICAL RECORD.

[April 2-j, \Gfyj

ous forms of poisoning, acted as predisposing fac-
tors in the production of a suprarenal insufficiency.
From these observations it is quite apparent that
the pathology of the suprarenal glands is not ex-
hausted by a knowledge of Addison's disease and
that other affections of the glands may e.\ist. The
diagnosis under any circumstances is surrounded
by many difficulties. In the more chronic cases the
administration of suprarenal extract is advised, and
when a suspicion of beginning renal insufficiency
exists a prophylactic treatment is indicated. Ber-
nard states that this should consist of avoiding over-
exertion, traumata, infections, and intoxications, as
well as the administration of tonics.

The Use of the Opsonic Index in the Diagnosis
OF Tuberculosis.

A further contribution to this subject was recently
made by Drs. I. S. Stewart and L. C. Ritchie in a
paper presented to the Edinburgh Medico-Chirur-
gical Society {Lancet, March 23). The method
which they submitted and at which they had been
working for some time was one which rendered
possible a diagnosis of tuberculosis even when the
signs and symptoms were not conclusive. It con-
sisted in the injection of a minute dose of tuberculin
R. in conjunction with the observation of the tuber-
culoopsonic index of the blood before and after
inoculation. The conclusions were based on ob-
servations made on 122 consecutive cases of medical
and surgical tuberculosis. The cases were divided
as follows: i. Those in which there was reasonable
ground for diagnosing tuberculosis. In many diag-
nosis was based on pathological proof (examination
of discharges, operation, etc.), and in the remainder
by continued clinical observation. 2. Either normal
cases or those suffering from diseases other than
tuberculosis. The authors drew attention to the
fact that several observers had shown that the tu-
berculoopsonic index varied slightly in health. The
normal limits of variation were from 0.8 to 1.2. The
first group (tuberculosis) consisted of 82 cases.
The indices of 41 fell within the normal limits and
41 outside. In the second group there were 40 non-
tuberculous cases, of which 29 were within and 11
outside the normal limits. A diagnosis based on one
examination of the tuberculoopsonic index would
have resulted in an error of diagnosis in one-half
the number. In the nontuberculous cases 27.5 per
cent, were outside the normal limits, and a reliance
on this test would have led to error to this extent.
In acute tuberculous cases the swinging index might
also lead to error in diagnosis. In a paper in con-
junction with Dr. D. Lawson of Banchory it had
been shown that if a small quantity of tuberculin R.
were injected into a tuberculous patient there was a
diminution in the index, but the reverse occurred in
a healthy case. The conclusions were : ( I ) the
opsonic index per se was an unsatisfactory means of
diagnosis, as both tuberculous and nontuberculous
cases fell within and without normal limits; (2) if
a negative phase appeared after inoculation the
existence of tuberculosis might be diagnosed ; and
(3) the absence of a negative phase indicated the
absence of a tuberculous infection.

of both may closely agree, and it is only by the
microscopical examination that the difference can
be detected. In this connection it may also be as-
sumed that in many instances a "cure" can be traced
to the fact that the offending tumor removed by
operation was not really of a malignant character.
In the large intestine particularly a neoplasm may
closely simulate malignant disease, not only in its
general appearance, but also in the symptoms which
it causes, and tuberculous lesions of the cecum or
the ascending colon may produce effects which can
only W'ith difficulty be distinguished from those of
cancer. Moynihan, writing in the Edinburgh Medi-
cal Journal for March, 1907, states that he has twice
performed colectomy for supposed carcinoma, when
subsequent examination of the tumor showed its
undoubted tuberculous nature. Aside from these
cases, which are very uncommon, there are certain
tumors of the large intestine and the sigmoid flexure
which present all the characteristic signs and symp-
toms of malignant disease, yet prove to be nothing
more than simple inflammatory conditions. Moyni-
han gives the detailed histories of six cases in which
this error was made, and although they differ in
many respects, they all present a close resemblance
if not an actual identity of symptoms with those
of malignant disease. It would appear that the
inflammatory tumors of the large intestine are per-
haps more frequent than we have supposed. The
pathological features are not always the same. The
inflammation may begin in and penetrate the
mucosa, a false diverticulum may form and may
perforate, extensive undermining ulcerative proc-
esses may be combined with a form of polypoid
growth, and finally the inflammatory deposit may
affect the peritoneal coat chiefly or solely, leaving
the mucosa supple or intact.

The ;\Iimicry of M.\ligx.\nt Diseases.

It is verv often a most difficult matter to differen-
tiate between malignant and benign growths, for
the clinical features and macroscopical appearances

The Pathology of Burns.

As considerable doubt still exists regarding the
cause of death in fatal burns, all investigations on
the subject, particularly if they are of an experi-
mental nature, will prove of general interest.
Among the most recent of these is one by Pfeiffer
{l'ircliozi''s Archiv, Vol. 180, No. 3), which was
carried out on a large number of rabbits. He claims
that death from burns in typical cases is caused by
a toxin which circulates in the blood and is ex-
creted by the kidneys unchanged. It is probably a
disintegration product due to the action of heat on
the albumin molecules. Other investigators have
claimed that this toxin exerts a hemol\-tic or ag-
glutinating effect, but this Pfeiffer denies. He
thinks, moreover, that if death results within a pe-
riod of about three hours, it is due to the nervous
shock rather than to any toxic action. This may
also exert an influence at a later period, from two
to three .weeks, by weakening the organism in such
a manner that it readily succumbs to a secondary
infection. Weidenfels and von Zumbusch (Archiv
fiir Dermatologic und Syphilis, Vol. 76), working
independently, come to a similar conclusion, believ-
ing that the to.xic material is absorbed directly from
the burned skin. These obser\-ers also made some
experiments to determine a suitable method of treat-
ment, and found that excellent results attended the
subcutaneous infusion of decinormal salt solution
even w'hen one-third of the entire skin area was in-
volved. Cardiac stimulants are immediately indi-
cated, including caffeine or coffee, alcohol, camphor,
and strophanthus or digitalis. Heart depressants

April 27, 1907]

MEDICAL RECORD.

693

such as morphine should be avoided. The infusions
may be preferably given under the healthy skin in
several places at once in order to save time and ob-
tain an immediate effect. As the results with the
infusion treatment have been so uniformly good, the
procedure, which is simple and easily applied, com-
mends itself to further trial.

Domestic Anim.-^ls in the Etiology of Infec-
tious Diseases.

The role which the ordinary household pets may
play in the dissemination of a considerable number
of infectious diseases is not sufficiently appreciated
by the laity. Attention has often been called to
the danger which attends the more or less intimate
contact between such animals and the members of
a household, and yet the warning is little heeded.
Among children particularly the fondness for cer-
tain pets is not limited to such association during
the daytime, but must be satisfied by taking the
animal to bed. Letourneur, in an interesting
article in the Bulletin general de Thera-
peutique, October 23, 1906, calls attention to the
large number of infectious conditions prevalent
among domestic animals which can be readily trans-
mitted to human beings. Prominent among these
is a series of parasitic skin diseases of dogs and
cats which are very difficult to get rid of in the
human patient, especially if the original source of
the infection is not eliminated. The Tania echin-
ococcus also spends part of its life cycle in the in-
testinal canal of the dog, and it is most often found
in persons who come into frequent contact with
these animals. Investigation has shown that cats
are also apt to contain this parasite, and so the
danger of infection is correspondingly increased.
There is moreover a form of diphtheria found in
birds which is readily communicated to the human
subject, and parrots are often afflicted with a type
of infectious enteritis which has likewise been dem-
onstrated in persons who had come into contact with
these animals. It has also been frequently shown
that tuberculosis may be communicated from man
to dogs, cats, and birds, and although it has never
been definitely proved that the reverse can take
place, the possibility of such an occurrence must
not be lost sight of. If in conclusion we remember
the readiness with which rabies may be communi-
cated from cats and dogs to human beings, it is
quite evident that if we desire to keep such animals
about us and live in more or less immediate con-
tact with them, a most careful watch must be kept
over their health and general condition.

Syphilis and Tabes.

The belief that tabes is directly dependent upon
syphilitic disease has gained such widespread recog-
nition that those who oppose the idea find it neces-
sary to carry their studies in the most varied direc-
tions in order to substantiate their contentions. A
French surgeon. Dr. Peyronie (Centralblatt fiir
Nervcnheilkimde tind Psychiatric, No. 229, Vol.
XXX.), who has had considerable experience with
syphilis among the Arabs of Northern Africa, states
that among many Mohammedans the disease is
looked upon as a holy visitation, and that the pos-
session of a syphilitic necrosis of the nasal bones is
regarded as an honor. The disease has, therefore,
become widespread, and it has come to be a rule
among physicians practising in these countries that
in treating an Arab it may be safely assumed that be

has had syphilis. One writer is referred to who
found that among 4,000 Arabs who consulted him
in a professional capacity only 100 were free from
acute or hereditary syphilis. It is a well-known
fact, however, that among these people, tabes and
other paralytic affections are comparatively rare or
entirely unknown, and this fact is brought forward
by Peyronie in opposition to the theory of these
diseases with which the names of Erb and Fournier
are so closely identified. The direct dependence of
tabes on syphilis has not as yet been satisfactorily
demonstrated, although it has been very widely
accepted as a fact.

NfuiH of tijp Wttk,

Insanity in Murder Trials. — Senator Agnew
has introduced in the State Senate a bill adding a
new section to the criminal code relating to the
insanity of a defendant indicted for a felony. It
is provided that either the defendant's attorneys or
the District Attorney may apply to any justice of the
court in which the indictment is pending, for an
order committing the defendant to a State hospital
for the insane for observation. The motion must
be based upon aiBdavits, executed by two duly quali-
fied examiners in lunacy, which must show that a
personal examination within ten days before the
notice of motion satisfied the examiners that the
defendant was insane. If the judge be satisfied
that the interests of justice so require, he shall
make an order committing the defendant to a State
hospital for the insane for observation for a period
of not less than three, nor more than six, weeks.
The Superintendent of the hospital or the physician
in charge of the defendant shall report to the court
at the end of three weeks the results of the observa-
tion, and should the defendant be detained in tlie
hospital for more than three weeks a second report
shall be made when he is returned from the hospital.
Another bill introduced by -Assemblyman Duell pro-
vides that in any criminal action wherein the issue
of insanity is involved no evidence of statements
made to the person alleged to be or to have been in-
sane by a third party shall be introduced as showing
or tending to show such insanity, or as aggravating
such insanity unless the facts alleged to have been
narrated be first proved.

Another Fire at McGill. — Less than two weeks
after the disastrous fire which wiped out the Mac-
Donald engineering building of McGill University,
the Medical Building was also completely destroyed
by fire on April 16. In addition to the usual equip-
ment of a medical school the building contained
one of the best medical museums in the country.
The financial loss is placed at $500,000, though of
course much of the material destroyed was prac-
tically priceless. It is supposed that the fire was of
incendiary origin.

For a Federal Health Board. — The committee
of one hundred appointed last June by the Ameri-
can Association for the Advancement of Science to
further the project of founding a Federal Depart-
ment of Health, held a meeting in this city on April
[Q. These Vice-Presidents were elected after Prof.
Fisher had been elected President of the larger com-
mittee : President Eliot of Harvard, Felix .Adier.
Dr. William H. Welch, Dr. Lyman Abbott, Presi-
dent Angell of the University of Michigan. Jane
Addams,' Andrew Carnegie, Archbishop Ireland,
Judge Lindsay of the Juvenile Court of Denver, and
John D. Long, ex-Secretary of the Navy.

694

MEDICAL RECORD.

[April 27, 1907

German Hospital and Dispensary Prizes. — On

the occasiiiii vi the tiflidh aiini\ersary of the Ger-
man Dispensary Dr. Charles H. Jaeger announced
the foundation of three yearly prizes to be known as
the Marie Jaeger Alemorial Prizes. The prizes are
to be awarded for medical essays and consist of a
first prize of $100, a second prize of $75, and a third
prize of $50. The competition is to be open to
members and collaborators of the German Dispen-
sary and to members of the house staff of the hos-
pital. The prizes are to be awarded on December
31 of each year. The essays are to be based on cases
occurring in the service of the hospital and dispen-
sary, and preference will be given to those embody-
ing original thought or work. The right is reserved
to withhold any or all prizes if the quality of the
essays submitted is not sufficiently high or the num-
bers not sufficiently large. A committee is to be
appointed to pass on the essays.

Plan for Hospital for Tuberculosis in Chicago.
— A plan to establish in Chicago or its environs a
free hospital for the treatment of tuberculosis pa-
tients is being considered. Dr. \Vm. A_. Evans, the
new Commissioner of Health, will be one of the prin-
cipal promoters of the project. It has been the ob-
ject of a number of Chicago physicians to have a
tuberculosis hospital, supported by the city, and
Dr. Evans is ambitious to give this city an institu-
tion for the proper treatment of this disease.

In Honor of Lord Lister's eightieth birthday
the Munclu:ner mediciuische Wochenschrift in its
issue of April 2 prints a translation into German of
Lister's classical series of articles containing the
rudiments of the antiseptic theory as applied to the
treatment of wounds, which began to appear in the
Lancet of March 16, 1867.

Objection to Staten Island Tuberculosis Hos-
pital.— The representatives of certain taxpayers
have appeared before the Supreme Court at Rich-
mond, Staten Island, and asked to have made per-
manent a temporary injunction obtained in December
restraining Comptroller Metz and Charities Com-
missioner Hebberd from building a tuberculosis hos-
pital on Staten Island. The Board of Estimate
and Apportionment passed a resolution in favor
of such an institution on the island, and it was ap-
proved by the Board of Aldermen. It is proposed
to put up the building at Four Corners, near West
Brighton, at a cost of about $50,000.

The Tuberculosis Question in Richmond. — The
City of Richmond. \'a.. in response to an appeal
from its health officer for funds to be used in fight-
ing tuberculosis, decided to dispense with summer
music in the parks, and turned over to the health
department the sum of $2,800 usually expended for
the former purpose.

The American Mosquito Extermination So-
ciety held its fourth annual meeting in this city
last week, and Dr. O. L. Howard of Washington
and Dr. E. Porter Felt, the New York State Ento-
mologist, among others, described what had already
been done in the way of checking the multiplication
of the mosquitos in certain parts of this and other
countries. It was shown that the complete exter-
mination of the insects was simply one of funds and
an enlightened public spirit.

A Heraldic Recompense. — An uncommon
honor has been granted by King Edward to Sir
Frederick Treves and Sir Francis Laking in recogni-
tion of their services during his attack of appendi-
citis in 1902. The King by royal warrant has
granted them "honorable augmentation" to their

arms, consisting in the addition to their shields of one
of the lions from the royal arms. James I.'s apothe-
cary, Gideon Delaune, received a similar reward for
services rendered to his sovereign.

A Society of Eternal Youth. — The newspapers
state that a society which already has several hun-
dred members has been formed in Iowa for the
purpose of prolonging life and preventing illness.
All members upon joining must sign a pledge that
they will continually assert that it is nothing but
custom and habit of thought that causes people
to be sick, grow old, or die. Any member who is
reported sick from any disease, and is confined to
his bed for a continuous period of three days is to
be fined for the first offence, for the second offence
he is to be suspended from membership, and for
the third offence expulsion from the society is the
])enalty.

Legislation Against Tobacco. — The State As-
sembly of Wisconsin has adopted a bill prohibiting
the sale of tobacco in any form to persons under
sixteen years of age. The bill also prohibits such
minors from using tobacco. The Illinois House has
passed a bill prohibiting the selling of cigarettes
or cigarette papers in that State.

Smoke Nuisance Award. — The Court of Ap-
peals has just affirmed a verdict for $4,000 damages
recovered by a plaintiff' against a large corporation
for damages arising out of the defendant's violation
of the smoke nuisance law.

New Property for Lincoln Hospital. — The
entire block bounded by 141st street, I42d street, the
Southern Boulevard, and Wales avenue has iDeen
bought for a sum said to be in the neighborhood
of $100,000, by the trustees of the Lincoln Hospital.
The property is to be given to the institution, Morris
K. Jesup and Miss Emily Booth being the principal
donors. The Lincoln Hospital was established
where it now stands, on the block bounded by 141st
and I42d streets. Concord avenue, and the Southern
Boulevard, about ten years ago. The increasing
population of the Bronx has overtaxed the present
building, and it is proposed to build additional wards
on the property just bought. A convalescent ward
will also be established.

Ambulance Accident. — While a Roosevelt Hos-
pital ambulance was conveying a woman ill with
pneumonia and her ten months baby to Bellevue
Hospital last Sunday, the ambulance was run into
by a crosstown car at the intersection of Thirty-
fourth street and Broadway. The ambulance was
badly smashed and the patients were severely jolted
about, but through the surgeon's quickness of action
were kept from serious injury. They finished their
trip to the hospital in a New York Hospital am-
bulance.

Coney Island Hospital Opened. — The formal
opening of the Coney Island Reception Hospital was
held last week in the nresence of a number of city
officials. The hospital was started in 1901 for
emergency cases, and has been kept open only dur-
ing the summer montlis. It will now be operated
the year around until the completion of a new and
larger structure, now contemplated, which will be
located in Surf avenue, near Fifth street. The hos-
pital has eight beds and additional accommodations
for emergency demands.

The Pathological Society of Philadelphia,
which is one of the oldest, if not the oldest society,
of its kind on this continent, will celebrate its semi-
centennial in May. 1907. The celebration will ex-
tend over two days, Friday, May 10, and Saturday,

April 2~, 1907]

MEDICAL RECORD.

695

May II. On the first day addresses will be deliv-
ered by Dr. Frederick G. Novy of Ann Arbor, Mich-
igan, on "The Role of Protozoa in Pathology" ; by
Dr. Simon Flexner, of the Rockefeller Institute,
New York, on "The Newer Pathology" ; and bv Dr.
A. E. Taylor, of the University of California,
on "The Dynamic Point of View in Pathology."
In the afternoon, at four o'clock, a commemorative
meeting will be held in the Pennsylvania Hospital,
where the first meetings of the society, in 1857, took
place. At this meeting. Dr. William Osier, Regius
Professor of Medicine, Oxford University, will de-
liver an address on "Pathology and Practice." At
a dinner in the evening 'prominent men from all parts
of the country will respond to toasts. An exhibition
meeting of interest to pathologists, clinicians, and
surgeons will be held on Saturday, May 11.

Plague in India. — According to despatches
from Simla there were 75,000 deaths from the plague
in India during the week ended April 13. Seventy
thousand of these occurred in Bengal, the United
Provinces, and the Punjab. Since the disease be-
gan in the Punjab in October, 1897, nearly 1,500,000
deaths have occurred.

Professor Politzer's Retirement. — At the end
of the summer term of 1907 Hofrat Pro-
fessor A. Politzer will have arrived at the
age limit beyond which, according to the laws of
Austria, he may not retain his chair at the
University of Vienna, and will, therefore, re-
sign his position, as well as the directorship
of the Vienna Ear Clinic. At the same time the
lectures which he has delivered throughout forty-
six years will cease to be given. A committee has
accordingly been formed for the purpose of or-
ganizing a suitable testimonial of the world-wide
esteem in which this master of otoloey is held, to be
presented on the occasion of his relinquishing the
chair he has occupied so long. It was originally in-
tended to hold a formal public celebration to which
representatives of the world's otological societies
should be invited, but Professor Politzer on becom-
ing aware of these preparations requested that owing
to several recent deaths in his immediate family no
public demonstration take place. It has been de-
cided, therefore, to issue a medal bearing a portrait
of the master. A copy of this in gold is to be pre-
sented to Prof. Politzer on the designated day ; other
copies, some in silver and some "in bronze, will also
be struck of? to serve as souvenirs of the eminent
scientist. These will be put at the disposition of
those who wish to subscribe to the celebration. To-
gether with the medal an address, containing the
names of all the subscribers, will be presented to
Prof. Politzer. .^11 communications should have
plainly written the names, titles, and the exact ad-
dress of the sender and should be accompanied bv a
remittance of $5 for the silver or $2.50 for
the bronze medal and be sent to the treasurer.
Dr. D. Kaufmann, Vienna, VI., Mariahilferstrasse
37. Any surplus that there may be, after the neces-
san- expenses have been met, will be put at Prof.
Politzer's disposal as a fund to further some scien-
tific object. Subscriptions must be in the hands of
the treasurer before May 15, 1907.

Appointment of Dr. Evans. — Dr. Wm. A.
Evans has been appointed Health Commissioner
of the Citv of Chicago by Mayor Busse.

Jefferson Medical College. — Dj-. John H. Gib-
bon has been elected professor of sureery and of
clinical surgerv in succession to Dr. John H. Brin-
ton, deceased.

Association of American Medical Colleges. —

The next meeting of this association will be held in
Washington, at the Hotel Raleigh, Alonday, May 6,
beginning at 10 a.m. The program will consist of
two parts, one of which is educational and open
to visitors. The second part of the program relates
to the business of the association, and will be taken
up in executive session at the conclusion of the
first part. The president is Dr. George i\I. Kober
of Washington and the secretary is Dr. Fred. C.
Zapffe, 1764 Lexington street, Qiicago.

Association of American Physicians. — The
twenty-second annual meeting of the Association
of American Physicians will be held in Washing-
ton on May 7, 8, and 9, 1907, under the presidency
of Dr. Francis P. Kinnicutt. An amendment to the
constitution and by-laws will come up for action,
providing that not more than thirty papers shall be
presented at any meeting of the association, these to
be selected by the Council from among the titles
handed in by March i of the year in which the
meeting occurs. On May 7 there is to be a reception
by President Roosevelt at the White House to mem-
bers of the association and ladies accompanying
them. The secretary is Dr. Henry Hun, 149 Wash-
ington avenue, Albany.

American Gastro-Enterological Association. —
The tenth annual meeting of this organization will
be held in Atlantic City, June 3 and 4, 1907, under
the presidency of Dr. H. W. Bettman of Cincinnati.
The secretary is Dr. Chas. D. Aaron of Detroit.

National Association for the Study and Pre-
vention of Tuberculosis. — The third annual meet-
ing of this association is to be held in \\'ashinPton
May 6 to 8, 1907. The preliminary program pro-
vides for a very active series of sessions, and in addi-
tion to the o^eneral meeting there will be five sec-
tions as follow-s : Sociological section, clinical and
climatological section, pathological and bacteriologi-
cal section, section of tuberculosis in children, and
surgical section. The meeting will be held under
the presidency of Dr. Hermann M. Biggs. The
secretary is Dr. Henry Barton Jacobs of Balti-
more, and the executive secretary is Dr. Livingston
Farrand of this city. The chairman of the local
committee of arrangements is Dr. George M. Kober
of Washington. President Roosevelt will receive
the members of the association, ladies, guests, and
visitors at the White House on the afternoon of
May 7.

American Academy of Medicine. — At the an-
nual meeting of this organization to be held in At-
lantic City June i to 3, 1907, the president. Dr.
Casey A. Wood of Chicago, will take as the subject
of his address "The Medical Career and the Intel-
lectual Life." One symposium will be devoted to
considering the relation of the medical profession to
the housing of the people, and another to the relation
of the medical profession to legislation.

Mississippi State Medical Association. — At the

meeting of this organization held in Gulfport on
April 12 officers were elected as follows: President,
Dr. R. S. Currv. Columbus : Vice-Presidents, Dr.
H. R. Shanck, Jackson; Dr. T. F. Elkin, Tupelo;
Dr. R. D. Sessions, Natchez; Secretary, Dr. E. F.
Howard, Vicksburg; State Board of Health, Dr.
L. D. Dickerson, McComb City; Dr. G. S. Bryan,
Amory; Dr. E. A. Cheek, Arcala ; Dr. John Dar-
rington, Yazoo City ; Dr. D. J. Williams, Ellisville.
The next meeting will be held in Natchez in April,
1908.
Central Oklahoma Medical Association. — At

696

MEDICAL RECORD.

[April

27. 1907

the annual meeting of this organization, held in
Guthrie on April 10, officers as follows were elected
for the ensuing year : President, Dr. H. Coulter
Todd, Oklahoma City; First Vice-President, Dr.
J. H. Barnes, Helena; Second Vice-President, Dr.
N. Rector, Henessey; Secretary and Treasurer, Dr.
Geo. A. Boyle, Enid.

Otoe County (Neb.) Medical Association. — .'N.t
its annual meeting, held in Nebraska City on April
6, this society elected the following as officers:
President, Dr.' Claude Watson ; Vice-President, Dr.
M. M. jMacVean-Edmonds ; Secretary and Treas-
urer. Dr. C. P. Crudup.

Washington County (111.) Medical Society.—
At the annual meeting, held in Nashville on April
12, this society elected the following officers : Presi-
dent, Dr. W. D. Carter of Nashville; Vice-Presi-
dent, Dr. H. W. Wolf of DuBois; Treasurer, Dr.
S. P. Schroeder of Nashville ; Secretary, Dr. D. S.
Neer of Beaucoup.

Hampden (Mass.) Medical Society.— At the
annual meeting held in Springfield on April 16 offi-
cers for this society were elected as follows : Presi-
dent, Dr. C. A. Allen of Holyoke; Vice-President,
Dr. George S. Woods of Springfield ; Secretary and
Treasurer, Dr. T. S. Bacon of Springfield.

Fairfield County (Conn.) Medical Society.—
Officers as follows were elected at the one hundred
and fifteenth annual meeting of this society, held in
Bridgeport on April 9: President, Dr. Edwards
M. Smith of Bridgeport ; J "ice-President, Dr. David
C. Brown of Danbur>- ; Treasurer, Dr. J. D. Gold
of Bridgeport; Secretary, Dr. Frank W. Stevens
of Bridgeport.

Henry County (la.) Medical Society.— The
annual election of officers for this society, held at
the meeting in Mt. Pleasant on April 9, resulted as
follows : President. Dr. F. T. Stevens of Mt. Pleas-
ant; J'icc-Presidcnt, Dr. Pittman of Salem; Secre-
tary and Treasurer. Dr. J. N. Day of Mt. Pleasant.
German Medical Congress.— The seventy-ninth
Congress of German Men of Science and Physicians
will be held at Dresden this year from September
15 to 2't.

Golden Belt (Kan.) Medical Society.— At the
meeting of this organization held in Abilene on
April 4. officers were elected as follows: President,
Dr. Howard N. Moses of Salina ; Secretary, Dr.
William S. Yates of Junction City ; Treasurer, Dr.
John D. Riddell of Enterprise.

Middlesex County (Conn.) Medical Society.—
The following officers were elected at the one hun-
dred and fifteenth annual meeting of this society,
held in Middletown: President, Dr. Charles B.
Young of Middletown; Vice-President, Dr. James
]\Iurphv : Clerk, Dr. John E. Loveland ; Censors,
Dr. John E. Bailey, Dr. C. H. Hubbard, and Dr.
M. C. Hazen ; County Reporter, Dr. John H. Moun-
tain.

Massachusetts Homeooathic Society. — .\t the
sixty-seventh annual meeting of this society, held
in Boston on April 10, officers were elected as fol-
lows: President, Dr. John P. Rand, Worcester;
Vice-Presidents. Dr. Fred W. Halsey, Boston, and
Dr. Nathaniel R. Perkins. Dorchester ; Correspond-
in s: Secretary, Dr. Charles T. Howard, Boston;
Recording Secretary, Dr. Thomas E. Chandler, Bos-
ton : Treasurer, Dr. Thomas M. Strong. Boston.
Tt was decided to hold the next meeting in Worces-
ter.

Cass County (111.) Medical Association. — .\t

the annual meeting of this society held in Virginia
on -April 12 officers for the coming year were elected
as follows : President, Dr. C. E. Soule, Beards-
town ; Vice-President, Dr. J. W. Houston, Virginia ;
Secretary, Dr. J. A. McGee, Virginia; Treasurer,
Dr. C. M. Hubbard, \'irginia.

The Late Dr. George B. Fowler. — At a meet-
ing of the Medical Association of the Greater City
of New York, held April 15, 1907, the followin'r
report was presented and adopted. Whereas, It
has pleased the Almighty to call from his earthly
labors George Bingham Fowler; Resolved, That
the following minute be entered upon the records
of the Medical Association of the Greater City of
New York: Dr. Fowler was born in Alabama in
1847 a"d died in the Borough of Manhattan, New
York City, on March 6, 1907. He was graduated
from the College of Physicians and Surgeons, New
York, in 1871. He served as assistant in the De-
partment of Physiolog}' in that school under the
late Professor John C. Dalton, and for many years,
in one or another capacity, he was connected with
the Metropolitan Board of Health. He was asso-
ciate editor of the American Journal of Obstetrics,
contributing many articles on the diseases of chil-
dren. Under Mayor Strong he was Commissioner
of Health of the City of New York. He served for
years as Attending Physician to the New York In-
fant Asylum and the Bellevue Hospital. In the
latter hospital he was instrumental in founding the
Training School for Male Nurses. He was Pro-
fessor of Clinical Medicine in the New York Poly-
clinic, and later at the Post-Graduate Medical
School, and he was an active member of many of
the local and national societies. He was twice
elected president of the Medical Society of the
County of New York, .\midst all these activities
his genial temperament prevailed to form warm
friendships and deep loyalty on the part of a wide
circle of patients. He carried sunshine into the
sick-room and imparted courage to the ailing. Here
his presence was indeed a benediction. In civil life
he set an example of fidelity to duty which might
well be emulated by others. (Signed) Egbert H.
Grandin, William H. Porter, Leonard Weber, Com-
mittee.

Obituary Notes. — Dr. R. F. Michell of Mont-
gomery, Ala., died on April 19 at the age of eighty
years. He was born in Charleston, S. C, and served
as surgeon in the Confederate army. He was the
author of several books on medical subjects.

Dr. WiLLi.xM M. Taylor of Talladega, Ala., died
on April 7 at the age of eighty-one years. Dr.
Taylor was a native of Sumner County, Tenn., but
in 1839 his parents removed to Talladega and he
continued to reside there for the rest of his life. He
served as surgeon in the Seventh Alabama regiment,
and as chief surgeon of Wilcox's brigade. Dr. Tay-
lor was largely instrumental in the foundation of the
Mobile Medical College, and was one of the incor-
porators of the Alabama School for the Deaf. He
was a member of the Alabama legislature in 1876
and 1880.

Dr. W. Fr-^xk Morrison of Providence, R. L,
died suddenly on April 9, at the aee of forty-nine
vears. He was born in Alillville, Mass., and was
graduated from Harvard Medical School in the
class of 1882. Shortly afterward he began practice
in Providence, where he had resided ever since.

Dr. George F. Gale of Brattleboro, Vt., died on
.\pril 14 at the age of seventy-nine ■'■ears. He was
born in Petersham. Mass.. and was graduated from
the Berkshire Medical College in Pittsfield, Mass.,

April 27, 1907]

MEDICAL RECORD.

697

in 1855. He practised for a time in Cumniington
and Deerfield, and for a year was in charg'e of a
smallpox hospital in San Francisco. He was sur-
geon of the Eighth Vermont regiment in 1861 and
1862.

Dr. WiLLi.\M R. Campbell of Niagara Falls died
on April 9 after a lingering illness. He was born
in New York City in 1854 and received his medical
degree from Buffalo University in 1880. Imme-
diately afterward he began to practise in Niagara
Falls. Dr. Campbell was a curator of Buffalo Uni-
versity and president of its alumni association ; he
was also president of the Niagara Falls .\cademy of
Medicine, and was a surgeon in the New York State
National Guard.

Dr. ST.^NLEY A. De Paul of Carlton, Mich., died
on April 7 at the age of forty-eight years. He was a
graduate of the Detroit College of Medicine, and
practised in Carlton for over twenty years.

Dr. J. S. KoRN of Texarkana, Ark., died sud-
denly on April 4 at the age of fifty years. He was
president of the Howard County Aledical Society,
and had practised for many years in Southwestern
Arkansas.

Dr. J. C. Kilgore of Monmouth, 111., died on April
9 of septicemia, resulting from an infection con-
tracted while performing an autopsy. He was born
in Holmes County, Ohio, in 1840, and served three
years in the Civil War in the Sixteenth Ohio Infan-
try. He was graduated from Rush Medical College
in Chicago in 1869.

Dr. IsA/\c Lechtman of St. Joseph, Mo., died on
April II at an advanced age. He was born in Rus-
sia and received his degree from the military medical
school at St. Petersburg. After serving for some
time as army surgeon, in 1871 he came to this
countrj' and settled in St. Josepli. He was president
of the Missouri Medical Society in 1893.

Dr. E. A. Woodward of Madison, Wis., died on
April 8 of grip, at the age of ninety years. He was
born in Litchfield, Conn., and received his degree
from the Berkshire Medical College in 1842. He
practised in Connecticut until 1855, in which year he
removed to Madison. He ser\-ed as surgeon in the
Civil War.

Dr. James D. Pendleton of Bedford City, Va.,
died on .A.pril 10 at the age of eighty-seven years.
He was the son of Dr. Micajah Pendleton, who prac-
tised for fifty years in Buchanan, Va.

Dr. William W. Genge of St. Johnsbury, Vt.,
died on April 10 of pneumonia at the age of thirty-
nine years. He was born in Canada, and in 1891
began practice in Hyde Park. Three years ago he
removed to St. Johnsbury.

Dr. W. H. JoPES of Greenfield, Mo., died on April
9 at the age of seventy-three years. He was born
in Gallatin, Tenn., and had practised in Greenfield
since 1853.

Dr. xAusTiN S. TiNSLEY of Augusta, Ga., died on
April 16 after an illness of two weeks.

Dr. Alfred J. Yost, Mayor of Allentown, Pa.,
died on April 16 of pulmonary tuberculosis, at the
age of thirty-seven years. He was graduated from
the Medical Department of the University of Penn-
sylvania in the class of 1893. I" 1895 he was elected
Coroner of Lehigh County, and he was re-elected
in 1893. He was elected Mayor of Allentown in

1905-

Dr. Wm. J\L Kern died at Philadelpliia on .A.pril
17, at the age of eighty-seven years. He was gradu-
ated from the Medical Department of the University
of Pennsylvania in the class of 1847.

©bUuary.

THOMAS HENRY WAKLEY, F.R.C.S.,

LONDON.

With Thos. H. Wakley, who died on April 5, passes
away the second generation of editors of the Lancet
in the same family, for he was the eldest son of the
founder of this important medical journal. On the
death of his father in 1862 the two sons came into
the possession of the Lancet. The younger son,
James, took the more active part in the conduct of
the journal, devoting himself entirely to it, but
Thomas contributed as joint editor though he kept
on his surgical practice for some vears. His brother
James died in 1886 and from that time Thomas be-
came senior editor. His son, who has been for sev-
eral years joint editor, survives him, so the third gen-
eration of Wakleys continues to control the Lancet.
The late Thomas H. Wakley was an alumnus of
University College and also studied in Paris. Fie
took his M.R.C.S. in 1845 'ind the fellowship four
years later, having been elected assistant surgeon
to the Royal Free Hospital, which he continued to
serve as surgeon and consulting surgeon and as lec-
turer on surgery. He took much interest in anes-
thesia and contributed to his paper a recond of one
hundred experiments on animals with chloroform
and ether, and other surgical papers during the
fifties. A still earlier contribution was on the "entire
removal of the os calcis and astragalus with the
malleolar processes of the tibia and fibula." The
urethral dilator which he designed while in practice
will be known to specialists in that department. He
contributed to Cooper's Surgical Dictionary, but
practically all his writing was in the Lancet. The
Hospital Sunday Fund owed much to the unwaver-
ing support of the two brothers, who were largely
concerned in founding it. More recently Mr. Wak-
ley and his son, as joint proprietors, founded the
Lancet Relief Fund to help medical men overtaken
by acute distress, the whole of the money being pro-
vided by them. Other agencies for the benefit of the
profession always enlisted the sympathy and help of
Mr. Wakley.

OUR LONDON LETTER.

(From Our Special Correspondent.)

lister's BIRTHD.W — TUBERCULOSIS — PYOKRHCE.\ ALVEOLARIS —
GL\NT GROWTH OF FEET — ENLARGED CLAVICLE AND JAW —
OSTEOARTHROPATHY — OPERATIONS IN ASCITES — TEMPER.\TURE
CHANGES — HYGIENE OF CHILDHOOD — OBITUARY.

London, .^pril 5. 1907.
This is Lord Lister's eigluietli birthday. As you are
keeping it as well as we and the rest of the civilized
world. I will confine my notice of the event to reporting
that the arrangements made for its celebration here have
been duly carried ont. Yesterday the meeting convened
by the Lister Institute was held at the Royal College of
Surgeons, the president. Mr. Morris, occupying the chair.
It was indeed a notable gathering, representing medicine
and surgery, scientific and practical. As was intended
members of the editorial committee were appointed, the
republication of all Lord Lister's writings being the
principal part of the celebration. A deputation was also
appointed to wait upon Lord Lister to-day with the best
wishes of the meetin.g. This, too. has been done, and we
are all pleased to think that the venerable surgeon has
expressed himself as gratified with the manner in whicli
the esteem of his profession has been shown.

The appendix to the second interim report of the
Tuberculosis Commission contains the comparative his-
tological and hacteriolo.gical investigations made for the
commission by Dr. Eastwood. The morbid processes set
up experimentally by Bacilli tuberculosis of bovine and hu-

698

MEDICAL RECORD.

[April 27, 1907

man origin and their cultural characters arc compared.
The general result is to emphasize the underlying unity
of the morbid processes with every variety of Bacilli tu-
berculosis. Differences in severity were noted, due in
part to the dose and virulence of the bacilli used and
partly to the vary susceptibility of the animals inocu-
lated. But even when animals of high resistance, as
calves, are inoculated with bacilli of low. virulence, lesions
are produced in situations remote from the point of inocu-
lation, such as those in bovines by bacilli of high virulence
when the experimental conditions favor resistance. In
highly susceptible animals, as monkeys and anthropoid
apes, lesions are caused not only more chronic, but more
acute by these less virulent bacilli. These and other con-
siderations show the underlying unity of the morbid proc-
esses induced and the general resemblance in the char-
acters of their growths on artificial media. But though
Dr. Eastwood insists on the stability of the growth as a
rule, he says at the same time there is interesting and
very important evidence that the cultural and pathogenic
characters of some of the viruses are not absolutely fixed.
Instances were recorded of both diminution and increase
of virulence, also of cultural luxuriance. These examples il-
lustrate the variability and capacity for modification of
the Bacillus tuberculosis, and from the evidence of the
pathogenic and cultural instability Dr. Eastwood finds
reason for assuming that during the course of a long
residence in the human body a bacillus, originally of
bovine origin, might undergo a modification of some of
the characteristics which are met with in bacilli freshly
isolated from the bovine, and that owing to this modifi-
cation it might be indistinguishable from bacilli derived
from cares of human disease.

The College of Surgeons did an excellent thing in ap-
pointing a dental surgeon to one of the lectureships, and
no better selection could have been made than that of
Mr. Kenneth Goadby. The result was a most suggestive
contribution to our knowledge of a very troublesome
affection which will interest every observant practitioner.
Mr. Goadby is one of the foremost scientific dental sur-
geons, has devoted long years to bacteriological investi-
gations in his specialty, and wisely based his lecture on
these researches, taking for his subject pyorrhcea alveo-
laris. From careful examination of ninety cases, besides
others of ulcerative stomatitis and allied conditions, he
showed that a great many varieties of organisms are to
be found, though there is not one so constant in pyorrhoea
alveolaris as to appear as its cause. In fact, the bacteria
found in these cases closely resemble those met with in
gingivitis and ulcerative stomatitis. He described the
bacteriological finds in thirty-six cases accompanied by
general symptoms. In some he isolated a bacillus, which
had the power of fermenting lactose, and referred to the
observation of McConkey. who traced such an organism
to a fecal origin. It may be that these bacteria are
concerned in the production of the disease, but other
organisms, including both varieties of staphylococci, are
often found in inilk. The suggestion, therefore, that
contaminated milk may carry infective organisms along
the alveolar margin and give rise to the general symptoms
observed deserves consideration, or at any rate further
investigation, especially as pyorrhoea alveolaris not seldom
follows infectious diseases during which a milk diet has
been employed. Mr. Goadbv has successfully treated the
disease by the injection of vaccines of organisms on the
lines laid' down by Sir .\. E. Wright. He is unable to
endorse the common opinion that extraction of the affected
teeth arrests the disease, having seen an increase of symp-
toms after removal of a number of teeth, and this vievv
is enforced by records of the opsonic index. He advised
therefore, that only two or three teeth should be extracted .
at any one sitting.

Among interesting exhibits at Clinical Society the
first place is due to one of congenital hypertrophy or
giant growth of the feet, shown bv the president. Mr.
Glutton, who propose to amputate. The patient is a girl,
now seventeen ; her deformity was noticed at birth and
increased slowly up to her fourteenth year. For the last
three years the growth has been more rapid. The feet
are now enormous, fairly equal in size. The whole left
extremity is enlarged and nearly three inches longer than
its fellow. Mr. Glutton proposes a Chopart operation for
the shorter limb and a Syme for the longer one.

A case of enlargement of the clavicle and left side of
lower jaw was shown at the same meeting by Br. Betham
Robinson. It was in a boy of thirteen, and appeared of
a chronic inflammatory nature. The swelling of the
clavicle dated from a fall against a wall five months
previously, that of the jaw from a toothache. There was
also some enlargement of the right side of the thyroid,
as to which Mr. Tubby remarked that he had seen such
a condition of the clavicle secondary to a thyroid tumor.

Mr. Robinson had given iodide with some benefit and he
proposed to push it and also give mercury.

A woman of twenty-one, with hypertrophic osteo-arthro-
pathy of the lower extremities, was shown by Drs. B. Shaw
and II. Cooper. The patient was cyanosed, there was
well-marked clubbing of the fingers, toes, and nose, swelling
of both legs, due apparently to bony growths. There was
a systolic murmur, but the lungs were free from signs
of disease. The patient had always suffered from pal-
pitation and breathlessness. Radioscopy showed both tibiae
and fibulae to be enlarged, more markedly on the right
side. There was uniform thickening of the lower two-
thirds of these bones and irregular deposits at the attach-
ment of periosteum to the interosseous membranes. The
upper halves of the shafts of both femora showed similar
changes, more marked on the right side. The other parts
of the femora did not seem to be affected.

.\n infant of eight weeks was shown as an example of
osteogenesis imperfecta, or more probably syphilitic. There
had been fractures of thigh and leg bones and several
ribs, which had united under mercury. The spleen w-as
large, there was ulceration about the arms, and Dr. Suth-
erland, who showed the case, considered it most likely
syphilitic, though it was suggested that it might be arrested
development.

At the Medical Society a paper on the operative treat-
ment of the ascites occurring with cirrhosis of the liver
was read by Mr. Laurence Jones, who said the most suit-
able cases were those which had survived tapping of fluid,
which was shown to be of mechanical rather than inflam-
matory origin. The common object of all operations was
to increase the communication between the portal and
caval systems, and the omentum was the portal area
usually selected, and it was sutured 1 > the abdominal wall
outside the peritoneum. Various addi onal procedures had
been suggested, but he did not ad\ jcate them. About
one-third of the patients died within ii month of the opera-
tion, another third were definitely improved, their lives
being prolonged for some years in comfort. The other
third were only slightly improved or not at all. The
operation mortality should not exceed ten per cent.

One speaker thought the mortality depended on the
case, not on the operation, as to which it_ought to be nil.
.■\nother urged that the possibility of syphilis should al-
ways be considered, especially in the younger patients.
.Another remarked that in a febrile case, if the fever
promptly abated under mercury, it was probably syphilitic.
.Another urged early operatiorL and vet another that suc-
cess depended on the selection of the case.

Normal temperature, allowing for the fluctuations es-
tablished by Ogle, Liebermeister. etc., seems not to be dis-
turbed in its range by moderate changes of conditions in
the health of individuals. Dr. Carter has reported to the
Liverpool Medical Institute the results of observations
made by the cooperation of the night nurses in his hospital.
Each nurse towards the end of three months' night duty
took her temperature, three-hourly, when not asleep in
the day. The charts exhibited proved that the normal
depression about .3 a.m., under ordinary conditions of life,
also occurred after turning night into day for a period
of about three months. The fall would, therefore, appear
to be independent of changing conditions so far as these
observations go.

Mental Hygiene in Childhood is the subject of an article
in the new number of the IVestiniuster Revien; from the
pen of Dr. Robert Jones, whose experience for some years
at the Earlswood Asylum was extensive. He speaks of
his interest' in failures rather than successes as a reason
for writing the article which is directed to the impor-
tance of a sound physical state in relation to mental
development and activity. The child, he says, owes its
possibilities to Nature, but the realization of them to
nurture — the last term implying all those physical, mental,
and normal agencies which surround the child, as well as
those domestic, social, and scholastic influences brought
to bear upon it. Such questions as maternal nursing and
pure milk, he holds, concern .both the state and munici-
pality as does the feeding of poor school children, and
he speaks of the improvement in the waifs and strays of
our great towns on Canadian farmsteads. Speaking of
lunacy his asylum experience tells him that the admissions
are generally of persons poorly nourished and in impaired
health, and as improvement takes place in the bodily state
so does a simultaneous mental change occur. As a preven-
tive of insanity he relies greatly upon the successful effects
of societies which call attention to the hygiene of the
voung.

Dr. A. S. Myrtle, J.P. of Harrogate, died on the 29th
ult.. in his eighty-second year. He was M.D. Edin., 1844.
He had been long identified with Harrogate and was a
great authority on its mineral waters and the diseases in
which they are most useful on which he had written prac-

April 27, 1907]

MEDICAL RECORD.

699

tical brochures. He was consulting physician to the hos-
pital, had been president of the County Medical Society,
and also to the British Bacteriological and Climatological
Society.

The death is also announced of Dr. Parcell of Man-
chester Square on the ist inst. in his seventieth year.

ProgrrsH of IHe^iral ^rirurr.

New York Medical Journal, April 13, 1907.

Atypical Phagocytic Cells in the Circulatory Blood.

— M. R. Rowley enumerates the varieties of white cells
found in normal or pathological blood as polynuclear leuco-
cytes, lymphocytes, eosinophiles, mast cells, and myelo-
cytes. The author has found cells quite different from
those mentioned, in the blood of a patient with tertian
malaria, and in three cases of lymphatic leukemia. In
size and shape they vary much, but generally they are
much larger than any of the usual blood cells. They are
sometimes round in shape and so.metimes irregular in out-
line, with protoplasmic processes. Pieces may break off,
these resembling blood plates. They may have one or more
nuclei which contain a fine reticular network, and in the
majority of cells are kidney shaped. In the Wright modi-
fication of Leishman stains they resemble the large lympho-
cj'te, the nuclei staining a reddish purple, and the proto-
plasm various shades of dusky blue. Occasionally reddish
spots are scattered in the protoplasm, but in the majority
of the cells there are no distinct granulations. The author
presents illustrations showing the phagocytic action of these
cells, ."^s to their nature, they seem to resemble somewhat
one of the elements found in e.xudates into the serous cavi-
ties, in the spleen, the so-called "endothelial cells."

Premature Detachment of the Normally Situated
Placenta. — To three cases previously reported W. R.
Nicholson adds two more, one recovering and the other
dying. The general points in diagnosis are discussed and
the author makes the following plea : First, that aberrant
pain and unexplained bleeding, even if slight, during preg-
nancy should always suggest the possibility that placental
separation is taking place. Second, that such cases should
be watched with the greatest care. Third, that as soon as
the provisional diagnosis is moderately certain, an active
interference should be practised up to the point of the pro-
duction of an amount of cervical dilatation sufficient for
immediate delivery. Fourth, that in the rare cases in which
the rigid unobliterated cervix is encountered, together with
severe bleeding, valuable time should not be wasted,
but that either a vaginal or a' classical cesarean section
should be performed according to the predilections and
circumstances of the operator.

Milk as a Carrier of Infection. — C. Harrington says
that the non-bovine diseases capable of being spread by
milk are typhoid fever, dysentery, scarlet fever, diphtheria,
and the so-called cholera infantum group of bowel troubles.
The most important (excluding the bowel class) is typhoid.
The author claims that the purchasing public is the element
in the community which can correct the present faults in the
question of milk supply in large cities. He says that it
is the purchasing public that holds the key to the situa-
tion and can apply the remedy for all milk-borne in-
fections ; it is the man behind the dollar who can secure
insurance against milk sickness by refusing to give any of
it for milk as ordinarily produced and sold, and .by a will-
ingness to give a little more of it for the right kind. But
no. the extra few cents daily appears to be an insurmount-
able obstacle, even to those who are free even to waste-
fulness in other ways: and they are content to buy dirt of
all kinds, including cow dung and pus, with their milk, se-
cure in the thought that by heating the mixture for a few-
minutes it is made much safer to drink. It seems unfair
to the public and, in a business way, especially unfair to
the clean dairyman, that dirty dairies should be permitted
to exist; but the public is apathetic and will do nothing,
and it appears that the only way to insure reducing milk-
borne infection is S'tate and municipal regulation of dairies
and distribution.

Journal of the American Medical Association, April 20,
1907.
Protozoa and Disease. — C. W. Stiles discusses cer-
tain questions relative to the protozoa as disease factors, es-
pecially those at present somewhat disputed. He thinks the
differences of opinion are largely justified, considering the
difficulty of accurately defining the group. If zoologists
can differ as to what are protozoa and what are not, cer-
tainly physicians and pathologists, to whom zoolog\' is a
side issue, can be excused for differing, and their difference
of opinion, based on the imperfect present knowledge of the

protozoa, are bound to be the inost important factors in ul-
timately bringing out the truth. He defends the view, an-
nounced by him in 1901, that the diseases mechanically trans-
mitted by insects are, with few exceptions, due to parasitic
plants, particularly bacteria, and that those dependent on
insects or other arthropods for their dissemination and
transmission are caused by parasitic animals, particularly by
sporozoa and worms. To this second rule he holds no ex-
ception has yet been proved. Such diseases as surra, which
can be transmitted by inoculation, coition, etc., cannot be
said to be biologically dependent on insect carriers, and he
holds that this has not yet been proved to be the case with
Rocky Mountain spotted fever or African tick fever. The
claim made by Novy and Knapp that the parasite of African
tick fever and of .A.merican spirillosis of chickens are vege-
table rather than animal in their nature has more than im-
pressed him, he says, but the possibilities of their trans-
mission are not yet determined and these instances certainly
do not disprove his rule. Stiles thinks that from what is
known of the incubation period of yellow fever in a man
and the life cycle of the microorganism in the mosquito
and in man the biologic indications are that the specific
cause is a protozoon ; but he is in doubt as to whether it
will prove to be a sporozoon or a tlagellate. It is fortu-
nate, he says, that the non-sexual reproduction of some of
the protozoa is limited, as, were it otherwise, untreated
malaria, for example, would be necessarily fatal.

Chronic Gastritis. — R. F. Chase remarks that chronic
gastritis, understanding by the term a chronic inflammation
of the stomach accompanied by pathologic changes, usually
a diminution of the acidity with more or less impairment
of the rennin and pepsin secretions and an excessive secre-
tion of mucus, is a much less common disorder than is gen-
erally supposed. The diagnosis from the subjective symp-
toms merely, instead of by the well-known tests, is respon-
sible for many incorrect diagnoses in the past. It is a dis-
order of rather long duration, often many years, more com-
mon in males. Ewald says that many patients said to
die of old age, really succumb to gastric atrophy. Chase has
not found evidence of this and his patients ranged between
twenty and fifty years. It is impossible to ascribe it to any
single cause, though alcohol has been considered as one of
the most important. Chase agrees with Einhorn that loss
of weight is not a usual symptom, the patients are often
well nourished, appetite may be good, and pain, other than
discomfort after meals, may be altogether lacking. Other
symptoms that inay occur are constipation, flatulence, eruc-
tations, etc., but no one symptom or set of symptoms is
characteristic. Diagnosis must be based on the objective
findings obtained by reneated examinations of the stomach
contents and observation of the progress of the case. It
seems that a rapid emptying of the stomach contents is
rather common, and it is not positively determined whether
this is due to hypermotility or to pyloric insufficiency. It
is difficult to overcome and if, as some think, it is com-
pensatory, hurrying the food into the intestine where most
of the digestion is accomplished, it is better not combated.
Chase thinks that most patients can be practically cured by
measures to restore the hydrochloric acid secretion, care in
diet and douches to free the stomach of the excessive
mucus. Starches are better digested in the stomach in
this condition than are proteids, and bearing this point in
mind and remembering that all thermal, mechanical and
chemical irritants are to be avoided, we have, he says, the
key to dietetics in this disease. He advises lavage twice a
week, using 30 grains each of sodium chlorid .and sodium
bicarbonate to a pint of water at 100° F. For the purpose
of dissolving mucus and increasing the secretion, he uses
from 10 to 15 grains of sodium chlorid and sodium bicar-
bonate in a glass of warm water to be taken about fifteen
minutes before meals. Pepsin and hydrochloric acid are
not relied on by him as agents to increase the hydrochloric
acid secretion. Vacations and out-of-door occupations are
important aids.

A Graphic Method in Practical Dietetics. — Irving

Fisher proposes a new method of estimating the amount
and proportion of proteids, fats and carbohydrates by
taking, not units of weight, but units of food value as the
starting point. This unit or standard portion is defined as
that amount of food which contains 100 calories and a table
is constructed which gives the weight of a standard portion
of each particular kind of food, and out of the 100 calories
contained therein, the number in the form of proteids, fats
and carbohydrates. In order to carry out this method food
should be served in standard portions or simple multiples
of the same. Fisher has prepared a table, computed chiefly
from the tables of Atwater and Bry.int. and for made
dishes from those of Kellogg. The main portion of his
paper is devoted to the explanation of the use of this table
and of a mechanical diet indicator which is figured and de-

700

MEDICAL RECORD.

[April

1907

scribed. By the apparatus thus devised the patient can
avoid the necessity of having scales at the table, and after
a little practice he can regulate his diet without any ap-
paratus by simply exercising his visual memory of the
same. The mechanical diet indicator was used for five
months in an experiment on nine Yale students in the win-
ter of i<x>ti. No diet was prescribed and the indicator was
used only to record the diet wliich the men themselves
chose. It was found that by following Fletcher's rules as to
mastication and obedience to appetite the men naturally
and gradually reduced their proteids. The effect on their
worknig powers was described in Science, November 16,
1906. Its value in pathologic cases has not yet been thor-
oughly tested, though one physician is reported to have
found the apparatus of value in his practice.

Dilating the Gravid Uterus. — E. P. Davis describes
the methods that are advisable in dilating the uterus in the
later months of gestation for toxemia, placenta prsvia and
premature separation of the normally situated placenta. In
the toxemic cases he does not include those due to the
nephritis of pregnancy, but those of acute toxemia of
hepatic origin with altered pulse tension, nervous disturb-
ances of toxemia and the evidences of blood disintegra-
tion that accompany the condition. In such cases the uterus
should be emptied as soon as consistent with safety, and
for rapid dilatation he prefers bimanual dilatation with one
or more fingers of each hand working synchronously in op-
posite directions, as most efficient. If unmanageable by
the fingers, Bossi's dilator employed to one-half or two-
thirds of its full capacity for from thirty to forty-five min-
utes with anesthesia has proved harmless and efiicient. Ex-
cept in rare cases, full dilatation with the instrument should
be avoided. Vaginal Cesarean section is not favored in
these cases by Davis, as he has never seen a case where
he thought it clearly indicated. In many of these cases the
patient is too far gone for anesthesia to be safe, and it
should be avoided when pulmonary lesions are present. In
placenta previa the hand is also the best instrument for
dilatation. As a rule the elastic bag is too slow in opera-
tion in these cases, as it is in toxemia. Bossi's dilator,
Davis thinks, is a dangerous instrument to use in the vas-
cular softened cervi.x of placenta praevia. In premature
separation of the normally situated placenta, immediate de-
livery is called for, and Cesarean section, vaginal or ab-
dominal, is the operation demanded. If this can not be
done, multiple incision of the cervix followed by rupture
of the membranes and dilatation by the hand as rapidly as
is consistent with the integrity of the mother's tissues
should be chosen. With the patient in good condition and
not much hemorrhage, Bossi's dilators and the hand may
be sufficient. The author emphasizes the importance of
complicated cases of labor and the necessity of skilled and
surgical assistance in such. The general practitioner should
not depend on himself alone in these cases any more than
he would in appendicitis or strangulated hernia requiring
operation, and whenever possible such cases should receive
attention in a hospital.

Multiple Aneurysm of the Aorta. — A. A. Eshner
gives a very full account of a puzzling case which was
first diagnosed as pleuritic, pericardiac effusion being also
simulated. There were found on postmortem examination,
however, five separate aneurysmal dilatations of the aorta,
one of which had caused an erosion and penetration of the
trachea. Pulmonary- tuberculosis existed and was sus-
pected during life, but the bacilli were not found in the
sputum. No trace of pericarditis was found. The patient
died suddenly of a hemorrhage which was entirely unex-
pected. The case is interesting as illustrating the possible
difficulties of diagnosis, even by thoroughly competent phy-
sicians.

The Southern Maine Climate for Hypertonia Vaso-
rum. — L. F, Bishop advocates the southern Maine coast
as a climatic resort for persons suffering from disorders
of the circulation due to mental overwork and worry. Such
individuals show signs of chronic high tension in the ar-
teries, which is followed later by cardiac dilatation and
the well-known train of symptoms in these cases. .\ chronic
vascular nervous overtone has been develoned. He has
seen such patients make satisfactory- progress toward re-
covery in a single summer's sojourn in this region, which
has a climate with an unusual combination of coolness and
dryness. The recession of the coast makes the fogs, com-
mon elsewhere, infrequent, and. the character of the soil is
such that it very quickly dries. Excessive heat in summer
is almost unknown. The pleasurable qualities of the south-
ern Maine climate in hot weather are, he says, well known,
but its advantages for this class of invalids should be better
appreciated.

The Lancet, April 6, 1907.

The Pathology of Melanotic Growths in Relation to
their Operative Treatment. — \V. S. Handley describes

the results of some of his work with pigmented growths
arising in the skin. From examination of strips of tissue
taken from the inguinal region of a cadaver containing
a considerable number of melanotic growths the author
concludes that (l) from the fairly regular distribution of
skin nodules around the embolically invaded right inguinal
glands it may be inferred that a process of local centrifugal
spread, independent of the direction of tlie lymph current,
took place around these glands as a focus. Examination
of a radical strip of the parietal tissues extending from
these glands showed (2) that permeation of the lymphatics
is the principal agent in this local centrifugal spread, and
that it occurs primarily and most extensively in the plane
of the deep fascial lymphatic plexus. (3) Invasion of skin
and muscle is due to upstream permeation of the lymphat-
ics which carry lymph from these layers to the fascial
lymphatic nlexus. (4) Owing to the fact that arteries and
veins usually run in close contiguity to lymphatic vessels,
lymphatic permeation is followed by infiltration of the walls
of the veins, and later of arteries, and by intrusion of the
growth into the lumen of the blood-vessels. The import-
ance of invasion of the veins with regard to pulmonary and
systemic dissemination is obvious. (5) The order in time
of these various events is deduced from the orderly se-
quence of processes seen as the strip of tissues is traced
from its distal end towards the mass of glands which
formed the local center of infection. (6) Regressive
changes, due to inflammation excited by the growth, may
occur in melanotic sarcoma.

The Area of "Acute Abdominal Conflux" and the
"Incision of Incidence." — Under the former title C. P.
Childe refers to an area located by the following rule : The
esophageal opening of the stomach is situated behind the
seventh costal cartilage, on the left side, about one inch
from the sternum. A perpendicular line (a) is dropped
from this point to Poupart's ligament. Then a line (b) is
drawn from the right anterior superior iliac spine perpen-
dicularly upwards to the lower border of the thorax. The
author claims that within the area bordered by these two
lines almost every acute abdominal crisis either must occur,
or, as a matter of fact, does occur. He therefore terms
this area the "area of acute abdominal conflux." It may be
divided into upper and lower compartments by a horizontal
line at the umbilical level. The incision which will lay bare
this area is the vertical one midway between the lines (a)
and (b), that is on just about the outer border of the right
rectus muscle. This is the '"incision of incidence" in an
acute abdominal case. The advantages claimed for this
incision are: (l) That it directly exposes to sight that
part of the abdominal cavity which in a large proportion of
cases must contain the offending organ, and which in an-
other large proportion of cases does as a matter of fact do
so. (2) That therefore in the large majority of cases it
will enable the surgeon to deal directly with the offending
organ, and without the necessity for any second incision
unless this be required for drainage. (3) That for these
reasons it makes, in the majority of cases, for the avoid-
ance of delay and difficulty, two essentials of success in
these operations, and will therefore give the best aggregate
of results. (4) That in the minority of cases, in which it
fails to expose the offending organ, the abdomen can be
examined by touch just as well through the right semi-
lunar as through the median incision. ( ^) That in those
cases of intestinal obstruction where the patient can bear
no more than the establishment of an artificial anus it is
close to the seat of election for this operation — the cecum
or lower ileum.

Amyl Nitrite in Hemoptysis. — G. .\. Grace-Calvert

does not think that any of the drugs usually given in pul-
monary hemorrhages such as ergot, adrenalin, morphine,
calcium chloride, or lactate, are of supreme value, though he
admits that some of them may help if there is time for
them to act. He places his faith in amyl nitrite. He car-
ries three minim capsules of the remedy with him and
breaks one, telling the patient to inhale the vapor quietly
and regularly and not to be disturbed at the feeling of full-
ness in the head. The bleeding usually stops almost at
once, though the patient may go on coughing up clotted
blood which has been already effused. Later, if the pa-
tient is excited or alarmed, and the lungs appear to be
irritable, he gives a hypodermic of morphine. The amyl
nitrite oroduces such an immediate fall in the general blood
pressure by dilatation of the vessels throughout the body
that the pressure at the bleeding point is lowered and there
is time for clotting to take place, and the hemoptysis usu-
ally ceases almost instantly. Even if the pulmonary ves-
sels are dilated the ill effects are more than counterbalanced
by the fall in blood pressure, and experiments seem to
prove that it has a direct vasoconstrictor action on the ves-
sels of the pulmonary periphery in spite of a vasodilator

April 2-], 1907]

MEDICAL RECORD.

701

action elsewhere. It may, however, be urged that this
constriction of the pulmonary vessels is bad in that it must
raise the blood pressure in those vessels, but this seems to
be more than counterbalanced by the fall in general pres-
sure, whereas in the case of adrenalin, ergot, etc., there is
no corresponding fall in general pressure. Moreover, nitrite
of amyl causes no reactionary pulmonary hyperemia (after
the anemia), while adrenalin apparently does. Again,
nitrite of amyl has a further good point, and that is the
fact that it does not interfere with coughing and so doei
not place any obstacle in the way of the patient getting
rid of the effused blood, and hence it considerably lessens
the risk of septic trouble later.

British Medical Journal, Af'ril 6, 1907.

Coincident Embolism of Cerebral, Mesenteric, and
Femoral Arteries. — T. R. Rodger reports the case of a
woman of si.xty-seven years who was seized with severe
abdominal pain and soon began to pass blood by rectum.
Four hours later it was noticed that the patient's speech
had become indistinct and that there was a hemiplegia af-
fecting the left arm and leg and the left side of the face.
The discharge of blood had ceased, the abdominal pain
W'as a little less, and the diminished rigidity rendered dis-
tinctly palpable a large tender swelling in the right iliac
region. The question arose whether this might be an in-
tussusception with secondary cerebral apoplexy due to
straining, but the patient, who was quite conscious, said
there had been no straining; the blood had merely trickled
from her — indeed, she was uncertain from which nassage
it came — and examination of the blood showed it to be free
from mucus. Moreover, the tumor had not the rounded
outline of an intussusception, but was flat and extended
more towards the middle line. The heart was rapid and
irregular, and no distinct murmur could be detected, but
five months previously the patient had been attended for a
Pott's fracture, due to a fall, which she could not properly
explain, but which seemed to be the. result of a fainting
turn, and at that time a mitral murmur was found. The
diagnosis of embolism w'as further confirmed when, within
a day or two, the right leg — the one unaffected by the
hemiplegia — became cold and discolored with a bluish
mottling from six inches above the knee downwards. No
pain in this limb was complained of. but by this time the
patient was semicomatose and could not feel pain. She
died on the fifth day from the onset of the abdominal symp-
toms.

Sprains and their Consequences. — A. F. Shoyer re-
ports the case of a man who fell on the doorstep. His
right wrist was painful and there was a slight abrasion on
the radial side of the joint. The patient applied lotions and
carried the arm in a bandage and sling for two weeks be-
fore seeking advice. At that time the wrist joint was
found swollen, red and painful. There was a small amount
of fluid in it, and on movement there was distinct crepitus
on the dorsal surface, which mir^Iit or might not have been
tendinous. A splint was applied, and two days later an .r-
ray photograph was taken, when it was seen that a large
triangular piece of bone had been wholly or partly broken
away from the dorsal edge of the lower or articular surface
of the radius and projected above the dorsal surface of the
bone. The splint was kept on for several days and both
passive and active movements used every evening. The
crepitus soon disappeared, and. movements .being without
pain, the splint was dispensed with at the end of a week.
At the time of reporting the case the author states that,
measured with the calipers, the anteroposterior diameter
of the right radius at its lower end was about 1-4 inch more
than that of the left. Flexion was slightly limited, and
there was slight tenderness over the seat of fracture. It
was expected, however, that full movement would eventu-
ally be secured at the wrist joint.

Iodine Spirit Catgut. — J. S. Riddell commends the
use of ioduie catgut, employing a solution of one part
tincture of iodine to fifteen parts of proof spirits and keep-
ing the catgut immersed eight days before using. He has
used this material for ligaturing and suturing in hundreds
of operations and strongly advocates it. He finds that it
IS sterile and antiseptic, loses none of its tensile strength in
preparation, is readily and simply prepared, without any
undue expense. All that is required is a glass jar, the solu-
tion above named, commercial catgut, and glass spools.
The following suggestions are given : Ordinary glass
tubing about the thickness of the little finger sliould be
cut in lengths of two inches. This is long enough to take
one length of Hartmann's catgut in single layer without
knotting. The catgut must be tightly wound on the tube,
or. what is better, the tube should be rolled into the catgut.
The catgut is first fixed, either by tying it through or round
the tube, and when wound on is fixed with a slip limp be-

low the last turn. The spools are immersed in the solution
and are kept there indefinitely till they are to be used.
They must not be used till the eighth day after immersion,
and for guidance the date of immersion and the size of the
catgut should be noted on a small label on the side of the
glass jar. The author finds No. 2 catgut most useful for
ordinary purposes, and a larger supply of it should be pre-
pared than of the other sizes. If many spools are im-
mersed in one jar and are not used for some weeks after
immersion, it is well to add fresh iodine spirit solution at
intervals of two to three weeks, so that one may be certain
that there is always an excess of iodine bathing the catgut.
Finally the catgut is absorbed completely, but only after it
has subserved its purpose.

Hughling Jackson's Views of the Functions of the
Cerebellum. — \'. Horsley reviews the opinions of Hugh-
lings Jackson with reference to cerebellar functions as il-
lustrated by recent research, and gives a brief resume of the
various steps by which we have come to our present knowl-
edge. He contends that all research, both ancient and
modern, confirms the view that the cerebellar cortex is the
first chief station of representation of the afferent basis
of all the skeletal muscles. He notes tliat in determining
cerebellar effects due allowance must be made for accom-
panying influence of the cerebrum and of the spine. The
cortex cerebelli and the nuclei cerebelli must be considered
as two distinct organs. Naturally nothing particularly new
is brought forward in such a paper as this, but it serves
as an interesting commentary on the gradual and logical
development of the views of the distinguished English
neurologist.

Berliner klinische Wochenschrift, April i, 1907.

Injections of Oxygen into the Knee-joint. — Rauen-

busch employed the injection of chemically pure oxygen into
the knee-joint for the purpose of obtaining a better jr-ray
picture, as recommended by VVerndorf and Robinson a few
years ago. He was surprised to find that patients suffering
from chronic joint diseases requested a repetition of this
procedure, as it brought them so much relief from their
pain. The experiments were continued and a number of
cases of chronic arthritis and arthritis treated by this means
with very favorable results. The gas was injected through
a small canula under strict aseptic precautions, directly into
the cavity of the joint. The intervals at which this was
done varied from one to three weeks. In the presence of
a synovial tuberculosis, the method was also attended
with good results. The treatment is entirely empirical and
the author is not prepared to state whether its effects have
any permanent value, but recommends its use in selected
cases as a means of alleviating the distressing symptoms.

A Contribution to the Treatment of Hay Fever. —
Heymann publishes his experiences with the administration
of thyroid extract in this disease. He examined a large
number of cases and found that these patients are no more
apt to be afflicted with nasal deformities than a correspond-
ing number of others who are free from the attacks. He
did find, however, that if the obstructions in the nares were
removed a marked improvement always occurred. The best
results with drugs were noted with the administration of
thyroid extract. He gave this in tablet form, one to
three daily, each containing 0.3 gin. of thyroid substance.
The improvement in twenty-one cases was very favorable,
and although no conclusions are possible as to the etiology
of the disease the writer thinks that it is probably dependent
upon a nervous diathesis in the domain of the sympathetic
nerves. In a considerable number of the patients who were
under treatment for the disease he found an enlargement
of the thyroid gland, although not of sufficient extent to
demand treatment for itself.

Congenital Stricture of the Urethra. — Posner calls
attention to the possibility of this occurrence, although
from the general prevalence of gonorrhea one is led to at-
tribute almost every case to this source. It is possible that
main- cases of incontinence in children are due to this
cause, where the lesion may be situated not only in the an-
terior portion of the urethra, but also at the junction be-
tween the membranous and bulbous portions. Posner re-
ports a case of urinary retention in a boy eleven years old,
which disclosed on passage of the catheter an obstruction
in the region of the bulbous portion. The boy had been
afllictcd with enuresis and also occasional attacks of hema-
turia. Improvement followed gradual dilatation with elas-
tic catheters.

Miinchcner medicinischc Wochenschrift. March \2 and
26. icx)7.

The Avoidance of Perineal Lacerations During La-
bor.— Toff discusses a niethnd for preventing this ac-
ciilent which is very easily carried out. It depends on

702

MEDICAL RECORD.

[April 27, 1907

keeping the head flexed as much as possible until the
greater part of the occiput is delivered before allowing,
extension to take place. The less the occiput is permitted
to come out under the symphysis the greater the sagital
diameter of the child's skull which must come through
the vulva. The delivery, as advocated by the author,
necessitates the lateral position on the part of the patient.
The hand of the attendant is placed on the occiput as
soon as this appears, and then the latter is pressed down
and pulled out both during and between the pains. By
this means flexion is increased, and when the neck is
engaged under the arch, then extension may be permitted
to take place. By this procedure the writer claims to have
saved lacerations in many cases where rigidity of the soft
parts and a narrow vulvar outlet would have resulted in
a tear.

The Alexander-Adams Operation. — Spaeth calls at-
tention to the fact that in Germany this operative pro-
cedure is not appreciated as fully as it should be, notwith-
standing its many advantages. It is applicable in cases
where a more extended operation is impracticable or un-
necessary, as in a virgin where a simple retroflexion with-
out any descent may serve as the basis for a very severe
reflex neurosis. It is also applicable in sterility and nu-
merous instances have been recorded of its successful appli-
cation in such cases. The writer reports a series of fifty
cases in which a modified Alexander-Adams operation was
done. Thirty of these were accessible for subsequent ob-
servation and in all the uterus was in a normal position.
Pregnancy had occurred in ten of these women and in four
instances it had taken place twice. In only four cases,
however, did the pregnancy continue to term, and although
this would lead one to attribute the abortions to the opera-
tion the author is of the opinion that the accident was due
rather to the presence of an endometritis and most of the
patients had already aborted at different occasions before
the operation. The fact that only one-third of the patients
became pregnant at all may be ascribed to the age at which
the operation was undertaken. The labors were all
normal, without any particular pains in the groins. The
round ligaments, when doing the operation, should be
shortened about 8-10 cm., and the writer thinks that many
of the failures are due to excessive shortening.

Ocular Paralysis After Lumbar Anesthesia. — Ach re-
ports four cases of abducens paralysis occurring in a series
of 400 patients where lumbar anesthesia was employed.
In three of the patients there was a unilateral and
in the other a bilateral paralysis. This appeared on the
fourth to the eleventh day after the operation and lasted
anywhere from eight days to three weeks. In all these
cases there were present sever_e headaches, pains in the
back, and restlessness, and the anesthetic effect was either
very brief or absent altogether. A comparatively small
number of similar cases have now been reported by other
authors, and from a study of the subject Ach has ■formu-
lated a theory for the production of this paralysis of the
abducens muscles. He believes that the latter depends on
the direct action of the toxic material on the nerve rather
than on its nucleus in the fourth ventricle. The phenome-
non is similar to the paralysis of respiration seen in other
cases, where the condition is also due to a direct action on
the phrenic nerve rather than on the respiratory center in
the medulla. In order to avoid the possibility of this com-
plication, the writer advises the use of the most harmless
preparations for the injections. The anesthetic should be
used in tlie smallest possible doses and in a weak solution.
Absolute rest on the back is essential, with the trunk
raised.

Healing of a Carcinoma by Sunlight. — Widmer refers
to the good results obtained irj chronic ulcerative processes
by exposure to the direct rays of the sun, and details a
remarkable cure observed in a woman of eighty-one -ears
who presented a circumscribed epithelioma of the back of
the hand. Operative treatment being refused, the icsion
was exposed to the sunlight for several hours daily, and
after a period of three months the ulcerated area v/.is com-
pletely healed, and remained so. The writer found tnat
reflected light apparently increased the efficacy of the di-
rect rays for the purpose indicated.

Deutsche medizwische Wochenschrift, March 21 and 28,
1007.

The Intravenous Administration of Strophanthin. —
Starck places the three requirements of an ideal cardiac
stimulant as follows: a selective action on the heart
without the production of harmful after-efifects on any
other organs, ease and certainty of dosage, and lastly a
rapid effect. Digitalis has usually been accepted as the
standard drug for the treatment of cardiac condition.

but it cannot be said to completely fulfill all of the
requirements. Endeavors have repeatedly been made
to overcome its disadvantages by the introduction of
preparations of its various active principles, which could
be used subcutaneously. It was found, however, that
such preparations were not readily soluble, and caused
a great deal of pain at the site of injection. When a
more soluble preparation of digitalis was finally ob-
tained, the intravenous injection was proposed and car-
ried out with good results. Strophanthin was similarly
employed, and with equally good, if not better results.
Starck reports seven cases of acute and chronic cardiac
disturbances, all of a severe character. The only bad
result was in a case of advanced sepsis, which was
practically hopeless at the start. The dose varied from
0.005 to 1.25 gm., advancing with caution from the
smaller to the larger amount. There were no evidences
of any after-effects, nor was any cumulative action
noted. A well marked sedative action was absorbed
after the injections, which relieved the patients greatly.
Starck thinks that this sedative action is manifested on
the central nervous system. The effect on the pulse
seems almost immediate, and the dyspnea, if present,
is relieved. The strophanthin injections may be recom-
mended as the most efficient form of treatment for the
purposes indicated.

Intermittent ArticiUar Hydrops. — Kamp calls atten-
tion to this peculiar condition for which no remedy has
apparently been found. The term is applied to a recurrent
swelling which affects more particularly the knee joints, and
is quite rare. In Kamp's case it was present in an elderly
lady in whom the swelling came on at regular intervals
of from five to nine days. The acute swelling came on
within twenty-four to thirty-six hours, lasted about two
or three days, and then gradually subsided. There is no
fever present in these patients and very little pain. The
writer thinks that the complaint has nothing to do
with rheumatism or gout, as is commonly believed.
Its exact cause is as yet unknown, but it probably
depends on a trophic vasomotor neurosis of the joint
The condition is very chronic, but may disappear for a
time, thus simulating a period of cure. Treatment has
thus far proved valueless, at least the use of water and
bath cures, the salicylates, quinine, arsenic, etc., have
not had any effect on the course of the disease.

Spirochetes in Framboesia Tropica. — Mayer confirms
the findings of Castellani as to the presence of spiro-
chetes in this tropical disease, the clinical similarity of
which to syphilis has been noted by a number of
writers, although no actual identity has ever been dem-
onstrated. Mayer found in five cases of framboesia in
Ceylon and Eastern .Africa the typical form of spiro-
chete described by Castellani, which closely resembles
the Spirochata pallida discovered by Schaudinn. The
organisms were found in the serum from recent papules.
Mayer claims that these spirochetes are the probable
etiological factor in the production of this tropical
disease.

Contusion Pneumonia. — Litten discusses this form of
pneumonia, of which a considerable number of instances
have been described, and which differs from the so-
called traumatic pneumonia, in that there is no wound of
the lung by the penetration of objects from without. The
injury is due to a blunt force and produces a suddon
and extensive compression of the pulmonary tissue. No
evidence of any injury can be detected on the outside of
the chest, although this may have been sufficient to have
caused a complete tear of one of the lobes of the lung.
Ecchymoses are more likely to be found in cases where tne
lungs have escaped injury. The pneumonia need not reces-
sarily occur at the site of the external injury, but may take
place in the opposite side of the chest, and if there are any
old adhesions or tubercular foci present these act as a locus
minoris resistentiae. The lesion is most often the result of
a fall from an elevation, b.ut it may also be produced by a
severe blew, by compression, or by being run over. An-
other cause to which the writer calls particular attenl'cn
is the lifting of heavy weights, an instance of which he .'e-
ports in the present paper. A man engaged witii a num-
ber of others in lifting a heavy truck was soon after seized
with severe pains in the chest, and was prostrated. Two
days later a pneumonia was diagnosed, and within five d:ys
the man was dead. Three other similar cases were pre-
viously observed by the author, from which it appears
that the cause referred to is an important factor in the
etiology of the condition. The chief characteristic of this
form of pneumonia is its sudden onset, brief course and
high mortality rate, for as far as can be determinr^d from
the cases thus far reported the latter is appaiently about
68 per cent.

April 27, 1907]

MEDICAL RECORD.

703

Sunk SftlteMJH.

Pulmonary Tuberculosis. Its Modern and Specialized
Treatment, with a Brief Account of the Methods of
Study and Treatment at the Henry Phipps Institute
of Philadelphia. By Albert Philip Fr.\ncine, A.M.
(Harv.), M.D. (U. of P.). of the Staff of the Henry
Phipps Institute, Philadelphia; Examining Physician
to the White Haven Sanatorium ; Instructor in Medicine
and Physician to the Medical Dispensary of the Univer-
sity of Pennsylvania; Medical Registrar to the Phila-
delphia Hospital. Philadelphia and London: J. B. Lip-
pincott Company, IQ06.
This work contains a considerable number of facts and
no inconsiderable number of unproved theories regarding
pulmonary tuberculosis. It would appear from a perusal
of the chapter on "Hints and Helps to Tuberculosis Pa-
tients" that this work is intended not only for medical
men but for the tuberculous laity as well, and there is
scarcely a doubt but that the layman will be interested
and edified ( ?) to discover, as the author so frequently
points out all through his work, what an ignorant, un-
scrupulous, careless, and altogether mischievous individual
is the general practitioner of medicine when he comes to
deal with the problems of tuberculosis. Indeed, the general
practitioner does not alone suffer from the authors criti-
cism. For instance, in the chapter on "Climate" (page
47) occurs the following: "Poor people often make a
financial effort and pay one visit to some well-known physi-
cian for an opinion or diagnosis. The latter finds them
suffering with tuberculosis, usually well advanced, and
with self-complacent irresponsibility advises them to 'go
out West.' He may even go so far as to tell them that in
this course lies their only chance of getting well. Such
advice cannot be too strongly condemned, both from a pro-
fessional and humanitarian standpoint." Again ■ in the
same chapter one can imagine the feelings of the layman
who has heretofore reposed some measure of confidence
in the medical profession when he reads as follows :
"Certainly one cannot condemn too strongly the advice so
commonly given, founded on false conceptions, ignorance,
and irresponsibility — to go away, live out of doors, take
plenty of milk and eess, and not 'overdo' exercise. Those
who follow such unfortunate and reprehensible advice,
and there are many thousands who do, are victims to the
ignorance of the profession, and are hourly frittering away
their chances of recovery." Yet, this does not seem such
unreasonable advice — to "live out of doors, take plenty
of milk and eggs, and not 'overdo' exercise."

The lengthy "Prefatory Word" under which title the
author introduces his subject, is not merely prefatory
but fundamental. Though on the whole most of the
author's statements, when he is not attacking the members
of his own profession, are no doubt sound, they are un-
convincing because, on the one hand, of the dogmatism
which characterizes the work throughout, and, on the
other, of the haphazard manner in which the thoughts
are grouped, and again because of the fact that some
statements which must strike many as embodying entirely
new ideas, are made without the least reference to au-
thority.

In the chapter on "Koch's Tuberculin" and in that on
"Serumtherapy" the autlior has exercised much better
judgment and exhibited comparative freedom from the
assertiveness and dogmatism which characterizes the rest
of the book, but two chapters of sound, unprejudiced,
good reading cannot serve as iustification for the balance
of the book which contains but little that is new or
instructive on the subject of phthisis.

The Nervous System of Vertebr.\tes. By J. B. John-
ston, Ph.D.. Professor of Zoology in West Virginia
University. Philadelphia: P. Blakiston Sons & Co., 1906.
The author's own view of this work is given in the
preface : "The attempt has been made in the following
pages to give an account of the nervous system as a
whole, to trace its phylogenetic history, and to show the
factors which have determined the course of evolution.
The functional point of view which is the chief character-
istic of the present book, brings the treatment of the
nervous system into close relation with the work of recent
years on the behavior of animals." Dr. Johnston has had
before his mind at all times the fact that the inherited
organization of the brain is actuallv the product of the
experience of the genus, species, and variety (sometimes),
and of the individual parents, although of these last the
influence is but small ; that the brain as inherited by the
individual man contains the results of untold ages of
experiences, the experiences of the individuals who are
a given man's progenitors, for example, which experiences
at times reach the plane of the individual consciousness,
and we recognize them as instincts or prejudices, which

instincts and prejudices we but too well know as forces
impelling, and sometimes compelling, us to action.

Syphillis du Poumon, chez I'Enfant et chez I'Adulte. Par
le Dr. Beriel. ancien interne des hopitaux de Lyon,
preparateur au laboratoire d'anatomie pathologique.
Paris; G. Steinheil, 1906.
This volume is a capable summary of our present knowl-
edge of pulmonary syphilis, and contains an extensive
bibliography of the more important publications bearing
on the subject. The author studies in detail the gross
and minute pathology of the various lesions, and their as-
sociated symptoms. He is verv cautious in his acceptance
of reputed cases, rejecting many of those reported as
being tuberculosis occurring in a syphilitic subject. A
few pages at the end of the volume are devoted to the
results of treatment, the technique being omitted, as out
of place in a special work of this nature.

Animal Micrology. Practical Exercises in Microscopi-
cal Methods. By Michael F. Guyer. Ph.D., Professor
of Zoology in the University of Cincinnati. Chicago:
The University of Chicago Press, 1906.
When KoUiker's Microscopical Anatomy appeared in Eng-
lish the only reagents in common use, so far as anything in
the references to technique told the reader, were 5 per
cent, solutions of caustic soda, a solution of acetic acid
of the same strength, and a solution of chromic acid of a
strength not definitely given. Frey's Microscopical Tech-
nology, translated by Cutter and published in the '70's,
tells iis in the preface that the methods of technique have
become so numerous that they must be discussed in a
volume other than one given up to the description of the
tissues. But to-day, if one wishes to keep up a working
knowledge of general technical development outside of his
own small special field, a whole library is in demand.
This fact is well illustrated in this admirable handbook
which, so far as certain matters are concerned, leaves but
little, if anything, unsaid.

Chapters l and 2 give a broad general view so that the
beginner can see the end for which he is working, and
Chapters 3 to 6 give an accurate insight to the way of
handling the great development of modern technique, the
section, the consecutive section, and finally, reconstruction
to scale. Chapter 3 gives methods of killing and fixing,
but omits the morphine method in reference to micro-
scopical animals which in many instances is notably better
than that with chloroform water or its substitute.

Then follows an exhaustive discussion on the processes
of sectioning, the paraffin, celloidin, and freezing. There
is no mention of the Bumpus modification of celloidin
methods, which are truly admirable. The student
who has mastered these chapters has also mastered the
whole essential technique of sections and is to be con-
gratulated accordingly. The discussion of stains and re-
agents is accurate and generally sufficient, but the tech-
nique described suggests a special interest in the nervous
system. Appendix C is important, as it gives in full
detail the best method of hardening and preparing every
tissue of the body.

Diseases of Children. A Manual for Stuslents and Prac-
titioners. By George M. Tuttle, M.D., Attending
Physician to St. Luke's Hospital ; Martha Parson's Hos-
pital for Children; Bethesda Foundling Asylum; and
Professor of Therapeutics, Medical Department of
Washington University. St. Louis. Series edited by
Bern B. Gallaudet, M.D. Second Edition. _ Revised
and Enlarged. Illustrated with five plates in colors
and monochrome. Philadelphia and New York : Lea
Brothers & Co.

Most books dealing with diseases of children can be
divided into two parts ; the first consisting of chapters on
the special conditions of infancy and childhood, an-d the
other treating of practice in general, but sli.ghtly modified
to suit the requirements of voung patients. The first part
is, by far, the more important ; and it is usually much the
smaller of the two. In the present volume, this first or
introductory nortion consists of about sixty pages, and
contains chapters on the infant at birth, normal develop-
ment of the infant, examination of the child (one page
only), diseases of the new-born infant, and the feeding of
infants. This last chapter, which is probably the most im-
portant in the book, is clearly written, and deals ably with
the subject. The remainder of the volume is concerned
with the various diseases, arranged as in books on general
practice; but following Diseases of the Digestive Systern
there is another valuable chapter on Disorders of Nutri-
tion, dealing with malnutrition, marasmus, scorbutus,
rachitis, diabetes, and rheumatism. The book is well
adapted to the requirements of the beginner in the study
of pediatrics.

704

MEDICAL RECORD.

[April 27, 1907

NEW YORK ACADEMY OF MEDICINE.

Regular Meeting, Held April 4, 1907.

The President, Dk, John A. Wyeth, in the Chair.

This meeting was held under the auspices of the Section
on Public Health.

Street Dirt and Public Health. — Dr. W. Oilman
Thompson said that it should be admitted that the ncxious
influence of such dirt upon the human organism might
constitute a predisposing cause of disease by maintaining
a constantly irritated or congested condition of the respira-
tory mucosa, quite as much as it might act as a medium
of the direct conveyance of disease germs. Street dirt
he regarded as comprising any or all of the following in-
gredients : ( I ) The ashes, house sweepings, etc., which
were freely blown about from exposed ash carts and ash
barrels; (2) the excrement of horses and dogs voided in
the streets, to become dried, pulverized, and distributed by
wind and traffic; (3) the irritating, powdered asphalt,
ground from the surface of the pavements, and often
mixed into a slimy paste with mud, horse dung, and the
petroleum drippings from automobiles ; (4) pulverized
earth, plaster, iron dust, cement, etc., derived from build-
ings undergoing construction or demolition, and carried
about the streets in loosely constructed wagons; (5) the
earth from street e.xcavations. usually impregnated with
sulphides and other products from leaking gas mains ; (6)
the soot from chimneys which eventually settled in the
streets; (7) the garbage which, in the tenement districts,
was frequently overturned into the street; (8) human ex-
creta which, in the crowded tenement neighborhoods, was
often voided by children or adults in blind dark alleys and
ill-lighted streets. It was no exaggeration to state that
nine-tenths of the diseases of this type, i.e. the acute inhala-
tion diseases and chronic catarrhal diseases, were directly
due to dirt inhalation. During the winter the masses of
dirt-covered snow melted slowly and so modified the
local climate by begetting moisture and chilliness of the
atmosphere, which favored the development and main-
tenance of coughs, colds, and rheumatism. The sewers
became clogged with street refuse and the crossings were
often left ankle-deep in slush, making it impossible to
keep the feet dry. In the tenement districts where the
street life constituted so large an extension of the house
life, the condition of the streets was most importatit from
a social, moral, and economical standpoint. Articles of
fresh food, such as milk, fish, vegetables, and fruits, were
more or less exposed to contamination by street dust and
coated with bacteria. As long as dirt remained moist it
was relatively heavy but also sticky ; this favored its
being carried into dwellings, public buildings, street cars,
and subways, there to be dried and pulverized. Dry dirt
remained comparatively harmless while at rest. But in
the streets it seldom remained at rest. The longer dry
dirt remained in a given street, the more it became pul-
verized and the more widelj' was it disseminated in the
atmospheric air. Sufficient nonspecific germs were con-
veyed by street dust to excite catarrhal or purulent in
flammations. and by thus fostering a chronically diseased or
irritated condition of the respiratory passages, the latter
were rendered liable to more serious infections. Herein
lay the chief menace to health from street dirt. The
danger was complicated by the fact that the sputum of
patients having chronic tuberculosis, bronchitis, or naso-
pharj-ngeal catarrh, e.xpectorated when the}' were at large
in the streets, was swept from the sidewalks and added to
the general street dirt. Dr. Thompson said that one of
the great difficulties in obtaining permanently clean streets
in New York City appeared to reside in the multiplicity of
authorities controlling them. Such a degree of subdivi-

sion was doubtless necessary in these days of extreme
specialization in all classes of labor, but unfortunately it
left a, loophole of escape from complaints by shifting the
responsibility perpetually from one department to another.
Dr. Tli^mpson submitted the suggestion that after further
discussion of this important topic a resolution be acted
upon to the effect that :

Owing to the accumulation of street dirt in this city,
the health of many citizens was impaired so as to render
them frequently and unnecessarily subject to serious and
often fatal respiratory diseases, and that in order to secure
permanent improvement in street cleanliness, the Mayor
of the city be urged to appoint a commission to study and
report upon the matter and formulate a proper scientific
plan for permanent relief from conditions which afforded
a constant menace to health, as they now existed.

Such a commission would consider the whole subject
from its medical aspects as well as its engineering prob-
lems, its economic side, its administrative efficiency and
responsibility, and its permanence. Its report would fur-
nish an appropriate basis for legislation and secure per-
manent relief.

Practical Difficulties in Cleaning the Streets of New
York City. — Capt. F. M. Gibson, late Deputy Commis-
sioner, Department of Street Cleaning, New York City,
addressed the Academy on this subject. He said that
after hearing Dr. Thompson's paper, he must enter upon
a defense of the Street Cleaning Department. The matter
of cleaning the city streets and keeping them clean must
necessarily be predicated upon a number of prerequisites.
First, the streets must be properly paved to be properly
cleaned, as broken places made perfect cleaning absolutely
impossible. In a city so congested as was New York, so
crowded with traffic, there were limitations which made
this a serious problem. In a conversation with President
Ahearn he was told that between December 17 and March
I" there were but nine days when the asphalt could be
repaired. Another prerequisite rested with the people
themselves; it was necessary to have the cooperation of the
public in observing the citj' ordinances. Many people
swept the pavements into the streets after 8 o'clock in
the morning, and orange, lemon, and other skins were
thrown into the streets. Another obstacle to street clean-
ing was the restricted use of water ; there should be a free
and unrestricted use of water and when the weather con-
ditions permitted, street flushing. Capt. Gibson said that
if the Academy was going to make any recommendations,
it was very important that the unrestricted use of water,
when available for the purpose, should not be denied the
Street Cleaning Department. He was a firm believer in
flushing the streets. Another prerequisite was the earnest
and hearty cooperation of the city departments which for
some cause or causes seemed to be seriously lacking. This
remark applied with special force to the city magistrates
who, through kindliness or good heartedness perhaps, were
much too lenient with old and persistent offenders. He
said that so soon as the Bingham Police Bill was passed
and became a la%v, it would be an excellent thing to dis-
continue the Board of City Magistrates and then to turn
these old offenders over to the police captains of each
district. They would be made to do their duty. Another
important thing and serious obstacle to proper street clean-
ing was the licensing of pushcarts. There should be a
discontinuance of pushcart licenses. As long as this was
practised, and this kind of traffic was permitted, it would
be absolutely impossible, especially on the lower East Side
of the city, to keep the streets in anything like a sanitary
or cleanly condition. The city would save about $70,000
a year by their discontinuance. The cit>- of Xew York
should not be placed at such an expense. There were ap-
proximately 5,000 pushcarts in New York City; each one
must have a license which cost $2; thus the city only
obtained Sio.ooo a year. Another prerequisite was the

April 2;, 1907]

MEDICAL RECORD.

705

maintenance of the strictest discipline possible, for, with-
out it, in such a large aggregation of men, one's best
efforts counted but for very little. More positive rules
should be made, and if a man broke one he should be dis-
missed for good, and not be allowed to come back to the
Street Cleaning Department, or any other. Another pre-
requisite was the total elimination of politics. Another
was the definite fixing of responsibility for the furnishing
of proper receptacles for refuse, and the necessary number
of them, especially in the tenement house districts. The
law required that they be filled only to four inches of the
top; instead of this they overflowed and became scattered.
Another prerequisite had to do with permits for building
material. New York City in recent years had grown to
be a city on top of a city; therefore, the work of cleaning
the streets should be conducted on broad, bold, intelligent,
and common sense principles, and, to do so, the laws gov-
erning such work should be as elastic as the honest inter-
est of the city would permit. For instance, broader civil
service regulations, extension of the Commissioner's
powers in selecting officers of the uniformed force, etc.
He should also have greater latitude in procuring the
necessary supplies for his department. Captain Gibson
then gave a few statistics which he thought might be of
interest in regard to the quantities of material collected
and disposed of.

Cart Loads. igo6.
Ashes. Rubbish,

Manhattan 1.074,725 225,227

Bronx 145,000 16,996

Brooklyn 522.525 1 12.71 1

Garbage. Total.

230,697 2,130,646

20,632 183.639

102,822 737,058

2,342,256 354,934 354,151 3,051,343
Population, December 31, 1906.

Manhattan 2.232,828

Brooklyn 1,448,095

Bronx 308,256

Total 3,989,179

In excess over 1905 by 119,178.

.•Appropriations.

1906 $6,011,537.48

1907 $6,258,257.17

Increase for 1907 of $246,719.69.

Miles of Payed Streets. December 31, 1906.

Manhattan 433.20 Decrease 5.69

Brooklyn 647.08 Decrease 1308

Bronx 90.98 Decrease 4.76

2353

Total 1,171.35

Number of Men Employed.

Uniformed force, including officers 5. 302

Clerical force 55

Mechanics and help 219

Engineers, firemen, etc 25

Total 5,601

Captain Gibson closed his remarks by suggesting a
practical change of municipal government, eliminating the
boroughs and their machinery.

Practical Ideals of Street Cleaning — Mr. Rudolph
Hering read this paper. He said tliat under practical
ideals of street cleaning they should understand the near-
est approach that could be expected from a modern mu-
nicipal government, to keeping the streets of a city
perfectly free from the accumulation of all kinds of dirt,
which might propagate disease, be unpleasant or annoying
to them, or injure property within buildings. Such din
consisted chiefly of finely comminuted solid matter or
dust, originating both in the houses and in the streets,
or dragged into the city by conveyances, animals, or
pedestrians, or blown into it by strong winds. Ashes,
garbage, and rubbish were excluded from his discussion.
The street dirt or dust consisted of organic and inorganic
waste matter and was traced to the following sources :
Buildings, pedestrians, horses and wagons, earth working
up between pavements or paving stones, small litter, and
dust and soot carried by the winds. Asphalt and wood
generally gave the best satisfaction in keeping down the

quantity of dirt generated upon the streets, and from their
comparatively smooth surfaces allowed of the most per-
fect cleaning. A good, even, and smooth pavement, laid
upon a firm foundation, was the first and most important
practical ideal for street cleaning. He emphasized the
importance of having narrow joints for stone blocks. The
second most practical requirement for the best practi'-al
street cleaning was water. In some European cities some
of the most important asphalt streets were washed tW\\\
with hose, connected either directly to the water mains or
to a water truck. A squeegee, having a blade of rubber,
was used to scrape the material thus loosened from the
center of the streets to the gutters, where it either entered
the sewers, as in Paris, or its water was allowed to drain
away, as in Berlin, and the dried material was then carted
away. With generally good grades for sewers, as in New
York, there appeared no good reason why the Paris
method should not be applicable here, except that a large
amount of road detritus or silt would be deposited in
the rivers near the sewer outlets and later require removal
by dredging. Naturally all street cleaning with water was
not applicable during freezing weather, but it had been
demonstrated that if the streets were clean when winter
began, and if the snow was promptly removed and no
rubbish was cast upon the streets, there was no objection-
able accumulation during the winter and no special cleaning
was required until flushing or sweeping could be re-
sumed. Another important requirement for perfect street
cleaning was sweeping. On most of the streets of large
cities the dirt was now removed by machine sweepers.
The greatest defilement on busy streets came from the
horse droppings; it was necessary to scoop them up as soon
as possible after dropping and to deposit them into dust
bins situated at convenient places, or into portable recep-
tacles immediately at hand. Another important require-
ment to secure practical street cleaning related to the
organization for effecting it. To do the best work in the
shortest time and at the least expense meant high effi-
ciency on the part of the managers and workmen. In
conclusion he suggested that a careful and thorough col-
lection of facts be made by the city covering this service
in other principal cities of the United States and Europe,
and basing it on properly comparable elements so that
definite and practical conclusions were clearly indicated
by them as to the best means for securing the highest
attainable degree of cleanliness.

Dr. Fr.^ncis p. Kinnicutt said he wished to emphasize
the importance of the hearty cooperation of the public in
the work of street cleaning. An ordinance against throw-
ing litter in the streets was not sufficient. He remembered
that Col. Waring said that a great deal of his success
in keeping the streets clean was due to the cooperation of
the citizens of New York ; he was able to develop in
them a civic pride. With regard to this civic pride, if
1,000 citizens should take a daily interest in street cleaning,
as they saw it done before their own doors, and would give
tlieir ideas, or observations of defects or faults, much
might be accomplished. It was preposterous to say that
it was impossible to clean the streets of New York, or
that this city should be less clean than the cities of Great
Britain, or continental Europe.

Dr. S. A. K.voPF said that to sweep a street when it
was dry was a crime against one's fellowmen. It was a
mistaken idea to think that dust which did not contain
pathogenic, i.e. specific disease-producing microorganisms,
was harmless. It was on the contrary most harmful, be-
cause of its irritating influence on the mucous membranes
of the respiratory organs. The relative increase of tuber-
culosis among the New York street sweepers which was
first noticed a few years ago was, in his opinion, not
solely due to the inhalation of tuberculous sputum which
might have been expectorated in the streets by consump-
tives and which had most likely been rendered innocuous

7o6

MEDICAL RECORD.

[April 27, 1907

by sunlight and air ; but it was due to the irritating influ-
ence of dry dust, raised by the street sweepers themselves,
because they did not sprinkle the streets before sweeping.
The pulmonary tissue thus irritated invited an invasion
of the bacilli to which the street cleaner, in his unsanitary
tenements and other unhygienic environments, was as much
exposed as anybody else. When the streets were sprinkled
before they were swept there would be less tuber-
culosis among the street cleaners. As proof of all this
he cited the well known fact that the street cleaners of
Berlin were the healthiest body of men of all the city's
employees and virtually free from tuberculosis. Much
had been said of cooperation between the various depart-
ments and the citizens at large. He approved of this
most heartily, and even went a little further and said that
they should not only have the cooperation of the adult
citizen, but also that of the young rising generation, and
should teach them civic pride. Some would perhaps recall
the excellent service rendered by cooperation of the chil-
dren, which was brought about by the late Col. Waring
when he was at the head of the Street Cleaning Depart-
ment. However, they needed above all things the co-
operation of the corporations, surface and elevated street
car companies, and all corporations who now constantly
violated the law by burning soft coal. If these corpora-
tions would do their duty and obey the laws, there would
be less dust in the air, less dirt in street cars, and less
dust swept down from the elevated platforms on the
pedestrians by the ignorant or wilfully careless porter.
Lastly, there should be a training school for street cleaners
as well as there was one for policemen and firemen, and
the advancement in the ranks should not depend upon any-
thing but practical knowledge of street cleaning and the
record as to the performance of duty in previous positions.
With trained sanitary engineers at the head, practically
trained foremen and practically taught men in the ranks,
a cooperation of all the city departments interested in
the work, a cooperation of corporations, citizens at large,
young and old, they should have as clean a city as any in
the world.

Dr. T. R. Maxfield believed that the danger from street
dirt was due more to the irritation produced than to any
specific infection. One of the first things that struck him
was the matter of educating the inhabitants, especially
in the tenement districts, to keep dirt, ashes, garbage, etc.,
in proper receptacles. He believed the streets could be
cleaned at night ; the night air was heavier and was less
conducive to the spread of the dust through the air. The
ashes should be removed at night. Pushcarts should be
abolished. A lack of cooperation of the different depart-
ments was a serious thing of to-day. There should be a
more hearty cooperation of the police in enforcing the
sanitary ordinances ; it was now a dead letter. There
should be proper cans for ashes and garbage. In Brooklyn
this was being enforced as rapidly as was possible.

Mr. G. A. SoPER agreed that the injurious effect of dust
was due more to the irritating effects than to its mi-
crobic character. It was very necessary to get rid of the
waste in the houses. A large quantity of street dirt was
carried away by the sewers and rivers; the rivers finally
became the depositories of this waste. The Department
of Docks removed from between the slips and piers over
870,000 cubic yards of material, a large part of which came
from the streets, carried there by the waters in the sewage.
The cost of this was not far from $200,000. The govern-
ment would be forced to continually dredge these chan-
nels in order to permit the ocean-going vessels to get by.
It had recently been proven that the garbage that was
emptied into the middle and upper bay had not been car-
ried out to sea ; most of it was not carried beyond the
narrows. Again, much of this garbage came back. After
the houses on Barren Island were destroyed by fire, the
refuse was carried fiftv miles bevond the New York

harbor and, it was found, this garbage littered the coast
of Long Island for fifty miles and the coast of New
Jersey for seventy-five miles, some going even to Atlantic
City.

Mr. Baker said that street cleaning was as important
as was garbage disposal. He said that one of the great
faults of American cities was the large amount of money
expended in municipal works and the comparative neglect
in their maintenance after. This applied particularly to
the care of the street pavements.

THE MEDIC.\L SOCIETY OF THE COUNTY OF
NEW YORK.

Stated Meeting, Held March 25, 1907.

The President, Dr. Walter Lester C.^rr, in the Chais.

Report of the Comitia Minora. — Dr. John Van Doken
Young read this report and recommended the dismissal of
the charges of malfeasance in office against the counsel of
the society, Mr. Champe S. .Andrews, by Dr. Charles J.
Mooney. After a discussion, partaken in by Dr. Egbert Le
Fevre, Dr. John J. MacPhee, and Dr. Samuel Lloyd, the
motion was lost. A motion was then made that the charges
against Mr. Andrews be considered at a special meeting
of the society; this was carried.

Multilocular Glandtilar Cystoma of the Ovary Com-
plicating Pregnancy. — Dr. B. S. Talmey presented this
clinical report, which showed that large tumors did not
always produce dystocia (to be published later).

The papers of the evening were devoted to a discussion
on gonorrhea in women.

Pathology of Gonorrhea in Women. — Dr. Henry C.
CoE read this paper. (See page 684.)

Infection of the Urethra, Vagina, and Glands of
Bartholin. — Dr. William S. Stone read this paper.
(See page 685.)

Gonorrheal Invasion of the Uterus and Fallopian
Tubes. — Dr. Brooks H. Wells read this paper. He said
that the subject chosen for discussion was one of the
most wide-reaching importance and interest, and had to do
with an evil that was born of the unbridled passions of
man, a creature of darkness that stole the bloom and joy
of life not only from the frail sister of the street, but too
often also from the fairest and most carefully guarded
daughter, striking her through him she had chosen and
trusted as her husband and protector. He asked for how
many childless homes was this evil responsible, for how
many lives made sunless by the cloud of a chronic pelvic
invalidism, how many marriages made failures by marital
incapacity? For as many or more than from all other
causes of pelvic ills combined. Twenty-five years ago
gonorrhea was hardly considered as a cause of pelvic dis-
ability, of chronic invalidism, of sterility; now, we knew
how widespread and serious were its ravages. It was
difficult to find reliable statistical evidence of the relative
frequency of gonorrheal endometritis and salpingitis, as
compared with the frequency of infections of other por-
tions of the genital tract in the female, but from his own
experience he believed that at least one case in four de-
veloped a gonorrheal endometritis, and one in eight or ten
had gonorrheal infection of the tubes. Although he had
seen many cases of gonorrhea in little girls (infancy to
six or eight years of age) he knew of none in which it
could be shown that the disease had invaded the infantile
endometrium or tubes. At or about puberty, however, with
the development of these parts, the conditions were
changed. Gonorrheal endometritis might be primary, but
was more often secondary to infections of the lower por-
tions of the genital tract. The only positive means of
diagnosis was the microscope. It usually began within two
or three months after the primary infection and sometimes
within a few days. The s\-mptoms were intensified just
before, during and after menstruation, at which time the

April 27, 1907]

MEDICAL RECORD.

707

gonococci became more numerous and virulent. Gonor-
rheal salpingitis was caused by an extension of infection
from the uterus, and the interval between the primary in-
fection and the invasion of the tubes might be only a
few days, or might be after a long time and after periods
of symptomatic health. A gonorrheal salpingitis was usually
bilateral and might exist for some time without showing
any distinctive symptoms. More often the symptoms were
fairly well marked and rarely they might be so virulently
intense as to produce a picture of acute peritoneal shock.
The invasion was apt to be marked by a slight chill fol-
lowed by a moderate rise in temperature, together with
more or less malaise and prostration. There was pain in
the ovarian regions, most often to the left side. The pain
was at first sharp, cutting or pulsating, and was followed
later by a dull steady ache or severe paro.xysmal pain,
sometimes both. The pain, when severe, was apt to radiate
along the sacral plexus or sciatic nerve. The symptoms
were aggravated by defecation, exertion, or coitus. Men-
struation was usually profuse, irregular, and painful as a
result of the accompanying endometritis and the disturb-
ance of the pelvic circulation by the disease process. Mic-
turition was frequent and painful. The general health
suffered from the absorption of toxins and the effect of
pain and anxiety. The patient often became more or less
of a neurasthenic invalid. A bimanual examination re-
vealed the enlarged tubes behind or at the side of the
uterus and gave the familiar picture of a periuterine in-
flammation. There was sometimes a symptomatic cure,
but more often the improvement was only temporary and
the patient suffered recurrence of the trouble. The cases of
rupture of the tubal abscess and discharge through some
hollow viscus were very rare and he had never seen one.
In the mild cases sterility was the most important result;
in the more severe an increasing invalidism ; in the rare
fulminating type death might occur within a few days.

Abortive Treatment of Gonorrhea in Women. — Dr.
Frederic Bierhoff outlined the following method of treat-
ment; He said that by abortive treatment we meant that
which brought about a cure upon one or two applications.
The term was used in contradistinction to prophylactic or
preventive methods. If women early in the course of a
gonorrheal infection became aware thereof, and would go
to the doctor, an abortive treatment might be possible in
a fairly large number of cases. Unfortunately in almost
all of the cases of gonorrhea in females, the patient pre-
sented herself for treatment when the process had already
gotten a deeper foothold in the urethra, or when the
urethral crypts, or the cervix uteri, had become infected.
Then, of course, an "abortive cure" was impossible. In
order to make the positive diagnosis of a gonorrhea early
a microscopic examination of the urethral, vaginal, and
cervical secretions was a sine qua non. If the cervix uteri
was infected an abortive cure was impossible. Similarly
with the Bartholinian glands, or periurethral crypts. If
the diagnosis could be made early, before the gonococci
had had a chance to penetrate deeply into the mucous mem-
brane, or before the occurrence of complications, as men-
tioned above, and when the urethra alone, or the vulva,
or vagina, or a combination of these, was the seat of
infection was an abortive cure possible? When the con-
ditions were favorable he employed the following proced-
ure : I. Microscopic examination of the urethral secre-
ti'in or scraping, and of the vulvar secretion. 2. Cleansing
'if the meatus, and irrigation of the urethra and surround-
ings with a solution of one-fourth to one-half per cent, of
soluble silver. The hand syrinp-e or irrigator was employed
and no forcible pressure was applied. In all about 300
c.c. was used for this purpose and some of the fluid was
injected through the urethra into the bladder, to be there
expelled by the patient. 3. Cleansing of the vulva by a
stream from the irrigator. 4. .\ vaginal scraping was now
made and examined. 5. The nozzle of the syringe was
gently inserted into the vagina, so that the body of the

syringe blocked the outlet. The vagina was then distended
under gentle pressure, with the solution, and this was
tlien allowed to flow out. .^bout 300 c.c. were used. 6.
A sterilized speculum was inserted into the vagina and all
secretion gently wiped off, and the cervical orifice cleansed.
7. A microscopical e.xamination of the cervical secretion
was made. Should it be free from gonococci, then the
vagina was lightly tamponed with absorbent gauze, satu-
rated with five per cent, soluble silver solution, and the
speculum withdrawn. He employed the tamponade whether
the vagina was infected or not. 8. A urethral bougie of
five per cent, soluble silver in cocoa butter was
inserted into the urethra. 9. A pad moistened with one
per cent, soluble silver solution was placed over the
urethral and vulvar orifices and kept moist with the solu-
tion. 10. Rest in bed, if possible, bland diet, and a daily
warm sitz bath completed the treatment. The patient
must be subjected to the same tests as the male patient
before being pronounced cured.

General Treatment of Gonorrhea in Women. — Dr.
H. J. BoLDT read a paper on this topic. He said that, so
far as treatment was concerned, it was essential to bear
in mind that in the greater majority of acute cases the
disease was limited to the lower part of the urogenital
tract and that, if we could bring the patients under proper
care early enough, we could almost always hold the dis-
ease in check so that the upper parts of the genital tract
would not be infected. The opinions as to treatment were
as divergent as in the case of diphtheria before the dis-
covery of the diphtheritic serum of Behring. Each method
of treatment had its advocates and likewise its opponents.
Most authors were, however, unanimous in stating that no
active treatment should be employed during the acute
stage. Cleanliness, restricted diet, and rest were most
approved of in this stage. When the acute stage had
subsided, local treatment was begun; but in the employ-
ment of local treatment, the use of vaginal douches was
generally discarded. The secretion should be wiped out
dry with absorbent cotton. The most favored remedy for
local applications was a five per cent, solution of soluble
silver. If the ducts of Bartholin were involved they must
be treated on surgical principles. If a cyst formed it should
be exsected. If an abscess formed it should be opened
by a long incision parallel to the inner lip of the labium.
The cavity after being cleansed might be swabbed with
pure carbolic acid, which should immediately be wiped
out again with pure alcohol. The cavity should then be
packed with iodoform gauze. Where the infection re-
mained obstinate in the small ducts he split them and
used the actual cautery. Condylomata were best removed
with a cautery knife. Personal observations in the matter
of the various silver solutions seemed to show that it took
about the same length of time to effect a cure, no matter
which one was used. Some patients were cured in from
four to six weeks and others were not entirely cured after
six months' treatment. Patients with subacute infection
did much better if they could keep themselves free from
physical exertion. It was important to see that the hus-
band was put under the care, of some one who appreciated
the danger of reinfection, so that cohabitation was not
permitted until both husband and wife were cured. While
for a time the gonococci infection might remain limited
to the cervical mucosa, it must be admitted that it was
extremely difficult to tell some patients when the invasion
had encroached into the uterine cavity he had, therefore,
placed himself on the side of those who at once attacked
the entire uterine mucosa. If the patient permitted it
he put her under an anesthetic and disinfected the genital
tract, and then before proceeding to dilate the cervical
canal the uterus was copiously irrigated with a double cur-
rent bladder catheter; then the cervix was dilated slowly
and gently, but effectually, and a thorough curettage was
done with a sharp curette. He preferred a Martin curette
for the first general abrasion of the mucosa, followed by

7o8

iMEDICAL RECORD.

[April 27, 1907

a small sharp curette used around the tubal openings. The
uterus was tiien again copiously irrigated with plain sterile
water, or a mild antiseptic solution, and was tamponed
with a long strip of gauze soaked in a five per cent, solu-
tion of soluble silver. The rest of the genital tract was
tamponed with iodoform gauze and the patient put to bed.
If urethritis was still present it should be treated at this
time, and also the ducts if infected. The gauze was re-
moved on the following day, and on the third day the
entire treatment, with the exception of the curettage, was
repeated. If consent to curettage was not given ofKce
treatment was used. An intrauterine application was made
by means of the intrauterine applicator syringe. The intra-
uterine tampon was left in the uterus for two or three
hours and the patient directed to remove it by means of the
attached string. A medicated tampon was placed in the
upper part of the vagina, if desirable, and was held in
place by a plain non-absorbent wool tampon. The strings
of the tampon were so marked that the patient could know
which to remove first. After removal of the tampons a
copious antiseptic douche was used by the patient. This
treatment was not as desirable as the first, as it was
fraught with more risk of causing subsequent pelvic inflam-
mation. The treatment should be repeated every two or
three days, and the advantage of a perfectly made intra-
uterine applicator could not be overestimated. In case
menorrhagia complicated gonorrheal endometritis, he had
found patients benefited by the internal administration
of hydrochloride of cotarnine, in doses of three grains,
given in gelatin capsules, three tiines daily, if the previ-
ously instituted treatment did not have the desired efifect.
Alone, without local treatment, especially curetting, it gave
unsatisfactory results. In that class of patients in whom
metrorrhagia and menorrhagia were almost uncontrollable,
he awaited a non-bleeding period and then made intra-
uterine applications of pure carbolic acid, leaving the
intrauterine tampon in situ for a couple of hours. The
treatment was repeated every second day until six or eight
treatments had been applied, and at the next menstruation
interval it should be repeated. He had no untoward results
from the application of pure carbolic acid to the uterine
cavity. In acute gonorrheal infections of the adnexa, with
or without invasion of the pelvic peritoneum, rest, the ap-
plication of the ice coil, or ice bags, a narcotic, preferably
in the form of suppositories for the purpose of lessening
peristalsis, and the avoidance of subsequent local examina-
tions should be insisted on until the acute symptoms had
subsided, when one might begin with warm vaginal douches
containing a mild antiseptic. The cold applications should
be continued until the temperature was normal and the
patient free from pain. The patient should not leave her
bed until the temperature had remained normal for one
week, and upon any exacerbation of sjmiptoms the rest
treatment should be resumed. If at any time the Fallopian
tubes became distended with pus, and sunk to the floor of
the pelvis, further delay with conservative treatment should
not be practised. The patient should be anesthetized and
the cul-de-sac of Douglas widely opened. The tubes could
then be incised and evacuated. There was a class of
patients who, while they made a temporary recovery, had
more or less pain either constantly or at varying intervals,
with menstrual irreg^ilarities and perhaps occasionally
acute exacerbations. Bimanual examination revealed the
symptoms of salpingo-oophoritis with a metroendometritis.
The Fallopian tubes were more or less distended and
sometimes the adnexa and uterus were matted together in
the perimetric exudate. It might be impossible in these
cases to demonstrate the presence of gonococci. In these
cases local treatment had proved useless in his experience.
Surgical intervention was the only form of treatment that
held out hope. There was another class of patients in
whom the disease had, to a large extent, became sponta-
neously cured, so far as pyosalpinges were concerned, but
the residue of the old chronic pelvic inflammation, con-

sisting of tubes thickened and adherent, ovaries in a con-
stant state of inflammation, and uterus perhaps smaller
than normal; in some cases larger. Menstruation with
this class of patients was likely to be at longer intervals,
six weeks to three months, though in some instances it
might be frequent, at intervals of two or three weeks, and
the amount of blood lost variable. Severe dysmenorrhea
might be present. Local therapy seldom benefited this
class of women, who usually had been sterile or had
but one child. If their suffering made it difficult for them
to pursue their vocation, and they were past the middle
thirties, a radical vaginal operation was most expedient.
If younger, then a salpingectomy should be resorted to.

Dr. James N. West said, speaking on the treatment,
that there was the greatest field of usefulness in prophy-
laxis. The disease which had produced such ravages on
mankind was so little under control and the reason was,
he believed, because it was accepted as a social evil among
all, and all feared to speak of it in good society. At the
Post-Graduate Hospital they had adopted active measures,
measures which were practical, and which instructed peo-
ple in regard to the nature of the disease, gonorrhea as
well as syphilis. Also, the Society for Moral Prophylaxis
in this city was discussing this question, agitating it, and
bringing it before the public mind, by which the public
had their eyes opened to the ravages of this disease. At
the Post-Graduate Hospital a slip of paper was given to
every patient suffering from either gonorrhea or syphilis,
having on it printed instructions, given in simple language.
They were fundamental instructions, and they went to the
root of the matter. Dr. West hoped that those who were
connected with clinics, and those in private practice as well,
would have something of this sort to present to every
patient suffering from gonorrhea or syphilis.

Dr. Lapowski discussed the papers.

Dr. Wells and Dr. Boldt closed the discussion.

Gonorrhea During Pregnancy. — Dr. J. Clifton Eixjar
read this paper. (See page 687.)

NEW YORK PSYCHIATRICAL SOCIETY.

Stated Meeting, Held March 6, 1907.

Dr. Allan McLane Hamilton in the Chair.

The Psychogenetic Factors in Some Paranoic Condi-
tions, writh Suggestions for Prophylaxis and Treatment.

— Dr. August Hoch read this, the paper of the evening.
He pointed out that among the paranoic states there were
cases, and that they probably represented a large pro-
portion, in which the psychogenesis could be clearly traced
when the facts of the cases were really accessible. The
theory of the development of paranoic states Dr. Hoch
summarized briefly as follows, stating that besides basing
his ideas upon facts of his own studies he had been in-
fluenced by the work of Adolf Meyer, Freund, Bleuler,
and Jung: Every person has certain points on which he
is especially sensitive. He has ideas or complexes of ideas
which are associated with very strong feelings. These
complexes refer either to personal defects, shortcomings,
limitations, or to feelings of guilt, remorse, shame ; on the
other hand, to certain longings and desires. We may,
therefore, generally speaking, say that they belong either
to the realm of self-assertion or to the sexual sphere, in
the broadest sense of the term. Now, most people are
able to get square with such things, partly because their
nature is such that these feelings never reach anything
like a great intensity^ or partly also because they have a
healthy way of dealing with these matters. Other people
do not get square with such difficulties. They do not
acquire balancing, healthy habits, such as a healthy turning
away from one's difficulties to outside interests, or a
habit of unburdening or a certain aggressiveness and the
like. While, then, such undercurrents, as we may call these
complexes, when they are of any intensity have them-

April 27, 1907]

MEDICAL RECORD.

709

selves a tendency to set narrower and narrower limits to
the interest and to create a certain fascination, they often
become a menace to the sanity of mind, also because they
are not balanced sufficiently by sound mental tendencies.
In this way there develops a growing disharmony which
gradually, or sometimes under the intluence of acute causes,
physical or mental, may suddenly lead to an unbalancing of
the mind when, finally, the undercurrents break through
to the surface. But the mind, even in the cases in which
the undercurrents are not handled properly, makes certain
miscarried attempts at readjustment. Thus, the feelings
of defect and the longings do not come to the surface as
such, but are transformed ; the former give rise to a general
suspiciousness and delusions of persecution, probably for
the same reason that we are inclined to Blame everyone
else except ourselves when anything which we do goes
wrong; the latter give rise to ideas that the innermost
longings are fulfilled. And there are still other forms
of such miscarried adjustments. We see, then, that we
have two things, the undercurrents and the abnormal man-
ner of dealing with these undercurrents, upon which we
should lay stress as important in the causation of these
paranoic states. To a certain extent this division is,
of course, artificial and the two principles often enough
overlap greatly. Then again it is often difficult to find
a correct or a definite formula for that which we have
called abnormal mental habits, or difficult to pick out
from among the complex fabric of mental reactions those
which are disastrous, to estimate the dangers of certain
combinations, or to correctly gauge the value of saving
traits. Naturally it will often be a combination of traits
rather than single traits which we have to consider, and
while we speak of some reactions as dangerous mental
habits they may exist in certain combinations in which
they are sufficiently safeguarded. It is also very evident
that causes other than an unhealthy manner of dealing
with the undercurrents may enter into the causal con-
stellation as well — such as influences which increase the
strength of the undercurrents, or influences which, in other
ways than those indicated, lessen the resistance, such as
the action of alcohol, the menopause, and the like. These
principles were demonstrated by means of careful analysis
of four cases and certain .indications for treatment were
discussed.

Dr. H. R. Stedman of Boston, in discussing the paper,
was inclined to lay more stress on the influence of heredity
in affecting the progress of a genuine paranoia than did
Dr. Hoch. Numbers of cases of the disorder were seen
in patients who had been sensibly brought up and w-ho were
treated afifectionately by their families, nothing being left
undone to make their surroundings congenial and their
lives smooth and happy, yet in spite of it all they de-
veloped paranoia. Little could be hoped for, he believed,
in the way of materially modifying the psychogenetic fac-
tors so as to make any real impression on these cases
of typical paranoia, a disease arising on a defective con-
stitutional basis and gradually and logically developing
into an inflexible system of delusional thought and con-
duct. He thought, however, that after the disease had
developed, when family, friends, and a normal development
had proved powerless to influence the disease, and the
patient was sent to the hospital, his condition was more
susceptible of improvement than is generally thought to
be possible. He had not infrequently found the paranoiac
to be rendered decidedly more manageable and his life
made far more comfortable by regular friendly and ex-
planatory talks, answering his questions, making the en-
deavor to set him right, and satisfying such of his minor
demands as were not wholly unreasonable. The fact
that many of them are hopeless and cannot be reached at all
by such means — in fact, only become worse in consequence
— accounted, he thought, for the tendency that exists to pay
them as a class little or no systematic attention such as

Dr. Hoch adopts with his cases. Dr. Stedman questioned if
the reader had not chiefly in mind the paranoid state
rather than the paranoiac, that symptomatic, persecutory
condition so often found in dementia praecox. If so, he
was wholly in accord with his view that much might be
done in the way of prophyla.xis. Dr. Hoch's masterly
analysis of the psychogenetic conditions in his cases
showed this plainly and he believed it to be due to the
fact that the morbid direction of their thought had be-
come less impaired than in the true paranoiac. Dr. Sted-
man felt the same confidence that he had expressed at
length several years ago, that not a few cases of this
kind, when recognized early by the psychiatrist while
yet the patient is comparatively comfortable may be saved
from an attack by well directed medical oversight and
guidance and regulation of his habits and sourroundings.
He attached little importance to the menopause as a spe-
cial causative factor in insanity, as individual experience
and statistics seem to show quite conclusively that paranoia
develops to the same extent in both se.xes during the
period of life in which the menopause occurs.

Dr. Ch.mu.es L. Dana said that he had been interested
in Dr. Hoch's analysis, which was instructive as showing
that in a certain group of cases of paranoia conditions
might be improved by careful therapeutic effort. He had
not been in a position to carry out this method of treat-
ment, which could not be very successfully employed by
those not connected with institutions. He agreed with
Dr. Stedman as to the importance of hereditary taint in
all these cases, and that a goodly proportion of paranoiacs
develop in spite of careful bringing up. Few of these
patients could be influenced unless they were taken in
hand very early. He had been much interested in two
or three cases of paranoia which illustrated that the
undercurrent does not always break through in a way
that particularly disturbs the mental makeup or general
life of the patient. Such a case was a woman, about fifty
years of age, now under his care, who was first seen by
him when she was forty years old. She was married and
the mother of two healthy children. About fifteen years
before he first saw her she had developed delusions of a
certain kind of persecution — that when she went out on
the streets people made remarks about her, trying to an-
noy her and to injure her. She had these delusions
throughout her married life and during her pregnancies.
She was a good mother, however, and to most people who
knew her she remained a good, kindly woman, about whose
mental condition no one had suspicions except her husband,
some members of her family, and Dr. Dana. She was
probably preserved from a general paranoiac state by the
fact that she was able to stay in the house and keep away
from sources of irritation. He had had under observation
also a man, now forty years old, who had been engaged
in business all his life. For fifteen or twenty years this
patient had had similar delusions of persecution — that
the police and detectives were after him and that attempts
were being made to watch him. But this undercurrent
delusion never broke through except in one little spot in
his brain. One or two of his children developed dementia
pra!co.x at the age of sixteen. Such very limited types
of paranoia certainly lent themselves to treatment by
instruction and by careful selection of environment, which
was all essential. As to the general correctness of Dr.
Hoch's analysis there could be no question.

Dr. Maurice C. Ashley of Middletown, N. Y., agreed
with Dr. Hoch in the main, but he questioned whether the
therapeutic talks with paranoiacs would accomplish very
much as a curative measure. In his experience there had
been no such beneficial results. He recalled one paranoiac
who, for ten years, had believed that he had been givmg
him poison. At first the patient was inclined to re-
taliate; he threatened, and made definite efforts to take
the life of the doctor's children. The man had some

no

MEDICAL RECORD.

[April 27, 1907

somatic symptoms which he himself attributed to the
poison which he thought had been given him. He still
has the delusions, but no longer attempts to execute his
threats. Another patient, a woman, for eight years had
believed that he had been turning an electric current upon
her for the purpose of annoying her. Every argument
had been used to convince her that this was impossible,
but without effect. As the disease progresses the reason
of such patients becomes enfeebled and less active, and
while they continue to have their delusions they become
accustomed to them and cease to react much to them.

Dr. William Hirsch thought that in forming a definite
opinion concerning the cases analyzed by Dr. Hoch, it
must first be determined whether one had to deal with
genuine paranoia, or with a paranoical state of another
disease. Genuine paranoia is always a congenital and
not an acquired disease, although the true paranoical symp-
toms often do not manifest themselves during the earlier
part of life. But there is always a congenital condition,
a constellation of mental factors, which not only pre-
disposes to, but which necessarily develops, at some time .
of life, such a combination as to produce that mental con-
dition known as paranoia. When such a point in any
given case would be reached cannot be determined in ad-
vance, but we are, in most cases, able to predict the
development of a true paranoia. Various conditions, such
as environment, worry, etc., might have something to do
with it, at least with a premature manifestation of the
condition. He did not believe, however, that in any
given case anything could be done to prevent the mani-
festation of the paranoical condition, even though it were
recognized that the development of such a condition
existed. This opinion was not based merely on theory.
In his practice he had had children brought to him whose
parents realized that they were a little peculiar, nothing
more, but whom he recognized as abnormal individuals
who in later life would become paranoiacs. In such of
these cases as he had been able to follow for ten or
fifteen years he had found that they developed genuine
paranoia in spite of all the precautions w'hich had been
taken. He had warned the mother not to let the child
have any impressions which would stimulate the imagina-
tion or fancy of the child, not to let it read any fiction,
to guard it against any undue emotions ; all this was carried
out with the greatest care. But at some time in life,
generally after an unusual emotion, such as falling in love,
slight business troubles — something which otherwise would
be of no importance — would develop a true paranoia. A
normal individual, normal from the start, would never
develop paranoia. A normal individual might develop
melancholia, or some other acute disease, but never par-
anoia. When he said one must differentiate between types
he meant cases in which there was genuine paranoia and
those in which there was a paranoical state. The para-
noical state might occur in a great many psychoses. He
had seen such a case lately. A man of si.xtj' j'ears of
age, a good business man, perfectly normal all his life,
suddenly developed a paranoical condition ; he had delu-
sions and hallucinations, imagined there was a conspiracy
against him, that his neighbors tried to kill him, etc.
After remaining in this condition for nine months he grad
ually became demented. He is still living, and is suffering
from a condition of general arteriosclerosis. The case
could be defined as dementia senilis, but not as paranoi-i.

Dr. P. C. Kn.\pp of Boston thought it a mistake always
to regard delusions of persecution, with hallucinations of
one form or another, as constituting paranoia, and that
we should be guarded in speaking of such conditions as
paranoiac states. He agreed entirely with Dr. Hirsch's
opinion that true paranoia, while not a congenital condi
tion, is dependent upon a congenital malarrangement, so to
speak, of the brain. Tanzi had taken the same position,
viz., that, whereas other forms of mental disease might be

spoken of as true diseases, paranoia was not a disease, but
a morbid congenital state which, later in life, unde' the
influence of various factors, might develop into typical
paranoia with hallucinations and delusions. He thought
that the "undercurrent" did not always "break through."
In this connection he cited the case of a woman who. for
years had had a limited type of delusion. She had lived a
secluded, narrow life in one of the smaller New England
cities ; for many years she had been active in the care
of her household and family and in church work ; she had
been trained in the old New England habit of keen theo-
logical discussion and argument, and for many years ;he
had had the very definite idea that she had been excom-
municated from the church. In the main the idea had
been suppressed, many of her church associates did not
know of it, and those who did kept it secret. The idea ex-
isted for many years without going on to any real mental
disturbance. Cases were not uncommon in which the de-
lusions occupied a limited field in the consciousness and
affected but little the conduct. With a true parar.oiac,
however, he questioned very much the real importance of
any emotional stress, or of any psychical ideas as influenc-
ing materially the genesis of the disorder. They might
influence the development in so far as changes in mode.rn
belief influence the character of delusions. As Dr. Hirsch
had suggested, it was impossible to protect these patients
from all influences that might give rise to the condi-
tion. Not infrequently delusions of persecution developed
in normal individuals in connection with hallucinatory con-
ditions having a distinctly physical basis. He had recently
seen such a case, a man with well systematized delusions on
an alcoholic basis, derived largely from tactile disturb-
ances, which proved to arise from the paresthesias of a
very mild alcoholic neuritis.

Dr. Pierce Clark was of the opinion that the cases
cited by Dr. Hoch might be called paranoid states rather
than typical or true paranoia. The therapeutic sugges-
tions outlined would be of undoubted value in these para-
noid states. During the past three years he had been
treating several cases by analyses and talks, and the
method had been very advantageous. He thought the
method was of little use in true paranoia, as the mental
state was too fixed ; his experience in asylum service had
proved this fact to his entire satisfaction.

Dr. SwEPSON J. Brooks of Harrison, N. Y., was very
glad to know of the success Dr. Hoch had had with thera-
peutic talks. He had tried this plan and found it pro-
ductive of results in many cases, but the patients would
relapse into the old condition after being released from
institutions. He presumed that Dr. Hoch had reference
in his paper to simple paranoid states. The question of
paranoia was a hard one to go into, and sometimes one
almost concluded that paranoia and paranoid states were
the same, only differing in degree. The forcing of pa-
tients to do things, as suggested by Dr. Hoch, was often
neglected. He had in mind two cases in which it certainly
had a very salutary effect. One case was a woman,
forty-five years of age, who had delusions of persecution.
She was put in a very quiet hall. She complained that she
was merely brought to the place to be put in jail, that
there were no sick people there, and that she would like to
see some sick people. She was allow'ed to see some sick
patients ; the next morning she was convinced, and she
got well. That was four years ago and she had remained
well since. The other case was of the manic-depressive
type. The patient confessed after her recovery that her
family physician had had to force her to take medicine,
that he would stand her up against the wall and knock
her head against it if she did not take the medicine, and
that she believed his method did good.

Dr. Smith Ely Jelliffe said that Dr. Hoch's paper had
offered glimpses into a large and but partly explored
territor}'. To him, four different trends of thought were

April 27, 1907]

MEDICAL RECORD.

711

suggested, all of which were the subjects of much inves-
tigation. In the first place, the importance of the study
of the mental development of the child w^as emphasized.
The work of Weygandt, on Abnormal Children ; of Koch,
on Pathological Inferiority; of Hall, in his masterly work
on Adolescence; and of Sommer, on Character and Per-
sonality, were instances in point as to the activity of these
lines of investigation. As to the psychogenic origin of
certain types of delusions, Dr. JellifTe was in accord with
Dr. Hoch. He spoke of the help that might come from
the literary side, as evidenced by the stories of Henry
James, "The Turning of the Screw." and "The Two
Magics"; Weir Mitchell's "Constance Trescott," and
Ansty's "Statement of Stella Maberly." In all these this
type of delusion formation is beautifully brought out, with
great literary charm, if not with scientific pedantry. Thera-
" peutically, he ileemed Dr. Hoch's paper as stimulating,
and he himself regarded certain phases of the subject
with optimism. Paranoia, he said, was too large a term
to use in a general blanket manner. While it is true that
little can be accomplished by the most tactful of psycho-
therapeutic conversations in chronic lunatics -who have
been in the asylums for years, yet the important factor in
the whole problem is to recognize the beginning stages, be-
fore the delusional ideas have become too firmly crystal-
lized. Greater success had not been attained because the
psychogenic origin of many delusional states' had not
been sufficiently understood. It required a rare tact to
work on these patients, and the outlines given by Dubois.
Dejerine, and Oppenheim were but the beginnings of a
scientific psychotherapy which for some time had been
grasped at by pseudoscientists. Dr. Jelliffe desired to
rank himself with those who saw a hopeful outlook for the
amelioration, if not cure, of certain cases of dementia
' praecox, and of the paranoid states, by early and intelligent
psychotherapy.

Dr. George H. Kirbv had been interested of late in the
management of paranoic states along the lines suggested
by Dr. Hoch, and thought that much could be accomplished
in this way toward the correction of morbid trends. Dr.
Hoch's work was particularly important in regard to the
study of delusions in general. Such a method of analysis
opened the way to an understanding of certain mechanisms
which heretofore had been practically inaccessible.

Dr. Hoch, in closing the discussion, stated once more
that what he wished to bring out was the fact that certain
paranoiac states were produced by purely mental causes.
i.e. by conflicts and unhygienic ways of dealing with
them, and that they were more or less amenable to treat-
ment early in the course, but that naturally he did not
mean to claim that old cases of paranoia could thus be
influenced. It was necessary in order to help such cases
that one could still get at the root of things and explain
to the patient the genesis of his delusions and train him
to healthy mental habits. The criticism that his cases
were not cases of typical paranoia, he could not quite under-
stand, because he was unable to see where the line could
be drawn between cases such as his and cases of so-
called typical paranoia. Again, to say that paranoia was
caused by heredity was an exceedingly unsatisfactory way
of stating the situation because it did not mean enough.
He had claimed that some paranoiac states were due to
an unhealthy dealing with conflicts. Such an unhealthy
dealing may be due to tendencies which were uMrc or
less inherited, but that it was time to make an attempt
at determining what these tendencies were, because the
mere statement of heredity was absolutely barren, that
the same may be said about the statement which had been
made that paranoia was due to a congenital malarrange-
mcnt. If Dr. Hirsch said that a normal individual would
not develop paranoia, this was doubtless true, if by normal
individual was meant one who had perfectly healthy mental
habits.

^tatp Iflfftiral SittFuatUij i&cuxths.

STAIT': BOARD KXAMl NATION QUESTIONS.

Oklahoma Territorial .\Ieuical Kxamining Board,

December iO, 1906.

ANATOMY.

1. Describe the femur, its articulations and what por-
tions of it are not covered by periosteum.

2. Give the number of sutures and fontanelles in the
skull, and by what and how is each formed?

3. Where is tlie reticular elastic cartilage found, and
locate the coracoid and acromion process.

4. Give origin, insertion and uses of the following mus-
cles; trapezius, supinator-longus, latissimus-dorsi, internal-
oblique and the gracilis.

5. Describe the right ventricle of the heart, give its
capacity and name the valves connected with the ventricle.

6 and 7. Locate and give uses of the Fallopian and
Eustachian tubes, lacrymal duct, prostate gland. cr\stalline
lens, antrum of Highmore, clitoris, spleen, ureter, supra-
renal capsule, the abdominal and thoracic cavities.

8. Give origin and branches of inferior dental and the
mastoid arteries.

9. Name the bones, main nuiscles, arteries, nerves, and
other fascia gone through in amputating leg at the thigh.

10. Enumerate the changes the bones of the lower jaw
undergo in very aged persons.

physiology.

1. Define special and comparative physiology.

2. Name the digestive juices and the organs that pro-
duce them, and give their actions on bread, eggs, milk, and
butter.

3. Name the ferments found in the digestive juices and
give source of glycogen and dextrose.

4. Give the composition of normal and healthy urine,
and of urine in a case of diabetes mellitus.

5. Give structure and functions of the liver and kidneys.

6. Where and how is urea formed, and give cause of
rigor mortis.

7. How do the products of digestion find their way
into the blood?

8. What would be the results of eating in excess of
albuminous, oleaginous, and farinaceous foods.

9. Give the changes of the air in respiration and the
respiratory changes in the blood.

10. Name the heat-producing tissues of the body.

CHEMISTRY AND URANALYSIS.

!. Define (a) chemistry, (b) matter, (c) atom, (d)
molecule, (e) element.

2. Differentiate between chemical and physical changes
in matter and illustrate.

3. Define chemism, atomic weight, specific gravity.

4. Name the alkaline elements; give symbols for the
gaseous elements.

5. Name two ic and two ous salts of mercury and give
formula.

6. Give common name, fornnila, and uses of four zinc
salts.

7. Give common names of following formula, CO»,
H:0=, FeSO., NACl, HgCl=.

8. Give chemical name and formula of borax, marble,
blue vitriol, Rochelle salts, oil of vitriol.

Q. Discuss arsenic, mention its properties, compounds,
and uses.

10. Name four normal, and give in detail tests for four
abnormal constituents of urine.

MATERIA MEDICA AND THERAPEUTICS.

1. Give therapeutics of quinine, iron, strychnine, digitalis.

2. Give dosage of remedies you use in pneumonia, mem-
branous croup, typhoid fever.

•It Is proposed In this department to publish from time to
time the examination papers of the various State Boards,
In order that a candidate may become familiar with the
character of the examination and so in some measure free
himself in advance from the nervousness and dread which
the unknown inspires. In furtherance of the same object
answers to some of the questions will be published in order
to show the candidate what the examiners expect of him.
Not all the questions of all the papers will be so treated,
for the answers to many, especially In the anatomical papers,
are obvious or can be found in the index of any text-
boolc on the subject; the answers to other questions, especially
In the surgical papers, must sometimes be omitted because of
the space they would demand. The candidate for a medical
license will not find in these answers a short and easy road to
success in the examination, for he is not llltely to meet the
same questions in the papers placed before him by the
examiners. The object of publishing- the questions and
answers is only, as noted above, to acquaint the candidate
with the general character of these examinations and to
ln«pire him with confidence in the result of his trial.

712

MEDICAL RECORD.

[April 27, 1907

3. Give dosage and indications for four remedies you
use in jaundice, rheumatism, nnlarial fever.

4. Give habitat, preparation, dosage, and uses of twelve
leading remedies you carry in your medicine case.

5. Give indications that guide you in the use of each
of the remedies you mention in answer to previous ques-
tion.

PHYSICAL DIAGNOSIS AND PATHOLOGY.

1. Name the topographic lines of the thorax, outline
and locate the heart's area of absolute dullness and the
upper border of the normal liver.

2. Describe the usual course of parenchymatous ne-
phritis, also interstitial nephritis. In what class of patients
is the latter most frequently observed? How would you
differentiate one from the other?

3. Under what conditions would occur a physiological
leucocytosis? Under what pathological conditions would
you expect to find a polymorphonuclear leucocytosis? A
lymphocytosis?

4. Designate which component part of the spinal cord is
involved in locomotor ataxia and describe the metamor-
phosis of structure characterizing the pathological process.

5. What pathological changes occur in cirrhosis of the
liver?

6. Give differential diagnosis between septicemia and
pyemia.

7. Give the principal diagnostic points of difference be-
tween mitral regurgitation and aortic regurgitation.

8. Give differential diagnosis between scarlet fever and
erysipelas in their early stages.

g. Give differential diagnosis between phlebitis and
lymphangitis.

10. Give differential diagnosis between variola and vari-
cella.

PRACTICE OF MEDICINE.

1. What are the intrinsic and extrinsic causes of dilata-
tion of the heart with broken compensation? How would
you treat the latter condition when very extreme?

2. Describe Bell's paralysis, Cheyne-Stokes respiration.

3. What are the early manifestations of pulmonary
tuberculosis and give your method of management in a
case.

4. Give the etiology, pathology, symptoms, treatment,
dietetic, medicinal, hygienic and prophylatic of enterocolitis.

5. Give symptoms and treatment of acute ptomaine
poisoning.

6. Give symptoms and treatment of pulmonary edema.

7. Give cause, symptoms, and treatment of herpes
zoster.

8. Name one infectious and one contagious disease and
give diagnosis of the diseases named.

9. Describe a case of uremic coma and your treatment
for same.

10. Give symptoms and diagnosis and treatment of fol-
licular tonsillitis.

OBSTETRICS AND GYNECOLOGY.

1. Define menstruation, give duration, age of appearance
and cessation, and abnormal manifestations.

2. Name and give measurements of female pelvis; of
fetal head.

3. Give briefly the anatomy of uterus, ovaries, placenta.

4. Give theory of menstruation; of conception.

5. Name the three important forms of hemorrhage met
with in obstetric practice and give causes and treatment of
each.

6. Define ectopic gestation, caput succedancum, vitellus,
amnion.

7. Into what stages is labor divided, and where does
each stage begin and end?

8. How would you treat mastitis, puerperal eclampsia?

9. Give in detail technique of repairing laceration of
perineum involving floor of vagina.

ID. How would you prepare your patient for delivery
and yourself for attendance in a case of labor?

SURGERY.

1. Diagnose, give prognosis and treatment of the follow-
ing diseases: Erysipelas, rhinitis, pyemia, and traumatic or
surgical fever.

2. Describe and differentiate the following, viz. : Con-
cussion and contusion, an incised, punctured, lacerated,
gunshot and poisoned wounds.

3. Give signs of fracture, dislocation, reduction, and the
process of repair.

4 and 5. Give differential diagnosis and treatment of
fracture of the surgical neck, capsular fracture of the
femur, and a case of hip joint disease.

6. Define and give treatment of tinea-vcrsicolor. tinea-
circinatis, herpes zoster, and scabies.

7. How would you diagnose? Give prognosis and
treatment of septicemia, pyemia, and septicopyemia.

8. Give differential diagnosis between coma the result
of an injury and that produced by opium poisoning, alco-
holic intoxication, apoplexy, and uremic poisoning.

9. Describe and give treatment of hydrocele, hypospa-
dias, varicocele, hematocele, and epispadias.

ID. Give symptoms, prognosis, and technique of the
operation for an ectopic gestation, or an extrauterine preg-
nancy.

MEDICAL JURISPRUDENCE.

1. In a medicolegal sense, what constitutes a dying
declaration and what is necessary to make it evidence in
a court of justice, and how should it be taken?

2. Determine in a case of supposed infanticide whether
the child was still-born or killed after birth.

3. What are the symptoms and treatment of corrosive
sublimate poisoning?

4. \\. what period will a body float after being drowned ?

5. In a case of opium poisoning, what are the post-
mortem symptoms?

6. What is malpractice?

7. How would you treat a patient suffering from poison-
ing by coal gas?

8. What are the symptoms and treatment for poisoning
by the castor bean and what is considered a lethal dose?

9. What are symptoms of poisoning by wood alcohol
and treatment for same?

10. Give symptoms and treatment for poisoning by tur-
pentine taken internally.

.WSWERS TO STATE BOARD EXAMINATION
QUESTIONS.

OKLAHOMA TERRITORIAL MEDICAL EXAMINING BOARD.

December 26, 1906.

AN.«0MY.

3. Reticular elastic cartilage is found in the external
ear, in the Eustachian tube, in the epiglottis, in the cartil-
ages of Santorini and of Wrisberg in the larynx.

9. Bone: the femur. Main muscles: rectus femoris,
vastus externus, crureus. vastus internus. biceps, semiten-
dinosus, semimembranosus, adductor magnus, gracilis,
adductor longus. sartorius. Arteries: femoral, profunda
femoris. Nerves : great sciatic, small sciatic, e.xternal cut-
aneous, middle cutaneous. Fascia : superficial fascia, fascia
lata. _ ■

10. "The changes which the lower jaw undergoes after
birth relate (i) to the alterations effected in the body of
the bone by the first and second dentitions, the loss of
teeth in the aged, and the subsquent absorption of the
alveoli: (2) to the size and situation of the dental canal,
and (3') to the angle at which the ramus joins with the
body.

"At birth the bone consists of lateral halves, united by
fibrous tissue. The body is a mere shell of bone, contain-
ing the sockets of the two incisor, the canine, and the two
temporary molar teeth, imperfectly partitioned from one
another. The dental canal is of large size, and runs near
the lower border of the bone, the mental foramen opening
beneath the socket of tlie first molar. The angle is obtuse
( I7S degrees), and the condyloid portion nearly in the same
horizontal line with the body; the neck of the condyle is
short, and bent backward. The coronoid process is of
comparatively large size, and situated at right angles with
the rest of the bone.

"After birth the two segments of the bone become joined
at the symphysis, from below upward, in the first year; but
a trace of separation may be visible in the beginning of
the second year near the alveolar margin. The body
becomes elongated in its whole length, but more especially
behind the mental foramen, to provide space for the three
additional teeth developed in this part. The depth of
the body becomes greater, owing to increased growth of
the alveolar part, to afford room for the fangs of the
teeth, and by thickening of the subdental portion, which
enables the jaw to withstand the powerful action of the
masticatory muscles : but the alveolar portion is the deeper
of the two. and, consequently, the chief part of the body
lies above the oblique line. The dental canal after the sec-
ond dentition is situated just above the level of the mylo-
hyoid ridge, and the mental foramen occupies the position
usual to it in the adult. The angle becomes less obtuse,
owing to the separation of the jaws by the teeth. C.^bout
the fourth year it is 140 degrees.")

"In the adult the alveolar and basilar portions of the
body are usually of equal depth. The mental foramen opens
midway between the upper and lower border of the bone,
and the dental ciual runs nearly parallel with fhe mylo-

I

April 27, 1907]

MEDICAL RECORD.

7^3

hyoid line. The ramus is almost vertical in direction, and
joins the body nearly at right angles.

"Ill old age the bone becomes greatly rednced in size ;
for with the loss of the teeth the alveolar process is ab-
sorbed, and the basilar part of the bone alone remains;
consequently, the chief part of the bone is bchrn.' the
oblique line. The dental canal, with the mental foramen
opening from it, is close to the alveolar border. The rami
are oblique in direction, the angle obtuse, and the neck of
the condyle more or less bent backward." (.Gray's An-
atomy.)

PHYSIOLOGY.

1. Sltccial Physiology treats of the nature and function
of particular organs, as the lungs, heart, etc.

Comparative Physiology treats of the study and compari-
son of the physiology of different animals (or plants).

2. The digestive juices are: (i) Saliva, produced by
the salivary glands (parotid, submaxillary and sublingual).
(2) Gastric juice, produced by the stomach. (3) Pancre-
atic juice, produced by the pancreas. (4) Succus entericus,
produced by the small intestine. (5) Bile, produced by the
liver.

Bread consists of proteid, fat, and carbohydrate; eggs
of proteid and fat; milk of proteid, carbohydrate, and fat;
butter of fat. and a little proteids. They all contain water.

For the effect of the digestive juices on these constitu-
ents, see ne.xt answer.

3 —

Ferment

Fl'nction

Saliva

Changes starch into dex-
trin and sugar.

Pepsin

Changes proteids into pro-
teoses and peptones in

Gastric juice

an acid medium.

A curdling ferment.

Curdles the casein of
milk.

Trypsin

Changes proteids into pro-
teoses and peptones, and

afterwards decomposes

•

them into leucin and
tyrosin; in an alkaline

Pancreatic juice. . . .

medium.

Amylopsin

Converts starches into
maltose.

Steapsin

Emulsifies and saponifies

fats.

A curdling ferment . .

Curdles the casein of
milk.

Glycogen is formed in the liver, chiefly from the carbo-
hydrates of the food, and also from the proteids.

Dextrose is derived from the digestion of starch and
cane sugar.

4. The following table (from Dunglison's Medical Dic-
tionary) gives the average composition of normal urine:

Water gso.oo

Urea

Uric acid

Hippuric acid

Creatinin

Extractives

Sodium chloride. . . .

Phosphoric acid

Sulphuric acid

Lime (CaO)

M agnesia ( MgO ) . . . .
Potash (K2O) and soda,
(NaaO)

(Parts in

Voided P

ER Day

looo.)

Grains

Grams

gso.oo

28.00 1
0.60
0.3s
0.65
8.00
8.00

Organic

matter,

37-6o

520.80

11 . 16

b.fi

12.00

148.80

14S.S0

35 00
0-75
0.44
0.81
10.00
10.00

2.00
0.25

Inorganic
matter.

37.20
23.45
4.65

2. so

1.56
0.31

0.30

12.40

s-ss

0.37

0.60 .

II. 16

0.7S

Total 1000 . 00

62.49

In diabetes mellitus the total quantity voided is greatly
increased, the specific gravity is higher, and it contains
amounts of sugar varying from an ounce to two pounds
per day; the urea and uric acid are also increased.

5. The functions of the liver are: (l) The secretion of
bile, (2) the formation of glycogen, (3) the formation of
urea and uric acid, (4) the manufacture of heat, and (5)
the conversion of poisonous and harmful into inert ma-
terial.

The functions of the kidney are: (i) The secretion of
urine, and (2) the secretion of an "internal secretion."

6. Urea is formed in the liver, from proteids, by a pro-
cess of hydrolysis and of oxidation.

Rigor mortis is caused by the lowering of the body tem-
perature and the coagulation of the albumin of tlie mus-
cles.

7. By absorption throu,gh the portal vein and the lac-
teals. The portal vein absorbs the greater part of the
water, salts, peptones, sugar, and soaps, and a trace of fats.
The lacteals absorb the greater part of the fat, some water,
and peptones, and a trace of salts and sugar.

8. "Albuminous food in excess promotes the arthritic
diathesis, manifesting itself as gout, gravel, etc. Oleaginous

food in excess gives rise to the bilious diathesis. Farina-
ecous food, when long continued in excess, favors the
rheumatic diathesis by the development of lactic acid." —
(Brubaker.)

9- The changes of the air in respiration are shown in
the following table :

In-spired Air

Expired Air

O.xygen

16.6 per cent.
79 per cent.
4.4 per cent.
Often present.
Saturated.
That of body.

Other gases

Watery vapor

Rare

Variable

Variable

Bacteria

Dust..-

Always present

Always present

None.
None.

The respiratory changes in the blood: (i) In the lungs,
the blood is changed in color, gains oxygen, loses carbon
dioxide, loses heat, and loses watery vapor. (2) In the
eafillaries of the body, the blood loses oxygen and receives
carbon dioxide.

ID. The heat-producing tissues of the body are: (l)
The muscles, during contraction; (2) the secreting glands,
during functional activity; (3) the brain, during mental
activity; (4) all the tissues of the body are capable of add-
ing to the total amount of body heat, but the first three
named are the chief contributors.

CHEMISTRY AND URANALVSIS.

1. Chemistry is that branch of science which treats of
the composition of substances, their changes in compo-
sition, and the laws governing such changes.

Matter is that which occupies space, or is evident to one
or more of the senses.

An atom is the smallest quantity of an element that can
enter into chemical action.

A moleeule is the smallest quantity of any substance (ele-
ment or compound) that can e.xist in a free state.

An element is a substance which cannot by any known
means be split up into two or more dissimilar substances.

2. ".\ bar of soft iron may be made to emit light when
heated, or soimd when caused to vibrate, or magnetism
when under the influence of an electric current. Under
the influence of these physical forces the iron suft'ers no
change in composition, and, on cessation of the action of
the inciting force the iron returns to its original condition.
But if the iron be heated in an atmosphere of oxygen, both
the iron and a part of the oxygen disappear, and a new
substance, a new chemical species, is produced, having
properties of its own. different from those of either tlie
iron or the o-xygen. In this case there has been chemical
action, causing change of composition, as the new sub-
stance contains both iron and oxygen. The result of such
action is, moreover, permanent, and the new product con-
tinues to exist, until modified by some new manifestation of
chemical action."— Witthaus' Manual of Chemistry.)

3. Chemism is the force which holds together the atoms
in a molecule.

.4lomie weight is the weight of an atom of an element
as compared with the weight of an atom of hydrogen.

Specific gravity is the weight of a substance compared
with the weight of an equal volume of another substance
taken as a standard.

4. The alkaline elements are: (l) The alkali metals:
lithium, sodium, potassium, rubidium, cesium, and (2) the
metals of the alkaline earths : calcium, barium, strontium.

The symbols of the gaseous elements are: H, O, F, CI,
N, He. Ne, A, Kr, and Xe.

.S. Mercuric chloride. HgCU; mercuric oxide, HgO ;
mercurous chloride. HgiCU; mercurous oxide, Hg=0.

6. (i) Zinc chloride, butter of zinc, ZnCU, used as a
caustic, disinfectant, antiseptic, and for embalming.

(2) Zinc sulphate, white vitriol, ZnSO,, used as a styptic,
astringent, and emetic.

(3) Zinc oxide, tutty, ZnO, used in the arts as a pig-
ment.

(4) Zinc carbonate, calamine, ZnCOj, used as a dusting
powder and astringent.

7- CO2, common name carbonic acid: 11=0:. onnnon
name peroxide of hydrogen : FeSOi. common name green
vitriol, or copperas; NaCl, common name table salt:
HgCl:. common name corrosive sublimate.

8.—

Borax

Marble

Blue vitriol. . .
Rochelle salts
Oil of vitriol. .

Chemical Xame

F"kMULA

Disodic tetraborate

Calcium carbonate

Cupric sulphate

Potassium sodium tartrate.
Sulphuric acid

Na . B, O7
Ca CO,-,

KXaC, H^Ob
H., SO,

714

MEDICAL RECORD.

[April 27, 1907

9. Arsenic is an element, with atomic weight of 75,
molecular weight 300, valence three or hve; the molecule
contains four atoms. It occurs chiefly in combination in
orpiment, realgar, mispickel or iron pyrites. It is a crys-
talline solid or an amorphous powder; the vapor has an
odor of garlic; it is insoluble in water; it unites with
nascent hvdrogen ; it burns m oxygen; on being hejited in
air it is converted into arsenic trioxide, As^Oa. It is used m
the manufacture of shot, flypapers, fireworks, and pigments.
Its chief compounds are: Hydrogen arsenide, arsenic tri-
chloride, arsenic trioxide. arsenic pentoxide, ar.senous acid,
arsenic acid,- arsenic bisulphide, arsenic trisulphide, arsenic
pentastdphide.

10. l-'our normal constituents of urme : Water, urea,
uric acid, and sodium chloride.

Test for (l) /Ubumin: The urine must be perfectly
clear. If not so, it is to be filtered, and if this does not
render it transparent it is to be treated with a few drops of
magnesia mixture, and again filtered. The reaction is then
observed. If it be acid, the urine is simply heated to near
the boiling point. If the urine be neutral, or alkaline, it is
rendered faintly acid by the addition of dilute acetic acid,
and heated. If albumin be present, a coagulum is formed,
varying in quantity from a faint cloudiness to entire solidi-
fication, according to the quantity of albumin present. The
coagulum is not redissolved upon the addition of HNO3.

Test for (2) Sugar: Render the urine strongly alkaline
by addition of NajCOj. Divide about 6 cc. of the alkaline
liquid in two test tubes. To one test tube add a very
minute quantity of powdered subnitrate of bismuth, to the
other as much powdered litharge. Boil the contents of
both tubes. The presence of glucose is indicated by a dark
or black color of the bismuth powder, the litharge retaining
its natural color.

Test for (3) Acetone: Add a few drops of a freshly pre-
pared solution of sodium nitroprussid, and then KHO or
NaHO solution, when, in the presence of acetone, the
liquid is colored ruby red. and on supersaturation with
acetic acid changes to purple.

Test for (4) Indican: The urine is mixed with one-fifth
its volume of 20 per cent, solution of lead acetate and fil-
tered. The filtrate is mixed with an equal volume of fuming
hydrochloric acid containing 3:1000 of ferric chlorid, a few
drops of chloroform are added, and the mixture strongly
shaken one to two luinutes. With normal urine the chloro-
form remains colorless, or almost so: but if an excess of
indoxyl compounds be present the chloroform is colored
blue, and the depth of the color is a rough indication of the
degree of the excess.

— (From Witthaus' Essentials of CItemislry.)

PHYSICAL DI.AGNOSIS .\ND P.\THUI.0GV.

I. The topographic lines of the thorax are Lerlical tines
and horizontal lines, as follows:

"The 'certieal lines are from front to back: fi^ The
midsternal line and its prolongation upward. (2) The
sternal line, corresponding to the lateral border of the
sternum. (3) The [>arasiernal line, midway between (2).
and (4) The mamillary' or nipple line, which, even in the
male thorax, does not always pass through the nipple, but
may be more exactly defined as a vertical line dropped
from the center of the clavicle. (5) The anterior axillary
line, drawn through the point at which the great pectoral
muscle cleaves the chest wdien the arm is raised sidewise to
a horizontal line. (6) The middle axillary line, drawn
through midway between (5) and (") The posterior axil-
lary line, which is drawn through the point at which the
latissimus dorsi leaves the chest, the arm being raised as
in (5). (8) The scapular line, drawn through the inferior
angle of the scapula. (9) The midspinal line.

"The ho.rizontal lines are. in front and at the side, from
above downward: (i) A line running frpm the cricoid
cartilage to the outer end of the clavicle. (2) The line
of the clavicles. (3) A line through the third chondro-
sternal articulation. (4) A line through the sixth chondro-
sternal articulation. Posteriorly they are: (51 A line
through the spines of the scapul;e. (6) A line through the
inferior angles of the scapulae. (7) A line through the
spine of the tw-elfth dorsal vertebra."— (Butler's Diagnos-
tics of Internal Medicine.)

3. A physiological leucocytosis is found : In the new-
born, after parturition, after exertion, after a cold bath or
massage, during pregnancy, and during digestion.

A polymorphonuclear leucocytosis is found in all acute
inflammatory diseases, in certain of the acute infectious
diseases, and accompanying the cachexia of malignant dis-
ease.

A lymphocytosis is found in lymphatic leukemia, and
sometimes in sarcoma, and whooping cough.

4. In locomotor ataxia the posterior columns of the
spinal cord and the posterior nerve roots are involved.

The process is destructive and progressive ; it is not a
simple wasting, although the nerve fibers are atrophied,
but it is characterized by irritation, changes in the axis
cylinders, overgrowth of the connective tissue, and some-
times congestion. The spinal ganglia may be affected; the
membranes over the affected parts are adherent and opaque.

6. Septicemia begins with a rigor, followed by a rise of
temperature up to about 104° F., which remains constant.
The pulse is weak and progressively rapid ; there is an-
orexia and constipation, which is followed by diarrhea; the
urine contains albumin ; the temperature may become sub-
normal. There are no repeated rigors and no secondary
(metastatic) abscesses.

Pyemia begins with a rigor, which may last for half an
hour, and is repeated every one or two days. The temper-
ature rises as in septicemia, but rapidly falls, and at the
same time the patient suffers a profuse perspiration. The
pulse is weak and rapid ; there is anorexia ; and there may
be delirium, with jaundice and signs of abscesses in the
lungs, joints, etc. In pyemia there are repeated rigors and
secondary abscesses.

7. In mitral regurgitation there is a systolic murmur,
heard loudest at the apex, transmitted toward the left
axilla, and often heard at' the angle of the left scapula.
The heart is enlarged.

In aortic regurgitation there is a diastolic murmur, heard
loudest at the second interspace, transmitted down the
sternum. The left ventricle is hypertrophied. There will
also be present Corrigan's pulse, and pulsating arteries in
the neck.

8. In erysipelas the rash is local: it is not punctate; the
surface of the skin is smooth and edematous; bullae are
often present, and have a well-defined margin ; the skin
of the affected part is burning, tender, tense, and painful.

9. Phlebitis is apt to begin in a varicose vein ; the vein
is felt as a hard cord; edema is present, and the skin has
a dusky hue.

Lymphangitis generally begins in a sore, the neighboring
lymph glands are involved, it tends to spread in a spiral
line, and the skin has a rosy tint, which appears before
the edema.

10. (i) Very young children are attacked with vari-
cella, whereas variola usually shows itself in adults. (2)
Vaccinated children readily take varicella; not so variola,
even in the modified form. (3) Children who have had
varicella may contract variola, even soon afterwards ; or
the two diseases may co-exist. (4) Varicella is non-inoc-
ulable. w'hereas variola is notoriously so. (5) The erup-
tion of varicella appears in twenty-four hours ; that of
variola not till the third day. (6) The febrile symptoms
continue after the eruption appears in varicella ; those of
variola subside. (7) In varicella the spots come out in
successive crops ; this is never seen in variola. (8) The
■pots in varicella are unilocular, and collapse on being punc-
tured; the spots in variola arc multilocular. and do not
collapse on being punctured. (9) In varicella the erup-
tion is very irregular, and appears over the body generally;
m variola it appears in groups of threes and fives, and is
always seen on the limbs. (10) The papule in varicella
IS soft, and disappears on stretching the skin ; in variola
it is hard and shotty, and does not disappear on stretching
the skin. (From J. W. Moore's work on Variola and
I 'aricella.)

PR-\CTICE OF MEDICINE.

2. In Bell's paralysis "the muscles of the face being
.ill powerless, the countenance acquires on the paralyzed
Mde a characteristic, vacant look, from the absence of all
expression ; the angle of the mouth is lower, and the par-
alyzed half of the mouth looks longer than that on the
other side ; the eye has an unmeaning stare, owing to the
paralysis of the orbicularis palpebrarum. All these pecu-
liarities increase the longer the paralysis lasts, and their
appearance is exaggerated when at any time the muscles of
the opposite side of the face are made active in any ex-
pression, or in any of their ordinary functions. In an at-
tempt to blow or whistle, one side of the mouth and cheeks
.icts properly, but the other side is motionless, or flaps
loosely at the impulse of the expired air ; so. in trying to
■^uck, one side only of the mouth acts : in feeding, the lips
and cheek are powerless, and. on account of paralysis of
the buccinator muscle, food lodges between the cheek and
the gums." — (Kirkes' Phvsiology.)

In Cheyne-Stokes respiration the respirations gradually
increase in volume and rapidity until they reach a climax,
when they gradually subside, and finally cease for from ten
to forty seconds, when the same cycle begins again.

3. The early manifestations of pulmonary tuberculosis

April 2-j, 1 907 I

MEDICAL RECORD.

are : ( i ) Physical signs : Deficient chest expansion, the
phthisical chest, slight ckilhiess or impaired resonance over
one apex, fine moist rales at end of inspiration, expiration
prolonged or high pitched, breathing interrupted, (2)
Symf'tonis : General weakness, lassitude, dyspnea on ex-
ertion, pallor, anorexia, loss of weight, slight fever, and
night sweats, hemoptysis.

OBSTETRICS .AND GYNECOLOGY.

2. The pelvic diameters are easily remembered from the
following table :

An'tero-posterior Oblique Transverse

Brim

Mid-plane. .
Outlet

4 inches , 4* inches .

4i " 4i

5 " 14* "

5 inches.

4*' ••

The fetal head has the following diameters ; Occipito-
frontal, occipito-mental, bitemporal, biparietal, suboccipito-
bregmatic, trachelo-bregmatic, and mento-bregmatic. Of
the.se the occipito-frontal is 45-'2 inches, the occipito-mental
is s'A inches, and all the others are approximately y/2 inches.

MEDICAL JURISPRUDENCE.

I. Any statement made by a dying person who believes
that he cannot recover and that he is, at that very time, in
actual danger of death. The statement need not be sworn to ;
it should be voluntary and sincere ; and it is admissible as
evidence in a court if the individual dies. An official or
someone else should take down the deposition in the e.xact
words of the patient, who should, if possible, sign the
declaration.

3. Syiiif'toiiis of poisoning by corrosive sublimate are:
A burning pain in the mouth, pharynx, and stomach ; the
mouth and tongue are white ; the vomitus is white, with
shreds of mucous membrane, and tinged with blood ; there
may be bloody stools, also salivation.

Ireatment : The antidote is white of egg, but too much
must not be given at one time ; this should be followed by
an emetic.

4. "The time at which the bodies of the drowned will
float varies with the temperature of the air, the water, the
age, sex, and corpulence. As the human body is slightly
heavier than water, it must remain submerged until it be-
comes lighter through the development of gases of putre-
faction. Hence, in summer the body may rise within
twenty-four hours. In salt water it will float sooner than
in fresh ; very fat bodies float sooner than lean ones ; the
bodies of women and those of young children sooner than
those of men. Hence, in infanticide by drowning, the in-
fant's body speedily rises to the surface." — (Reese's Medi-
cal Jurisprudence. )

5. "The postmortem appearances are neither certain nor
characteristic. There is usually some fullness of the ves-
sels of the brain ; occasionally, e.xtravasation of serum into
the ventricles, very rarely of blood. Sometimes there is
congestion of the lungs and other vascular organs. The
blood is apt to be fluid. The stomach and bowels may be
perfectly natural in appearance. The odor of opium may
be observed in opening the lx)dy. It is hence impossible to
diagnosticate a case of opium poisoning from the post-
mortem appearance exclusively." — (Reese's Medical Juris-
prudence. )

6. Malpractice is a failure on the part of a medical
practitioner to use such skill, care, and judgment in the
treatment of a patient as tlie law requires; and thereby the
patient suffers damage. If due to ne,gligence only, it is
civil malpractice. But if done deliberately, or wrongfully,
or if gross carelessness or neglect have been shown, or if
some illegal operation (such as criminal aJKirtion ) be per-
formed, it is criminal malpractice.

7. The patient should be removed to pure air; inject
normal saline solution; the patient should be bled; arti-
ficial respiration may be necessary; inhalations of oxvgen
under pressure have been reconunended. The body temper-
ature should be maintained by external heat.

8. The symptoms arc: Vomiting, purging, collapse;
the secretions ( including the urine) are suppressed, and tlic
pupils may be dilated.

Treatment: Emetics, lavage, and mucilaginous drinks,
with opium to relieve pain.
Lethal dose: Three beans have proved fatal.

9. Symptoms: Headache, verti.go. Ijlindness. we:ikness.
and neuritis.

Treatment : Lavage, and strychnine hynodcnnicallv.

10. Symptoms: Contracted pupils, odor of turpentine
on the breath, stertorous breathing, collapse, convulsions,
odor of violets to the urine.

Treatment: Lavage, Epsom salts, and mucilaginous
drinks, with opium. ,

BULLETIN OF .\PPR0ACH1NG EXAMINATIONS. t

STATE. NAME AND ADDRESS OP PLACE AND DATE OP

SECRETARY. NEXT EXAMINATIOV

AJaljama* W. H. Sanders. Montgomery. . Montgomery . . May 1-6

Arizona* Ancil Martin, Phoenix Phoenix July 1

Arkansas* F. T. Murphy, Brinkley Little Rock. . .Jul\ 9

Cahfomia Chas. I.. Tisdale. Alameda. . . .San Francisco. Aug. ;c

Colorado S. D. \^an Meter. 1723 Tre-

mont Street, Denver Denver July j

Connecticut*. . .Chas. A. Tuttle. New Haven. . New Haven. . . July o

Delaware I. H. Wilson. Dover Dover June 18

Dis. of Col'bia. .W.C.Woodward. Washington. Washington.. .July 1 1

Florida* J. D. Fernandez. Jacksonville. Jacksonville. .May 15

Georgia E R. Anthony. GrifTin I Au^sm!.' .' ..■.May'' 'I

Idaho J. L Conant. Jr. Genesee Boise .October i

Illinois. .
Indiana..

.1. A^Egan, Springtield.

.E. St. Louis.. ..May
T. Got't. 'i 20 State House.

Indianapolis Indianapolis. . May 28

Iowa Louis A.Thomas. Des Moines. .Des Moines . . .June —

Kansas T. E Raines. Concordia Topeka June 11

Kentucky* J. N. McCormack. Bowling

Green Louisville October 2 _•

Louisiana F. A. La Rue. 211 Camp St..

New Orleans New Orleans.. .May 9

Maine Wm. J. Mayburv. Saco Augusta July 9

Maryland J. McP. Scott, Hagerstown.. . .Baltimore June —

Massachusetts* E. B. Har\'ey, State House,

*^^ Boston Boston May 14

Michigan B. D. Hanson. 205 Whitney

Building, Detroit Ann Arbor. . . .June 11

Minnesota W. S Fullerton. St. Paul. . . .St. Paul June 4

Mississippi J. F. Hunter. Jackson Jackson May 14

Missouri J. A. B. Adcock. Warrensburgj KaiJ"sSsCity } ~~ ~

Montana* Wm. C. Riddell. Helena Helena October i

Nebraska Geo. H. Brash. Beatrice Lincoln

Nevada S. L. Lee, Carson City Carson City. . .May 6

N. Hamp're*. . .Henry C. Morrison. State Li-
brary, Concord Concord July 9

New Jersey l- ^ Bennett. Long Branch. .Trenton June 18

New Mexico. . . . B. D. Black, Las Vegas Santa Fe June

( New York,

New York C.F.Wheelock

of New York

N.Carolina*... .G. T. Sikes, Grissom Morehead City.May —

N.Dakota H. M. Wheeler. Grand Forks. .Grand Forks... July 2

Ohio Geo. H. Matson, Columbus... Columbus June 11

Oklahoma*. . . .J. W. Baker. Enid Guthrie June —

Oregon* B. E.Miller. Portland Portland May 8

Pennsylvania.. N. C. Schaeffer. Harrisburg. | pJ'^^buJ^'''* } J""= ~

Rhode Island.. .G. T. Swarts. Providence Providence.,

S. Carolina W. M. Lester. Columbia Columbia.

S. Dakota H. E. McNutt. Aberdeen Sioux Falls. .

f Memphis.
Tennessee* T. J. Happel, Trenton { Nashville. ^ May —

C Knoxville, J

Texas T. T- Jackson, San Antonio. . . Austin April 30

UUh* R. W. Fisher, Salt Lake City. .Salt Lake City. JuH- 7

Vermont W Scott Nay, Underbill Burlington. .. .July 9

Virginia R. S. Martin, Stuart Lynchburg.

Las Vegas Santa re..

t New York,
c Univ.of State ) Albany,
■k, Albany. . . . "i Syracuse.

( Buffalo.

Mav

...July 4

. . .June —
. . -July 10

Virginia R. S. Martin, Stuart Lynchburg.. . .June i

Washington*.. .C. W. Sharpies. Seattle Seattle July

W. Virginia*. . .H. A. Barbee, Point Pleasant .Charleston . . . .July

Wisconsin .|. V. Stevens. JefTerson Madison July

Wyoming b. B. Miller. Laramie Cheyenne. . . . June 19

*No reciprocity recognized by these States.

tApplicants should in ever>' case write to the secretary for latest
details regarding the examination in any particular Stale.

West Virginia. — L'nder the new law which took effect
on Feliruary i.i. 1907. undergraduates are no longer per-
mitted to take the State Board Examinations.

New York and Ohio. — Medical reciprocity no longer
exi^^ts between these two States.

Fibromyomata in Uteri of Defective Conformation. —

Andrea Boni describes an interesting case of fibromyo-
mata in a uterus which had a single cervix with double
vagina and fundus. The anomaly of the uterus was not
diagnosticated until the examination previous to operation
on the fibroids showed a double vagina, and the operation
showed a double fundus. There were fibromata of both
ftmdi, an ovarian cyst with a cystic lube on the right, and
enlarged adnexa on tlie left. The cause of this anomaly is
unknown, and we nuist he content to say that there is some
force which prevents the union of the two ducts of Miillerto
form a single fundus at an early period of intrauterine life.
The :iuthor has collected fifty-eight cases, to which he adds
his own. He finds that fibroids occur in anomalous uteri
most frequently between the ages of tliirty-five and forty-
five, and they are rare after fifty. They ;ire most frequent
in nullipara and bear some relation to the presence of ster-
ility. As uterus bicornis unicollis is the most frequent an-
omaly fibroids occur most frequently in that form. The
symptoms do not differ from those of ordinary fibroids,
and the diagnosis of the anomaly is usually made at the
operation for the removal of the tumor. — .-Irchivio Italiano
di liinecologia.

7l6

MEDICAL RECORD.

[April 27, 1907

Angina Pectoris. — During the attack Barber recom-
mends that amyl nitrite be inhaled at once; a capsule
containing three or five minims should be broken in a
handkerchief and the vapor inhaled; if this fails to
relieve in a minute or two chloroform may be tried,
which is best administered on a sponge in a smelling
bottle by the patient himself; and for pain which is
persistent, morphine, gr. 1-4 hypodermically, is required,
which in a feeble patient may be counteracted by an in-
jection of strychnine. At the same time, if at hand, the
following stimulant should be taken;

5 Spirit, ffitheris TIJ' xxx

Spirit, ammonii aromatici TIP xxx

Aquae camphorsE q. s. ad 5j

Or failing^that.i^f 3ss of brandy. ^' ^^ J 1

Erysipelas. — The following local application is recom-
mended by Meunier:

5 Menthol gr. xl

Pulv. camphorse gr. x

Olei betulas 3j

Guaiacol ITr x

Petrolati liq 3iij

Lanolini 3iv

M. S. : Apply locally with sUght friction.

— International Journal of Therapy.

Burns. — For burns of the third degree Prager uses the
following dusting powder:

Jt Iodoform 3i

Acidi borici ovii

M. S.: Apply locally over the area involved.
For extensive burns Leweson recommends the ap-
plication of a 6 per cent, solution of aluminum acetate.
After twenty-four hours' use of this a powder should
replace it:

IJ Zinci oxidi 3ii

Bismuthi subnit 3iv

Lycopodii 3i

M. S. : To be applied locally, freely.
For the pain of severe burns Dale advises first a hypo-
dermic injection of morphin and after the initial shock:

5 Chloral, hydrat gr. x

Sodii bromid gr. xx-xxx

M. S. : Give in water at a dose, and every three hours
until relief is obtained.

—.^ew York Medical]Journal.

Gonorrheal Rheumatism.

IJL Acidi salicylici oi

Mentholis gr. xv.

Guaiacolis oSS.

Alcoholis f3i

M. S. : To be painted over the affected areas, and the
parts covered with cotton and oil silk.

■ — Merck's Archives.

Iron-Lemonade.

B Tinct. ferri chlor oiv

Acidi phosphoric, dil ovi

Spt. limoius oii

Syrupi Svi

M. S. : A dessertspoonful, in water, after meals.

GOODELL.

Dermatitis Venenata. —

5 Sodii hyposulphit 3i

- Menthol gr. v

Spir. vini rect oi

Spir. ceth. nit 3i

Aquas dis ad Oi

M. S.: Apply locally.
^ i ^ '^ < j( •. — Medical Times and Hospital Gazette.

Chamomile Enema. — For obstinate postoperative in-
testinal atony the following is often successful:

5 Infus. chamomil 3viii

01. terebinth rect oii

Carbo. lig 3ii

-Aq. menth. pip oii

M. ft. Enema. S.: Inject wairo.

Chapped Skin. — For chapped face or hands, or for
sunburn, the following is highly recommended:

IJ Acid acet. dil '

Glycerin aa. 5i

Bismuth subnit q.s. ad. ft. massa.

S.: -Apply locally.

Anorexia. —

R Tr. nucis vomic oiv

Ferri et. quin. citrat 5iii

Tr. gent, comp 3i

Vini xerici q.s. ad. Svi

M. S.: A teaspoonful in water before meals.

iKrbtrol 3ItrmB.

Infantile Asthma and Its Treatment. — Mery, in his
discii.ssion of this subject, says that infantile asthma often
exists in patients with adenoid vegetations or in those who
have repeated colds. In certain cases the coexistence of
other manifestations of arthritism have been noted. This
affection must he difTerentiated from capillary bronchitis
anil from tracheobronchial adenopathy. Cardiac and renal
affections must be looked for. The cause of this affection
should be searched for and removed. Treatment of the
attack consists in the application of moist dressings to the
chest. In cases without fever warm applications are pref-
erable.— Journal de Medicine de Paris.

Health Reports.— The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital
Service, during the week ended April 19, 1907:

SMALLPOX — U.NITED STATES.

California. San Francisco Mar. 23-30. . . .

Plotida. Duvall Co., Jacksonville.. .Mar. 30-Apr. 6'

Hillsboro County Apr. 6-13. . . .

Polk County Apr. 6-13. ...

Santa Rosa County .^pr. 6-13. . . .

Georgia. Augusta Apr. 2-q

Illinois, Chicago Mar. 30-Apr. i;

Galesburg Mar. 30-Apr. 6

Peoria Mar. 30-Apr. 6

Indiana, Indianapolis Mar. 3 i-Apr. 7

South Bend Mar. 30-Apr. 6

Iowa, Everly Mar. 30

Spencer Mar. 30

Kentucky, Louisville Mar. 38- Apr. i

Louisiana, New Orleans Mar. 30-Apr. 6

Massachusetts, Chelsea Mar. 30-Apr. 6

Haverhill Mar. 30-Apr. 6

LawTence Mar. 30-Apr. 6

Michigan. Detroit Mar. 30-Apr. i,

Minnesota, Winona Mar. 30-Apr. 6

Mississippi. Natchez Mar. 23-Apr. 6

Missouri. St. Joseph Mar. 30-Apr. 6

St. Louis Mar. 30-.\pr. 6

New Jersey. Hoboken Apr. 6-13. ...

New York, New York Mar. 30-Apr. 6

North Carolina. Charlotte Mar. 30-Apr. i;

Ohio, Cincinnati Mar. 29-Apr. s

Cleveland Mar. 24-.\pr. i ;

Tennessee. Nashville Apr. 6-13.

Texas. Bell County Mar. 23-.\pr. 6

Galveston Apr. 5

San .\ntonio Dec. 2g-Apr. 6

Washington. Spokane Mar. 30-Apr. 6

Wisconsin, .\ppieton Mar. 30-Apr. 6

Milwaukee Mar. 23-30 . . . .

CASES. DEATHS.
I

i&i Total, J
7
7
6
I
4
3
17
4
2

Present

206
5
9
6

I Imp't'd

SMALLPOX — INSULAR.

Porto Rico. San Juan Apr. 2 . . . .

SMALLPOX — FOREIGN.

Brazil, Rio de Janeiro Mar.

Canada, Winnipeg Mar.

China, Niuchwang Jan.

Shanghai Feb.

Egypt, Cairo Mar.

France, Marseille Mar.

Paris Mar.

India, Bombay Mar.

Calcutta Feb.

Rangoon Feb.

Italy. General Mar.

Turin Mar.

Mexico. Aguas Calientes Mar.

Mexico City Mar.

Tuxpam Mar.

Portugal, Lisbon Mar,

Russia, Moscow Mar.

Odessa Mar.

Riga Mar.

St. Petersburg Mar.

Warsaw Feb.

Spain. Valencia Mar.

3-10. ..

30-Apr.

i-Feb,

27-Mar.

1-31. ..
16-23. ..

5-12. ..
23-Mar.
23-Mar.
21-28. .

9-16. .
23-30. .

2-9. . .
26-Apr.
16-23. .

2-16. .

g-i6. .
16-23. .

9-16. .
23-Mar.
17-24. .

Present
7

238
68

Brazil. Rio de Janeiro.

YELLOW FEVER.

Mar. 3-

CHOLERA.

India, Bombay Mar. s-io

Calcutta Feb. 28-Mar. 2.

Madras Mar. 2-8

Rangoon Feb. 23-Mar. 9

4
33

Hawaii, Honolulu.

PLAGUE — INSULAR.

-^pr. IS-.

PLAGUE FOREIGN.

Australia. Queensland. Brisbane.. ..Feb. 2-9 3

Port Douglas Feb. 2-9 6

New South Wales, Syd-
ney Feb. 2-9 4

Kempsey Feb. 2-9

(Total : cases, 4: deaths, 3)

Brazil. Rio de Janeiro Mar. 3-10 6

Egypt, Ismailia Mar. jo-16 3

Port Said Mar. 8-17 i

.\ssiout Pro\-ince Mar. 8-16 15

Beni Souef Pro\ance Mar. 12-19 4

Girgeh ProWnce Mar. 9- 16. ,

Keneh Province Mar. 11-18. .

Minieh Pro\nnce Mar. 13-18. .

30
26

7

3

23

India, General Mar.

Bombay Mar.

Rangoon Feb.

2-9

S-19. .. :.
23-Mar. 9.

3.426

2.0" I

9-S
124

Medical Record

A Weekly Journal of Medtchie and Surgery

Vol. 7t, No. 18.
Whole No. J904.

New York, May 4, 1907.

$5.00 Per Annum.
Single Copies, lOc.

O^nginal Artirl^s.

PULMONARY TUBERCULOSIS; SOME OF
THE DETAILS OF ITS MODERN HY-
GIENIC TREATMENT WHICH CAN
BE APPLIED IN TREATING
THE PATIENT AT HIS OWN
HOME.*

By HERBERT C. CLAPP. M.D..

VISITlNG^PHYSrCIAN TO THE MASSACHUSETTS STATE SANATORIUM FOR

INCIPIENT CONSUMPTIVES AT RUTLAND; PROFESSOR OF DISEASES

OF THE CHEST IN BOSTON UNIVERSITY.

In many walks of life a careful attention to details
often explains the difference between success and
failure. In none is tliis more true than in the treat-
ment of tuberculosis. In my early professional days
wc sometimes advised consumptives to go logging
in the Maine woods, to work on a ranch in Col-
orado, or to go lumbering in Minnesota. Very little
more was said, and they were left in the main to
regulate their own manner of living and to rely on
their own devices. Occasionally one got well, but
most of them died !

Now, if we know enough and are careful enough
in our supervision, and if we have the cooperation
of the patient, we can cure the great majority of
incipient cases and some of those more advanced.
The difference consists in attention to detail.

Since this subject has been brought so forciblv
before the nublic within the past few years, many
laymen and not a few physicians, with a big swing
of the pendulum from their former pessimism, have
come to think that the cure of consumption is now
a very easy matter ; that there is no need of drugs,
nor even of physicians, but that all that is really
necessary is to live in the open air and to eat plenty
of good food. Would that it were so! We may be
sure that shipwreck would inevitably be the lot of
large numbers of those who followed this partially
good advice if they did nothing more. A greenhorn
may sail a boat when everything is propitious, but
wait until the storm comes ! A novice, after a few
lessons, may seem to run an automobile well, but
surely pride goeth before a fall, and trouble on
trouble is his before the season is over. What does
he then think of detail ?

Nobody now considers climate so important a
factor in the cure of tuberculosis as formerlv. We
now know that the disease can be cured in almost
any climate. It does not make so much difference
where one lives as how one lives. Although there
are sometimes advantages in seeking another cli-
mate, yet manv people for one reason or another,
even if they have monev. will prefer to stav at
home. Good care at home is far better than the
best climate anywhere with less care.

In sanatoria supervision by the physician and

*Read before the Hughes Medical Club.

nurses can be more perfect, and more careful atten-
tion can be given to detail than in a private house.
It is easier for a victim of tuberculosis to be good
where everybody else is good, and the force of ex-
ample is strong. The new patients are greatly
encouraged and helped by the evident improvement
of those who have entered a few weeks ahead of
them ; and this encouragement from their fellows
ensures more willing obedience to possibly irksome
rules. A new patient, entering among older ones
who have learned some lessons, does not dare to
object to this rule or that or to growl too much,
for fear of the ridicule of his comrades who have
by pleasant experience proved the value of the rule.
Thus much time and effort are saved to the physi-
cian and nurse in the supervision which in some
form or other is absolutely necessary.

But there is not now nor will there ever be suffi-
cient sanatorium accommodation for all, and even if
there were, many people cannot or will not go to a
sanatorium.

Although it is not so easily done, yet patients can
be cured in private practice if, on the one hand,
the nhysician is sufficiently posted and will take time
enough to give definite directions and to see that
thev are carried out; and if, on the other hand, the
patients have will power, character, and intelligence
enough to obey the rules understandingly and faith-
fully. It may be necessary to write out for these
patients the directions x'ery carefully, giving them
the more general ones in print, and to impress on
them as forcibly as possible the importance of carry-
ing them out conscientiously. If they become care-
less in little things, their carelessness may put them
back a long time or even cause their death, as has
frequently been demonstrated.

To get well is a constant fight, but it is worth the
while. It requires much patience, perseverance, and
great self-denial, sometimes even heroism, on the
part of the patient to submit himself to the neces-
sarily rigid restrictions.

If a physician has several patients to treat in the
same locality, it will be a great saving of time to
him. and may be of some advantage to his patients
likewise, for him to form a tuberculosis class, ac-
cording to the system originated by Dr. Charles S.
Miner of Asheville, S. C, and practised by him for
several years among his well-to-do patients. Prac-
tically the same system has been carried out for over
a year by Drs. Pratt, Hawes, and others in Boston,
among the very poor, where it has been successful
bevond reasonable expectation. Of course, in the
latter cases financial aid in the way of food, tents,
blankets, etc.. has often been necessary and has been
furnished by Emanuel Church and other charitable
agencies. But the success of this latter work shows
that even in the slums of a great city on the seacoast
much can be done bv inducing poor people to live
])roperly by day and by night and to breathe the fresh
air in tents on housetops high above the street dust,
or in less crowded districts in tents or shacks in the

MEDICAL RECORD.

[May 4, 1907

backyard, or on a piazza or fire-escape, or balcony.
Of course, it is better still out in the suburbs ; but
careful medical supervision in a bad locality brings
better results than a free and easy life in the best
regions obtainable. The members of these classes
bring to each meeting, once a week or oftener, their
record books containing reports of the morning and
afternoon temperature and pulse, taken by them-

f

Fig. 1.

selves, the amount of exercise and rest, number of
hours in the twenty-four spent out of doors (often
over twenty), cough, sputum, amount and kind of
nourishment and hour at which it is taken, etc., etc.
They are weighed once a week, the gain in weight
is announced, and they are given a plain talk con-
taining encouragement and directions for proper
living. They are also regularly visited by a nurse.
to see that tliey are carrying out these directions.
Their lungs are examined once a month. This com-
bination method is surely very helpful with poor
people, and certain modifications of it may some-
times be found useful with people in better circum-
stances.

It is manifestly impossible in the limits of a
short paper to present all the necessary details. It
it also impossible, no matter how much space or
time is at hand, to give directions so explicit as to
cover all exigencies or emergencies in individual
cases. In this, as in many other diseases, very much
must be left to the judgment of the experienced and
resourceful physician. Patients who have any re-
gard for their own welfare and who do not care to
take too many chances should put themselves under
the supervision of a competent physician and be
guided by him rather than try to manage their own
cases alone. A few of the most important points
are here given.

Out-of-Door Life in Warm Weather. — In the
summer in New England, except in the crowded
parts of cities and large towns, it is easy enough
to live out of doors all of the time without much
urging; and when indoors all of the windows can
be kept open with very little inconvenience. Owing
to the fact that the circulation of the air is less
active in the summer, it is very advantageous to
the patient to sleep also out of doors in this season ;
whereas in midwinter in New England a fair sized
bedroom with two or more open windows is by
far more convenient, and is practically good enough
in most cases, superseding the necessity for any-
thing more strenuous.

In summer a patient can sleep on a piazza or
jjorch, preferably on the second floor. If it can be
so planned, it is better not to have the porch face
the east, for the rising sun wakes one too early. Nor
should it face the direction of the most frequently
prevailing storms. If the sides of the house do not
at all times intercept violent winds, a canvas curtain
can be arranged so as to be put up at short notice,
or a screen of glass or boards. Gentle zephyrs or
moderate breezes should always be welcomed,
whether out of doors or in a room. To this extent
drafts are beneficial, when the air is all around one,
but not in narrow shafts or pencils from a slightly
open window striking on the body, especially when
the body is covered with perspiration. A consump-
tive after a little while delights to feel the play of
breezes about his face, and he must have at all costs
air which is not stagnant. A very powerful wind
(especially if it is cold) is, however, unfavorable
and needs to be guarded against. If one sleeps on
a piazza in summer he needs to have a mosquito
netting of cloth or wire tacked up to exclude in-
sects, and if the piazza is on the ground floor, the
netting should be strong enough to keep out cats
and dogs likewise. A common tent can be utilized
for sleeping out, but it should have a board floor
raised from the ground, and at least two of its sides,
if not all four, should be more or less open. .\n
occupied common tent with its canvas spiked to
the ground all around, as some use it, in the morn-
ing contains air which is perfectly horrible. If can-
vas were as pervious to air as some people think,
it would be useless for sails of ships, .'^rmy tents
are apt to be stuffy.

A tent with a conical shape like the Indian "te-
pee'" and open at the top afifords fair ventilation
if a space is left between the walls and the floor
I which is raised from the ground) through which
the air enters and rises, going out at the top. The
Gardiner tent is built on this principle and costs

Fig.

about $100. Prof. Fisher of New Haven a few years
ago invented a remarkably ingenious "up draught
louvre tent," and lately a sensible square tent-shack,
which also combines the advantages of the rotating
kiosk. Neither is patented.

Still better than a tent is a shack made cheaply
of boards, with overhanging eaves, with windows,
and with one side entirely open and furnished with

May 4, 1907]

MEDICAL RECORD.

719

curtains to be lowered in case of a driving storm on
that side. Some like a hammock swung between
two trees, with a canvas cover for a watershed ; but
most hammocks become very uncomfortable after
one or two hours.

In cities the flat roofs and fire-escapes, and some-
times the back yards have been utilized for sleeping
as well as for sitting out daytimes.

Fig. 3.

In hot weather a patient should not have his
head exposed for too long a time to the direct rays
of the sun, and in great heat he should seek the
shade for his whole body.

The house of the patient must have an abundance
of sunlight and good ventikition, and therefore
must not be too closely surrounded by trees, must
stand on ground well drained to avoid dampness,
must be kept clean by means of dampened cloths
or mops, and must not have the dust moved from
one place to another by dry sweeping, must have
rugs instead of carpets, and no heavy draperies.

Night Air; Rain and Sn02t'. — A great many peo-
ple, even after having been convinced of the wisdom
of exposure to fresh air in pleasant weather, are
even now horrified at the idea of a "consumptive"
being out in the damp, raw, or foggy weather or
in rain or snow storms, or in having the windows
open nights in such weather. First, as to the latter,
some still imagine that night air is bad air, even
if the sky is clear. After persuading them that the
opposite is true, we should address ourselves to the
harder task of inducing them to let the night air in,
even in stormy weather, provided that the rain docs
not actually wet the bedclothes or soak through
the floor and loosen the plaster ceilings of the room
below. A few flakes of snow in the room will do
no harm, unless the bed is wet by its melting. Alost
of a beating rain can be kept out without exclud-
ing the air, if the outside blinds are closed, the win-
dows remaining open. If there are no blinds, and
if there are enough windows in the room (four or
more) and on different sides of it, during the actual
downpour the windows on the windward side can

be closed more or less and on the other side left
open. If the room has not enough windows, addi-
tional air can be obtained right along by taking out
all the sashes. This I have often done with advan-
tage, especially in the warmer parts of the year.

A consumptive if well protected should not hesi-
tate to go out because it rains. He should continue
to sit on his piazza, if the overhang of the roof is
sufficient to prevent the rain from actually falling
on him. He should not abandon his walk, but put
on his waterproof and rubbers or heavy boots and
carry an umbrella. If when already out he gets
caught in the rain without these safeguards, it will
not hurt him to ggt wet, if he continues to walk and
thus keeps warm. The same principle applies with
rowing, riding horseback, or any other exercise. If
he is tired and feels obliged to sit down in his wet
clothes, if covered up well with a blanket or extra
clothing, he may rest for quite a while without in-
jury. But, on the other hand, if he Has no extra
covering, and sits or drives until he is thoroughly
chilled, aggravations or complications are very apt
to follow. In either case he should on reaching
home take a dry rub or a bath and put on dry
clothing and drink something hot.

Ont-of-Door Life in Cold Weather.- — The real
task in making people take the fresh air is appre-
ciated when cold weather comes. Then comes the
tug of war. At least, this is so to begin with. After
a patient has gotten used to it and has become con-
vinced by actual experiment that he is not going to
freeze, and is conscious of great improvement in his
symptoms, he generally delights in it, and often re-
bels if asked to go back to his old ways; becoming,

Fig. 4-

in fact, a so-called fresh-air fiend. But in the brcak-
ing-in process perhaps all our persuasive power.-
may be necessary, and even a little bulldozing. Heie
much of our success depends on how we carry out
details. Some take to this life naturally, but most
people need a good deal of instruction and encour-
agement. Our strongest argument with them is
tile fact that practically everywhere consumptives

720

MEDICAL RECORD.

[May 4, 1907

make better and more satisfactory progress in win-
ter than in summer. All sanatorium physicians in
this country and abroad will testify to this fact.

All patients have to sit out much of the time ;
some have to sit out all of the time, not beins
allowed anv exercise at all. The location for this
sitting out is important. Sanatoria are generally
built, if possible, on a hillside, with a hilltop to keep

Fig. s-

off the worst winds, which generally come from the
north and west. The exposure should be mostly
to the south, with the additional purpose of getting
the sun all day. In a private house it is nice to
have the piazza or balcony on the south side, in a
jog or angle of the house for protection against
the wind. If not, this should be obtained by means
of some kind of a wind-shield. Glass is nice because
it admits the light, but other material will do. This
does not mean a glass-enclosed piazza or what is
sometimes called a sun-room. In winter the strong
winds (generally from the northwest) must be kept,
off, as they have a more cooling effect on the body
than a still atmosphere many degrees lower. Trees
often make a good windbreak. If the patient can
afford it, a fine protection is secured by a revolving
shed (a kiosk) enclosed on three sides, so as to
meet and oppose the changing winds. A movable
canvas curtain on a piazza, however, does very well.
The best kind of a chair to sit out in is a steamer
chair, of which there are several modifications and
various prices, from $2 to $20. The more expensive
have comfortable adjustable backs and cushions or
mattresses. The steamer chair position is easiest to
maintain for long stretches of time. Even more
important is the fact that when the legs are mainly
horizontal, they can be kept warm by wraps, which
is almost impossible in cold weather if the feet
touch the floor or ground.

During all seasons the patient should aim to be
out of doors at least eight of the day hours, and
more if he can. This may be reduced a little if the
patient lies on his bed with open windows for an
hour after the noonday meal, and if he goes to bed
early, to have a long night in the fresh air. Count-
ing these times, he should if possible be in the fresh
air twenty out of twenty-four hours. He should
have a warm room in which to dress, undress, and
take his morning cold bath, as w^ell as for his meals ;
and occasional] v he may be allowed a little more
liberty, but not much. If he is strong enough to see
friends, he can entertain them on the piazza or
other place where he is sitting out. He surely
should not go to places of amusement or religious

meetings, where the air is bad on account of crowds
of people or of burning lamps or gas.

Occasionally, but not often, it happens that a pa-
tient, after experiencing benefit from the fresh air
treatment, becomes oz'£?r-enthusiastic in exposing
himself to very cold and boisterous weather and
needs to be restrained, but the opposite is far more
common.

In very cold weather it is sometimes wise to in-
troduce a certain amount of artificial heat into the
room, the windows still being open. Many people
confuse cold with fresh air, and heat with foul air.
Even they on reflection will recognize the falsity
of this and the fact that the air in a room may be
very foul and unbearable with a temperature near
zero, and pure at 90°. Here again we have to em-
phasize anew the statement that fresh air is what
we should cry for and not necessarily cold air. The
patient must have fresh air all the time; and yet
he does best if the air is as cold as he can stand,
while he is exposed to it constantly.

Clothing. — I often say to patients, "I do not care
how you dress, provided you are fairly comfortable.''
Whether it is wool or cotton or mi.xed, linen mesh,
silk, fur, leather, or paper, it makes little difference.
Some need more and some less. Some lean towards
too much clothing on the ground that they are deli-
cate. The effort should be to wear the lightest
weight and the least amount of clothing that will
keep one fairly comfortable.

According to an old custom, a man having once
put on his winter clothing in the fall, or a woman
her furs, should never leave them off until the cal-
endar says a certain spring month has arrived. How
ridiculous! Instead they should change back and
forth as the weather changes each day. They should
suffer neither from the heat nor from the cold.

Cotton and wool mixture for underclothing is the
best for most people and is not costly. Sweaters,
cardigan jackets, chamois vests are all right. For
walking, a short leather jacket, such as hunters
wear, and lined with lamb's wool, is better than
a heavy and clumsy fur coat, which, however, in its
turn is far preferable for sitting out. Nowadays,

Fig. 6.

good warm fur coats can be bought for $15 or more.
I have seen great satisfaction experienced by sitters
out (not so much by walkers) from a long, heavy,
shaggy, woolly waterproof coat made in Buffalo,
called the Saskatchewan, which seems to defy the
attacks of the coldest weather. I have kept per-
fectly warm in one in long sleigh rides with the
thermometer below zero, when I should have suf-

May 4, 1907]

MEDICAL RECORD.

721

fered in my fur-lined overcoat which cost seven
times as much. Their price is only $18 for men
and S20 for women. Now quite a number of our
country doctors are using them in their long daily
rides. If a patient can afford only one coat, how-
ever, they will not do, because they are too warm
for most days. A coat of any kind should have a
high collar, and there should be elastics in the
sleeves at the wrists, or something else to prevent
the wind going up the arms. A Canadian sash
about the waist adds to its warmth.

For the hands common mittens of wool or of iur-
lined leather are far more effective than gloves in
zero w'eather, and they should be large and loose.
If it is not quite so cold, and the patient is anxious
to use his hands, he can put on thin cotton summer
gloves, and over them warm mitts without fingers
and made of worsted, or long worsted wristlets com-
ing well down over the hands.

The protection of the feet is very important, and
if they are not properly clothed much suffering fol-
lows. The shoes should not be tight. Rubber soles
and heels are splendid when the ground is wet or
cold. If they are not available, common rubbers
should always be worn in rainy and especially in
slushy weather. Arctics over the shoes for walking
in the snow or for sitting out are much worn ; less
often felt shoes or soft moccasins. For sitting out
or for riding foot-muffs made of quilted material
stuffed with cotton and with layers of new-spaper
are good. If money is plenty, the automobile foot-
mufts made of fur are satisfactory, and hot bricks
or soapstones are often a necessity.

For the head a cap of cloth or fur or a tam-o'-
shanter is most used. It should pull down over
the ears or else have ear-tabs. A Derby hat or a
woman's stiff hat will not allow the head to rest
against the high back of the chair.

Before sitting out, the patient should be well
wrapped up below the waist with steamer rugs or
a fur robe, or common blankets or horse blankets,
the blankets being perhaps five or six feet square.
There is something of a knack in putting them
around one to the best advantage. Some kind of a
rug or blanket over the chair or hammock before
getting in is a necessity, just as an extra mattress
or a blanket over Uie mattress will add greatly to
comfort W'hen sleeping on a bed with windows open.

Sleeping Out in Cold Weather. — In our rig-
orous New England winters it is not very often
really necessary to sleep out of doors. If the bed-
room has two or more windows, generally enough
air will circulate. But if the patient is anxious to
sleep out it can be done, and no doubt it is more
thorough in critical cases.- A tent in winter is not
so desirable as a rough shack containing a stove
and open on one side, the open side to be closed
with a curtain when dressing. Or without the stove
and curtain the patient, to wash and dress, may slip
into the warm house if it is near. Better still is a
second floor piazza, properlv protected.

Best of all, if the patient can aft'ord it, is a sleep-
ing porch specially built onto the house. Fig. i
shows a remarkably nice one w'hich an intelligent
and educated gentleman had attached to a jog in
his house last fall in the suburbs of Boston, and
which he has slept in every night during this in-
tensely cold w'inter, with great comfort and advan-
tage. I have seen him several times in consultation
with his physician, and he is very enthusiastic and
loud in his praises of its merits. It is on the south-
east side of the house and thus protected from the
most common winds. For access from the house a

W'indow was cut down to the floor, making a door.
The canvas curtains can be easily raised and lowered
at w'ill, and he can dress and undress and bathe in
a warm room in the house. The whole structure
cost about $100, It would be better still if the
eaves projected more.

Fig. 2 shows an ingenious sleeping porch, large
enough for two beds, built by another patient of
mine in the Berkshires at a cost of $45, which has
proved very successful. There being no piazza nor
angle to the house, this was built against its flat
side. As this was a hired house, it was put up with
an eye to its easy removal without defacement to
the walls, and the window was not cut down, boxes
inside and out serving as steps. I have several times
recommended others of similar pattern. Cheaper
porches and also tents in actual use are shown in
Figs. 3, 4, 5, and 0, from the third report of the
Cambridge Anti-Tuberculosis Association.

To sleep out of doors in one of these porches a
patient must dress especially for it. Some need
more clothing than others. Dommet or outing flan-
nel makes a fine, warm and inexpensive nightshirt,
which should be made large and come to the floor
when the patient is standing. Under this can be put
on a woolen shirt and outside of it a sweater. A
worsted skull cap, coming dowm over the ears and
nose, is desirable on cold nights. Over this some
wear a knitted helmet, covering the head, neck, and
shotilders. Bed socks of wool or worsted are de-
sirable, and if these do not keep the feet warm a
hot water bottle or hot soapstone should be used,
Kenwood sleeping bags, warm and well padded,
closed in at the feet and coming well up aroiuid the
body, are very comfortable for camping out.

The bed should either have two mattresses for
warmth, or newspapers under one, or a blanket over
one. A common amount of bed clothing in zero
weather is eight thicknesses of woolen blankets, be-
sides a quilt and either a down puff or an overcoat
thrown on top. Old-fashioned comforters are too
heavy. Down puffs, on the contrary, are very light
and warm, and as commonlv found in the stores cost
about five or six dollars, with sateen covering. If
made larger and thicker and of a higher grade of
down and covered with silk, the price mav be from
$20 to $25.

If it rains and there is danger of the bed getting
wet, some kind of waterproof cloth or a horse
blanket can be thrown over all. Some like woolen
sheets, but with all the bed covering mentioned
above most prefer cotton. Two pillows may be
used, one being tucked in around the shoulders and
the other in front, to keep the cold air out, the
head resting where they overlap. Of course, as
the weather moderates the amount of bed clothing
must be reduced so as not to make the patient too
warm.

Exercise and Rest. — The careful regulation of
the exercise is one of the most important features
of the treatment. Very often it has happened that
one act of indiscretion in this direction has entirely
spoiled the patient's chances for recovery, and still
oftener it has put him back for weeks or months,
when he was previously progressing finely. More
consumptives have been killed bv overexertion than
bv anvthing else. In no particular is there more
call for judgment and experience on the part of the
phvsician and nurse. No absolute rules can be laid
down. The physician must individualize his patient.
The stage and activity of the disease and the special
symptoms are largely the determining factors.

Exercise should never be pushed to the extent of

^22

MEDICAL RECORD.

[.May 4, 1907

inducing exhaustion or fatigue which cannot be re-
covered from by a little rest; nor should it be car-
ried to the extent of inducing increase of tempera-
ture, shortness of breath, or marked acceleration of
the pulse, or cough, nor should it be taken too soon
after a hemorrhage. A good rule to determine
whether or not exercise really increases the temper-
ature is to have the patient rest for twenty minutes
or more alter exercising and to take the tempera
ture after this rest. If it is not elevated then, no
harm has been done.

When the patient first comes under observation he
should generally be kept still for from one to three
or four weeks, even if his pulse and temperature
would otherwise allow action. Then he can take
a fresh start, after his rest has given him a surplus
of energy to draw from.

If a patient's afternoon temperature is over 101.5°
he should be kept in bed for awhile, as a rule. If
over 100.5° he should be recumbent most of the
time: if over 99.5° he should sit out without exer-
cise on that day and on the day following. All
should observe the quiet hour after the noon meal
bv Iving down. In many cases it pays to keep the
patient quiet after each meal : and in some, rest
should be enjoined for half an hour before each
meal, so that the stomach should not undertake its
work in too tired a condition. If the morning tem-
perature is 99° the rule is to take no exercise on
that day. When a patient begins to sit up after be-
ing abed, he should not be up for long at a time.
^^l^en he begins to walk about he should increase
his amount very gradually. Worry and mental ex-
citement or any decided mental exertion must be
guarded against as well as physical efforts. A
game of cards will sometimes raise the temperature
decidedly. W'hen his condition allows and he in-
creases ills exercise more and more, he should still
be watched carefully to see that he does not overdo.
Walking is the first thing, at the outset very slow,
then faster on a level, and then gentle hill-climbing
at a slow pace. As he progresses, horseback riding,
if the horse is easy, and carriage or sleigh, or slow
auto-driving are allowable, and a little later croquet
or golf, or mild rowing, or skating, or garden work.
Tennis and baseball are more violent and are only
to be undertaken by those whose disease is prac-
tically arrested, and then only with care. Football
is out of the question. In all games the influence
of the competitive element should be reduced as
much as possible. The consumptive should never
exercise for the purpose of developing muscle and
of becoming an athlete.

When the call for rest is a loud one and the rest
needs to be mental as well as physical, complete se-
clusion is often advisable : or if this tends to de-
pression, the patient can be rolled from his single
room to the veranda, when for a short time each
day he can see a few of his fellows.

During the active progress of the disease there
are so many indications either for limiting exercise
more or less or for entirely forbidding it, that some
patients almost get the idea that they are never
again to resume it. Often a patient, when teasing
to be allowed to go home from the sanatorium a
little before the proper time, has told me that he
would promise not to do a bit of work or take a bit
of exercise all winter if he could go. Of course,
more or less exercise is necessary for all of us. It
promotes nutrition, assists the aeration of the blood,
strengthens the nervous system, and helps the elim-
ination of various substances through the lungs,
kidneys, bowels, and skin. Just as soon as the contra-

indications are done away with, exercise both of the
body and mind must be resumed. If prolonged rest
really has m.ade the patient lazy, as sometimes hap-
pens, he should be encouraged to exercise to an ex-
tent proportionate to his condition.

SURGERY IX DIABETES.*

By JOSEPH WIENER, M.D..

NEW YORK.

DJUN'CT ATTENDIN'G SURGEO.S', UT. SINAI HOSPITAL.

The subject of surgery in diabetes is of such vast
importance, our textbooks say so little on the sub-
ject, and there is such a diversity of opinion among
medical men, that a careful study of the entire sub-
ject has seemed both profitable and- desirable.

Some authors would prefer to see only absolutely
necessary operations done. Others warn of the dan-
gers of coma and gangrene. Still others, and this
growing class includes one who is peculiarly fitted to
decide the question, namely Naunyn, hold that the
old rule of not operating in the presence of diabetes
can no longer be maintained. Israel, writing in
1882, advises that only imperative operations should
be done on diabetics. No plastic operations should
be undertaken ; no benign tumors removed. He ad-
vised postponing operation if posible until the sugar
had disappeared from the urine. Tuffier, in 1888,
advised against operation unless the sugar in the
urine could be reduced by diet. Among the more
modern writers Kiimmell is one of the most en-
thusiastic. In his experience diabetic patients stand
major operations very well. According to Baldy the
belief that diabetes contraindicates operation is a
superstition.

At the very outset we must divide the entire sub-
ject into two parts: i. Lesions or diseases which
have developed independently of the diabetes. 2.
Lesions or diseases which have developed as the
result, or as a complication, of diabetes. With the
first class of cases this paper will have but little to
do. A diabetic patient who requires an amputation
of the breast, or the removal of a kidne}', or even
a plastic operation, should have that operation done.
And the wounds will heal, and the mortality will be
but little different from the non-diabetic cases. The
writer would refer here in passing to his three cases
of prostatectomy in diabetics reported elsewhere,
which made as good recoveries as the ordinary
cases.

\\'hen the disease for which we are called upon to
operate is the result or a complication of the change
in the tissue metamorphosis, we are confronted by
a much more serious problem. And it is with this
problem that this paper will chiefly deal.

I. Changes in Metabolism. — As is well known,
we find in diabetes an increase in certain normal ex-
cretions, together with the presence of certain ab-
normal excretions. So we find in the urine of
diabetics glucose, acetone, diacetic acid, oxybutyric
acid, and an increased excretion of ammonia. The
exact role which these different ingredients play is
not yet definitely settled. We know by experiment
that the virulence of pyogenic bacteria is increased
by the presence of sugar in the tisues. The sugar
in the blood and in the tissues makes a favorable
culture medium for the growth of bacteria, pro-
vided the percentage of sugar is not too great. If
the medium contains much sugar the growth of bac-
teria is hindered. The blood of diabetics contains
0.2 to 0.8 per cent, of sugar, rarely more than 0.5
per cent. And it is just this percentage of sugar

♦Read before the Eastern Medical Society.

May 4, 1907]

MEDICAL RECORD.

723

that is most favorable for bacterial growth. There
is a common but erroneous belief that the greater
the amount of sugar excreted the worse the prog-
nosis. The worst feature is the acidity of the blood.
The presence of these abnormal acids in the blood
injures the tissues and makes them more prone to
infection. These acids are furthermore in all prob-
ability causative factors in producing premature
arteriosclerotic changes. The increased excretion
of ammonia, the presence of acetone, diacetic acid,
or j3-oxybutyric acid, if it cannot be reduced by diet,
certainly makes the prognosis worse. Phillips holds
that no operation save of the extremest urgency
should be done if more than one gram of ammonia
is excreted in twenty-four hours, until tliis has been
reduced to normal. He further advises that an
operation should be postponed if diacetic acid is
present, even though there is no marked increase in
ammonia.

2. Arteriosclerosis plays a very important role
in diabetic gangrene. The first systematic examina-
tion of the vessels in this disease was undertaken
by Fr. Koenig in 1887. He found marked arterio-
sclerosis and calcareous deposits in the walls of the
vessels. In from 65 to 100 per cent, of the cases
various authors have found tliese changes in the
vessels. Some patients who do not know they have
diabetes complain for a long time before the devel-
opment of the gangrene of symptoms due to faulty
circulation. These symptoms are coldness, anes-
thesia, paresthesia, or severe pain in the limb. Sooner
or later the black spot that is the precursor of the
gangrene appears on one toe, or on the sole of the
foot. The arteriosclerosis causes either a marked
narrowing of the lumen or even a complete oblitera-
tion. This applies to veins as well as to arteries.
As the process is progressive, less and less blood
is carried to the furthermost part of the extremitv'.
Finally there is almost complete stasis. Then
thrombi form in the capillaries and terminal vessels,
and the gangrene begins. Or, there may be a throm-
bosis of one of the larger vessels which is quickly
followed by gangrene. Or again, the gangrene may
result from an embolus lodging in one of the larger
vessels ; this is rare.

The rare occurrence of diabetic gangrene in
women is another proof of the importance of the
arterial changes. Out of 118 cases only thirteen
were in women. Tlie upper extremity is very rarely
affected, because the arterial changes are found in
tlie lower and not the upper extremity. It is now
generally held that the gangrene is largely depend-
ent on arterial changes, and that in the absence of
arterial changes gangrene will not develop in dia-
betes.

3. Coma. — We all know that in a certain number
of cases, even following minor operations, diabetic
patients go into coma and die. Even a prolonged
anesthesia, not accompanied by any operation, may
bring about a fatal coma. Conversely, coma may
follow an operation for which no anesthetic had been
given. At times the most trivial incident or acci-
dent will bring about coma, while in other cases a
severe injury, or an extensive operation will cause
no ill effects. The fear of an operation, loss of
blood, starving and purging before operation, all
have an influence in causing coma. Hirschfeld em-
phasizes the fact that diminished nutrition is a
marked predisposing cause of coma. Psychic in-
fluences, worry, and overfatigue, likewise predispose
to coma. In diabetic coma the urine contains one
or more of the following products : acetone, dia-
cetic acid, ,3-oxybutyric acid. According to Naunyn,
if more than three grams of ammonia per diem

are excreted, there is great danger of coma; if the
amount exceeds four grams, coma is inevitable. We
often, in non-diabetic cases, find acetone or diacetic
acid in the urine after a prolonged anesthesia. Kast
and Master found after prolonged chloroform an-
esthesia increased proteid destruction, with an in-
crease in the amount of acids excreted. We thus
see the danger to a diabetic of general anesthesia.
If we accept the coma as the result of an acid in-
toxication, it is not wise to reduce the percentage
of sugar by a strict meat diet, because an exclusive
meat diet will increase the acidity of the urine.

4. Diet and Medication. — Here again we must
differentiate as to whether the disease for which
we are operating is the result or a complication of
diabetes, or whether it has developed independently
of the diabetes. If the disease is merely an inter-
current one, the indication for dieting is not very
urgent. Indeed, if we are dealing with patients of
advanced years, whose general condition is none too
good, we would probably do more harm than good
by a strict diet. Their nutrition would suffer, and
though we might be able to reduce the amount of
sugar in the urine, we would be dealing with a two-
edged sword. In cases of diabetic gangrene, if
there is time, a moderate antidiabetic" diet before
operation will often be of benefit. If the excretion
of ammonia is in excess, sodium bicarbonate should
be given daily in large doses until it becomes normal.
If the stomach will not tolerate the large amounts of
soda, it can be given by rectum. The dangers of
coma and of sepsis are lessened by the alkaline
treatment, which should be kept up for some time
after operation. Rumpf suggests sodium citrate in
place of the bicarbonate. Salol or sodium salicylate
are also useful. Noble made it a rule to emplov a
moderate preliminary diet and to give codeine and
strychnine. After operation he advises a strict diet,
codeine, morphine, and salt solutions by rectum and
subcutaneously. He stated, however, that the diet-
ing and medication before operation had not, in his
experience, reduced the number of cases of coma.
The giving of large amounts of water before and
after operation is of great importance, just as re-
fraining from removing too much fluid from the
body by starving and purging is important. It may
be safer to operate in the absence of sugar, but, as
was pointed out above, the sugar should not be
made to disappear by increasing the acidity of the
urine (by an exclusive meat diet), because the
greater the acidity the more likely is coma. With
a good general condition and a large percentage of
sugar, the prognosis is better than with a poor
condition and a small percentage of sugar. Ru-
disch has recently pointed out that the administra-
tion of atropine in doses of gr. 1-150 to gr. i-ioo
three times a day, together with codeine, will very
rapidly and very markedly diminish the amount of
glucose in the urine. If this method proves satis-
factory it may take the place of dieting before opera-
tion. It certainly is not open to the objection of in-
creasing acidity.

Phillips collected thirty-four cases that were given
preliminary treatment with six deaths, four from
sepsis and two from coma. In eleven other cases
no preliminary treatment was given and four died,
two from sepsis and two from coma. The number
of cases, however, is too small to draw conclusions
from, although a larger proportion of the dieted
cases in tliis series recovered. Most authorities
agree that a moderately strict diet is desirable after
operation.

5. Technique of Operation. — The principal dan-
gers of operations on diabetics are: i. The anes-

724

MEDICAL RECORD.

[May 4, 1907

thetic. 2. Infection. 3. Hemorrhage. Ether and
chloroform should be avoided as much as possible.
From all reports ether is a little less dangerous
than chloroform in these cases. Nitrous oxide,
spinal anesthesia, and local anesthesia should be the
methods of choice. If local anesthesia is used, only
small quantities of fluid should be injected into one
locality to prevent too much stretching of the tis-
sues. Many major operations can be done under
laughing gas if given by a skilled anesthetist. The
writer was able in one non-diabetic case to do a
nephrectomy lasting a half hour, and only gas was
given.

The field of spinal anesthesia is also a broad one.
The writer recently performed an amputation of
the thigh in an old lady under spinal anesthesia.
A hvpodermic injection of 34 gr. of morphine was
given, and the patient not only suffered no pain,
but was actuallv asleep during the operation. Ger-
sunv collected 'eighty-six narcoses from various
sources without a single case of coma. Ether and
the A. C. E. mixture were the anesthetics used.
Witzel has reported in a similar vein. But, as was
pointed out above, it is not only the anesthetic that
brings on coma. The dread of operation, the loss
of fluid by preliminary purging and fasting, are
also contributing factors. All these elements should
be reduced to a minimum. It is well to operate in
the morning, after the physiological fasting of the
night. If neither ether nor chloroform is used,
the patient can have his ordinary food up to the
time of operation. There will then be no vomiting
after operation, and the patient can take nourish-
ment very soon. We have seen why diabetics are
peculiarly prone to infections. Everything possible
should be done in preparing the field of operation,
and, during the operation itself, to prevent infec-
tion. Asepsis should be most rigid. Antiseptics,
inasmuch as they lower the vitality of the already
compromised tissues, should not be allowed to come
in contact with the wound. Rubber gloves should
be worn, and the tissues handled as gently as pos-
sible. The operative technique as well as the
dressings should be as simple as possible. The loss
of blood should be reduced to a minimum. Reynier
lays great stress on the absence of the knee jerks
as giving a bad prognosis. He claims that no major
operation will be successful if the knee jerks are
absent. Honzak advises against operation in the
presence of chronic interstitial nephritis. On the
other hand, as Grossman after an exhaustive study
of the subject points out, the results of operation
under strictest asepsis are improving from year to
year. And, in view of the sad results of non-
operative treatment, an operation should often be
done even where the outlook is bad. In doubtful
cases the urine should be examined for the percent-
age of sugar, acetone, diacetic acid, and -oxybu-
tyric acid. The total amount of ammonia excreted
should be determined. If there is serious disease
of liver, heart, or lungs, the prognosis of operation
is bad. If there has been much loss of flesh not de-
pending on the surgical lesion, it will be well to
improve the general condition before proceeding to
operation.

6. Fractures. — Fractures in diabetics heal well,
though often more slowly than in healthy subjects.
Phillips reported three cases from St. Bartholo-
mew's Hospital which united promptly and well.
He reports, however, an empyema following a frac-
ture of a rib which ended fatally. Naunyn. in his
monograph on diabetes, stated that he had never
seen an empyema in a diabetic. He further states
that suppurative inflammation of serous membranes

is very rare in diabetics. Legendre reports a per-
fect result in four weeks in a fracture of the hu-
merus ; the woman was sixty years old. Phillips re-
ported an excellent result in a subtrochanteric frac-
ture of the femur in a man of fifty-eight. He also
reported a good result in a man of fifty-five, with
a Pott's fracture. S]5itzer reported a case of frac-
ture of the clavicle in a man of forty-six. There
was 4 per cent, sugar and 1-20 per cent, ammonia.
Sodium bicarbonate was given freely. There was
improvement for four days, then the man became
worse and died of coma, evidently due to shock, on
the seventh day. Smith and Durham quote three
cases in which fractures took four to five months to
consolidate, and two in which non-union occurred.
Naunyn states that imperfect union may occur even
though at the time no sugar is e.xcreted. He also
refers to the frequent absence of pain in fractures
in diabetics. He reports twelve cases of fracture.
Three died ;oneafter a primary amputation, one from
coma induced by the shock of the accident, and one
from pyopneumothorax caused by fractured ribs. In
five cases there was delayed union or non-union;
in four cases the union was normal. According to
the researches of Toralbo, Van .'^ckeren, and Ger-
hardt, diabetics often excrete such an excess of
phosphoric acid and lime salts over the quantity in
the food ingested, that these ingredients must come
from one of the tissues of the body. This can only
be from the bones. Gerhardt attributes this to the
increased acidity, and states that the administration
of alkalies diminishes the excretion of lime. It
would therefore seem rational in these cases to ad-
minister alkalies in order to lessen the excretion of
lime, and perhaps to administer lime salts in order
to make up for the increased excretion.

7. Operations for Diseases Not Due to Diabetes.
— Noble of Philadelphia, in a paper on this subject,
called attention to the wddely spread belief that the
healing process in wounds in diabetics is markedly
interfered with, and that the sloughing rather than
the healing of wounds is to be expected. Frequently
have we heard doctors say that they would like to
have a certain patient operated on, but that the pa-
tient had diabetes, and they had therefore advised
against operation. Noble reported seven cases, one
amputation of the breast, a ventral hernia, a va-
ginal hysterectomy for prolapse, a colpoperineor-
rhaphy, a post-operative hernia, a case of appendi-
citis, and a rectovaginal fistula. Of these seven
cases one patient died in coma on the sixth day.
This woman of fifty had had diabetes for many
years, with a large excretion of glucose. In the
other six cases the healing of the wounds was not
different from that in patients without diabetes. The
writer has elsewhere reported three cases of pros-
tatectomv in which the wound healing was satis-
factory'. Sternberg reported sixteen major opera-
tions from Gersuny's clinic. He concludes that any
necessary operation should be done, that a prepara-
tory diet is desirable but not absolutely necessary.
The operations included two cases of amputation of
the breast, one case of cancer of the rectum that sur-
vived operation two years, one case of cancer of the
ja\\- that survived two extensive operations, one
case of myoma of the uterus removed by morcelle-
ment. one case of cholecystitis, and one case of pro-
lapse of the vagina with rupture of the perineum,
necessitating two extensive plastic operations within
three months. Four of these cases had severe
diabetes, one case had 7 per cent, of sugar. Noble
collected sixty-nine cases involving the breast,
the female genitals, and the abdomen ; fifty-
two cases recovered and seventeen died. From

May 4, 1907]

MEDICAL RECORD.

725

1900 to 1905 eleven cases have been operated
on in Dr. Lilienthal's sen-ice at Mount Sinai Hos-
pital. The cases included amputation of the breast,
radical operation for umbilical hernia, suprapubic
prostatectomy, partial excision of cancer or pharynx,
and gastroenterostomy Of these eleven cases the
wounds healed satisfactorily in ten. The only case
that died was a g-astroenterostomy with a button in
a cancer case. Death was due to peritonitis. We can
but agree with the conclusions arrived at by Phillips
after the study of a large number of cases. We
should operate : i . For malignant disease. 2. Large
abdominal tumors. 3. Cosmetic operations, if the
general condition is good. 4. Emergency operations,
even under the most unfavorable conditions.

8. Gangrene of Skin, Furuncle, Carbuncle. —
Griesinger figures that inflammatory gangrenous
processes develop in 10 per cent, of all diabetic
cases. The ages vary from twenty-two to eighty-
years. Forty per cent, occur between fift>- and sixty
years. The most common lesions are furunculosis
and carbuncle. As the mild forms of diabetes occur
chiefly in middle age, so we also find most of the
cases of furuncle and carbuncle at that time of life.
As a rule the urine contains only a moderate amount
of sugar, and not much attention had been paid
to the diet. The development of these lesions shows
that there are serious errors in the body metabolism,
and they should act as warnings of the storm to
come. According to Grossman there is no case on
record in which diabetes was cured after carbuncles
had developed. The prognosis of gangrene of the
skin per se is not bad ; healing is often spontaneous.
But the ultimate prognosis is bad, because only too
often the gangrene of the skin is but the forerunner
of more serious lesions. The necrosis of the skin
generally occurs in the lower extremity. It be-
gins either as a bluish red discoloration or
as a blister. It may be caused by a scratch,
by the scraping or cutting of a corn, or by
any slight trauma, or even by exposure to cold.
The gangrene is usually preceded by local numb-
ness, cold, or pain. The treatment of furunculosis
and of grangrene of the skin is chiefly dietetic. Some
recommend mild antiseptic washes. Carbuncles gen-
erally develop on the dorsum. Thev should be
treated by early and free incisions through the
deep fascia. During convalescence the patient
should be dieted. Of seventy-five large carbuncles
reported from Gersuny's clinic five died of sepsis
after operation. The earlier the incisions are made
the less likely is sepsis to develop.

9. ]\Ial Perforant. — It was formerly believed that
every ulcus perforans was on a diabetic basis. It is
found almost exclusively among men between forty
and sixty years. In most of the cases the diabetes
had not been recognized before the ulcer developed.
In about 25 per cent, of the cases there were some
symptoms of tabes. But, as Grossman points out,
we often see pseudo-tabes in diabetics. The site of
the ulcer is at one of the three points of pressure
on the sole of the foot, i.e. the head of the first or
the fifth metatarsus, or the heel. There is regularly
a preexisting callus at the point of perforation.
The prognosis is good. If we see an ulcer in this
location which has a tendency to bleed, to become
infected or gangrenous, especially if there is redness
or edema of the leg, we must strongly suspect dia-
betes. The ulcer can generally be made to heal with
stimulating dressings. In one case Gersuny excised
the ulcer together with the head of the metatarsus
with good result.

10. Abscesses. — As is well known, the diabetic is
vers- prone to develop abscesses. In addition to the

lowered vitality produced by the circulation of an
abnormal amount of sugar, the presence of arterio-
sclerosis, and nerve degeneration, must also be taken
into account. All these are contributory factors in
the production of the various trophic lesions which
affect the diabetic. The sugar directly lowers the
vitality of the tissues, and, by producing chronic
vascular and nerve lesions, it still more adversely
affects the body economy. One of the commonest,
as w-ell as one of the most fatal, forms of abscess is
the ischiorectal. A few years ago the writer had
a case of this kind, which after free incision im-
proved for several days and then went into coma.
A prominent surgeon, who was asked to see the pa-
tient, remarked that he had never seen a case of
this kind end in recovery. However, we recently
had a successful case in Dr. Lilienthal's service.
And last winter the writer was fortunate enough to
save a far advanced case, and the patient is still
alive, though suffering from a severe diabetes. As
these patients stand suppurative processes very
badly, the rule should be very early and very free
incision.

II. Dry Gangrene and Wet Gangrene. — The three
principal factors at work in causing gangrene are:
(i) alcohol, (2) arterial changes, (3) bacteria. Al-
cohol acts by lessening tissue resistance, weakening
the heart's action, and by predisposing to arterio-
sclerosis. The severity of the arteriosclerosis and
the virulence of the bacteria are the great determin-
ing factors. We have seen above how the arteries-
sclerosis plays its role. The idiopathic or dry gan-
grene is largely due to the changes in the arteries
and veins : the altered metabolism plays but a pre-
disposing role. By the introduction of bacteria from
without die dry gangrene is converted into an in-
flammatory or moist gangrene. How often this hap-
pens is shown by the fact that we see many more
cases of moist gangrene than we do of dry gan-
grene. The comparative rarity of gangrene in
women is less striking, if w-e recollect how muc.i
less frequent arteriosclerosis and alcoholism are in
women than in men.

The following tables are from Grossman :

Character of
Gangrene

Females .

Drinkers,

Arterio-
sclerosis.

Latent

Diabetes.

TotaU

4

I
\o
13

1
6
7
S

8

27
1%

0

22

36

26

Dry gangrene

Wet gangrene

65
7:!

Total..

?8

24 '^4

so

iS5

DIABETIC GANGRENI

Giron.

Mayer.

Grossman.

Total.

Female

Male

23- i8.6g%
100 = 81.31%

10= 7.86%
46 = 82.14%

39-ir.4i%
185-82.59%

7 3

331

Total

123

$6

274

In the overwhelming majority of the cases the
lower extremity is the seat of the gangrene, just
as the lower extremity is the favorite seat of the
arterial changes. As Lilienthal says, "necrosis due
to arterial obliteration is commonest in structures
of little vascularity, such as tendon and fascia, while
it is uncommon in very vascular tissues, such as mu-
cous membrane. Fingers and toes being supplied
by a terminal circulation, and being composed almost
entirely of skin, bone, and tendinous structures, are
especially liable to the disorder. The tension in the
tissues which is caused by even a slight degree of
infection will not infrequently so impair the circu-
lation that necrosis occurs."

Drv gangrene cannot be attributed to outside
causes. In a large percentage of the cases there are

726

MEDICAL RECORD.

[May 4, 1907

marked arterial changes. The diseased vessels must
be considered the predisposing cause, to which is
added an exciting cause s.uch as a tight shoe, expo-
sure to cold, overexertion in walking, etc. As the
result of one of these exciting causes the circulation,
w-hich had been poor enough owing to the arterio-
sclerosis, becomes completely cut off and gangrene
results.

In wet gangrene there is always the added ele-
ment of infection from without. A cellulitis is thus
superimposed upon the gangrene. We have seen
how the presence of sugar in the tissues predisposes
to this infection. Once it has taken place we are
further handicapped in combating it by the compro-
mised arterial and venous systems and by the faulty
metabolism. With varying rapidity the process is
progressive. The infection spreads along the cellu-
lar planes between the muscles and tendons and
along the l}Tnphatics. The deeper tissues also be-
come gangrenous and phlegmons, which endanger
life, result.

12. Treatment of Gangrene. — Haidenhain gives
three conditions under which spontaneous gangrene
may occur : ( i ) A deficient supply of normal
blood (senile) ; (2) a normal supply of abnormal
blood (noma) ; (3) a deficient supply of abnormal
blood (diabetic). At the very outset of the gangrene
everything possible should be done to improve the
local circulation. The patient should be in the re-
cumbent position, the limb should be elevated and'
external heat applied. At times massage may be of
use. Our aim should always be to keep the gan-
grene dry, and if it becomes moist to transform the
moist gangrene into a dry gangrene. To bring
this about dry antiseptic dressings and pow^ders are
employed ; wet dressings of all kinds should be
avoided. Antidiabetic diet will often aid in limiting
the gangrene, especially if the patient has not had
the benefit of diet for a long time. This is particu-
larly true of the wet gangrene. In the dry form the
general condition is usually much better, because the
patient has been careful with his diet ; accordingly,
we cannot expect to influence the gangrene in these
cases to any great extent by diet. As long as the
gangrene remains dry, i.e. free from infection, no
operation should be done until a line of demarcation
forms. Limitation of the gangrene will be aided by
elevation of the limb and dry dressings. Even when
the line of demarcation is well established no opera-
tion should be done unless there is infection. With
the expectant treatment one toe or several toes will
gradually fall off, and leave a granulating wound
\\-hich will often heal with little or no assistance.
If there is infection, w^e try to limit it and bring
about a condition of dry gangrene. To accomplish
this blebs are opened as soon as they form, necrotic
skin is cut aw^ay, a phlegmon is freely incised, the
limb is elevated and covered with a dry dressing.
The patient in the meantime is carefully dieted and
everything done to improve the general condition.
The urine is frequently examined not only for sugar
but also for acetone, diacetic acid, and for the
amount of ammonia excreted. Often we find im-
provement in the local condition go hand in hand
with improvement in the condition of the urine.
And we have seen above how important it is to
limit acidity as well as the excretion of ammonia
before proceeding to operation. If in spite of treat-
ment fever persists and the phlegmon progresses,
we must operate even without a line of demarcation.
If there is no fever, which means that there is no
infection, the waiting period will usually be from
one to three weeks. During this time water should
be given freely, also bicarbonate of soda; and, ac-

cording to the suggestion of Rudisch, atropine in
large doses together with codeine. Infection, when
it takes place, is always from without. If, in spite
of local and constitutional treatment, the infection
is progressive, an amputation must be done to save
life. We are then confronted by the vexed question
of the site of amputation. The point of election
will depend on (i) the condition of the arteries, (2)
the extent of the phlegmon. According to Gerster,
"if the popliteal pulse is felt, an amputation below
the knee is admissible. In case of doubt, however,
the higher amputation deserves the preference."
Lilienthal advises against amputation at the knee,
because there is so much tendinous tissue and so
little muscle there that necrosis is very apt to appea*
in the stump. He suggests making all flaps of skin
and muscle. Gussenbauer advises that the condition
of the arteries should be carefully investigated on
both sides. If the pulse is distinctly present in
both tibial arteries, as well as in the dorsalis pedis,
he claims that the removal of the diseased parts will
suffice. But he adds that this rule has exceptions.
He further states that if there is popliteal pulsation
and none lower down, an amputation should be done
below the knee, provided the gangrene has not
spread beyond the dorsum of the foot and that the
leg is free from phlebitis and lymphangitis. Where
the phlegmonous process is rapidly progressive all
are agreed that a high amputation must be done.
As a rule operations on the toes or on the foot are
insufficient if there is any infection. Haidenhaim's
rules still hold good: (i) If there is extension of
the process to the dorsum or palmar aspect of the
foot the amputation should be made above the con-
dyles of the femur; (2) amputation below the knee
is frequently accompanied by gangrene of the flaps
and jeopardizes the patient's life; (3) high ampu-
tation is indicated when the gangrene is progressive,
although there may be no rise in temperature.

The statistics of G. B. Smith, Haidenhain, Kus-
ter, and Smith and Durham, all go to show that
where the gangrene affects more than three toes a
high amputation gives the best results. We have re-
ferred above to the choice of anesthetic and to the
preparation for and general technique of operations
on diabetics. In amputations the Esmarch con-
strictor should not be used ; digital compression of
the femoral or external iliac should be employed in-
stead. Long flaps are apt to become gangrenous;
the flaps should be short and should consist of skin
and muscle. No sutures should be used ; the wound
should either be left open or approximated in part
or entirelv with strips of Z. O. plaster. Drainage
should be free. The result will usually depend on
three factors: (i) The severity of the diabetes ; (2) .
the condition of the heart; (3) the extent of the
phlegmon.

Grossman collected 58 cases of amputation for
diabetic gangrene : 22 leg amputations with 9
deaths ; 21 thigh amputations with 9 deaths ; 7 Gritti
knee amputations with 4 deaths ; 2 Pirogoff amputa-
tions with I death ; i Chopart amputation with O
death ; 3 toe exarticulations with o death ; i toe am-
putation with O death ; i finger amputation with O
death. Total, 58 amputations with 23 deaths, a mor-
talitj' of 39.6 per cent. This mortality may at first
sight seem high, but we must remember that in cases
of extensive gangrene the mortality without opera-
tion is fearful. Phillips reported from St. Bartholo-
mew's Hospital, from 1884 to 1899, eleven cases of
gangrene not operated on and they all died. The
chief causes of death after operation are coma,
sepsis, and cardiac failure.

May 4, 1907]

MEDICAL RECORD.

7^7

TABLE. OF OPERATIONS.'

Name

AND

Date.

Age

ANO

Sex.

1

Lesion.

Duration of
Present
Illness.

Tre.\tment.

Resl-lt.

Remarks.

S. S., 1901..

M.. S2

3 weeks

1. Pirogoff amput. 2. Amp
lower third thigh.

+ 3 days, alter
2d operation.

ii% sugar, albumin, hyaline

and granular casts.

M. D., iQoi . .

M., 44

2 weeks

+ 6 hours

1% Sugar, albimiin, gran, casts

R. W., 1901..

F.. 50

Strangulatei umbilical hernia

3 days

Cured

S. I,.. 1901.. .

M., s6

Luetic orchitis mistaken for
T. b. c.

7 W'eeks

2% to 5% sugar.

B. A., 1902..

M., s8

Gangrene of foot, lymphangi-
tis of le^..

2 weeks \

Amput. middle thigh

+ coma 24 hrs,

3% sugar, acetone, albumin,
hyalo-granular casts.

I. G., 1902. ..

jM.

9 weeks before admission toe
amput. Gangrene spread to
foot.

9 weeks

Amput. middle ot thigh

+ 4 days after
operation.

4%-5% sugar, acetone.

J. S., 1902. . .

M.. 59

■S days

Amput. middle of leg

+ 3 days

M. M.. 1903. .

M., s6

Carcinoma of pancreas

4 months

Exploratory laparotomy and
drainage.

Unimproved.. ..

^%-3% sugar.

S. S., 1903 ..

M., 63

Prostatic hypertrophy

Several years..

Suprapubic prostatectomy. . .

Cured

For several years had had up

to \\% sugar.

W. C, 1903-

M.. 5 7

Prostatic hypertrophy

Several years..

Suprapubic prostatectomy. . .

Cured

Sugar present for several years

M. A. S., 1903

M., 60

Cellulitis of foot

4 weeks

Incision and drainage

Cured

1% sugar, acetone, trace of

albumin.

S. G., 1903. .

F. 54

Gangrene of fout

R days

Amput. lower third thigh. . . .

Cured

Up to 4% sugar, acetone.

M. S.. 1903.. .

M., 55

i weeks

I, Incision foot, amput. toe,
2. Amput. middle thigh ....

Cured

^% -5% sugar, acetone, dia-

cetic acid.

I. B.. 1903...

F., 62

I week

Amput. lower third thigh , . . ,

+ Coma. S days

2%~^% sugar, acetone, dia-

cetic acid, albumin.

N. R., 1904. .

M., 58

2 years.

Cured

i%-2% sugar, trace albumin.

N. T., 1904...

M., 48

5 years

Partial excision

Improved

acid.

B. H., 1904 . .

F.. 56

6 weeks

Excision of tumor

Cured

S. K., 1904,, .

M., 53

Several mos. . .

Post-gastroenterostomy with

button.

+ 3 days peri-
tonitis.

M. K., 1904. .

M.. 55

Stones in gall-bladder and

duct.

S weeks

Cholecystectomy and chole-
dochotomy.

Cured

^%--'ih% sugar, trace albumin

S. S., 1904. . .

F., 53

2 weeks

Amput. finger

Slow healing. . .

1% sugar, acetone, diacetic

acul.

R. R., 1905...

F.. 32

Scirrhus breast

Radio, amput. breast

Slow healing. . .

6/10% sugar, acetone, diacetic
acid.

H. B., 1905...

M.. 5 2

Gangrene of foot

3 weeks

Amput. middle thigh

Slow heahng. .

iA%-2% sugar.

J. E., J905, . .

F.. 54

I. Gangrene toe. 2. Secondary
gangrene foot.

2 weeks — ...

I. Amput. small toe. 2. Amp,
lower third thigh.

ISt op. Nov. 27-

2d op. Dec 2:
-(- Coma, Dec.

29c~7% sugar, acetone, di-
acetic acid, albumin, hya-
line and granular casts.

*The operations were performed by Drs. H. Lilienthal. C. A. Elsberg and J. Wiener.

Conclusions, i. ^^'e must distinguisli between
diseases due to diabetes, and those that occur inde-
pendently of the disease.

2. All necessary operations for diseases not due
to diabetes should be performed just as in ordinary
patients.

3. The abnormal products (acetone, diacetic acid,
i8-oxybutyric acid, lactic acid) which circulate in
the blood in diabetes do harm, (a) by injuring the
tissues and making them prone to infection; (b)
by acting as contributing factors in producing pre-
mature arteriosclerotic changes.

4. Arteriosclerosis plays a very important role in
producing diabetic gangrene.

5. There are two kinds of diabetic gangrene: (a)
that caused by changes in the arteries and veins ;
(b) that caused by the effect of virulent bacteria
on weakened tissues.

6. We should always endeavor to transform wet
gangrene into dry gangrene.

7. If more than three toes are afifected, especially
if there is any cellulitis, a high amputation is gener-
ally indicated.

8. If the infection is progressive a high amputa-
tion should be done.

9. If in doubt about the site of amputation, a high
amputation will give the best results.

ID. If more than one gram of ammonia is ex-
creted in twenty-four hours, operation had better

be postponed until by careful diet the amount of
ammonia is considerably reduced.

11. The prognosis does not depend on the per-
centage of glucose in the urine but on the degree of
acid into.xication.

12. .A. strict meat diet will reduce the amount of
sugar, but it will often bring on fatal coma by in-
creasing acidity.

13. Sodium bicarbonate given before and after op-
eration can do no harm and may do good.

14. Ether and chloroform should be avoided as
much as possible.

15. .All operations on diabetics should be per-
formed as simply and as rapidly as possible.

BIBLIGGR.^PHY.

Becker: Die Gefahren der Xarcose fiir d. Diabetiker.
Dcutsch. med. IVoch.. 1894, p. 394.

Cumston : The Question of .\mputation in Diabetic
Gangrene, Clin. Jour., London, 1905, Vol, 26.

Fisk : Surgery in the presence of sugar in tlie urine.
Annals of Surgery. 1900.

Fowler, H, A.: Surgery in diabetes. Maryl. Med. Jour.,

No. 46, p. 57- ^ . r, ,

Futli: Diabetes Mellitus «, Gynrek. Operationcn, Deulsch
med. U'och.. 1903, No. 29, pp. 65, 82,

Gerster : Surgical aspects of diabetes. A', Y. Stn'r J<'ur.
of Med., March, 1902.

Grossman : Ueber Gangr.in bei Diabetes Mellitus, Berlin,
A. Hirsclnvald, 1900,

Gussenbauer: Ueber d. Bebandl. d. Gangran bei Diab.
Mell. Wiener klin. Woch., 1899, p. 4S.V

/

'28

MEDICAL RECORD.

[May 4, 1907

Haidenhain : Uebcr d. Behandl. d. senilen Gang., etc.
Deutsch med. IVocli., 1891, Vol. 17.

Hildebrandt : Ueber diab. Extremitatengangran. Deut.
Zeit. f. Chirurgie, 1904, Vol. 72.

Hirschfeld: Die Zuckerkrankheit, Leipzig, Geo. Thieme,
1900.

Karewski : Ueber Wechselwirkungen zwischen Diabetes
u. chirurg. Eingriffe. Bcil. kliii. IVoch., 1905, 10, 12.

Konig. Fr. : Ueber diab. Brand. Berl. kliii. IVoch., 1896,
No._25.

Koerner: Mittlicil. aus den Grenzgeb. d. Med. u. Chir.,
Vol. 12, Xo. s.

Lilienthal : The treatment of so-called diab. gang, of the
extremities. N. Y, Med. Journal, July 4, 1903.

Xaiinyn : Der Diabetes Mellitus, Wien., 1898.

Xoble, C. P. : Personal experience in operations upon dia-
betic patients. Amcr. Medicine. 1903, V'ol. 6.

v. Xoorden : Die Zuckerkrankheit und ihre Behandl. Ber-
lin. 1898.

Phillips, L. C. P. : Some of the surgical aspects of glyco-
suria and diabetes, Lancet, May 10 and May 17, 1902.

Rumpf: Untersuchungen uber Diab. melF. Zeit f. klin.
Med.. igo2, Vol. 45.

Stern, Heinrich : Memoranda anent the treatment of gan-
grene in the diabetic. Medical Record, April 21, 1^06.

Sternberg, J. : Ueber Operationen an Diabetischen.
Wiener med. IVoch., 1903, No. 53.

Wolf, H. : Ueber Gangran bei Diabetes. Wiener med.
Pressc. 1901, No. 48,

looi M.ADisoN Avenue.

RARE FORMS OF CHORIOIDITIS :

OXE V.\RIETY DUE TO GENERAL MAL.\RIAL INFECTION

AND ONE TO AUTOINTOXICATION FROM

INTESTINAL PTOMAINS.*

By CHARLES STEDMAN BULL, A.M., M.D.,

N'EW YORK.

These forms of chorioiditis are not often met with
by the ophthalmic surgeon. In posterior uveitis,
due to either of the above causes, the disease must
be regarded as caused by the microorganisms con-
veyed to the eye from elsewhere within the body
by the blood current, and these organisms must
perforce be arrested and adhere to the walls of the
vessels before they can cause damage ; such arrest
or stoppage being commonly promoted by the
microorganisms being contained in coagula or par-
ticles of broken-down tissue, or aggregated in col-
onies.

The first variety of chorioiditis referred to, that
due to general malarial infection, is a rare ocular
complication. Severe forms of malaria, and the
accompanying profound anemia thereby induced,
met with in tropical countries and in certain regions
of our own Southwestern States, must be regarded
as the more or less frequent cause of chorioiditis.
Malarial inflammation of the entire uveal tract, in-
cluding chorioid, ciliary body and iris, not infre-
quently occurs in patients suffering from severe
malarial poisoning, like jungle fever, and these
attacks of uveitis may come on years after the origi-
nal exposure to the fever. Some of the character-
istics of these attacks are their periodicity and their
tendency to relapse. Their course is most tedious,
though the patients usually recover their vision
almost completely.

In malarial attacks certain e\e symptoms may
form part of the attack, and have even been known
to be a substitute for the general attack. Supra-
orbital neuralgia, ptosis, spasm of accommodation,
amblyopia, and even complete amaurosis, without
ophthalmoscopic findings, have been observed, not
only in severe atacks of malarial fever, but even in
latent malaria. Why, then, may not chorioiditis
develop as one of the symptoms of profound ma-
larial saturation of the whole organism ?

* Read before the New York Academy of Medicine,
November i, 1906.

It has been my experience in the past to meet with
a goodly number of cases of severe intraocular le-
sions occurring in profoundly malarial patients, and
in most of these a distinct type of chorioiditis was
present. As is generally known, after the malarial
poisoning has lasted a long time, a series of com-
plications often occurs, such as difltuse vitreous
opacities and multiple retinal hemorrhages, but I
have not found in literature any mention of a dis-
tinct type of chorioiditis, consisting of small patches
of yellowish exudation, fairly circular in form, but
with little elevation above the surface, which occur
all over the fundus, and do not tend to coalesce.
These are distinct from the pigmentary deposits
not infrequently found in the fundus after malaria
of long standing, which are undoubtedly due to pig-
ment emboli, the result of gradually developing
melanemia. This type of chorioiditis is very often
accompanied by a general uveitis with fixed punc-
tate opacities of the vitreous, and the patches of
chorioidal exudation may be entirely hidden by
these opacities, and only become visible when the
vitreous has cleared up. These yellow patches are
very different from the shining white spots in the
retina left after retinal hemorrhages.

As corroborative evidence of the occurrence of
these patches of exudation, at autopsies on malarial
patients, changes have been found in the chorioid
which were not recognized before death, consisting
of small inflammatory foci with thromboses of the
chorioidal vessels. The vitreous opacities are often
absent throughout the entire course of the disease.

One of the striking features of these cases is the
marked disproportion which exists between the de-
gree of the acuity of vision and the actual amount
of chorioidal disease present. The whole fundus
may show an extensive inflammatory process, and
yet the central vision may be very good, provided
no vitreous complications are present.

These cases are very chronic in their course, and
show but little sign of improvement under the usual
treatment of chorioiditis. It is not until quinine
has been administered in steadily increasing doses,
accompanied by arsenic and iron, that the chorioid
begins to clear up, and the vitreous opacities dis-
appear. Yet the prognosis is good if the cause is
recognized and the disease is properly treated, and
the ultimate vision is normal, or nearly so.

The second variety of chorioiditis, above referred
to, is still rarer than the malarial, and, if possible,
still more interesting. For some years Elschnig
has been making a special study of gastrointestinal
autointoxication as a factor in the development of
ocular affections. He regards it as especially im-
portant as a cause of ophthalmoplegia interna, and
more rarely of paralysis of the external ocular mus-
cles and of affections of the optic nerve. He has
also found intestinal intoxication to be a cause of
diseases of the cornea and sclerotic, and of affec-
tions of the uveal tract, especially of recurring iritis
and of insidious iridocyclitis.

Following on somewhat dift'erent lines of investi-
gation, Groyer discovered that, in a large number
of cases of eye disease, for which he could discover
no primary cause, the test for indican in the feces
and urine resulted strongly positive. In all of these
cases there were evidences of digestive disturbance.
As indican is an indication of putrefactive processes
in the intestines. Groyer assumes that its presence
in these cases indicates that poisons from the intes-
tines are circulating in the body and affecting all
the organs in the body, and these disturbances are
visible in the eye, and' attract attention. The rela-
tion of chorioiditis to autointoxication is ven.' inter-

May 4, 1907]

MEDICAL RECORD.

esting. A careful search of ophthalmic literature
reveals very few well-authenticated cases of lesions
of the deeper tissues of the eye due to autointoxica-
tion. Intestinal poisoning from ptomains represents
a sort of transition to acute infectious diseases. The
toxic products of the disassimilation of food vary
greatly in character, and some of them have a spe-
cific action on the eye. While we are all familiar
with the commoner general symptoms of intestinal
intoxication, the localized ocular symptoms are
much less evident. Conjunctival injection, paraly-
sis of accommodation of the levator palpebrse, and
of the external muscles of the eyes, are not infre-
quent symptoms. In many of these cases vision is
not impaired, but a number of cases of amblyopia
without ophthalmoscopic findings have been re-
ported, for which no satisfactory explanation has
been offered. These visual disturbances are doubt-
less primarily due to putrefactive changes occurring
in the animal tissues.

During the past few years I have seen quite a
number of cases of autointoxication, accompanied
by marked lesions of the deep tissues of the eye,
notably a chorioiditis of an unusual type. They all
presented the usual ocular symptoms of conjunctival
injection, paralysis of accommodation, and mydri-
asis, but in addition the fundus presented an unusual
picture. Scattered all over the fundus of both eyes
were patches of yellowish-white exudation in the
chorioid, of varying size and shape, very flat, with
scarcely any elevation above the general level of the
fundus. Some were in the stage of efflorescence
and others in the period of retrogression and ab-
sorption. The older patches were surrounded by a
reddish margin, but no masses of pigment could be
seen anywhere in the fundus, and no retinal or
chorioidal hemorrhages. The vitreous remained
entirely clear, and the vision was but slightly af-
fected, showing that the retina was but little, if at
all, involved in the process. There was no limita-
tion of the field and no scotoma, and no disturbance
of the color perception.

The patches of exudation in the chorioid pre-
sented a very different appearance from that of
chorioiditis areolaris disseminata, or from that of
the chorioretinitis associated with general constitu-
tional syphilis.

Occasionally I have seen faint peripheral striae
of opacity in the lens of both eyes, but these did not
extend, and eventually entirely disappeared. These
cases all showed a marked cutaneous eruption of
the pemphigoid type, some of the bullae on the
abdomen and inner surface of the thighs being
quite large. The contents of these bullae have fre-
quentlv been e.xamined by Elsching, \'alude, and
others, and a diplococcus has been isolated from the
bulls and injected into the veins of rabbits, and in-
variably caused death. The diplococcus removed
from the blood of the poisoned rabbit was identified
with that removed from the pemphigus bullae, and
when injected intravenously into a pig produced a
pustular eruption.

The prognosis as to vision in these cases is good,
especially if the patient gradually recovers from the
general toxic infection.

As regards the treatment of these cases, before
the administration of any drugs specifically directed
towards the chorioiditis, it is at first wise to intro-
duce such dietetic and therapeutic measures as seem
best indicated to regulate the digestive tract, for
such measures will essentially improve or cure the
chorioiditis, after failure of all other forms of
treatment.

The treatment should later consist of the admin-

istration of iron, arsenic, and strychnia, the two
latter drugs being given separately, so that the dose
of each may be increased or diminished according
to indications. Under this treatment, the patches
of exudation lose their yellow color, and become
paler, slowly diminish in size and become less clearly
defined, the red ring rapidly fading away. At the
periphery of the fundus the patches disappear en-
tirely, while those in the vicinity of the posterior
pole of the eye are more or less permanent, though
in several patients, after a lapse of three years,
they were distinguished with difficulty.

THE TREATMENT OF TYPHOID FEVER
AND PNEUMONIA.

Bv LEONARD WEBER, iVI.D.,

N'EW YORK.

Symposiums on typhoid fever, pneumonia, etc., we
have had in our societies, and continue to have.
They are often good to attend, and the newcomers
in our ranks will always be glad to listen to what
clinicians of experience may have to say to them.
When the discussion is ended, there is a mass of
individual testimony as to pathology and therapy,
and the hearer — particularly the younger disciple of
the healing art — can make his choice of what he
thinks best for diagnosis and treatment in his next
case.

A summing up and final agreement upon the best
mode of treatment which ought to hold good for a
year or more or, at all events, until the ne.xt sym-
posium goes over the same ground again, would be
serviceable, I opine, and be heartily welcomed by
many members, so far as I have been able to ascer-
tain.

It is a matter of common experience that every
active practitioner not only watches and nurses a
case of pneumonia or typhoid fever, but really treats
it, hoping by such treatment to insure the favorable
outcome which he trusts or e.xpects will take place
anyway. For this very reason I may be allowed to
state briefly what mode of treatment has served me
well in

'1 yphoid Fever. — Far be it from me to belittle
the laboratory — etiological — diagnosis of typhoid
fever, yet I have always held and taught that a case
of this disease can be diagnosed by its well-known
syndrome, and be under safe care and management
before, and often many days before, the agglutina-
tion test confirms our diagnosis. Now, when we
witness an epidemic of typhoid or examine a spo-
radic typhoid case brought into the hospital ward
in the second week of the fever, there will be no
difficulty in diagnosing the case correctly, but it is
in some of the milder sporadic cases of typhoid and
typhoid-like diseases that the difficulty of exact
diagnosis presents itself. I am ready to confess that
it is mainly through cases in private practice that I
have learned that typhoid fever is not a uniform
disease, and that there are not only different de-
grees of real typhoid, but al.so some typhoid-like
diseases which it may be difficult and sometimes
even impossible to distinguish and classify properly.
We have known for quite a while that the Bacillus
coli may become virulent and produce a sort of
typhoid ; we have learned in recent vears of the
paratyphoid bacillus giving rise to somewhat of a
true typhoid. Last July I had a case of scarlatina
in a lad of nineteen, followed by typhoid fever fif-
teen days after the initial sore throat and rash, and
running a typical course. In September last I
observed two cases of subacute enterocolitis which

730

MEDICAL RECORD.

[May 4, 1907

had been clinicalls- diagnosed as typhoid, but the
agglutination test remaining negative as often as
it was made, the diagnosis could be properly cor-
rected, l-'our weeks ago 1 was called to see a pa-
tient who had eaten badly cooked or spoiled liver
sausage early in January of this year, and within a
few hours after ingesting the stuff he was seized
w:th nausea and vertigo, but not vomiting. He
took one ounce of castor oil early the ne.xt morning,
with good effect, felt better for a day or two, and
then went into a low state of fever lasting three
weeks, and presenting the usual clinical symptoms
of mild typhoid, but the agglutination tests remain-
ing negative, the diagnosis of typhoid fever could
be replaced by the proper one of enterocolitis.

In all cases of the kind mentioned, and others of
a similar nature, the agglutination tests are indeed
of great help, but if the physician comes to believe
that one or two early tests are adequate to settle
the diagnosis pro or con, further experience will
soon tell him that this is not so. and that the agglu-
tination tests do not always show up when we think
they ought to.

Whether the Eberth bacillus, the paratyphoid ba-
cillus, or the colon bacillus will be found to be the
etiological factor in typhoid fever need not make a
bit of difference in the treatment.

Ever since I read of the splendid results which
Erb and Binz had in treating typhoid fever with a
single full dose daily of quinine, in the German field
army during the Franco-German war of 1870, I
have followed pretty much the same method. The
results which those authors had at the time were
far better in their cases than in those which were
treated by coal-tar antipyretics, or by the expectant
plan, that is, by doing nothing for the patient until
something serious demands action, and when that
action not infrequently does not avail.

In the initial stage of typhoid fever almost every
physician orders calomel or some other purgative to
clear the bowels. It is done not only in this, but in
every acute infection : surgeons do the same, and it
is well, for by it offensive material will be removed
from the intestines ; but as to calomel or any other
so-called germicide doing much good by sweeping
C'.'.t a lot of typhoid bacilli and thereby diminishing
the virulence of the infection, that is truly a forlorn
hope. For at the stage of infiltration of the intes-
tinal follicles, the blood already swarms more or le-^s
with typhoid bacilli, not only so, but it is very proo-
able that the bacilli enter the blood current before
any intestinal localization has taken place. A mod-
erate dose of sulphate of magnesia would answer
our purpose as well, I think, here as it does in
abdominal surgery cases. This having been done.
I order a dailv evening dose of quinine muriate, fif-
teen grains to an adult, one-half of that to a patient
under fourteen years of age. to be given in one dose
or in two or three divided doses, and to be continued
daily until the chart shows defervescence. In cases
in which the temperature reaches its maximum to-
ward the end of the first week, and all circumstances
point to a severe infection, I have ordered 7,i/4 grains
at four, six, and eight p.m., with singularh' good,
and never with harmful results. To be sure, a case
of idiosyncrasy will be met with once in a great
while, where quinine will not be borne by the patient.

In such a case, tubbing, after Brand, is probably
the best thing we can do. for the resports from our
city hospitals, where the Brand method is practised,
show us many more convalescents from typhoid
fever than they had before, by the expectant treat-
ment and good nursing alone. In private practice,
liowever, two competent nurses are needed for giv-

ing the Brand baths in the proper way, and careful
supervision on the part of the doctor is essential.
Where these requirements cannot be fulfilled a modi-
fied course of hydrotherapy, in the manner so ably
described and explained by Dr. Baruch in his book
on hydrotherapy, may be confidently applied.

In regard to the diet appropriate for the typhoid
patient, the last word can be said, I think. Pepton-
ized milk and farinaceous foods, and pure water ad
libitum, until the disease is at an end, and then soft
diet for a week or two longer. I have seen mischief
follow the introduction of solid food in some cases
of typhoid with more or less pronounced intestinal
localization, and I hold that no conscientious prac-
titioner ought to take it upon himself to go contrary
to the rules for diet laid down by Osier and other
e.xperienced clinicians.

Pneumonia is a self-limited disease, so Austin
Flint said and wrote many years ago. If so shrewd
an observer and physician as Austin Flint looked
rather kindly on lobar pneumonia as it ran its course
in his davs — and how many cases may he not have
seen before he uttered his dictum — he must have had
very good reason for it, but pneumonia as we have
had it with us the last twenty-five years is an alarm-
ing and frequently fatal disease, and always a source
of considerable anxiety to the attending physician.

It seems to me that the classical chill and rapid
filling up and consolidation of an entire lobe of the
lung are not so much the fashion as in years gone
by, and resolution by lysis is at least as frequent as,
if not more so, than by crisis. Not infrequently a
part of a second lobe is affected before the first has
cleared up. and further, we meet with cases in which
we have two or more days of anxious waiting be-
fore the pneumonic process starting from the center
reaches the periphery and permits us to be certain
in our diagnosis. Again, we have had the grippe
with us since 1889, and those who have seen much
of grippe pneumonia w-ill know how tedious such
cases are and what a long wait it is before they re-
cover.

In treating pneumonia I have put my faith in
quinine, digitalis, and the cold, wet compress ap-
plied around the aft'ected side from sternum to spine,
and frequently changed ; eventually heart excitants,
such as hypodermics of camphorated oil and stimu-
lants ; and in so doing I have been but seldom dis-
appointed as to the outcome of the disease.

.■\s soon as the diagnosis is fairly well established,
a daily evening dose of 7^2 or 15 grains of quinine
muriate, according to the age of the patient, is given
in one or in divided doses, then the cold-wet com-
press is snugly applied, covered with oil-silk and
flannel, and frequently changed. By this applica-
tion the pleuritic stitch and dyspnea will soon be
relieved and a hypodermic of morphine is generally
avoided. Delirium and insomnia I find best relieved
by five grains or more of Dover's powder, and oc-
casional enemas of tepid water ; a good large room
and a plentiful supply of fresh air day and night are
essential for the welfare of the patient. To take
the pulse frequently, carefully count and prove its
strength, is very important indeed. At the first sign
of cardiac weakness quinine is discontinued, and a
freshly-made infusion of English digitalis leaves
{y2 dram to six ounces), I/2 ounce every two or
three hours, administered until cardiac action has
improved. \\"hen we cannot afford to wait for the
sometimes slow action of the infusion of digitalis
we have now a rapidly acting preparation in Cloet-
ta"s soluble digitoxin, a prepared solution of which
may be given by mouth or hypodermatically. This
is reliable and prompt in its effect. For quickly

May 4, 190?]

MEDICAL RECORD.

731

stimulating' a failing heart I prefer hypodermics of
camphorated oil in one-half dram doses every half
of one hour, to combinations of strychnine and
nitroglycerin, though I would not object to their use
if another man should wish to give them the prefer-
ence of camphorated oil.

Barring the rapid consolidation of an entire lung
or the greater part thereof, in which a copious vene-
section is indicated to save the heart and the patient's
life, it is not the overloading of the right heart in
the average case of pneumonia which threatens to
paralyze the organ, but rather the acute and severe
intoxication of the system by the pneumonic toxins ;
I do believe that in quinine, given in fairly large
doses once in twenty-four hours, we have a remedy
which really counteracts such toxins and thereby
probably diminishes the severity of the infection.

Grippe pneumonia, on the other hand, is a differ-
ent proposition altogether : it may come slow, it may
come fast, it almost creeps over various portions of
one or both lungs, it lingers, and when it finally gets
well convalescence is slow. I know of no remedy
which could be called a remedy here, and therefore
careful nursing and judicious symptomatic treat-
ment are our main reliance.

as West Fokty-sixth Street.

PUS TUBES IN THE MALE.

TREATMENT BY INJECTIONS THROUGH THE VAS
DEFERENS.

Bv WM. T. BELFIELl), M.D..

ASSOCIATE PROFESSOR OP SURGERY (GENITOURINARY), RUSH MEDICAL
COLLEGE.

Pus infection of the seminal tube, including the
vesicle, appears to be quite as frequent as pus in-
fection of the Fallopian tube in the female. It is,
however, not so often recognized, for its usual
symptoms — pyuria, frequent and painful urination,
and partial or complete retention of urine — are usu-
ally referred to the bladder and prostate, and the
patient therefore treated for cystitis and prostatitis.

The infections of the seminal tubes are three —
the gonococcus, pyogenic bacteria, and the tubercle
bacillus ; as the last induces suppuration only with
the aid of the pyogenic bacteria, it will be omitted
from consideration as a cause of pus tubes in the
male. The pus infections of the seminal tube are
extensions from the deep urethra; they result from
(i) gonorrhea, (2) stricture, (3) prostatic concre-
tions, and other causes of prostatic suppuration in
middle-aged and elderly men.

Invasion of the seminal vesicle by the gonococcus
induces the symptom complex usually considered in-
dicative of prostatic abscess— frequent and painful
urination, complete retention of urine terminated
by a sudden discharge of pus, often an ounce or two,
into the urethra. These phenomena are usually due
to abscess formation in the seminal vesicles, as em-
phasized by Lloyd' fifteen years ago; or in the
utricle,- as shown by myself twelve years ago.

A typical gonorrheal abscess of the utricle was
recently observed by Dr. L. E. Schmidt and my-
self; the symptoms were those usually ascribed to
prostatic abscess, but the fluctuating swelling was
greatest midwav between the lateral borders. With
the fingernail the abscess was incised from the rec-
tum ; after the escape of perhaps an ounce of pus,
the lateral lobes and median groove were distinctlv
felt.

Stricture of the bulbous urethra favors pus in-
fection, which, beginning in the poorly nourished

tissues, extends backward through the deep urethra
into the seminal duct and vesicle, at times even to
the ei-iididymis. As the infection may extend for-
ward in the urethra also, and thus produce a pus
discharge from the meatus, the entire clinical pic-
ture simulates a gonorrhea, and by physicians who
neglect to examine the pus with the microscope it is
often so called — to the disgust and indignation of
the innocent patient.

The nongonorrheal infections of the seminal tube
in men over forty years of age are, like everything
else causing bladder symptoms in these patients,
labeled "prostatic hypertrophy"; and they do indeed
cause the same symptoms, including even complete
retention of urine. These are the cases of alleged
prostatic enlargement that were benefited by vasec-
tomy, when that operation was popular. The preva-
lent rage for prostatectomy causes the unfortunate
subject of vesiculitis to be accused of harboring an
enlarged prostate and to be condemned to prostatec-
tomy. .V typical example of this common ailment
of elderly men was a patient seventy-two years old,
seen with Dr. Henrotin nearly three years ago. He
suffered from the usual symptoms of "cystitis" for
several weeks, culminating in complete retention of
urine. The left seminal vesicle was distended and
tender, the prostate merely swollen; incision of the
abscess was declined, but the pus traversed the vas,
causing an abscess of the epididymis. When this was
opened and the vesicle thereby drained, the bladder
function was completely restored and the patient
has had no urinary trouble since. A case practically
the duplicate of this was seen with Drs. Billings and
Phillips about the same time. By all the canons of
the general surgeon, both these old men should
have been subjected to prostatectomy — though their
prostates were in no wise to blame, unless indeed
because of the irritating presence of prostatic con-
cretions, universally found in men past middle age.

The pus infections (nongonorrheal) of the sem-
inal tube, especially in elderly men, constitute an
almost wholly neglected field ; the obvious e.xplana-
tion is that already indicated — namely, the practical
identity of symptoms with those caused by infections
of the prostate and bladder, from which pus tubes
have not been clinically distinguished. One whose
attention has never been directed to this topic will
be surprised to discover the number of cases treated
for cystitis, prostatitis, and "prostatic enlargement."
whose lesions are really pus infections of the sem-
inal tube and vesicle. The differential diagnosis
is by no means difiicult ; the usual mistake in diag-
nosis arises from the habitual failure to recognize
pus tubes as the cause of pyuria, frequent and pain-
ful urination, and partial or complete retention of
urine.

Gonorrheal infection of the seminal vesicle, on the
other hand, has been frequently identified, since
Lloyd^ called attention to its occurrence and advised
incision of the suppurating vesicle with a long-
bladed knife through the perineum. About the same
time Dittel,* the father of perineal prostatectomy,
used the incision which he had devised to attack the
prostate, for exposing and incising gonorrheal ab-
scesses of the seminal vesicle. Dittel's operation
was later modified and developed by Fuller,' who
has reported 74 cases in which he has attacked the
vesicle for suppuration and other lesions through
this extensive perineal dissection.

The Dittel-Fuller operation is admittedl\- severe
and bloody, entailing risks and requiring weeks of
confinement to hospital. It seems justified, if at all,
only in cases of perivesiculitis, since the immediate

"32

MEDICAL RECORD.

[May 4, 1907

relief sometimes demanded by pyovesiculosis is fur-
nished far more simply and safely by incision with
a cautery knife from the rectum. (The cautery' is
preferable to the knife for this incision, because it
avoids bleedinsf, averts infection, and prevents pre-
mature closure of the wound.) But a much simpler
and more eiifectual medication of the seminal tube
and vesicle is secured by the operation that I have
devised and practised," which can be done in the
ofKce. It consists essentially in opening the vas,
stitchins: the cut edges to the skin, and injecting
through a curved hypodermic needle any chosen
solution into the proximal vas ; this liquid traverses
the vas and ampulla and enters the seminal vesicle.
By digital massage from the rectum, the injected
liquid can be expressed into the urethra if desired.
Through the fistula daily injections of the vesicle
can be made so long as seems necessary, after which
the fistula is easily closed. Complete transverse sec-
tion of the vas may safely be made, if preferred,
since anastomosis of the cut ends and restoration of
the lumen is easily accomplished. For injections
through the vas the solutions commonly employed
in the urethra are used ; but the first injections
should not exceed thirty to sixty minims, lest sper-
matic colic and retention of urine be provoked.
Both of these effects I witnessed in my earlier work ;
the spasmodic contraction of the vesicle seems to
cause spasm of the bladder sphincter — an item of
both clinical and physiological interest. The influ-
ence of the seminal ducts upon the bladder and its
sphincter suggests an explanation of the cause and
cure of "irritability" of the bladder in some cases.

1. Lancet, 1891, II, p. 974.

2. Journal of the American Medical Association, April

21, 1894,

3. British Medical Journal, 1889, I, p. 882.

4. Wiener medizinische Blatter, 1894, p. 261.

5. American Journal of Urology, December, 1966.

6. Journal of the American Medical Association, April

22, 1005; Surgery, Gynecology and Obstetrics, November,
1906.

100 State Street.

THE PREAPPENDICITIS STATE.

By JOH.X G. SHELDO.N, .\I.D..

KAN'SAS CITY, MO.

It is generally believed by the laity and the medical
profession, and it is taught by our modern text-
books, that acute appendicitis is sudden in its onset,
and that it develops without previous svmptoms sug-
gestive of the disease. (The well known varieties
of chronic appendicitis that may be subject to acute
exacerbations are, of course, not considered in the
foregoing.) Recently, there seems reason to believe
that our views regarding the onset of acute appendi-
citis will undergo a change. Some clinical observers
no longer hold that acute appendicitis should be
looked upon as a primary and very acute affection,
but consider it, at least in some instances, as the re-
sult of a chronic process that has paved the way for
its occurrence. Mumford and Stone, after consider-
ing appendicitis from all standpoints, state that "it
seems as though we were often justified in regarding
appendicitis as a chronic disease clinically, and sub-
ject to acute exacerbations."

A limited operative and clinical experience, asso-
ciated with the ordinary work of a general prac-
titioner, has led me to believe that acute appendicitis
rarely occurs without previous, more or less definite,
symptoms having been complained of for three
months to one year. This conclusion has resulted
from the obtaining of definite histories of acute ap-
pendicitis cases operated upon ; and, by examining.

and keeping in touch with the developments in
patients complaining of obscure and very mild gas-
trointestinal symptoms. An accurate history of the
symptoms of the patients whom I have operated
upon for primary attacks of acute appendicitis dur-
ing the last three years, has shown in almost every
instance that, while the patients invariably date the
history of their illness from the beginning of the
acute attack, they have suffered from slight and oc-
casional abdominal pain, and many times constipa-
tion and flatulency, for a period of several months
before the acute involvement of the appendix began.
These so-called preappendicitis symptoms have been
found to be so often present in cases of acute ap-
pendicitis that it seems probable to me that their
occurrence is the rule and not the exception. Their
existence is easily overlooked. They are mild and
of long standing, while the acute attack is so definite
and so serious that it completely overshadows the
patient's previous complaints.

It is a common experience in general practice to
be consulted by patients, who have been apparently
well in every respect, complaining of unusual, mild,
and diffuse pain in the abdomen, with perhaps a loss
of appetite and moderate constipation. A careful
examination of these patients revealed, in most in-
stances, no cause for the symptoms. A cathartic gen-
erally relieved them. When, however, these symp-
toms had existed for a period of three to six months,
during which time the symptoms would disappear
for a week or ten days at a time, examination re-
vealed in most instances a very slight tenderness
over the appendix. Repeated examinations showed
that this tenderness was not constant. The symp-
toms and findings did not warrant a diagnosis of
chronic appendicitis, consequently no diagnosis was
made, but the patients were kept under observation.
Eighteen such patients developed acute and serious
appendicitis within three months to one year after
the first complaint of the mild and indefinite abdom-
inal symptoms. Five others gradually developed
chronic appendicitis for which operation was done.
Three patients are still under obsen'ation, who
supposably have been in the preappendicitis state
for four months, seven months, and nine months
respectively.

If it is true that acute appendicitis is many times
preceded by the so-called preappendicitis state, the
symptoms of this period, according to the cases ob-
served, would be intermittent diffuse, but slight
abdominal pain in all of them ; moderate constipa-
tion in approximately three-fourths of -them ; notice-
able abdominal distention in a few ; and slight, but
not constant, tenderness over the appendi.x on deep
pressure. The frequent finding of these symptoms
in a patient who later developed acute appendicitis,
together with the history of the frequent occurrence
of such symptoms preceding a primar\' acute ap*-
pendicitis, suggested the existence of a preappendi-
citis state.

The practical importance of recognizing the pre-
appendicitis state, if such exists with any degree of
constancy, bears directly on the present m.ortality
of acute appendicitis. \Ve are perhaps not justified
in advising operation for patients in the preappendi-
citis state ; but we should warn them of the proba-
bility of suffering from an acute attack of appendi-
citis in order that they may seek competent advise
at the beginning of the acute symptoms. Such ad-
vise mav seem unnecessary when we consider a!l that
has been said regarding the diagnosis and treatment
of appendicitis : but the present mortality of acute
appendicitis should be reduced. Entirely too many
cases are brought for operation after perforation
and' local or general peritonitis have occurred.

May 4, 1907]

MEDICAL RECORD.

733

Medical Record.

y/ fVeekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A.M.. M.D.. Editor.

PUBLISHERS
WM. WOOD &. CO , 51 FIFTH AVENUE.

New York, May 4, 1907.

THE FUNCTION OF ALIsL\LOIDS IN
PLANT LIFE.

The study of the vegetable alkaloids has been pros-
ecuted so diligently and so successfully in recent
years that the chemical structure of fifty of these
substances is now known in detail, and twenty of
the structural formulas have been confirmed by arti-
ficial synthesis of the corresponding alkaloids. The
origin of these bodies and the part played by them
in the life of the plant are discussed by Aime Pictet
in a paper recently read before the Swiss chemical
society of Neuchatel.

The sources of alkaloids, he says, and the proc-
esses by which they are formed in vegetable cells,
have long been matters of discussion. The old
theory of Heckel that the alkaloid is the first result
of assimilation, and represents a stage in the forma-
tion of albuminoids has been shown to be erroneous.
Lartz and Clautrian have proved that the true alka-
loids, such as quinine, atropine, cocaine, morphine,
caffeine, solanine, and betaine, cannot serve as plant
food, that the quantity of these alkaloids in the seed
increases, instead of decreasing, during germina-
tion, and that a diminution of the quantity of alka-
loid is never accompanied by a corresponding in-
crease in albuminoids. So that we are led to regard
the alkaloids, not as products of assimilation, but as
results of the partial decomposition of more com-
plex substances. Certain groups of atoms, or parts
of the complex molecule, appear to be more stable
than others, and these groups resist disintegration
and appear as alkaloids. The alkaloids, being nitro-
genous decomposition products resulting from vege-
table metabolism, are analogous to the urea, uric
acid, and bile pigments of animals. But the plant
cannot, like the animal, promptly get rif^ 'A the waste
products because it has no elin^inating organs.
Some plants, no doubt, find means of destroying
their alkaloids so rapidly and completely that they
do not appear to produce any. In other plants this
process, if it occurs at all, is slow and imperfect, so
that the organism is compelled to retain its excreta
for a time and to confine them to certain cells and
tissues where they cannot injuriously affect the gen-
eral life of the plant. Hence the characteristic local-
ization of alkaloids in such peripheral parts as roots
and fruits, where, as they are poisonous to many
animals, they incidentally serve as a protection to
the plant. This power of localization of alkaloids is,
therefore, of advantage in the struggle for exist-
ence, and it is most strongly developed in the most
highly organized plants.

Such localization, however, is not the only means

by which the plant can protect itself against the in-
jurious effects of substances which it can neither
eliminate nor destroy. In the animal organism poi-
sons, whether resulting from metabolism or intro-
duced from without, are not usually excreted
unaltered, but undergo various changes which make
them less poisonous or more soluble, and therefore
easier of elimination. The change may be simple
oxidation, combination with other substances, or
both. That plants, which possess greater powers of
synthesis than animals, adopt similar methods, and
that the alkaloids extracted from plants represent
the poisonous products of excretion not in their
original form, but in combination, appears probable
for the following reasons : In most vegetable alka-
loids the molecule is composed of two distinct parts,
a nitrogenous nucleus and one or more groups of
very different chemical character. Again, when a
plant yields several alkaloids, which is usually the
case, all have the same nucleus, and differ only in
the number and character of the secondary groups.
Finally, the plant, like the animal, makes its nitro-
genous excreta more complex, thereby neutralizing
the atomic groups which have a poisonous action on
protoplasm.

Caffeine, theobromine, and theophylline, the alka-
loids of coffee, cacao, and tea, as well as many
others, have an origin identical with that of their
animal analogues, such as uric acid, from which
artificial caffeine is now made. They may be re-
garded as decomposition products of nuclein.
The alkaloids of the choline group have a similar
origin. Choline, a nonpoisonous alkaloid, is found
in toadstools and hops, and also in pickled herrings
and human corpses. In the animal tissues it arises
from the saponification of one of its compounds,
lecithin. Vegetable choline and its immediate de-
rivatives, muscarine (the poison of toadstools) and
sinapine (found in white mustard seed), undoubt-
edly owe their existence to a similar reaction. We
must, therefore, regard all these alkaloids as de-
composition products of vegetable lecithin. Nico-
tine, atropine, cocaine, and strychnine may be de-
rived directly from albuminoids, which appear also
to be the indirect sources of the alkaloids of opium,
cinchona, and some others.

TROPICAL NEURASTHENIA.

The experiences of many of the Americans who
have gone to the Philippines illustrate only two
well the fact that prolonged sojourn in tropical
regions is usually attended, in white persons coming
from the temperate latitudes, by a great deprecia-
tion in the powers of mental and physical applica-
tion, often going on to such a degree as to render
imperative a speedy return to more accustomed
climatic conditions. Strange to say, writers on
tropical life do not appear to have given this
form of neurasthenia the attention it deserves : at
least there have been but few contriliutions to the
literature of the subject. Among the niijre im-
portant writings on this matter are those of Alajor
Charles E. Woodruff, who speaks of the condition
as being so common an occurrence as to merit the
special term of tropical exhaustion, and states that
in addition to its more patent manifestations it re-

734

MEDICAL RECORD.

[May 4, 1907

duces the powers of resistance to every disease as, it
lessens the natural immunity.

A careful study on the subject by Louis H. Fales
appears in the American Journal of the Medical
Sciences, April, 1907. He states that from his
Philippines experience he believes that nearly all
American women and a large proportion of the
men who have been in the islands for a year or
more sufifer at least to some extent from nerve
exhaustion. A conservative estimate, he says,
would be that 50 per cent, of the women and 30
per cent, of the men are afifected to such an extent
that they are in a state of semi-invalidism. They
lose the power of mental concentration, sufifer from
loss of memory, become easily fatigued, and are
inefficient as workers. The women become nervous,
irritable, and anemic, lose weiHit, sulfer with neu-
ralgia and insomnia, and almost invariably are
troubled by menstrual irregularities. Fales further
expresses the opinion that, directly and indirectly,
tropical neurasthenia incapacitates more white men
in the Philippines than all other causes combined,
and seems to be the main difficulty in the process
of acclimatization.

In general the nerve exhaustion of the tropics
does not differ greatly from the neurasthenia seen
in this country, but menstrual derangements such
as menorrhagia, metrorrhagia, and dysmenorrhea
are unduly frequent in the w^omen patients. Vaso-
motor symptoms such as angioneurotic edema and
pemphigus, localized sweatings, etc., are also com-
mon. Fortunately, the condition responds to treat-
ment more promptlv than ordinary neurasthenia,
and change of climate is usually effective. The
greater prevalence of the condition in the tropics
naturally leads to inquiry regarding the special eti-
ological factors that may exist in such regions. No
doubt the lack of willingness or ability to conform
to the habits of the native in regard to hours of
work, the noonday siesta, and other time-wasting
but health-conserving customs of the country plays
a large part in the dow-nfall of the energetic white
man in hot countries, and there must be added to
this the predisposition to nervous exhaustion at-
tending certain common tropical diseases such as
dengue and amebic dysentery. Fales expresses
himself rather conservatively in speaking of the
alcohol question and in this connection quotes
Woodruff's figures, which appear to show that the
use of alcohol is not especially detrimental in the
tropics. He suggests that the moderate use of al-
cohol may serve to prevent infection by in-
testinal parasites by stimulating the action of the
gastric secretions and by a direct antiseptic action
on the parasites themselves.

Rather more importance is accorded to Wood-
ruft"s theory of overstimulation by the excessive
quantity of actinic rays present in tropical sun-
shine, which has already been discussed in these
columns, and concerning which the author says
that there can be no doubt that this effect of the
violet and ultraviolet rays plays an important part
in the etiolog}' of tropical nerve exhaustion. He
lays most stress, however, on the high temperature
and high humidity that prevail in the Philippines,
as the result of which there is an almost constant
abnormal dilatation of the arterioles of the skin.

This leads to an anemia of the internal organs, of
course including the central nervous system, with
the result of nervous malnutrition and derange-
ment. An ingenious portion of the author's argu-
ment is that in w'hich he points out that, owing
to the smaller relative skin surface of large men,
these require more active cutaneous circulation in
order to effect a sufficient cooling of the blood,
and that in consequence they must be particularly
prone to evidences of nervous anemia and cardiac
overactivity, a supposition which is borne out by
the facts.

From these considerations it is evident that the
proportion of persons for whom a prolonged stay
in the tropics is likely to be possible without more
or less risk must be a rather small one. Woodruff
has stated that the best age is from twenty to thirty
or thirty-five years, and that no man over fifty-
five should go there for more than a short visit
Fales believes that the tropics should be avoided
especially by blondes, large men with great mus-
culature, those with tuberculous tendencies, those
having gastric or intestinal disorders, neurasthenics
of all sorts, women, children, and old men. The
requirements of tropical hygiene involve avoidance
of the actinic rays as much as possible, including
the use of sun shades and clothing properly se-
lected as to color and material, and refraining from
overwork, especially from exertion during the mid-
dle of the day. Five hours is to be considered a
fair day's work. In regard to diet, it is a mistake to
believe that dwellers in the tropics need little meat.
The greatest care is also necessary in preparing the
food in order to avoid intestinal infection, and green
vegetables and unboiled water must be shunned.

From all of this it appears that only such per-
sons as are physically and mentally fitted for it
should go to the Philippines, and that while there
they should use common sense in conforming to local
customs regarding work, rest, and clothing, and
what might be termed uncommon sense in the se-
lection of their food and in the supervision of the
details of its preparation. These conditions com-
plied with, the dangers are perhaps not so very
great, but it is evident that infractions of the rules
of hygiene are even more likely to be fraught with
serious consequences in the tropics than in the
temperate latitudes.

PYELITIS IX CHILDHOOD.

AiioxG the uncommon and unfortunately often un-
suspected conditions found in children is an in-
flammation of the renal pelvis. This may be due to
the ingestion of certain medicaments or to mechani-
cal or toxic irritants. In older children it may also
be due to a faulty diet leading to an excess of uric
acid or urates in the urine. In exceptional cases the
presence of certain parasites such as echinococcus,
strongylus, or distomum, may lead to the disease
on account of the deposit of eggs or embryos in the
urinary passages. E.xtreme degrees of phvTnosis,
hypospadias, or pressure exerted on the bladder or
ureter may lead to infection of the mucous mem-
brane of the renal pelvis by producing decomposition
of the urine. A pyelitis maj- occur during the later

May 4, 1907]

MEDICAL RECORD.

rjs

stages of one of the infectious diseases, particularly
scarlatina or variola. Tubercle bacilli which
have found their way into the urine may
also lead to a tuberculous infection of the pelvis,
and the gonococcus may likewise produce a spe-
cific local inflammation by direct extension from
a vulvovaginitis of this character. In every case the
disease is ushered in by a chill, followed by a mod-
erate elevation of temperature unless urinary stasis
is present, when the fever will be much higher.
\Mien there is profuse suppuration present, localized
pain is also complained of, and this may be referred
to the bladder, the meatus, the perineum, or the
thigh. There may also be a severe dysuria. The
most important point in the diagnosis is to be gained,
however, from the uranalysis. The total quantity
of urine may be unaffected or slightly increased,
but the pus which is invariably present gives the
fluid a cloudy appearance, which increases on stand-
ing. The sediment on microscopical examination
will be found to be mainly pus, together with the
characteristic cells from the pelvis of the kidney.
Albumin is present in varying degree depending on
the amount of blood or pus.

The prognosis is fortunately good in most cases
if the condition is not neglected. In acute cases in
which the condition is due to medicinal or even
mechanical irritants, healing takes place within from
one to four weeks. When the pyelitis is due to uri-
nary decomposition recovery is likewise prompt if
the cause of the latter can be removed, but when a
growth is present the outlook is less favorable, and
a fatal result may be determined by uremic poison-
ing. A pyelitis due to one of the infectious diseases
is apt to run a protracted course, and even when
recovery takes place recurrences are frequent. In
treating this disease, Monti (Allgeineine JJ'iciicr
Medizinai-Zeitung, 1907, No. i) calls attention to
the importance in all acute cases of absolute rest in
bed and a milk diet, and this must be continued
until the urine is entirely normal. As soon as a re-
currence is noted this same regime must again be
instituted. Diuretic measures are also indicated,
and much good results from the use of warm baths
lasting from fifteen to twenty minutes, of either
plain or sea water, mud, or the water of some natural
thermal springs. When an irritating medicament is
at fault, its administration must be stopped and the
excretion favored by various means. Local meas-
ures, including bladder irrigation, are required in
appropriate cases, and the urinary antiseptics may
also be given, though with care, as they are very apt
to cause considerable disturbance.

The Scrotal Tongue.

This is the rather inelegant name applied to a pe-
culiar condition of the tongue which is occasionally
met with, and in which the dorsal surface of the
organ is the site of a number of symmetrical fur-
rows which give it a shriveled appearance similar to
that seen in the skin of the scrotum. It is necessary,
as shown by Chambardel in a recent article in tlie
Archives Gcnerales de Mcdecine, No, 44, 1906, that
this condition be carefully distinguished from the
pathological furrowing of the tongue which is asso-
ciated with carcinoma, syphilis, tuberculosis, and
similar lesions, and the physiological furrows which

are found in many persons on either side of the
median line. From both of these the deformity of
the tongue in quetsion may be distinguished by the
symmetry and depth of the furrows which extend
over the entire dorsal surface of the organ and
around on the sides. An hypertrophy of the labial
papilla is frequently seen, but this has no apparent
connection with the other condition. The tongue
thus afflicted is of a bright red color, and is usually
broad and flat. The mouth itself may be perfectly
normal in other respects, except that there is very
apt to be an enlargement of the salivary glands,
and their secretion is increased. In isolated in-
stances an hypertrophy of the lacrymal glands has
also been observed. .Although a tongue of this kind
may not give rise to any symptoms, it offers a favor-
able field for the development of leucopiakia, glos-
sitis, ulcers, and a variety of other local processes.
We know practically nothing of the etiology of tliis
condition, and the histology is likewise uncertain.
The only direction in which an insight into the true
nature of the lesion may be gained would seem to be
from the stand]:M)iiit of embryology or cotnparative
anatomw

Meningeal Irritation from Spinal .Anesthesia.

The not infrequent reports of serious complications
attending the employment of cocaine for purposes
of medullary anesthesia must naturally dampen the
entiiusiasm with which this procedure has been advo-
cated by many surgeons. It is of undoubted value
in many instances as a substitute for ether or chloro-
form, but from the number of accidents which
occur as the result of its administration it would
appear that the indications for its use have not thus
far been completely formulated. Among sequelae
of spinal cocainization which are less frequently
observed are evidences of meningeal irritation. A
few instances have been reported, and to these an-
other is now added by Schick {Wiener klinisch-
thcrapciitische Wochenschrift, No. 46, 1906), who
undertook to do a curettage for an incomplete abor-
tion, in a very nervous patient, by the aid of medul-
lary narcosis. The injection was made in the usual
manner and the patient then placed in the Trendelen-
burg position for a few minutes. The operatioti
was successfully done, and the woman made an
apparently good recovery. On the third day, hov/-
ever, she was seized with a severe headache, which
was accompanied by an increasing rigidity of the
neck muscles. The pulse rate then dropped to from
48 to 54 beats per minute. There were no psychic
disturbances and no ocular symptoms. Vomiting
was also present, and this, with the other symptoms,
persisted for about eight days, when a gradual im-
provement took place. These phenomena, which
were most marked, gave every evidence of being
due to a meningitis, and \et i\\t latter could with
considerable certainty be excluded. It is possible
that severe nervous disturbances of this kind may
depend, to a large extent at least, on some peculiar
idiosyncrasy regarding the drug manifested by
nervous persons. If so, patients of this clas.s would
seem to present a particular contraindication against
the employment of the procedure in question. I:i
omitting the elevated pelvic position, the writer
thinks it might be possible to limit the field of action
of the anesthetic, and this is applicable to most of
the gynecological operations. To the impartial ob-
server the occurrence of such serious sequel;e con-
stitutes, however, a drawback to the use of the spinal
anesthesia which is hardly counterbalanced by its
assumed advantages.

736

MEDICAL RECORD.

[May 4, 1907

Decision Riigarding Abortioxists.

The Appellate Division of the Supreme Court on
April 19 wrote an opinion which will prove of great
assistance in securing convictions of professional
abortionists. Some time ago the Medical Society
of the County of New York, through its counsel,
caused the arrest of a woman who had placed in
certain New York City newspapers an advertise-
ment of unequivocal import. She was charged
with maintaining a public nuisance in violation of
Sections 385 and 387 of the Penal Code, inasmuch
as she received into her house pregnant women and
used instruments upon them to procure unlawful
abortions. The defendant was tried in the Court
of Special Sessions and sentenced to one year in
the penitentiary and to pay a fine of $500. The
case was annealed on the ground that no crime un-
der Section 385 of the code was committed, and
that no adjudicated case has been found in which
it has been held that the maintaining of a house
* for the purpose of practising the vocation of an
abortionist constitutes a nuisance. The Superior
Court, however, affirmed the conviction, stating
that it is a nuisance for a person by public adver-
tisement to invite and receive a class of the public
to his premises for the purpose of violating the laws
of the State, as was done in this case. It is further
stated that the ofifense of abortion is one thing, but
that of maintaining premises open to the public for
the purpose of consummating that crime is another
and separate ofifense against the peace and good
order of the State. It is an inducement to moral
laxity and to crime, and is within the letter and
spirit of the sections of the Penal Code under con-
sideration. The counsel of the County Medical
Society state that this is the first case of its
kind recorded either in this country or in England,
and that now that this precedent has been estab-
lished it will be much easier to secure convictions
for illegal abortion, as there will no longer be the
necessity of laying elaborate traps to catch a de-
fendant ^ac''Q"/<' delictit.

sume that, in children particularly, where no organic
disease can be found to account "for a continued
high temperature, the rise in temperature is of
purely hysterical origin.

Hysterical Fever.

TjiE existence of a rise of temperature depending
on an hysterical basis has often been questioned, and
yet cases undoubtedly occur in which no other cause
than a nervous one can be found to account for the
fever. An instance of this kind is referred to by
Comby in the BnUetin Medical, 1906, No. 36, as hav-
ing taken place in a girl of thirteen who was rather
weakly, and had been the subject five years pre-
viously of an attack of what was called subacute
peritonitis, which was probably of a tuberculous
nature. The symptoms improved, but several years
later she became afflicted with a tremor of the arms
following a mild attack of influenza, which was
characterized by a relatively slight rise of tempera-
ture. After this the course of the temperature pre-
sented several points of interest ; although never over
100° F. in the morning, it would rise to 107° F. in
the evening. Notwithstanding this enormously high
temperature in the evening, there was apparently no
marked effect on the patient's general condition,
and after the fev.er subsided the child spent the rest
of the night quietly. The general character of the
case led to the thought that an hysterical basis was
the underlying factor in the production of the high
fever, and the patient was treated with wet packs
and psychical influences, which finally resulted in
complete recovery. .Such instances have occasion-
ally been reported in the literature, and we may as-

Tuberculous Meningitis without Tubercles.

Ix a recent issue of the Lancet (April 13) refer-
ence is made to an interesting case recently re-
Ijorted by Sireday and Tinel, who call attention to
the fact that, although tubercles of various forms
anatomically characterize tuberculosis, they are in
some cases absent, especially wdien the disease is
located in the central nervous system. Thus men-
ingitis may be occasioned by a diffuse bacillary in-
filtration or even tuberculous toxins. The authors
referred to report the case of a boy admitted to
lios]Mtal in a comatose condition. He had been
sick for two weeks with headache and vomiting,
and gradually became comatose. Rigidity of the
neck, photophobia, wasting, mydriasis, irregularity
of the pulse, the meningeal streak, Kernig's sign,
and lesions at the anices of the lungs left no doubt
as to the diagnosis of tuberculous meningitis. Lum-
bar puncture showed marked lymphocytosis of the
cerebrospinal fluid and some polynuclear cells. The
case ran the ordinary course and death occurred
after an illness of almost eight weeks. At the ne-
cropsy the most minute examination failed to show
any tubercles on the meninges or in the cerebral
cortex. To the naked eye the changes consisted in
an intense congestion of the nervous centers, of
which the vessels were much distended. The men-
inges had lost their transparency and at several
points showed a slight thickening with a milky tint,
little pronounced. The meninges could be raised
without tearing the adjacent cerebral substance.
The subarachnoid space and the ventricles con-
tained a notable quantity of liquid. The lungs
showed diffuse tuberculous lesions, large granula-
tions of the size of a lentil confluent in some places,
disseminated in others. Microscopic examinations
revealed numerous tubercle bacilli in these granula-
tions. To the naked eye the kidneys showed noth-
ing abnormal, but the microscope disclosed lit-
tle tuberculous nodules. Microscopic examination
of the meninges showed a diffuse leucocytic infil-
tration without any tuberculous granulations. In
some places the cells were agglomerated into little
nodules, but nowhere was there a definite tubercle.
The case exactly corresponded to the type de-
scribed by Delille as "diffuse leucocytic infiltration,
predominantly perivascular, and with tendency to
nodules." In no preparations could giant cells or
caseous degeneration be seen — nothing suggestive
of formation of tubercles. But large numbers of
tubercle bacilli were disseminated wherever there
was leucocytic infiltration of the membranes. They
were especially grouped around the blood-vessels,
forming in certain places little agglomerations
without modification in the form or grouping of the
neighboring cells.

Abscess of the Liver. — Excellent results may be
obtained in liver abscess cases (solitary abscesses),
which drain for a long time, by applying a Bier cup
over the superficial opening once a day for five
minutes. One must be especially cautious in these
cases not to increase the vacuum too rapidly, as
rupture of the vessels in the liver might easily ensue
and cause serious damage. — American Journal of
Surs:ery.

May 4, 1907]

MEDICAL RECORD.

737

"Nms of tlje 0fpk.

Civil Service Examinations for the State and
County Service. — The State Civil Service Com-
miision will hold e.xaminations May 25, 1907, for
the following positions : Coroner's physician, Al-
bany county, $600 : night superintendent. Erie
County Hospital, S420 and maintenance. The
last day for filing applications for these positions
is May 18. Full information and application
forms may be obtained by addressing Charles S.
Fowler, Chief Examiner of the Commission, at
Albany.

Joint Conference of Illinois State Board of
Health and Officers of Medical Societies of the
State of Illinois. — A joint conference was held
April 24, 1906, at the Great Northern Hotel, Chi-
cago. During the meeting the following com-
mittees submitted reports, which were freely dis-
cussed and adopted: Committee on Reciprocity;
Committee on Medical Legislation in Illinois;
Conmiittee on Relation of State Board of Health
to Local Boards of Health : Committee on Exam-
ination of Candidates and ^Methods Pursued in
Connection with the Administration of the Med-
ical Practice Act in the Case of Unlicensed Prac-
titioners; Committee to Promote Cooperation
Between the State Medical Societies and the State
Board of Health, and also a Committee on Coopera-
tion Between the Different Schools of Medicine.
One of the committees in its report urged the hold-
ing of such a conference yearly, and it is believed
that this suggestion will be carried out.

For More Park Milk Booths. — .A committee
acting in behalf of several charitable organizations
interested especially in the care of the children of
the poor, has requested the Board of Park Commis-
sioners to make application to the Board of Esti-
mate and Apportionment for an emergency appro-
priation of $8,000 for the purpose of erecting eleven
additional milk booths in the parks. If the booths
are provided Mr. Nathan Straus has agreed to bear
the cost of furnishing pasteurized milk for distri-
bution, and of the iiecessan.- attendance.

Health Conditions on the Isthmus. — According
to the report for the month of iMarch, of Col. Gorgas,
chief sanitary officer of the Canal Zone, the con-
ditions on the Isthmus are now so satisfactory that
much improvement can hardly be expected. Since
last August the number of sick among the em-
ployees has steadily declined, until it is now 19.40
men per 1,000, as against 33.72 in August. Among
4,600 American white employees there were only
two deaths from disease during the month of
March. Among 1,200 American women and chil-
dren living in Canal Commission quarters there
were no deaths, and very little sickness of any kind.
The negro employees continue to show the highest
mortality, and the American whites the smallest.

Alvarenga Prize. — The next award of this prize
which consists of the income for one year, amount-
ing to $180, of the fund left for thi's purpose by
the late Sefior Alvarenga, will be made on July 4,
1907. provided that an essay deemed worthy of the
prize shall have been offered.

Italian Prizes. — Among the subjects for which
prizes are offered by the Reale Institute Lombardo,
are the following : For the Cagnola prize for IQ08,
the so-called nuclei of origin and termination of the
cranial nerves; for the Secco Comnenn prize for
1907. a discovery relating to the virus of rabies :
for 191 1, on the physiological action of hi^i-fre-

quenc}- currents. For the present year the prize
awards of the Reale Institute Lombardo include a
Cagnola prize of £100 and medal of the value of £20
to Dr. Augusto Moschini of Pavia, for his essay on
the pathology of the suprarenal capsules : a prize of
iSo to Dr. Guido Sala of Pavia. and awards of £20
to Professor Domenico Lo Monaco and G. Pito of
Rome for essays on the anatomy of the visual cen-
ters of higher vertebrates under'the Fossati founda-
tion.

Dr. Charles H. Peck, the Senior Attending Sur-
geon to the French Hospital of this citv, has re-
cently received from the French Government,
through the Minister of Public Instruction and Fine
.•\rts. the decoration of Officier de I'lnstruction Pu-
blique.

Dr. Theodore H. Weisenburg has been elected
neurologist to the Philadelphia Hospital and con-
sultant to the Insane Department, and also professor
of neuropathology and assistant professor of neu-
rology in the :\Iedico-ChirurgicaI College, in succes-
sion to the late Dr. \\'m. Pickett.

Dr. John B. Deaver has been elected consulting
surgeon to the Philadelphia Hospital in succession
to the late Dr. John H. Brinton.

Resignation of Dr. Mettler.— Dr. L. Harrison
Metiler has resigned from the facultv of the Chi-
cago Clmical School.

A New Clinical Society.— The members of the
medical stait of the New York Throat, Nose, and
Lung Hospital have organized a society known as
the Clinical Society of the Hospital. :Members and
ex-members of the staff are eligible for membership.
The officers for tiie first year are as follows : Presi-
dent, Dr. E. A. Miller: Vice-President, Dr. S. Gold-
stein: Secretary, Dr. Qias. F. \\'alter : Treasurer,
Dr. .M. C. Tracy. The next meeting will be held
at the hospital, 229 and 231 East Fiftv-seventh
street, on Wednesday, :\Iay i, 1907. The pro-
gram for the evening embraces the presentation
ot patients, specimens, and instruments, and the
reading of a paper on tinnitus aurium bv Dr C F
Walter.

Memorial Hospital Plans.— .\ committee of the
Iroquois -Memorial Hospital Association has pre-
sented a plan for a memorial emergencv hospital
in the downtown district of Chicago, to 'the Presi-
dent of the Cook County Board. It is proposed
by the committee to lease the ground at 43 and 45
La Salle street, at an annual rental of 85,000, and
to erect thereon a three-story building to cost
about $30,000. The Hospital Association is will-
ing to pay for the building, but it asks the countv
to pay for the lease of the land.

An International Congress of First Aid to the

Injured.— Under this title an international con-
gress is being planned for, to be held in Frankfurt
a. M., Germany, in the spring of 1908, and to be
devoted to the subjects of first aid and life saving
in factories, on railroads, in agricultural pursuits,
in mines, at sea, etc. The methods and appliances
in use in different countries are to be exhibited and
discussed. The chairman of the committee of ar-
rangements is Oberbiirgermeister .Adickes of
Frankfurt.

Board of Food and Drug Inspection. — Secre-
tary Wilson has created a Board of Food and Drug
Inspection, whose duty it shall be to administer the
national pure food law. The board consists of Dr.
Harvey W. Wiley, chairman ; Dr. Frederick L.
Dunlap. and George R. McCabe.

738

MEDICAL RECORD.

[May 4, 1907

Hospital Conference. — At the recent meeting

of the Hospital Conference of the City of New
York the subject of dispensary management was
discussed. In view of the constantly growing num-
ber of persons requiring dispensary treatment it was
decided to make a statement to the Mayor and to
the heads of hospitals regarding the necessity for
increased dispensary facilities.

The Presbyterian Hospital will receive between
$120,000 and $150,000 by the will of the late Peter
Cumming, founder of the Broadway Savings Insti-
tution.

New Public Bath for the Bronx. — Plans have
been tiled for a new two-story free public bath to be
erected at the southeast corner of Elton avenue and
156th street. It is to be of brick, with trimmings of
ornamental stone, and will front 67 1-2 feet on both
avenue and street and have a depth of 58 feet. It
is to cost $140,000.

Hospital Saturday and Sunday Association.—
The distributing committee of the Hospital Satur-
day and Sunday Association met last week to dis-
tribute the undesignated fund of the collection of
1906. The total collection was reported as $103,110,
of which $1,555 was derived from the offer of Mr.
and Mrs. James Speyer to duplicate all gifts after
$100,000 had been collected. Of the total, $14,-
610.88 was designated by the donors to particular
institutions, and $4,492.12 was reserved for future
expenses, leaving the sum of $84,000 for distribu-
tion. The allotment was made on a basis of the
free work done by each institution. The Monte-
fiore Home and Hospital and Mount Sinai Hospital
got the largest awards, $8,400 each. St. Luke's,
Roosevelt, the Lebanon, and German Hospitals each
received amounts e.xceeding $4,000, and thirty-three
other institutions received smaller apportionments.

Death from X-Rays. — The death of Wolfram C.
Fuchs, which occurred in Chicago last week, makes
at least the fifth instance in which .r-ray workers
have succumbed to lesions caused by continual ex-
posure to the rays. Mr. Fuchs about three years ago
suffered serious burns of both hands, which neces-
sitated his retirement from active work, but in spite
of this and of repeated amputations, the condition
progressed, and the lesions finally involved the trunk
and internal organs.

Suicide in Japan. — According to recently pub-
lished statistics, the practice of self-destruction is
steadily increasing in Japan, and during the year
1904 6,200 men and 3,900 women ended their own
lives. This is an increase over the figures for the
year 1890 of 14.5 per cent, for the men and 16 per
cent, for the women. Hanging and drowning are
the two methods most often used.

Museum for Haeckel. — The municipality of
Jena has given a plot of land, on which a philoge-
netic museum will be established in honor of Profes-
sor Ernst Heinrich Haeckel.

Medical Inspection of Immigrants. — In refer-
ence to the editorial in a recent issue of the Med-
ical Record on the relation of immigration to the
prevalence of insanity. Dr. Thomas W. Salmon in-
forms us that Surgeon George W. Stoner of the
Public Health and Marine Hospital Service is in
charge of the medical inspection of immigrants at
Ellis Island, and that Dr. Salmon is one of several
officers of this service assigned to duty there.

Scurvy in Russia. — Scurvy has become very
prevalent in the famine districts of Russia. Official
reports show that in the last two weeks of March
1,055 cases were discovered in the province of Ufa

alone, and up to April 25 11,000 cases in all had been
reported in the same province.

Typhoid Fever in Warsaw. — An outbreak of
typhoid fever has occurred among the thousands of
political prisoners confined in the overcrowded pris-
ons of Warsaw, and the disease has become epi-
demic throughout the city.

The Syrian Protestant College of Beirut, Syria,
in which Dr. George E. Post is professor of surgery,
has received from ;Mrs. Russell Sage the sum of
$75,000 for the erection of an American hospital.

international Congress of Physiotherapy. — The
twelfth international conveinion of tliose interested
in this branch of therapeutics will be held in Rome,
October 13 to 16, 1907.

Harlem and Fordham Hospitals. — The new
buildings of these two hospitals are ready for occu-
pancy. The new Harlem Hospital occupies nearly
lialf a city block on Lenox avenue, between 136th
and 137th streets, fronting on the former. Besides
the main building, which is a five-story brick and
stone structure, there are separate buildings for the
ambulance station and power house. The new Ford-
ham Hospital main building, which, like the Harlem
Hospital, is but a part of a svstem of contemplated
structures, is five stories in height and is built of
stone and brick. To the rear of the main building
are the ambulance stables, laundries, and servants'
quarters. Beside it to the west is a large four-story
stone and brick building to be devoted to the nurses.
The buildings are at the Southern boulevard and
Crotona avenue.

Michigan State Board of Health. — Dr. Angus
McLean of Detroit has been elected president of the
State Board of Health, succeeding Dr. Victor C.
Vaughan of Ann Arbor. Dr. F. W. Shumway was
reelected secretary.

Bequests to Philadelphia Institutions. — In ac-
cordance with the terms of the will of the late Ed-
ward T. Dobbins of Philadelphia, the executors
have distributed the following legacies : Scholar-
ship in the Philadelphia College of Pharmacy, S25,-
000; Hospital of the Women's Medical College,
$10,000; Christ's Church Hospital, $10,000; Bur-
lington County Hospital, Mt. Holly, X. J., $5,000;
Children's Hospital, $5,000; Home for Incurables,
$5,000: Free Bed ^^'omen"s Medical College, $5,000.

The Congress of American Physicians and Sur-
geons.— The seventh meeting of the Congress of
American Physicians and Surgeons will be held
in Washington, D. C, May 7, 8, and 9. The meet-
ings of the congress will be held in the convention
hall of the Arlington Hotel. The subject to be
considered at the first session is "The Historical
Development and Relative Value of Laboratory
and Clinical ^lethods in Diagnosis." In the eve-
ning there will be the address of the President
of the Congress, followed by a reception to him.
On Wednesday the subject for discussion will be
"The Comparative Value of the ]\Iedical and Surgi-
cal Treatment of the Immediate and Remote Re-
sults of Ulcer of the Stomach." On Thursday
evening there will be the usual smoker.

American Society of Sanitary and Moral Proph-
ylaxis.— At the meeting of this society held
April II, 1907, the following officers were
elected for the ensuing year: President, Dr. Prince
A. Morrow ; Vice-Presidents, Dr. Stephen Smith,
Prof. Edwin R. A. SeHgman, and Mr. Francis
Lvnde Stetson : Secretary. Dr. Edward L. Keyes,
Jr. : Treasurer. Dr. Smith Ely Jelliffe.

American Therapeutic Society. — The eighth
annual meeting: of this organization will be held in

May 4, 1907]

MEDICAL RECORD.

739

Washington on May 4, 6, and 7, 1907, under the
presidency of Dr. Robert Reyburn of Washington.
The secretary is Dr. Noble P. Barnes of Washing-
ton.

American Laryngological Association. — The
twenty-ninth annual congress of this association will
be held in Washington on May 7, 8, and 9, 1907.
The president of the society is Dr. Arthur W. de
Roaldes of New Orleans, and the secretary is Dr.
James E. Newcomb of this city.

American Medical Editors' Association. — The
thirty-eighth annual meeting of this organization
will be held at Atlantic City on Saturday, June i,
and Monday, June 3, 1907. The annual editors'
banquet will be held at the Marlborough-Blenheim
Hotel on the evening of June 3. The opening ad-
dress by the president. Dr. James Evelyn Pilcher,
will be on "The Future of Medical Journalism," and
numerous other speakers w'ill discuss the present
•conditions of medical journalism. The secretary is
Dr. Joseph MacDonald, Jr., of this city.

The West Virginia State Medical Association
■will hold its annual meeting at Huntington on May
15 to 17, 1907. The officers for this year are:
President, Wm. W. Golden, Elkins ; I'ice-President,
V. T. Churchman, Charleston ; Secretary, T. W.
Moore, Huntington ; Treasurer, T. L. Barber,
•Charleston.

South Carolina State Medical Association. — At
the meeting of this society held in Bennetsville on
April 18 officers were elected as follows: Presi-
dent, Dr. LeGrand Guerry, Columbia ; First J 'ice-
President, Dr. J. Adams Hayne, Greenville ; Sec-
ond Vice-President, Dr. Marsh, Edgefield; Third
Vice-President, Dr. Mary R. Baker, Columbia;
Secretary, Dr. Walter Cheyne, Sumter; Treasurer,
Dr. C. P. Aimar, Charleston ; State Board of
Health, Dr. Robert Wilson, Charleston; Dr. Hall,
Aiken ; Dr. C. C. Gambrell, Abbeville ; Dr. J.
Adams Hayne, Greenville ; Dr. W. J. Burdell, Lu-
goff; Dr. James Evans, Florence; Dr. C. F. Will-
iams, Columbia.

St. Joseph Railway Surgeons. — At the annual
meeting of the Society of Surgeons of the St. Jo-
seph and Grand Island Railway, held in St. Joseph
■on April 18, officers were elected as follows : Presi-
dent, Dr. B. F. Hatch of Beattie, Kan. ; Vice-Presi-
dent, Dr. G. A. Birdsall, Alexandria, Neb. ; Secre-
tary and Treasurer, Dr. R. A. Todd of St. Joseph.

Worcester North (Mass.) Medical Society. —
The forty-ninth annual meeting of this society was
held in Fitchburg on April 23. Officers as follows
were elected : President, Dr. A. E. Mossman of
Westminster ; Vice-President, Dr. J. G. Henry of
AMnchenden ; Secretary, Dr. Walter F. Sawyer of
Fitchburg ; Treasurer, Dr. E. R. Fiske of Fitchburg.

Georgia State Medical Association. — At the an-
nual meeting of this society, held at Tybee on April
19, officers were elected as follows : President, Dr.
M. A. Clark. Macon ; First Vice-President, Dr.
Ralph M. Thomson, Savannah; Second Vice-Presi-
dent, Dr. E. E. Murphy, Augusta. The 1908 meet-
ing will be held in Fitzgerald.

Florida State Medical Association. — The elec-
tion of officers at the annual meeting of this society,
held in Tampa on April 18, resulted as follows :
President, Dr. W. P. Lawrence of Tampa ; Vice-
Presidents, Drs. S. R. M. Kennedy of Pensacola,
J. D. Love of Jacksonville, and W. H. Powell of
Ocala; Secretary, Dr. J. D. Fernandez of Tampa.

Cole County (Mo.) Medical Association. —
Officers as follows were elected bv this societv at

the meeting held in Jefferson City on April 19:
President, Dr. C. P. Hough; J'ice-President, Dr.
H. T. Leach; Secretary, Dr. Bedford; Treasurer,
Dr. J. P. Forth.

Tolland County (Conn.) Medical Society.— At
the one liundred and fifteenth annual meeting of this
society, held in Rockville on April 16, officers were
elected as follows: President, Dr. T. F. Rockwell,
Rockville; Vice-President, Dr. Tas. Stretch, -Staf-
ford Springs; Clerk. Dr. E. P. Flint, Rockville.

Plymouth District (Mass.) Medical Society. —
Officers were elected as follows at the annual meet-
ing of this society, held in Brockton on April 17:
President, Dr. F. G. Wheatley ; Vice-President, Dr.
Fred J. Ripley ; Secretary and Treasurer, Dr. Alfred
C. Sniith.

Litchfield County (Conn.) Medical Society. —
The forty-third annual meeting of this association
was held at Winsted on April 24. Officers were
elected as follows: President, Dr. G. D. Ferguson
of Thomaston ; Vice-President, Dr. L L. Hamant
of Norfolk; Clerk. Dr. S. G. Howd of Winsted.

Death of Mosetig-Moorhof. — Professor Albert
von Mosetig-Moorhof, the Viennese surgeon, well
known, among other things, for his method of treat-
ing bone cavities with an iodoform-paraffine filling,
was accidentally drowned on April 26. He was
subject to syncopal attacks due to arteriosclerosis,
and while walking along the Danube is thought to
have felt a seizure coming on. He was seen to
stoop at the river's edge, apparently to wet a hand-
kerchief in order to bathe his face, but lost his bal-
ance and was carried away by the swift current. He
was sixty-nine years old.

Obituary Notes. — Dr. Junius F. Smith of
Brookfield, Conn., died on April 22 of pneumonia
at the age of forty-two years. He was a native of
New Marlboro, Mass., and was graduated from
the Long Island Hospital Medical College in 1890.
He began to practise in Brookfield in the same
year, and for some time before his death had been
the medical examiner for the town. Last year he
was elected Representative from Brookfield in the
General Assembly and was a member on the Com-
mittee of Public Health and Safety.

Dr. Fr..\nk p. Webster of Norfolk, Va., died
suddenly on April 25 of heart disease. He was
fifty-four years of age.

Dr. W. B. Fletcher of Indianapolis died in Or-
lando, Fla., on April 25, after a long illness.

Dr. Charles D. Mattison of Minetto, Oswego,
county, N. Y., died suddenly on April 22, at the
age of thirty-five years. He received his medical
degree from Johns Hopkins University.

Dr. I. D. Young of Bordentown, N. J., died on
April 26 at the age of eighty-two years. He was
born at Rockland, Del., and was graduated from
the Pennsylvania Medical College of Philadelphia
in 1848. A year later he began practice in Borden-
town, where he had resided ever since. He was
consulting surgeon to the Meyer Hospital at Tren-
ton.

Dr. Winthrop Butler of Vineyard Haven,
Mass., died on April 22 at the age of sixty-eight
vears. He was born in Tisbury and studied medi-
cine with his uncle. Dr. S. W. Butler of Newport,
R. I. He received his degree from the Harvard
Medical School in 1866, and after practising for a
time in Groveland, Mass., removed to Vineyard
Haven, where he had since resided.

Dr. Herbert S. Olney of Detroit died on April
18 at Fresno, Cal., at the age of thirty years. He

"40

MEDICAL RECORD.

[May 4, 1907

was .graduated from the medical department of the
University of Michigan in 1901, and in 1903 began
to practise in Detroit. A year ago he was forced
to go West on account of ill health.

Dr M C Cristensen of Omaha, Neb., died on
April' 17 after an illness of several months. He
was a native of Denmark and was graduated from
The Omaha Medical College in 1892. He served
as Alderman from 1900 to 1902.

Dr ESROM A. Du Clos of Fhnt Village, Mass.,
died on April 20 at the age of sixty-four years. He
was born in Ouebec and received his medical edu-
ca'onTn Bishop University and McGiU Lniversity.
He had practised in Flint Milage tor about four

'^Dr' Francis E. Corbix of Los .\ngeles, Cal,
died suddenly on April 17. He was educated in
the University of Michigan and the Michigan Med-
ical College. After practising for a time m Lan-
sing he removed to Los Angeles about eleven years

^'Sr GusTAVE ScHOENBERG died at Philadelphia
on April 20 at the age of eighty-one years He was
a native of Prussia, his ancestors being the Dukes
of Schoenberg. He was graduated from the Uni-
versity of Berlin in 184S and was engaged m medi-
cal practice in Berlin until i860, when he came to
the United States. In 1873 he went to Japan and in
the following year he was made Surgeon-in-Chiet
To the Japanese Army. While m the Orient le
went to Formosa, and he was one of the first white
men to explore that country. He also visited many
parts of China that up to that time had been closed

to foreigners. ^-r ,,■ , .

Dr George W^ Smith died at Hollidaysburg,
Pa., on April 22, at the age of seventy-three years
He was graduated from the medical department
of the University of Pennsylvania in the class ot
186-, He was for manv years president ot the
Blair County Medical Society and for ten years
president of the Hollidaysburg Board of Health.

Dr Andrew M. :Mills of Newark died sud-
denly on April 21 at the age of thirty-six years. He
had 'lived in Newark all his life and had practised
there since his graduation from the New \ork Lni-
yersity Medical School in 1892. At the time of his
death'he was County Physician of Essex county.

Dr Reuben Bigelow Burton of this city died
on \pril 22, after a brief illness. He was born in
Chester, Vt., June 15. 1827. He was graduated
from Union College and subsequently from Albany
Medical College in 1855. He practised in Chester,
Vt but came to settle permanently in New Vork
in February, i860. He was in active practice up
to the week before his death.

OUR LONDON LETTER.

CFromlOur Special Correspondent.)

^\LIC\-LATES— EXTENSnT: VOLVULUS— ALCOHOL, A NEW DEC-
" LAJRATION-KING'S HONOR TO HIS SURGEONS-COLLEGE OF

PHYSICIANS— ITEMS— OBITU.\RIES.
^. LoNDOX, .April 12. 1907.

The administration of salicylates was the subject of a
oaoer at the Hunterian Society by Dr. Dav.d Lee=, \vho
ho'ds these preparations to be among our most certam
remedies He said, indeed, that sodium salicy.ate was as
directly antagonistic to acute rheumatism as mercury to
svphilis or quinine to malana. I haye met men who set
a\rte as high a yalue on this drug. On the other hand, I
have d scu?sed it with others who hold >t to be mtich less
certain, and in some cases dangerous; they have recounted
to me in fact such cases, in some ot which they thought it

hastened death. I have therefore been interested in what
Dr. Lees said, and will summarize his views. First of all,
he said it is too often given in too small doses, on account
of the unpleasant symptoms which it sometimes produces,
and on account of the general opinion that it is a cardiac
depressant. In children he made light of the disagreeable
symptoms, except vomiting, and this he said is arrested
by omitting two or three doses. He always combined it
with full doses of bicarbonate of soda. Potassium salts
were depressants of the heart, but he considered sodium
salts as distinctly cardiac stimulants and likely to diminish
the tendency to dilatation in acute rheumatism. He in-
creased the dose every day, or on alternate days, up to a
maximum of 450 grains in twenty-four hours for adults.
He had given a boy of fifteen 600 grains in twenty-four
hours, and 500 grains for si.x days a week for three weeks.
It was not necessary to omit it during pericarditis. If the
salicylate were given without the bicarbonate a sort of
acid intoxication might occur resembling diabetic coma.
In chorea. Dr. Lees said, small doses of salicylate of soda
were no use; from 200 to 300 grains a day were required.
Dr. Lees does not appear to have availed himself of salicin,
which so many regard as equal to any of the salicylates as
an antirheumatic and as a distinct tonic rather than depres-
sant to the heart. It can be taken in very large doses and
continued over long periods. It has been said not to cause
noises in the ears, but this is an error. It does this, if not
so much as sodium of salicylate.

At the Medico-Chirurgical, Mr. Hutchinson, Jr., showed
a series of drawings and radiographs to illustrate disloca-
tions of the thumb and great toe. He also related a case
of acute obstruction by a band of the vermiform appendix
and omentum, with general septic peritonitis, the patient
recovering after operation. Mr. Hutchinson also contrib-
uted the paper of the evening, in which he described a case
of volvulus of the entire small intestine, the cecum, and the
ascending colon, in which operation was successful. Nine
other cases had been recorded of complete volvulus. In
nine out of the ten the whole intestine supplied by the
superior mesenteric artery, from the duodenum to the
transverse colon, had undergone torsion, bringing the
cecum and ascending colon behind the mesentery, which
acted as a band. In the other case the rotation was in the
opposite direction. The greatly distended cecum might
occupy the left iliac fossa, or might be found close to the
spleen. Even after opening the abdomen the condition
was not easy to recognize, and it was necessary to draw
the intestines outside in order to reduce the volvulus. It
was also desirable to evacuate the cecum by tapping. Only
two successful operations seemed to have been recorded —
Hutchinson's in 1901, and one by Brentano in 1904..

Mr. Barker said he had recorded a somewhat similar case
in which the volvulus comprised the whole of the small
intestine, though not the cecum, nor the ascending colon.
The patient was a woman at the fourth month of preg-
nancy, who had undergone a gastrojejunostomy two years
previously. The volvulus was untwisted without removing
anything from the abdomen, and recovery occurred in ten
days. The pregnancy went on to normal labor at term.

Dr. Keith expressed the opinion that the peculiar manner
in which the intestine was fi.xed in the abdominal cavity-
was connected with the erect posture. He considered the
case belonged to the class of congenital malformations.
Mr. Hughes described a case parallel to that of Mr.
Barker, in which the whole of the small intestine was
involved. In reply, Mr. Hutchinson, Jr., thought his case
was of a type of volvulus scarcely recognized. He dis-
agreed with Mr. Barker as to not removing the intestines,
and felt sure the omission was the cause of some failures,
the condition not having been relieved because it had not
been recognized.

The two great "declarations" of the profession on the
use of alcohol, which were so numerously signed as to be
regarded as completely representative of medical opinion
in the last generation, seem now like ancient history. We
have therefore been somewhat surprised by a feeble imita-
tion of those documents in the shape of a letter to a med-
ical contemporary signed by a few distinguished medical
men. and which tends to support the moderate use of
alcoholic beverages. The newspapers have got hold of the
new manifesto and are treating it as far more authoritative
than it deserves, for although it must be admitted that the
signatures are those of able men, it is impossible to regard
them as of equal weight to the old "declarations." A
curious thing about the matter is that these gentlemen
should just now consider the expression of their opinions
called for. If intended to controvert the former declara-
tions, it is strange they should have taken a generation to
arrive at their conclusions. How came they to agree that
the time had arrived when they were required to issue a
joint statement of their views? It is impossible to sup-
pose they desired to arrest the progress of the temperance

May 4, 1907]

MEDICAL RECORD.

741

movement, or that they regarded the diminution of ex-
cessive drinking as other than satisfactory. Someone sug-
gests to me they had been dining together, and discussed
the use of alcohol afterwards, when the wine in the glass
seemed moving itself aright. Others wonder whether
some astute person connected with "the trade" had got
hold of them. Such suggestions seem unworthy of their
position, and the manifesto must be accepted for what it is
worth.

.^t the annual meeting of the Society for the Study of
Inebriety held on Tuesday the subject was naturally dis-
cussed. Dr. Harry Campbell, who presided, said the refer-
ence in the recent manifesto to the universal belief in the
use of alcohol could not he the object of its issue. It was a
misstatement, for such belief was not entertained by the
millions of Japanese, Buddhists. ^lahomedans, etc., and
what he said was meant by a "moderate use of alcohol."
Did it mean one glass of wiskey a day, or three, or four, or
five? He had asked a person who told him that half a bottle
was moderate, and if he only took two glasses he was "prac-
tically a teetotaler"— a statement which elicited laughter.
Proceeding, he asked what the signatures meant by "an
adult." If they meant anyone who had reached his twenty-
first year he calculated that such a young person as a mod-
erate drinker of two glasses a day consumed about eighty
bottles a year, so that in fifty years four thousand bottles
passed through that unromantic organ of his, the liver.
Then they ought not to lose sight of the fact that the main
supply of whiskey to the working classes was immature,
and therefore bad. Further, if everyone restricted himself
to a moderate amount of sound alcohol he could not regard
the manifesto as other than misleading, harmful, and dan-
gerous.

The King has granted another honor to Sir Frederic
Treves and Sir Francis Laking in recognition of their
"great skill and unremitting attention" in his illness in
1002. The new distinction is an "honorable augmentation"
to their arms consisting of an addition to their shields of
one of the lions from the Royal arms, which is to be
borne by their descendants. The late Sir William Gull re-
ceived a similar distinction — an augmentation by the Prince
of Wales' feathers. It is a new form of recognition in
modern times, for we must go back to Charles II. for any-
thing similar.

Sir R. Douglas Powell was reelected to the presidency of
the Royal College of Physicians on the 25th ult. In his
address he gave obituary no'ices of nine Fellows of the
College who had died during the year, and the deaths of
whom I had reported on the several occasions.

The report of the Hospital Saturday Fund, of which I
sent you the chief items a fortnight ago, was duly adopted
at the meeting on the 6th inst.

The newspapers are according unusual space to obituary
notices of Thomas Beecham. Xo wonder, for it is re-
corded that he spent £100.000 a vear in advertising his pills,
and what will some papers do for such a prince of puffery?
The puffs gave him a turnover of ^150,000. Great is the
gullibility of the public !

Ed. Thos. Harrison. F.R.C.S., J. P.. who died on .\pril
3 in his eighty-eighth year, was formerly consulting surgeon
to the Welshpool Dispensary. He took the M.R.C.S. and
L.S..\. in 1842-3, served in the S. Wales Bonderers, and re-
tired as surgeon-major.

OUR PARIS LETTER,

(From Our Special Correspondent.)

TYPHOID EPIDEMIC DUE TO OYSTERS — BIER'S BAND.\GE FOR IN-
FECTIONS OF THE EXTREMITIES — ELECTRIC SLEEP — THE .ABO-
LITION OF ABSINTHE — DEATH CAUSED BY MERCURIAL
INJECTIONS — NECROLOGY.

Paris. March 2, 1007.

At the -\cademie de Medecine the interesting question of
the part played by oysters in causing epidemics of typhoid
fever caine up for discussion. Netter reported the his-
tories of thirty-three cases of the disease attributed to the
ingestion of oysters coming from the city of Cette. In
these thirty-three cases the symptoms appeared from ten
to twenty-five days after eating the oysters, and seven of
the patients died. In almost every instance the oysters
had been eaten on the day of shipment and their flavor
was unimpaired. The source of the trouble was there-
fore to be found in the oyster beds at Cette, which are
situated close to the sewer outlets of the city. The
Academie has appointed a commission to study the ques-
tion and to make recommendations regarding the means
to he taken to prevent a repetition of such occurrences.

The important subject of malaria in the French posses-
sion of Madagascar was made the subject of a communi-
cation by Kermorgant. The speaker reported on a recent
epidemic of large proportions. While the disease in-

creased rather slowly it had spread steadily, so that finally
more than 274,000 cases and 13,700 deaths were reported;
that is, about 5 per 100 of the population were affected.
Kermorgant considered the importance of the various etio-
logical factors, such as the mosquito, the telluric factors,
and finally the squalor of the natives, and expressed the
opinion that all three of these entered into the question.
The enforcement of hy.gienic regulations and the distribu-
tion of quinine have already been followed by great im-
provement.

In the meeting of the Societe de Chirurgie Tuffier pre-
sented a paper on the use of the elastic bandage of Bier
in acute infections of the extremities. He reported the re-
sults w-hich he had obtained by Bier's method in acute
inflammatory processes of this nature excepting infections
of the bone, and pointed out the necessity for skilful tech-
nique, without which success could not be obtained. The
bandage itself should be a very thin strip of English rub-
ber, not too inelastic and yet sufficiently resistant to make
it possible to secure a compression which should be neither
too strong nor too weak. The degree of tension could be
determined at first with the finger and afterward by the
patient's sensations, for pain should never be caused. The
lianda.ge should never be applied over the injury itself, but
this should be covered with a dressing of dry gauze sim-
ply to protect it from the air. It should be applied at first
for from twenty to twenty-two hours out of the twenty-
four, diminishing gradually to about twelve hours a day.
The number of applications would depend upon the dura-
tion of the inflammation. Tufiier had obtained in a general
way excellent results by this inethod, and in cases cf
panaritium and of suppurative arthritis of the wrist he
had secured complete and rapid cures. The method was,
however, not without certain drawbacks, if there was a
tendency to perspiration, ervthemas of varying degree might
be produced, but this could be avoided by interposing a
thin layer of bandage between the rubber and the skin.
He had never seen any serious complications, such as
gangrene of the limb, but to avoid any possibility of this
he had always refused to make use of the method for
ambulatory treatment.

Professor Leduc of Nantes has published the remark-
able results he has obtained by means of his electric sleep.
He gives this name to a condition comparable to chloro-
form narcosis, in which the subject lies without any
powers of sensation or of voluntarv motion, only certain
reflex movements and the action of the heart and of the
respiratory function persisting. This condition is pro-
duced by the action on the brain of a certain form of
electric current, and may be maintained for hours, and
brought to an end instantly with the interruption of the
current. The current used to produce the electric sleep
is intermittent, of low tension and constant in direction,
that is to say, it flows for a certain period, stops, and then
flows again at perfectly regular intervals. It is generated
by means of a source of continuous current and of a spe-
cially constructed form of interruptor. On applying it to
the head sensations of taste and of light are produced,
and vertigo depending to some extent on the manner in
which the electrodes are annlied is caused. In order to
inhibit motility and sensation the current should attain a
voltage of about six, but if it is increased to ten volts
respiration and heart action cease and death follows.
Leduc has subjected himself to this action and has reported
in a very interesting manner the sensations experienced
during a period of narcosis lasting twenty minutes. A
remarkable fact is, that when the flow of current is in-
terrupted the subject awakes immediately without any of
the after effects that follow chloroform narcosis.

One of the questions considered by the Society of Public
Health was the abolition of the manufacture and sale of
absinthe. When one reflects on the frightful ravages of
alcoholism in general and of absinthism in^ particular, rav-
ages that are steadily increasing and which may lead a
country to its ruin, it may well be said that absinthe is a
serious social peril. Legrain, physician to the Ville-Evrard
insane asylum, has stated that of the .=;oo or 600 alcoholics
who enter his service even' year, the absinthe habitues
form 90 per cent. It is therefore important to combat the
evil and check this scourge which is threatening the future
of the race.

Oettinger and Fiessinger presented before the Societe
Medical des Hopitaux a case of death ^ from mercury
poisoning following injections of gray oil. The patient
was a woman of nineteen years, suffering from a svohihtic
ulceration of the elbow. She was given two intramuscular
injections of I c.c. of 40 per cent, gray oil, and a third
injection was given fifteen days after the second. The
symptoms of poisoning did not appear until a month later,
and death occurred seventy-nine days after the last injec-
tion. The mercurv was absorbed very slowly, but never-

742

MEDICAL RECORD.

[May 4, 1907

theless it was not possible to discover in the gluteal re-
gion where the injections had been made, the least nod-
ule which might have been excised in order to prevent
further dissemination of the poison. The lesions pro-
duced were especially marked in the kidnej-s, and consisted
in changes in the cells of the convoluted tubules, the
glomeruli remaining almost intact. The cells of the tu-
bules were very largely degenerated, and this lesion ex-
plains the anuria that is nearly always observed in
nephritis of mercurial origin. The speakers pointed out
that most of the fatal cases of this nature have occurred
when gray oil was used rather than any other insoluble
preparation, like calomel for example. The case reported
shows what care is necessary when injections of gray oil
are resorted to in the treatment of syphilis.

French science has suffered the loss of one of its most
illustrious representatives in the death of Dr. Mathias
Duval, professor of histology in the University of Paris,
professor in the school of anthropology, and member of
the Academie de Medecine. A native of Strassburg, he
was, in 1873, made assistant professor of the Pari.s medi-
cal faculty, and a little later he was made director of the
laboratory of anthropology and professor of anatomy in
I'Ecole des Beaux-.Arts. For more than twenty years he
had been professor of histology. He was the author of
numerous books on histology and physiolog'- which have
become classics. His courses on histology always attracted
large audiences that he charmed by the simplicity of his
delivery and the clearness of his instruction. Among his
writings mention should be made of his masterly study of
the brain of Gambetta.

Reference must also be made to the death of Moissan,
who was one of the most famous chemists of our period.
He died suddenly of acute appendicitis in the midst of a
brilliant scientific career prematurely arrested. By means
of the electric furnace of his invention he made remark-
able observations on the diamond and succeeded in pro-
ducing artificially microscopical specimens of this form
of carbon. He opened new provinces to chemistry _and.
in recognition of his discoveries, was awarded the Nobel
prize, which lie recently received in person in Norway.

OUR LETTER FROM COPENHAGEN.

(From Our Special Correspondent.)

rovsing's operation for c.'lRcinom.a of the bl.\dder —
hypopharvngoscopy — bronchoscopy — the finsen monu-
ment— one hundred and fiftieth anniversary of the
ROY..\L Frederick's hospital.

COPEXHAGEX. April 2. IO07.

At a meeting of the Medical Society in Copenhagen Prof.
Th. Rovsing read a paper on a new method he had devised
for the radical removal of the urinary bladder in malignant
disease of this organ. When the older methods were ad-
hered to, the ureters were left in the wound produced by
the operation or were implanted into the rectum, both of
which procedures were connected with grave disadvantages
to the patient. With the former method urinary infiltra-
tion might take place and with both of them cicatricial
stricture of the peripheric ureteral opening was not un-
frequently observed, as also ascending infection of the
kidneys from the cavity into which the ureters now opened.
The chief original feature of the operation as performed
by Prof. Rovsing is the way in which he protects the
patients against the mentioned dangers. After the com-
plete removal of the bladder he dissects the ureters en-
tirely free for a long distance. Then he makes a button-
hole-like opening in each lumbar region, stretching from
the peritoneal cavity to the skin of the back, pulls the cor-
responding ureter through the buttonhole, and sutures the
mucous membrane of the ureter to the adjacent skin. A
specially adapted silver capsule is subsequently applied to
the skin of the lumbar region round the ureteral opening,
and the urine is led from the two capsules to a portable
urinal of the ordinary sort. This appliance has proved
sufficient so that there has been no oozing out of the urine
and no urinary smell attached to the patient. Prof.
Tscheming and Dr. Niels P. Ernst congratulated Prof.
Rovsing on the important new method. The latter speaker
asked if it would not be well to secure further the efficiency
of the silver capsule, by making a flap of the skin in the
lumbar region and then folding this flap up in such a way
as to form a penis-like prominence, on the top of which
the ureter then might open.

At the same meeting Dr. P. Tetens Hald read a paper on
hypopharyngoscopy, a new method for examination of the
deepest laryngeal part of the pharynx, the part behind the
lamina of the cricoid cartilage. The method, devised by
V. Eicken of Freiburg, Germany, was demonstrated by die
speaker before the members of the society. It consists in

introducing a very strong laryngeal probe through the
glottis into the infraglottic space, and then by means of the
probe to pull the larynx forward, away from the posterior
wall of the pharynx. The region behind the plate of the
cricoid then opens widely and may be inspected at ease
with the laryngoscope. In an obscure case, where all
hitherto known methods of examination had failed to give
certainty, hypopharyngoscopy had enabled Dr. Tetens Hald
to diagnosticate a carcinoma of the deepest laryngeal part
of the pharynx and the beginning of the gullet, and to
verify the diagnosis by excision of a piece of tissue for
microscopical examination.

.\t a meeting of the Danish Otolaryngologica! .Associa-
tion Prof. E. Schmiegelow communicated a case in which
he had removed a grain of maize from the right bronchus
of a child four years old by means of Killian's direct
superior bronchoscopy. What gave a particular interest
to the case was. however, the circumstance that the child
died some hours after the removal of the foreign body,
under pronounced symptoms of cocaine intoxication. Be-
sides chloroform a quantity between five and six cubic cen-
timeters of a 10 per cent, solution of cocaine had been
used on a swab of absorbent cotton in order to procure
the necessary anesthesia of the upper respiratory tractus
during the somewhat lengthy operation.

About one year ago I wrote you about the war waged
by the Danish sculptors against the committee for the erec-
tion of a monument for Niels Finsen, the committee
seemingly not being inclined to pay the sum of money ex-
pected by the sculptors. In this farce another and very
exhilarating scene has recently been played. Aiter much
debating the sum for the monument was fixed at about
$10,000, and several Danish sculptors sent in their sketches.
Of these sketches one has now been chosen by the com-
mittee. However, the chairman of the committee, the
Danish premier, formerly a teacher in a little village
school, who has proved to possess rather peculiar ideas
about art and science, has had the following rider added
to the acceptance of the sketch ; that the sculptor remove
from tlie monument the gloomy and heartwringing im-
pression produced by it. Everybody is an.xious to see how
the happy sculptor is going to meet this trifling demand.

A few days ago, in fact, on March 31, the Royal Fred-
erick's Hospital celebrated its one hundred and fiftieth
anniversary. For so long a space of time it has been the
teaching hospital of the University of Copenhagen, but now
its days are counted. It goes without saying that, though
it was for its time an excellent institution, and has con-
stantly been patched up here and there, it is no longer fit
to be judged according to the modern standpoint. As ia
a few years a new and greater hospital with the best
modern equipment will be ready for the service of the
University, the speeches made at the festival were most of
a valedictory nature. The anniversary has also been cele-
brated in a scientific way. Prof. Kund Faber, with some
of his present and former assistants, having published a
splendid volume with papers on various questions apper-
taining to the pathologv- of the digestive organs.

AV:^' York Medical Journal, Afril 20, 1907.

Tuberculous Peritonitis. — Several case reports are
uiven by E. Novak, who discusses their interesting features
and whose general conclusions are embodied in the fol-
lowing propositions: (i) the exciting cause of tuberculous
peritonitis is the Bacillus tuberculosis. (2) This disease
occurs most frequently between the ages of twenty and
forty, and, according to clinical experience at least, is more
common in females than in males. (3) The disease is, in
the great majority of cases, secondary to a tuberculous
focus in some other part of the body, most frequently the
lungs. (4) There seems to be no doubt that infection
through the Fallopian tubes may occur, but its frequency
is disputed, (s) The onset of the disease is usually slow
and insidious and its clinical course presents few definite
or characteristic svmptoms. (6) The diagnosis is generally
difficult, and is often not made until operation or autopsy.
(7) The prognosis in the ascitic form of the disease is
comparatively good, and in the nonexudative variety bad.
In any forjn it is of course correspondinglv modified by
the existence of tuberculous disease in other parts of the
body. (8) The treatment in most cases should be opera-
tive, consisting in laparotomy, w-ith removal of the Fal-
lopian tubes w-hen practicable, (g) No satisfactory ex-
planation has as yet been offered as to the reason for the
cure w'hich so often follows operative treatment in this
disease.

May 4, 1907]

MEDICAL RECORD.

-43

Cases of Appendicitis, with Comments. — J. A. Wyeth
contributes a synopsis of the histories of seven cases of
apnendicitis and comments thereon. Concerning tlie tech-
nical features of the operation \n general, he notes the
fact that so rapid is the formation of an e.xudate after irri-
tation of the peritoneum that within a few hours silk
material is covered in and entirely hid beneath a rapid
cell proliferation. Regarding the preferable incision, he
favors the longitudinal or Deaver incision because it not
only gives a perfect command of the operative field, but
in cases which turn out to be complicated and necessitate
a freer incision^ it can be extended upward or downward
indefinitely, exposing practically the entire peritoneal cavity
with a minimum of danger of ventral hernia as a result of
the operation. Wyeth employs the McBurney incision only
where an abscess is to be opened, and under such circum-
stances the opening into the pus cavity is not more than a
half or three-quarters of an inch in extent. This incision
cannot be sufficiently enlarged to meet every emergency,
without great danger of ventral hernia. The Kamnierer
incision, which opens the sheath of the rectus as just de-
scribed, and then displaces the right edge of the rectus
muscle toward the median line, holding it out of the way
until the peritoneum is opened and the operation completed,
is objectionable in that the replaced muscle prevents the
employment of free drainage when this is found to be nec-
essary. The method given of dealing with the stump of
the appendix is, in the author's opinion, in every way
preferable ; it is simple and safe. So far as his know-ledge
goes, no accident was ever recorded against it. It can
be done with the minimum of traumatism. Moreover, a
number of accidents have occurred from other methods.
Under no circumstances should the appendix be tied off
W'ith catgut. The method referred to consists in clamping
the appendix about half an inch from its cecal attach-
ment while slight traction is made and a No. 2 silk
ligature encircles it about one-quarter of an inch from
the cecum. When this is done a gauze swab is split and
carried on either side of the appendi.x. This swab is held
between the thumb and finger of the operator, grasping
with it that part of the cecum immediately at the base
of the appendix, which is now divided with the curved
scissors about an eighth of an inch beyond the ligature.
The swab prevents any possible contact of infectious ma-
terial with the peritoneal covering of the cecum. The
funnel shaped end of the stump is now burned by a drop
of pure carbolic acid carried upon a small wisp of cotton
upon a metal probe. The excess of carbolic acid is imme-
diately removed by a drop or two of alcohol applied in the
same wav- The ligature is divided close to the knot, and
the cecum allowed to drop back into its normal position.

Treatment of Typhoid Spine. — V. P. Gibney reviews
some of the recent literature on this subject and adds the
histories of two personal cases. He says that the value
of the cautery as a counter irritant has proven so valuable
in his hands that he prefers it to all other remedies of its
class. The plaster-of-Paris jacket or corset has not proved
so valuable an agent as has the simple Knight spinal base
or the posterior spinal assistant of Taylor. The criss-
cross strapping with zinc oxide adhesive plaster has been
a valuable adjunct, especially in the milder forms of this
disease. Potassium iodide has been given in certain cases,
but not with any definite results. Where deformity exists,
as it undoubtedly does in certain instances, it is necessary
to wear apparatus for longer periods. In conclusion the
author insists on the Paquelin cautery as a regular line of
treatment as long as tenderness and pain on movement
continues. Even after all tenderness subsides it is a good
plan to employ the cauterv occasionally, say once a week or
once in a fortnight. It has been shown that even these de-
formities and areas of infiltration, bony, or muscular, dis-
appear after a while, and fortified by this assurance, the
surgeon can decide when to begin the convalescing part
of the treatment, namely, douches, hot baths, and sys-
tematic graded exercises, the object of which is to correct
the stiffness developed in the muscles which have been
for a time out of commission, and to restore the tone
generally to the spinal column.

Modified Buttermilk in Infant Feeding. — C. F. Jud-
son and R. O. Clock give thuir experience in a series of
twelve cases. This food should not be relied on, even
with the addition of cream, for a longer period than three
months, but it is a useful food in tiding over a crisis. The
average composition of whole buttermilk is proteid 2.5
to 2.7 per cent., sugar 3 to 3.5 per per cent., and fat 0.5 to

1 per cent. In preparing for use the casein was consider-
ably diluted so as to make the proportion present 1.5 to

2 per cent., and sugar added only in sutificient amounts to
bring the proportion present in the mixture up to 5 per
cent. Moreover, the mixture was heated onlv to from

140" to 155° F. for ten minutes, so that the lactic acid
bacteria were not destroyed. Robinson's barlev flour was
added, one half ounce to each pint and a half, and cane
sugar solution (6 to 9 per cent, strength) used to dilute
the casein. The method of preparation of the weaker
mixture was as follows Ingredients used were one pint
of buttermilk, ei.ght ounces of a six or nine per cent, solu-
tion of cane sugar, one half ounce of Robinson's patent
barley, (i) Make a paste of the flour and a small quan-
tity of the sugar solution. (2) Add buttermilk and the
remainder of the sugar solution to this paste and mix
thoroughly. (3) Heat the mixture to 155° F. for ten to
fifteen minutes, stirring constantly. (4) Remove from
stove, cool, and place on ice. At first this diet gave brown,
pasty, and offensive stools, which later turned to yellow.
They contained mucus as a rule, showing intestinal catarrh.
Later the mucus disappeared. The twelve children treated
were several cases of malnutrition, marasmus, enteritis,
or enterocolitis. The prostration and other toxic symptoms
quickly disappeared in most cases after buttermilk diet
was instituted. Eight infants gained in weight (in one
the gain was onlv temporary), while four infants could
not tolerate the diet. The gain in weight was in most cases
irregular, but steadily upward, and averaged one-half ounce
daily. Some gained more rapidly for shorter periods.

Jounial of the America)! Medical Association, April 27,
1907.
The Digestion of Cow's Milk Proteids by Infants. —

-According to F. X. Walls the proteids of cow's milk
give rise to no digestive or nutritive disturbances in
young infants, and the theories now prevalent as re-
gards the artificial feeding of infants will have to be
modified. The notion of proteid indigestibility has been
based on some crude test-tube experiments and the
misappreciation of certain appearances in the baby's
stools. The common whitish or yellowish lumps in
infant stools — the so-called curds — are not proteid ma-
terial, he asserts, but fats or fatty soaps ; rarely are they
inspissated mucus or clumps of bacteria. In hundreds
of cases in which he has given fat-free undiluted milk
to infants he has never after careful examination found
curds in the stools. He reports two cases of infants
suffering from enterocolitis fed on centrifugalized fat-
free milk without any digestive disturbance and with
excellent therapeutic effect. He says that there is no
symptom or group of symptoms from which we can
conclude that there is any injury to the infants from
the albuminoid material in cow's milk, and this being
show-n, all the methods advocated to assist in the diges-
tion of the proteid are without foundation and may be
harmful. This does not mean that we are to feed babies
on a fat-free or skim-milk diet. The normal child de-
mands a proportion of fat in its food and this is a mat-
ter for individual determination. An excessive amount
of fat, as shown by Brenneman. is the most frequent
source of overfeeding, and the most dangerous foods
are the cream mixtures. For a normal infant Walls
would advise a dilution of one part whole milk and two
parts water, gradually decreasing the dilution till in six
months or a year whole milk is reached, and such whole
milk containing not to exceed two or three per cent, of
fat. Feeding, after the first week, should not be oftener
than once in four hours in the daytiine and twice at
night, and the amount should be enough to satisfy the
infant's appetite. The caloric value of the food taken
during the twenty-four hours should be estimated as a
check against overfeeding, though as a rule babies fed
not over once in four hours are not likely to overfeed.
The author's conclusions are given substantially as fol-
lows: I. There is no evidence that the proteid of cow's
milk causes any digestive disturbance in the infant. 2.
.\11 experiments prove that cow's proteid is easily di-
gested and resists putrefaction. 3. The method of
proteid modification as aids to digestion are therefore
erroneous. 4. In sterile, fat-free milk we have an un-
equaled therapeutic agent in the treatment of the nutri-
tive disorders of infancy.

Clinical and Radiodiagnostic Findings. — C. M. Cooper
gives the results of four years' experience of combined
use of the .r-ray with the clinical symptoms in diag-
nosis, with details of a number of cases. .-Xmong these
is one in which the .r-rny revealed a bilateral functional
spasm of the diaphragm, causing temporary embarrass-
ment of respiration; others show the value of the ray in
determining the presence of old apical indurations and
central pneurnonic patches in which the clinical symp-
toms alone might be misleading. He emphasizes the
importance of estitnating the percussion resistance,
which his observations indicate to be of greater value

744

MEDICAL RECORD.

[May 4, 1907

in diagnosis in these cases than the percussion note. The
radiograms were also found of value in the diagnosis of
peribronchial glandular enlargements. He believes from
this evidence that intralobular effusion sometimes may
be serous instead of purulent. Other conclusions
reached are stated substantially as follows : So-called
functional dilatations of blood-vessels are really tem-
porary aneurysms and may change at or after death.
As Tallant has shown, many persons present the Broad-
bent retraction of the left lower posterior chest wall.
In cases in which there are no adhesions he has found
that the position of the maximum retraction varies with
the respiratory phases, being higher during expiration,
lower during inspiration, while with adhesions this
change does not happen. In patients presenting a pouch
of the esophagus a change of pulse rhythm may occur,
according as the pouch is empty or full, this variation
being better marked during full respiration. Pericardial
effusions are often unrecognized, and probably some
cases of dilated hearts which have undergone extreme
reduction in size from the Nauheim treatment have
been instances of pericardial effusion. Cooper thinks
that the correlation of clinical and Roentgen diagnosis
will increase the percentage of successful diagnosis,
will give certainty in various conditions which other-
wise could be only suspected, will render unnecessary
certain dangerous diagnostic methods, w-ill render the
clinician more skilful, will be of aid in teaching, and
may be of some assistance in the relations between the
physician and the patient.

Mtiltiple Neuritis (Non-Diphtheritic) in Children. —

After noticing the general opinion given in text-books
as to the comparative rarity of multiple neuritis in chil-
dren, H. M. Thomas and H. S. Greenbaum remark on
its possible occasional confusion with anterior poli-
omyelitis and say that it is probably more frequent
than is generally thought. Their experience in the
Neurological Dispensary of the Johns Hopkins Hos-
pital is somewhat unusual: in the past sixteen years,
with an average of 1.200 new neurologic cases annually,
they have seen but twenty-one cases of non-diphtheritic
multiple neuritis and eight of these were in children
under twelve years of age. This does not include hos-
pital cases; the severer cases in adults are apt to be
sent directly to a hospital. The children ranged be-
tween three and twelve years; three of the cases fol-
lowed typhoid, in the others the etiology could not be
ascertained. The clinical picture was typical in all; on-
set acute with lassitude, fever and loss of appetite, arms
and legs^ both affected in every case and practically
symmetrically. Electric changes generally present and
deep reflexes lost in every case but one (No. 4, a possi-
ble case of lead poisoning). All the patients improved,
the arms first in all but No. 4, in whom there still re-
mains, nine years later, a paralysis of the intrinsic
muscles of the hands. The recovery in all was slow,
lasting over several months. Short histories of the cases
are given and the symptomatology, diagnosis, etc., are
discussed. The chief difficulty is in differentiating mul-
tiple neuritis in children from poliomyelitis, but the
former is usually more insidious in its onset, may have
an obvious cause, subjective and objective pains are
more likely to be present. The widespread symmetri-
cal paralysis is characteristic as compared with' the con-
trary condition in poliomyelitis and the recovery is apt
to be complete or nearly so. The prognosis in multiple
neuritis of children is generally good. Treatment calls
for removal of the cause if possible, nourishing diet,
laxatives, rest in bed in the early stages, quinine in
malarial cases, massage, electricity, passive exercise,
mild gymnastics, and hydrotherapy are useful. Tonics
may be required. If a permanent wrist or foot-drop
continues, the orthopedic surgeon may be consulted.

Inoperable Cancer of the Uterus.— G. Gellhorn rec-
ommends the use of acetone as a valuable palliative
remedy in inoperable uterine cancer, as it destroys the
distressing odor, checks the hetnorrhage, and improves
the general condition. Its use was suggested bv the
employment of this drug in laboratory work for haVden-
ingtissues. If the ulcerated surface 'could be hardened
during life Gellhorn assumed that the discharge could
be checked until the escharotic surface could be thrown
off and the process might be repeated for deeper and
deeper portions. The treatment should begin with
thorough shelling out of the ulcerating area. The
curetted_ cavity is thoroughlv dried with cotton sponges,
the pelvis raised, and from half to one ounce of acetone
is poured into the wound through a tubular speculum.
The narcosis is then interrupted and the patient left in

the same position for from fifteen to thirty minutes.
Then, by low-ering the pelvis, the acetone is permitted
to run out through the speculum, and the cavity is
packed with a narrow gauze strip soaked in acetone.
The healthy mucosa of the vagina and vulva are
cleansed with sterile water and dried. Beginning on
the fourth or fifth day after the operation, the process
of applying the acetone is repeated two or three times
a week, without narcosis, and as the cavity decreases
in size a smaller and smaller speculum can be used.
The treatment almost immediately checks the discharge,
which, with its odor, gradually disappears. The hemor-
rhages fail to recur and, with the cessation of the drain
on the system, the general condition improves. The
treatment causes no special pain, but anodynes may
still be necessary for that due to the deeper extensions
of the cancer. Urinary examinations so far have given
no evidence of absorption of acetone. Two cases are
reported, showing the value of the treatment when
other treatment had failed.

Acute Overstraining of the Heart. — Theodor Schott
discusses excessive heart straining at some length. He
states that we must distinguish between acute and
chronic overstrain and calls attention to the fact that the
latter can result only from an accumulation of repeated
single overstrains. In studying this subject Schott had
wrestling performed by strong, healthy men in such man-
ner that they alternately inhibited their movements by
forcibly resisting each other, or by each lifting his an-
tagonist. Before the wrestling began, the heart limits
and the apex beat were correctly outlined, sphygmo-
graphic curves and blood pressure were registered, the
position of the diaphragm and of the posterior pul-
monary limits were located, the frequency of the res-
piration and of the pulse, the quality of the pulse waves
and of the heart sounds were also accurately deter-
mined. So long as no dyspnea appeared, only an in-
crease in the frequency of respiration was noticeable;
everything else remained as before. But even in a few-
minutes after dyspnea manifested itself, the picture was
changed. He notes in detail the changes occurring
after the violent exercise, and reports cases. The article
is illustrated by numerous pulse tracings and diagrams
of the heart limits. He states that in acute overstrain-
ing of the heart rest is of the utmost importance, and
that among drugs digitalis is in the lead. For quieting
the action of the heart the application of ice or sina-
pisms on the anterior pectoral surface is indicated. It
will hardly be possible, he states, to dispense with the
use of morphine in order to alleviate the severe pains in
the cardiac region, nevertheless it is advisable to be
cautious in the long continued use of large doses of
this drug. The use of stimulants is indicated in exces-
sive cardiac weakness, and in threatened heart failure.
When by such therapeutic means the patient is rescued
from the threatening condition and when recovery from
the injuries already present has taken place it may be
advisable to resort to tonics to counteract the heart
weakness, this being liable to persist for a considerable
time. Generous nourishing of the patient is one cf the
most important tasks of the physician. A rational bal-
neologic treatment, the careful use of gymnastics, suit-
.-ible exercise in the fresh air, with the avoidance of
any kind of straining, all come into consideration.

The Lancet, April 13, 1907.
Treatment of Prostatic Congestion by Electrical

Methods. — T. S. Bolton refers to the effect of the .r-ray
on the testicles and asks if by this effect the ray will in
anywise ameliorate the condition of a patient suffering from
enlarged prostate. Can we hope for an effect equal to
that of castration without any mutilation of the body or
danger to the individual? The author notes that the pa-
tient presenting himself with prostatic trouble is usually
found to be suffering from piles and congestion of all the
parts about the anus. The large submucous veins of the
prostatic urethra are engorged with blood and the pros-
tate is like a sponge distended with fluid. The weakened
bladder is unable to force the urine through the blocked
urethra. The indications for treatment are the relief of
local stasis and restoration of the circulation and the im-
provement in tone of the muscular fibers of the bladder.
These indications are met by electrical applications. As
electricity will relieve, and in many cases cure, chronic
piles, so will it relieve prostatic congestion. The author
adds the histories of two personal cases in both of which
high frequency currents were emplo\*ed with gratifying
results.

One Hundred and Thirty Consecutive Extractions
cf Cataract without a Failure. — C. Higgins thus de-

May 4, 1907]

MEDICAL RECORD.

745

scribes the operation. The eye having been thoroughly
cleansed and cocainized he first passes a silk suture through
the conjunctiva below the lower corneal margin; next
direct the patient to look downwards, and having got the
eye into the required position draw the suture moderately
tight and have it fixed on the cheek by the thumb or finger
of an assistant. He uses no other fixation. He next draws
the upper eyelid upwards sufficiently to expose the iipper
margin of the cornea. He never uses a speculum or fixing
forceps, but keeps the lid in the required position with
the index finger and steadies the globe by pressing very
lightly upon its inner surface with the second finger of
the same hand. Then with a Griife's knife he makes a sec-
tion in the sclerocorneal junction forming a flap of rather
m.ore than one-third of the cornea. As soon as the incision
is finished he tells his assistant to let the suture go, holds
it himself, and lacerates the capsule. He then removes
the lens by pressure with the thumb or forefinger applied
to the surface of the lower lid, just below the lower margin
of the cornea, aided by counter pressure applied in the same
manner above the incision. If the pressure is properly ap-
plied the incision begins to gape, the iris protrudes, the
pupi! dilates, and the lens escapes through it. Having
removed the bulk of the cataract he takes care to press
out all cortex, and then if the iris has not returned to its
normal, position he replaces it by rubbing the upper lid
lightly upon it and if that does not sulfice he pushes it
back with the curette. In some cases pressure through the
lid will not cause the lens to escape ; in such he removes
it by light pressure with the curette applied directly to the
eyeball. He never hurries over the operation, but when the
lens has been entirely removed and the iris has returned
to its normal position he leaves the eye exposed to the
light for a few moments ; by so doing the pupil contracts
and remains contracted and the risk of prolapse is les-
sened. After the operation he covers both eyes either with
a pad of wool and gauze or Gamgee tissue, or pads
specially made for the purpose, secures the pads by a light
bandage, and puts the patient to bed. where he remains for
three days. He removes the dressing on the second day, but
reapplies it, and afterwards dresses the eye every day, but
keeps both eyes bandaged for a week, without opening either
unless there is some special reason for doing so, such as
pain, swelling, or redness of the lids, or unusual discom-
fort. If prolapse of the iris occurs to any considerable
extent he removes it as soon as found; small prolapses
he leaves alone.

Pathology of Melanotic Growths. — W. S. Handley,
in a further lecture on this subject, discusses among other
topics that of the clinical dia.gnosis of malignancy and
moles. He says that when a pigmented wart or mole in-
creases in size, ulcerates, or gives rise to bleeding and
discharge, it should invariably be treated as a malignant
tumor. To wait for the establishment of the diagnosis by
palpable enlargement of the regional lymphatic glands is
to court trouble. The complete operation as for removal
of a melanotic sarcoma should be carried out. The re-
moval of the surgical lymphatic glands is not a very severe
surgical procedure as an insurance policy against such a
terrible surgical disease. Some surgeons may consider,
wrongly in the author's opinion, that removal of the glands
is unjustifiable until conclusive evidence of the malignancy
of the tumor has been obtained. For this purpose micro-
scopic e.xamination of a small portion of the primary tumor
is often valueless, for an innocent mole may present the
typical appearance of an alveolar sarcoma. Proof of malig-
nancy can only be obtained by a systematic examination of
the whole of the excised piece of tissue at the center of
which lies the suspected mole. Two adjoining diametric
slices are taken, vertically to the skin surface, through the
center of the suspected tumor. Each slice should be about
one-eighth of an inch thick. The slices are fi.xed, hardened,
and cleared. One of them is preserved as a translucent
naked-eye specimen; the other, divided into pieces of suit-
able size, is submitted to microscopic examination. If be-
yond the limits of the primary growth in the naked-eye
specimen anv trace of black cords or dots can be seen, and
if in the microscopic specimens permeated lymphatics or
perivascular infiltration can be detected beyond the obvious
edge of the neoplasm, the malignancy of the tumor is
shown beyond the possibility of doubt. Removal of the
regional lymphatic glands must in such a case be under-
taken without delay. If the surgeon waits for obvious
enlargement of the lymphatic glands, permeation of their
tributary and efferent trunks may probably by that time
have carried the disease beyond the reach of his knife.

British Medical Journal. April 13. 1007.
Relative Opsonic Power of the Mother's Blood
Serum and Milk. — This question has been considered

in a series of experiments by E. Turton and R, Appletoa.
From their results it would apear that while the opsonic
power of the mother's blood serum for both the tubercle
bacillus and the Staphylococcus pyogenes aureus is within
the normal range, that of the milk from the same source is
very low, averaging 0.077 for the tubercle bacillus and o.ii
for the Staphylococcus pyogenes aureus. The cow's blood
serum appears to have about half the opsonic power of
human blood for the tubercle bacillus and rather more
for the Staphylococcus aureus. The presence of antitoxin
has been demonstrated in the milk of animals immunized
against various toxins, e.g. tetanus and diphtheria toxins.
It has also been shown that the milk of animals immunized
against the typhoid bacillus and of mothers who have suf-
fered from typhoid fever contains agglutinins for that or-
ganism, but it would appear that the amount of these
protective substances in the milk is very much less than in
the blood. Comparisons of the opsonic power of the child's
serum with that of the mother's serum and milk showed
that the opsonic power of the child's serum was much less
than that of the mother, and the authors consider it an
interesting question whether any absorption of opsonins can
take place from the mother's milk. They note that author-
ities seem to be divided on the question of absorption or
nonabsorption of agglutinins and antitoxins in the intestinal
canal of children.

Suggested Modification in the Opsonic Estimation
of Tubercle. — R. D. Campbell has found that for op-
sonic estimation the tubercle bacilli may be prepared stained
beforehand. In common with ordinary dead tubercle ba-
cilli, the stained bacilli in simple admixture with leucocytes
are not taken up, but, like the ordinary bacilli in the pres-
ence of serum, the dried bacilli were roughly powdered and
then placed in a fair quantity of carbolfuschin and stained
in the cold for twenty-four hours. The mixture was then
centrifugalized. the supernatant fluid siphoned off, and the
sediment shaken up with distilled water. This process was
repeated three of four times to wash the bacilli. The sedi-
ment of stained bacilli was then used in the same manner
as the ordinary bacilli, ground with saline solution in an
agate mortar, and the bacillary emulsion prepared as usual.
The stained bacilli may be kept as a stock. The process
is then as usual up to the staining of the filins, when, in-
stead of the carbolfuchsin and counterstaining process, a
self-fixing blood stain is used, .Tenner's being, perhaps, the
best. With this stain very fine films may be obtained, with
only one slight disadvantage — that the fine eosin-stained
granules of the polymorphonuclear leucocytes are apt to
cause confusion with the fuchsin-stained bacilli. With ex-
perience, however, the difficulty is slight. The fact that
bacilli treated with such a powerful stain as carbolfuchsin,
containing roughly about 46 per cent, carbolic acid, can be
influenced by the opsonin to the extent of allowing phago-
CNtosis is of interest. Is the virus, asks the author, con-
tained in the bodies of the dead bacilli neutralized by the
staining process? If so, then there must be another non-
virulent body present, which, in combination with the op-
sonins in the serum, forms the substance causing chemio-
taxis in the leucocytes.

Vaccine Treatment of Tuberculosis in Children. — C.
Riviere believes that in tuberculin we have a most valuable
remedy for localized tuberculosis. There is nothing dra-
matic in its effects, but. with proper dosage, a steady uphill
progress occurs both in the local conditions and in the
general health. That this improvement corresponds with
an increase of opsonic power the author has satisfied him-
self bv observing the alternate im.provement and relapse in
superficial lesions with the rise and fall of the opsonic index
of the blood. Tuberculin, especially suitable for localized
tuberculosis, is also of value in many cases of less local-
ized infection, especially if nutrition be not greatly impaired.
Many of the author's cases appeared hopeless from the
outset, being either chosen for the purpose of testing the
limitations of tuberculin or handed over to him because
other treatment had failed. With marked wasting and gen-
eral illness no good results should be expected : yet even
under such conditions tuberculin is occasionally the turning
point in a downhill course, so that unless the lesions are
known to be widespread it is still worthy of trial. Tuber-
culin cannot take the place of surgical procedures but should
be used in conjunction with these. Especially must caseous
material, unless small in quantity, be removed, and this
should be done at a time when the opsonic index is at a
high level. On the other hand, many cases would escape
the necessity for surgical measures if tuberculin were given
sufficiently early. The secondary infection, always present
with open tuberculous lesions, generally lessens with im-
provement in the tuberculous proce-s. The advantage of
and occasional necessity for a second vaccine is a point to

746

MEDICAL RECORD.

[May 4, 1907

which the author is giving special attention. Tuberculin
treatment should only be undertaken by those who have
given it special study. This must be obvious to all who
remember the results of its use in the old days.

The Influence of the Antituberculous Serum on the
Opsonic Index. — Histories of five cases are given by
W. C. Bosanc|uet and R. E. French. These cases were
heated with Marmorek's serum and from their experiments
the authors conclude that a series of doses of this serum
will, when administered rectally, usually produce a rise in
the tuberculoopsonic index ; this rise begins after the first
three or four doses and soon reaches a maximum, close to
which the index remains for three or four weeks, while
serum is being given, and does not fall till nearly a week
after injections have been omitted. This rise in the op-
sonic index is coincident in some cases with an improve-
ment in the general condition of the patient and a diminution
of the diurnal variation of the temperature. Subcutaneous
injections of the serum do not seem to have such a good
effect; possibly a series of such injections given at longer
intervals might be preferable as avoiding an accumulation
of negative ohases. If, as is suggested by the authors' ex-
perience, a rise in index is produced by the administration
of Marmorek's serum, but is not maintained for long after
the serum has been omitted, the action of the serum might
be explained by its containing an excess of opsonins. This,
however, is scarcely to be expected, as a serum, when
kept ill vitro, gradually loses its opsonic power, so that at
the end of two weeks the index is only about an eighth part
of what it was when the serum w-as fresh. To prove that
Marmorek's serum was not loaded with opsonins the au-
thors tested its opsonic index in the usual way; in the
slide made from normal serum they found 568 tubercle
bacilli in 200 polymorphonuclear leucocytes, and in the slide
made from Marmorek's serum only 72. This gives an
index of 0.127. Some other explanation, therefore, must
be found for the action of Marmorek's serum.

Mitiichcncr mcdizinische VVochenschrift, April 2, 1907.

The Treatment of Gangrene Due to Arteriosclerosis.

— Ropke refers to the fact that where this variety of
gangrene is present in the toes, an amputation is usually
accented as the only form of curative treatment. It is
not always easy to know, however, to what point the tissues
are still in such a condition that recovery may take place.
The loss of pulsation in the dorsalis pedis or the posterior
tibial arteries need not always prove a contraindication,
as shown in the case reported by the writer. The patient
was a gouty man of fifty-nine years of age, who developed
a gangrene of the toes and at the same time showed an
absolute loss of pulsation in the two vessels mentioned.
The patient w'ould not permit anything more than an
exarticulation of the toe, which was accordingly done and
the tissues foiyid to be bloodless. The process extended
and required further removal. Hot antiseptic foot baths
were then employed for cleansing purposes and the writer
was surprised to find that the previously exsanguinated
areas began to bleed. The hot baths were repeated daily
and after a period of eight days pulsations could be de-
tected in the dorsalis pedis artery. The wound also gradu-
ally healed. The procedure indicated apparently constitutes
an efficient diagnostic and curative measure in these cases.
Tuberculosis of the Eye Treated with Tuberculin. —
Erdmann reports an instance in which this agent was ap-
plied in the treatment of a case of tuberculous iridocyclitis
in a young girl who was also afflicted with tubercular
arthritis. Koch's new tuberculin was employed, the solu-
tions being made with normal salt solution in order to
avoid the irritation usually produced by glycerin. The
initial dose was 2/1,000 mg. injected into the upper arm
every other day. The quantity was increased by this same
amount at every treatment until lo/l.ooo mg. were given.
Fever and headache were then complained of and a local
reaction was noticed in the eye. The dose was again in-
creased until 4/10 mg. was given, and during a period of
four months the patient had been given sixty injections.
No other treatment aside from the use of a dark glass
and the occasional instillation of atropin was employed.
The eye became practically well again and the patient's
general condition was improved at the same time. No re-
currence was noted up to the time the report was made,
although no further injections had been given in almost a
year.

Deutsche mcdizinische U'ochcnschrift, March 21 and April
4. 1907-

Pseudoleukemia with Periodical Attacks of Fever. —

Tschistowitsch describes a condition of high-grade anemia
in a woman who was greatlv emaciated and in whom there

were attacks of fever lasting from ten to fourteen days, al-
ternating with similar periods in which there was no rise
of temperature. The writer states that there is no other
infectious disease which presents the same temperature
curve and from the fact that a number of similar cases
have already been observed by others, he thinks that we
may regard this condition as a clinical entity to which he
has given the name "pseduoleucsmia cum febri periodica."
During the febrile attacks the spleen and the liver become
enlarged and during the afebrile interval these organs re-
turn to their normal size. Later on in the disease they
remain more or less enlarged all the time. The lymphatic
glands are also enlarged. In all cases which are known
from the literature there is progressive loss of strength
and anemia without any increase in the white blood cells.
During the afebrile intervals the patients feel quite well.
The disease seems to be invariably fatal, although in the
author's case a recovery seems to have taken place. He
attributes this improvement to the administration ot potas-
sium iodide, and for this reason believes that syphilis must
be regarded as an etiological factor in the production of
the condition. This also seems to be borne out by the
clinical histories of the other reported ca.^es.

The Treatment of Mediastinal Tumors with the
Roentgen Rays. — Elischer publishes a further report
on two cases of mediastinal tumors treated with the
Rontgen rays, in which the effect of this agent could be
studied in the autopsy findings. In both of these cases the
.r-rays brought about a marked improvement in the pa-
tients' condition, although they later succumbed to the
effects of the metastatic deposits. The autopsy showed
that the tumors were sarcomata of a very malignant type,
but in the mediastinum they had been largely replaced by
connective tissue. The author is of the opinion ihat if
the application of the .r-rays had been made earlier, before
any metastatic development had taken place, a more perma-
nent cure would have resulted. The cases are interesting
as being among the first in which such a demonstration of
the effects of the rays was possible.

Enteritis and Appendicitis. — Sonnenburg refers to the
difficnl^j' in making a diagnosis when the symptoms are
those of a general intestinal or peritoneal infection and
there are very few local signs. .\n example of this is the
gastroenteritis which may follow an influenza, where the
pains are of a colicky character, marked by a sudden onset,
and accompanied by a high fever and a rapid pulse. The
leucocyte count is low. however, and this, according to
Sonnenburg, constitutes one of the main features in the
differential diagnosis. A secondary appendicitis is not un-
common after these attacks and unfortunately its prog-
nosis is usually bad. Where there is any doubt, however,
of the presence of a mere catarrhal condition of an in-
fluenzal or similar character, the administration of a
suitable dose of castor oil will clear the intestine and
often alleviate the symptoms. Sonnenburg claims that this
remedy will not increase the danger of perforation or
gangrene in an inflamed appendix by merely increasing
the peristalsis. One should always be prepared, however,
to do an immediate operation if no relief is secured.

Chronic Articular Rheumatism and Arthritis Defor-
mans.— Hoffa refers to the uncertainty which exists re-
carding the pathological classification of these diseases.
He claims that there is a distinct difference between the
two and that a classification may be made which is based
on etiological factors. Three groups of chronic joint
diseases may be recognized: (i) .■'l typical arthritis de-
formans; (2) a chronic progressive polyarthritis or de-
structive polyarthritis, and (3) a chronic articular rheu-
matism which follows an acute variety of the same. .-Ks
regards their etiology, these may be classified as infectious
or non-infectious, although much of the following scheme
rests largely on h\-pothesis. The non-infectious group in-
cludes chronic traumatic, irritant, constitutional, deforming,
and functional arthritis. The infectious group includes
both primary and secondary varieties. Hoffa finds that in
these chronic cases various forms of braces and supporting
anoaratus is often of greater value than the medicinal or
physical measures.

The Transmission of Syphilis to Dogs. — Fromme
reports the results of his preliminary experiments with
the inoculation of syphilitic virus from the human subject
in does. In two cases bits of a penile chancre were inocu-
lated in the anterior chamber of the eye and soon afterward
a typical specific keratitis resulted. The period of incuba-
tion was sixteen days in one case and twenty-one in the
other. The Spirochcrta pallida was also obtained in smears
made from material taken from these ocular lesions. Fur-
ther experiments inthisdirection are promised at a later date.

May 4, 1907]

MEDICAL RECORD.

747

Essentials of Medical Electricity. By Edward Regi-
nald Morton, M.D., CM., Trinity University, Toronto;
D.P.H.. Fellow of the Royal College of Surgeons, Edin-
burgh; AJedical Officer in charge of the Electrical De-
partment London Hospital ; Honorary Secretary of the
British Electrotherapeutic Society, etc. With eleven
plates and seventy illustrations. Chicago : W. T. Keener
& Co., 1905.
In this little volume the author has succeeded in present-
ing the essentials of this important subject both clearly and
concisely. The book is well written, readable, sufficiently
illustrated, and is a .good example of the best class of
compend.

Jahresbericht user die Leistungen und Fortschritte
AUF DEM Gebiete der Erkrankungen des Urogenital-
apparates. I. Jahrgang. Bericht iiber das Jahr, 1905.
Berlin : S. Karger, 1906.
This work is similar to others issued in Germany in
which is considered the progress made during a given time
in some special field of medicine. It is believed to afford
a complete and ready means of reference to what has
taken place in the science of urology during 1905, and a
glance through its pages will show that the labor expended
on this subject has been enormous. It is evident that
the constantly growin.g literature has been reviewed in
order to be made accessible to the body of the profession
as well as to the specialist. The book opens with an
account of the life and labors of Nitze, who was one
of the founders and editors of the book and is generally
recognized as a leader in the field of .genitourinary dis-
eases. The manner of arranging the text is very con-
venient: each writer is given a paragraph containing a
brief abstract of his paper and each division is supple-
mented by a voluminous bibliography. The work is very
complete and will undoubtedly meet with a favorable re-
ception among those engaged in this particular field of
medicine.

Conservative Gynecology and Electro-Therapeutics. A
Practical Treatise on the Diseases of Women and Their
Treatment bv Electricity. By G. Betton Massey, M.D.,
Attending Surgeon to the Oncologic Hospital, Phila-
delphia, etc. Fifth Revised Edition. Philadelphia:
F. A. Davis Company, 1906.
The work under discussion is one of a comparatively
small group devoted to the electrical treatment of gyne-
cological affections. Electricity is undoubtedly a most valu-
able therapeutic resource, but its universal application to
almost every phase of gy'necological disease is a visible
departure from the realms of common sense. As a means
of aiding diagnosis it can in the form of appropriate ap-
paratus be said to constitute a most efficient aid to gyne-
cological practice, but as a cure for all pelvic conditions
from fibroids to cystocele it will hardly meet with general
approval. The book is an excellent example of what en-
thusiasm in the belief of one therapeutic resource will
lead to — an enthusiasm which leads the author, who has
set out to write a book on gynecolo.gy. to devote a chapter
in the middle of the book to the cosmetic application of
electricity. The chapter on the treatment of uterine
fibroids by the electric current will probably meet the
greatest amount of attention because it is in this field that
the author has been most frequently heard. The final
result in the no cases thus treated is hardly favorable
and some of the measures advocated, such as abdominal
puncture with a special electrode, will hardly appeal to
one on the score of safety. About half the book is de-
voted to the technique of the various procedures advo-
cated in the previous chapters, and imoresses one with the
exceeding complexity and corresponding expense of the
annaratus needed for carrying out these methods of gyne-
cological treatment.

Indications for Operation in Disease of the Internal
Organs. By Prof. Herman Schlesincer, M.D.. Ex-
traordinary Professor of Medicine in the University of
Vienna. Authorized English Translation bv Keith W.
Monsarrat. M.B.. F.R.C.S. Ed., Surgeon to the North-
ern Hospital, Liverpool. New York : E. B. Treat & Co.,
1906.
The far-reaching activities of modern surgical endeavor
make the appearance of a book of this kind opportune, for
the question of operation is one which constantly pre-
sents itself to the general practitioner and is often very
difficult of decision. To meet this want the book in ques-
tion has been produced. Prof. Schlesinger is one of the
best known clinicians in Europe and the book is the result
of his many vears of practical experience. Although
written by one who is essentially an internist and physi-
cian, there is no lack of sympathy for the surgeon and his

aims. All discussion has been avoided, but in each chap-
ter are included a few remarks on the etiology, pathology,
clinical course, diagnosis, and differential diagnosis, in
order that the subject under consideration may be more
thoroughly grasped and appreciated. The main purpose
of the undertaking, however, is to enable the general prac-
titioner who is not in hospital practice, to arrive at an
independent opinion on the advisability of operation in the
presence of internal lesions. The scope of the book is
quite extensive, all the structures which may be included
in a general way in the interior of the body being sep-
arately discussed. At the end in an appendix, are three
very good chapters on the induction of premature labor,
operations on diabetics, and the general influence of opera-
tions on the body. The book is well written and not
burdened with illustrations for which there is no neces-
sity. It will undoubtedly meet the demand for which it
was written, as it stands practically alone in this field.

The Technique of Operations upon the Intestines
and Stomach. By Alfred H. Gould. M.D., of Boston.
Philadelphia and London : W. B. Saunders Company,
1506.

This book may be regarded as a departure in works on
surgery, as it practically represents the results of an ex-
tended research expressly undertaken for the purpose of
simplifying or improving the best known gastrointestinal
operations. The experimental study of the technique was
made upon animals, mainly cats and dogs, and then car-
ried out on the human cadaver for purposes of anatomi-
cal corrections. Not all the methods in vogue are given,
but those included will aft'ord to the reader a sufficiently
comprehensive view of the requirements of gastrointes-
tinal surgery. The opening chapter includes an account
of the very interesting studies on the " oair of intestinal
wounds made by the author in conjunct. on with Dr. F. B.
Harrington which are already well known. The technique
of operation is considered in great detail and constitutes a
very valuable feature of the book. The suggestions are too
numerous to mention here, but all have been thoroughly
tested by the author in his extended operative experience.
The text is clear and concise, although in some instances
conciseness is obtained at considerable sacrifice of other
desirable qualities. .\ few words must be added regarding
the illustrations, which are beautiful and often help out
where the text fails in bein.g sufficiently explanatory.
They are well drawn and well executed and constitute an
important factor in what will certainly prove a most ac-
ceptable book on surgical technique.

E'EvALUATiON des Inc.vpacites Per.m anentes. Basee sur
la Physiologic des Fonctions Ouvrieres des Diverses
Parties du Corps. Par le Dr. Ch. Remv. Professeur
agrege a la Faculte de Medecine de Paris, Membre de la
Societe de Biologic, Chirurgien Honoraire de la Maison
Departementale de la -Seine. .-Xvec 63 figures dans le
texte. Paris: Vigot Freres. IQ06.
This book fills well a place which no book in English
more than attempts to occupy; only one does this and
even its author recognized its tentative development, while
this one has a logical foundation which gives it a peculiar
value to the special public for which it is intended, the
adjusters of the companies, which by insuring the workmen
of an industry against the accidents of their daily tasks
protect the employer from "accident suits" for damages.
Hitherto, both since the passage of the "new law" and
previously, the basis of settlement has in every case been
hv mutual agreement on an arbitrary valuation in which
the agent of the company endeavored to settle for the
lowest possible figure and the injured workman or his
agent attempted to get all he could, and usually neither
was satisfied. The aim of Dr. Remy is to substitute for
this unsatisfactory system another having rational foun-
dation. While for the most part the discussions are tech-
nical, some have very general interest.
1.A Regeneration des Familles et Races Tarees. Pro-
phylaxie et Hygiene Therapeutique de I'Heredite Mor-
bide. Par Dr.E. Contet. Paris: Vigot Freres, 1906.
This rather unusually interesting book treats of a sub-
ject much too seldom considered, the consideration of the
physical condition of the possible parents and their family
inheritance of physical and mental traits in relation to
their possible and probable offspring. In effect it is an
amplification and development, in large measure a fulfil-
ment, of the precept in Raymond's book of last year,
I'Heredite Morbide.— that it is the duty of the family
physicians to point out to the contracting parties the con-
sequences of physical misdoing, as their legal adviser might
advise them not to break the law of the land. The book
is well written and certainly sets the reader thinking,
whatever his opinion of the author's teaching may be.
It is well, very well, worth reading, and we trust that an
English translation will not be long delayed.

748

MEDICAL RECORD.

[May 4, 1907

NEW YORK ACADEMY OF MEDICINE.

SECTION ON SURGERY.

Stated Meeting, Held April 5, 1907.
Dr. John F. Erdmann in the Ch.me.

A Case Showing Result of Operation for Habitual
Dislocation of the Patella by a Modification of Krogius'
Method. — Dr. William C. Lusk presented this patient,
who was forty-one years old. Six years ago, while run-
ning, he slipped on some ice and fell over backwards, dislo-
cating both his patellae outwards. Afterwards, always on
flexion of the legs, the patellae slipped outward over the
external condyles. He was admitted to Bellevue Hospital
and operated on January 14, 1907. The right knee was
operated upon by a modification of Krogius' method. Kro-
gius divided the aponeurotic structures down to the capsule
of the joint along the outer side of the patella and the ilio-
tibial band above to relieve the shortened tissues on the
outside of the joint, then making a musculo-aponeurotic
flap on the inner side of the joint without entering the joint
on this side either, he carried this flap in front of the quad-
riceptus extensor tendon around the upper border of the
patella and laid the extremity of it in the wound which had
been made in the aponeurotic structures at the outer side of
the joint and sewed it there. Then the edges of the wound
at the inner side cf the joint, made by the removal of the
musculo-aponeurotic flap, were sutured together, thus short-
ening to this extent the tissues at the inner side of the
patella, by the support of which the tendency to outward
dislocation would be counteracted. The operator in this
present case found it necessary to carry the incision for the
relief of the restraining structures at the outer side of the
patella, upward and inward through the muscle fibers of the
vastus externus to the outer edge of the quadriceps ex-
tensor tendon. Then finding furthermore that by Krogius'
method only the tip of the musculo-aponeurotic flap would
reach into the wound in the divided structures at the outer
side of the joint, instead of carrying this flap in front of the
quadriceptus extensor tendon, he made a blunt dissection
beneath the tendon above the subquadricipital bursa and
carried the flap through the opening thus made and then
laid it in the musculo-aponeurotic wound at the outer side
of the knee-joint, which it was found to fit accurately from
its upper limit down to within half an inch of its lower
end. The flap was sutured in place with chromic gut. An
anatomical specimen was shown illustrating the surgical
anatomy of the operation. The outer edge of the aponeu-
rotic insertion of the vastus externus into the patella, receiv-
ing the terminations of the muscular fibers, corresponded
to the edge of the underlying portion of the subquadricipital
bursa, so that division of the muscular fibers above this line
could be made without entering the joint. The division of
the muscle fibers at this situation was an important part of
the operation since they were shortened and on flexion of
the leg they alone pulled the patella outward over the ex-
ternal condyle, after the shortened tissues attached to the
outer border of the patella had been cut. It seemed equally
important that this upper muscular portion of the wound
made at the outer side of the knee-joint to relieve the
shortened tissues, as well as the lower aponeurotic portion,
should be filled in by the transplanted flap from the other
side, so as to prevent a hard scar from forming at this situa-
tion where a re-establishment of pliability instead seemed
essential. A branch of the superior internal articular artery
entered the muscular portion of the flap transplanted from
the inner side. The width of the flap was planned so as to
remove the exact amount of tissue that would leave behind
edges of muscle and aponeurotic structure of a sufficient
length to be brought together with the right amount of
tension to hold the patella firmly inward. The result of the
operation was primary union. On March 12, 1007, the pa-

tient gave up the use of his cane, no longer having the feel-
ing of insecurity in his gait. On April S, 1907, he had vol-
untary flexion of the right leg of ninety degrees, and forced
flexion of about another ten degrees. The right patella did
not dislocate.

A Case of Fracture of the Patella. — Dr. Clarence A.
McWiLLi.\MS presented a man, who had been admitted to
the hospital last May, two days after he received an injury
to the left knee. He fell down an areaway, striking a board.
He then walked one block and, two days later, was admitted.
There were two infected skin wounds. It was impossible to
palpate the bony structures at all, but the .ar-ray plate
showed the patella fractured in five or six pieces. Twelve
days after the injury he was operated upon, the operation
having been delayed because of the infected wounds on the
knee surface. He preferred the transverse rather than the
vertical incision, because it allowed the lateral tears in the
vasti expansion to be sutured. Three loose pieces of bone
were removed. The joint was filled with blood, which was
spooned out and the cavity cleansed. A purse-string suture
was placed around the remaining fragments, as well as a
vertical one. The joint was kept in splints for twenty-one
days, then massage was given and the patient was allowed
to walk on the twenty-eighth day. He made a good re-
covery.

Dr. How.\RD LiLiENTHAL believed that these were the
cases that should be treated by operation, and he congrat-
ulated Dr. McWilliams upon the beautiful results obtained.
In the ordinary transverse fractures, however, he had been
in the habit of using a massage treatment. In this non-
operative treatment the patient was out of bed, but in splints,
on the eighth day, and a cure was accomplished which
was as perfect as in the patient presented on the forty-
eighth day. He called attention to the fact that King
Edward's fractured patella was not sutured and yet good
results were obtained. In cases of comminuted fracture,
however, operation was proper; also, in open fractures.

Dr. John F. Erdmann asked Dr. Lilienthal what he
did, in this massage treatment, to bring the fragments
together.

Dr. Lilienthal said that the first thing to do was to
place an arrangement of tapes above and below the
patella, strapping the fragments together, an ordinary
bandage being placed on. During massage, however,
everything was taken off, and the fragments held in place
by an assistant. The massage was given with the limb in
an inclined plane, completely relaxing the quadriceps
muscle. Massage should be begun above and continued
down. It should be given fifteen minutes both morning
and afternoon. On the eighth day it was supposed that
adhesions had taken place which would hold the frag-
ments together and the patient then was allowed to get
up, but with the splint on.

Dr. McWilliams said that, if the separation was half
an inch, he always operated, and with magnificent results.

Dr. Lilienthal said that Dr. McWilliams was very
fortunate in not having seen or encountered infection of
the knee joint following the opening of an aseptic articu-
lation. He had seen several such cases, and one need
only see it once to make him extremely careful in opera-
tion about this joint.

Dr. Erdmann said that he never opened the knee joint
without fear and trepidation.

Dr. .\. Ernest G.\llant said that he had had cases treat-
ed by the rest treatment and massage, relieving the ad-
hesions which had formed, and he thought that Di. Lilien-
thal had not been given sufficient credit for the good results
he had obtained.

Extensive Removal of Bone after Depressed Frac-
ture of the Skull. — Dr. Joseph B. Bissell presented a
man who had been admitted to Bellevue Hospital on
September 14. 1905. He had been hit on the head by a
falling brick, was brought into the hospital on a stretcher,
and recovered consciousness in the ward and never lost

May 4, 1907]

MEDICAL RECORD.

749

it afterwards. A cut on his head was three inches m
length, and a depressed fracture was found when the
wound was being dressed. The next day he developed
symptoms of paralysis of the left leg and arm. The de-
pressed fracture was cut down upon and a large amount
of bone was removed. The longitudinal sinus bled pro-
fusely. The patient made an uneventful recovery so far
as the head lesion was concerned. Within five or six
months epileptiform convulsions appeared, but conscious-
ness was never lost until recently. These attacks had in-
creased lately. He had also recently gastric crises. There
was partial anesthesia of the left arm. He had great
difficulty in getting up from the chair and he dragged the
left foot.

Dr. Howard Lilienthal asked if another operation was
not indicated in order to loosen possible adhesions; he
thought this to be strongly indicated, especially in view
of the fact that the epilepsy had only recently developed.
The patient, too, should be carefully watched during an
attack. He had had a child with such attacks and he
saw the patient in several of them. During the attacks
the scar was drawn in. He believed that in this case
there was a decided indication for the removal of more
bone.

Dr. Bissell replied that at the first operation much
bone had been removed. At the same time he believed
that the indications now pointed to another operation.

Drainage in Operations upon the Biliary System. —
Dr. Howard Lilienthal read this paper. He said that the
surgery of the biliary passages was still in a decidedly
unfinished state, and in spite of the earnest work of many
conscientious surgeons. The number of deaths, except in
the uncomplicated cases, was still great. Operative re-
covery after work upon an uninfiamed gall-bladder was
almost constant, and the percentage mortality after the
simpler operation upon this viscus, even in acute cases,
was low. When jaundice appeared as a complication, how-
ever, and surgical interference with the common duct was
required, the picture changed, and even in the most skilful
hands the death rate was shocking. The impressions re-
cited in his paper were from a collected experience with
more than 300 cases, including examples of nearly every
known operative procedure on the gall-bladder and its
associated ducts. He had reached the conclusion that in
operative jaundice, especially the chronic variety, the skil-
ful use of biliary drainage was the most essential meas-
ure in reducing the operative mortality. He also believed
that the longer the jaundice had existed the greater must
be the caution in relieving the condition. Chronic ob-
struction led to secondary cirrhosis of the liver with its
attendant dangers, not the least of which was hemorrhage;
also, just as reflex anuria might occur after the operation
for the relief of renal obstruction, so in long-continued
hepatic blocking, constant, or intermittent, the attempted
surgical drainage of the liver through its ducts might be
followed by suppression of bile. This suppression might
be gradually relieved after a few days, or it might persist
and become the cause of a fatal cholemia. He then gave
illustrative cases. Dr. Lilienthal summed up the vital
points of this subject as follows: (i^ That the scientific
and judicious employment of preliminary drainage in ob-
structive jaundice would probably lessen the dangers of
such steps as might be necessary for permanent cure. (2)
That this drainage should form the sole object of the
surgeon's work until the factor of cholemia had become
eliminated. (3) That radical operations should, in most
chronic cases, be postponed until hepatic engorgement and
icterus no longer existed.

Dr. Samuel Lloyd said that the point brought out by
Dr. Lilienthal regarding the deaths from cholemia had
bothered all of them.

Dr. Joseph B. Bissell said that the conclusions given
by Dr. Lilienthal were very valuable. He had had many
cases in which he wished that he had not finished the
operation at one sitting.

Dr. John F. Erdmann reported a case that he had
operated upon for cholangitis and had washed the liver
out well. The other day he washed the hepatic ducts out,
getting small stones and sand. This was followed by
hemorrhages from the nose and stomach and death.

Dr. A. V. MoscHcowiTZ said that many might consider
his views somewhat erratic, but he had never been a
believer in hepatic drainage. It always appeared to him
that, in all cases requiring drainage, the common duct was
either free, or it was not free. If it was not free no
operation was complete until it was made free; but if the
common duct was made free there was then sufficient drain-
age into the intestine.

Dr. Lilienthal, in closing the discussion, said tliat some
had missed the point of his paper, because he agreed with
what had been said. In one of the cases he recorded he
took out the gallstone and sutured the parts. If there
was a deep jaundice, a chronic jaundice, the correct thing
to do was to drain the gall-bladder and to drain it slowly.
He emphasized the importance of draining the liver through
the gall-bladder by a slow method, and gradually increas-
ing the flow and avoiding shock. If icterus was present,
attack the common duct and remove the obstruction and
complete the operation.

New Operation for Cystocele in Women. — Dr. J.
Riddle Goffe presented tliis communication, illustrating
his remarks with diagrams. He presented what he claimed
to be a novel procedure for the cure of cystocele. After
reviewing the history of the various operations for the
cure of cystocele in brief, he said that these previous opera-
tions had two objections : first, in attempts to diminish the
size, wrinkling up the base of the bladder, sulci were left
in which urine would accumulate; second, the fundamental
principle which underlay the question, trying to get sup-
port tinder an organ to hold it up. Dr. Goffe said that
nature's plan of retaining organs in place was not in placing
anything under an organ, but in suspending it from a bony
framework. The uterus was not held up, but was sup-
ported by ligaments in accordance with nature's law. The
bladder normally was suspended by its ligaments which
hung from above; it was supported chiefly by its attach-
ment to the uterus, the broad ligaments, and the lateral
fascia on either side. It was the giving way of that sup-
port, as well as the giving way of the fascia at the base
of the bladder, that produced the hernia they must deal
with. Dr. Goflfe's plan was to dissect away the bladder,
freeing it entirely from all structures except those above.
He then rotated this viscus on its transverse axis, carried
it up, and stitched it to the uterus. The work was dona
per vaginam. The technique of the operation was de-
scribed. He had had from fifty to sixty cases under
observation and the results so far had been entirely satis-
factory. He had not yet learned of a single recurrence.

Dr. Herman L. Collyer said that all knew what dead
failures the operations for the cure of cystocele had been,
and believed that this operation described by Dr. Goffe was
the first that offered them chances of success.

Dr. Howard Lilienthal thought that the operation was
a perfect anatomical one. He asked Dr. Goffe if the male
bladder was suspended or not. He believed the male blad-
der was supported "from below."

Dr. Joseph B. Bi.ssell said that most cystoceles were
due to prolapsus uteri, and he asked if Dr. Goflfe did not
first fasten the uterus up. He did not see how one could
suspend the bladder without first suspending the uterus.

Dr. Howard Lilienthal asked Dr. Goffe if he had had
pregnancy following this operation he described, and with
what results.

Dr. Smith of Hartford. Conn., said that the Mayos, in
Rochester, Minn., had been doing successfully the old-
fashioned English operation, whicli was similar to the one
described by Dr. Goffe. But they did it in women past
the menopause and not in young women.

Dr. J. Riddle Goffe, in answer to Dr. Lilienthal, said
that anatomists did not describe differently the male and

750

MEDICAL RECORD.

[May 4, 1907

female bladders in regard to the supports. In answer to
Dr. Bissell's query, he said that the uterus must be sup-
ported before a cure of the cystocele could be effected, first
shortening the sacrouterine ligaments. He had had two
patients that became pregnant after this operation and they
went through all right.

The Surgical Anatomy of the Esophagus. — Dr. Chas.
R. L. Putnam presented this communication. The esoph-
agus began at the lower border of the cricoid cartilage,
which was opposite the sixth cervical vertebra, or the
intervertebral disc below it. It ended near the level of the
eleventh dorsal. From its origin to the second dorsal it
was called cervical ; from that point to where it passed
through the diaphragm it was called thoracic; from this
point to where it entered the stomach it was called ab-
dominal. Its total length was 25 cm., the cervical portion
averaging 5 cm., the thoracic 15-17 cm., and the abdominal
3-4 cm. The caliber of the esophagus varied very much
at different levels, as shown by casts and drawings that he
presented. It was shown that the least distensible places
were at the beginning and at a point behind the summit of
the aortic arch. This point might be pressed upon by
aneurysm of the arch, and, therefore, constriction in this
region should have history and physical signs most care-
fully studied. These narrowings, as shown by the casts,
had surgical significance as follows: First, they were
supposed to determine the points at which ingested caustic
solutions would be most apt to be the cause of ulceration
and stricture; second, they might cause an arrest of foreign
bodies ; third, where the narrowing in the esophagus was
partly due to relations of other organs, changes in the
latter might increase the degree of narrowing to the extent
of producing a clinical stricture. Thus aneurysm of the
aortic arch was said to cause dysphagia; he also had
been told of a case of pericarditis giving this symptom.
Enlargement of the peribronchial, peritracheal, or eso-
phageal lymph nodes might produce the same result. This
accounted for the apparent relapses in cases of stricture
of the esophagus which occurred during attacks of pneu-
monia. The approach to the esophagus in the neck was
best made from the left. In his experimental work on
the cadaver the so-called extrapleural routes were not
promising, and vifhatever was accomplished would be by
the transpleural route, which shortened distances and avoid-
ed dead spaces. This was shown by an examination of the
mountings.

Dr. W. C. LuSK discussed this communication.

Instrument Table, Sterilizing Drums, and Dressing
Boxes. — Dr. H. H. M. Lyle made this exhibition of in-
struments and apparatus devised for the purpose of expe-
diting work in hospital operating rooms.

SECTION ON OBSTETRICS AND GYNECOLOGY.

Stated Meeting, Held March 28, 1907.
Dr. Howard C. Taylor in the Chair.

Cyst of Kidney Simulating Ovarian Cyst. — Dr. G. H.

Balleray presented this and the following specimens : No
diagnosis of the condition was made until operation. The
patient was thirty years old, and had had one child. When
he saw her she had a child seven or eight months old. She
had a growth in the abdomen, but it was decided not to
operate immediately. Two months later she was operated
on and a growth was found that filled the abdominal cavity.
It could be felt per vaginam. It occupied the median line.
When the incision was made the growth had the appear-
ance of an ovarian cyst. When about eight pints of fluid
was withdrawn he found that it was impossible to with-
draw the cyst by gentle traction. The uterus, tubes, and
ovaries were perfectly free. The question of removal of
the tumor came up. He removed the secreting surface, cut
off the redundant part of the tumor, and brought the sur-
faces together and stitched them. The woman never had

any elevation of temperature, and in three weeks time was
sitting up. The interesting point was that the tumor was
peculiar in that it was not unilateral, but seemed to be as
much on the right as the left side, although the cyst in-
volved the left kidney. .A.s a rule these tumors were
unilateral and gave but little difficulty in diagnosis. Even
after its removal he was not satisfied but that it might
have been a Wolfian cyst. The specific gravity of the
fluid was 1.005 and the fluid did not coagulate on the appli-
cation of heat.

Dr. Howard C. Taylor said that he had had a case in
the hospital which turned out to be a tumor of the kidney
and which was taken to be an ovarian cyst when she was
first examined. The woman had an endowment bed and
was admitted to the medical division, refusing operation.
She was on this service for six or eight months and then
transferred. She had been tapped six or eight times and
more or less fluid had been removed. She was finally in-
duced to submit to operation. She was along in years,
seventy years old nearly, and the operation was done
hurriedly, removing what was supposed to be an ovarian
cyst. The tumor was sent to the pathologist, who sent
back word that it was a hydronephroma. This case was
of interest because she was under observation so long
and had been tapped a number of times. He operated upon
what was supposed to have been an ovarian cyst, but
the pathologist reported that it was a hydronephroma.

Cyst of Fallopian Tube with Twisted Pedicle. — Dr.
Balleray's patient came to the hospital for the purpose of
having her perineum repaired, there being a tear through
the sphincter, with loss of control over the bowel function.
While undergoing preparation for operation, she complained
of pain in the pelvis and an examination revealed a small
tumor back of the uterus which seemed to press upon
the rectum. Before entering the hospital she said she
felt something pressing upon the rectum. The pain had
somewhat increased. Later the mass became tender and it
was then decided to open the abdomen and find what it
was. A cyst of the Fallopian tube was found and the
pedicle was twisted upon itself. It looked like a dropsical
hydatid Morgagni. In all probability a puncture through
the vagina would have been all sufficient in this case.

Ruptured Dermoid of the Ovary. — Dr. Balleray saw
the patient one week before she was operated on, and,
at that time, the tumor reached one and one-half inches
above the umbilicus. The increase in size was very rapid;
it doubled its size in two months time. On the day she
came to the hospital she complained of intense pain and
was given a hypodermic of morphine, one-quarter of a
grain, which had to be often repeated. Her pulse was
150, temperature 104°. There was vomiting, the face was
sunken, the abdomen tender and distended, and her con-
dition seemed to be desperate. She was removed in an
ambulance to the hospital, the abdomen was opened, and
there was found a ruptured dermoid cyst, with the con-
tents extravasating into the abdominal cavity. It held a
quart or more. There was more or less general peritonitis.
The tumor, together with the ovary of the other side,
was removed. A good recovery followed. The case was
of interest in showing how such growths might produce
very distressing conditions in such a short time. He
thought that probably there was a process of degeneration
going on inside the cyst and probably some large vessel
was broken into, with hemorrhage into the cavity of
the cyst causing its rupture.

Dr. Howard C. Taylor thought this condition, dermoid
of the ovary, must be more or less rare; he had never seen
si'ch a case.

. Fibroid of Uterus. — Dr. Balleray presented this speci-
men, not because of any special interest in the tumor itself,
but because it gave him an opportunity to say what he
had always endeavored to practice or preach, that often
one might deviate from the rule of practice. The woman

May 4, 1907]

MEDICAL RECORD.

/3'

wai forty-three years old, and the tumor had existed for
some time. The family physician stated that witliin the
last si.x months it had doubled in size. The general con-
dition of the woman was not bad. She had a small pulse
and suffered from mental depression. She was opposed
to any operation. The tumor was such that it blocked the
pelvis. There was found one large band extending from
the sigmoid flexure and rectum, across, and very adherent
to the surface of the tumor. It was attached to the cecum
on the other side. The tumor was removed and the re-
covery was slow, but satisfactory. His contention had
always been that when a woman was approaching the
menopause, with a fibroid that was not causing pain, or
not growing rapidly, she should be left alone.

Adenocarcinoma of the Uterus. — The speaker pre-
sented two specimens of adenocarcinoma of the uterus.
In both cases the tumor was in the body of the uterus,
which was comparatively rare. Carcinoma of the cervix
was quite common. There were probably fifty cases of car-
cinoma of the cervi.x to one case of carcinoma of the
body of the uterus. The two cases presented themselves to
him within six weeks of each other. The first case was
a woman, fifty-six years old, who ceased to menstruate at
forty-five and had been free from any bloody discharge
from the vagina since until three months ago, when she
had irregular hemorrhages from the vagina. The physician
who examined her could find nothing about the cervix.
Dr. Balleray examined her and found the uterus enlarged,
the cervix normal, and he expressed the opinion that it
was probably a case of malignant disease of the body of
the uterus. She went away and returned after six months
time with the report that she had been bleeding con-
tinuously all that time. He removed by curettage a con-
siderable amount of material and sent to the pathologist
who reported it to be adenocarcinoma. The uterus was
removed and the subsequent progress of the case was
not of special interest. The pathologist's report was
read. The second case occurred in a woman, forty-three
years old. She had menstruated up to one year ago regu-
larly. Then it became irregular. When she was sent to
the hospital five weeks ago she had been flowing continu-
ously, but not profusely, for some time. He found the
uterus to be somewhat enlarged. Upon examination of
the scrapings, and the pathologist's report that it was
malignant, an adenocarcinoma of the uterus, the uterus was
removed.

Ruptured Tubal Pregnancy. — This woman had not
escaped a period when she was seized with severe ab-
dominal pain, and when the physician saw her she was
absolutely pulseless. The diagnosis of ruptured ectopic
was made and she was removed to the hospital. Her
pain occurred at 11 o'clock in the morning; at 6 o'clock
she was pulseless and he doubted if anything could be
done. At operation the abdomen was found to be filled
with blood. The sac was extirpated and all the blood
was removed. The abdomen was full of blood, even
filling the spaces under the diaphragm and liver, and
was found in the flanks. She was flushed with six
gallons of water. The morning following the pulse was
112 and could be felt. That afternoon she began to vomit,
the abdomen became distended, the vomiting then became
continuous, and with a fecal odor, she gradually became
worse, and, that evening, the temperature was 104° ; at
midnight it was 105°, the distention became very marked
and she died. Some of the fluid contained the Bacillus
coli communis. The corpus luteum of pregnancy was found
on the side opposite to the rupture.

Dr. Howard C. T.^wlor said that he did not take the
time to wash all the blood out of the abdominal cavity and
thought that Dr. Balleray made a mistake in doing this.

Dr. Egbert H. Gr.andin thought that Dr. Balleray did the
right thing. Years ago they tried to remove all the blood
from the peritoneal cavity and prolonged the operation.
They gradually came to the conclusion that the peritoneum

could take care of itself. Dr. Balleray's case, he believed,
died from the general toxemia, chiefly intestinal. His
technique was in accord with that which was to-day fol-
lowed by all operators of experience.

Dr. Balleray believed that a certain amount of pure
blood did no harm, but bloody serum was different, and
was not disposed of so rapidly. Blood or serum did not do
much harm ; but bloody serum did.

Placenta Praevia. — Dr. Leon.^rd S. R.\u read this, the
paper of the evening. While it was true that this condi-
tion had been recognized and treated as far back as 1683,
still to-day it was dreaded, for the results were far from
gratifying. Placenta prsevia was no longer considered a
rare condition, and to-day the proportion was about one
case in 500. The statistics depended on whether they were
taken from hospitals or private practice. In the former
the cases occurred much oftener because these cases were
the ones that the practitioners were only too glad to get rid
of and to send to the hospitals. Placenta praevia was
more common now than formerly and the cause was rather
difficult to explain, especially in this country and France,
for as he said he would show later, frequent and rapidly
following labors were considered among the important
etiological factors, but to-day they did not see women who
had many children, for it was certainly an exception to
deliver a woman who had had more than two or three
children. This referred particularly to those who practised
among the better classes. Placenta praevia was usually
divided into three classes, central (total), partial (lateral),
and marginal. The central implantation was the rarest
of the three, and some even denied its existence. Of the
thirteen cases personally reported to him by Dr. Edgar,
four occurred in primiparae. Of forty cases reported by
Dr. Marx, ten were in primiparae. The lower the implan-
tation of the ovum the more likelihood of a placenta
pr.-evia. This implantation might be due either to condi-
tions in the ovum itself (Hofmeier), or changes in the
mucous membrane of the uterus. Women doing manual
work were prone to placenta praevia partly on account of
the work itself and also because the uterus did not have
a chance to undergo subinvolution, because of the early
rising from bed after delivery and immediately beginning
work, and, furthermore, because this was the class of
women who had many pregnancies at very short intervals.
He oflfered as an additional etiological factor to explain
why placenta praevias were more common to-day than
formerly : that the women of to-day so often had abortions
performed because they wanted no children shortly after
marriage, or else did not want a second one. Consequently-
they got rid of the products of conception and, as this
might happen many times, it explained to his mind why,
when they did allow pregnancy to go on to term, the case
was likely to be one of placenta praevia. .\fter treating of
the symptoms, especially hemorrhage, he considered the
diagnosis and said that on several occasions he had been
able to make a tentative diagnosis by external examination
alone, for he found on inspecting the abdomen a very
distinct depression just above the symphysis. The prog-
nosis was always grave for the child; for the woman, it
depended upon a number of conditions. It also depended
upon the method of delivery adopted. Dr. Edgar sent him
a report of thirteen cases with two maternal deaths ; Dr.
Marx sent a report of forty cases with four maternal deaths.
The treatment he divided into expectant and operative.
If a woman had slight bleeding in the sixth or seventh
month, which yielded at once to rest in bed, she might
be left alone with the warning that she must keep very
quiet, exercise little, and she should be instructed to
send for medical aid as soon as possible if the bleeding
again started. If the bleeding continued, one could tampon
the vagina tightly and await further developments. In
the severer forms of hemorrhage interference became im-
perative. When the cervix admitted one or two fingers
and was easilv dilatable, some recommended manual dila-

752

MEDICAL RECORD.

[May 4, 1907

taticn, version or forceps, and immediate deliverj-. This
might favor the prognosis for the child, but it increased
the danger to the mother. The temptation to hasten the
termination of labor was naturally very great, but per-
sonally he did not favor this method. He preferred to
introduce a bag, which usually stopped the hemorrhage
and caused dilatation. Then, after sufficient dilatation had
taken place, he did a version in head or transverse posi-
tions, brought down a foot, attached a weight to it, allowed
the breach to act as a tampon, and left the delivery to
nature. The results to the child might not be as brilliant
as in the rapid method, but they were infinitely better for
the mother. When this method did not control the hemor-
rhage one must then terminate the labor by immediate
delivery, and, if necessary, pack the uterus after the placenta
had come away or been extracted manually. When the
cervix was not patulous, rapid dilatation by the Harris or
Bossi dilator must be considered. Some preferred cesarean
section, vaginal, or abdominal, but it seemed questionable
to add to the patient's condition by an abdominal operation,
or the difticulty and increased bleeding during a vaginal sec-
tion. During delivery it might be necessary to stimulate
freely, or to do a transfusion or hypodermoclysis, also
to give a high enema with whiskey or brandy immedi-
ately after the delivery. In every case he gave hot douches,
a hypodermic of aseptic ergot, and made his nurse hold
the uterus for at least two hours. The after-treatment
consisted of prolonged rest in bed, no e.xcitement, etc. The
greatest aseptic precautions should.be maintained in all
cases of placenta praevia, for it was most unfortunate to
pull a woman through a difficult labor to have her suc-
cumb to sepsis. It was an open question whether they
were justified in advising a woman against becoming preg-
nant again, if she had been safely delivered of a living
child, and not allow her to take the chances of another
placenta prasvia with all the risks that this condition en-
tailed.

Dr. Clifton C. Edg.\r said he was not in accord with
Dr. Rau in his statement regarding the frequency of pla-
centa previa, for it seemed to him that it was more fre-
quent than one in 500 or 600 cases of confinement. One
to 200, or even 175, would not be out of the way. There
were many cases of accidental hemorrhage which were
really cases of marginal or lateral implantation. As to
the etiolog>', he said he was interested in the statement that
it was more frequent in those who had had frequent crimi-
nal abortions performed. Personally he knew but little
about the etiology e.xcept that it occurred more frequently
in multiparas than in primiparae. He said that Dr. Rau
had stated that he was inclined to believe that subinvolu-
tion was an etiological factor and occurred more often in
the upper than in the lower classes, because of the fre-
quency of abortions among them. iJr. Edgar was not
in accord with this view. Among the lower classes there
were no reliable statistics to show that they were more
prone to placenta prjevia than the woman of the higher
classes. In the maternity hospital these women refused
to remain in as long as they should. Any woman attended
by a midwife was usually up and at work inside of a
week. With regard to the prognosis, the condition of
the cervix determined that to a large extent. The ques-
tion should be asked: Is the fetus dead? If one could
ignore the fetus and confine the attention to the mother
alone, a better prognosis would attend. .Also, the question
should be asked: Is she a primipara or a multipara? Pla-
centa pr<evia was four times more common in the latter,
but in primiparae the prognosis was infinitely worse than
in women who had given birth to several children. These
three features in cases of placenta prfevia were very im-
portant in determining the prognosis, i.e. the condition
of the cervix, whether the fetus was living or dead, and
v\'hether the patient was a multipara or a primipara. Dr.
Edgar said he was in accord with what was stated regard-
ing the treatment. But he could not recommend the hy-

drostatic bags as Dr. Rau did. The more cases of
placenta praevia he saw the less aggressive was he as
regards treatment. The treatment depended upon that bar-
rier, the cervix. If it was partially dilated he used gauze,
which answered two or three purposes ; it changed the
cervix into a condition which admitted of easy dilatation;
it controlled hemorrhage ; and lastly, it set up uterine
contractions.

Dr. Egbert H. Grandin considered the question of
vaginal cesarean section, and said that if one could make
a positive diagnosis of placenta prsevia at or near term
the ideal operation might be cesarean section as offering
the child a better chance and not subjecting the mother
to greater risk. The diagnosis of placenta praevia was not,
as a rule, made until after one or more hemorrhages had
occurred ; then resorting to cesarean section would possi-
bly nullify the chances of the mother, and might not in-
crease the chances of the child. As to the vaginal cesarean
section there was not one logical reason why it should be
performed in cases of placenta praevia. In case where it
was a marginal or a total implantation, the cervi.x was
certainly dilatable. With regard to treatment, what he had
taught twenty-three years ago he taught to-day, and had
not changed his method of procedure. He had never used
the bags, such as the Barnes' or McLean's modification.
He saw no use in the Bossi dilator. Its use often pro-
duced what rational surgery aimed to avoid. So soon as
the diagnosis of placenta praevia was made the indications
were clear, empty the uterus with as much speed as was
consistent with maintaining the integrity of the maternal
parts. Always consider the life of the mother before that
of the child. When the cervix was dilatable, the indica-
tion was for the use of one instrument, and that instru-
ment was the hand. Dilate the cervix until the fist could
enter, then do a version. For the interest of the child
the version should be followed by rapid delivery or extrac-
tion. In primiparae, when the cervix was not dilatable, he
still used the gauze tampon, dilating the cervix up to
the internal os as much as he could ; he packed the cer\-ix
full of sterile, not iodoform gauze, and the upper part
of the vagina. Then in sixteen or twenty-four hours he
anesthetized the patient, removed the gauze, and completed
the extraction of the child. The gauze had softened and
rendered dilatable the hitherto undilatable cervix, and the
complete dilatation could then be done manually, version
performed, and a rapid extraction effected.

Dr. S. Marx was entirely in accord with Dr. Rau, al-
though he believed his subdivision was rather a compli-
cated one. He tried to teach a simpler one, dividing pla-
centa praevia into the complete and incomplete. He asked
Dr. Rau if he understood him to say that frequent abor-
tions was an etiological factor. He met with more cases
among the upper than the lower classes. Placenta praevia
was due to too frequent pregnancies and too early getting
up. It was the subinvolution which gave rise to placenta
praevia. As to prognosis in the forty cases, reports on
which he had given to Dr. Rau, the prognosis of the mother
was ten per cent. The average number of cases was one
to 500. The maternal mortality should be less than ten
per cent. If the children were viable every one was born
alive. These were the cases he had seen in consultation
practice. In over 200 cases in which he had tried to dilate
the cervix with the hand he had failed in but five. When
one used the Bossi dilator tears would certainly result in
the lower uterine zone ; tears not only in the cervix, but
clear into the broad ligament. He saw no reason for doing
a cesarean section pure and simple. In certain pathological
conditions, or in those cases associated with a contracted
pelvis, for instance, the performance of a cesarean section
was indicated, but not for the placenta praevia; it was
indicated for the accompanying condition. To-day Dr.
Marx said he was less radical than he was years ago; he
was now less active and more conservative in the treatment
of those cases.

May 4. 1907]

MEDICAL RECORD.

753

Dr. Joseph B. Cooke said that the matter of diagnosis
was one of the easiest things, and that he had frequently
made such a diagnosis over the telephone. The mere fact
that there was a bright arterial hemorrhage, without pain
or apparent cause, was enough to make the diagnosis one
of low placenta prsevia. He believed that this affection
was more frequent than generally supposed, and many so-
called miscarriages were in truth cases of placenta praevia.
The individual maternal prognosis was good, but for the
fetus was bad; the fetus was usually a premature one.
Frequently there was a malposition, or a malpresentation,
because the placenta was low in the pelvis and the child
could not assume its proper normal position. As to safe-
guarding the fetus the mother's life should be considered
before that of the fetus. He believed that placenta prsevia
was as much an ectopic pregnancy as was a tubal preg-
nancy, and the duty was to ignore the fetus and deliver
the mother. After delivery he invariably packed the uterus
because of the possible bleeding from the lower uterine
sinuses.

Dr. Rau closed the discussion. He said he was opposed
to the cesarean section, through either the abdomen or the
vagina. He had had no experience with the Bossi dilator
to any extent. For many years he had used the method
of manual dilatation and rapid extraction of the child,
but only lately had he become afraid of that method;
such a method subjected the mother to greater risk, the
risk of a severe tear. As to bright, red blood in the diag-
nosis of placenta praevia, this occurred also in cases of
premature detachment of the placenta, and this was not a
placenta previa.

Dr. Cooke replied that what he said was "bright arterial
blood, without pain or apparent cause."

Dr. Edgar said he intended to say that the Bossi dilator
had a place in the treatment of these cases.

Pathological Society of Philadelphia.

.•\t a stated meeting held April 10, Dr. B. A. Thomas ex-
hibited two specimens of gangrene of the foot, one of which
was secondary to thrombosis of the popliteal artery and the
other to proliferative endarteritis. The first specimen was
obtained by amputation from a man in whom the operation
of Matas for the relief of a femoral aneurysm was per-
formed. The second specimen was obtained following sur-
gical removal for the relief of the results of vascular
occlusion due to senile endarteritis. Recovery ensued in
both instances. Dr. Joseph McFarland presented a speci-
men of multiple echinococcus cyst of the gluteus maximus
muscle. The cyst was obtained in the dissecting room from
the body of a colored woman between thirty and forty
years old, concerning whom the only thing that could be
learned was that she was a native born American. Many
daughter-cysts were present but booklets could not be found.
Dr. Alfred Gordon presented a specimen of tuberculoma of
the spinal cord. The patient had been a colored individual
who had presented paralysis of three extremities, with
paresis of the fourth, and abolition of the reflexes, but for
the last few weeks of life entirely free from pain. After
death a tumor was discovered arising from the seventh
cervical vertebra and invading the dura and pia and the
cord. In addition to the direct involvement of the cord
there was the usual ascending and descending degeneration.
Histological examination disclosed the structure of a tuber-
culoma. Dr. Aller G. Ellis presented a communication en-
titled "Accessory Pancreas." He referred to the relative
rarity of this condition and he reported two cases under hi';
personal observation. In one of these the supernumerary
structure was situated in the hilus of the spleen and in the
other within the walls of the stomach. The latter pancreas
was undergoing adenocarcinomatous transformation. Dr.
Leo Loeb read a communication entitled "Further Observa-
tions on the Endemic Occurrence of Cancer, and on the
Inoculability of Tumors." He presented a judicial analysis

of the reports that have been made as to the etiology and
inoculability of malignant growths, and he cited observa-
tions of his own made during a period of eight years or
more. He pointed out that certain animals exliibit a definite
susceptibility to certain forms of new growth, both spon-
taneously and by inoculation, and he showed how some
degree of immunity and some therapeutic effect could be
brought about by inoculation and by other means. He
thought that there must be something in the character of
the growth and something inherent in the subject that de-
termined the question of inoculability He had no
final opinion as to the fundamental etiological fac'
tor in malignant diseases. For him the entire
subject must be studied from the purely biologi-
cal standpoint, and any practical results from such a
study must be awaited with patience. Dr. John B. Deaver
said that, as a surgeon, he took all precautions against in-
oculation and infection in operating on cases of malignant
disease. Dr. Allen J. Smith contended that it was not
necessary to look for extraneous parasites in a study of
the etiology of malignant disease, but that this may be
found to reside in the cells of the neoplasm itself. Dr.
Ernest Laplace discussed the part played by the Micro-
coccus neoformans in the etiology of carcinoma and the
utility of a serum obtained from cultures of that micro-
organism. In his own experience he had obtained only
negative results from the employment of the serum. Dr.
Jos. McFarland pointed out that the question of the inocu-
lability of carcinoma has already been discussed for many
years. He spoke of various observations on this subject and
said that his own studies had led him to believe that trans-
plantation from one person or animal to a healthy person
or animal is not common and that the existence of a new
growth rather predisposes to the readiness of reinoculation,
accidental or experimental.

Philadelphia County Medical Society.

At a stated meeting held .^pril 10, Dr. Chas. W. Burr pre-
sented a communication entitled "Paranoia: Its Varieties
and Medicolegal Importance." He pointed out the diffi-
culties in the way of a satisfactory classification of the
different forms of insanity and showed the great diversity
of opinion as to the exact limitations of the disorder desig-
nated paranoia. He contended that insanity results from
forces operating without the body of the affected individual
or arising from inherent conditions, and especially hered-
itary influences. Tlie paranoiac is the descendant of an
abnormal ancestor. His striking feature is his pronounced
egotism. He considers himself different from and superior
to his fellows, and he is likely to be boastful and vainglori-
ous. He is, moreover, extremely suspicious. He is deficient
in moral sense and is likely to be a se.xual pervert. His
promises and his hopes fail of realization and his career is
always one of unsuccess. He may appear to possess good
reasoning power, but his premises often are false, .^t times
the disorder is so little marked as to escape detection at a
single observation, but more protracted and more frequent
scrutiny will disclose the earmarks of the disease. Dr.
Robert H. Chase read a paper entitled "Insanity: A De-
fense in Homicide." In order to obviate the conflict of
expert testimony so frequently observed in trials for mur-
der. Dr. Chase suggested the appointment of a State Board
or committee to pass upon the qualifications and fitness of
would-be experts in insanity. Dr. Chas. K. Mills con-
tended that under prevailing conditions it is doubtful if
any deviation from the present method of presenting ex-
pert evidence would be an actual improvement. Dr. Francis
X. Dercum emphasized the distinction between paranoia
and paranoid states. The discussion was further partici-
pated in by Drs. John B. Chapin and .Alfred Gordon, who
spoke of the problems involved in the classification of in-
sanity from the forensic standpoint.

754

MEDICAL RECORD.

[May 4, 1907

Medical Jurisprudence Society of Philadelphia.

At a stated meeting held April 12, Dr. Arnold Lorand of
Carlsbad, by invitation, presented a communication entitled
"The Pathogeny of Crime." He considers crime a manifes-
tation of disease, and will power and facility of reasoning
the two most important means for its prevention in the
individual case. These forces become impaired in connec-
tion with disorders in the function of the ductless glands.
He dwelt on the mental symptoms attendant on myxedema
and exophthalmic goiter, disorders dependent on diseases of
the thyroid gland. He contended that criminal judges
should be assisted by sworn experts in diseases of the
nervous system, employed neither by the defense nor by the
prosecuting attorney, but by the government. Religious
fervor reaching to the height of superstition is one of the
causes of crime. Oiristian Science is such a superstition,
leading to manslaughter by negligence. A great curse is the
idleness of the children of the rich. Criminals should be
treated as if diseased mentally, and they should be placed
at hard work, preferably in the open air.

The Treatment of Acute Suppurative Conditions by
Bier's Method. — Kaefer praises Bier's congestion
method very highly, and states that he has found it of
value in a great variety of inflammatory conditions. One
application of the principle of hyperemia to which he
attaches great value is in the treatment of operation
wounds. At the first signs of infection, such as redness or
pain, the hyperemia is induced, by bandaging if an extrem-
ity is involved, or by suction apparatus if the wound is on
the trunk, instead of following the customary plan of
removing the stitches. The latter procedure usually can be
avoided entirely in this way and the threatened infection
be staved off so that healing by first intention is secured.
The plan has been found especially useful in dealing with
amputations of fingers on the necessarily very dirty hands
of factory operatives. — Zcniralhlatt fi'ir Chirurgic.

Congenital Malformations and Transposition of the
Viscera. — Garrod and L.ingmead have recently had this
case under their care. The patient was a girl nine months
old. She was brought to the hospital suffering from se-
vere constipation. Her general condition was poor. On
the day following birth she was operated on for imperfor-
ate anus. The child had the appearance of an idiot of
the Mongolian type. Physical examination showed that
the heart was on the right and the liver on the left side.
This was confirmed by the ;r-ray. Autopsy showed that
the heart was not only displaced, but that it was also de-
formed. There was persistence of Botallo's foramen, the
interventricular septum was incomplete, and the arterial
channel was permeable. The superior lobe of the right
lung was absent. Garrod has often remarked the coinci-
dence of the transposition of viscera with malformations,
and a special conformation of the head relating to the
Mongoli;in type. — La Presse Medicate.

Uterine Inversion. — Pinard reports the case of a mul-
tipara who was delivered with forceps. Uterine inversion
followed, which was reduced by the hand of the ac-
coucheur. The fourth day, as the patient was at stool, the
inversion occurred again. At this time a Champetier de
Ribes bag was applied and the uterus was replaced.
Pinard insists upon the rarity of spontaneous uterine in-
version. This condition is most often due to violent trac-
tions on the cord. Nevertheless there are other causes.
h. case was observed by Queirel in which the placenta was
inserted on the fundus of the uterus. At other times this
catastrophe occurs from uterine inertia, which is sometimes
primary and sometimes secondary. In recent cases repo-
sition may generally be obtained by the hand of the phy-
sician. In cases not amenable to this treatment the Cham-
petier de Ribes bag is a wonderful instrument. — Le Bulle-
tin Medical.

While the Medical Record is pleased to receive all new
publications which may be sent to it, and an acknowledg-
ment zvill be promptly made of their receipt under this
heading, it must be with the distinct understanding that its
necessities are such that it cannot be considered under
obligation to notice or review any publication received by it
which in the judgment of its editor will not be of interest
to its readers.

EiNFUHRUNG IN DIE GeRICHTLICHE MeDIZIN FUR PrAK-

TiscHE Kriminalisten. Vier Vortrage von Dr. Hugo
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A Compend on Bacteriology. By Robert L. Pitfield,
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Son & Co., Philadelphia.

Essentials of Obstetrics. By Charles Jewett, A.M.,
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A Pocket Formulary. By E. Quin Thornton, M.D.
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Medical Diagnosis, A Manual for STUbENTS and Prac-
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A Study of the Human Blood- Vessels. By Arthur
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Diseases of the Lungs. By Robert H. Babcock, A.M.,
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Trans.\ctions of the American Gynecological Societv,
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A Textbook of Ophthalmic Operations. By Harold
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Polypus of the Nose. By Eugene S. Yonge, M.D.
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Tumors Innocent and Malignant. By J. Bland-Sut-
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The Johns Hopkins Hospital Reports, Vol. XIIL 4to,
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Alcohol, the Sanction for Its Use. By Dr. J. Starke.
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Maladies de la Nutrition. Par H. Richardiere et J. A.
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May 4, 1907]

MEDICAL RECORD.

755

Nfui d/ustrumfitts.

A NEW GAS-ETHER INHALER.

Bv HENRY D.WVSON FURNISS. M.D..

NEW YORK.

INSTRUCTOR I.N GYNECOLOGV, NEW YORK POST GRADUATE SCHOOL AND
HOSPITAL.

The instrument consists of three portions : neck
piece, to which the rubber bag for the nitrous oxide
is attached: the ether chamber, and the face piece..

Fig.

The neck piece is so constructed that when the
slot on the top is open the passage to the gas bag is
closed by a window shutter. Distal to this is a valve
on a seat like the damper to a stove. This valve
opens on inspiration, closes on e-xpiration, and is out
of play when the valve seat is thrown into the long

outer portion of the inhaler. For this fastening ar-
rangement I am indebted to Mr. Sorensen of the
Kny-Sheerer Company. Reference to the outline
cut will show the construction better than any
words. The figure to the left shows the instrument
in the position for gas inhalation ; that to the right
when it is set for ether. It is clearly seen how the
gas is conducted around the side of the inhaler bv
means of the tube "D." "C" is a metal cap soldered
over an opening cut in the inner revolving portion
of the ether chamber. The dotted line represents a
U'ire cage, which is so constructed that it is
separated from the wall of the inhaler one-
eighth inch to allow of the free passage of air
around it. This cage is to be packed with
gauze or sponge. The cap on the side of the
inhaler is for the opening and closing of the
hole through wliich ether is to be poured on
the gauze.

The face piece has a valve that opens on ex-
piration, closes on inspiration, and which is
out of commission when the fenestrated cap
covering it is closed. \Mien this valve and the
one on the neck piece are both in plav the pa-
tient receives undiluted gas; when both are
thrown out the patient breathes to and fro into
the rubber bag. .A.cross the middle of the face
piece is placed a wire screen, the use of which
is given below.

The connections between the different por-
tions of the inhaler are made by slip joints,
which is easier to manipulate, less liable to
injury, and just as efficient as screw joints.
The neck piece is so constructed that it can be
joined directly to the face piece when it is de-
sired to administer nitrous oxide alone, all the
necessary valves being contained in these two
portions.

_ It was due to the inability to keep some robust
mdividuals under the influence of ether with one of
the popular gas-ether inhalers that this inhaler was
devised. The defect to be overcome was the inade-
quate capacity of the ether chamber. Realizing that
this would have to be overcome by ridding the
inhaler of any tubes passing through 'it, the idea of
having the gas passage on the outside was hit upon.
This advantage made possible another, a very large
opening into the bottom of the ether chamber, which

a.xis of the tube by turning the pointer to "to and
tro." When the valve is not working air passes
freely in either direction.

The ether chamber consists of two portions, the
one fitting within the other, and revolving through
about 60°. They are locked together by means of a
pin that passes under a collar into the slot cut in the

in this inhaler has an area three times as great as
that of some of the most popular models now offered
the profession. These inprovements have been made
without complicating, but rather simplifying the in-
strument.

The space above the wire screen in the face piece
can be packed with gauze or sponge when it is de-
sired to use this as au.xiliary ether space, or when
the drop method of administration is desired. This
part of the instrument also makes a very desirable
chloroform mask.

30? West End .Avenue.

756

MEDICAL RECORD.

[May 4, 1907

Contagious Diseases— Weekly Statement.— Report ot
cases and deaths from coiiiagious disease reported to the
Sanitary Bureau, Ileahh Department, New York City, for
the weeks ending April 20 and 2", 190/ :

Tuberculosis Pulmonalis

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough .■•;■•
Cerebrospinal Meningitis
Malarial Fever

Tv^tals

Week of

■\pril 20

Cases

Deaths

401

210

331

40

411

8

47S

27

2

—

64

—

lOO

13

66

II

15

20

1 863

329

Week of April 27
Cases Deaths

407
339
477
534
I

96'
100

60 1

20'|

227

39

I"

26

I

iS
II

Health Reports. -The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital
Service, during the week ended April 26, 1907:

SMALLPOX — UNITED STATES.

CASES. DEATHS.

California, Los Angeles Mar- 3 i-Apr 13. • . ■ «

District of Columbia. Washington. .Apr. 13-ao i

Florida: Duval County, Jackson-
ville Apr. 0-13 I ■

Hillsboro County — Tampa

and Port Tampa Apr. 6-20.. .

Polk County Apr. 0-20...

Santa Rosa County Apr. &-20.. .

Illinois: Chicago Apr. 13-20..

Galesburg Apr. 6-20.. .

Indiana: Elkhart Apr. 0-20...

Indianapolis Apr. 14 21. •

" La Fayette Apr. 8-15.. .

" ~ South Dend Apr. 6-20.. .

Iowa. Davenport Apr. o-is-- •

Kentucky. LouisWlle Apr. ii-i»..

Louisiana. xNciv Orleans Apr. b-20.. .

2034

14
8

16
I
3
0

s

(4 cases imported)

Phlebosclerosis. — Agostino Carducci has studied the
occurrence of sclerosis of the veins and the clinical symp-
toms arising from the condition in eighteen cases, of which
he gives us the histories. These changes in the veins are
manifested by diminution in the caliber of the vein and
absence of any coagulations in the vessels. There is a pro-
liferation of the intima without any tendency to regressive
alterations. It is more frequent in the subjects of arterio-
iclerosis, tuberculosis, malignant tumors, and malarial
cachexia. There is no definite knowledge of the pathogen-
esis of this condition. It has no particular symptomatic
syndromes, the functional results being inconstant. It may
be diagnosed when it attacks the superficial veins, but not
in the deep veins. It must be diagnosticated from spasm
of the veins and from thrombosis. Prognosis is good, and
tre.itment is unknown.—// Policlinico.

Significance of Hypothermia with Slow Pulse in the
Puerperium.— C. Merletti has studied the pulse curve
in about a thousand cases in the puerperium and has ob-
served that whenever there is an infective process of the
genitals, no matter what the location or the severity of
the process, the pulse rate rises in proportion to the rise
of temperature. On the other hand there are cases in
which with a rise of temperature there is no increase of
pulse rate, or it is even lower than normal ; in none of
these cases is there any sign of genital affection, and the
fever goes down without any treatment for the genitals.
There is also no alteration in quality, such as dichrotism, in
these cases, as is found in ordinary febrile affections. Such
fevers are due to gastrointestinal troubles, intercurrent
diseases, anomalies of lactation, or of the lochia, nervous
conditions, etc. The practical deduction from these facts
is that in cases in which with the rise of fever the pulse
remains normal we should abstain from treatment of the
genitals. — La Riforma Mcdka.

The Prevention of Puerperal Mastitis.— Doderlein
states that a solution of iiuiia rubber in benzine, to
which I per cent, of formalin is added, can be used as
a local application to prevent the formation of minute
fissures about the nipples of nursing women. The en-
tire nipple is painted with this solution and as soon as-
the benzine evaporates a little sterile talcum powder is
sprinkled over the area treated. In this way a delicate
membrane is formed which occludes the lacteal ducts,
but the first time the infant nurses the act of suction
perforates the thin layer of rubber over the mouth of
each duct. The nipple remains protected against all in-
fection or abrasion, however, and in the 200 cases in
which Doderlein has employed the method he has
found it an extremely valuable prophylactic against
mastitis. The applications are repeated every two or
three days and by this means it is stated that the dis-
comfort of nursing due to tender nipples is very greatly
alleviated.— t:(?)!«ra;67o(f fiir Gynakologie.

•" Shreveport Apr- 6-13

.Massachusetts, Chelsea Apr. 6-20

I , ^ Lawrence Apr. 6-20

Michigan. Detroit Apr. 13-20

Saginaw Apr. ^-^o

Minnesota, Stillwater Mar- 1-31

Winona -'J-Pr- 6-20

Missouri, St. Jcseph Apr. 6-20

St. Louis Apr. 13-20

New York, New York Apr. 6-20

North Carolina, G eensboro Apr. &-20.. . . ... .

Ohio, Toledo ^ =«■■ ^^Apr. 20. .

South Carolina. Charleston -Mar. 1-3 1

Texas, Corpus Christi Apr. '3'-: •••••■■

Houston Mar. 30-Apr. 13. .

Laredo Apr. 13

3
3

4
17

3
3
7
S

18

16-30..
16-30..

Utah, Ogden *'"• »-3i

Washington, Spokane Apr. 6-13

Wisconsin, La Crosse Apr. o-is-- • • • ■ •

Milwaukee Mar. 30-Apr. 20.

SMALLPOX — FOREIGN.

Brazil, Bahia J{ar- 0-f3

p^j.^ Mar. 16-31

Pemambuco.V Feb. 15-28

Rio de Janeiro Mar. 10-31

Canada. Sherbrooke Apr. 13-20 ■ • ■

Italv, General "af ^^-Apr. 4. .

Naples Jar. 23-Apr. 13

Turin Mar- ^6-ii

Luxemburg Jar. 9-3°-- - ,'

Madeira. Funchal Mar- "^AP^- 7-

Mexico. Aguas Calientes Mar. 31-Apr. 13

Mexico City Mar. g-23

Monterey Apr. 7-14. ■ ■ - ■ •

Kogales Mar- 2- Apr. 6 .

Portugal. Lisbon Mar. 29-Apr. 6

Russia, Moscow Mar-
Odessa Mar.

Riga Mar- 'i-^"--

St. Petersburg Mar. 16 23. . .

Warsaw Mar. 16-23...

Siberia. Vladivostok Feb. ^^f--

Spain. Barcelona Mar. i6-Apr.

Cadiz Mar. i-3i-..

Cartagena Mar. 23-30.. .

Se\-ille Mar- i-3i.. . ■

Valencia Mar. 23-.'^pr.

Syri.a. Damascus Mar. 9-30.. . .

Switzerland, Geneva Mar. 23-30- -

YELLOW FEVER.

Brazil Manao Mar. ^^'i--

Para Mar. 16-31...

Riode Janeiro Mar. 17-24.-

Ecuador. Guayaquil. . . . . -Mar. 16-30..

Westjndies. Tnnidad-Port of^^^^ ^^__^^_^

CHOLERA.

Bombay Mar- 10-26

Calcutta Mar-
Madras Mar-
Rangoon -"ar.

PLAGUE INSULAR.

Honolulu Apr. 19-23

PLAGUE — FOREIGN.

Japan. Formosa Mar. 16-23

t)— Callao Mar. o

Chepen Mar- U-- • •

Chiclayo Mar. T-iS--

Eten Mar. 7-13.-

MoUerido Mar. 13

(Imported from Mexico)

6
7

5
7
0

18

3

18
24

India,

Hawaii.

Peru,

62
5

Present

4

>5

10-
2-16...
19-23..
0-16..

98

p^{fa Mar. 7—

San Pedro an.i Pacasimayo. .Mar. 13.

Trujillo Ma.-- 7-

Str.aits Settlements, Singapore Mar. ?-■

Russia, Cronstadt Mar. 20.

(Imported from Areqmpa)

iR

(At Laboratorv' of
Imperial Institute"'

PI.AGVE — FOREIGN.

Brazil. Para Mar. 16-31

Pemambuco feo. 4-20

Rio de Janeiro Mar. 10-31

Chile. .A.ntofag.-ista Mar. '6-23.. . . .

Santiago Feb. 23-Mar. 2.

China. Hongkong Mar. 2-9

Eei'Dt, .\ssiout Province -Mar. 23-27

Girgch Pro-.-ince Mar. 23-25

Kenek Pro\'ince Mar. 20-27

India. General Mar. ,o-.6 5S.099

Bombav Mar. 19-26 6,.,

Calcutta Mar. 2-J6

Rangoon Mar. o-t6

9
42

27

23
24

20

49.440
152

72

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 71, No. 19.
Whole No. 1905.

New York, May i i, 1907.

$5.00 Per Annum.
Single Copies, lOc.

©rtgtnal Artirks.

A DISTURBANCE OF VISION DUE TO EX-
AGGERATION OF BINOCULAR
ASSOCIATION.*

By PIERRE JANET, M.D.,

PARIS
PROFESSOR OF PSYCHOLOGV IN THE UNMVERSITV OF PRANCE.

In replying to the courteous invitation of the New
York Neurological Society, by which I feel myself
greatly honored, I wish to present briefly a rather
curious case which, in my opinion, shows well the
value of the studv of pathological psychology
for the understanding and oftentimes for the treat-
ment of nervous diseases. t First allow me to review
the previous historv- of the patient, without which
it would not be possible to understand the partic-
ular condition which we wish to study.

The patient, Mme. Z., now sixty-five years of
age, has always been a very neurasthenic person.
She has shown during her entire life a series of man-
ifestations of a characteristically hysterical nature.
Overwhelmed at the age of fourteen years by a
violent shock following the accidental death of her
sister, she lost the use of her limbs and remained
paralyzed for a year. Since that time she has had,
successively or simultaneously, hysterical attacks
with catalepsy, disturbances of speech, contraction
of the neck, spasms of the right arm. various ]jains
affecting the fingers, the nape of the neck, the
tongue, and varied paralyses. The last well-defined
occurrences of this kind took place at about the age
of fifty years. At that time she still had some slight
crises of uncontrollable logorrhea, a last remnant of
the old somnambulism. Since that time the strictly
hysterical conditions have yielded to phenomena of
another nature of which we need not here discuss
the pathogeny.

Three years ago. after some pronounced svmj.itoms.
she was attacked by disseminated retinal hemorrhages
in both eyes. M. the close of a few weeks the hem-
orrhage, which had not been very severe on that side,
had entirely disappeared in the right eye, leaving,
as Dr. \'alude had reported, only some points of
insignificant sclerosis in the outer part of the retina
incapable of disturbing vision. On the other hand,
the ophthalmologist noticed from the outset very
abundant punctiform hemorrhages in the left eye,
with marked localization near the macula. As a re-
sult the left eye recovered onlv a little visual power,
but for a short time, and that was defii'iitely effaced
by the progress of sclerosis, so much so that at the
end of two months the vision was completelv lost in
the left eye and almost wholly restored in the right
eye. At that time, however, disturbances bes^an

*Read before the New York Neurological Societ}',
November 28, 1906.

tThe more comolete details of the eye conditions <if this
patient were published in the Annalcs d'Ocitlistiquc. July,
190,?- I have here dwelt only upon the interesting psyclio-
logical manifestations.

which progressed continuously. The patient com-
plained of experiencing in her left eye phe-
nomena of light — "streaks of fire, flashes, Roman
candles," and these flashes were accompanied by vio-
lent pains which graduallv developed to an incred-
ible degree. This intolerable conilition lasted more
than a year. Finally, in a consultation between Dr.
N'alude and Dr. Dufour of Lousanne it was decided
that the absolutely useless left eye ought to be sac-
rificed, since it had not the slightest vision and was
only a cause of optic nerve irritation. Enucleation,
which the patient did not wish at any cost, did not
seem indispensable, and it was decided to limit our
interference to section of the optic nerve, an opera-
tion which had already been advised by von Graefe
in like circumstances. The operation was performed
by Dr. Valude and was successful. When the
dressings w-ere removed it was seen that the left
eye had admirably preserved its vitality and pre-
sented an absolutely normal appearance. However,
the movements of the eye were seriously disturbed.
To reach the optic nerve one is obliged to section
the external rectus, wdiich is sutured after the opera-
tion. Perhaps the point of the scissors slightly cut
the internal rectus. After the operation the eye ro-
tated strongly to the outer ane'ie. Later it took
on more motion and could turn strongly to the
right side, when the patient made an effort, but
even then the movements were not entirely recov-
ered, and there remained a certain amount of di-
vergent strabismus. The right e\e had suft'ered not
at all. either from the operation or its results. When
the dressings were removed, it was found to be nor-
mal, and a cursory e.xamination showed that vision
was preserved. The visual acuity was .good, the
field of vision was very wide, almost normal, scarcely
affected by the original hemorrhage, and colors
were well distinguished. It was thought that the
patient coifld henceforth use that eye and, being no
longer troubled by pains in the left eye, would see
correctly.

But now commenced the peculiar disturbance of
vision which developed following the operation and
which has given rise to my psychological researches.
Mme. Z. saw correctly at the first glance, but she
complained that she was unable to profit by that
vision, for she said that there was before her a
strange cloud, always in motion, which hid from her
the appearance of the objects looked at. In vain
she made every effort to fix an object, to follow
a line. The vision was disturbed by this moving
cloud and it was impossible for her to see anything
with accuracy. Not only was reading impossible,
but the vision of objects in the room was so dif-
ficult that the patient had trouble in moving about.
Moreover, this moving cloud soon caused vertigo
and nausea, so much so that to recover her normal
condition it was necessary to close the eyes. In a
word, the patient was without doubt delivered from
pains which had tortured her previously, but she
complained of not having made any progress, for

758

MEDICAL RECORD.

[May II, 1907

she considered herself still more incapable of help-
ing- herself with her rig-ht eye. These peculiar
troubles continued to increase for almost a year
without any apparent progress, and the despondency
of this very neurasthenic patient still further ag-gra-
vated her previous troubles.

Evidently phenomena of this kind deserve to be
called nervous disorders of vision and, given the
symptoms which the patient had presented up to
the age of fifty, one would naturally speak of a hys-
terical condition. However, it is scarcely possible
to admit ordinary hysterical amblyopia, when one
recalls that the vision of the right eye seemed nor-
mal at the time of the medical examination, that its
acuity is almost normal, that there is no disturb-
ance of color vision, that the visual field is almost as
extended as that of a normal eye. Any existing:
hysterical disorder must be of a very peculiar nature.
In order to discover the trouble it is necessary to
analvze the circumstances in which vision is es-
pecially found to be altered, and the conditions if
such exist, in which the trouble diminishes and in
which vision is found to be momentarily re-
stored. \'ision is preserved only at the first in-
stant under one condition ; it is that the patient
limits herself to describing the object placed be-
fore her, whatever it may be. without herself choos-
ing it. As soon as she attempts to fix any thing or
to accommodate, the trouble begins. Mme. Z. is
able to read letters or words off-hand in a book
opened before her, but everything is immediately
invaded by the brilliant cloud. If she seeks to fol-
low a line with her eyes, the more she attempts to
look with fixedness and attention the more the visual
troubles appear to increase. The circumstances
which directly or by association evoke the superior
functions of vision are the occasion of the visual
trouble.

On the other hand, it is necessan,- to note a rather
large number of somewhat peculiar conditions under
which the trouble, if not suppressed, is at least re-
duced. It was observed that at the instant of open-
ing the eyes vague vision, without choice and with-
out fixation effort, was fairly well preserved. In the
morning at the moment of waking, while she was
still half asleep, Mme. Z. noticed that she saw well.
A peculiar lighting, a chance position, sometimes
brings on a sudden change and for some moments
she is astonished to see as heretofore, but that vision
is short, and the patient does not know what to do
to recover it. She seems to have observed that it
is necessary to receive the light upon the left side
of the face in such a manner that the shadow of her
nose, which is rather large, completely protects her
right eye. She desires a very tight bandage over her
left eve or she tries to press it strongly with her
fingers, but as soon as the eye escapes and begins
to move again a mass of brilliant clouds comes to
obscure the visual field. These few observations
seemed to show that the right eye was capable of
seeing whenever it was disassociated from the
left eye and that the intervention of the left eye,
although blind, was the origin of the trouble. To
verif}- this I tried some experiments in which
the monocular vision of the right eye was brought
out still more clearly. Here is a peculiar one. Alme.
Z. was formerly accustomed to shoot with a pistol
and could aim with the right eye. I have asked
her in holding the pistol, or even a simple piece of
wood, to repeat the effort of aiming. To her great
surprise she then saw perfectly well the object
aimed at. without clouds, etc. In another experiment
I made her look through a field glass and she then

saw objects at a distance perfectly. I took a mi-
croscope to her and she was able to use it and de-
scribe preparations. At last I made her look
simply through tubes of paper and by this very
simple means she became able to read without dif-
ficulty. Hence we have a collection of facts which
seem to show us that the trouble in sight disappears
when we suppress the association of the two eyes.
How are the preceding phenomena to be inter-
preted ? Here is an explanation that I offer you for
at least a working hypothesis. It is said that there
exist in man two different visions, binocular vision
with convergence, and monocular vision in which the
two eyes functionate independently of each other,
but one is not disposed to speak ordinarily of these
two visions when there exists but a single eye. At
first one thinks that a one-eyed person can have only
monocular vision. This is probably true for those
who lose an eye in early infancy, but those who
become blind as adults -^reserve the cerebral mechan-
ism of binocular vision in all conditions in which
that vision is used ordinarily, and they use only the
cerebral mechanism of monocular vision in unusual
conditions. Ordinarily the preservation of that as-
sociation of the two eyes scarcely annoys them, per-
haps because the subject troubles himself little about
the incorrect movements of the blind eve. It is likely
that Mme. Z., in spite of the section of her left optic
nerve, every time that she is wide awake, or that
she pays attention, or that she attempts to follow a
line, still tries to use binocular vision. She still at-
tempts to make the two eyes converge, to accommo-
date both in the same manner, and she does not
limit herself in doing the work of fixation and ac-
commodation to the right eye only.

What is the cause of this obstinacy, as it were, in
using binocular vision in spite of the loss of one
eye? One might say at first that it is one of the
fijced ideas, or, if one chooses, one of those fixed
psychological states such as we see continually in
the hysterical. It may be added that Mme. Z., old
and neurasthenic, is less able than another to change
her visual habits and to adapt herself to a new situ-
ation which demands a new action of her visual per-
ception. This is the one important reason why the
patient perseveres in her search after binocular
vision. Binocular vision, however, has become en-
tirely impossible, for not only is the left eye blind,
but the movements themselves cannot be accom-
plished as in the right eye. It has been seen that the
operation has left a divergent strabismus. It has
also been noted that the pupil, which has only slight
mobility, does not give correctly the consensual re-
flex, i am disposed to believe that it is this con-
sciousness, more or less confused by the defect of
convergence and by the defect of accommodation in
the left eye, which, in a subject who is very neu-
rasthenic and obstinate in seeking to obtain an im-
possible binocular vision, causes trouble in the fixa-
tion and accommodation of the right eye.

Some therapeutic experiments bring an interest-
ing verification of these hypotheses regarding the
pathogeny. I have attempted to submit the patient
to a reeducation of vision by taking as a point of
departure, as one must do in these reeducations, that
part of the function still remaining. Here the vision
remaining is the monocular vision under certain def-
inite conditions. I wished to force the patient to
develop monocular vision by placing her under con-
ditions which called for it. I had made for Mme.
Z. a pair of peculiar glasses. Upon the frame of the
right eve was set a little metallic tube as large as
the orbit and five centimeters in depth. Through

May II, 1907]

MEDICAL RECORD.

759

this tube the patient easily obtained distinct vision.
When she became a httle more used to it, I had the
deoth of the tube reduced, as it became unnecessary
in the outer part, until it had a depth of not more
than a centimeter and a half in the inner part.
Thus reduced, the tube did not necessarily give
monocular vision, but it acted as a stimulus to
cause favorable conditions to obtain that vision
which was already used in the tube of a field glass
or in aiming with a pistol. This very short tube, or
rather this little rim, placed in the inner angle of
the eye suffices not only for the patient to guide her-
self, but for her to read easily for more than an
hour.

I hope that, little by little, in spite of the age of
the patient and in spite of her neurasthenic past,
the habit of monocular vision may develop and
that it may even take place in the absence of all
special apparatus.

The treatment of nervous troubles, as has been
said, very often consists in reeducation, but it is
necessary to determine accurately through psycho-
logical analysis the factor on which this reeduca-
tion must work.

APPENDICITIS IN INFANTS AND CHIL-
DREN.*

WITH A STATISTICAL ABSTRACT OF ONE HUNDRED
CASES OPERATED ON IN FIVT: YEARS.

By JOHN F. ERDMANN, M.D.

■ NEW YORK.

CLINICAL PROFESSOR OF SURGERY. UNIVERSITY .\ND BELLEVUE HOSPITAL
MEDICAL COLLEGE.

The difficulties in making a diagnosis of appendi-
citis in occasional adult patients, even with all scien-
tific aids added to a well-developed history, are
greatly multiplied in infants and children who are
unable to express themselves, or in whom there is,
from a sense of fear, a distinct reticence in giving
up such factors as are great aids in reaching a sat-
isfactory conclusion. In addition, in infants the
many gastrointestinal complaints which they may
be subject to cloud our reasoning, and thereby
delay our diagnosis.

Of the factors in obscuring our diagnostic acumen
are the teachings that meats, etc., substances of
diet that the young and adult take, are causative
factors in the production of this disease, and there-
fore that a milk baby cannot have it, and that an
appendicitis is an exception in certain tribes of the
Orient who subsist on vegetation only. Such teach-
ings, especially when given by observers of note,
must of necessity place appendicitis in infants (milk-
fed subjects ) as a rarity rather than as an occasional
disease. Nevertlieless, this disease does exist in
the milk and prepared food infants frequently
enough to give us cause for alarm when seeing in-
fants or children under three years of age suffer-
ing from abdominal pains, distention, etc.

Kermisson, in the Revue de Chinirgie, p. 2042,
1906. abstracted in the Journal of the American
Medical Association. December 22, 1906, reports a
case in an infant eleven months old, and says he
has found reports of twenty-five under two years,
nine of which were under twelve months. Of this
number (twenty-six) nineteen died and seven re-
covered, appendectomy having been done in nine-

* Read before the East Side Physicians' .'\ssociation.
New York City. February 15. IQO" ; and the Bridgeport
Medical .Association, Bridgeport, Conn., March 5, 1907.

teen cases, with a mortality of twelve, seven deaths
being in those under twelve months. Conclusions
cannot be drawn from this great mortality, as he
further states that only those operated upon at once
recovered.

I have recently operated on a patient twenty-one
months old, in the second day of the disease, finding
a concretion one and a half inches long by about
three-fourths of an inch wide in a perforated and
gangrenous appendix, with general suppurative peri-
tonitis, with a fatal termination in twenty-six hours.
One thing is apparent, and that is the rapidity of
intoxication due to the spreading of the peritoneal
invasion in these cases, and the inarked lessening
of resistance in the patients under three years.

Kermisson further states that no meat had been
given in any one of the cases cited in his paper, and
thereby disposes to a great degree of the argument
that meat is a factor in the production of the dis-
ease; but he also states that in twelve of the cases
in which the particulars were known all except three
were bottle babies. It would appear to me that at
present we cannot lay stress upon any particular
food articles as being productive of this disease,
and whether food preservatives, such as boric acid,
etc., have any weight in the consideration of the
cause, I am not prepared to say.

To diminish the great mortality in appendicitis
occurring in infants under three years, we must first
recognize that this disease is an established fact,
even in breast-fed babies. Then we must improve
our diagnostic sense by summarizing such symp-
toms in infants as have been shown to be accom-
panied by appendicitis, and finally to insist upon
early operation as we do in adults.'

It is a recognized fact by all that this disease
may be insidious in onset, and is rapid in its prog-
ress as to spreading, loss of resistance, and toxemia,
The time of descent of the cecum with its appendix
must be recognized, for frequently the appendix is
not in the abnormal site before the third or fourth
year, but lies high up, even under the costal arch,
and therefore in these cases palpation with elicita-
tion of pain in the usual site is negative, while pal-
pation in the loin or high up may be productive of
the sign we are seeking. The same may be said
of the localization with mass formation.' I have
frequently, in the series abstracted in this paper,
been compelled to reinove the appendix almost at
the lower border of the costal arch.

In arriving at a diagnosis we must consider
gastroenteritis, invagination, and obstruction due to
hernia, etc.

In gastroenteritis tiie symptoms dovetail so thor-
oughly in many instances with those of appendicitis
as to prevent a diagnosis being made before one of
the evidences, such as peritonitis, obstruction, or
mass, be present. In invagination one might mis-
take the tumor, which is usually symmetrical when
present, for an inflammatory mass, but the bloody
and mucous stools, the peculiar rhythmic cramp-like
pains, and a degree of shock not seen in appendi-
citis, all should be sufficient to make a correct diag-
nosis possible. In hernias the external lesion "is
usually present, whereas, if it be a concealed hernia,
it would be a rare diagnostician who could make a
proper differentiation.

Symptoms. — Pain, witli nausea and vomiting
either preceding or accompanying, and with follow-
ing temperature elevation, increased pulse, dif-
ference in the sense of resistance in the abdominal
wall, distention in varying degree, crving of the

760

MEDICAL RECORD.

[May II, 1907

child upon palpating' the abdomen, fitful ci^-ing and
sleep. The patients, in the majority of instances,
ward off the examinint;: hand. In an article on ap-
pendicitis in children [New York Medical Journal,
March, 1904) 1 called attention to the above sign,
stating that to me it is almost pathognomonic, as fol-
lows : "Almost invariably the little patients uncon-
sciously place their hands in the region of the ap-
pendi.x to ward off manipulation in this region."

Rectal palpation rarely is an aid in these cases.
The blood count does not help when the question
is between a low placed pneumonia and an appendi-
citis. The same applies to the painful area in low
placed pneumonia or diaphragmatic pleurisy. In
these latter diseases the movements of the costal
arch in respiration must be carefully watched.

I have found pinworms as foreign bodies in ten
patients, and in almost every instance the symptoms
were the same, and peculiar to the general cases.
There is pain, with temperature of 104° to 105° for
twenty-four hours, then a subsidence in temperature
to 99.5° to 100.5°, ^"d the pulse not accelerated;
pain diminished but present ; and then in the follow- ^
ing day or two an elevation of temperature of a de-
gree or two, without marked increase of pain.

The removed appendix is seen to be slightly con-
gested, and the interior distinctly so, with perhaps
one or more macroscopic spots of epithelial destruc-
tion, and pinworms varying in number.

Intercurrent Conditions. — I have operated twice
in cases of floating kidney, one on a girl eleven years
old, and recently on a boy fifteen years old, and
have seen a third, a girl of fourteen, with a marked
history of mild attacks, having a kidney almost in
the iliac fossa.

There was right inguinal hernia in three cases,
the operation for both conditions done through the
hernial incision. One of these cases was in a male
child, one year old, who had a strangulated hernia,
and an inflamed appendix.

Pertussis occurred in one case, that of a boy of
seven vears: gangrenous appendix; no drain; re-
covery.

One patient with an acute fulminating attack was
exposed to the sun, and a long, tedious train jour-
ney, on a hot day in August, 1905, and suffered for
three days all the symptoms of an insolation.

Strangulated ovarian cyst occurred in a girl thir-
teen years old. with recovery.

Pvosalpingitis, gonorrheal in origin, was noted
in one child five and a half years old, from whom I
removed the appendix thoroughly incorporated with
a pelvic abscess and right pyosalpinx ; also with
a distinct tuboovarian abscess of the left side. The
patient recovered.

No consideration in this series is made as to the
time of seeing cases, as all but five were acute.

The postoperative complications, barring those of
intestinal paresis from spreading peritonitis, were
in this series of cases pneumonia and subphrenic ab-
scess. Two of the deaths recorded were due to
pneumonia, and one to subphrenic abscess and ex-
haustion at the end of the sixth week. This latter
was the case in which marked evidences of insola-
tion were present for three days. One other case
of subphrenic pleurisy recovered.

The total number of cases operated upon by me
from January, 1902. was too, of which 41 had for-
eign bodies, including 10 with pinworms. Twenty-
lour had perforated, with or without general gan-
giene: 50 were gangrenous, with or without per-
fcrat n and pus. Thirty out of y^ seen since Jan-

uary, 1904, had pus, either localized or general, and
with or without gangrene and perforation, while
onlv 3 were interval cases. Thirty-seven cases were
drained.

Of the 60 cases operated upon in which the
sex is recorded in my file, 35 were male and 25 were
female.

Ninety-five cases operated upon in which I have
the actual age recorded occurred in the following
numbers, as to years : One at 1 year, one at 21
months, one at 2 years, three at 3 years, seven at 5
years, four at 6 years, ten at 7 years, seven at 8
years, eight at 9 years, nine at 10 years, fourteen at
II years, eleven at 12 years, five at 13 years, four at
14 years, and ten at 15 years.

There were seven deaths in this series, a percent-
age of seven. The following were the causes of
death ; Pneumonia, two ; subphrenic abscess, ex-
haustion, etc., one ; general suppurative peritonitis,
four. The children dying of general suppurative
peritonitis were aged 10 years, 21 months and 11J/2
years respectively : the age of the fourth was not
given. AH were in a most profound septic con-
dition ; one, 10 years old, dying within ten hours ;
the infant in twenty-six hours, and the 11 1-2 year
child, a boy ill seven days, who was cyanotic, etc.,
with an abdomen distended, as the two others had
been, dying in about eight hours. Records in the
fourth case are not definite.

While these four cases presented conditions of
profound gravity. I cannot but feel that if any
chance was to be given them it was that of operating
rapidly, with little or no great contusion of the
abdominal contents being made, and then followed
by the Murphy-Fowler-Ochsner treatment.

Although these steps were carefully carried out,
and the result no better than if no operative pro-
cedure had been instituted, a sufficient number of
cases similar in nature but not in intensity having
recovered, would still cause me to operate in like
instances.

Treatment. — I am a firm believer that once an
appendicitis has occurred the patient is always in
danger until the organ is removed, and I advise that
the patient seen in all such cases be submitted to
operation.

The usual preliminary steps that can be taken in
emergency operations should be followed. The in-
cision is either that of McBurney or Kammerer, or
that which splits the rectus, no matter whether we
feel that drainage is likelv to be necessary or not.
The McBurney is done when no mass can be felt,
or when the mass is well confined to the iliac fossae,
while the Kammerer or split rectus is used in those
cases where the mass lies more to the median line, or
down in the region of the bladder.

The incision when first made is never over two
inches long, and is more than likely to be that of
Morris, one to one and a half inches in length. As
a rule I use no gauze protecting dam, but make a
very careful finger dissection, recognizing readily
when- the rupture of the abscess, if an incUided one,
takes place. The discharge is rapidly taken up by
small sponges in forceps ; the opening into the ab-
scess cavity is gradually enlarged as the leakage
diminishes, the cavity finally wiped out with dry
gauze sponges, the appendix sought for and ad-
hesions broken up. \Mien the appendix is freed,
the usual procedure of ligating the mesoappendix
is followed, then the appendix is excised and the
stump treated in any of the following ways ; The
Dawbarn inversion method ; clamping with a strong

May II, 1907]

MEDICAL RECORD.

761

forceps, on the principle of tlie angiotribe, near the
base, cutting otf above the forceps, then inverting
the crushed stump ; and the usual method, that of
ligating the appendix at its base and cauterizing
with carbolic acid the exposed and everted mucous
membrane. Should the appendix be bound down to
other viscera so closely that freeing it would impair
the integrity of any of the surrounding organs, I
strip it out by splitting the serous and muscular
coats at some point where possible, and then shell
or strip out the mucous canal, ligating at the usnal
site. This stripping method is exceptionally easy
and can always be used in difficult adhesion cases.
Recently I stripped out an appendix seven inches
long that was followed to the cecum, which had not
descended, but lay in the site usually occupied by
the hepatic flexure of the colon.

When free pus of the serous variety is present
in the general cavity, I sponge the pelvic cavity
as dry as possible and close the wound with or with-
out drain. When gangrene of the appendix and
suspicious mesoa])pendix are present, drainage for
from twenty-four hours to the time required as
shown by the discharge, or by temperature chart,
and pulse, is done.

I do not wash the entire cavity, having given up
this method six or eight years ago, nor do I wipe
out the circumscribed abscess cavities with perox-
ide and salt solution, as formerly, but I sponge
these abscess cavities dry, and may wash out with
a salt solution sponge, and then drain or not, as ex-
perience has taught me. The drainage is usually a
small cigarette drain, made with rubber tissue, in-
cluding a piece of sterile gauze loosely rolled. This
passes down into the pelvis, or simply into the iliac
fossa, as indicated by the extent of the abscess,
etc., calling for drain.

The incision is closed to the emergence of the
drain, when such is used, by layers, and a pro-
visional suture is placed quite close to the drain,
so that, in case the conditions a^rise- that will war-
rant the removal of the drain in a day or two, this
suture can be tied, thereby allowing a primary clos-
ure to take place.

After Treatment. — A movement of the bowels is
desirable in the first twenty-four hours following
the operation, and it is my custom to give from
five to ten one-tenth of a grain calomel triturates as
soon as the vomiting ceases. When free seropus has
been present and the abdominal wound is sewed up,
from half an ounce to one ounce of magnesium
sulphate and from eight to twelve ounces of water
at 100 ° F. is given b'- the rectum before the pa-
tient is out of the influence of his anesthetic. Noth-
ing is given by mouth in the more serious cases un-
til the bowels have moved or flatus has been e.x-
pelled per rectum. After the bowels have moved,
the patient is allowed milk and broth diet for twenty-
four hours; then if the temperature is under 101°
F., light diet is given, and regular diet as soon as
the chart shows a temperature of 99.5° F. or under.
A standing order for cathartics, if necessary to pro-
duce a movement daily, is given.

When drainage has been used change the ab-
dominal dressings as often as discharge and odor,
demand, but do not remove or change the (Irain un-
til the third to fifth day, and even as late as the
seventh day.

The patient is allowed to roll whenever he likes,
and is allowed to sit up in bed, if not drained, on
the third or fourth day ; out of bed on the fourth or
fifth day. If drained, he is placed in a semi-sitting

position as soon as he is out of ether, and sits uj)
in bed the earliest possible moment that the wound
will allow.

60 West Fiftv-second Street.

PITYRIASIS ROSEA: WITH A REPORT OF

SEVERAL CASES OF THIS DISEASE

MISTAKEN FOR CUTANEOUS

SYPHILIS.

Bv FRED WISE, .M.D.,

new YORK.

CLINICAL ASSIST.^NT ANP ASSISTANT RADIO-THERAPEUTIST, NEW YORK
SKIN AND CANCER HOSPITAL.

It is a common occurrence in the public clinics for
diseases of tlie skin, as well as in private practice,
to see patients with nonsynhilitic cutaneous lesions,
who give fairly reliable histories of having under-
gone antisyphilitic treatment for the skin diseases
with which they are afflicted. Some of these pa-
tients mav complain of mild, but unpleasant symp-
toms which accompany the ingestion of mercury in
moderate doses ; others, however, often present tell-
tale evidences of this treatment — carried up to the
point of severe mercurial poisoning — prescribed by
the physician, under tlie impression that he is deal-
ing with a case of syphilis.

Not a few practitioners, many of whom may be
acute diagnosticians and skilful therapeutists in
otlier branches of the medical art, will frequently,
when confronted with an unfamiliar lesion of the
skin, follow the time-honored dictum which has
lieen laid down by their predecessors: "When in
doubt, call it syphilis, and treat it as such," It
must be admitted that the dermatologist of large
e.xperience sometimes resorts to this measure to de-
termine the nature of the disease he is called upon
to cure, and to establish the existence — or nonexist-
ence— of active syphilitic disease in his patient.
This procedure, however, is gradually falling into
disuse, thanks to the development of more exact
diagnostic methods, and to the more frequent em-
ployment of biopsies as a routine measure, in cases
where doubts exist regarding the nature of the dis-
ease in question. Very often, patients are seen, in
whom only a tentative diagnosis of sypiiilis can be
made, relying upon the so-called "therapeutic test"
— a very uncertain weapon — to settle any doubts as
to the presence or absence of snecific disease. That
this unscientific method of diagnosis may be super-
seded, in the near future, by a simple procedure in-
volving the microscopical search for the spirochete
of syphilis, is conceded by the majority of writers
on the subject to-day ; whether it will be possible to
dispose of the doubtful eruptions of late syphilis
in the same facile manner, time alone will show.

Pityriasis rosea, or pityriasis maculata and cir-
cinata, is not one of the common diseases of the
skin (according to Crocker, it occurs once in about
250 cases) — but its lesions present one of the many
pictures which the unpractised eye is prone to con-
found with dermatoses of totally different origin
and character, \Mien it is considered that diseases
of as common occurrence as acne, eczema, psoriasis,
and even scabies, are only too frequently submitted
to antisyphilitic treatment by the general practition-
er, it is small wonder that pityriasis rosea, with its
acute onset, wide distribution, and occasional ade-
nitis is consigned to a similar fate in the hands of
the wellmeaning but hasty diagnostician.

During the past year, I obtained the histories of

762

MEDICAL RECORD.

[May II, 1907

several dispensary patients affected with pityriasis
rosea, all of whom had been treated for supposed
syphilis before coming to the New York Skin and
Cancer Hospital. These patients had been as.sured
by their respective doctors that the eruption on
their skins was a manifestation of syphilitic disease,
and that a long course of treatment was necessary
to "purify the blood," and to prevent further seri-
ous complications.

Case I. — John F., age thirty-three, single; cab-
man. General health good, ruddy complexion. The
patient shows no evidence of syphilitic disease, but
lie admits having had a preputial chancre at the age
of twenty-two, followed shortly after by an erup-
tion of "spots and pimples" on the chest and ab-
domen. He states that his physician made the diag-
nosis of syphilis, and that he took medicines at ir-
regular intervals, during a period of two years.
.Since the subsidence of the roseola, he has been
free of any eruptions on the skin, and apparently
has had no symptoms referable to syphilitic dis-
ease. During the last two weeks he has been
troubled with alternate attacks of diarrhea, fol-
lowed by constipation, but has felt well in other
respects, and has taken no medicines whatever to
relieve the intestinal trouble. Ten days ago, after
a night of excessive indulgence in beer, he noticed
two reddish spots, each about as large as a dime,
situated near the right nipple, his attention being
directed to the lesions by a slight itching sensation.
Eight days later he discovered that his chest, upper
arms, and back were, more or less, diffusely cov-
ered with an eruption resembling the initial lesions
on the chest, and that the itching, though not severe,
had become uncomfortable. He now decided to
consult his doctor. Suspicion as to the nature of
the treatment he had been receiving was at once
aroused by the foul breath of the patient. Exam-
ination of the mouth revealed a decayed condition
of most of his teeth, and a well-marked mercurial
stomatitis.

The skin presented an eruption bearing some re-
semblance to a maculopapular syphilide. The ma-
cules ranged in diameter from a pea to a ten-cent
piece, were pale-red in color, and partly disap-
peared under pressure with the finger. Those on
the shoulder-blades and below the clavicle were
beginning to clear up in the center, leaving a slight-
ly scaly ring at the periphery ; two or three of the
lesions, viewed with tlie light striking them at an
angle, presented a parallel wrinkling of the center
of tlie discs — an appearance considered to be of
diagnostic importance. The papular elements were
limited to the axillae, and the skin covering the
shoulder- joints; they ranged in size from a large
pin-head to a lentil, were rose-red in color, the
majority being tipped with a tiny scale. Infiltration
■was present, but the characteristic "solidity" of the
papules of syphilis was not felt. Adenitis could not
be demonstrated. The patient complained of mod-
erate itching, which always increased toward even-
ing. He was given a sedative and antipruritic lo-
tion for the skin, which, together with the internal
administration of rhubarb and soda mixture, re-
sulted in a complete disappearance of the eruption
within two weeks of his application at the hospital.

Case II. — Elizabeth D., age twenty-seven, mar-
ried ; seamstress. Has had two children, both liv-
ing and healthy : no miscarriages : menstrua! his-
tory is normal. She has been troubled, almost since
puberty, with frequent attacks of rosacea and acne.
Her general health had been good until about

a month ago, when she began to complain
of obstinate constipation, accompanied by fre-
quent attacks of headache and anorexia. The
patient states that with the exception of a
few pimples on the back and chest, she was
not aware of ever before having had an
eruption on her body. She noticed the beginning
of the present eruption twenty days ago, while tak-
ing a tub-bath. She describes the lesion as a sp)Ot
about as large as a twenty-five-cent piece, pinkish in
color, situated on her breast, a few inches below
the right clavicle. At the time of the appearance
of the eruption, her two children were being treated
for ringworm of the scalp, to which she was making
daily applications of the tincture of iodine. Under
the impression that she had somehow contracted
ringworm from her children, she applied the iodine
to this " initial lesion " (the primitive patch of
Brocq), resulting in an exfoliation and partial dis-
appearance of the patch ; a few days later, fresh
patches made their appearance on her neck, chest,
and buttocks. She consulted a physician, who made
the diagnosis of syphilis, and who advised a course
of antisyphilitic treatment, not only for her, but for
her indignant husband as well.

On examination, the skin presented a multitude
of circular and irregular oval lesions, typical of
pityriasis maculata and circinata. The skin of the
neck, trunk, and buttocks was involved, while a few
pale, scattered blotches were apparent on the thigin
and upper arms. The eruption bore some res^-m-
biance to the circinate, scaling syphilide; the face,
head, and hands, however, were free — an impo"c:m':
point in dift'erentiating pityriasis rosea and sypnilis.
.\s in Case I, so in this patient, a closer inspection
'ji the patches above the clavicle revealed a wrink-
hng of the superficial layers of the skin, light-
brown in color, surrounding which was a narrow,
ill-defined, pale-red zone, slightly raised above the
normal skin, and bearing fine scales. Below the
clavicle, and near the nipnle, were seen a number
of pale-red rings — some of them comnlete, others
broken — enclosing fawn-colored patches of skin,
most of which were beginning to desquamate in
fine scales. On the back, between the shoulder-
blades, the individual circinate lesions had given
place to a diffuse, pink and yellowish, blotchy ap-
pearance, with here and there a large, greasy scale
adhering to the skin, assuming a resemblance to
seborrhoic eczema. The scattered lesions on the
arms, buttocks, and thighs were chiefly of the small,
macular variety, none of them exceeding a dime in
size, and showing no tendency to spread peripher-
ally, or to clear up in the center. The eruption
apparently caused no itching or discomfort through-
out its entire course. A slight enlargement of the
poststernomastoid glands could be made out by
palpation. As a matter of precaution, and in view
of the presence of ringworm in the patient's home, a
microscopical examination of the scrapings from
some of the lesions was made, but no spores or
mycelia of the trichophyton were discovered.

Case HI. — Fanny S., age twenty-five; single,
puella ptiblica. General health good. Nothing in
the patient's history seems to have an\' etiological
bearing upon the present skin disease. She noticed
the eruption about four weeks ago. It appeared
simultaneously upon the buttocks and in the axillae,
and. in her own words, consisted of "a few reddish
pimples and spots, which itched slightly." A few
days later, the patient observed that the rash had
spread, from the buttocks upward toward the small

May II, 1907]

MEDICAL RECORD.

763

of the back, and from the axilte up toward the
shoulders, the back of the neck, and behind the
ears. Subsequently a few spots appeared upon the
abdomen, chest, and upper arms ; the face, hands,
and feet remaining free. Her physician pronounced
the case to be syphilis.

The skin now shows the eruption in the process
of involution. The lesions on the back, and those
on the chest and abdomen have partially faded,
leaving on their sites light-yellowish, finely-scaling
patches of skin. Upon the buttocks, and on the
skinfolds of the axills, are a number of papules,
flat, pink in color, varying in size from a large
pinhead to a split pea. The infiltration is rather
more pronounced than is usually the case in those
eruptions of pityriasis rosea, in which papular ele-
ments obtain. On the back of the neck, behind the
ears, and on the arms are a few scattered, indis-
tinct, yellowish snots, surrounded by pale-red rings,
enclosing small discs of glistening skin.

There is a trifling enlargement of the glands in
the groins. She complained of a slight degree of
itching. The serum from three papules was stained
with Goldhorn's prenaration and examined for the
spirochete of syphilis, with a negative result. While
palpating the papular lesions upon the buttocks, a
half-dozen rounded, marble-sized, infiltrated nodules
were plainly felt in various parts of the gluteus
muscles : the -woman had been receiving intramus-
cular injections of an insoluble preparation for her
supposed syphilitic disease. In this case, the pa-
tient's calling, in all probability.' prejudiced the
doctor in his diagnosis.

C.\SE IV. — (Seen in private practice.) Jos. L.,
age twenty-nine, single ; engineer. General health
has always been good. He gives an indefinite his-
tory of having had sores on the prepuce four years
ago, which probably were either chancroidal or
herpetic in character. The patient, who is strong
and well-nourished, had been perfectly well until
two weeks ago, when he was suddenly attacked
by what is known as "the bends" (caisson disease),
upon emerging from one of the subaqueous tunnels
under course of construction around the city. He
recovered from this attack within a few hours, and
has felt well since. About three days after his at-
tack, his attention was directed, by one of his fel-
low-workers, to a few reddish spots on the lower
part of the abdomen, near the right groin.

.A.S these spots caused no discomfort, little at-
tention was paid to them at the time. Within a
week, the eruption had spread over the entire right
side of the abdomen, the upper part of the thigh
on the same side, and over the left side of the chest
and shoulder. At this stage the itching became
marked, especially when his work caused the skin
to perspire and become overheated. The patient
now consulted his ]3hysician, who made the diag-
nosis of syphilis.

Examination revealed the fact that blue oint-
ment, some of which was evident on the skin, had
been employed — whether prescribed for the local
or for the constitutional effect, or, perhaps, for both,
is a matter of conjecture. About four drachms of
the ointment had been rubbed into the skin during
the week, and already the patient evidenced symp-
toms of mercurial poisoning — abdominal pains,
fetid breath, and diarrhea. The inunctions had al-
tered the natural appearance of the eruption to some
extent, causing a mild inflammation of the lesions
themselves, and of the unaffected skin surrounding

them ; still, the diagnosis of pityriasis rosea was
made without difficulty. The lesions consisted
mainly of well-defined, slightly raised, rose-red
rings, varying in size from the diameter of a lentil
to that of a dime, bearing fine scales on a narrow
peripheral zone, and enclosing light-yellowish
patches of skin in the center. The eruption was
limited to two distinct groups — one on the right
side of the abdomen, the other on the left side of
the chest — a distribution which remained unaltered
throughout the course of the disease, and which, in
itself, would strongly favor the diagnosis of a non-
syphilitic rash, .\denitis was absent, and no dis-
turbance of the general health was apparent, aside
from the symptoms due to mercurial poisoning,
alread}' mentioned.

Crocker, in the "Twentieth Century Practice,"
speaking of pityriasis rosea, says: "Tf it were not
for the errors in diagnosis to which it may give rise,
it would not be an important disease." The his-
tories of these cases bear evidence to the fact that
considerable harm may result from errors made in
the diagnosis and treatment of a cutaneous disease,
bearing a superficial resemblance to, but having
nothing more in common, with syphilitic eruptions.
To avoid mistaking, and, what is worse, mistreating
— this self-limited and comparatively trifling skin
disease for an eruntion due to syphilitic infection,
certain points in the diagnosis of cutaneous diseases
in general, should be borne in mind. The considera-
tion of these points should be based, not upon the
patient's indefinite and, frequently, distorted his-
tory, but upon the picture which presents itself as
the patient stands stripped for examination.

As in other diseases, so also here, the symptoms
are subjective and objective. Of the former, itch-
ing is the only symptom requiring consideration ;
of the cases described above, tw^o complained of
itching : but that this was not very marked was
shown by the fact that in neither did the skin pre-
sent evidences of scratchmarks — j.iroof that the
fingernails were not resorted to for the alleviation
of this symptom : and although itching of the af-
fected parts in pityriasis rosea is sometimes severe
in degree, the majority of patients do not even men-
tion it. This symptom is of some importance, in a
negative sense, in dift'erentiating the eruptions of
pityriasis rosea and syphilis ; for the absence of
itching may prejudice the diagnostician in favor of
syphilitic disease, in which itching of the skin is
but seldom complained of.

In considering the objective symptoms, accuracy
of observation comes into play, and should be di-
rected toward certain diagnostic elements — namely,
the distribution, configuration, color, and consistency
of the eruption under consideration.

Pityriasis rosea appears most frequently upon the
abdomen and chest, the buttocks, and the shoulders.
In the more extensive cases, the rash involves the
arms, almost to the wrists, and, on the lower limbs,
it may e.xtend nearly to the ankles. Very often,
the rash appears on the neck, up to the line of the
jaw and behind the ears, but it is seldom seen to
attack the hands and feet, the face and scalp. Here,
the distribution of the lesions becomes an impi;)rtant
factor in dift'erential diagnosis ; for, in the early
syphilitic rashes, it is most common to find that the
eruption involves the very regions, which, in pit}Ti-
asis rosea, remain free : that is, the palms of the
hands, soles of the feet, face, and scalp. In some
cases, the lesions on the trunk arrange themselves

-64

MEDICAL RECORD.

[May II, 1907

in lines, parallel to the slant of the ribs, or radiating
from the sulcus of the axilla toward the chest and
shoulders — a form of grouping not observed in
syphilitic eruptions. Cases are seen, in which the
eruption is limited to one or two separate groups
of lesions, situated on opposite sides, or on the same
side of the body, the intervening area of skin re-
maining perfectly free; and a few cases have been
reported, in which the lesions were limited, through-
out the course of the disease, to one small area on
the trunk, or on one extremity. It may be said,
however, that in the majority of cases of pityriasis
rosea, in which the eruption has been of two or
three weeks' duration, the lesions appear most fre-
quently on the abdomen and chest, the upper arms
and back, the buttocks and the thighs.

A well-marked case of pityriasis rosea displays
individual lesions of various types. Thus the skin
may present a simultaneous eruption of macules,
papules, rings, and circular or oval scaly patches,
van-ing in size, color, outline, amount of desquama-
tion, and depth of infiltration. The macular and
papular elements are most frequently observed at
the advancing border of an active eruption — in the
axilla, on the upper arms, the thighs, and sides of
the abdomen ; the older lesions, consisting of irregu-
lar, oval, and circular patches, having complete and
incomplete peripheral bands, with here and there
two or three rings coalescing to form irregular
gyrate lesions, are seen usually on the chest, abdo-
men, and back. Interspersed among these large
and small patches are seen irregularly outlined,
brownish-yellow, slightly scaling plaques, gradually
fading into the normal skin. Usually on the upper
part of the chest and back, closer scrutiny will re-
veal, within some of the smaller and more recent
ringed patches, a peculiar, buff-colored folding or
crumpling of the skin into parallel folds — the so-
called "cigarette-paper crinkling" — mentioned above
as being considered of importance in the diagnosis
of pityriasis rosea. As the eruption approaches the
stage of resolution, the various lesions become more
coiifluent. gradually less-defined, assuming a light-
brown color, and, desquamating in small scales,
finally give place to a slightly discolored, but other-
wise normal skin.

In color, the lesions vary, as they do in configura-
tion. As the name implies, the usual shade is a rose-
red or pink ; but cases frequently are seen in which
the color cannot be depended upon as an aid to
diagnosis; for the papules and macules often as-
sume the darker shade of syphilitic eruptions,
whereas the color of the ringed lesions can hardly
be said to differ vers- materially, in the majority
of cases, from that of a seborrhoic eczema, or a
superficial psoriasis. The buff or fawn-colored ap-
pearance in the center of the ringed patches is often
an aid to the diagnosis.

Infiltration of the skin in pityriasis rosea is al-
ways slight or altogether absent, most of the lesions
being on the same level with, or only slightly raised
above the niveau ; but in several cases of the disease
in which the papular elements predominated, I have
noted a marked infiltration of the papules, especially
when located in or near the axilla. The amount of
desquamation also varies ; the scales from the arms,
thighs, and buttocks are usually fine and branny,
while those from the back and chest may be large,
thick, discolored, and greasy, like those of sebor-
rhoic eczema.

Mention has already been made, in the descrip-

tion of the efflorescence in Cases I and II, of the
initial patch, or group of patches, which appears
between one and two weeks before the eruption
proper becomes generalized. This lesion, or group,
described by Brocq as the "plaque primitive," is
usually situated on the enterior asyxct of the trunk,
the favorite site being the abdomen, although it may
occur also on the back or the thigh. In patients who
present themselves with a well-developed rash of
several weeks' standing, it is wellnigh impossible
to pick out this or that blotch on the skin with the
idea of naming it the initial ^laque; in recent erup-
tions, however, the patch may sometimes be identi-
fied by its larger size, darker color, and more abun-
dant scaling. From observation of dispensary pa-
tients, I would say that in the majority of cases of
pityriasis rosea, the initial patch of Brocq is more
often conspicuous by its absence than by its pres-
ence. It is, therefore, of little value as an aid to
the diagnosis, and the interest which attaches to it
lies chiefly in its relation to the etiolog>', as yet un-
determined, of this dermatosis.

From the foregoing description it will appear
that in pityriasis rosea we have an e.xanthem ex-
hibiting lesions often multiform in character, vary-
ing in different eruptions and in different regions
of the same eruption, but presenting, in its entirety,
a picture to be distinguished and differentiated from
the other dermatoses to which it bears a resem-
blance.

In considering the question of differential diag-
nosis between this disease and the early syphilides,
it would be natural to ask : Can not the diagnosis
of syphilis be made and confirmed by the various
concomitant symptoms to which syphilitic infec-
tions give rise? In the majority of cases the answer
to this query would be in the affirmative. But there
still remains a large number of patients, who, aside
from their cutaneous lesions, present not a single
additional symptom, or group of symptoms, that
would tend to point the way to the correct diagnosis
of their maladies.

The scaly and circinate syphilides, for which the
rash of pityriasis rosea is most likely to be mis-
taken, commonly appear at the end of the first, or
beginning of the second, year of syphilis. By this
time, the usual concomitant symptoms have dis-
appeared, the chancre itself often healing, without
leaving a trace behind.

It is in this class of cases, chiefly, that errors in
diagnosis most often occur. It is well to bear in
mind, therefore, that the nature of a cutaneous dis-
ease should be primarily determined, whenever pos-
sible, from the lesions seen on the skin, and on the
skin alone ; in many instances, such a diagnosis
would necessarily be a tentative one, to be subse-
quently strengthened by any corroborative evidence
which may be present (for example, on the mucous
membranes), and which may tend to confirm the
original impression made upon the mind of the
diagnostician. This mode of procedure, if per-
sisted in, will soon enable the practitioner to gain
a clearer and more correct conception of the various
cutaneous diseases which he may encounter in his
practice.

53 East Fifty-eighth Street.

Hemorrhage Following Spinal Anesthesia. — Kopf-
stein reports a case of severe parenchymatous secondary
hemorrhage occurring after an amputation performed under
spinal anesthesia, and attributes it to vasomotor paresis. —
Cenlralblatt f. Chirurgie.

May II, 1907]

MEDICAL RECORD.

765

INSUFFICIENCY OF THE GASTRIC MUS-
CLE.*

Bv M. GROSS. M.D.,

NEW YORK.

Although I am fully aware of the fact that the
various gastric functions are intimately related to
each other, I have made muscular insufficiency a
separate subject for discussion. The reason for
doing so is not only that this function is to a cer-
tain extent actually independent of the other gastric
functions, but also because the consideration of this
subject affords an opportunity to demonstrate the
advanced position attained at the present day in ar-
riving at an early diagnosis of these important af-
fections, for the diagnostic aim consists not so
much in the recognition of a well pronounced con-
dition of the tissue, as rather in unraveling the evo-
lutionary process underlying the affections, and
in the recognition of the transition stage from mere
fatigation to positive disturbance of the tissues.

Axioms. — I. Insufficiency of the stomach, also
called atony, is a relatively frequent affection.

2. The difference between atony and ectasy, or
mechanical insufficiency, is one of principle and not
of degree. Simple atony is a part manifestation
of local or general disturbance of nutrition ; of dis-
turbances of the circulation ; of disturbances which
lead to general muscular and nervous debility.

3. Only by reason of mechanical impediments and
also of complicating more permanent hvpersecre-
tion and its consequences, a simple insufficiency may
be changed into a mechanical one.

4. In a simple atony the stomach contents arc
always evacuated, even though tardily ; an ectatic
stomach never evacuates its contents except with
artificial aid, even though food is withheld for a
lengthened time.

5. Insufficiency of the gastric muscle is rarely
of a serious nature, and then only if a mechanical
impediment is superadded at the pylorus. .As a rule
this affection is favorable to a spontaneous cure and
complete recovery: it readily yields to a removal of
the causative factor.

Physiology. — The stomach is really never entirely
at rest ; even when completely empty gentle move-
ments run along its walls in rather long intervals
and irregular, short waves. During this relative
standstill the secretory apparatus also seems to dis-
play some slight activity, most certainly the mucous
glands, which cover the entire lining of the stom-
ach with a thin protective mucous layer in order to
protect the mucous membrane from extreme degrees
of temperature of ingesta and from slight acid ef-
fects.

It is only after food has been introduced into the
stomach that the peristaltic movements of the mus-
cle display their vigor, the extent of which is dis-
tinctly dependent upon the quantity and quality of
the ingested material.

We may look upon the normal mode of gastric
movements as in the semblance of a wave, one limb
of which is steeply ascending and one slowly de-
scending, followed by a prolonged moment of rest,
corresponding to the height of digestion ; and of a
second, somewhat lower wave movement of an un-
dulating character and a jerking, descending
limb. The first part of the movement oc-
curs in the fundus, while the second cor-
responds to the action of the pylr)ric part,

*Read before the Eastern Medical .Societv, at its meeting
in March, 1907.

the ingested food being once more vigorously
thrown back, and again and again brought into con-
tact with the walls of the stomach in order better
to effect its mechanical distribution and thorough
saturation with chyme. The conclusion of this
motor mechanism is formed by the opening and
closing of the pyloric ring, which is only now ef-
fected with some degree of regularity.

Aside from this kind of motion there is another
one of a totally different nature. In consequence of
the contraction of the powerful longitudinal fibrinous
bundle radiating from the cardia toward the pylorus,
an approximation takes place of these two ostia
which serves to elevate the fundus. By this motion
the contents of the stomach are brought up to a level
with the pyloric orifice, thus facilitating the removal
of the chyme.

As a matter of course, in cases of considerable
distention of the stomach and weakening of the
muscular wall this lifting factor is absent, exacer-
bating the pathological condition.

.A.bility of motion is even shown by the exsected
stomach to a certain extent, which is probably due
to the action of ganglia diffusely distributed in the
stomach wall, while the actually regulating element
of the uniform movements is probably principally
furnished by the vagosplanchnic plexus by way of
reflex action.

Pathology. — If the normal activity of the muscle
is interfered with by whatever obstacle there may
be, the following eventualities may take place :
The muscle overcomes the obstacle ( i ) completely,
(2) imperfectly, or (3) not at all.

One of the factors which may enable the gastric
muscle to overcome the impediment completely is
the reserve force stored u]i in it. In referring to
reserve force it should be remembered that experi-
ence has established the fact that the organs of the
body are only in exceptional cases called upon to
perform the maximum task of which they are
capable.

The normal stomach of a healthy man, which
for a lengthened periotl has done but little work on
little food, is capable, if required, of suddenly dis-
posing of a large meal. This latent power of an or-
gan, which may at any time be drawn upon, is called
the reserve force, and it is owing to this reserve
force that the gastric muscle is enabled to accomtno-
date itself, as we are wont to term it, to increased
demands. This is still a physiological process.

On the other hand, an obstacle may be completely
overcome by compensation, in which case we have
to deal with a balancing of padiological disturbances,
deficient capacity being compensated by hypertrophy,
which, however, may still be susceptible to subin-
volution.

Each regulation of function presupposes a cer-
tain degree of integrity of the regulating system and
its reintegration by the general process of nutrition.
The task of regulation therefore has its limits
in all directions, even though it is capable of con-
siderable nerformances ; above all, it is dependent
upon the circulation of tlie blood and body fluids,
and on innervation.

If, therefore, the gastric muscle is impeded in
its compensatory activity, as, for instance, by re-
peated demands on the part of accommodation, by
local inflammations and their sequela; in hepatic af-
fections, and by intestinal atony or constitutional
affections, there will be no complete balance — no
sufficient compensation ; the condition termed atony
develops, whicli is at first associated with relaxa-

766

MEDICAL RECORD.

[May II, 1907

tion of the tissue and later followed by a distinct
enlargement of the organ, clinically shown by the
retardation of the digestive process.

In the extreme cases of pyloric stenosis we have
to deal with ])ronounced eccentric hyi^ertrophy with
immutable anatomical changes — the "dog stomach,"
as the surgeons call it. Total inabilitv to overcome
an obstacle is a tenij)orary occurrence, an excep-
tional condition in consequence of acute indigestion,
spastic contractions in the nvloric region, etc.

I stated before that the first sign of insufficient
compensation is diminished capacity of the gastric
muscle, /.('. a retardation in the process of diges-
tion. Here we are confronted with a new difficulty,
namelv. that of detemiining the normal period of
digestion. It certainly happens frequently enough
that the stomach is empty two hours after a test
breakfast, or si.x hours after a test meal, but in
almost an equal number of cases it may not be
empty, without our being justified in describing such
an occurrence as abnormal. The fact is tliat the
process of digestion is subject to slight variations
even under normal circumstances, as, for instance,
in the case of middle-aged people, workmen, or large
eaters, so that it will be necessary to make some
slight changes in the above named time limits estab-
lished by Ageron.

In the initial stages of the so-called atonic con-
dition a restitutio ad integrum is of course perfectly
possible ; also in pronounced anatomical changes a
return to approximately normal conditions is pos-
sible. A stomach of this kind is constantly some-
what enlarged and tlie evacuations occur at normal
intervals.

Then again there are stomachs resembling a [Pen-
dulous sac, a distinctly fluctuating cyst, which, re-
markable as it may appear, are under normal cir-
cumstances still capable of performing their task, al-
though there is always a delay, especially when the
demand upon them is increased. To this category
belongs the various forms of gastroptosis and the
atony associated with hypersecretion.

Diagnosis. — The safest method for recognizing
the insufficiency of the gastric muscle consists in
drawing out the contents of the stomach a certain
time after the ingestion of a test meal. This gives
at one glance the undisnutable result of the work
performed by the stomach. If, according to Mathieu-
Redmond, a quantity of more than 180 to 200 c.c.
is found to be present one hour after the test break-
fast, it is indicative of a retarded function of the
gastric muscle. Eisner establishes a comparative
measure between the solid residue and the total
quantity, a method by which hypersecretory simula-
tions may be excluded. The normal solid residue
does not exceed 100 c.c.

When it is impracticable to draw out the contents,
other methods should be employed which will like-
wise enable us to establish an approximately cor-
rect diagnosis.

In suitable cases mere inspection is sufficient to
enable us to draw certain diagnostic conclusions ;
there is. above all, the so-called stiffening of the
stomach to which Boas has called attention, due to
contractions of the muscle which are more or less
visible at the fundus of tlie stomach and demonstrate
the exertion made by the gastric muscle in order to
overcome a stenosis which is either commencing at
the pylorus, or is already in existence. In cases of
pyloric spasm the same manifestations may also be
observer!, although only temporarily.

The other methods of determining the capacity of

the gastric muscle are by means of the splashing
sound, by percussion, and examination according to
Dehio's method, all of which are easily accessible to
the practitioner.

The examination of the stomach is carried out
at two different periods : ( i ) on an empty stomach
and ( 2 ) after the ingestion of a test meal. The colon
having been evacuateil, the empty stomach is slight-
ly inflated in order to determine its i)osition and
to exclude thereby any 'possible simulation of an
enlarged stomach. Following this ]>rocedure percusT
sion should be carried out to determine the size of
the organ, as the best results are being achieved
after these preliminaries.

The next step is to establish by clapolement (suc-
cussion) the presence of a possible noise, to de-
termine the size of the stomach and, above all, the
elasticity of the stomach walls. This examination
is concluded bv the application of Dehio's procedure.
One to three glasses of water drunk on an empty
stomach determine the area of dullness and, conse-
quently, also the position and size of the stomach,
whereas a rapid lowering of the dullness after a
further ingestion of water provides a certain indi-
cation of the dilatability of the stomach, or rather
of its loss of elasticity, although this is not neces-
sarily equivalent with decreased motor power.

An atonic muscle, however, will often render good
service as a first indicator of a commencing dis-
turbance in the performance of a muscle. On the
other hand, an enlargement of the stomach is in-
dicative of a diminution of the tonus and a reduc-
tion of the concentric pressure, because it is just
the fundus which has to suffer most, the weight of
the stomach contents resting upon it ; besides, it is
this part of the stomach which possesses the thin-
nest layer of muscle.

A second examination is made after the inges-
tion of a test meal. In this case, too, the capacity
of the gastric muscle is determined by percussion in
the recumbent and erect position, by the production
of a splashing sound a certain time after the in-
gestion of tlie test meal.

The combination of these double examinations
will enable us to arrive at definite results. In re-
gard to the method of examination, the inflation
with carbonic acid gas should, as was said above,
be only slight, because excessive inflation often
causes delusive results.

As to percussion, I often employ the ausculta-
tory method, the stethoscope being placed below the
xiphoid process or in the pyloric region. Ver}'
gentle percussion being simultaneously carried out,
tlie sounds are conveyed to the ear more perfectly,
every slight difference in note being distinctly per-
ceptible. I start from tlie idea that every fair-
sized hollow organ produces a certain timbre.

As to the splashing sound, it may be generally
stated that its constant and extensive presence is
the outwardly perceptible sign of a diminution of
the concentric state of tension, i.e. of the counter-
pressure exercised by the stomach wall after the
ingestion of fluid. It is the time and place of its
occurrence which makes tlie splashing sound an
important diagnostic symptom. In gastroptosis the
splashing sound is of no diagnostic value.

Preceding, in point of time, the splashing sound,
and therefore being the very first indicator of a loss
of elasticity, and occurring, as it does, at a time
when there can hardly be a question yet of dilata-
tion of the stomach, is a flabby sound, produced

May II, 1907]

MEDICAL RECORD.

767

only on an empty stomach, wliich may be explaineil
by the relaxed walls banging together.

The value of the splashing sound as a diagnostic
sign is. however, curtailed by the fact that investi-
gations of Zvveig, Calvo, and. more recently, Boas,
have demonstrated that the finding of fairly large
residual masses a considerable time after the in-
gestion of a test meal is by no means always indica-
tive of a motor insufiiciency of the gastric muscle,
but is often attributable to increased secretion of
gastric juice, the so-called digestive hypersecretion
of gastric juice. But experience has taugiu that
the motility is generally also diminished n\ these
cases.

The prognosis is favorable, if the nature of the
affection has been recognized earl}. But hIso in
the dilating stage a restitution is frequently po>siMe
if the underlying causes can be reached. Should
this not be the case, it is certainly possible to estab-
lish complete compensation and to maintain the
muscle in that state. This also refers to benign
pyloric stenoses, in which it is possible to maintain
a relatively good capacity of the organ for decades.

It is important to recognize the affection when
it manifests itself in little children by a tendency to
functional dilatation associated with great liability
of the function of the organ, which is clinically
demonstrable without diffculty. Occasional regurgi-
tations in early childhood should direct our attention
to this condition, for there is no doubt that some-
times an affection which had been wrongly diag-
nosed as nervous has turned out to be purely or-
ganic.

Therapy. — A few remarks on this head w-ill be
sufficient. Insufficiencies of a light degree undergo,
as we have seen, spontaneous cure if they are given
the opportunity to do so. But even in advanced
cases an alleviation of the manifestations can be
attained by enjoining partial or, if necessary, com-
plete rest, by finding out the cause, etc. The same
applies to the compensatory disturbances of me-
chanical dilatation.

Irrigation or douches will be indicated in afipro-
priate cases, and then a few sittings will nearlv
always suffice to achieve a satisfactory result.

Mechanical, electric, and hydronathic measures
will be crowned with success in a number of cases,
although often rendered superfluous by a system-
atic hygienic dietetic regime, where such can be car-
ried through.

But here, as well as in many other sections of
pathology, the physician will be obliged to leave a
great deal to the slow but unmistakable influence of
vis medicatrix natur?e ; a more negative treatment
— prevention of untoward influences — being likely
to lead to better results than exaggerated inter-
ference.

315 Second Avenue.

Abadie's Symptom in Tabes Dorsalis. — C. Xegrn de-
scribes Abadie's symptom .ts liyper.ilgesia of the tendo
.'\chillis when pressure is made on the sides of the tendon
at the level of the malleoli. This is present in normal
persons, but according to some authors it is absent in
those suffering from tabes dorsalis. The author has ex-
perimented on ten cases of tabes to see if this sign was
always absent. The analgesia was found in three out of
the ten patients, while .^hadie found it in So per cent, of
those he observed. It may be found only on one side.
There may occur hyperalgesia instead cf analgesia to
pressure. — Rivista Ncurof'athologica.

VULVOVAGINITIS IN CHILDREN WITH
ESPECIAL REFERENCE TO THE GON-
ORRHEAL VARIETY AND ITS
COMPLICATIONS.*

Bv HERMA.N B. SHEFFIELD, M.D.,

NEW YORK.

INSTRUCTOR IN DISEASES OF CHILDREN AT THE NEW YORK POST-GRADUATE

.MEDICAL SCHOOL AND HOSPITAL; VISITING PEDIATRIST To THE

YORKVILLE HOSPITAL, AND THE GERMAN POLIKLINIK.

Notwithstanding recent advances in bacteriology
and microscopy, the profession is not as yet in ac-
cord as to the exact nature of vulvovaginitis in chil-
dren. Some physicians still doubt the fact that most
cases are due to the gonococcus of Neisser and are
highly contagious, hut tenaciously cling to the
"scrofulous" theory of the disease and recommend
tonics to combat it. As a result, innumerable cases
run at random, leaving sources of contagion in pub-
lic schools and baths, homes, and hospitals, with ap-
parently no one in authority to check the further
spread of the affection.

The necessity of presenting the subject in question
in a clear, concise manner, and repeatedly discussing
it so as to arouse the interest of the profession is,
therefore, quite obvious.

Accordingly, permit me to offer a classification of
the different varieties of vulvovaginitis from the
etiological point of view. Thus :

(i) Catarrhal vulvovaginitis, which is generally
due to (a) lack of cleanliness or (b) chemical irrita-
tion.

(2) Traumatic vulvovaginitis, which is caused by
(a) masturbation ( ?), (b) mechanical injury, or (c)
indecent violence.

(3) Parasitic vulvovaginitis, which is due to (a)
oxyurides, (b) saprophytes, or (c) pathogenic bac-
teria, especially the gonococcus.

The first variety of vulvovaginitis is usually met
in poorly nourished children of overcrowded tene-
ment districts, who receive a thorough cleansing on
very special occasions only. As a rule, these cases'
begin with vulvitis, the vagina becoming gradually
involved by extension of the inflammation. Catarrhal
vulvovaginitis is not always limited to the very poor,
and the physician need not hesitate to suspect dirt
even under the most elaborate apparel.

This variety of vulvovaginitis is also frequently
observed in children whose genitalia are exposed to
excessive wetting by irritating, decomposing secre-
tions, and excretions — sweat, diarrheal stools, hyper-
acid urine — and to undue pressure and friction. In
former years, when bicycle riding was a national
fad, vulvovaginitis was not rarely met in assiduous
bicycle riders, undoubtedly as a result of the afore-
said causes.

The consideration of the second, traumatic, va-
riety of vulvovaginitis does not, strictly speaking,
belong to the domain of medicine, except as regards
the treatment. We are dealing here with faulty
habits and criminal traits which deserve serious at-
tention on the part of teachers, the clergy, and
jurists. However, as it is the physician who is
usually consulted first, a few points of information
will prove useful to him, particularly as a warning
not to be too hasty in expressing a positive opinion,

I believe that entirely too much stress is being
laid by some authors upon masturbation as an etio-
logical factor of vulvovaginitis. It is much more
probable that inasturbation is a result rather than a
cause of it, the undoubtedly existing irritated state
of the erectile tissue inducing that bad habit.

*Read before the Gynecological Section of the Eastern
Medical Societv.

768

MEDICAL RECORD.

[May II, 1907

The presence of foreign bodies in the vagina is
not infrequently found to be the cause of vulvovagi-
nitis. While some girls will introduce foreign bodies
in the vagina with lascivious intent, the great ma-
jority of foreign bodies, e.g. safety pins, will find
their way in the vaginal canal accidentally, and
should always be looked for, particularly in cases of
long standing.

Occasionally cases of vulvovaginitis are encoun-
tered which are the result of indecent violence. The
purulent discharge is either nongonorrheal or gon-
orrheal, the latter only if the criminal who attempted
rape had at the time been suffering from gonorrhea.
It is well to remember that not every case of vulvo-
vaginitis reported to be due to rape is really such,
and unless the vaginitis is associated with actual
penetration of the hymen and concomitant signs of
inflammation due to violence, the physician should
be very cautious in venturing a positive opinion.

Saprophytic microorganisms are responsible for a
great number of cases of vaginitis. To them is
attributable the vaginitis not infrequently met after
acute exanthematous diseases (with or without des-
quamation) and in conjunction with diverse forms
of cutaneous eruptions. The same cause accounts
also for the vaginitis observed in strumous and debil-
itated children suffering from purulent discharges
from the nose, ears, etc. Indeed, the number of
cases . of saprophytic vulvovaginitis would by far
exceed all those arising from all other sources col-
lectively were it not for the antagonistic action of the
bacillus of Doederlein which normally inhabits the
vagina. This vagina bacillus, which is anaerobic
and may be cultivated on ordinary media, produces
lactic acid during its growth, a quality to which is
due the presence of lactic acid in the healthy vagina.
In its presence saprophytes, as well as numerous
other bacteria, such as the staphylococcus and strep-
tococcus, are unable to develop, and within a short
time perish. Gonococci, however, do not yield as
promptly to the destructive effect of the vagina ba-
cillus, hence the frequency with which gonorrheal
vulvovaginitis is met, notwithstanding the resistance
offered to the entrance of gonococci into the vagina
by the stratified squamous epithelium lining it.

As stated before, contamination of the vagina by
criminal assault is comparativelv very rare. Much
more frequently infection takes place by voluntary
sexual act or accidentally. Little girls sleeping with
their parents, elder brothers, sisters, or nurses suf-
fering from gonorrhea, may contract the disease by
coming in contact with soiled bedclothes, cotton
pads, or other articles used for cleansing purposes.

Gonorrheal vulvovaginitis runs a more or less
virulent course, and in hospitals and asylums, where
many children are congregated in comparatively
close quarters, and frequently make common use of
infected bathtubs, toilets, etc., the disease is very
apt to become epidemic as well as endemic. In one
epidemic under my care, in an orphan asylum, com-
prising over one hundred cases, it required many
months of very active treatment to eradicate the
affection. Arrest of further spread of the gonorrhea
was not effected until every patient was isolated and
kept in bed for several weeks. A biweekly examina-
tion of every female inmate of the institution (in-
cluding the nurses in charge) for vaginal discharge
was continued for several weeks after disappearance
of the last case of vaginitis.

Sucli procedures form the main prophylactic
measures against the disease. Of course, the pa-
tients must be restricted from the common use of
chambers, bedding, bathtubs, etc. In hospitals and
asylums, admitting physicians should be particularly

careful to exclude all children having purulent vagi-
nal discharge, unless provisions are made for the iso-
lation and treatment of such cases. This point is
well worthy of consideration, as it would greatly aid
in checking further transportation of the disease.
As the majority of cases of vulvovaginitis is ob-
served among school children, a suggestion to the
health authorities is, perhaps, in order, viz., to in-
struct the school inspectors to pay more attention to
the detection and isolation of the cases of gonorrhea
in children than they do now.

As gonorrhea in adults, that of children presents
a marked tendency towards grave complications.
Among 148 cases under my care, the following seri-
ous complications were observed : Purulent oph-
thalmia, 7; local peritonitis, 4; proctitis, 3; arthritis,
4; adenitis, 12. Several cases of pyosalpinx, endo-
carditis, and pleuritis are on record. However, the
more familiar I became with the course of the dis-
ease, and the best means of checking and eradicating
it, the less numerous became the complications and
sequelae in my new cases.

After extensive experimenting I found that gon-
orrheal ophthalmia can best be prevented by fre-
quent cleansing of the genitalia and hands of the
patients, and by the employment of a large, tightly
fitting vulvar pad. The latter should be changed for
a clean one at least every three hours. The child
should wear one-piece night-drawers during the
night as well as day. The ophthalmia may some-
times be arrested in its incipiency — I succeeded in
two cases — by instillation of silver solutions
after Crede's method. In view of the unusually
rapid progress of the ophthalmia, unfortunately, it is
not often that the physician has the opportunity to
resort to the prophylactic measures, and nothing
else remains but to treat the disease actively and
skilfully, and, if not already involved, to endeavor to
save the other eye from the dreadful infection.

Involvement of the uterus and adnexa secondarily
to gonorrheal vulvovaginitis in most instances results
from injudicious use of douches by forcing the vagi-
nal discharge upwards into the uterus, Fallopian
tubes, etc. The treatment should, therefore, not be
intrusted to the inexperienced.

I believe that I am entitled to the credit of having
been the first to call attention {American Medieo-
Stirgical Bulletin, May 30, 1896) to the occurrence
of gonorrheal proctitis as a complication of vulvo-
vaginitis. The rarity with which this complication
is observed, notwithstanding the constant exposure
of the anus to the gonorrheal vaginal discharge,
would seem to prove the comparative immunity of
the skin and mucous membrane of the anus and rec-
tum to gonorrheal infection. Moreover, as proc-
titis usually does not develop until late in the course
of the vaginitis, i.e. until the skin of the anus and the
adjacent structures has become abraded and denuded
by the continued irritation of the vaginal discharge,
or by scratching for the relief of the not infrequently
accompanying intense itching.

The diagnosis of gonorrheal proctitis is rendered
positive by the presence of the gonococcus in the
mucopurulent stools.

Like the former complication, arthritis, the so-
called gonorrheal rheumatism, also develops late in
the course of vulvovaginitis. In the majority of
cases the inflammation is limited to one joint, usually
that of the knee, and occasionally ends in suppura-
tion and ankylosis.

Inguinal adenitis is quite a frequent complication.
The glandular enlargement mav increase up to a
well-marked bubo. It sometimes suppurates as a
result of an additional infection by pus microbes.

May II, 1907]

MEDICAL RECORD.

769

The differential diagnosis between the different
varieties of vulvovaginitis can readily be made by
bearing in mind the previously mentioned classifica-
tion. No e.xamination should be considered com-
plete without a very careful microscopical scrutiny of
the vaginal discharge. In doubtful cases a culture
will settle the diagnosis. Furthermore, it is well to
remember that several etiological factors may be
operative in the production of the vaginitis in one
and the same patient. Hence, the finding of pin
worms, for example, in the vagina should not lead
us to conclude the absence of gonococci.

The treatment of the different varieties of vulvo-
vaginitis is fully outlined in most modern text-books
of pediatrics and gynecology. It is, therefore, super-
fluous for me to offer suggestions in this direction.
All I desire to emphasize is that recurrences of the
aft'ection after a period of latency are frequent even
under the most careful method of treatment. No
case of gonorrheal vulvovaginitis .should, therefore,
be considered cured, unless three or more thorough
microscopical examinations nf the vaginal discharge
prove the absence of gonococci and pus.

329 E.\ST FiFTV-FIRST STREET.

IS AN HERPETIC ORIGIN OF PLEURISY
POSSIBLE?

Bv WOODBRIDGE H.\LL BIRCHMORE, M.D.,

BROOKLYN. NEW YORK.

It has been said by more than one pathologist of
note that when a certain lesion is a symptom of a
condition such lesion ma)- alternate with any other
lesion symptomatic of the same condition. The con-
dition which we call "gouty" or "rheumatic" is said
to be characterized by a distinct grou]) of skin lesions
which are described en bloc as "herpetic ;" this same
condition is said to cause inflammatory processes of
the serous membranes, notably is this believed, judg-
ing by the contributions to periodicals, in respect
to the pericardium and pleura.

It is quite certain that if the familiar "cold sore"
is in any proper sense an "herpetic eruption." and
officially it is "herpes labialis," then certain alterna-
tions can be predicated, no matter what this lesion's
cause may be. .Also, if like eruptions beginning as
insignificant bulla; followed by a tenderness, and
even persistent painfulness, out of all proportion to
the initial lesion, and by the characteristic cicatricial
process, are all to be classed as "herpetic," then wc
can safely sav that some of the eruptions which
occur in individuals who complain of "attacks 01
rheumatism," which to a small degree interfere with
the free motion of certain joints, are alternatives to
such attacks.

But how about such a case as the following?
C. A., aged forty-two years, man, white, weight 182
pounds, height five feet ten inches, chest measure
(insp.) 44-^4 inches, is in the habit which is so
usually called "gouty" or "rheumatic." Has fre-
quent attacks of an illness which has been diagnos-
ticated by various practitioners as "rheumatism,"
and these attacks impede the usefulness of the ankle
and knee on the right leg. Less frequent and less
severe have been like attacks of the right elbow, and
he remembers that on a number of occasions a pain,
very sharply defined in its localization, has interfered
with activity. The patient locates this pain upon
the right side, and he says that when he has tried
to take a long breath this same pain has hurt him
"like a knife," but this pain has never lasted more
than two or three days, and on no occasion has he
been forced "to go to bed and nurse it." As we

were rather intimate friends, knowledge of these
attacks was not wanting me, and I noted that the
"herpetic eruption" referred to would follow the
muscle soreness and accompany the pain described
as within the chest, and on two occasions I had
heard, or believed that I had heard, as distinctly as
could he wished for any diagnostic purpose, the
"friction sound" of the visceral against the parietal
pleura.

The question raised had never been pressino-, and
yet I was often constrained to wonder what sort of
condition existed within the chest, especially since,
if fever was present, the body temperature was
hardly above normal, and the small difTerence could
be easily accounted for without the diagnosis of
"inflammation of the pleura."

But early in February I had an opportunity to see
an attack, which gave interest to the question which
gives title to this note but did not answer it —
satisfactorily. Missing him from our ordinary
meeting-places, I asked what had put our plans
awry, and learned that he was ill at home and was
said to be confined to his bed. In a very short time
I was at his bed-side, and fortunately the attending
physician called to see his patient while I was still
with him, and it was but a few minutes before the
question, "Is an herpetic origin for pleurisy pos-
sible?" was interesting all three of us. From the
outset the attending physician declared that the case
was peculiar and its course abnormal — decidedly so
for any well-behaved classic pleurisy. The physician
had heard the friction sound, but was sure that he
had not seen any signs of a superficial lesion. He
also bade me note that his patient did not appear to
find his chief distress in the stab-like pains, from
which he should have suffered, but said that the con-
stant muscular pain, "like a neuralgia," was so much
more severe that he hardly perceived the other at
all. For this reason his chest to the limits of the
painful area, as defined by the patient himself, had
been poulticed with a clay compound put on hot. In
the course of the conversation, the attending physi-
cian said : "Contrary to all my previous experience,
a slight irritation of the skin has appeared since the
poultice was applied." This interested me as sug-
gesting the previous "herpetic eruption," and I
asked to see the same. None objecting, as I rather
feared the physician would, I saw the eruption in
the accustomed location, and mutat. mutand. in the
very condition I expected.

It is worthy of note that it was already the sixth
day, and the "friction sound" was still to be heard
at the proper times and places (immediately under
the area of eruption), when the needed precautions
were taken, and the "friction sound" was still ac-
companied by the characteristic pain.

This fact at once suggested to me the question
which I had more than once put into words in m^'
note-book. "Is there an eruption upon the pleura
identical with this superficial one?" and the mental
question was answered, or seemed to be, by the
facts in hand. Certainly "the pleurisy" was not at
all improving, and the case had been under observa-
tion nearly, or quite an entire week, during which
time the symptoms usually diagnostic of pleurisy,
except the pain and the friction sound, were quite
wanting, and the treatment so far as it was special
to pleurisy had been quite without result, or at least
without expected result. The circumstance most
impressing the attending physician was the absence
of any perceptible effusion, but it was equally inter-
esting to me to note that the jiatient was less
impressed by the respiratory pain than by the
muscle-located "soreness," about which he, as usual,

770

MEDICAL RECORD.

[May II, 1907

complained most bitterly. It appeared to be quite
in accord with the experience of previous attacks
that the fear of pain should be extreme, and that the
temperatures should agree in various details with the
temperatures noted in previous attacks rather than
with those supposedly typical of a pleuritic inflam-
mation.

Not wishing- to interfere, and having in mind that
professional comity must take precedence of friend-
ship, I left, but that same evening the discussion
was renewed by a call made at my room by the at-
tending physician, who after my departure was
informed of the many attacks of "neuralgia" located
on the right side, and specifically in reference to the
attacks of pain accompanied by an eruption located
almost, if not quite, in the same area. To my sur-
prise I found my friend the physician very much
inclined to regard this attack from my point of view,
as being simply one of the frequent and almost peri-
odicallv appearing bits of evidence that the condition,
which was the foundation for one and all these
symptom-groups, was a diathesis, rheumatic or
gouty, as the evidence might impress the diagnosti-
cian. For my own part, I admitted that I was quite
willing to believe that gout and rheumatism were
but the best-known faces of a nutrition disorder
concerning whose true meaning we still lack the
most essential facts. The attending physician had
sufficient confidence in mv good will to ask to see
my clinical notes in relation to this case, which I at
once, and gladly, put at his disposal. In the course
of the next few, two, or three weeks I heard that
my friend had been sent to a somewhat more genial
climate, and I also received a letter from the attend-
ing physician, in part as follows :

"While I cannot say that I am converted to your
theory, that the outbreak in our friend's case was
due to an eruption on the pleura cognate to the ves-
icles upon the skin, yet I am obliged to admit that,
although I had been treating the case for a whole
week, on the theory of another origin, no progress
had been made."

In my own mind, the case still is open to argu-
ment, for certainly the pleurisy acts in most cases
as if it were like the eruption upon the cuticle, in a
way self limited. Up to now I have collected eight
instances of this seeming alternation of a localized
pleurisy with an herpetic eruption upon the corre-
sponding area of the skin. Yet we are as far as ever
from a perfectly satisfactorv answer, either by logic
or demonstration, to the question. "Is an herpetic
origin to pleurisy possible?" the question which
heads this note.

X63 FuLTON" Street.

UTERUS OF THE OPOSSUM.

SOME NOTES ON COMP.\RATIVE AN.\T0MY .^XD EM-
BRYOLOGY, WITH DEDUCTIOXS.

By JOHN P. FURNISS. M.D..

SELMA. AL.k.

\\'hile serving as assistant surgeon, French's
Division Hospital. 1863, I was associated with Sur-
geon H. D. Schmidt, late curator of the ^luseum
Charity Hospital. New Orleans. La. \\'e made
dissections of the opossum, and I have been inter-
ested in the subject ever since, but it is only recentiv
that I have acquired some new facts connected with
it. These facts I have gathered from observation,
literature, and personal communication.

Of the tvi^enty-four living species, the common
Mrginian opossum ( Didclphys ^larsuf^ialis) is the

largest, and the only one of the marsupials in the
United States of America. There is a difference
in the sizes of those of the Middle States, Florida,
and Texas. Ordinarily it measures, head and body,
twenty-two inches, and tail fifteen inches.

There are no living species on the European Con-
tinent, though Buffon states that fossil remains are
found there in the lower tertiary formation.

They are closely allied to the Australian Dasy-
riridcc, but are distinguished by the hind foot having
an inner toe, which, though nailless, is capable of
being opposed to the other digits : by the number of
their incisor teeth, of which there are five pairs in
the upper, and three in the lower jaw ; by their per-
fectly naked muzzles, and their long, naked, scaly
prehensile tails, which enable them to be expert
climbers. They have the same (two) marsupial,
or pubic bones.

-A K>(/ ^' ocf

Fig. I. — Various forms of uteri; A. B.'C. D. diagrams showing the
different stages in the fusion of the Mullerian ducts: A. uterus duplex;
B,_ uterus bicomis; C, uterus bipartitus; D. uterus simplex: E. female
urinogenital apparatus of Mitstelina. containing embr\'os (*. *) in
the uterus: F. ditto of Hedgehog {Eritiaceus); Od. Fallopian tube;
Ut, uterus; Vg. vagina; Ce. cer\-ix uteri; Ot. abdominal aperture of
Fallopian tube; t. t. accessory- glands; r. rectum; Sttg. urinogenital
canal; .V. kidney; .V?i. adrenal; Cr, ureter; B. urinar>' bladder.

The idea that these bones serve only for attach-
ment of the muscles of the marsupium has been dis-
couraged, as they exist in the male as well as the
female.

The animals are nocturnal in their habits, omniv-
orous, and possess the characteristics of the other
marsupials in their low order of intelligence and
their great tenacity of life. Their highest exhibition
of intelligence is displayed in feigning death in the
presence of danger. An entertaining and admir-
ably illustrated account of their appearance, habits,
and mode of capture by the Southern negroes is
given in Nature Librar\-, \"ol. IV. Especial interest
is attached to the urinogenital development X)f these

May II, 1907]

MEDICAL RECORD.

IJ-i-

animals. In the human female fetus the Muilerian
ducts are first noticed in the fifth week of ein-
bn-onal life, and are parallel to the course of the
Wolffian ducts. During the second month the ducts
unite at a point near their centers ; during the third
and fourth months they are blended in their lower
parts : at the fifth month the cervix uteri can be dis-
tinguished. The Muilerian ducts continue to di-
verge and form the Fallopian tubes. It is at this
stage that there is the greatest resemblance to the
development found in the adult opossum.

In the marsupials the fusion of the two oviducts
is much less marked than in the higher mammals.
According to Wiedersheim and Parker, a dilated
portion of each oviduct, giving rise to a

J^ f/

Fig. 2 — Female generative apparatus of Didelphys Sorsigerj (juv.);
NN, kidneys: Ur, ureters; Ov. ovary; Od, oviduct; Ut. uterus; f. bend
between uterus and vagina, Vg; B. urinary bladder; r. rectum, whicli
opens to the exterior (CJ> at rl\ g. clitoris; *. rectal gland

uterus, is plainly distinguished from the rest, and
its narrowed posterior end comes in close contact
with its fellow in the middle line. At this point each
uterus communicates with the vagina by a distinct
OS uteri. The vagina curves sharpiv outward and,
then backward, opening close to its fellow into the
elongated urinogenital canal.

The anus and urinogenital aperture are sur-
rounded by a common sphincter. This fact, or rather
ignorance of it. has led many observers to declare
that the female opossum had no vulva, and to give
expression to many speculations as to how copu-
lation was effected. A clitoris is present in the fe-
male of all mammals, and Buffon, quoting Dr. Ed-
ward Tyson, an English physician, who claims to

have dissected one, states that in the opossum it is
double. I am not able to verify this statement, but
I do know that the glans penis is bifurcated, the
urethra opening in the center. These points of the
glans are one-third to one-half inch long. In man,
and in most other mammals, the urethra traverses
the glans, which is generally rounded, oval, or
pointed.

The opossum is a nonplacental mammal. Buf-
fon states that the period of uterogestation is not
known. The author of the article on this subject
in the Encyclopedia Americana says that it is twenty-
six days, and that the young are carried in the
pouch five or six weeks. The young are generally
born in the spring, and there may be several litters
during a season. When expelled from the uteri
they are naked, like the young of mice, much more
immature, and not larger than an ordinary bean. I
have captured them in different stages of develop-
ment, and at different seasons.

The mother attaches them to the teats, of which
there are thirteen in her pouch. In this larval con-
dition the margins of the lips become partially fused
to form a suctorial mouth. Strong compressor mus-
cles surround the mammary glands of the mother,
and the milk is injected into the throats of the
young. They remain attached to the teats until
capable of motion and covered with hair.

Hill in classifying malformations of the uterus of
the human female gives the following varieties of
the aberrant class: (i) The nonfundated and
grooved uterus. (2) The septate uterus, which has
been more frequently reported than any others, ex-
cept the bicornate and the double uterus. (3) The
bicornate uterus, (4) The double uterus, or uterus
didelphys. ( 5 ) The uterlis with two cervices and
one body. (6) Unicornate uterus. (7) Absence of
the uterus. (8) The accessory uterus.

He says that uterine malformations are more fre-
quently the result of defectiveness in the right Mui-
lerian duct : that in birds and reptiles the right ovary
and oviduct are very rudimentary : that in the mono-
tremes we find a better development of ovary and
oviduct on the left side : that from the marsupials
through the ascending forms of animal life there
are many stages of placental development represent-
ing the unerring approach to the perfectly formed
structure found in the human race. So. also, are
there many uteri representing the gradual fusing of
the Muilerian ducts to completeness as is found
in the single organ in the woman. Is this para-
phrase justified? Wherever a malformation of the
human uterus occurs its analogue can be found in
the development of some of the lower order of ani-
mals.

THE TREATMENT OF STUTTERING.

Bv E. W. SCRIPTURE, PH.D., M.D.,

NEW YORK.
aSSISTWT neurologist, V.WDERBILT clinic, C0LUMBI.\ V.MVE?.-ITV.

Few departments of medicine have been so ne-
glected as that referring to defects of speech. Per-
haps this has been due to the lack of well-developed
sciences of mind and speech on which to base the
pathology. The following notes give an account of
a system of psychological and phonetic principles
that may be useful to those who have to care for
speech troubles.

The terms '"stuttering" and "stammering"' are
applied in a confused way to a group of speech de-

772

MEDICAL RECORD.

[May II, 1907

fects that arise from three causes: (i) Excessive
innervation of the speech organs, (2) deficient in-
nervation, and (3) defects of the vocal organs them-
selves.

The first case may be termed "superenergetic pho-
nation ;" there is an excess of nervous discharge to
the vocal organs, producing tonic and clonic cramps
at various points. This is the condition in what has
been called "convulsive stammering" and in ordi-
nary stuttering where a sound is repeated. "Sub-
energetic phonation" in which the innervation is
defective in amount and distribution, produces de-
fective articulation such as is found in alcoholism ;
this defect may properly be termed "stammering."
In the present paper only superenergetic phonation
will be considered.

In a case of superenergetic phonation the first
problem is to restore control over each group of the
vocal organs. Breathing exercises are introduced
to reeducate the control of the diaphragm, the ab-
dominal, and the chest muscles. By having the pa-
tient place his hands over the abdomen or the chest,
he can control his movements by the sense of touch
in his hands. When this does not succeed we can
apply the fundamental principle of reeducating the
muscle-sense by using the sense of sight. A Marey
receiving tambour is so arranged that its lever rest's
on the abdomen or chest; the recording tambour
registers the movement on a slow-moving drum
which is in front of the patient. Every deviation
from an even, steady movement can be seen by him ;
in this way he controls his breathing movements by
his eye. The superenergetic stutterer often cannot
control his larynx well ; exercises in producing tones
are therefore introduced. Defects in articulation are
to be cured by showing him how to place his lips
and tongue for each sound.

The next step is to teach him to have his organs
ready for use when they are wanted. Before he
speaks a sentence he must have a supply of air
ready by drawing in his breath. At all times he
must have ready the first sound of any word he may
wish to speak ; this I accomplish in the following
way :

The typical consonant sounds are first taught. The
following list gives the phonetic letters, their names,
and some words in which they appear :
p] pa, as in "par."
h] ha, as in "bar."

zl
J]
[2]

k]

g]
m]

n]
11

fa, as in "far."
va, as in "z'ary."
ta, as in "tar."
da, as in "darling.'
fia, as in "thin"
oa, as in "//;ine."
sa, as in "sir."
za, as in "ccar."
sa, as in "shah."
za, as in "/ardin"
ka, as in "car."
ga, as in ""■arden.
ma, as in "niark."
na, as in "110."
la, as in "/ark."

(French) or 'asure."

"a] Ja, as in "rah."

This phonetic alphabet is learned by daily prac-
tice till it is spoken to perfection and till it becomes
almost as familiar as the ordinary alphabet. It is
possible to get along without learning the vowels.
The patient has also daily written exercises in m-
dicating the sound of the first consonant in each
word. Then he is told to write under each word of
a selection of verse the phonetic letter for its first
consonant. For example, the first two lines of Long-

fellow's "Psalm of Life" would be treated as fol-
lows :

Tell me not in mournful numbers
[t] [m] [n] [n][m] [n]

Life is but an empty dream.
[1] [z][b] [n] [m] [d]

Next he is practised in promptly producing any
consonant sound at will. Thus, at each tap of a
pencil he must promptly say [pa]. He goes through
the whole phonetic alphabet in this way until the
tap of a pencil automatically releases any sound
called for.

This method is sufficient to enable a patient to
read perfectly. He simply takes a breath before
each sentence or phrase, and begins each word by
thinking of its phonetic letter. The whole process
finally becomes automatic, and the patient is cured
as far as concerns reading.

For conversation we have a more complex condi-
tion to which we must apply certain psychological
principles. In order to express a thought the person
must first have the thought. The stutterer is often
in such a condition of embarrassment and mental
distraction that he cannot hold a thought long
enough to express it. For example, when he in-
tends to say that he needs a motor for his phono-
graph, he becomes so afraid of being unable to get
out the word '"motor" that the fear drives the idea
out of his mind. He no longer has the picture of
the motor with which to set off his speech center;
rather, all that he has is the thought of stuttering,
which of course sets off the stuttering cramps.
Again, he knows that he must begin with the word
"the ;" he has failed so often that he is anxious
about it. He thinks of "the," thereby driving the
motor out of his head ; but his fear also drives "the"
out, and his cramps come on. This flightiness of
thought often shows itself in the involved sentences
that the stutterer attempts.

To cure this condition, I oblige the patient to de-
scribe the objects in the room or in a picture in
short sentences. Here is an example: "I am in
the doctor's oiifice. A desk is in the middle. The
lamp stands on the desk, etc." The description he
repeats over and over, not in exactlv the same words,
but with sufficient sameness to place the exercise
half way between the fixed sequence in reading and
the entire freedom of conversation.

In this exercise the patient is told first to pick out
the thing he is to talk about, e.g. "I," "desk,"
"lamp," etc. If he has any difficulty he can begin
by writing a list of them. Then he is to speak the
name of the thing; if he has any difficulty he is to
think of its first sound. He is not to bother about
any articles or adjectives ; if he has trouble with
"the," he is simply to leave it out.

These exercises are made freer and freer until
they pass imperceptibly into conversation. The pa-
tient is finally warned that he must always first grasp
the thing he wants to talk about, and that he must
get its name out, even if he has to omit all articles
and adjectives.

30 East Forty-fifth Street.

The Head Zone sometimes aids in distinguishing be-
tween acute appendicitis and salpingitis. If the zone com-
mences at the level of the umbilicus, extends to the right
lumbar region and to just below Poupart's ligament, it is
probably acute appendicitis. If the zone begins a little
below the umbilicus with a broad base on the abdomen and
extends to a point between the hip-joint and the knee, the
case is probably one of acute salpingitis. — .American Jour-
)Kil of Surgery.

May II, 1907]

MEDICAL RECORD.

773

Medical Record.

A Weekly 'Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A.M., M.D., Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, May W, 1907.

THE APPLICATION OF NEW JMETHODS

OF CLINICAL COPROLOGY TO THE

DIAGNOSIS OF DISEASES OF

THE INTESTINE.

The older methods of coprology, including' the
chemical method of Hoppe-Seyler and the micro-
scopic method of von Jaksch, sought merely to de-
termine the principal constituents of the feces,
without regard to the character and quantity of the
ingesta and their consequent effect on the digestive
organs. The physiological method of the Vienna
school abandons minute analysis, and merely deter-
mines the proportions of proteids, carbohydrates,
fats, and ash as indicative of the mode of nutrition
and the power of intestinal absorption. ( Rene Gaul-
tier, La Science ait XXinc Sicclc. January 15,
1907).

The new methods, as employed by Dr. Albert
Robin, are based upon the examination of the fecal
residuum of a test meal, so composed as to call forth
the activities of the various intestinal glands, so
that, in the case of normal digestion, only traces of
the constituents of the meal appear unchanged in
the feces, and in other cases the condition of the
intestine and its glands may be inferred from the
degree to which the various aliments have been as-
similated. The dejecta of the test meal are easily
differentiated from other feces by the administration
of a capsule of carmine powder before and after the
meal. The feces, thus differentiated, are examined
microscopically, chemically, and, if necessary, bac-
teriologically, and the time occupied in traversing
the intestinal tract is also noted.

This method of examination, in the first place,
makes possible a more precise diagnosis of certain
disorders designated as duodenal dyspepsias. These
dyspepsias are merely symptomatic manifestations
of organic or functional disturbances, which, what-
ever their primary cause may be, have their seat in
that part of the tract which, by its production of
such substances as secretin and enterokinase, and
by its reception of the biliary and pancreatic secre-
tions plays a very important role in digestion. The
method enables us to detect, almost with certainty,
the existence of pancreatic in addition to biliary de-
ficiency, and to distinguish certain affections of the
pancreas from suspected or coexistent biliary lithi-
asis. In a word, this method of studying the func-
tional activity of the intestine completes the clinical
diagnosis by giving infomiation of defect, excess,
or other abnormality in secretion, absorption, and
peristaltic action.

From these data the physician imbued with the

principles of functional therapeutics as taught by
Robin may deduce a treatment that will modify the
perturbed functions, instead of combating imper-
fectly known causes of disease by theoretical
methods. In diseases of the liver, for example, the
determination of the degree of activity of that organ,
combined with the knowledge of the action of vari-
ous foods and drugs, will give precise and practical
indications for the treatment of disorders of its
function. The same remark applies to certain varie-
ties of acid dyspepsia. The authors have also found
the new method very useful in the diagnosis and
treatment of the varied intestinal troubles of tuber-
culosis, including the diarrhea of secretion of the
incipient stage of that disease, the gastrointestinal
atony and catarrhal enteritis, which accompany the
second stage of pulmonary tuberculosis, and the
colliquative diarrhea and ulcerous enteritis of the
final stages.

Finally, the list of the practical applications of this
method of functional exploration of the intestine
includes digestive troubles, in which no well-marked
lesions of the alimentary canal have been discovered,
and which apparently are purely functional. In
these cases the method becomes a reliable guide in
the construction of a rational diet, adapted to the
digestive capacity of the patient. Some persons, for
example, digest and assimilate fats very well, while
others, because of some physiological idiosyncrasy
which is not suspected until after the examination
of the feces, allow much of the fat ingested to pass
through the alimentary canal unchanged. Some
persons, again, possess the power of assimilating
all the albuminoids ingested, while others lose in
their stools two-thirds or even three-fourths of the
proteid constituents of their food. These various
digestive idiosyncrasies may be detected and differ-
entiated by the regular and systematic analysis of
the feces. Thus the physician can compute the
quantity of each of the proximate principles re-
quired by each of his patients, increase the amount
of foods that are well assimilated, and diminish the
proportion of those not assimilated, in accordance
with the cardinal principle that a man lives, not by
what he eats, but bv what he digests.

THE TOXIC REACTION FOLLOWLNG EX-
POSURE TO THE X-RAYS.

Evidence has been accumulating within recent years
that the deleterious effects of the Roentgen rays are
manifested not only on the skin and superficial struc-
tures of the body, but also on the internal organs.
C)f these eft'ects the most marked, and perhaps the
most dangerous, is the reaction which in many ways
simulates an acute into.xication. This may be of
such an extreme type as to produce a fatal ending,
and it is therefore a most important matter to deter-
mine the character of the trouble in order that suit-
able means may be devised for overcoming or pre-
venting this complication of a very valuable thera-
peutic procedure. The subject has recently been
studied by Edsall and Pemberton ( American Jour-
nal of the Medical Sciences. March, 1907), who
report three cases in which a most severe reaction
occurred after one exposure to the rays. Two of
these ended fatally, while the third patient became

774

MEDICAL RECORD.

[May Ti, 1907

profoundly ill, but ultimately recovered. Fortu-
nately, the writers had, for another purpose, made
some studies of the metabolism in two of these pa-
tients, before the application of the .r-rays, and
were thus enaliled to determine the alterations at the
time of the reaction. In one case the .i--rays were
applied for the treatment of a pernicious anemia, the
exposure being- brief and of mild intensity. Within
a few hours the man became violently ill. there was
a chill, the temperature rose to 103.4° F., the pulse
became rapid and weak, and general prostration was
marked. During the following week there was some
improvement, but the change was slight and three
weeks later the patient died.

The second patient presented the typical lesions of
rheumatoid arthritis, and .r-ray exposures were or-
dered for the treatment of his joint conditions. Only
one was given, and this involved merely the arm,
but as the trunk was not screened it received a more
or less diffuse exposure. Here also there followed a
condition of prostration which verged on a moribund
state, but from which recovery took place within a
week. It should be noted that in lx>th of these cases
there was evidence of a general toxic condition, as
shown by the slight rise of temperature, nausea and
vomiting, loss of appetite, and moderate prostration.
The chief point in the metabolism of these two pa-
tients is the remarkable drop in the excretion which
followed the exposure, this drop being followed by
an equally striking rise in the excretion to a point
much beyond that which it had previously been.
This drop was not due to a reduction in the food,
for in one instance it occurred before any reduction
in the food had taken place, and in the second there
was no marked reduction in the intake.

In explanation of this curious phenomenon, the
authors venture to suggest a theory based partly on
what we already know regarding the action of the
.f-rays in increasing tissue destruction. It is prob-
able that, when the patient suddenly becomes toxic,
this is due to the fact that the organism is over-
whelmed by the necessity for carrying on the com-
plete disintegration of a mass of products of tissue
destruction, and, as the body reacts, the complete
disintegration is accomplished and the products are
excreted. The fact that the patients were already the
subjects of toxemia helps to explain the reason for
the occurrence of the condition under circumstances
which would not normally have been present. It
also offers an explanation of the fact that a toxic
reaction occurs only occasionally, and serves as an
indication of w-hen to beware of employing the .r-
rays as a remedial measure : for, when a certain de-
gree of general intoxication is already present, the
additional demands upon metabolic activity pro-
duced by the rays may serve to turn the balance in
an unfavorable direction.

VON BERGMANN'S LAST ILLXESS.

It is not unusual to find that the fatal illness of
well-known medical men is surrounded with con-
siderable mystery, and the daily press in particular
is apt to contain speculations without number as
to the probable cause of death in such instances.
Thus in the case of the celebrated surgeon von
Bergmann it was variously reported in the cable

dispatches to the American press that he had died of
appendicitis, of peritonitis, and of cancer, and we
find that even among the German papers no
authentic account ajjpeared regarding a matter
which was the subject of so much interest on the
part of his colleagues.

This entirely legitimate desire for information
has been satisfactorily met by the publication of a
report in the Deutsche mcdicinische Wochenschrift
(April II, 1907) by Professor H. Schlange. who
attended von Bergmann in his last illness. It
seems that the latter had suft'ered more or less
from intestinal disturbances which were traced to
an attack of dysentery contracted during the Russo-
Turkish war, in which campaign Professor von
Bergmann ti:)ok an active part as a military sur-
geon. During the succeeding years several attacks
occurred whicii sinndated intestinal obstruction but
were invariablv relieved by local treatment. Dur-
ing the past year the patient gradually lost weight
and strength and was troubled a great deal with
sciatica. In ]\Iarch last evidences of chronic in-
testinal obstruction again appeared, and this was not
relieved by the usual means. The distention in-
creased, the abdomen became very tender, and it
appeared to Professor Schlange, who had been
called in consultation, that an incomplete obstruc-
tion of the gut had been converted by the presence
of a peritonitis into a complete one. On account
of the extreme weakness of the patient, it was
thought advisable to make an artificial anus under
local anesthesia, which was accordingly done in the
region of the cecum. The distended cecum was
opened within a very few minutes, and after the
passage of considerable flatus and some fecal mat-
ter, the patient for a time felt greatly relieved.
Very soon he grew weak again and within twenty-
four hours the distention returned. The pain be-
came intense and von Bergmann begged that re-
lief be given by the formation of another artificial
anus on the left side. This was accordingly done,
a section of the descending colon being brought
out and sutured in the wound. There were many
evidences of an extensive peritonitis, and although
some relief was secured after the gas was passed,
there was no improvement in the objective symp-
toms. The patient grew gradually weaker, and
death followed about twentv^ hours later without
any attendant suft'ering.

Von Bergmann himself had asked that an autopsy
be made, and this showed the presence of very
■ extensive peritonitis. The ascending and trans-
verse colon was so intensely dilated that rupture
seemed imminent, and at the site of the splenic
flexure was a sharp, angular constriction which
was firmly fixed by dense bands of adhesions. The
pancreas was considerably hypertrophied, and there
were numerous areas of fat necrosis scattered
throughout the abdominal cavity. Otherwise no
abnormal lesions were found. The complicated
nature of the case shows that there was little pos-
sibility that a previous operation could have saved
the patient's life, and the autopsy findings prove
conclusively that there were no evidences of malig-
nant disease pre-^ent as was stated in some of the
earlier reports.

;\Iay II, 1907]

MEDICAL RECORD.

775

A Suggestion in Regard to the Treatment of
Leprosy.

The therapeutic problem of leprosy has so long
baffled solution that one is inclined to view with
some scepticism the report of a new method of
treatment which is considered very promising by
its originators. Deycke and Reschad, who in the
Gulhane Hospital of Constantinople have abun-
dant opportunities for observing lepers, describe in
the Deutsche inedidiiische IVochenschrift, January
17, 1907. the steps by which, after a period of ex-
perimentation extending over more than two vears,
they have been enabled to produce a therapeutic
agent by means of which they believe that a great
deal may be done towards the cure of the disease.
This substance, a crystallizable fatty body, to which,
on account of its firm consistency, the name
"nastin" is given {laarii. close-pressed), is derived
by a process of ether extraction from cultures
of a variety of streptothrix obtained from a case of
leprosy. The fatty substance in question appears,
like the fatty component of the tubercle bacillus,
to render the organism more resistant to the bac-
teriolytic powers of the body fluids. On injecting
it subcutaneously into normal individuals no re-
action is produced, but in lepers bacteriolvsis seems
to be markedly favored. This is explained by the
assumption that the nastin causes an active im-
munity whereby the body fluids acquire an increase
in antibodies hostile to the specific organism of lep-
rosy. This reaction is possible in leprosy because
owing to the extremelv chronic nature of the malady
the general powers of resistance are not impaired
to any great extent during the earlier stages of the
disease. The authors do not claim that the nastin
injections are of value in the severest or even in the
ordinary advanced cases, but they are convinced that
by this means it is possible to arrest the disease
process in slight or moderately severe cases and in
some instances to effect an actual cure. So far their
results have been obtained from the unaided use of
the new remedy, but now. having satisfied themselves
of its value, they are about to combine its admin-
istration with the usual therapeutic measures, in the
hope that in this wav still better results may be
secured.

Solar Baths in Tuberculous Peritonitis.

ConsiderjVELe divergence of opinion still exists with
regard to the treatment of tuberculous peritonitis.
Many contend that the serous form particularly is
susceptible of spontaneous cure, while others ener-
getically claim that laparotomy is the only salvation.
Among those who have had an opportunitv to follow-
up the results in a large number of cases in which
laparotomy had been done, the favorable opinion
previouslv held has been considerably modified and
internal treatment is credited with a greater pro-
portion of recoveries than the purely surgical pro-
cedures. The reason for the favorable effects after
a laparotomy has not as yet been determined, al-
though there may be some truth in the assumption
that "letting the daylight in" has brought about the
curative reaction. In the belief that sunlight was
actually the important factor, Oppenheimer {Zeit-
scbrift fiir physikaHsche nnd diafcfische Therapie,
January, 1907 ) was led to try solar baths in pa-
tients the subject of tuberculous peritonitis. He
employed the procedure in two cases with good
success, the children gaining in weight as the
ascites disappeared. The rays of the sun were

allowed to shine for definite ]ieriods daily directly
on the abdomen while the children were out in the
open air. Oppenheimer thinks that the therapeutic
effect of these sun-baths is due entirely to the local
hyperemia of the peritoneum which is produced by
the sun's rays, and that in this respect their action
is analogous to the condition lirought about bv the
performance of a laparotomy, for Xassauer among
cithers has observed that this is what actually takes
|)lace. The results obtained in Oppenheimer's cases
are by no means conclusive, but they suggest pos-
sibilities which may be employed before any more
radical measures are resorted to. We have begun
to realize that fresh air and sunlight are among the
most important curative factors in the treatment of
tuberculosis, no matter what its location in the
body, and Oppenheimer's observations lend support
to this view.

Some Dangers of the Rubber Nipple.

Apart from the fact that mothers' milk is the best
food for nursing infants, artificial feeding is at-
tended with dangers peculiarly its own. Cow's
milk is, for various reasons, more liable to contami-
nation and deterioration than mothers' milk. More-
over, the conmion method of feeding through a nip-
ple, and also the use of the device known as a com-
forter or pacifier, may be responsible for deformities
of the jaws and other secondary disorders. The
subject is considered at some length in a communi-
cation by Dr. T. F. Pedley in the British Medical
Journal for October 20, 1906, on the basis of ex-
perience in India, but his facts and conclusions are
equally applicable to other localities. As he points
out, the infant at its mother's breast takes the nip-
ple far into its mouth and exerts compression by
means of the lips and of the tongue against the pal-
ate, thus effecting expulsion of the milk. The jaws
take little or no part in the act. On the other hand
the rubber nipple of the ordinary nursing bottle,
and more especially of the comforter or pacifier, is
held firmly between the lips and is pressed by the
encircling tongue against the middle of the hard
palate, while the cheeks are drawn inward. Owing
to the small orifices often present in the rubber
nipple, the milk, instead of flowing in, must be
sucked in, and with it enters a certain amount of
air. _As a result of the conditions described, de-
forrnities of varying degree occur in the superior
maxillary bone, whoj^e transverse diameter becomes
dinnnished. witli elevation of the palatal arch and
projection forward of the alveolar process. In con-
junction with these changes the nasal fossne become
narrowed, the septum buckled, the deflected vomer
approximated to the displaced tiu-binated bones on
one side, or any or all of these delicate bones to
each other, with resulting obstruction to or abolition
of nasal respiration. Mouth breathing is thus fa-
vored, with all its unpleasant consequences. Some-
times the arch of the lower jaw is narrowed from
Contraction of the symphysis during the jirocess
of bony union. In addition there is the danger of
infection from the introduction of bacteria with the
rubber devices under consideration. The evil re-
sults described are naturalK- the greater the earlier
in life the use of the rubber nipple is begun and
tlie longer it is continued, and they are more pro-
nounced from the employment of the pacifier than
from that of the nipple. For the use of the pacifier
there is no legitimate excuse, and as a substitute
for the nipple Pedley recommends a good-sized rub-

776

MEDICAL RECORD.

[May II, 1907

ber finger stall attached to the spout of a vessel like
a feeding cup or an ordinary feeding bottle. Older
children can be taught to drink from a cup.

The Pungency of Tobacco Smoke.

A RECENT Lancet article calls attention to the fact
that probably not more than one-seventh of the
nicotine survives in the smoke. Un the other hand
some observers have failed to find any nicotine at
all in the smoke, and have considered pyridin as
the harmful constituent. This body forms a large
element in the oil which collects in the tobacco pipe,
and this oil is very poisonous. It would appear,
therefore, that the toxicity of tobacco may not have
any relation at all to its nicotine content, and it is
well known that some tobaccos contain a very
small proportion of nicotine yet yield a smoke which
is decidedly toxic. Certain Turkish tobaccos, for
example, are almost free from nicotine, while they
produce a pungent toxic smoke. It would be pretty
safe to assert that all smoke is more or less toxic.
If wooden shavings were substituted for tobacco
in the pipe there can be little doubt that the smoke
Avould have evil eflfects, but there is no nicotine in
wood. The fact is, that the toxicity and pungency
(though the terms are not necessarily interchange-
able) of tobacco smoke are dependent chiefly upon
the nature of the products of destructive distilla-
tion of the plant fiber. The pungency of tobacco
smoke seems, at any rate, to bear some relation
to the proportion of organic acids present in the
leaf. The amount of these acids, amongst which
citric and malic acid are chief, varies widely, and
as a rule that tobacco gives the softest and least
irritating smoke which contains the smallest amount
of organic acid. The citrates and malates on de-
structive distillation give acid products. Of two
cigarettes the tobacco of which contains approxi-
mately the same amount of nicotine, one may be
found to give an unirritating and the other an acrid
smoke. \Mien the two tobaccos so concerned are
further examined it may be found that one gen-
erally yields a larger ash than the other, corre-
sponding with a larger proportion of organic acid.
The tobacco wdth a larger proportion of organic
acid is more liable to give an irritating smoke. In
spite, however, of all the learned, and oftentimes
unlearned, ratiocination that has been devoted to
the subject of tobacco smoking, it appears that we
still have not progressed much further than the
empirical observation that the injuriousness or
harmlessness of the w-eed depends not so much on
its character or on the way it is used, as on the kind
of man who does the smoking.

Acute Pulmox.-\ry Edem.\.

Edema of the lungs is most commonly met with in
states of lost compensation during valvular or mus-
cular heart disease, in conditions of cachexia, in
grave infectious diseases, or in the terminal phases
of acute or chronic nephritis. In addition to this
form there is another which is independent of the
above factors, but which from the suddenness of its
onset, the alarming character of its symptoms, and
the mortal peril in which it places the patient,
closelv resembles angina pectoris, and should there-
fore demand an equal degree of attention. Riesman,
writing in the American Journal of the Medical
Sciences for January, 1907, calls attention to the
fact that, although this condition has been recog-

nized for a long time, it receives very little or no
mention in our textbooks. The condition, as shown
by the cases hitherto reported, including six by
the writer, comes on without apparent cause, and
often kills within a short time. It is associated
with a variety of affections which in the clinical
sense may be considered in the light of causes,
among which are arteriosclerosis, nephritis, angina
pectoris, myocarditis, valvular lesions, asthma, the
acute infectious diseases, pregnancy, angioneurotic
edema, and certain other obscure conditions such as
hysteria. Recovery from an attack is frequent, but
there is a striking tendency to recurrences. The
pathogenesis is obscure ; Riesman considers that
vasomotor disturbances and a disproportionate activ-
ity of the two ventricles, in which the right pre-
dominates, are the two chief factors. The leading
symptoms of this state are agonizing dyspnea, cya-
nosis, cough, expectoration of frothy, albuminous
fluid, and profound prostration. The characteristic
moist rales of pulmonary edema are always heard,
more over the upper portions than over the lower.
Treatment to be effective, must be prompt. The
most valuable remedies have been found to be
venesection, dry cupping, and cardiac stimulants.
As Riesman truly states, this condition is of suffi-
cient importance to warrant its being accorded a
special chapter in medical textbooks commensurate
with that given to angina pectoris.

5Jpuis of til? Wttk.

Council on Medical Education of the American
Medical Association. — The third annual educa-
tional conference of this Council was held at the
Auditorium Hotel, Chicago, April 29. There were
present eighty-four delegates, representing twenty-
two State Examining Boards, eighteen State Medi-
cal Societies, the three departments of the Govern-
ment services, three college associations, and
seven colleges of liberal arts, in addition to
the members of the Council. The W'Ork of
the past year was pointed out in reports by
the chairman and secretary. Accounts of the
inspection of medical schools were given, as
well as the classification of schools based on the
State Board examinations during 1904 and 1905,
inclusive. Forty-four colleges have adopted the re-
quirements for admission to medical study of at
least one year fn a college of arts to be devoted to
physics, chemistry, biolof"- and one lansruage, to
become effective Januarv 1, 1910. Eighteen of these
will require two years or more of university work,
or plan to give the combined course for the degrees
of B.S. and ]\I.D. Several committees reported.
Dr. Arthur Dean Bevan was chairman of the con-
ference.

Confederation of State Medical Examining and
Reciprocating Boards. — This body met at the
Auditorium Hotel. Chicago. April 30. At the meet-
ing a definite step was taken towards the elimina-
tion of undesirable medical colleges which issue
diplomas to incompetent and ignorant medical stu-
dents. A committee was appointed by the Confed-
eration to investigate that class of medical colleges
throughout the country and report as to their qual-
ifications to carry out the work for which they
were established. Accordingly President Spurgeon
appointed the followinsf committee : Drs. W. A.
Spurgeon, Indiana : B. D. Hanson. Michigan : B. F.
Bailey. Nebrasica : J. B. Stephens, Wisconsin, and
A. H. Hamel. Missouri.

May II, 1907]

MEDICAL RECORD.

777

Pennsylvania Antivivisection Bill Killed. — An

act intended to prevent vivisection and animal ex-
perimentation of any kind, either for demonstration
in physiology, for scientific research, or for any
purpose whatever, which had been quietly intro-
duced into the Pennsylvania Legislature, and had
already passed the second reading, was summarily
withdrawn from the calendar on the personal ap-
peal of a group of distinguished medical men headed
by Dr. S. Weir Mitchell of Philadelphia. Dr. Mit-
chell pointed out, among other things, that by the
provisions of the proposed act it would be impos-
sible to prepare in the State virus for vaccination
and also diphtheria antitoxin, as well as to perform
various operations on animals common in the farm-
ing industry.

New Dispensary for the Philadelphia Poly-
clinic.— Plans have been completed and estimates
have been invited for the erection of a two-story
brick and granite dispensary building as an addition
to the present accommodations of the Polyclinic
Hospital. The new building will be about 80 by 80
feet in size and will contain seven bedrooms, a stu-
dents' lunch room, kitchen, pantry, four wards, a
room for delirious patients, a laboratory, two nurses'
rooms, a matron's room, rooms for the treatment of
diseases of the skin, nervous system, eye, ear, throat,
and nose, lecture rooms, rooms for orthopedic dem-
onstrations, for resident physicians' offices, a stu-
dents' room, a record room, a pharmacy, a room
for massage, two operating rooms, an etherizing
room, a sterilizing room, and a large solarium.

Medical Unification Bill. — On May i the Sen-
ate at Albany passed the so-called medical unifica-
tion bill by a vote of 40 to 7. This substitutes one
board for the present three Medical Examining
Boards; and also gives greater recognition to the
osteopaths.

Women's Labor Bill. — The Senate at Albany has
passed the Hooper bill, which provides that women
or minors shall not be employed before 7 .\.m or
after 10 p.m., nor for more than ten hours in any
one day, except on .Saturday, or except for the pur-
pose of making a shorter workday of some one day
in the week.

Railway Accident Mortality. — The bulletin re-
cently issued by the Interstate Commerce Commis-
sion for the three months ended December 31 last
shows that during that quarter the total number of
casualties to railroad passengers and to railway
employees while on duty was 20,944, an increase
of 1,094 over those reported during the preceding
three months. The number of passengers and em-
ployees killed in train accidents was 474, an in-
crease of 207 over the number reported in the last
quarter. The number of passengers killed, 180, is
the largest on record, except that for the quarter
ended September 30, 1Q04.

Trachoma Among School Children. — According
to the Health Department figures, trachoma is rap-
idly decreasing among school children in this city.
There are only 8,700 cases in New York schools
now, as compared with the 15,000 of a few years
ago. Further accommodation for the operative
treatment of the disease is advocated and the sub-
ject will be discussed at the next meeting of the
board.

Dr. Bryant Honored. — At the regular quarterly
meeting of the faculty of the New York University
and Eellevue Hospital Medical College, Chancellor
MacCracken announced that the university cor-
poration had conferred the degree of Doctor of

Laws upon Dr. Joseph D. Lryant, Professor of
Anatomy and then of Surgery for the past twenty-
nine years, and President of the American Medical
Association. The degree was conferred by the Rev.
Dr. George Alexander, chairman of the university
corporation.

New York Academy of Medicine. — At the
stated meeting of tiie Academy, held May 2, the
report of the work of the surgical research labo-
ratory of Columbia University, 1906-1907, was
made. There were presentations of specimens, in-
struments, and papers, with lantern slide demon-
strations.

Osteopathic Bill Vetoed by the Governor of
Pennsylvania. — Dill No. 211, passed by the Legis-
lature of the State of Pennsylvania, has been velued
by Governor Stuart. The bill, known also as the
\V'ickersham bill, provided for the establishment of
a fourth Board of Medical Examiners in addition
to the three already in existence, and the granting
of representation to osteopaths on the Medical Coun-
cil. It is pointed out by the Governor that only
physicians of ten years' graduation or more are
eligible for membership on the Medical Examining
Boards, while the new bill contemplated the appoint-
ment of osteopaths of four years' standing or more.
It was further provided that any regularly gradu-
ated osteopath who had been in practice in the State
at the time of the passage of the act should be en-
titled to license without examination, and also that
regularly graduated practitioners of ten years'
standing or more in other States should, upon the
recommendation of the State Board of Medical Ex-
aminers, be entitled to a license without examination,
while not regularly graduated osteopaths engaged in
practice for two years should be eligible to exam-
ination.

Cocaine Bill. — The attempt to change by an
amendment the original Smith anticocaine bill, now
before the State Senate, was voted down last week.
The Senate codes committee instroduced an amend-
ment whereby the selling of the drug without a phy-
sician's prescription would have been made a mis-
demeanor instead of a felony, as in the original bill
passed in the Assembly. By a vote of 42 to 2 the
bill was restored to its former form.

Workingmen's Health Insurance in Holland. —

A measure providing for obligatory workingmen's
insurance resembling the system now in use in
Germany is under consideration by the States-
General of Holland. The principal provisions of the
law are : Every laborer regularly employed, includ-
ing domestic servants, who has reached the age of
sixteen years, is obliged to insure himself and fam-
ily against the risk of illness. Those whose annual
income is higher than 1,200 florins ($480) are not
required to insure. The insurance can take place
either in a district bank, instituted by the Govern-
ment and subsidized by the State, or in any private
or corporate insurance company, provided such in-
stitution shall give a sufficient guaranty to the Gov-
ernment of its ability to fulfill their obligations to
the district bank. The premium is paid by the em-
ployer, who deducts the amount from the worker's
wages. The whole country is divided into insurance
districts, so that each community or aggregation of
more than 5,000 people has its own district insurance
bank. The indemnity in case of illness consists of
free medicine, medical attendance and a sick bene-
fit if the illness lasts more than two days and causes
inability to work. If the disability is complete "o per
cent, of the wages is paid out ; if only partial 35

778

MEDICAL RECORD.

[May II, 1907

per cent, is jiaid. The coiiiiJensation is paid during
180 days at the utmost.

To Inspect Cuban Hospitals. — Surgeon-General
O'Reilly, after a tour of inspection in Porto Rico,
has gone to Cuba to inspect the hospitals of that
island.

Queen's Medical Laboratories. — The corner-
stone of the new medical laboratories building at
Queen's, Kingston, Ont., for which the Ontario
Government voted $50,000, was laid on Wednesday,
.\pril 24, by Lieutenant-Governor Clark of Toronto,
immediately following the convocation proceedings.
The building is now well under way. Besides be-
ing used for biological purposes, the pathological,
bacteriological, and public health laboratories will
be in it.

For New Italian Hospital. — The Supreme
Court has signed an order permitting the Italian
Benevolent Institute to mortgage its property at
165. 167, and 169 Houston street, in order to raise
funds for the building of a new hospital. The Ital-
ian Government has contributed $60,000 for the en-
dowment of the proposed hospital. The real estate
at present held is estimated to be worth $62,000,
and the personal property $76,000. The indebted-
ness of the society is no.w $15,000. The proposed
mortgage is for $57,000, and bears no interest.

Jefferson Medical College (Philadelphia). — In
connection with the dedication of the new hospital
the members of the faculty of this institution have
arranged for a series of clinics, ward walks, and
demonstrations for visiting physicians, to be held
on June 8, 10, 11, and 12. The committee of ar-
rangements has the following members : Dr. H.
Augustus Wilson (chairman). Dr. Henry W. Stel-
wagon. Dr. Edwin E. Graham, Dr. J. Chalmers
Da Costa.

Additions to the Michael Reese Hospital Staff. —
The followin,g additions have been made to the staff
of this institution : Attending surgeons, Drs. L. A.
Greensfelder, D. N. Eisendrath, and E. Friend ; at-
tending physicians, Drs. M. F. Rubel, and T. B.
Sachs ; attending gr}'necolo.gists and obstetricians,
Drs. L. Simon and .\. W. Schramm ; dermatologists,
Drs. E. A. Fischkin and D. Lieberthal ; attending
pathologist. Dr. ^Maximilian Herzog: attending
The Senate codes committee introduced an amend-
ing genitourinarv surgeon. Dr. Louis E. Schmidt;
orthopedic surgery. Dr. C. M. Jacobs ; children's dis-
eases. Dr. J. H. Hess.

Appointment of Dr. Wilder. — Dr. Wm. H.
\\'ilder has been av)i)ointcd Professor of Ophthal-
mologv in the medical department of the University
of Chicago (Rush Medical College), a position va-
cated by Dr. F. C. Hotz.

Professor E. v. Behring, who some months ago
was compelled to give up all work owing to severe
neurasthenia, is reported as being completelv re-
stored to health and about to return to Germany
from Italy, where he has been spending the winter.

Meningitis at Newport. — Another death from
cerebros]iinal meningitis has occurred at the New-
port Naval Training Station. The patient was an
apprentice seaman who enlisted four weeks ago.
and the other men of the same draft are being held
in the detention building, though no other cases
have developed. •

The Clinical Society of the Jewish Hospital. —
This society held its first meeting at the Jewish Hos-
pital, Classon and St. Mark's avenues, Brooklvn.
on Friday, Mav lo. Its membership will consist of
the house, visiting, and dispensarv staffs of the hos-

pital. The object of the society is to further the
interests of medical science, with the aid of the
large and varied clinical material at the disposal of
its members.

International Congress on Tuberculosis. — Plans
on a large scale have already been formulated for
the International Congress on Tuberculosis to be
held in \\'ashington, D. C, durinar the last ten days
of September and the first ten days of October,
1908. In addition to the scientific conventions it
is expected to have a very extensive and complete
tuberculosis exhibition, with exhibits from a great
number of different countries. The attendance of
foreign delegates is likely to be a large one, and
thirty public lectures by visiting scientists have been
arranged for. The congress is to be held under the
auspices of the National Association for the Study
and Prevention of Tuberculosis, and the committee
engaged in the work of organization at present in-
cludes Dr. Lawrence Flick of Philadelphia, Dr.
Vincent Y. Bowditch of Boston, Dr. .Alfred Mever
of New York, Dr. J. J. Walsh of Philadelphia. Dr.
Lawrence Litchfield of Pittsburg, and Dr. Charles
J. Hatfield of Philadelphia. The committee has ap-
pointed a Secretary-General, Dr. John S. Fulton,
of Baltimore, who has opened an office in the Colo-
rado Building, in \\'ashington, and will devote all
his time to the organization of the Congress. The
sum of $100,000 Inas already been pledged to de-
fray expenses.

International Medical Association for the Pre-
vention of War. — A meeting will be held in the
Hotel Holmhurst, Atlantic City, on June 5 at 8 p.m.
to organize formally the American Section of the
International Medical Association for the Preven-
tion of War. .\I1 physicians interested are invited
to be present. The president of the American Sec-
tion is Dr. Wm. Benham Snow of this city and the
secretarv is Dr. George Brown of Atlanta, Ga.

New York Entomological Society. — At the
meeting of this society, held at the American Mu-
seum of Natural History on May 11, the subject of
the transmission of disease through the mediation
of insect'; was di'^cussed by Mr. C. Schaeffer.

Berkshire County (Mass.) Medical Society. —
At the meeting of this society, held in Pittsfield on
April 25. officers were elected as follows: Presi-
dent, Dr. George L. Rice of North Adams ; Vice-
President. Dr. T. I. Hassett of Lee: Secretarv. Dr.
I. S. F. Dodd "of "Pittsfield; Treasurer, Dr. W. L.
Paddock of Pittsfield.

Southeastern Michigan Homeopathic Society.—
Officers as follows were elected at the meeting of
this society, held in Detroit on April 26: President,
Dr. E. J. Kendall; First Vice-President, Dr. Hale
of Memphis. Mich.; Second Jlce-President, Dr.
E. L. Orneman : Secretary, Dr. F. E. Thompson;
Treasurer. Dr. James I. Murray.

Windham County (Conn.) Medical Society. —
At the one hundred and fourteenth annual meeting
of this organization, held in Norwich on April 25,
officers as follows were elected : President. Dr. C. J.
Le Qaire of Danielson ; J'icc-President, Dr. R. O.
Paine of Thompson : Secretary and Treasurer, Dr.
Tames L. Gardiner of Central ^'^lIage.

Calcasieu (La.) Medical Society. — At the meet-
ing of this society held on April 26 officers were
elected as follows : President, Dr. V. A. Miller of
Lake Arthur: ]' ice-President, Dr. T. H. Watkins ;
Secretary and Treasurer, Dr. George Kreeger.

Dr. Paul Poirier, Professor of Anatomy in the
L^niversitv of Paris, died last week.

]\Iay II, 1907]

MEDICAL RECORD.

779

Obituary Notes. — Dr. William H. Hotch-
Kiss of New Haven died on j\lay 2 at the age of
sixty years. He was oraduated from the Yale
Medical Scliool in 1869 and had at one time prac-
tised in St. Louis.

Dr. Charles Laigiit, son of the late W'ni. £.
Laight. died in Rome. Italy, March 31, 1907. He
was graduated from the College of Physicians and
Surgeons of this city in 1868, served as interne on
the surgical division of the New York Hospital
1868-70, and later was connected with the New
York Eye and Ear Infirmary until 1880. For many
years he resided in Rome, Italy, coming to this
country each summer to spend the season at his
place in Keene Valley, in the Adirondacks. In-
terment took place at Rome,

Dr. George H. Fossard of Brooklyn died on JNlay
3 at the age of sixty-eight years. Dr. Fossard was
^born in Albanv and was graduated from the Al-
bany Medical College. After serving through the
Civil War as surgeon he practised medicine in j\Iid-
dletown. Port Jervis, and this city. He had not
practised for many years.

Dr. Wilson C. N. Randoli'H of Charlottesville,
Va., a great-grandson of Thomas Jeflferson, died
on April 26 at the age of seventy-three years. He
was graduated from the medical department of the
University of Virginia in 1855 and for sixteen years
was a member of the Board of Visitors of the Uni-
versity.

Dr. J. B, Charlton of Clear Lake. la., died on
April 27 after a long illness. He was born in 1845
in Pennsylvania, but in 1856 his family settled in
Keokuk. He served in the Eighteenth Iowa Infan-
try through the Civil ^\'ar, and in 1872 received his
medical degree from the Iowa State L^niversity.
He immediately began jiractice in Clear Lake, where
he had resided ever since. He was four times
mayor of the city.

Dr. John ^^'ILS0N of Liberty, Mo., coroner of
Clay County, was killed in a runaway accident on
April 19, at the age of thirty-six years. He re-
ceived his medical education in Kansas City and
had practised in Libertv for the past eleven years.
Dr. C. B. Currier of San Francisco died on April
18. He was a native of New England and prac-
tised for a time in Vermont. In 1875 he moved
to New York city and four years later went to San
Francisco, where he had practised ever since. He
was one of the founders and the first dean of the
Homeopathic Medical College of San Francisco,
and in 1906 was president of the California State
Homeopathic Medical Society. He was also a
trustee of the San Francisco Societv for the Pre-
vention of Cruelty to Animals.

Dr. Herbert K. Stiles of Somerville, Mass., died
of pneumonia on April 27, at the age of thirty-
eight years. He was a graduate of Amherst and
received his medical degree from the Harvard Med-
ical School in 1895. He had practised for a time
in Roslindale, removing to Somerville seven vears
ago.

Dr. B. F. ToMLiN of St. Louis died on April 26.
after an illness of ten days. He was born in Pen-
dleton, Ky., in 1834 and was graduated from ^^'il-
liam Jewel College, Liberty, Mo., in 1857. He was
Cfraduated from the Cincinnati Medical College in
1865.

Dr. Felix Ferriere of St. Louis died on .\pril
29 at the age of eighty-six vears. He was born
in Bordeaux. France, and came to this conntrv in
1847. After practising for a time in New Orleans
he removed to St. Louis in 188^.

Dr. Henrv R. Havden of Los Angeles died on
April 20 at the age of sixty-two years. He was born
in Winchester, la., and after serving in the Civil
War was graduated from Keokuk Aledical College
in about 1867. He practised for a time in Camden
and Crete, Neb., and five years ago removed to Los
Angeles.

Dr. Ray P. Roeeins of Portland, Ore., died on
April 16 of cerebrospinal meningitis. He was a na-
tive of Minnesota, and had practised in Portland
for about three years.

Dr. Fr.^nk p. ^^■EE^TER of Norfolk, Va., died
suddenly on April 20. He was born in Portsmouth,
but had resided in Norfolk for manv vears.

(EorrpBpouJipttrp.

VENEREAL DISE.-\SE IN THE CONTINENTAL
ARMY.

To THE EniTOR OF THE AIedic.\l Record :

Sir:— .-Xs the years roll on the character of the Revolu-
tionary soldiers becomes heroic in our minds, largely be-
cause of iteration of their real achievements and partly
from a general consciousness of the great importance to
us and all mankind that their struggle for liberty involved.

But, although it comes with something of a shock, sober
history reveals them as pretty much like other soldiers
away from home. The Continental Congress found it
necessary to make venereal disease expensive to the sol-
diers of freedom. On January 6, 1778, Congress voted:

"That the ■<um of ten dollars shall be paid by every
officer, and the sum of four dollars by everv soldier, who
sli:dl enter or be sent to any hospital to be cured of the
venerea! disease; which sums shall be deducted out of their
pay. and an account thereof shall be transmitted by the phy-
sician or surgeon who shall have attended them, to the
regimental paymaster for that purpose; the money so aris-
ing to be paid to the director-general, or his order, to be
appropriated to the purchasing of blankets and shirts for
the use of sick soldiers in the hospital."

Thus, it appears, that the followers of Mars who dallied
with Venus were mulcted for the benefit of the patriots
whose forms of illness had more claim upon the gratitude
of a struggling republic. The humanness of the conditions
which led to the vote may shatter an ideal or two. but the
fact brings the American Revolutionary soldier much nearer
to us in actual life than he ever appeared before.

John G. Coyle, M.D.
226 East Thirty-first Street.

OUR LONDON LETTER.

From Our Special Correspondent. < E^3

•XMEBIC hepatitis and dysentery — INDIAN FEVERS — HYS-
TERECTOMY— PUBIOTO.MY- — DR. RENTOUL ON WO.MAn's HEALTH
COLLEGE OF SURGEONS' PRIZES — PROPOSED BIRMINGHA.M SAN-
ATORIUM— OBITUARY.

London. ,\pril ig. 11J07.
In a paper on amebic hepatitis at the Medico-Chirurgical,
Prof. Leonard Rogers related fifteen cases of fever, in
nearly all of which acute hepatitis was present with a pe-
culiar form of leucocytosis. He regarded this as the early
stage of amebic dysentery which usually went on to sup-
puration, constituting amebic abscess of the liver. Large'
doses of ipecacuanha were given in most cases, even in the
absence of any symptoms of dysentery, with a view of
arresting latent disease of the larger bowel. The result was
a rapid cure of the hepatitis and of the dysentery when
present, with cessation of the fever. In some cases there
were no symptoms of hepatitis, the cause of the fever re-
maining unknown until a blood examination showed the
leucocytosis. Then the ipecacuanha was given and the
fever ceased. In one-third of the cases exploratory opera-
tion for liver abscess was tried with negative results, but
the patients recovered under ipecacuanha, and Prof. Rogers
said this dru.g should be administered before operative
procedures whenever there was a doulit about abscess hav-
ing been found in the liver.

Sir Patrick ^lanson said ipecacuanha was a specific in
amebic dysentery, but useless in the bacillary form. It
had too often been given in insufficient doses or not con-
tinued long enough. He gave large doses for a week fol-
lowed by smaller ones for at least a month. In amebic

78o

MEDICAL RECORD.

[May II, 1907

hepatitis its accidental use had given him some success,
and ui future he would use it in threatening abscess of the
liver.

Sir I,. Brunton suggested that ipecacuanha killed the
anicba and that the leucocytosis might be due to the irrita-
tion of Peyer's patches by the dysenteric process.

Dr. .\nderson said he had found that chloral given with
the ipecacuanha greatly lessened the distress caused by the
nausea and vomiting. Chloral he found much better than
opium for this purpose.

Mr. Cantlie remarked that the temperature very often
fell and the symptoms disappeared in cases of hepatitis
after merely putting a needle into the liver.

Prof. Rogers having made some remarks in reply, read
another paper on a short fever which he thinks should be
differentiated from malaria or continued fever, as which it
has hitherto been returned. From a study of 1,350 consec-
utive cases of fever in Calcutta he has separated this type
by the blood changes and symptoms. It begins with severe
headache and pain in the back and limbs, lasts six or seven
days, and may be mistaken at first for typhoid, as the pulse
is slow relatively to the temperature, contrasting with that
of malaria. This seven-day fever occurs in the later hot
weather and early monsoon months in Calcutta and de-
clines when the malarial rise takes place at the close of the
rainy season, the two fevers making one curve through
both seasons, and so have been regarded as one. The sea-
■sonal prevalence differs from influenza. It has been re-
garded as dengue, but the temperature curve and other
characters are very different. It has probably been con-
fused with both dengue and malaria.

Dr. Anderson said this fever reminded him of a common
type in the Northwest Province, called "ardent fever," in
which quinine was useless but cold sponging and bromides
relieved.

Sir P. Manson said there were many different types of
fever in India and thi-- ■' • -- ■"■■ He thought them protozoal
— not bacillary.

Obstetricians have i what preoccupied w'ith sur-

gical procedures. At their society ilr. J. D. Malcolm has
strongly advocated the removal of the cervix in hysterec-
tomy. He argued that when left with the blood supply
partly cut off and its narrow central tube lined with mucous
membrane, the cervix offered a favorable nidus for the de-
velopment of microbes in the divided uterine tissues, while
the provision for drainage of discharges w'as imperfect.
This view was controverted by other speakers. Mr. Doran
said the cervix was an important part of the pelvic floor
and it might be that not only the cervix but a little more
of the uterus should be spared. Long after-histories were
important and by them he had shown the value of the so-
called sub-total operation in sixty cases. Dr. Amand
Routh said he, too. was not convinced by Mr. Malcolm's
arguments. He did not think the blood supply was cut oflf
nor that the cervix when left tended to de.generate. The
mortality of panhysterectomy was undoubtedly larger.
Pozzi's statistics of l.ooo collected cases showed a mortality
of 10.4 per cent, against 7.4 per cent, for the sub-total opera-
tion. It was also certain that the cervix had an internal
secretion. If organs were removed on account of possible
future dangers, where should we stop? Dr. Eden said he
had been satisfied with both operations, but preferred the
sub-total except in special circumstances. He was not con-
vinced by IsIt. Malcolm's arguments. The President, Dr.
Herbert Spencer, said he had performed many total ab-
dominal hysterectomies to the entire exclusion of partial
operations for the past six years. He still held that the
total operation, performed by Doyen's method, was best.
It provided drainage, gave security against injury to the
bladder or ureters, and against unreco.gnized hemorrhage, it
removed the cervix, which might become infected, slough,
or develop malignant disease: further, it was less likely to
be followed by intestinal obstruction. The supposed ad-
vantage of the internal secretion and slight shortening of
the vagina could not be set against those advantages.

.\nother operation occupying obstetricians is Doderlein's
subcutaneous pubiotomy, wdiich seems an important im-
provement on Gigli's open incision of the os pubis as a
substitute for the rather unsatisfactory symphyseotomy.
The subject has been brought before the Royal .■\cademy of
Medicine in Dublin, where the school of midwifery has so
long held a reputation second to none. Dr. M. J. Gibson
of the Coombe Hospital related three cases. The patients
refused cesarean section but had no dread of the minor
proceedings and neither of them subsequently show^ed any
difference from a normal labor. .Ml three infants were
suckled. The advantages over symphyseotomy were stated
to be that the pelvis is prevented by the undivided soft parts
from springing suddenly apart, the bladder and urethra are
less liable to iniury, and the operation is more easily and
more rapidly performed. It is a mode of overcoming the
difficulties of the lesser degrees of contraction of the pelvis
without iniurv to mother or child.

The Master of the Rotunda, Dr. Hastings Tweedy, de-
tailed a case of a primiparous woman whom he had deliv-
ered of a living child through an internal conjugate of 6.5
cms. at full term by this operation. Hemorrhage had been
very severe with considerable collapse. Deliverj' had to
be hastened on account of prolapse of the cord and there-
fore the operation was done. Laceration of the cervix,
perineum, and soft parts between the severed bones required
catgut sutures. The patient left hospital in the ninth week
with a living child.

Sir A. V. Macan remarked on the ease with which the
operation could be done. There was nothing in it to deter
anyone who had been through the Dublin school and it
gave the country practitioner the chance of saving mother
and child w-hen forceps had been tried and failed.

Dr. Neil said the risk of sepsis was less than in induction
of premature labor, and Dr. Alfred Smith said the opera-
tion had come to stay.

Dr. Jellett suggested that there were two classes of cases,
those in which there was reason to believe forceps would
fail and those in which forceps had been tried and failed.
The ease with which pubiotomy was done would tend to
diminish mortality.

Dr. R. D. Purefoy (President) said cesarean section in
some cases could not be sujierseded. The danger of pubi-
otomy, had. perhaps, been passed over • ';' 'ly. Injury
to the bladder had been recorded, a fat;: :a hemor-

rhage had occurred in Vienna. .\gree;i.-. ,.^ ij the value
of the procedure, he still wondered if the locomotive powers
of the patients had been satisfactory afterwards or if time
enough had elapsed to determine that point.

In reply it was stated that the bladder was not so closely
connected with the os pubis that tearing would result un-
less there were adhesions from previous puerperal sepsis,
and the undivided soft parts gave additional protection. If
hemorrhage could not be stopped by compression the wound
could be opened and the source of bleeding found. The
operation was safer than cesarean section up to a conjugate
above 6.75 cm. It was the easiest plan for the practitioner
far from skilled assistance.

Dr. R. R. Rentoul lectured on Monday at the Institute
of Hygiene on "Woman's Health: Our Greatest National
.^sset." He vigorously denounced our neglect of this sub-
ject, as well as woman's increasing desire to avoid the
duties and responsibilities of motherhood. He declared
that the child-hating married woman w'as a demoralized
person whose desires were limited to a rich husband, a flat,
a poodle, and a male hanger-on. She was a menace to the
race, while the mentally healthy woman represented the
. best thing in life — motherhood. He advocated drastic re-
form of the marriage laws, encouragement of the healthy,
and discouragement of the unhealthy to marry. He pro-
posed to raise the marriageable age to 25 for men and 21
for women, to require a prenuptial medical certificate of
good health, to make it illegal for diseased persons to
marry, to abolish actions for breach of promise w'here dis-
ease existed, to prohibit paupers and vagrants from marry-
ing, to tax bachelors, to reduce taxation to those who had
small incomes and large families. There is a nrjgram that
even the present government, which sei 1 destruc-

tion, might consider beyond its power. ul further

blamed the profession's leaders for having increased puer-
peral mortality by degrading the practice of midwifery and
handing it to an inferior

The Jacksoniah Prizt .as last week awarded to

Mr. Donald John .\rmoiir. i lie subject was the diseases
and morbid growths of the vertebral column, spinal cord,
and canal, which are amenable to surgical operations. The
subject for 1908 was chosen, viz., diseases of the colon
relievable by operation. The ne.xt Triennial prize is to be
on the lymphatic and hemolymphatic glands, especially as
to their changes in infective processes.

Birmingham City Council on Tuesday decided to estab-
lish a sanatorium for consumptives on a site costing il7,ooo,
.A.ccommodation for forty patients, who w'ill be kept under
observation after leaving will be provided. A minority
opposed the scheme on the ground that the treatment is in
the experimental stags, and it would therefore be better
at present to board out patients in private sanatoria.

We are all regretting here the death of Dr. W. H. Drum-
mond. the Canadian poet and physician. I say all ; assur-
edly that will be true of those who know his "Habitant" and
other pieces so racy of the soil. His "Docteur Fiset" is a
favorite with many who know that only. He was born in
Ireland, but was taken to Canada in childhood, and becarne
in every way a true Canadian. You probably know his
career as well as we do.

Dr. William Henry Ransom. F.R.S.. consulting physician
of the Nottingham Hospital, died on Tuesday evenin.g. He
took the M.D. of the London University in 1850. He was
among the Senior Fellows of the Royal College of Physi-
cians, his election dating 1869. and he served on the Coun-

May 11, 1907]

MEDICAL RECORD.

781

cil 1S91. 1892, and 1893. In 1870 the Royal Society elected
him a Fellow.

Dr. Edward Ferrand Astley, J.P., died on the 12th inst..
in his ninety-sixth year. He was for a long time physician
to the Dover Hospital. He took L.R.C.S. Ed. in i8j3
and M.D. the next year. He did not join the College of
Physicians until i860.

OUR BERLIN LETTER.

(From Our Special Correspondent.)

THE DE.\TH OF VON BERGMANN — DISCUSSION OF THE SPIROCHETE

QUESTION.

Berlin, April 5. 1907-.

The physicians of Berlin are still mourninij the loss of the
eminent surgeon Ernst von Bergmann. What he was in
the medical life of the city was well shown only a short time
ago when he celebrated his seventieth birthday, apparently
in perfect health. It is now generally known that some time
ago he diagnosed his own case as one of carcinoma of
the rectum, and even in his clinic made his own symptoms
the subject of a discussion of this malady. For some time
he continued at his manifold and arduous duties, until
early in this year to his great sorrow he was compelled
to give up his lectures on account of the severity of the
sciatic pain from which he suffered. He then delivered a
farewell address and went to Wiesbaden, where finally
symptoms of total intestinal obstruction supervened. He
was operated on by his pupils. Schlange and Borchard, but
without success. On March 29 an impressive funeral ser-
vice was held at the scene of his labors, at which the
Crown Prince was present.

An interesting series of discussions on the spiroclu-te
question have been held at the recent sessions of the
Berlin Medical Society. These were started by two papers,
one by Biaschko, entitled "Observations and Demonstra-
tions on the Spirochete Question," and the other by Benda
on "The Critical Consideration of Levaditi's Method of
Silver Staining, with Demonstrations." Biaschko opposed
the statement that has been made by other observers that
non-meduUated nerve fibers in the organs are stained by
Levaditi's silver impregnaticjn method and may be con-
founded with the Sf^iroclurta pallida. He said that unn-
medullated nerve fibers did not stain at all by LevaditiV
method, and that it w-as out of the question for a trained
observer to confuse elastic fibers with spirochetes. He had
discovered spirochetes only in syphilitic tissues, and in
twenty-five chancres he had found the organisms always
only in one spot, and there in great numbers. According
to the direction in which the sections were cut the cluster
of spirochetes would be discovered or not. The spirochetes
are not found in the cells, but lie in the interstices between
them, and appear to wander in a direction parallel to the
fibrils of the tissues. They also are disseminated througli
the lymphatics and blood, and often occur free in the lumen
of the blood-vessels. The chancre is formed as the result
of toxins given off by the organisms.

Benda said that he considered a criticism of the Levaditi
silver stain justified because in all such methods depend-
ing on impregnation with metals it was difficult to determine
the conditions under which the staining took place. In
some instances the method was effective in demonstrating
spirochetes, but in others doubts were justified as to
whether the structures seen were spirochetes or not. Cell
boundaries or the edges of erythrocytes could easily be dis-
tinguished from spirochetes, although these structures had
been spoken of in this connection by some observers, but
the end bodies of Krause of the nerve fibers in striated
muscle might give rise to error as well as certain fibrils
of undetermined nature in the central nervous system.
Non-medullated nerve' fibers were not stained by the
method, and of the medullated fibers only the larger ones,
so that the size of the stained structures indicated whether
they were spirochetes or nerve fibrils. Against the objec-
tion that spirochetes could be stained in the tissues only by
one method he offered an observation made on unstained
sections of congenital syphilis of the liver, which he ex-
amined by ultra violet light. It appeared that certain giant
cells without nuclei in the gummata were composed of a
mass of fibers and granules apparently representing de-
generated spirochetes.

In the discussion. Hoffman presented four questions, (i )
Is the silver spirochete a true parasite and not a component
of the tissues? (2) Is it identical with the spirochete found
in smears? (3) Is the spirochete the causative agent in
syphilis? (4) What is its significance in practice? The
first question he thou.ght should receive an affirmative
answer, since the spirochetes could be found in the lumina
of veins, in the testicular canals, and in epithelium, but
only where syphilis existed. Other spirochetes, for ex-
ample, those of fowls, can be demonstrated by the same

method. Tlie difference between the structures stained by
the Levaditi method and the Giemsa method is easily ex-
plicable, owing to the nature of the procedures. In the
process of fixation and imbedding in paraffin a consider-
able amount of shrinkage takes place, and in the Levaditi
method the silver is precipitated on the organism in tninute
granules, whereas the Giemsa stain colors the spirochete
itself. In regard to the question as to whether the
Spirochccta pallida is the cause of syphilis, important in-
formation might be gained by resorting to dark ground
illumination. In most cases by this means it was possible
to demonstrate the living Spirochata pallida in early
chancres, secondary papules, etc. The importance of this
lay in the fact that the diagnosis of syphilis could now be
made without waiting for the appearance of the roseola.

Saling looks on the Spirochicia pallida as a harmless
parasite, occurring incidentally also in syphilis, and con-
siders that the silver spirochetes are artefacts formed of
nerve fibrils, elastic fibers, etc. It may be found every-
where where degeneration is .going on, and degeneration
can always be taken for granted in syphilis, even in the
primary lesion. As a reason for believing that the necrosis
may have a direct connection with the occurrence of the
silver spirochetes it may be pointed out that in acquired
syphilis, that is. in the organs of adults, which are more
resistant to necrosis, the silver spirochetes are found but
rarely, and they have not been discovered in the organs
of infected apes, whereas they are abundant in macerated
fetuses and in foci of necrosis not caused by syphilis; for
example, in the spirillosis of fowls. The producers of this
disease are spirilli that occur in the blood, but not in the
tissues. If necrosis is present, however, the spirochetes
are found also in the latter. When spirochetes are seen
free in the lumina of vessels it may be alleged that these
appearances may be caused by tangentially cut endothelial
cells, that they may have been displaced by the microtome
knife, that the edges of red blood cells may contract into
spiral forms and take up the silver, or that many varied
constituents of macerated tissues may be detached and
transferred mechanically into the interior of the vessels.
The speaker's strongest argument against the identity of
the silver spirochetes with the Spirocliaia pallida was the
fact that by inoculation with street dust he had been able
to produce a keratitis with silver spirochetes that were
only nerve fibrils.

Bab had been able to prove through the method of the
deviation of the complement that the Spirochccta pallida
was the cause of syphilis, for organ extracts free from
spirochetes were free from antigen, while organs contain-
ing spirochetes also possessed antigen. He had found silver
spirochetes only in syphilitic tissues, and he was also of
the opinion that they could not be either nerve termina-
tions or elastic fibers.

Friedenthal pointed out especially the differences in size
of the various spirochetes. He was of the opinion that the
silver spirochetes were only nerve ends, and stated that by
this method he had been able to demonstrate about cells
minute nerve fibers which were no larger than the
spirochetes.

Ort demonstrated preparations to show that silver im-
pregnated bacteri.a always seem larger than stained speci-
mens. What Saling regarded as maceration in syphilis
was a coagulation necrosis, that is, the opposite of macera-
tion, and therefore Saling was in error in stating that the
tissues must be macerated in order for the silver spirochete
to appear. The variations in size also were no argument
against the validity of these structures, for such differences
occurred in all microorganisms of the same species. The
argument that the spirochetes occurred only in certain
spots was unimportant, for tubercle bacilli, for example,
do the same thing. Ort considered that the silver spiro-
chetes were not artefacts.

Hoft'man opposed to Saling's statements the fact that by
means of the dark ground illumination he had been able
to discover spirochetes in the blood taken from the finger
of a child with hereditary syphilis. He had also been able
to obtain positive results on inoculating monkeys with
syphilitic virus from the cornea of the rabbit. The so-
called rabbit syphilis described by Siegel was not syphilis
at all, but sepsis.

The discussion continued for some time longer and
several other speakers expressed their opinions. It ap-
pears to be settled that the spirochete is not an artefact,
but, according to the views of those taking p.art in the
debate, proof that it is the cause of syphilis is still lacking.

Identical Finger-Prints. — Two men tried recently for
petty offenses in South Africa were subjected to the usual
finger-print records, and a subsequent comparison of these
records showed that tliey were identical in every line and
curve.

782

MEDICAL RECORD.

[May II, 1907

Xc~u' Voi-k Medical Journal, April 27, 1907.

Cystoscopy in Tuberculosis of the Urinary Tract. —

Willy Meyer I'lnds this method of (li;iKiio>is absolutely
necessary. It should be preceded by palliation, e.\amination
of the urine and its centrifugal sediment for bacilli, but
should itself precede the use of tuberculin. We should
always think of a descending tuberculosis when a patient,
especially a younger one without any gonorrhea or in-
strumentation, suffers from painful micturition with uni-
lateral lumbar pain and sudden frc<|uent urination in small
quantities with the crucial test of bacilli in the urine, yet
some of the foregoin.g symptoms are mi.<Ieading in the
earlier stages, as experience shows. In tlie more advanced
cases cystoscopy is often impossible, as the bladder will not
tolerate a sufficient amount of urine to enable us to pro-
ceed, and the vesical ulcerative catarrh is often so pro-
nounced that a preliminary preparation of the bladder is
imperative. This should consist in gentle irrigation with
very small amounts of sterile boric acid solution two or
three times weekly, frequently injected and allowed to run
out, followed by bichloride solution or iodoform emulsion.
The bladder should now be forced to contain more than
120 10-150 c.c. of boric acid solution. The author de-
scribes in detail his method of procedure. The coexistence
of prostatic tuberculosis may render cystoscopy impossi-
ble. If the irrigating cystoscope is used, the effect of bleed-
in.g from the neck of the bladder may be readily overcome
by having an assistant slowly inject the boric acid solution
through the afferent tube while passing the instrument
over the diseased area. This keeps the prism clean during
the procedure.

Severe Ocular Pain Associated with Grippe. — The
essential features of the four cases reported by J. T.
Krall are thus summarized : There was a distinct history
of endemic influenza vera in all four cases, two of which
were males and two females, ages twenty-four to thirty-
two years. From the second to the sixth day of the dis-
ease there developed sudden excruciating pain in the eye-
ball, affecting one in the right and three in the left eye, last-
ing from two to five days, gradually subsiding. At no
time during the course of the disease were there any
symptoius of inflammation of the eyeball or its appenda.ges,
no pain on movement of eyeball, no tenderness on pressure
over parts supplied by the trigeminus, no hyperesthesia or
vasomotor affections, such as pallor or coldness, or redness,
heat, or edema, and no trophic phenomena. In one case
there was severe deep-seated boring headache, associated
with nausea and vomiting. Temperature ran.ged from gg°
F. to 103° F. The examinations of the urine were practi-
cally negative. No examination was made for the Pfeiffer
bacillus. The disease was followed by physical weakness
and mental depression. The author believes that the lesion
in these cases was neuralgia of the ciliary nerves. The
way in which the bacillus causes it is still a matter of dis-
cussion. It has been referred to the irritation of those
terminal branches of the trigeminus which are situated in
the sinuses in the vicinity of the nares. It may be due to
a blood toxemia acting on the nerve centers or nerve
fibers, no true inflammation bavin.g taken place.

Some Application of the Roentgen Rays in Derma-
tology.— R. H. Eoggs gives his experience with
A'-ray therapy in eczema, acne, psoriasis, keloid, cutaneous
tuberculosis, and alopecia areata. Concerning its employ-
ment in eczema, he says that it is certainly not necessary in
the acute form unless it be to control the pruritus, other-
wise unrelieved, nor in most forms of subacute eczema. It
is, however, useful in many chronic cases rebellious to
treatment. The good effects are most marked in the
squamous form. It requires more intense radiation to re-
lieve the pruritus, and there is a greater tendency to recur-
rence than in any other form of the disease, .\fter a few
applications the discharge and itching cease and the des-
quamation is arrested. In weeping eczema the desquama-
tion usually ceases after four or five treatments. In eczema
of the legs, with a complicating varicose ulcer, radiation
should be entirely different in application from that em-
ployed in the squamous form, as there is marked difference
in the vitality of the tissues. The rays here relieve the
eczematous condition, greatly increase local metabolism,
and assist the other methods of curing the ulcer. The
author says, with reference to keloid, that the .i--ray ther-
apy has been more successful than any other method up to
the present time. However, by the Roentgen method it
requires considerable time to remove a keloid, and rays
of such character as to stimulate normal tissue processes
and promote absorption should be employed. Rays which
are very destructive, if given in large amounts as in carci-
nomatous tissues, are contraindicated in the treatment of
keloid. It has been advocated by some to have the keloid

removed and then give a series of treatments. This short-
ens the length of treatment, but the author would not
advise the removal unless the tumor is extensive, as cut-
ting a keloid occasionally stitnulates the activity of its
growth.

An Unusual Symptom in Chorea. — Three cases of
chorea are reported by G. E. Price, m which excessive
secretion . of saliva with drooling was a prominent
symptom. The patients were a boy of twelve years and
two girls of fourteen and si.x years respectively. In each
case the patient had had one prior attack of chorea. .'Ml
were severe, and two h;id distinct mitral inurmurs. No
history of rheumatism could be obtained in any of the cases.
The author believes that the symptom is of purely me-
chanical origin, the movements of the tongue and of mas-
tication e.xciting the salivary glands to increased activity
and the involvement of the tongue, jaw. palate, and pharynx
so interfering with swallowing that the saliva is retained
in the mouth or drools from the corners. Under the use
of the usual remedies for the chorea, the symptom men-
tioned was relieved in all the cases reported.

Journal of the American Medical Association, May 4,
1007.

Infantile Atrophy of Intestinal Origin. — D. L. Edsall

discusses the pathogenesis of infantile intestinal
atrophy and offers the theory that it is the result of
disorder of the ferment function of the intestine. That
is, when the proteid of the ingested food is progressing
in the breaking down or fragmentation necessary for its
reconstruction into homologous form, the final attack
by the ferment of the intestine does not occur or is
ineffectual, and the rebuilding into the patient's tissues
fails or is imperfect, hence the atrophy'. The foreign
protein may be either incompletely fragmented and the
reconstruction therefore rendered impossible to the e.x-
tent of producing a homologous protein, or the intesti-
nal ferment failin.g or reduced, reconstruction would
also fail. This hypothesis is consistent with the fact
that the difficulty lies in the utilization of the milk of a
foreign species. There is no good evidence, he de-
clares, that infants ever fail to assimilate human milk
unless they are desperately ill. provided that the milk is
not so rich as to upset digestion or so poor as to be
insufficient; and provided also that the mother or nurse
is not in such a physical or emotional state as to render
the milk unsuitable. He has tested his hypothesis by
studies of the proteolytic power of the intestines ob-
tained at autopsy in three cases of children dying of
typical progressive atrophy: also in three control cases
of persons dead with extreme emaciation due to other
causes, and also in two cases of older persons with con-
tinuous and final extreme emaciation for which the
autopsy showed no cause. His method of investigation
is given in detail, and the results in the cases of infan-
tile atrophy appear to support his theory, inasmuch as
they show a great reduction or entire loss of proteo-
lytic power in the intestinal mucous membrane. The
control cases show a much greater proteolytic power.
The two older patients were stuporous and were fed
by the stomach tube. In both, the intestinal extract
showed no proteolytic action, but, contrary to the in-
fantile atrophies, the extract of the gastric mucosa
showed little, if any. evidence of the presence of pepsin.
The suggestion of Pawlow that in such cases the lack
of psychic stimulus to the production of digestive fer-
ments may play a part, is referred to. and Edsall thinks
that here also there is a field for study.

Hemolysis in Pernicious Anemia, Augmented by Uri-
nary Retention. — H. .X. Freund reports a case very sim-
ilar to that reported by Cunningham (Annals of Surgery,
February. 1907) of pernicious anemia complicated with
urinary retention. He does not. however, accept Cun-
ningham's view that the urinary retention was secon-
dary to the relapses of the anemia which caused weak-
ness of the bladder musculature. On the other hand,
he is inclined to think that the enlarged prostate, which
was present in both cases, was priinarily responsible
for the urinary retention, and that following this there
was a retention and absorption of the hemolysins which
failed to be excreted, with consequent changes in the
course of the disease. \Vhen the poison that is nor-
mally being excreted from the kidneys is added to that
in the general circulation, increased hemolysis is to be
expected. He discusses the origin of the hemolysis in
pernicious anemia and remarks that his observation
and that of Cunningham suggest new questions for
profitable study: the constancy of hemolysins in the
blood and urine in pernicious anemia, together with
their relation both quantitatively and qualitatively: the
absorbability of these substances, and the presence of
the products of hemolysis in the urine. A method for

May II, 1907]

MEDICAL RECORD.

■83

estimating hemolysins that will give uniform results
is also to be desired.

Erythema Induratum (Bazin). — The ervthema indu-
ratum of Bazni, according to L. Weiss, stands about
third in the list, and is a very important exponent oi
the group of cutaneous tuberculides of Darrier, being
preceded by lichen and acne scrofulosus and the papulo-
necrotic tubercle. In more than half the reported cases
it has been proved to be associated with tuberculosis,
and in a very few cases the tubercle bacillus has been
found in the lesions. In other cases inoculations m
guinea-pigs have given positive results, while in still
others the tuberculin reaction has been demonstrated
on the patient. The characteristic features are the for-
mation of subcutaneous deep-seated nodules, more
easily recognized by touch than by sight, and devel-
oping into hard, deep-seated indurated nodes not ad-
herent to the skin at first, but becoming so later. The
skin is at first purplish, then as the nodes become
larger and work toward the surface it changes into a
dull violaceous hue. The size of the nodules varies
from that of a cherry to even double that size. Their
development is slow, and when they ulcerate, which is
seldom, necrosis begins at the summit of a nodule,
rarely more than one, and is attended with a scanty,
scmipurulent discharge. The scarring and pigmenta-
tion is not so pronounced as that of ulcerous scrofulo-
derma. It occurs chiefly in young females, occasionally
in older ones, and very rarely in men. It is usually on
the legs, but in the case reported by Weiss it occurred
also on the nates, which, he thinks, has not been before
recorded. There was a stormy tuberculin reaction in
this case. The histological features were much the same
as those found by other investigators; an atrophic de-
generation of the subcutaneous fat tissue, and forma-
tion of giant cells with radiating nuclei and epithelioid
cells and endothelial proliferation of the vessels. The
symptoms disappeared spontaneously. As regards the
differential diagnosis from erythema nodusum, he re-
marks on the brighter color and more inflammatory
and painful character of the latter, the rarity of the
lesions breaking down and the manner of their disap-
pearance resembling that of an ecchymosed contusion,
as contrasted with the more chronic, slighter pain, and
inflammatory symptoms and more evanescent diis-
appearance of erythema induratum. The differentiation
from syphilitic gummata. which it resembles very
closely, can be made by the multiplicity of the nodes
in erythema induratum. the chronic course and systemic
symptoms, and the therapeutic test with specific treat-
ment. The confusion, with lepra to which it bears a
far-away resemblance, is not very imminent.

Interesting Gynecological and Obstetrical Cases. —
T. S. Cullen gives detailed reports of several cases of
more than usual gynecolo.gical or obstetrical interest.
The first is that of a patient from whom he removed
a cystic uterine myoma wei,ghing eighty-nine pounds.
The patient had been aware of its presence for twenty
3'ears. and notwithstanding its size was able to do her
household duties up to three weeks before the opera-
tion. Her principal inconvenience had been the danger
of suffocation if she turned on her back in bed. Though
considerably larger myomatous uterine tumors have
been reported, this appears to be the largest success-
fully removed. Owing to exigencies of the case no
part of the abdominal wall was resected, but the tissues
contracted remarkably well, and the patient rapidly
regained her strength and suffered much less inconve-
nience than might have been expected. This tumor
was nourished mainly from the omentum, some of the
vessels being 7 or 8 mm. in diameter. ,\nother case is re-
ported of a pedunculated myoma weaned away, so to speak,
from the uterus, presenting the rather unique feature of a
rope of omental vessels to the tumor 6 cm. in diameter.
In the hardened preparation after removal, some of the in-
dividual blood-vessels are I cm. in diameter. A considerable
series of such cases have been studied by Dr. Kelly and the
author, and will be published at some future date. Other
cases reported are one of death of fetus with suppuration
and anterior perforation of the uterine wall, the pus being
walled off by adhesions and the patient recovering after
supravaginal hysterectomy : one of abdominal pregnancy in
which a seven or eight months' fetus was carried for four
years without causing serious symptoms, and one of clio-
riofpithelioma with apparent recovery after hysterectomy.
The article is illustrated.

Treatment of Traumatic Gangrene. — Van Buren
Knott define? traumatic gangrene as that variet>' of gan-
grene following severe crushing injuries of the extremi-
ties complicated by virulent and often fatal sepsis. He
discusses the unsatisfactory course pursued in many cases
and gives his present method of treatment as follows:

Being confronted with a case of traumatic gangrene of an
extremity, estimate as exactly as possible the line between
the diseased and healthy soft parts. Under anesthesia
make a most careful and complete disinfection and cleans-
ing of the skin, puncturing all bulke and removing all dis-
chaiges, envelop the gangrenous area in a sterile towel up
to the line selected, and then, at this point, make a circular
amputation, cutting through soft tissues and bone at the
same level. Ligate carefully all bleeding points, including
none of the perivascular tissue in the bite of either the for-
ceps or the ligature. Leave the wound open, not intro-
ducing a single suture, and apply moist dressings of gauze
saturated with salt solution, these dressings to be changed
from two to four times in twenty-four hours, as the cir-
cumstances of the particular case demand, .\fter seven to
ten days, if the wound is perfectly clean and the condition
of the patient favorable, the classic circular amputation
may be made by dissecting up the flap already outlined and
sawing the bone at the proper level. If for any reason the
circular method may seem undesirable, any other procedure
may be substituted, but in the class of cases under discus-
sion a typical circular amputation will be found entirely'
satisfactory.

Eyestrain and Epilepsy. — H. O. Reik argues for the
importance of eyestrain as a causal factor of epilepsy, and
quotes extensively from Dr. Spratliiig's work on "Epilepsy
and its Treatment." as giving unintentionally valuable evi-
dence of this possibility. Reik says that if only I in 100
epileptics can be cured by relieving measures for eyestrain
it would practically double the number of cures of epilepsy.
He reports four cases in which epileptic attacks appeared
to be entirely suppressed for considerable periods by the
correction of optical defects, and also the notes of two
others observed by Dr. J. F. Crouch of Baltimore. In
seme of these cases at least the temporary disuse of cor-
recting glasses seemed to increase nervousness and to
bring on a tendency of the original attacks. He does not
claim, therefore, to remove the original nervous instabilit)-
altogether, but to have removed the exciting cause. "The
removal of the reflex excitant does not, of course, cure the
disease; the predisposition is always there, .and if the
patient be again subjected to eyestrain the attacks will
probably recur ; or if the eyes be kept in perfect condition
some other exciting factor, such as a pregnancy shock or
great anxiety, may precipitate a convulsion." It is never-
theless necessary that the eyes, like all the other special
organs, should be thoroughly examined by experts to insure
the utilization of every possible means of relief from the
attacks and for preventing aggravations of the underlying
unstable conditions by such irritating factors.

The Lancet, April 20. 1907.

Scopolamine Poisoning. — .'\. W. Moore reports the
case of a girl of four and a half years in each of whose
eyes one drop of a one per cent, solution of scopolamine
was dropped. The child soon became restless, and in one
hour she was definitely delirious. Color remained good. ^ The
pulse was 80 and temperature normal. Later the delirium
became more marked and was of a busy, happy type. She
tried to get out of bed, had various hallucinationsof sight,
would warm her hands before an imaginary fire, etc. ;
would not eat, but took a little milk. This state lasted
about eight hours, gradually ceasing during the night,
although the child did not sleep. The next morning she
seemed more rational, quiet, and obedient, .\bout twenty-
four hours after the instillation of the eye drops drowsi-
ness came on. If the child was awakened she would im-
mediately turn over and go off into a deep sleep. There
was, however, no real coma, and in about two hours the
child seemed well. A small injection of strychnine was
given when she became drowsy. There were no disagree-
able after-effects.

Some Indications for the Treatment of Cholera. —
K. B. Choksy enumerates under this heading the destruc-
tion of the virus I'li .sifii, and has had good results with
cyanide of mercury. He gives one-tenth of a gram in an
ounce of syrup and water every two or three hours, ac-
cording to the stage of the disease and frequency and
character of the motions. The loss of fluid to the system
is made good by saline transfusion, hypodermoclysis. or
cnteroclysis. The circulation is maintained and the renal
function reestablished bv the following, every two to tour
hours: Sodiosalicvlate of caffeine. 2% grains; sparteine
sulphate. Vz grain; liquor atropin.-e (B.P.), i mimm. the
whole in 20 minims of brandy. .-Ml food and dietetic al-
coholic preparations must be cut off. Hot coffee, without
milk or sugar, is freelv given as often as the patient asks
for a drink, and it quenches thirst far better than cold
solutions. Then sweetened arrowroot may be given and
milk gradually added. The patient must be carefully
watched during the stage of reaction. .\i\ alkaline mix-
ture with digitalis and nux vomica generally does well

784

MEDICAL RECORD.

[May II, 1907

here. Symptomatic treatment may be required for occa-
sional persistent vomiting, diarrhea, prostration, or slug-
gish kidneys. Dry cupping is of special service. The fore-
going plan of treatment has been tried in 395 cholera pa-
tients, 226 of whom were treated during the epidemic in
India, 1906. With the e.xception of some 46 sporadic cases,
the rest were treated during epidemic periods. The mor-
tality rate was 51.39 per cent, as contrasted with a rate of
89 per cent, in the surrounding regions.

The Lymphatic System of the Stomach. — In the
course of an elaborate article on this subject, J. K. Jamie-
son and J. F. Dobson note that the study of the spread of
malignant disease of the stomach to the other groups of
abdominal lymph glands is much facilitated by an accu-
rate knowledge of the course of the lymphatic vessels. The
groups of glands usually found affected in the late stages
of the disease are the glands at the hilum of the liver, the
glands around the celiac axis, the superior mesenteric
glands, the biliary glands, the mesocolic glands, and the
lumbar glands. There are no direct vessels connecting the
stomach or any of the gland groups receiving direct vessels
from the stomach with the glands at the hilum of the liver.
These glands receive vessels from the liver and transmit
them to the right suprapancrcatic and biliary groups. In
advanced carcinoma of the stomach they must become
diseased either by retrograde infection along their efferent
vessels or secondarily to a growth in the liver. The paths
by which the middle suprapancreatic glands are aft'ected
can be easily followed ; from the coronary groups, the sub-
pyloric group, or the splenic group. They transmit efferent
vessels not only to the receptaculum chyli, but also to the
lumbar glands around the aorta and vena cava. It is
obvious that these glands may readily become diseased by
the direct transmission of cancerous emboli from the mid-
dle suprapancreatic glands. The superior mesenteric
glands receive vessels from the subpyloric group. This
group is frequently diseased, and infection will spread
readily along its efferent vessels. It is not necessary to
assume that the glands lying below the level of the celiac
glands become diseased by means of a process of retrograde
infection or secondarily to obstruction of the thoracic duct,
or to the development of metastases in the liver. There
are direct paths, as the authors have shown. The affection
of the mesocolic glands is not so readily explained. They
may become diseased by retrograde infection from the
superior mesenteric glands to which their efferent vessels
run; a more likely explanation is that the primary disease
has spread from the stomach into the gastrocolic omentum,
possibly to the colon or into the mesocolon, thus invading
the lymphatic area draining into the mesocolic glands. The
biliary group of glands receive direct vessels from the upper
part of the pylorus, and by this path they may become
affected.

Britisli Medical Journal. April 20. 1907.

Oxyuris Vermicularis. — A. N. Davies calls attention
to the use of quassia in an enteric pill, two grains coated
with keratin. It is a useful adjunct to the employment of
other remedies.

Salicylism and Epistaxis. — Referring to recently re-
ported cases of nose bleed in grippe cases, E. Leach is in-
clined to think that the former may have been due rather to
salicylates given than to the grippe poison. This mani-
festation of salicylism may be unattended with any head
or kidney symptoms. It may be that only impure speci-
mens of the salicylates cause nose bleed.

Hernia of the Gall-bladder. — A case is reported by
H. B. Hanson whose patient was a Hindoo woman of fifty
years. On the right side of the abdomen was a soft, round,
tender swelling, diameter one and one-half inches, its cen-
ter two inches to right of midline, and three inches below
the margin of the ribs. Slie complained of having had
indi.gestion for the last two months, and said that the
swelling had appeared suddenly one month previously,
when she was doing some heavy grinding. Pain, she said,
had been present only ten days, but histories in Indian
women are very unreliable. On operation below the sub-
cutaneous fat and beneath the abdominal muscles was the
fundus of the gall-bladder enclosed in a peritoneal sac.
The edges of the stricture round the neck, formed by the
abdominal muscles, were snicked, a few adhesions betw'een
stricture and sac and bladder and sac separated, most of
the latter removed, and the fundus returned into the ab-
domen. Both the right and left lobes of the liver were
enlarged. The stitches were removed in twelve days and
the patient discharged two weeks later.

Intestinal Origin of Leprosy. — H. L. Clift notes that
in certain parts of China where leprosy is common, there
are lepers who sell eatables on the street. They and the
food they sell are surrounded by flies, who come in con-
tact with their sores. These flies may settle on fish, which

in turn becomes contaminated. It makes, when putrid,
an excellent nidus, and if eaten half-cooked some of
the bacilli must certainly enter the gastroenteric canal in
a living state. Now if this is true of fish, why is it not
true, the author asks, of other eatables? Does not this
explain, he continues, why Hutchinson's theory sometimes
appears so plausible and at other times appears to break
down? He means that the practice of eating putrid fish in
a more or less raw condition is not essential to the spread
of the disease. The bacilli can reach the intestine through
the medium of other food also. Leprosy may be fairly
common in a district and yet very little food be eaten
there. Comparing the disease with tuberculosis, the author
notes that in the former the bacilli are carried by leu-
cocytes which lose their ameboid movement. In leprosy
the bacilli have been found occasionally within white blood
corpuscles ; perhaps the lepra cells were originally leu-
cocytes? The taking of common salt really seems to
benefit the patient ; this may be because of increased
hydrochloric acid, which helps the digestive juices to de-
stroy the germs, and the system is thus relieved from in-
gesting more li'c'inii bacilli. Three points leprosy has in
common with tuberculosis : There must be a pre-
disposition, natural or acquired, in the patient ; both may
have a long incubation period; and both are incurable —
the patient is said to be "'cured" because treatment and
environment have "stayed" the disease.

Calcium Salts in the Blood and Tissues. — The part
played by the calcium salts in the blood and tissues is dis-
cussed by W. B. Bell with special reference to their in-
fluence in regard to female genital functions. He also adds
a description of a simple method of quantitative analysis,
for which he has described a special apparatus. There are,
he says, three calcium periods in a physiological sense.
First, the period of growth, when the young person or
animal requires all the calcium salts obtainable for the
formation and growth of the bony skeleton. Secondly, the
period of reproduction, when a calcium equilibrium as
regards growth is reached, and an "excretion" of the
excess occurs. This is most obvious in the reproductive
processes of women, when large quantities of the calcium
salts are first given up to the fetus and then for the forma-
tion of milk, during which the menstrual function is in
abeyance. Some observations the author has made seem
to show that pregnancy is terminated when the fetus ceases
to absorb (or receive) calcium salts from the mother's
blood and a large accumulation occurs in her system,
bringing about contraction of the uterine muscles. The
third period is that of late life, when no calcium salts are
required for the building-up processes or for those of
reproduction. These salts then accumulate in the tissues,
especially in the vessels (and it is interesting to note how
rare this is in women in middle life), atrophy occurs, and
the individual gradually declines.

Pulsus Bisferiens. — According to T. Lewis, this term
is now applied to a form of palpably double pulse. It has
two beats, the second of which is really a reinforcement of
a prolonged systole. If we define this type as one which is
double to the finger, it follows that every observer will
have a standard of his own, dependent on the delicacy of
his tactile sense. The author takes as his standard a
sphygmogram in which the apices of the two waves are sep-
arated by a time interval of less than one-tenth of a sec-
ond, and in which the second wave is not prominent.
Lewis found such a pulse in thirteen out of twenty un-
selected cases of aortic regurgitation. This form of pulse
has been referred to as suggestive of aortic stenosis with
senile arterial degeneration. A point of interest is that a
double beat is frequently more easily palpable and gives a
more distinct tracing on one or the other side of the body.
One type occurs in those cases in which there is .great
enlargement of the left heart associated with or caused by
disease of the aortic valves or larger arteries, but there is
no constancy between the double wave and the degree of
hypertrophy or dilatation. One type is associated with
arteriosclerosis, but in the other type this lesion is wanting.
The author's views are illustrated by several pulse tracings.
The pulsus bisferiens has been observed after the admin-
istration of digitalis. It has been noted also in pericardial
adhesions or excess of fluid, and, lastly, in ballooning of
the aorta.

Berliner klijiischc Wochcnschrift. April 15. 1907.

The Treatment of Chronic Bronchitis with the X-
Rays. — Immelmann made use of this procedure in a
scries of cases following the suggestion of Schilling that
the .r-rays had an excellent effect in bronchitis and bron-
chia! asthma of the chronic type. In the patients in whom
the method was applied the results were excellent, the
asthma being particularly benefited. The application is
made for ten minutes on the anterior, posterior, and lateral
aspects of the chest, and only a limited number of expos-

May II, 1907]

MEDICAL RECORD.

785

urcs are necessary to produce a result. In cardiac asthma
and that depending on a nervous basis no effect was ob-
served.

Physical Measures in Nervous Diarrhea. — Tobias
states that all forms of diarrhea respond to physical, and
especially hydrotherapeutic measures, whether they are due
to anatomical changes in the gut or exist without any
pathological lesion. The nervous type according to the
writer seems to be particularly benefited by physical meas-
ures. Three varieties of this condition may be distin-
guished according to the mode of origin. In the first we
have to deal with some idiosyncrasy against certain articles
of food. In the second, which constitutes the principal •
group, any nervous excitement will bring about an attack.
Fright and fear are the commonest causes, although
changes in the weather are often at fault. In the last class
we have to deal with some reflex irritation from neighbor-
in.g organs, such as a retrofle.xed uterus or disturbances in
the sexual apparatus. There may be other asso-
ci;;ted nervous symptoms, or the diarrhea may be the only
manifestation of trouble. Tobias has found that cool half
baths, preceded by a few minutes' session in a steam or
light bath. The temperature should not be reduced below
24° C. Cold douches and packs are also of value, but warm
baths only serve to further soften the patient. A procedure
of this kind should not be continued for more than t.hree
or four weeks, and then if necessary repeated after a suffi-
cient interval. The diet is very important, contrary to the
views of many, who claim that the nervous character of
the disease makes any adherence to dietary rules superflu-
ous. The food should be nourishing and of sufficient
amount. Fats are particularly useful, as well as cereals,
but meats should be restricted, and spices are not to be
used. Alcoholic, as well as all other cold or carbonated
drinks are absolutely contraindicated. Massage and gym-
nastics are only of value as a help to improve the general
condition.

Miinchencr incdizinischc Wochcnschrift, April 9, 1907.

Endocardial Murmurs. — Geigel calls attention to the
difficulty of distmguishing at certain times between endo-
and pericardial murmurs. He thinks that in fresh cases
of endocarditis the murmur is produced by a rubbing of
the edges of the valves similar to what occurs in a pleurisy.
The segments of the valves are not properly approximated
owing to the presence of excrescences, and one may there-
for be taut, while the other is still more or less relaxed,
resulting in a rubbing of one on the other.

The Bier Treatment of Mastitis. — Zacharias finds that
this procedure is an excellent one for the purpose indi-
cated, as in a series of thirty-three cases operative inter-
ference was found to be necessary in only two, and this
was due to late application of the treatment. Among the
advantages attending Bier's procedure is the fact that
nursing need not be stopped during the treatment, and if it
is on account of pain and tenderness the secretory activity
of the breast is not stopped. The apparatus is best applied
about thirty minutes at a time from two to three times
daily, the globe being taken off and reapplied about every
ten minutes. As a rule, it was not found necessary to
keep up the treatment for longer than three or four days.
When applied early the method affords very satisfactory
results, and although it is very simple, the writer advises
against permitting the patient to apply it herself, as the
results of the treatment cannot be judged by the latter.

The Treatment of Anthrax. — Barlach describes a
method which he has used successfully in a considerable
number of cases. A deep groove is made with the thermo-
cautery around the pustule, and the latter is thoroughly
incised with the knife. The tension in edematous areas
is relieved by extensive incisions, and around the entire
circumference of the pustules injectionsof tinctureof iodine
are made. The affected areas may then be covered with
compresses of bichloride. The procedure stated can be
quickly carried out, and does not seem to be particularly
painful. The results were excellent, and are ascribed by
the author to the fact that the cauterization immediately
limits the spread of the infection. The iodine seems to act
as an antito.xic, although in what manner the writer is not
prepared to say.

Deutsche mcdhiuischc IVochcnschrift, April II, 1907.

Radiographical Findings in Apical Tuberculosis. —

Vierhuft' refers to the fact that although very good results
with this procedure have been obtained, it has not met with
a sufficiently extended reception in the diagnosis of the
early lesions of pulmonary tuberculosis. In contrast to the
older methods, it is possible to demonstrate both superficial
and deeper foci, which would give no physical signs under
other circumstances. In doubtful cases it may even assume
the importance of a positive bacteriological finding. The
technique must necessarily be absolutely correct, and a

thorough experience is necessary in order to properly in-
terpret the findings. The writer cites a number of cases
which show that thickening in the pulmonary tissue can be
ilemonstrated by the .I'-rays before any auscultatory or per-
ciitory signs are present. In cases where the usual physical
signs disclose the presence of the lesions, its boundaries can
be much more sharply defined by the rays than by any
other method.

Complex Hemolysin Derived from the Pancreas. —
Fiiedemann details the results of some recent experiments
which are of considerable interest. He found that among
mammals it was possible to isolate hemolysins which are
analogous to the poisons found in the venom of snakes and
bees. These are lecethids, and may be secured from the
discharge of a pancreatic fistula. It is also possible to
extract a complex hemolysin with alcohol from the sub-
stance of this gland. The active principle of the pancreas
acts like an amboceptor, for it may unite with the blood
cells, but can be distinguished from the ordinary ambo-
ceptors by its high degree of thermolability. The hemo-
lytic action of this substance is also manifested against the
blood cells of the same species of animal (autohemolysis).
Tlie writer concludes that the pancreas contains a poison
which is characterized by a paralyzing and hemorrhagic
action, and is therefore very similar to the crotalus poison.

Tetrachlormethan as a Solvent. — Wederhake refers
to the dangers attending the use of certain materials neces-
sary for the solution of drugs or for other purposes.
.Among these the best known are ether, chloroform, and
benzine. In cases where the skin has been cleaned with
ether or benzine before the application of a cautery, severe
mjuries have been known to result. The writer suggests
tetrachlormethan as a satisfactory substitute. This sub-
stance is obtained by the action of chlorine on boiling
chloroform either in the sunlight or on the addition of
iodin. It may also be prepared by the action of chlorine
on bisulphide of carbon. This fluid constitutes an excel-
lent solvent for bromine, iodine, oils, paraffin, rubber, resins,
and tar, and at the same time possesses the advantage of
not being inflammable. It penetrates into the deeper layers
of the skin, and therefore acts as an efficient disinfectant
when used in conjunction with iodine in solution. The fol-
liwing formula is proposed for the disinfection of the
hands: iodine, i.o; solid paraffin (43° C), 0.5; tetrachlor-
mtthan, loo.o. The results are stated to be superior to
those obtained with Furbringer's method.

Frciuh and Italian Journals.

Preventive Surgery in Epitheliomata of the Appendix
and Mammary Gland. — L. Longuet states that in the
course of examinations of specimens of the appendix that
have been removed by operation some are found that are
of a distinctly atrophic type, small, firm, fibroid, and con-
taining islands of epithelium, which remain as vestiges of
the old lining. These occur in persons over forty years of
age. This epithelium is very apt to degenerate into a
cancerous growth. The author believes that cancer of the
vermiform appendix is of frequent occurrence. He advo-
cates a preventive operation on the appendi.x after the age
of forty, to relieve from the possibility of degeneration into
cancer. In the same manner the degeneration of the
mammary gland after the menopause exposes the woman
to the dangers of epithelioma of the breast, a disease that
can be cured if operated on in the period of inception, but
that, owing to its insidious approach, is frequently not
seen by the surgeon until it is so far advanced that opera-
tion, although successful at the time, results in the end in
recurrence and death. In such conditions the author ques-
tions whether we should not be justified in making a sub-
cutaneous operation for the removal of the gland tissue
after the menopause to prevent possible degeneration. The
objections to this procedure are that many women never
suffer from the disease, and that there is no use in sub-
mitting to a surgical procedure for a trouble that may
never occur. Recurrences after operation are given by
authors as from 20 to 40 per cmt. nf nil cases ^operated
on. The operation could be limited to cases in which
there was a suspicion of coming trouble. Either cancer is
a general disease with local manifestations, in which case
the treatment should be serotherapeutic or constitutional ;
(ir it is local and operation is the proper resource and
preventive. The operation proposed is somewhat in the
nature of vaccination, which has become general at the
present day. A surgical vaccination will do away with
manv cases of epithelioma of the breast and appendix. —
Lc Progrcs Medical. February 2. 1007.

Surgical Treatment of Puerperal Pyemia.— A. Faix
says that puerperal pvemia will remain with n-; as l.tng
as criminal abortion exists. Its frequency and severity have
not been lessened bv anv methods of treatment that have
been adopted. Bacteriology shows that the germs invade

786

MEDICAL RECORD.

[May II, 1907

the uterus, and pass by way of the sinuses into the venous
circulation, creating endovenous lesions that favor the
formation of a clot. From this clot emanate septic emboli
containing bacteria on whose degree of virulence depends
the severity of the infection. This may be acute, with con-
tinued high temperature and frequent chills, having a rapid
course and early metastases, and ending soon in death.
Another form is much slower, showmg the action of
much less virulent bacteria. Soon after labor there is a
septic endometritis, but it is not until some weeks later
that irregular chills begin, each fresh chill indicating a fresh
thrombosis. The germs penetrate to the ben-inning of the
uteroovarian and hypogastric veins, and form thrombi,
which by liquefaction become sources of fresh infections
through the circulation. Ligation of thrombosed veins has
been successful in the sinuses of the skull and in other lo-
cations, and it seems logical to expect that it will be of
service here if undertaken before there have been met-
astases and diffusion of the infection through the general
circulation. Infection of the great veins of the pelvis and
parametritis are contraindications to operation. Opitz con-
siders criminal abortion an indication for 'operation. Se-
vere infections always occur after placenta prsevia. manual
removal of the placenta, or artificial delivery. Pulmonary
embolism contraindicates operation. If the process has
been successfully resisted by the system for some time it is
reasonable to suppose that the infection is less virulent,
and the hope of staying it is better. There must be a
heart and kidneys in good condition to justify operation.
When there is a hard cord running along the infi,'.ndibulo-
pelvic ligament we may be sure that the spermatic vein is
involved. Absence of edema indicates that the large veins
of the pelvis are not involved. As to the side that is af-
fected we may be guided by the location of tenderness on
pressure. The veins should be denuded carefully, ligated.
and the diseased portions removed. Out of twenty collected
case; thirteen died and seven recovered. We should oper-
ate promptly in acute cases, later in chronic ones. — Gazette
des Hopitaux. February 2. TO07.

Symptomatology and Early Diagnosis of Cancer of
the Cervix. — Polosson speaks strongly of the necessity
of early diagnosis of the cancer cj. the cervix, since de-
lay allows the patient to pass into the inoperable stage.
Cancer in the cervix occurs much earlier than cancer of the
body of the uterus, being most frequent from forty to fifty
years of age, and occurring as early as the twenty-first
year. It does not affect the general health for a long time.
It does not occur in virgins and is more frequent in multi-
pars, lesion of the cervi.x as a result of delivery predis-
posing to cancer. Irregular hemcyrhage before the meno-
pause, or return of hemorrhage after it should lead to an
immediate examination. Hemorrhage generally occurs after
connection, a simple douche, or a violent movement. When
a fetid, rose-colored discharse appears, the disease is al-
ready advanced. Pain is a late symptom, resulting from
compression of the nerves in an involved broad ligament.
Early diagnosis depends on examination of every case that
has irregular hemorrhage, and the finding of an ulcerating,
vegetating mass that is very friable and bleeds easily. In
some cases there is a hard cervix, in which the ulceration
is found in the canal. The uterine cavity should be ex-
plored and a fragment removed for examination to aid in
diagnosis when necessary. Immediate operation alone will
save the patient. — Gazette de Gynecologie. February i,
1907.

Treatment of Surgical Tuberculosis at the Seaside. —

Riccardo Sabatucci describes the benefits of treatment of
cases of surgical tuberculosis by a sojourn at the seaside
as of value in improving the general conditions as well
as the local ones. The observation of these cases by the
author has led him to change entirely his opinion with
regard to the value of earlv operation in such cases. He
now treats them by a sojourn in the open air at the sea-
side. Such treatment has been given for some years in
France and Italy especially. The author's experience re-
fers to the hospital at Anzio. which is located on a
point of land 400 feet above the sea. in a villa formerly
used by one of the popes, surrounded by a large and
beautiful garden. The greatest benefits are received in
glandular and osseous tuberculosis, and in those cases
that have not undergone operation. The good results are
to be had in eightv-four per cent, of the cases. Only
immobilizing apparatus was used, with drainage and scrap-
ing when necessitated by sinuses. The effect on the blood
was marked, there being found by careful examination
increase in the number of red corpuscles, diminution of
the leucocytes, increase of hemoglobin, diminution of poli-
nucleosis of neutrophiles. increase of eosinophiles. and diini-
nution of lymphocytes. — Cazetta Medica di Roma. Decem-
ber I and 15. igo6.

looks Msmmh.

While the Medical Record is pleased to receive all new
publications which may be sent to it, and an acknowledg-
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heading, it must be 7vith the distinct understanding that its
necessities are such that it cannot he considered under
obligation to notice or review any publication received by it
which in the judgment of its editor wilt not be of interest
to its readers.

Progressive Medicine. A Quarterly Digest. March i,
1907. 8vo, 280 pages, paper. Lea Brothers & Co., New
York.

The New Hygiene. By Elie Metciinikoff. l6mo, 104
pages, muslin. W. T. Keener Co., Qiicago, Price, $1.00.

Diseases of the Nose and Throat. By J. Bruce Fer-
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Textbook of Psychiatry. By. Dr. E. Mendel. 8vo, 311
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Dining and Its Amenities. 8vo, 470 pages, muslin.
Rebman Co., New York.

Derrick's British Report, February, 1907. 64 pages.
Paul E. Derrick, London.

Practical and Theoketic.\l Esperanto. By Dr. Max
Talmey. Universal Language Publishing Co.. 62 W. 126th
street, New York. Price, $1.00.

The International Medical .Annual. Various contrib-
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Co.. New York.

Psychology Applied to Medicine. By David W. Wells,
M.D. i2mo, 141 pages, illustrated, muslin. F. A. Davis Co.,
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Pediatrics. By Thomas Morgan Rotch, M.D. Fifth
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trated, muslin. J. B. Lippincott Co., Philadelphia.

Die Syphilis. \'on Dr. Orlowski. 8vo, 37 pages, paper.
A. Stuber's V'erlag, Wiirzburg.

Der Tripper. Von Dr. Orlowski. 8vo, 46 pages, paper.
A. Stuber's Verlag, Wiirzburg.

Dr. Jessner's Dermatologische Vortrage fur Prak-
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The Nursling. By Pierre Budin. 8vo, 199 pages, illus-
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Manuale Pratico Dell' Igienista. 32mo, 368 pages,
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La Tudercolosi. Con Prefazione Del Prof. Augusto
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Principles and Applic.'\tion of Local Tre.\tment in
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.■\iDS to the Di.\gnosis and Treatment of Diseases of
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Aids to Dental Surgery. By Arthur S. Underwood
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Le Cerveau et la Moelle Epiniere. Par Ch. Debierre.
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May II, 1907]

MEDICAL RECORD.

7S7

Innk Spimtoa.

Handbuch der Sauerstofftherapie. herausgegeben von
Dr. AIax Michaelis. Universitaets-Professor. Berlin:
August Hirschwald, 1906.
This book may well serve as an example of German
thoroughness in going into detail, for we have presented
here a volume of about 600 pages on the therapeutic uses
of oxygen by a number of the best known medical men of
Germany and Austria. The work is a manual and prop-
erly opens with an historical review of the subject from
which we learn that the emnloyment of this gas for
medicinal purposes was practically coincident with its dis-
covery. Priestly and Lavoisier both recognized the value
of oxj-gen in restoring asphyxiated subjects. It was not
until comparatively recent years, however, that the employ-
ment of oxygen in medicine was placed on a scientific
basis, for it was natural that a reaction would follow the
claims made for the substance as a panacea for all the ills.
The chemical and mechanical difficulties which attended
the production of the gas havin.g been removed, it rapidly
came into favor again as a therapeutic agent and is now
quite generally employed within proper limitations. The
book in question is divided into two parts, the first of
which includes the physiological and experimental basis
for the administration of the gas. the technique of the latter,
and its indications. The second portion comprises details
of its use in the prophylaxis and treatment of pulmonary
diseases and in noisonine. Its employment in surgery,
obstetrics, children's diseases, internal medicine, and other
fields is discussed in a thorough manner and the work
may be described as a most valuable book of reference
in a field where such are infrequent.

Lectures on Diseases of the Lungs. By James Alexan-
der Lindsay, M.D., F.R.C.P. CLond.), M.A., Professor
of Medicine, Queen's College, Belfast; Physician to the
Royal Victoria Hospital, Belfast: Consulting Physician to
the Ulster Eye, Ear, and Throat Hospital, Belfast; The
Ulster Hospital for Children and Women, Belfast, and the
Coleraine Cotta.ge Hospital; Examiner in Medicine in the
Royal University of Ireland; Late President of the L'lster
Medical Society and of the L'lster Branch of the British
Medical Association. Second Edition. Enlarged and
rewritten. New York: William Wood & Company, 1006.
In this excellent revision of his work on diseases of the
chest, the author has, with advanta.ge. considerably elabo-
rated a series of lectures on physical diagnosis and diseases
of the lungs, wisely omitting the lectures on diseases of the
heart contained in the first edition. The first few chap-
ters the author devotes to a consideration of physical ex-
amination of the chest with reference to the lungs, and a
brief discussion of radiography and radioscopy. In these
chapters the a\ithor pays fitting tribute by frequent refer-
ence to the pioneer work of Laennec and Skoda on auscul-
tation, which, as he points out, has been but little elaborated
since the writings of these illustrious clinicians. A few
chapters devoted to the study of pulmonary symptoms fol-
low and within the limits of the work touch practically all
of the salient points.

In his discussion of pleurisy, pneumonia, bronchitis, etc.,
the author is perhaps ultra-conservative, though, on the
whole, little exception can be taken to the subject matter. .A.
considerable part of the work is naturally devoted to the
subject of pulmonary tuberculosis, and if one bears in mind
that these lectures are not intended to replace more ex-
haustive treatises upon the subject, they will be found most
valuable for the purpose of hurried reference. In the matter
of treatment the author is somewhat old-fashioned and
ambiguous. For instance, at the present day an author
should be more specific and definite than to advise "suitable
change of climate." "due regulation of nutrition," etc. It is
probable also that many mi.ght take issue with the author's
views on etiolo.gy. especially as regards "house infection"
in tuberculosis. However, on the whole, the work is a
valuable addition to the library of the practitioner or the
student of medicine. It is adequately indexed, pleasant
reading, and not too cumbersome.

High Frequency Currents. Their Production, Physical
Properties, Phvsiolo,gical Effects and Therapeutical Uses.
By H. Evelyn Crook. M.D.. B.S.. Lond., F.R.C.S., Eng.,
etc. New York : William Wood & Co., 1006.
There are very few books that come so apropos as this
handy volume on high-frequency currents. This method of
electrotherapy has become very popular within the last few.
years, among both general practitioners and specialist?.
While formerly a static machine was the height of a phy-
sician's electric equipment, nowadavs one must possess a
high-frequency apparatus in order to be up-to-date. The
present volume gives a concise but quite comprehensive de-
scription of the apparatus used, the methods of application.

the physiological effects, and the therapeutic value of the
high-frequency currents. While the reader is supposed to
possess an elementary knowledge of electrophysics, the
technical parts of the subject are not so difficult that they
cannot be grasped by any physician, even by beginners in
electrotherapeutics. The book will repay close study and
is quite sufficiently elaborate for physicians who do not
wish to make electrotherapy a specialty, but who want to
know what they are doing and why they are doing it when
they apply the high-frequency current in their offices.

Stohr's Histology, arranged upon an Embryological Ba-
sis by Dr. Fred'k T. Lewis, Assistant Demonstrator of
Embryolo.gy at the Harvard Medical School. From the
Twelfth German Edition by Dr. Philipp S'tohr, Pro-
fessor of .\natomy at the University of Wiirzburg.
Sixth American Edition. Philadelphia: P. Blakiston's
Son & Co.. 1906.
Stohr's textbook on histology has long been considered
one of the classics of German medical literature, but in
adapting it to American needs the translator has arranged
it on an embryological basis in order to meet the want for a
book of this kind in schools where embryology is made part
of the curriculum of medical studies. This has necessi-
tated certain changes in the German text which have been
made, however, with Prof. Stolir's permission. Consider-
able attention has been paid to the nomenclature, the
widely used system adopted by the German Association
of .Anatomists bein.g employed, which favors the simplest
Latin descriptive names and discards the numerous per-
sonal a'^iellations formerly used. Since the cell consti-
tutes the unit of development as well as of structure, it
would seem perfectly rational to study histolo.gv, which
is practically a study of cells or their immediate deriva-
tives, froiti the developmental standpoint. And yet most
textbooks on the subject are a mass of collected, inde-
pendent facts which afford to the student a very confused
idea of this important matter. Dr. Lewis' book may be
commended as a valuable addition to textbook literature.

Woman. A Treatise on the Normal and Pathological Emo-
tions of Feminine Love. By Bernard S. Talmev. M.D.,
Gynecologist to the Metropolitan Hospital and Dispen-
sary. New York. For Physicians and Students of Medi-
cine. With twenty-two drawings in the text. New
York : The Stanley Press Corporation.
This volume, which is evidently a "labor of love" on the
part of the author, is divided into eight parts, entitled
respectively: Introductory, Evolution of Sex, .Anatomy of
tlie Genitals, Physiology, Pathology, Hygiene. Psychology,
and Morality. It contains ninety-seven chapters, some of
them less than a page in length, and deals with well nigh
everything connected with the emotions of feminine love.
There is certainly no lack of books treating of sexual
matters, and the present volume is the result of the
author's gleanings in this field of literature. In spite of
the statement on the title page, we do not expect to see this
book among those recommended to medical students in the
catalogues of the various medical colleges, nor do we
ima.gine that the professors in those coUe.ges will take this
book as the basis of a course of lectures, or that they will
begin now "to impart to their pupils all their knowledge
about the nature of things concerning Love that tliey have
gathered in their lon.g and extensive experience." We
very much question the utility of books of this sort, for
they are sure to fall into the hands of those to whom they
will be apt to do harm. The well-instructed physician
gains all necessary knowledge of sexual matters from
purely scientific works.

A Manual of Prescription Writing. With a Full Expla-
nation of the Methods of Correctly Writing Prescrip-
tions, a Table of Doses Expressed in Both the .Apothe-
caries' and Metric System ; Rules for Avoiding Incom-
patibilities and for Combining Medicines. By Matthew
D. Mann, A.M., M.D., Professor of Obstetrics and
Gynecology in the Medical Department of the L'niversity
of Buffalo. Fellow of the N. Y. .Academy of Medicine,
of the American Gynecological Society, and Correspond-
ing Fellow of the N. Y. Obstetrical Society. Revised
by Edward Co.x Mann, M.D., Lecturer on Obstetrics,
Medical Department of the L^niversity of Buffalo, Fel-
low of the Buffalo Acadeiny of Medicine. Sixth Edition.
Revised, Enlarged, and Corrected according to the I'. S.
Pharmacopoeia of 1906. New York and London : G. P.
Putnam's Sons, 1907.
To those who need instruction in the matter of prescrip-
tion writing this book will be serviceable. In this new
edition, the chapter on Incompatibilities has been rewritten,
and that on Doses has been revised. The volume is of
handy size, and contains all that a student will want on
the subject vv-ith which it deals.

788

MEDICAL RECORD.

[May II, 1907

#ortrtii ^r;inrts.

CONGRESS OF AMERICAN PHYSICIANS AND
SURGEONS.

Seventh Triennial Session, Held at Washington, D. C,
May 7, 8, and 9, 1907.

Dr. Regin.\ld H. Fitz of Boston, Mass., President, in
THE Ch.mr.

(Special Report to the Medical Record.)
Tuesday. May 7 — I'lrst Day.

The Evolution of the Idea of Experiment in Medicine. —

Dr. Wm. Osler of Ci.xfi:ird, England, read this paper. He
said that the fact that man could interro.^ate as well as ob-
serve nature was a lesson slowly learned in his evolution. Of
the two methods by which he could do this, the mathemati-
cal and the e.xperimental, both had been equally fruitful ; by
the one he had gauged the starry heights and harnessed the
cosmic forces to his will ; by the other he had solved
many of the problems of life and lightened many of the
burdens of humanity. He traced the beginnings of experi-
mental science from its foundation with the Sumarian
race. These old Greeks had anticipations of nearly every
modern discovery, and there were details of one funda-
mental experiment, that of the discovery by Pythagoras of
the dependence of the pitch of sound on the length of the
vibrating chord. The Greel<s, however, did not add to
their genius for brilliant generalization and careful ob-
servation the capacity to carry out experiments, and neither
Plato nor Aristotle understood the value of experiment as
an instrument of the progress of knowledge. Hippocrates
had appreciated the fact more than any of his contem-
poraries, but even to him facts as obtained by observation
were the beginning and end of the art. The great masters
of the Alexandrine school were the first great anatomists,
and they had an extraordinary quality of zeal for experi-
mentation which, according to Celsus, led to the vivisec-
tion of criminals. Among the Empirics arose the science
of toxicology and the study of poisons and their antidotes,
and not only animals, but criminals were used to test the
effects of poisons and the idea of protection by gradually
increasing doses of the poison, and the use of the blood
of animals rendered immune were understood. Galen was
not a greater observer than Hippocrates, but he stood out
in our history as the first physician who had a clear con-
ception of medicine as a science. In brilliant experiments
upon the heart and arteries he had almost demonstrated
the circulation of the blood, and in his work on the nervous
system he had anticipated the discovery of Bell and Mar-
shall Hall, and laid the foundations for our knowledge of
the physiology of the brain and spinal cord. In none of
the writings of the Arabian school was there to be found
any solid contribution to anatomy or physiology. Grad-
ually, however, the paralytic-like torpor passed away, and
independent spirits like Paracelsus defied all traditions
and threw the doctrines of Galen and Avicena to the winds.
Throughout the sixteenth century, however, there had been
very little experimental work in medicine. Then came the
instruments of precision in medicine with the construc-
tion of the thermometer by Sanctorius and the pulsilogum
of Galielo. Contemporaneously with Sanctorius, Harvey
had demonstrated the circulation of the blood, but neither
Sanctorius nor Harvey had had the immediate influence
upon their contemporaries which the stimulating character
of their work justified. In the latter half of the eighteenth
century experimental science received its greatest impetus
through the work of Spallanzani, who demonstrated the
chemical nature of the digestive process, and John Hunter,
who was able to raise pathology into a science. In the
beginning of the last century the art of observation had
found its fullest development in the hands of the French
school, by which the diagnosis of disease was put upon a

sound basis, and in the forties Virchow revealed for the
first time the true seats of disease. The last half of the
century could be called the era of experimental medicine,
and the great results had been along three lines — the dis-
covery of the functions of organs, the discovery of the
causes of disease, and the discovery of new methods of
treatment. A single generation had witnessed a complete
readjustment of our outlook on physiology, pathology,
and practice, and this had all come from a recognition
that experiment is the very basis of science. Only a begin-
ning had been made, however, and there was not a depart-
ment in practical medicine in which there were not
innumerable problems awaiting solution, and what was
needed was clinicians who could keep in close touch with
physiology, pathology, and chemistry, and who were pre-
pared to transfer to the wards through proper channels
the knowledge of the laboratory.

Neurological and Psychiatric Diagnosis. — Dr. Lewel-
LYS F. Barker of Baltimore, Md., said that no hard and
fast line could be drawn between laboratory and clinical
diagnosis; the clinic was the mother of the medical labora-
tory. The anatomical laboratory dated back three hun-
dred years, but the physiological, pathological, and chemical
laboratories were creations of the nineteenth century. The
establishment of psychopathic laboratories now promised
to be of great significance in the advancement of psychiatric
diagnosis. The diagnosis of nervous and mental diseases
had made but slow progress until very recent times. The
relation of symptoms to lesions in neurology were more
difficult to determine because of the difficulties in open-
ing the brain and getting at the seat of the trouble. It
was much easier to study alterations in the liver or kidneys
than to investigate the lesions of the central nervous sys-
tem, and yet, as had been said, a pin prick in such a part
might cause more damage to the general system than the
•passage of a crowbar through another. Slow but sure
progress, however, had been made by the study of autopsies.
Helmholz's invention of the ophthalmoscope had done
much to advance the science of neurolog}-, and every neu-
rologist now made use of it. The tendency of modern
psychology was to become more and more objective and in
this way only was it possible to obtain scientific results.
The certainty with which a diagnosis in dementia para-
lytica could now be made was one of the great advances
in psychiatry. Dr. Barker thought that a great impetus
would be given to this work if psjxhiatric clinics could
be established in connection with every hospital and medi-
cal school in this country and he expressed the hope that
that would soon be done.

On Chemical and Biological Diagnosis. — Dr. .\lfred
Stengle of Philadelphia had been led to the conclusion
that the work of the laboratory man, whether in chemistry
or biology, must be constantly checked by the equally im-
portant work of the clinician, just as the work of the
clinician requires the check of the laboratory worker. His
results might be far more erroneous than those of the
clinician, but they might be able to advance the science in
a way that would never be possible by mere clinical ob-
servation. The introduction of chemistry into medicine
had begun with the discovery of oxygen, when the possi-
bility of estimating the oxidation going on in the living
body w-as shown. It had been thought then that this would
throw a great deal of light upon diseased processes, but
so far as diagnosis was concerned the most important
thing we had learned was that in diseases where oxidation
is supposed to be reduced a reduced oxidation doesn't
really exist, as in anemia. It had been thought that the
amount of oxidation might be obtained by the studies
of urea elimination, but the estimates of urea, without
taking into consideration the question of absorption and
the intake of food, were absolutely w-orthless. So far as
the total nitrogen was concerned the same thing could be
said. As to the production of uric acid and its estima-
tion, fanciful theories of uric acid diathesis had been aban-

May II, 1907]

MEDICAL RECORD.

789

doned. As to the carbohydrate metabolism the presence
of sugar in the urine was known to be an abnormal con-
dition and when combined with certain clinical symptoms
constituted the disease of diabetes. The most important
principle that physiological chemists discovered, perhaps,
was that the defence of the body against chemical poisons
was due to a pairing with other substances in the body, as
of one of the acids with an alkali; that urea and bile salts
combined with other substances for their elimination. This
theory of pairing had led to the discovery of the only
genuine autointoxication of which we had any accurate .
knowledge, that of acid intoxication which occurred in a
variety of conditions. In diseases of the stomach a great
deal had been expected from investigations of the gastric
juice, but the quantitative estimates of the stomach contents
had not proven as valuable as studies of the motility of
that organ. Conrad's method for diagnosis of typhoid
the writer considered an improvement over the Widal re-
action. As to tuberculin he thought the views of Dr.
Trudeau deserved more general acceptance, namely, that
if carefully used small amounts of tuberculin were safe
and the diagnosis was greatly facilitated by its use. Witl;
regard to the opsonic index there could hardly be a positive
expression of opinion as yet, and certainly the difficulty of
making the examinations rendered the test of doubtful
value to practitioners.

Physical Diagnosis. — Dr. Rich.^rd C. Cabot of Boston
hoped tha't this Congress and the year 1907 would mark
and end of the false and harmful distinction between lab-
oratory and clinical methods of diagnosis, for the dis-
tinction could not be defined and did not, in fact, e.xist,
although we attempted sometimes (and most disastrously)
to approximate to it. There should be no diagnoses made
merely in the laboratory and none merely at the bedside.
The degree of exactness in any technical procedure de-
pended wholly on the end to be secured. We might have
too nmch exactness as well as too little. But, we could
not have too much clearness in the e.xpression of ou^
results. Modern physical diagnosis showed (among others)
two dominant tendencies: (a) to seek for and prize the
most direct methods of examination; (b) to lay stress
upon the present functional capacity of an organ rather
than upon the present appearance of anatomical lesions.
The writer believed that the oldest methods — inspection
and palpation — were still the best. Among recent additions
to our technical resources three could be mentioned as like-
ly to stand the test of time. These were: (a) .r-ray ex-
amination; (b) blood-pressure measurements; (c) palpa-
tion of the abdomen beneath the surface of the warm bath.
In the examination of sputa we had progressed from thf
complex to the simple. Reduced to its essentials, sputum
work to-day meant a good look at the sputum in bulk, the
judicious use of one's nose, and the search for tubercle
bacilli. Curschmann's spirals, Charcot-Leyden crystals, fi-
brinous casts, influenza bacilli yielded no clues for diag-
nosis, prognosis, or treatment.

The Borderland of Medicine and Surgery. President's
Address. — Dr. Reginald H. Fitz. Boston, delivered thi>
address. He said that on the front of the building erected
for the Harvard Medical School in 1883 were inscribed
the names, Hippocrates, Celsus, Galen, Vesalius, Pare,
Haller, Harvey, Sydenham, Hunter, Bichat. Of all the
names in medical history these had been deemed the most
worthy of such distinction, as each of these men repre-
sented a new epoch, and the influence of each in his turn
had been of undying influence in the progress of medicine
from the age of Pericles to the present day. Medicine
had become divided and subdivided into its various special-
ties and advance had been made now in one direction,
then in the other, but the unity of medicine had ever re-
mained paramount and whatever had benefited a part had
always proved an advantage to the whole. Dissensions
had lessened, distinctions had become recognized, and a
borderline had been traced, shadowy to be sure, but ever

changeable and surrounding a territory open to each and
productive for all. The speaker called attention to some
of the landmarks in this borderland of medicine and paid
tribute to those who had been instrumental in establishing
tliem and indicated some of the means by which this region
should continue productive. He traced the advance of
medicine from the Hippocratic period, four or five centuries
l)efore Christ, when but one healing art was recognized,
that of medicine, when the physician was conversant with
disease only and there was no surgeon, through the Alex-
andrine period when the separation of surgery from medi-
cine began, through the Roman period when Celsus re-
corded the state of medical knowledge at and before his
time, during the period when Galen who lived a century
after Celsus, when the distinction bi^tween medicine and
surgery became well established, through the period when
the Arabs preserved and maintained the best of Greek
medicine, the further developmnt of medicine and surgery
as fostered in the schools of S'alernum and Montpelier and
later by the Universities of Italy and France, which later
gave way to the Universities at Xaplcs, Bologna, and
Padua, down to the present time, when surgery had become
a science. To John Hunter, anatomist, physiologist, pa-
thologist, and surgeon, was due, more than to any other
man, the scientific foundation of surgery as a science. The
efifect of Hunter's work was greatly enhanced by that of
Bichat, equally distinguished for breadth of mind, intensity
of application and genius for generalization. After the
construction of the microscope and the progress made in
chemistry, the recognition of pathological histology and of
cellular pathology, scientific medicine, and scientific sur-
gery became definitely established and the practitioners be-
gan to appreciate the value of the broader training. The
center of scientific thought became transferred to Germany
and became lustrous chiefly through the teachings of
Virchow, pupil of Johannes Muller and of Schonlein. The
discoveries in medicine during the latter half of the nine-
teenth century had added more to the welfare of man, as
manifested by relief from suffering and disease, than the
sum of all known efforts in this direction since the origin
of man. Common to medicine and surgery they had been
alike beneficial to each and had resulted in a redistribution
of the borderland of medicine and surgery, adding more
and more to the domain of surgery, while opening fresh
fields to the labors of physicians. With due appreciation
of the great benefits that had arisen from the surgical
invasion of the borderland, there still existed sufiicient
reason to progress slowly and cautiously, as operative
success was not* necessarily a justification for operation,
as had been recognized by those who were brought in con-
tact with the failures. The successful invasion of the bor-
derland by the surgeon was due mainly to the fact that
surgery had become science. Thorough training in the
laboratories was the best preparation for contact with dis-
ease and the more thorough the preparation of the phy-
sician and surgeon the more skillful and beneficent would
be their art and the more exact and productive their
science.

IVLdncsday, May S— Second Day.

The subject for discussion was "The Comparative Value
of the Medical and Surgical Treatment of the Immediate
and Remote Results of Ulcer of the Stomach."

Indications for. Methods of, and Results to be Ex-
pected in the Medicinal Treatment of Ulcer of the
Stomach. — Dr. John FI. Musser of Philadelphia opened
the discussion of this subject, and, after reviewing volumi-
nous statistics, concluded that gastric ulcer is a medical
disease. Gastric ulcer with complications and sequela; is
sometimes a surgical disease, and if perforation occurs
it becomes a surgical affection at once. If hemorrhage
occurs acutely it is rarely a surgical affection; if repeated
and chronic, it is surgical. If the ulcer is productive of
perversion of secretory function alone, it remains a medical

790

MEDICAL RECORD.

[May II, 1907

affection. Inasmuch as hypcrchlorhydria is in part a neu-
rosis, the secretory function can be balanced chiefly by
medical, dietetic, and hygienic measures. Even if pyloric
spasm attends the hypersecretion and hyperacidity, it does
not necessarily take the case beyond medical care. It is
wrong to submit such a class of cases to operation, unless
motor disturbances come to the foreground. If tlie symp-
toms and physical signs of retention from obstruction, dila-
tation, hour-glass contraction, or adhesions supervene and
persist, the case is a surgical one. If tlie symptoms of
gastric ulcer become continuous in spite of medical treat-
ment, and incapacitate or threaten life, if hemorrhage recurs
and secondary anemia aiises, it is a surgical disease. Such
cases are always attended by organic sequelae. The e.xtra-
ordinary frequency of chronic gastric ulcer with sequelae
requiring operation at the present day is due to neglect of
the treatment of an ulcer in its incipiency. Statistics show
that most cases are operated on between the thirtieth and
fortieth year, and have an ulcer history of live to ten years'
duration. The evidence is not sufficient to show that gas-
tric ulcer is a forerunner of gastric cancer. After the
surgical procedures of necessity are carried out, the case
must be treated medically. Medical treatment must be con-
tinued over a period of four months at least ; hygienic and
dietetic over a period of years; the best permanent relief
and the most complete restoration to health occurs in those
cases which recover after perforation of the gastric ulcer;
an operation which if possible could approach this accident
in an anatomical result would be the best.

Dr. Charles G. Stockton, Bufifalo, New York, said that
Dr. Musser had assembled the evidence that recent e.xperi-
ence had made possible in the medical treatment of peptic
ulcer, and pointed out what advance had been made, and,
to decide in view of all these facts the most judicious
course to pursue, without attempting to press overmuch the
importance of any particular method of treatment, was a
task. Did we permit ourselves to take a brief in champion-
ing some method with the zeal that success in a compara-
tively small group of cases sometimes suggests, we would
undoubtedly fail. It was very important at this period not
to array against each other the comparative advantages of
medical and surgical practices. Rather there should be
made the deliberate effort so to view the matter that we
might concur in deciding upon the place of each in the
treatment of this disease. We should attempt to exclude
certain cases that closely resemble in symptomatologj- pep-
tic ulcer, but in which, despite the occurrence of pain,
tenderness, spasm, vomiting, and hemorrhage, no ulcer
actually exists. He denied that it was aN'ays true, as had
been asserted in some quarters, that these cases do in fact
sutler from undiscovered ulcer or fissure, because oozing
of blood might be seen through the turgid, deeply-
congested mucosa, that showed no lesion even under the
magnifying glass, and because superficial erosions or fis-
sures in an otherwise healthy stomach are rapidly cured
by nature, and are practically without symptoms. Those
ulcerated processes dependent upon special infections. like
sv'philis, tuberculosis, and pyemia, should be excluded from
the consideration. There remained two distinct divisions
of peptic ulcer ; first, the more frequent type, the acute,
which occurs in younger patients and appears often in
chlorotic young women, and, second, the type more com-
monly developing in older patients, those past middle life.
The prevention of gastric ulcer could be summarized thus :
maintain a calm nervous system in a well-conditioned body ;
the medical treatment : to make a positive diagnosis begin
treatment early, and carry out with painstaking attention
the details for a long time; general rest; in some cases
discreet feeding, in others periodical starvation, depending
for support upon frequent small enemata of normal salt
solution. For the control of hemorrhage, in addition to
rest, local treatment through the stomach tube, using ice
water, adrenalin solution, and gelatin water. In irritating
hyperacidity one should use local general sedatives and

antacids. To relieve hypertension and spasm of the
stomach, in addition to suitable drugs, the external applica-
tions of Von Leube. Treatment should be continued long
after apparent cure and the stools studied for occult blood.
The indications for surgery were for the relief of results
of gastric ulcer rather than for the cure of the disease itself.

The Contribution of Surgery to a Better Understand-
ing of Gastric and Duodenal Ulcer. — Dr. William J.
Mayo, Rochester, .\lniii,, divided ulcers of the stomach or
duodenum into two classes, indurated or nonindurated.
The indurated ulcer involves all of the coats of the
stomach or intestine, and its existence may be demon-
strated from the exterior of the organ. All of the notable
contributions of surgery to our knowledge of ulcer con-
cerned this group. Surgical investigation had shown, first,
that ulcer of the duodenum in the upper inch and a half
is as common as ulcer in the whole of the stomach. Sec-
ond, that the majority of ulcers, called pyloric, have their
origin in the duodenum. Third, that the male sex is more
frequently afflicted with ulcer of the stomach and duo-
denum (62 males to 38 females) by reason of the fact
that 77 per cent, of duodenal ulcers are in the male, true
gastric ulcer being about even in the two sexes, 52 males
to 48 females. Fourth, that cancer frequently has its
origin in ulcers. In 54 per cent, of 69 cases of cancer of
the stomach submitted to resection by Dr. Chas. H. Mayo
and the writer in 1905-06, cancer could be demonstrated to
have had its origin in ulcer. Nonindurated mucous ulcer,
also described as clinical or medical ulcer, gives no evi-
dence from the exterior of the stomach or duodenum of its
existence, and unless the interior be successfully explored
the diagnosis remains in doubt. Nearly all the failures in
the surgery of ulcers concerned this group. The existence
of acute nonindurated mucous ulcer was shown by opera-
tions for acute perforations, hemorrhage, and post-mortem
investigations of deaths from these causes. Chronic non-
indurated mucous ulcer was certainly very rare. The
large majority of cases so diagnosed were in reality non-
surgical conditions, such as pyloric spasm, atonic dilata-
tion, gastroptosis, and the gastric neuroses. If a diagnosti-
cated chronic nonindurated mucous ulcer (clinical ulcer)
cannot be demonstrated at the operating table, it probably
does not e.xist, and operation should not be done on an
improved hypothesis, unless complications such as hemor-
rhage, perforation, or obstruction coexist.

Dr. John C. Munro, Boston, had made an analysis of
Ijo cases. Of these 87 showed gross ulcer of the stomach
or duodenum ; 16 belonged to the class of so-called medical
ulcer, where no gross ulcer could be found at operation;
25 showed well-marked adhesions, without evidence of
ulcer; 15 were the so-called neuroses, and 9 classed as
ptosis, spasm of the pylorus, etc. As to the question of
immediate gastroenterostomy in perforation, he believed
the anastomosis shortened convalescence and tended to
obviate the necessity of secondary operations. The simpler
the technique and the nearer we followed anatomical lines
the better the result. The different methods of operation
were gone over in detail. Excision of the ulcer area, w-hich
is also the cancer area, he considered the ideal operation
after middle life. The decision upon the type of operation
depended upon the individual case and the experience of
the operator. The simplicity and cleanliness of the clamp
and suture operation spoke highly in its favor, and he
thought was to be preferred to any other. When relief
was obtained in these cases it excelled that in almost any
other class of diseases, besides relieving the chances of
engrafted malignancy.

Dr. A. J.1COBI. New York, in discussing the subject, said
that ulcers of the stomach, both acute and chronic, were
frequent at every age. There were those whose e.xperience
permitted them to say that from two to five per cent, of
the population suffer from it. Brinton collected 226 cases,
of whom 2 were under 10 years of age: 18. from 10 to 20;
43. from 20 to 30: 38, from 30 to 40: 38. from 40 to 50;

May II. 1907]

MEDICAL RECORD.

791

32. from 50 tu 00; and 32, from 60 to 70. Similar results
had been obtained by Cruveilheir and by Rokitansky. A
late case had been published by Immerwuhl, the patient
being four years old, with a chronic ulcer and nephritis,
dying of uremia. Ulcer of the stomach, in its most danger-
ous form, was not infrequent in the infant. Between the
seventh and thirteenth year was not at all rare. Most
ulcers were found on the posterior wall near or in the
small curvature ; the next locality of predilection being the
neighborhood of the pylorus, while some were found in the
cardia or in the fundus, in the .-interior wall and the large
curvature. The size might be no larger than the head of
a pin. detected with difficulty at autopsy, while they might
be the size of a hand. .\s to the occurrence of hemorrhage
his own observation, e.xtending over a period of fifty-four
years, of private and hospital practice, coincided with that
of Leube, that it occurred in less than one per cent. His
experience as to perforations also coincided with that of
Leube that they occurred in about one to two per cent. .\s
to the mortality reports the vast differences ranging from
2.4 per cent, to 50 per cent., proved for the thousandth time
that statistics :nay be the most deceptive and most irra-
tional method of dealing with any clinical question. The
experience of the general practitioner in a large practice
among the poor or among the rich, among men or among
women, the general physician with a family practice only
or an office practice preeminently, the consultant who is
called in to see bad cases only, the stomach, specialist, the
surgeon in general practice, the hospital physician in whose
wards bad cases only take refuge, the hospital surgeon
who never sees anything but hemorrhages and perforations,
gives a variety of observers but a variety of cases. E.x-
clusive hospital physicians and surgeons have little ex-
perience with the average ulcer of the stomach ; theirs
being only an experience with bad or fatal cases. Their
statistics referred to hemorrhages and perforations, not to
chronic ulcer of the stomach. The main symptoms of
gastric ulcer were given as pain, hyperacidity, and some-
times hemorrhage. The presence of ulcer required con-
stant alkalinization of the stomach, the administration of
an alkali at long intervals being insufficient. He gave
an alkali before every meal and at intervals of two hours
for months, and preferred those which contained no car-
bonic acid, which inflated the stomach. The best was mag-
nesia, magnesium oxide, three to four grams a day. Bis-
muth subcarbonate, not subnitrate on account of its gritty
condition, might be safely added. The speaker felt posi-
tive from what he knew of the frequency of gastric ulcer
in general practice and of the long time it takes negligent
or indigent patients to nurse their illness up into the stage
of hemorrhage or perforation that it was often cured and
prevented from the necessity of getting into the medical
or surgical hospital ward. Conservative surgeons admitted
that seventy-five per cent, of gastric ulcers were cured by
internal treatment. After the operator had performed his
duty the case became again that of the practitioner and
there might be an organ of doubtful utility, for the crea-
tion of a funnel was not the restoration of a normal stom-
ach.

Dr. E. G. J.\NE\v.\y, New York, believed that the medi-
cal men and the surgeons were now pretty well agreed on
this subject; certainly they were in entire accord as to
perforatinn : where there was perforation operation was in-
dicated and indicated at once if the best results were to
be expected. The same was true of stenoses and obstruc-
tion of the pylorus with cicatrices. He did not feel that
lavage was advi'.able in these cases and referred to two
instances where death had been produced Iiy its employ-
ment. He had the same objection to the use of subnitrate
of bismuth that Dr. Jacob! had mentioned; it could be
seen under the microscope to consist of crystalline flakes
with sharp edges, and why it had remained so long a
favorite remedy he could not understand : he had had one
case in which the sharp flakes were found in the passages.

He preferred the subcarbonate or subgallate. He did not
advocate the use of subnitrate of silver in these cases, as
there was no certainty of touching the ulcer with it. He
advocated Truseau's method of requiring the treatment to
extend over a period of two years. The patient should
be put on his guard and told that he has a chronic disease
for which the treatment must be kept up for a long time»
.\t the conclusion of the meeting the Secretary, Dr.
\\"ni. H. Carmalt, was presented with a silver loving cup
by the presidents of the Congress and presidents of its
constituent associations in appreciation of his faithful and
untiring efforts for the success of the i>rganization.

ASSOCIATION OF AMERICAN PHYSICIANS.

Tzccnty-sccoitd Annua! Mccliw. Held in Washington. D. C

May 7, 8, and g. 1907, in Conjuitction zvith tlic Congress

of Juwriian Pliysicians and Surgeons.

Fr.^ncis p. Kinnicutt. M.D., New York, Preside.vt, in"

THE Ch.\ir.

(Special Report to the Meuic.^l Record )

Tuesday. Mav 7 — First Day.

The President's Message. — Dr. Francis P. Kinnicutt
of New York City, in formally opening the meeting, em-
phasized the mutual dependence of the science and
practice of medicine, as would be clearly illustrated by
the scientific program to be presented to the associa-
tion at this time. He briefly reviewed the professional
careers of Dr. James Stewart of Montreal, Dr. Isaac
Edwaril .Atkinson of Baltimore, and Dr. Thomas Lat-
timer of Baltimore, all deceased since the last meeting
of the association.

The Connection of the Occipital Lobes and the
Present Status of the Cerebral Visual Functions. — Dr.
.■\dolf Meyer of New York City presented this paper,
which was illustrated by a munber of lantern slides.
The foll')wing points were developed: (i) Isolation of
the geniculocalcarine trace (two cases). (2) Subdivis-
ion of sagittal marrows and their course. Marking of
the calcarine area. (3) Degeneration of the occipital
efferent path and the geniculocalcarine tract, following
degeneration of the calcarine cortex. (4) Marchi-
degenerations from a small wound of the postparietal
cortex, involving the optic radiations: (a) Afferent
character of the external sagittal marrow; (b) efferent
character of the internal sagittal marrow (contributing
to the lateral part of the crus) ; (c) subcortical (ex-
ternal sagittal) fibers towards the motor area; (d) no
fibers to the frontal lobe. (5) .-Knatomical data for clinical
correlations.

Dr. L. F. B.\RKER of Baltimore emphasized the im-
portance for diagnostic purposes of such studies as
Dr. Meyer had outlined. He believed that it was only
through such careful study that any definite knowdedge
could be obtained concerning the cerebral visual func-
tions.

Certain Features of the "Nervous Breakdown" virfth
Special Reference to Treatment. — Dr. James J. Put-
N.M! of Boston, Mass.. in this paper, emphasized the
view that the acute "nervous breakdown" really typi-
fied processes which were characteristic of more chronic
neurasthenic conditions, but which afforded especialh-
good chances for observation, because the illness ran
its course, practically, under the physician's eye. The
^o-called "traumatic neurosis" was perhaps the most strik-
ing example of this acute breakdown, being characterized
by its period of predispo.-.ition, followed by periods of ner-
vous shock, of apparent absence of symptoms, of gradually
increasing illness, of an apparently stationary sta.ge. of
convalescence and recovery. Similar processes were fre-
quently observed as a result of nontraumatic shock, of
strains during school and college life, and many analogous
influences, while diminutive periods of like type were fre-

792

MEDICAL RECORD.

[May II, 1907

quently met with as intercurrent events in the course of
chronic illnesses. The controlling influence in the causa-
tion of these states, and the controlling means of treat-
ment, was the mental state of the patient. To the consid-
eration of this factor the paper was chiefly devoted. The
means of increasing the patient's availahle stock of mental
energy were among the principal therapeutic points con-
sidered. In this connection Ur. Putnam emphasized the
importance of the different methods of reeducation, as
developed by S. Weir Mitchell and others. While philos-
ophy and ethics could not be presented to the patient in"
a technical way, yet if physicians were more trained in
this department of learning, their efforts would be more
effectual. A strong plea was made for such training. The
relation between the mental processes and the physiologi-
cal functions having to do with nutrition, etc., was also
emphasized.

Dr. John K. Mitchell of Pliiladclphia asked for en-
lightenment in the management of the acute stage of
"nervous breakdown."

Dr. Adolf Meyer of Xew York was of the opinion
that the abstract statement that physicians should teach
philosophy and ethics to patients would lead to a mis-
conception on the part of many physicians of the whole
movement. As modern psychology had arisen largely
out of the experience of physicians, so the philosophy and
ethics of the future would find a large source of facts in
the experience of physicians. Taken from this point of
view — not of abstract ethics, but the formation of habits,
the arranging of definite regimes of habits and reaction
types — the suggestion was important in the treatment of
neurasthenics and other mental disturbances.

Dr. Charles L. D.«iN.-\ of Xew York City thought that
in the majority of instances of "nervous breakdown" if
the patient were put under ordinary common-sense envi-
ronments recovery would take place within six months or
a year. Many cases of neurasthenia, however, were not
merely nervous breakdowns, but were psychoses. A cer-
tain percentage of persons were of a nervous disposition,
and in the event of a breakdown such an individual would
have a psychosis; this, however, would run its course.
The majority of neurasthenic cases, put under proper
mental, moral, and physical surroundings, would recover.

Dr. A. J.\coBi of Xew York, speaking as a physician
and not a neurologist, would examine such patients from
an additional point of view. The cases he had seen had,
almost without exception, suffered from mild cardiac
changes. Upon exertion on the part of the patient a feeble
murmur could invariably be heard, and this physical
change, whether of the nerves or muscle of the heart,
should be treated as well as the psychical condition.

Dr. S. Weir Mitchell of Philadelphia called attention
to the fact that a nervous breakdown might be brought on
by mental conditions and emotional disturbances, and
sometimes by a physical breakdown.

Dr. Putnam, in closing the discussion, agreed with all
the speakers. Replying to Dr, John Mitchell's question
concerning the treatment in the acute stage, in traumatic
cases he had found that rest and encouragement had con-
siderable effect, though sometimes little could be accom-
plished thereby. He agreed with Dr. Meyer that the
whole matter should be put on the simplest and most
matter-of-fact basis possible. In a measure he agreed
with Dr, Dana's suggestion that these accidents and strains
initiate a psychosis which must run its course. This psy-
chosis, as Dr, Jacobi suggested, was not a pure psychosis,
but had its physical side.

The Clinical Study of Aphasia. — Dr. Ch.\rles L, Dana
of New York City presented, in this paper, the analysis
of a series of cases of aphasia, clinically studied, with the
object of securing a grouping of the aphasias as they are
seen at the bedside, with a description, so that such groups
might be recognized by the phs'sician and taught to the
student. The views of Professor Pierre Marie were dis-

cussed in the paper. Dr. Dana presented a method of
diagranunatically representing the type of aphasia upon
certain charts devised by himself. He thought it would be
best to teach students to make the classification of aphasia
on an anatomical basis, to find out the kind of aphasia
the patient had and then locate it, in the temporal, frontal,
parietal, or occipital lobe, as the case might be,

Dr, W, M. Thompson of New York City, from his
own clinical experience, was not inclined to attach much
importance to the cases of aphasia detailed by Marie in
which it was claimed that each one was accompanied
with motor symptoms, showing that the lesion had ex-
tended to the motor region.

Dr. James J, Putna.m of Boston was glad to hear Dr,
Dana put himself on record as recognizing the various
types of aphasia,

Dr, Morton Prince of P^oston did not accept Marie's
view that all aphasias are intellectual aphasias expressing
themselves in this or that direction.

Dr, Dana, in closing the discussion, said that he hacj
not brought out Marie's point of view, although it was
difficult to treat the subject without reference to it, Marie
had not proven that the frontal lobe is not a language
center; there was much absolute evidence that it was, clin-
ical and pathological reports leaving little doubt on the
subject. Aphasia was not sensory, nor was it motor, but
sensorymotor.

The Presence of Inflammatory Masses in the Abdo-
men Simulating Malignant Grovrths. — Dr, E. G. Jane-
way of New York City presented this paper, citing in
detail a number of cases in which masses, discovered by
palpation and ordinary examination, or by these and
laparotomy, were considered malignant, but disappeared
later. Of the cases mentioned two occurred in connec-
tion with ulcer of the stomach, the others in different
places in the abdomen. He did not advocate exploratory
laparotomy in these cases, but thought it better to wait.
Many of the cases of tumors reported as having disap-
peared under treatment with .r-ray and other measures
he believed to owe their disappearance to time,

Dr, William Osler of Oxford, England, said these
cases might be divided into the following groups : those
associated with the gall-bladder, those associated with the
stomach, the appendicular cases, and those in which the
trouble is in the cecum. He had had his attention called
to cases in which there was a mass in the left iliac fossa.
This might be due to thickened glandule epiploicte. This
was found to be the case in two instances. In another
case there was thickening due to perforation by a foreign
body. He agreed with Dr. Janeway's attitude concerning
surgery, and yet in many instances operation was very
satisfactory, being followed by disappearance of the tumor,

Dr, Charles Bond of Richmond, Indiana, cited a case
in which it would not have been well if the patient had
fallen into the surgeon's hands. The tumor disappeared in
the course of two or three years.

The Etiology of Acute Pancreatitis. — Dr, H, U,
A\'iLLiAMS of Buffalo presented this paper, which detailed
experimental work done by Dr, Williams and Dr, F, C.
Busch, also of Buffalo, The part played by gallstones in
the production of acute pancreatitis was considered, and
cases of this kind analyzed.

Dr. Eugene L. Opie of New York City, in discussing
this paper, said he was surprised to find that the number
of cases of acute pancreatitis in connection with gallstones,
as given in the extensive literature collected by Dr,
Williams, was so small. This was probably due, as sug-
gested, to the fact that the bile ducts were often neglected
in the examination.

The Calcium, Magnesiimi, Phosphorus, and Nitrogen
Balances in a Case of So-called Phosphatic Diabetes, —
Dr, L, F, Barker of Baltimore, Md,, read this paper, which
was prepared jointly with Dr, C, Voegtlin of Baltimore.
The paper included the results of a metabolic study in a

May II, 1907]

MEDICAL RECORD.

793

case of so-called phosfihatic diabetes. A woman who fur
years had suffered from dry skin, cracking of die heels,
and nervousness, and who had had constantly urine uf
high specific gravity and high acidity, was placed upon
Folin standard diet, and the calcium, magnesium, nitrogen,
and phosphorus balances studied. The metabolism was
abnormal in that the urine on a standard diet presented a
very high organic acidity not due to uric acid, to phos-
phates, or to lactic acid.

Dr. WiLLi.\M OsLER, under whose care the patient had
come from time to time, said that the chief point of inter--
est was the fact that the symptoms would lead anyone to
the diagnosis of diabetes, and yet repeated examination
failed to discover any trace of sugar. He had always
regarded it as a case of prediabetic condition, and ex-
pected each time the patient presented herself to find
sugar in the urine.

Dr. A. E. T-JWUiR of Berkeley, California, detailed ex-
periments which he had carried out upon himself, with a
calcium free diet. The symptoms were those of lassitude
up to the si.xth day, when there was marked nniscular
twitching, loss of sleep, and extreme irritability. Real-
izing at this stage of the e.xperinicnt that the danger point
was being reached, he returned to the normal diet, tlie
equilibrium returning immediately.

Dr. B.^RKER. in closing the discussion, said the sahs
were just as important in the food as were the other ele-
ments. He emphasized the importance of maintaining the
balance of the inorganic substances. Working along this
line, it might be found that neuroses and psychoses had an
organic basis.

The Relations Between Diabetes and Pregnancy. —
Dr. Augustus A. Eshner of Philadelphia maintained, in
this paper, that diabetes was micommon during preg-
nancy in proportion as it was uncommon during the child-
bearing period. E.xceptionally it had recurred during suc-
cessive pregnancies. Pregnancy rarely occurred in dia-
betics, partly because diabetes in women is most common
after the menopause, partly because of the debilitated
general state of the diabetic patient, and partly because
of the functional derangement and the structural altera-
tion of the generative organs. The complication of the
one condition with the other usually increased the gravity
of both. Often the fetus died i';; utcro. or premature labor
set in, the fetus dying at birth or shortly thereafter. The
liquor amnii had been found increased, and, in some
instances, also to contain sugar. The mother sometimes
died of the disease shortly after labor. In Dr. Eshner's
case of diabetes the sugar disappeared from the urine with
the inception of pregnancy, remaining absent until after
the birth of a macerated fetus at term and reappearing
shortly afterward.

{To be cotitinucd.^

AMERICAN GVXECOLOGICAL SOCIETY.

Thirty-second Annua! Meeting. Held at H'asliington. D. C.

May 7, S. (!)i(/ 9. IQ07. in CnniiDtetion ivith the Congress

of American Physicians and Surgeons.

Dr. Clement Clevel.nxd of Xew York, President, in
THE Ch.mk.

Tuesday. May 7 — First Day.

Metastatic Carcinoma of the Tube and Ovary in Cancer

of the Cervix Uteri.— Dr. Fred J. T.^ussIC of St. Louis.
Mo., read a paper on this subject, in which he concluded
that mild, chronic inflammatory conditions of the tube
and ovary were frequently met with in cancer of the cervix
Whether this was merely coincidence or not he would be
unwilling to say. On the other hand, cancerous metastases
in these organs were extremely rare in cervical cancer.
In fact, he could find no record of such metastasis in an
operable case. In carcinoma of the body, however, tliey

were not infrequently seen in tube or ovary, or both.
Hence it would seem logical to advise the removal of both
tubes and ovaries in every case of cancer of the body.
If, however, the patient was still five to ten years from the
time of the menopause, and the site of the cancer be in
the cervi.x, the saving of one ovary would be attended with
practically no risk to the patient and might relieve her
of the disagreeable symptoms of the premature menopause.
Since this could be done without interfering with the
complete removal of the lympliatics directly tributary to
the cervi.x, he believed it logical to leave one ovary, or
a portion of one ovary, in every operation for cervical can-
cer in a woman under forty years of age.

Dr. J. Wesley Bovee of Washington, D. C, said me-
tastases in cancer of the uterus were by no means com-
mon, and that as the disease spread metastases occurred.
This emphasized the fact that in the cases brought to the
attention of the gynecologist he was helpless in the treat-
ment of cancer of the uterus ; that in the cases in which
the conditions would ordinarily offer great hope of suc-
cess we would find that metastases occurred in those
structures which we would not remove, the result being
that cancer recurred or continued unsuspected. At best
the treatment of cancer of the uterus was not hopeful,
notwithstanding the claims of radiographers and the dem-
onstrators of radium, etc., and those who did the most rad-
ical surgical operations. He was not prepared in the present
light of surgery of cancer of the uterus to accept the
suggestion of the essayist, that it is safe to leave a
portion or even one ovary in extirpating cancer of the
uterus. His own conviction was that the operation should
be as radical as it could be consistent with saving the
life of the patient.

Dr. L.1PTHORN Smith of Montreal, reported a case of
cancer of the cervix in which operation was done early
by another surgeon, with every possibility of a complete
recovery of the patient and freedom from recurrence; yet
this woman came to him a year later with no sign of re-
currence in the vagina, but with two distinct masses in
the ovaries which could be readily felt. He considered
it too late to do anything in an operative way. This case
made such an impression on him that ever since, when
doing vaginal hysterectomy, he always removed the tubes
and ovaries. He did not think it was safe to leave an
ovary or a piece of an ovary wlien there was such a tre-
mendous risk of recurrence.

Dr. Reuben Peterson of Ann .\rbor, Mich., desired to
place himself on record as voicing the sentiment of Dr.
Bovee against the leaving of one ovary, or part of an
ovary, in the operation for cancer of the uterus. This
was a step backwards, and vi^as not in accordance with
the progress that had been made in the last ten years in
the treatment of cancer of the uterus. He was not con-
vinced that the leaving in of one ovary, after the removal
of the uterus, helped the patient, so far as the menopausal
changes were concerned. He had been unable to see much,
if any, difference where an ovary had been left in, and
where it had been removed, after the removal of the
uterus for cancer.

Dr. Walter M. Chipman of Montreal doubted whether
it was a wise thing to leave even one ovary, or even a
part of one, after the removal of the uterus for cancer,
no matter where the cancer was situated. While it was
true that the ovary was not in the direct path of the
Ivniphatic distribution of the pelvis, yet so great and so
rich was the anastomosis that be thought the leaving
of ovaries must always be a risky procedure.

Dr. Taussig, in closing the discussion, said he antici-
pated that most men would hardly agree with him as to
the advisability of leaving a portion of an ovary in the
class of cases under discussion ; but be believed, however,
from the statistics that the procedure was not at all unsafe,
and it seemed to him that it was just as logical to advise
the removal of the appendix as to advise the removal of

794

MEDICAL RECORD.

[May II, 1907

the other ovary. The appendix was a useless organ; the
ovary — at least, in the opinion of some — helped to make
the menopausal disturbances less severe in women under
forty years of age, if left.

A New Method of Version.— Dr. .'\. F. A. King of
Washington, D. C, spoke of the correction of transverse
presentations by the hitherto unrecognized factor of thigh-
pressure upon the abdomen, induced either (i) by posture,
or (2) by manipulating the lower limbs. The former, he
said, was Nature's method of preventing and correcting
cross-presentations ; and in primitive races w-as daily exer-
cised by the squatting posture during defecation, etc.
Squatting was not a symmetrical proceeding; the two
thighs did not press equally. One foot was flat upon the
ground and in advance, the other in the rear, rested only
on its toes. The thigh of the front foot would press
high up upon the breech end of the fetus; the thigh of
the rear foot would press low down upon the head, forcing
it from the iliac fossa into the pelvic brim, as was illus-
trated by diagrams.

The Superiority of Primary Over Secondary Ce-
sarean Section; Feasibility and Advantages of a Pre-
determination of the Method of Delivery. — Dr. Edward
Reynolds of Boston spoke of primary operations being
determined upon in advance of labor and performed at an
elected date, or with the advent of the first pains. Sec-
ondary operations might be performed as soon as a test
in labor had shown that the natural powers were likely to
fail and before serious exhaustion set in. Late opera-
tions were considered in the light of a last resort. Late
sections were already discredited, while secondary sec-
tions were still the most frequent class. He gave the
statistics of primary, secondary and late sections of the
last ten years. Primary section was a very safe operation,
while secondary section was only moderately safe. Late
section was attended with a high mortality. In general,
the mortality was roughly proportionate to the amount
of labor endured before operation. Decision before labor
was a matter of great moment. The doubtful cases were
constantly narrowing and should be done away with. Ac-
curate prediction of expected difficulty required : estima-
tion of the shape and relation of the pelvis (measure-
ments alone were entirely unreliable) ; of the probable
muscular character of labor ; of the size and ossification
of the head. Methods of estimation of the maternal ob-
stacles required knowledge of the maternal powers (these
could be foretold with considerable accuracy) and of the
mechanical character of the head. He emphasized the
value and importance of obtaining a previous history in
multipara?. He submitted the following classification : A.
undoubtedly cesarean section cases ; B, cases clearly capable
of delivery without the cesarean ; C, doubtful cases.

As to the treatment, in class A he would resort to
primary section ; in class B labor and the intrapelvic opera-
tions. In class C a final examination under ether at the
date of election, the method finally decided on, and decision
adhered to. The predetermination of methods was work
for experts only. Lastly, he pointed out that a more
friendly relation between the specialist and the genera!
practitioner was desirable.

Pubiotomy. — Dr. Henry D. Fry of Washington, D. C,
read a paper on this subject. Pubiotomy was a satisfac-
tory operation, so far as the operation itself went, for
enlarging the pelvic girdle in moderate degrees of pelvic
contraction. It was easy to perform and could be em-
ployed in simple flat pelves with a conjugata vera of 7 or
75^2 cm. Separation of the severed bone for 4 or 5 cm.
was usually sufficient to enable easy extraction with for->
ceps. The principal objection to the operation was the
difficulty encountered in the after-treatment. These diffi-
culties were little, if any, less than those which brought
symphyseotomy into disrepute. The pelvis must be im-
mobilized and the patient kept in the dorsal position sev-
eral weeks. Maternitv institutions could overcome the

objection to a large degree by the use of a special bed,
as the hammock suspension bed described by Ayres. Wil-
liams used the Bradford frame after two of his opera-
tions. Jewett employed an ordinary hospital stretcher,
"the poles of which were lashed to the top rails of an
iron bedstead. A trapdoor was provided for the dejecta."
Montgomery recommends a pelvic sling suspended from
the ceiling and attached to a compound pulley. Ordinarily,
after pubiotomy and symphyseotomy, the evacuations of
the bladder and bowels were attended with discomfort,
and it was a hard task for the nurse to keep the parts
clean, which was the more important after secondary
operations where the patient was already septic and the
soft parts contused and lacerated. In consequence, there-
fore, of the unsatisfactory convalescence after pubiotomy,
the operation would obtain in this country a limited field
of usefulness as an elective operation. Cesarean section
offered a substitute free from this objection, and its indica-
tions would be extended to embrace these cases of minor
degrees of pelvic contraction. With a head movable above
the inlet, and one which would not descend by suprapubic
pressure, that operation should be performed primarily.
When the head was moulded and engaged, forceps might
be tried tentatively before resorting to section. The in-
dications for pubiotomy might be stated as follows : A liv-
ing child and some contraindication to cesarean section.
The usual conditions presented were : a moderate degree
of pelvic contraction, which had been unrecognized gen-
erally, ineffectual efforts employed to deliver with high
forceps, the woman exhausted, and infection probably
started. If the child were dead, craniotomy; if alive, pu-
biotomy, in spite of the objections raised against it. It
was better to have a live woman at the end of a
tedious convalescence than a dead one after a "successful"
operation.

Induced Labor and Delivery by Abdominal Section.
— Dr. Edward P. Davis of Philadelphia said that among
obstetric operations there was none which in selected
cases gave better results than the induction of labor. This
was especially true in disproportion between mother and
child, whether caused by pelvic contraction, excessive fatal
size, or prolonged pregnancy. Private patients were espa-
cially benefited by this operation, as they usually came
early under the care of the obstetrician and gave him a
better opportunity to study their cases than did hospital
patients. Private patients who had passed through a disas-
trous first confinement were often safely delivered in
subsequent labor by the induction of labor. Experience,
however, and the study of statistics showed that induc-
tion of labor was not without serious disadvantages ; it
was a process uncertain in duration, often exposing the
patient to considerable loss of rest and to prolonged suffer-
ing. Labor was rarely terminated without some active in-
terference, and this was most often to be accomplished
through a cervix poorly prepared for dilatation. Some
of the methods employed to terminate induced labor pro-
duced unfavorable presentations and positions of the fetus,
increasing the risks to mother and child. While it was
possible, considering the interests of the mother first, to
have a low mortality and morbidity rate for her, the best
results so far published gave a very considerable mor-
tality and morbidity for the infant. He believed that the
induction of labor compared in gravity, when the interests
of both mother and child were considered, with other major
obstetric operations. The author then cited six cases to
illustrate the statements he had made. He strongly urged
the importance of conducting cases of induced labor in
such a manner that the patient should be in favorable con-
dition for a major operation, if necessary. He did not
believe it justifiable during induced labor to make efforts
at delivery by forceps or version unless the conditions were
such as to make it reasonably certain that these operations
would be immediately successful. If engagement of the head
did not develop during induced labor the use of the forceps

JNIay II, 1907]

MEDICAL RECORD.

795

was a dangerous procedure. If the operator was sure of
the size and contour of the pelvis, and reasonably certain
of the comparative size of the fetus, version, where the
head did not engage, was the safer operation. The writer
would not resort to delivery by section in a case where
efforts at delivery by forceps or by version had been made.
He believed that with careful antiseptic technique it was
possible to introduce bougies within the uterus, or even
to employ dilating bags without infecting the patient. These
procedures should not cause lacerations and should not
essentially wound the epithelia of the genital tract. It
was impossible, however, to make tentative traction with
forceps, or to practice the manipulations necessary in at-
tempting version without producing lesions in the genital
tract through which infection might enter. It was his
practice, then, to decline celiohysterotomy in all cases where
forceps or version had been tried. In severely septic cases,
the child being dead and unsuccessful eiiforts having been
made at delivery, he believed that the Porro operation
would give the best results. In cases where forceps or
version had been tried without success, if the child was
living, he believed that the consultant should again try
which ever of these procedures he thought best, utilizing
Walcher's position if advisable ; failing in these craniotomy
should be done. As to pubiotomy, a sufficient number of
cases had ben published to show that the operation, like
all other surgical procedures, was not without its dangers
and disadvantages. A maternal mortality of from 5 to 7
per cent, and a fetal mortality of 17 per cent, indicated
its severity. As to delivery by abdominal section, all things
considered, and especially when the fetal mortality was
taken into consideration, the claims of abdominal section
for safe delivery of mother and child could not be disre-
Tgarded. He did not believe that at the present time a
■dogmatic opinion could be formed concerning any one
method of delivery. Another factor of importance was
the value placed by parents upon the life of the child.

Dr. Egbert H. Gr.^ndin of New York said the con-
clusions and line of argument advanced by Dr. Reynolds
were in accord with those which he presented in a thesis
read before the society seventeen years ago entitled, "A
Plea for the Elective Cesarean Section." He contended
then that this operation was ideal, and although seventeen
years had elapsed since, he had not seen fit to change his
position. As to pubiotomy, he would advise it in prefer-
ence to symphyseotomy, although he had not done the
former operation, but had performed symphyseotomy twice.
with living mothers and living children, and, so far as ha
"knew, with no disability on the part of the women.

Dr. Lapthorn Smith of Montreal condemned pubioto-
my. Last summer he performed two cesarean sections,
and could testify to the surprising ease with which the
operation was done in both cases.

Dr. James Clifton Edcar of New York was uncertain
as to where to draw the line between Class A and Class B
in the cases discussed by Dr. Reynolds ; that is, the ante-
partum cases, and the early intrapartum cases. It oc-
curred to him that if Class B, or the early intrapartum
class, was moved a little forward, and the women not
allowed to stay in labor quite so long, instead of a mor-
tality of three per cent., as reported by Dr. Reynolds, it
would approach one per cent, in the antepartum cases.
Where cesarean section was undertaken in the latter part
of pregnancy there was difficulty in securing good drainage.
Pubiotomy did not appeal to him, although he had never
done it. He Tiad, however, done six symphyseotomies.

Dr. Robert A. Murray of New York thought that event-
ually, in the vast majority of cases, obstetricians would
gradually come to the point where they would let women
go to labor prepared to do a cesarean section, and not
interfere with high forceps, or version, or any other method
that would produce traumatism of the cervix and possibly
cause infection which would defeat the result to be gained
from a clean cesarean section.

Dr. Robert L. Dickinson of Brooklyn, N. Y., said the
only cesarean section case he lost was a young woman
who suffered from toxemia throughout her pregnancy.
She was operated on at the beginning of labor pains, but
gradually died from a lack of resistance after an easy
cesarean section. For many years obstetricians had had
control of the second stage of labor, and with cesarean
section, forceps, and version the obstetrician could do what
he chose. But the obstetrician had stood helpless before
the difficult dilatations and before badly developed cervical
conditions. He thought it was unobstetrical to insert a
bougie into the uterus, as it might loosen the placenta and
carry infection. We could not be sure of absolute clean-
liness.

The papers were further discussed by Drs. E. W. Gush-
ing of Boston, George Gellhorn of St. Louis, Mo.; Seth
C. Gordon of Portland, Me. ; Malcolm McLean of New
York; Willis E. Ford of Utica, N. Y. ; Philander A.
Harris of Paterson, N. J., and the discussion was closed
by the essayists.

(To be continued.)

AMERICAN SURGICAL ASSOCIATION.

Tuvnty-eighth Annual Meeting, Held in Washington,

D. C. May 7. 8, and 9, 1907, in Conjunction with the

Congress of American Physicians and Surgeons.

(Special Report tu the Medical Record.)

Tuesday, May 7 — First Day.

The Address of the President. — Dr. Dudley P. Allen
of Cleveland took as the subject of his address, "the train-
ing of the surgeon." He said that during the past genera-
tion the progress of surgery had been tremendous, due
mostly to the introduction of anesthesia and of asepsis.
It did not seem possible for another generation to make
as great strides. The main problem at present that needed
solution was in the line of the nonoperative treatment of
cancer. .A. very practical problem that was always with
us was, not only how to impart to students our knowledge
of what has been done, but how to advance our knowledge
in the future. In country districts there would always be
a demand for men with a general training but in the popu-
lous centers there would always be need of the specialists,
and it was of them that this paper specially treated. The
specialists should have a thorough training in all medicine,
so that the surgeon might be a competent judge as to
the advisability of operation, and should be able to make
a diagnosis for himself as to the region of the operation,
as, for instance, in distinguishing the location of pus col-
lections in the lower pleural, upper abdominal, or liver
regions. The surgeon should be able to make a diagnosis
of early pregnancy in order to avoid operation on the
gravid uterus; he should be able to appreciate ear condi-
tions and their relation to brain work, etc. All of these
were needed even though he limited his work to general
surgery. Above all he should be able to say when opera-
tion was the best treatment. Some surgeons took ad-
vantage of every possible surgical condition, and operated
with the consent of the patient as the only other necessary
requirement. The public had not yet learned that the
benefit of the hospital depended on its administration and
on the surgeon. As to the methods of instruction of the
medical student opinions varied greatly. Some believed
that didactic work was essential, others that it was useless,
some would teach in large clinics, others only in sections;
some said that operative work on the cadaver was essen-
tial, others that it only begot carelessness. Some said
that the only operative work worth doing was on mam-
mals. Some said that the elective course in the medical
school was desirable, others that it was bad. The schools
all differed as to the method of instruction, but all agreed
that four years were not enough for specialist training, that

796

MEDICAL RECORD.

[May II, 1907

a specialist developed in four years of medical study must
be very narrow. The end might be attained in various
ways but all needed training in two branches — surgical
pathology and surgical diagnosis. They needed to be
taught to write accurate histories, to do which they must
make accurate examinations. Section work was necessary
to enforce accurate knowledge. The student by recitation,
discussion, and written report, must show what he had
learned. The student should be taught to be not merely
a consumer but also a producer of knowledge. To advance
knowledge he must understand the pathology of his dis-
eases both gross and microscopical, and on that base his
diagnosis. Laboratory teaching was most important for
the teaching of pathology, but the laboratory diagnosis must
not be considered sufficient to set aside the clinical diagno-
sis. Again it must always be borne in mind that the labo-
ratory diagnosis was no more certain than the man behind
the microscope. The student must learn to apply Iiis labo-
ratory work to his clinical material. It was desirable to
remember the teachings of the earlier days, for our modern
anesthesia and asepsis had tended to lead to laceration
of the tissues and delay in operation. It was necessary to
keep up the clean-cut and the rapid work. The tendency
to omit all didactic work from the fourth college year
was a bad one, not only for the student, but also for the
teacher; because the teacher became wearied of repetition
of the same work to section after section and finally the
better men gave it up, and it fell to the lot of the younger
and less e.xperienced members of the teaching staff. Dog-
matic teaching was always popular but the broad clinician
as a teacher was also always needed. It was time enoug's
to begin the study of a specialty after the end of the
fourth year. In Canada five years would soon be required,
and in Europe six years was demanded for the general
training of the medical man. There was no training better
than a hospital service, and that long enough for the stu-
dent to become competent to do operative work. It would
be a great advance if the latter years of a man's study
could be spent in the hospital and in the study of the patho-
logical work. To answer in a single word "How shall we
train our surgeons," we must answer "tlioroughly." .\nd
the test might well be made by a board of national examin-
ers which would soon create an international recognition
of that standard. The instruction should be thorough and
broad, there should be a long hospital service, and post-
graduate study. There should be a national standard of
proficiency.

Lumbar Anesthesia. — Prof. E. Kuster of Marburg,
Germany, the guest of the association, read this paper.
He said that lumbar anesthesia was used largely in Ger-
many but seemed to be distrusted in America. Quincke
of Kiel gave the initiative to lumbar anesthesia in 1891.
In the speaker's clinic lumbar anesthesia was used for all
operations in and below the pelvis, and also for many opera-
tions on the kidney, gall-bladder, and stomach. Regarding
the injection of the fluid he spoke of the desirability of
puncturing the filuni terminale of the spinal cord. The
injection was made in the middle line, the needle being in-
troduced first alone and carried through the dura when
the cerebrospinal fluid would begin to flow. The fluid
was allowed to flow until clear if the first few drops were
bloody, though if tlie needle allowed the escape of pure
blood a second puncture was desirable. The escape of
fluid, was the only sure way of indicating entrance into
the dural canal. A{ times he let 15 c.c. flow before inject-
ing the anesthetic. The solution used was a 5 per cent,
.solution of novococaine with suprarenalin, supplied by the
pharmacist in sterile solution in sealed ampoules. For
operations on the uterus and pelvic organs they used 2 c.c.
and for abdominal operations 3 cm. Anesthesia appeared
in a few minutes after the injection. There were two
methods of extending the anesthetic area upwards, one by
putting the patient in the elevated pelvic position for ten
minutes or longer after the injection, the other ("head

obstruction"; by putting a bandage around the neck, so
increasing intracranial pressure. The bandage was applied
before the injection, and on removal afterwards the anes-
thetic ascended with the blood, and anesthesia of the
abdomen was obtained with very litle anesthesia of the
legs. Paralyses were very rare, for the anesthetic did not
readily circulate in the space anterior to the ligamentum
denticulatum of the spinal cord. If the patient was turned
on his abdomen paralyses were promptly obtained. The
operation could be begun after five to ten minutes. At the
time of opening the peritoneal cavity slight pain might be
evidenced, but in disarticulations of the hip very little shock
was observed. The period of anesthesia lasted about forty-
five minutes, after which nausea usually was felt. After
an hour and a half true pain appeared, and there might be
weakness in the legs suflicient to interfere with walking.
These would last a few hours. Headache occurred in
12 per cent, of the first three hundred cases ; this was re-
lieved immediately by lumbar puncture, removing 10 c.c. of
fluid. Another unpleasant after-effect was paralysis of the
bladder, rectum, or legs, but this generally disappeared in
from 4 to 8 days. There was a postoperative pneumonia in
one case in which ether was also given. There was fever
in one case. A great advantage of the method was that it
completely prevented postoperative aspiration pneumonia.
It did not upset the general health ; it was safe in delicate
people and those suffering from disease of the heart, lungs,
or kidneys.

Dr. T. W. IIuxTiNGTOx of San Francisco said that two
years ago he began to use lumbar anesthesia with great
doubts ; that he tried it systematically and got results
similar to Prof. Kuster's. He used the anesthetic in solu-
tion in the spinal fluid, removing about two c.c. of the
fluid, dissolving in that the required dose of the drug,
and reinjecting it. He considered the fluid used as the
solvent as a very important element. He rarely had any
headaches after puncture. There were no psychic effects.
There had been no postoperative vomiting or shock, but
only postoperative comfort. He believed that lumbar an-
esthesia had come to stay.

Dr. Bristoe of Brooklyn said that he had tried the
method a few years ago, using cocaine. Some of his pa-
tients had had persistent severe headaches : in about one-
third of the cases he had not had satisfactory anesthesia;
and in six of his fifty cases there had been delusions of
persecution lasting tw'O or three weeks. He modified the
technique slightly by making an incision through the
skin before inserting the needle.

Dr. Schmieden of Bonn, Germany, said that they had
been eminently satisfied with the method at Bier's clinic
and used it in all operations below Poupart's ligament,
and in all kidney cases.

Dr. Willy Meyer of Xew York said that he believed
lumbar anesthesia was not used in the United States be-
cause of the reported bad effects, the bad technique, and
the fact that in America we had special anesthetists who
had improved the results of general anesthetics. He had
used lumbar anesthesia for seven years, trying various
cocaine salts and allies, and had also tried magnesium
sulphate, but this latter drug caused paralysis of bladder
and rectum. He had stopped using the method, however,
after having had two deaths from tropococaine, which,
after boiling, had split into atropine and hyoscine. He
believed the method the best for cases of diabetic gan-
grene and prostatic h>-pertrophy.

Dr. G. E. Brewer of New York asked regarding the
mortality of this method. He said that he had been going
on the assumption that the mortality was one in five hun-
dred as reported at a recent Paris congress, and had not
used the method, as he considered the risk too great.

Dr. W. G. M.\cDoXALD of Albany said that he con-
sidered novococaine as bad as the other cocaine prepara-
tions, and he had seen one death on the table from the very
preparation used by Dr. Kuster, and that in the dosage of

:\Iay II, 1907]

MEDICAL RECORD.

797

but two-thirds of an ampoule. He liad seen vomiting with
every drug used.

Dr. Kuster, in closing the discussion, said that he knew
of no statistics for general anesthetics that took into ac-
count the deaths from the postoperative pneumonias and
other complications ; but that even if lumbar anesthesia
did have a mortality of one in five hundred it would
still be as safe as the general anesthetic.

Continuous Passive Congestion in the Treatment of
Delayed Union of Fractures. — Dr. J. B. RoiiEKXS of Phil-
adelphia read this paper, lie said that he used an elastic
bandage above the seat of fracture to cause passive
congestion in the cases of nonunion when he was satis-
fied that there was no interposition of ti>sue between the
two bone fragments. He had used tlie method also in
recent fractures to hasten the union. At the same time
he used diet, exercise, and fresh air, and frequently cal-
cium salts, and tried also to get the psychic effect of en-
couragement of the patient. He thought the ulcers pres-
ent in old compound fractures might be delayed by the
congestion treatment, but that this delay was not to be
considered in view of the acceleration of bony union. The
application of the bandage should produce a cyanosis of
the part distal to the bandage, but should not cause pain.
It might be necessary to change it to allow for variations
in position of the limb and consequent swelling.

Mr. Robert Jones of Liverpool, in discussing this paper,
said that the same method had been used by Mr. H. O.
Thomas of Liverpool fifty years ago, and he had person-
ally used it in seventy or eighty cases since then with
great advantage. He applied a rubber band above and an-
other below the fracture, increasing the duration of the.
application a^ the patient could stand it.

Resection of a Sound Femur for Gigantism and
Asymmetry. — Dr. R. W. Johnson of Baltimore read thi>
paper. He proposed resection of the sound femur in women
of unusual height, who by this height were conspicuously
deformed. He would resect two to two and a half inches
from the middle of the femur, miiting the lioncs preferably
by square ends, and operating on one leg at a time. He
also suggested resection of the femur when there was a
limp from one leg being longer than the other.

Dr. J. B. Roberts of Philadelphia, in discussing the
subject, said that he had recently proposed the same treat-
ment to a candidate for the army who was debarred by
a limp.

A New Method of Rhinoplasty, by Means of One of
the Fingers. — Dr. J. M. T. Finney of Baltimore read
this paper, in which he described a palstic nasal operation
after the bridge had been lost by congenital syphilis, and
in which there was absence of the bony framework and
very thin skin covering. He reported two cases in which
he had done the operation, showing diagrams and photo-
graphs. He chose the ring finger of the left hand as the
one most easily spared, and after removing nail, matrix,
and skin from the dorsum of two phalanges and the entire
skin on the distal phalanx, he inserted the finger through
a slit in the columns, making no incision in the skin of
the bridge of the nose. After two weeks he amputated
the finger at the metacarpophalangeal joint, flexing the
proximal phalanx on the other two to form a new- column,
and leaving the two distal phalanges to support the bridge.
Later small plastic operations united the soft parts, but
not the bony parts. One great cosmetic advantage was
the absence of scars.

Dr. C. A. Powers of Denver said that he remembered
a somewhat similar case operated on by Dr. Sal)ine in
New York in 1879, in which the ressult had been very sat-
isfactory.

Treatment of the Posterior Capsule of the Thyroid
in Thyroidectomy. — Dr. C. H.M.wo of Rochester, Minn.,
read this paper, which was based on 375 cases of thyroid-
ectomy. He spoke of the anatomy of the capsule of th..'
thyroid, showing layers of the capsule between which lay

the recurrent laryngeal nerve, pressure upon which often
produced paralysis of the vocal cord. He spoke of thq
parathyroids as lying behind the thyroid on the capsule,
two on either side, the upper one being near the larynx.
They might be in the capsule and be removed with it in
extirpation of the gland. He operated always with local
anesthesia and morphine, the patient being in the reversed
Trendelenburg position. After the capsule had been
opened the gland was brushed toward the median line
to avoid taking with it the posterior capsule. He was care-
ful to check all hemorrhage and to drain by a separate
incision. In his series there had been one case of tetany
and five cases of increased hoarseness. He was careful
to save the posterior capsule and thus avoid many of the
dangers of thyroidectomy. Dr. Mayo presented photo-
graphs of the patients operated upon and of the pathologi-
cal specimens, both gross and microscopical.

Dr. W. S. H.ALSTEAD of Baltimore said that one could
not tell how often tetany would ensue and that therefore
while he removed a large portion of the gland he never
excised it all. He had had only one case in his own
experience, but had seen more in the operations of others.
Recent injections of the thyroid arteries had demonstrated
that the parathyroids got Uieir blood supply from the
thyroid arteries and principally the inferior one. Only
two of the eleven cases injected showed blood supply to
the parathyroids from the superior arteries. Therefore
he ligated the vessels well inside the gland.

Aneurysmal Varix; a Case of Pulsating Exophthal-
mos, and Two Cases of Enormous Dilatation on the
Cardiac Side of the Wound. — Dr. G. T. V.\ugh.\n of
Washington, D. C, presented this paper. In the case of
pulsating exophthalmos the diagnosis was clear and the
treatment was the only subject for consideration. Com-
pression of the internal carotid arrested the pulsation and
relieved the murmur, and so the vessel was tied. The pa-
tient developed paralysis on the second day and died, but
no other form of treatment seemed available. In the
two cases of varix on the iliac veins the tumor was on
the pro.ximal side of the communication between the ves-
sels. In one patient with varix of tlie carotid, wdio died
under ether, the swelling was in the jugular vein. Dr.
\'auglian sought an explanation of the occurrence of the
dilatation on the cardiac side of the communication and
aekcd if it was the rule.

Graduated Vertical Traction in Its Application to
Congenital Dislocation of the Hip.— Dr. O. H. Allis of
Philadelphia presented this paper and showed an apparatus
for the application of the traction to any measured degree,
the traction being made by a screw and registered by a
spring balance. The force was applied from a framework
that allowed of full motion of the hip-joint during trac-
tion. .\fter the complete rela.xation of the muscles by
the traction the apparatus was removed and the reduction
of the dislocation was completed by gentle manipulations.
(To be continued.)

NATIONAL ASSOCIATION FOR THE STUDY AND
PREVENTION OF TUBERCULOSIS.

Third Annual Mrcting. Held at ll'ashington. D. C. May

6, 7, and S, 1907.

(Special Report to the Medical Record.)

gener,\l meeting.

The President. Dr. Herm.\nn M. Biggs of New York,
IN THE Ch.mr.

Tirst Day, Monday. May 6.

Address by the President. — Dr. Biggs said that two
years ago the first annual meeting of the National .\sso-
ciation for the Study and Prevention of Tuberculosis was
held in Washington under specially favorable auspices.
The .Association had completed its lirst year of successful

798

MEDICAL RECORD.

[May II, 1907

work, having been organized in Atlantic City the previous
year, with a comparatively small membership, under the
presidency of Dr. Trudeau. During the year, through his
efforts, a considerable sum of money had been contributed
for the support of the Association, and a permanent or-
ganization had been effected, with the installation of Mr.
Livingston Farrand as E.xecutive Secretary, and the estab-
lishment of permanent headquarters in New York City.
The national crusade for the study, prevention, and treat-
ment of tuberculosis had been given a very distinct impetus
during these three years by the work of the Association,
and popular knowledge and interest in the subject had
become much more widespread. A large number of local,
municipal, and State associations had been organized
throughout the country, in addition to many associations
especially designed to promote the establishment and
maintenance of local sanatoria for the care of incipient
pulmonary tuberculosis. In practically all of the older
States of the Union there now existed some local or State
organizations, and the general knowledge and interest in
the movement was steadily extending. In most of these
associations physicians had been the leading spirits in
their organization, as was the case in the formation of the
National Association. It had been, and was, still far
more difficult to enlist the cooperation of laymen in this
work than that of the physicians, and it was particularly
this interest and cooperation of the laymen which was now
needed to advance more rapidly the cause. The member-
ship of the National Association now numbered about
1,300, including a large percentage of the leading physi-
cians of the United States, and many prominent laymen.
The formation and development of the local and State
associations, in the very nature of things, often detracted
materially from the interest which their members took in
the National Association, for these local associations were
concerned in extending relief in their immediate neighbor-
hood, and had a far more personal interest. It was also
considered desirable in the early history of the National
Association that the membership should be most carefully
scrutinized, in order that during this period particularly no
persons should become members who were likely in any
way through their conduct to discredit the Association or
impair its reputation or usefulness. Therefore, the efforts
to increase its membership had not been as great as they
might have been, and outside a few of the Eastern S'tates
its representation was very small. It was believed that
with the general interest which would be aroused in the
subject of tuberculosis by the coming meeting of the Inter-
national Tuberculosis Congress in Washington in 1908
the membership of the National .Association should and
could be rapidly increased five or ten-fold within the next
year, and one of the first objects and efforts of the mem-
bers during the coming year should be to add to the mem-
bership by personal solicitation, directed not only to physi-
cians, but to laymen who were prominent in various locali-
ties of the country, and who, by their position, influence,
and contributions, could materially aid in extending the
work of the National .■Association. Up to this time. Dr.
Biggs said, but little had been done in attempts to initiate
or influence legislation with reference to tuberculosis in
various cities or States, and this he believed was the line
of endeavor which should now be actively followed by the
National Association. In the attainment of these purposes
its influence should be paramount. Not only should
its efforts be directed to the initiation and encouragement
of legislation, but when such legislation had been obtained,
its influence and support were not less needed for the
enforcement of the law-s enacted. Legislation should in-
clude not only measures designed for the administrative
control of tuberculosis, but also measures directed to the
establishment of municipal dispensaries and of local and
State sanatoria and hospitals for the treatment and care
of the tuberculous poor. The movement toward the es-
tablishment of State sanatoria had gained considerable im-

petus, and It should be rapidly extended, and the annual
appropriations for the extension and establishment of
such institutions should in many States be materially
increased. The attitude of the sanitary authorities gen-
erally toward the National Association and its work had
been somewhat disappointing, for while there had been
notable exceptions, the municipal and State health officers
throughout the country as a whole had not up to this
time taken any very active interest in the work of the
Association. The United States was very far behind in
respect to the efficiency of its sanitary organizations as
compared with those of Great Britain or Germany. Un-
fortunately, here there was no central authority, and in a
majority of the States the State Boards of Health had but
limited jurisdiction and small appropriations, which often
served for little more than the registration of vital statis-
tics. The health officers were not generally appointed
because of their knowledge or interest in sanitary affairs
and their peculiar fitness, but on account of their personal
or political affiliations. There was no institution in the
United States, so far as he knew, in which a complete
course of instruction was given for the purpose of fitting
medical men to become medical officers of health, and the
degree of Doctor of Medicine was the only requirement
for eligibility. It would seem as if we had now progressed
far enough along the path of higher civilization to expect
and require that sanitary affairs in every locality should
be administered intelligently, judiciously, and in the inter-
ests of all the people of the community by those who had
special training in such matters, so that a consistent sani-
tary policy might be everywhere continuously followed.

Report of the International Congress on Tubercu-
losis, 1908. — Dr. L.wvRE.xcE F. Flick of Philadelphia read
this report. He stated that the International Congress on
Tuberculosis came into existence in Paris in 1898; it re-
convened in Berlin in 1899, again in Naples in 1900, in
London in 1901, and finally, as an International Congress
in the full sense of that term, in Paris in 1905. It was
organized by the leaders of the crusade against tuber-
culosis for the purpose of directing the movement and
keeping it under control. America did not participate in
the organization of the Congress nor take any part in its
proceedings to any great degree prior to the meeting in
London in 1901. This was largely due to the lack of or-
ganization in this country. The founding of the National
Association for the Study and Prevention of Tuberculosis
in 1904 put this country upon a competent basis to take
part in the international direction of the crusade, and
-America w-as better represented at the Congress in Paris
in 1905 than on any previous occasion. A delegation of
the National .Association, at the direction of the association
and with the endorsement of President Roosevelt, conveyed
through Ambassador McCormick, extended an invitation
to the International Congress to meet in the United States
at its ne.xt session, and this invitation was unanimously
accepted. The time was fixed in the autumn of 1908, and
the place of meeting was Washington. Immediately after
the adjournment of the Congress in Paris in 1905, the board
of directors of the National Association appointed a com-
mittee on the Congress, with instructions to prepare plans
which were to be submitted to the board of directors. In
accordance with this a plan was adopted which was pub-
lished in full in Cluirities and Commons of December 9,
1905, and which included, among other features, the col-
lection of one hundred thousand dollars as a permanent
fund for the scientific and philanthropic part of the Con-
gress. Of this fund thirty thousand dollars had already
been subscribed in the form of six subscriptions of five
thousand dollars each. Dr. John S. Fulton of Baltimore
was selected as secretary-general of the Congress. Under
the plans adopted, the Congress was to last three weeks,
one week of which was to be devoted exclusively to scien-
tific work, and tw'o w-eeks to entertainment and the in-
spection of institutions. During the three weeks thirty

May II, 1907]

MEDICAL RECORD.

799

lectures by the most prominent workers in the tuberculosis
field outside of the United States were to be given. The
fund of one hundred thousand dollars was to be used
exclusively for the scientific part of the Congress, and if
there was any balance left over, it was to be divided pro
rata among institutions devoted to tuberculosis. The plans
adopted contemplated the offering of prizes on a great
many subjects in the interest of the crusade against tuber-
culosis. One prize had already been offered by the com-
mittee, and would be announced throughout the entire
world. The prize consisted of one thousand dollars for the
best evidence of efficient work done by any voluntary asso-
ciation since the last Congress on Tuberculosis. As rapidly
as the money could be raised, other prizes would be an-
nounced. The matter of interesting medical societies and
the societies for the prevention of other diseases than
tuberculosis and various organizations interested in sani-
tary science and philanthropy was under consideration by
the committee, but as yet nothing definite had been done.
An effort would be made to bring all organizations which
either directly or indirectly might have to do with the
prevention of tuberculosis into the Congress. Such steps
would have to be worked out very carefully, and thus far
action regarding it had been deferred. The National As-
sociation for the Study and Prevention of Tuberculosis
had made itself responsible to the world for the proper
management of this International Congress, and would
therefore have to maintain control of the Congress, but
other organizations could be brought in to cooperate on a
satisfactory plan if their cooperation was sought in the
proper spirit. Every effort would be made by the commit-
tee to coordinate all the available sources for the best
interests of the Congress.

Election of Officers. — The following officers were
elected: President, Dr. Frank Billings of Chicago: Vice-
Presidents, Drs. Mazyck of Philadelphia, Ravenel of Phila-
delphia, and Foster of New Haven ; Secretary, Dr. Henry
P. Jacobs of Baltimore ; Treasurer, Dr. George M. Stern-
berg of Washington. Dr. Wm. H. Welch of Baltimore
was chosen president of the International Congress for the
Study of Tuberculosis, to be held in Washington in the
autumn of 1908.

F.'^THOLOGICAL SOCIETY OF PHILADELPHIA.

At a stated meeting held April 26, Dr. H. E. Radasch pre-
sented a special apparatus for laboratory technique. This
consisted in a portable rack made of aluminum for the pur-
pose of carrying a number of slides mounted with serial
sections through successive solutions. The device is sim-
ple, light, and inexpensive, and it has proved its usefulness
in actual practice. Dr. R. S. L.\venson presented speci-
mens of organic heart-lesions. He showed a series of
hearts obtained at autopsies made on subjects at the Phila-
delphia Hospital. One was a beautiful specimen of tuber-
culous pericarditis, exhibiting clearly tubercles beneath the
epicardium and presenting adhesions in places. Another
was a specimen of mitral obstruction and insufficiency.
Another was an example of mitral valvulitis with ulcera-
tion extending almost to the adjacent aortic leaflet. One
was an example of aortic stenosis, with little or no insuffi-
ciency. Tw'o of the aortic cusps were calcareous, while
the third retained a certain degree of elasticity and free-
dom of motion. Dr. D. L. Despard exhibited a specimen
of purulent pericarditis. Dr. J. A. Kelly exhibited a speci-
men of cyst of the appendix. The formation had attained
considerable size, and it contained gelatinous material.
Its communication with the bowel was cut off. Dr. Kelly
presented also an ectopic supernumerary pancreas. The
organ was attached to the small intestine in the neighbor-
hood of the jejunum, and presented the histological struc-
ture of the pancreas. Dr. William Pepper demonstrated
"va of the Unciiwrici duodcnalis obtained from .in lt:ili:!;i

patient in the Philadelphia Hospital who presented anemia,
asthenia, and looseness of the bowels. Mature worms were
developed by incubating the egg in sand or soil. Dr. G.
Canby Robinson presented a communication entitled
"Heart-block, with Pathological Specimens from a Case,
iLiid with Tracings from Various Forms of the Condition."
The specimen exhibited was from the pathological museum
of the Pennsylvania Hospital, and was obtained in 1879
from a man about sixty years old, who presented dyspnea,
cyanosis, bradycardia, and convulsive seizures. Death took
.place suddenly, and post-mortem e.xamination disclosed the
presence of multiple gummata in the heart, one of which
occupied the situation of what has since been described as
the conducting bundle of His. From the clinical report
and the pathological exhibit there is little doubt that the
case was one of heart-block. Dr. Robinson demonstrated
also a normal heart, exhibiting in a beautiful manner the
conducting bundle. He also showed tracings from several
cases that had come under his observation, exhibiting vary-
ing degrees of heart-block, together with the apparatus for
making tracings. Dr. E. Crispin read a paper entitled
"Metaplasia of Epithelium in Cysts of the Breast." He
reported a case and presented the specimen in which the
cylindrical cell structure of a cyst of the breast underwent
transformation into stratified epithelium. Dr. J. H, W.
Rhein presented a communication entitled "Syringobulbia,
with Report of a Case." The excavation of the central
nervous system was marked and extreme, extending from
the conus medullaris to the medulla oblongata, and it was
attended with degeneration of several cranial nerves and
of tracts in the cord. Dr. H. E. Radasch read a paper
entitled "Unilateral Absence of the Urogenital System and
Its Relations to the Development of the Wolffian Duct,"
He traced the embryonic evolution of these structures and
analyzed the comparatively small number of cases of the
kind recorded in the literature. Dr. R. C. Rosenberger
made a further communication on "The Presence of Acid-
fast Bacilli in the Stools." He had been able to repeat
previous observations on a large scale, showing the pres-
ence of acid-fast bacilli, conforming to the requirements of
tubercle bacilli, in the intestinal discharges from patients
clinically or pathologically shown to have tuberculosis in
some part of the body. He expressed the view that such
bacilli must be considered as having been excreted by the
bowel, and not necessarily indicative of the existence of a
lesion of the intestine. He had succeeded also in finding
similar bacilli in the intestinal discharges of guinea-pigs
that had received subcutaneous inoculation of tubercle
bacilli in the absence of intestinal lesions and sometimes in
the face of disappearance of the local lesion.

A Simple Method for Performing Resection of the
Thorax. — Bayer says that although in some cases it is
necessary to resort to S'chede's operation in order to
cure neglected cases of empyema, this operation is so
bloody and severe a one that it should be employed as
rarely as possible. He states that by the following pro-
cedure one is enabled to secure almost the same results
as by means of Schede's very radical operation, while the
tax on the patient's powers of recuperation is not nearly
so great. A vertical incision beginning in the axilla and
running parallel to but two inches posterior to the an-
terior axillary line is practically bloodless and does not
divide any important muscles. Through this incision
a short segment of each rib from the ninth upward is
resected subperiostally .ind the soft parts are then cut
through with the thermocautery to avoid any further
hemorrhage. On inspecting the thoracic cavity it can
lie determined whether or not the thoracic pleura must
be removed, and the resection of the stumps of the ribs
can be very conveniently carried out. The author con-
siders the rapidity of operation and the slight loss of
blood achieved in this way as the principal merits of the
mHhod.—Zentralblatt fiir Chirurgie.

8oo

MEDICAL RECORD.

I May II, 1907

iE^biral 3Itfms.

Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious disease reported to the
Sanitary Bureau, Health Department, New York City, for
the week ending May 4, IQO":

Tuberculosis Pulmonalis

Diphtheria

Measles

Scarlet Fever

Smallpox

Varicella

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis
Malarial Fever

Totals

Cases

Death!

445

189

342

38

534

12

492

19

74

88

23

56

9

■'I

20

2061

310

Surgical Treatment of Thrombophlebitic Puerperal
Infection. — Giuseppe Guicciardi indicates thrombo-
phlebitic puerperal infection as a rare form that is dis-
tinct in symptoms, diagnosis, and prognosis from tlie other
forms of puerperal infection. The fever is not an index
of the pulse rate, which is independent of the height of
the rise of temperature. The temperature curve is pyemic
and is accompanied by severe chills that are repeated as
long as the disease goes on ; the general condition and
color are bad, and the abdominal pain is peculiar in char-
acter; bimanual examination enables the operator to feel
the thrombosed veins as hard cords. Bacteriological ex-
amination gives such different and contradictory results
that it is of little value. The leucocifte formula gives lit-
tle information. Ordinary obstetric treatment is useless,
and only surgical intervention promises good results.
Both abdominal and vaginal hysterectomy are useless and
resection of the thrombosed veins is dangerous. The
method of election is ligation of the veins. It results in
the disappearance of the infective local process and of all
pain, and ends in the recovery of a fair proportion of pa-
tients. The best time for intervention is about tlie twen-
tieth day. — Anr.nli di Oslctiicia r Ginccologia.

Epithelioma of the Lacrymal Sac. Recurrence. —
C. L. Lafon reports this case. The patient was a farmer
forty-eight years old. In 1896 he noticed a condition of
epiphora affecting both eyes. About the beginning of 1898
the region of the left lacrymal sac began to swell, and
finally a bloody ulceration developed. Later on operation
was performed. Incision showed that the growth involved
the sac itself and the galvanocautery was used for destroy-
ing the diseased tissues. Histological examination of the
debris showed the growth to be an epithelioma, .^gain
in 1899 the patient returned to the hospital with a growth
in the region of the wound ; this was destroyed by the
thermocautery. Three months later there was a recur-
rence. Again for the third time the patient was operated
upon and recovery appeared definite. But at the beginning
of 1905 the patient again appeared, showing the lacrymal
region in a diseased condition. This case is of interest for
several reasons. The epithelioma appears to have begun in
the mucosa of the sac, a very unusual occurrence. The
interval of five years and a half which elapsed after the
first interventions is worthy of note. Finally, recurrence
extending slowly up under the skin without appearing to
have a tendency to destroy it is interesting. Lafon has
the intention of operating again in order to remove as far
as possible all of the diseased tissues. — Journal de Mede-
cinc de Bordeaux.

Spontaneous Ruptures of the Aorta.~.A.ndre Berge
in his comprehensive paper on this subject speaks first of
the various conditions under which the aorta ruptures or
becomes perforated. Indirect violent trauma may be fol-

lowed by rupture of the aorta. The aorta may become per-
forated secondarily as an effect of a neighboring lesion
such as abscess of the mediastinum or cancer of the esopha-
gus. An aneurysmal sac may be the cause. Finally, aside
from the various causes which have been enumerated, the
aorta may rupture in an apparently spontaneous manner.
The first and essential cause of aortic rupture, aside from
the cases of traumatism, consists in a previous alteration
of the arterial wall. The most frequent location of per-
foration is in the ascending aorta in its intrapericardial di-
vision. Perforation is nearly always single. In the large
majority of cases the alteration of the internal surface of
the aorta is manifest to the naked eye. In general, the
symptoms are precordial pain and syncope, and cardiac col-
lapse. The clinical picture may present itself in one of
three forms — sudden, rapid, or slow. The cause of death
is probably not due to one process only. Hemorrhage,
compression of the heart, and syncope by inhibition all
play a part. — Gacette des Hopitaux Civils et Militaircs.

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital
Service, during the week ended May 3, 1907 :

SMALLPOX — UNITED STATES.

California. San Francisco April 13-20.

Illinois. Belleville April 13-20.

Chicago .\pril 20-27.

Kentucky. Louisville April 18-25 .

Massachusetts. Haverhill Mar. 9-16.

Michigan. Detroit Mar. 20-27 .

New Jersey. Hoboken April 18-25.

Ohio. Cincinnati April ig-26.

Texas. Houston April 13-20.

Washington. Aberdeen April 17 . . . .

Spokane April 13-20.

Tacoma April 13-20.

CASES. DEATHS.

SMALLPOX — INSULAR.

Philippine Islands. Manila Mar. 9-16.

S.MALLPOX — FOREIGN.

Africa, .\lgiers Mar. 1-3 1

Austria. Trieste .Mar. 3o-.\pr. 5. .

Brazil. Para Mar. 30-Apr. 6. ,

Canada. Pictou County .\pril 20

Vancouver .April 13-20

Winnipeg .April 13-20

Chile, Coquimbo Mar. 30

China, Hankow -Mar. 1 1-25

Shanghai Mar. q- 23

Tiensin Mar. 16-23

Ecuador. Guayaquil Mar. 30-Apr. 6.

Egypt. Cairo Mar. 3 i-Apr. 8 .

France. Nice Mar. 1-31

Paris A.pril 5-13

Germany. Bremen Mar. 16-Apr. 6.

India. Calcutta Mar. 16-23

Madras Mar. 23-29

Italy. Turin Mar. 31-Apr. 7.

Madeira. Funchal April 7-14

Mexico, .Aguas Calientes April 13-20

Monterey April 14-21

Tuxpam April 16-23

Vera Cruz April 13-20

Portugal. Lisbon .April 6-13

Russia, Moscow Mar. 30-Apr. 6.

Odessa Mar. 3 i-Apr. 6 .

Riga Mar. 30-Apr. 13.

St Petersburg Mar. 23-Apr. 6.

Warsaw Mar. 23-30

.■\lmeria Mar. 1-30

Valencia., April 7-14

Turkey in Asia, Bagdad Mar. 0-16

Damascus Mar. 16-Apr. 6..

14

18

Spain.

YELLOW FEVER.

Brazil. Manao Mar. 23-Apr. 6. .

Para Mar. 30-Apr. 6. .

Ecuador. Guayaquil Mar, 30-Apr, 6, ,

Java. Bata\-ia Mar. 16-23

West Indies. Bridgetown. Barbados. .April 13-20

Port of Spain Feb. g-.Apr. ij.

S
13

Present
Present

I Imported
8 4

India. Calcutta.

CHOLERA.

Mar. 16-23.

.Australia, Brisbane Feb.

lDS^\nch Feb.

Kempsey Feb.

Sydney Feb.

Brazil. Para Mar.

Chile. Antofagasta Mar.

Iquique Mar.

Santiago Mar.

Talcahuana Mar.

India. General Mar.

Calcutta Mar,

S-Mar, g.

8-16

8-15

8-Mar. 0,
30-Apr. 6.

30

30

14

14

16-23 6J.IS5

16-23

5
16

3

5

Present

Present

Present

.53.004

94

Medical Record

A Weeklv journal of Mcdiciiie and Surgery

Vol. 71, No. 20.
Whole No. 1906.

New York, May iH, 1907.

$5.00 Per Annum.
Single Copies, JOc.

(Original Arttrbs.

SANITARY WORK (JN THE ISTHML'S OF

PANAMA DURING THE LAST

THREE YEARS.

By COL. W. C. GORGAS. U. S, .■\..

CHIEF SANITARY OFFICER. ISTHMIA.V CANAL ZONE DErARTMF..NT OF
HEALTH.

My wish in this article is to give a general descrip-
tion of the sanitary conditions which existed on the
Isthmus at the time the United States assumed con-
trol ; to explain the methods which have been taken
to improve these conditions, and to point out the re-
sults attained b\- these methods.

The Isthmus of Panama at the point where the
proposed canal is being constructed extends from
east to west. The canal course runs nearly north
and south. At this point has been located the prin-
cipal route of crossing since the discovery of .Amer-
ica. The Spaniards, however, built a very good
causeway for pack animals from the old town of
Panama to Porto Bello. This causeway was paved
with cobblestones and is still in a fair state of
preservation. The old town of Panama is some six
or seven miles east of the present town of that
name, and Porto Bello is about thirty miles east
of Colon. The advantages of the Chagres as a
means of getting across the Isthmus were soon ap-
preciated and travel was gradually transferred to
the Chagres river until about the year 1670, when
Morgan, the famous English buccaneer, captured
the old city of Panama. After this the old overland
trail to Porto Bello was abandoned, the city of
Panama changed to its present location, and the
Chagres almost exclusively used as a route for cross-
ing the Isthmus. The Chagres empties into the
Carribean some ten miles west of the present town
of Colon. Porto Bello. which has an excellent
harbor, remained the port on the north coast. All
vessels crossing the ocean from Europe were un-
loaded at Porto Bello. the cargoes transshipped in
smaller vessels to the mouth of tlie Chagres, wherf
they were loaded into small dugouts and carried
up the Cliagres to the south some forty miles to
the i>oint where the Chagres changes its course.
From this point they were carried overland on pack
animals to the present city of Panama. -\ paved
road was built from this point, Las Cruces, to the
present city of Panama. This formed the main
route of crossing up to tlie time of the building of
the Panama Railroad. .\ large portion of the pop-
ulation which went from the eastern states and from
all parts of the civilized world to California in 1S40
and the immediately succeeding vears, crossed by
this route. In 1853 the railroad was thrown open to
traffic. This road practically followed the former
routes of crossing, went south up the Chagres to
the point where the Chagres turned. From this
point it followed up the valley of one of the large
tributaries, the Obispo, until it crossed the divide,

tlien followed the valley of the Rio Grande, which
empties into the Pacific near Panama.

Colon is not situated at the mouth of the Chagres
river. The railroad strikes the Chagres at Gatun,
some ten miles from its mouth. The canal route
practically follows the line of the railroad from
Colon on the north to Panama on the south.

Some thirty years after the completion of the
railroad a French company under the leadership
of ilonsieur De Lesseps commenced building a sea-
level canal between Colon and Panama, following
tile route of the railroad. This company, after some
seven years' work, and having done considerable ex-
cavation, failed.

The United States has acquired a strip of terri-
tory ten miles wide, with the canal as a central line,
extending entirely across the Isthmus from Colon
on the north to Panama on the south. The country
is low and swampy for the first fifteen miles : the
rest of the route, some thirty odd miles, is through
a mountainous country. The temperature all the
year round in this territory is tropical, varying very
little between January and July. Conditions as to
warmth are thus such that the mosquito will breed
prolifically all the year round. Over the mountain-
ous part of the route the peaks are from 100 to 1,000
feet in height, nowhere being high enough to in
any way inhibit from a temperature standpoint the
breeding of mosquitos. Water is abundant everv-
vvhere, in the mountainous section little streams
coming from every ravine, forming ideal places for
the anopheles, and in the swampy section stagnant
pools of fresh water are on every hand. The towns
of Panama and Colon were formerly dependent en-
tirely for their water supply upon stored rain water.
The dry season, when very little rain falls, lasts for
some four months, and rain water had to be stored
for use during this dry season. The large number
of tanks and receptacles containing rain water thus
made ideal breeding places for the vellow fever
mosquito.

Now for four iiundred years we have had a con-
stant stream of imacclimated persons of the white
race crossing this Isthmus. This constant stream
infected the territory with both malaria and yellow
fever and kept up the infection to a very nnich
higher degree than in the neighboring tropical coun-
tries which did not have this stream of whites con-
stantly in their territory. The travelers in a great
many cases were dignitaries of importance, mer-
chants, and people of wealth. Everybody who tra\-
eled from the west coasts of North and South .Amer-
ica, in general, crossed at Panama, so that many
important personages sickened or died at Panama.
For this reason it has acquired a re]iutation for had
health which is second to that of no other locality
in the world.

The French began the construction of a canal
in this same territory in the year 1881 and kept
on the Isthmus some 10.000 laborers. 2,200 of whom
were whites. This large body of men remained
here some seven years working on the canal. The

802

MEDICAL RECORD.

[May i8, 1907

infection of both yellow fever and malaria being
already present and other conditions beins;' favor-
able, this large access of unacclimated people greatly
increased the ordinary mortality, and as the project
interested all the world the health conditions be-
came widely known and gave to the Isthmus the
very bad reputation it had when we came down here.
The hxality, however, is not naturally unhealthful.
On the whole, it is a pretty and attractive country,
with pleasant climatic conditions. Conditions as to
temperature, rainfall, and local water supply hap-
pen to be favorable to the development of the stego-
m\ia and anopheles mosquito, and then for four
hundred years unacclimated whites were introduced
in a steady stream, sometimes in very large num-
bers, such as during the construction of the rail-
road, and of the canal under the French, but I am
inclined to think that such a thing would occur
anywhere else in the world where the altitude was
less than 2,000 feet, the minimum temperature not
less than 60° Fahrenheit, and the rainfall more
than thirtv inches, provided the unacclimated whites
had been brought there in the same way.

This, in general, had been the history of the Isth-
mus when the United States acquired possession in
1904. In April of 1904, just before the property
was transferred to the United States, I w'as one of
a party of .\merican officials who spent a month
on the Isthmus looking carefully into the then ex-
isting conditions. At this time there were some
40.000 people in the territory at present under our
sanitary control, about 6,000 in Colon, about 24,000
in the city of Panama, and some 10,000 scattered
in twenty-two villages along the line of the railroad.
The principal business of the communitv was that
connected with the railroad. The French were em-
ploying about a thousand men in digging on the
canal, but they annarently were doin'- this only to
hold their franchise. Business of all kinds was
practically dead and the whole community was very
poor and financially much depressed. The health
conditions were about those common to the neigh-
boring tropical countries. A case of yellow fever
occurred now and then and malaria was jiretty gen-
eral. Two years before Panama had sufifercd rather
severely from yellow fever on account of the intro-
fluction of a considerable body of troops from the
interior of Colombia, but by the time we arrived
this had quieted down to a few scattered cases.
Colon had no water supply or sewage system, was
built in a swamp, and every house had several water
barrels for the collection and storing of rain water.
Panama, though built on high, well-drained ground.
was the same as Colon with regard to collecting of
rain water. The French had some 2,000 buildings
for the accommodation of their working force, scat-
tered at various points along the line of the canal
between Colon and Panama. The jungle everywhere
had grown up to the railroad track, and on the
whole the country presented a desolate scene of
dilapidation, business depression, and financial fail-
ure. After considering the matter, it was clear that
\ellow fever was the disease that would interfere
particularly with our success, and to which most
attention would have to be given, and that the canal
would probably not be completed unless we could
protect our force from this disease. Yellow fever
infection was evidently in Panama, and as our un-
acclimated force of whites was introduced from the
I'nilcd States T knew it would affect them just as it
did the whites amonsr the French force, unless we
took measures to prevent it. The stegomvia mos-
(Uiito'; were evervwhere in abundance, their breed-
ing places were to he found on evcrv hand, and the

temperature was such all the year round that they
could breed uninterruptedly. Malaria I also found
everywhere. If this were not checked it would
cause considerable mortality and a still larger rate
of inefficiency among our forces, but even if un-
checketl would not have the moral effect that yel-
low fever woidd have. I know of no disease that
causes the panic among the whites that yellow fever
does. I found there was some dysentery, but not
a great deal, considerable beriberi, principally lo-
cated in the cities of Panama and Colon, and a great
deal of .\siatic plague in the cities of Peru to the
south of us. T also found considerable ankylosto-
miasis amontr the popidation, and these diseases
might have to be considered in bringing a large
force to the Isthmus. With the assistance of Dr.
John ^^■. Ross, U.S.N. , and Dr. Louis .\. LaGarde.
U.S.A., I drew up plans for meeting these con-
ditions. Major C. E. Gillette of the Engineering
Corps of the Army drew up plans for water supplies
and sewage systems for the cities of Colon and Pan-
ama. We introduced systems based, so far as thc\'
applied locally, on the plan we followed in Havana.
We established health departments in each town,
with functions in general similar to those of our
health departments at home, such as sweeping the
streets, disposing of garbage, and such general sani-
tary work as is done in a city of the same size in
the United States, but our energies were principalh
concentrated upon the question of yellow fever. For
this purpose the towns were divided into small dis-
tricts, such that an inspector could get around to
each house twice a week. This inspector looked after
the premises, principally with regard to breeding
of stegomyia. On his report a force would be sent
to the house to make all water barrels and cisterns
mosquito proof. This was done at public expense,
and all other collections of w^ater were either gotten
rid of or oiled. All unacclimated persons sick with
fever were treated as if they were suspected of
having yellow fever. Physicians were renuired to
report all such, and in case they had yellow fever
they were either removed to a screened ward at the
hospital or the houses in which they were sick were
carefully screened. After the case was disposed of.
the houses occupied, and all contiguous houses, were
fumigated for the purpose of killing all infected
mosquitos. A record was kept of all tiie unac-
climated people in the city, and houses occupied by
such people were visited daily by an inspector, and
when he foimd any such persons sick he reported
them at once to the Health Office. In addition to
this, in both cities anopheles work was done, ditch-
ing, draining, and oiling in the suburbs. The
Canal Zone. Ijctween Colon and Panama, was divided
into some twenty odd districts and a sanitary in-
spector was placed in charge of each district. His
duties were to attend to the general sanitary work
of his district. look out for the proper care of night-
soil, disposal of garbage, ditching, and draining for
anopheles work, the stegomyia work around houses,
isolating and screening for vellow fever, etc.

In order to prevent the introduction of yellow
fever and other contagious diseases from the outside
a strict quarantine was established at the two ends
of the zone. Colon and Panama.

For the care of the sick employees a hospital sys-
tem was established, but as it was of great import-
ance from a sanitary point of view to get hold of
contagious diseases early these hospitals were thrown
Qpen to the whole Isthmian nooulation. This .scheme
has been elaborated for the past three years, until
at present we have the Sanitarv Department organ-
ized into the following divisions : The Hospital

.May 18, 1907J

MEDICAL RECORD.

«03

Division, the Quarantine Division, the Health Di-
vision of Panama, the Heahh Division of Colon,
the Health Division of Bocas del Toro, and the
Division of the Chief Sanitary Inspector, which has
supervision of health matters alone;' the line of the
canal between Panama and Colon.

The Quarantine Division maintains a maritime
quarantine at the ports of Ancon, i'anama, Colon
and Cristobal. This division has been most ef-
ficiently organized under the supervision, first, of
Dr. Henry R. Carter, and afterwards under Dr.
J. C. Perry, both of the Public Health and Marine
Hospital Service.

The Hospital Division was organized first by Dr.
John \\^ Ross of the U. S. Navy, who, when he left
on account of ill health, was succeeded by Dr.-Henr'-
R. Carter. It consists of two principal hospitals at
each end of the line. Colon Hospital in the city of
Colon, and Ancon Hospital at Panama. Colon
Hospital is built on a coral reef, over which the
sea washes freely, and is beautifully located as far
as exposure to the breeze is concerned. Ancon Hos-
pital is situated on the side of a mountain just back
of Panama, and is most favorablv located both as to
beauty of view and accessibility to the breeze. \\"c
also have a convalescent hospital of some seventy
lieds, which is located at Taboga Island, twelve
miles distant from Panama in Panama Bay. Be-
tween Colon and Panama, on the line of the rail-
road, we have some twent--five hospitals, having;- a
capacity of from ten to forty beds each. Colon Hos-
pital has 500 beds, and Ancon 700. On account (if
the exjiected increase in force, we are at present ex-
tending Ancon Hospital with the expectation that b\
the end of the present year we shall have some 1 .200
beds, the idea being to have the two base hospitals
equipped with all modern aiipliances, with a com-
petent nursing force and men more or less special-
ists in their various branches, so that anv class
of cases could be well cared for. The twenty-five
line hospitals are onh- intended to care fur the
patients until the\ can be moved to the liase he is
pitals, and for such of the seriously sick and in-
jured whom it is thought not advisable to move.
Last summer when our sick rate was at its max-
imum we were able to accommodate in these hos-
pitals some 1,700 patients.

The Health Division of the zone is under the able
management of Mr. J. A. LePrince, a sanitary en-
gineer who did similar work in Havana, Cuba. He
has under him some twenty-five sanitary inspectors
and about one thousand laborers to attend to the
ditchin;"- draining', and sanitary work generalK' of
the 40.000 peonle scattered along the line of the
canal between Panama and Colon.

The Health ( )ffice of the city of Panama is under
Dr. John H. Purnell, who emplovs some 200 men
in street cleaning, ditching, draining, garbage col-
lecting, and sanitary work in general of the cit\' of
Panama.

The Health ( )fifice of Colon is under the charge of
Dr. E. H. Wheeler, who employs aliout 200 men in
draining, ditching, and brush cutting in the swamps
in which Colon is built, and attending to an\' other
matters pertaining to the health work of the city.

As there was some yellow fever last vear at Bocas
del Toro. the President of the Panaman Republic
appointed one of the officials of the Sanitary De-
partment as Health Officer of Bocas. We ernploy
some twenty men at this small port doing general
'sanitary work there.

Tliis work has so far acconinlisbed ver^• satisfac-
tnr\- result':. "W-lJow fever has apparently been en-
tirelx' eliminated, ^^''e have had onlv one case on

the Isthmus during the last fifteen months. .\ re-
cent critic of Isthmian sanitary affairs has stated
that this is merely accidental ; that there have been
times in the past when Panama was free from \el-
low fever for several years in succession, and that
we would certainly have an epidemic of yellow fever
some time in the near future which would stop the
construction of the canal. It is true that Panama
has been free from yellow fever for several years
in succession at various periods in the past. This
is the case in all small tropical cities subject to
yellow fever, and it occurs for this reason; b'or
one cause or another the native population, wherever
yellow fever exists continuously, becomes immime
to yellow fever. This is a well-recognized fact
everywhere. Such being the case, it is the non-
immunes, or strangers, who keep up the disease.
Take a place of 25,000 or 30,000 inhabitants such as
Panama, and in ordinary times the strangers who
settle in the community are comparatively few. The\
soon all have yellow fever and then the disease dies
out; but a few strangers continue to come in and
in the course of a few years quite a number accumu-
late. Then when yellow fever is introduced from
the outside enough nonirnmune material is present to
keep the disease going for a time, but if for any
reason a large number of strangers come in every
year then the epidemic of yellow fever becomes con-
tiiiuous and keeps up as long as the strangers con-
tinue to come in. This has been exeniplified at
prett}' much every town where yellow fever has
lirevailed in the tropics. At Rio de Janeiro yellow
fever has prevailed continuously for the last fiftv
years, due to the large foreign immigration con-
stantly coming into the city. At Havana it was pres-
ent for considerably over one hundred \ears contin-
uously froni the same cause. .At Panama the inter-
mittent condition was well exetnplified. In ordinary
times they would have yellow fever for two or three
years and then be free of it for two or three years,
but whenever they had a considerable foreign imrni-
gration yellow fever was continuous. Thus yellow
fever was continuous all during the construction of
tlie railroad and again to a greater extent during
the work on the canal bv the old French company.
The French, of course, brought over a large num-
ber of European employees. During the construc-
tion by the old company, from 1881 to 1889, con-
siderable numbers of these European eiiiployees
came over every year. This continuous influx kept
yellow fever goinr during the whole tirne of con-
struction by the old French company. In Ancon
Hospital alone the old hospital records show that
1 .200 deaths occurred from yellow fever during:
this period, and when it is remembered that these
came from a force which at no tinie exceeded 3.000
nun. one can appreciate what a heavy tax it was
upon this force. The French during all these years,
frr)m t88i to 1880. w-ith a white nonimmune force
wliich had as its maximimi 3,000 men. did not pass
a month in which one or niore deaths from vellow
fever did not occur in this force. With a non-
innrimie force four tiiries as larp'e, for we now Ivaw
over To.ooo whites, if we include women and chil-
dren, we have passed fifteen months \yith not a sm-
cle case of yellow fever. The case which occurred
in May, 1006, was in a man not an employee of the
Cornmission. There never has been a time in the
whole history of the Tsthnnis. froni the time it was
discovered b\- Columbus up to the present time,
when there have been anywhere near as many men
subject to vellow fever present on the Isthnnis as
there are now, Tiie disease was on the Isthnnis
when we came in ,\pril. r<)04. and remained with

8o4

MEDICAL RECORD.

[May i8, 1907

us up to December, 1905. During' this time \ve were
constantly increasing- our noninmiune population.
I therefore feel confident that the same methods
which eliminated yellow fever from Havana have
accomplished the same results at Panama. 1 do not
believe that our present freedom from yellow fever
is in any way accidental. Our work here, 1 think,
is another evidence of the great obligation mankind
is under to the Army Board, of which Major Walter
Reed was chairman and Lazear and Carroll were
members, for establishing the fact that the stego-
myia mosquito was the transmitter of yellow fever.
Without this know'ledge I do not believe we could
have done any better than did the French, and, judg-
ing from the alarm that was caused by the compara-
tively mild epidemic which we had among our em-
ployees in 1905, I doubt, in case we w-ere having
the same amount of yellow fever that the French
had, whether we could keep a sufficient force of
white employees here to carry on the work. And
even if w'e could keep white employees here under
such circumstances, I doubt whether public senti-
ment in the United States would allow the canal to
be built at such a sacrifice of human life.

In this connection I would like to call atten-
tion to the little credit the French white employees
get for the heroism which they exhibited in coming
to Panama. Every Frenchman who came to Pan-
ama knew that he was going to have yellow fever,
and he also knew that every second man would die
with it. To face such chances took no little cour-
age.

The most useful result of our work, I think, how-
ever, as far as the canal work is concerned, is the
extent to which malaria is held in check. While
vellow fever was the fatal disease to the French, it
did not affect their sick rate to a very great ex-
tent; that is. if you take their sick report day by
day you \vould find thirty to forty men sick from
vellow fever and 400 or 500 sick from malarial
fever, so that malaria was causing eight or ten times
the financial loss that yellow fever did. Malaria is
still with us the principal cause of sickness : I mean
we have a good many more men every day sick
from malaria thati from any other one cause, but
our whole sick rate is very small. Last month
I March) 1907 our sick in hospitals amounted to less
than 20 per 1,000, and our total excused on account
of sickness from all causes to about 23 per i.ooo;
that is, out of every thousand men we had absent on
account of sickness in hospitals, their homes, and
evervwhere, an average every da\ during the month
of twenty-three men. This is as small a rate as we
would probably have if we were working in the
United States, and I doubt if we are ever able to
obtain a smaller rate than this. I am inclined to
think that our sanitary work, as far as the sick rate
is concerned, has reached its maximum efficiency,
and that all we can expect to do for the future
is to hold it up to that rate, though to keep this rate
a great deal of work will have to be done.

The good water su'^"'!- furnished all our em-
ployees has kept dysentery from being troublesome,
so that I think we can claim that our sanitary work
has directly controlled malaria, yellow fever, and
dvsentery, the three tropical diseases to which we
are liable. Bubonic plague is pretty firmly estab-
lished in some of the Peruvian ports to the south of
us, and we have been very anxious on this subject
(luring our occupancy of Panama. In the summer
of 1905 two cases of plague occurred at La Boca,
the Pacific terminal of the railroad and canal. Both
men had been living there for some time and evi-
(Icntlv contracted the disease there, but a very care-

ful isolation and disinfection of the town of La
Boca, under the supervision of Dr. J. C. Perry,
Chief Quarantine Officer, eradicated the disease at
this point, and we have had no cases since. Beriberi
was nuite prevalent on the Isthmus during our first
year, but it is now entirely confined to the city of
Panama, and much reduced in numbers.

I think, therefore, that the United States authori-
ties can fairly make the following claim for their
sanitary work : That when they got control of the
Isthmus in May, 1904, the territory along the route
of the canal was in its normal condition as to health.
It was overgrown by a dense tropical jungle ; the
natural conditions were everywhere ideal for breed-
ing stegomyia and anopheles mosquitos. The re-
gion was inhabited by a considerable population,
which was very poor, as the result of the failure of
the French canal company and the recent bloody and
destructive war which had involved the whole coun-
try for some three years. Malaria, dysentery, and
smallpox were prevailing among these people about
as they would anywhere in the tropics under similar
conditions. Yellow fever infection was present in
both Panama and Colon. In fact, the conditions
were more favorable for producing a high mortal-
ity upon the introduction of a large force than they
had been at any time in the past. Into this region
the Canal Commission has introduced the largest
force ever before present on the Isthmus, some forty
thousand persons, ten thousand of whom are white
nonimmunes. Yet the sanitary measures taken by
the L^nited States during the period of the introduc-
tion of this unprecedented force have been such that
yellow fever has disappeared, malaria been held
in check, and the total sick rate in this force dur-
ing the month of March, 1907. was only 23 per
I.ooo.

I think that there can be no reasonable doubt that
there is a direct relation of cause and effect between
the sanitary measures taken by our Government and
the present health conditions on the Isthmus.

.\kcox, c. z.

A NEW TYPE OF ATAXIA.

Bv .M. .\LLE.N STARR, M.D.. LL.D..

NEW YORK.

PROFESSOR OF NEVROLOGY, COLOMBIA UNIVERSITY.

.\t.-\xi.\ is usually a symptom of either locomotor
ataxia, or of cerebellar disease, or of disease of the
tracts leading to and from the cerebellum as they
pass through the medulla, pons, and cruri cerebri.
It occasionally develops as a secondary symptom
in ophthalmoplegia, when double vision misleads the
patient as to the position of objects he is about
to step on, and it occasionally appears as a tem-
porary symptom under certain toxic conditions, as
in alcoholic mulitple neuritis.

In the- following patient the ataxia cannot be
placed in either of these categories. The patient, a
man of si.xty-si.x years of age. whose family history
is good, and who has been a healthy, strong, and
active lawyer all his life, began to suffer about
eight months ago from deafness, w'hich has gradu-
ally increased and is shown by appropriate tests to
be a nerve deafness, probably due to a progressive
atrophv of the auditory nerve. Along with this
svmptom there has gradually developed a condition
of static ataxia. He feels unsteady on his feet, he
finds it difficult to balance himself when standing or
walking, and he staggers greatly unless supported
bv«the aid of an attendant and the use of a cane.
This staggering has gradually increased little by

May i8, 1907]

MEDICAL RECORD.

803

little as his deafness has increased, so that at present
he is unable to walk without the assistance either
of a cane or of an attendant. On rising from a
chair he sways and would fall if not supported. In
walking, his feet are placed irregularly, the steps
being of uneven length and the body swaying with-
out any special tendency to fall in any one direc-
tion. His gait is that of cerebellar disease rather
than of locomotor ataxia, as there is none of the
stamping of the feet or throwing of the legs in ir-
regular directions. When seated there is absolutely
no indication of any incoordination either m the
movement of the legs or of the arms. His writing
is perfectly good, and there is no trace of ataxia
excepting in the act of standing and walking. It
is impossible to stand with his eyes closed, but while
this lack of balance is very marked, it is not at-
tended by any vertigo, and it appears to be the only
symptom that is present. His ocular muscles are
normal and there is nothinp^ abnormal in the action
of his nupils. His vision is good and optic discs nor-
mal. He has never suffered from vertigo, vomiting
or any evidence of primary cerebellar disease. Hi,"
knee jerks are normal and he has never had any
lightning pains or difficulty with the action of his
bladder. There is no paralysis or disturbance of
sensation in any part of the body.

Under these circumstances, it seems probable
that along with the atrophy of the cochlear division
of the auditory nerve, which has produced his deaf-
ness, there has been a progressive atrophy of the
vestibular division of the auditory nerve, cutting
off from his brain those impulses from the labyrinth
which are necessan,- for the preservation of balance.
It is well known that in labyrinthine disease of sud-
den onset, as described by Meniere, there is very
great dizziness and consequent ataxia of movement
and inability to walk. It seems possible, therefore,
that in a progressive atrophy of the nerve the dis-
turbance of equilibrium may appear as a symptom.

In the absence, then, of other evidences of dis-
ease, it seems warrantable to ascribe the ataxia to
a progressive atrophy of the vertibular division of
the auditory nerve.

Rossi' has recentlv described a primary narenchy-
matous atrophy of the cortex of the cerebellum pres-
ent in old persons between fifty and seventy years of
age and advancing progressively. The symptom in
this condition is a gradually developing ataxia of
movement without other symptoms. He cites three
cases in support of his statements, with one autopsy.

A. Thomas- has described an atrophy of the in-
ferior cerebellar peduncles and of the olivary bodies
as a result of chronic arterial sclerosis, producing a
gradually increasing ataxia. But in this case there
were other symptoms of bulbar disease. Dejerine^
and Thomas have also described an atrophy of the
olivary bodies and pons with cerebellar tracts, caus-
ing ataxia, but there were also other symptoms in-
dicative of bulbar disease. In our patient, how-
ever, there were no signs of any bulbar affection,
which enables us to exclude such a lesion in his case,
and although his age was such as to warrant the
supposition of some beginning arterial sclerosis, yet
the absence of cerebral symptoms, the unusual activ-
ity of his mind, his quiet sleep, and the absence of
high-tension pulse, all make it unlikelv that any
serious atrophy of the brain from arterial di-ea^e
can be in progress. The case is presented as an in-
teresting instance of ataxia of auditorv origin.

REFEREN'CES.

I. Tconogrnphie photographiqiie de la Salpetriere, 1907,
January-February.

2. .A. Thomas : Le Cervelet, These Doctoral, 1S97, Obs.,
v., p. 215.

3. Icon, photographiqiie de la Salpetriere, igoo, p. 330.

THE DIAGNOSTIC VALUE OF THE CYSTO-
SCOPIC EXAMINATION IN CARCI-
■ NOMA CERVICIS UTERI.*

Bt BEN.I.\.MIN' S. B.^RRINGER. M.D..

-VEW YORK.

.\TTt.NDl.VG SURGEON, CORNELL U.N'IVERSITV DISPENSARY. GENITO-
URINARY DEPARTMENT.

In this paper I have attempted to determine what
constitutes the complete cystoscopic examination in
carcinoma cervicis uteri ; to classify the various find-
ings in order of their importance, and to indicate in
these cases the diagnostic value of such an examina-
tion. Fifteen cases have been methodically exam-
ined. In each of these cases operation had been
refused because of the extent of the growth.

The reasons why I have chosen inoperable cases
are : ( i ) In carcinoma confined to the cervix, and
manifestly operable, there is no question of bladder
involvement. Only in those cases where the growth
invades the vaginal wall and extends toward the
bladder does the question of bladder involvement
arise. (2) In such cases pronounced inoperable I
had hoped to find some cases on the borderland
between operable and inoperable. In reality such
was the case, four of the fifteen being borderland
cases. (3) Finding such borderland cases, I had
hoped to determine the transitional steps between
operable and inoperable cases, as shown by the cysto-
scopic examination.

The various modes of extension of the carcinoma
into the broad ligaments, into the vagina, into the
uterosacral folds, and into the rectum, may all be
fairly accuratelv determined by palpation with one
exception, namely, where the carcinoma extends an-
teriorally toward the bladder. When this occurs
the extent of the bladder involvement and the con-
dition of the vesicovaginal septum cannot be esti-
mated by palpation. W'inter (Lehrbuch der Gyna-
kologische Diagnostik) says: "These alterations
[i.e. those of the bladder] appear to me to have
value in judging the condition of the vesicovaginal
septum. That portion of the parametrium cannot
be accurately palpated, and even with examination
by means of a catheter introduced into the bladder
only the thickness of the remaining tissue layer may
be accurately judged, but not the condition of the
septum.

As to the necessity for the cystoscopic examina-
tion, Kelly says (Operative Gynecology, Vol. II.,
page 318) : "In the early stages, when the cervix is
not much enlarged and the uterus is probably mov-
able, and a rectal examination shows that the broad
ligaments are probablv clear, the operation may be
undertaken without any further investigation.
Later, when the cervix is more extensively diseased,
the minutest possible examination should be made
before proceeding to operation."

In a recent article, Sampson says ("The Relation
Between Carcinoma Cervicis L^teri and the Blad-
der." Johns Hopkins Hasp. Bulletin, May, 1904) :
"The nineteen instances of accidental injury to the
bladder in 157 hysterectomies for carcinoma cer-
vicis uteri emphasize the close anatomical relation
between the two organs, and that the extension of
the disease soon involves the bladder."

The literature on this subject is not extensive. I
shall only mention the results of the work of Winter

*Read before the Eastern Medical Society, Gynecological
Section.

8o6

MEDICAL RECORD.

[May 1 8, 1907

(quoted by Caspar, Cystoskopie, 1905, page 318).
He arrives at the following conclusions as the result
of the examination of 43 cases of uterine carcinoma,
9 of which were recurring: "When the carcinoma
approaches the bladder wall, the nearest portion is
simply pushed forward, and we may have marked
displacement of the bladder wall ; then the mucous
membrane over the afi'ected place gradually begins
to swell and to lie in thick folds which run parallel
or appear with deep valleys. Sometimes the folds
are bullous edematous. One often finds the larger
vessels deeply injected, sometimes ecchymoses." In
this series he has seen only two cases of carcinoma
of the bladder wall. The bladder alterations develop
only when the carcinoma approaches the bladder
wall from the anterior and lateral portions of the
cervix and vagina. With entirely free parametrium,
and with (from general appearances) operable car-
cinoma, he never found bladder alterations, but in
these cases the carcinoma was never limited to the
anterior cervical wall. The bladder alterations occur
very late, and, as a rule, only with inoperable carci-
noma. Winter continues: "When one compares the
alterations appearing with carcinoma to those which
appear witli paravesical inflammatory processes, it

Jijirf<

Fig.

is found that, except in the rare cases of carcinoma-
tous nodes of the bladder wall, they are similar;
they depend in both cases upon the swelling of the
mucous membrane caused by circulatory disturb-
ances."

Kustner (Lehrbuch der Gynakologie, page 230)
quotes Winter and Zangemeister, and says that W.
Hirts, after the examination of a large number of
cases from his [Kustner's] clinic, confirms the re-
sults of Winter and Zangemeister, and adds that
the conditions found with carcinoma and those of
inflammatory processes are identical, and are only
to be used in diagnosis when their etiology has been
established.

In the cystoscopic examination of tlie fifteen cases
the following routine has been carried out :

1. In the vaginal examination have been ob-
served: (a) The portion of the cervix involved,
and any encroachment on the vaginal wall. (Z?)
The condition of the parametrium.

2. When the anterior vaginal wall has been in-
volved, it has been attempted to find the relation
between this involvement and the bladder. The
trigone and its posterior boundaries, the ureteral
openings, are the most constantly fixed portions of
the bladder; also because of their anatomical posi-

tion, the trigone and the vesical portion of the
ureters are almost always the first parts of the blad-
der to be involved in the growth. Any distortion of
the trigone and of the ureters, aside from simple
elevation or depression, may be very accurately esti-
mated by measuring the distance from the meatus
urinarius externus to either ureteral orifice.* Using
the same common point to measure from, the meatus
urinarius externus, we may measure the distance in
the vagina to where the growth involves
the vaginal wall. These measurements give us
roughly two triangles, both having their ape.x at the
meatus urinarius, the base of one formed by the
posterior limit of the trigone, and the base of the
other limited by the growth. The relation between
the bases of these triangles indicates fairly accu-
rately the proximity of the carcinoma to the bladder
trigone and the vesical portion of the ureters (Fig.

3. Any limitation of the up and down mobility
of the cystoscope in the urethra, and in conjunction
with this the position of the trigone, whether nor-
mally placed or elevated. Normally, the up and
down mobility of the cystoscope in the female
urethra is about 90°, and the general trend of the
urethra very slightly upward (Fig.
2). With encroachment of the
carcinoma this mobility becomes
much restricted, and may not be
W^va^/<?ei.s /^^r^z '"ore than perhaps 35°, and with

this restriction the general direc-
tion of the urethra always tends
upward (Fig. 3). The elevation
of the trigone varies directly with
this restriction and upward trend
of the urethra.

4. Any conditions within the
bladder itself indicating involve-
ment of the bladder by the growth.
Discussion of Cases. — In the 15 cases, 11 were
inoperable and 4 were on the borderline between
operable and inoperable. The reason why these 4
cases were considered borderline cases will be dis-
cussed later.

One of the cases was carcinoma of the body of
the uterus with slight enlargement of the cervix.
Another was a carcinoma extending to the cervix,
but probably primary in the vagina. The remaining
13 were carcinoma of the cervix.

In these 13 cases the vaginal examination was as
follows : (a) In one of the cases the anterior vagi-
nal wall was not invaded. In the remaining 12 the
anterior or lateral vaginal walls were invaded, the
carcinoma extending along the vaginal wall in 2 of
the cases to w-ithin 25^2 cm. of the meatus urinarius
externus ; 3 within 4 cm. ; 5 within 5 cm., and the
remaining, distances varying from 5 cm. to 10 cm.
The vaginal carcinoma extended to within yi cm.
of the meatus urinarius externus. (b) In all of the
borderline cases the parametrium was not markedly
involved. In each of the remaining cases the para-

/^yi//

*These measurements were made by means of an indi-
rect cj'stoscope. When the ureteral orifice was directly in
the center of field and in focus, the length of the portion
of the cystoscope within the urethra and bladder was taken.
This measurement is fairly accurate, as I have proved
by e.xperiment upon a clay phantom, the maximum varia-
tion from the true measurement bein.sr but three milli-
meters. The methods of Kelly and Sampson in ascertain-
in.? these measurements by means of the Kelly cystoscope
would perhaps be applicable to these cases and would be
perhaps more exact with normal or fairly normal bladders,
but with the extreme distortion of the trigone in some
of the cases I imagine that it would have been impossiblq
to have found the ureteral orifices at all with the Kelly
instrument.

May 1 8, 1907]

MEDICAL RECORD.

807

metrium was involved, and, as a rule, markedly
involved.

Relation Between the Involvement of the Anterior
Vaginal Wall and the Trigone and Ureteral Orifices.
— I soon found that the position of the ureteral ori-
fices and their relation to the meatus urinarius ex-
ternus was but little affected by the carcinomatous
encroachment, even when this was extensive. The
comparison of Figs, i and 4 demonstrates this. In
Fig. 4 the carcinoma is but 3^/2 cm. from the meatus
urinarius externus, while in Fig. i it is 5J/2 cm. dis-
tant. The only ureteral opening that could be found
in the case which Fig. 4 represents is more normally
placed than either of the ureteral openings in Fig. i.

In the majority of the cases, therefore, these meas-
urements were not taken, being of no value.

Direction of Urethra and Elevation of Trigone. —
In the 4 borderline cases there was practically no
limitation of the up and down mobility of the cysto-
scope in the urethra ; the general direction of the
urethra was normal, and the trigone not elevated.

In none of these cases was the parametrium of
both sides extensively involved, although in 2 of the
cases the parametrium of one side was considerably
thickened.

Fig. 2, — Cystoscopy. ;A B C. angle of cystoscopic mobility.

In the remaining eleven inoperable cases, exclud-
ing those of corporeal carcinoma and vaginal car-
cinoma, the limitation of cystoscopic mobility in the
urethra was marked ; there was a decided upward
trend to the urethra, and the trigone was decidedly
elevated. There was one exception to this, where
the trigone and urethra were normal and the para-
metrium of one side only was considerably involved.

In the vaginal carcinoma, although the entire
vault of the vagina was involved, the carcinoma
extending to within 3^ cm. of the meatus urinarius
externus, the trigone was normally placed and the
urethra normal, neither the cervix nor the para-
metrium being involved.

In these 9 cases the carcinoma was situated at
varying distances — from 2j< cm. to 6 cm. — from
the meatus urinarius externus.

These three conditions, i.e. the limitation of mo-
bility of the cystoscope in the urethra, the upward
trend of the urethra, and the elevation of the trigone,
seem to be caused by, and are present with marked
enlargement of the cervix, more or less extensive
involvement of the anterior vaginal wall and the
parametrium of both sides, and unquestionably in-
volvement of the vesicovaginal septum. So far as I

have observed, these occur only in inoperable cases.
The cystoscopic examination, however, adds nothing
to the knowledge that may be gained by palpation.

Changes in the Bladder.— (a) Tumor masses en-
croaching upon the bladder or retractions of the
bladder caused by the adherent tumor. In one of the
borderline cases in which the left parametrium was
much infiltrated and the right hardly at all, just
behind the left ureteral orifice there was a marked
depression or pit which could not be brought into
focus. This was taken to be a retraction of the
bladder caused by adherence of the growth to the
bladder. The bladder was otherwise normal. Oper-
ation in this case would be undertaken much more
intelligently with the cystoscopic examination in
mind. The surgeon would know where to expect
trouble in freeing the growth from the bladder.

In three of the inoperable cases there were tumor
masses encroaching upon the bladder wall, indi-
cating adherence of the carcinoma to the bladder ; in
these three cases the cystoscopic findings simply em-
phasized the futility of operation.

These encroachments or retractions of the bladder
still further indicate involvement of the vesicovagi-
nal septum, when associated with other bladder
changes, caused by circulatory disturbances which,
in turn, are dependent upon the attachment of the
carcinoma to the bladder. In two of the cases the
mucous membrane of the bladder was normal. In
the other two there were associated in one case con-
gestion of the entire bladder, and in the other
chronic cystitis of the mucous membrane covering
the tumor mass, folding, and chronic cystitis of the
trigone.

(h) There are a number of bladder conditions
seen in carcinoma which are dependent upon circu-
latorv disturbance caused by attachment of the car-
cinoma to the bladder,
and which are en-
tirely similar to those
seen in different vesi-
cal and paravesical
inflammations. These
are : (i) folding and
swelling of the blad-
der mucous mem-
brane, giving the ap-
pearance of ridges
and valleys: (2) varicosities of the bladder vessels;
(3) submucous hemorrhages; (4) congestion of the
bladder; (5) cystitis; (6) bullous edema.

These conditions appeared in the series with the
following frequency, either alone or combined : Con-
gestion, 3 times ; cystitis, 3 ; hemorrhages, 2 ; fold-
ing of the mucous membrane, 2 ; varicosities, once ;
bullous edema, none.

Congestion or cystitis unassociated with other
bladder changes does not mean, as far as I have been
able to observe, involvement of the vesicovaginal
septum.

A condition resembling cystitis is not infrequently
seen. That is, the urine is clear ; the bladder wash-
ings contain no flakes; the portion of the bladder
nearest the growth gives a cystoscopic picture fairly
typical of cystitis, i.e. swelling, folding of the
mucous membrane, no vessels seen. This is prob-
ably always caused by chronic congestion dependent
upon involvement of the vesicovaginal septum.

Aside from the cause, the importance of recog-
nizing the presence of a cystitis is extremely impor-
tant. " Sampson savs in the article above quoted :
"The frequency of cystitis following these more rad-
ical operations [hysterectomy for carcinoma cervicis

8o8

MEDICAL RECORD.

[May i8, 1907

uteri] is another indication of the close relation be-
tween carcinoma cer\-icis uteri and the bladder, and
indicates that as a result of the operation the bladder
is left in a condition of lowered local resistance, and
that this condition is responsible for the cystitis

Fig. 3. — Cystoscopy, D E F, angle of cystoscopic motility.

which may later develop, as maintained by Wer-
theim in the report of his second series of 30 cases."

In 16 cases obser\-ed by Sampson in which the
radical operation for uterine carcinoma was per-
formed, cystitis (acute) occurred in 12, resulting in
renal infection and death in 2 cases. How much
more likely is it to occur if an old chronic cystitis
be present. And yet how many radical operations
are performed when the only means of estimating
the bladder condition is through the laboratory ex-
amination of an uncatheterized specimen of urine.

As to the varicosities, in the one case in which
these were observed there could be no question as
to their indicating adherence of the carcinoma to the
bladder and resultant venous engorgement. The
vessels were large, often occupying half of the
cystoscopic field, appearing around the circumfer-
ence of the sphincter and radiating posteriorly. If
these occur in a less marked degree, perhaps only
one or two small varicosities around the sphincter,
they mean nothing.

In summing up. tumor masses encroaching upon
the bladder, "swelling and folding of the mucous
membrane, marked varicosities may all mean in-
volvement of the vesicovaginal septum. When these
appear in conjunction with one another, as they fre-
quently do, the diagnosis is more certain.

(c)'ln 4 of the cases the bladder was carci-
nomatous. In these cases the carcinoma appeared
as irregidar tumor masses of the base of the blad-
der, reddish-yellow, perhaps hemorrhagic, easily
bleeding, no vessels perceptible, or as grape-Hke
masses. A description of this latter appearance,
from my notes on one of the cases, is as follows :
"At the base of the bladder covering an area of per-
haps 9 cm. by 2V2 cm., w-as a condition which re-
sembled exaggerated 'bullous edema.' Large blebs.

each covering one-half or three-fourths of the cysto-
scopic field; yellowish-red in color, translucent, no
vessels. Directly next to the tumor mass normal
mucous membrane appeared." Any combination of
the above may occur. There are cases where the
folding and swelling of the mucous membrane at the
place of attachment of the carcinoma presents a pic-
ture verv like carcinoma of the bladder itself. As
both of these, however, usually occur in and are
indications of inoperable cases, the differentiation is
not a matter of importance.

The Four Borderland Cases. — As before men-
tioned, each of these cases had been pronounced
inoperable. In two of these cases the bladder was
entirelv normal. In one there was a chronic cystitis
around the sphincter, which could have been cleared
up under treatment, and in the fourth there was a
retraction of the bladder wall caused probably by
adherence to the carcinoma. In three of the cases
the parametrium was but slightly involved, and in
the- third the parametrium on one
side was decidedly thickened.

In two of the cases the carcinoma
extended along the anterior vaginal
wall to within 6>4 cm. of meatus
urinarius externus. In the other
two the anterior vaginal wall was
not involved.

Operation upon these cases would
have involved perhaps extensive
dissection of the parametrium;
sacrificing a considerable part of
the vagina, and perhaps a portion
of one or the other ureter and
transplantation into the bladder, or
nephrostomy ; but the bladders
were practicallv normal, as far as
could be determined, r.ot adherent to the growth, so
decreasing the dangers of infection. If a more
careful e.xamination had been made the cases would
probably have been operated upon. They should at
least have had the chance of operation.

Conclusions. — i. In the early stages of carcinoma

J/ic/v \

Fig. 4.

cervicis uteri, where the carcinoma is probably con-
fined to the cervix, the cystoscopic examination is
of little use other than to determine the presence or
absence of a cystitis.

2. In all cases of carcinoma cervicis uteri involv-
ing at all the anterior or lateral vaginal walls,_ the
most accurate means of ascertaining the condition

May 1 8, 1907]

MEDICAL RECORD.

809

of the vesicovaginal septum is by means of the
cystoscopic examination.

3. The cystoscopic examination includes (A)
Estimation of the direction of the urethra and the
position of the trigone, marked elevation of the
trigone meaning practically always inoperable car-
cinoma; {B) Conditions within the bladder; [i]
Tumor masses encroaching upon or causing retrac-
tion of the bladder; [2] The alterations of the blad-
der which are similar to those occurring with ves-
ical or paravesical inflammations. These are (0)
folding and swelling of the bladder mucous mem-
brane, (b) varicosities of the bladder vessels, (c)
submucous hemorrhages, (d) congestion of the
bladder, {e) cystitis, (f) bullous edema. The most
important among these conditions within the blad-
der which indicate involvement of tlie vesicovaginal
septum are: Tumor masses encroaching upon or
causing retraction of the bladder ; folding and swell-
ing of the bladder mucous membrane ; marked vari-
cosities.

3. Those alterations which are unquestionably
caused by the carcinoma. Alone under this head
stands carcinoma of the bladder.

4. Aside from ascertaining the condition of the
vescovaginal septum, the cystoscopic examination
is important in revealing any inflammatory condi-
tions of the bladder, as cystitis, etc.. which if un-
recognized and untreated before operation might be
the determining factor in causing the failure of the
operation.

5. Finally, this examination becomes progres-
sively more important as the growth extends, and
the nearer it approaches the borderland between
operative and nonoperative.

I am indebted to Dr. E. J. Gallagher and to the
Superintendent of the House of Calvary for many
courtesies extended and for the use of many val-
uable cases.

THE INTERNAL AND EXTERNAL REME-
DIES IN URINARY DISEASES AND
THEIR COMPAR.\TI\"E
VALUE.*

By C. R. O'CROWLEY. M.D..

CLINICAL ASSISTANT. GENITOURINARY DEPARTMENT, NEW YORK POST-
GRADVATE HOSPIT.\L: MEMBER OF THE AMERICAN VROLOGICAL

ASSOCIATION.

With IX the past decade the medical therapeutics
of urinary diseases has progressed so rapidly and
has suffered so many fluctuations that it has been
my object in preparing this paper to bring to your
notice the comparative value of the drugs more
commonly used in urology, especially contrasting
the old and the new. JNIy conclusions have been
drawn largely from the use of the various prepara-
tions both in my office work and in the clinic. In-
cluded in this paper will be the consideration of the
drugs used and found of value by competent ob-
servers in treating diseases of the urinary tract,
while such therapeutic agents as rest, diet, baths,
electricity', etc., will not be considered in order to
avoid a too lengthy paper.

Diluents. — To begin with the internal remedies,
we might speak first of the diluents, and water, no
matter whether in an admi.xture or alone, is a true
diluent. It is therefore useful in nearly all the
urinary diseases, as a good diuretic and solvent,
and. when taken hot. has a diaphoretic action.

*Read before the New York Reno-Vesical Society. Jan-
uary 30, 1907.

Of the many mineral waters used it is doubtful
whether the results claimed are due to the drinking
of the water at the spring or to other agencies such
as travel, change of mode of life and of habits and
of doctors, although the strong saline-aperient
waters, as Carlsbad, Friedrichshall and Hunyadi
and some of the lithiated spring waters have quite
a reputation in the treatment of the uric acid dia-
thesis and vesical calculous affection*.

The acids which are used to counteract the mor-
bid alkalinity of the urine are few in number. Very
dilute nitrohydrochloric acid, in doses of five to
twenty drops, is of service in the treatment of phos-
phaturia. Benzoic acid and its salts occupy a
prominent position, particularly in genitourinary
diseases. They are used to render the urine acid,
especially when there are alkaline concretions in the
bladder, as phosphatic calculi. In acute, subacute,
and chronic cystitis they undoubtedly prevent and
moderate alkaline fermentation of urine in the
bladder; sodium benzoate being our choice of the
group. Lithium benzoate is intended for use solely
in the uric acid diathesis. Salicylic acid is used
very little, having a tendency to irritate the kidneys
and is apt sometimes to produce hematuria and
albuminuria. Phenyl salicylate, or salol, obtained
from salicylic acid, will be spoken of under the
more appropriate heading of antiseptics.

The alkalies or neutralizers are employed to
lessen the acidity of the urine. A point worth
remembering about the giving of potassium bi-
carbonate is that, if given on an empty stomach, it
enters the blood unchanged, meets the neutral phos-
phate of sodium, and is decomposed and forms acid
phosphate of sodium, thus rendering the urine more
acid. On the other hand, given on a full stomach,
the acids of the gastric juices decompose it. increas-
ing the alkalinity of the blood and rendering the
urine less acid. The salts of potassium with vege-
table acids (acetate, citrate, tartrate, etc.) enter the
blood as such, are decomposed there, forming free
carbonic-acid gas, form alkaline carbonates, and
are eliminated as such, alkalinizing both blood and
urine. They are diuretics also, increasing the
urinary water and solids, and by causing increased
oxidation, decrease the amount of uric acid. Of
the mineral salts potassium nitrate is a most active
diuretic. Potassium acetate is the most certain
diuretic, but for long-continued use it is best to
eiuploy the citrate, especially when aimino- to alka-
linize the urine. The untoward effects of the
citrate are very slight even when used for a long
time.

The sodium salts are much weaker in their ac-
tion than the salts of potassium, bein? diffused
more slowly. They are not absorbed or e.xcreted
so readily, and possess a much diminished diuretic
action. The lithium salts, particularly the citrate,
are of value sometimes in the treatment of stone and
the uric acid diathesis.

Antiseptics. — Of the urinary antiseptics, hexa-
methylene-tetramine is by far the best, and is in-
valuable in acute and chronic inflammatory diseases
of the urinary tract, in acute, subacute, and chronic
cxstitis. in pyelitis and pyelonephritis. In bacteri-
uria it has no equal. Especially good results have
been obtained from its use in the uric acid diathesis
as it diminishes the uric acid excretion and develops
urisolvent properties in the urine. Casper found
that the drug caused complete cessation of all visible
phosphatic excretion in a case of phosphaturia.

The salicylic ether of phenol, called salol, is
another useful remedy and is an efficient disinfectant
in subacute cystitis, its component parts being e.x-

8io

MEDICAL RECORD.

[May i8, 1907

creted with the urine, hence coming in contact with
the vesical mucous membrane for a considerable
length of time. Salol should not be given when
there is any disease of the kidneys, because of the
carbolic acid of its constitution.

Sodium benzoate, already mentioned above as an
antacid, may be justly styled a urinary antiseptic,
being very mild in its action and has the advantage
that it can be used for a considerable length of time
with little or no untoward manifestations. Cystitis
is its best field of employment. Methylene blue
has been classed as an antiseptic and used success-
fully in chronic cystitis.

Sedatives and Astriii<;cnts. — The urinarv and
vesical sedatives and astringents when taken in-
ternally act through the medium of the urine in a
sedative manner upon the whole extent of the
urinary tract. They alleviate pain, decrease the
bladder irritability, and lessen the desire to mic-
turate. The antispasmodics may also be grouped
under this heading.

Opium and its alkaloids are unequaled in the
symptomatic treatment of renal colic, retention of
urine, and pain due to vesical calculi. Belladonna
is the best antispasmodic we have, and invaluable in
the trigonitis of cystitis. The bromides, hvoscya-
mus, cannabis indica, are good in lessening the
irritability of the nerves.

The mucilaginous drinks, such as barlev-water
or linseed tea, and the astringents like buchu, uva-
ursi, and pareira, lessen the irritation due to chronic
c}stitis, and such antiseptics as copaiba and cubebs
act in the same manner, being carried bv the urine to
the bladder, Pichi, an unofficial preparation, has
done good service in the hematuria and pain of
renal calculus.

Antihemorrhagies. — The internal administration
of antihemorrhagies is of little value. The ex-
tract of suprarenal glands, ergot and iron are the
ones most commonly used. Gelatin is employed
subcutaneously, but as it is almost impossible to
obtain sterile gelatin, and as the tetanus bacillus
and other pathogenic germs grow readily in com-
mercial gelatin, the method is not very popular.
Calcium chloride has been used internallv in hemo-
philia, being given for a few days prior to an opera-
tion on the urinary tract. The injection of fresh
human serum subcutaneously has been tried very
recently by Weil of Paris for preventing bleeding
in hemophilic patients. These methods may be of
importance in operating upon "bleeders" with uri-
nary diseases.

Tallies and Alteratizes. — The tonics and altera-
tives are brought into use very frequently in uri-
nary diseases, particularly in the chronic and com-
plicated cases. In tuberculosis of anv" portion of
the urinary tract, such drugs as guaiacol carbonate,
cod liver oil, iron, "uinine, and strychnine are indi-
cated. In fact, most of the tonics in general use.
In chronic cystitis and incontinence of urine due
to want of muscular tone buchu has proven of great
value.

Diuretics. — Although many of the foregoing
remedies have a more or less diuretic action, I think
it would not be amiss to speak of a few direct
diuretics. Digitalis, though frequently used in
Bright's disease, is an unsuitable diuretic. In the
acute form, when used alone, it aggravates the
condition, while in chronic nephritis it is still more
injurious, owing to the increased arterial tension
set up in the renal circulation. In such cases it is
better to use a diuretic pill made up of digitalis
leaves in powder, calomel, and squill, a grain of each
made into pill with extract of hyoscyamus. Digitalis

is one of the most efficient diuretics we have, but it
must be used with much discrimination. Digitalis,
in small repeated doses, acts as a diuretic, not in
virtue of its effect on the kidney itself, which is
practically nil, but because of the increased arterial
pressure it produces. In dropsy, in which it is prin-
cipally used, there is a stasis in the renal circulation.
The drug, by increasing blood pressure, causes an
excess of urine to be secreted and thus relieves the
dropsy. We must remember, however, that an over-
dose may cause a spasm of the renal vessels and
thus produce suppression and cumulative effects of
poisoning. For these reasons the infusion, which
contains a small dose of the drug, is preferred by
many as a diuretic preparation, though the tincture,
given in small amounts, is preferable, being more
staple. When there is disease of the renal tissue, as
shown by casts, albumin, etc., digitalis should be
combined with more active diuretics as caffeine or
squill. In giving digitalis it is important to watch
the pulse and the heart's action as well as the quan-
tity of urine. Thus we can detect at once suppres-
sion or exaggerated tension. We must remember
that digitalis is contraindicated in arteriosclerosis
and fatty hearts.

Sodiotheobromine salicylate is supposed to be a
very good diuretic and is practically a theobromine
rendered soluble by sodium salicylate. The theo-
bromine compound is really inferior to caffeine in
its diuretic powers and is not a stimulant as caffeine
is. It should not be given in acute nephritis, as it
has a stimulating effect upon the renal secreting
structures. In very chronic cases, in which the
tissue of the kidney is largely destroyed, it is, of
course, useless, as it acts directly upon renal tissue.

Caffeine, an alkaloid from coffee, is a heart stim-
ulant and diuretic, especially valuable in dropsy,
but should not be used in acute nephritis because it
is also a stimulant to the kidney. It dilates the
renal vessels also and increases both solids and
liquids in the urine.

Antiblenorrhagics. — Our treatment of urethritis
has been greatly enhanced since we have found a
specific microorganism as the most common etio-
logical factor. Copaiba was first given internally
by Markgraf and Pison (1648) and introduced into
the treatment of urinary diseases by Daniel Turner
(1729) and J, Thorn (1827), Ricord (1849) and
Roquelle ( 1854) showed that it merely acts locally,
by passing into the urine. The urine, saturated
with the balsam or its disassimilative products,
passes through the urethra and thus produces its
action. Both of these writers treated specific ure-
thritis patients who were suffering from urethral
fistula with copaiba internally. That portion of
the urethra situated behind the fistula, and which
was constantly being washed by the urine, recov-
ered ; the portion in front of the fistula remained
blenorrhagic and did not heal until injections of
the patient's urine were made into it, Ricord then
administered copaiba to a patient in his clinic who
was not suffering from blenorrhea. and injected a
few urethritis patients with his urine. This virus
proved effective, a distinct evidence of the topical
action of the balsam. Sandal wood oil was first
brought into use in urinarv diseases bv Henderson
(1865) and Panas (1865).

The antiblenorrhagics, also known as the bal-
samics. have gained great prestige in recent years,
particularly in treating genitourinary diseases. The
balsamics are given to relieve the subjective symp-
toms in acute urethritis, and tend to lessen the pain
and tenesmus and diminish the discharge and make
the urine thinner. They inhibit the growth of gono-

May 1 8, 1907'

MEDICAL RECORD.

81 1.

cocci by rendering the soil less favorable and pre-
vent complications, as Finger has shown. The
remedies most commonly used in this class are
sandal-wood oil, balsam of copaiba, cubebs, extract
of kava-kava, oil of cedar, oil of turpentine, oil of
juniper, buchu, niatico, and pichi. Of these, sandal-
wood oil and conaiba are the best, although the
unpleasant irritating symptoms often produced, par-
ticularly by copaiba, such as pain in the kidneys,
nausea, and skin eruptions, restrict its use for any
length of time in a great many cases. Vieth (Aled-
iciiiisclic Kliiiik, 190=:) found that these irritating
symptoms, on the part of the kidney and stomach,
depended largely upon the proportions of terpenes
in these balsams. To a lesser extent they dependeil
upon the proportion of terpene alcohols, and to a
still lesser degree ui)on the resin acids. It is inter-
esting, therefore, to know that, according to chem-
ical analysis of the various balsamics, one can ascer-
tain in advance the amount of unpleasant symptoms
they are apt to produce. Thus the most irritatiii"-
substance of this group is turpentine. East Indian
sandal-wood oil, or that ordinarilv employed, con-
tains 6 per cent, of terpene and 94 per cent, terpene
alcohol. Copaiba balsam, the best variety of which
comes from ]\Iaracaibo, contains 55 per cent, of
terpene and 40 ])er cent, of resin acids. Extract of
cubebs has (1::; ptr c-cnt. mC teriiene and in per cent,
of resin acids. It will be seen from this that the
last-mentioneil drug is the most irritating to the
stomach and kidneys ; copaiba is next, and least of
all sandal-wood oil. Unfortunately, the skin erup-
tions sometimes occurring in patients taking these
drugs do not seem to depend upon the chemical
constitutions of these balsamics, but to the idiosyn-
crasy of the skin. When we speak of copaiba we
mean the balsam. The oil of copaiba is a decided
renal irritant. The balsam also has a cathartic
effect upon the bowels. In prescribing sandal-wood
oil one should be sure it is the product of the East
Indies one is using and beware of the kind some-
times substituted by unscrupulous dealers, because
the latter contains from 30 to 35 per cent, of ter-
pene. Even the best sandal-wood oil is not an i<leal
remedy, as it often disturbs the appetite and may
cause renal pain.

In order to eliminate or decrease to a mininnmi
the unpleasant symptoms occurring in patients tak-
ing the balsamics. various jiharmaceutical manu-
facturers have tried to extract the active ])rinciple
of sandal-wood oil and endeavor to increase its
therapeutic value by the addition of some syner-
gistic remedy, such as salol, the active principle of
kava-kava, etc.

It is a question whether the admi.xture of any
drug improves the action of sandal-wood oil. and
it has been my experience that when sandal-wood
oil is given judiciously and its action carefully
watched in everv individual case, there will be
very little complaint on the part of the patient.

The indications for the use of the balsamic- are
not altogether definite in spite of the many \ears
these remedies have been employed. Many of the
older authors and a few of the recent ones ( Leed-
ham-Green, Treatment of Gonorrhea in the Male,
1906) recommend the balsamics in the acute stage
at the very onset of the disease, when no local treat-
ment is to be used. Others, as Taylor, say that they
should be used in the 'iubacute stage, and nijt be-
fore, and are contraindicateil in the acute form of
a urethritis. .\t tlie Xew York Post-Graduate
Clinic we have been in the habit of prescribing our
antiblenorrhagic mixture upon the first visit of the
patient with an acute discharge, and for the most
part with gratifying results. After the discharge

has become scanty and the process is beginning to
become chronic these remedies should be discon-
tinued, as they are of no further value.

Spcciiics. — Among the local remedies used in
urology the most prominent are the newer silver
compound? regarded as specific in the treatment of
urethritis. There are quite a number of these now
ujion the market, and the manufacturers of each are
an.xious to impress us with the superiority of their
particular jiroduct. One point seems certain, how-
ever, that the bactericidal powers of these remedies
have little to do with their clinical value in specific
urethritis. The various synthetic compounds of sil-
ver which have come to riur notice in the past
decade, if used early enough in acute urethritis and
in sufficient strength, in manv instances will abort
the attack or shorten its course, without causing
the urethral irritation iiroduced by silver nitrate.
One of the chief characteristics claimed for the vari-
ous organic silver salts is the fact that solutions
of these salts do not coagulate in albuminoid solu-
tions, with which the urethral mucous membrane
is covered, and many observers ])oint to the fact
that there is a greater penetration of these solu-
tions into the urethral sulnnucosa, and thus exert
a direct bactericidal effect uiion the gonococci
lodged there.

The extensive study of clinical cases rather dis-
proves this theory, and a recent report of the com-
parison of the various silver compounds as bac-
tericidal agents, sent to the Therapeutic Committee
of the British Aledical Association (August 18,
i90<:i) embodies the fact that the amount of silver
which a compound mav contain is no criterion of its
bactericidal power, and that a few of these salts
which possessed practically no bactericidal action
whatever had given the best results, and it seems
impossible to attribute the good effects which many
clinicians have obtained with them to their bac-
tericidal action.

The non-irritating etTect of these salts is the
most favorable feature about them, and .some of
them can be used in very high strengths without
producing any unpleasant symptoms. They seem to
diminish the urethral discharge in a vast majority of
cases to a marked degree, and the actual course
of the disease is shorter than b\' any other local
treatment. .Solutions should always be made up
freshlv. and used as soon as possible after the
appearance of the discharge, and the treatment kept
up as long as anv (low containing gonococci is vis-
ible, at wdiich time we are to change to one of the
astringent solutions. Solutions of these silver salts
can be given in deep instillations two or three times
a week in chronic posterior urethritis, or they can
be cmployeil as irrigations to both urethra and
bladder.

Drills Used for li-ri,i;atiii-^. — .-\ warm saturated
solution of boracic acid is used to irrigate the urethra
and bladder for cleansing purinises jirior to an oper-
ative procedure for the recovery of shreds. Solu-
tions should always be made with sterile distilled
water. Formalin solutions in strengths of i-ioooo
to 1-8000 make an excellent medium for irrigating
and filling the bladder in preparing patients _ for
cvstoscopy. Potassium permanganate in solutions
1-8000 to' 1-2000 is still used bv some in the treat-
ment of acute and chronic urethritis. At the clinic
we never use it for irrigating purjjoses, as we have
found it produces complications. Acute cases should
not be irrigated anvway. as treatment with either
salts gives "much better results. Permanganate is
useful in treating nonspecific or septic urethritis in
which the silver salts do not seem to do much good.

Silver nitrate is resorted to bv sume in obtainiog

8l2

MEDICAL RECORD.

[Mav- 1 8, 1907

an abortive or quick curative treatment in acute
anterior urethritis of gonorrheal origin. The sur-
face of the anterior urethra is endoscoped for a
distance of about three inches and an appHcation
of an aqueous solution of nitrate of silver, fifteen
grains to the ounce, is made from within outward
as the instrument is withdrawn. This procedure ,is
attended with such intense pain and ardor urinse,
and for the most part with unwarranted results, that
it has practically fallen into disuse. In chronic
urethritis and cystitis, however, silver nitrate solu-
tions in strengths from 1-16000 up to 1-2000, given
by the Janet method, have proven of great value. In-
stillations, by means of an Ultzman syringe, of silver
nitraje solutions 1-500 to 1-250 are excellent in
treating posterior urethritis. Ayres has had excel-
lent results in treating catarrhal pyelitis, by renal
lavage, with mild solutions of silver nitrate in a boric
acid medium (New York Medical Journal, August
II, 1906).

Astringents. — In addition to the office treatment
in the chronic stage of gonorrhea we give astrin-
gent injections which, of course, act upon the an-
terior urethra alone, but seem to aid in curing the
disease. The astringents are only indicated when
the discharge has stopped and there are no gon-
ococci present. Zinc, either the sulphate or the
sulphocarbolate, is the best urethral astringent. It
is better to combine it with alum, hydrastis, or liquor
plumbi subacetatis, when prescribing for urethral
injections.

Anesthetics. — Cocaine is used in the bladder in
one-tenth of one per cent, strength. On account of
such a large area as the bladder walls, absorption is
apt to take place rapidly, and for this reason cocaine
is used very little in the bladder. Instillations of a
two to four per cent, solution are sometimes given
to the posterior urethra when we experience diffi-
culty in passing instruments into the bladder. This
method is very useful in cystoscopy. Solutions in
five to ten per cent, strengths can be safely used in
the meatus prior to a meatotomy. Always have the
solutions freshly prepared with sterile salt solution
with the addition of a few drops of adrenalin. Sev-
eral substitutes, as eucaine. beta-eucaine, etc.. are
available, but a cautious use of cocaine will answer
our purpose.

An ethereal oil, made from a plant growing in
New Caledonia, and containing a camphor-like men-
thol substance which gives it a cooling taste and
odor, is said to be antiseptic and anesthetic and is
used in twenty to fifty per cent, strength. In urol-
ogy, it is chiefly used as an aid in passing dift'erent
instruments as fili forms, etc., through ditficult stric-
tures and acts as a lubricant. It is also used in
injections and instillations into the bladder in vari-
ous forms of painful cystitis, particularly in tufjer-
culous cystitis with ulcerations. It not only relieves
pain, but also creates a pleasant cooling sensation
in the bladder and diminishes the frequency of
urination. It is, of course, a palliative remedy, but
a useful one.

I have tried in the above lines to confine myself
to the practical side of urinary therapeutics, and
wish only to add a plea for a more thorough ap-
preciation of the value of some of the old as well
as the new remedies useful in this branch of medi-
cine, for a deeper study of their action and the
indications for their use, and for a due conservatism
in accepting the statements of manufacturers or en-
thusiasts whose motto seems to be ''de novis nil nisi
ionnm." A thorough trial by competent and im-
partial observers should be the basis for the accept-
ance of a new remedy into our list of drugs.

13 LoMBARDY STREET.

TWEXTY-FIVE YEARS' EXPERIENCE IN

THE TREATMENT OF MALIGNANT

NEW GROWTHS WITH

ESCH.AROTICS.*

WITH PRESENT.\TI0X OF C.\SES.
Bv WALL.^CE E. BROW.N", M.D.,

NORTH ADAMS, MASS.

At this my first available opportunity, it is my pur-
pose to place before you and the medical profession
throughout the world, a method of treatment that in
my hands has effected permanent results in all forms
of cancer and other malignant as well as benign
new growths that are situated outside of the thoracic
and abdominal cavities. This may to you seem pre-
sumptuous, particularly so in view of the current
literature on the subject, much of which has been
based upon ideas that could not possibly have been
gleaned from clinical observations. Many of you
know the circumstances that led my father to this
special field of practice, so I will not relate them at
length, Escharotics have been used with varying
success for ages, but I believe my father was the first
to employ them with a view solely to their me-
chanico-chemical, rather than elective qualities. Up
to the time that he began his experiments various
escharotics had been used, and applications were
confined strictly to the new growths, the adjacent
infiltrated area not being attacked, consequently
cures were more or less of an accidental nature,
rather than based upon a logical calculation. Early
in the year 1878 I entered my father's office as a
student. He was a dentist, having selected that pro-
fession in 1862 so that he might better equip himself,
if possible, to cope with a very troublesome tumor
that had been in the roof of his mouth from the
thirteenth year of his age, and had been cut and
otherwise unsuccessfully treated many times. These
facts are well known to all of the older physicians
of this city. This tumor we successfully removed in
1S84 by the use of escharotics. and we had before
this removed many other new growths in various
situations, and they had not reappeared. Encour-
aged by our results, we entered this special field of
practice.

There is no disease or class of diseases that pre-
sents more diagnostic features than does cancer, all
views that may be expressed to the contrary not-
withstanding, and a clinician can readily differen-
tiate between a malignant and a benign new growth
by macroscopic and digital observations. With the
utmost respect for that most valuable of all instru-
ments, the microscope, as yet its use in this particu-
lar disease does not imply science, nor will it until
the microscopist combines with it his personal clini-
cal observations. This point affects neither the
utility of the instrument nor the eyes of practical
observers. As a rule, cancer attacks i>ersons that
are otherwise in perfect health. In its incipiency it
never presents premonitory symptoms, nor even a
slight sensation, nor a rise in temperature either
local or general. In short, it is a disease of health,
something of a misnomer but nevertheless true, con-
sequently there can never be a successful precancer-
ous treatment.

It is conceded by all that cancer is primarily a
local disease, and curable if the last vestige can be
removed. Its incipient stage of invasion is micro-
scopical. \\'hen it first attracts our attention we
find a grouping of cells ven.- diverse in size, shape,

*Paper read before the Berkshire (Massachusetts) Dis-
trict Medical Society and the Medical .\ssociation of Xorth-
ern Berkshire at their December meeting, held jointly at
North Adams, Mass., December 27, 1906.

May i8, 1907]

MEDICAL RECORD.

S13

and color, so much so that our nomenclature fails to
describe them. In these heterogeneous masses
which are distinctly palpable, and discernible to the
naked eye, we have what is designated as true ma-
lignant disease, or cancer, a word without histologi-
cal meaning. This is a permanent change, and un-
doubtedly due to a perversion of cellular activity
or dynamics of the cells. In my opinion this struc-
tural' change will never be logicaly explained, so in
justice to sutterers from cancer I feel that they
should have the full benefit of the means at hand.
We have to-day but two methods by which such
growths can be removed — the knife and escharotics.
I can in no better way explain the effect of the
former than by quoting the exact language of that
distinguished surgeon and teacher. Prof. Maurice
H. Richardson. In an article on cancer read before
the Obstetrical Society of Boston, he says': "The
prognosis as to recurrence in even the most radical
operation upon a cancerous cervix is bad ; for, under
the most favorable circumstances, the margin of
healthy tissue seems utterly inadequate. A small
cancerous nodule in the center of a large breast
demands excision of the whole organ, and even then
recurrence is the rule. An infiltrating epithelioma
of the lip requires in its proper removal the broadest
possible margin of healthy tissue, and if that margin
is a close one we look upon recurrence as almost
certain." These views as expressed by Dr. Richaril-
son concur with those of many other distinguished
surgeons in this and other countries.

In attempts to increase my armamentarium ther-
apeuticum, many escharotics have been tried, but
experience has taught me that those agents which
are the most actively hygroscopic produce the most
perfect granulating surfaces, and to-day I use in
combination those most active of all escharotics,
potassium hydrate and zinc chloride (granular).
These are equally applicable both to skin and to
mucous surfaces. In the mouth and throat I use a
combination of chromic and carbolic acids which I
will explain later. Potassium hydrate, the most de-
structive and least painful of all escharotics of which
I have knowledge, is prepared by me as follows :
Take one or more pounds, place it in a mortar, add
just sufficient water to dissolve it thoroughly : this
is best accomplished by keeping it agitated with the
pestle. When dissolved add a suiificient quantity of
ground hydrastis canadensis to make it assume the
consistency of a paste that will not gravitate read-
ily, when placed upon a perpendicular surface. The
advantage of the hydrastis lies in the fact that it
does not cake or dry up, making a perfectly stable
mixture, one that will keep for years and not lose
its destructive properties.

The zinc chloride is prepared separately in the
same manner, with a view at all times of making
them as near saturate as is possible, a quality which
produces a degree of anesthesia in the tissues at-
tacked rather than pain, the difference being analo-
gous to that between the red-hot iron and one heated
to a white heat when applied to flesh. The one
notable point upon which I wish to center your at-
tention is the fact that these escharotics when
applied to any given area of tissue cut off all circu-
lation and completely occlude all lymph vessels,
which in my opinion are the main channels for the
dissemination of cancer. This is a point that de-
mands more thought on the part of the medical pro-
fession than has heretofore been accorded it, and
which is an element that contributes largely to the
success of the escharotic treatment. Of this there
can be no doubt.

I cannot dwell at length upon any particular point,

as time will not admit of it, but I wish to refer in a
general way to the diagnosis of new growths, and
can best do this by quoting the following from a
clinical lecture by Prof. John C. Minor, M.D.. of
New York City : "Educate yourselves and your
patients to a proper detestation of tumors, and,
although you may be unable to prove that the case
which you suspect to be one of cancer is so without
doubt, yet I am confident that among a number of
tumors removed in their early stages of development
never to reappear there will be a large proportion of
genuine cases of cancer."

The technique of my work in all cases is to outline
the growth by palpation, seeking its most distant
ramifications. This done, I make an application of
the potassium hydrate, completely covering the
entire growth, and extend the application in all di-
rections as far beyond its most remote infiltrations
as the situation of the growth will admit of doing,
never with a view to conservatism. The application
should be graded in thickness according to the depth
and consistency of the growth, gradually lessening
the thickness at the outer edges, using great care
and design to have as much symmetry as possible,
leaving a clean-cut edge. After this is applied, cut
a piece of lint the exact size of the area you have
covered. Just beyond your lint on the healthy tissue
applv a heavy petroleum product. Then surround
the application with a quantity of absorbent material
sufficient to catch and hold the watery elements that
will be attracted by the hygroscopic qualities of your
escharotic, and which, if not prevented, will cause
the escharotic to gravitate and destroy tissue wher-
ever it reaches. This application will do its full
work in from fifteen minutes to five hours, varying
according to the nature and size of the growth and
resistance of the skin of dififerent patients. During
the time that this application is in place the patient
should be kept very quiet, particularly so in exten-
sive growths, such as those of the breast.

The application should be removed, as above
stated, in from fifteen minutes to five hours, and
after removal the parts destroyed will be found in a
perfectly soft pulpy gelatinous mass. The pain,
which is very slight — but emphasized differently by
each individual — immediately subsides, and there
has not been produced the slightest soreness, swell-
ing, or inflammation. In extensive cases of cancer
of the breast this is absolutely true, and the patient
sleeps that first night and is perfectly comfortable
without the use of opiates.

The following day I make an application of the
zinc chloride in exactly the same manner that I
applied the potassium, except that I do not extend
the zinc to a point of contact with the healthy or
undestroyed skin. If the application is thus made
with care there will be absolutely no pain resulting
from it, the patient remaining perfectly comfortable.
This application of zinc chloride penetrates the first
completely, also hardens and contracts the eschar
made by the potassium, causing more or less tension
on the edges according to the extent of the growth ;
this traction causes inconvenience, not pain, and is
probably the condition that has characterized eschar-
otic treatments as drawing plasters. The eschar
thus produced exfoliates in time ranging from four
to twentv-one davs, varying in each individual case.

After the eschar has' ex'foliated you have le_ft a
smooth and perfectlv healthy granulating surface,
absolutely bloodless,' and perfectly free from any
obscuring eletnents. It is not sensitive to the touch,
all sensory nerves having been destroyed. Before
the escha'r is exfoliated" the edges show marked
signs of healing, and these edges are so far wide of

8i4

MEDICAL RECORD.

[May i8, 1907

the diseased area tliat should you have failed to
reach all of the disease in the deeper tissues it will
be discernible to the eye, and easily felt by a slight
touch of the fingers, the cancerous cells having a
decidedly hard and shot-like feel, the same as metas-
tatic growths that ajjpear in the skin surrounding
advanced cases of carcinoma. To all such cells re-
peated applications of the zinc can be made, the
applications causing no pain, nor do they retard the
healing process. The care of these wounds is very
simple, but demands the attention of the operator
daily, so that any evidences of disease that may
remain can be recognized at once. I use a dressing
of wood wool, which is a i-ierfect absorbent. First
wipe the wound lightly with absorbent cotton, then
cover freelv with a petroleum product which is of
such high melting point as not to be absorbed.
This is used for the dual purpose of excluding air
and protecting the delicate granulations. Should
giant granulations appear, treat them as you would
the stray cell of malignant disease; continue these
dressings daily until the wound is perfectly healed.
The time necessary for this treatment varies accord-
ing to the extent of the disease and amount of tissue
necessary to be removed, ranging from two to six-
teen weeks in early discovered cases. In the more
advanced cases the larger the area circumscribed,
and the longer the time required for healing, the
greater safeguard does the patient have.

The combination of chromic and carbolic acids
above referred to I use in cases of malignant and
benign growths in the mouth and throat and on the
tongue, and small benign growths and granulations
that appear upon the cervix uteri. The remedies
should be used in saturated solutions only. First
making an application of the carbolic acid completely
covering tlie growth and adjacent healthy tissue,
then at once apply the chromic acid with the utmost
care, keeping well within the area circumscribed by
the carbolic acid. \\'hen the remedies come in con-
tact destruction of that portion of the growth
reached is immediate and the patient suffers no pain.
Should you fail to destroy all of the growth by your
first applications, make repeated applications in the
manner described.

In cancerous growths of the womb I use the com-
bination of potassium and zinc chloride ; little or no
pain is experienced by the patient if care is observed
in protecting the vaginal walls, and the results of
this method of treatment in that situation are suc-
cessful.

In my experience no patient has ever been con-
fined to his or her bed or room a single day from
the effects of the escharotic treatment. With an
early diagnosis and prompt treatment, there should
be as large a percentage of recoveries by this method
as are recorded in any class of the more serious dis-
eases that afflict the human family, such as eruptive
and continued fevers. Taken in its incipiency (and
by this I mean the earliest stage at which the new
growth may be discovered and observed macro-
scopically), there should be absolutely no failures to
cure, except such as come through complications or
causes extraneous to the cancer itself. With this
method we can operate in many places where the
knife cannot go, and in all places where it can be
used, and with a more certain isolation and separa-
tion of all cancerous elements. As in all modern
surgery, this is a line of work which gives best
results under institutional rather than home treat-
ment, and the necessary qualifications are the same
as required to become a successful strrgeon, namely,
a thorough knowledge of anatomy, a delicacv of
touch, a constitutional steadiness of nen-e, and me-

chanical order of mind. In selecting cases for clin-
ical demonstration, I have taken those that best
demonstrate the size of the growths that can be
successfully removed and those that show the work
in its various stages from the making of a first
application to the completion of the healing, and
which demonstrate that we have no disfiguring cica-
trices left as unpleasant reminders.

C.\SE I. — Tumor first discovered in upper border
of the right breast about seven years ago. When I
first saw the patient the growth extended from the
center of the breast (which was extremely large)
to the lower border of the clavicle, and from the
inner border of the left breast to, and involving the
right axilla. The mass in that situation was fully
four inches in diameter. The entire growth was
nodular, presenting two high points at the upper
extremity, near the clavicle, that were necrotic.
From a surgical point of view the case was inoper-
able. Ten physicians of this city examined the
patient before treatment was commenced. In mak-
ing the first application of potassium hydrate, I
covered 127 square inches of surface; the following
day the same surface was covered with an applica-
tion of zinc chloride. The eschar that resulted from
these two applications weighed four pounds and
nine ounces, and represented about one-half of the
entire growth. The patient has not been confined
to her room a single day from the eft'ects of treat-
ment, nor has she failed to sleep nights. Xo opiates
or other remedies have been administered. As seen
to-night she is in perfect general health, and as there
are no glandular involvements or other evidences of
cancer remaining, I believe the treatment will be
permanently successful. I shall give the case daily
attention until circulation is fully established in the
new tissue. This case plainly shows that the treat-
ment leaves little evidence of the work accom-
plished. The surface treated shows no cicatricial
tissue, and the patient has perfect use of her arm,
and has not been reduced in flesh.

Case II. — Tumor in right breast, first discovered
about two and one-half years ago. Examinations
were made by three physicians at her home in the
West, all agreed as to the nature of the growth, and
pronounced it to be cancer of scirrhus type. She
arrived here on December 14, 1906. The following
day I called three local physicians, who examined
the patient, and concurred in the opinion given by
her home physicians. The case presented many
characteristics that were diagnostic, including
marked drawing of the surrounding tissues toward
the tumor, atrophy of the breast, complete retraction
of the nipple, etc. On December 16 I made an appli-
cation of potassium hydrate covering an area of fully
thirty square inches of surface ; this was followed
on the next day by an application of zinc chloride.
As seen to-night the entire breast seems to have
been destroyed. The patient has not lost a night's
rest from the eft'ects of treatment, and she shows no
signs of physical disability. Xo opiates or other
remedies have been administered. The eschar is
fast exfoliating, and there is no inflammation or
swelling in the surrounding tissues.

Case III. — This case shows involvement of the
glands in the left axillary space, and metastatic
growths along the line of incision following a pre-
vious surgical operation for cancer of the breast.
The application of potassium hydrate was made
December 19, 1906, followed by an application of
zinc chloride on the 20th. The eschar exfoliated
completely on the 25th. To-night, eight days after
the first application, we have twenty-one square
inches of open area. This case illustrates many

May 1 8, 1907]

MEDICAL RECORD.

815

points mentioned in my paper. It shows a bloodless
surface, is not sensitive to the touch of the fingers,
as all can plainly see, and the evidences of remain-
ing disease within the circumscribed area are per-
fectly visible to the eye and touch ; the edges are
flat and show marked signs of healing. This case
also shows the rapidity with which some eschars
exfoliate as compared with others with the same
treatment and under similar conditions.

Case IV. — This patient came under treatment on
October 23, 1906, afflicted with a very extensive
cancer of tlie right cheek. With its infiltrations, it
covered an area extending two and one-half inches
from the nose across the cheek, and from the upper
!ip to, and involving the lower eyelid. This growth
was examined by two of the physicians here to-
night, and the applications were made in their pres-
ence on October 24 and 25. There is evidence of
disease remaining, but it would not be recognized
by a casual observer. This will necessitate another
application, and when the disease is all removed, and
the wound healed, I believe there will be no cicatri-
cial tissue or drawing of the eyelid or lip. This
patient has an additional growth on her forehead,
which is of the same character as was the growth on
her cheek. She has given me permission to make
the first application to this growth to-night. I have
covered the growth and the infiltrated area sur-
rounding it, a space three-quarters of an inch in
diameter. The potassium hydrate was applied, and
after fifteen minutes the remaining escharotic and
dressings were removed and the growth found to
be completely destroyed. The patient declared that
no pain or inconvenience was experienced, and the
surrounding tissue showed no evidence of swelling.
Case V. — This patient came under treatment
June 19, 1906. Four of the physicians present saw
the case before I commenced treatment. The
breast was completely necrotic, the axillary glands
were involved, and the tissues surrounding the
breast were also extensively involved. To cover the
diseased area, and reach healthy tissue on all sides
of it, required an application twenty-nine inches in
circumference. The case was inoperable from a
surgical standpoint and had been treated bv the
A'-ray before coming to me. I show the case to-night
simply as evidence of what may be accomplished by
this method in very extensive cases of cancer with-
out depleting the patient's general health and pre-
serving perfect mobility of the arm following in-
vasion by escharotics of the entire axillary space.
Case VL— This patient came under treatment
November i, 1906. I introduce him to show what
can be accomplished in cancer of the lip. This was
a typical case, and had been treated at his home with
tlie .r-ray, over one hundred exposures. That treat-
ment disseminated the disease. I found the free
border of the lip extensively involved. .A.s you see
him at this time the wound is perfectly healed, the
lip is not shortened, and its contour is perfectly pre-
served.

Case VII. — I have invited this patient here to-
night to show those present the delicate character
of the work that can be accomplished with eschar-
otics and its permanency. He was treated here ten
years ago. The case was cancer of the penis ; he
had been unsuccessfully treated for several months
by his family physician and others. When I first
saw him about one-third of the organ was involved,
and the disease was infiltrating rapidly. To go wide
of the disease I found it necessary to make my appli-
cation at the root close to the pubes. I made an ap-
plication of potassium hydrate completely encircling
the organ, and followed this the next day with an

application of zinc chloride. During the time of ex-
foliation of the eschar, the patient did not experience
the slightest difficulty in urinating, nor has he since.
I have seen the patient but once, before this evening,
in ten years. There has been no treatment of any
kind since he was discharged in 1897.

Case VIII. — The history of this patient's case
may be of interest. At this time, twenty years after
treatment for sarcoma of most malignant type, we
find her in perfect general health, and but little evi-
dence to be seen that would show what had been
accomplished. The growth comjiletely covered the
right popliteal space. She was first examined by a
prominent surgeon in the eastern part of this State,
who advised an immediate operation. When I saw
the case a degenerate change had taken place ; the
greater portion of the center of the tumor had
assumed an osseous condition. Its gross appearance
resembled honeycomb and its consistency that of a
very thin egg shell. The outer edges of the tumor
had so involved the muscles as to make it most diffi-
cult to place the heel upon the floor when walking.
The same remedies I employ to-day were used in
this case, but not in saturated strengths, conse-
quently there was more pain and inconvenience at-
tending the treatment : however, she was not con-
fined to her room from its effects. The tumor was
removed and the wound healed in thirteen weeks.
There was no hemorrhage during treatment. There
is no muscular contraction and she has perfect use
of the limb.

The first patient treated for cancer of the breast
bv this method is alive and in perfect health after a
period of thirty \-ears. No subsequent treatment has
been necessary. She resides in Springfield,- Mass.,
and would have been here to-night but for a mis-
understanding as to tlie date of this meeting.

PREOPER.\TIVE R.\DL\TION AND SUR-
GICAL TRE.\TMEXT OF CANCER.*

By \ULLI.AM JAMES >:0RT0N",i.M.D.,

NEW YORK.

PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM AND OP

ELECTROTHERAPEUTICS, NEW YORK roST-GRADUATEtMEDICAL

SCHOOL AND HOSPITAL.

Based upon the conclusion that cancer is at first a
focal and consequently a local disease, surgery has
rightlv demanded the very earliest possible exter-
minat'ion of the small offending tumor. But surgery
seldom has an opportunity to operate as soon as it
would desire. The patient fails to notice the tumor
earlv or fails to appreciate its deadly significance.
Likewise, the conservative attending physician is
loath to arrive at a prompt decision. Hence, by the
time that what is apparently an early operation is
decided upon, the tissue in the immediate neighbor-
hood of the small tumor is already infected and
quite possiblv, by the wav of the lymphatic vessels
and the blood circulatorv svstem, fairly distant tissue
is also infected. Hence, if by the older practice, the
small tumor alone is now removed, there is almost
inevitablv a recurrence in the neighboring tissues
due either to the "soiling of the wound" or to actual
nonremoval of diseased areas.

This state of affairs led to the adoption of the
sweeping plans of general removal, as in carcinoma
of the breast, of the entire breast, and underlying
muscles and glandular contents of the axilla. By
this plan a far higher percentage of ultimate cures
was secured, thanks to the teachings of Heidenham

* Read at the seventh annual meeting of the American
Therapeutic Society, New York City, May 4. I9<30-

8i6

MEDICAL RECORD.

[May i8, 1907

of Berlin, Halsted of Philadelphia, and Willy Meyer
of New York. It is claimed by Redman of Phila-
delphia that out of a total of 629 individuals oper-
ated upon by American surgeons 44.16 per cent.
survived the three-year limit. Certainly, the com-
plete operation and the recognition of the importance
of early operation have very largely augmented the
number of ultimate survivals. Such was the thesis
of cancer up to the time of the appearance of the
.f-ray upon the scene.

A new problem was now presented. The :ir-ray
showed a hitherto unknown but indubitable action
upon cancer growth. It seemed at first, judging
from its efifects upon comparatively superficial
growths, that all cancer might be cured by it, espe-
ciallv if applied in an early stage, and indeed many
cases have been cured by it, for the neoplasm cell is
more vulnerable to radiation than its neighbors.

But with experience and time it was found there
were limits to the depth at which an absorption of
the curative portion of the total output of the
Crookes tube would 'take place. These limits surely
could not be a limit of penetration, for the fluoro-
scope reveals penetration through the densest bodily
tissues. It would appear rather that a given inter-
vening mass of tissue can screen out that class of
rays which destroys cancer cells. But at what depth
.t--radiation ceases to act no one can as yet say. I
have seen nodules one inch beneath the skin disap-
pear and large tumors of the abdomen become
greatly reduced in size. I maintain, therefore, that
.(■-radiation is indicated in such growths — not to the
exclusion of operative procedure, but preparatory
to it.

I contend, as I have long contended most strongly,
that radiation should precede every operation for
cancer. In epithelioma of the face, in carcinoma of
the breast, or in sarcoma of the skin, the case may
go on to a complete cure without any surgical inter-
ference. If after six weeks to two months operation
is necessary, it may then, in my opinion, be per-
formed with a greatly diminished prospect of recur-
rence, or what is equally of importance, the area of
operation may be reasonably limited.

Preoperative radiation would undoubtedly im-
prove the statistics relating to the ultimate success
of surgical intervention.

Against this plan of preoperative radiation it has
been urged :

1. That the patient "loses valuable time." Per
contra many an inoperable case of cancer of the
breast is rendered operable by reason of the great
reduction of the area of the disease, and many a so-
called operable case, by reason of the same reduc-
tion, may undergo a safer operation, so far as ulti-
mate recovery goes, or may undergo with safety
a limited operation. The wandering cancer particle,
as in carcinoma of the breast, is deprived of at least
some of its virulence by reason of the radiation. In
operable deep-seated tumor it is no doubt better to
operate at once.

2. That radiation itself produces cancer or aids
its growth. In support of this contention, examples
are cited of intense .r-ray burns in the case of several
zealous .i--ray workers, who have burned themselves
to the point of, or almost to the point of, necrosis.
Epithelioma has then developed. The authors of
this contention are to be congratulated upon having
discovered the causation of cancer; the discoven,- of
its radical cure should surely follow. Perhaps a
more rational view would be that one generally re-
ceived that a constant source of severe irritation fre-
quently offers a favorable site to the development of
cancer.

Certainly no radiotherapeutist to-day ever repeats
upon his patient the mutilations which those martyrs
of science in the early days of experimentation un-
wittingly produced in their own persons. Such in-
stances have been accidents of experimental physics,
and have never occurred as a result of skilled radi-
ation therapeutics.

3. That Roentgen toxins are produced and thus
the patient's vitality is reduced. The objection has
been raised that the breaking down of the neoplasm
sets free a toxic debris causing nausea and rise of
temperature, with general reduction of the patient's
vitality. I have never seen such a case due to the
action of the .r-ray. On the contrary, I have fre-
quently observed the entire disappearance of the
patient's cachexia and return to good general health,
due without question to the influence of radiation.

4. That metastases are established. Metastases,
sooner or later, are the inevitable accompaniment of
cancer. They may occur early, but not manifest
themselves for a long time. Radiation, for instance,
may be initiated at any time during the latent (to
our senses) period of metastasis. How unjust, there-
fore, to refer the metastatic developments, when at
last obvious, to a coincident radiation. The charge
rests upon mere conjecture and is contrary to the
views of the majority of the best authorities on .r-ray
therapeutics. As a rule, in the case of many of the
patients referred to me, undoubted, but possibly not
very obvious, metastatic conditions have been over-
looked. In self-defense the .I'-ray operator should
examine every case as to this point with great care.

5. That gangrene may develop in the wound
after operation upon a case which has been pre-
viously .r-rayed. This may be true, if the patient
has been .r-rayed prior to operation up to the point
of necrosis — a very improbable supposition. But
I have referred many cases to surgeons for opera-
tion after a preliminary course of x-ray, and I have
yet to see the first case of gangrene as a result of
radiation. Xor have I observed delay in the healing
of the wound. It would seem in many cases that the
process of cicatrization was accelerated. I quote a
case to substantiate this view, and could quote many
more.

Mrs. W. R., age 40, wife of a physician. Pri-
mary carcinoma of the breast. Tumor size of a
large walnut. Peremptorily and continuously re-
fused operation ; .r-rayed beginning September 6,
1905, 40 times in 1905. and 27 times in 1906, up to
the very day of limited operation, which she at last
consented to. Operation by Dr. J. N. West in Sep-
tember. 1906. Dr. West reports that the wound
healed promptly by first intention, that there had
been no discharge, that the stitches were removed on
the fifth day, and that he had never known a wound
to heal more kindly or more promptly. The re-
maining cicatrix is excellent.

Dr. West, who has performed probably a dozen
operations for me, after the extensive use of the
x-ray on my part, authorizes me to sav that in all
cases he has had union by primary intention and
without the slightest trouble, with the exception
of one in which failure to unite promptly was due
to other causes. He also states that these cases
heal as quickly, if not more quickly, than the aver-
age case, and that he has seen more instances of
failure to unite in cases which never had had the
.r-rav than in the above series of cases which have
had 'it.

Concerning one such case, however, which has
been often quoted to sustain the allegation that gan-
grene of the wound may result from preoperative
radiation, I will say a word. The case was one of my

May i8, 1907]

MEDICAL RECORD.

own, and the surg-eon to whom I referred it for oper-
ation is the one who cites it. The patient, a woman,
had developed in less than six months an enormous
tumor of the breast. It was of the encephaloid, or
rapid-growing, type. When she began .r-ray treat-
ment with me the case was already inoperable. A
distinguished surgeon of this city gave it as his
opinion that operation would be followed by im-
mediate and extensive recurrence. The center of
the tumor was extensively broken down into a foul
smelling and deep gangrenous mass. After four-
months of the use of the .r-ray the tumor shrunk
fully one-half in size, two large purplish foci on the
point of breaking down disappeared. I then thought
that if the remaining and still large bulk of the tumor
could be removed, including the huge gangrenous
area, the chances for continued treatment by the
x-ray would be better. The operation was decided
upon and was performed. I was present. The gan-
grenous contents of the large ulcer were squeezed
out by the necessary handling of the operator and
his assistant, and hands soiled with this material
delved into the clean tissues of the axilla and else-
where during the dissection. I should add, in all
fairness, that an attempt was made to obviate this
untoward result by covering over the gangrenous
ulcer with cotton and superficially-applied collodion.
But this flimsy barrier quickly broke loose, and was
of no avail to pen in the gangrenous fluids. It nat-
urally followed that the virulent microorganisms of
the preexisting gangrene were planted in the new
soil, and as the surgeon naivelv says in his report,
"the patient almost lost her life in consequence." To
say the least, it seems to me that a better case than
this should be cited by the operator to prove the
allegation that the gangrene was due to the prior
use of the .r-ray.

The patient's welfare certainly is not promoted
by extreme views, and it is against such views that
I would protest in this paper, while claiming at the
same time the patient's right to the advantages of
preoperative. radiation. But there prevails, fortu-
nately to a limited extent, in this country, an ultra
surgery which, as regards cancer, will listen to no
claims for the benefits of radiation, if possiblv we
may except a grudging acknowledgment of the ben-
efits of postoperative radiation. To what extent this
spirit of intolerance may go is illustrated in the fol-
lowing quotation. "In advising such treatment [.r-
ray] after operation, the patient * * * *
should not be kept ignorant of the fact that in a
number of cases the prolonged exposure to the .r-
rays had caused cancer in a previously healthy indi-
vidual."

Testimony from all over the civilized world has
demonstrated that recurrent cancer has been, in a
great number of cases, benefited by .r-radiation. If
cancer mav be about to occur, does not the same rnk-
hold good, and is not the hope of prophylaxis well
founded ?

This class of surgeons is contented to ask of radi-
ation, what cases have you cured? May not radia-
tion equally ask what cases have you cured? Can
either claim an overwhelming mass of cures? It i-
exactly this uncompromising position which I would
protest against. I claim that radiation and surgery
should not be arraigned against each other as mu-
tually opposite methods, but rather that each shouM
mutually sustain the other, that each should har-
moniously walk hand in hand to the attainment of
as successful an ultimate result of cure of cancer
as modern science, up to the p"resent moment, offcrs-
The .r-rav should be as much of an adjunct to sur-
gery as the knife — the ultimate result of safety U'

the patient is in neither case a positive one — but the
two agencies conjoined will prove to be the patient's
greatest present advantage.

Cytodiagnosis of the Cerebrospinal Fluid. — Gioac-
chino Maiella has made clinical and experimental observa-
tions as to the c>-tological changes in the cerebrospinal fluid
in cerebral abscess and meningitis produced by the injec-
tion of streptococcus. There is always in any form of acute
meningitis a regular series of cytological changes in the
fluid, beginning with polynucleosis, and going through the
regular stages of mononuclear leucocytosis and lympho-
cytosis to return to the normal later. This series of changes
is most marked in pyogenic meningitis. In cerebral abscess
as long as the abscess is confined to the white substance
there are no cytological changes, but as it approaches the
cortex and reaches the meninges the regular series of
changes begins. Lymphocytosis is the most delicate in-
dication of meningeal reaction. In chronic meningitis there
is lymphocytosis, especially in the presence of syphilis. In
neuroses, cerebral tumors, and peripheral neuritis, as well
as in cerebral focal lesions, there is no meningeal reaction
and no lymphocytosis. In tuberculous meningitis lympho-
cytes are present. In tabes and paralysis there are numer-
ous lymphocytes and some mononucleated leucocytes. —
Giornale Intenw^ionale dcllc Science Mcdichc.

Periodic Vomiting with Acetonuria in Children. —

Vincent Dickinson describes the abrupt ons'=t. the absence
of previous gastrointestinal disturbance, the absence of
anorexia, the absence of gastric pain, and the slight eleva-
tion of temperature, which, together with the character of
the vomiting, are the most important signs to be considered
in this affection which he has so carefully observed. The
vomiting is produced by regurgitation, and is generally
watery. The vomited matter is at first abundant, but
diminishes by degrees. The attacks occur several times
a day, either spontaneously or excited by movement. Dur-
ing the attack the breath has a distinct smell of acetone.
The urine is scanty, and analysis sliows a definite amount
of acetone, and also often of indican. These attacks occur
in the midst of perfect health in a child who is usually
of a nervous or arthritic diathesis. The prognosis is almost
always favorable. Different authorities advocate different
methods of treatment, the only specific one founded on a
conception of the pathology of the condition being that
of Edsall. He considers it due to an acid intoxication,
and gives a diffusible alkali, such as bicarbonate of sodium,
in large doses. — The British Journal of Children's Diseases.

The Causation of Renal Dropsy. — F. A. Eainbridge
concludes that the causation of renal dropjv is still very
obscure, but he sums up the factors concerned in its pro-
duction as follows: (i) A scanty output of urine which
has been observed by Dickinson, and the fact that in
chronic nephritis the onset of cardiac hypertrophy and in-
creased urinary flow are often accompanied by diminution
c! the dropsy. (2) The retention in the body of sodium
chloride and possibly other salts, owing to deficient ex-
cretory power on the part of the kidney; as a result of
osmotic changes, retention of salts necessitates the retention
of water as well. (^) Increased katabolism in the muscles
in consequence of a partial or complete I'lss of control over
muscular metabolism by the kidneys; this excessive katab-
olism brings about the accumulation in the muscles and
tissue-spaces of waste products. These wa<te products by
a process of osmosis attract water from the blood into the
tissue-spaces; when the amount of liuid in the tissue-spaces
cannot be carried off by the lymph channels, edema ap-
pears. As a rule, none of these factors is in itself a suffi-
cient cause of dropsy, but at least two of them are always
involved. — The Practitioner.

8i8

MEDICAL RECORD.

[May i8, 1907

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A.M., M.D., Editor.

PUBLISHERS
WM. WOOD &. CO., 51 FIFTH AVENUE.

New York, May 18, 1907.

TYPHOID BACILLI CARRIERS.

The general acceptance of tlie dogma of the water-
borne character of typhoid fever, so eloquently
preached by the late i\Ir. Ernest Hart, did much to
open the eyes of sanitarians to what must still be
regarded as one of the chief sources of typhoid in-
fection, nevertheless a too great insistence upon this
as practically the only mode of extension of the
disease has worked harm in a way, by retarding the
recognition of other sources of infection. The great
epidemics of typhoid fever, excluding those in-
stances of camp infection occurring through the
agencv of insects, are usually no doubt traceable to
contamination of the water supply, but we are be-
ginning to appreciate the fact that there are also
other sources of infection which must be recognized
and guarded against if we are finally to succeed in
exterminating this disease.

It has long been known that convalescents from
typhoid fever may harbor for a time the specific
bacilli, and that consequently the excretions from
these persons may be a source of danger, but it is
only recently that it has been discovered that the in-
testinal canal or the gall-bladder of a perfectly
healthy person, who may have had the disease at
some remote period or who has merely been in
intimate relation with typhoid patients, may afford a
more or less permanent culture place for the Eberth
bacillus. Such persons, all unconsciously to them-
selves and to others, are constantly excreting typhoid
bacilli which may find their wav into the food pre-
pared in the houses where they dwell or which may
be carried into the water supply of a community
and so initiate an epidemic the origin of which ap-
pears inexplicable. Kayser of Strassburg reported
last year an instance of this sort in the person of the
proprietress of a baker\-. She had had tvphoid fever
two years ago, but had recovered and was in
apparently perfect health. It was noticed, however,
that almost all of the employees of the bakerv suf-
fered from intestinal troubles soon after beginning
their work, and several died of typhoid fever. Sus-
picion was at last directed against her, and an ex-
amination of her fecal discharges revealed the fact
that they were loaded with typhoid bacilli. The em-
ployees took their meals in the bakerv, and these
were usually prepared by the proprietress.

At a recent meeting of the Biological Society of
Washington a similar case was reported by Dr.
George A. Soper of this city. The account which
he gave was one of a household epidemic of typhoid
fever occurring in Oyster Bay, X. Y., during the
summer of 1906. Of ti persons 6 developed posi-

tive cases of typhoid fever between August 27 and
September 3. Several suspected sources — water,
milk, vegetables and fruit, and soft clams — were
excluded by careful study and examination. Re-
peated sanitary analysis of the water supply and
failure to detect subsoil pollution by fluorescein tests
of the drainage showed the infection was not water-
borne. Typhoid fever was unusual in Oyster Bay,
and there were no cases immediately preceding or
following those under consideration. The milk and
food supply of the infected household was common
to others of the village without the occurrence of
other cases. None of the patients had been absent
for several weeks prior to the outbreak, and they
therefore must have acquired the disease at home.
The house and surroundings were in an entirely
hygienic condition. The investigator inferred the
occurrence of some unusual event prior to August
20, and found it in a change of cooks August 4.
The new cook's term of service with this family
covered a period of three weeks prior to and three
weeks subsequent to the outbreak. She refused to
give any information tending to connect her with
the cases, but an independent investigation of her
previous service disclosed a startling and significant
history of typhoid fever. Despite the fact that her
record for nearly two of the past five years is yet
unknown, 26 cases of typhoid fever, including one
death, are known to have been associated with her
service in seven families during this time. The
cases were almost, entireh' among the servants, and
the initial case frequently occurred soon after the
arrival of the cook. She did not admit to Dr. Soper
that she had herself suffered from typhoid, but to
three persons she is said to have previously testified
to a mild attack. Thd evidence indicating the cook
to be a competent cause of typhoid, she was taken
into custody by the New York City Department of
Health, March 11, 1907, and at the detention hos-
pital a bacteriological examination was made. She
was a large, healthy Irishwoman, 40 years of age.
The urine was free of typhoid bacilli, but the stools
showed great numbers nearly ever\' day for the
several weeks of observation. The blood gave a
positive W'idal reaction. Thus a healthy and vigor-
ous subject was shown to be a chronic typhoid fever
producer. It is probable that the gall-bladder har-
bored the ofifending organisms, but as the gall-blad-
der could be reached without operation this re-
mains a conjecture.

The discovery of the existence of these bacilli car-
riers raises the question of what is to be done with
them to protect the community from the infection
which they carry. It is evident that they cannot all
be segregated and kept prisoners until they consent
to the removal of the gall-bladder, which is assumed
to be the chief, though very possibly not the only,
culture place of the typhoid organism. It would
be difficult to obtain popular sanction to such inter-
ference with the liberty of apparently healthy in-
dividuals, and even if the measure were recognized
as justifiable the number of the bacilli carriers would
render it difficult of execution. An examination in
Germany of 1,700 persons who had at some more or
less remote period suffered from typhoid showed
the persistence of the specific organism in the dis-
charges of 3 per cent. If that proportion holds

May 18, 1907]

MEDICAL RECORD.

819

throughout the community, the number of infection
distributors must be very large, and it is probable
that they play no inconsiderable part in preventing
the reduction of the typhoid morbidity, despite care-
ful inspecetion of the water supply and other usual
sources of infection.

ACUTE DILATATION OF THE STOMACH.

This is a condition to which apparently little atten-
tion has been extended in this country, although
numerous references to it are to be found
in foreign literature. The condition is ijne
of considerable clinical interest and importance,
for it may be met with during normal con-
valescence from operations or from severe
illness, and may be of such acute onset as
to change the whole aspect of a given case. In
most of the cases which have been reported the
disease has progressed rapidly to a fatal termination,
but with accumulated experience it is found that life
may be saved by timely recognition and suitable
treatment. The most recent study of the subject
from the cases known in the literature has been
made by L. A. Conner {American Journal of the
Medical Sciences, March, 1907), whose analysis
includes these to the number of one hundred and
two. In a case observed by the author, the symp-
toms w'ere of remarkably short duration, and vomit-
ing was entirely absent. No immediate cause for
the dilatation could be discovered, the only other
pathological condition being an acute general mili-
ary tuberculosis. Conner thinks that the dorsal
position in which the patient was constantly kept,
and the almost complete abstention from food
favored the production of mesenteric obstruction of
the duodenum, and that this may have been a causa-
tive factor in the proiluction of the acute dilatation
of the stomach.

A study of the collected cases shows that acute
gastric dilatation is especially frequent after opera-
tions under general anesthesia. In a majority of
the cases there was an associated dilatation of the
duodenum. The most common cause of such
duodenal obstruction is apparently a constriction of
the lower end of the duodenum between the root of
the mesentery, which crosses in front of it, and the
vertebral column. This can occur only when the
mesenteric root, with the superior mesenteric artery
which runs in it, is stretched tightly across the
duodenum. Such a state of affairs is apparently
possible only when traction is exerted by the small
intestine hanging over the brim of the pelvis. The
development of mesenteric constriction is favored,
therefore, by whatever facilitates the entrance of the
small intestine into the true pelvis. Such conditions
are the dorsal position, a mesentery of suitable
length, and an empty and collapsed state of the gut.
In addition to these, we have those factors which
render the duodenum more liable to compression,
such as increased lordosis of the lumbar vertebras
and a low position of the duodenum. It is uncertain
whether the dilatation of the stomach or the mesen-
teric obstruction of the duodenum constitutes the
first step in the vicious cycle by which both condi-
tions are made worse, but there seems to be little
doubt that in some cases at least the duodenal
obstruction is primary.

The physical signs and symptoms of acute gastric
dilatation are usually so distinct that the diagnosis
should not be difficult if the possibility of such an
occurrence be kept in mind. The mortality is high,
/2 per cent., but there is evidence at hand that the
condition can be controlled and cured if the diag-
nosis is made and suitable treatment instituted
before complete collapse of the patient has occurred.
The effectiveness of such measures will depend to a
large extent on the time at which they were applied.
The first thing to do is thoroughly to empty the
stomach, and this should be repeated at regular in-
tervals. Nutrition should be maintained by rectal
feeding. As duodenal obstruction has been found
to be present in 36 per cent, of the fatal cases, it is
well to assume that it may be present in more, and
postural treatment should always be tried. This
consists in allowing the patient to rest on the ab-
domen instead of on the back. The results of oper-
ative treatment have not been satisfactory as a gen-
eral thing.

THE SUBCUTANEOUS INJECTION
SALT SOLUTION IN CHILDREN.

OF

In no department of medicine should therapeutic
simplicity be so assiduously cultivated as in pedi-
atrics. The infantile organism is particularly sus-
ceptible to infection and intoxication and the mani-
festations of both of these conditions are more sud-
den and violent, cause greater febrile disturbance
and marasmus, and are also more frequently accom-
panied by grave adynamic conditions in the child
than in the adult. The heart, although its resisting
power does not appear to be inferior, is apparently
more apt to be attacked by toxic action, whether of
exogenous or endogenous origin. This fact is
especially evident in those forms of disease which
are characterized by excessive drain of fluid from
the body, in which we have to deal not only with
the intrinsic action of the toxic substance on the
heart, but also with the difficulty of maintaining
the normal circulation of the blood under the abnor-
mal conditions present.

The free use of stimulants was formerly the com-
mon mode of combating these conditions, although
now we have come to recognize the value of dilu-
ents to restore the normal density and physiological
condition of the blood, and thus to ease the strain
on the heart muscle. The i"troduction of physio-
logical salt solution into the blood stream by direct
infusion or hypodermic injection seems the method
par e.vcellence for accomplishing this purpose.
Baginsky (Phlia Therapeiitica. January, 1907)
again calls attention to the particular value of saline
infusions in preventing damage to the heart in a
variety of conditions, and also in replacing fluid lost
through diarrheal or other diseases. He reports a
number of cases in which the method was employed
with signal success. The most effective manner of
application, according to this author, is with a large
hypodermic syringe, by means of which from 100
to 200 c.c. may be injected at a time. Even in the
case of very young infants of only a few weeks, con-
ditions of extreme prostration and marasmus were
successfully treated bv this method.

820

MEDICAL RECORD.

[May i8, 1907

The Effect of German Universitv Life ox the

Heart.
A dissertation of peculiarly Teutonic flavor ap-
pears in the Mi'tnclicncr iiicdhiiiische U'ochcnschrift
of January 8, 1907. Its author, Dr. Bingel, has made
it his task to investigate the condition of the heart
and blood-vessels of a large number of university
students, particularly with a view to determining
whether or not the conventional overindulgence in
beer and the unduly violent exercise embodied in the
student duels was followed by any immediate and
demonstrable bad results. It appears that a very
considerable proportion of the students during the
first months of the university career suiter from
mild symptoms of circulatory disorder, such as un-
comfortable sensations in the cardiac region, palpita-
tion, sensations of thoracic compression, gastric dis-
turbances, bodily fatigue, etc. The occurrence of
these symptoms the author explains by the complete
change in the manner of life that takes place when
the }'0ung man leaves his home and begins his
universitv course. As three potent factors he recog-
nizes the consumption of large quantities of alco-
holic beverages, principally beer, the unwonted phy-
sical exercise attending the customary pursuits of
fencing and horsemanship, and finally, the active
social intercourse that is so important a part of
German student life. As the result of his examina-
tions of a considerable number of students made at
varying intervals, and also in conjunction with fenc-
ing contests, he arrives at the consoling conclusion
that the conditions above mentioned, while sutificient
to give rise in some cases to a certain degree of
subjective disturbance, are not likely to have any
actuallv damaging effects on a previously healthy
heart. On the other hand, if this organ has already
been subjected to severe strain or actual injury as
the result of infectious diseases or other factors in
early life, there is a distinct danger that a condition
of cardiac insufiiciency mav arise. The question of
the eftect of violent exercise on the circulatory
system has already been made the subject of ex-
tensive study in the cases of our own college ath-
letes, with results that in general are in accord with
those of Bingel ; but it must always be remembered
that overexertion or abuse of any sort consistently
persisted in in early manhood, even if it gives rise
to no immediate lesions that can be demonstrated,
may. and undoubtedly often does, predispose to a
breakdown later in life.

The Public Control of Tuberculosis.
The committee on the prevention of tuberculosis of
the Charity Organization Society of the City of New
York, in a recent bulletin, calls attention to the wide-
spread public interest in the subject of tuberculosis
and notes how systematicallv and energetically the
work of organization is being pushed forward
throughout the whole country. At the meeting of
the National Association for the Study and Pre-
vention of Tuberculosis, held last week in \\'ash-
ington, it was reported that 15 States are now
actively working along State lines to prevent tuber-
culosis', while in 8 other States definite steps have
been taken which it is expected will lead to similar
organizations within the year. An equally en-
couraging outlook is presented in the secretary's
report of city organizations. Nine of these local
committees have been formed among cities of over
100.000 population in the past year, and definite
plans arc imder way in Toledo. St. Paul, Los Ange-
les, and Fall River, so that of the 38 cities of this
class onlv San Francisco. Kansas City, Omaha. St.

Joseph, and ilemphis remain without local organiza-
tion at the present time, and of these only Omaha
and Memphis are without plans for the early forma-
tion of such organizations. While carrying on this
work communities of lesser population have not been
neglected, definite organizations having been formed
during the }ear in 42 cities and towns, Massachu-
setts and Xew Jersey heading the list in this re-
spect, each with 10 local societies. The movement
for organization is also well advanced in 20 other
cities, and there are now 23 States and nearly 100
cities and towns in which there are active societies
or definite plans for forming such.

Dr. Knopf Misquoted.
In a report of the recent meeting of the Tuber-
culosis Association in Washington, the Philadel-
phia North American quoted Dr. Knopf of this city
as favoring the use of morphine in the last stages
of tuberculosis in order to hasten the inevitable
end. The remarks of Dr. Knopf were misinter-
preted by the reporter of the lay journal. He
advocated the use of morphine in doses sufficient to
relieve the patient's suft'erings, but that, as every
medical man knows, would prolong life instead of
shortening it. It is unfortunate that representatives
of the lay press can publish reports of medical meet-
ings without having these previously submitted to
some one competent to revise them when necessary,
and it is strange that the editors of these journals
do not see that such revision would be to their
own advantage in insuring the accuracy of the re-
ports. \Miat the accounts would thereby lose in
sensationalism they would gain in truthfulness, and
physicians would be spared the pain of misrepre-
sentation. The instance here noted is a familiarly
flagrant one. as Dr. Knopf was reported to be in
favor of shortening life when he really advocated
measures for prolonging life to its utmost limit.

?rpujs nf thr 30rrk.

The New Medical Examination Law. — Gov-
ernor Hughes of this State has signed the bill abol-
ishing the three existing State board of medical
examiners and providing for a single board of ex-
aminers to be representative of the various schools.
The new board is to be composed of nine members.
Under this act the osteopaths for the first time se-
cure recognition in this State. The bill recognizes
as "practising" osteopaths the three hundred now
exercising their calling in this State, but in future
all persons desiring to practise osteopathy must pass
an examination before the State Board of Exam-
iners.

Child Labor Bill Signed. — Governor Hughes
has signed the Page child labor bill, which provides
that no minor under sixteen years of age shall be
employed or permitted to work in any factory in this
State before 8 a.m. or after 5 p.m., or more than
eight hours in any one day. At present the per-
mitted hours are 6 a.m. to 7 p.m. The act will not
take eft'ect until January i. 1908.

Hospital Transfer Bill Vetoed. — Mayor Mc-
Clellan has vetoed the bill recently passed by the
Legislature prohibiting the transfer, under certain
conditions, of patients from the different hospitals
of 'the city to Bellevue Hospital.

Defeat of the Osteopathic Bill in Illinois. — A
bill to place an osteopath on the Illinois State Board
of Health failed of passage in the House, May 2.
Another bill introduced was designed to establish

May i8, 1907]

MEDICAL RECORD.

8ji

a standard for medical and osteopathic schools, to
license osteopaths without examination, and to con-
fer on them all the rights and privileges which
physicians in the State now have. This bill, like
many other osteopathic bills introduced in the Illi-
nois General Assemlil}- since 1S97, was killed.

A Temperance Movement. — Under the auspices
of the American Medical Society for the Study of
Alcohol and Other Narcotics it is proposed to hold
at the Atlantic City meeting of the .American ;\Ied-
ical Association a so-called temperance lunch, at
which the alcohol question is to be discussed in a
more or less informal way. The lunch will be
given at the Hotel Alarlborough-Blenheim on June
5 at one p.m., and all members of the American
Medical .Association and their families are to be
invited to be present. .\ number of prominent
physicians and ex-presidents of the American Med-
ical Association will make brief addresses. The
president of the American ]\Iedical Society for the
Stud\- of Alcohol and C)ther Narcotics 'is Dr. Henry
O. Marcy, and the secretary is Dr. T. D. Crothers.

For an International Language. — The Delega-
tion for the choice of an International Auxiliary
Language, an organization having its headquarters
in France, has issued an appeal requesting learned
societies, professional associations, chambers of
commerce, and other kindred organizations, to re-
cord their apnroval of the project of encouraging
the adoption of a universal auxiliary language, and
to name a delegate to act in the matter. The or-
ganization is prepared to send to the offices of so-
cieties a supply of circulars giving all useful details
of its organization, and to send blanks for the sig-
natures of individual University professors. The
Secretary for the United States is J. F. Twombly,
34 Green street, Brookline, Mass.

The Bicentenary of Linne. — The two hundredth
anniversary of the liirth of Linnaeus will be cele-
brated by the Universitv of Upsala and also by the
Academy of Sciences in Stockholm, beginning May
23. The name of Linnaeus is closely connected with
the Stockholm Academy. Before he was appointed
to a professorship in L'ljsala he lived in Stockholm
as a practising physician, and together with five
other men founded the Swedish Academy of Sci-
ences, of which organization he was the fii"st presi-
dent. In connection with this celebration the
Academy will issue a number of publications, among
which are important writings of Linnaeus now out
of print, and also a series of discussions of Liim;eus's
work in dift'erent branches of natural science, no-
tabl\- botanv and zoology, geology, mineralogy, and
medicine. In addition the .Academy is having a set
of Linnjeus medallions struck in gold, to be given
as special prizes for noteworthy work in the natural
sciences. The botanical seminary of the University
of Nebraska is also to celebrate the anniversary.

Vegetarian Recruits in Germany. — Some curi-
fius statistics are reported as ha\ing been gleaned in
southern Baden during the recent enrollment of re-
cruits. In the Lindau and Allgau districts out of
CxD4 young men liable to service only 20 were found
to be up to the physical standard of the military
authorities. Two hundred and seventeen were
placed on the doubtful list, and the unusual inim-
ber of 367 were put aside as wholly unfit for active
service. It is stated that the peasantry of those
districts were at one time among the most robust
in the empire, but owing, in the first place, to the
dearness of meat and the fact that milk, which once
was a staple article of food, is now carefully col-
lected for the cheese factories, their physique has

sunk to a dangerously low level. Their principal
food for years has been potatoes and skimmed milk.

Genius and Hydrocephabus — Professor von
Hanseman of the Berlin University, who has re-
cently examined the brain of Theodore Mommsen,
the historian, states that he, like Hermami von
Helmholtz the physiologist, and Adolph Menzel the
painter, was the subject of hydrocephalus. He sug-
gests that on this basis an explanation may be of-
fered of Mommsen's eccentricity. Menzel's extreme
irritability and occasional fainting fits, and the spas-
modic seizures from which Helmholtz suft'ered.

Health Statistics in New Jersey. — According
to the monthly repijrt of the New Jersey State
Bureau of Statistics, the total number of deaths in
that State during April was 3,653, an increase of
512 over the previous month and 812 more than the
monthly average for the past nine months. In
e.xplanation of this increase it is sun-o-ested by the
Bureau that the unusual weather conditions of the
month may have played a part in the high mortalitv.

Vacancies in the Naval Medical Service. — •
Owing to the lack of applicants for positions there
are now sixty-four vacancies in the naval medical
service, and Congress is to be asked to take measures
to make the positions more attractive. Surgeon
General Rixey of the Navy has undertaken to give
temporary appointments as acting assistant sur-
geons" to candidates who will pass a satisfactory
preliminary examination and come to Washington
for instruction. They will receive six months' spe-
cial training at the Naval Medical School and Hos-
pital, recently established there, or at the Mare
Island Naval Hospital. .At the end of that course
they will receive appointments as assistant surgeons,
with an annual salarv of 81,760, supplemented bv
allowances for mileage, and other inducements.

Syphilis in Monkeys. — Geheimrat D. Neisser,
who has been conducting a series of experiments on
the syphilization of monkeys in Batavia, has been
granted a further leave of absence until (Jctober.
He will then return to Breslau, where he will con-
tinue his investigations.

To Study the Tsetse-Fly Disease.— Dr. Schil-
ling, the chief of the Department of Tropical Dis-
ease in the Berlin Institut fur Infektionskrankhei-
ten, and his assistant. Dr. Jaft'e, have been sent to
Togo, where they will conduct a series of experi-
ments on imnuniization against the tsetse-fly disease.

Famine Relief in Russia. — The Czar has signed
a bill appropriating §3.000,000 for the relief of
famine sufllerers. Most of the amount is to be used
for medical assistance in the scurvy stricken prov-
inces.

Chinese Lepers in Canada. — The entire leper
colony on D'.Arcy Island, near \'ictoria, consisting
of eighteen Chinese, has been sent to Canton. China.
This comes as a result of an agreement between
the Chinese and the Dominion Government. The
Dominion held it was unfair for it to treat foreigners
for a disease contracted in a foreign country.

A Suit for Slander. — The Pacific Medical Jour-
nal states that the College of Physicians and Sur-
geons of San Francisco has entered suit for §75,000
damages against Dr. Dudley Tait, foriner President
of the Board of Medical E.xaminers. and Dr. Philip
Mills Jones, editor of the California State Journal
of Uledicinc. for slander and libel.

Filth in Cheap Lodgings. — Violations of all the
laws in the city code or State statutes on the sub-
ject of health and comfort in the lodging houses of

822

MEDICAL RECORD.

[May i8, 1907

Chicago were discovered by Inspector James T.
Sullivan, of the Sanitary IJureau, during a recent
inspection of West Side houses. Mr. SulHvan acted
under orders of Health Commissioner Evans.
Houses where eighty men slept in stifling rooms,
with no ventilation, no fire escapes, but a narrow
wooden stairway leading down from the front, walls
caked with dirt, and tioors covered with filth of
every description were some of the things found.
Commissioner Evans will endea-vor to have these
conditions corrected.

Clinic For Mothers. — It ^s believed that Chi-
cago is to be the first citv in the United States
to have a regularly established system of mothers'
clinics for the free instruction of parents in the care
of children. Plans have been jirepared for a build-
ing in which this novel scheme is to be inaugurated,
and building operations will soon begin. The plan
of establishing such a clinic is a direct outgrowth
of a kirmess held last fall by the Children's Ale-
morial Hospital. With the $25,000 raised by the
Cribside Committee, a pavilion is to be erected as a
part of the hospital's projected new equipment. In
a specially equipped room of this building the first
of the clinics will be held.

Antitoxin for Gratuitous Distribution. — The
Illinois State Board of Health has been allowed $15,-
000 annually for free distribution of antidiphtheritic
serum outside of Chicago. The appropriations of
the State Board of Health have been materially in-
creased by the Legislature, the sum of $119,200
having been appropriated for the work of the board.
This is ver\- gratifying, when the General Assembly,
in 1905, onlv ajipropriated the sum of $83,320.

New Prize Fund in Laryngology. — .\t the re-
cent meeting of the American Laryngological Asso-
ciation in W^ashington, announcement was made of
the establishment of a prize fund of five hundred
dollars by gift of the retiring President. Dr. A. W.
de Roaldes of New Orleans. Further announce-
ment as to time and conditions of the award of
the prize will be made when such details shall have
been considered bv the Council of the Association.
The fund will be known as the de Roaldes Prize
Fund.

To Combat the Plague. — The Japanese Gov-
ernment has announced its intention of accepting
President Roosevelt's proposal for the holding of an
international conference at Tokio to consider meas-
ures for stamping out the plague.

Changes in the Columbia University Faculty. —
At the last meeting of the Trustees of Columbia
University Dr. Frederick R. Bailey, .\iljunct Pro-
fessor of Histology and Embryology, was assigned
a seat in the Faculty. The resignation of Dr. George
H. Fo.x, Professor of Dermatology, was accepted.
Dr. Francis Huber was appointed Professor of Clin-
ical ^Medicine, Dr. Frederick Peterson, Professor of
Psychiatry, Dr. Andrew J. McCosh, Professor of
Clinical Surgery, and Dr. Pearce Bailey. Adjunct
Professor of Xeurology.

Medical Department for Louisiana State Uni-
versity.— According to Science, it is said that the
Louisiana State University will establish this year
a medical department in New Orleans.

Board of Surgeons for Fire Department. — Fire
Commissioner Lantry has formed the surgeons of
the Fire Department into a board resembling that
of the Police Department. The following are the
officers of the board : President. Dr. E. B. Rams-
dell ; Vice-President, Dr. Joseph E. Smith ; Secre-
tory, Dr. Herman L. Reis. Newlv appointed sur-

geons are Dr. Robert W. Hall and Dr. John J.
White.

Dr. A. Rose of this city has been elected a
corresponding member of the IMedical Society of
Athens. The honor was conferred in recognition
of his efforts in behalf of reform in medical nomen-
clature.

Dr. O. H. Pinney, class of 1903, Medical Col-
lege of Ohio, now of Madisonville. has been ap-
pointed by the Presbyterian Board of Foreign
Missions as Medical Missionary to Benito, a port
on the west c^iast of .Africa.

Dr. E. S. McKee of Cincinnati has been elected
a member of the New York Medico-Legal Society
and api)ointed one of the editors of the Neiv York
Medico-Lc'^al Journal.

Dr. William L. Richardson, Dean of the Har-
vard Medical School, has handed in his resignation,
to take effect on September i, 1907. Dr. Richard-
son has been professor of obstetrics since 1886, and
dean since 1893.

Dr. L. Blake Baldwin of Chicago has been ap-
pointed City Physician bv Mayor Busse.

International Congress of Physiologists. — The
seventh Intcrnalitjnal Congress of Physiologists will
be held this year at Heidelberg, August 13 to 16,
under the presidency of Professor A. Kossel. The
previous congresses w'ere held at Basle, in 1889;
Liege, in 1892 : Berne, in 1895 ; Cambridge, in 1898;
Turin, in 1901. and Brussels, in 1904.

Polish Men of Science and Physicians. — The
tenth congress of this organization will be held this
vear at Lemberg some time between June 16 and
July 24. There will be a scientific and medico-
livgienic exposition in connection with the congress.

Norfolk South (Mass.) District Medical So-
ciety.— .\l the annual meeting of this society, held
in Boston on May 2, the following officers were
elected for the ensuing year : President, Dr. N. S.
Hunting of Ouincy; I'ice-President, Dr. O. H.
Howe of Cohasset ; Secretary, Treasurer, and Li-
brarian, Dr. Charles S. Adams of Wollaston.

Essex North (Mass.) Medical Society. — .\t the
meeting of this society held in Lawrence on May I
officers were elected as follows : President, Dr. W.
I. Sullivan, Lawrence ; Vice-President, Dr. C. E.
Dnrant. Haverhill : Secretary and Treasurer, Dr.
M. D. Clarke, Haverhill; Corresfondinii Secretary,
Dr. R. D. Hamilton. Xewburyport.

Southeastern Michigan Homeopathic Medical
Society. — ( ifticers were elected as follows at the
meeting of this society held in Detroit on April 26:
President, Dr. E. J. Kendall ; First Vice-President,
Dr. Hale of Alemphis, ]Mich. : Second Vice-Presi-
dent. Dr. E. L. Orneman: Secretary, Dr. F. E.
Thompson ; Treasurer, Dr. James T. Murray.

Taylor County (W. Va.) Medical Association.
— At the meeting of this association held in Grafton
on April ^o officers as follows were elected : Presi-
dent, Dr.'C. A. Sinsel: Vice-President. Dr. D. C.
Peck; Secretary. Dr. T- H. Dovle; Treasurer. Dr.
A. H. Thaver. - ■ ■

Cuming County (Neb.) Medical Association. —
.At the meeting of this society recently held at West
Point officers were elected as follows : President,
Dr. W. H. Francis, Bancroft; Vice-President, Dr.
C. S. Grabin. Beemer ; Seeretary-Treasu.rer, Dr.
H. L. Wells. We.st Point.

Missouri Institute of Homeopathy. — This or-
ganization, at the meeting held in Kansas City on
April 25. elected the following as officers : Presi-

May i8, 1907]

MEDICAL RECORD.

823

dent. Dr. F. M. Martin of Maryville : Vice-Presi-
dents, Dr. Edward Andruss of Holden and Dr.
J. H. Gilkerson of Warrensburg ; Secfetary, Dr.
]\IacLay Lyon of Kansas City ; Treasurer, Dr. D. M.
Gibson of St. Louis.

Jackson County (Ark.) Medical Association. —
At the recent meeting of this organization held at
Newport, the following officers were elected : Presi-
dent, Dr. H. O. Walker: Vice-President, Dr. O. A.
Jamison ; Secretary, Dr. G. K. Stephens ; Treasurer,
Dr. C E. Jones.

Maine Medical Association. — By a vote of the
censors of this society the date of the annual meet-
ing has been changed so as not to conflict with the
meeting of the American Aledical .\ssociation. The
new dates are for Wednesday, Thursday, and Fri-
day, June 12, 13, and 14, 1907, at Lewiston.

"The Diagnostician" is the title of a new month-
Iv medical jounial which has made its appearance in
Cincinnati.

Hospital Bequests. — By the will of the late
James Henry Smith, who died suddenly in Japan a
few weeks ago, St. Luke's Hospital and the Ortho-
pedic Hospital, of both of which the testator was a
trustee, are to receive the sum of Sioo.ooo each.

The Late Dr. Otis. — The following resolu-
tion was passed at the recent meeting of the Society
of Genitourinary Surgeons:

Resolved, That in the death of our President,
Dr. William K. Otis, we have lost an honored asso-
ciate, active, talented, and devoted to the interests of
his profession. More still, we have lost a sincere
and true friend who had endeared himself to us
all and whom we shall greatly miss.

Voted, That this Resolution be sent to Dr. Otis'
familv with assurances of our sincere sympathy and
reeard.

Obituary Notes. — Dr. Marvin S. Buttles of
this citv died on May 9 after a long illness. Dr.
Buttles was born in Otis, Berkshire County, Mass.,
in 1833, and was graduated from the medical de-
partment of the University of the City of New
York in 1864. He was for some years president of
the East River Medical Association, and was also
professor of obstetrics in the medical department
of the University. From 1865 to 1872 he was sur-
geon of the 71st regiment. New York State Na-
tional Guard, and was the founder of the Olivet
Female Infirmary. He had been for many years
president of the Hotel Savoy Company, and presi-
dent of the Hamilton Fire Insurance Company.

Dr. George Nichols of Northfield, Vt., died on
April 27 of nephritis. He was born in Northfield
in 1827. and in 1831 was graduated from the \'er-
mont Medical College at Woodstock. He served
as surgeon in the 13th regiment \'ermont Volun-
teers, and in 1865 was appointed Secretary of the
State of \'ermont. He had also held numerous
other official positions. He retired from active life
about ten years ago.

Dr. WiLLi.\M H. Leon.-\rd of [Minneapolis, Minn.,
died on .April 28 at the age of eighty-five years.
He was the oldest practising physician in the cit-
and came to St. Anthony Falls in 185";. He served
in the Civil \\ay as surgeon, and was the first health
officer of the city after the union of Minneapolis
and St. .\ntliony. For twenty-five years he was a
member of the State Board of Health, and was
prominent in the establishment of the State Board
of Charities and of the State Lunacy Commission.
He was three times president of the Minnesota
State Homeopathic Institute. He was a graduate

of Yale Universit\", and of the University of the
City of New York.

Dr. John T. M.-mn of Jackson, Mich., died on
May I at the age of seventy-si.x years. He was
born in Albion, Me., and was graduated from Har-
vard University in 1857. He had practised in Mich-
igan for nearly fifty years, and had served as presi-
dent of the State ^ledical Association. He served
as a member of the Jackson Board of Health and
in other official positions.

Dr. Thom.\s M. M.^rcellus of Charlottesville,
Va., died on Alay 7 of cancer of the stomach, at
the age of fifty-si.x years. He was born in Canada,
and after spending his boyhood in Mimiesota was
graduated in medicine in the University of Michi-
gan. For seventeen years he practised in Sleepy
Eye, Minn., but about twelve years ago removed to
Charlottesville on account of failing health.

Dr. John M.-\cMill.'\n of Pictou, N. S., died on
May 2 at an advanced age. He was a native of
London, but came to Nova Scotia about fifty years
ago, and had practised in Pictou for over thirty
years.

Dr. J. N. ^Iedberry of Webster City, la., died on
May I at an advanced age. He was the oldest prac-
tising physician in that part of the State, but two
\ears ago was obliged to give up active work on
account of a paralytic stroke. He had been a resi-
dent of Webster City for thirty-two years.

Dr. S. G. MiLNER of Detroit, Alich., died on May
2 at the age of si.xty-one years. He was graduated
from the University of Michigan in 1S72. .After
practising in Grand Rapids he removed to Detroit
in 1900.

Dr. John W. Brenn.an of this city died at the
age of seventy-eight years on May 10. after a long
illness. He went to California in 1849, but later
studied medicine, and in 1862 was 'graduated from
the College of Phvsicians and Surgeons of this city.
During the Civil War he was surgeon to General H.
Berdan's regiment of sharpshooters, and was wound-
ed at Gettvsburg.

(Unrrpsiiouiipitrp.

THE TRUE "MORRIS APPENDIX."

To THE Editor of the Medical Record:

Sir:— Notwithstanding the detailed description of harm-
ful involution of the appendix, in the Medical Record for
.\pril 6, 1907, a physician recently explained to another in
my presence that "the true Morris appendix was one in
which scar tissue following inflammation entrapped nerve
filaments." .-^n extract from one of the journals also gets
the thing wrong, althou.gh the Medical Record was prob-
ably in the hands of the writer of the note. It seemed
to me that the description which I gave was clear enough
to avoid the possibility of misquotation.

If physicians are bound to call a certain type of appendix
Iiy my name, it puts me in a responsible position. The
appendix that I am trying to bring to the front is not one
in which scar tissue following inflanunation entraps nerve
filaments. The scar tissue is hyperplastic connective tis-
sue, representing a process of evolution, and resulting in
involution of the appendix. Not only docs the involution
change not follow inflammation (according to my observa-
tions), but it is an actual safeguard against infection, be-
cause it removes the structures which are involved in the
infections. The hyperplastic connective tissue irritates
nerve filaments which persist, and it sends patients to the
doctor with "intestinal dyspepsia" and a question about
the appendix, but it does not put patients in bed. The part
which this type of appendix plays in some chronic digestive
disturbances' was noted rather accidentally. In going over
some specimens of normal looking appendices which had
given chronic symptoms. I noticed under the microscope
that persisting nerve filaments were surrounded hy such
groups of new cells that a high degree of irritation must
have been present, and the subject was worked out back-
ward from this observation.

824

MEDICAL RECORD.

[May 1 8, 1907

A "scar appendix" following an irffective process is an-
other affair altogether. Such appendices often do cause
digestive disturbances, but chiefly, 1 think, because of
mucous inclusions and adhesions, rather than from irrita-
tion of entrapped nerve filaments, as in the appendix which
is undergoing harmful involution. The "scar appendix"
causes occasional digestive disturbance. The appendix
wjiich I describe causes persistent discomfort, and so-called
intestinal dyspepsia, and is probably the most common fac-
tor in obscure cases of this sort of d'-'--"''sia. Almost any
physician engaged in general practice can find from one to
ten of the appendices which I describe among the patients
at present under his care. Robert T. Morris, M.D.

616 M.\Disox Avenue, New York.

OUR LONDON LETTER.

(From Our Special Correspondent.)

GLASGOW UNIVERSITY AND INFIRMARY — SILVER FILIGREES IN
HERNIA — ABSCESS IN MUSCULAR TISSUES — SERUM FOB
APPENDIX CASES — UTERINE HEMORRHAGE — STYPTOL-MER-
CURY — HYGIENIC AND TEMPERANCE CONFERENCE.

London. April 26, 1Q07.
The Prince and Princess of Wales, who are visiting near
Glasgow, drove into that city on Tuesday to open the new
buildings of the University and fulfill some other public
engagements. The additions will be devoted to the accom-
modation of the departments of physiology, materia med-
ica, forensic medicine, natural philosophy, and public
health, and have cost f 100,000. The Prince made an
effective speech, mentioning that the money had been
found by the ever generous west of Scotland, and saying
that if in years to come further extensions should be
required he was confident they would be carried out in the
same generous spirit which had characterized the under-
taking of which the completion was that day celebrated.
The Prince and Princess had the degree of Doctor of
Laws conferred upon them, and there was great enthusiasm
as they ascended the dais in their academic robes to be
capped by the Cliancellor. Lord Kelvin. Other distin-
guished persons also received honorary degrees. Their
Royal Highnesses had previously received the freedom of
the city with all the ancient ceremonial and the enthusiasm
of all present, the Prince thus becoming a burgess and the
Princess a burgess and Guild Sister of the City and Royal
Burgh of Glasgow. Their Royal Highnesses signed the
roll, and the Prince returned thanks to the city and cor-
poration for the cordial welcome they had received, and
expressed pleasure that one of their first duties as the
youngest burgesses was to lay the foundation stone of
what would be a complete reconstruction of their Royal
Infirmary, a work which testified to the liberality of the
richer members of their community in providing the best
means of alleviating the sufferings of the sick poor.

On Wednesday the Prince and Princess again went to
Glasgow from Blythswood House, and were again received
with the utmost enthusiasm. The first ceremony that day
was the laying of the foundation stone of the reconstruc-
tion buildings of the Royal Infirmary. On both days the
weather was proverbially royal, and the lavish decorations
of the route were therefore unspoiled and the gaiety of the
proceedings throu.ghout a satisfaction to the enormous
crowds. The foundation stone of the existing Royal
Infirmary was laid in May, 1792, and the silver trowel
presented to the Prince recorded the fact. The new build-
ings will cost about half a million sterling and will provide
for 600 patients. The Prince, havin.g "truly laid" the
foundation stone, replied to an address presented in
another speech, in which he referred happily to the value
of such institutions, the necessity of keeping pace with dis-
coveries like those of Lord Lister, whose eightieth birth-
day we have lately celebrated, and of whose work at this
hospital you are so justly proud. He congratulated Glasgow
on making the reconstruction a memorial to Queen Vic-
toria, as nothing would have more appealed to her heart,
and said every year's experience impressed him with the
importance of guaranteeing to the public, through whose
liberality these institutions are maintained, a wise, sound,
and businesslike administration. He concluded by com-
mending this "splendid work to all who can afford assist-
ance toward its completion." A review at Govan and
other public engagements were duly carried out amid
the greatest enthusiasm, but as they have not the claim on
your space of the medical and university schemes, I must
pass them by.

Mr. Law'rie McGavin has introduced to the Clinical
Society a modified method of applying prepared filigrees
of silver wire for the cure of very large or recurrent
inguinal hernia in males. The success of Bartlett's method
of dealing with abdominal hernia had led him to modify

that method of implantation to meet the requirements in
inguinal hernia, the object being to establish an operation
which would justify the term a "radical cure," and do away
with the use of a truss. This object had been effected in
cases beyond the scope of ordinary operation, and no com-
plication had arisen in any instance. Pain and discomfort
had been entirely absent. Mr. Spencer said he thought the
plan an important advance in surgical technique. He was
supported by Mr. Drew. Mr. Barker thought the plan
might be valuable in bad cases, though he had no experi-
ence with filigrees.

Mr. \V. G. Spencer described a case of solitary acute
suppuration in the psoas and iliacus muscles in a healthy
boy of thirteen, who died four days after the onset without
being relieved by incision. There had been no strain. The
pus yielded a pure cultivation of Staphylococcus pyogenes
aureus. At the postmortem no other lesions were found
and no distant septic focus, such as has been discovered in
other cases. There are a number such on record, but there
seems no explanation of them, and it may be supposed to be
a distinct affection.

Mr. S}-monds had seen two cases, and attributed them
to a general infection with a local strain. One had
occurred in the pectoral muscle after a very slight injury.
Mr. Drew had seen three cases, w'hich followed impetigo in
children. Dr. W'ynter described a case which ran a typhoid
course, and was found after death to have been infective
suppurative psoasitis. Dr. Gordon Watson compared the
cases with osteomyelitis, and described two occurring dur-
ing the puerperium. Both recovered after incision of the
abscess.

Messrs. Makins and Sargent presented a tabular state-
ment of twenty-five cases of acute appendical peritonitis
treated by injections of a multivalent serum from different
strains of Bacillus coli coiiiiiiunis. The cases were all severe,
and six of them annarently such that no good could be ex-
pected. Of the twenty-five, recovery occurred in nine. In
all the others improvement followed, toxic symptoms were
relieved, localization of the infecting area was eft'ected,
and in the fatal cases death was delayed beyond the usual
period. The improvement in the patients' comfort, the
quietude and sleep that ensued, with a fall of temperature
and pulse, justified e.xtensive trials. Relief from vomiting
in many cases was also obtained. The treatment appeared
to be curative and was in no way dangerous. A successful
case of treatment by this serum of an acute infection of the
urinary tracts with Bacillus coli cotnmunis, under the care
of Dr. H. G. Turney. was attended to, also report on the
treatment of three cases of puerperal sepsis by Dr. Gordon
of IManchestcr. Dr. L. Dudgeon thought the serum of
great value if used early enough, but that it was no use in
chronic cases \vithoHt constitutional symptoms.

The use of drugs to restrain hemorrhage maintains its
interest for every practitioner, and in estimating their value
the majority will probably be influenced by their eft'ect in
menorrhagia. It is easy to say that in every case the
cause of the bleeding should be determined before attempt-
ing treatment, which should be placed on a pathological
basis. There are. however, a number of cases in which
the most experienced physicians and expert .gynecologists
are unable to arrive at a positive dia.gnosis. Some enlarge-
ment of the uterus may be present, but it often is without
producing hemorrhage. Want of tone in the uterine muscle
is only a conjecture. The most careful bimanual examina-
tion finds no sufficient cause. Surgery being excluded,
what are the remedies? The whole list of so-called
astringents has been freely administered with more or less
success in various cases. Sir A. E. Wright's researches
have brought about a change in practice by showing that
the coagulability of the blood may be increased by chloride
of calcium. In the course of some operations surgeons
have found that the blood has a watery appearance and its
coagulability was below normal. The administration of
calcium chloride is therefore being given with a view of
inducing a more normal condition, and so lessening the
tendency to hemorrhage. • Gynecologists report that the
calcium treatment is of great use in menorrha.gia. Hand-
field-Jones combines with it cotarnine phthalate with the
best results where the excessive uterine hemorrhage cannot
be shown to depend entirely on the condition of the mucous
membrane, or be to some degree due to morbid state of the
blood. If permanent good is expected, he says it must be
continued for a long time. Dr. Jervois Aarons of the Hos-
pital for Women has also used the remedy w-ith good
results in a variety of cases, and has scarcely ever found
it to fail to arrest bleeding— in climacteric cases never.
Abel has used this drug locally in inoperable cancer, and
thinks it is anal.gesic as well as astringent.

Speaking of drugs reminds me of the rehabilitation of
mercury which has been going on for some years : not that
we are likely to return to the excesses at one time prac-
tised, but that it is common enough now to hear "altera-

Alay iS, 1907]

MEDICAL RECORD.

82:

tive action" ascribed to the drug, though a few years ago
such expressions were mostly regarded as behind the age.
It is not unusual to see small doses given as "correctives
of the liver," and, again, repeated small doses or inunctions
as absorbent. A person in my room spoke of the use of
;4-grain of calomel as an excellent "hepatic," and that
elicited the remark of another that he had for many years
given in doses of 1/5 gr. for that purpose.

Professor William Carter lately stated at the Liverpool
Medical Institute that he thought mercury too much
neglected as apart from syphilis. He cited cases of peri-
tonitis, meningitis, and other diseases in which he had seen
it of value. Where organic change rendered recovery
impossible it might atlord relief. He showed specimens of
bile alone, and others to which calomel had been added,
the former very offensive, the latter not so. Both had
been kept about ten days. To a third specimen calomel had
been added after decomposition, and had deodorized it.
He remarked that its insolubility allowed the drug to reach
the duodenum unaltered, and there it came into contact
with the bile, and might render absorbable toxins harm-
less. Dr. Carter's views were indorsed by several mem-
bers, one remarking that it was difficult to overestimate
the alterative action of mercury, another commending it in
chronic valvular disease of the heart when compensation
seems about to fail, a third saying it was the best intestinal
antiseptic, but considering this effect as indirect, beiijg
caused by the increased flow of bile produced. One gentle-
man mentioned the occasional salivation set up by small
doses, especially in old patients with septic mouths. How
different this discussion seems to what some of us heard
when mercury was said to be discrowned and podophyllum
about to take its place!

A conference on the teaching of hygiene and temper-
ance in all the universities and schools of the Liritish Em-
pire was held here on Tuesday. It was attended by many
doctors, some of the Colonial premiers and ministers now
in London, and some enthusiasts about education. Among
the latter, some who think themselves experts did not do
justice to their assumption, but. on the whole, the con-
ference will be useful, for it showed us what the colonies
had done in the matter. Lord Strathcona, presiding at
the morning sitting, said that the teaching of these sub-
jects in Ontario had been productive of great good. ^Ir.
Deakin, premier of the commonwealth of Australia, said
that there, too, the importance of such teaching was not
only recognized but acted upon as a matter of administra-
tion. Sir Philip Jones, Sir William Collins, and Sir J.
Cockburn all spoke in the same sense. In the afternoon
session papers were read showing what had been done in
France and Scandinavia. Sir Victor Horsley urged the
need of reform in the Board of Education. He held there
ought to be an anthropometric survey and medical inspec-
tion of all the children, all available facts to be collected
for the benefit of the education minister. As to temper-
ance, he said "2 per cent, of the secondary schools might
be truthfully described as total abstinence schools. They
owed thanks and appreciation to those masters who had
quite quickly trained the nation in temperance Ijv their
precepts and example. It was amazing what sensele-s hab-
its were persisted in by some old established schools,
where custom froze up intellect and boys were given
alcohol. They could not conceive how this could be, but
it was simply continuing an ancient custom. The whole
system of education needed revision from a medico-
scientific point of view. After some discussion a resolution
was adopted to the effect that to meet the responsibility of
the State, it is essential that a medical department be insti-
tuted in the Board of Education.

OUR PARIS LETTER.

(From Our Special Correspondent )

THE TRE.\TMENT OF SLEEPING SICKNESS — HEM0ST.-\SIS IN
HEMOPHILIA — DIET IN DI.\BETES — NECROLOGY.

P.^Ris. .\firil 15, 1007.
At the Academic de Medecine Prof. Laveran made an
interesting report on the treatment of sleeping sickness.
He recommended the use of atoxyl as indicated by
Wolferstan Thomas of Liverpool. L'nder the action of
this drug the febrile attacks disappear, the swollen glands
diminish in size, the nervous symptoms improve, the pa-
tients increase in weight, and the trypanosomes disappear
from the body, except from the cerebrospinal fluid ; but
relapses occur if the treatment is withheld too long. For
the administration of the atoxyl the hypodermic injection
seems to be the best method, using a i to 100 solution.
For serious cases intraspinal injections are made.

At the meeting of the Societe de Chirurgie, Broca read
an interesting paper on Dr. Paul Emile Weil's work on

heinostasis in cases of hemophilia. Although hemophilia
is somewhat rare, it is not so much so but that surgeons
sometimes find themselves confronted by an uncontrollable
hemorrhage or find it necessary to perform emergency
operations on patients suffering from hemophilia.

The principal blood change in hemophilia consists in the
great slowness of coagulation, which does not take place
in less than from one to nine hours. The important fact
demonstrated by Dr. Emile Weil is that in cases of hemo-
philia the serum of man or of animals used when fresh
favors coagulation to a marked degree, so that it takes
place regularly within five or ten minutes. To check a
hemorrhage in an adult. 10 to 20 c.c. of serum from fresh
blood injected into the veins, or 20 to 30 c.c. injected sub-
cutaneously is ordinarily sufficient. Sera from the blood of
man, rabbits, horses, and cows are equally good so long as
they are fresh. Following the report of Broca, Tuffier
spoke of the well-known action of artificial serum on
coagulation. .As artificial serum consists of a solution of
sea salt in the proportion of 8 to 100, and this solution can
easily be prepared at all times, he thought that even if iti
effect was not quite so good as that of other sera, still
that its use should be advised and it should be considered
as a useful agent.

Dr. Marcel Labbe presented an interesting communica-
tion to the Societe Medicale des Hopitaux de Paris on the
comparative value of the diff'erent foods prescribed in the
dietaries for diabetics. According to >Iosse the potato
seems to be one of the best articles of diet and superior
to the other carbohydrates. It proves more acceptable even
in large amounts, it can be used instead of bread, and lends
itself to various preparations in which a large amount of
fat can be used. Oatmeal is also easily taken by diabetics,
but has several drawbacks. Patients tire of it quickly, and
it can be takeS only in small quantities, and, moreover, it
often causes diarrhea or indigestion. Dry vegetables are
extremely Sood and may be prescribed in the dietary. They
contain a large proportion of albuminous material as well
as mineral salts and so are very good articles of diet. Cakes
of rice are also pleasing to the diabetic patient, and on ac-
count of their digestibility can be used as a substitute for
bread. Milk is not to be recommended, and bread also has
always been found an unsatisfactory article of food for
diabetics' dietary.

Berthelot, the world-renowned and illustrious chemist,
has just died at the age of eighty years, thus bringing to
a close his marvelous and fruitful scientific career. The
work which he has done is well known, but for two things
he is especially famous. The first is thermochemistry,
which, entirely built up by Berthelot. permits one to see
a priori the results of chemical reactions. The second is
his research work on synthetic chemistry. He was the
creator of organic synthesis and on account of that he
deserves to be called the founder of organic chemistry.
With his extraordinary ability to work and his unusual
memory Berthelot was able to do an almost inconceivable
amount of investigation upon explosives, the formation of
alkaloids, on the persulphates, on electricity, and on the
chemical reactions caused by radium, etc. He received
many honors and distinctions ; he was President of the
School of Pharmacy. Member of the Academic de Mede-
cine, Professor of the College de France, Alember and
Life Secretary of the Institute. As Minister he fulfilled
the various and diverse duties of his position. His entire
life was a splendid lesson of work, of perseverance, and of
disinterestedness, for he made no financial profit from his
discoveries. He has been given the honor of burial in
the Pantheon.

Professor Hergott of Nancy has also died and with him
there is lost one of the great figures of the old French
School of Strassburg. He taught obstetrics and p.it
and will be remembered on account of his work on the
treatment of fractures and the invention of the plaster
splints which bear his name.

OUR LETTER FROM THE PHILIPPINES.

(From Our Special Correspion'ient)

SEGREG.ATION of lepers — ROENTGEN-R.^Y TR£.\TMENT OF LEP-
ROSY'—ME.-^SLES AMONG SOLDIERS— ARTESIAN WELLS-
CHOLERA — PERSONALS.

Manmla. P I . April i, 1907.

The work of concentrating the lepers of the Philippine
Islands at the Culion Leper Colony is bemg steadily pushed
forward bv the Bureau of Health as rapidly as the neces-
sary appropriations for this purpose become available. It
is proposed, during the early part of Aprd, to send out a
vessel to gather in the remaining cases from those Lslands
from which lepers were removed heretofore. If the plan

826

MEDICAL RECORD.

[May 1 8, 1907

followed by the Bureau of Health for freeing the islands of
leprosy results as contemplated, there should not be many
more cases of leprosy occurring in such islands in the future.
In addition to tile foregoing, it is proposed to remove all
the lepers from the islands of Samar, Leyte, and Marin-
duque. to Culioii. Willi the clearance of these islands fully
one-tliird of tlie territory of the Philippine Islands wiil
then be free of this disease.

The treatment of leprosy by the .r-ray is still being
continued at the San Lazaro hospitals in Manila. Of the
seventeen lepers who have been under treatment during
the past few months, all show signs of considerable im-
provement. In two cases it has not been possible to find
leprosy bacilli for the past two weeks in the skin scrapings
taken from places in which they had been abundant here-
tofisre. It is stated that as soon as this work is further
advanced a complete detailed report will be published.

The transport Logan, which arrived here during the
early part of March, had on board two cases of measles
among soldiers, and upon tlieir being transferred to Fort
McKinley several additional cases occurred. Owing to the
prompt measures taken by the military authorities, no fur-
ther spread of the disease took place. Measles is a disease
that is rarely encountered in the Philippines, and there is
no record of authentic cases occurring, except by direct
hnportation, so tliat, whether this disease does not flourish
in a tropical climate, or whether it has simply been due to
good fortune that measles does not gain a foothold here,
is an open question. There are several instances on record
during the past few years in which cases were imported,
but no special measures looking toward their isolation w^ere
observed ; yet the disease did not seem to spread among
the native population. The records of the San Lazaro
contagious disease hospitals, however, show that a few
cases occurring in Filipinos have been admitted.

The drilling of artesian wells in the provinces is going
on continually, and several more artesian well-drilling
outfits have been ordered from the United States. The
value of this great hygienic boon is gradually being ap-
preciated by the Filipino people themselves, and from
many towns applications are received requesting to have
wells installed. The geographical formation of some sec-
tions of the Philippines is such that they are well adapted
to this form of water supply. Experience in the past has
demonstrated that in the Philippines particularly, where
so many forms of intestinal parasites occur in such pro-
fusion, great improvement takes place in public health in
almost all places in which they are exclusively used.

The committee which was appointed by the Governor-
General for the purpose of making an investigation into,
and fixing the blame for the inoculations which were made
by Dr. R. P. Strong upon some prisoners in Bilibid prison
last November, has rendered its report. The Coroner has
also submitted his report to the Governor-General, but the
contents of neither of these documents has yet become
public property. It is generally understood, however, that
the Coroner exonerated Dr. Strong from all blame, but
that the general committee appointed by the Governor-
General did not make its report quite so favorable. It is
announced that the reports will soon be made public, and
when this is done, more detailed information will be .given.

Cholera in the Philippine Islands has practically disap-
peared, a few sporadic cases being reported from remote
districts in the provinces of Occidental Negros and Capiz.
Repeated efforts have been made to have these diagnoses
confirmed by bacteriological examination, but, owing to
the remoteness of the places in which they occur and the
lack of facilities on the ground, these efforts have so far
not met with success.

Major William E. Purviance. Surgeon, U. S. .A.rmy,
who has been on duty as visiting physician in the city of
Manila, has completed his tour of service in the Philippine
Islands, and returned to the United States 011 the 'transport
Logan, which sailed from here March 15.

Dr. J. R. McDill, the surgeon of the St. Paul's Hospital,
who has been in tlie Orient for the past seven years, left
on the steamship China for a vacation to be spent in Chi-
cago.

Appendiectomy. — Duval has operated with success
on three cases of appendicitis, using the transverse incision
which has been proposed bv Chaput. In the re.gion of
this incision the muscular fibers of the internal oblique
and the tranvcrsalis are parallel ; no muscular fascia is
cut and there is less chance of eventration. There is a
better opening from this incision than from that of Mc-
P.urney. Besides, in case of need the incision can be
easily prolon.ged to the median line. No nerve filament
01 the rectus is sacrificed and the integrity of the abdomi-
nal wall is best preserved by this method. Finally this in-
cision allows drainage in all directions. — Gazette des
Hofitaux Ciiils et MiHtaires.

^rngrpss nf i^p^iral *rtrurr.

AVw York Medical Journal, May 4, 1907.

Raynaud's Disease. — J. V. Shoemaker reports one
case, his patient Ijcing a woman of thirty-four years, seen
in the second or congestive stage of the disease, her fin-
gers being swollen, red, and cold to the sense of touch.
The author states that the aflfection may be mistaken for
diabetic or for hysterical gangrene. In diabetic gangrene
the onset is rather sudden ; there are signs of weakness
and malaria, emaciation is marked, sugar is found in the
urine, and the gangrene is rarely symmetrical. In Ray-
naud's disease, on the other hand, the onset is insidious,
general health remains good, there is no emaciation and
no sugar, while the gangrene is always symmetrical. In
hysterical gangrene, there is the history of hysterical at-
tacks, pain is constant, and gangrene is symmetrical. There
is periodic pain in Raynaud's disease and no hysterical his-
tory. In the author's case the etiology may be referred to
a long-standing diarrhea disturbing the vascular and
hematopoietic systems. The blood was pale scarlet in color
with normal coagulability, erythrocytes 3,240,000, leuco-
cytes 7.400. hemoglobin 70 per cent. The treatment of such
cases should be hygienic, dietetic, electrical, and medicinal.

Mental Responsibility and Crime. — A. Gordon sums
up his ideas on this subject in the following propositions:
(i) The legal conception of responsibility is not in accord-
ance with the principles of science, and does not satisfy
the practical exigencies of life. (2) The dogmatic prin-
ciples of law should be replaced by more real and vital,
viz., by biological principles. (3) A special psychiatric
service should be established in prisons for study of all
criminals, or else an alienist be attached to prisons, re-
formatory schools, houses of refuge. C4) The function of
the law should be not only to find criminality, but also to
correct the criminals themselves. (5) Legal instruction
should consist of study of crime as a social phenomenon,
and of criminals as individuals. (6) .A.dministration of
justice in such cases should be confided to a jurist and to
an alienist. (7) .Administration of houses of correction
should be placed in the hands of alienists and pedagogues,
because the majority of criminals bear stigmata of de-
generacy which require special attention. (8) Youthful
criminals should be isolated and placed in special institu-
tions in which proper medical and pedagogic measures will
prove to be most beneficial.

Mucous, Mucomembranous, and Membranous Colitis.
— J. P. Tuttle presents an elaborate discussion of the
various features of this malady and says that the treatment
is usually medical and along the following lines: Diet:
Meat or fish twice daily, animal broths, a limited amount
of dry toast or crusts of bread, rice, hominy, green veg-
etables, milk, butter, and salads. No sweets, potatoes,
peas, shelled beans, or alcoholic drinks are allowed. Regu-
lar catharsis, preferably by castor oil and glycerin, every
three days. Colon flushing with normal saline, sodium
bicarbonate, or weak silver nitrate solutions. Intestinal
antiseptics such as phenyl salicylate, boric acid, or zinc
sulphocarbolate. Regular hours for business, exercise, and
rest, and sometimes, if need be, change of climate. Some
of these cases, however, especially those due to latent or
remittent amebic dysentery, do not yield to this treat-
ment. When such is the case we are forced to employ
surgical measures such as Gibson's cecostomy or appendi-
costomy. The author prefers the latter.

Journal of the American Medical Association, May 11, 1907.

Recent Studies in Heredity.^E. B. Wilson gives an

account of some of the more recently developed facts in
regard to heredity and of the methods of research em-
ployed. The studies have thus far followed three principal
lines : the statistics or biometric, the experimental method
from wdiich the Mendelian principle or law of the persist-
ence of the parental dominant and recessive characters in
the germ cells of the hybrid by which the results of cross-
ing may be predicted widi appro.ximate accuracy has been
deduced, and, lastly, the method attempting to study in
detail the physical basis of heredity in the germ cells. It
is to this last method that he particularly addresses himself,
and as a preliminary he reviews the more striking facts
of Mendelian inheritance in some detail, as shown by color
inheritance in mice. In Mendelian inheritance the so-
called unit characters behave almost as if they were ma-
terial substances that can be combined in definite propor-
tions. This, he s.ays, would be intelligible if the material
bases of the characters in the germ cells were also sep-
arable and capable of combination. These are sought for
in the chromosomes, and Wilson gives the facts that point
to the connection of these bodies with the transmission

May 1 8, 1907]

MEDICAL RECORD.

82

/

of the unit characters and the general close relationship
of the Mcndehan principle to chromosome characteristics.
Thus it seems to be pretty definitely proven that a certain
chromosome in some of the insects has to do with the
inheritance of sexual characters, thus affording a detinite
basis for the assumption, amply warranted by other facts,
that the other chromosomes are concerned with the trans-
mission and development of still other characters. The
double series of chromosomes in the nucleus, their mater-
nal and parental origins, respectively, which have been
practically proven, and their behavior in synapsis also
shows the closed parallelism to the behavior of the unit
characters in Mendelian hereditv and aft'ord a rational
basis for a working hypothesis, if not quite sufficient for a
fully demonstrated theory.

Bacteriology of the Respiratory Tract. — D. J. Davis
gives his conclusions as follows: I. Influenza-like bacilli
are commonly found in the upper respiratory tract in
various infectious diseases, and especially in whooping
cough. Occasionally they occur in normal throats. 2.
\'arious organisms occur in the discharge of otitis media,
the streptococci being the most common; occasionally in-
fluenza bacilli are found. 3. The Micrococcus catayrhalis
is a common inhabitant of the respiratory mucosa in infec- -
tious conditions and is sometimes found in almost pure
culture. It does not seem to produce specific lesions. 4.
The influenza-like bacillus of whooping cough is patho-
genic for man ; its specificity is dubious. Present data
permit us to consider these bacilli as secondary invaders
wherever they are found. The possibility of a primary in-
vasion should, however, be considered. 5. Influenza-like
bacilli are readily taken up in the test tube by unwashed
leucocytes and less readily by washed leucocytes. This
spontaneous phagocytosis is not affected by varying the
concentration of the salt solution between 0.6 per cent, and
1.4 per cent. 6. Injection of these bacilli into animals
causes the production of specific agglutinins and probably
also an increase of opsonins in the serum. Because of the
occurrence of spontaneous phagocytosis and agglutination
in such sera the determination of the opsonic inde.x for
these bacilli is rendered unrelialile.

The Gradual Cure of Hysterical Paralysis. — II. T.
Pershing says that the sudden cure by suggestion or other-
wise of hysterical paralyses, however practicable and tempt-
ing in cases in which one can be sure of the diagnosis and
of his power to impress the patient, is not the one to lie
generally chosen. Failure may compromise future success,
and too prompt success may have its disadvantages in de-
priving the patient of the discipline and enlightenment
that are necessary to a permanent cure. The safer way
is more gradually to arouse and exercise the dormant
kinesthetic centers, overwhelmed by inhibitory impulses
from other centers, due to the perverted emotional condi-
tions and ideas, by first raising the emotional tone, en-
couraging the patients to believe they will recover, and if
such cheering is opposed or resented, appealing to their
amour (iropre by judicious suggestions. The physical
measures — rest, food, tonics, and sedatives — while of gre.Tt
importance, are sometimes overvalued, he thinks, but both
mental and physical treatment should be employed in these
cases in harmonious combination. While doing this, the
dormant kinesthetic centers can be acted on specifically by
sensory stimulation. Hysterical anesthesia is not absolute
and strong faradic currents, applied to the skin and mus-
cles, followed by vigorous and even rude, passive motion
of the affected limb, have a powerful tendency to restore
the lacking sensations and ideas of motion. The patient's
close attention should be directed to the anesthetic p.irt
and every slightest beginning of sensation noted. ibis
will tend to bring the cortical sensory centers again into
relation with the other centers in the cortex. .\fter
aw-akening some degree of normal sensibility and overcom-
ing inhibitory fears, the cure can be completed by exer-
cises in voluntary motion. If the paralysis is nearly total
it is as well to let the first attempts be favored by gravity,
which will assure some motion and encourage the patient to
increase it. A beginning once made, the attempts can be
gradually increased, every encouragement being given, till
at length some normal control is obtained, and the patient
is able to practice some assigned exercises in the physi-
cian's absence. The length of time taken in accomplishing
the cure may be made an advantage by using it to carry on
a reeducation in composure and self-reliance, without
which permanent recovery is impossible. Two cases of
typical hysterical paralysis are briefly described in which
this method had been employed with complete success.

Conservative Surgery of the Limbs. — J. E. Cannailay
publishes several case histories illustrating the value of
conservatism in the surgery of the arms and legs. When-
ever the circulation is fair in the limb there is a possibility

that it can be saved, and the niudern advances in the
surgery of the blood-vessels give promise of better results
in the future in what were formerly considered hopeless
cases. The age of the patient has also much to do with
the establishment of collateral circulation, and by grafting
very extensive damage to the skin can be repaired. He
objects to haste in operation, the use of the tourniquet,
and too meddlesome first-aid methods, and states his con-
clusions substantially as follows: I. The conservative
treatment of severe injuries to the limbs is essentially
modern, and primary amputations should be avoided (ex-
cept when the limb is held only by a few shreds'), and we
should wait for shock to pass and the patient regains
strength. 2. Normal salt solution should be used for irri-
gation instead of antiseptic solutions. 3. Bones should
not be permanently sutured and too much should not be
attempted in the beginning. 4. Moist gangrene calls for
radical treatment. 5. Drainage is usually necessary and
the rubber tube is to be preferred. 6. Good functional re-
sults can be obtained in spite of great apparent odds, and
a saved limb is better than a stump.

Buttermilk Feeding. — H. C. Carpenter reports twelve
cases of babies with infantile atrophy, gastroenteritis, etc.,
in whom he had generally good results from the use of the
following mixture : Buttermilk. I quart ; wheat flour, 3'/3
teaspoonfuls ; granulated sugar, 15 teaspoonfuls. The in-
greciients were carefully mixed, heated up to the boiling
point but not boiled, and then rapidly cooled and kept till
used. Full directions are given for the preparation, pre-
cautions against curdling, etc. The cases were not selected
as likely to do well, but in every case regular milk mixtures
had been tried and failed before the buttermilk was begun.
The ages ranged from one to fifteen months ; the average
gain in wei.ght during the use of buttermilk was eight
ounces a week. Carpenter remarks the advantage of cheap-
ness in the buttermilk feeding and believes it a most e.xcel-
lent food for infants suffering from intestinal indigestion,
enteritis, and marasmus. lie has observed no unpleasant
eft'ects from its use; children almost invariably take it well.
A few, when first put on the diet, vomited slightly, but,
with one exception, this ceased in a day or two. The point
he specially emphasizes is that the success is not so much
due to the' absence of fat as to the great ease with which
the proteid of buttermilk is digested. He has observed
this in almost every case Several of the infants who were
unable to digest 0.75 per cent, of calcium casein digested
perfectly the 2 or 3 per cent, of casein lactate in the but-
termilk.

Cardiac Murmurs Developing in Biliary Colic. — D.
Riesman reports two cases recently oliserved bv him of sys-
tolic murmur originating during attacks of biliary colic,
and reviews the literature of the subject.^ The cases re-
ported by Gangolphe are reproduced in brief abstract, and
other observations and the theories proposed to account
for the symptoms are referred to. Riesman thinks that
the transitory character of the murmur and the absence
of signs indicating grave infective lesion renders endocardi-
tis unlikely as a cause, while the symptom usually appears
too early in the case to be accounted for by anemia. If
jaundice were responsible it ought to be more common,
and. moreover, the murmur usually outlasts the jaundice.
The bile acids and bile salts may cause changes in the
cardiac innervation or in the myocardium, but pain, he
thinks, is the principal factor in the production of the
murmur. The excruciating pain of hepatic colic, he savs,
may cause dilatation of the heart with a temporary insuf-
ficiency of the mitral valve; perhaps also of the tricuspid.
There' must, however, be a predisposition, the heart must
be potentially dilatable. This does not account, it is true,
for the murmur in Gangolphe's cases of emotional jaun-
dice nor for that somethnes observed in catarrhal jaun-
dice and hepatic cancer. With regard to the last he holds
that anemia and cachexia constitute an adequate explana-
tion ; he can not say what the factors are in the rather
dubious emotional jaundice, which he has never seen.^ The
practical importance of the murmur in these cases is the
evidence it gives of a somewhat abnormal condition of
the cardiac muscle which enforces some caution in the
choice of the anesthetic and possibly also in the operative
technique. A too prolonged operation might be dangerous.
On the other hand, the finding of a murmur might lead to
the error of assuming that an old endocarditis existed a
belief that might readily influence a surgeon's advice. The
knowledge that such a murmur may arise dc novo in cases
of biliary colic, and that it is an index of a W'eakened myo-
cardium, a weakness that may not be serious, will be of
value in the treatment of a given case.

Torsion of the Great Omentum.— W. \\'. Richard-
son reports a case of twisted :nid acutely strangulated
great omentum, partially included in the sac of a postop-

828

MEDICAL RECORD.

[May i8, 1907

erative hernia, which was successfully operated on. He re-
views the subject generally, classifying the cases according
to their association with hernia and intraabdominal and
extraabdominal location, and also according as one or
more points of torsion exist, and describes the mechanism
and etiology. The essential condition for the occurrence
of an omental torsion is the formation of a matted mass at
its free end or the formation of an adhesion of this free
end to some oilier structure. A hernia is the most fre-
quent factor in the production of these torsions, as is
shown by the published cases, and it can not always be
excluded in those in which it is not mentioned as exist-
ing. Symptoms of strangulation only appear when the
torsion is sufficient to obstruct the return circulation, and in
most of the cases this occurs suddenly. Diagnosis is diffi-
cult; in only one published case— that of Rudolf— was it
correctly made before operation. It is impossible, there-
fore, to make positive statements regarding the prognosis,
as we do not know how many patients may have recov-
ered without operation. That unaided recoveries may oc-
cur is probable from what we know of strangulated epiplo-
cele. in wliich many such have occurred. As in other cases
of strangulation of abdominal organs, the mortality de-
pends on the stage of operative intervention. In all the
cases in which early operation was done, without exception,
recovery ensued. Several of the cases reported in the
literature are briefly reproduced and cuts are given illus-
trating the varieties of the condition. The desirability
of accurate and full reports of future cases is mentioned.
If the possibility of omental torsion is borne in mind in
every case in which the symptoms point to strangulation of
sorhe abdominal organ, there will be more correct diag-
nosis in the future.

Blocking of Auricular Extrasystoles.— A. W. Hewlett,
reports a case of arhythmia due to blocking of the extra-
systoles on their passage from the auricles to the ventricles,
a type that, so far as he is aware, has not hitherto been
described. He is inclined to explain the absence of the
ventricular contractions by a failure of impulses to cross
the aunculoventricular junction rather than to a lack of
contractility on the part of the ventricles. Every extra-
systolic first sound was followed by a second soimd indi-
cating that the ventricular contractions, when present, were
sufficient to send the blood into the aorta or pulmonary
artery. The article is illustrated bv sphygmographic
tracmgs, which are elaborately explained.

Puncture and Disinfection for Abscesses.— DeW'itt
Stetten advocates puncture and disinfection for abscess
instead of incision and drainage, in order to avoid mu-
tilating scars and slow convalescence. His method is as
follows: J. After careful disinfection, and under infiltra-
tion anesthesia, he punctures the most dependent portion
with a large trocar or pointed scalpel and gently ex-
presses the pus. This is better than aspiration. 2. The
cavity is then thoroughly irrigated through the trocar
with a i-iooo solution of corrosive sublimate. This can
be used in large quantities, as the abscess wall does not
absorb. He has_ found this strength most satisfactorv. 3.
The remnants of the corrosive sublimate solution are 'care-
fully squeezed out and the abscess is partly distended with
a solution of from 5 to 10 per cent, iodoform glvcerin. .-V
moist dressing with a firm pressure bandage is' then ap-
plied. He uses this method in every form of acute external
abscess, following the principle originally laid down by
Henle for cold abscess. To date he has treated thirtv-
seven cases with good results in all except abscesses of
caseous tuberculous glands, which generally required a
secondary curetting, though they were none the worse for
the preliminary conservative treatment.

The Lancet, Afil 27, 1907.

Suggestion for Treatment in Snake Bite. — \V. H.

Haw records two ca^cs of snake-bite, one recovering and
one proving fatal. With regard to treatment he says
that the great difficulty is to keep the venom out of the cir-
culation. If this could be effectually done until such
time as the venom might be destroyed, it would be pos-
sible to^ save some cases now lost. 'The usual method of
preventing the venom entering the circulation is the liga-
ture, and one is advised to slacken it occasionally to allow
of the poison being worked off in small nonlethal doses.
It seems to the author that if the circulation be brought
to a standstill at the seat of injection it might be possible,
if this be done early enough, to prevent any venom at all
entering. The venom would be imprisoned, as it were,
and could be dealt with by permanganate of potash and
incisions. He suggests, therefore, that in cases seen early
enough the part be frozen with ethyl chloride spray dur-
ing the making of the incisions and the rubbing in of per-

manganate of potash. Where the subcutaneous cellular tis-
sue is loose the part containing the imnrisoned poison might
be shut off from the general circulation by ligature should
needles and thread be handy. All the operations would be
painless. A tube of ethyl chloride would not be a large
addition to a snake-bite outfit.

Recent Development in the Therapeutical Applica-
tions of Arsenic. — J. Snowman ii^ies that the great
value of alteratives in therapeutics is that they often
change pathological processes brought about by disease
into (physiological processes. Their failure frequently
arises from the circumstance that they introduce into the
body their own toxic pathological processes. This is ex-
ceedingly well exemplified by arsenic, which is able to
produce a mimicry of several diseases, much to the dis-
comfiture of diagnosticians. In the nervous system w'e may
have peripheral neuritis with rapid muscular atrophy, or
definite myelitis. The intestinal canal may present appear-
ances closely resembling cholera, with granular changes
proceeding to fatty degeneration in the epithelial lining,
the interstitial tissue and Peyer's -^tches being invaded
by large round granulated cells. The liver may be affected
in such a manner as to suggest a diagnosis of acute yellow
atrophy. The skin may be the site of lesions the number
of which is almost legion. Every anatomical manifestation
known to dermatology from a slight erythema to a bulla
is represented. The most characteristic appearances, how-
ever, are pigmentation, herpes zoster, and hyperkeratosis
of the palms and soles. Hutchinson maintains that these
thickenings may develop into true epitheliomatous growths.
The sphere of action of arsenic is obviously very exten-
sive when it is allowed to act on the general healthy or-
ganism. Its danger lies in its tendency to cause fatty infil-
tration and degeneration, and its therapeutical applications
are accordingly very much hampered, though practical
medicine still indicates a considerable field for its em-
ployment. The art of employing arsenic successfully con-
sists in gainincr control of its pharmacological action and
making it subservient to therapeutic aims.

Goiter Removed Under Cocaine Anesthesia. — J. L.

Thomas presents a ' series of cases. He has operated
fifty-five times under local anesthesia (cocaine i per cent.),
including one case in which no anesthesia was used. All
these recovered. He has used a genera! anesthesia seven- '
teen times, including five Graves' cases. Of this latter
series, three died ; one from respiratory complications, one
from hyperthyroidism (both Graves'), and one from sepsis.
Another Graves' case died suddenly just as she was about
to be operated on but before any medicament had been
used. The cause of death was unknown. The author
always uses Kocher's collar whenever possible, as it gives
ample room and exposes the blood-vessels at right angles
to their courses, and leaves a scarcely perceptible scar.
The position of the patient is on an inclined plane, the
higher end being under the shoulder while the head rests
slightly extended on a cushion. Full operative details are
given by the author. Everything being ready, the neck is
marked by drawing the edge of the scalpel very lightly
round it in the position which later forms the collar in-
cision ; by this maneuver no pain is inflicted but sufficient
blood exudes to form a thin red line under which from
one to two drachms of a I per cent, solution of cocaine
are injected by means of Kocher's syringe from end to
end so as to form a continuous subcutaneous ridge. As
soon as the injection of cocaine is completed the collar in-
cision is made at once and the upper flap is first dis-
sected upwards and consists of skin, subcutaneous tissue,
platysma myoides, and the fascia covering the anterior
surface of the neck muscles. Every blood-vessel exposed is
first clamped 'oy two Kocher forceps and divided between
them so that the amount of blood lost is a mere trifle.
The lower flap is then formed. The author notes that in
certain cases it is necessary to divide the sternohyoid
and sternothyroid muscles in order to facilitate the de-
livery of the goiter ; in order to prevent atrophy of these
muscles they must be divided near their upper or lower
ends according to the exigencies arising, and by so doing
the nerve supply to the muscles will not ht interfered with.
In order that the condition of the neck should be restored
as nearly as possible to its normal appearance, one must
endeavor in the first place to restore to their normal
conditions every divided muscle by carefully reuniting the
ends, and in the next place to sew the skin together by
means of a very fine needle to avoid puncture scars, and
lastly the drainage-tube must be removed at the expiration
cf from eighteen to twenty-four hours, together with the
skin sutures. Special attention must also be given to
accurate apposition of the edges of the aperture left by
the removal of the drainage-tube, otlierwise slight pucker-
ing will take place.

May i8, 1907]

MEDICAL RECORD.

829

British Medical Journal, April 27. 1907.

Calcium Iodide in Leg Ulcers. — K. G. Peter com-
mends the use of this remedy, stating that in his ex-
perience, ulcers which have for years stubbornly resisted
all kinds of treatment, and whose owners have without
avail beet) simply saturated with potassium iodide, in a
week or two showed clean granulating surfaces, and have
in almost all cases healed up. Two or three cases, which
are healine more slowlv. though immensely improved, are
due, the author thinks, not to any deficiency in the drug,
but to the ingenuity displayed by their owners in counter-
acting its effects — to put off the evil day of their discharge
from hospital. In all cases the induration around the
ulcers greatly diminished or entirely disappeared. He also
observed in a few cases of syphilitic necrosis of the nasal
bones considerable benefit from its administration, and
great relief was obtained in headaches associated with
syphilis. The dose given in all cases was two grains in
mixture three tiines a day, and there did not appear to be
any increased advantage from augmenting the dose. Any
tnild external application seemed equally efficacious ; in
most cases he used a mild mercurial or iodoform oint-
ment.

Muscular Spasm Under Chloroform Anesthesia. — .\.

C. Stark refers to the case of a prnuipara of twenty-six
years, to whom chloroform was administered from a mask
until the corneal reflex was abolished. The moment the
fingers touched the vulva the legs were violently extended
and became so rigid that the united efforts of the assistant
and himself were insufficient to*fle.x them. The anesthetic
was pushed, and another attempt made to introduce the
finger, only to reproduce the same phenomena. It was
only on the establishment of deep anesthesia that delivery
was effected with considerable difficulty. The patient made
an uneventful recovery. The same specimen of chloro-
form had been given to other patients without any unusual
incident. The author remarks that although muscular
rigidity in the early stage of chloroform anesthesia is com-
mon enough, such reflex spasm as that described, after
the loss of the corneal reflex, seems sufficiently rare to
be worth reporting. The spasms appeared to be limited
to the legs, and he assumes the cause to be a reflex im-
pulse from the lumbar centers, these centers having failed
to reach the general level of depression of the rest of the
cord. The reasons for this failure are not easy to find.

Lesions of Spinal and Cranial Nerves Experimentally
Produced by Toxins. — D. C'rr and R. G. Rows record
their experiments on rabbits. Their method consisted in
filling a celloidin capsule with a broth culture of a certain
organism. The sciatic nerve being exposed, the sealed
capsule was placed in apposition with it, after which the
gluteal muscles were stitched in their original position and
the wound closed. As toxins are known to diffuse through
the wall of these capsules, we assumed the- would find
their way into the asceuding lymph stream of the nerve
and so to the cord, where their presence would be demon-
strated by the ensuing degeneration. The organisms they
first employed were Staf'hvlococcns pyogenes aureus. Ba-
cillus pyocyaneus. Gaertner's bacillus, and the Bacillus coli.
They present the following findings: (i) Toxins readily
travel up spinal and cranial nerves to the central nervous
system. (2) While these nerves in their extramedullary
portion possess a neuriletnma sheath and are protected
by its vital action, in their intramedullary part, having
lost their neurilemma, they immediately undergo degen-
eration. (3) The first change is a primary degeneration
of the myelin; axis cylinders and nerve cells are evidently
affected later.

Oatmeal in the Dietary of Children. — Basing his opin-
ion on the results of feeding of oatmeal to rats w'itk a
resultant thyroid overgrowth. C. Watson makes a plea
for the liberal use of oatmeal in the dietary of children
after the third year. Breakfast is the meal into which it
should most largely enter, the best form of administration
being porridge and milk, which should be followed by a
glass of milk and some bread and butter. It is not, in
the author's opinion, advisable to supplement the meal by
meat in any form, for two reasons: First, because it is not
necessary and may be harmful: and, secondly, because the
use of the meat tends to create a distaste for the more
wholesome but less appetizing meal of porridge. If a
child be given for its breakfast a little porridge, followed
by bacon, it is certain that in nine out of ten cases, the
chief element in the meal is, in the child's opinion, the
bacon. Two facts, however, must be remembered. In the
first place, a porridge diet per se is not good for children
on account of mastication not being essential for this diet.
This fault may be counteracted by including in the diet
crusted bread, rusks, \'ienna rolls, and the like, which

should be taken "dry," and not tnerely washed down with
fluid, as is often the case. The inclusion of such articles
of diet in the breakfast will ensure that due attention is
paid to the developtr.ent of the muscles of mastication,
salivary glands, and jaws, a point of very great import-
ance in the dietary of children. Secondly, clinical ex-
perience teaches us that certain children cannot properly
digest and assimilate oatmeal. This feature is, in the
author's experience most frequently observed in the off-
spring of typically gouty parents. The parents of such
cliildren tell us that they cannot take porridge because of
its "heating" properties, the objective indications of dis-
• turbed nutrition being found chiefly in a concentrated
urine and in various skin eruptions. These symptoms
are, however, much less frequently observed if the por-
ridge forms the main article of the meal and is not fol-
lowed by other highly nitrogenous food, such as bacon and
eggs, as is frequently the case. There are, however, some
children who cannot properly digest and assimilate por-
ridge, and these are better without it, but if careful
attention be paid to the details of the dietary as a whole, it
will be found that these cases are much rarer than is com-
monly supposed.

Maniacal Chorea. — J. >I. Faring follows a case his-
tory with a general- review- of the history of this particular
variety of chorea in medical literature. His patient was
a girl of seventeen years and the most important features
of the case were the following : Rheumatic pains in the
legs for a fortnight, upon which chorea supervened. A
mitral systolic murmur, audible on .-idmission, of varying
loudness, and lasting up to the ninth da.v — the day of her
death. The pulse quiet and regular, about 80 each day up
to the last three days, when it rose to no, 130, 140. The
temperature normal or subnormal until the day before
death, when it touched 103.4°. The choreic movements
were slight for about forty-eight hours, and then became
so violent that two special nurses were required to watch
her and prevent her from falling out of bed and from
striking her limbs against parts of the bed. (The idea
of treating her by placing her mattress on the floor, w-ith
pillows around, w-as considered, Jjut discarded in favor
of the bed with nurses at either side.) The psychical phe-
nomena were prominent, out of all proportion, and at first
quite overshadowed the motorial. They differed, however,
by the absence of incoherent speech and w-ild garrulity,
from the forms one is accustijmed to associate with the
acute delirium of fever or acute mania. .Another point
worth noting was the occasional, though temporary, mental
calm, which the physician's visits, once or twice a day up
to the last three days of her life, seemed to produce. .A.t
these times she w-ould cease shouting, the movements be-
came quieter, she could always understand what was said
and occasionally she made intelligent replies. Treatment
by medicines totally failed to have any eft'ect on the course
of this terrible disease, and the only help it gave was
by securing some hours of sleep, and muscular rest during
sleep. The drug w-hich seeined most useful for that pur-
pose w-as chloral. On two days 1-200 grain hyoscine hy-
drobrom. (once repeated) was successful in calming the
violence of the delirium, but it failed to have any eft'ect
the last tw-o days of her life; while morphine hypodermi-
cally w-as practically useless. The occurrence of a systolic
murmur at the mitral area, w-hich w-as considered on
admission to be probably due to rheumatic endocarditis
of some two or three weeks' duration, must now, in the
light of the autopsy, be judged to have been dynamic,
and due to simple and acute ventricular dilatation. It is
not to be explained on the grounds generally accepted —
namely, anemia and choreic cardiac excitement. The
heart was somewhat atrophic but showed no other changes.

The 'Value of an Abnormal Rise in the Average
Level of the Diaphragm as a Guide to the Volutne of
the Blood in Active Circulation. — The object of the

paper of T. S. Wilson is to brmg forward clinical evidence
in favor of the following propositions: (i) When, from
any cause, the total volume of the blood in circulation
is materially diminished, the total bulk of the intrathoracic
viscera is correspondingly diminished by the relative empti-
ness of the thoracic biood-vessels, especially those of the
lungs. This diminution in the bulk of the intrathoracic
contents shows itself by an elevation of the diaphragm,
which has to be maintained at a higher .-iverafe level than
the norinal in order to adjust the cubic content of the
thorax to the altered volume of its contained viscera. (2)
That such a rise of the diaphragm may frequently be de-
tected clinically, and, when present, is of value in diag-
nosis, and affords important indication for treatment. The
position of the diaphragm can be recognized clinically by
ascertaining the upper level of the gastric resonance in the
left nipple line, or of the upper border of the liver in the

830

MEDICAL RECORD.

[May i8, 1907

right nipple line. The author prefers the gastric method
for the following reasons: (i; There is much variation
in the upper level of the liver dullness of healthy individ-
uals, dependent upon the degree to which the lungs have
been expanded by exercise or athletics, etc. (2) The
respiratory movements of the lower edge of the lung
render exact accuracy of record as to its level impossible.
(3) The level of the dianhragm on the right side is more
apt to be interfered with by ill-defined pathological con-
ditions of the lung than is tlie case with the level of the
central tendon which underlies the heart. An elaborate
series of photographs accompanies the paper. The author
considers the high diaphragm an important danger signal
in some severe typhoid cases. It is a useful E-uide as to the
extent to which rectal feeding may be pushed. It must
also be borne in mind because in cases of suspected rup-
ture of a gastric ulcer the absence of a liver dullness
cannot, as is now well recognized, be relied on as an indi-
cation of free gas in the peritoneal cavity. In heart dis-
ease also the level of the diaphragm is a useful guide as
to the condition of the. circulation. If the weakness of the
heart muscle be the prime factor, we shall expect a high
diaphragm, unless, as in advanced age, the tissues be too
rigid to yield easily; if, on the other hand, some obstruc-
tion to the circulation, such as valvular defect, be the chief
cause of failure, there will he excess of blood in the veins
of the thorax, and a normal or a low diaphragm would
be found.

Berliner klinisehc Woehensehrift. April 22. IQC7.
Experimental Researches on Diabetes. — Zuelzer pre-
sents ihc results of his recent investigations with reference
to the experimental production of diabetes with suprarenal
gland extract. The writer has studied the manner in
which this toxic action occurs and the point at which the
invasion takes place. The effect of suprarenal extract was
first studied on the liver because this organ stands in
intimate relation to the production of sugar in the organ-
ism. In dogs which had received the suprarenal extract,
the blood from the liver showed a marked increase in
sugar. Where the pancreas had been extirpated, the in-
crease in sugar w'as considerably less. The same effect
seems to be obtained therefore with the subcutaneous injec-
tion of suprarenal gland as with extirpation of the pan-
creas. The writer thinks that under normal circumstances
the secretion from the suprarenals is neutralized by the
pancreatic secretion. It would seem therefore that by the
simultaneous injection of artificial pancreatic and supra-
renal extracts, the appearance of a glycosuria might be
prevented. In order to obtain a pancreatic preparation
free from marked toxic action, the various albuminoid
bodies must be eliminated. The experiment previously
indicated was performed in a number of rabbits and it was
found that the subcutaneous injection of pancreatic ex-
tract prevented a glycosuria in animals which had pre-
viously presented this phenomenon after the injection of
suprarenal substance.

Miinehcner medi:iiiisehe irochensehrifl. April 16, loor.

Treatment of Bone and Joint Tuberculosis by Hyper-
emia.— Deutschlander, in an extended article on this
subject, considers that the elementary principles involved
may be summarized as follows : The hyperemia must be of
short duration, not more than one-half hour daily, and
should give an appearance similar to an acute inflamma-
tion. It must not give rise to pain or to edema. After
several weeks of treatment, it is wise to omit the same
for several days before resuming. Where fistuls or ab-
scesses are present, the congestion hyperemia may be
favorably combined with that produced by the vacuum cup.
In every case treatment should be started as early in the
disease as possible and continued for a considerable period
after all active symptoms have subsided, in order to pro-
vide against recurrences. The ordinary acute abscess
should be incised early, but cold abscesses and accumula-
tions of fluid may be punctured while suction is being
applied without^ using iodoform injections. Immobiliza-
tion is not required where hyperemia is employed ; on the
contrary, moderate movements of the joints are of value
in preserving their functions. Tuberculous joints must
always be protected and favored. The writer looks upon
the Bier method as a most valuable one and the most con-
servative we possess at the present time. For it not only
produces a cure in cases of joint tuberculosis, but does
this with resulting movable joints of good function. Op-
erative interference is by no means eliminated when this
method is employed, but when necessary, these will be
found to be of a more limited extent and not of the
usual mutilating character.

Treatment of Severe Anemias with Transfusion. —
Morawitz refers to the loss in popularity which this pro-

cedure has sustained in recent years. He thinks that it is
especially indicated in those cases of anemia where there is
a deficient regenerative action of the bone marrow, which
may, however, be stimulated to proper activity. .Although
arsenic will often produce the required result, there are
cases in which no effect is obtained, and in these, Morawitz
thinks that the transfusion method is indicated. » He em-
ployed the procedure in six cases of grave anemia due to
various causes and in only one did he fail to obtain a result.
Here the patient was too far gone and subsequent autopsy
showed that the marrow was in such a condition that re-
generation of red cells was impossible. In three of the
cases the results w^ere surprising, as the patients were
steadily declining under other methods of treatment. In
all of the cases from 150 to 200 cc. of defibrinated human
blood were injected directly into one of the arm veins.
Complicating after-eft'ects failed to appear, except in one
case where tlurc was some dyspnea, but nothing more.

A Method for Determining the Mobility of the Heart.
— Herz describes an ingenious and simple method for de-
termining the mobility of this organ. Usually the apex
beat and the area of cardiac dullness arc examined with
the body in different positions. Changes in the position
of the organ may be due to adhesions of the pleura, to
emphysema; the sclerosis of the aorta and an abnormal
degree of mobility is also noted in certain cases of neu-
rasthenia. Herz proposes that, instead of making use of
changes in position, changes in attitude of the body be
employed. The patient is examined in a standing po-
sition as to the position of the ape.x beat and the left
boundary of absolute cardiac dullness. Unless the pa-
tient has been told, he is very apt to assume an attitude
of relaxation. He is then asked to stand erect ''in a
military fashion,'" and the same signs determined. It will
be found that under normal conditions the apex beat and
the left border of cardiac dullness will be moved over
towards the right, and this usually amounts to lYz cm.

Deutsche medicinischc IVochenschrift, Ai'ril 18, 1907.

Treatment of the Gouty Diathesis. — Ebstein considers
that a common basis underlies gout and adiposity and the
treatment of the two conditions is practically the same.
.As the two are so often associated both are benefited and
the plan is one which it is not difficult to enforce. Albumi-
nous material should be given in considerable amounts,
it being immaterial whether that of plant or animal origin
is employed. Fat should also be administered in suffi-
cient quantity, anywhere from 60-100 gm. daily. The in-
gestion of carbohydrates must be restricted, for these not
only influence the gouty state but also tend to the pro-
duction of adipose tissue. Thorough intestinal activity
must always be provided for. These are all the dietetic
precautions considered necessary and a strict regetarian
diet such as has been advocated in certain quarters is en-
tirely unnecessary and useless.

Inoculation of Animals with Lepra. — Jezierski refers
to the many unsuccessful attempts which have been made
to transmit this disease to animals for experimental pur-
poses. The material was obtained from a boy who was
the subject of the tubercular form of the disease. This was
introduced into the bodies of rabbits and guinea pigs in
various ways, but the results were invariably negative, no
matter what method was pursued. This is in accord with
the results obtained by most of the other investigators who
have made similar experiments.

"A Sure Cure for Asthma." — Alfred Terry Short de-
scribes the following curious remedy. The patient was a
young woman who had been afflicted with asthma since
childhood. She was a native of Luzon, P. I. Large sums
of money had been spent for treatment, but the family
finally reached the conclusion that the disease was incurable.
About this time the patient's sister went to the cemetery
and selected some pieces of bone of a skull which were
dry and 'olcached. These she washed and pulverized in a
mortar, adding the powder to a quart bottle of water. A
teaspoonful of this mixture was given to the patient three
times a day. By the time half of it had been taken, her
condition was very much improved. This solution had a
watery chalk-like appearance. Before the bottle was fin-
ished the asthma had almost entirely disappeared and the
treatment was discontinued. Since then about two and a
half years have elapsed, but there has been no recurrence.
The girl has continued in the best of health. — Journal of
the Association of Military Surgeons of the United States.

May 1 8, 1907]

MEDICAL RECORD.

S31

Maak ^tvlsvos.

A Text-book upon the Pathogenic Bacteria. For Stu-
dents of Medicine and Physicians. By Joseph McFar-
LAND, M.D., Professor of Pathology and Bacteriology in
the Medico-Chirurgical College, Philadelphia ; Patholo-
gist to the Philadelphia Hospital and to the Medico-
Chirurgical Hospital, Philadelphia; Fellow of the Col-
lege of Physicians of Philadelphia, etc. With igo Illus-
trations, a number of them in Colors. Fifth Edition.
Thoroughly Revised. Philadelphia and London: W. B.
Saunders Company, 1906.

In this fifth edition of Dr. ]McFarland"s work on the
Pathogenic Bacteria a large amount of new matter has
been added, and at the same time much that was out of
date has been eliminated. The chapters on Infection and
Immunity have been entirely rewritten, and they contain
an accurate ar.d up-to-date presentation of these most
important subjects. The volume contains a brief but
sufficient account of the technical procedures necessary for
a proper study of bacteriolo.gy. a short account of the life
history of all the important patho.genic bacteria, and a de-
scription of the pathological lesions caused by the invasion
of these bacteria. The book is nearly twice the size of the
first edition, issued ten years ago. and while the original
plan is still adhered to, the successive editions have indi-
cated the progressive march of this most progressive
science. As it now stands, the work fulfils the intention of
its author ; it contains all the essential facts of the sub-
ject : it indicates the literary sources from which the facts,
theories, methods, and sug.gestions are gleaned, and it is
■written in such a way as to retain the reader's interest.
For use in the laboratory and also in the library this
volume can be confidently recommended to the medical
student and to the practising physician.

Karl Weigert und seine Bedeutung fur die medizin-

ISCHE WiSSE.N'SCHAFT UXSERER ZeIT. Vou Dr. RuBERT

RiEDER. Berlin: Julius Springer, 1906.

This little publication is more than a mere biographical
sketch; it is not limited to a description of the life and the
works of this distinguished master of pathological anatomy,
but it shows how Weigert's numerous contributions to
medical literature were developed, and their relation to
each other and to the conceptions of pathology which were
in vogue when he began to write. The book is divided
into chapters dealing with patholo.gical histology, general
pathology and biolo.gy, bacteriology neurology, and micro-
scopical technique. In the final chapter, entitled "Weigert
as Investigator, Teacher, and Man," Rieder appears as the
champion of his teacher, who for many years was niis-
understood, ridiculed at times, and insufficiently appreciated.
Although among the ablest of men, Weigert, by a chain
of unfortunate circumstances, was kept from realizing the
height of his ambition — a call to a professorship in one of
the German universities which would be in accord witli
his attainments as scientific investi.gator. Wei.gert's pupils
include the foremost names in histology and pathology,
and the publication here noted constitutes an eloquent,
though perhaps an incomplete tribute, to one of the mas-
ters of modern medical investigation.

A Manual of Paihologv. By Guthrie McConnell,
M.D., Pathologist to the St. Louis Skin and Cancer
Hospital and to St. Luke's Hospital; Bacteriologist to
the Missouri State Board of Health ; formerly Assistant
Pathologist to the Philadelphia City Hospital. Illus-
trated. Philadelphia and London: W. B. Saunders
Company, 1906.
In the preface the author states that the object of the
volume is to enable the student to acquire the salient points
of the subject. As far as it goes, the work fulfills its pur-
pose admirably. It is well arranged, fairly well written,
and the illustrations are very good, especially those on the
various tumor formations. The classifications of the ani-
mal and vegetable parasites are well selected. The ,-hapter
on "Infection and Immunity" barely touches the salient
points, and that is all. It will take considerable more read-
ing on the student's part to understand the theories of
immunity. While the book is very good in its way there
is little real need for such a volume.

How TO Suppress a Malpractice Suit, and other Medical
Miscellanies. By Thomas Hall Shastid. A.M., M.D.,
LL.B. Marion, 111.: Marion Publishing Company. IQ06.
The author of this book wants to fight fire with fire. His
theory is that most malpractice suits are inspired by some
envious rival of the accused physician, and his remedy is
to collect all the facts possible reflecting on the character
of this rival and use them to discredit him. This is small
business. If the defendant in a malpractice suit is not
sufficiently sure of his own inte.gritv and honesty of pur-
pose, he will gain little by besmirching the character of
witnesses for the prosecution.

Biographic Clinics. 'Volume 'V. Essays Concerning the
Influence of Visual Function, Pathologic and Physiologic,
upon the Health of Patients. By George M. Gould,
M.D., Editor of American Medicine, Author of "An
Illustrated Dictionary of Medicine," "The Practitioner's
Medical Dictionary," etc., "Borderland Studies," "The
Meaning and the Method of Life," etc. Philadelphia:
P. Blakiston's Son and Company, 1907.

In this volume there are no "bio.graphic clinics," strictly
speaking, the cases reported being those of actual patients
who "had sufi"'ered many things of many physicians" be-
cause these same physicians did not recognize the fact that
the ills from which their patients sufl'ered were not organic
diseases, at least not in their origin, but were simply ocular
reflexes. Many of these histories are pathetic in the
extreme, and they teach one lesson at least, which is that
sometimes, if not always or even often, very grave dis-
turbances piay arise from eyestrain. An eye examination
is not a serious matter, surely, and it seems but fair that
patients should be given this chance after other measures,
addressed more directly to the organs apparently at fault,
have been tried without avail. W^e cannot doubt the cor-
rectness of the narrations in this interestin,g book, even if
we may be tempted to regard them as exceptional. The
titles of some of these chapters will serve to indicate the
nature of the histories recorded. One is: "A Case of
Hyperchlorhydria, Indigestion, Constipation, etc., as
Treated by One Gastrologist, Three General Physicians,
One 'Mechano-Neuralist.' One Hospital, One Professor of
Medicine, and One Refractionist." Another is: "A Case
of "Neurasthenia' as Treated by Two General Physicians,
One Homeopath, One Quack, One Osteopath, One Preg-
nancy, Three Ophthalmic Surgeons, Two Gynecologists,
One Diagnostician, One Neurologist, One Resident Sani-
tarium Physician, and One Refractionist." Still another
is : "One Patient's Experience with Two General Physi-
cians, One Neurologist. One Leading Physician, One Gas-
trologist, Two Ophthalmic Surgeons, One Diagnostician,
and One Refractionist." "A Life and Career Blighted by
Ignored Eyestrain," "Thirty-five Years of Treatment by
Seventeen Physicians for Strabismus, Tinnitus, Headache,
Indigestion, Eyestrain, etc," are two other titles. There
are twenty-two essays and case histories in the book, all
of which are worth reading and digesting. Whether the
reader will be converted against his will to the eyestrain
theory- is doubtful, but he will he interested at all events,
as everyone must be by anything this gifted and polemic
writer publishes.

Medical Di.^gnosis. A Manual for Students and Practi-
tioners. By Charles Lyman Greene, M.D., Professor
of the Theory and Practice of Medicine in the L'niver-
sity of Minnesota; Attending Physician, St. Luke's Hos-
pital, the City Hospital, and the St. Paul Free Dispen-
sary; Member of the Association of American Physi-
cians, the .American Medical Association, .American
-Association for the .Advancement of Science; .Author of
"The Examination for Life Insurance and Its Associated
Clinical Methods." Philadelphia: P. Blakiston's Son
and Company, 1907.
This work on diagnosis differs from others of the kind in
several particulars. The book itself is of a very handy
size, much smaller than most medical books, light in
weight, bound in flexible morocco, and with gilt edges.
The paper is thin and tough, so that the nearly seven hun-
dred pages make a book no thicker than one of three
hundred pages of ordinary paper. The type is small but
distinct, and the illustrations, which are also small but
numerous, are for the most part excellent in design and
execution ; there are seven colored plates, and some of
the pictures in the text are also colored.

The work itself is of the most practical character, the
language is clear and concise, there is nothin.g superfluous
in the description of the symptoms and the diagnostic
methods, and of the latter only those are referred to
which have been found of value and are retained in daily
use. The arrangement of the text with running page
heads and marginal notes facilitates ready reference to a
reinarkable degree, and this is aided further by an analyti-
cal table of contents and a very complex index. .After intro-
ductory sections on the outward signs of disease, the diag-
nostic significance of age, sex, social status, etc., and the
aid to diagnosis afforded by the previous history, the
diseases of special organs and parts of the body are con-
sidered; then follow the symptoms of diseases associated
with changes in the blood and ductless glands, infectious
diseases, intoxications, parasitic diseases, the group of rheu-
matic affections including gout, the nervous system, and
the symptoms and treatment of acute poisoris ; an excelleiit
summary of malingering and the means of detecting it is
also included. The chapter on the physical diagnosis of
valvular affections is particularly worthy of cnmmendation.

832

MEDICAL RECORD.

[May 18, 1907

^nrt^ty Sptiorts.

NATIONAL ASSOCIATION' FOR THE STUDY AND
PREVENTION OF TUBERCULOSIS.

Third Annual Meeting, Held at Washington, D. C, May
6, - and 8, 1907.

(Special Report to the Medical Record.)

{Continued from Page 799.)

section on tuberculosis in children.

Dr. Thom.\s Morgan Rotch of Boston, Chairman.

Address of the Chairman. — Dr. Thomas Morgan Rotch
of Boston made this address, choosing as the subject
of his remarks, "The Living Pathology of Tuberculosis
of the Bones in Early Life." He said that in order
to diagnosticate tuberculous conditions as such, and
to enable them to differentiate tuberculous from non-
tuberculous conditions, it was of the utmost importance
that they should recognize the normal living anatomy
of the bones at different periods of development, as
portrayed by the Rontgen ray. This was especially
necessary in the early stages of tuberculous disease
where the pathological changes were often slight and
obscure, and yet where an early diagnosis was ex-
tremely valuable; not only often enabling them to ar-
rest the disease by treatment, but to determine whether
the condition was merely a slight anomaly of healthy
bone, or some nontuberculous affection. In both these
latter conditions they could often decide that the case
was not tuberculous and, therefore, not fit to be sent
to tuberculosis hospitals or homes for two reasons.
First, because they had none too much accommodation
for tuberculous cases who had the prior right to be
looked after; and second, because they should not ig-
norantly expose a nontuberculous patient to tuberculous
infection. It was also important that the treatment
in tuberculosis should be begun very early, so as to
protect the ear and other organs from resulting in-
fection. There was no diagnostic means so valuable
for the detection of tuberculosis of the bones as the
Rontgen ray in the hands of an expert in its technique.
Over and over again it became a most important factor
in the chain of evidence which might lead, unless re-
futed by the ray, to stamping an individual as syphilitic,
and thus perhaps ruining his social life. He said that
one should witness the possible dift'erentiation of the
tuberculous bone process from the periosteal lesion of
syphilis, and the special lesions represented by dacty-
litis. Again the importance of differentiating by the
ray a nontuberculous from a tuberculous arthritis, and
a tuberculous hip from an osteomyelitis, or an acute
eczema. The moral to be drawn from what h«d been
said was that in the past, and very often in the present,
many groups of conical symptoms were taken for
granted from the very first to be tuberculous in origin
when they were by no means reallj- so. The Rontgen
ray made it evident that tuberculous conditions should
be treated for tuberculosis, and that nontuberculous
conditions should not be so treated, but treated ac-
cording to what was indicated by their special infecting
organisms. Dr. Rotch then cited cases, illustrating
them with Rontgen ray pictures, showing not only the
importance in diagnosis, but made the treatment con-
spicuously obvious.

Recent Advances in the Knowledge of Tuberculosis
of Early Life. — Dr. Charles Hunter Dunn of Boston
read this paper. He said that important conclusions,
based on the immense number of autopsies, had been
drawn as to the frequency of tuberculosis in early life,
and the most striking fact brought out in the autopsy
statistics was that the frequency of occurrence of
tuberculosis increased regularlv with the age. It was

rare in the first three months of life, and increased
steadily throughout childhood, not only from year to
year, but also, in the first two years, from month to
month. This fact was of great importance in connec-
tion with the question of source and mode of infection.
The same statistics showed that tuberculosis as the
cause of death in those cases in which it was found at
autopsy decreased with advancing age. Tuberculosis
in infancy and childhood was essentially a disease of
the lymphatics. Tuberculous adenitis represented the
chronic tuberculosis of childhood, as phthisis represented
the chronic tuberculosis of the adult. They knew that in
children the bacilli did not usually cause demonstrable
primary lesions of the skin or mucous membranes, but
localized themselves in the lymph nodes. Here they
set up a chronic process which authorities agreed to
be a reaction of defense, directed toward the prevention
of a further extension of the virus. In proportion to
the completeness of this protective reaction, the bacilli
were either prevented from multiplj-ing, and thus might
retnain indefinitely latent, or they multiplied, though
prevented from spreading. In the former case, there
were no clinical manifestations; in the latter, there was
faulty nutrition, loss of weight, and occasionally fever.
A metastasis of chronic tuberculosis was not the usual
method in which further spreading took place. The
usual method was the acute tuberculosis of early life.
It was now generally recognized that the only source
of tuberculous infection was the tuberculous man or ani-
mal. There were four theories that had been held as
the source of the infection: First, the congenital the-
ory, that tuberculosis was always intrauterine in origin,
due to placental infection; second, that infection took
place from the inhalation of dried tuberculous sputum;
third, that the source of infection was the fine moist
drops expelled in coughing; fourth, that the source of
infection was the milk of tuberculous animals. It was
now known that the bovine type could produce tuber-
culosis in man. In Japan, where there were no cattle,
and where milk was never used as an infant food,
tuberculosis was just as common, in just the same
forms, as in milk-drinking countries. The whole
history of tuberculosis in early life was against the
idea of any one exclusive source of infection. The chie£
factor in tuberculous infection was the surroundings of
the infant. It was probable that in infancy the com-
monest portals of entry were (he lungs, the tonsils
and nasopharynx, and the intestine. Corresponding to
these three portals of entry, they found primary in-
volvement of the bronchial, cervical, and mesenteric
lymph nodes. Dr. Dunn then called attention to some
theoretical considerations, and especially those recently
advanced by Dr. Theobald Smith. As to the diagnosis
of tuberculosis in early life, much work had been done
with a view to determining the exact diagnostic value
of the tuberculin reaction, and Schick believed that a
local reaction was less apt to fail than the general con-
stitutional reaction, and he concluded that no known
case where tuberculosis had been excluded with cer-
tainty had given a local reaction, and that this reaction
was often the only positive sign. As to serum diagno-
sis, final conclusions as to its value could not yet be
drawn. D'Espine believed that he had found a reli-
able method of diagnosticating enlargement of the bron-
chial lymph nodes, by auscultating the voice. The most
important diagnostic method, however, which they now
had at their disposal was due to the recent perfection
of radioscopic diagnosis. He said that there had been
much discussion recently as to the possibility of re-
covery from tuberculous meningitis. In the literature
of the last twelve years he found only three cases of
recovery in which the diagnosis was satisfactorily es-
tablished. The central problem had been the con-
ferring of artificial immunity; this was so complicated

;May 1 8, 1907]

MEDICAL RECORD.

S33

tliat, as far as human beings were concerned, but little
positive and practical value had been accomplished.
The human being was undoubtedly in a fairly good
state of general resistance toward tuberculosis, and
there was much hope that a method would be devised
by which, by the creation of local foci under the con-
trol of the observer, general immunity might be at-
tained.

The Present Status of the Transmissibility of Bovine
Tuberculosis, as Illustrated by Infants and Young
Children. — Dr. Henry Larxed Kieth Sh.\w ci Albany
presented this communication. He said that Koch in
1901 called the attention of the medical profession to
the question of the intercommunicabilitj' of bovine and
human tuberculosis. Koch was the first to authorita-
tively state that tuberculous cattle were not the source
of infection to human beings. Behring took the oppo-
site view and claimed that all tuberculosis was of bo-
vine origin. No attempt was made in Dr. Shaw-'s paper
to review or analyze the vast amount of literature that
was accumulating on this subject. Ravenel, in this
country, Kossel in Germany, and the Royal Commis-
sion in England, had all produced bovine tuber-
culosis from the human bacillus. It was experimentally
shown that the human bacillus was not very virulent to
cattle; on the other hand, the bovine bacillus was very
virulent to cows and swine. The question of greatest
concern was whether the bovine bacillus was transmis-
sible to man. and, if 30, to what extent. This was a
question that could not be demonstrated experimen-
tally, but must be judged from inferences. Do bovine
bacilli occur in milk and, if so, are they pathogenic
for children? It was generally believed that the udders
must be affected before bacilli were found in the milk.
It was difficult to state the exact frequency of tuber-
culosis in cattle. The statistics showed that tuberculo-
sis in cattle in the United States was far from an
uncommon occurrence. If bovine tuberculosis was
transmissible to children, it must be through the milk,
and if all milk containing tubercle bacilli was capable
of producing tuberculosis, very few would escape. In
view of the very confusing literature, and wishing to
establish a scientific clinical justification for the trans-
mission theory, Dr. Shaw addressed a circular letter
with questions bearing on this point to the members
of the .American Pediatric Society, to teachers of pedi-
atrics not members of the society, and to several promi-
nent pathologists who had contributed to this subject.
Seventy-nine letters were sent out, and 67 answers re-
ceived. The first question was: "Do you believe that
bovine tuberculosis is transmissible to man?" Five
replied in the negative, 25 would express no opinion,
the remaining 37 answering "Yes," but 10 of these
qualified their answers. The second question was:
"Have you in your personal experience seen cases
which you believed to be such?" There were only
9 affirmative answers to this question. The remaining
twelve questions pertained to the clinical, pathological,
and bacteriological points. Dr. Shaw gave a personal
experience to show the importance of making a thor-
ough examination of all the factors entering in the
study of a clinical case. There could be little doubt
in the mind of an unbiased observer after a careful
study of the literature that infection took place both
through the air and the food. Statistics from all
sources showed that tuberculosis was relatively rare in
the first six months of life, and that the greatest num-
ber of cases occurred between the second and sixth
year. If tuberculous milk was such a great source of
danger, the greater number of cases would appear be-
fore the second year.

Dr. Theobald Smith of Boston, Dr. Mazyck P. Rav-
enel of Philadelphia, Dr. Alfred IMeyer of Xew York,
and Dr. Hess of New York discussed these papers, and
Dr. Dunn and Dr. Shaw closed the discussion.

Are Tuberculous Infants and Children in the First
Five Years of Life Liable to be Sources of Infection? —

Dr. Samuel S. Ada.ms of Washington read this paper.
He said that the answer to this question must of neces-
sity involve theoretical reasoning rather than practical
deductions, because data bearing directly upon this phase
of the problem of tuberculosis were not to be found. As
to the frequency of tuberculosis in young children, the
statistics of the numerous clinicians precluded the possi-
bility of reaching a definite percentage. In the Children's
Hospital of the District of Columbia during the past
twelve years, 2.2 per cent, of all patients admitted to the
baby ward were tuberculous ; the percentage of deaths
from tuberculosis being 5.4 per cent, of the mortality of all
causes. Of the pulmonary type, 0.88 per cent, were admit-
ted, of which so per cent, died; of general tuberculosis,
0.66 per cent, were admitted and 83 per cent, died, and of
the tuberculous meningitis 0.66 per cent, were admitted,
and all died. The statistics of this institution, excluding
infants under eighteen months, would show the frequency
of tuberculosis approximating the percentage of cases ex-
amined by Mviller of Munich, in which 40 per cent, were
tuberculous. On the other hand, the records of the
Washington Hospital for Foundlings gave a percentage
less than that of either the New York Infant Asylum
(8 per cent.) or the New York Babies' Hospital (14 per
cent.). The large number of cases in the first named
Washington institution was due to the admission of
negroes, in whom it was the exception not to find tubercu-
losis at necrop'sy. whatever the immediate cause of death.
Its frequency in the Washington Hospitals for Foundlings,
when compared with similar institutions in other cities,
might be attributed to racial and social influences. Suffi-
cient evidence was at hand to establish the fact that infants
and young children were more frequently affected by
tuberculosis than was generally supposed, and that the
organs involved in the greatest number were the lungs,
as in the adults, but this did not prove that they were the
sources of infection. It was generally conceded that the
respiratory and gastrointestinal tracts were the avenues
of entrance for the infection ; but it was also admitted
that as long as the tubercle bacillus remained with the host
it was not dangerous to others. If they admitted that in
90 per cent, of tuberculous children under five years dying
of the disease the respiratory tract was the portal of entry,
and the lungs, pleura, and bronchial lymph nodes were
the seat of disease, could they assert that such subjects
did infect others? No one would deny that the youth or
adult with pulmonary tuberculosis might infect others by
his sputum, which contained the tubercle bacilli ; but did
the young child do this? In many cases of pulmonary
tuberculosis, even in the worst forms, cough was absent
and there was no expectoration. That being the general
rule, how might such a child become the source of infec-
tion ? It was true that the young child did not expec-
torate; but it was equally true that the exudate passed
from the lung to the pharynx and was swallowed. Under
such conditions tubercle bacilli might be found in the
saliva, the vomited matter, and in the stools. If in the
saliva, the opportunity for dissemination was offered.
Tuberculosis of the mesenteric lymph nodes, the intestines,
and peritoneum was next in frequency. So long as the
tuberculous process was confined to the peritoneal cavity,
there would seem to be little likelihood of the child being
a source of infection other than autn. In tuberculosis of
the intestines, especially with ulcerations, tubercle bacilli
were found in the stools. If, tlien. the stool-; of the child
having pulmonary, mesenteric, peritoneal, or intestinal
tuberfulosis did contain tubercle bacilli, they were a;
liable to spread this disease as were the stools of a
patient with typhoid. Dr. .Adam? closed his paper by
saying that we might assume that the young child
affected with tuberculosis of the upper air passages, the
lungs, or the intestinal tract, from which the tubercle
bacillus had egress through the mouth, nose, or anus, was

834

MEDICAL RECORD.

[May i8, 1907

a source of infection, and, reasoning from analogj', should
be subjected to the same restrictions appHcable to the
adult similarly affected. In those cases, however, in which
the tubercle spent its force in the cranial or peritoneal
cavities, and in which there was apparently no direct exit
for the microorganism, more or less uncertainty con-
fronted them.

A Committee on Bovine Tuberculosis. — Dr. Hexry
Larned Keith Sh.wv of Albany said that in view of the
practical bearing of this subject from a sanitary, hygienic,
and dietetic point of view, and the evident confusion and
lack of positive knowledge, he earnestly urged that this
Section take up a further and systematic study of bovine
tuberculosis and its transmission through milk. A com-
mittee, to consist of a pathologist, bacteriologist, veteri-
narian, and two medical men (clinicians), could be formed
to make a report at each meeting of the work being done
in different countries, and to urge and see that a differen-
tial diagnobacteriological examination be made of all sus-
pected cases. Therefore he offered the following motion :

"That the Chairman of the Section of Tuberculosis in
Children, National .Association for the Study and Preven-
tion of Tuberculosis, appoint a committee to study this
question of the transmissibility of bovine tuberculosis, such
committee to report at each meeting of the Society." This
was duly seconded and carried.

(To be continued.)

ASSOCIATION OF AMERICAN PHYSICIANS.

Tiventy-second Annual Meeting, Held in JP'ashington, D. C,
May 7, 8, and 9, 1907, in Conjunction with the Con-
gress of American Physicians and Surgeons.

Francis P. Kinnicutt, jNI.D., New York, President, in

THE Chair.

(Special Report to the .\Iedic.\l Record.)

(Continued from page 793.)
Wednesday, May 8 — Second Day.

Experimental Fibrinous Pleurisy.— Dr. Eugene L. Opie
of New York read this paper, giving the results of his ex-
periments on dogs. Serofibrinous pleurisy was produced by
a sterile inflammatory irritant, such as turpentine, injected
into the pleural cavity of the dog. -Accumulation of fluid
reached a maximum at the end of three days, and fluid had
completely disappeared at the end of six days. Resolution
of fibrin began (first stage) while fluid was present, and
was completed (second stage) after the disappearance of
the fluid. In the first stage the fibrin of the exudate
digested itself in the presence of weak alkali, but in the
second stage it had completely lost this power, and digested
itself only in the presence of weak acid. It was possible
that carbon dioxide in the body, acting as an acid, produced
resolution of the exudate by the enzyme. By aspiration of
fluid and by other means the characters of the exudate
might be modified.

On Certain Acoustic Limitations of the Stethoscope
and their Clinical Significance. — Dr. Lewis .\. Connor
of New York City gave, in this communication, a sum-
mary of his findings in a series of heart and lung cases
subjected to auscultation by means of the ear and of the
stethoscope. Certain types of sounds in both lungs and
heart could be more clearly heard with the naked ear than
through the stethoscope. He cited three cases of aortic
insufficiency in which a murmur was distinctly heard with
the naked ear, yet neither he nor anyone else could hear it
through the stethoscope. He had found again and again in
lung cases that no bronchial breathing could be heard with
the stethoscope, whereas with the ear a high-pitched, blow-
ing sound could be heard twenty-four hours before audible
with the stethoscope. He discussed the theoretic e.xplana-
tion of this peculiarity and its practical bearing, and em-

phasized the importance of medical students being taught to
use the naked ear for purposes of auscultation.

Dr. SoLo.MON SoLis-CoHEN of Philadelphia emphasized
the point made by Dr. Connor with reference to teaching
medical students to use the naked ear. As a teacher of
medicine, he came in contact with students at the bedside
who have been using the stethoscope only, and he found
it very difficult to make them hear what he heard. He
considered the sole use of the stethoscope that of localizing
sounds previously heard with the naked ear.

Dr. E. G. Janeway of New York City said that in pneu-
monia certain sounds could be heard with the ear which
could not be heard with the stethoscope.

Dr. A. Jacobi of New York City suggested that not in-
frequently over the area covered many sounds could be
heard with a large stethoscope which could not be heard
with a small one.

Dr. Connor in closing the discussion said that all his
cases at the time the diagnosis was made were complicated
cases, other signs were uncertain, and the diagnosis rested
on the findings of the ear; the diagnosis later, however,
became clear, and sounds could be recognized with the
stethoscope.

Some Points Regarding Tuberculosis in Infancy.—
Dr. L. Emmett Holt of New York City gave, in this paper,
interesting data relative to the great frequency of pulmo-
nary tuberculosis in children, the sources of infection, and
the methods of obtaining sputum for examination from
infants. He gave contagion in the home as the most fre-
quent cause, the disease, as a rule, being contracted by
infants living in infected households. The early symptoms
were usually indefinite. He cited a record of thirty-si.x
cases of tubercular meningitis in which the bacilli were
found in the fluid by lumbar puncture. The proportion of
cases in which the bacilli were also found in the sputum
was large, even though no pulmonary signs or symptoms
were present.

Dr. George M. Koeer of Washington, D. C, asked if
any investigation had been made to recover the bacilli in
the feces. In over 4 per cent, of the cases he had exam-
ined thus far bacilli had been found in the feces.

Dr. Richard C. Cabot of Boston, Mass., emphasized the
importance of following up the children of tuberculous
parents, as had been done at the Massachusetts General
Hospital. Twenty-six out of a hundred children whose
parents had been admitted to the hospital with a diagnosis
of tuberculosis had been found to have the disease in one
form or another, though not complaining of the disease,
and going regularly to school. Such children were taken
to the hospital and put under treatment.

Dr. Holt, in closing the discussion, said it was surprising
how much fluid could be withdrawn in these cases. It
varies from one-half to two and even three ounces, the
average amount withdrawn being one and a half ounces.
He had made no study of the feces. Judging from the
lyge number of bacilli swallowed, they should be present
in the feces in large numbers.

A Study of Normal Living Anatomy in the First
Twelve Years of Life.— Dr. Thomas Morg.\n Rotch of
Boston, Mass., emphasized the necessity of having a series
of Roentgen rays taken which would show the development
of the different parts of the bod}-, organs as well as bones,
from premature birth up to adolescence. He drew especial
attention to the importance of observing the changes which
take place in the zone of proliferation and in the develop-
ment of the epiphyses. By means of this series of Roentgen
ray pictures, which he intended to put into book form later, a
physician or surgeon could, after having a radiograph taken
of the especial disease case, compare the plate with that of a
child of the same age and supposedly average anatomical
conditions. The radiograph should be taken upon a standard
basis, that is, the part being taken should be at a standard
distance from the tube, it should be taken at a standard
angle, and if the plate used be of natural size it should be

May i8, 1907]

MEDICAL RECORD.

^00

so stated; if enlarged, it should be stated how much
enlarged; if reduced, how much reduced. A series of
children of the same age should be taken before deter-
mining what the normal average picture at that age would
be. He then exhibited a series of radiographs taken by
Dr. A. W, George, Roentgenologist to the Children's Hos-
pital, Boston. Of especial interest were the radiographs
of twin premature babies at seven and a half months. He also
showed radiographs of the stomach at various ages, empha-
sizing the value of such rays in cases of pyloric stenosis,
where both diagnosis and treatment were somewhat uncer-
tain. This had been accomplished by the introduction of'
bismuth into the stomach, and also by dilating the stomach
with gas, the idea being that this should be done before
resorting to exploratory laparotomy. He also showed how
by this means the relations of the pericardium to the heart
could be seen, and whether the pericardium should be
tapped. The subject was of especial interest as something
new and something which would be another instrument of
precision in the hands of physicians and surgeons for diag-
nosis and treatment.

The Life-Saving Value of Diuresis. — Dr. S. J. Meltzer
of New York City reported a series of experiments on
animals instituted for the purpose of determining the value
of diuresis as a life-saving measure. Experiments were
made with subcutaneous injections of magnesium salts,
seven different species of animals being employed for the
purpose. It was found that one and a half grams per kilo
would produce profound anesthesia, with complete rela.xa-
tion of the entire musculature of the animal, but the animal
would recover. If one and three-quarter grams per kilo
be injected the animal would die of paralysis within an
hour. It was found, however, that if the animal urinated
between the anesthetic and the fetal stage recovery would
ensue. Magnesium was eliminated through the urine iu
quantity varying between anesthetic and toxic doses. It
was eliminated largely through the kidneys, but this as-
sumption could not be accepted without further proof, as
a number of alkali earths were eliminated through the
gastrointestinal canal. Alkali earths were eliminated
through the gastrointestinal canal and alkali metals through
the kidneys. The degree of toxicity of magnesium salts,
especially in rabbits, was studied, and it w-as perfectly evi-
dent that nephrectomy increased the toxicity, eight-tenths
of a gram producing deep anesthesia in a nephrectomized
animal when administered subcutaneously. Experiments
with artificially produced nephritis gave similar results.

The Hemorrhagic Diathesis in Blight's Disease. — Dr.
D.wiD RiESMAN of Philadelphia reported two cases of un-
controllable bleeding in Bright's disease. He said the hem-
orrhagic diathesis occurring in the course of Bright's dis-
ease might take the form of spontaneous bleeding from the
mucous membranes — nose, mouth, uterus, intestine — or
there may be bleeding into the skin, a true purpura. The
condition was met with in all forms of chronic nephritis,
perhaps more often when there was an associated arteri-
osclerosis ; the latter, however, was not a necessary factor.
The cause was to be found in toxemia, as well as, in some
cases, in an altered state of the vessel walls.

A Case of Secondary Carcinoma with Recurrences in
Unusual Sites. — Dr. George L. Peabody of New York City,
in tliis paper, detailed the case of a woman forty-three
years old, who, four years after removal of the right breast
for carcinoma, developed pains especially marked in the
lower extremities, small of the back, and shoulders. There
were no joint pains and no swellings, e.xcept that the
thyroid had always been large. The pains were severe
and prostration became intense. The urine was greatly in-
creased in amount, often over 200 ounces. The specific
gravity was low and it occasionally showed many patches
of pigment. Her chest and abdomen showed many patches
of pigment. Electric reactions normal. No treatment re-
lieved her pains ; she slept but little, and gradually became
mildly delirious. Lumbar puncture gave normal fluid.

About a week before death she developed partial ptosis of
the right eye, partial paralysis of the muscles of the right
side of the face, weakness of the right palate muscles, and
partial deafness of the right ear. Diplopia in part of' field
of vision. Pain in thighs and legs persisted, and pain in
lumbosacral region on attempting to sit upright, and on
pressure. No alteration in sensation otherwise. Eve-
grounds normal. Urine and feces became involunta'ry.
Muscles of deglutition gradually became impaired; water
regurgitated through the nose. She died three weeks after
coming under observation of edema of the lungs. Autopsy
showed metastatic carcinoma of the thyroid, of one supra,
renal gland, of one lung, of wall of an old cyst in cerebellum
numerous small metastatic growths in pia and medulla,
without lesion of pons or medulla. Diffused intiltration of
perineural lymph sheaths of one trunk nerve of cauda
equina, with carcinoma, and in one place the nerve trunk
itself was similarly invaded. Pia covering cord showed
small metastatic growths. New growths in lung showed
several large vessels completely filled with carcinomatous
tissue, and these carcinomatous thrombi suggested an ex-
planation for secondary metastases.

Drs. Pe.mjody, Meltzer, and Solis-Cohen discussed this
paper, and the reader closed the discussion.

Experimental Observations Upon the Action of In-
testinal Antiseptics.— Dr. J. Dutton Steele of Philadel-
phia read this paper, which discussed the difficulty of find-
mg an index for the amount and character of bacterial
activity in the intestine; the method of estimating the
amount of bacteria in the feces by weight (Strasburger) ;
the fact that scientific investigation of intestinal antiseptics
has until recently been insufficient, leading to somewhat
contradictory results, and the writer's experience witlT
bismuth, salicylate, and beta naphthol, using the total
amount of fecal bacteria as an indicator of their efficiency.

Dr. Lewis A. Connor of New York City called attention
to the fact that it was as necessary to preserve the bac-
teria, which are normal and useful, as to destroy those
which are harmful. He thought that in giving an intestinal
antiseptic one was going blindly, and that by giving atten-
tion to diet and other measures one would be working in a
mucli more hopeful direction.

Observations Regarding the Hygiene of Medical
Cases, Particularly in Hospital Wards.— Dr. D. L.
Eds.\ll of Philadelphia gave a collective review of a num-
ber of groups of ward infections of various sorts. Part
of these had been previously -recorded, and part had not
been published. He gave some suggestions as to tha
influence of superinduced gastrointestinal infections upon
the cause of typhoid fever in particular, with recommenda-
tions regarding some points in ward hygiene, especially
regarding ward nursing.

Dr. Victor C. Vaughan of Ann Arbor, Mich., called
attention to the great epidemic of t)'phoid fever during the
Spanish war, when both the laity and the medical profes-
sion in the LTnited States got the impression that it was
due to the fly, when in reality over 60 per cent, of the cases
were due to contact infection.

Dr. George M. Kober of Washington, D. C, called atten-
tion to the fact that large numbers of cases of typhoid
fever in nurses may be accounted for to some extent by
the fact that they are as a rule at a susceptible age. He
called attention, also, to the fact that the great epidemics
of typhoid fever are reported by England and America, not
by Germany, France, and Italy, noting the significant fact
that the first two nations are in the habit of taking raw
milk. Ten per cent, of the cases in the city had been
traced to the milk supply. He emphasized the importance
of pasteurization of the milk.

Dr. William H. Park of New York City cited severaf
ward epidemics traceable to careless methods on the part
of the nurse.

Dr. E. G. Janewav of New York City thought physicians
should take better care of the nurses. As it is, they are

836

MEDICAL RECORD.

[.May i8, 1907

weakened by overwork and are very susceptible. They
should be given more rest.

Dr. A. C. Abbott of Philadelphia emphasized the untrust-
worthiness of isolation, epidemics not infrequently follow-
ing the release from isolation of a person apparently well.
He cited one or two such instances.

Dr. W. P. NoRTHRUP of New York City cited the case
of two roommates, teachers, who came down with typhoid
fever. Investigation revealed the fact that they drank only
distilled water, drank no milk, and ate only cooked food.
The source of infection was traced to the glass jar in which
the distilled water was kept.

Dr. Solomon Solis-Cohen advocated the more complete
segregation of infectious cases in hospitals. The present
imperfect system leads to many ward epidemics.

Dr. Edsall in closing the discussion agreed with the
other speakers concerning the importance of isolation. Sat-
isfactory isolation, however, was impossible with the pres-
ent hospital facilities. The proper precautions would
greatly reduce the number of epidemics.

Antitoxin and Post-Diphtheritic Paralysis. — Drs. M.
J. RosEXAU and J. F. .Anderson of Washington, D. C, had
carried on a series of experiments on guinea-pigs which
fully justified the drawing of conclusions in respect to
man. Dr. Rosenau, who read the paper, said that all the
pigs received the same dose of toxin and antitoxin mixture,
which was so nicely adjusted that none of them died.
Those given 250 units of antitoxin twenty-four hours after
infection recovered, w-hereas those given forty-eight hours
after infection developed paralysis and died later. Those
receiving one thousand units forty-eight hours after infec-
tion rapidly recovered. The pigs that received antitoxin
in repeated doses daily told a similar but better story.
Those that received 250 units twenty-four hours after infec-
tion and in repeated doses rapidly recovered ; of those that
received it forty-eight hours after infection two lived and
one died. If antitoxin is given just before the symptoms
begin it has no effect upon the paralysis or in saving life.
The experiments emphasized the importance of giving the
remedy early, and of giving large doses when the ease is
seen late.

Effects of Egg-White and Its Split Products Upon
Animals; A Study of Susceptibility and Immunity. —
Dr. Victor C. Vaughan of Ann Arbor, Mich., read this
paper, which outlined the work done by himself and Dr.
May Wheeler. For a number of years, he said, they had
been studying the products obtained by splitting up various
proteid molecules. The proteids with which they worked
were bacterial, vegetable, and animal. All of these, they
found, may be split up into poisonous and nonpoisonous
portions. We have ascertained that the nonpoisonous
products obtained by the cleavage of the proteids of the
colon bacillus and of the typhoid bacillus induced specific
immunity to the microorganisms of these diseases. Some
two years ago we split egg-white into poisonous and non-
poisonous portions. The experiments of Drs. Rosenau and
Anderson, on the susceptibility of animals to second injec-
tions of blood serum, led Drs. Vaughan and Wheeler to try
the effect of the nonpoisonous portion of egg-white upon
animals. They found that this part of egg-white sensitizes
the animal to the unbroken egg-white, and that the sensi-
tization thus induced corresponded in all particulars with
that produced by the injection of unbroken egg-white. An
attempt would be made to explain the sensitizing effect of
the nonpoisonous portion of egg-white, and to show that
this was along the same line as the immunity induced to
the typhoid and colon bacilli by the nonpoisonous portions
obtained from the cellular substance of these organisms.
The claim would be made that when egg-white, or the non-
poisonous part of egg-white, is injected into a fresh animal
certain cells of the body are so influenced that they elab-
orate a new ferment, which, in the form of zymogen, re-
mains in the cell until activated by the second injection,
when it is set free and splits up the egg-white in a manner

similar to that which they had used in the laboratory, and
that the effect induced is the same as that caused by the
poisonous portion of egg-white, as they had split it up in
the retort. Similar phenomena occurred when animals
were immunized or sensitized with the nonpoisonous por-
tion of the typhoid or colon bacillus, and subsequently
inoculated with the living organi.^m.

A Symposium on the Opsonins in Medicine. — The re-
mainder of the session was devoted to this subject, the fol-
lowing papers being read :

A Review of the Experimental Basis of the Opsonic
Phenomena. — Dr. E. L. Opie of New York City opened
the sympo.sium with this paper, giving as the experimental
basis for the existence of opsonins the following: (i)
The normal blood serum so modifies bacteria that they are
readily ingested by phagocytes. (2) The power of the
blood serum to promote phagocytosis is increased by im-
munization. (3) Xonvirulent bacteria are more readily
prepared for phagocytosis than virulent bacteria. The
properties of the opsonins and their relation to other bodies
concerned in the processes of immunization are not clearly
understood. The opsonic power of normal blood serum is
subject to considerable variation, and this variation ma-
terially affects estimation of the so-called opsonic index.

The Opsonins in Tuberculosis. — Dr. Edward R. B.\ld-
wiN of Saranac Lake, Xew York, reviewed the experi-
ments on immunized animals. The opsonic function -/as
less marked in immunized rabbit serum than in controls
after test inoculations though at site of tubercles, phago-
cytosis was much stronger, and agglutination power of the
serum higher. Of this he gave a provisional explanation.
He called attention to the difficulties in determining the
relation betw'een the agglutinating and the opsonic func-
tions, and the apparent independence of each, ".\ggressin"
from fatally poi.5oned guinea-pigs retained opsonic func-
tions ; virulent bacilli "opsonified" by immunized cow serum
retained virulence. There was an apparent absence of
bacteriolysis in test-tube, but a possible connection with it
in the animal. Apropos of von Behring's statements appli-
cation to the vaccine therapy was suggested. The paper
closed with some remarks on the technique of the opsonic
test and its application in pulmonary tuberculosis.

The Opsonic Index in Certain Acute Infectious Dis-
eases.— Dr. LuDwiG Hektoen of Chicago presented this
paper, in which he discussed the course of the opsonic
index in typhoid fever, pneumonia, diphtheria, and erysip-
elas. He presented a series of charts illustrating the strep-
tococcoopsonic index in scarlet fever, with and without
complications, and called attention to the effect of sup-
purative scarlatinal otitis on the opsonins for the bacteria
concerned.

A Summary of the Studies on Opsonins Carried Out
at the Rockefeller Institute. — Dr. E. H. Schorer of
Xew York City read this paper. The opsonic index in
cases of erysipelas was constantly ncuher nigher nor lower
than normal. Vaccines were prepared from streut■^cccci
isolated from wound infections and from cases .)f erysipelas.
Fifty cases of erysipelas were inoculated with such vac-
cines, the opsonic index being determined at intervals by
use of the same microorganisms. The inoculation of vac-
cine was not followed by a constant modification of the
opsonic inde.x or of the course of the disease.

A Summary of the Work on Opsonins at the Johns
Hopkins Hospital. — By Drs. L. F. B.^rker and Rufus I.
Cole of Baltimore, Md. The paper epitomized the .vork
done during the past yc-ar in the medical and surgical wards
of the Johns Hopkins Hospital, and In the biological di-
vision of the Clinical Laboratory. The report included the
results of the determination of the opsonic index for diag-
nostic purposes and as a guide to vaccine therapy. It also
dealt with the results of investigations concerning the re-
liability of the methods now in vogue, the specificin- of
opsonins, the possibility of the production of sera of high
concentration in opsonins, etc.

May 1 8, 1907]

MEDICAL RECORD.

«37

A Summary of the Studies on Opsonins Carried Out
Under the Auspices of the Commission for the Inves-
tigation of Respiratory Diseases of the New York
Board of Health. — l!y Ura. Hermann M. Bighs. \Vm.
H. Park, and Nathaniel B. Potter of New York City.
The results of these studies were presented in two papers,
one read by Dr. Park and the other by Dr. Potter, the
latter being illustrated with lantern slides. From all the
work done it was concluded that the opsonic index must
be considered an approximate, and not a real index of the
amount of opsonins in the blood in any given test. The
errors were inherent in the method, and probably could not
be eliminated by any other method. It was found in the
treatment of a number of cases by vaccine that, as a rule,
the index had not been a sullicient guide to the treatment
by the injections. In some of the cases, especially those due
to local staphylococcus infections, good results had been
obtained by vaccines, while in cases of mixed infection and
of inflammation of mucous membranes the results on the
whole had been satisfactory. In tuberculosis the results
in those treated under the guidance of the opsonic index
liad not differed from those treated in other ways.

Dr. Charles E. North of New York City presented a
number of charts showing the variation in the findings of
twelve laboratories working simultaneously with the same
organism according to the Wright-Douglass method.

Dr. Thomas Morgan Rotch of Boston presented the
results of his clinical work in his wards at the Children's
Hospital in Boston. He had treated a series of cases of
cerebrospinal meningitis in children, and had studied the
opsonic index in connection therewith. Some of the cases
were acute and some subacute. The dose of the menin-
gococcus vaccine given was one hundred and twenty mil-
lion. He explained that he had at the head of the bed a
chart showing the temperature. pul<e. and respiration, and
also the opsonic index. In connection with each clinrt he
gave the age, the duration of the disease, the char.-icter of
the especial case, whether acute, chronic, mild or severe,
also the effect on the opsonic index when spinal puncture
was made, when inoculation was given, and when antitoxin
was given. There seemed to be interesting relations be
tween the use of antitoxin and the meningococcus vaccine.
In cases where the meningococcus vaccine did not raise the
index antitoxin was found to do so. Two or three years
ago he had treated in his wards twenty-five cases of cere-
brospinal meningitis in children with antitoxin, with some
interesting results, but on the whole they were not satis-
factory from a curative sen<e

Dr. Ross of Montreal, Canada, who had worked with
Wright for three years, spoke very enthusiastically of the
work and of the clinical value of the opsonic theory, but
said he would welcome some easier method which would
enable him to obtain the same results.

Drs. Barker, Webb, and others took part in the discus-
sion, which was closed by the readers of tlie various papers.
(To be continued.)

AMERICAN SURGICAL ASSOCI.\TION.

Twenty-eighth Annual Meeting, Held in ir'iT.v/iH/j;/.)"

D. C, May 7, 8, and 9, IQ07, in Conjunction with the

Congress of American Physicians and Surgeons.

(Special Report to the Medical Record )

(Continued from foge 797.^
Jl'edncsday. May S^Second Day.
Ancient Egyptian Surgical Instruments. — Dr. M. Soi is
Cohen of Philadelphia demonstrated these instruments,
which were said to have been found in the tomb of a
physician east of the Nile, near Thebes. The instruments,
made of bronze, were probably the earliest surgical instru-
ments existing in the world, the date of their nianuf.ic-
ture being somewhat more recent than 2,000 years B.C.
Their use had been conjectured as possibly for cataract

End Results Following Operations for Carcinoma of

the Breast.— This was the title of all the papers read
at the session. Dr. W.\i, S. Halsted of Baltimore read
the first paper of the series. He said that statistics could
be varied by selecting the cases and by classifying the cases
according to different standards. All statistics, he thought,
should exclude the totally inadequate operations that were
recognized by all. Excluding the incomplete operations
done at Johns Hopkins Hospitnl, there had been 89 cases,
43 per cent, of which were free from recurrence at the end
of three years. As to the point of recurrence, bone meta-
stases in forearm and lower leg had not been recorded,
and subcutaneous recurrences had been limited to an area
still sli.ghtly nearer the primary growth, extending to mid-
thigh and to mid-arm, hence he did not consider blood
metastases as probable, but the spread as due to the
lymphatics by way of the fascial planes. In support of
this were the bone lesions in the femur, most often at the
great trochanter, and in the humerus at the insertion of the
deltoid. Similar lymphatic spread could account for lesions
in brain and liver. Of the cases that at the time of opera-
tion had had no glandular involvement there were 64,
of which 70 per cent, had remained cured. Of no cases
with axillary gland involvement 25 per cent, remained
cured. Of loi cases with cervical gland involvement only
7 per cent, remained cured. To confirm the diagnosis of
a cure he would insist on a negative autopsy at the expira-
tion of five years. He removed the glands of the neck in
most of the cases with the exception of adenocarcinoma.
He expected to recognize cancer cysts by their containing
blood-stained fluid, their having very thin walls, and the
presence of papillomata ; but he had failed in this in the
first few cases and had had to do an early secondary
operation after the pathologists' report. He considered
the extension most rapid beneath the skin, and so did au
extensive removal of skin and neighboring muscle planes.
He presented the following table of results:

Cancer cysts 6 cases, 2 cured. 3,i ,1 per cent.

Adenocarcinoma 32 " 24 " 75

Medullary carcinoma ....25 " 12 " 48 '"

Circumscribed scirrhus. . .28 " 13 " 46.4
Small infiltrating scirrhus.80 " 30 " 35.5 "
Large infiltrating scirrhus. 39 " 8 " 20.5 "

Dr. J. C. Warren of Boston read the next paper. He
Have the statistics of the Massachusetts General Hospital,
which represented the work of numerous surgeons. The
work of collaborating the material had been done by Drs
( ireenough, Simms, and Barney, who had seen and examined
the cases, at their houses if necessary, to determine the
late results of the operations. The statistics were for a
continuous series of cases operated on at the hospital in
the ten years ending three years ago. Of these there had
been 376 patients with 416 operations ; 64 were alive and
well from three to thirteen years after the operation. Seven
had died of some other disease after the lapse of three
years, making a total of 71 cases, 20.9 per cent., that had
been cured without recurrence for three or more years.
.Ml but one of these had good use of the arm. There
had been a swelling of the arm in some of the cases for
a shorter or longer period. Of the unfavorable conditions
.it the time of operation he mentioned adherence of the
tumor to the skin or to the chest wall and involvement of
axillary and cervical glands. Of all the cases in which the
cervical glands were felt, only two had survived, and in
those two the glands that were felt and removed had not
been cancerous. In none of the cases, where both breasts
were involved, had the patient survived. Of the different
types of cancer the medullary seemed to have had the
greatest malignancy and the adenocarcinoma to have been
relatively benign. The type of cancer and the extent of
involvement were the most signficant factors to be con-
sidered in the prognosis. Of 160 cases where the complete

83S

MEDICAL RECORD.

[May 18. 11)07

operaliun liad btcii done, removing gtands in the axilla and
neck, 60 had been cured. The removal of a large area of
skin had given better results than removal of small areas.
In the incomplete operations 25 per cent, were free from
recurrence. This apparently better result from the incom-
plete operation than from the complete operation was due
to the extent of the lesion and the character of the tumor
chosen for the incomplete operations. Of the cases in
which merely palliative operations had been done, not ex-
pecting a cure, four were cured. Perhaps these patients
had been able to combat successfully with the small amount
of tissue that had been left. Recurrences in the scar had
occurred in 48 per cent, of the cases. There had been
four cases of late recurrence ; two in the scar, one at
eight years, and one at eight and a half years ; there had
been a metastasis in the spine at seven years, and another
recurrence at six years. Eighty-eight cases that had passed
the three-year limit had died later.

Dr. A. T. Cabot of Boston read the next paper. In this
he discussed his own private cases. He had made no se-
lection of cases except to exclude one woman who had a
bad heart and an adherent cancer. Of these forty-two cases
nine were free from recurrence from four to nineteen
vears. Five others are living, but had had recurrences
which were removed more than three years ago. Of the
nine cases that were well three had been adenocarcinoma,
three small scirrhus, one Pagct's disease, one medullary
cancer, and in one the diagnosis had been lost. Of these,
in six there had been no cancer in the lymph glands re-
moved, and in the other three only slight involvement. He
used .v-ray treatment to check growth in the inoperable
cases. Recently he had begun to give .r-ray treatment in
all cases immediately after operation, but none of these
cases were included in the report, because they were all
too recent.

Dr. J. C. .MfNRo of Boston said that he wished to make
merely a preliminary report on 105 cases. 27 per cent, of
which had remained free from recurrence for from three
to fifteen years. The longest were cases in which he had
removed axillary glands and fascia, but not muscle. Of
the recurrences four-fifths had been inside of two years.

Dr. Willy Meyer of New York reported eighty-seven
personal cases operated on since 1894. Of these thirty per
cent, had been well from five to twelve years. He did not
consider the neck operation desirable as a routine unless
the glands were found involved. During the operation
sometimes the subscapular nerves could be sacrificed to
advantage, and also the axillary vein removed. Edema
of the arm was rare, and usually due to the cicatrix. Neu-
ralgia was present in some of the cases. .\11 had full use
of the arm. In cases where the primary tumor involved
the upper quadrants involvement of the neck glands were
more likely. He did the radical operation on all cases ex-
cept where metastases were present, taking out breast,
axilla, and all tissues en masse.

Dr. L. S. PiLCHER of Brooklyn spoke especially of the
cases in which the neck had been involved and its glands re-
moved with the breast and axilla. The main opposition
was the argument that in such cases the mediastinum was
also probably involved. He recognized the fact that all
such cases were well advanced, but knew that some could
he saved. He had had one case that seven years after oper-
ation had died of heart trouble, and two other cases alive
and well, one seven and one nine years after operation.
Of eleven cases, nine had been free si.K months or more.
In four cases the neck glands had been felt before cutting
the skin ; in eleven others only after the skin incision.
Tlu- point of suspicion in the neck is in the subclavian
triangle around the jugular vein. He considered no opera-
tion complete without exploration of the base of the neck

Dr. A. Vander Veer of Albany, reporting his personal
cases and hospital cases over a period of forty years, spoke
of tlio m.-irked improvement in the results of the operation

since his first cases. He had operated on 103 patients, of
whom thirteen were well. The longest period after opera-
tion in which he had seen recurrence was twelve years. He
cleaned out, now, the axilla in all cases, but tried to save
the nerves. He had had three cases with lumps in the
breast for from six to twenty years, after which they had
developed adenocarcinoma of very rapid development. He
had had ten cases of traumatic history, and one case of
worry and fear that cancer would appear until found a
year later. After that the patient had worried about the
other breast, and the development of a cancer there had
followed a year later, and after that had been promptly
removed by death from metastases.

Dr. A. J. OcHSNER of Chicago had been able to trace to
a final report lOi of his 164 cases. Of these 57 were living,
and all but two well. All were operated on more than a
year ago, 39 living more than three years after operation;
25 more than five years, and 5 more than ten years. Of
the 57 living cases 10 had stiffness of the arm. All of
his cases in the past six years had had .r-ray treatment.
One woman operated on in 1891 had a recurrence in the
scar within six months. This had disappeared under the
.r-ray, and the woman was still alive and well five years
after. One case of recurrence where the .r-ray had no
effect had been cured by a paste, .\nother case of cancer
had been cured by some patent medicine given hypoder-
mically. One case of cancer of the neck and axilla had
been cured by the .r-ray. .■Vn isolated node appearing
later liad been excised and followed by the .r-ray, and
the patient was alive five years later.

Dr. N. Jacobson of Syracuse spoke of the jnarked varia-
tions in virulence even in tumors of the same type. In
one case of scirrhus cancer, w-hich is usually so slow in
development, a mass the size of a hen's egg, with axillary
involvement, had appeared within ten days. There
had been recurrences inside of a month, and the patient
died of metastases inside of six months. In another case
of scirrhus cancer the operation was done with a wide ex-
cision two days after the cancer was first noticed. Three
months later there were recurrences over all the chest wall
and back, and the patient died in a few months. He seemed
to think that there was a special predisposition to cancer
in some persons with recurrence in various organs. He
had had one case with cancer in uterus, breast, and stom-
ach. He had had three cancers of the breast in men, all
with recurrences and death.

Dr. J. C. Oliver reported thirty-five personal cases, all
operated more than three years ago. He had had two cases
with a radical operation done on one breast and a simple
operation done later on the other breast : both patients
were alive and well, one five and the other seven years after
the operation. He had had one case with fatal recurrence
after fourteen years. He had had two rapid, malignant
cases recurring in tumors that had been in the breast, one
for ten years and one for twenty years. He considered
supraclavicular recurrence less frequent than involvement
of the opposite breast. Tumors in the central portion and
lower quadrants gave the most recoveries. He hoped to
learn more of the prophylaxis and nature of cancer in the
future.

Very Late Recurrences after Operation for Cancer
of the Breast. — Dr. J. R..\nsohoff of Cincinnati read this
paper. IK- s.iid that twenty per cent, of the cases that
passeil the three years limit for cure died of recurrence,
and he would rather put the limit of recurrence at five or
seven years. He considered the improved end results after
such operations to be due to the increasing intelligence of
the people. He had been able to collect reports of cases
living 22, 26, and 29 years after operation and that after an
incomplete operation. He considered one great danger of
the operation from excessive manipulation of the tumor.
He said that local recurrence took place in fifty-eight per
cent, of the cases. That recurrence appeared during the

I

May 1 8, 1907]

MEDICAL RECORD.

«3y

first year in sixty-two per cent, of the cases; that recur-
rence occurred principally in the scar or neighboring skin,
but that after three years this local recurrence was less
frequent. He had found reports of sixty-two cases with
recurrences after six years, the latest at the end of nine-
teen years. In several cases there had been distant, but no
local recurrence. In one case after twenty-one years there
had been a recurrence in the scar. The later appearances
in these remote organs were probably primary cancers. In
some of the cases with the longest interval before the re-
currence there had been no a.xillary involvement at the time
of operation. A possible explanation of the long interval
would lie in cell deposits that have remained dormant
just as retrograde processes were known to follow giant
cell action upon some condition. Or again that the scar
tissue was especially subject to disease and degenerated
anew in the site of tlie former operation.

The Law of Accelerating Risk Clinically Tested in
Breast Cancer; End Results Compared with the Pre-
dictions.— Dr. E. W. Andrews of Chicago read a paper
explanatory of the theory that cancers follow the law of
squares in their rate of development, the cancer growing
incessantly with no acquired resistance to combat it and no
retrogression. On the contrary, the vigorous people seemed
to show more susceptibility to cancer. Cancer seemed to
grow at an accelerating rate, so that in a short time the
danger from the growth became extreme. He charted
the time required for the cancer to double in size, and
when the size had doubled the risk had quadrupled. He
reported one case in which the mass had doubled in a week,
and five months later, in spite of operation, the patient
died from cancer of both breasts. This was an exceeding-
ly rapid growth and probably no operation could have
saved the patient.

(To be continued.)

AMRRICAN CLIMATOLOGICAL AS.SOCIATION.

Tivcnty-fourth Annual Meeting, Held at Washington. U. C,

May 7, 8, and 9, 1907, in Conjunction xmth the

Congress of American Physicians and Surgeons.

(Special Report to the Medical Record)

The President. Dr. Thom.\.s D.arlington of New York,
IN THE Chair.

Tuesday, May 7 — First Day.

President's Address. — Dr. Darlington warned against
the possible tendency of the .Association to focus too large
a share of attention upon pulmonary tuberculosis, worthy
and important as the subject was. and presented suggestions
for future achievement in other lines of work. The results
of the Association toward the elimination of tuberculosis
were dwelt upon, and attention called to the need of more
work along the line of the mode of infection of pulmonary
tuberculosis. Particular emphasis was placed upon the
question of intestinal infection caused by the ingestion of
contaminated food. In referring to the potential possibili-
ties of the Association in research work, attention wa<
called to the increased mortality from heart and kidney
diseases. Charts were exhibited showing most graphically
this increase in New York City. Figures were given show-
ing, the death rates in a number of cities of the United
States, the most marked increase being in Boston, where
the rate from heart disease was 11. 71 in 1880 and 18.17 per
10,000 population in 1905. New Orleans gave the greatest
increase in the mortality due to Bright's disease, the rate
being 5.21 per 10,000 population in 1881 and 17.30 in 1905.
Using the complete tables as a basis, it was shown that the
death rate from these diseases in Boston. New York, and
Chicago had nearly doubled in the twenty-five-year period,
while the general death rate had shown a decided decrease.
A study of the causative factors of this alarming increase
naturally suggested the part played by the nervous activity

of the modern city business man and the equally strenuous
social whirl of the city woman. The doctrine of the restful
life, of individual self poise and mental and physical well
being was advocated. The relation of influenza to the
causation of cardiac difficulties was mentioned as an almost
untilled field for investigation. Pneumonia among infec-
tious diseases also demanded attention. While the hope of
its specific medication seemed to lie in the field of serum
tlicrapy, it was suggested that the profession was probably
too quiescent in its attitude toward general prophylaxis and
the methods tending to eradicate the disease. The question
of climate in relation to the prevalence of disease should
receive more attention than it has heretofore. Reference
was made to the fact that the Esquimaux brought by Com-
mander Peary from the Arctic regions in 1898 practically
all succumbed to pneumonia soon after reaching New
York, while the disease is unknown in their home climate.
An investigation of the causes of the acute respiratory dis-
eases was urged as a subject well wortliy the attention of
the Association.

The Search for a Suitable Climate.— Dr. Samuel .\.
FiSK of Brimfield, Mass., read tins paper, givmg his per-
sonal experience as a basis of judgment. As a young man
of twenty-four, broken down with consumption, but with a
tendency to repair, he had gone to Colorado. He had
found it preeminently a place of outdoor life, flooded with
sunshine, abounding in a dry, pure air, with ideal temper-
ature and a dry soil. The comparative advantages of Min-
nesota, Colorado, Nassau, Southern California; the hills
of New England, of New York, Arizona, New Mexico, and
life on shipboard, were considered, and Colorado was
given decided preference as a place of residence for one
presenting the conditions manifested by the author in his
early life.

Dr. Delancey Rochester of Buffalo would send tubercu-
lous patients to Colorado or North Carolina. His choice
as a substitute for these localities would be the Adirondack
Mountains, and his last resort the employment of home
treatment.

Dr. W. Jarvis Baklow of Los Angeles said that the fogs
mentioned by Dr. Fisk as peculiar to Southern California
were to be found only near the coast. An advantage of
the fogs was their tendency to make the weather cooler.
Persons with kidney and heart troubles, he thought, did
better in Southern California than did those with pulmo-
nary affections.

Dr. Charles Denison of Denver called attention to the
great value of the personality of the author bearing upon
the paper forming an authoritative statement from the
membership of the Association of the value of the climate
of Colorado.

Dr. F. I. Knight of Boston expressed his appreciation of
the beautiful manner in which Mrs. Fisk had read the
Doctor's paper.

Dr. J. Edward Stubbert of New York City was particu-
larly interested in the paper, in that his own experience in
the development of tuberculosis had been somewhat similar
to that of Dr. Fisk. In contrast to Dr. Fisk. however, he
had taken short trips into various climates, but had not
been to Colorado. He had been to sea in the tropics and
returned with the disease apparently cured, but it had re-
developed. He had then gone to China and lived in a cli-
mate where the sun shone for five minutes in twenty-eight
days. He had subsequently entirely recovered. The appli-
cation of the same rule in the treatment of many of his
cases of tuberculosis had given good results. He would
send patients south on a sea trip in preference to the North
.Atlantic, because of their ability to live on deck in the
open.

Dr. William C. Rives spoke of the invigorating effect of
climates of high altitude upon persons of ordinary health,
arguing that tuberculosis, preeminently a disease of malnu-
trition, therefore should be benefited by the appropriate
climate.

940

MEDICAL RECORD.

May 18, 1907

Dr. Vincent Y. Bowditch agreed with Dr. Fisk in his
opinion of the climate of Colorado for tuberculous cases.
For the vast number of patients who cannot possibly go
away he advocated the home treatment. Every case should
be judged upon its own merits.

Dr. R. H. Babcock of Chicago thought that Dr. Stub-
bert's recovery was not because, but in spite of the short
trips ho had taken. Regarding climate, Dr. Babcock be-
lieves that patients can recover at home, but that recovery
is much more easily accomplished in a proper climate.

Dr. James A. Hart agreed in the opinion of Colorado
being a favorable climate for tuberculous cases.

Dr. Fisk, in closing, said that he did not wish to take
issue with Dr. Barlow, except to say that when in
Southern California in 1902 his clothes, if hung by a win-
dow at night, were too damp for wearing the next morn-
ing.

Leishman-Donovan Disease or Assam Fever.— Dr.
JuDSON Daland of Philadelphia read this paper, referring
to the synonyms commonly employed for this disease and
making mention of the geographical distribution of kala
azar. The cause and relationship of the Leishman-Dono-
van body to the disease was established. The author holds
the opinion that already sufficient evidence exists to justify
the belief that the alternate host is the bedbug. That the
disease is a house infection, probably carried by a biting
insect, has long been the opinion of Major Leonard Rogers.
Captain Fatten of Madras had been able to demonstrate the
life cycle of the parasite in bedbugs fed upon blood from a
case of Assam fever. In the opinion of the author kala
azar was transmitted from the sick to the well by the
bedbug. Diagnosis, differential diagnosis, and the compli-
cations of the disease were discussed, special stress being
laid upon the method of securing the blood for the detection
of this parasite by splenopuncture. Long-continued, irreg-
ular, alternating, intermittent or remittent fever, enlarged
painful spleen, enlarged liver, progressive loss of flesh,
strength and color, leucopenia with mononuclear increase,
and pigmentation of the palms of the hands and soles of the
feet were mentioned as being highly diagnostic, especially
in tlie absence of the malarial parasite from the peripheral
blood. The only treatment of value was said to be the
prophylactic, and but moderate benefit was to be expected
from the use of from 60 to 90 grains of quinine each
twenty-four hours.

Dr. Frank Fremont-Smith inquired whether the dis-
ease occurred in the Southern States.

Dr. Daland said that until within a few years ago the
disease was supposedly confined to Assam and the region
of Madras, but that recently in Eg>'pt and Arabia the iden-
tification of the disease has made it seem not impossible to
find it in our Southern States or in the West Indies.
(To ht' continued^

Health Reports. — The following cases of smallpox.
yellow fever, cholera, and plague have been reported to
the Surgeon-General. Public Health and Marine-Hospital
Service, during the week ended May lo, 1907:

SM A I, I. PO .\ — I N ITK i> ST AT KS.

Florida, Hillsboro County... .

Georgia, Augusta

Illinois. Aurora ,

Danville ,

ii Plaintield

SprinRlield

Indiana, Elkhart

Indianapolis

Jefferson ville

La Fayette

Marion

Michigan City ,

South Bend ,

Iowa, Ottumwa

Kansas. Kansas City

LauTence

Kentucky. Louisville

Louisiana, New Orleans

Massachusetts, Chelsea

_ ^ . 1 Lawrence . . .

Michigan, Ann Arbor

fcjA- ' Saginaw

Minnesota, Stillwater

't ^•Jn; Winona

New Jersey, Hoboken..,,. .

New York, New York

North Carolina, Greensboro.

Ohio, Cincinnati

Cleveland

Toledo

Texas, Bell County

Houston

San Antonio. . .

Washington. 'Spokane.
Tacoma. .

. Apr.
.Apr.
.May
.Apr.
-Apr.
. Apr.
.Apr.
.Apr.
.Apr.
.Apr.
.Apr.
.Apr.
-Apr.
. .Apr,
.Apr.
.Mar.
.Apr.
..Apr.
.Apr.
.Apr.
.Apr.
.Apr.
-Feb.
. Apr.
.Apr.
.Apr.
.Apr.
..Apr.
-Apr.
..Apr.
.May
.Apr.
/Mar.
lApr.
.Apr.
. . Apr.

20 —27
23-30..

23-30

17-May 2. . .
2S-May 2. . .

20—27

21-28

1-30

22-29

1-30

1-30

20-27

6-27

27-May 4. . ,

1-31

2s-May 2. . .

20-27

20-27

20-27

20-27

20—27

1-28

20-27

27-May 4. . .

20-27

26-May 3 .

10—26

20-27

3

20-27

30- Apr. 6.
20-27

20-27.,

SMALLPO.X — INSULAR.

Philippine Islands. Manila Mar. 16-23.,

SMALLPOX — FOREIGN'.

Brazil,! Para Apr.

Canada. Toronto j a^Z^j.'

Chile. Coquimbo Apr.

Iquique Apr.

China. Hongkong Mar.

Nanking Mar.

Shanghai Mar.

Tiensin Mar.

France. Paris Apr.

Toulon Mar.

Germany. General Mar.

Gibraltar Apr.

India, Bombay Mar

Calcutta Mar-
Madras Mar.

Rangoon Mar.

Italy. General Apr.

Madeira, Funchal Apr.

Mexico. Jalapa Apr.

Mexico Mar.

Veracruz Apr.

Peru. Lima Mar.

Russia. Odessa Apr.

Siberia. Vladivostok Mar.

Spain, Valencia Apr.

Straits Settlements. Singapore Mar.

Turkev in Asia. Bassorah Mar.

6-13.-.

6-13...
20-27..
6

6

9-23

23-30

23-jo

23-30

13-20 . ...

1-3 1

16-30

14-21

2 6- Apr. 9. ,

23-30

30- Apr. 5.,

16—^0

4-18

t4-2I

19-26

23-Apr. 6..,

20-27

31-Apr. 6.

^13

21-28

14-21

16-23

30- Apr. 6.

YELLOW'FEVEO.

Brazil, Manaos Apr. 6-13.,

Ecuador. Guayaquil Apr. 6-13..

Present

2 Imported

16 2 imported

Presen!

35
60

Present

Treatment of La Grippe in Children.— Laumonier

call? attention to the important influence of grippal in-
fection on the functions of the organistn of a child during
the period of convalescence. At this time the patient is
a prey to general asthenia. The tissues offer a good soil
for grave infections and the natural forces of the organi-m
shoiild be fortified in order to prevent such dangers. The
hodv cavities, especially the nose, should be cleansed with
weak boracic acid solution. The child should be kept in
bed in a large, well-aired, and sunny room until conval-
escence is fully established. A very light diet should be
given. Drugs should be suited to the special indications for
them. Great care should be taken of children who have
been exposed to this infection. The nose, mouth, and
throat should be kept clean and all clothing or other ob-
jects that have come in contact with the patient should be
thoroughly disinfected. Every child suffering with grippe
should be isolated from the rest of the household. The
convalescent patient should be sent to the country. A
month's time will generally be sufficient for restoring the
health. — Franchise de Medicine et de Chifitroie.

India. Bombav Mar. 26-Apr. 9 .

gfe^Calcutta Mar. 23-30

"^^ Madras Mar, 30-Apr. 5.

S!*" Rangoon Mar. 16-30

Straits Settlements. Singapore Mar. 9-16

PI.AGVE — IN'SULAR.

Hawaii. Honolulu..

.Apr. 2o-May'6.

PLAGITE FOREIGN-,

Brazil. Para Apr.

Chile. Antofagasta Apr.

Santiago Apr.

Talcahuana Apr.

China. Hongkong Mar.

Egypt, Alexandria Mar.

Assiout Pro\-ince Mar.

Beni Souef ProWnce Mar.

Cirgeh Pro\-ince Mar.

Keneh Pro\"ince Mar.

Minieh Province Mar.

India, Bombay Mar.

Calcutta Mar.

Rangoon Mar.

Peru, Eten Mar.

Lambayeque Mar.

Lima Mar,

Paita Mar.

Santiago de Cao Mar.

Trujillo Mar

6-13..

6

6

. 6
Present

6

«■

16-23

3

3

28-Apr. 11...

2

2

2S-Apr. 11...

10

4

2S-Apr. 11...

2

2

2S-Apr. II...

6

-

28-Apr. II.. .

6S

.t»

28- Apr. 11...

12

4

26-Apr. 0

1.262

23-30

166

16-10. .f

161

20-Apr. 6. . . .

6

5

30-Apr 6.. . .

7

3

30-Apr. 6. .. .

601

30-Apr. 6.. . .

II

s

30-Apr. 6.. . .

I

r

30-Apr. 6. , . .

S

7

Medical Record

A Weekly Jourjtal of Medicine and Surgery

Vol. 71, No. 21.
Whole No. 1907.

New York, May 25, 1907.

$5.00 Per Annum.
Single Copies, tOc.

(IPriginal Arttrks.

THE ANTRUM OF HIGHMORE AS AN ETI-
OLOGICAL FACTOR IN THE PRODUC-
TION OF HAY-FEVER (SO-
CALLED).*

By JACOB E. SCHADLE, M.D..

ST. PAVL, MINNESOTA.

The following paper is presented for the pur-
f)Ose of drawing special attention to a certain
phase of a familiarly known disease, the cause
and treatment of which have always been perplex-
ing to understand. According to recent experi-
ments, the disease appears to be based on an-
atomical deviations in its pathological aspects.
These anatomical malformations act both as pre-
disposing and contributory local factors. In accord-
ance with this view, clinical investigations demon-
strate that the antrum of Highmore holds an im-
portant position in the etiology of hay-fever and
in some of the commoner forms of catarrhal and
nervous disturbances of the nose. A series of a
large number of cases coming under this class of
affections. I have studied during the past number
of years with considerable interest. The results
of my observations have been of such a character
as to corroborate the theory. To discuss empyema
of the antrum in this connection is not the province
of this report. In the first place the design is to
deal with nonsuppurative processes. While of the
pus-producing conditions of the antrum much has
been said in recent years, and medical literature
abounds in valuable contributions on the subject,
reference will be made to suppurative maxillary
sinusitis only for the purpose of illustrating path-
ological and symptomatic relationships.

It is my belief that the nervous catarrhal mani-
festations of the nose, in their relation to the pres-
ence of a catarrhal maxillary sinusitis, arc of suffi-
cient importance to merit attention and suggest
further investigation. Is it not logical to associate
disturbances of the maxillary sinus with the vari-
ous forms of nervous coryza. when it is remem-
bered that an intimate anatomical and physiological
relationship exists between this cavity and the nasal
passages in their nerve supply and mucous mem-
brane connections ?

In order to show the ground for believing that the
antrum forms an etiological factor in the causation
of hay-fever, I will quote in this connection the his-
tory of my first case treated in the manner herein de-
scribed : F. N. D.. aged forty-three years, lawver,
suffered from hay-fever for a period of twenty-five
years. Nine months before his first attack. lie sus-
tained an injury to the nose from a blow received on
the right side over the region of the maxillar\-

*Read at Denver. Colorado, February i6. 1907. before
the \Vestern Section of the American Laryngological, Rhi-
nological, and Otologica! Society.

sinus. This injury was followed by stenosis of the
left nostril, which at the time of my examination
twelve years ago, when he first consulted me on ac-
count of hay- fever, was found to be obstructed by
the presence of a deviation and exostosis of the
septum. The patient contended that the hay-fever
resulted from the traumatism, as prior to the inflic-
tion of the injury he experienced none of the symp-
toms peculiar to the disease. This occurred early
in the spring, and the attack of hay- fever came on in
the autumn of the same year. At the time of our
first interview (twelve years ago) his suffering was
intense and the symptoms of the disease were pro-
nounced, chief among which was an orbital cellulitis
of a serious character. With a view to lessening the
severity of the symptoms, I suggested correction of
the septal deformity as soon as the urgent symptoms
had sufficiently subsided to warrant operative inter-
ference. Removal of the exostosis and correction of
the deviation improved his respiration and general
condition ; but he still continued to suffer thereafter
more or less severelv from the disease during subse-
quent years. It was a common occurrence for him
to be incapacitated for work from six to eight weeks
out of the year, and he was left at the end of each
season in a state of general physical debility. In
the latter part of December, 1903, he be?an to com-
plain of facial neuralgia and severe pain over the
right superior maxillan,- bone. He consulted me
in reference to this trouble, and I found that the
antral cavity was very much disturbed, as was evi-
denced by the presence of offensive discharges in
the right nostril. The antrum was cleansed by irri-
gation through the opening communicating with the
nose. A warm normal salt solution was used. The
contents of the sinus as they appeared in the drain-
age basin, were found to be most offensive, the
discharge consisting of inspissated mucopurulent
material which had undergone fermentation and de-
composition. A number of similar irrigations at
different intervals succeeded in affording complete
relief both as to maxillary pain or tenderness and
the condition of the sinus itself. Of considerable
interest was the fact that the opening of the an-
trum in this case was extremly abnormal, as it was
possible to introduce a large-sized Eustachian cathe-
ter. This unusual openir • ^vithout doubt, by virtue
of its admitting readily into the sinus particles of
extraneous irritating or infective substances, con-
tributed in no small degree toward creating the dis-
turbance of w'hich he was suffering at the time.
Having known the man so well as a hay-fever vic-
tim in previous years, it occurred to me that, per-
haps, the diseased antrum and its abnormal opening
formed the basic lesion of his autumnal catarrh.
The suspicion that this might be so, ended in a mu-
tual understanding that when the next hay-fever
season arrived. I should treat the antrum for ex-
perimental purposes. About the middle of August
( 1904) he was seized with the usual symptoms of
the disease, but he did not visit me until tw'o weeks

845

MEDICAL RECORD.

[May 25, 1907

later, when he recalled our mutual arrangement.
During these two weeks he had suffered about the
same as on former occasions, and on the day of
his visit the S}-mptoms were well marked. I washed
out the antnim with a very warm solution of boric
acid, the return fluid from the cavity containing
quantities of retained and decomposed secretions ;
the syringing of the sinus was continued at each
sitting until the solution appeared -clear in the
catchbasin. These irrigations were followed by in-
jections of a warm 5 per cent, solution of mentho-
lated oil into the antrum. The next day the symptoms
had materially abated and I again treated him as on
the day previous. He did not return until two
weeks later, when he -^resented himself more for
the purpose of making a report than to be treated.
He said after the second treatment all the symptoms,
both local and general, disappeared. In 1905, he
p-ave the method a thorough trial. During the sea-
son, beginning August 15, he was treated on five
different occasions every other day and thereafter
once a week, which treatment had the desired effect,
and his suffering as compared with other years
was minimized to such a degree as to render him
absolutely comfortable. As the mentholated oil
was rather pungent and painful, it was abandoned,
and in lieu thereof thymol iodide was substituted
and used in the form of an insufflation into the
maxillary sinus after it was cleansed with the boric
acid solution, thereby rendering the treatment more
tolerable and efficacious. The past year (1906) for
experimental purposes, the patient permitted me to
apply the treatment occasionally, with a view of see-
ing whether or not the hay-fever season could be
passed without the appearance of any of the symp-
toms. Once or twice a month during the year this
was done, and it is satisfactory to state that last
season ( 1906) the patient remained unaffected with
but one exception ; namely, one day he was making
researches among old, stored-away, dusty legal
books and pamnhlets, when exposure to the dust
brought on an array of nasal symptoms simulating
those of hay-fever, whereupon the patient imme-
diately came to my office for relief, and the antral
cavity was subjected to the same procedure as be-
fore, with the "ratifying result of at once eradi-
cating the trouble. Further experimentation will
be required to solve the problem of immunity not
only as concerns this case, but also others in which
similar results were obtained. Just now it is too
early to consider the question. It will be noted,
however, that I have spoken of the right antrum
only ; the left side having received no attention.
The patient's suspicion that the trauma twenty-five
years ago brought on the hay-fever may have some
foundation : the injury of the nose and maxillary
bone evidently had the effect of impairing the integ-
rity of the sinus and of the ostium as well, and the
history of the case and the results of treatment in
a wav strongly confirm this view. The patient
speaks of the treatment as follows: "The result of
these treatments has been surprising and most grat-
ifying. I have passed through the hay-fever season
W'ithout any annoii'ance whatever. I have lost not
a moment's sleep. I have not been incapacitated
for business in any wav. I have attended the the-
ater, taken long drives in the country, and long
walks in the woods and fields, things not to be
thought of in seasons past. In fact, I have escaped
all annoyance and distress incident to hay-fever, and
feel that hereafter I shall be at once relieved and
need no longer dread the hay-fever seasons."

^^"e have presented in this instance an example

furnishing facts as related to hay-fever, that are
worthy of recognition and serious reflection with
rep^ard to the etiology of the disease. The history
of the case and the results of treatment almost con-
clusively demonstrate that the antrum was primarily
at fault and formed, as it were, the basic lesion.

The Ostium Maxillare. — The '^ivotal point of the
antral theory of hay-fever is the ostium maxillare.
The anatomic condition and location of the orifice
of the antrum determine the etiological and patho-
logical features of the part played by the maxillarv
sinus in the production of hay-fever phenomena.
Generally speaking, the antrum of Highmore is
practically a sterile cavity, particularly, so long as it
remains uninvaded by active pathogenic germs, but
when irritation or infection is present, it will be seen
by investigation that a supplementary or a mal-
formed opening of the antrum exists, and funda-
mentally contributes to the sources of irritation or
infection of the sinus.

Bacteriologists may say the antrum is not sterile,
for the reason that various bacteria are always pres-
ent in the nasal passages with which the sinus com-
municates. In the main this is true, but are they
not inactive germs? When it is taken into account
that the ostium maxillare in a strictly normal sense
is of definite construction, and by virtue of its loca-
tion has but one function, namely, that of supply-
ing air to the antrum and guarding its integrity
against the entrance of infective or irritating agents,
it is altogether natural to consider it sterile, in spite
of the presence of nonactive bacteria. As soon,
however, as the ostium deviates in size and course
from what nature desifrned it to be, then the antral
cavity may at any time become subject to the action
of morbific influences. Reasoning from analogv it
can be argued that, if the middle ear or cavum tym-
panum is practically sterile, in the absence of germ
activity, despite its communication through the
Eustachian tube with the nasopharynx, the maxil-
lary sinus for like reason is entitled to the same
consideration. Therefore it would seem that the os-
tium ma.xillare bears the same relation to the maxil-
lary sinus as does the Eustachian tube to the cavum
tympanum, and consequently to maintain normal
integrity of the respective cavities, no alteration of
the tubes or ducts should exist.

The normal opening of the antrum is intricately lo-
cated with reference to anatomical landmarks which
are not constant and often make exploratory pro-
cedures difficult or impossible. Situated in the
middle meatus underneath the middle turbinated
body and at the posterior end of the hiatus similu-
naris. between the uncinate process and the bulla
ethmoidalis, the openine of the antrum is more or
less concealed. \\'e can readily understand how un-
due development of the bulla and of the uncinate
process mav contract the semilunar hiatus and in-
crease the amount of concealment, thus rendering
the ostium absolutely inaccessible. It has been
shown by Hajek that the opening of the antrum is
not constant as to size in all individuals. The normal
ostium is about 2 mm. bv 3 mm., and leads to the
maxillary sinus in a direction downward, sharply for
ward and outward. It would seem that the obscure
location of the ostium and its tortuous direction, so
to speak, indicate nature's design with regard to the
function of the opening. In my opinion it has but
one function and that is to supply the antrum, a
pneumatic cavity, with air. In a perfectly normal
state, it is very doubtful whether it was ever in-
tended to serve the purpose of a drainage canal : its
very location favors this opinion when viewed from

May 25, 1907]

MEDICx^L RECORD.

843

a physiological standpoint. The openina: exists at
the extreme upper part of the nasoantral wall in the
region of the middle meatus of the nose where the
inspired current of air reaches the channel and an-
tral orifice in full volume, and thereby ventilates
the antrum. This physiological principle furnishes
abundant reason for the location of the ostium, and
it is only on abnormal or pathological grounds that
tlie oritice can be safely regarded as a drainage
canal. The question is sometimes asked : How is it
possible to wash out or irrigate the antrum through
the normal opening? It is not possible to do so.
It is practicable only when the opening is abnor-
mally large or when there exists a supplementary
communication between the nose and the antrum.
When the opening of the antrum deviates from its
normal dimensions (2 mm. by 3 mm.) and departs
from its natural course, it no longer sustains its
primary relation, but becomes an avenue of com-
munication, fraught with morbid influences produc-
tive of antral disturbances.

In certain instances on dissection the opening has
been found to measure in its anteronosterior diam-
eter as much as 18 mm. (Turner). Where so great
a change, or even less, in the diameter of the os-
tium takes place, it may be concluded that the course
of the duct is also changed and proceeds more
directly toward the antrum than otherwise. This
variation undoubtedly is due to anatomical defects,
or, in cases of sclerosis of the nose, to atrophic
changes of the tissues.

There frequently exists a supplementary or ac-
cessory opening of the antrum, and, according to
Zuckerkandl, it may be present in 10 per cent, of
cases. Logan Turner found it to be present four
times out of nine dissections, while Douglas says it
occurs in 50 per cent, of cases and clinical observa-
tions confirm the statement of the last-named au-
thority. These statistics are important and shed
considerable light on the antral theory of hay-fever
and catarrhal maxillary sinusitis.

The location of accessory ostia is usually above
the inferior turbinated body at the junction of the
middle with the posterior third of the bone on a
line without and below the posterior end of the semi-
lunar canal. They occur in the membranous por-
tion of the nasoantral wall and range in size from
the head of a pin to 8 mm., and sometimes more
than one exists on the same side ; but whether these
accessory openings are formed during the develop-
mental period of the antrum or whether they are
mainly due to disease or trauma, is not fully under-
stood.

Taking into consideration their varying dimen-
sions and the frequency with which they occur in
a given series of cases, the supplementary openings
of the antrum form a conspicuous part played by
the maxillary sinus in the production of the disease
under consideration. Further than this, they oc-
cupy a favorable position in the middle meatus for
the accomplishment of exnloratory and therapeutic
ends. In the presence of these anatomical nas-oantral
irregularities, so far as they nertain to the orifice
of the antrum, it is not difficult to comorehend the
vtodiis operandi of the various extraneous exciting
agents peculiar to the induction of hay-fever, and
for the same reason it is not hard to understand
how a catarrhal maxillary sinusitis produces hyper-
secretion of the cavity and in turn provokes nasal
irritation and nervous coryza.

A comparative study shows that as to size the
antrum varies in different individuals. It is lined
by mucous membrane consisting of ciliated epithe-

lium and a rich distribution of muciperous glands,
and it is, in part at least, analogous to that of the
nasal fossje.

I. Gasserian ganglion. 2. Ophthalmic division. 3. Superior ma.xil-
lary division. 4. Inferior maxillary division. 5. Meckel's ganglion.
6. vidian nerve. 7. Pharyngeal nerve. 8. Posterior palatine g.
Middle palatine. 10. Anterior palatine. 11. Inferior nasal, la.
Nasopalatine. 13. Superior nasal. 14. Posterior dental. 15. An-
terior dental. 10. Labial. 17. Nasal, and 18. Palpebral: on external
aspect. 19. Orbital. 20. Large petrosal. 21. Carotid. 22. Carotid
plexus of sympathetic. 25. Anastomoses of anterior, posterior, and
superior nasal branches to supply antrum. 24. Ganglion of Boch-
dalek. 25. Facial nerve with geniculate ganglion.

Xcrve Connections. — The antral mucosa receives
numerous sensitive nervous filaments given off by
the superior maxillary division of the trigeminus,
and it is also abundantly supplied by secretory ner-
vous fibers. The anterior dental, the posterior den-
tal, and the superior nasal from Meckel's ganglion,
form the nervous supply of the antrum (Gray).
Sympathetic fibers come from the Vidian, com-
Ijosed of the great petrosal and carotid. The caro-
tid forms a connection between the carotid plexus
of the sympathetic and Meckel's ganglion. Nervous
filaments are given off from the lower border of the
posterior dental which forms a minute plexus on
the outer wall of the superior maxillary bone imme-
diately above the alveoli. From this plexus, fila-
ments are distributed to pulps of molar and second
bicuspid teeth, the lining membrane of the antrum
and a corresponding portion of the gums. The
anterior dental is given oft' just before its exit
from the infraorbital foramen ; it enters a special
canal in the anterior wall of the antrum and anas-
tosmoses with the posterior dental and superior
nasal branches. From this nerve some filaments are
distributed to the incisor, canine, and first bicuspid ;
others are lost upon the lining membrane covering
the fore part of the inferior meatus. In this situa-
tion it forms a connection with a nasal branch
from Meckel's ganglion called the ganglion of Boch-
dalek. From Meckel's ganglion are branches (de-
scending or palatine) sup|ilying the lining mem-
brane of the nose. It has three sets of fibers : motor,
sensory, and sympathetic. Internal branches are
distributed to the septum, and outer wall of the
nasal fossa ; one branch ( posterior) is distributed
to the outer wall of the antrum and forms a com-
munication with the anterior dental in the ganglion
of Bochdalek.

From this we see the antrum to he abundantly
supplied with nerves. The posterior dental, an-
terior dental, and the branches from Meckel's gan-
glion give motor, sensory, and sympathetic fibers
not less to the antrum than to the meati of the nose.
Irritation of these fibers in the antrum is not only
capable of producing the sensory and sympathetic
disturbances seen in hay-fever, but neglect to re-
lieve the antrum from sources of irritation and dis-
ease explains the discouraging failure to cure the
condition by operative and other theranv upon the
nasal cavities. Moreover, the continued irritation
of these sensory and sympathetic fibers is capable
of establishing in those of unstable nervous organ-
ization that distressinp- chain of neurasthenic symp-
toms which are the secondarv and coincident con-

844

MEDICAL RECORD.

[May 25, 1907

ditions in most cases, for under emotional and mor-
bific influences a reciprocal relationship between
the sympathetic and central nervous system exists.
In hay-fever the sensitive nerve endings present in
the antral and rhinal cavities are kept in a state of
excitation as a result of local irritation.

Pathological Connections. — The maxillary sinus,
apart from its orifice, is a closed cavity where
warmth and moisture have ample chance to en-
gender fermentation and generate bacterial prod-
ucts. Its mucous membrane is continuous with that
of the nasal passages through the ostium maxillary.
This arrangement, under abnormal anatomical condi-
tions, with regard to the nasoantral orifice, forms
the pathological connection between the antrum and
the nose, and shows how readily an inflammation
of the antrum can reflect itself to the nose by ex-
tension or by irritation consequent to its discharg-
ing contents. In hay-fever, the secretions arising
from inflammation of the antrum are the source of
the vasomotor nasal disturbances and the associated
reflex svmptoms, which are relatively augmented or
diminished in proportion to the quantity and irrita-
tive properties of those discharges.

The query arises, how does the antrum get rid
of its fluid contents when hypersecretion in the
cavity obtains? In the first place, gravity performs
an important part in the function. Various posi-
tions or movements of the head favor the exit of
the secretions. In the second place, it is demon-
strable that the act of respiration or of blowing the
nose drains the cavity by a process of suction. The
peculiarly favorable position of the accessory or
malformed ostium, as it is related to the middle
meatus and the middle and upper turbinated bodies,
makes drainage possible in the manner described. I
have frequently observed that after washing out the
sinus for therapeutic purposes, the fluid was thor-
oughly evacuated bv the time the patient had fin-
ished blowing the nose, as was illustrated by the
use of the air bag, and insufflation of medicinal
powders.

With regard to the so-called extraneous exciting-
causes of hay-fever, such as pollen from weeds,
grasses, and flowers, odoriferous emanations, dust,
certain drugs, etc., etc., how are they related to the
antral theory of the disease ? Is it not possible, and
is it not a fact, that these external excitants, after
reaching the nasal passages, enter the antral cavity
and through their action induce hyperemia and
catarrhal inflammation productive of hypersecretion
and. in cases of chronic preexisting antral disease,
intensify the activitv of the lesion ?

I am of the opinion that when the communication
between the nose and antrum is absolutely anatom-
ically normal as to size and situation, disturbances
of the character mentioned are not likely to take
place in the absence of alveolar or dental irritation,
but in instances in which the ostium is abnormally
large, or in which there is an accessory opening, an
avenue is created for the favorable entrance into the
cavity of extraneous irritative or infective sub-
stances by air in motion or the act of respiration.
Thus we can readily see how these foreign sub-
stances can enter and lodge in the antrum, induce
irritation and infection, and give rise to inflamma-
tion which usually is secretory in character. Funda-
mentally speaking, the whole theory rests on ana-
tomical abnormalities.

In 1904 Emanuel Fink, Hamburg, Germany, in
a contribution, drew attention to the antrum of
Highmore as furnishing the probable source of the
disease, and successfullv treated it in accordance

with these views. In support of the antral theory,
I'ink quotes Helmholtz, who himself was a suiiferer
from the disorder, and ascribed the affection to the
influences of certain vibrios contained in the secre-
tion of the nose, thrown oflE by violent attacks of
sneezing, while, on the other hand, Helmholtz con-
tended that a secretion which passed from the nasal
passages, drop by drop, did not present the vibrios ;
they were lodged in the variously hidden recesses of
the sinuses of the nose. It is maintained that even
if the vibrios could not be regarded as a specific
form of disease, Helmholtz's observations would
prove that the secretion must come from the sinuses,
especially from the antrum of Highmore. Sneez-
ing, a constant accompaniment of hay-fever, is, ac-
cording to Sandmann, the result of irritation of
the ethmoidalis nerve. This irritation may be
caused either directly through the agents contained
in the inspired air, or indirectly through the secre-
tion flowing from the antrum. Concerning asthma,
it has been shown by reliable authority (Francois,
France, and Lazarus), that through excitement of
the nasal mucous membrane, spasm of the bron-
chial muscles can be produced reflexly. Recent
ph\siological researches show that the mucous mem-
brane of the antrum of Highmore when disturbed
stands in the same relation to bronchial spasm as
does that of the nasal passages.

It is no longer questioned that a number of re-
spiratory, as well as associated diseases, are both
directly and indirectlv due to sinus affections ; for
instance, the source of nasal polypi, headache, oph-
thalmic disorders, chronic rhinitis (atrophic in par-
ticular), mental derangements, trifacial neuralgia,
odontalgia, bronchial asthma, etc., etc., is often ca-
pable of such demonstration by operative and other
measures.

Neurasthenic Aspects. — Earlier as well as more
modern writers maintain that hay-fever is a neurosis
and in display of symptoms perhaps it may be true,
as the nervous characteristics of the disease largely
form the symptomatolo.sr^-. and, in fact, it is this
feature of the affection that gives rise to the trouble-
some complications with which the physician is
called upon to contend. Do the nervous manifesta-
tions constitute the disease, per se, without the ex-
istence of a primary lesion? It is hardly logical to
assume such a position, when it is known that patho-
logical states involving other organs of the body
are often responsible for the presence of neuras-
thenic symptoms.

When the late Dr. George M. Beard introduced
into our medical nomenclature the term neuras-
thenia, he did not intend that the use of the name
should be applied to diseased processes inducing
a group of peculiar nervous symptoms hitherto mis-
understood, for the purpose of disguising erroneous
diagnoses or concealing sins of omission and com-
mission. He maintained that these neurotic s}Tnp-
toms sprang from definite, tangible causes, and that
bv grouping them together under one general des-
ignation he thereby would give them a special sig-
nificance : for instance, when they accompanied a
gastric disease, it was termed '"gastric neurasthenia."'
and when associated with a disturbance or abuse of
the sexual organs, "sexual neurasthenia," and so
on. Therefore, with the same propriety, the neu-
rotic phenomena attending nasal nervous catarrh,
due to sinus origin, may be called sinus neuras-
thenia. There has always been a tendency to em-
nhasize the importance of the nervous symptoms of
hay-fever : this is exemplified by the many different
forms of treatment adopted with a view to meet

May 25, 1907]

MEDICAL RECORD.

f^45

symptom emergencies only, while its organic phase
is lost sight of or not inquired into.

There are those also who contend that the nervous
features are partly imaginary. Few ailments of
the body can justly be ascribed to the power of the
imagination alone. Under extraordinary circum-
stances, perhaps, such a belief is tenable, especially
when hysteria is present, but it is not infrequent,
however, that on closer scrutiny of existing condi-
tions as to origin, a hidden morbid state, regardless
of its location, is often found in given cases to be
at the bottom of the hysteria.

In hay-fever subjects where a nervous state of
the individual predominates, causal factors oui^ht
always to be considered, because if the neuras-
thenia is a secondary factor, and simply constitutes
a reflection of disturbed nervous harmony or equi-
librium, induced by distinct lesions acting directly
or indirectly on an unstable central nervous sys-
tem, the solution of the problem becomes easier.
It is also true that certain basic conditions of disease
are capable of creatine in patients of nervous insta-
bility, a special susceptibility to exciting causes.
These persons are those of idiosyncratic tempera-
ment, so-called. 1 believe this to be the case in
hay-fever, the phenomena of which are ascribed by
some authors to a special idiosyncrasy. In other
words, the idiosyncrasy is the result of tnorbid cen-
tral evolutionary processes, in which the svmpathetic
and vasomotor nervous systems play a conspicuous
part in establishing the hay-fever predisposition.
External excitants are only contributory factors and
hold a subordinate pnDsition in etiology, and excite
into action a lesion over which they exercise an
influence. Internal disease must be present in order
to enable impressions to exert their effects on
the central nervous system.

Hav-fever belongs to this category of neuroses.
It is a general observation that diseases, hampered
bv obscurity respecting their fundamental sources,
always make rational therapeutics difficult ; for this
reason the physician is not infrequently called upon
to make an uncertain diagnosis and employ a symp-
tomatic therapy in order to satisfy the patient, and
in so doinfT he himself unfortunately becomes satis-
fied and makes no further research. From the pa-
tient's point of view and demands, not a few symp-
toms of the disease require special attention, thus
increasing the number of remedies for purposes of
alleviation. A multiplicity of remedies will, how-
ever, become necessary, when we once fully under-
stand the source of the disease and adapt our reme-
dial measures accordingly and pay less attention to
individual symptoms.

^^'ith reference to the so-called sensitive areas of
the nose, acting as etiological factors of hay-fever,
anatomicalb- considered, they consist of a localized
distribution of sensitive nervous filaments in certain
parts of the nasal mucous membrane. Under local
stimulation or irritation they are readilv excited :
thev ser\'e both physiological and pathological pur-
poses and their degree of sensitiveness normally
varies in dififerent individuals. Phvsiologicallv tliev
serve as safeguards to the upper air tract, but on
the other hand, by oft-repeated and prolonged local
irritation, the sensitiveness increases with a result-
ing hyperesthesia, which in turn becomes a pathol-
ogical condition. Hyperesthesia of the nasal passages
thus appearing is prone to lead to functional de-
rangement of the sympathetic nervous system, and
induce reflex s\Tnptoms and vasomotor disorders,
such as coughing, sneezing, nasal fullness and dis-
charges, tinnitis aurium, etc., etc. Though charac-

terized by a neurotic physiognomy, it is nevertheless
contended that the disease may be primarily or-
ganic, and that a pathological state of the antrum of
Highmore, so far as my present observations and
experiments extend, is the seat of the chief etio-
logical lesion. Personal experiences demonstrate
the theory in a practical way and set aside the illogi-
cal conclusion that the neurasthenia constitutes the
malady. Errors are sometimes committed, by
hastily formed conclusions with regard to the im-
mediate cause of a sudden onset of the disease, as
is instanced by the celebrated case of "rose-cold," or
hyperesthetic rhinitis, which was presumably pro-
duced bv the presence of an artificial rose, reported
some years since, and which account is still fresh
in the minds of many rhinologists. This singular
circumstance will continue to be referred to when-
ever discussions arise with reference to the causa-
tion of hay-fever. Is it not possible that the arti-
ficial rose served only a coincident circumstance pe-
culiar to the situation during the patient's visit?
The history of the case is not sufficient to strengthen
the argument in favor of "suggestion" as related to
hav-fever, because a series of cases similarly
afifected would be required to give scientific value
to the observation.

The will has a definite power over the operations
of the body, both in health and disease, but psychic
influence, however, must not be overestimated in
its control over the physical organization. It no
doubt serves a valuable purpose under extreme cir-
cumstances, as when faith in what is being done
for the relief of suffering is exercised, because then
an element of expectancy is introduced into the
treatment, and the mind is thereby put at rest, and
nutrition of the nervous system is reestablished and
physical forces reassert themselves. This we see
illustrated sometimes in physical ailments as well as
in mental conditions of grief, fear, or undue anxiety.
.\s applied to the induction of organic disease, psy-
chic doctrines should not be too enthusiastically
considered in these days of scientific medicine, as
their supposed miraculous power in great measure
is a relic of past ages. In the days when medical
empiricism prevailed and the physician had no
patholog}- and only a meager etiology to govern
him in the selection of his remedies, there was some
color of reason for such doctrines.

In the consideration of the alleged mental aspect
of the disease the foregoing statements have been
made, because hay-fever is not a disease of the
mind ; it is a disease under the domain of cause and
cft'ect, and in all probability, due to an organic
lesion in which the antrum of Highmore is an im-
portant contributory factor.

Description of Cases. — As tre limits of this paper
will not permit a detailed account of each and every
case under observation and treatment during the
past three years, I will confine myself to descrip-
tions of salient points developed in the experience in
order to illustrate as specifically as possible the
intimate connection between the antrum and hay-
fever. In the period mentioned, there were under
mv observation ninety-one cases of hay-fever and
rose-cold in varying degrees ; two were treated in
1904, fifteen in 1905, and seventy-four in 1906, with
uniformly good results. To justify myself against
possible criticism, I said to each new patient, that
while I firmly believed the treatment logical, yet the
method was an experiment, and, apart from safety,
no promises would be made as to the outcome. The
results realized during the first two years were
sufficiently satisfactory to encourage further inves-

846

MEDICAL RECORD.

[May 25, 1907

ligations in a more extended manner, wherefore in
the past year an especial effort on tlie part of some
of my professional friends and myself was made to
bring under observation as many instances of the
disease as was expedient, whereby the gist of the
theory could be verified.

Accessory Ostia and Typical Symptoms. — Mrs.
B., aged thirty-three years, wife of a physician and
mother of eight children, consulted me about eigh-
teen months ago, with reference to hay-fever. She
was of lithemic diathesis and suffered at times from
intercostal and facial neuralgia. She contracted the
disease in .August, 1895, and has been a yearly suf-
ferer since then with progressively greater severity ;
a dry, dusty day, a shopping tour, or smoke, suf-
ficing to bring on an attack ; the most troublesome
symptoms being sneezing, hydrorrhea, pain in the
nose, and asthma. At the height of the attack there
were usually present excessive lacrymation. burn-
ing, and itching sensations of the eyes. Vriar to her
consultation with me, she had tried various reme-
dies, such as Dunbar serum, adrenalin, cocaine, anti-
lithemics, and many others ; and besides these, intra-
nasal surgen.- was employed for the reduction of
hypertrophic and other irregularities of the nose,
with the hope of overcoming the affection, all, how-
ever, without obtaining relief. Examination of the
nose revealed an intensely red, swollen mucous
membrane of both sides, which was very sensitive,
as evidenced by violent refiex disturbances when
the sound was used. The middle meatus on the left
side around the orifice of the antrum was engorged
and hypersensitive, whereas the right side in this
respect was not involved in the same degree. After
reducing the sensitive and swollen membrane by
applications of cocain and adrenalin, thereby im-
proving the local field of vision, I found by sound-
ing that the opening of the antrum was supple-
mentary and very large, and therefore concluded
that this case came within the purview of the antral
theory, and about the latter part of that season,
treated her accordingly. After the first treatment,
the eye, throat, chest, and severity of the nasal symp-
toms practically disappeared within twenty-four
hours, and it is interesting to note that the patient's
first night was passed comfortably, and upon a sec-
ond application, within a very short time all the
signs of the disease were dissipated. Prior to
the treatment, she was unable to attend thea-
ters, go shonoing. or come in contact with hot
winds or dust, or drive where exposed to weeds,
without suflFering discomfort or being compelled to
remain in her room with closed doors and windows,
and in order to test the theory, the patient attended
the theaters, went shopping, and withstood the ac-
tion of the elements and contamination of weeds,
with the result that she slept well, felt no discom-
fort therefrom, and her asthma entirely left her.
The malformed ostia favored instrumentation, as it
was quite jiossible to introduce the cannula of the
syringe or powder blower into the antrum. Appli-
cations of a warm solution of boric acid in the form
of injections, removed from both sinuses an un-
usual amount of retained secretions, suggesting in-
flammation and hvnersecretion. Mrs. B. continued
well until housecleaning time arrived, when she was
exposed to dust and odors from new grass-matting
on the floors, an environment which in the past was
always accompanied by an array of hay-fever symp-
toms regardless of the time of year, thus showing
that some certain organ associated with the nasal
air tract was implicated in the morbid process and
formed the basis of disturbance on the?e occasions.

owing to irritants acting from without. Between
the season of 1905 and 1906, at the suggestion of
her husband, a physician, Mrs. B. visited me at
stated intervals for purposes of treatment to see
whether the oijinion that the ma.xillary sinuses were
organically involved in the production of these
symptoms, could be verified. The antra were regu-
larly cleansed at intervals and afterwards medicated
with an application of thymol iodide or a 25 per
cent, solution of silver salt. Thereafter she fre-
quently tested herself and found that she could ex-
pose herself to irritants, dust, and odors, with im-
punity. The past hay-fever season went by without
much trouble, only one attack lasting about four
days manifesting itself, and further treatment at this
time being impossible owing to the delicate con-
dition of the patient. She has since declared herself
well and is perfectly able to go about and attend to
her usual duties.

Asthma. — September, 1905, Air. W., aged forty
years, a furrier, constantly exposed to dust and odor
peculiar to his occupation, was referred to me on
account of asthma contracted two and one-half years
previously, and which from its inception has in-
creased in intensity both day and night. Upon
careful examination, and beyond a periodic dis-
charge from the nose, I was unable to find the pres-
ence of the usual lesions of the nose which would
account for the paroxysms. There were no intra-
nasal deformities or pressure contact and the only
suggestion that the nose might have been responsible
for the attacks was an intumescent thickening of
the mucous membrane of the septum directly oppo-
site the middle turbinate bodies, which fact was
taken into consideration as a causative factor. I was
of the opinion that the case was one of bronchial
asthma, produced by the inhalation of fur dust, and
with this view he was advised to keep away from
his occupation, be exposed to the open air as much
as possible, e.xercise judiciously, and take the medi-
cine prescribed. Iodide of potassium alone, as well
as in mixtures containing other antiasthmatic agents
was faithfully tried without avail, and in fact al-
most the whole category of remedies recommended
for the cure of asthma was resorted to in the course
of time, with negative results. Concluding that con-
stitutional treatment was a failure, the patient was
given local treatment accompanied by intrabronchial
injections of warm mentholated oil, and while this
procedure yielded partial relief it did not cure him.
The hypertrophied tissue on the septum opposite the
middle turbinates was then cauterized, but with-
out results, and as I was at this time directing my
attention to the maxillary antra of patients afflicted
with hay-fever, it occurred to me that perhaps his
sinuses were affected by the entrance of dust or
other infection arising from the character of his
business and that similar treatment might dissipate
the asthma. I treated him accordingly, and it was
highly gratifying, and I found that the same sub-
stance came from the cavities as did from the hav-
fever subjects, that is. a flaky-white or milk-curdle
denosit. Upon receiving a visit from the man the
following day he greeted me with, "You struck it
this time; I had no asthma last night." At stated
intervals he was treated six or eight times. At
present writing the patient is free from asthma,
and, after obtaining relief, he resumed his business
and has been thus engaged ever since. I feel con-
fident he will remain permanently free until such
time, at least, as when the conditions of his environ-
ment may again disturb the sensitive nerve supply
and mucous lining of the maxillar\- cavities.

May 25, 1907]

MEDICAL RECORD.

847

Xciirasthciiia and Ncnviis Xasal Catarrh. — On
June 18, 1906, Mrs. A., aged forty years, the mother
of four children, came to me and stated that for
a number of years she had been afflicted with the
hysterical type of neurasthenia manifesting itself in
various ways. After a long continued course of
treatment by a gynecologist who entertained the
opinion that the nervous symptoms were due to a
diseased state of the pelvic organs, a nervous dis-
turbance of the nose developed. Later on hyper-
esthesia of the skin of the right side of the face,
extending down and over the shoulder and arm of
the same side, appeared. The throat and tongue
became involved, and she at first imagined that an
apple seed had buried itself in the tissues of the
right side of the throat and formed a focus of dis-
turbance. The symptoms were accompanied by
burning and itching of the mucous membrane, eyes,
mouth, tongue, and throat, which still existed when
she consulted me. There were present frontal and
occipital headache, frequent paroxysms of sneezing,
and excessive discharges of the nose, restless nights,
and loss of appetite. Evidences of impaired nutri-
tiOii and a feeling of melancholia which so often
accompanies these conditions, existed in a marked
degree. Coupling the signs of nervous nasal ca-
tarrh with these general nervous manifestations, it
occurred to me that the chief causal factor of the
complaint was of sinus origin. On examination of
tlie nose, I found turbinal hypertrophy, hyperes-
thesia, and soggy appearance of the mucous mem-
brane. The report of this case is not presented as
one of genuine hay-fever. It is offered as an admi-
rable illustration of a type of neurotic afifections of
the nose known as nervous coryza, characterized by
a significant display of neurasthenic phenomena,
strongly resembling the symptoms of hay-fever and
coming from the same organic lesion located in the
antrum of Highmore. Sounding the maxillary
sinuses with a probe developed painful sensations
in the middle meati. In fact, the whole interior of
the passages of the nose was hyperesthetic and made
the use of the instrument almost unbearable. In
order to reduce the swollen mucous membrane and
render instrumentation of the sinuses possible,
adrenalin and cocaine were applied. The cavities
were cleansed with a syringe and warm boric acid
solution. From the left cavity came a fluid (four
drachms in quantity) resembling buttermilk, while
the right discharged a seromucous secretion. An
interesting circumstance in connection with the case
is that about nineteen years ago, Mrs. A. was struck
on the right side of the nose and in consequence
suffered total loss of the sense of smell as well as
periodic attacks of intense facial neuralgia and pain
in her upper teeth. Percussion over the cheek in
the region of the antra elicited pain in the deeper
structures. The patient was regularly treated for
about two weeks and it is interesting to note that
the sense of smell has returned in an exaggerated
form ; the nasal, head, and throat symptoms as well
as the hyperesthesia of the skin, are dissipated and
the improvement in every way is marked. She is
now able to sleep all night ; her appetite has re-
turned ; her mentality is changed, and the neuras-
thenic phases of the case have disappeared. Xo
medicines except those used in the local treatment,
were prescribed.

Test Case- — One man in particular. Mr. D., cap-
italist, consulted me seven days before the date of
his periodic attacks of hay-fever, which always
had been on August 7, to find out whether or not
something could be done to prevent his having the

disease. He informed me that he suffered severely
for many years and that it rendered him perfectly
miserable and melancholy for at least two months
during each season. In fact, his mental condition
was of such a character as to cause him to stay in
the attic of his residence day and night in order to
get away from fancied atmospheric influences of
hay-fever. As he was urgently advised to see me
by Mr. D., whose case is quoted at the beginning
of this article, he came not wholly without confi-
dence. Examination showed large accessory ostia
on both sides and the maxillary sinuses catarrhally
affected. The malplaced ostium and the readiness
with which it could be entered, made me feel that
the case was highly amenable to treatment and 1
so expressed myself to him. Treatment was begun
on the same day of the examination and continued
daily for some time thereafter for the reason that
he looked upon it as a luxury. Results : The sev-
enth day of August arrived, and no sign of hay-
fever; the eighth, the ninth, and the tenth were
likewise negative. About the eleventh, out of curios-
ity, he tested himself by making a tour of one
hundred miles with an automobile through the
country where all the elements peculiar to the ex-
citing causes of the disease existed. The next day
he reported his experience and aside from itching at
the end of the nose, he made no complaint. Upon
washing out the antra, however, I was amazed at
the quantity of milk-curdle secretions that appeared
in the catch basin. This evidenced valuable in-
formation with. regard to the fact that the antra were
undergoing an inflammatory disturbance and in a
lirief length of time would have ushered in an array
of hay-fever symptoms through nerve irritation ;
insufflation of thymol iodide, however, arrested the
process and no trouble came from the e.xposure. For
a further test this same experiment was resorted to a
number of times during the season, but nothing
came from it to mterrupt the comfort of the pa-
tient, except an occasional itching of the end of the
nose.

Antral z'S. Dunbar Treatment. — Mr. S., aged for-
ty-five years, teacher, a victim of hay-fever for seven ■
years ; symptoms, sneezing, nasal discharges, cough-
ing, and severe paroxysms of asthma. He first
visited me August 10, 1905, at which time the Dun-
bar serum was prescribed in powder form and was
continued until September 6, without effecting any
benefit, and during this visit the antral method was
recommended and applied, with the result that the
asthma disappeared within the first twenty-four
hours and after several subsequent treatments,
and within a week he was able to follow
his profession without any inconvenience and
considered himself practically cured. At the
beginning of the hay-fever season and about
the first of August, 1906, while upon a busi-
ness trip through Ohio, he was taken seriously
ill with the disease, and, upon his arrival at his
destination, he was again given the Dimbar serum
treatment which was continued for about ten days
and until his arrival in St. Paul, when he presented
himself at my office. I found him suffering from
his former usual symptoms, and asthma in partic-
ular. On request of the patient, I again applied the
antral treatment, with the resiflt that within one
week he enjoyed perfect reUef.

Large Sxtt'plcmcntary Ostia. Deep Antral Cavi-
ties, and Decided Neurasthenia. — Dr. ^^^, aged
thirty-two years, neurotic temperament, good family
history, came to me September last, complaining of
neurasthenia, restless nights, stenosis of the nose.

848

MEDICAL RECORD.

[May

1907

paroxysms of sneezing, pain and congestion of the
eyes, asthma, and profuse discharges from the an-
terior and posterior nares : these symptoms, with-
out doubt, denoted an attack of hay-fever. Ten
years before, he experienced his first attack, and
suffered thereafter more or less severely. During
this time surgical procedures brought about bene-
ficial results, but as time elapsed their good effects
gradually disappeared, as damoness, drafts, dust,
overheated rooms, exposure of extremities while
asleep, and decided weather changes always induced
recurrence of the symptoms, regardless of the time
of year; the symptoms intensifying themselves only
during the hay-fever period, 'wherebv the suffering
was augmented. Four years ago the patient came
to me afflicted with one of these violent seizures
and I prescribed the usual palliative remedies then
in vogue, but accomplished nothing beyond tem-
porarv relief. On seeing him the past season he was
suft'ering unbearable tortures and the status of the
case at this time was as is outlined above. He went
East for the purpose of consulting with medical
authorities regarding his case, and after being in-
formed that his symptoms were largely imaginary,
he returned to the West dissatisfied and discouraged
with his Eastern experiences, and visited my office
ostensibly for antral investigation and treatment.
On examination I found the nasal passages unusu-
allv irritable and engorged, the mucous membrane
being soggy and edematous. After intranasal sensi-
tiveness and engorgement had been reduced by ap-
plication of cocaine and adrenalin, it became possible
to explore the location and character of the maxil-
lary openings. They were found to be supple-
mentarv, very large and readily sounded, and occu-
pied a position in the membraneous part of the naso-
antral wall rather near the upper border of the
inferior turbinated body. It was ascertained that
both maxillary sinuses were of unusual size and
had a capacity of six or eight drachms. The an-
trum on both sides was first washed out with a
normal salt solution, and as the retained secretions
proceeding from the cavity, mixed with the injected
solution, appeared in the catch basin, they presented
a reddish, muddy, and coft'ee-grounds aspect. Be-
cause of the unusual size of the antra, a certain
percentage of the injected fluid was retained, which
made it necessary to use the syringe in order to
withdraw the remaining contents which resembled
what was caught in the basin. This irrigating-
process was continued until the sinuses were thor-
oughlv cleansed. Injections of a 25 per cent, solu-
tion of a silver salt were then made and the patient
was requested to lie down and keep quiet for an
interval of an hour so as to give the antiseptic a
chance to remain in contact with the antral mucous
membrane in order to accomplish its ulterior pur-
pose. In this manner Dr. W. was treated for a
period of a week at intervals of a day, each subse-
quent visitation evidencing improvement. .A.mong
the first symptoms to subside was the excessive
nasopharyngeal discharge which always gave much
atjnoyance and interrupted the comfort of the pa-
tient at night when in the recumbent oosition. Next
to disappear was the asthma, and at the end of the
week the symptoms were entirely absent and the
patient considered himself cured. In order to prove
the i.icrmanencv of the results he afterwards took
fre'^uent drives in the country and exposed himself
to the exciting causes of the malady without recur-
rence of any of the symptoms. Chiefly to be con-
sidered in this instance, in their bearing on the
periodic nervous manifestations, are the various con-

tributory external causes, the accessory openings
and capaciousness of the maxillary sinuses, the high
degree of antral inflammation, and the character of
the hypersecretion of the cavities.

Preexisting Chronic Catarrhal Maxillary Sinusi-
tis and Hypercsthetic Rhinitis. — On October 29,
1905, a man, aged forty-six, contractor, consulted
me relative to excessive catarrhal discharges from
the nose, persistent coughing and retching spells,
regularly oresent in the mornings and usually after
breakfast, dyspeptic symptoms with loss of appe-
tite, and consequent decrease of body weight. This
state of phvsical impairment existed for a number
of years without apparent cessation. Twelve years
prior he was attacked by vertiginous seizures, the
dizziness lasting for long periods at a time. The
vertigo was thought by his nhvsician to have been
of stomachic origin. On examination of the nose
and postnasal cavities I found the former more or
less occluded by turbinal hypertrophies and the lat-
ter occupied by disagreeable, tenacious secretions ; a
mustv odor emanating from the air passages led me
to believe that the so-called foul breath was due to
the furred tongue and general gastric derangement.
With the idea in mind that perhaps the obstructed
nose had a great deal to do with the symptoms for
which he chiefl_\- sought relief, I reduced the intra-
nasal hyperplasia, which made nasal respiration
comfortable. The postnasal space was treated by
local applications of iodine and nitrate of silver pig-
ments, used interchangeably. This therapy in a man-
ner aft'orded some benefit, but not enough to satisfy
either myself or the patient. The morning retching
continued and the oft'ensive odor remained un-
diminished. During August last, after a long inter-
val between visits, he again saw me with the state-
ment that he had a severe "cold in the head," as was
manifested by nasal stenosis, sneezing attacks,
watery discharges from the nose, itching and burn-
ing sensations of the eyes and throat, and on in-
spection of the nose and taking into account the
symptoms presenting, I diagnosed it a clear case of
hay-fever. Inquiry developed that he had had sim-
ilar attacks in previous years, but he supposed they
were due to catching cold. At the time he came
under my observation on this occasion, I was ex-
perimenting on the antrum of Highmore in other
cases of hay-fever with regard to the relationship
existing between the disease and the maxillary
sinuses, ostensibly with the object in view to prove
or disprove the correctness of the theory. The con-
clusion irresistibly impressed me that this case
offered an excellent example for the purpose.
Sounding the antral cavities demonstrated the prac-
ticability of entering them through the nasoantral
opening with suitable instruments. It was discovr
ered by the method employed that an opening or
communication of the antrum in both nasal cham-
bers was present in the middle meatus at a point
posterior and inferior to the meatal termination of
the hiatus semilunaris : these openings proved to
be accessory ostia. This anatomical malformation
both as to position and size of the opening, a con-
dition frequently present in hay-fever subjects ac-
cording to my investigations, gave rise to the
suspicion that the maxillary sinuses w-ere diseased
and formed the basic lesion of the patient's trouble.
Both cavities were washed out with a normal salt
solution, the irrigation being continued until the
return fluid as it appeared in the catch vessel w-as
entirely clear and free from sediment or retained se-
cretions. The discharge thus forced from the antra
was not exactlv characteristic of what is usuallv

Mav

1907]

MEDICAL RECORD.

849

noted in hay-fever conditions ; it was offensive in
odor and peculiarly muddy and granular in appear-
ance, intermixed witli mucoid material. A bac-
teriological examination of a specimen revealed a
green bacillus, B. pxocyaiiciis. Six or seven con-
secutive treatments directed to both antra at inter-
vals of twenty-four hours had the desired effect
in curing the patient of his hay-fever. He grew
fond of the treatments because of the good systemic
effect produced, and after the hay-fever had disap-
peared, he wanted the treatment often and regularly.
It was not long until he remarked that the cough-
ing, vomiting, and retching had wholly disappeared
as well as the postnasal discharges ; his appetite and
digestion at once improved, his weight increased,
and the offensive odor was also brought under con-
trol and eradicated.

A point of particular interest so far as subjective
signs are concerned in antral disturbances of this
sort, is that those patients usually know when a
storm is brewing in the antral cavities, as is recog-
nized by a disagreeable, burning sensation in the
region of the middle meatus of the nose and in the
neighborhood of the ostium. The patient is always
cognizant of what is going on at these periods and
comes for a cleansing of the sinuses just as soon as
the nasal sensations indicate the necessity, and one
treatment usually suffices for a number of weeks.
Catching cold or exposure to dust are the chief ex-
citing causes in his case. The deductions are : First,
that the opinion is substantiated that one or more of
the associated sinuses of the nose when in a diseased
catarrhal state, is as a rule one of the chief causes
of so-called postnasal catarrh and its attending
symptoms; second, that the history of the case fur-
nishes a convincing argument in favor of the antral
theory of hay-fever; and, third, that an abnormally
large or an accessory ma.xillary ostium is a local an-
atomical predisposing factor in the etiology of ca-
tarrh and hypersecretion of the sinus.

General Remarks and Deductions. — The observa-
tion is borne out by this experience that in those
cases in which unusually developed abnormal open-
ings of the antra prevailed, the results of treatment
were more prompt and satisfactory than in those
where the abnormal dimensions of the communica-
tions were much less ; the former favoring and
facilitating instrumentation and the application of
remedies, and the latter increasing the difficulties.
The observance of this point offers a rational ex-
planation on atomic grounds for therapeutic fail-
ures. Dissections have shown that the antrum of
Highmore is a variable cavity as to its dimensions
in dift'erent individuals, and also that an anomalv
may sometimes exist, particularly as regards sub-
division of the sinus into compartments bv bony
walls or partitions.

It was also observed that "rose-cold" or "hav-
fever" of one or two seasons' existence in certain
individuals, yielded on an average to treatment
more readily than it did in those who had had the
disease for many seasons or where it extended over
a long period of time. It may be concluded from
this that as yet the antral mucous membrane
had not undergone permanent inflammatory degen-
eration or changes in those patients who thus were
readily cured. If this observation can be further
verified in the future, it certainly adds a valuable
factor to prognosis.

Of the whole number of cases heretofore referred
to, one was a total failure. Though treatment di-
rected to the antrum was faithfully followed for a
reasonable period, yet no impression could be made

and the symptoms refused to yield. The ostia were
abnormal in size and no difficulty encountered in
the use of the probe or cannula, but whenever a
fluid was injected or a powder blown into the an-
trum it was found to rebound instantly into the
nasal passage. Experimenting in different ways
with a view of forming some explanation for the
presence of an impediment, it was finally thought
that the sinus was anomalous, there evidently being
present a number of cavernous compartments. In
given cases, therefore, of catarrhal maxillary sinusi-
tis or hay-fever in which local malformations obtain
with regard to the location and size of the opening
of the antrum, anomaly of the sinus must also be
taken into account when dealing with a certain class
where insurmountable barriers to treatment arise.

Also of this number three did not respond for
lack of adequate treatment. Among the number
there were twelve who were entirely relieved within
a period of about two and one-half weeks and who
had suft'ered in former years six to eight weeks
each season, and the remainder were fully and com-
pletely relieved of the disease and its symptoms
in a week or ten days, and, in exceptional instances,
some in four days, treatment of the last two classes
having been administered daily.

My observation has been that the reflex symptoms
first to disappear were burning and other disturb-
ances of the eyes, pruritus of the throat and ears,
finally sneezing and discharges from the nose, and
last asthma and cough.

That chronic catarrhal maxillary sinusitis is a
morbid process productive of intranasal and post-
nasal catarrhal disturbances is not to be questioned,
when it is understood that, by directing treatment
to the antrum, many of these cases are relieved and
get well. The history of the last case quoted in
this paper is an illustration and corroborates the
opinion, and, other instances coming under the same
class can be referred to in detail as proving the
fact.

For bacteriological investigations specimens of
retained secretions were taken directly from the
maxillarv sinuses of a certain type of cases and
it was found that the green bacillus, B. pyocyaneus,
was present in 65 per cent, of the number. While
this indicates nothing conclusive with regard to
the role nlayed by the pyocyaneus bacillus, yet it
suggests further inquirv in this connection.

Will antral therapy prove productive of im-
munity ? In a certain class perhaps immunity can
be attained, provided a systematic therapy be ap-
plied to the antrum during the intervals between
seasons ; especiallv so in cases where degeneration
of the mucosa is not advanced or intractable and
where anatomical deviations are pronounced and ad-
vantageous with reference to the opening of the an-
trum.

Then again, in instances in which the antral cav-
ity cannot be reached via a nasoantral communica-
tion, one would be justified in making an artificial
opening with trocar and cannula into the sinus un-
derneath the lower turbinated body for therapeutic
purposes. Recently I adopted this method for the
treatment of catarrhal maxillary sinusitis in three
cases with excellent results following.

Considerable strength is added to the argument
by results attained from treatment that in instances
of asthma of antral origin, the irritation productive
of the bronchial spasm, primarily takes place in the
antrum. As has already been referred to in the
description of the nervous circle involved in the
creation of central nervous instabilitv. reflex and

850

MEDICAL RECORD.

[May 25, 1907

vasomotor disturbances of the upper air tract, the
mucous lining of the maxillary sinus is abundantly
supplied by sensitive nerve endings and secretory
nervous fibers to render it possible for such a phe-
nomenon to occur and give rise to the asthmatic
storm destined to follow.

It is not intended that the above statement should
convey the idea that all cases of bronchial asthma
organically arise from the antrum, but the opinion
is clinically demonstrated that not a few come from
this source and that when all other means are ex-
hausted as to cause and treatment the antrum of
Highmore should always be interrogated before
one's efforts should cease in ascertaining the founda-
tion of the disorder. Within the past month only,
and while this contribution was in course of prep-
aration, a man whom I had previously seen in at-
tacks of hay fever asthma, consulted me in refer-
ence to an obstinate and disabling attack of asthma
from which he was then suffering. I found the
nasoantral membranous wall of the left side of the
nose badly disintegrated and for the greater part
absent, thus forming an opening of unusual size
communicating with the sinus. No difficulty was
experienced in inserting into the cavity an instru-
ment one-eighth of an inch in diameter. The sinus
was washed out and the contents removed, followed
by injections of a 25 per cent, solution of silver.
Subsequent daily applications of a similar character
were made and in a week's time he was well. The
antiseptic had the happy effect of reducing the in-
flammation and checking hypersecretion of the
sinus.

In instances in which hypertrophic or polypoid
changes of the mucous membrane e.xist and induce
stenosis or intranasal contact, the condition should
be remedied as early as possible in order to modify
or lessen irritation and vasomotor disturbance of
the nasal mucosa, consequent to the action and ef-
fects of discharges proceeding from the antrum, due
to inflammation and hypersecretion of the cavity.

The same rule applies to defonnities of the sep-
tum narium. I frequently found that those cases
in which intranasal pathological irregularities had
previously been properly dealt with, the nasal and
refle.x symptoms of hay fever yielded more readilv
and permanently than otherwise to treatment di-
rected exclusively to the antrum of Highmore.
From the earliest days of rhinology to the present
time the fact has been generally recognized that
intranasal contact or obstruction is not infrequently
productive of serious interference in some form or
another with the function of respiration, and that
surgical intervention alone was sufficient to alle-
viate the difficulty.

It stands to reason, therefore, that to enhance
the efficacy of any line of treatment of the disease
under consideration all important intranasal ab-
normalities should be removed.

In conclusion I beg to say that in the presenta-
tion of this report I do not wish to overestimate my
observations or to appear too enthusiastic; I desire
simply to slate what my e.xperience has been and to
declare that, clinically, the antral theory of hay fever
and its allied disorder, asthma, has a basis for ex-
istence and recognition.

Deformity in Pott's Disease. — Eikenbary says of this
that : Cases seen before the stage of deformity should
nevei' be allowed to develop deformity. Deformities in the
acute or subacute stage can be reduced one-half or en-
tirely. Children under three years are best treated on the
bent gas pipe frame ; those over three years by a solid
plaster-of-Paris jacket. — Chicago Medical Recorder.

A CLINICAL VIEW OF ULCER OF THE
STOM.A.CH.*

By FEXTON" B. TfRCK, M.D.,

Out of all the tragedy in the life of the busy prac-
titioner, there can hardly be drawn a more pathetic
and discouraging picture than that of his relation-
ship to the patient suft'ering from ulcer of the stom-
ach. The uncertainty of diagnosis, the failure of
all his plans for the alleviation of his patient's con-
dition reflect in his countenance and conduct ; that
pinched, haggard face haunts his path of duty by
day and dominates his dreams by night ; the patient
himself, alternately urgent for relief and overcome
with despair, finally turns from the adviser and con-
fidant of many years, seeking other counsel ; while
the suft'erer's family, full of an.xiety long sustained,
demand help for the afflicted one, and alas ! how
often there has been no help.

But it seems to me the veil that has hitherto
clouded this most distressing and perplexing malady
is slowly but surely vanishing, and that at last
we have a fair working basis upon which to build
a solid and safe structure of etiology, diagnosis,
and successful treatment. It is not my purpose in
this brief address to survey the scientific field of
gastric ulcer, but to bring, if I may, a message of
light and hope from the laboratory, the microscope,
and the clinic, to that pioneer in the realm of medi-
cine— the man at the bedside.

Etiology. — For hundreds of years scientific men
have busied themselves with the question why the
stomach did not digest itself, even when in a physio-
logical condition. Stahl, more than two hundred
years ago. decided at the end of a long study of the
subject, that the protection of all living bodies from
self-destruction in the various life processes, was
due to "the sensitive soul," and reasoned that "in
any case the fermentation which takes place in the
alimentary canal is not an ordinary fermentation,
such as occurs in a merely compwund, nonliving
body, but a most special character is. impressed on
the change by the energy of the soul."

John Hunter, in a most learned dissertation on
"The Digestion of the Stomach After Death," in
1772, exnressed this same idea of the self-orotection
of all living bodies, but instead of "the sensitive
soul," he called the medium the "vital power."

So we see that for centuries investigators have
been diligently seeking, with the crude light their
day afforded, an answer to the same question we are
asking ourselves to-day, and the answer to which
will be a clear light upon the etiolo'^-- of gastro-
intestinal ulcer and a number of kindred diseases.

Dating from these investigators of old, two ideas
seem to have had their birth, the one expressed by
Stahl and Hunter, that ulcer was due to some gen-
eral or constitutional condition, and the other that
it was merely a local affair, to be treated locally.
Virchow expressed this second view in his hypoth-
esis that ulcer of the stomach was due to some
local vascular obstruction or aneurysmal dilatation
of vessels, and Cohnheim. Silberman and others fol-
lowed in the footsteps of the great pathologist by
attempting to cause gastric ulcer by such local dis-
turbances as the injection of laked blood or some
chemical, or by the infliction of some direct mechan-
ical injury to the gastric mucous membrane. All
these attempts were only ne^^atively successful, how-

*Read at the annua! meeting of the North Te.xas Medi-
cal .Association, at Dallas. December II, 1906.

May 25, 1907]

MEDICAL RECORD.

851

ever, since in nearly all the cases such ulcers healed
quite as promptly as would have similar injuries in-
flicted on any other part of the body.

In an earlier series of exhaustive experiments of
my own, long ago reported as having negative re-
sults, I gave to dogs increasing doses of mustard
oil, every two or three days, covering a period of
from nine to fourteen months. At the end of nine
months dog No. i died, and two months later dog
No. 2 died, but there was no ulcer in the stomach
or intestines of either. At the end of fourteen
months do? No. 3 was chloroformed, but while
there was dilatation of the stomach and chronic gas-
tritis, no ulcer was found in either stomach or in-
testines.

I then made a series of experiments on the hypoth-
esis that ulcer was due to systemic changes or
constitutional conditions, and in this series I con-
fined dogs and guinea pigs to exceedingly close
quarters for periods runnine to nine months, giving
Uiem little air, no light, no exercise, but an abund-
ance of food. All possible precautions were taken
in these experiments, by a comprehensive system of
sterilization, to prevent infection. I will not go into
these experiments further than to say that in a few
cases typical ulcer was formed, but in so small a
number of instances that the results were reported
as wholly negative, since I had not been able to di-
rect the results and had achieved my purpose appar-
ently by chance.

Aly last experiments, finally reported in a paper
read before the International Medical Congress at
Lisbon last spring, were likewise based upon the
hvpothesis that ulcer of the stomach and intestines
was due to general and not alone to local conditions.

These experiments were begun with the common
colon bacillus, because this is the organism found
normally in large numbers in the intestines, and
that which multiplies luxuriantly in catarrhal con-
ditions of the stomach. Cultures of the bacilli were
used, made up in bouillon of meat extractives, first
by injection directly into the circulation, but later
on they were fed to the animals with their ordinary
meat diet. In some cases the meat extractives were
increased until the total of the extractives fed
amounted to twice the amount in the untreated meat
they ate. The bacilli used for the cultures were
taken from the feces of patients with ulcer of the
stomach.

During the experiments observations were made
of the blood changes, such as the agglutinating,
hemolytic, and coagulating power, the bacteria in
tlie blood and stomach, the systemic disturbances,
the evidences of infection, and the symptoms of ulcer
such as pain, hemorrhage, etc. The serum a"'""Iutin-
ated colon bacilli in high dilution, the normal pro-
tective influences were reduced, the opsonic index
was below the normal, the coagulating time of the
blood was slower ; but at no time were colon bacilli
found in the blood, nor were the systemic disturb-
ances great. . I have covered the field of these ex-
periments so fully in my former paper, which is
reported in the proceedings of the International
Congress, also in the Joiinia! of the American Med-
ical Association for June 7, 1906. that it will suf-
fice here to say that every animal employed in the
experiments developed a typical ulcer of the stom-
ach, without round cell infiltration, and without
the capacity to heal in the way of those ulcers for-
merly induced artificially by Cohnheim, Silberman,
and their colaborers.

Not long since, in a paper read before the patho-
logical section of the British Medical Association at

the Toronto meeting, and published in the British
Medical Journal for April 20, 1907, I followed an-
other feature of these experiments, and showed that
where the feeding of the bacilli was stopped before
perforation or hemorrhage had occurred, and a
month or six weeks were allowed to elapse during
which the dogs were 'ilaced under treatment for
ulcer, post-mortem examination revealed ulcers in
various stages of healing, thus showing the direct
relationship between the feeding and the formation
of the ulcer, showing also that when the ulcer-
producing conditions were removed at a sufficiently
early stage of the disease, and the general conditions
were improved, the ulcer healed. This point may
be remarked as a lesson in prognosis as well as in
treatment.

Diagnosis. — It is never easy, and often impossible,
to detect the presence of a gastric or duodenal ulcer
in the early stages, and even later on, when the dis-
ease has become typical in its manifestations, a
clear differential diagnosis as against carcinoma
in the early stages, gallstone diseases, gastric atony
and displacement of one or all of the abdominal or-
gans, often hinges upon so small a detail that it
will baffle all but the keenest and most experienced
observer. The acidity or otherwise of the stomach
contents is by no means a safe guide, though hyper-
chlorhydria is a dominant characteristic ; there may
or may not occasionally be found a blood reaction
in the feces, indicating some new break-down in the
ulcer surface ; usually there is pain, which in the
later stages is focused upon some well-defined area,
but this pain is by no means invariably present, nor
when present is it always greatest after eating,
though this is oftenest the case ; this circumscribed
pain is often associated with pain penetrating
through to the back.

But these signs, or any of them, must be taken
in conjunction with the patient's general condition;
almost invariably sufferers from gastric or duodenal
ulcer are of a low order of nutrition, and though
sometimes fat and apparently well nourished, the
experienced observer will detect the fact that this
outward appearance is deceptive, and due largely to
faulty metabolism. Sometimes there is puftiness
over the epigastric region, "gases on the stomach,"
the patient will tell you, but this is not always the
case, and while there is faulty digestion, and a re-
tention of food beyond the physiological period, in
manv of the cases, this is not always so, and can
only be regarded in conjunction with a vast number
of other symptoms.

Indeed, it may sometimes happen that the phy-
sician is reduced to the humiliating necessity of
carefully and laboriously excluding every other pos-
sible disease, before he can arrive at a satisfactory
diagnosis of peptic ulcer. This question of the
blood changes is highly significant in the diagnosis,
especially the serum reaction. Its subnormal op-
sonic index to the intestinal flora, the lessened ag-
glutinating fwwer, the indications of under-
nutrition— all have a distinct bearing on the diag-
nosis of ulcer.

Prognosis. — Naturally it will be one of the first
offices of the physician, immediately after he has
concluded his examination of the patient, to inform
him or his family of the chances of recovery. The
literature on this point has not been reassuring; a
close study of this literature, however, discloses the
fact that nearly all the premises contemplate a diag-
nosis at a late stage, oftentimes after hemorrhage
has occurred, or even after the ulcer has perforated
into the peritoneal cavity or into some other part

8S2

MEDICAL RECORD.

[May 25, 1907

of the intestinal tract. Of course the prognosis at
this stage is grave and the mortality high. But as
we come to understand better the distinctions of
diagnosis at a far earlier period, learn more and
more of the underlying factors concerned in the
condition, we must of necessity achieve better re-
sults. I will not burden you with recitations of
the experiences of special obserevrs in this field,
and will only pause to assure you that the unfavor-
able outlook of even the most recent years is not a
criterion of what we have a right to expect of the
present, nor a fair comparison of what the near fu-
ture holds for us in the way of a promise to these
stifferers.

For mv own part, when I have arrived at a safe
position in the diagnosis of my case, at a stage
before marked hemorrhage has occurred, and where
the general conditions aside from the local mani-
festation have not reached a grave state of them-
selves, endangering the patient's life, independent of
the ulcer, I am prone to draw upon the records of
mv more recent cases for a favorable promise. Es-
pecially is this true of younger persons who may
naturally be expected to respond more readily to
measures for the improvement of nutrition and
metabolism — in which the splanchnic circulation
can be quickened under some of the methods we
shall have occasion to discuss in consideration of
treatment.

And, too, I think that as we come to understand
ulcer and its causes better, the range of non-
operative treatment grows constantly broader, and
hence the hazards of surgical interference have less
frequently to be taken.

From the cases of the dogs in the last experi-
ments, where the ulcer inducing diet of colon bacilli
was stopped after certain periods of time, and
treatment for ulcer was instituted, and where post
mortem revealed ulcers in various stages of healing,
much is to be learned of importance in the prognosis
of the disease in the human family, especially from
the standnoint of general systemic conditions.

One of the most important considerations in the
nrogfnosis of gastric or duodenal ulcer and one that
is likely to bring us many grave misgivings is the
tendency of the disease to merge into mahgnancy.
Ulcer ofifers a most suitable nidus for the de-
velopment of cancer. Whether there is even the re-
motest relationship between the two diseases, we
do not yet know ; but the fact of the one supervening
upon the other appears the more evident in the
light of recent observations of serum changes oc-
curring in cancer showing the general character of
the diseased condition, which permits its develop-
ment on the site of such an injury as ulcer of the
stomach. So that, in determining, even in our own
minds, the results we are likely to achieve in any
case, we must assume not only the facts of the dis-
ease as it exists at the time, but must take into con-
sideration the general condition of the patient as
pointing toward or away from a mali.gnant sequel.

Treatment. — Assuming, now, that we have a
clearly defined case of ulcer to deal with, what are
the indications for treatment? Primarily, of course,
if we are correct in our judgment that the lesion
is a general and not a whollv local one, and that it
is induced by alterations in the pabulum of the in-
testinal flora, thus lowering the resistance of a gas-
tric or duodenal mucous membrane rendered pecu-
liarly vulnerable by malnutrition, defective metabol-
isrn, visceral atony and a lonp- train of predisposing
elements, we must address our efforts toward the
improvement of these constitutional conditions, and

"erhaps the steps of treatment may be divided into
three, namely (i) proper nutrition for the whole
body; (2) the reestablishment of functional activ-
ity or tone in the diseased organ, so that its power
of resistance may be increased; (3) the employment
of measures to inhibit the multiplication and change
the character of the offending intestinal flora.

Nearly all these requirements point in the direc-
tion of a proper diet. It is good practice to relieve
the patient's immediate pain and distress from the
sense of bloating, especially after meals, that most of
them suffer, by withholding all food until hunger
becomes a pressing matter, then give those foods
best calculated to furnish the greatest amount of
nutrition compatible with the greatest amount of
rest to the stomach, and these foods will be given
at long intervals at first, say once a day, gradually
increased to twice, and then oftener, as the stomach
reassumes its normal functional activity. Foremost
in the diet I employ is meat freed of its extractives
by a process of maceration and boiling, in which
the meat is allowed to stand for some hours in cold
water, and is then boiled thoroughly. The ex-
tractives are now pressed out and discarded; the
absence of the extractives of the meat deprives the
harmful intestinal bacteria of the necessary media
for development, and hence the toxins which they
produce are reduced to a minimum ; the maceration
and boiling have also the effect of hydrolyzing con-
nective tissue into gelatin, thus rendering it more
easily digestible in its fine state, and there is less
excitement to the production of hydrochloric acid
in harmful amounts. Meat treated in this way
passes out of the stomach before milk or any other
food, thus obtaining the ideal condition of the great-
est amount of rest to the stomach with the maximum
amount of nutrition. Xot only is this meat more
easily dio^ested and more com'^Ietely assimilated, but
in actual food value it contains 55 per cent, of pro-
teid as against 20 per cent, in the ordinary meat
that is scraped and fed partly cooked. Milk in va-
rious forms is employed as a most excellent liquid
diet, whey, either alone or with the myosin of this
meat product ; also whole milk after it has been
coagulated with rennett : milk administered in a
fresh state is apt to clot in the stomach when acted
urion by the gastric iuice, and hence likely to act as
an irritant. Koumvss may be employed in the same
way. The lactic acid in milk fermentation seems
to have a -^owerful inhibitory action on the intestinal
bacteria, and at the same time it seems to be pecu-
liarly free from the irritating effect on the mucous
membrane such as we attribute to hydrochloric acid.

Mineral waters have a two-fold action in these
cases ; they are in a measure contraindicated be-
cause they excite the formation of hydrochloric acid,
but oftentimes their utility more than compensates
for this contraindication, because they serve to
flush out the gastrointestinal tract, and thereby help
to prevent the formation and absorption of toxins.
The gases of carbonated waters are extremelv use-
ful in assisting gentle peristalsis and in helping to
force the food out of the stomach and thus obtain
rest for that organ. But the use of any water,
whether mineral or otherwise, only sen-es to ag-
gravate the atony of the stomach because of its
dead weight under pressure, which has the effect of
discouraging peristalsis.

Other foods than those outlined will occur to the
practitioner that will furnish a laree amount of
nutrition at the least possible expense in the way
of irritation, such as rice, cornstarch, fresh eggs, the
more easily digested vegetables such as potatoes in

May 25, 1907]

MEDICAL RECORD.

853

the form of puree, combined with meat prepared as
suggested, the leguminous grains such as peas,
beans, etc.. but always with their hulls removed,
to prevent irritation, and placed in the autoclave
under steam pressure of one and one-half atmos-
pheres. It is the purpose in all these foods to so
preoare them that hvdrolysis or partial predigestion
is accomplished, again obtaining necessary rest for
the stomach.

While the excitation of peristalsis is a prime con-
sideration, to aid in the restoration of the tone of
the gastrointestinal musculature the means em-
ployed to bring about this physiological activity
must be carefully chosen, especially as applied to
the site of the injury — that is, the stomach. \\'e can-
not know the depth of the ulcer or the extent of the
destruction of the gastric wall, so the introduction
of a tube must therefore be carefully undertaken, if
at all. and instead of the rhythmic air pressure gym-
nastics that we would like to employ we must con-
tent ourselves with the more indirect administra-
tion of bicarbonate of soda in water, which, acted
upon the hydrochloric acid of the stomach, sets free
carbonic acid gas for purposes of mechanical but
gentle distention when resident hydrochloric is al)-
sent. citric acid in the form of lemon juice may l)e
added, which also adds to the palatability of the
drink. We employ this distention because, as 1
have shown in other work, the only means we have
of exciting contraction in the stomach muscle i>
stretching; it will respond to no other form of
irritation. Similar excitation of gastrointe^tinal
peristalsis in these cases of ulcer is more efficacinus
when applied through the colon, because irritation
throus'h the reservoir at either end of the aliment;ir\
canal has the effect of influencing action along the
whole tract. To this end we employ alternate hot
and cold water lavage of the colon, introducing ;.
single or double tube as high as the sigmoid and
injections either by reservoir or pump, small
amounts of water, allowing each douche to flow
awa'- before another is used. The hot water is used
at 50° C. (122° F.), and the cold at a little above
the freezing point. Only small amounts of either
are injected at a time. If desirable some antise]itic
may be used toward the last of the douching, fnr its
bactericidal effect on the intestinal flora. In cnn-
sonance with this colonic lavage I am accustomed
to stimulate rliytlimic contraction and distention
along the alimentary tract by the introduction of air
passed through some disinfecting fluid, as high up
as the -transverse colon. This air pressure, sus-
tained onlv momentarib- and released, then repeated,
speedily brings a responsive peristalsis higher up
and the procedure is usually followed bv an empty-
ing of the whole lower intestine. This exerci'-c is
also of great utility in arousing the splanchnic cir-
culation, thus clearing the whole area of a sluggish
blood supply and increasing the metabolism of the
injured organ.

The "rest cure" or confineinent to bed is often
helpful in these ulcer cases, and sometimes may lie
a necessity. The patient is ordered to bed : he ma\-
see friends, read light literature, and enjov light
conversation. He must not transact business or
exert himself in any way. mentallv or phvsically.
This rest mav he continued until all the mo't press-
ing symptoms of pain, anorexia, and flatulence are
removed. The duration of this period of re-t may
extend from two weeks to six weeks, according to
the condition.

1820 Michigan .^venve.

A METHOD OF REDUCING OLD COLLES'
FRACTURES: STIFFNESS FOLLOW-
ING APPARENT CONTUSIONS OF
THE ELBOW.

By CL.^REX'CE A. .McWILLl.^MS. .M.D..

NEW YORK.

I.VSTRUCTOR ON SURGERY, COLUMBI,\ VXIVERSITY; ASSISTANT Sl'RGEON TO
THE PRESBYTERIAN HOSPITAL; SURGEON TO TRINITY HOSPITAL.

One occasionally meets a patient who complains of
what is called a sprain of the wrist of some weeks'
duration. L'sually there is a history of a fall upon
the hand three or four weeks prior to seeking ad-
vice. Often at that time no medical opinion has
been sought, or, if so. many times the erroneous
diagnosis of a simple sprain of the wrist is made.
The swelling and disabilit}' of the wrist, not im-
proving at the end of a niduth. cause the patient to
seek expert advice. A tentative diagnosis of an
old unreduced Colles" fracture is made and this is
confirmed b^• an .r-ra}' ilate. Such a conditiiin is
shown in the accompanying illustration ( I'ig. i ) of
one month's ■-tandiuL;'.

Fig. I. — ^Old unreduced Colles" lr.a,ture. obli jue transverse iracture
at .-v. with dislocation upw.iros ot Ira,^nieat carrying carpus w'ith it
.\'ote styloid processes ol ulna ana laaius on the same level.

The fracture is then f. lund consi.ilidated and the
question comes up at uiice whether anything can
be done to improve the injsition ot the fragments.
Even with considerable deformit\, in some cases
the disability nia_\ be so slight as to indicate that
good judgment would be shown in advising that
nothing be done to impri.ive the deformity, since in
an attempt to correct this the disability might be
increased. In other cases the disability and de-
formity are both marked, so tint -•' attempt to over-
come these by refracture is stron-' ■ to be advised,
providing that this can be done without too great
damage to surrdunding structures. By using the
hands alone it is almost ini'iossible to produce a re-
fracture in the same line as the old fracture, for it
is difficult to obtain sufficient purchase with the
hands alone on the small lower fragment to ac-
complish this. In this method the wrist structures
are also severelv strained, which is a great disad-

854

MEDICAL RECORD.

[May 25, 1907

vantasfe. A procedure which has given me uniform
satisfaction is the following. I do not claim any
orig-inality for it since I learned it from mv chief,
Dr. Ellsworth Eliot, Tr. ^Iy only reason for pub-
lishing it is that I have not seen it in print.

Fig. 2. — Method of refracturing an old Colles' fracture by means
of^a large monkey wrench.

1 he method is as follows : A large engineer's
monkey wrench is procured and the blades are well
padded. (Fig. 2.) The patient is anesthetized and the
blades so placed on the wrist that they are entirely
proximally situated to the fracture line, the edge of
the dorsal blade resting against the posteriorly pro-
jecting upper edge of the lower fragment. The
blades are then screwed together, so as to fairly
tightly embrace the tissues. \Vith the expenditure of
very little force, a refracture through the old fracture
line may readily be produced by twisting the wrench
so as to flex the lower fragment on the upper.
There is no strain whatsoever brought upon the
structures of the wrist itself, which consequently
remains uninjured. The damage to the tendons bv
the blades of the wrench is trifling and is soon re-
covered from. The after treatment is similar to
that which obtains in cases of fresh Colles' frac-
tures. Anterior and posterior wooden splints art-
used, which do not extend further than to the
metacarpophalangeal joints, aflr'ording free play for
the fingers. Three weeks is usually ample time
to maintain immobilization in the splints. This
method in almost all cases will do away with the
necessity for any cutting operation.

Traumata to joints in general are most puzzling
from a dia^Tiostic stanHnoint, and in no joint is
this more true than in the elbow, where the struc-
tures which make up the mechanism are so numer-
ous and complicated. A'-ray photographs are here
invaluable and their s\-stematic use even in slight
injuries to the elbow is to he emphasized. By their
emnloyment I have lately explained a phenomenon
which has several times before puzzled me. A
typical case exhibiting this condition is as follows :
A patient who has suffered a trauma to the elbow
af^nlies for treatment immediatelv after the injurv.
Careful palpation and exen an .r-ray photograph re-

veal no fracture of any of the bony structures in or
about the joint. Treatment apnropriate to a con-
tusion or sprain is instituted. Then, to one's sur-
prise and chagrin, about the third or fourth week
after the accident, the elbo wbegins to show consid-
erable restriction in the motion's of flexion and
extension. An .r-ray photograph at this stage re-
veals a fragment of bone in the joint which did not
appear in the previous picture taken immediately
after the injury. The explanation of this seems
clear that at the time of the accident a piece of
the periosteum without any attached bone has been
torn free from some of the bony structures of the
joint. This periosteum does not appear distinctly in
an .r-ray picture. It. however, in the course of time
proceeds to produce a fragment of new bone, which
may lie between the bony articular structures, caus-
ing the gradually increasing restriction of motion.
Usually by forced, persistent, passive motions, the
new bony fragment may be crowded away from be-
tween the joint surfaces and good joint functions
obtained. This would, however, be the final result
only in cases where the patients were seen at a pe-
riod of time after the injury before the new frag-
ment was thoroughly ossified, while it was still mal-
leable. In old standing cases it might be necessary
to remove the fragment by open operation. The
following picture shows an .r-ray photograph of
the elbow of a boy of ten who had fallen upon it a
few hours before the picture was taken. There is
no definite bony lesion to be made out distinctly.
On looking at the plate (Fig. 3) carefully, one sees
just below the external condyle at A a faint shadow
which, in the light of the later picture, was prob-
ably a piece of periosteum torn off the condyle. This

Fio.

latter seemed normal, its outlines being perfectly
regular and showing no defect. The boy was
treated for a contusion of the elbow and did not re-
turn after a week's time.

Four weeks later the boy presented himself again,
complaining of considerable restriction of flexion

May 25, 1907]

MEDICAL RECORD.

8S:

and extension of the elbow. Fig. 4 represents what
had occurred to cause the limitation of motions,
namely, a proliferation of new bone beneath the ex-

ternal condyle at A, due evidently to a piece of
periosteum torn off at the time of the injury. Daily
passive bending of the elbow soon restored almost
normal mobility to the joint.

112 West Fifty-fifth Street.

A STUDY OF BLOOD PRESSURE IN COM-
PRESSED AIR WORKERS.*

By H.\RL0W brooks, M.D..

NEW YURK.
VISITING PHYSICIAN TO THE CITY HOSPITAL.

During the middle of the eighteenth century com-
pressed air was very extensively employed, espe-
cially in Germany for the treatment of disease, and
the literature of that day is replete with reports as
to the wonderful results achieved b'- this method.
The Germans employed compressed air in the treat-
ment of practically every known disorder of the
body and institutes or sanatoria devoted to this one
method were scattered throughout the entire land.
The idea was really first suggested by Henshaw, an
Englishman, in 1664. A very considerable impetus
to work both with artificially compressed and rare-
fied atmospheres was contributed by the Dutch
school in the seventeenth century, but the thera-
peutic employment of compressed air had been
largely discarded by the English and Dutch investi-
gators before its rediscovery and widespread appli-
cation in Germany. The result of all this work has
been that compressed air is now but little employed
as a remedial measure except in a few conditions
in which it really appears to be an efficient agent.
Very little of value is found in the older writings
concerning the actual effect of compressed air on
the blood pressure, though it was assumed to act

*Read at a meeting of the New York Academy of Medi-
cine, April 16, IQ07.

chiefly through its influence on the vascular func-
tions. Most of the observations then recorded were
liased chiefly on guesses or on prejudiced clinical
observation and not on accurate scientific deter-
minations.

The importance of the study of compressed air
to us to-day is mostly on account of its relationship
to certain occupation diseases rather than as a reme-
dial measure, for we have among us an already
large and increasing class of workmen who live a
considerable period of their working life in com-
pressed air and the numerous recent experiments in
aeronautics renders this also a possible future field
for studies of the reaction of the. human organism
to marked and sudden variations in atmospheric
pressure. The demands of modern engineering now
so frequently require high air pressures that it be-
comes particularly necessary for us to record all ob-
served data in regard to the effects of engineering
[iressures on the human organism.

Caisson disease is no longer misunderstood, at
least by those physicians who are in frequent con-
tact with cases of this complaint, for its cause and
most efticient manner of prevention have been fully
demonstrated, hence these observations are not di-
rected with especial attention to this condition, but
are an attempt to clear up certain points in regard
to the behavior of the circulation under these abnor-
mal but very necessary conditions. It is hoped that
my results may be of some value in the selection
or exclusion of candidates for work in compressed
air and also that these experiments may throw a
new and important, though largely negative side
light on the ever interesting and pregnant question
of the physiology of blood pressure and the manner
in which it readjusts itself under rapidly variable
external conditions. The matter is also of consid-
erable general clinical interest since it applies very
materially to the question of selection of the proper
altitude for various classes of patients suffering
from cardiovascular diseases. The recent communi-
cations of Zuntz and Loewe and of Miiller and
Caspari, ably summarized by Sewell of Denver,
render all matters bearing on this subject of vital
interest to every physician, and although the studies
just cited are exclusively directed to blood pressure
at high altitudes, they apply with almost equal force
to conditions in which the pressure is augmented
instead of decreased.

It has been currently believed, I feel warranted
in stating, that the blood nressure is greatly in-
creased under compressed air and most accounts
describe the superficial vessels as compressed, con-
tracted, and anemic with corresponding engorge-
ment of the large trunks of the internal viscera.
Most physicians in charge of the medical end of
these engineering operations are of this opinion
and most of the literature pertaining to the subject
also leads to the same conclusions, in which I at first
entirely coincided from my own personal experience
and observation. Nevertheless it seemed to me
worth while to make a systematic studv of this
question and the opportunity has been lately oft'ered
to me through the courtesy of Dr. McCort of the
Belmont tunnel. With the assistance of ^Ir. Turn-
bull, his assistant, the following series of seventy-
five cases has been compiled.

Of the seventy-five men on whom observations
were made, all but two had been working in com-
pressed air over one month and may therefore be
considered as habituated compressed air workers.
Forty-four had worked in compressed air less than
one vear. twentv-three o\er one year and less than

856

MEDICAL RECORD.

[May 25, 1907

five, SIX over five and less than ten. Two men,
both engineers, had worked ahnost continually with
compressed air, one for twelve and one-half and the
other for twenty-two years. No substantial differ-
ence in results was found in any of these various
groups, hence it seems fair to assume that the sta-
tistics collected from the entire group is fairly
characteristic for healthy men, for all these men
had been subjected to physical examination and all
were in the prime of working life, that is from
twenty to forty-five years of age. Forty-three of
them admitted using- both tobacco and alcohol habit-
ually, some of them to great excess, but without
apparent effect on the point in question. Four used
alcohol and four tobacco alone and the rest claimed
freedom from both habits.

The instrument used for our determination was
the familiar Janeway sphygmomanometer, the 13-
cm. armlet being employed in every case. The
pressure was taken from the right brachial artery
with the armlet placed just above the bend
of the elbow. Two consecutive estimations of the
systolic pressure were made in each case and the
results were averaged. The diastolic pressure was
taken but once, and when it could not be satisfac-
torily obtained the case was thrown out of the series
considered. The pressure in each instance was
first taken just before entering the air, before which,
at least theoretically, the subject is supposed to
have been resting for not less than three hours.
The determination in the compressed air chamber
was taken after from one to two and one-half
hours' work at a tube pressure which averaged
about thirty-one pounds above atmospheric. The
general lighting and hygienic conditions of the tun-
nel throughout were excellent and the physical work
ne\er excessive. The measurements taken after
decompression were secured after the men had been
returned to normal atmospheric pressure for from
ten to fifteen minutes. Only one of the subjects
was suli'ering fiom too rapid decompression, that is
from caisson disease.

The average systolic pressure of the seventy-five
men, taken before entrance to the air, was 1 16.19
mm. Hg. The average diastolic oressure taken at
the same time was 91.08 mm. Hg. The average
systolic pressure taken in the air was 128.88 mm.
Hg. and the average diastolic pressure taken at this
time was 87.68 mm. Hg. The average systolic
pressure taken soon after decompression was 112.76
mm. Hg., and the average diastolic, 90.78 mm.
Hg.

It then appears that the difference in systolic
pressure of the resting man outside the compressed
air and after an hour or more work in thirty-one
pounds plus is but 12.69 'iirn- Hg., no more dif-
ference than would certainlv be expected between
a resting man and a man immediately after heavy
exercise at ordinary atmospheric pressures. The
dilterence in the diastolic pressure was but 3.4 mm.
Hg., but in this case the diastolic pressure was de-
creased 3.4 mm. while the systolic pressure was
raised 12.69 mm., so that the difference between
systolic and diastolic pressure outside the air was
25.11 mm. while this same space under compression
was 41.2 mm., again practically the same conditions
found under ordinary atmospheric pressure after
active exercise.

After decompression, which terminated a three-
hour shift in the air, the difference between systolic
and diastolic was 11.98 mm., or a loss in cardiac
energy or vascular tone as compared with the rest-
ing condition of 13.13 mm. The difference between

the diastolic after decompression as compared with
that under the pressure showed the pressure under
the air to be exactly 13.1 mm. lower.

The significance of these figures appears to me
to be very simply and yet accurately expressed in
the sentence that in so far as these experiments go,
the changes in blood pressure after labor under a
pressure of thirty-one pounds plus are practically
the same as under usual atmospheric pressure and
that about the relative space exists between systolic
and diastolic in both conditions, again practically
like those in the normal atmosphere.

It is entirely to be expected that after three hours'
labor in the air the decompression systolic pres-
sure should be decreased, but as only 3.43 mm. Hg.
difference exists it is strongly confirmatory of the
statement of the average workman that labor under
the air is more easily accomplished than at ordinary
pressures and this small loss is negative as regards
the contention of Jaminet that excessive waste of the
body energy takes place under these conditions,
due, Jaminet asserted, to the too rapid oxidation
of tlie tissues which he assumed, entirely on theo-
retical grounds, to take place. I must, however,
admit that this slight fall may be otherwise ex-
plained according to the determinations of Zuntz
who found a corresponding fall taking place in the
rapid change to higher altitudes.

Several points bearing on the question of com-
pressed air labor arise in connection with these de-
terminations. One of the most important of these
is the disproval of the theory that many of the
deleterious effects on the circulatory apparatus of
compressed air workers follows as a result of the
high external pressure on the superficial vessels,
Were this the case as asserted by many, notably by
Smith and Bouchard, a marked rise in blood pres-
sure must inevitably take place, due to peripheral
compression, and on the contrary a lack of such
rise indicates that the intracorporeal air or gaseous
pressure is proportionately increased until finally
balanced in compressed atmospheres, a fact which
has also been abundantly proven by numerous ex-
perimental studies as well as indicated by the post-
mortem findings in caisson disease, though still
denied by some theoretical workers.

From these experiments and from other re-
searches conducted on animals by myself I believe
that very slight disturbance of the vascular distri-
bution takes place under moderate decrease or
increase of atmospheric pressure, when slowly accom-
plished, a point also corroborated by the conclu-
sions of Zuntz who believes that variations in
anterial and capillary capacity are altered more due
to deficient or overly abundant oxygenation in rari-
fied or compressed atmospheres. Brief observation
of the respiratory activities in compressed air work-
ers convinces me that this statement is thoroughly
sound. If this fact is true we must completely re-
orient many of the ideas now commonly accepted
which forbid patients afflicted with cardiovascular
disease from living at high altitudes on the one
hand, or at sea level on the other.

I hesitate somewhat in a further, but not un-
natural deduction, and that is that moderate degrees
of renal or circulatory disease should not necessarily
exclude workers from labor under moderate com-
pressed air pressure. I certainly think that this is
indicated by these observations, and furthermore I
know that this fact is well recognized by engineers
and workmen, for a very large percentage of
caisson workers are highly alcoholic and therefore
nephritic, when you can get them to admit the

May 25, 1907]

MEDICAL RECORD.

857

truth, which they will rarely do in this respect,
since they fear disqualification.

The exhaustion expatiated on by some observers
after labor in the caisson is negatived in so far as
the circulatory functions are concerned, by the rela-
tively slight loss in cardiac energy after return to
normal pressures.

Finally, it appears demonstrated that the blood
pressure is not abnormally raised under compressed
air, and these few observations but confirm the now
well established theory of gaseous liberation in the
causation of caisson disease, and I hope put at rest
forever the theory of vascular hypertension and un-
balancement as etiological factors in the causation
of this condition.

44 West Ninth Street-

POPULAR EDUCATION IN MATTERS
MEDICAL.

A PLEA FOR A MORE THOROUGH AND WIDESPREAD

DIFFUSION OF KNOWLEDGE IN HYGIENE AND

THE PREVENTION OF DISEASE.

Bv H. W. WRIGHT. M.D.,

ASTORIA. XEW YORK.

The present ignorance of the average citizen in
regard to the care of his health and that of his chil-
dren is a distressing sight to anyone who cares for
the preventive side of medical work. W't see the
effects of such ignorance and carelessness in every
community and among all classes of society. But
it is especially among the poor that preventable
misery is so w-idespread, from whom its results are
so much further reaching than we realize.

It is not that the old-time superstitions regarding
disease and in respect to remedies have any con-
siderable influence to-day : but it is the indifference
to the importance of simple cleanliness in the per-
son, the food, and the home, the importance of nor-
mal, regular habits of living, of hydrotherapy and
ventilation that is keeping up the foci of epidemics
and the existence of all manner of digestive and
respiratory disorders. I do not think it an exag-
geration to say that a very large majority of our
young people are growing up in total ignorance of
and indifference to their own physiology and the
simple rules of hygiene. When these marry they
know even less about the care of their children.
They may have "studied physiology" in the jyublic
schools, they may have even passed an examination
in the subject, and so have been promoted to a grade
where it is thought unnecessary to teach it ; but the
results of such study are not apparent, except that
they are conspicuous by their absence. Consequently
when these children become older they and theirs
are an easy prey to the patent medicine or any other
form of quackery, and charlatanism (including
"Christian Science") that comes along.

Another disastrous result of such ignorance is the
widespread perversion of the sexual functions and
the spread of venereal diseases, with all their at-
tendant miseries. The young are not taught at
home regarding these matters because in many cases
the parents don't know themselves, and in other
cases because the subject is thought too "indecent"
for consideration.

We see the results of this indifference to personal
health more especially in large cities and crowded
communities; among such tjie circumstances of life
render people more susceptible. But I am willing
to venture the belief that if popular education in

hygiene were as thoroughly conducted as it ought
and could be, the percentage of cases of all the in-
fectious diseases, of chronic respiratory disorders,
of chronic digestive disorders, and of venereal dis-
eases would be reduced more than one-half in the
next generation after such teaching had been so
propagated. Such knowledge should be available
by all, even the poorest. It is a mistake to expect
dirt and disease to be inevitable and necessarv ac-
companiments of poverty. They are rather accom-
paniments of ignorance, indift'erence, and loss of
self-respect. Why are people's persons and homes
dirty? Because they do not realize the necessity of
keeping them clean. Why is their food badly cooked
and unwisely chosen ? Because they know no better.
It isn't because it costs any more to do otherwise.
Why are houses built in unsanitary places and badly
ventilated, and poorly equipped with plumbing ?
It is in most instances because the builders do not
knozi' enough about the dangers of such conditions
to care. Indifference goes with ignorance ; as knowl-
edge increases indifference diminishes. The same
may be said of factories, unhealthy methods of
manufacture, of child labor and long hours for
women and children in unhealthy workshops. Most
of the evils of these establishments are due to
thoughtlessness, i.e. ignorance.

What then should the public be taught, and how
should it be taught them ? In the first place, they
should be taught the physiology of digestion, res-
piration, and procreation, the nutritional values of
various foods and how to prepare them, the science
of ventilation, the danger of bad air and the safety
of fresh air, in order to dispel the popular fear of
tlie latter ; the value of hydrotherapy ; the physiology
of infant life and nutrition; the sources of bacteria
and how to prevent the introduction and spread of
infectious diseases.

These, in a general way, are some of the subjects
for popular education. How should these subjects
be taught? The most available place for the in-
struction of the young is the school. Here there
should be competent instructors and directors of
physical culture and athletics who wotild also be
teachers of physiology and hygiene, and preferably
physicians. The present method of teaching physi-
ology in the public and private schools is little short
of an absurdity, so little time and care are given
to it in proportion to its importance. Furthermore,
such teaching is usually done by some one who needs
the instruction quite as much as the pupils. In
addition to the school instruction there should be
public lectures and demonstrations for children and
adults, with special courses for the latter in mat-
ters pertaining to procreation and the care of chil-
dren. The public lecture on medical subjects of the
present day is usually confined to a few vague re-
marks on the "Circulation of the Blood." A recent
notable departure, however, should be greatly com-
mended, namely the public stereopticon lectures on
tuberculosis given by the New York City Health
Board. The fact that these were received with in-
difference mixed with ridicule (according to the
newspapers) is a strong argument in favor of their
continuance and extension. The recent exhibits
on the same subject are also steps in the right di-
rection.

Another way of spreading such knowledge would
be by more complete medical inspection in the homes
of the poor and by the help of district nurses who,
after such inspection by a physician, would be sent
to correct unhealthy conditions of living by prac-
tical instruction and help. Literature upon these
matters could be circulated freely in the form of a

8.^8

MEDICAL RECORD.

[:May 25, 1907

monthly or weekly paper issued by the health board
of the community.

In order to carry out such a system of popular
education there would be necessary greater authority
in the hands of the boards of health and education.
Such authority could be obtained by proper legisla-
tion, just as the authority in matters of health has
been acquired heretofore. Sickness is unquestion-
ably an economic loss to everyone, directly and in-
directly ; and it is everyone's duty, from both a
selfish and altruistic point of view, to do all that he
can to prevent it.

INACCURACY OF DARE'S HEMO-
ALKALINOMETER.

Bv FR.\NK P. VALE, M.D.,

\\'ASHI.N'GTON. P.C.

As some authorities had attempted to show a rela-
tion between the alkalinity of the blood and the ac-
tivity of the organic exchanges between the blood
and the tissues, I thought there might be alterations
of the alkalinity of the blood of interest in shock
and collapse. A little over two years ago, with the
desire of following up this idea, I looked over the
literature on the alkalinity of the blood, for the pur-
pose of adopting the most satisfactory technique.
In this way I became acquainted with the method
of Dare {Johns Hopkins Hospital Bulletin, Vol.
XIV., No. 148, 1903), and undertook its use with
considerable enthusiasm on account of its ready ap-
plicability.

To compare the point of the disappearance of the
oxyhemaglobin bands with the alkalinity as ascer-
tained with litmus as an indicator, I was advised by
my friend, Dr. E. R. Hodge, a practical chemist, to
employ Vju H^So^, instead of a like strength of tar-
taric acid. As a preliminary to a further use of the
method, I examined forty patients suffering from
various conditions, in many of which one might ex-
pect to find changes in the alkalinity of the blood,
and obtained, in addition in each case, the hema-
globin percentage and number of red blood cells, so
that the color index might enter into the data, as
suggested by Dare.

The results were very constant ; i c.c. of the sul-
phuric acid solution caused the disappearance of the
absorption bands in three to five minutes ; an addi-
tional 0.1 c.c. or 0.2 c. c. caused their disappearance
in one-half minute. According to the instrument's
scale, this meant an alkalinity of 133 mg. of NaOH
per 100 g. of blood. Then I found with litmus as an
indicator there was required but 0.4 c.c. to 0.6 c.c.
to neutralize the same amount of blood — .018 g.
With a standardized t^u tartaric acid solution, pre-
pared by Dr. Hodge, there was a still further dis-
crepancy, as 4.5 c.c. was required to cause the disap-
pearance of the absorption bands. (A tartaric acid
solution, made according to Dare's formula, and not
standardized, required 2.2 c.c.) A ■?-(.« oxalic acid
solution gave still a different result — 3.9 c.c. \
specimen of blood in which i.i c.c. of the sulphuric
acid solution caused the immediate disappearance of
the oxyhemaglobin absorption bands, 0.5 c.c. caused
their disappearance by the end of twenty-four
hours.

Dare found that 2 c.c. of rSu tartaric acid solution
was required to neutralize .013 g. of blood. (The
pipette supplied with my instrument held .018 g.)
Two cubic centimeters of any half centinormal acid
solution is the equivalent of .0004 g. NaOH. To
express the alkalinity of the blood in milligrams

in terms of NaOH per 100 g. of blood the equation
becomes : ^''^"^ multiplied by .0004, which is 2666.
mg., and not 266. mg., as given by Dare.

As 2666, mg. of NaOH per 100 g. of blood is
about four times as great as that given by any in-
vestigator, and as the alkalinity varied with the acid
employed, I discontinued the use of the "hemoalka-
linometer," concluding that others had found these
inaccuracies, and that the method was being con-
demned by insufficient praise, for I noticed no fur-
ther journal articles concerning it.

The method has, however, been noted in several
text-books, some of them foreign, e.g. H. Labbe,
Analyse Chemique du Sang. An authoritative
monograph on Clinical Diagnosis just from the
press (Chas. P. Emmerson, Johns Hopkins, 1906),
describes the method as very ingenious and ex-
presses the anticipation that some practical results
may be obtained from its use.

I should not have related my experience, which
was carried no further than a demonstration of the
inaccuracy of the method to my own satisfaction,
were it not for having read within a few days an
article which appeared a year ago in the Journal of
Patholoi^y and Bacteriology, by Dr. Mercier Gam-
ble (March, 1906), in which the above fallacies of
the method are extensively set forth. I was led
to this article by a recent review of hematological
literature, in which Dr. Gamble's paper was referred
to as questioning the reliability of the Dare method.
The mildness of Dr. Gamble's phraseology, in criti-
cism, might leave in the mind of the reader a hope
for the Dare method, but any assimilation of the
data there set forth would not, and it is the object
of this memorandum to call attention to the latter.

1616 Eye Street, N. W.

THE USE OF PILOCARPINE FOR THE RE-
LIEF OF PRURITUS, ESPECIALLY IN
REGARD TO PRURITUS VULV^.

Bv JOHN' J. REID, M.D,,

NEW YORK.

It does not seem to be be generaly recognized that
pilocarpine has a specific effect in different forms
of pruritus. ]\lv first knowledge of the value of
pilocarpine in this way came from the late Dr. G, D.
Holstern of Brooklyn. Dr. Holstern used it in
pruritus coincident with jaundice and with happy
effect. Since that time I have used it in pruritus
vulvfe, pruritus associated with skin disease, and
general pruritus without any assignable cause.

Pruritus seems to be a neurosis in some way
allied to neuralgia, and has this in common with
neuralgia that it is periodic and may occur without
any immediate cause. In pruritus vulvae I have
found the same benefit from pilocarpine in cases
occurring with and without diabetes. The ordinary
dose is one-quarter grain to be given only when the
itching manifests itself and is not to be repeated
unless the itching returns. It is well to begin with
one-eighth grain, inasmuch as some patients are
very susceptible to the drug.

It may be of interest to note a case of pruritus
occurring on a medical student at the time of his
final examinations. Without the use of pilocarpine
he would have found it impossible either to think
or write. In this case 1-120 grain of atropine in
conjunction with the pilocarpine prevented the
sweating. In all of the-cases referred to pilocarpine
was given by the mouth.

853 Lexington .■\venve.

May 25, 1907]

MEDICAL RECORD.

S59

Medical Record.

A Weekly Journal of Medicine and Surgery,

THOMAS L. STEDMAX, A.M., M.D., Editor.

PUBLISHERS
WM. WOOD <t CO., 51 FIFTH AVENUE.

New York, May 25, J907.

THE RESPONSIBILITY OF THE COUNTRY
PRACTITIONER FOR THE EXIST-
ENCE OF TYPHOID FEVER.

There is nothing more definitely established in
medicine than that typhoid fever is usually a coun-
try-bred disease and that its existence in cities
whose water supply is drawn from running streams
is due almost wholly to infection brought therein.
We do not dispute the fact that the disease may be
spread by the agencv of flies, but this occurs chieflv
or wholly in the country ; nor that it is often ac-
quired through eating of salads and raw fruits and
vegetables, but these are brought from the country
and the infection which they convey is of extra-
urban origin. Certain of the lake cities which draw
their water from the same place into which they
empty their sewage may be exaninles of self-infec-
tion, but observation has shown that the water they
drawn even from this source is not always polluted,
and were the disease not continually reintroduced
from without in the ice or in the raw food supplies
it would soon die out. Dr. William G. Daggett of
New Haven, Conn., stated this fact very forcibly
in a paper presented to the Connecticut State Medi-
cal Society in May, 1904.

\\ e have alreadv commented upon this paper on
two separate occasions ( Mkdical Record. Septem-
ber 3 and October 15, 1904), but it is a subject that
will bear frequent repetition. Dr. Daggett's rem-
edy for the evil .was a system of control by a State
sanitary police, the officers of which should inspect
regularly and frequently privies and cesspools and
also the wells and other sources of the water supply
in rural districts. This would go far toward an
abatement of the evil, but not far enough. Public
officials could investigate the water su|)iil\- in each
community, but they could not supervise the man-
agement of each case of typhoid fever occurring
therein. Such inquisitorial methods would become
most unpopular and would arouse an antagonism
which would surely defeat their ends. However
ideally placed the well may be, its contamination or
the contamination of some stream emptying into
another from which a distant city may draw its
water supply could not be prevented liy official su-
pervision.

The source of infection is the discharges, feces
and urine, from one actually suffering or con-
valescent from typhoid fever, and the phvsician
attending such a patient is the one to whom the
community must look for protection. If every at-
tendant upon a case of typhoid fever in the countrv

were as insistent upon the disinfection of the dis-
charges as upon the following out of his directions
in regard to diet and medicine, the disease would be
confined to the individual sufferer and there would
be no possibility of its transmission to others in a
city ten, twenty, or fifty miles away. We fear the
practitioner in the country does not always appre-
ciate the load of responsibility he carries for the
health of his fellows in other communities. He is
too often concerned with the individual case, and as
long as this case is conducted to a successful issue
he forgets the potentiality for evil it contains. If
the discharges from every typhoid fever patient
throughout the entire country were thoroughly dis-
infected before leaving the vessel in which" they
are received, the disease would soon be as rare as
typhus, and thousands of lives would be saved.

RENAL DECAPSULATION FOR
ECLAMPSIA,

The severity which characterizes an cclamntic seiz-
ure has stimulated the introduction of certain pro-
cedures of a most radical nature. Thus Edebohls
suggested and carried out decapsulation of the kid-
neys as a means of arresting the progress of this
dreaded condition. Although a number of appar-
ently successful cases have been reported, the
method has by no means met with general approval
and reports of its application by others are naturally
of interest. De Bovis {Semainc lui'dicale, No. 10,
1907) performed a renal decapsulation in a voung
woman who developed a severe eclampsia soon after
delivery. None of the usual remedies seemed to
have any effect and the patient grew rapidlv worse.
As a last resort, the capsule was removed from one
kidnev without any trouble, disclosing an exten-
sive ecchymosis of the organ. The coma which had
been present disappeared soon after the operation
and the urinary secretion was at once increased.
The patient recovered.

The number of cases in which this operation has
been performed is not sufficient, however, to warrant
the drawing of any definite conclusions regarding its
value in eclampsia. Of five known cases, a fatal
edema of the lungs was reported in one. and as
the mortality of eclampsia has been stated to be
about 20 per cent., the statistical evidence so far
does not seem to warrant operation. As a matter
of fact, however, it is usually only the severe cases
in which uremia and anuria are prominent svmp-
toms which are subjected to the operation in ques-
tion. Another point to be borne in mind is that the
kidney is not the only organ involved in eclampsia,
so that it seems rather difficult to account otherwise
for the improvement which has been noted in those
instances where renal decapsulation has been car-
ried out. Neither can the loss of blood be regarded
as a possible factor, for it does not compare in ex-
tent with that which would be lost in an ordinary
phlebotomy. It is quite e\i<Ietit that for the [ires-
ent. the value of the operation referreil to will
remain sub jiidice, although future experiments and
observations may contribute to its better under-
standing and appreciation.

86o

MEDICAL RECORD.

[.May 25, 1907

THE SEVERE TYPES OF RUBELLA.

Rubella, or, as it is more commonly called, Ger-
man measles, is usually regarded as a harmless
disease which presents the characters of a mild
febrile disturbance and requires but little treatment.
Reports are to be noted here and there in the lit-
erature, however, which show that the disease, par-
ticularly in weak and emaciated children, may be
accompanied by very severe complications dating
from an involvement of the digestive or respiratory
svstems, among them being enterocolitis and bron-
chopneumonia. It has been claimed that these are
cases of true measles rather than the so-called Ger-
man variety, but this claim may with propriety be
placed on the same plane, according to Cheinisse
(Scmainc mcdicalc, No. 52, 1906), as the view that
the disease in question is not a clinical entity but
must be regarded as a mixed form of scarlet fever
and measles. A typically severe case of rubella
is reported by this writer as having occurred in a
young woman of twenty-two years, w'ho on the
sixth dav after the eruption was observed, developed
a temperature of 105° F., became hoarse, and ex-
perienced diificultv in swallowing. The tonsils be-
came greatly enlarged and the entire oral mucosa
was markedly swollen. The tongue presented a
thick coating which, in contrast to this phenomenon
in scarlatina, was limited to the tip and the edges
of the organ. There was also considerable general
depression. With appropriate local and systemic
treatment, the patient was well in a week, although
she was considerably prostrated for some time after-
wards.

Similar cases of secondary angina following ru-
bella have also been described by a number of other
writers and in one instance the appearance of an
epidemic in a hospital was characterized by the
development of bronchopneumonia, adenitis, men-
ingitis, and otitis media in some of the patients.
In this series of twentv-seven patients there were
eight fatalities. It would seem from these adverse
reports that we are not justified in regarding ru-
bella as a disease without danger to those who may
have contracted it.

The Etiology of R.\ciiitis.

The theories relative to the nature and pathogenv
of rachitis are very numerous, but it must be ad-
mitted that thev appear to be either directly incor-
rect or at best far from satisfactory. A large pro-
portion of the investigators who ftave interested
themselves in this problem have taken as the basis
of their views some error of nutrition. Some in-
criminate a too short period of nursing, others too
protracted breast feeding, some seek the cause of
the malady in some deficiency of the maternal milk,
others in unsuitable artificial nourishment. Even
the practice of pasteurizing or sterilizing the milk
has been alleged as having an important bearing
in the etiologv of rachitis. Another suggestion in
this regard is put forward by Esser {Milnchener
mcdhinische Wochcnschrift, April 23, 1907) who
considers that the anatomical changes in rachitis
are the result of an increased formation of imma-
ture cartilage and osteoid tissue together with an
abnormally increased absorption .of the already
formed bony structures. In order to explain this

vice of development he endeavors to bring it into
association with the function of the bone marrow,
and points out that in rachitis there is always a
hyperleucocjiosis resembling in type that occurring
in cases of long-continued overnutrition. As the re-
sult of the excessive stimulation of the bone mar-
row, growth is at first encouraged, but later the
function is overtaxed and a perversion of develop-
ment results. Esser supports his theory both by
experimental evidence obtained by overfeeding ani-
mals and by clinical observations on a very large
material. In every case of rachitis, he says, no
matter whether the children were breast or bottle
fed, and irrespective of any hereditary tendency,
he found that there was a history of persistent over-
feeding. While this theory will no doubt meet with
opposition from many pediatric physicians it has at
least the merit that it appears to render the thera-
peutic problem gratify ingly easy to solve.

The R.\pid Demoxstration of Tubercle Bacilli.

The method of securing certainty in suspected
cases of tviberculosis by injecting some of the sup-
posably infectious material into guinea pigs is sat-
isfactory so far as reliability is concerned, but labors
under the disadvantage of the length of time that
must elapse before a definite result, particularly a
negative one, can be obtained. In spite of this
drawback the method at present, especially in view
of the apparent complexity of the acid-fast group
of bacilli, appears to be indispensable. This is par-
ticularly true in dealing with cases of genitourinary
infection, in which the urinary sediment is so likely
to contain confusing organisms that the guinea
pig must nearly always be called upon to give the
final decision. Bloch, working in Gaspers' clinic,
suggests {Berliner klimsche IVochenschrift, April
29, 1907) a modification of the technique of the
method by means of which it is possible to obtain
a definite result in from nine to eleven days instead
of from three to six weeks, as is ordinarily the case.
It consists in encouraging the rapid proliferation
of the injected tubercle bacilli by lowering the
vitality of the tissues into which they are intro-
duced. The centrifnged urine sediment is injected
into the groin of the animal and the tissues of this
part are rolled between the thumb and forefinger.
On detecting the lymphatic glands 'as minute ker-
nels thev are crushed by strong pressure. If tuber-
cle bacilli were present in the injected material the
author states that they will multiply with unusual
rapidity in these damaged tissues, and that they
may be demonstrated in films or sections made at
the expiration of the period mentioned. Smegma
bacilli do not appear to be a source of error, and
the method has given accurate results in the cases
in which the author has tested it. If a more ex-
tended trial of the plan demonstrates its reliability
it must be regarded as a valuable adjunct to our
dia£?nostic procedures ; but owing to obvious con-
siderations a great many control obser\'ations will
be required before it can be accepted among the
trustworthy clinical methods.

Tuberculous Disease of the Bronchial Glands.

It occasionally happens that marked reactions to
tuberculin injections manifest themselves in patients
in whom no clinical evidences of tuberculosis are
recognizable In this class of cases, however,
the subjective symptoms are usually well developed
and are of such a character as to lead to suspicion

May 25, 1907]

MEDICAL RECORD.

861

of tlie presence of true tuberculous disease. They
consist mainly of pains in the back and chest, a dry
cough, fatigue, and occasional night sweats. Neisser,
who refers to this condition in the Archiv fiir klin-
ische Mcdizin, Vol. 86, No. 3, states that, although
we may be quite certain as to the -presence of a
tuberculous infection in the chest cavity, the ques-
tion remains as to what particular organ is involved
in the process. He believes that in such doubtful
cases attention should be directed to the bronchial
glands. If one of these has become painful in conse-
quence of an inflammatory process evidence of the
fact is obtainable in two ways. Indirectly it will
give rise to tenderness in certain portions of the
spinal area and directly the pain may be elicited by
the pressure from a sound or bougie in the esopha-
gus. Neisser found that in most instances in which
the symptom complex noted was present he could
elicit the sensation of pain in the region of the
bronchial glands by an esophageal exploration in
the manner referred to. The writer thinks that
in these cases the symptoms are due to the develop-
ment of a fresh tuberculous focus in one of the
glands. Notwithstanding the many advances made
in our knowledge of tuberculosis, there are many
diagnostic points in the more obscure cases regard-
ing which we need enlightenment, and consideration
should be given to any procedure which will aid in
clearing up this uncertainty.

The Action of G.-\rlic in Tuberculosis.

The claim was made some years ago by Carazannis,
an Italian investigator, that the ordinary garlic con-
tained an ethereal oil which manifested a well-
marked specific effect in tuberculous infection. The
subject has again been made the subject of experi-
ments in animals by Kathe (Ccntralblatt fiir Kin-
derheilkuude. 1907, No. 2), who administered a cer-
tain quantity of the juice to guinea-pigs daily. After
three weeks the animals were twice subjected to an
inhalation of dried and pulverized tuberculous
sputum for a period of almost an hour. In both the
control and previously treated guinea-pigs a tuber-
culous infection appeared, but strange to say in the
latter group the mesenteric glands were not in-
volved. Kathe explains this by assuming that the
bacilli which were necessarily swallowed during
the inhalations were destroyed by the oil of garlic
in the intestinal tract, which acted as a local anti-
septic, and whatever infection occurred took place
through the medium of the respiratory passages.
In another series the animals which had previously
been treated with the garlic juice, received pure
cultures of the tubercle bacilli subcutaneously. No
inhibitive effect was apparently exhibited by the
substance in these cases. The juice of the garlic,
or rather its contained essential oil, therefore seems
to manifest its antiseptic action only in the intestinal
canal, and has no effect whatever on any tubercu-
lous processes which may become localized in the
lungs.

The Decomposition of Chloroform.

An ingenious device for automatically indicating
decomposition occurring in chloroform intended for
use as an anesthetic has been suggested by Breteau
and Woog. It consists in making use of the indicator
Congo red for determining the development in the
chloroform of even the minutest traces of hydro-
chloric acid. In order to do this conveniently a
small disc of elder pith stained with a solution of

Congo red in absolute alcohol is placed in each bot-
tle containing the chloroform. Normally the stained
disc retains its color indefinitely, but if, as the result
of the action of air, light, moisture, etc., decomposi-
tion begins, hydrochloric acid is set free and the
indicator chanees from red to blue. The chloroform
then should be either discarded for internal use or
he repurified. The Lancet states that it has tested
this method and has found it extremely delicate.

Tre.\tment of Inn'ersion of the Uterus.

Among the interesting suggestions for the relief of
this condition when it occurs after labor, is that
made by Pinard, who advises the introduction of a
rubber bag such as the de Ribe, in order to return
the organ to its natural position. He has success-
fully employed this method in five instances. In
the last, which occurred in a multipara with an
easy forceps delivery, only a moderate amount of
traction was made on the placenta, but the act re-
sulted in a complete inversion of the uterus. The
latter was readily reduced, and the patient suffered
very little shock, but a few days later the organ
again became inverted during an attempt to empty
the bladder. Eft'orts at manual reduction then
failed, and a de Ribe's bag was introduced and
inflated with air. Its pressure caused no pain what-
ever, and w'ithin twenty-four hours the uterus re-
turned to its normal position. Pinard in recom-
mending the bag for this purpose states, however,
that it should not be allowed to remain in place for
more than eight hours.

Medical Milk Commissions. — The Aledical Milk
Commissions in the I'nited .States will hold a con-
ference at the St. Charles Hotel, .\tlantic City,
N. J., on Monday, June 3, 1907. There will be three
sessions: 10 o'clock a.m., 3 o'clock p.m., and 8
o'clock P.M. The main objects of the conference
are to determine the scope of the Medical Milk
Commission, harmonize its working methods and
requirements, and establish uniform standards for
certified milk. Any member of a regularly or-
ganized iMedical Milk Commission may be, by vir-
tue of such membership, a member of the conference.
The temporary chairman is Dr. Henry L. Coit, 277
Mt. Prospect avenue, Newark, N. J., and the tem-
porary secretary is Dr. Otto P. Geier of 124 Garfield
place, Cincinnati, (Miio.

The "Index Medicus." — The Carnegie Institute
of \\'ashington, which has been bearing most of
the cost of publication of the present series df the
Index Medicus. announces that as the journal has
not met with the support from the profession that
was hoped for, unless it appears that the Index
Medicus is of greater service to the medical pro-
fession and can help to support itself to a greater
extent than in the past, it may become advisable to
discontinue its publication. The Index Medicus
was established in 1879, under the editorship of
Dr. John S. Billings and Dr. Robert Fletcher, and
was discontinued in 1899. The iiresenl series be-
gan with the number for January, 1903. Each num-
ber of the I)idcx presents the literature of the month
named on its cover and is issued as early as possible
in the succeeding month, time being allowed for
the arrival of foreign journals. The present editors
are Robert Fletcher, M.D., and Fielding H. Garri-
son, M.D. Communications relative to subscrip-

862

MEDICAL RECORD.

[May 25, 1907

tions should be addressed : Carnegie Institution of
Washington, Washington, D. C. Communications
concerning the bibliography should be sent to:
Editor of Index Mcdicus, Army Medical JMuseum,
Washington, D. C. No numbers of the first series can
be supplied. Copies of later volumes and numbers
are available. The volume for 1905 contains 1,241
pages and the index to the volume 208 pages, the
latter in double and triple columns.

Civil Service Examinations. — The State Civil
Service Commission will hold an examination June
15, 1907, for Resident Physician, State Hospital for
Crippled and Deformed Children, salary, $goo and
maintenance. The last day for filing applications
for this position is June 8. Full information
and application forms may be obtained by address-
ing ;\Ir. Charles S. Fowler, Chief Examiner of
the Commission, at Albany.

American Surgeons Honored. — The Russian
Surgical Society recently celebrated in St. Peters-
burg its twenty-fifth anniversary and elected as
honorary members a number of foreign surgeons,
among them being Professor Roentgen of Munich,
Dr. VMlliam H. Watson of Utica, N. Y., and Dr.
Nicholas Senn of Chicago, 111.

Gifts to Mount Vernon (N. Y.) Hospital-
Mrs. James A. Bailey has contributed the sum of
$io,oo"o to the maintenance fund of the Mount \ er-
non Hospital, and has announced her intentionof
donating a further sum of $100,000 for the erection
and equipment of a new hospital building to be
placed next to the present structure and called the
Bailey [Memorial Hosnital. Mrs. Bailey has also
promised to endow the new memorial hospital. By
the will of the late Martin L. Sykes the ]\Iount
\'ernon Hospital is to receive the sum of $5,000.

An Endeavor to Save the Lives of Christian
Scientists. — A bill has been introduced into the
legislature at Albany which amends the Penal Code
bv making it a felony for a person having in his
charge, care, custody, or control a sick or disabled
liuman being, to fail or omit to provide the sick
person with the medical attendance of a competent
licensed physician. If such person is unable to fur-
nish a competent licensed physician he shall imme-
diately notify the local board of health, and it shall
be the duty of the board to furnish a physician with
such medicines as may be prescribed.

Centenary of the College of Physicians and Sur-
geons.— The centennial celebration of the College
of Physicians and Surgeons of this city is to be held
in conjunction with the commencement exercises
at Columbia University. On June 10 and 11 it has
been planned to present to the visiting alumni an
opportunity to see and inspect the modern methods
of instruction and the present equipment of the
College of Physicians and Surgeons. The labora-
tories and museums of physiology, anatomy, pa-
thologv, bacteriology, clinical pathology, and biolog-
ical chemistry will be open for inspection, and the
work in clinical branches at the \^anderbilt Clinic
will be demonstrated. In addition there will be pre-
sented a number of clinical exercises in the several
hospitals which will be conducted by the officers
and professors in the school. On the evening of
June IT an alumni dinner will be held at Delmoni-
co's, and on June 12 the commencement exercise?
will be held at the University and a general alumni
luncheon will be given.

The Treatment of Pauper Cases. — .\t a recent
m.eeting of the Champaign County (l\].) Medical
Societv resolutions were adopted providing that in

all cases operation fees and full fees for attend-
ance should be charged for treating pauper pa-
tients on orders from supervisors.

Tonsillitis at Bryn Mawr. — Following a class
celebration at which a loving cup was passed from
mouth to moiith, twenty-eight students at Bryn
Mawr College developed tonsillitis.

Plague in India. — The gravity of the plague
situation in India is evident from a report stating
that during the week ended April 13 there were
87,161 cases of plague and 75,472 deaths, an in-
crease of 14,000 in the number of cases and 12,000
in the number of deaths from the previous week.
During the six weeks ending May 11 the deaths
reached a total of 451,892. From October, 1896,
to December. 1906. the total deaths from the plague
were 4,411,242, and during the first three months
of the present year 495.000 deaths are known to
have occurrerl. There has also been increased mor-
tality from all other causes. The death rate for
the whole of India has increased steadily for the
last five years from 29 per 1,000 in 1901 to 36 in
1905.

Scurvy in Russia. — The report of the Medical
Inspectors in the famine districts, made public on
May 17, records the steady spread of scurvy in
the famine provinces of Samara and Ufa and in the
Turgai Stenoes, Asiatic Russia. A large propor-
tion of the patients are children. Since January
15, when scurvy first became menacing in Ufa
Province, the cases officially registered have aver-
aged 107 dailv, but the average now is several times
greater.

Opium Restrictions in China.^ — All the opium
smoking dens in Foochow are reported to have been
closed by the authorities, and it is declared that
the A'iceroy of Pe-chi-Li Province has ordered all
the local magistrates to establish "anti-opium shops"
for the reception of poor and needy opium smokers,
who will be induced to live in these places free of
charge with a view to curing themselves of the
habit.

Cancroin Case Non-suited. — Prof. Adamkiewicz
of the University of Cracow, wdio is the inventor
of the so-called cancer cure, "cancroin," some time
ago brought suit against a prominent chemical
manufacturing firm, alleging breach of contract.
Adamkiewicz had made a contract w-ith the chemical
firm nroviding that this should have the commercial
rights to the remedy for a period of twenty-five
vears, and that in case of unjustified violation of
the contract the offending party should pay a penalty
of 250,000 marks. Adamkiewicz sued the firm for
this sum. for after a short period it abandoned the
manufacture and sale of the remedy. The testi-
mony of the experts called was unfavorable to the
remedy and the case was non-suited by the court.

Dr. C. W. Pilgrim has resigned as president of
the New York State Lunacy Commission and has
been reappointed to his old post as superintendent
of the Hudson River State Hospital.

Defeat of Pasteurization. — The Aldermanic bill
requiring the pasteurization of all milk sold in the
citv which fails to reach a determined standard of
purity was defeated by a small majority on Tues-
dav of this week.

American Laryngological. Rhinological, and
Otological Society. — The thirteenth annual meet-
ing of this organization will he held in this city on
Mav 30, 31. and June i. 1907. at the .Academy of
Medicine. The president is Dr. ^^'endell C. Phillips

Mav

1907]

MEDICAL RECORD.

863

of this city, and the secretary Dr. Thos. J. Harris
of this city.

International Laryngo-Rhinological Congress.
• — It has been decided by those in charge of this
congress, wliich is to be held in \'ienna April 21 to
25, 1908, to include an exhibition of instruments,
apnaratus, books, etc., relating to laryngology and
allied TDranches, and all those interested are invited
to take part in this undertaking. All communica-
tions, accompanied by an exact description of the
objects to be exhibited, are to be addressed not later
than December 31, 1907, to the Secretary of the
Congress, Professor Dr. ^Michael Grossniann, W'ien,
IX., Garnisongasse 10, in order that they may be
correctly catalogued. Exhibits should be sent not
later than February 15, 1908, to Herrn Ober-In-
genieur Jaroschka, Inspektor des k. k. Univer-
sitatsgebJiudes in \Men, with whom they will be
deposited. All objects will be insured against theft,
fire, and damage. The import and export of ex-
hibits has been declared as duty-free by the authori-
ties. Exhibitors are requested to apply to the sec-
retary for all information in connection with the
exhibition.

Utah State Medical Association. — .A^t its annual
meeting held in Salt Lake City on May 8 this or-
ganization elected officers as follows for the com-
ing year : President, Dr. H. D. Niles of Salt Lake ;
J'ice-Presidents, Dr. C. G. Plummer of Salt Lake,
Dr. E. H. Smith of Ogden, and Dr. H. A. Adam-
son of Richmond ; Secretary, Dr. W. S. Ellerbeck
of Salt Lake ; Treasurer. Dr. J. H. Harrison.

Nebraska State Medical Association. — Officers
were elected as follows at the annual meeting of
this association held in Omaha on May 9 : Presi-
dent, Dr. H. Gifford; J'ice-Presidents, Dr. M. L.
Shaw and Dr. Inez E. Philbrick ; Secretary and
Treasurer, Dr. H. \\'. Orr.

Bristol South (Mass.) District Medical Society.
■ — At the annual meeting of this society, held in
New Bedford, officers as follows were elected :
President, Dr. Garry Hough; J 'ice-President, Dr.
W. T. Learnard of Fall River ; Secretary and Treas-
urer, Dr. A. J. Abbe of Fall River.

Middlesex East (Mass.) District Medical So-
ciety.— Officers as follows were elected at the
meeting of this organization held at Stoneham May
9: President, Dr. C. W. Harlow of Melrose; J 'ice-
President, Dr. F. E. Park of Stoneham ; Secretary,
Dr. H. A. Cole of Winchester; Treasurer, Dr. Chas.
Dutton of Wakefield.

Hampshire Country (Mass.) Medical Society.
— At the meeting of this association held in North-
ampton on May 10 officers as follows were elected :
President, Dr. J. G. Hayes of Williamsburg; I 'ice-
president. Dr. G. B. Thayer ; Secretary, Dr. A. G.
Minshall ; Treasurer, Dr. H. A. Hoadley.

The Mississippi Antituberculosis League. — At
its session held in ^leridian on May 10 officers for
the ensuing year were elected as follows : President,
Dr. R. W. Shipp of Gulfport ; Secretary, Dr. R. F.
Hall of Clinton ; Treasurer, Dr. D. P. Price of
Boonville. The next meeting will be held at Gulf-
port on the second Wednesday in January.

National Association of U. S. Pension Examin-
ing Surgeons. — At the sixth annual meeting of
this organization held in Washington on 3. lav 8
officers were elected as follows : President. Dr. G.
Lane Tenevhill of Baltimore : Vice-Presidents. Dr.
Porter Farley of Rochester. X. Y. ; Dr. J. W. Hous-
ton of Lancaster, Pa. : Dr. D. S. B. Armsburg of

Chicago, III., and Dr. :\I. P. Creel of Center Citv,
Kan.; Secretary, Dr. P. Y. Eisenberg of Norris-
town. Pa.; Treasurer, Dr. Chas. H. Gl'idden of Lit-
tle Falls, N. Y.

Texas State Medical Association. — Officers

were elected as follows at the meeting of this so-
ciety held at Mineral Wells on May 9: President,
Dr. C. E. Cantrell, Greenville; Vice-Presidents, Dr!
H. S. Barnes, Tulia : Dr. D. S. Weir, Beaumont! and
Dr. A. B. Small, Wa.xahachie; Treasurer, Dr. C. A.
Smith. Texarkana : Secretary for three years. Dr.
I. C. Chase, Fort Worth.

Kansas State Medical Society. — The election of
officers for this society held at the annual meeting
in Kansas City on May 11 resulted as follows:
President, Dr. J. E. Sawtell, Kansas Citv; Vice-
Presidents, Dr. T. Kirkpatrick, Garnett ; Dr. M. E.
Jarrett, Fort Scott, and Dr. G. M. Gray, Kansas
City; Secretary, Dr. C. S. Huffman, Columbus;
Treasurer. Dr. L. H. ]\Iunn, Topeka.

American Laryngological Association. — Offi-
cers for the ensuing year were elected as follows
by this organization at its closing session in \\'ash-
ington on May 9: President, Dr, H. S. Birkett,
Montreal; ]' ice-Presidents, Dr. J. Payson Clark',
Boston, and Dr. J. E. Rodes, Chicago; Secretary
and Treasurer, Dr. James E. Xewcomb, Xew York ;
Librarian, Dr. J. H. Bryan, Washington.

lov^^a State Homeopathic Medical Association.
— This association at its meeting held in Iowa City
on :\Iay 9 elected officers as follows: President,
Dr. T. F. H. Sprong of Siou.x City; Vice-Presi-
dents, Dr. Genevieve Tucker of Davenport, and Dr.
R. W. Homan of Webster City; Secretary, Dr.
Gardiner A. Huntoon of Des Moines ; Treasurer,
Dr. M. .\. Royal of Des Moines.

The Late Dr. Solly. — .\t a meeting of the Board
of Directors of the Xational Association for the
Study and Prevention of Tuberculosis, held in
Washington May 7, 1907, the following resolutions
on the death of Dr. S. E. Solly, a former member
of the board, were unanimously adopted : Whereas,
The Directors of the National' Association for the
Study and Prevention of Tuberculosis have learned
with sincere sorrow of the death of their colleague.
Dr. S. E. Solly of Colorado Springs, and Whereas,
by his great medical ability and no less by his un-
usual personal charm he had both endeared himself
to them and proven a wise counsellor in their de-
liberations, therefore be it Resolved: That in his
death they have lost a member whose place cannot
easily be filled ; one whose distinguished professional
attainments did honor to this body to which he
belonged and whose remarkable gifts of heart
equally with those of mind made him ever welcome
in their midst ; and be it further Resolved : That the
secretary be directed to send a copy of these resolu-
tions and assurances of our deep sympathy to this
bereaved family : that a copy be spread on our
minutes, and that they be published in Colorado
Medicine, the official organ of the Colorado State
Medical Society, in the Journal of the American
Medical Association, in the Medical Record, and
in the Journal of Outdoor Life, the official organ of
the National Association for the Study and Preven-
tion of Tuberculosis.

Obituary Notes. — Dr. Is.\.\c M. Ridge of Kan-
sas City died on Ma\- 7 at the age of eighty-one
\-ears. Dr. Ridge was born in .\dair Countv, Ky.,
and in 1834 was brought by his family to Lafayette
County. "Mo, Fourteen years later, after receiving
his de.a:ree frnm Transylvania Lniversitv, Lexing-

864

iMEDICAL RECORD.

[May 25, 1907

ton, Ky., he began the practice of medicine in Kan-
sas City. He had retired from active work many
years ago.

Dr. Albert H. Humes of Boston died suddenly
at his home in Woburn on May 8 at the age of
fifty-two years. He was born in Douglas and was
a graduate of the New York College of Physicians
and Surgeons. He had practised in Boston about
twenty years.

Dr. Charles Willl\ms Ottley of Atlanta, Ga.,
died in Baltimore on May 9 at the age of thirty-
si.x years. Dr. Ottley was a graduate of Princeton
and Johns Hopkins University. For four years he
had been a medical missionary to Turkey.

Dr. NoYES N. Le.\rnard of Charlestown, Mass.,
died on May n at the age of eighty-two years. He
was a native of Vermont and had practised in the
south end for many years.

Dr. John G. Broadnax of Greensboro, N. C,
died suddenlv of heart disease on j\Iay 9 at the age
of seventy-five years. He had served as Confed-
erate army surgeon through the Civil War and was
one of the oldest practising physicians in that part
of the country.

Dr. John M. Harlow of Woburn, Mass., died on
May 13 at the age of eighty-seven years. He was
born in Whitehall, N. Y., and was graduated from
the Jefferson !\Iedical School in Philadelphia in
1844. After practising for fifteen years in Caven-
dish, Vt., he went to Minnesota for his health and
some vears later settled in Woburn. He had held
numerous public positions, both in the municipal and
the State governments, and was a trustee of the
Massachusetts State General Hospital.

Dr. Charles A. Foster, physician to the New-
York State Hospital for the Insane on Ward's
Island, died suddenly on May 19 at the age of fifty-
eight years. He had formerly been a resident of
Saugerties, N. Y.

Dr. Eugene Wiley died at Philadelphia on May
17 at the age of sixty-two years. He was grad-
uated from Jeft'erson Medical College in the class
of 1869.

Dr. David H. Goodwillie of Yonkers, N. Y.,
died on May 17 at the age of seventy-four years.
He was a native of Barnet, A^t.. and received his
medical education at the college of medicine of the
University of A'ermont and in Edinburgh, Scotland.
He had practised for many years in this city as a
larvngologist and was a member of numerous medi-
cal organizations. He retired from active work
about six years ago and went to Yonkers to live.

Dr. Charles Neill of Toronto died suddenly on
board a railroad train near Chicago on May 15
w'hile on his way to Texas for his health.

Dr. J. A. CuMMiNGS of Omaha, Neb., died of
pneumonia on May 12 at the age of thirty-five
years.

Dr. Shuler Craft of Denver, Col, died of pneu-
monia on ]\Iay 12. Dr. Craft was born in Fort
Wayne, Ind., in 1878 and was graduated in medi-
cine from the University of Denver two years ago.
Dr. John C. StuRois of Seattle, Wash., died after
a brief illness on ^May 6. He was born at Charles-
ton, Ind.. in 1858 and received his medical degree
from the University of iMichigan. After practising
for a time in Indiana he went to Seattle in 1889.

Dr. James E. Casey of Mohawk, N. Y., died on
May 19 at an advanced age. He was graduated
from the Albany Medical College in 1835, and had
practised in Herkimer county for over fifty years.

DR. K-VOPF :\IISQUOTED.

To THE Editor ok thi; .Mf.hk ai. Kf.iokd:

Sir: — I take this method of trying to correct the out-
rageously fal.se impression given by many of the news-
papers of tlie country of the statement of Dr. Knopf before
the Clinical and Climatological Section of the National
-Association for the Study and Prevention of Tuberculosis,
at its recent meeting in Washington. I was present as
chairman of the section when Dr. Knopf made his remarks.
He was within a few steps of where I sat, and I was pay-
ing close attention to his remarks. I understood him, and
all others with whom I have spoken on the matter since
the meeting understood him, to state plainly the need of
using morphine to relieve painful symptoms in the last
stage of the disease. Any physician who heard the re-
marks must have known that the morphine was used not
for shortening life, but solely for making it easier, and
every physician also knows that life is generally prolonged
by that sort of treatment. .-Vs I have expressed myself be-
fore this regarding the shortening of lives of seriously sick
people, I need hardly say that had Dr. Knopf advocated
anything like the administration of large or dangerous doses
of morphine I would have vigorously protested. I hope
that physicians who are asked about the matter will con-
tradict the newspaper statements and seize the opportunity
of explaining the real object of the treatment.

George Dock, M.D.

Ann .Arbor, Mich.. May 17, 1907.

OUR LONDON LETTER.

(From Our Special Correspondent.)

BENINDEN S.\N.^T0R^UM — BILL TO PREVENT PR.»kCTICE BY COM-
PANIES— SURGICAL .\FFECTIONS IN THE RIGHT ILI.\C REGION
— LOCAL .\NESTHESIA FOR OPER.^TI0NS FOR GOITER — ADDI-
SON'S DISE.\SE — DE.\THS UNDER ANESTHETICS IN RELATION
TO LYMPH.\TISM — DE.\TH OF MARKHAM SKERRITT.

London, May 3. 1007.
The Princess Christian of Schleswig-Holstein opened the
first part of the new self-supporting sanatorium for working
class persons suffering from tuberculosis, I have previ-
ously given you particulars of this movement. Nineteen
beds are already occupied, and when completed the institu-
tion will have 200. Sir Clifton Robinson, one of the vice-
presidents, said he would like to see a supplementary
organization, by means of which those who had been
brought into the country and cured would be enabled to
settle for good on the land, instead of returning to the
dense centers of overcrowded towns. There would then be
the best chance of their cures being permanent.

The bill to prevent the evasion of the medical acts by
companies engaging in practice has passed the second read-
ing in the House of Lords with the blessing of the Govern-
ment, who. Lord Crewe said, are of opinion that it meets
something which nearly approaches a public scandal. .A.
doctor should be personally responsible, and not able to
shelter himself behind a company. .A doctor who allowed
himself to be employed by a company would be a derelict
of the profession, and it was better not to encourage this
sort of practice by companies. The bill, and the parallel bill
respecting dental companies, having passed this stage, some
are hoping that both may become law. But note the
reasoning of the Government spokesman. He had no
notion of protecting the profession, or even the public. It
was just as well not to encourage companies, but he had
not the courage to declare such companies swindlers or im-
postors. Free trade must deal gently even with such com-
binations— much as the public may suffer.

At the Medical Society of London, Mr. Waring read a
paper on certain iliac affections which simulate more or
less closely appendicitis. He restricted his remarks to
cases of acute or subacute attacks of pain beginning mostly
in the umbilical or epigastric regions, sudden in onset,
and localized later in the right iliac fossa, with nausea or
vomiting, and muscular rigidity of the lower part of the
wall of the abdomen on the right side. He related two
cases of acute infective osteomyelitis of the ileum, where
it forms the deep boundary of the fossa. So tuberculous,
deep glands in the fossa might last some time without
decisive symptoms. Glands which became the seat of sec-
ondary infection might also imitate appendicitis : so might
abscess secondary to a septic state of the right broad liga-
ment or Fallopian tube. In one instance adenopapilloma of
the mucous membrane of the cecum around the opening of
the appendix set up the symptoms. Hematoma of the right
ovary at an early stage, a displaced right ovary, injury to

May 25, 1907]

MEDICAL RECORD.

865

the region, breaking down of a malignant growth, rupture
of a blood-vessel, and other affections, had given rise to
difficulties. In all cases it was necessary to ascertain, if
possible, the precise mode of onset and the chronological
sequence of the symptoms, as well as to consider carefully
all the facts available in connection with the previous his-
tor.v, to make a complete clinical examination of the abdo-
men and pelvis, and, if still in doubt, to examine the blood.

Mr. Lynn Thomas described a mode of producing local
anesthesia he had found effectual for removing goiters.
He draws his scalpel along the line of Kocher's collar in-
cision so lightly as to cause a thm red line, under which
he injects one to two drams of i per cent, cocaine solution,
thus forming a subcutaneous ridge from end to end. The
cellar incision is then made and the operation completed
with very little loss of blood, every exposed vessel being
clamped by two Kocher's forceps and divided between them,
as it appears.

At the Medico-Chirurgical the paper was on Addison's dis-
ease, by Dr. Griinbaum. and chiefly as to early diagnosis. He
said the two chief symptoms, asthenia and pigmentation,
might both or either be present in other diseases. He
found that oral administration of suprarenal extract did
not raise the blood pressure of healthy persons, but that a
rise followed this medication when there was renal inade-
quacy. In doubtful cases three-grain doses ter die for
three days could be utilized, and if there was a distinct rise
it was very suggestive of Addison's disease in the absence
of valvular heart disease. The opsonic index after inocula-
tion with tuberculin often pointed to a tuberculous condi-
tion of the adrenals.

Dr. Rollestun agreed as to the effect of the extract given
by the mouth on the blood pressure, and said that a con-
dition of inadequacy existed short of Addison's disease,
and might perhaps be thus indicated. He attached little
importance to pigmentation of the mouth, which might be
induced by bad teeth. Dr. F. P. Weber said prolonged
asthenia after infection suggested .\ddison's disease, and
told of such a case, when months after influenza pigmenta-
tion took place and death occurred in a syncopal attack,
both suprarenals being found at the postmortem caseous
and matted across the aorta. Dr. Tooth remarked that
bromide occasionally caused pigmentation. Dr. Ewart
referred to the variation in the symptoms of Addison's
disease. In one case asthenia was most prominent, in
another pigmentation, the latter being less severe than the
former. He related one case in which pigmentation was
present for many years

In his reply. Dr. Griinbaum said he had not met with
a case of pigmentation produced by bromide. If the supra-
renals were removed in animals pigmentation did not fol-
low, but if they were damaged or infected it did. In rapid
destruction of them, as by cancer, there was no pigmenta-
tion. The more rapid the disease the less pigmentation
occurred. In a case in which only the solar ple.xus was
involved there was pigmentation on the trunk more than
on the limbs.

The death of a young baronet under an anesthetic
(chloroform and ether combined) was the subject of an
inquest last Friday, when a verdict of death by misadven-
ture was returned. The evidence showed that Sir H. L.
Huntington was twenty-one years of age, 6 feet 3^2 inches
in height, and was thought to have outgrown his strength,
but was in good health. Dr. Frankish said that two years
ago he had a mild attack of diphtheria, but made a good
recovery. He prepared him for the operation and called in
Dr. Hiiliard to give the anesthetic. On the first incision
the patient stopped breathing and changed color ; he re-
covered at once, and the operation was resumed, but before
it was completed the pulse stopped, the breathing became
shallow, and artificial respiration was resorted to without
effect. Dr. Spilsby. pathologist of St. Mary's Hospital,
made the post mortem and found fatty degeneration of the
walls of the heart with a little dilatation, a very unusual
thing in a young man. He added that "he also found the
status lymphaticus, a condition that only recently en.gaged
the attention of pathologists in this country, and not recog-
nizable during life, although its subjects seemed specially
liable to sudden death from trivial causes." In this case
death was due to syncope. In reply to a question, he said
the condition named represented a new danger in anesthe-
sia. Dr. Hiiliard, asked if he had seen such a death, said
he had never seen a death under anesthesia, although he
had dealt with 12.000 cases.

.Another inquest was held on Saturdav which may be
compared with the above. It was on a boy of nine, who
died at Guy's Hospital under ethyl chloride. The Coroner.
Dr. Waldo, said he knew of twenty-two fatalities, and had
held four inquests following deaths from this anesthetic.
The clinical assistant said three cubic centimeters were
given. Deaths under ethyl chloride were one in .1,000. There
were less under ether or chloroform. It was given in this
case, as the operation was a short one — appendicitis. The

house physician said 3 c.c. was a careful dose. He had
made a post mortem and found fatty degeneration of the
heart. 'The direct cause of death was the anesthetic, but
the poor condition of the child had a bad effect. Verdict,
misadventure and no blame to anyone.

In connection with the foregoing cases I am reminded
of some remarks made last month at the Dublin .'\cademy,
when Dr. Peacocke related a case of cerebrospinal men-
ingitis in a child of five, the subject of lymphatism. The
attack was fatal in eleven hours. .\t the oost mortem Dr.
Peacocke found very large thymus, enlarged mesenteric
glands, hypertrophied Peyer's patches, and solitary folli-
cles, and on section of the spleen prominence of the nial-
pighian corpuscles. The idea of lymphatism did not occur
during life, for there were no symptoms, and the only sign
likely to be detected was such dullness as the large thymus
might cause. Dr. Kirkpatrick said the condition of lym-
phatism had been found in a number of cases in which sud-
den death had occurred during the administration of anes-
thetics, so that its recognition if possible would be of prac-
tical importance. Professor White thought lymphatism
had much to do with infection. Most fatal cases of cerebro-
spinal meningitis had had trouble with adenoids, and it
was possible they were infected through the lymphoid tis-
sue at the back of the nose, where there were a number of
diplococci in some healthy persons. It was difficult to
distinguish some of these organisms from that of cerebro-
spinal fever. In the only case he had examined post mortem
in the present epidemic lymphatism existed.

Bristol is mourning the loss of the senior physician to
her General Hospital. Dr. Markham Skerritt, who died on
Monday and was buried yesterday amid signs of the city's
regret for one who had served her long and faithfully.
Dr. Skerritt was a man of great attainments. He took the
B..A.. of London University in 1868, proceeding to M.B.
and B.S. with honors in 1873, and M.D. the next year. In
his college course he took numerous prizes and the chief
scholarship. At the University he was gold medalist in
medicine and obstetrics at both the M.B. and M.D. examina-
tions. In 1875 he was elected physician to the Bristol
Hospital, and continued to serve it for the rest of his life.
He became one of the most distinguished consultants in
the west of England. A member of the London College
of Physicians in 1876, he was elected a Fellow in 1885,
Bradshaw Lecturer in 1897, and Councillor in 1904. He
served the chief offices in various medical and scientific
societies, and contributed valuable communications to them,
as well as to the journals. He was E.xaminer in Medicine
for the R. A. M. C. For more than a quarter of a century
he was Professor of Medicine and Dean of the Medical
Faculty in the L'niversity College of Bristol. He resigned
these and some other appointments in 1905, having some
time previously lost his daughter and only child, and his
wife liaving begun to lose her sight. He was an active
man, and used to hunt until his bereavement. Modest and
rather reserved, he was destitute of push, and attained
his great position by merit and the good will and affection
of his patients and his fellow citizens by his kindliness and
consideration for all. He was in his usual health until
Sunday week, when he felt indisposed, on the Wednesday
he took to his bed, and was found to be suffering from
pneumonia of a severe type, which terminated fatally on
Monday, in his fifty-eighth year. The city and the profes-
sion join in deep sympathy with his widow.

THE PHILIPPINE ISLANDS MEDICAL ASSOCIA-
TION.

(From Our Special Correspondent.)

Manila. P. I.. March i, 1Q07.
The fourth annual meeting of the Philippine Islands Med-
ical .Association was opened most auspiciously on the after-
noon of February 27. Delegates from China, Japan, and
Hongkong were in attendance, and the meeting promised
to be one of the most successful that had yet been iield.
The great interest manifested, not only by medical men, but
by the laity, and the governments in nearby countries, was
a great inspiration to the medical men of the Philippine
Islands who are engaged in combating the diseases that
prevail here, and who are making a study of the many
problems connected with tropical medicine.

The first session was a general one, and not devoted to
strictly scientific purposes. The Governor-General of the
Philippine Islands made the opening address, and stated, in
substance, that it gave him great pleasure to meet the men
who are engaged in organized efforts to combat disease in
the tropics. He said he felt that he expressed the feeling
of the community when he stated that everyone is deeply
appreciative of tlie fact that many of the medical men here
were sacrificing their time, and in some cases everi their
lives, in the interests of their fellow men. He said that

866

MEDICAL RECORD.

[May 25, 1907

it was with particular pleasure he noted that scientific
men who were born and reared in the Orient, and thor-
oughly conversant with the best means of combating the
diseases which have lieretofore made severe inroads into
Oriental life, had come here to take part in this meet-
ing of the Association. He invited particular attention to
the fact that up to twenty-five years ago the medical man
was not an important political factor in the community, be-
cause he devoted himself so exclusively to the interests
of his patients that he did not seem to find time to form
medical associations which would make his iniluence felt,
but by the general organization of the medical profession
throughout the civilized world the influence of the medical
man was now felt in almost all legislative bodies, and that
many measures which had found their way into the statute
books durnig this period had done nmcli to improve public
health and lessen diseases, and was ample testimony of the
value of medical organization. It was by such unions that
the great opposition which was often encountered in en-
forcing sanitary regulations was successfully met, and that
furthermore it gave him great pleasure to state that his
experience with medical men, which had been a large one,
had shown conclusively that even though the faithful dis-
charge of public duties often led to much unpleasantness,
yet he had never found that the medical man shirked this
responsibility.

The next feature on the program was an address by Dr.
Paul C. Freer, the President of the .\ssociation, entitled :
"A Consideration of Some of the iModern Theories on Im-
munity" Dr. Freer took the ground that the indications
now are that the future progress in immunity must be
rather through chemistry than through biolo.gy. He stated
that after having given this subject most careful study dur-
ing the past few years, and by observation of natural and
acquired immunities under various environments, he felt
convinced that in the future the preservation of public
health must be looked for more through vaccines and
serums than through hygiene. His address was a very able
one and will be published in full in the Philippine Journal
of Science.

In the evening, at 8:30. Colonel John Van R. HofT, As-
sistant Surgeon General of the United States Army, gave
a picture talk on "Russian Sanitary Ways and Means in
Manchuria, 1905." The data, statistics, and other evidence
which he presented came as a matter of surprise to many
of the audience, because it seems to have become the gen-
erally accepted view that the Russians did very little in a
sanitary way. The evidence presented by Colonel HofT
showed conclusively that practically as favorable results
were obtained by the Russian medical officer as by the Jap-
anese medical officer. The proportion of disability and
deaths due to disease, which has heretofore obtained in pre-
vious wars, was reversed in the case of the Russians just
as in that of their opponents ; three men dying on
the field of battle as against one from disease.

The next on the program was a naper entitled "Mosquitos
in the Philippines, Their Breeding and Habits, with Meth-
ods for Their Suppression," by Charles S. Banks, Ento-
mologist, Biological Laboratory, Bureau of Science. His
exhibition of the various forms of mosquitos was most ex-
cellent. The specimens showed great care in their prep-
aration. His talk was also profusely illustrated, showing
the places in which mosquitos breed. He stated that the
two mosquitos that caused the greatest discomfort to the
residents of the Phili'^-'ines were the stegomyia in the day-
time and the Ctilex fatigans at night. In Manila practically
no anopheles are encountered.

On the evening of February 28 Dr. R. P. Strong gave a
dinner in honor of the foreign guests, and to the members
of the society. Among the foreign guests present were Dr.
J. M. Atkinson, the Honorable Principal City Medical Of-
ficer at Hongkong; Dr. Kannosuke Miyajima, Delegate
from His Imperial Japanese Majesty's Government; Dr. Sia
Tien Pao, Delegate from His Imperial Chinese Majesty's
Government ; General Wood, and the chief medical officers
of the .\rmy. Navy, and Public Health and Marine Hos-
pital Service were among those present. The dinner was
most successful and will probably be very productive in ce-
menting those friendships and unions which are so necessary
and helnful to a better understanding among medical men.

At the third session, held on February 28. the first paper
read was entitled "The Prevalence of Ilvdrophobia in the
Philippine Islands," by Dr. F. W. Dudley. St. Paul's Hos-
pital. The writer stated that the object of his paper was
to show the prevalence of hydrophobia in the Philippine
Islands, and the necessity for making available, modern
prophylactic treatment for the purpose of combating it. He
posted notices in practically every pueblo in the Philippine
Islands and corresponded with all medical men from
whom he could expect to obtain some data, and in this way
he was able to collect, during the period from March i.
1902. to February 28, 1907, 36 cases in human beings, 225

cases in dogs, i in a cat, i in a carabao, 2 in horses, 10 in
pigs, 3 in rats, and i in a monkey. In his opinion, the incu-
bation period in the Philippine Islands was rather long.
One authentic case was reported within ten days, but there
were also three authentic cases with incubation periods of
eight, nine and ten months respectively. During the month
of February a dog bit a child in the city of Manila. The
dog was immediately killed and taken to the Bureau of
Science for investigation but no Negri bodies were found
nor have any symptoms appeared in the rabbits which were
inoculated from material taken from the dog. He had
nothing particularly new to ofifer in the way of treatment.
He recommended that the Pasteur method should be em-
ployed, and stated that the same is not available in the
Philippine Islands. In conclusion, he urged that the Gov-
ernment make available immediately a modern prophy-
lactic treatment for this disease.

The next paper was entitled "Clinical Observations on
Uncinariasis," by Dr. Edwin C. Shattuck. .\ttending Phy-
sician, Bilibid Prison. He stated that during the past few
months 849 inmates, taken in the regular order in which
they were admitted to the prison, were examined. Of
these, 243 were found to have uncinaria. or about 24 per
cent. They occurred in prisoners who were received from
practically all the diliferent provinces m the islands, which
shows that the distribution of the disease must be wide-
spread. He reported that at first thymol was used in the
treatment, but later the treatment by eucalyptus oil, as rec-
ommended by Phillips in the London Lancet, February 3.
1906, was adopted, which consists of 2.5 c.c. of eucalyptus-
oil, 3.5 grams of chloroform, and 40 c.c. of castor oil. This
is divided into two doses, given on an empty stomach, at
intervals of one-half hour. He increased the dosage to
30 c.c. with excellent results. The use of the oil is pre-
ceded by a dose of magnesium sulphate, and two hours
after the last dose of oil another dose of magnesium sul-
phate is administered, .^fter this has acted, light diet is
permitted. Of the 345 cases treated with eucalyptus oil,
270 only required one treatment, 58 two and 16 three, and
in one case four treatments were necessary before the
stools were negative.

The next paper. "Nectalor americanus in Natives of
the Philippine Islands," was read by Lieut. Clarence L.
Cole, .\ssistant Surgeon, U. S. Army. His experience was
practically that of other observers in this field.

Then followed an address entitled "Methods of Com-
bating Plague in Hongkong," by Dr. J. M. Atkinson, the
Honorable Principal Civil Medical Officer of Hong-
kong. He stated that the methods of combating plague ir»
Hongkong were now practically the same as those em-
ployed in most civilized states where this scourge exists.
He brought out one new point, however, that is, that in a
house where plague has been encountered guinea pigs are
now set free, with the idea of having any fleas that may
be about the premises collect upon the guinea pigs and
capturing them by this method. Otherwise the usual dis-
infection of premises, with the obliteration of the rat-runs
and general cleanliness, were carried out, the cases them-
selves being isolated at the plague hospital.

The next paper, entitled "The Physiologically .Active
Constituents of Some Philippine Medicinal Plants, .^rrow
Poisons, and Fish Poisons." by Dr. Raymond F. Bacon of
the Chemical Laboratory of the Bureau of Science, was
most instructive and by far the most exhaustive treatise
that has appeared upon the medicinal plants since Amer-
ican occupation. The paper will be published in full \n
the PhiUippinc Journal of Science.

The last paper of the Third Meeting, entitled, "Native
Medicinal Plants," was read by Elmer D. Merrill, Botanist,
Bureau of Science. He stated that Phili^nine systematic
botany has been in a chaotic state since the publication of
Blanco's "Flora de Filipinas." and that in 1837. due to the
fact that Blanco and some of his successors, notably Lan-
yos, Fernandez-Villar, and Naves, had no conception of
the geographical distribution of species, and credited to the
Philippines plants that did not grow in the archipelago, and
accordingly, referred to extra-Philippine species a great
number of local plants which were really very distinct from
those which are described by various authors for the
.-Vsian continent and Malaya. Subsequent workers, how-
ever, Vidal among them, did much to clear up this con-
fusion, but after his death, in 1899, very little work in
Philippine flora was done up to the advent of the .Amer-
icans, who resumed the work in 1902. He stated that the
two essentials for a thorough revision of the Philippine
botany were a complete herbarium and a representative
botanical library, and both of these were supplied by the
Bureau of Science. He stated that sufficient material and
data was already on hand to warrant the commencement
in the near future of a publication on the flora of the
Philippines that will be fairly complete and accurate, but

I\Iay 25, 1907]

MEDICAL RECORD.

86

/

that such a work must treat of from eight to ten thousand
different species of plants, and it would of necessity be
greatly delayed in its compilation. He stated that many
official and officinal plants were found in the Philippines
either wild or cultivated, and that some of these were of
especial interest, the principal ones being castor oil, strych-
nos ignati, otherwise known as St. Ignatius bean, and that
the latter contains a larger proportion of strychnine than
the strychnos nu.^c vomica, from which it is usually ob-
tained, and also that this is only found in the Philippines.
He laid special stress upon the fact that most pharma-
copceias erroneously referred to it as Chinese. Among
others, he mentioned papaya, pomegranate, and the tama-
rind. He also stated that many of the plants would no
doubt be commercially profitable if pains were taken to e.x-
ploit this feature of the work.

Prngrrss nf iUpJitral ^rirurr.

Xcw York Mt-dical Journal, May 11, 1907.

Unrecognized Diphtheria in Children. — I. Friesner
calls attention to the fact that nasal diphtheria in children
is very often overlooked. The patient does not seem
very sick, has but a slight rise in temnerature, not much
change in pulse or respiration and may eat well. Often
these children are credited with only a cold in the head.
Occasionally the nasal discharge is confined to one side
and the nasal vestibule on that side, together with the lip,
is red and slightly swollen. The cervical glands are not
always enlarged. There is as a rule a discharge of yellow,
glairy mucus, which may later become greenish. Sneezing
may occur, but it is not as common as in coryza. In fact,
the discharge and lip discomfort are the symptoms prin-
cipally complained of. In the early stages examination of
the nares shows only an acutely inflamed mucosa. Later,
as the disease develops, a more or less typical membrane
develops. The grave danger of such cases both to the pa-
tient and those about him render careful bacteriological ex-
amination necessary so that if the disease proves diphther-
itic the proper precautions may be taken. Two illustrative
cases are detailed. The author thinks that careful examina-
tion of the nose in sick children is just as imoortant as the
examination of the throat, which is now so regularly done.

Danger of Fire in Formaldehyde Disinfection. — C. H.
LaWall calls attention to the dangers attending the mod-
ern method of disinfection by the formalin-permanganate
plan, stating that on several occasions the mixture has
been known to take fire spontaneously. In the formalin-
permanganate method it has been customary to use tvOo
parts of formalin to one part of permanganate, adding the
latter to the former and quickly leaving the room before
the violent evolution of gas which shortly takes place has
time to afifect the operator. Working with quantities in
some cases as high as one pound of permanganate, the
amount of heat developed must be very great, and if there
are any uncertain factors present, such as organic mat-
ter in the container which has been imperfectly cleaned,
the danger of possible ignition is that much greater. The
flame which has a^^eared on these occasions of combustion
has been of a pale blue appearance, reaching several feet in
the air from the container. The -- may be ignited from
a 40 per cent, solution of formaldehyde by simply heating
it and applying a match to the surface after ebullition has
begun, and when the formalin-permanganate disinfection
proportions are used in as small a quantity as one ounce
of formalin and one-half ounce of permanganate, using a
beaker for a generator, the flame of the ignited gas has
been observed to have a length of more than one foot. In
view, therefore, of the uncertainty regarding the cause of
the ignition of the vapor in these observed cases and in
recognition of the hitherto overlooked fact that formalde-
hyde vapor is very inflammable, it would be well to practise
this method of disinfection with the precautionary measures
of using small quantities of the ingredients (not over one-
quarter or one-half pound of permanganate to a charge) in
several containers, surrounding these containers with larger
ones containing water, being careful to extinguish all gas
jets, pilot lights, fire, and other possible causes of ignition,
and keen the generators away from the sides of the room
where a flame might be communicated to inflammable ma-
terial. It is not believed by the writer that this method
of disinfection need necessarily be abandoned, but it is es-
sential that its limitations and dangers he not overlooked
in its future use.

Appendicitis in Pregnancy. — H. N. Vineberg calls
attention to this subject and gives some interesting statis-
tics. He refers to the figures taken from the Mt. Sinai
Hospital records covering a period of eight years. During

this time there were 2,003 cases of appendicitis, 731 occur-
ring in females. The association of pregnancy occurred in
only nine cases. Two of these were not operated on and
the diagnosis was based on clinical manifestations alone.
The author therefore concludes that pregnancy does not
predispose to the development of acute appendicitis. Dif-
ferential diagnosis compels the consideration of the fol-
lowing possible conditions : Pain in the riMit side of the
abdomen, which is not uncommon in pregnant women,
rupture of an ectopic gestation sac at an early date, pyelitis
of pregnancy, disease of the right adnexa, and typhoid
fever. As regards treatment, the author declares that sim-
ply because pregnancy is present in an undoubted appendi.x
inflammation one should not become panicky and consider
that an immediate operation is always necessary. If the
attack be a mild one, the patient can safely be treated pal-
liatively, and one may wait for further developments.
Should another attack occur within a short time and ex-
hibit symptoms of greater severit}-, then, it seems to him,
one should not defer surgical intervention, in the hope that
further attacks will probably not recur. In an attack man-
ifesting very acute symptoms one should act just in the
same way as if pregnancy were not present. It is well to
administer opiates freely during the first seven or eight
days after the operation, so as to avert premature termina-
tion of pregnancy. If abortion or premature delivery be-
comes inevitable, one should follow the recognized method
of treatment, of emptying the uterus completely. In the
presence of a large appendicular or postcecal abscess, one
should not attempt to do more than make an incision and
employ drainage, disturbing the relation of the abscess cav-
ity as little as possible. The absurd procedure advocated
by some to empty the uterus by forcible intervention im-
mediately after operation met with the fate it deserved, be-
ing universally condemned. With ordinary precaution the
uterus, even in the abscess cases, will not expel its con-
tents until after the lapse of several days, when the local
conditions will be such that no danger will ensue from the
altered relations of the abscess cavity that such an event
will bring about.

Chronic Muscular Diseases of the Heart and Their
Treatment. — T. Schott states that whatever may be the
etiology of this class of maladies, in special processes of
change' in the substance of the muscle of the heart, and
the collateral symptoms, one fact is common to all, the
final incapacity of the heart to perform its work, which is
commonly defined as "muscular insufficiency." This latter
condition generally follows chronic myocarditis, be it with
or without symptoms of angina pectoris, whether conse-
quent to fatty changes of the heart, with or without
valvular lesions, or whether it follow overexertion or
the changes due to chronic poisoning through such sub-
stances as alcohol or nicotine. The author then goes on to
describe the plans of treatment which are generally known
as the Nauheim treatment, placing his reliance on weak and
always carefully controlled thermal saline baths, contain-
ing carbonic acid. For a lower percentage of such patients
the strongest form of the so-called effervescent flowing
baths is very beneficial. On many occasions we have dem-
onstrated this method of treatment and the marked success
which attends it; and we have given proof that the effect
of the baths is very similar to that of gymnastics, indeed,
almost identical. The difference is merely that what the
baths do by means of the sensory nerves the therapeutical
exercises do through the motor nerves. The mechanical
treatment presents itself under three different forms :
Climbing exercises according to the teaching of Oertel ;
the Zander treatment by machinery ; and the treatment
by exercises with resistance and self-resistance as taught
by his brother August Schott and himself. It is certain
that, although the chief impulse toward this line of treat-
ment was due to the labors of Oertel, the Tcrrainkur which
he advocated is only fit for a limited number of patients
suffering from heart disease. It is most effective in the
case of fatty heart in a young patient with normal muscular
strength and quality of blood. In such cases it has been
used with the best "results. In the fatty heart of later life,
however, or in connection with other complaints, cardiac or
others, the greatest caution should be observed. Climbing
exercise has in such cases often proved to be a most dan-
gerous remedy, and especially in complicated forms of
chronic muscular disease of the heart, whether associated
or not with valvular trouble. The author gives an inter-
esting series of pulse tracings before exercise and after
various forms of exercise, and details the clinical histories
of five personal cases. He says that, according to his ex-
perience, we have a reliable criterion as to the advisability
of the treatment in the following effects, .\fter a mild
brine bath (i to i 1-2 per cent.) of 93° to 9S° F-, five to
eight minutes' duration, or after gymnastic exercises with
slight resistance, the heart, even if there is a passing ac-

868

MEDICAL RECORD.

[May 25, 1907

celeration, will beat more quietly and with stronger im-
pulse, hence the pulse must be of a fuller volume and the
breathing easier. If we obtain these results from the baths
or the exercises and continue this treatment slowly and
prudently, we can look for success even in long standing
cases of muscular diseases of the heart.

Journal of the American Medical Association, May 18,
1907.

Adrenalin in Unilateral Renal Hematuria. H. H.

Voung reports a case of unilateral renal hematuria, of
supposed traumatic origin, of si.xtcen months' duration,
and without evidence of nephritis, cured by adrenalin.
Pam was constant on the right side, the side of the injury,
but the hemorrhage was from the left kidney. The adren-
alin was mjected through the urethral catheter; only one
mjection of 6 c.c. of a 2 c.c. adrenalin in 8 c.c. of sterile
water was given. Some pain was caused at first, but soon
disappeared and the urine cleared up entirely in about ten
days, and there was a general improvement in the patient's
condition. Three months after the treatment the man was
in almost perfect health, having only occasional slight pains
in the back and headaches much less severe than those
formerly troubling him. Young reviews the recent liter-
ature of unilateral hematuria without nephritis, which he
thinks shows the great importance of study of these cases,
and the need of due efforts to determine their etiology.
Bilateral catheterization should always be performed. The
case reported, he thinks, demonstrates the importance 0I
attempting to stop the hemorrhage by the injection of
adrenalin through the ureteral catheter, and the excellent
result in this case proves conclusively its therapeutic value
in certain cases. Even with delinite lesions present it would
appear riot to be contraindicated. and it may be of great
diagnostic value. The weakening efTect of the hematuria
would be abolished and a more careful study of the urine
facilitated. If in this way we can effect a cure, as in the
case reported, the patient would be saved the ordeal of a
cutting operation. In case of an ulceration of a tumor into
the urinary passages, the use of adrenalin would not neces-
sarily delay an exploratory operation if indicated. Young
IS convinced that tlie intraureteral injection of adrenalin is
practically free from danger.

Vascular Lesions Following Laparotomy. W. A. N.

Borland calls attention to the vascular lesions— hemor-
rhage, thrombosis, and embolism— as after-complications
of laparotomy. The case of hemorrhage he reports was
not due to slipping of the ligature, but to rupture of a dis-
tended broad ligament vein, an accident which he considers
rare, though Byron Robinson speaks of it as frequent, but
easily explained by the thinness of the vascular walls
caused by the development of the tumor and the increased
vascular pressure from its removal, the ligation of the
arteries, etc., in the operation. The change from the Tren-
dtlenburg posture after the operation also favors the oc-
currence of bleeding from an obscure open vessel or torn
adhesions, as Buckmaster has shown; hence the abdomen
should not be closed until after thorough ocular inspection
in the normal position. Primary postoperative hemorrhage
may be intraperitoneal, due to (i) slipping or loosening
of the ligature; (2) oozing from large raw surfaces; (3)
spontaneous rupture of pelvic veins; (4) subperitoneal
hemorrhage from imperfect ligation of the peritoneum or
connective tissue over and in front of the open mouth of a
retracted vessel. In any case, the danger is from the
lowering of tension from loss of fluid rather than from
diminution in number of red corpuscles; hence the value
of physiological salt solution injection to restore the tension.
The second case Dorland reports was one of tvpical. light,
right-sided phlegmasia alba dolens occurring on the elev-
enth day after a simple salpingo-oophorectomv without
complications. There had been no excessive handling, no
evidence of sepsis, the operation had not been prolonged or
severe or hemorrhagic, and the patient was not unusually
anemic or run down in health. There had been, however,
some excess of traction on the left broad ligament to bring
the diseased part in view. He remarks on the comparative
infrequency of postoperative thrombosis and the scantiness
of its literature, and quotes Dearborn's suggestion that
probably some of the cases are overlooked, and that it is
possible that some of the pulmonary complications of
surgical operations may be due to this cause. He says
that, except in the comparatively small percentage of
cases resulting from sepsis, hemorrhage, and severity of
operation, we do not yet know the true etiology of this
curious and frequently fatal condition. There is here a
field for interesting original research. The most important
fact in the symptomatology is the persistent frequency of
the pulse, out of proportion to the rise of temperature, and
this occurring during convalescence from an operation
should always suggest, as Dearborn says, the possibility of
a thrombosis. The main point in treatment is absolute rest.

Immobility of the affected limb, external warmth, emollient
and antiphlogistic applications along the course of the
thrombosed vein, and thorough asepsis of the primary
wound, comprise about all that can be done to relieve the
patient.

The Tuberculin Test. — C. P. Ambler maintains that
the use of tuberculin with proper precautions is the most
efficient remedy we have in the fight against tuberculosis,
and that is a most valuable early diagnostic test. A
tuberculin test will frequently clear up the diagnosis where
without it the condition would have remained obscure until
the disease had become more advanced, and valuable time
had been lost. Experience shows that the more recent
case will give a better reaction and to a smaller dose than
will one more advanced. All other available means, how-
ever, should be first exhausted ; not because the test is dan-
gerous or aggravates the disease, but because the depres-
sion, fever, etc.. of the reaction are not desirable if they
can be avoided, and this is especially true in tuberculosis.
It is particularly useful, he says, in joint troubles, bone dis-
ease, persistent wasting without pulmonary symptoms,
chronic pleurisy, bladder trouble, and especially in adenitis.
Ambler thinks that the slowly increasing method of using
the test is faulty, as sometimes producing a tolerance that
interferes with the reaction, and himself gives in the aver-
age adult case 2 mg. at the first injection, preferably late
in the evening, and continuing the temperature record
begun several days before at three- or four-hour intervals
for two days more. If no reaction has then occurred, 5 mg.
is given on the third day. The tuberculin is diluted with ai»
0.5 per cent, solution of carbolic acid and filtered sterilized
water; the local discomfort is slight. The general and
local reactions are described, the symptoms are sometimes
severe, but may be very slight. The most characteristic
sign is the change in temperature. The reaction, as has
been said, is less positive in the more advanced than in the
recent cases, a certain degree of tolerance or partial im-
munity having been gained. In conclusion. Ambler reiter-
ates his belief in the efficacy, safety, and positive diagnostic
value of a properly conducted tuberculin test, and says
that, while a failure to react is not proof positive that the
disease does not exist, a clearly defined action must be
accepted as diagnostic proof of the existence of tubercu-
losis.

The Metric System. — The advantages of the metric
system over the present measurements used in medical
prescribing are pointed out by W. A. Jolley, who also gives
details of methods to convert the measures now in use
to the metric measurements. The convenience of the
system is shown by a number of practical examples. He
also gives a table by which the tablet triturates in com-
mon use can be prescribed according to the metric nomen-
clature, and shows how to use this system in prescribing
ointments and liquids. One advantage of the system is
the facility with which it can be adapted to the dosage
required for children. Consider as 20 the age of an adult, and
use that age as the denominator and the child's age as the
numerator. Let the dosage for an adult be the total
required in a mixture containing 100 c.c. then allowing
5 c.c. for a teaspoonful, this will be the dose for a child
I year old. For a child 2 years old twice as much, and so
on up to the adult. Actual practical work with the adap-
tation of the common measures to the metric equivalents
will soon produce familiarity with prescribing by this
method.

Tlie Lancet, May 4, 1907.

Animal Blood-Serum in Surgery. — Some preliminary
notes are offered by W. Stuart-Low on this subject. He
has had some recent and satisfactory experiences with the
healing of wounds under an oiled-silk dressing, a revival
of a practise which was given up long ago. In thinking
over the matter, he came to the conclusion that the good
results were due to the blood serum or lymph and the
assistance given to the surface circulation. Dry dressing in
contact with a healing part absorbs the normally e.xudini;
serum and becomes adherent to the growing tissues, and
thus blocks the exudation and therefore the surface circu-
lation and dries the granulations. The oiled silk does not,
but allows a constant exudation of serum from the surface
vessels, and being itself nonabsorbent keeps the wound
always bathed in serum. Such a surface serous bath pre-
vents sepsis and aids superficial circulation in the healing
region. In the one case the growing tissues are continu-
ously having the blood serum sucked from their surface,
whereas in tlie other case this is not so, there being
always a layer, even though sometimes only a thin one. of
blood serum maintained upon the healing area. Low sim-
ply washes the protective in sterile water or boric solution
before applying it to the wound. In order to have a sup-
ply of serum on hand, he procures supplies of fresh beef
blood, which he allows to clot, and siphons off the clear

May 25, 1907]

MEDICAL RECORD.

869

supernatant scrum at the top of a tall cylindrical vessel.
The blood supply from the butcher's is renewed every
three days, and on alternate days the serum is drawn oft
and placed in smaller receptacles. This serum is used
to wash and dress wounds. It is alkaline in reaction, and
from albuminous matters held in solution has a slight
viscosity that gives it to a considerable degree air-exclud-
ing, and to a lesser degree adhesive, covering, and protec-
tive properties which are all conducive to healing. It is
now admitted by all pathologists, too, that normal blood
serum possesses restraining influences on bacterial growth
because of the antibodies it contains, and Sir A. E. Wright's
researches have proved that blood serum also contains
those substances which have the marvelous power of pre.-
paring microorganisms for ingestion by the white blood
corpuscles — viz.. opsonins.

Primary Sarcoma of the Liver in a Child Aged Four
and a Half Months. — The case is reported by E. VV.
Carmichacl and H. Wade. The growth was of the round-
celled variety. The abdomen enlarged rapidly, an increase
of four and one-half centimeters taking place in the cir-
cumferential measurement at the level of the umbilicus in
three days. There was no associated emaciation, no vomit-
ing, no diarrhea. There was a marked degree of infiltra-
tion of the whole organ by the neoplasm, the few liver
cells which remained being in a state of extreme degenera-
tion. Only two cases have been recorded in younger
patients. The patient was admitted to hospital on ac-
count of swelling of the abdomen — nothing more. This, as
stated, increased so rapidly that a laparotomy was done,
under the idea that some inflammatory process was pres-
ent. The liver was found to be of a mottled purple color,
soft and elastic in consistency. A trochar and cannula were
inserted deeply into the substance of the organ, but the
enlargement was found uniform throughout. The child
died in tw-elve hours. The investigation of this case
would seem to show that from the clinical standpoint pri-
mary sarcoma of the liver in children, although of rare
occurrence, presents definite characteristics, which, although
simulating an acute infective condition of that organ,
are sufficiently distinctive to warrant a diagnosis of a ma-
lignant condition being made.

The Opsonic Power of the Serum with Reference to
the Meningococcus of Cer-brospinal Fever Occurring
in the Belfast Epidemic. — .\ series of sixty-three deter-
minations of the opsonic power of the serum in cases of
cerebrospinal fever occurring in the recent Belfast epi-
demic is tabulated by T, Houston and J. C. Rankin. The
deductions which the authors seem inclined to draw from
their tabulated results are as follows; (i) From the
sixth day onwards all the cases examined (with one ex-
ception on the seventh day) showed an opsonic index of
over 4; several of the cases from the second day onwards
also gave an opsonic inde.x of much above 4. (2) The
opsonic inde.x seems to be a more delicate test of infec-
tion than an agglutinative experiment (dilution i in 3,
incubator temperature, limit 15 minutes) ; the agglutinative
eftect was never noticed until the index reached five times
the normal, while after that, with one exception, it was
always well marked. (3) The combination of this agglu-
tinative eft'ect and the opsonic determination will furnish
in this disease a specific test of great value in diagnosis.
The low opsonic power always found in normal or non-
infected sera, so that even when moderately thick emul-
sions are used two or three cocci were the maximum found
in any leucocyte, and the uniform absence of all agglutina-
tive eft'ect in all preparations containing normal serum
forms a striking contrast with the very high opsonic effect
found in preparations containing the serum from all cases
of the disease on or after the sixth day and in several cases
before this date, such preparations always showing leu-
cocytes packed with cocci and also dense clumps of cocci
not yet ingested. In fact, the picture is so characteristic
that a diagnosis could in the majority of cases be made by
simply mixing some washed corpuscles, serum from the
patient, and meningococci, and incubating the mixture
for a short time w-ithout the use of any control. Usually
opsonic determinations for purposes of diagnosis require
most careful and accurate counts, while in the case of this
disease a glance at the preparation is usually sufficient.
(4) From the very definite nature of the results obtained
it would seem likely that this method will prove of value ;
(a) in diagnosing sporadic cases of the disease; (b) in
settling the etiology of posterior basic meningitis in in-
fants, and (c) in determining the nature of a doubtful
coccus. In the presence of an epidemic it will always be
possible by this method to decide whether or not a coccus
isolated from a case is the true meningococcus. Several
pathologists are of opinion that some strains of the menj
ingococci may be Gram-positive. This test would, the
author believes, definitely settle the nature of such a coc-
cus. In this epidem:c two Gram-positive cocci isolated

from the blood and one from the cerebrospinal fluid proved
not to be meningococci wdien tested by this method, al-
though at first sight they closely resembled it. (s) Two
of the main elements on which the process of immunity
in this disease depends are the opsonic and agglutinative
powers of the serum. A therapeutic serum therefore hav-
ing no opsonic or agglutinative power on the menin-
gococcus could not be expected to have much value as
a remedial agent in this disease. Several samples of
serum on the market were tested by the author and found
to have neither opsonic nor agglutinative power.

Berliner kliniselie JVoehensehrift, April 29, 1907.

Exophthalmic Goiter and Pseudoleukemia. — Caro
suggests that possibly exophthalmic goiter and pseudoleu-
kemia may have something in common and offers the
opinion that the pseudoleukonnc stage may be the result
of the general condition of intoxication that we term
Basedow's disease. He relates the historv of a case in
point in which death took place under evidences of hyper-
thyroidism after a partial strumectomy. An evidence of the
severity of the autointoxication is the fact that the patient's
urine taken before the operation and injected into a guinea
pig produced no symptoms, but the same quantity taken
during the period of hyperthyroidism and injected into
another guinea pig produced death in a comparatively short
time. Another noteworthy feature of the case was the high
percentage of iodine present in the thyroid gland.
Miiiiehencr mcdiciiiische IVoehcnschrift, April 23, 1907.

The Rontgen Ray Treatment of Exophthalmic Goiter.
— Freund prefers the medical treatment of this condition
to surgical procedures and states that he believes the .v-ray
treatment to be the most satisfactory of all. He describes
five cases of his own in which either great improvement or
an apparent cure was effected by this means. In three of
the cases no other remedial measures were employed, so
that the complete relief of the symptoms that resulted must
either be attributed to the action of the rays or it must be
taken for granted that the condition had undergone spon-
taneous retrogression, the latter being an assumption which
the author does not believe is justifiable. In another case
the symptoms disappeared only after the radiotherapy had
been begun, and in the fifth case, althou'-h great improve-
ment in the subjective conditions had been effected, the
ultimate result is not yet certain. The author believes that
the Rontgen rays fulfill the causative indications in ex-
ophthalmic goiter, since they cause the abnormally active
thyroid gland to diminish in size. They always exert a
beneficial influence on the body weight and on the nervous
manifestations, while the other symptoms, such as heart
murmurs and exophthalmos, may also be caused to disap-
pear. The prognosis is best in dealing with soft vascular
goiters, which may completely subside under the treatment,
while in the cases with hard nodular growths this is less
likely to occur. The effects are more satisfactory the
shorter the duration of the case has been.

A Case of Drug Eruption with Unusual General Man-
ifestations.— Gregor, in speaking nf drug eruptions, re-
ports a case that is unusual on account of the severity of
the general symptoms that accompanied it. The patient
was a woman forty-two years of age, suffering from para-
noia, accompanied with marked motor excitability, in order
to control which various sedatives and hypnotics were ad-
ministered. In consequence of the administration of two
doses, "iven twenty-four hours apart, of 2 g. each of
chloral hydrate, an eruption appeared, covering most
of the body and consisting of dark red maculopapular le-
sions, which in some spots were hemorrhagic. About the
face large bulla; filled with serous fluid developed, and it
was something over two weeks before the symptoms had
entirely subsided. The appearance of the rash was accom-
panied by a rise in temperature, which on the eighth day
reached '30.8° C. and other manifestations were hem-
orrhagic bronchitis, conjunctivitis, and marked somno-
lence.

Deutselic mediziiiiscUe U'ochensehrift, April 25, 1007.

The Staining of the Spirochaeta Pallida, — Gienisa con-
tributes a very detailed disquisition on the theoretical and
practical considerations involved in staining microorgan-
isms and discusses particularly the demonstration of the
Spiroclurta pallida. He says that of the many methods
that have been devised for this purpose the most satisfac-
tory for routine clinical use is the modification of the
Giemsa stain, suggested by Preiss. Giemsa, however, pre-
sents a further improvement of this method, which he con-
siders superior and by means of which he says it is pos-
sible to secure satisfactory preparations in about three min-
utes. The tissue iuice obtained vmder proner precautions
is smeared on a slide and is fixed by passing three times
through a flame. The slide is held in a clean forceps and

870

MEDICAL RECORD.

[May 25, 1907

the freshly prepared staining fluid, consisting of 10 drops
of the stock Gienisa solution in 10 c.c. of distilled acid-free
water, is poured on it. The slide is held about 5 cm. above
the flame until steam begins to rise, and is set aside for
fifteen seconds. The stain is poured off and the film is
irnmediately flooded again ; the warming is repeated, the
slide is set aside for fifteen seconds, and the procedure is
carried out four times in all, e.xcept that the last time the
stain is allowed to act for a minute. The preparation is
quickly washed off in running water and is then ready for
examination. It is of the greatest importance that all the
glass ware and also the forceps used be scrupulously clean
and the presence of even the minutest traces of acid must
be avoided.

The Treatment of Ischemic Muscular Contractures. —

Kleinschmidt says that V'olkmanu's original teaching in
regard to the paralyses with contractures following the
application of tight bandages to the extremities was that
the muscular lesion was the result of deficient oxygenation.
The paralysis was a direct consequence of injury to the
muscle itself and a primary affection of the nerves was
to be excluded from the etiology of the condition. Klein-
schmidt believes that this view must at least be modified
owing to animal experimentation that has been carried
out by several authors, and considers that it is no longer
possible to maintain that affections of the nerves play no
part in the development of the condition. In addition to
the restricted supply of arterial blood the stasis in the veins
is an important factor, and in some instances the condition
may be caused in severe injuries, such as fractures, with-
out any compressing bandage having been applied. Par-
ticularly in fractures about the lower end of the humerus
should careful investigation be made in order to determine
whether the large vessels have been injured or are com-
pressed. The treatment of contractures of this sort may be
carried out according to two methods : One of these con-
sists in resecting portions of the long bone or bones in-
volved in order to shorten the distance to be covered by
the muscle or its tendons, and the other consists in length-
ening the tendons by a plastic operation on each one. The
author prefers the former method, as the latter especially
in injuries of the forearm is likely to require operation on a
large number of tendons. He describes one case in which
resection of the radius and ulna for this condition was
performed with very good ultimate functional result, al-
though_ the patient's recovery was delayed through the
non-union of one of the resected bones. To correct this
condition at a secondary operation a portion of periosteum
was taken from the patient's own tibia and wrapped like a
cuff about the two juxtaposed fragments, union promptly
following this procedure.

French and Italian Journals.

Study of Four Cases of Hereditary Syphilis in the
Fetus. — C. Fouquet has studied the pathological find-
ings in four fetuses that died of hereditary syphilis .at
birth. The author gives us his conclusions. The more
we search for the Spirocheta pallida in the tissues the
more are we convinced that it is the pathogenic agent in
syphilis. All the organs may contain the organism in cases
of hereditary syphilis, even when macroscopically they ap-
pear healthy. The abundance of the parasites in a viscus
bears a relation to the extent and gravity of the lesion
in that viscus. In three cases in which there was an
infection a short time before pregnancy, parasites were
very abundant. When syphilis in the parents was of long
standing the lesions were less marked and the parasites
fewer. In many cases the parasites are so abundant that
the product of conception succumbs before birth to a true
syphilitic septicemia. Xot all of the parasites die, and it
is allowable to ask what becomes of them. In all prob-
ability their number and virulence grows less under the
influence of antisyphilitic treatment. Some become dor-
mant either as spirilla or in some unknown form and are
capable at any time of taking on new activity. When the
organisms reach the ductus coledochus they "set up a true
edematous inflammation of the bile ducts,' which may be
the cause of icterus in the newborn. In the kidneys, espe-
cially in the glomeruli and uriniferous tubules, they may
be present in the urine. When in abundance in the spleeii
they explain the destruction of the red corpuscles, and
the anemic and pseudoleukemic forms of syphilis. In the
testicle they explain the infection of the spermatoid. A
practical conclusion is that every child of svphilitic parents
should be treated, whether they show any evidence of
syphilis or not, since the parasites may be dormant.— Sh/-
Ictin dc la Socictc d'Ohstetriquc de Paris. January 17, 1907.

Curves of Weight and Temperature in Gastrointes-
tinal Diseases of Infants.— Lucien Rivet has made a
study of the curves of temperature and weight in infants
afflicted with gastrointestinal affections as they were seen

in the Children's Hospital. He gives us the conclusions
derived from his studies and the use of different methods
of feeding. The water diet is the best method of com-
bating these diseases, and at the end of twenty-four
to forty-eight hours the substitution of cereal gruels. Vege-
table soups retard the apuearance of emaciation, but do not
prevent it, and may cause retention of chlorides and
anasarca. The emaciation may last a long time after
the disease is cured and may progress to a cachectic con-
dition. Secondary infections must always be taken into
account since they may produce true septicemia or gland
suppurations. Flesh may be gained under any diet, but
the best is breast milk. In other cases raw meat or cereals
are useful. In debilitated subiects with an hereditary taint
it is difficult to cure the lesions under any diet, but they
go on to cachexia and emaciation. — Revue Mensuelle des
Maladies de I'Enfance. February, 1907.

Meningo-Cerebellar Syndrome in Tertian Malaria.

— Ficucci records a case in which a child of fifteen years
of age, with alcoholic heredity, subject to epilepsy, was
attacked by symptoms of general weakness, rigidity, and
pain in the cervical region of the column. Konig's sign,
anisocoria, staggering walk with a tendency to fall back-
ward and to the left, intense headache, and vomiting. He
had quotidian fever, which fell after ten hours with sweat-
ing. All the symptoms mentioned were worse during
the fever, remitting between the attacks. The blood ex-
amination showed tertian parasites. After two weeks'
treatment with quinine the symptoms disappeared. Lum-
bar puncture and the ophthalmoscope gave no grounds for
a diagnosis of meningitis. The intimate connection of
the symptoms with the fever, absence of paralysis, clearness
of the mind, excellent effects of the quinine, and quick
recovery of the patient supported the diagnosis of malarial
infection, and excluded tubercle and meningitis of the cere-
bellum.— La Riforma Medico. March 2, 1907.

The Employment of Antidiphtheritic Serum in the
Diphtheria of Birds. — Battier reports an epidemic of
diphtheria which attacked birds housed in his aviary. Three
of the birds had already succumbed to the disease when
it occurred to the writer to try the effect of antidiphtheritic
serum on the remaining birds. The result of the injec-
tions of I c.c. of this serum were excellent. Besides this
treatment the throats were cleansed with antiseptic lotions.
This treatment put an end to the epidemic and the birds
recovered. The incident is interesting from several points
of view. From the standpoint of comparative pathology
one may ask if human diphtheria is not a modified form of
the diphtheria of birds, the human antidiphtheritic serum
having an effect on the latter. From the viewpoint of
general patholo.gy the observation shows the tonic effect
of the antidiphtheritic serum. Finally by this treatment
these epidemics which are so common and of such im-
portance to the bird fancier can be quelled. — Le Bulletin
Medical. December 20, IQ06.

Latent Appendicular Alterations in Cases Cured
Medically, — I'. Fiori describes cases of appendicitis
that were supposed to have been cured by medical means
in which there were continuous symptoms that indicated
that the cure was only apparent. In three of the patients
the symptoms were slight, while in the fourth they were
of severe nature. In the slight cases the symptoms lasted
but a few days, while in the severe one treatment extended
over a month or more. In the slight cases the recurrence
occurred in two or three months after the first attack,
and the author calls our attention to the dangers of opera-
tion in the interval and the inadvisability of allowing the
patient to believe himself entirely cured when the cure
is only apparent and operation may be needed at any
moment. Late observations demonstrate the accord be-
tween the clinical symptoms and pathological findings and
the advantages to be derived from examination of the
blood. — La Riforma Mcdica. December 22. 1906.

Poisoning by CO and COi and Pneumonic Infections.
— Cesare Biondi and Francesco Leoncini, having observed
two cases of accidental poisoning by CO and C6s in which
a pneumonic infection was precipitated by the poisoning,
have experimented on dogs to ascertain whether there
were evidences that the asphyxia produced by gas poison-
ing continued for some hours would so reduce the resistance
of the tissues as to render them peculiarly susceptible to
the action of the pneumococcus. The animals were sub-
jected to inhalations of CO and COj, and afterwards injec-
tions were made into the trachea of a moderately virulent
culture of the bacillus of Fraenkel. The conclusions at
which the authors arrived were that both of these gases so
reduce the resisting power of the lung tissues as to make
the animal ari easy prey to the infection. Animals treated
by the same injections without gas poisoning did not take
pneumonia. — Rivista Critica di Cliniea Medica, December
8 and 17, 1906.

May 25, 1907]

MEDICAL RECORD.

8-1

Hysterical Tachypnea with Organic Respiratory Af-
fection.— Mercuric Candela says that in hysterical cases
the severe symptoms frequently appear to bf due to or-
ganic causes. Ihis is especially so with respiratory symp-
toms. Hemoptysis, dyspnea, and tachypnea may occur.
Hysterical dyspnea is due to four causes — spasm of the
glottis, paralysis, or contracture of the diaphragm, spas-
modic condition of the bronchi, and thoracic hyperesthesia,
or gastric disturbances. These symptoms supervene in
debilitated persons. Glottic spasm is not rare, and is so
severe in some cases as to necessitate tracheotomy. The
attack comes on suddenly, with frequent, shallow respira-
tion, and incomplete movements of the abdomen. The
patient cannot speak or swallow, but is conscious. The
pulse becomes quick and the extremities covered with cold
sweat. In paralysis of the diaphragm there is retraction
of the epigastrium and hypochondrium and absence of
abdominal movements. Spasm and contracture of the
diaphragm is rarer. It may be clonic, or in the form of
hiccough, and vomiting may occur. Tachypnea should not
be confounded with dyspnea, as the first may occur with-
out the second being present. The patient breathes very
rapidly without any difficultv of respiration, and while
lying quite calm and comfortable. Respirations may be as
fast as 180 to the minute, and attacks may appear several
times a day and last for some hours. Temperature and
pulse will show no variation. Suggestion or distraction nf
tire patient's mind will stop the attack, and it disappears in
sleep. The author describes a case of this kind in which
the hysterical symptoms had continued for some time in
a man, when an organic disease of the nleura supervened
which caused his death. — Giornale Intcrna:ionalc dellc
Science Mediche, January 31, 1907.

Experimental Chronic Tuberculosis in the Rabbit.^
Askanazy has recently performed some interesting experi-
ments on animals in relation to the production of chronic
tuberculosis. Since the discovery of Koch, innumerable
inoculations have been made in rabbits and guinea pigs
in order to produce e.xperimental tuberculosis. Askanazy
in his experiments has especially insisted upon one con-
dition as being necessary for the attainment of success.
In order to provoke processes closely resembling the af-
fection in man, he considers it important to inoculate very
few bacilli and to seek to produce pulmonary phthisis with-
out appreciably afifecting any other organs. Askanazy has
injected extremely small quantities of the bacilli of ihc
bovine type in the vein of the ear of a rabbit. The annual
seemed in good condition for several months, but finally
it began to lose flesh. .•\t the end of eight months it died.
Autopsy revealed the existence of a chronic tuberculosis
of the lungs without tuberculous focus in any other organ,
save a few miliary tubercles in the hypertrophied right
kidney. The left kidney had been previously extirpated. —
La PriTsse Medicale, January 2, 1907.

The Galvanic Current of High Intensity in Trigemi-
nal Neuralgia. — Francesco Blasi. after having tried the
C'^ntinuous current of ordinary intensity in trigeminal neu-
ralgia, and found it successful in obtaining a cure only in
the slighter cases, began the use of a current of high in-
tensity, used with great care to prevent any shock due
to interruption of the current. He obtained the best of
results in the exceedingly severe cases that are not relieved
by any other form of treatment and that render the life
of the patient unbearable. The apparatus in use must be
capable of giving a current of very high intensity, but of
the greatest smoothness. The ordinary machines are use-
less for this form of treatment. The current must be in-
creased very smoothly and gradually and reduced in the
same way. The positive pole is placed over the painful
point or over the entire surface supplied by the trigeminus,
and should be a large fiat plaque. Several thicknesses of
gauze must be placed over the skin so as to prevent elec-
trolytic effects on the skin. The sittings should
be from twenty to thirty minutes long when the
current is very intense, or of one hour if of less intensity.
It has a calming, paralyzing action on the nerves. In
the neighborhood of the electrode there develop by sec-
ondary action acids which act on the ultimate ramifications
of the sensitive nerves, diminishing irritability.- — Anncli Ji
EU'ttricita Medkalc Terapia Fisca, December, 1906.

Prophylaxis of Syphilis. — G. Petges considers proph-
ylactic measures against syphilis in the light of recent
discoveries and experimental researches. As to the e.x-
cision of the chancre, it may lessen the amount of the sec-
ondary phenomena, and thus by preventing the patient
from taking a thorough mercurial treatment early in the
disease, may precipitate late manifestation of great sever-
ity. For these reasons it is not to be advised. Previous
application of mercurials, that is, before a dangerous con-

tact, has been shown to be of use in experimental cases.
Friction with an ointment of calomel, thirty-three parts to
one hundred parts of lanolin, an hour before inoculation
has prevented infection. This may be of use to physicians,
nurses, and laboratory workers who must handle dangerous
material, but as to the general public taking any practical
advantage of such prophylaxis there is very small prospect.
A false security would be worse than doing nothing. The
only true prophylaxis, then, must be by abstention from
dangerous contact. — Gacctte Hcbdomadairc dcs Sciences
Medicales, February 3, 1907.

Uterine Fibroma Complicated with Grave Anemia. —

Paul Petit tells us that when a patient is near the meno-
pause and is suffering from fibroma uteri, if there are no
signs of acute malignant degeneration, and no marked
symptoms of compression, it is wise to abstain from oper-
ation, even if there is a severe anemia. Expectant treat-
ment by rest, medication, and electrolysis to restrain hem-
orrhage are the best measures to use. If, on the contrary,
the patient is in active genital activity and there are serious
symptoms, it is best to operate. If she is anemic and there
is degeneration of the internal organs, as a result of fre-
quent and severe hemorrhage, it is necessary to temporize
and to use supportive treatment until the patient is in a
sufficiently good general condition to bear the strain and
shock of operation. Hydrochlorate of hydrastine is the
best hemostatic, used by hypodermic injection. Locally
tampons of a solution of chloride of zinc, fifty per cent.,
are an efficient hemostatic, cause no pain, and are exceed-
ingly well borne. When the patient is prepared for opera-
tion, if the tumor is hard, benign, hemorrhage is only
menorrhagic, and development abdominal, a double castra-
tion will produce rapid atrophy. If the serious conditions
mentioned are present a hysterectomy should be done. —
Gazette des Hopitaux, February, 1907.

Chloroanemia of Infants. — Mery says that there are
certain cases of anemia which arise without any appreciable
cause, or which seem to arise from digestive troubles, and
yet are not cured by changes in foods, that are much better
affected by medication containing iron. The best form to
administer is the protoxalate of iron. The symptoms are
pallor of skin and mucous membranes, apathy and intel-
lectual slowness, and weakness, but without emaciation.
There is no enlargement of the glands or spleen. There
may be a slight elevation of temperature and insomnia.
There is a marked decrease of the hemoglobin, while the
number of blood corpuscles is not much changed. In the
infant, soon after birth, the amount of iron that is stored
up in the tissiies is much greater than in the adult. There
is little iron in milk, and this stored-up iron is used in
place of that which would be furnished by the food. This
iron is probably contained in the hemoglobin to a great
extent, while some of it is in the o.xydases, or blood fer-
ments, and here it exercises a very complicated function. —
Journal de Mcdecine et de Chinirgie Pratique, February 10,
1907.

Spontaneous Cure of Tasnia Nana. — Scipione Riva-
Rocci states that tasnia is less common in infants and chil-
dren in Italy than in other countries. Concetti found but
thirteen cases among 40,000 children observed during six
years. This small proportion is not so remarkable as it
seems when we remember that it is the custom to treat
these cases at home without the aid of a physician. Tasnia
is the rarest of all tapeworms according to the published
literature. But the author found that in many cases the
parasite became unrecognizable a few hours after the pass-
age of the stools, all that was left being shreds that
appeared very much like the ordinary shreds of mucus that
are observed in gastrointestinal diseases or that may be
mistaken for o.xyuris. The parasite becomes rapidly de-
composed, and even microscopic examination of stools will
not reveal the true nature of the threads. Preservation of
the feces by solutions of formalin were not successful in
preserving the parasite intact. The author describes a case
that came to him in a healthy child that had manifesta-
tions of an acute gastrointestinal catarrh, and it was the
microscopic e.xamination of the stools that showed the
presence of ta;nia nana. In some of the stools examined
it was found that the parasites were so changed that they
were unrecognizable. This was the case in stools passed
after the second day of the disease, although no anthelmin-
tic had been given. There were absolutely no symptoms
that could be referred to the presence of the worms and
no symptoms of a chronic gastrointestinal trouble. The
disease was recovered from without treatment, and observa-
tion extending over four years has not shown any return
of the worms. The author refers the cure of the disease
to the production by the acute catarrh of the intestine^ of
some substance that was poisonous to the parasite. — Riz'ista
di Clinica Pcdiatrica, January, 1907.

872

MEDICAL RECORD.

[May 25, 1907

Unnk iSpmema.

DiCTIONNAIRE DE I\IeDECINE EI UE ThERAPEUTIQUE MEDI-

CALE ET Chirurgicale. Comprenant le Resume de Toute
la Medecine et de Toute la Chirurgie. Par les Docteurs
E. BoucHUT, Medccin de I'Hopital des Enfants Malades,
Professeur agrege a la Faciilte de Medecine de Paris, et
Arm and Despres. Cliirurgien de I'Hopital de la Ciiarite;
Professeur agrege a la Faculte de Medecine de Paris.
Septieme Edition, Revue et Mise au Courant de la
Science, par les Drs. G. Marion, Professeur agrege a la
Faculte de Medicine de Paris, Chirurgieai des Hopitaux,
et F. BoucHUT. Paris: Feli.x Alcan, 1907.
In the seventh edition of this encyclopedia of medical
science, the revisers have brought the subject matter thor-
oughly up to date, the revision being most carefully done
in the articles relating to bacteriology, opotherapy, orrho-
therapy. hygiene, and electrotherapy. In the surgical arti-
cles the newest operative measures have been fully de-
scribed, and many new instruments and prosthetic ap-
pliances have been pictured. The therapeutic indications
for each disease are given with great care, and other sub-
jects fully treated are those included under the heads of
obstetrics, ophthalmology, dentistry, materia medica, and
mineral waters To the reader of French the book will
prove very useful as a work of ready reference, and as a
dictionary to define various French terms occasionally
employed in English medical literature.

L'ame et le Syste.me Xerveux. Hygiene et Pathologic.
Par .A.rGUSTE Forel. .Incien Professeur de Psychiatrie
a rUniversite de Zurich. Paris : G. Steinheil, 1906.
This is a semipopular treatise on the mind and nervous
system, with special reference to the prophylaxis of psy-
chical disorders. Professor Forel's writings on this theme
have already had a wide circle of readers. His recent
book, particularly "La Question Sexuelle. Exposee aux
Adultes Cultives," has attracted wide attention, and is one
of the best examples of semipopular medical writing "for
intelligent adults." Beginning with a sketch of the ele-
ments of psychology, the general anatomical facts pertain-
ing to the brain, the cord and the nerves, Forel leads the
reader by very easy gradations into the mysteries of mental
pathology. He dwells upon the causes of nervous and
mental disease, and thus brings the reader to the rules
for their prevention. Here he speaks of every phase of life,
of school life, family life, etc., and preaches the doctrine
of moderation in living, in work, and in pleasure, as a
mode of preventing insanity and nervous affections. He
closes with a chapter on the sociological or public aspect
of the hygiene of the nervous system.

The book should be translated into English. It would
make most interesting reading for our cultured patients,
and also would bring its useful teachings more generally
before the American medical profession.

This Labyrinthine Life. .\ Tale of the Arizona Desert.
By George Alexander Fischer, .Author of Beethoven :
a character studv. New York : B. W. Dodge & Co.,
1907.

This volume describes camp life in the desert. It is not
only the tuberculous, but also the overworked and those
on the verge of nervous prostration, who might benefit
much by a sojourn in the open air of the desert. But
the conditions must be favorable, and many hesitate to
avail themselves of this method of treatment through
ienorance of the conditions involved; and some who
do undertake it make a failure of it for the same reason.
What these conditions are will be found fully discussed
in this tale of the Arizona desert. Physicians will be
benefited by reading the volume, and many families will
welcome the information so entertainingly provided therein.

A Text-Book of Ophthalmic Operations. By H.\rold
Grimsdale, M.B.. F.R.C.S.. Ophthalmic Surgeon and
Lecturer on Ophthalmic Surgery to St. George's Hos-
pital ; Surgeon to the Royal Westminster Ophthalmic
Hospital : and Elmore Brewerton, F.R.C.S.. Ophthal-
mic Surgeon to the Metropolitan Hospital ; Surgeon to
the Royal Westminster Ophthalmic Hospital. Chicago :
W. T. Keener & Co., 1907.
The volume is one of .^49 pages, is well printed and quite
fully illustrated by simple, rather crude, original, and very
effective drawings. Onlv two or three of the illustrations
are borrowed from other works. The authors have en-
tered upon their task without indulging in the time-hon-
ored custom of writing a preface, and have omitted appen-
dices. The subject is treated in a masterful, terse, direct
manner. The work is not exhaustive, the operations on
the eye and its adnexa that are of greatest value only
being described. A short bibliography is found at the
end of each chapter. Fifty-one pages are devoted to a

description of the anatomy of the extrinsic ocular muscles,
physiology, and the operations on these muscles. Then
follow chapters on operations for ptosis, operations on the
lids, enucleation and its substitutes, operations on the
lacrymal apparatus, bones of the orbit, cataract, after
cataract, for glaucoma, operations on the cornea, sclerotic,
and iris. The value of each procedure, according to the
opinion of the writers, is given. Much consideration is
given to the more modern methods. The book is evidently
written by men of experience, and its teachings can be
relied upon. It will find its widest usefulness as a ready
reference work for the busy ophthalmic surgeon.

Exploration de l'.-\ppareil L'rinaire. Par le Dr. Georges
LuYS, Ancien .Assistant du Service des Voies Urinaires
a THopital Lariboisierc ; Laureat de la Faculte de Mede-
cine de Paris. Paris : Masson et Cie, 1907.
The diagnosis of affections of the urinary apparatus is
becoming more and more nearly an exact science, thanks
to the new methods of precision which are now used in
the exploration of the urinary passages. Among those
who have done the most to further this branch of diagnos-
tic science — Xitze. Leiter, Albarran, Kelly, Valentine, and
others — the author of the work before us holds an enviable
place, his modification of the urethroscope having done
much to popularize the use of this valuable instrument in
France, and his ingenious method of separation of the
urine having greatlv facilitated the diagnosis of renal
lesions. In this book Dr. Luys treats in turn of all the
methods employed in the examination of the urinary tract,
describing in detail the various instruments and procedures
and illustrating them with numerous figures in the text
and five excellent colored plates of the urethroscopic and
cystoscopic images. The book is divided into four parts:
E.xploration of the urethra, exploration of the bladder, ex-
ploration of the ureter and renal pelvis, and e.xploration
of the kidney itself. The work treats not only of instru-
mental examination, but of every method — chemical, man-
ual, clinical, and instrumental — which may aid the surgeon
in his investigation of the urinarv organs. It is. indeed, a
complete treatise on the diagnosis of diseases of the
urinary tract, valuable alike to the specialist and to the
general practitioner. It is the most complete, as it is the
most recent, work of the kind published in any language
and is one which no genitourinary surgeon and no diag-
nostician can well dispense with.

Aids to Medical Diagnosis. By .Arthur Whiting, M.D.,
M.R.C.P.. Physician to the Tottenham Hospital and .As-
sistant Physician to the Mount Vernon Hospital for
Consumption and Diseases of the Chest ; Lecturer in,
and Dean of. the Xorth-East London Post Graduate
College. New- York : \\'illiam Wood & Co., 1907.
This little volume is written from the clinical, rather than
from the pathological, standpoint ; and appeals to the rea-
soning powers, instead of ta.xing the memory with a mul-
titude of diagnostic minutije. The book is not intended for
beginners, but for those who already have some knowledge
of systematic medicine. To such it will prove useful in
affording a help in the differentiation of diseases present-
ing somewhat similar symptoms.

Aids to Dental Surgery. By .Arthur S. Underwood,
M.R.C.S., L.D.S. Eng.. and Douglas Gabel, M.R.C.S.,
L.R.C.P. Lond., L.D.S. Eng. Second Edition. New
York: William Wood & Co., 1907.
This compend covers the subject of general dental sur-
gery, omitting all purely manipulative procedures. While
obviously intended for dental students, the book contains
material that may be of interest to the physician.
Aids to the Di.^gnosis and Treatment of Diseases of
Children. By John McCaw. M.D., R.U.I., L.R.C.P.
Edin., Physician to the Belfast Hospital for Sick Chil-
dren. Third Edition. Xew York : William Wood &
Co., 1907.
This is a very complete epitome of the Diseases of Chil-
dren. In addition to the chapters on the diseases of the
various organs and systems of the bodv. there are impor-
tant introductory sections dealing with the anatomy and
physiolog>' of infancy and childhood, and with the hygiene
and diet of infants and children. The volume contains
more information than is generallv found in compends;
important facts are duly emphasized, and there are several
tables containing much matter in a small space. In this
new edition will be found articles on Friedreich's ata.xia,
thrombosis of the cerebral sinuses, influenza, congenital
hvpcrtrophic stenosis of the pylorus, food fever. Still's
disease, rheumatoid arthritis, acute pyelitis, and a chapter
on the diseases incidental to birth. The writer has care-
fully gleaned from the best current literature on pediatrics,
and has produced a book which will be of real service to
students and practitioners.

May 25, 1907]

MEDICAL RECORD.

873

AMERICAN PEDIATRIC SOCIETY.

Nineteenth Annual Meeting, Held in IVashington. V. C,

May 7, 8, and 9, 1907, in Conjunction with the Congress

of American Physicians and Surgeons.

(Special Report to the Medical Record)

President B. K, Rachford, M.D., of Cincixxati.

Tuesday. May 7 — First Day.

The Use in Practice of the Theoretical Resources Pro-
vided by Percentage Feeding. — Dr. Charles Hunter
Dunn, Boston, said the chief step in advance had been
the chemical recognition of the component elements of milk
and the attempts to imitate nature as e.\actly as possible ;
the second great step was the recognition of the individual
idiosyncrasies of each baby. The fact remained, however,
that the subject of percentage feeding still presented diffi-
culties to the general profession. The failure of modified
milk feeding must be due either to limitations in the value
of the resources or their improper application, and the
writer suggested that it was due to the latter, and pre-
sented a plea for more careful use of the methods already
in our possession. He thought the difficulties due to two
factors: the inherent unsuitability of cow's milk to the
digestion of the infant, and the variability of the digestive
powers of different infants. Too much stress had been
laid upon the first and too little upon the second; we were
too apt to attribute the chief role to the unsuitability of
cow's milk. He referred particularly to the use of the
so-called split proteid feeding, and thought that by using
whey a very close conformity to human milk could be had.
The cereal diluents, he said, contained starch, which was
not indicated by nature as desirable for the infant, and in
practice the giving of these diluents was often protested
against by nature, although, of course, in many the starch
would be digested. When the starch digestive function had
been developed of course they could be used. The same
arguments as those against the indiscriminate use of cereal
diluents were applicable to the widely advocated use of the
alkalies, lime water, sodium bicarbonate, etc. Any of
these artificial methods might have a place in ceitain
individual cases, but must be due to the individual idiosyn-
crasies of digestion.

Some Conclusions from our Knowledge of the Pro-
teids of Milk. — Dr. Thomas S. Southworth, New York,
spoke of the early misconceptions concerning the proteids
of milk and the gradual steps of enlightenment which began
only with chemical analysis. The endeavor was made to
imitate breast milk closely by the so-called modified milk,
but it was soon found that many infants were not able to
digest the modified milk except when modified to each in-
dividual case. There were many difficulties in the way of
knowing the composition of breast milk, and therefore of
comparing it with cow's milk, and our chief knowledge of
cow's milk was derived from commercial, not medical, in-
vestigation. The writer referred to the close analogy be-
tween cheese-making and human digestion of milk ; the
important compounds formed with casein by ferments,
alkalies, and acids, and the necessity for the recognition
of these compounds, both as chemical entities, and of the
part they play in facilitating the digestion of cow's milk.
The real difficulty in infant feeding was not with the diges-
tion of casein but of paracasein. Lactate of casein was
readily digestible, as shown by the use of buttermilk, which
had had less vogue in this country than abroad. Decalci-
fied casein was easier of digestion, and sodium citrate made
milk more digestible by decalcifying it. The writer thought
a new departure was necessary if students were to learn
to feed intelligently and be enabled to overcome the diffi-
culties they met with in practice. An understanding was
necessary of the physiological and the pathological diges-
tion of the elements of cow's milk if empiricism was to

give way to intelligent scientific metliods in infant feeding.

Cane Sugar Feeding in Its Relation to Some of the
Disorders of Childhood. — Dr. Charles G. Kerley of
New York read this paper. The study was undertaken as
the result of an impression the writer had received by the
observation of many children that cane sugar was not
without harm to many. There was a class of cases defined
as sugar susceptibles, usually children of rheumatic or
gouty ancestry, with one characteristic peculiar to all, a
tendency to recurrence and to chronicity. He included
those who had recurrent persistent colds, asthma, urticaria,
eczema, rheumatism, and recurrent vomiting. Seventyt
eight cases comprised the series, fifteen from his own pa-
tients whom he had cared for from infancy. Recurrent
vomiting in 8; eczema, 7; asthma, 4; frequent colds, 17;
chorea, 11; rheumatism, 4; rheumatism and endocarditis,
6; urticaria, 2; recurrent bronchitis, 6. More sugar was
taken than was for the best interest of the individual cases
because of the craving of child life for sweets, and because
the sugar-eating habit is so easily acquired. In the major-
ity there was sugar incapacity. When a child was presented
for treatment cane sugar was excluded from the diet and a
small quantity of saccharine substituted. They very soon
adapted themselves to the deprivation of sugar from cereals,
and it did not appear to influence their well being or
growth. In those suffering from rheumatism, recurrent
vomiting, eczema, and asthma, there was also interrupted
medication. The most satisfactory results were obtained
in the affections of the upper respiratory tract . Abstinence
from free sugar in the diet broke up the tendency to recur-
rent colds in children in whom the removal of the tonsils
and adenoids had been without benefit. The writer con-
cluded that free sugar was sufficiently toxic in certain
individual infants to produce perversion of function, and
in some to allow bacterial invasion, as in acute articular
rheumatism and endocarditis.

Dr. Thomas Morgan Rotch, Boston, thought these in-
vestigations of Dr. Southworth of great importance as
tending to put the subject of percentage feeding on a proper
basis.

Dr. Freeman, Boston, considered the use of whey fluid
one of the most valuable aids in difficult cases, and thought
it should be ordered from the laboratories where that was
possible. It was important that it had been shown that
these recurrent colds in children might be due to indigestion
and not to exposure.

Dr. L. Emmett Holt, New York, had been following out
Dr. Dunn's suggestions with reference to the routine use
of whey mixtures for very young infants, and had been
surprised to see how it relieved chronic constipation. The
proteids could be raised gradually, the fats being kept low,
with relief of indigestion and avoidance of troublesome
symptoms. He agreed with Dr. Freeman that the mix-
tures should be ordered from the laboratories. He agreed
with Dr. Kerley as to the ill effects of free sugar in the
diet of many infants.

Dr. Charles G. Kerlev had used the wliey mi.xture
extensively for two years, and felt that while it was a very
useful measure, applicable in a considerable number of
cases, it was by no means a solution of the infant feeding
problem, its chief fault being that children did not gain
on it. He thought it could not always be relied upon.

Dr. J. P. Crozer Griffith called attention to the recent
studies upon the difficulty of digesting foreign albumins,
and said the albumins of the cow were necessarily not the
same, and not so digestible as those of the mother; there
were certain principles in the mother's milk necessary to
the digestion of many children, and they could not get along
without it.

Dr. F. S. Churchill, Chicago, did not see how anyone
who had used the split proteids or whey mixtures could
help being enthusiastic believers, because ihe majority of
babies so fed invariably did well. Whey mixture was such
a simple food that few babies could fail to digest it.

874

MEDICAL RECORD.

[Alay 25, 1907

Dr. Walter Lester Cars, New York, said Dr. Kerle/s
statement was borne out by his own experience, that whey
had a decided place in the feeding of premature infants and
congenitally weak children, but that after using it for a
time it seemed impossible to get a gain of weight. In elim-
inating the sugar it must be borne in mind that faulty
oxidation might be one of the features.

Dr. Eaton deprecated the habit prevalent in some parts
of the country of feeding babies according to a set of tables,
without regard to the individual idiosyncrasies. He had
used the whey mixtures with great satisfaction.

Dr. Saunders had used the whey mixture for many years
WMth great satisfaction. One of the mixtures with which
he had had most rapid gain was that of whey and con-
densed milk.

Dr. Crandall's experience bore out what Dr. Kerley had
said as to the use of the whey mixture.

Dr. Dunn, in closing, called attention to the fact that
some of the patients that seemed to do well on condensed
milk had done even better when fed on a laboratory pre-
scription of the same composition.

Dr. Southworth added his testimony to the value of the
split proteid feeding; he had had excellent results with it.

A Case of Hemothorax; Aspiration, Recovery. — Dr.
W. P. XoRTHRUP of New York reported this case, the
patient having been seen three times by a well-known
member of the society, who pronounced it bronchitis. He
saw the case after the child had been ill two months. .-\
poorly developed child of five months, pale, respirations 80
a minute; left chest flat; heart displaced to the right; no
fever. Taking the infant on a pillow on its back, nothing
happened as long as it lay quiet, but when turned toward
the right the child had an attack suggesting the cessation
of all vital functions. A'-ray showed the chest filled with
an opaque fluid. Two ounces of a black fluid was aspirated,
when the pulse improved and the heart returned to its
normal position. The fluid was blood, which coogulated
quickly in the bottle. A year after the aspiration the patient
is doing well, the only cause for anxiety being rapid
respiration.

Anorexia Nervosa in Children.— Dr. F. Forchhei.mer
of Cincinnati presented this paper, which referred to the
several previously reported cases under somewhat diflferent
names, the condition having been usually looked upon as
one of the manifestations of hysteria. According to the
present state of our knowledge, we were justified in calling
it a neurosis. As a rule, the children who have the disease
have grown up without discipline, being allowed to choose
their own diet. Female, 7 years; mother and father both
neurotic; child always had its own way; at the age of 6
made up her mind that she would not eat but certain
articles, practically nothing but cheese; none of the stig-
mata of hysteria were present ; she was intelligent and con-
sistent in her responses. Under proper treatment she soon
recovered. Female, aged 12; mother and father neurotic;
child brought up on artificial food; would only eat pickles
and olives; if they tried to get her to eat anything else
she vomited. Was very much run down, irritable and cross,
backward in studies, cried easily, and slept badly. Under
proper treatment she gained fifteen pounds in a few weeks.
Male infant, one year of age; mother and father neurotic;
father had had syphilis; child had never been ill in any
way; breast-fed. From the ninth month attempts made to
feed artificially. The child would not take any food. Was
taken to the hospital and for four days nothing given by
the mouth; then feeding began, but in vain; child would
take water, but nothing else. Gavage used for two weeks,
when the child recovered. Boy three years old, only child
of parents married late in lite. Neither of the parents
believed in disciplining the child. For some time the boy
had been cutting off articles of diet until he would touch
nothing for several days, e.xcept a piece of fried bacon or
a piece of banana. Had a degree of emaciation that the
writer had rarely seen surpassed; three weeks later the

child died from starvation. The writer believed all these
cases could be cured by proper treatment and discipline,
especial stress being laid upon discipline. Gavage should
be held out as a last resource.

Dr. Charles G. Kerley, New York, had had a case of a
four-year-old girl, who always vomited food, even at the
table, but who when allowed to eat in the kitchen never
had these attacks. The child was finally cured by removal
to the house of her aunt and association with other children.
Dr. Putnam, Boston, had often succeeded in the milder
forms of this disease by having the parents desist from
saying anything about food or trying to force the child to
eat.

Dr. J. P. Crozer Griffith referred to a case, the child
of a physician, some months over a year of age, who
could not be weaned, and in which gavage had to be used,
and now at the age of four they still had difficulty in get-
ting the child to take food.

(a) Three Cases Illustrating Typhoid Fever in the
First Year of Life, (b) A Case of Articular Rheuma-
tism in an Infant, (c) A Case of Congenital Biliary
Cirrhosis. — Dr. J. P. Crozer Griffith, Philadelphia, pre-
sented these cases, three cases of typhoid fever, one of five
months and the other two of nine months. In the first
case there was an excellent opportunity of studying the
beginning of the temperature record, and death occurred
from intestinal hemorrhage. There was absence of the step-
like rise characteristic of the adult's chart. There was
positive Widal, rose spots, and enlarged spleen. In the
second case, nine months, there was nothing unusual except
the instance of relapse, with the opportunity of studying the
temperature from the beginning to the end of the relapse.
It had been the custom of the mother when putting the
baby in the tub to cleanse the mouth with the spigot water.
Typical spots and enlarged spleen. Third case, nine
months; ordinary course; rose spots and enlarged spleen;
the history suggested the possibility of persistent house
infection. The child was fed partly by breast and partly by
unboiled cow's milk ; the bottles had been boiled, but the
nipples kept in unboiled cold water. The case of articular
rheumatism was a baby five months old, with rheumatism
of hands and ankles. Treated with orange juice to exclude
scurvy, without effect; under the use of salicylates it grad-
ually recovered. The case of biliary cirrhosis, five months
old, jaundice said to have been present from birth; child
lost weight steadily. After being brought to the hospital
there was intense jaundice; liver much enlarged; every-
thing possible done to make it gain in weight, but in vain.
Black material passed from the bowel, which appeared
to be decomposed blood. Child became steadily worse
and died; autopsy showed typical cirrhotic liver with the
duct of the gall-bladder entirely obliterated.
(To be continued.')

NEW YORK ACADEMY OF MEDICINE.

section on medicine.

Stated Meeting, Held April 16, 1907.

Dr. Warren Coleman in the Chair.

A Case of Larva Migrans. — Dr. N. E. Brill reported
this case. The patient was seen on October 25, 1906, when
he entered the hospital because of advanced emphysema
and endocarditis. On the dorsum of his hands was noticed
an eruption, and, when questioned regarding it, it was
found that two and a half years before he had been work-
ing in the fields in Florida. One noon he felt an itching
sensation on the ankles of both feet, along the inner
aspect of the malleoli, and, looking at his ankles, he found
an elevated pimple about one-eighth of an inch in diameter
and of the same height. The next day the pimple had pro-
gressed forwards and upwards for about two inches. The
progress of the eruption was steadily onwards and up-

May 25, 1907

MEDICAL RECORD.

875

wards until the eruption showed a long line running from
the ankle to the knee. It then continued on both legs
upward until it reached the groin. It stopped there on the
right side. On the left side, however, it went up pver
the left side of the abdomen, over the thorax and across
to the right side, then down the right side of the trunk,
down the abdominal region to the axilla, then under the
axilla to the back, and then across the back to the left
shoulder, down the left shoulder to the arm, then the
forearm, and finally to the hand. The eruption appeared
to be of parasitic nature. In looking up the literature
on the subject Dr. Brill found that the case reported was
exactly similar to one reported by Lustgarten under the
title of "Creeping Eruption of Lee."

The historj- of this disorder dated back to 1874, when
Dr. R. J. Lee made a communication to the Clinical So-
ciety of London with the title of "A Case of Creeping
Eruption," the nature of which he could not determine
and about which he could get no information. Three
dermatologists were appointed, W. Howship Dickinson, Til-
bury Fox, and Dyce Duckworth, who were to make further
investigations regarding it, especially on the microscopical
findings, but their results were negative. In 1884 Lee
again presented to the Clinical Society of London a sec-
ond case appearing in an adult, and he thought that the
linear eruption might be due to an "active parasite or
animalcule," as he called it. After that no mention was
made of this disease until 1890 when Crocker reported a
case similar to Lee's. In 1895 Neumann of Vienna showed
a wax model representing "a new skin affection," and
in the discussion Peterson referred to a communication
which showed that Samson had reported "a case of creep-
ing eruption" and had asked in an open letter whether
anybody in Russia had seen such a case. He had seen
such a case in Southern Russia. These observations were
contained in Vratch, dating from 1895. In answer to his
letter several communications were received, and in one
it was stated that in 1888 Sokolow had seen these cases
and had isolated from them a parasite which he said was
a worm which resembled the larva of a fly. This parasite
from Sokolow's patient was submitted to Prof. Cholod-
kowsky and an entomologist and it was proven to be the
larva of the bot fly. In 1898 Kaposi reported a case in
Austria and he called it "hyponomoderma," a "skin pass-
age," or tunnel. In 1893 Crocker gave it the name of
"larva migrans." In 1902 a doctor in Philadelphia re-
porting three cases, called the disease "creeping disease of
Lee." In 1903 Stelwagon reported another case. In 1904
Hamburger of the Johns Hopkins Medical School re-
ported an additional case occurring in a boy of four years,
and recognized it as the creeping eruption of Lee. In
1905 another case was reported from Russia and was
called the "linear creeping epidermatitis." The case re-
ported by Dr. Brill he claimed to be the only one reported
in the literature of New York.

The eruption was elevated and measured about 2x2
millimeters. It always extended in a linear way, and never
spread laterally and preserved the same diameter
throughout. It sometimes progressed seven inches
in twenty-four hours; at other times it might go no meas-
urable distance. In the case Dr. Brill reported it extended
2.S cm. The patient was in the hospital four weeks;
when he left the eruption had advanced from the thenar
eminence to the back of the first phalanx. Most of these
cases appeared in children and usually upon the exposed
parts, such as the ankles, buttocks, and hands. In
children the bare buttocks on damp ground favored its
development. In Dr. Brill's case the man wore low shoes
and worked in the field. Only sixteen cases had so far
been reported in the literature since 1874.

Dr. Harlow Brooks said that three years ago he re-
ported a case which he believed to be due to the direct
infection from the bot fly. The man gave a history of

having worked in Panama where the bot fly wms frequently
encountered. When he entered the hospital there were
two raised circular lesions which looked like boils, and
from the top of them the head of the larva was recognized;
when these were dug out the lesions healed.

Dr. Alexander Lambert said he had seen a case which
had extended from the clavicle to the elbow, over the
humerus, and upper part of the body. There was a black
oozing. When the "worm" was cut out it looked like a
chestnut worm and very fat. In this worm were two black
"stickers" and, when the worm was stirred up, the man
would squirm. On the isthmus it was called "castanea
del monte."

Dr. Brill said that only in the Russian cases had the larva
been extracted.

A Study of Blood Pressure in Compressed Air
Workers. — Dr. Harlow Brooks read this paper. (See
page 855.)

Dr. .\lexander Lambert said that his experience was
confined more to the higher air than to compressed air.
But w-hen the bridge was in course of construction across
the Harlem river a friend of his was in charge and he
complained that the veins of his legs were markedly
varicosed. So in order to learn the conditions he went for
the first time into compressed air. The air was compressed
about twelve or fifteen pounds above the pressure of the
atmosphere. He stayed down only a short time, and came
out slowly, and he learned that the veins were but little
affected. Then with the same pressure they were let out
as fast as they could be gotten out and the only effect
noted was a sudden distention of the internal saphenous
vein. It made a tremendous difference. Yet no trouble
was encountered when they came out slowly. Dr. Lambert
said that these men were very careless about it. The
application of an elastic bandage soon relieved him of his
complaint. His other experience was with two or three
patients who came to him with attacks of angina pectoris
and asked if it would be safe for them to go to Colorado
Springs, which was situated 6,200 feet above the sea level.
.'M first he said they should not go, believing that it was
wrong that they should go and that their condition would
be aggravated. One man listened to what Dr. Lam-
bert said and then went and spent the summer there.
He felt so much better and improved so that Dr. Lam-
bert said his eyes were opened when he saw the patient
in the fall. Two doctors, friends of his, in Colorado
Springs were interested in this patient and made studies
of the blood pressure on Pike's Peak, which had an alti-
tude of 14,000 feet. The blood pressure was much lower
on the peak than in Colorado Springs. As one increased
the altitude there was a decrease in the blood pressure.
So long as one did not overexert and was ordinarily care-
ful as regards exercise, he would be fairly comfortable.
Dr. Lambert said that it was a question of oxygen, and
that it should be remembered how quickly the red cells in-
creased in high altitudes within one month. From obser-
vations made in South America it was noted that the
red cells increased up to six or seven millions. This
was apparently a physiological endeavor to gain more
oxygen to the tissues. At 9,000 or 10,000 feet altitudes
even animals suffer from quick exertion or exercise. Dr.
Lambert said he had seen a black deer quickly aroused
when he approached near ; the deer stood with legs thrown
forward, with tongue out, and unable to move, although
he was seen. When the animal got its breath it ran
away. The animal was simply ga.sping for breath on
account of the high altitude.

On Some Therapeutic Applications of Adrenalin. —
Dr. George B. Wallace read this paper. He said that,
with the exception of the local action of adrenalin, its
hemostatic action, knowledge of the therapeutic effects was
in an unsatisfactory state, and marked differences of
opinion existed concerning the benefits, or lack of bene-

876

MEDICAL RECORD.

[May 25, 1907

fits, following its use. The purpose of his paper was to
attempt to define some clinical applications of adrenalin in
the light of experimental facts. He briefly recalled some of
the main facts brought out by animal experimentation, the
most striking of which was on the circulation. When a
fraction of a milligram of adrenalin was placed directly
in the blood stream there occurred a remarkable rise in
the blood pressure of not over ten minutes' duration, due
chiefly to the intense vascular constriction by a stimula
tion of the sympathetic, vasoconstrictor nerve endings. It
was the splanchnic vessels which reacted most strongly
and a fact of importance was that the pulmonary vessels
did not share in this constriction, a fact which was taken
as proof of the non-e.xistence of vasomotor nerves in
these vessels. These effects were seen when adrenalin
was placed directly in the veins, but it was generally
agreed upon by pharmacologists that they were entirely
absent when it was given by the mouth or by subcutaneous
injection. Another fact established was that adrenalin
had no dilating efifect upon the bronchioles. The efifects
on the central nervous system were not very striking. As
in the case with all new drugs of any promise, adrenalin
had been given a very extensive and indiscriminate trial
clinically. He then considered a few of the diseases in
which it had been used. In general there seemed to be
no specific vascular abnormality in which adrenalin was
especially employed, other than the indefinite one of cir-
culatory weakness. The reports of its beneficial efifects in
circulatory collapse from a sudden injury and in cardiac
dilatation from a long continued cardiac disease, and in
pulmonary edema, were not by any means entirely satis-
factory. The majority of the attacks of asthma were
immediately checked by subcutaneous injections of ad-
renalin. An understanding of the therapeutic application
of adrenalin could best be obtained by definite knowledge
of the range of action of adrenalin when given by subcu-
taneous or intramuscular injections. With this in view a
number of experiments had been performed on animals
by Dr. Diamond and himself, in which they confined them-
selves especially to the efifects on the circulation of sub-
cutaneous or intramuscular injections. An appreciable
rise of blood pressure in these animals, especially in the
case of a dog, from a subcutaneous injection of adrenalin
might be considered an exception and not the rule. With
intramuscular injections quite a different effect was seen.
In the rabbit intramuscular injections acted practically like
intravenous injections, the rise coming on quickly, being
marked and persistent only for a few minutes. They
were of the opinion that the injection was in truth an
intravenous one, that the manipulation resulted in the
tearing of a small vein, and that some of the adrenalin
thus gained entrance directly into a vein. This was in
harmony with the fact that the rise was by no means
constantly obtained, and further explained its short dura-
tion. They had endeavored to control their results by
injections into man ; and in considering the results ob-
tained, one was tempted to conclude that subcutaneous
injections of adrenalin caused a rise in blood pressure in
man. In one case, one of myocarditis, an injection of
I c.c. of water caused the pressure to rise from 92 to
loS mm. Adrenalin injected in the same amount raised
the pressure from 92 to no. Plainly in this case there
was no difiference discernible between water and adrenalin.
On the whole, there seemed little reason for explaining
them as due to the absorption and subsequent action of
the adrenalin injected. As a matter of fact, the more
negative animal experiments were much more satisfactory
and convincing. The animal was unconscious from the
anesthetic, and the effects of suggestion, mental activity,
and reflex stimulation were largely eliminated. They had
given adrenalin subcutaneously in a few cases of pul-
monary edema, from pneumonia and cardiac failure, and
in no instance was any improvement noticed. Concerning

the clinical bearing of these and other experiments, one
conclusion would be that in circulatory or cardiac dis-
orders requiring a stimulant treatment, but little depend-
ence could be placed on adrenalin given by subcutaneous
injection, and it would be more desirable to use instead
some drugs of proven value. In cases of pulmonary
edema, its general use would seem of no benefit. Finally
in cases of acute asthma there seemed to be no question
that adrenalin might relieve the attack. It should always
be borne in mind in using adrenalin for any period of
time that there was a possibility of inducing not only local
necrosis, but permanent pathological conditions in the liver
and arterial walls as well.

Dr. Egrekt Le Fevre said that he would take some ex-
ceptions to Dr. Wallace's findings from a clinical stand-
point. First in relation to the circulatory system. Since
its introduction, in spite of its uncertainty of action, it
had been extensively used in the hospital. He agreed
that in cases of myocardial disease, or primary valvular
lesions with consequent myocardial degeneration, with
failure of the circulation on account of muscular weak-
ness, adrenalin failed to improve, and generally produced
unfavorable results. On the other hand, in those cases
where there were disturbances of the circulation not de-
pendent upon cardiac power, but dependent upon loss of
control over the circulation, it had stood him in good
stead better than any other drug. In acute diseases of
toxic type, as in collapse during the second, third, or
fourth week of typhoid fever, where without previous
diseases there were evidences of degeneration in the heart
itself, the patient going into collapse, with marked cyano-
sis, in those cases where they usually depended upon
camphor dissolved in oil, the use of adrenalin had saved
many lives. In the past two years he had been unfor-
tunate enough to see four cases of that condition where,
under ordinary circumstances, imperfect results would have
followed the use of such cardiac stimulation as from hot
plates, etc., marvelous results followed the use of ad-
renalin. Dr. Wallace had stated that no good effects
followed the use of adrenalin in the pulmonary edema
of pneumonia. Dr. Le Fevre said that pulmonary edema
should be divided into two classes. First, where late in
the disease there was a gradual but progressive failure of
the heart, and with that some failure in the vascular con-
trol, in these cases better results were obtained from such
agents as camphor, caffein, or digitalis than from ad-
renalin. But, on the other hand, in those cases where,
early in the disease, without evidence of cardiac failure,
they had sudden attacks of edema, adrenalin was better
than other drugs. During the past three months Dr. Le
Fevre had at Bellevue Hospital five cases in which he was
able to show the immediate effects of adrenalin in this
type of edema. In vascular collapse, not cardiac per se,
adrenalin was indicated. With regard to asthma he agreed
that in the spasmodic types of breathing that occurred in
acute cardiac and renal disease, and in other forms of tox-
emia which also occurred in asthma, which once were called
spasmodic asthma, adrenalin acted but little. But in
the cardiac and renal diseases with intercurrent at-
tacks, that were nearly like true asthma, there was
some effect to be had from adrenalin, but not the marked
efifect one would get in true asthmatic conditions. He
said he had seen a number of cases of asthma where the
use of adrenalin was attended by unusual symptoms, es-
pecially the early blanching, and here a question arose as
to the cause of the blanching. Just how adrenalin acted
was still a mystery. In asthma, with spasm of the bron-
chioles, no efifects resulted from the administration of ad-
renalin. But in cases of angioneurotic edema, with the
peculiar condition of the nose, the sneezing, and profuse
discharge, etc., the giving of adrenalin would be accom-
panied by a blanching of the mucous membrane and much
relief given. The question, and an important one, arose

May 25, 1907]

MEDICAL RECORD.

35 to the danser of producing changes in the blood-vessels
of chronic asthmatics by the use of adrenalin, given in
amounts necessary to give relief. The case in which he had
used it longest extended over four and a half years, and
nothing of a permanent nature could he detected. Another
case had used it three and a half years. There was no
doubt that adrenalin was preferable to morphine for use in
these asthmatics.

Dr. W. SoHiER Bryant said he had been using the
suprarenal gland for ten years, and very extensively in
nasal work, and the variability ' '^ ti'ects was some-
thing none seemed to understa: He was fond,
of using it for diagnostic purposes to determine the nature
of the cause of asthma. If there was a local cause the
adrenalin controlled it immediately. In those cases the
asthma was a reflex disturbance caused by some pressure
upon or in the nose.

Dr. George B. Wallace said that no doubt there were
some types of asthma in which adrenalin had no effect
whatever. The question that most interested him was
how this agent produced its effect. As a whole the effect
upon the circulation was bad. The clinical cases in which
adrenalin was expected to do good were rare; in ten
cases there might be one case which showed improvement,
while the others w-ould not.

The Comparative Actions of Isopral and Chloral. —
Dr. R. A. H..\TCHER presented this paper. He said that a
student of materia medica could not fail to observe that
many substances came into notice, rose to popularity, and
sunk back into obscurity, only to give place to others
which followed the same course. This observation should
tend to make all conservative. While they were tardily
coming to appreciate the indecency of permitting them-
selves to be made the dupes and unpaid agents of the
makers of worthless compounds which were forced upon
their notice in high sounding, but often meaningless,
phrases, they should be more guarded in accepting too op-
timistically the statements of those who had an interest
in making reports upon compounds sold at fancy prices ;
they should remember that the enthusiast and the inves-
tigator who sold the report were prone to accept insuffi-
cient evidence as the basis for highly colored reports, if.
indeed, their reports were not pure fabrications. Isopral
was being extensively advertised as a safe hypnotic of the
chloral group, and as acting more efficiently than chloral
in one-half the dose, and without effect on the heart and
nervous system. The use of isopral by clinicians was
apparently based upon the pharmacological investigations
of Impens, who gave figures purporting to show that
isopral was much safer than chloral hydrate. It did not
seem to Dr. Hatcher that his conclusions were in any
way justified, and the table taken from Impens' article
was shown for comparison with results obtained by him
in experiments upon a number of animals, including 13
dogs, 10 rabbits, S cats, and 2 guinea pigs. His conclusions
were that he believed that his experiments on rabbits and
ca*s and Impens' experiments on rabbits showed that there
was no essential difference between the action of isopral
and hydrated chloral in effective doses on the respiratory
centers, while his experiments on dogs showed that isopral
was more than twice as active in depressing the vasomotor
and respiratory centers and the heart. Dr. Hatcher's fig-
ures for the relative toxicity were almost precisely the
same as those given by Impens for the relative efficiency
of the two drugs for the dog.

Dr. A. N. RicH.^RDS discussed the paper.

Dr. Hatcher closed the discussion.

Chloride of Ethyl in Neuralgias. — The local applica-
tion of chloride of ethyl spray has sometimes not only
relieved, but also cured some forms of neural.gin. Hemi-
crania, lumbago, and supraorbital neuralgia have all been
cured in this way. — The Hospital.

MEDIC.\L ASSOCLATIOX OF THE GRE.\TER CITY
OF NEW YORK.

Staled Meeting, Held April 15, 1907.

The President, Dr. Thom-\s E. S.\tterthw.\ite, ix the
Ch.mr.

Report of the Committee on the Death of Dr. George
B. Fowler. — Dr. Egbert H. Gr.\nuix, Chairman. (Read
by the Secretary. See page 696.)

Symposium on Milk. — The President, Dr. Satter-
thwaite, said that a word or two of introduction seemed
necessary, especially in view of the fact that he had re-
cently received a letter asking if the object of the meeting
was to advocate the municipal pasteurization of milk. His
reply was that this Jlilk Symposium was planned months
ago, when public attention was first called to the city milk
question. There was not, and never had been any inten-
tion or desire on the part of the .Association to advocate
pasteurization, inspection, modification, certification, or in
fact anything new, but it was intended and hoped that
through the cooperation of the best experts obtainable, the
milk question would enter on a new phase, rising above
the level of personal, political, or local considerations. He
felt that the whole subject would be reviewed from a com-
mon sense standpoint, and that some light would be
thrown, directly or indirectly, on such features as bovine
tuberculosis and infant mortality; the inspection of dairy
farms and their products; pasteurization, its benefits or
disadvantages, and its applicability; the adulteration of
milk; the proper bacterial standard for milk; the certifica-
tion of milk; raw milk and bottle-fed babies, and so on.
The milk question presented a number of difficult prob-
lems that could not be entirely solved in a day or a year,
so that it was too much to expect immediate harmony in
conflicting views. More facts were needed for the complete
solution of the question. There was no doubt, however,
from the published accounts, that much of the city milk
was impure, and also that the mortality among bottle-fed
infants w-as too high, and that our best efforts should be
directed toward checking it.

On the Bacteriology of Milk.— Professor H. W. Conn
of Aliddletown, Conn., Director of the Bacteriological Lab-
oratory of the Connecticut State Board of Health, dis-
cussed this phase of the subject. He stated that there was
entirely too much misapprehension concerning the relation
of bacteria to health. While some bacteria were harmful,
others were perfectly harmless, while still others were dis-
tinctly useful, and among the latter were those of the lactic
acid variety, which developed in milk, and might prevent the
growth of other and harmful organisms. To the manufac-
turer of cheese and butter they were indispensable. While
there were those who would advocate the destruction of all
bacteria in milk, on the same principle as that advanced
by the man who would kill all birds because a hawk occa-
sionally kills chickens, yet as a matter of fact, from the
standpoint of the bacteriologist, there were only certain
bacteria in milk that were to be feared. These were, first,
the tubercle bacilli; second, the typhoid fever bacilli; third,
the diphtheria bacilli, and, fourth, the germs of scarlet
fever, which were thus far unrecognized. Of these four,
only the first was positively known to come from the cow;
the other three were from some form of human contamina-
tion. In addition to these four, the speaker said, there was a
type of diseases which was characterized by intestinal dis-
turbances, such as were commonly known as summer com-
plaint, cholera infantum, etc., and though they were dis-
tinctly traceable to the use of milk in many in-
stances, their causation was as yet unknown. While
they were probably due to to.xic products contained
in the milk, we had no certain knowledge on that
subject, but we did know that lactic acid bac-
teria were not responsible for this type of troubles. Pro-
fessor Conn said that three chief methods of milk purifica-

878

MEDICAL RECORD.

[May 25, 1907

tion had been advocated and were more or less in use.
Each of these had its advantages, and each possessed certain
weaknesses. The first was that of proper dairy inspection.
This was fairly new, although it was first suggested about
fifteen years ago, and first adopted by milk supply compa-
nies in Berlin and London. While dairy inspection was of
extreme value, it did not furnish a guarantee that the
milk was fret from the germs of tuberculosis, typhoid fever,
diphtheria, or scarlet fever. While it might accomplish
much, it could not cover the whole question.

The second method was a bacteriological standard. The
bacterial standards of milk adopted by different cities varied
widely. One city, for example, placed its bacterial standard
at 500,000 per c.c. ; another city at 100,000, and another for
special purposes at 30,000. The speaker said that in his
own city of IMiddletown, Conn., it would be a very easy
matter to obtain milk with a bacterial standard as low ~as
10,000, while in New York City it was doubtful whether a
standard of 1,000.000 per c.c. could be satisfactorily main-
tained. That did not imply, however, that the milk in
Middletown, Conn., was one hundred times better than
that in New York; on the contrary, it was probably not
one iota better. Buttermilk had a bacterial content of two,
three, and even five hundred millions to the c.c, and still
there were many physicians who did not hesitate to recom-
mend it as a wholesome article of food. As a matter of
fact, these countless numbers of bacteria in buttermilk and
sour milk were practically all of the harmless and even use-
ful lactic acid type, and thus sour milk usually represented
a pure culture of lactic acid bacteria. It w-as not the number
of bacteria upon which the healthfulness of the milk de-
pended, but the kind. The wholesomeness of the milk de-
pended upon whether its bacteria belonged to the harmful or
harmless types, and it was a difficult, or even an impossible
matter for any bacteriologist to distinguish between the
different kinds ; while it could be done, the methods were
too slow and unreliable to be of practical application. Hence
too much reliance should not be placed upon bacterial milk
standards. Moreover, they did not always work fairly.
They were often unjust to the milk producer, and we in the
cities were too prone to lose sight of the other end of the
milk route. No milk standard could guarantee that a certain
sample of milk was entirely satisfactory. Its bacterial content
might fall below 500,000 per c.c. or any other standard,
and yet it might be filled with typhoid or tubercle bacilli. It
might, on the other hand, contain twenty or thirty millions
of bacteria to the c.c. and be perfectly harmless. Under
e.xisting conditions a bacteriological standard placed
the emphasis on the wrong spot. We should emphasize the
type of bacteria and not their number. Some day, perhaps,
that could be done; up to the present time it had not been
done, simply because it was impracticable to do it. Coming
to the third method of guarding the milk pasteurization.
Professor Conn said that much could be said for and
against it. In the first place, the fact should be borne in
mind that pasteurization was the only method within our
reach at the present time by which we could guarantee that
any sample of milk was free from the danger of the germs
of specific diseases, such as typhoid fever, tuberculosis, etc.
But, in order to accomplish that, the milk must be properly
pasteurized. Pasteurization which simply raised the milk
for a moment to a moderate degree of heat accomplished
little in the way of destroying the resisting pathogenic bac-
teria. It must be done thoroughly, and in the proper way
if the milk was to be guaranteed as free from the tubercle
bacillus. -Another fact to be borne in mind was that pas-
teurization destroyed the lactic acid bacteria and left
others alive, which afterwards developed rapidly, being
unhindered by the lactic acid bacteria. Therefore, after
pasteurization, the milk must be utilized without much
delay. Again, it had been said that pasteurization placed
a premium on carelessness in the dairy, because, if the milk
was to be thus treated, the farmer naturally might think it
would make no special difference whether he was cleanly or

not. While this objection might have some weight, it might
be overcome by proper dairy inspection. Some believed that
pasteurization decreased the digestibility of milk, but this,
he said, depended on the temperature to which the milk had
been subjected. Prof. Conn stated that he had reason to
believe that in the near future there might be placed upon
the market a type of milk known as concentrated milk, which
had about four-fifths of its watery content removed by ex-
posing it to a temperature of not more than 140 degrees
for a period sufficiently long to destroy all the pathogenic
germs. By this method of treatment, the bacterial con-
tent of the milk was reduced from any number of millions
to a few thousands, and the milk itself brought into a con-
dition in which bacteria would scarcely thrive. Prof.
Conn said he had been experimenting with this concen-
trated milk for several months, and he could state posi-
tively that when kept at a temperature of 50 degrees or
below it would remain unchanged for five or six days with-
out any appreciable increase in the number of bacteria, and
that when subsequently mixed with three times its bulk of
water it could not by any ordinary means be distinguished
from fresh milk.

Clean Milk. — Dr. Marv E. Pennington of the Bureau
of Chemistry, U. S. Department of Agriculture, Washing-
ton, D. C, said that because of the great difference in the
production of milk in various parts of the country, and the
time and conditions intervening between drawing it from
the cow and its delivery to the consumer, a bacterial stand-
ard was exceedingly difficult to fix. If such was main-
tained, it must be regarded in the light of an indication
as to what was going on at the dairy quite as much ai an
index of the condition of the milk itself. Clean milk was
that from healthy cattle, wholesomely fed, kept in clean,
light, airy surroundings, and drawn by clean milkers. It
should be collected in covered buckets, and then, as quickly
as possible, be cooled and bottled on the farm away from
the disease-bearing dust of the city. Being of all foods the
one most subject to deterioration, every effort should be
made for its rapid transportation to the consumer, and for
the continued maintenance of a temperature below 55° F.
during this interval. Milk so produced and cared for did
not contain polluting organisms from the barn, which were
generally those of cow manure, nor from dirty hands, nor
from foul air and water. If kept cold, the bacteria would
scarcely increase at all during the first twenty-four hours,
by which time, even in the large cities, it should reach the
consumer. If dirt entered, neither art, science nor pat-
ented machinery could remove such dirt, and leave intact
the original properties of the milk. Any process having
that end in view was objectionable, because it placed a pre-
mium on dirty, diseased milk, which was always more
easily obtained than the clean variety, and hence could be
sold at a greater profit by the dealer. Pasteurization, as
practised commercially, could not be guaranteed to kill
off pathogenic organisms, such as tubercle bacilli, typhoid
bacilli, streptococci, etc. It did kill the lactic acid formers
normally found in milk, because they were more easily
destroyed by heat, but, on the other hand, it left the heSt-
resisting spore formers and other organisms which com-
monly caused profound chemical changes in the milk with-
out first curdling it. and therefore without any indication to
the housewife that the milk was not fit for food. It did not
protect the milk from reinfection by dirty air, employees,
and containers. Furthermore, milk was often heated two
or three times before it was fed to the baby, by which time
it contained not only the life products of millions of or-
ganisms which might be toxic, but also their dead bodies
and excreta. The speaker emphasized the importance of
bending all energies toward the education of the people,
including the dealers, to know, demand, and pay for clean,
good milk.

Some Points on the Chemistry of Milk.— By Profes-
sor L. L. Van Slvke of Geneva. N. Y., of the Department
of Chemistry. N. Y. State Agricultural Experiment Sta-

Mav

H)07

MEDICAL RECORD.

871

79

tion. TIk- chief purpose of this paper was to point out
some of the common and widespread misconceptions re-
garding the chemistry of cows' milk, and add a few words
regarding some of the dairy prohlems that liad been inves-
tigated, and some of the unsolve<l problems that might be
of interest to physicians. After discussing normal mill;
and its composition, the speaker said that this varied widely,
but naturally less in milk derived from herds of cows than
in that taken from individual cows. Milk, as it often came
into a city market, varied in couiposition much less than
milk from individuals or from single herds. When, there-
fore, we spoke of the composition of normal milk, without
any qualifying statement, we were dealmg with quantitative
relations that might be about as detiuite and fixed as the
quotations of the stock-market. The average of about
S.300 .\merican analyses of milk, mostly made at the State
Agricultnral Experiment Stations and under known con-
ditions of production, gave approximately the following
figures: Water, 87.10; solids, i2.qo: fat. ,^.90; casein, 2.50;
albumiii, etc., 0.70; sugar, 5.10; ash, 070. .After referring
to the relation of casein to albumin in cows' milk, and the
action of acids and rennet on casein. Professor Van Slyke
said that the following were some of the problems that
had been under investigation; (i) Different breeds of
cows and the composition of milk ; ( 2 ) a study of the rela-
tion of milk to the manufacture of cheddar cheese; (3)
the ripening of cheddar cheese: {4) casein and its com-
pounds: (s) chemistry of the souring of milk: (6) kumyss
and carbonated milk. Some unsolved problems that still
called urgently for attention in the way of rigid chemical
investigation were (i) the action of rennet or pepsin upon
the casein of milk, (2) the chemistry of casein, especially
in relation to inorganic salts in milk; (3) the chemistry of
paracasein, the product formed by rennet coagulation : (4 )
the relation between the casein of human milk and the
casein of cows' milk. In concluding his remarks, the
speaker said he had tried to indicate in his paper ( i ") that
there were positive erorrs in literature regarding the com-
position of inilk, which needed correction; (2) that work
had been done and was being done in other connections
which found practical application to some of the problem^
of medical practice, and (3) that there yet remained for
solution problems of profound and far-reaching impor
tance.

Municipal Regulation of the Milk Supply. — Dr
George W. Goi.er. Health Othccr uf the City of Rochester,
N. Y.. presented this paper. The speaker first empha-
sized the importance of milk as an article of diet, and said
that before taking up the question of its municipal control,
he wished to present the milkman's view of the ease. Of
the several millions of milch cattle kept in this country,
50 per cent, were said to be kept at a loss. 25 per cent, re-
turned no profit, and only 25 per cent, were profitable to
their owners. The business of milk production and d'.;-
tribution was not generally, save by the large concerns,
ducted in a systematic manner. However practical "e
men engaged in the work might be, they were not scienf
fically trained in the different steps of tillage, planting,
storing, and feeding, nor in properly housing and caring
for cattle, nor in handling and transporting ,T'i-
men were all engaged in handling the most pfr;-lia'^Ie of
foods ; the only one that did not rise and fall in price with
the demand for it, and the cost of its production. Men in
the milk business worked every day in the year, in the heat
and in the cold, on Sundays and holidays. The demands
of the public compelled work and delivery at early and
unusual hours, so that fresh (?) milk might be on hand
for breakfast. The speaker then discussed in detail the
municipal regulation of the milk supply, beginning with
the inspection and control of the dairy, the proper method
of the transportation and delivery of the milk, and the
strict enforcement of the city milk ordinances. The latter,
he said, required a sufficient nutiiber of inspectors to really
inspect, and to collect from each wagon at least one

monthly sample for bacteriological and chemical examina-
tion, with at least a bimoinhly sample from each store
offering milk for sale. There should be ;i daily inspection
of the incoming milk at each radroad station ior (a) con-
dition of and housing of cans and bottles of milk in ship-
ment; (b) condition of empty cans reshipped; (c) tem-
perature of milk; (d) inspection ..f railroad samples to
guard the retailers against fraud on tin- part of the whole-
salers. Thus the city provided for the bacteriological and
chemical examination of the milk supply, the wagons and
stores, and inspection. The country end of the work w .is
of even greater importance. The territory from which the
city drew its milk supply must be mapped, the dairies plot-
ted, the roads examined, the railroad facilities noted, and
the routes laid out so that every farm shipping milk to the
city might in the beginning be subjected to systematic
bimonthly inspection. No milk must be permitted to enter
the city until the seal of inspection had been placed upon
it by the inspector.

State Regulation of the Milk Supply.— Dr. E. B.
VooRHEES of New Brunswick, .M. J., Director of the New
Jersey .Agricultural Experiment Stations, stated that
the objects to be attained by State regulation of
inilk supplies should be (i) to provide a healthy and
wholesome food product and (2) to encourage the pro-
ducer in his efforts to make a clean and healthful product.
This control should be both restrictive ;iud educative ■
restrictive in prohibiting certain methods of practice which
resulted in an unclean product, and ediualive because the
matter of control was reasonable. The laws that had been
enacted in the past had not been altogether reasonable, and
because many unnecessary, foolish, and impracticable meth-
ods of control had been adopted by State and municipal
authorities, much misapprehension existed in the minds
of both producers and consumers concerning the useful-
ness of any control, as well as the possibilities and proba-
bilities of danger from the use of milk that had not been
subjected to such control. The producer had rights upon
which unwise and unjust regulations infringed; be had
undoubtedly suffered in the past, and was now suffering
from exaggerated notions in reference to the dangers
of using milk, and methods of prevention which had been
incorporated into law. On the other hand, it was surely
right that the State should exercise proper supervision over
the possible sources of danger, mainly in the matter of the
production and sale of the milk, and along the following
lilies: (I) The health of the animals; (j) the food and
water supply of the animals; (3) the stabling of the ani-
mals and care of milk on the farm; (4) the sale of milk
of varying composition. In the first three directions the
control had reference directly to the conserving of the
public health; in the fourth it bad reference entirely to the
sale of milk as a commodity, and the regulations should not
be prohibitive, but permissible. The State should also
make such regulations for the retailer as shall guarantee
proper care in transporting and storing of the milk and
its distribution, as well as the retpiisite cleansing and re-
turn of the vessels in which the milk had been transported,
although in all cases the regulations should be so reasonable
as to make it possible to have them complied with. Dr.
Voorhees, after discussing in detail these various State
regulations, said the wdiole matter of milk control was
largely one of education and fair dealing. The State could
assist in securing it by limited and reasonable restrictive
measures, wdiose execution was in the hands of intelligent
officers.

Milk as a Food. — Dr. Henrv D. Cil^pint said that
milk was such a commonplace article of diet that it was
somewdiat difficult to approach the subject from a purely
scientific standpoint. Such an investigation would show
that milk was supplied to young animals for a certain
period after birth, and that it was a food, because growth
and increase in weight occurred when no other form of
nourishment was taken. A study of the processes of re-

88o

MEDICAL RECORD.

[May

= 0.

1907

production would show that milk was not the only form
of food supplied by the mother. Before birth occurred
three different methods of feeding were employed by the
mother and three different kinds of food were supplied,
these different methods of feeding gradually passing from
one into the other. The young animal, before birth, was
continuously changing its form and structure, and the form
of the food and the method of supplying it changed as fast
as the changes in the young animal took place. Milk was
not supplied at birth, but colostrum, which was gradually
displaced by milk, and the latter, in turn, was displaced by
solid food. Milk was the last of five special forms of food
supplied by the motlier during a period of very rapid devel-
opment, and it w-as especially adapted to young animals just
before they were ready to subsist on solid food. Compara-
tive e.xaminations of the milk of different species of ani-
mals showed that they were not alike in composition or
in their behavior with pepsin and acid. The digestive
processes of these different species of animals were also
unlike, which led to the conclusion that nature purposely
made milks unlike because they were intended to be suitable
for animals with different nutritive requirements and dif-
ferent digestive processes. Milk was a special form of
food supplied during the period in which the digestive
organs were developing ; milk was a complete food, but
this statement was correct only when applied to mother's
milk, for the milk of some species contained so much less
of the various ingredients than the milk of other species
that it would be a starvation diet for some young animals,
even if they had the proper digestive properties. The
attention of the medical profession could not be too
strongly directed to the fact that pure cow's milk was used
as a food only in feeding adults and older children, and
here it caused little or no trouble. The feeding of pure,
natural, fresh cow's milk to infants was not common,
especially when they were young. In feeding infants, mix-
tures or new' compounds derived from cow's milk were
generally employed, many of which had none of the diges-
tive properties of cow's milk. The properties of pure
cow's milk as a food were pretty well understood. What
the practising physician needed to become familiar with
was the properties of the derivatives of cow's milk he used
in his practice many times more frequently than he used
pure milk.

Dr. R.'iXSFORD E. Van Giesox of Brooklyn said that
careful attention to the papers of the evening had only
convinced him more strongly of the fact that we had still
a great deal to learn concerning the chemistry of the pro-
teids of human and cow's milk. For example, the dififer-
ence between cow casein and human casein was very great,
both in its physical and chemical properties. As regarded
the composition of cow's milk, the only figures to depend
or. were those derived from an average analysis of a large
number of animals. While the pasteurization of milk had
its drawbacks, it also possessed undeniable advantages, es-
pecially during the heated term, and to that extent it might
be regarded as a necessary evil.

Dr. Edward F. Brvsh of Mt. Vernon. X. Y., said he
had been interested in the milk question for many years.
While much had been written and said regarding the dan-
gers of tj'phoid and tubercle and other bacilli in milk, they
were not the only factors to be considered. During the
hot weather, cows were not infrequently tormented by
flies or dogs, or allowed to feed on poisonous weeds, and
under such conditions the milk of those animals might con-
tain toxins which were a potent factor in the causation c4
diarrheal diseases. The dairy cow was subject to almost
all the ailments to which the human being was subject, and
the speaker recalled several instances where he had been
able to convince himself that epidemics of scarlet fever
were conveyed through the medium of cow's milk. Dr.
Brush said he did not agree with one of the previous
speakers that the cow was naturally a clean animal, but in
view of the fact that we utilized her milk during life and

her riesh after death there was no reason why she should
not be given preference to the horse as regarded stable
care and pasturage; the contrary, however, was quite the
rule. In speaking of the tuberculin test in cattle, Dr.
Brush said that while he did not doubt its value, the work
in the beginning was too often intrusted to inexperienced
and at times ignorant men. with little else than a ther-
mometer to guide them, and he knew of instances where
excited and nervous, but otherwise healthy cattle were
sacrificed as the result of their overzealous efforts. On
the other hand, every possible ill which the cow was heir
to had been a'iributed to tuberculosis. This work should
be intrusted to skilled veterinarians, who were capable of
making a correct diagnosis and instructing the farmer how
to breed his cows.

Dr. Wii.i.iAM 11. Park said he did not agree with Prof.
Conn that the great majority of bacteria in ordinary milk
were harmless. The lactic acid variety covered a multitude
of types, including a colon bacillus which was not at all
harmless. The bacterial standard of milk, to which several
of the spe;ikers had referred, was employed chiefly to de-
tect whether the milk was clean or not, and how long it had
been on the market. In the present stage of our knowledge
regarding milk bacteriology', it was scarcely possible to
pick out the different types of bacteria. The essential fea-
tures in the proper care of milk were to keep it cold, to
keep the dirt out and to keep the time down. The term
"commercial pasteurization," which one of the speakers
had employed, was a rather indefinite one. One firm, for
example, might pasteurize milk by exposing it to a temper-
ature of 160° for one minute, while another might accom-
plish the same purpose by exposing it to a temperature of
140° for thirty minutes. In connection with pasteuriza-
tion, the time and temperature must be considered.

Dr. Charles E. Xorth said the problem of the milk
supply in New York City was unique and rather peculiar,
as he had learned from personal experience. The man
who sold the milk in the city did not own either the farm
or the cow. andhad utterly lost control of the supply. On
the other hand, it was dilficult to teach the dairy farmer
how to produce the kind of milk the public demanded.
Clean, raw- milk was what the public wanted, but under
present conditions it was absolutely impossible for the
average producer to supply it. To obtain it. we required a
new kind of farmer — men of more intelligence and capital.
.\t present, we were menaced by a flood of dirty and con-
taminated milk, and in order to protect the public from
the disease germs that it contained it was advisable to
resort to pasteurization. He believed that a large part of
our milk supply would require pasteurization for a long
time to come.

Mr. George L. Flanders of Albany. X. Y., an Assistant
Commissioner of .Agriculture of the State of New York,
said he had listened to a number of discussions on the
question of pure milk, particularly from a bacteriological
standpoint, and they had all impressed him strongly with
the view that, in order to obtain pure milk, the proper place
to begin was at the source of the supply. In the State of
Xew York there were 1.800.000 milk cows, and much work
had been done throughout the State during the past fifteen
years by the Department of .\griculture in trying to edu-
cate the milk-producing farmer how to care for the cows
and handle the milk. .As a result of this work, the people
in the cities of the State to-day were receiving better milk
than ever before. One of the great drawbacks, however,
in producing the result desired had been that the middle-
man had been able to manipulate the prices so that the
producer could scarcely afford to follow the instructions as
to the best methods of producing pure, clean milk. In
reply to a criticism made by Dr. Brush that the work of
examining cattle had been intrusted to" men who were
ignorant and inexperienced. !Mr. Flanders said that perhaps
Dr. Brush was unaware of the fact that these men were
all college graduates and experienced veterinarians.

May 25. it)Oj]

MEDICAL RECORD.

881

STATE B(JARl) IvXA.MIXAlIOX QLESITOXS.*

Ohio State Board of Registration and Examination.

December II, 12, and 13, ICK*.

PHYSIOLOGY.

1. How are foods classified? Describe each class.

2. Where and by what secretions are nitrogenons foods
digested ?

3. Describe the process of blood coagnlation.

4. Describe a heart beat.

5. What part of digestion takes place in the duodenum?

6. What changes does the blood undergo in respiration,
and how is it accomplished?

7. What conditions hasten and what retard absorption?

8. Describe a serous membrane, and name its office.

9. WTiat is meant by the term blood pressure?

10. How is the heat of the body maintained?

OBSTETRICS.

1. Name the varieties of ectopic pregnancy. Give briefly
the symptoms and signs by which it may be recognized.

2. How determine before labor the presentation and po-
sition of fetus without making a vaginal examination?

3. How, during pregnancy, may death of the fetus be
recognized ?

4. Name some conditions which W'ould warrant the in-
duction of premature labor.

5. How distinguish one shoulder from another when the
elbow and hand cannot be reached?

6. What conditions would cause you to make a crani-
otomy or embryctomy rather than a cesarean section?

7. How should labor be induced at about the seventh or
eighth month ?

8. Give briefly the pathology of so-called milk leg.

9. In about what period of time should the second stage
of labor be concluded? Why?

10. Give briefly the symptoms of rupture of the uterus
and outline its management.

DISEASES OF WOMEN.

1. Classify uterine hemorrhage and give some of the
causes.

2. Give treatmer.t for nausea and hypcremcsis of preg-
nancy.

3. Give some of the causes and treatment for pruritus
vulvse.

4. Give some of the aids and hindrances to involution.

5. Name three diseases of mammary glands; give their
treatment.

DISEASES OF CHILDREN.

1. Symptomatology and treatinent of rickets. From
what must it be differentiated?

2. How would you treat a child, age two years, who is
suffering Mth vomiting and diarrhea?

3. Diagnosis and management of chorea in children.

4. Diagnosis, prognosis, and treatment of inherited
syphilis.

5. Give the period of incubation of whooping cough,
measles, scarlet fever, diphtheria, chickenpo.x. and mumps.

1. Define surgical diseases: give an example with treat-
ment for same.

2. Classify fractures and dislocations of the shoulder.

3. How do you dress a fractured clavicle?'

4. Describe technique of surgical treatment for em-
pyema.

5. Describe technique of cholecystostomy.

6. How frequently should you catheterize an luicon-
scious patient?

7. Describe operation for \aricocele.

•It Is proposed in this department to publish from time to
time the examination papers of the various State Boards.
In order that a candidate may become familiar witli the
character of the examination and so in some measure free
himself in advance from the nervousness and dread which
the unluiown inspires. In furtherance of the same object
answers to some of the questions will be published in order
to show the candidate what the examiners expect of him.
Not all the questions of ail the papers will be so treated.
for the answers to many, especially in the anatomical papers,
are obvious or can be found in the index of any text-
book on the subject; the answers to other questions, especially
in the surgical papers, must sometimes be omitted because of
the space they would demand. The candidate for a medical
license will not find in these answers a short and easy road to
success in the examination, for he is not likely to meet the
same questions in the papers placed before him by the
examiners. The object of publishing the questions and
answers is only, as noted above, to acquaint the candidate
with the general character of these examinations and to
tnipire him with confidence in the result of hi» trial.

8. What is the danger of surgical treatment of corns
and bunions in old people, and why?

9. Give a simple formula for hypodermoclysis and what
conditions call for its use.

10. Give symptoms and tre;itment of intussusception of
bowels.

CHEMISTRY.

1. Define acid, base, and salt.

2. What inorganic salts enter into the formation of
bone?

3. What is chemical affinity, cohesion, and adhesion ?

4. What are the properties of an acid? of an alkali?

5. What is an oxide?

6. What is chloroform? How made?

7. What is the difference between fermentation and
putrefaction?

8. What is the antidote to carbolic acid?

9. Describe a method of prep;iring oxygen.

10. Name three mineral poisons and give their anti-
dotes.

• M.ATERIA MEDICA A.ND THERAPEUTICS.

1. Upon what docs the activity of hydrogen pero.xide
depend? How is it employed in medicine?

2. For what i>urpose is cold employed as a therapeutic
agent; how does it produce its effects?

3. In what way may exercise act as a therapeutic agent?

4. What is heroin? Describe its physical properties and
physiological action; give some indications for its use.

5. Write a prescription for a patient suffering from
cystitis with ammoniacal urine.

6. Describe the lethal effects of hydrocyanic acid.

7. Write a prescription for a patient with broken car-
diac compensation.

8. How does quinine produce its etTect in malaria?

9. From what is eserine obtained? Describe its action.

10. How graduate the dose of a remedy to the age of
a patient?

ANATOMY.

1. What vessels unite to form the inferior vena cava?
Describe its course and termination.

2. Give the origin, course, and branches of the axillary
artery.

3. Describe the inedulla oblongata.

4. Give the distribution of the pneumogastric nerve.

5. Describe the larynx.

6. WTiat are Peyer's glands? WTiere are they found?

7. Describe the gall-bladder, giving its location and re-
lations.

8. Give the names of five muscles of the shoulder and
arm.

9. What is the diaphragm? Where is it situated? Men-
tion the principal opening in the diaphra.gm.

10. Give the origin, insertion, and action of the deltoid
muscle.

PHYSICAL DIAGNOSIS.

1. How discriminate organic from functional murmurs
of the heart?

2. Give pathological significance of aortic murmurs.

3. State pathological significance of herpes labialis.

4. State indications suggested by the reflex vomiting.

5. What are the indications suggested by hiccough?

6. State pathological significance of blood in the stools.

7. State physical signs of an effusion in acute pleurisy.

8. Describe the methods of palpation to ascertain the
condition of the kidneys.

9. State pathological significance of the general disten-
tion of the abdomen.

10. State pathological significance of rigid recti muscles
of the abdomen.

PRACTICE .\ND PATHOLOGY.

1. Name some of the causes of constipation, and give
dietetic and hygienic treatinent.

2. Describe the changes that follow generalized ar-
terio-sclerosis.

3. Differentiate between catarrhal jaundice, gallstones
inthe common duct, and malignant growth affecting com-
mon duct.

4. Locate the lesion in paralysis of the right arm and
leg. and left side of the face.

5. Describe the process of healing by the blood clot
dressin.g. i.e. where the cavity is allowed to fill with blood
and is then closed.

6. How do c.-ircinoma and sarcoma differ from each
other?

7. Diagnose and give treatment of erysipelas.

8. Diagnose and give treatment for dysentery.

9. What is acne? How do you treat it? _

10. Give symptoms, dia.gnosis. and treatment of epi-
lepsy.

882

MEDICAL RECORD.

[May

'-D'

1907

ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.

Ohio State Board of Registration and Examination.

December 11. 12, and 13, 1906.

physiology.

1. Foods are classified as follows;

T T ( Water.

I. Inorganic <^ g.^,^^

1 Non-nitrogenous f Carbohydrates
II. Organic •! l Fats.

( Nitrogenous — Proteids.

2. Nitrogenous foods are digested in (l) the stomach,
by the pepsin of the gastric juice; and in (2) the small
intestine, by the trypsin of the pancreatic juice.

3. When blood is withdrawn from the blood-vessels of
the living body, it first becomes viscid, then sets, and is
converted into a jelly-like mass. This is due to the forma-
tion of fibrin. The jelly contracts forming the clot; and
at the same time the serum is squeezed out from the clot.
Various circumstances atid conditions will hasten or delay
the process of coagulation. In man, the blood generally
becomes viscid 111 from two to three minutes; it forms
the jelly-like mass in from five to six minutes; a few min-
utes later the serum begins to appear ; and the whole
process is completed in from twenty-four to thirty-six
hours. The clot then floats on the serum. The process
is thus summed up by Halliburton : In the plasma a proteid
substance exists, called Fibrinogen. From the colorless
corpuscles a nucleo-proteid is shed out, called Prothrombin.
By the action of calcium salts prothrombin is converted into
fibrin ferment, or Thrombin. Thrombin acts on fibrinogen
in such a way that two new substances are formed : one of
these is unimportant and remains in solution; the other
is importanti viz., Fibrin, which entangles the corpuscles,
and so forms the clot.

5. The proteids are converted into proteoses and pep-
tones, the starches are converted into maltose, fats are
emulsified and saponified, and the casein of milk is curdled.

6. The respiratory changes in the blood: (l) In the
lungs, the blood is changed in color, gains oxygen, loses
carbon dioxide, loses heat, and loses watery vapor. (2)
In the capillaries of the body, the blood loses oxygen and
receives carbon dioxide.

7. Substances in a liquid or gaseous state are absorbed
more readily than solids. The more dense the fluid the
slower the absorption. The more tense and full the blood-
vessels the slower the absorption. The more rapid the cir-
culation the quicker the absorption.

8. The pericardium may be taken as an example of a
serous membrane. It consists of two layers, a visceral and
a parietal. The free surface is covered with a single
layer of endothelium, which rests upon a connective tissue
stroma. Between the endothelial cells are stomata. Se-
rous membranes are supplied with blood-vessels, lymphatics,
and a few nerves. The office of a serous membrane is
to secrete a fluid for the lubrication and protection of the
organ or organs with which it is in contact.

9. By the term blood pressure is meant the press-
ure on the blood due to (i) the ventricular systole, (2)
the elasticity of the w-alls of the arteries, and (3) the
resistance in the capillaries.

10. The heat of the body is maintained by the thermo-
tactic centers in the brain and cord keeping an equilibrium
between the heat gained or produced in the body and the
heat lost. Heat is gained to the body by (i) the muscles,
during contraction; (2) the secreting glands; (3) the
brain, during mental activity : and (4) by the ingestion of
food and hot liquids.

Heat is lost to the body by (i) the skin, through evapo-
ration, radiation, and conduction; (2) the lungs; and (3)
the excretions (feces and urine).

obstetrics.

I. The varieties of ectopic pregnancy are: (i) Tubal,
(2) interstitial, (3) ovarian, and (4) abdominal.

In differentiating this condition from a normal pregnancy,
the following signs and symptoms are of most reliance.
"When extrauterine pregnancy exists, there are: (i) The
general and reflex symptoms of pregnancy ; they have often
come on after an uncertain peripd of sterility. Nausea
and vomiting appear aggravated. (2") Then comes a dis-
ordered menstruation, especially metrorrhagia, accom-
panied with gushes of blood, and with pelvic pain coinci-
dent with the above symptoms of pregnancy. Pains are
often very severe, with marked tenderness within the pelvis.
Such symptoms are highly suggestive. ('3) There is the
presence of a pelvic tumor characterized as a tense cyst,

sensitive to the touch, actively pulsating. This tumor
has a steady and progressive growth. In the first two
months it has the size of a pigeon's egg; in the third
month it has the size of a hen's egg; in the fourth month
it has the size of two fists. (4) The os uteri is patulous;
the uterus is displaced, but is slightly enlarged and empty.

(5) Symptoms No. 2 may be absent until the end of the
third month, when suddenly they become severe, with
spasmodic pains, followed by the general symptoms of
collapse. (6) E.xpulsion of the decidua, in part or whole.
Nos. I and 2 are presumptive signs: Nos. 3 and 4 are
probable signs: Nos. 5 and 6 are positive signs." {American

» Text-Book of Obstetrics.)

3. Symptoms of death of fetus are : cessation of the
signs of pregnancy, the abdomen and uterus are both dim-
inished in size, the fetal heart sounds and movements are
absent, there is no pulsation in the cord, the mother's
breasts become flaccid and occasionally secrete milk. If
the fetus has been dead for some time, crepitus of its cranial
bones may be elicited.

4. Conditions warranting the induction of premature
labor: (i) Certain pelvic deformities, (2) placenta prsvia,
(3) pernicious anemia, (4) toxemia of pregnancy, (s)
habitual death of the fetus toward the end of pregnancy,

(6) hydatidiform mole.

5. "Diagnosis of one shoulder from the other when the
hand and arm are not tangible: i. Observe the opening of
the axilla ; it always points toward the child's feet. If
the feet be. therefore, toward the right side of the pelvis,
the head will be toward the left side.

"2. The scapula, its spinous process especially, will indi-
cate whether the child's back be toward the pubes or toward
the sacral promontory.

''3. A moment's reflection will show that a child lying
across the pelvis (let the reader imagine himself to be
lying across it), with its head in the right iliac fossa, and
its back to the fubes, must be presenting its left shoulder
to the pelvic brim — the 'position' of the 'presentation' be-
ing, necessarily, right cephalo-iliac (dorso-anterior). If
the axillary opening show the head to be in the left iliac
fossa, and the position of the scapula show the child's
back to be toward the mother's sacrum, it will still be the
left shoulder presenting, the position, however, being left
cephalo-iliac (or dorso-posterior).

"The same data and deduction may be used for the right
shoulder and its two 'positions.'" (King's Obstetrics.)

6. "Embryotomy is indicated to-day in but two condi-
tions : First, in all instances in which the fetus is dead
and delivery of the unmutilated fetus would increase the
danger for the mother. Second, upon the Hiring fetus in
obstructed labor due to monstrosity ; and in exceptional
cases in which the mother's condition, from hemorrhage,
repeated attempts at delivery, sepsis, or shock, is such as
to render embryotomy by far the safer operation." (Ed-
gar's Obstetrics.)

8. Milk leg may follow puerperal sepsis in which there
is a thrombosis of the iliac or femoral vein. Sometimes
it occurs after a uterine phlebitis, in which clots are
carried from the uterine sinuses to the hypogastric veins,
where they cause obstruction to the blood flow in the
crural veins. The trouble may also begin as a crural
phlebitis. It is thus due either to cellulitis or to throm-
bosis.

9. The second stage of labor usually lasts from one
and a half to two hours. While this is the average time,
the process may be much prolonged. It may last twenty-
four hours without serious consequences. No rule can be
laid down as to when interference should be permittedt
Each case must be taken on its own merits. If labor is
unduly prolonged, much damage may be done to the ma-
ternal tissues, sloughing, fistulje, etc., may result ; and the
fetus may also suffer. Shock, exhaustion, and greater
liability to sepsis are also more likely to occur.

DISEASES OF WOMEN.

I. The following (from Gould and Pyle's Cyclopedia
of Medicine and Surgery) is a useful classification of
uterine hemorrhages, and also gives the causes of the same :

I. Hemorrhages Complicating Pregnancy, Labor, or the
Puerperium:

A. Hemorrhages of Pregnancy: caused by (l)
placenta praevia ; (2) premature separation of a
normally situated placenta; (3) apoplexy of the
decidua or placenta.

B. Hemorrhages of Labor: caused by (i) pla-
centa praevia : (2) premature separation of a
normally situated placenta; (3) relaxation of
the uterus; (4) laceration of the cervi.x; (5)
rupture or inversion of the uterus.

C. Hemorrhages of the Puerperium: caused by
(I't retained secundines ; (2) displaced uterus;

May 25, 1907]

MEDICAL RECORD.

883

(3) displaced thrombi; (4) fibroid tumors; (,5)
hypertrophied decidua; (6) carcinoma.
II. Hemorrhages Occurring in the Non-Pregnant
Woman:

A. In Virgins Before the Age of Thirty: caused
by (i) uterine congestion, the result of cold or
exposure; (2) endometritis; (3) polypi and
fibroid tumors.

B. In Married Women Before the Age of Thirty:
caused by (i) subinvolution; (2) laceration of
the cervix: (3) endometritis; (4) retrodisplace-
ments of the uterus; (5) polypi and fibroid tu-
mors.

C. In Women After the Age of Thirty: caused
by (l) carcinoma of the cervix; (2) carcinoma
of the body of the uterus; (3) sarcoma of the
uterus.

3. Pruritus vulva may be caused by: — parasites; dis-
eases of the vulva, as inflammation, edema, vegetations,
congestion, irritating discharges, lack of cleanliness, dia-
betic urine; it may also be of nervous origin, or idiopathic.

Treatment consists in removing the cause, if possible;
cleanliness, fresh air, tonics, and general attention to hy-
giene ; local applications of solution of bichloride of mer-
cury, 1:2,000; or carbolic acid, l:loo; or lead and opium;
dusting powders of bismuth subnitrate, calomel, or zinc
oxide are also useful.

4. The following are some of the aids to involution:—
good health before labor ; a labor not too long or fatiguing ;
absence of inflammation, sepsis, or laceration ; a sufficient
amount of rest after the confinement: neither too early
rising after the labor, nor too long lying constantly upon
the back; nursing the baby; and the administration of
err^ot. The opposite conditions are hindrances to involu-
tion.

DISEASES OF CHILDREN.

5. The period of incubation of whooping cough is from
three to fourteen days : of measles, ten to fourteen days ;
of scarlet fever, a few hours to seven days : diphtheria, a
few hours to seven days ; chickenpox, about fourteen days ;
mumps, fourteen to twenty-one days.

SURGERY.

I. A surgical disease is a disease that is amenable to
surgical treatment, e.g. a boil.

6. Every four to six hours.

8. Gangrene may ensue ; due to the enfeebled circula-
tion.

CHEMISTRY.

1. An acid is a compound of an electro-negative element
or radical with hydrogen, part or all of which hydrogen it
can part with in exchange for an electro-positive element,
without the formation of a base.

A base is a ternary compound capable of entering into
double decomposition with an acid to produce a salt and
water.

A salt is a substance formed by the substitution of an
electro-positive element for part or all of the replaceable
hydrogen of an acid.

2. Calcium phosphate, calcium carbonate, calcium fluo-
ride, magnesium phosphate, and sodium chloride.

3. Chemical atHnity is that force which holds together
the atoms in a molecule.

Cohesion is the force by which molecules of the same
kind are held together.

Adhesion is used with two meanings: (i) the force by
which unlike molecules are held together. (2) The force
which binds together the surfaces of masses when in con-
tact.

4. The properties of an acid are: (i) It contains hydro-
gen; (2) part or all of its hydrogen can be replaced by a
metal (or its equivalent), and a salt is thereby formed;

(3) it can change the color of many organic substances;

(4) when soluble in water it has an acid or sour taste.
The properties of an alkali are: (l) It is strongly basic;

(2) it is alkaline in reaction; (3) it will saponify fats.

5. An o.ride is a compound of oxygen with another
element.

6. Chloroform is a substitution product of methane.
Three of the four hydrogen atoms of methane are replaced
by three atoms of chlorine: hence the formula is CHCI3.
and the proper name would be Trichlormethane.

Chloroform can be obtained by heating chloral hydrate
with an alkali :
CaHCl., (OH), -f KHO = CHCIs + HCOOK -f H=0

7. Fermentation is the decomposition of organic matter
containing carbon, hydrogen, and oxygen only. When
it also contains nitrogen and sulphur the process is called
Putrefaction.

8. Alcohol.

g. Oxygen can be prepared by heating potassium chlo-
rate:

2KCIO3 = 2KCI + 30,

10. (l) Arsenic; antidote, freshly prepared ferric hy-
droxide. (2) Corrosive sublimate; antidote, white of egg
in moderation. (3) Phosphorus ; antidote (physiological),
old French oil of turpentine.

MATERIA MEDICA AND THERAPEUTICS.

1. The activity of hydrogen peroxide depends upon the
readiness with which it gives up oxygen to oxidizable
substances with which it comes in contact.

It is employed in the form of the solution : — .\qua Hy-
drogenii Dio.xidi, which contains about ten volumes of
available oxygen.

2. Cold is employed : — for its local effect on inflamma-
tory processes; for neuralgias: as a local anesthetic; to
reduce the body temperature; to relieve cardiac palpitation;
in meningitis; for insomnia; by rectal injection in dysen-
tery.

"Cold causes relief of pain in inflammation by produc-
ing contraction of the local blood-vessel walls. As a re-
sult inflammatory exudates do not occur, congestion is
relieved, and as the pressure on the nerve filaments ceases
the pulsating pain of inflammation passes away." (Hare's
Practical Therapeutics.)

3. The following from Parkes' Practical Hygiene will
answer this question : ''The eft'ects of exercise on the body
are as follows: (l) Increased force and frequency of
the heart's action, and the increased circulation of the
blood through all parts of the body. (2) The pulmonary-
circulation being quickened, more carbonic acid and water
are taken to the lungs and eliminated. The amount of air
inspired and expired is largely increased, and the oxygena-
tion of the blood is consequently accelerated. (3) The
action of the skin is heightened, and perspiration becomes
marked, large quantities of sweat being poured out of
the sweat glands. The evaporation of the sweat from the
surface of the body regulates the temperature and prevents
any rise above the normal. (4) The water and salt of
the urine are decreased owing to the large cutaneous se-
cretion, but the nitrogen (in the form of urea, uric acid, and
extractives) is unaffected. In the period of rest follow-
ing excessive exercise, the nitrogen elimination may be
slightly increased. (5) The voluntary muscles are brought
into active play ; the circulation of the blood through them
is accelerated ; waste products are rapidly carried away for
excretion; while the material for new tissue is brought
to them."

4. Heroin is a derivative of morphine; it is formed
from morphine by substituting acetyl for its two hydroxyls.
It is a colorless, odorless powder; crystalline, with a
somewhat bitter taste, and is insoluble in water. The
hydrochloride, however, is soluble in water.

Its action is to quiet the respiratory centers ; and it is
used chiefly for quieting cough.

5. B Hexamethylenaminse 5ij.

Aquae destillatie q. s. ad Jiv. M.
Sig. : — One teaspoonfu! every three hours.
g. Eserine is obtained from Physostigrna.
Its action is: — (i) to contract the pupil: (2) to stimu-
late involuntary muscle fibers: (3) a mild nervous seda-
tive; (4) it increases peristalsis.

.X

10. Let X = the age of a patient : then =

X+12
the fraction of the adult dose which the patient should
receive. Thus, a patient of four years old should receive

4 4 I

• ^ — — — of an adult dose.

4+12 16 4

PHYSICAL DIAGNOSIS.

1. Organic murmurs are due to stenosis or incom-
petency of one or more of the valves of the heart.

Functional murmurs are not due to valvular disease.
Organic murmurs may be systolic or diastolic ; may be
accompanied by marked dilatation or hypertrophy, and
there will probably be a history of rheumatism or of some
other disease capable of producing endocarditis. Whereas
a murmur, usually systolic, soft, and blowing, heard best
over the pulmonic area, associated with evidences of
chlorosis or anemia, and affected by the position of the
patient, is a hemic or functional murmur, and denotes as
a rule an impoverished condition of the blood.

2. Aortic murmurs may signify: (l) aortic stenosis;
(2) aneurysm of the arch of the aorta: (3) aortic regurgi-
tation. In the latter case the murmur is diastolic: in the
two former, it is sv^tolic.

884

MEDICAL RECORD.

[May 25, 1907

3. Herpes labialis may signify: — (i) slight feverish-
ness ; (2) coryza ; (3) bronchitis ; (4) pneumonia ; (5)
digestive disturbances; (6) cerebrospinal fever; (7) ap-
proaching menstruation; and (8) it may be a neurosis.

4. Reflex vomiting may indicate: — meningitis; preg-
nancy ; astigmatism : irritation of the fauces ; worms ;
uterine, tubal, or ovarian disease.

5. Hiccough may indicate: — several of the gastrointes-
tinal disorders : eoilepsy. hysteria, meningitis, cerebral
tumors: gout: diabetes: typhoid; alcoholism; nephritis.

6. Blood in the stools may indicate: — (i) traumatism;
(2) acute inflammation of the bowels, as in enteritis and
dysentery: (3) chronic heart or liver disease; (4) scurvy,
purpura or infectious fevers; (5) rupture of an aneurysm;
i6) ulcers in the intestine; (7) intussusception; (8) the
passage of blood from the stomach in hematemesis; (9)
hemorrhagic infarction of the bowel from embolism or
thrombosis of the mesenteric artery; (10) piles, fissure, or
fistula. (From Steven's Practice of Medicine.)

9. General distention of the abdomen may signify: —
Tumors, ascitfs. pregnancy, tympanites, peritonitis, cretin-
ism, enlarged mesenteric glands.

10. Rigid recti })iuscles may signify : — appendicitis or
peritonitis.

PRACTICE AND PATHOLOGY.

2. In the smaller blood-vessels the lumen may become
nearly obliterated (endarteritis obliterans). There may be
cardiac hypertrophy; thrombosis may occur; the thrombi
rnay become organized, or emboli mav be formed; connec-
tive tissue hyperplasia is apt to occur.

4. The lower part of the pons, on the left side.

6. Carcinoma is derived from the epiblast or the hypo-
blast; possesses a stroma, in which are both blood-vessels
and lymphatics; metastasis occurs by the lymphatics.

Sarcoma is derived from the mesoblast ; it has no
stroma and no lymphatics: metastasis occurs by the blood-
vessels which are in contact with the cells.

BULLETIX OF APPRQACHIXG EXAMlXATIOXS.t

TATE.

Alabama*.. . .

Arizona*

Arkansas*. . . ,

California

Colorado

Connecticut*. .

Delaware

Dis.ofCol'bia.

Florida*

Georgia

Idaho

Illinois

Indiana

Iowa ,

Kansas

Kentucky*

Xxjuisiana

Maine. .......

Maryland

Massachusetts*

Michigan ....

Minnesota. . .
Mississippi. . .

Missouri

Montana*.. . .
Nebraska. . . .

Nevada

N'. Hamps're*

New Jersey. .
New Mexico..

New York. . . .

N. Carolina*..

N. Dakota

Ohio

Oklahoma*. . .
Oregon

Pennsylvania

Rhode Island.
S. Carolina.. . .
S. Dakota

Tennessee*.. . .

Texas

Utah*

Vermont

Virginia

Washington*..
W, Virginia*. .
Wisconsin.. . .
Wyoming

N'AME A>JD ADDRESS OP PLACE AND DATE OF

SECRETARY. NEXT EX AMIS ATION.

■^^'- H. Sanders, Montgomery.. Montgomery . .June i

.Ancil Martin. Phoenix Phoenix Julv

.F T. Murphy. Brinkley Little Rock. . .July

. Chas. L. Tisdale, Alameda .... San Francisco . Augiist
.S. D. Van Meter. 1723 Tre-

mont Street. Denver Denver July

.Chas. A, Tuttle. New Haven. .New Haven. . .July

.J. H. Wilson. Dover Dover June

.W.C.Woodward. Washington. Washington. . .July
.J. D. Fernandez. Jackson\'ille. Jacksonville.. .

.E. R. Anthony. Griffin Atlanta October

.J. L Conant. Jr., Genesee Boise October

.J. A. Egan. Springfield Chicago June

.W. T- Gott. 120 State House.

Indianapolis Indianapolis. ..May

.LouisA.Thoraas.Des Moines. . Des Moines.. . .June

.T. E. Raines, Cotcordia Topeka June

. J. X'. McCormack. Bowling

Green Louisville October

.F. A. La Rue. 211 Camp St., . . New Orleans. ..

. Wm. J. Maybur>-. Saco.. ... .Augusta July

. J. McP. Scott. Hagerstown. . ..Baltimore June

.E. B. Harvey. State House.

Boston Boston

.B. D. Harrison. 205 Whitney

Building. Detroit Ann Arbor. . . . June

,W. S. FuUerton. St. Paul St. Paul June

J. F. Hunter. Jackson Jackson

.J.A.B.Adcock. Warrensb'g. . .Mexico Julv

, Wm. C. Riddell. Helena Helena October

.Geo. H. Brash. Beatrice Lincoln May

S. L. Lee. Carson City Carson City. . .

. Henr>- C. Morrison. State Li-

brarv-. Concord Concord July

. T- W. Bennett. Long Branch. .Trenton June

B. D. Black, Las Vegas Santa Fe June

New York
C.F.Wheelock.Unv.of State J Albany.
i- of New York. Albanv. . .. J Syracuse.
. Buffalo,

G. T. Sikes, Grissom Morehead City

.H. M. Wheeler, Grand Forks.. Grand Forks. .July

.Geo, H. Matson. Columbus. . ..Columbus June

.J. W. Baker, Enid Guthrie June

.B. E. Miller. Portland Portland

.X. C. Schaeffer. Horrisburg. { ^^4^^^^^^^ ;; } June

-G T. Swartz. Providence Providence.. . .July

. W. M. Lester. Columbia Columbia June

.H. E. McNutt. Aberdeen Sioux Falls.. . .July

f Memphis ]

.T. J. Happel. Trenton i Nashville \

[ Knoxville 1

.T. T. Jackson. San Antonio. . .Austin

. R, W. Fisher, Salt Lake City . Salt Lake City.July

.W. Scott Nay. Underbill Burlington.. . .July

. R. S. Martin. Stuart Lvnchburg. . . .June

.C.W. Sharpies. Seattle Seattle July

. H. A. Barbee. Point Pleasant. Charleston. . . .July

-J. V. Stevens. Jefferson Madison July

.S. B. Miller. Laramie Cheyenna June

, . .Santa Fe Jun

I New York. . . . )

; J Albany. f

. J Syracuse, f

( Buffalo, )

Health Reports. — The following cases of smallpox,
yellow lever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital
Service, during the week ended May 18, 1907:

SMAI.Ll'OX UNITED STATES.

Florida, Duval Co . Jacksonville. .April i7-May 4.

Santa Rosa County April 2~-May 4.

Georgia. Augusta April 30-May 7 •

IlUnois. Belleville April 20-27

Springtield May 2~<t

Indiana, Klkhart May 4-11

Indianapolis April 2ii-May 5.

South Bend Apri 28-May 1 1

Ipwa. Ottumva April 2S-May 4.

Kansas, Lawi'ence April 1-30

Kentucky, LouisWlle May 2-0

Louisiana, New Orleans April 27-May 4.

Massachusetts, Chelsea April 27-May 4.

..^ ... Lawrence April 27-May 4.

V Pittsfield May 4-1 1

Michigan, Detroit April 2S-May 11

Holly Dec. lo-April 3.

Minnesota. Stillwater April 1-30

Missouri. St. Joseph April 27-May 4-

St. Louis April 27-May 4-

New York, Buffalo April 27-May 4.

Xew York April 27-May 4.

Niagara Falls April 27-May 4.

Xorth Carolina. Germaboro Apri! 27-May 4-

Ohio. Toledo April 27-May 4.

Pennsylvania, New Castle April 1-30

South Carolina. Charleston April 1-30

Tennessee. Memphis May 4-11

Texas. Bell County May 6

San Antonio April 27-May 4-

Virginia. Richmond April 27-May 4.

Washington. Spokane April 27-May 4-

Wisconsin, Milwaukee April 27-May 4.

SMALLPOX — FOREIGN.

CASES. DEA

75 Estimated

13
6

17

3

Present
Present

16

iS

Austria. Trieste April 13-20

Brazil. Bahia Mar. 23-April 13

Para April 13-2?

Rio de Janeiro Mar, 30-ApriJ 14

Canada, Sherbrooke April 1-30

\'ancouver April 20- 27

Chile. Coquimbo April 13

Iquique April 13

China. Hongkong Mar. 23-30

Columbia. Barranquilla April 6-13 - . i

Cuba. Habana May 3 i onSS. Alphonso

Egypt, Cairo April S-15

France. Paris April 20-27 8 '

St. Etienne April 1-15 '

Germany. General April 13-20

Great Britain. Aberdeen April 13-20

;■** Liverpool April 20-27

India, Bombay April 9-16

Calcutta Mar. 30-April 8.

Madras April 6-12

Italy, General April 22-20

Palermo April 13-20

Torre Annunziata April 27..

Turin April 7-21

Mexico. Jalapa April 28-May 3.

Portugal. Lisbon April 13-20

Russia, Moscow April 6-13

Odessa April 13-20

Riga. . , , _ April 13-20

Spain, Barcelona April 10-20

San Feliu de Guixols, Spain April 20-27

Spain, Valencia April ?i-28

Turkey in Asia. Ba^sorah Mar. 16-13

Imported

87

YELLOW FEVER

Brazil Manaos April 13-20

Para April 13-27

Rio de Janeiro Mar. 30-April 14-

West Indies. Trinidad. Port of

Spain April 13-10

India. Bombay April 0-16

Calcutta Mar. 30-April 6. .

Rangoon Mar. 30-April 6. .

PLAGUE — INSULAR.

Hawaii. Honolulu May 10-12

* Ko reciprocity recognized by these States.

t Applicants should in every case write to the secretary for latest
details regarding the examination in any particular State

PLAGUE — -FOREIGN.

Bra7il Bahia April 6-13

Para April 13—27

Rio de Janeiro Mar. 30-April 13 .

Chile. Antofagasta April 13

Santiago April 13

Taltal April 13

China. Hongkong Mar. 23-30

India. General Mar. 23-30 62

Bombay April p-16

Calcutta Mar. 30-April 6. .

Rangoon Mar. 30-April 6. .

Peru. Chepen .'.. .April 3-10

Lambayeque April 3-10

Lima April 3-10

Paita April 3-10

Tnijillo April 5-10

Turkey in Asia. Oieddah Mar. 31-ApriI 14.

Tor — Quarantine
Station Mar. 31

807

46

Present

Present

2

53-681

461

200

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 71, No. 22.
Whole No. 1908.

New York, June i, 1907.

$5.00 Per Annum.
Single Copies, JOc.

(irigiual Arttrlrs.

THE PHYSIOLOGICAL ACTION OF THE
PANCREATIC ENZYMES, WITH SPE-
CIAL REFERENCE TO HEMATOLO-
GY, URINOLOGY, AND CLINI-
CAL PATHOLOGY.

By MARGARET A. CLEAVES, M.D.,

NEW YORK.

Digestive ferments should not be regarded thera-
peutically in any way other than medicinal agents.
To that end a study of their action upon the blood
and urine is not only of great importance, but of
the first consideration.

In trypsin we have a drug possessed of great po-
tentialities, and one which should not be allowed
to remain an unchartered derelict on the sea of
therapeutics, a perpetual menace, a veritable dan-
ger. I have no desire to enter the arena already
strewn with eminent pathologists and surgeons, nor
do I wish to advance or discuss "cancer cures" ; but
because of my experience in the enzymic treatment
of cancer, supplemented by careful laboratory ob-
servation, it is daily enforced on me by those seek-
ing mv assistance in an advisory way that many
are using the pancreatic ferments, with an impunit\-
that can only be accounted for by a lack of con-
crete knowledge. The fatal results which are chron-
icled are not always due to cancer, but often to
uremic poisoning from faulty therapeutic technique.

My reason for this paper is not to discuss the
merits or demerits of the treatment advanced bv
Dr. John Beard, but to call attention to the dan-
gers and discouragements of the treatment. That
the seeming advantages of the treatment outweigh
these dangers, from mv point of view, goes without
saving, or I would have discarded the pancreatic
ferments as therapeutic agents. A secondary and
very consideraljlc consideration in my mind is that
trvpsin opens up a new field to the experimental
physiologist and clinician in a certain class of dis-
eases hitherto not linked together.

Despite the fact that it is impossible to do other-
wise than to leave many gaps, it seems but logical t'l
embody my clinical experience in a tentative report
on the physiological action of the pancreatic fer-
ments.

Enzymes. — Before entering upon a consideration
of the physiological action and reaction induced by
the trypsin treatment, it is first necessary to take
up in detail the occurrence, nature, function, and
action of enzymes. The facts cited must of neces-
sity be fragmentarv, as the sum total of the knowl-
edge concerning enzymes is still in the stage of
debatable theorv.

Enzymes, of which trypsin is an example, are in
some degree characterized bv the following reac-
tions and characteristics : They are exclusively of

cell life, and no cell is without them ; hence the
deduction that enzymes are of necessity an accom-
paniment of proteid. Practically the only attempt
to fix definitely the action of enzymes is that em-
bodied in the theory of Arthus, who ascribed their
qualities simply to natural laws. He finds an analo-
gy between the enzymic properties of a cell and
magnetism, basing his deduction upon the facts that
enzymes and magnetism are both destroyed by heat,
dissolved by acid, each impossible of isolation, and
both are recognized by deeds rather than by percep-
tible matter.

The following formulas give the synthetic and
general chemical reaction of enzymes :

GH,— O— OC— GH,+H=0=GH50H+H00C— CsH-
Ethyl butyrate + water = ethyl alcohol -h butyric acid.

If water be added to ethyl butyrate the above
equation takes place. The reverse equation is true,
except that the reaction is never complete, but the
reaction is so slow in the reverse equation that
unless a catalytic agent is present the time required
is very long. This is well brought out in Wells'
Chemical Pathology,^ the latest and best authority
on the subject.

Synthetically. Taylor- was able to build up triolein
by the action of lipase upon oleic acid and glycerine,
and it is known that the intestinal wall splits pro-
teids, which are rebuilt in other parts of the body.
This must be done bv enzymes, which reverse their
usual action, and synthetically build up complex pro-
teids from simpler bodies.

All enzymic action depends on the fact that the
chemical reactions accomplished are everlastingly
reversible and tend to an equilibrium. The action
is also catalytic, and the tendency to find an equili-
brium before a complete chemical reaction takes
place must be remembered in connection with the
administration of trvpsin.

As a classical example of the synthetic action
of enzymes the formation of hippuric acid from
benzoic acid and glycocoll may be given. It is
probable that enzvmes can only act as dehydrating
agents and oxydizers. or in establishing the reverse
of these processes.

There are certain phenomena which enzymes and
toxins have in common. Both act on cells to pro-
duce immune bodies laiown as antienzymes and
antitoxins respectivelv ; a specific enzyme acting on
a suitable cell will produce a specific antienzvme just
as surely as diphtheria will produce antidiphtheritic
toxin. Toxicity is also a characteristic of the enzyme
when injected into a body. Fiquet^ gives the first
action of trvpsin as rendering the blood uncoagula-
lile, but afterward the opposite effect is observed.
W'ells^ in using trvpsin and lipase found an acute in-
Hammatory condition. A marked difl:'erence between
enzymes and toxins is that strong solutions of en-
zvmes are able to resist the action of the miMer

886

MEDICAL RECORD.

[June I, 1907

spermicides, when a weak solution of the enzyme is
rendered inert.

Enzymes exist in the cell as inert bodies, zymo-
genic in form, and their activities only come after
they are discharged from the cell, for example, in
the case of trypsinogen, which is acted upon by the
(.uterokinase of the intestinal wall to form active
trypsin.

It is probable that enzymes are of stereochemical
configuration in their construction ; that is, they are
Luilt up on a central element having a definite va-
lence, and hence, that all enzymes are capable of
entering into chemical action with only those sub-
stances "that attract and have an opnosite isomeric
form. Emil Fischer has proved that a different en-
zvme is needed for example to differentiate and act
on two sugars, no matter how closely they are allied.

The pancreas yields three enzymes : Trypsin,
amylopsin, and lipase. Of these trypsin is as ex-
clusive in its action on the proteids as lipase is on
the action of fats, and the third, amylopsin, acts on
the carbohydrates.

Cases. — For the purposes of this paper the con-
ditions treated of will be classified as follows, and a
single case from each class will be selected for
illustrative purposes : ( i ) Intestinal surgical inter-
ference; (2) postoperative; (3) inoperable; (4)
metastases; (5) nonmalignant.

(i) Intestinal Surgical Interference. — Rectal
adenocarcinoma. The original operation was per-
formed seven years since and artificial anus formed ;
microscopical examination made by J. H. Wright
of the Massachusetts General Hospital. Two sub-
sequent operations, one to reunite the intestine
( failed ) : the second fourteen to fifteen months since
to change the lateral incision in the intestine to
a cross cut, on account of the pocketing of the feces
in the colon. At that time the mesenteric glands
were found enlarged. This enlargement was re-
garded by the surgeon as malignant. At the time
treatment was instituted, ten months since, the
entire pelvis was filled with plaster-of-paris-like
induration, as is common in the female pelvis. There
was an ulcerated area about iy2 inches above the
internal sphincter of a ragged nodular feel, the ex-
amining finger and irrigating catheter passing to the
depth of four inches only. .\ condition of profound
neurasthenia of long standing existed. Morphine
had been taken off and on for two years, almost
constant!'' for one year, one to two grain? in
twenty-four hours. There were obstinate consti-
pation, loss of appetite, strength, and flesh, pain,
discharge, odor, sense of weight, bearing down, and
a sinking feeling in the pelvis, with inability to stand
or walk save for a few moments only, and very
short distances. In addition there were more or
less constant fluctuations of temperature, exhaust-
ing night sweats, and intense sciatic and sacral pain.
Length of life was estimated by the sur^^eon at one
vear, but the patient grew rapidly worse, leading
the family physician to put it at from two to three
months.

The enzyme treatment has been kept up for ten
months, at first vigorously, later less frequently.
At the beginning of .treatment continuous irrigation
of the cut off sigmoid flexure dislodged old fecal
matter which, upon examination, showed tubercle
bacilli. The masses are absorbed, there is absence
of weight in the pelvis, absence of pain ; no opiates
have been used in eight months ; there is no odor, no
discharge, appetite fair, food is taken in sufficient
quantities, the functions are normal, sleep good,
good mental vigor, better than for over a vear ; the

patient looks after his personal and professional
interests and presents no evidence of progressive
malignant disease ; weight fluctuates, at present
gaining.

At intervals of from four to six weeks during
past six months there have been discarded from
the rectum pieces of tissue, not necrotic, which
have been found by Dr. Wm. M. Higgins to be des-
titute of malignant characteristics and showing the
'Structure of an adenoma. The disused bowel has
been carefully irrigated and is now empty of its
fecal contents.

(2) Post Operative. — Carcinoma of uterus
and bladder wall. Panhysterectomy, January 9,
1907, bladder wall torn and reunited ; service of
Dr, Louis J. Ladinski, N. Y. Polyclinic Hospital,
by whose courtesy I w-as enabled to supervise the
postoperative treatment, which was begun January
19, 1907 ; twenty days after operation, characteristic
tryptoglycogenic reaction. (See Chart No. 1 for
temperature curve.)

Result to date : Improved appetite and meta-
bolism, softening of nodular tissues in vagina as in
the illustrative rectal case, Qass i. Still under
treatment. Odor and pain present at beginning of
treatment now in abeyance.

(3) Inoperable. — Uterine. Microscopic exam-
ination in service of Dr. Vanderveer of Albany,
who curetted one year since for hemorrhage.
Adenocarcinoma, infiltration of both broad liga-
ments. Seen by Drs. Clement Cleveland and
Robert T. Morris of New York City and declared in-
operable by both. Uterus fixed, hard, cervix in-
durated, and both broad ligaments infiltrated.

Treatment instituted February 11, 1907. By
March i, induration of broad ligaments was mark-
edly lessened, uterus movable. This case was seen
during the eight weeks of treatment four times by
Dr. Robert T. Morris, who on April 2 found that
improvement had progressed to the point where he
was willing to operate. Patient in good condition.
Much improved in every way. Operation was ar-
ranged for a week later, but patient was called
home on account of illness in family and despite
the future gravity of the case, decided not to have
the operation performed. In addition to the en-
zyme treatment, vaginal hydroelectric treatments,
with the continuous current, were given twice a
week. The bodv superficies was exposed to the
action of light and static electricity used pretty con-
stantly. This case showed the characteristic trypto-
glycogenic reaction, but followed a very regular
course from first to last. The daily range of the
temperature was from normal to 99° in the morn-
ing, 99° at noon, and 100° at night — occasionally
101° and 102°.

(4) Metastases. — Amputation of right breast
was performed in 1903 : the patient was seen in
1907. Scirrhus cancer of left breast of extreme
malignancy; microscopic examination by E>r. \\ m.
M. Higgins. One year in duration ; metastatic in-
volvement. Operable stage had been devoted to
Christian Science. Growth absolutely fixed, in-
volvement of cervical, axillary, mediastinal, subcuta-
neous, inframammary region, and inguinal glands.
An invalid for thirty years. Digestive disturbances
of years standing; insufficiency of hepatic atid
pancreatic function. Lender treatment for three
months. Pain in breast entirely relieved last four
weeks of life save night preceding death, no break-
ing down of tissue, nutrition improved. Seen by
Dr. Graeme M. Hammond of New York City
three days before death, who pronounced it the

June I, 1907]

MEDICAL RECORD.

887

most healthy looking: scirrhus cancer of the breast
he had ever seen.

Patient died of exhaustion probably referable to
action of toxins on vagus. Consciousness and men-
tal activity to the last. No uremic symptoms.

(5) Nonmalignant. — Abdominal hysterectomy,
October 18, 1906, by Dr. J. Riddle Goffe. Through
his courtesy I had charge of the postoperative treat-
ment. The indications for treatment were based
upon the report of the pathologist, who "-nve a diag-
nosis of carcinoma. Later examination by another
pathologist showed the section furnished to be be-
nign in character. There was no tryptoglycogenic
reaction. ( See Chart No. 2 for temperature curve in
contrast with Chart No. i, of temperature in case
illustrating Class 2.) Metabolism greatly improved
and a gain of twenty pounds in weight.

Preparations. — Of the pancreatic ferments (Fair-
child) two are used in every case, viz., an injection

In cases where there is very severe local reaction
at the site of injection, rather than discontinue the
use of trypsin, I have given it occasionally per rec-
tum diluted in twice to three times its volume of
sterilized water. In this way I have secured evi-
dence of the action of the ferments, but not in the
same degree as when used hypodermically. There
has been slight chill, rise of temperature, tension
and rigidity of diseased glands, and a slight but in-
sufficient increase of the eosinophiles.

Macafee^' reports a case of adenocarcinoma, uter-
ine primary, rectal secondary, in which he gave the
enzymic ferments (i) by mouth (2) in the colonic
opening. No reaction was noted save once there
were nausea, vomiting, and a rash which were con-
trolled by letting up on the oral administration. The
patient was markedly improved.

E. V. Leyden and P. Bergell" report that injec-
tions made directiv into a carcinoma in man were

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CaiKT I . Illustrative Ca.se. Class 2. Carcinoma of the Uterus The treatment was instituted January 28. igo: ; the chart shows^the
teraparature during the third and fourth weeks of treatment ; the doses of trypsin and amylopsin were 3 S minims each.

of trypsin which is prepared directly from the fresh
pancreas gland especially for hypodermic use.
It contains the trypsin in its normal association with
the other soluble enzymes and constituents of the
pancreas secretions. The second — amyolpsin — is a
solution of pancreatic diastase (amylopsin) devoid
of the proteolytic (trypsin) and fat-splitting (lipase)
ferments. It is also especially prepared for hypo-
dermic use.

Methods of administration: (i) Hypodermic,
(a) into the subcutaneous tissues, (b) into the tu-
mor mass; (2) by rectum; (3) by mouth. The ad-
ministration of the pancreatic ferments is almost
exclusively by hypodermic injections, combined
with the local application of a pancreatic lotion and
a trypsin powder in suitable localities. xA.ccording
to Graves,'' unless the ferments are directly injected
into the growth, no results are obtained. This is
in direct opposition to my own observations.

disappointing and that their experimental expe-
rience witli trypsin shows that larger amounts pass
into the blood when it is given by the mouth than
when it is injected subcutaneously. In the direct
injection into the cancerous tissue, the result was
always circumscribed. Given internally in large
amounts and over long periods of time, no decisive
influence could be demonstrated in cases of inac-
cessible internal carcinoma. On the other hand,
an unmistakable favorable reaction was noted in
nearly every case of carcinoma of the stomach not
too far advanced and still free from metastases.
They also found that a tumor whose cells have been
digested by the trypsin in some circumscribed area
never reacts to this interference with increased
growth either locally or in general. This is justly
regarded as significant and is believed by von Ley-
den to show an actual specific destructive process,
even if it is only temporary.

888

MEDICAL RECORD.

[June I, 1907

The dose of trypsin hypodermically varies and is
governed b_v ( i ) tiie pathological condition and
(2) by the condition of the kidneys before and
after treatment is instituted.

In nonmalignant conditions large and long con-
tinued doses are well borne, as there is no reaction
other than the local one at the site of the injection.
This is well shown in illustrative case of Class 5,
and also in the experiments of Pinkus" upon healthy
dogs. In the latter as much as six ampoules of the
original strength was given, with the result of im-
proving nutrition and increasing the body weight.
The same result was obtained in nonmalignant case
of Class 5. This patient was given injections of
trypsin of special strength daily for four weeks, in
the first week from one-third to one-half ampoule,
and afterward from one to two ampoules without

rule was followed, and two ampoules were given
first daily, and then on alternate days. Again in
case illustrating Class 3, from one-half an ampoule
to three ampoules of the trypsin injection (special
strength) was given daily excepting Sundays and
the few days on which amylopsin was given.

If given by rectum, the dose should be twice that
of the customary hypodermic dose, and it should
be diluted in from two to three times its volume of
cold sterilized water. The rectal tube should be
carried high up into the bowel for at least nine to
twelve inches.

There is no evidence of any localized inflam-
mation within the intestinal tract as with puncture.
The method, however, is not advocated save where
the discomfort, pain, swelling, and induration fol-
lowing upon hypodermic use is very badly borne

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Chart 2. Illustrative Case. Clas

.non-malignant. Teatment was 'nstituted December 20. 1906 ; the chart shows the temperature
from the seventeenth to the thirty-fourth days of treatment.

any amylopsin, without any reaction, and with
steady nutritive gain. This was evidenced by the
urine analysis as well as by the patient's appearance
and condition of improved metabolism, and her gain
in wei^-ht from December 2. 1906, to February 15.
1907, of twenty pounds. She never had a rise of
temperature, nor any save local reaction from the
punctures.

In patients suflering from malignant conditions
the doses must vary according to the patient's ability
to take care of them. Small and infrequent doses
seem to bear a definite relation to long and pro-
tracted toxic conditions.

In illustrative case of Class i the original strength
of trypsin injection was used, beginning with five
minims and rapidly increasing to two ampoules.

In a rectal case belonging to Class 3, the same

and the administration of trypsin and amylopsin is
imperative.

Amylopsin. — This, in the present state of our
knowledge should be administered in doses of from
one to two ampoules from the beginning of treat-
ment to control any bad symptoms, such as nausea,
vomiting, pain in the back, drowsiness, high arterial
tension, albuminuria, and edema generally. The po-
sition of amylopsin is a difficult one to define. There
is practically no literature on the subject nor are
there any laboratory experiments dealing with amy-
lopsin isolated from other ferments. It is. there-
fore, difficult to trace how far amylopsin acts as a
physiological antidote to trypsin. It does seem to
increase the urea output and apparently relieves
the distressing symptoms associated with the action

June I, 1907]

MEDICAL RECORD.

889

of trypsin, and until further studies and experi-
ments have been made as to its physiological role,
it should be administered as indicated, and later in
the treatment alternate with the use of trypsin,
while still further on it may be given alone. At all
times the blood must be regarded as the index, and
careful observations must be made of the urine as
well as the clinical picture to determine the indica-
tions for injections of trypsin, their frequency and
strength.

Site of Puncture. — This in my experience has in-
variably been into the subcutaneous tissues of the
back from the infrascapular region, and including
the buttocks, keeping well away from the vertebral
column and avoiding the use of both sides of the
body simultaneously in order that the patient may
lie on one side or the other without pain. In am-
bulant patients the buttocks are not used save
exceptionally. On the other hand, where patients
are obliged to be in bed, the buttocks may be used
as well as the back. In case illustrating Class i,
where collapse occurred in thirty seconds after the
injection, the puncture was made by my colleague
very near the spinal column, and about the third
dorsal vertebra. The explanation seems to be the
same as that governing surgical shock. Graves'* re-
ports a serious state of collapse, following upon
and two hours after the first injection of ten minims
into a rapidly proliferating squamous cell carcinoma
of the cervix uteri which for a time was alarming.
He states that the reaction resembled in general
character that which sometimes follows the injec-
tions of Coley's serum, but was more severe. The
explanation in both cases is undoubtedly the same.

Care in Administration. — The greatest care and
cleanliness should obtain of (i) the operator's
hands, (2) the syringe, and (3) the patient's skin.

Local Reaction. — The hypodermic administration
of trypsin in contradistinction to amyolpsin is ac-
companied by severe local reaction, not dissimilar
to that following deep-seated injection of mercury.
This varies in different patients.

Absorption of the Ferments. — This seems to take
place rather slowly, and patients comolain bitterly
if the whole back is used indiscriminately for hypo-
dermic injections.

Trypsin vs. Amylopsin.- — Subjectively there is
quickly acquired by patients an ability to differen-
tiate between trypsin and amylopsin (i) at site of
injection, (2) in systemic reaction.

With the former the burning sensation at site
of injection is intense and inflammatory reaction
marked, while with the latter there is very little sen-
sory disturbance following upon the introduction of
the ferment into the subcutaneous tissues, so little
that patients will say when amylopsin is given :
"Oh ! put it anywhere ; it does not matter." With
trypsin it is a matter of grave consideration if the
patient's point of view receives the consideration it
should. Graves* injects directly into the tumor masses
and states that there is no evidence in these cases to
show that trypsin affects cancer cells by circulatinp-
in the blood or that it affects them in any way ex-
cepting by direct contact. My experience and lab-
oratory work justify the reverse of this statement.

Tryptoglycogenic Reaction. — The marked eosino-
philia of each case treated by the pancreatic fer-
ments, with the exception of illustrative case of Class
5, suggests a comparison of the conditions in which
eosinophilia is found. The following conditions are
given by Wood' as being associated with eosino-
philia: (i) Bronchial asthma. (2) skin diseases,
(3) intestinal parasites. (4) trichinosis, (5) malig-

nant diseases, especially bone marrow, (6) post-
febrile eosinophilia, (7) toxic eosinophilia ttubercu-
lin, cinnamic acid, camphor), (8) hydatid cysts, (9)
gonorrhea (occasional), (10) scarlet fever.

To this list now may be added the administration
of trypsin. Nos. 3, 4, 3, and 8 are possessed of a
common factor in that glycogen is present in patho-
logical quantities as a concurrent element. To trace
the connection between the occurrence of eosino-
philia in some of the conditions mentioned by Wood"
would lead too far into the field of speculation, but
in view of the fact that malignant tumors are rich
in glycogen, and that under the enzymic treatment
there is established an eosinophilia, it is logical to
conclude that the classical eosinophilia of intestinal
parasites is due to the glycogen contained in the epi-

Week 1-3% 69 12 15 18 21 24 27

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Charts. — Showing the rapid eosinophil'a increase. The figures at the
top represent the eosinophile percentages: those at the side the weeks
of treatment. The white cells numbered 14.000 per cm. approximately
throughout the treatment; the red cells, over 4.000.000; the hemo-
globin percentage was 90.

There is present a sufficient glycogenic potential
to cause the reaction to be exhibited, for example,
where a panhysterectomy has been had as an illus-
trative case under Class 2. The temperature chart
of this patient graphically shows the characteristic
dermis of these parasites. It is of equal interest
to mention here that in hydatid cysts," a cvst very
rich in glycogen, as high as 50 per cent, of eosino-
philia has been found. Glycogen is also present in
all newly proliferating tissues. For example,
Bernard'" has shown it to be present in nails,
feathers, etc., and in moulting animals. This is sug-
gestive in view of the fact that in many skin dis-
eases a proliferation of the cutis vera is exhibited.

Systemic Reaction.— In a consideration of the
systemic reaction following upon the administration
of trypsin, it is necessary to differentiate between
those patients having pathoglycogenic accumula-.
tions and those without. It is necessary also that
the former condition should exist in order that a
"tryptoglycogenic" reaction should be obtained.

890

MEDICAL RECORD.

[June I, 1907

temperature reaction in a condition characterized by
pathoglyco^enic accunnilations, while the illustra-
tive case of Class 5 shows no such reaction. This
latter postoperative case was submitted to me for
the enzyme treatment by Dr. J. Riddle Gofife, with
the diagnosis of carcinoma, the diagnosis being
based on the microscopical pathological findings as
reported to him by the pathologist.

In view of previous experience, the absence of
systemic reaction caused me to question the patho-
logical findings. I reported this to Dr. Gofife and
asked for confirmation of the diagnosis of car-
cinoma. He kindly sent me the pathologist's report,

Week 1-3% 5 9 12 15 18 21

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Chart 4. — Showng the rapid eosinophila increase. The figures at the
top represent the eosinophile percentages; those at the side the weeks of
treatment. The whtte cells nutnbered before treatment. 5,100; during
treatment. 12.600; the da^- before death. iS,6oo; the red cells, before
treatment, 4.312,000; during treatment, 4,864.000; the day before
death, 4,600.000: hemoglobin peicentage. be;'ore treatment, 62, during
treatment, 02 ; the day before death, o5

which Stated that the section taken was a carcinoma.
In the continued absence of any tryptoglycogenic
reaction, and continued nutritive gain, I asked Dr.
Gofife if he could secure me a section, which he
promptlv did. This upon examination Dr. Wm. J\I.
Higgins diagnosed as benign, a diagnosis which
was confirmed by several pathologists in New York
City, by the State Cancer Laboratory at Buffalo,
and bv Dr. John Beard of Edinburgh. This is the
only case in which the cardinal symptoms of the
trvptoglvcogenic reaction uerc not present.

The only symptoms were the usual local ones ref-
erable to the hvpodermic injections, together with a
possible low-grade nephritis. Owing to the fact
that there is a possibility of setting up a subacute
ne])hritis. the burden of proving or disproving this
interesting confirmation of Dr. Beard's theory, as to
the selective action of the pancreatic ferments, must
await the appearance of sufficient wrongly diagnosed
cases.

Within from one-half to two hours after the in-
jection of trypsin, in the average case, sooner or
later in the treatment the patient exhibits many or

all the symptoms of a toxemia, i.e. chills, fever, tem-
perature ranging from ioo° to 102°- 103° F., sweat-
ing, rapid pulse, increased respiration, and not in-
frequently the skin is covered with a rash.

Blood. — In cases of cancer cachexia with the
moderate loss in hemoglobin, a marked improve-
ment is shown, although the daily deviations are
greater than 5 per cent.

A moderate leucocytosis immediately follows the
injection of trypsin, the count running from 9,000
to 14,000 per cubic centimeter within the first week.
There is no accumulative effect exhibited by the
white blood count. The red blood cells follow the
hemoglobin curve closely, giving an index approxi-
mating I throughout. The distinct and very char-
acteristic eosinophilia increase, as shown in Qiarts
Nos. 3 and 4, seems to be a fair and scientific basis
for a tentative working hypothesis as regards
the effect of trypsin and amylopsin, and is
of the greatest value from a clinical-pathologi-
cal point of view, especially in connection
with Habershon's" views on the close alli-
ance, if not the identity, of glycogen and eosino-
philia granules. The question of glycogen in tu-
mors has been well worked out by Lubarsch'- and
Gierke,'" stimulated by Brault's false theory that
the malignancy of a tumor varied directly as its
glycogenic contents. According to Wells, the two
factors that govern the presence of glycogen are
the embryonic origin of the tumor and local retro-
gressive changes. Tumors arising from embryonic
tissues containing glycogen are in consequence par-
ticularly rich in this carbohydrate. Fully 80 per
cent, of tumors in their final stages are associated
with glycogen in pathological quantities. Is trypsin
the catalytic agent that converts the proteid mole-
cule into glycogen? If so, is this a conservative
process, or merely a vagrant chemical reaction
which takes place without interfering with the
oathological metabolism of cancer ?

The presence of an intestinal parasite, rich in
glycogen, gives the characteristic eosinophilia pic-
ture of clinical microscopy. In cases of hydatid
cysts as high as 58 per cent, of eosinophiles have
been noted." Attention is constantly being directed
in the pages of medical literature to the high per-
centage of eosinophiles in all those conditions in
which glycogen is present in pathological quantities.
It is a common bond in all pathological conditions
associated with glycogen. These facts, combined
with Lubarsch's findings, that glycogen is constant
in horny degeneration of a squamous cancer, would
most strongly suggest that the eosinophile reaction
of trypsin is due to a degeneration of cancerous
grow'th, and should not be constant for all tumors,
but vary as their embrvological basis.

The only possible explanation of the effect of
trypsin on pathological conditions capable of giving
a tryptic reaction must be that certain proteid mole-
cules, r.s". in cancerous conditions, are capable of
being attacked bv trypsin, because of their special
configuration. This configuration allows the trypsin
to act on the proteid disturbing the point of equilib-
rium in the glycogen proteid synthesis, the equilib-
rium point as a whole being that of a simpler
molecule than the complex proteid molecule of per-
\erted cell metabolism met with, for example, in
cancer. That is, if a quantity of food represented
by lox would in the ordinarv course of metabolism
give 9x proteid and ix of glycogen as the final
result in the imfinished synthetic and catalytic re-
actions, the injections of trvpsin in the given patho-
logical condition will result in ix proteid and gx

June I, 1907'

MEDICAL RECORD.

891

glycogen, and a consequent faulty metabolic func-
tioning of the cell, and perhaps its death.

From these observations a hypothesis may be for-
mulated, namely, that trypsin acts on intercellu-
lar matter of a definite configuration, following tlic
selective law of enzymes, and that the result is a
pathological quantity of glycogen throughout the
body, manifested especially in the eosin granules
and to a certain extent probably stored up in the
muscles.

As glycogen is not stored up in dead cells, but
rather split off from them, and as it is associated in
nearly all cases with accumulation in the leucocytes
and muscle cells, it would seem fair to imagine
that in cases of trypsin reaction the body is saturated
with glycogen. Clinicall\' I would note in this
connection that the most marked results have been
obtained in cases of adenocarcinoma.

Action on the Sympathetic Nervous System. — .As
the result of the trypsin treatment of cancer there
is produced a profound irritation of the sympathetic
nervous system. This is markedly evidenced by
interference with the circulation in glandular struc-
tures— a breast, for example. The gland becomes
swollen, is tense and rigid, both to the observer's
touch and the patient's sensation. In adenocar-
cinoma there is great tumefaction, but there does
not appear to be the same tenseness and rigidity as
in scirrhus. The redness of the superficial struc-
tures still further emphasizes the disturbed circula-
tory conditions. Where there is glandular involve-
ment, as in illustrative case of Class 4, the entire
chain of involved glands, in this instance cervical,
axillary, mediastinal, and subcutaneous gland of
inframammary regions especially, and occasionally
the inguinal also, became extremely tense and rigiil
during the hours following the use of trypsin.

While the daily urine analyses have not estab-
lished clearly a definite relation between the treat-
ment and the output of urea, there does seem to
have been noted a tendency toward the lessening
of the urea following the injection of trypsin, which
can readily be e.xplained on the ground of the inter-
ference of the circulation in the glandular structure
due to the irritation of the sympathetic nervous
system ; while on the other hand, in a number of
instances, an increased output of urea has been ob-
served upon the administration of amylopsin. This
data, however, is not sufficient to establish the fact
that the output of urea is limited by tlje action of
trypsin or increased by the administration of amy-
lopsin. It is simply rational to believe that the cir-
culatory conditions in the kidney (vasomotor con-
striction) under the influence of trypsin should
limit botli the secretion of urine and the output of
urea. It is noted by all these patients with intelli-
gence, or by their nurses, that following the use of
the trypsin the urine is less profuse and of a darker
coloring.

Another and invariable evidence of the irritation
of the sympathetic nervous system is shown in the
complete relaxation of sphincter muscles, for ex-
ample, the anal sphincter, the urethral, that of the
OS uteri, according to the site of the disease.

In illustrative case of Class i the anal sphincter
has been continuously relaxed since the first two
weeks of treatment, now ten months since.

In the illustrative case of Class 3 the os uteri wa>
dilated at the end of two weeks and fully open in
eighteen days, the examining finger penetrating
freely beyond the internal os. So complete was thi'^
dilatation that the contour of the proliferating mass
within the body of the uterus could be readily out-
lined.

Eosinophiles in Pulmonary Tuberculosis. — The
behavior of eosinophile leucocytes in pulmonary
tuberculosis has been studied by J. M. Swan and
H. T. Karsner" and they present further evidence
as to the behavior of the eosinophiles in cases of
tuberculosis, with special reference to the prognostic
value of these cells found in the peripheral blood.
Dift'erential counts of the leucocytes in the blood of
thirty-one cases of pulmonary tuberculosis were
made. Of this number twenty-six cases were fatal
and five were stationary, or were improving under
treatment at the time the observations were discon-
tinued. In all the fatal cases except two the eosino-
phile cells were below i per cent, as a rule, at
periods from 102 days before death to the day of
death. In the cases which remained stationary, or
which were improving under treatment, the eosino-
philes, while subject to fluctuations, were present
in fair proportion, usually over i per cent. From
their observations the authors conclude that in cases
of pulmonarv tuberculosis the eosinophile cells tend
to disappear from the circulating blood as the prog-
ress of the disease brings the fatal termination
nearer, and that as the patient improves imder treat-
ment and as the disease shows a tendency to become
arrested, the eosinophile cells reappear in the circu-
lating blood.

A preliminary study of the same subject has been
made b}' Opie.^'' While the behavior of eosinophile
leucocytes has not been studied in the same careful
manner in conditions of intestinal tuberculosis, there
can be no question but that they must deport them-
selves in similar fashion.

In illustrative case under Class I, therefore, the
absolute disappearance of tubercle bacilli from the
discharge of the disused bowel may then be ex-
plained by the increased eosinophilia of the circu-
lating medium, consequent upon the administration
of the enzymic treatment. The enzyme treatment
was begun by the introduction of injections of tryp-
sin as originally put out, diluted with two volumes
of sterilized water introduced into the disused rec-
tum. The fecal discharge from the cut-oft' bowel —
sigmoid flexure — was much more profuse after
treatment in this way for a little over a week, and
contained, in addition to the semiconsistent old
grayish fecal matter, a number of ovoid bodies, the
size of an ordinary almond, which, when dried and
opened, had a pithlike appearance. This discharge
upon examination (August 10, 1906) revealed the
presence of tubercle bacilli. Their presence ac-
counted for the fluctuations of temperature, ex-
hausting night sweats, absolutely tubercular in their
characteristics, and in part for impaired appetite and
loss of flesh and strength.

On August 10, the trypsin was introduced di-
rectly into the circulation by hypodermic injections
into the subcutaneous tissues of the buttocks. This
was carried on daily w4th relief from night sweats,
improved appetite, and steady diminution of the
plaster-of-paris-like induration in and about the
rectum and bladder. Later on came the character-
istic tumefaction of the rectal tissues, which were
in a condition of cauliflower excrescence. V\'ithin
three weeks from the beginning of hypodermic in-
jections my case book records improved appetite,
lessened pain, lessened rectal discharge, better ap-
pearance of urine, increased vesical capacity with
longer intervals between rises of temperature (nor-
mal, 99-100), and disappearance of excessive night
sweats. The tumor mass of most recent formation,
apparently the result of severe attack of illness char-
acterized bv fever, sweating, imperfect functioning,
excruciating sciatic pain with exquisite sacral sensi-

892

MEDICAL RECORD.

[June I, 1907

tiveness, cheek of affected buttock swollen, hot as
well as painful, and later on a condition of complete
analgesia extending down the leg' and to the geni-
tals, the latter part of July, had disappeared, and
discharges of September 6, 1906, from unused
bowel showed in the granular detritus or well
digested matter a few tubercle bacilli present only.

On ScDteinber 6, the use of amylopsin was begun,
alternating in doses of two ampoules (original
strength) with injections of trypsin, two ampoules
also of original strength. Examination of rectal
discharge a week later (September 14, 1906)
showed no tubercle bacilli present ; nor have re-
peated examinations since, now ten months, of the
discharges from the disused bowel and urine re-
vealed their presence. If the behavior of eosino-
phile leucocytes in tuberculosis is constant, as per
the observations of Swan and Karsner," then in
the eosinophilia, established by the hypodermic use
of the enzymes, there is very suggestive evidence as
to the rationale of the disappearance of the tubercle
bacilli and the rapid improvement in this case. The
enlarged mesenteric glands in this case were, I be-
lieve, tubercular, not malignant. While one case is
not sufficient for proof, one case supported by this
scientific fact is sufficientlv suggestive to induce the
■careful and systematic use of enzymic treatment in
tuberculosis. The fact remains that this illustrative
case of Class i shows absolutely no evidence of tuber-
culosis save inability to make any marked gain in
weight, and periods when night sweats are slightly
in evidence. Experimental medicine must deter-
mine the appropriate place of these ferments in the
treatment of tuberculosis. Here it is only neces-
sary to say that laboratory experiments are under
way to prove or disprove the generalization of the
truth of this isolated observation.

For use in tuberculosis, as in cancer, the injec-
tions should be an extract, freshly prepared from
the pancreas p-land direct and containing the fer-
ments, trypsin and amylopsin. The absolute dis-
appearance in this case, followed upon six weeks'
use of trypsin, and four injections of amylopsin.
The place of the latter does not seem to be con-
clusive, although Beard believes it to be the im-
portant factor. The disappearance of the tubercle
bacilli was coincident with the period of treatment,
which has been found to be characterized by the
highest eosinophilia curve.

Dr. Edwin Lewis" has made an experimental
study of a preparation of the fresh pancreas gland,
not of trypsin alone, but other associated ferments.
in tuberculosis. His results, while not negative,
were not conclusive.

Excretion. — Trypsin and amylopsin are e.xcreted
mainly by the kidneys, producing a nephritis more
or less extensive. Granular casts appear in the
urine almost immediately after the first doses of the
ferments. The nephritis does not seem to be pro-
gressive, the casts and albumin remaining pretty
constant unless the dosage is increased. A single
superposed dose of three ampoules has been seen to
produce epithelial casts. It is difficult to disasso^
ciate the predisposition toward indicanuria resulting
from the ferment treatment from the characteristic
indican of cancer.

The presence of indican in pathological quanti-
ties is probablv due to an increased absorption of
indol from the intestine, and not to an increased
tryptophan, as the indicanuria may be controlled by
administration of i-ioo of a grain of calomel every
hour.

In every instance casts have appeared in the fol-

lowing order: (i) Occasional fine granular, then
coarsely granular, (2) hyaline, (3) epithelial. Un-
der the regimen which forms a part of the supple-
mentary treatment and hygiene of these cases, this
nephritis is kept pretty well under control.

Conclusion. — The justification of this treatment is
to be found in: (i) The pathological findings, (2)
relief from pain, (3) absence of odor and necrotic
discharge, (4) improved metabolism, (o) in cases
that do well, (b) even in those who succumb, (5)
increased mental vigor, and (6) by inspiring the
patient with hope.

On the other hand, it may result in shortening life
by a few months, but that short span of added ex-
istence would be characterized by breaking down of
tissues, odor, necrotic discharge, pain, imperfect
metabolism, loss of mental vigor, and by utter hope-
lessness on the part of patient and friends.

Treatment should be undertaken early in every
instance and should always be an adjunct to surgical
interference in every postoperative case.

Metastases should never be allow-ed to develop.
The importance of removing a diseased organ, as in
case illustrating Class 3, must never be lost sight
of, and the enzyme treatment should be carried on
with a full recognition of the value of skilled surgi-
cal interference when possible.

The indications are that the use of the enzyme
treatment will have to be continued over long pe-
riods of time and perhaps at intervals during life,
but as the absence of pain is a constant accompani-
ment, it would seem logical and better to have a
patient with the trypsin necessity rather than the
morphine habit.

To illustrative case of Class I. there has probably
been administered more trypsin than to any other
individual patient, yet daily urine analysis shows
that the kidneys are functioning to all intents nor-
mally.

REFERENCES.

1. Wells : Chemical Patholog>'. 1907.

2. Taylor: Univ. Cal. Pub. Path. (i). 1904.

3. Piquet: Arch. vs. Med. Exper. I^; II; 145.

4. Graves : Boston Medical and Surgical Journal. Jan-
uary 31, 1907.

5. Liverpool Medico-Chirurgical Journal. January- I.
1907.

6. E. V. Leyden and P. Bergell : Trypsin :Pankreatin-bei-
Karzinom. Zeitsclirift f. klinische Medisin, Berlin. Janu-
ary, 1907.

7. Beard : Personal Communication.

8. Wood : Chemical and Microscopical Diagnosis. Fag's
122.

9. Seligman Dudgeon: Lancet. June 21, 1908. Page
1,764.

10. Barfurth : .-irchiv. mikrosc, Anat. 1885. Page 269.

11. Journal of Pathology and Bacteriology. December,
1906.

12. Virchow's .-irchiv. 1906.

13. Zeigler's Beitrage. 1905 (37), 502.

14. Nczv York Medical Journal. March 3, 1907.

15. Opie : American Journal of the Medical Sciences.

16. American Medicine, .\ugust 18, 1906.
616 Madison* Avenue.

Significance of Cytodiagnosis and Therapeutic Value
of Lumbar Puncture in Tuberculous Meningitis. — Olim-
pio Cozzolino has made a careful cytological examination
of the blood of eleven cases of infantile tuberculous men-
ingitis, some of which he has treated by lumbar puncture.
He gives the conclusions at which he has arrived. He
believes that the cvtological examination of the blood is
of value in aiding to establish the diagnosis, but that other
means must be used to make the diagnosis absolute. Poly-
nucleosis is not rare in basilar meningitis, both where the
tubercle bacilli are manv and where they are few in the
blood. Lumbar puncture is of no diagnostic value and
rarely gives any therapeutic results. — Rivista di Clinica
Pediatrica.

June I. 1907]

MEDICAL RECORD.

893

EYESTRAIN AND OTHER DISEASES DUE
TO CROSSING, CROWDING, AND DAM-
MING OF THE RETINAL VESSELS.

By GEORGE M GOULD, M.D..

PHILADELPHIA

An ophthalmoscopic glance at the fundus of the
normal living eye makes it evident that the vascu-
larization and nutrition of the intraocular tissues,
especially of the retina, is not only of prime import-
ance, but that it is the first condition of vision. .And
the best possible vision is the sine qua non of the
motility, safety, and success of the dependent or-
ganism in the struggle for existence. The retinal
function is one of amazing delicacy ; it is condi-
tioned upon an unexampled complexity and micro-
scopic fineness of structure, and upon a state of
the highest instability of equilibrium of moleculai'
substance. The task of nourishing and reestablish-
ing this function, when temporarily exhausted, is
of almost incredible difficulty. Phases of this diffi-
culty throng upon the attention. For example, the
eye is a closed system, and the dominating struc-
ture, the retina, must receive its arterial supply and
discharge the venous blood within the million-
stranded bundle of nerves called the optic nerve.
To make transparent all the ocular structures fronr
the cornea to the pigment layer of the retina has
been a unique and next to impossible necessity, and
from nonsuccess follow a score of diseases such as
leucoma, cataract, etc. There is one difficulty na-
ture could not overcome : the blood supply of the
retina had to be carried by vessels made opaque by
the red blood corpuscles and coursing in front of
the retina. This was a necessity resulting from the
condition of the "closed system" of the globe of
the eye.

The normal intraocular pressure, moreover, was
required to give the globe its stability of form and
make the visual act a constant and certain function.
The relation of this tonicity of the globe to the
entrance aiKi exit of the blood and lymph and to
the passage of the blood through the retinal vessels
is one of close adjustment. A too soft globe would
plainly lessen the reliability of retinal response and
impair the all-important image-forming function ;
a globe too hard would lessen vascularization, nerve
function, etc.- — would mean all that the word glau-
coma means.

Embryologically studied, one sees how easily the
retinal vessels may become anomalous. One might,
indeed, describe those of each and every eye as
anomalous, so unlike is one from another. But the
norm, as shown in noncomplaining eyes, and in the
pictures of the textbooks, brings it about that the
larger trunks of the vessels do not cross over or
under each other in their courses, and that a single
vessel does not curl or circle so that it passes above
or below itself. If such a crossing takes place the
established and necessary intraocular pressure will
surely tend to, or actually bring about an impaired
passage of the blood within one or both the trunks
concerned. Whether the impeded circulation will
lessen the supply of arterial blood to the portion of
the retina it normally feeds, or whether the normal
venous outflow is prevented, will, of course, depend
upon the facts in each case, the peculiarities of the
crossing, the location of the block, the tension of
the eyeball, etc.

Ophthalmologists have evidently not been obser-
vant of these blockings or dammings, either physio-
logically or pathologically. Since I first suspected

their existence and pathologic significance I have
found them far more common than I had supposed.
Although they may be so slight as to produce no
serious or demonstrable symptoms, I am sure they
may be so severe as to produce the greatest and
longest suffering and even the life-tragedy of the
patient. If the choking is of an artery, and if it is
great, and if supplying the macular region, and es-
pecially of the right eye of a righthanded (and
righteyed) person, the consequences will be the
worst. If the impeded venous outflow is from that
region the morbid results will probably be as bad,
although different. The farther from the macula is
the region of the impaired nutrition, the less will
be the likelihood of morbid symptoms. It will be
apparent that vessels carrying red blood corpuscles
must not traverse the macular or perimacular
spaces, and hence that here collateral or anastomotic
circulation cannot, as elsewhere in the body, take
up the nutrition of the part impaired by the blocked
vessels.

And it is also equally plain that the blood supply
is not, and by the nature of the case cannot be,
wholly_ cut ofif (as in embolism or thrombosis), but
only lessened.

The symptoms may be intensified, varied, multi-
plied, or masked by the coexistence of ametropic
eyestrain^

Of the illustrative cases with certain and distinct
and logically consequent symptoms, I briefly epito-
mize two :

A woman, aged forty-six, for most of her life
had suffered intensely from many of the typical
symptoms of eyestrain. Her statements and history
as related by herself seemed so exaggerated that T
was at first suspicious of hysteria and a morbid
pleasure in pain, or in the belief that pain existed.
Study of her case and observance of the woman's
character in time convinced me that there was abso-
lutely no such mental factor present, and that the
suffering was most genuinely neurologic and physi-
cal. She had been under the care of many famous
ophthalmologists, none of whom had been capable
of helping her ; none could guess the exact nature
of the disease. The patient had lovally and faith-
fully carried out every kind of treatment, and had
worn all possible kinds of spectacles, until each
physician in turn confessed himself wholly mysti-
fied and unable to give relief. Except from one
other I never heard a more pitiful and harrowing
tale of suffering patiently borne, of hope renewed
with each new oculist or physician consulted, of
bitter disappointment as no cure followed. I was
to be the last!

Since she can remember the patient has had "diffi-
culty in seeing." The closer description of the
"difficulty" makes it clear that it consisted in a
failure of the right eye to hold the image, or see as
plainly or continuously as with the left eye. It is
what I have long been accustomed to denominate as
"fading image." All her life, also, th-e woman has
had headache. For the past eight years the worst
symptom has been constant pain and tenderness
across the brow and a "beating" in the right eye.
not lessened bv any treatment. At the menstrual
period there has been no headache, but an intense
pain across the eyes, with nausea but no vomiting.
There have long been insomnia, indigestion, consti-
pation, "nervousness," "fidgetiness," with the fre-
quently allied coupling of hypertension and depres-
sion of spirits. There has been a long and harrow-
ing history of "rheumatism," "neuritis," and an
eight-months'-Iong constriction of the throat during

894

MEDICAL RECORD.

1 J line I, 1907

which only hquids could be swallowed. There have
been many other symptoms which may here be
omitted.

She was formerly under the care, for five years,

of Dr. , a famous oculist, and then another

man of equal repute treated her for several years.
For a number of years again, another most rep-
utable and learned man also failed to give the pa-
tient the least relief. In 1902 he ordered:
R. -f Sph. 2.25 + Cyl. 0.50 ax. 80°.
L. + Sph. 2.25 + Cyl. 0.25 ax. 100°.
He plainly thought that the slight exorphoria pres-
ent was a great factor, because with the above pre-
scription he combined 1.5° prisms each eye bases
in. When no relief came he at last advised tenot-
omy, which the woman, with a wisdom greater than
that of the doctor, rightly refused. Even without
the foolish prisms the glasses were not correct, over-
correcting the error for distance, and undercorrect-
ing it for near. With failure evident, this oculist

advised the patient to consult Dr. of • , an

onhthalmic surgeon of wide renown, '"who," he
added, "always makes a point of disagreeing with
me in everything." This was done that the pa-
tient might have an entirely independent opinion.
She added, with a sickly smile, that "he did disagree
in every particular." But the disagreement brought
no help, and then another oculist was consulted
some nine months before coming to me. He or-
dered :

R. + Sph. 2.ooPrism 2° R. I.
L. -f Sph. i.soPrism 1.5° B. D.
This order was as bad as if it had been made by
"the leading oculist of the city."

Without a mydriatic I estimated the error of
refraction to be :

R. + Sph. 1.62 + Cvl. 0.62 ax. 180° = 20/50+
L. + Sph. 1.37 + Cvl. 0.37 ax. 180° = 20/30?
2° B. I., 1° B. D. L.

There was also evident subnormality of accommo-
dation. With paralyzed accommodation the errors
were found to be :

R. -f Sph. 2.00 + Cyl. 0.50 ax. 180° ^ 20/50+
L. -f- Sph. 2.00 + Cyl. 0.37 ax. 180° = 20/30?
With all the woman's good will to do as advised
she could not and would not trv bifocal spectacles,
because she had by bitter experience demonstrated
that they only increased her symptoms. This fact
was a hint to my mind, and one which stuck there,
that there was in this case an unsolved problem.
I gave proper distance glasses with "fronts" for
near, but the "unbearable pain" lessened no whit.
In a few weeks the error was not different, and I
demanded bifocals, to be used at meals, and in the
house. She vowed she "could not see with them."
I did not then suspect the reason they increased dif-
ficulty and pain, but this became apparent when
with search and study I found that she closed the
right eye when reading and ignored its image for
distance, and that she "had done this for years," as
she now confessed. I was now on the heels of the
mysterv.

At the first visit in using the ophthalmoscope I
spoke of a curious loop in the superior tem-
poral artery of the right eye. The patient
said : "Oh, everybody has noticed that," but
adding that it had no significance. The artery
close to the disc turned upon itself, form-
ing a circle about 10° in diameter, and passing
under itself proceeded onward toward the macula.
But in passing beneath the vessel was flattened by
the pressure of the vessel above it. and from that

point the artery was pale, half collapsed, and evi-
dently carrying but a small quantity of blood. The
macula was stippled and somewhat morbid in ap-
pearance, but otherwise the eye ground seemed
normal. My glasses had given no relief ; there was
a decided tendency to shut the right — the naturally
dominant and important dextral eye — out of
function ; no device had given hope ; the sub-
normality of accommodation of the right eye
was about i D. greater than in the left
eye — a significant fact : the amblyopia had not
bettered under proper glasses ; the symptoms,
partly those due to eyestrain, were so pecu-
liar as to arouse suspician that more than ame-
tropia was the matter, — such were the conditions
which directed attention to the hitherto neglected
looping of the upper macular artery, and the plainly
lessened blood supuly of the retinal area supplied by
it. I at once ordered a blinder worn nearly con-
stantly before this eye. A more certain test would
have been a bandage, because, according to the
physiologic law of imperative function, the right eye
must struggle for life and dominancy during all the
years it is dying. In a few weeks the report was
that while there was not by any means complete
comfort, there had been a decided lessening of the
severity of the pain, etc. The most significant fact
was this : \\'hile the blinder was worn there was
comparative freedom from pain, etc.. but when it
was removed a throbbing pain came on, which did
not disappear until the blinder had been worn again
for an hour. I then knew my theory was correct
and that there was nothing left but to exclude the
ailing eye from function. A large black lens was
provided to be worn absolutelv constantly, and pro-
gressive relief is being secured. I do not look for
entire happiness in this case, because too great in-
jury has been done, and the exclusion of the right
eve from function can never be complete ; it must
still desire or be forced to partial life and function
because it is the right eye. and because its exclusion
comes so late in life. The less of two tragedies is
chosen, and tliat is often the command of practical
medicine or ethics.

The moral of the tale is that knowledge of the
nature and cause of an incurable disease is in-
finitely better than blind groping in the darkness
and false, mischosen, and misapplied methods of
cure.

My second case was that of a healthy strong
young man of twenty, who began having "inability
to use his eyes" when he was about eight years of
ago. Since this time there has been a continued
blepharospasm, a rapid closing and opening of the
lids : the lids are nipped down tight and held almost
as long as thev are kept open. He has not had any
of the usual reflexes such as headache, dyspepsia,
"migraine." etc., and no amount of questioning is
able to elicit any more definite or satisfying details
as to the nature of his troubles than that "things
disappear," "fade out," etc., and he could not an
cannot read, write, or study. Do what he would
he could not use his eyes for constant or near work.
From ten to fifteen he went to school for about two
months at the beginning of the year, but after that
had to stay at home or travel. At fifteen he kept
at school for a year, but since then has lost every
other year, "not on account of health, but because
of impossibility of using his eyes."

Oculist Xo. I was consulted at the age of nine,
and his glasses were worn for six months, with
no relief.

Oculist No. 2 changed his glasses, and these were

June I, 1907]

MEDICAL RECORD.

895

worn two years, but without aiding the patient to

study.

Oculist No. 7, was consulted at the age of twelve

with some benefit.

Oculist No. 4 changed the prescription, and these

glasses were worn for but a little while. He now

went two years before consulting

Oculist No. 5, who told him nothing was the

matter with his eyes. But on attempting to resume

study he was at once compelled to stop.

Oculist No. 6 "tried and tried" to make it possible"

for the patient to study. Failing, he sent him off
to "the leading oculist" of a distant city, who in

1906 ordered :
R. + Sph. 0.75 + Cyl. o.37ax. 60° | r)- ..,,,-_
L. + Sph. 1. 00 + Cyl. 0.25 a.x. 90° ) ^''^^'^"^6.
L. + S. i.37andCyi. ( ., .r
R. + S.I. 1 2 and Cyl. * ^^*^^'^-
For a few weeks these felt comfortable, but then the
old symptoms returned despite the diagnosis, an-
tique, antiquarian, and though dead never buried,
of "gout and rheumatism of the eye."

Oculist jYo. 7, myself, imder cycloplegia diag-
nosed :

R. + Sph. 0.87 + Cyl. 0.37 ax. 70° = 20/20?
L. + Sph. 1. 00 + Cyl. 0.25 ax. 90° = 20/20
with perfect muscular Ijalance.

His greatest complaint, upon persistent question-
ing, is that he becomes suddenly blind, or nearly so,
when looking at anything. Things fade out and
become nearly or wholly invisible. Even in the
street, in looking at a person, the bodily figure
grows dim or invisible; when playing baseball, and
watching the course of the ball in the air, it will
disappear for a second or more and then again be-
come visible. In order to see anything plainly he has
to rub his eyes. In near vision it is more impossible
to hold the image. The peculiar and persistent ble-
pharospasm for twelve years, with the rapid fading
of the image, seems to point to difficult holding of
the retinal function due to faulty blood supply.
Competent general physicians have examined him
and pronounce him free from all recognizable sys-
temic or organic disease.

Having in mind the case above described, I was
quick to recognize the existence in this man's eyes
of the anomalies of the network of the retinal veins
and arteries. From the point of emergence or en-
trance at the disc they curled about each other,
crossed and recrossed each other, in a manner to
strike immediate attention. Description would lie
almost impossible. The upper temporal artery of
the right eye crosses over the vein on the disc, and
crosses under the vein twice after leaving the disc.
The lower temporal artery crosses over the vein
on the disc and does not recover full size and color
for 30° below the disc. The upper temporal artery
of the left eye passes over the vein on the disc, again
passes under the vein on the disc, and once more
passes under the vein about 40° from the disc. The
lower temporal artery passes beneath the vein on
the disc, passes over the vein 20° from the disc, and
again over the vein 40° from the disc. The arteries
are smaller and thinner and lighter in color on the
disc than toward the periphery, whereas the veins
are turgid and swollen as they approach the disc.
There was noteworthy general venous stasis, and
venous pulsation was present. Both eyes were af-
fected in the same way, but the right possibly in a
more decided manner. I felt justified in ordering
correct lenses, in explaining what I thought the
cause of his symptoms, their incurability, and in

urging a life-time renunciation of nearly all read-
ing, writing, or near-work occupations.

It seems probable that in such intercrossing of
blocked and choked vessels lessening the sunplv of
arterial blood and serum, or preventing the normal
out-passing of venous blood and lymph, we have
the distinct cause of a new type of ocular disease,
and especially of its results, another kind of in-
curable evestrain. The same or a similar result
mav be due to crowding of the vessels at the disc,
as they turn, or within the optic nerve sheath itself,
with venous pulsation, stasis, impaired nutrition,
etc. Is it also not possible that such blocking and
crowding may account for the rise of other retinal
and intraocular diseases, the etiology of which is
at present not clear? Such, e.g. as degenerative,
pin-mentary and atrophic macular diseases, the en-
largement of the globe and the lessening of hypero-
pia, its passage into myopia, the change, during
presbyopia, of 90° axes to iSo° axes of astigmatism,
all of which and more, are possible consequences of
the lessened outflow and disturbed nutrition which
would follow crossing and crowding of the vessels.
Would not such causes constitute preciselv the fac-
tors needed to clear up the etiology of the mysterious
and terrible disease, glaucoma? It appears highlv
significant that the several greatest ocular diseases,
glaucoma, cataract, presbyopia, the reversal of the
astigmatic axes. etc.. should all be coincidental and
fall upon the time of failing life-powers and lowered
blood pressure. It is presumable that, etiologicallv,
they may often depend upon the want of vasculariza-
tion or full nutrition of the intraocular tissues, a
process that even in the young has been of most
difficult biologic accomplishment.

Even the greatest of all ocular diseases, astig-
matism, and other forms of ametropia, with all the
morbid results of eyestrain upon the general sys-
tem, upon education, and social evolution, even these
indirectly depend upon the shape of the eyeball, i.e.
upon its tonicity, blood pressure, and nutrition. As-
tigmatism is largely dependent ujion the pressure
of the upper lid, which must rest upon the cornea
at the upper border of the pupil, in order to shade
the retina and thus aid in the reinstatement of its
unstable equilibrium when impaired bv everv visual
act. A greater tonicitv would prevent the indenta-
tion by the lid, but it would prevent also the trans-
mission of the nerve impulses and the currents of
the blood, Ivmph, and serum ; that is, a greater
tonicitv would be glaucoma.

ACID INTOXICATION OR ACIDOSIS: A
FACTOR IN DISEASE.

By EUGENE S. TALBOT. M.S.. D.D.S . M,D., LL.D .

CHICAGO.

More than twenty years ago, visiting the different
public and private institutions in this country and
Europe and private patients, pursuing my studies
in degeneracy, I was struck with the fact that the
teeth of diabetics, tabetics, and paretic dements were
badly worn away. Destruction of the alveolar proc-
ess was likewise very marked. Destruction of the
teeth in healthy, normal individuals was occasionally
noticed. An endeavor was made fifteen years ago
to ascertain the cause of this destruction desig-
nated as interstitial gingivitis or so-called pyorrhea
alveolaris.

In a paper on "Pyorrhea .Alveolaris,"' I men-
tioned that the disease had two origins, "local and
constitutional." The constitutional form was the re-

896

MEDICAL RECORD.

[June I, 1907

suit of faulty metabolism or autointoxication. Since
this, further researches have shown acid autoin-
toxication to be a great factor in erosion, abrasion,
and interstitial gingivitis.

Figures i and 2, the models of the jaws and teeth
of two physicians respectively thirty-ei'^^ht and for-
tv-two vears of age, show the destruction of the

Fig. I.

alveolar process. In men at these ages in apparent
perfect health, interstitial gingivitis has made rapid
progress. Figure 3 shows the condition of the
teeth and jaws of a diabetic fifty-five years of age.
Figure 4 shows the jaws in their original position.
The crowns of the teeth are worn away. The alve-
olar process is almost entirely destroyed. Some of
the teeth have already dropped out and others are
loose. The relation of acid autointoxication and
mouth acidity is very intimate. The acids taken
into the body and those produced by chemical
chansres within, such as hvdrochloric, lactic, acetic,
diacetic, ^-oxybutyric, uric, and other acids circu-
late in the system, passing out through kidneys,
lungs, skin, and mucous membrane especially of the
mouth. If the kidneys do not carry off the surplus
acidity, a greater strain is out unon the lungs, skin,
and mucous membranes of the mouth. The alveolar
process and gums, being doubly transitory, as well
as end organs, contain excretive and secretive
glands. The gums are the first structure of the
body which indicate svstemic defects particularly
noticeable in mercurial, lead, and brass poisoning,
scurvy, etc. The mucous glands normally secrete
acid fluid, while the salivary glands excrete alkaline
fluid. It not rarely happens, however, that the
kidneys fail in their function and the system be-
comes so saturated with acid that the salivary glands
secrete acid saliva. The acid secretion from the
gums soon sets up inflammation which causes ab-
sorption of bone and the teeth in time fall out. The
acid from the glands of the gums and the salivary
glands continues to cause destruction of the teeth.

Friction from the lips, teeth, and foreign bodies
assist ereatly in tooth destruction. Teeth softened
by faulty nutrition and acid states are easily de-
stroyed by acids and friction.

Researches into the cause of erosion and abrasion
of the teeth and interstitial ■^ingivitis causing de-
struction of the alveolar process from which all
suffered resulted as follows :

I. Uranalysis of Diabetic Patients. — Uranalysis
by the Columbian Medical Laboratories of three
hundred and ninety-four diabetics showed specific
gravity, one 1.003, one 1.005, one 1.007, one i.oio.

one 1. 01 1, eight 1.012, one 1.013, six 1.014, six
1.015, four 1.016, five 1.017, seven 1.018, six 1.019,
seven 1.020, five 1.021, thirteen 1.022, fifteen 1.023,
ten 1.024, twenty 1.025, thirteen 1.026, thirteen
1.027, eighteen 1.028, nineteen 1.029, twenty-five
1.030, twelve 1. 03 1, fifteen 1.032, twenty-eight
1.033, sixteen 1.034, twentv 1.035, seventeen 1.036,
eighteen 1.037, nine 1.038, twelve 1.039, ten 1.040,
eight 1. 041, eight 1.042, two 1.043, seven 1.044,
two 1.045, two 1.046.

Percentage of Sugar. — Twelve had O.i per cent.,
eighteen 0.2, three 0.3, eleven 0.4, seven 0.5, seven
0.6, one 0.7, four 0.8, eight 0.9, ten i, one i.i,
eight 1.2, seventeen 1.3, six 1.4, one 1.5, thirteen 1.6,
seven 1.7, four 1.8, one 1.9, five 2, three 2.I, six

2.2, three 2.3, seven 2.4, three 2.5, five 2.6 one 2.7,
three 2.8, three 2.9, four 3, one 3.1, five 3.2, six

3.3, one 3.4, two 3.5, ten 3.6, five 3.7, five 3.8,
fifteen 4, four 4.1, five 4.2, two 4.3, two 4.4, three
4.5, eight 4.6, four 4.7, five 4.8, five 4.9, five 5, two
5.2, ten 5.3, five 5.4, one 5.5 nine 5.6 seven 5.7,
five 5.8, one 5.9, nine 6, five 6.1, ten 6.2, ten 6.4,
one 6.5, five 6.6, one 6.7, three 6.8, five 6.9, three
7, one 7.1, two 7.2, two 7.3, two 7.4, one 7.6, one
y.y, three 7.8, one 7.9, one 8, one 8.2, one 8.5, one
8.7, one 9, one 9.1.

Degree of Acidity. — Two passed 4 degrees, two
6, one 7, two 8, six 10, five 12, sixteen 14, one 15,
fifteen 16, one 17, thirteen 18, twenty 20, one 21,
twelve 22, one 23. ten 24, two 25, fourteen 26, six-
teen 28, one 29, twenty-one 30, seventeen 32, thir-
teen 34, four 35, twenty 36, two 37, eleven 38, two
39, thirteen 40, one 41, eight 42, seven 44, two 45,
eight 46, two 47, five 48, five 50, five 52, one 54,
twelve 56, one 57, four 58, five 60, one 62, one 63,
three 64, two 66, two 68, two 70, three 72, one 74,
one 75, one 100, two 104, one 120, one alkaline, two
neutral.

Acetone. — Of this number of cases only nineteen
were examined for acetone. In eleven, acetone was
present, in eight absent. Thirty-two were exam-
ined for diacetic acid ; in six it was present and
twentv-six absent. Twentv-four were examined for

Fig. 2.

j3 -oxybutyric ; in all it was negative. It wull be
observed that the per cent, of acetone bodies in
diabetics is very small.

Uric Acid. — The examination for uric acid of
three hundred and seventy patients showed its pres-
ence to a greater or less degree in fifty-six and
negative in three hundred and fourteen, or about
15 per cent, had uric acid.

Indican. — Of the three hundred and ninety-four
examinations, three hundred and twenty showed in-

June I, 1907]

MEDICAL RECORD.

897

dican to a greater or less extent. Seventy-four
were normal in this respect.

2. Uranalysis of Tabetic Patients. — Degree of
acidity in thirty-tive was as follows : One passed 5
degrees, one 6, one 7, three 9, two 10, one 11, one
14, one 17, two 19, two 20, one 22, one 46, one 48,
one 49, one 50, one 56, one 62, one 73, two 76,
one 78, one 81, one 82, one 84, one 97, one 99, one
112, four alkaline. Those patients having the alka-
line urine had marked erosion of the teeth showing
that at some time there had been a high degree of
acidity. Cystitis caused the urine to become alka-
line. All showed indican to a greater of less
extent.

3. Uraiialysis of Paretie Dements. — Degree of
acidity : There were twenty-one males, four females.
Three passed 5 degrees, one 7, three 8, two 9, one
10, one II, one 12, one 13, one 15, two 16, one 17,
one 22, one 28, one 34, one 38, one 39, one 44,
one 51, one 52, one 70. These patients were in
a quiet state. If the urine could have been exam-
ined after excitement or an explosion the degree of
acidity would have been greater.

4. Uranalysi-s of Private Patients. — Degree of
acidity : I examined one hundred and twenty-nine.
Three were also sent to me by Dr. J. F. Keefe of
Chicago, making in all one hundred and thirty-two.
All were from eleven to eighty-four years of age.
All showed erosion and abrasion to a greater or
less extent. Three passed 2 degrees ; three 8,
two 10, two II, seven 12, two 14, two 15, five 16,
six 18, two 19, eight 20, five 22, five 24, six 2(S,
four 28, two 29, six 30, two 31, four 32, two 33,
three 34, nine 36, two 38, two 40, two 44, five
46, one 47, two 48, two 50, five 52, five ^4, four 56,
one 58. three 60, two 62, five 70, one 90, one 127,
one 132; only four or 3.8 per cent, had uric
acid. I quote here from a previous paper, "Inter-
stitial Gingivitis Due to Autointoxication,"- my first
fifty patients' degree of acidity, one had 1 1 de-
grees, two 12, one 14, two 15, one 16, two 17.5,
four 20, one 22, one 24, five 30, seven ^6, two 40,
two 44, one 46. two 56, one 58, one 59, one 60,
two 62 ; 3 per cent, had uric acid, all had indican.

The method of obtaining the degree of acidity of
the urine given by Neubauer and VogeP is very
simple. The instruments necessary for this work
are one burette 50 c.c, one wooden stand, one
Barnes dropping bottle, one lo-c.c. graduate, and
one small glass. Place the burette in the wooden
stand in an upright position ; fill the tube with the
solution (i-io normal sodium hydrate) to ex-
actly o. The degree of acidity is obtained by tak-
ing 10 c.c. of urine specimen, measured in the grad-
uate glass, then placed in the small glass : add four
drops of phenolphtalien ; then add drop by drop
NaC>H (i-io normal sodium hydrate) until a slight
pinkish color is produced. Having noted on paper
the number of c.c. of the NaOH in the burette
before and after the pink color is obtained, llie
number of c.c. displaced multiplied by 10 (in order
to find the number of c.c. NaOH necessary to reduce
100 c.c. urine) equals the degree of acidity. Each
step in this operation must be carefully performed :
each instrument must be kept perfectly clean in
order to get good results.

Tlie normal degree of acidity of the urine is
from 30 to 40. When the degree is below 30 (the
difference between the degree indicated and 30
shows the degree retained in the system), it indi-
cates either renal insufficiency or excessive sub-
oxidation products producing renal strain. In cases
in which the degree of acidity exceeds 40. there is

excessively imperfect oxidation which, irrespective
of the types of acid, underlies, as is now pretty
generally recognized, severe constitutional stress
allied to that of diabetic acidosis.

The question arises, does the quantity of urine
passed in twenty-four hours influence the degree of
acidity? Thus, if more than 40 ounces (the nor-
mal amount) was passed, the degree of acidity
would be low as compared with less than 40 ounces.
There is a relationship between the polyuria pro-
duced by nerve and other strains in seemingly nor-
mal persons. This occurs in students under exam-
ination and certain hysterics under excitement. The
eliminatory functions of the kidneys are Interfered
with, but the watery excretory powers are in-
creased. There is real, albeit not nosologic, renal
insufficiency producing a condition temporarily an-
alogous to diabetes insipidus. The state is not
normal but is not necessarily nosological.

On application of the phcnolphtalein, if the urine
specimen turns pink, it is alkaline, therefore no
degree of acidity can be obtained. Litmus paper
(held over ammonia until a deep blue is obtained)
is applied to the gums and lips to ascertain if the
mucus be acid. Acid mucus was found in every
case tested. The circle of evidence, therefore, is
complete.

It is not my intention here to discuss the uric
acid theory of disease except to point out that
modern research has shown that uric acid per se
is overestimated as a cause of diseases. The theory
obtained its impetus through Fothergill, thirty years
ago, and reached its climax when Haig'' of London
published his work. Modern research has shown
that uric acid is only occasionally found in disease.

Some years ago, uric acid was set forth as a cause
of interstitial gingivitis. At that time I instituted
a series of experiments in two laboratories.'' Two
hundred and fifteen specimens from mouths with
interstitial gingivitis were examined. Only 5.5 per
cent, contained uric acid. In three hundred and
seventy diabetics, 15 per cent, contained uric acid.
Of one hundred and thirty-one private patients suf-
fering with interstitial gingivitis, but 3 per cent
had uric acid. In the first fifty patients in another
series of experiments, 3 per cent, had uric acid.
While the number of patients examined for uric
acid is small and covers only a small range of dis-
eases, the statistics may seem to be of little etio-
logical moment to the general practitioner. Since
faulty metabolism and autointoxication are asso-
ciated and since all patients had interstitial gingi-
vitis and many erosion and abrasion, they are of
the greatest moment.

Few adult persons have not had an excess of acid-
ity at some period. The slightest change in the
action of the liver by which nitrogenous material is
not converted into urea and pass out through the
kidneys will cause acid excess in the system. Com-
plete oxidation is essential to a normal condition.
The organs and tissues of the body act as best they
can to bring about this condition. In some systems,
the liver has all it can do to care for the waste
products of the tissues themselves. That fruit acids
may be converted into alkaline substances in the
system is true. The liver and tissues become over-
worked. The acids which are taken into the stom-
ach as food are in excess, they are stored up in the
system. The fruit habit (especially grape fruit)
so generallv indulged in to excess in America is
producing havoc with the alveolar process, gums,
and teeth.

One case is sufiicient illustration of the manv

89S

MEDICAL RECORD.

Juut I, 1907

i-cc|uiring treatment. A twenty-scven-year-okl
woman had her teeth and mouth put in good condi-
tion in January, 1907. February 16, she returned
with vvfiat she thought a cavity at the cervical
margin of the left superior cuspid. L'pon examina-
tion, 1 found the gums inflamed and receding, not
only at that particular location but about all the
teeth. Previous to this, the gums and mucous
membrane were in fairly good condition. Litmus
test showed the mucus to be very acid. There was
no cavity, only sensitive exposed dentine. Much
gas was passing from the stomach. Upon interro-
gation in regard to her food she informed me she
had been eating grape fruit every morning for three
weeks. Uranalysis of a twenty-four-hour specimen
showed the degree of acidity to be fourteen. .Six-
teen degrees were retained in the system. The re-
cession of the gums and the sensitive dentine were
due to the acid retention. The skin, lungs, and
mucous membranes try to dispose of the surplus.
If these structures are unable to do so, they are ex-
pelled as gas, vomit, or fermentative stools. That
the acid excess of the system does pass through
the mucous and salivary glands of the mouth to
produce destruction of tissue, has already been
demonstrated. With these illustrations showing de-
struction of tissue in the mouth the question arises
how far does this acidity aiTect other tissues and
diseases of the body? For want of time, merely
a few uranalyses in diseases were ma<Ie.

DISE.ASE. DEGREE OF URIX.\Ry ACIDITY.

Arthritis C rheumatoid) One 70.

Backache (severe) One 10; one 25; two 30; one

35 ; one 36 ; one 40 ; one 50 ;
one 79 ; one 82 ; one 87 ; one
90; one 95; two 100; two no;
one 120.

Bronchitis One 56 ; one 58; one 60; one

01 ; one 67 ; one 120.

Constipation One 25.

Coryza (acute), children

3 to 13 years One 12 ; two i ' ■ one 14 ; one

15; one 16; one 17; one 20;
one 22 ; one 26 ; one 27 ; one
30 ; one 36 ; one 46 ; one 47 ;
one 50; one 56; three 58; one
70 ; one 72 ; one 90.

Cystitis (acute) One 50.

Diphtheria One 28.

Dipsomania One 44.

Eczema (hands) One 50; one 80.

Enlarged prostate One 100.

Enterocolitis (chronic) One 35; one 80; one no; one

112
E.xophthalmic goiter (pu-
berty stress) One 54.

Fibrillae tremor One 21.

Gastric hyperchloridice One 60.

Gonorrhea One 120.

Grip Two 25 ; one 40 ; one 50 ; on«

60; one 7>; one 76; one 80,
one 82; one 88; one 90; on<
04 ; one 97 ; one 1 10.
Hypertrophic r li i n i t i s

(acute) One 21 ; one 2- ■ one 113.

Hypertrophic r hi n i t i s

(chronic) One "iz : one -~ • one 90.

Laryngitis (chronic) One 65 ; one 85.

Middle ear, inflammation of. .One 25: one 32' one 90.
Middle ear. chronic sufiDU-
rative inflannnation of.... One 90.

Meniere's disease One 65.

Migraine One 40.

Myocarditis (chronic) One 80: one 100: one 112.

Neuralgia followinq- grip One 20: one 24: one 25; one

2": one 40; one 46.
Pneumonia One 18 ; one 26: one 27 ; one

Pregnancy One 10; one 12: one 14; one

16; one 18; one 29; one 30;
one 50; one =~: one 60; one
62 ; one 64 ; one 67 ; one 82 ;
one 84.

Rlieuniatism and gout One 14; one 15; one 18; one

19; one 20; one 24; one 27;
one 35 ; one 52 ; one 57 ; one
61 ; one 6": one 70.

Rheumatism and heart

trouble, 8 years of age One 40.

Scarlet fever One i^ : one 80.

S'ciatica One 55 ; one 108 ; one 132.

Sphenoid sinus, inflannna-
tion of One 57.

Sunstroke One 20.

Tired feeling One 25 ; one 40.

Tonsillitis (ulcerating) One 10; one 12; one 14; one

20 ; one 2" ■ one 48 ; one 72.
Tuberculosis One 16 ; one 20 ; one 21 ; one

,36; one 44; one 52; one 56;

one 78 ; one 81 ; one 88 ; one

102; one 108; one 115; one

142.

Tubercular hip disease One 80.

Typhoid fever One 76 ; one 88 ; one 90 ; one

109; one 120.
Urticaria One 47-

On comparing the office patients of the dentist
with those of other specialists and patients ill at
home or in a hospital, it is found that the degree
of acidity does not vary to any great extent. A
constant abnormal degree of uriiiary acidity, in an
individual attending to his affairs, means that sooner
or later an oro'an or structure is bound to give way.
This is particularly true at the senile period of
stress (about sixty) when the arteries degenerate.
The victim of abnormal degree of acidity is more
subject to disease than one with normal acidity.
Studv of the effects of high degree of acidity in an
otherwise normal individual whose teeth and alve-
olar process are being destroyed has exceedingly
interesting results. In the evolution of man, the
face, nose, jaws, and teeth are being lost for the
benefit of the brain under the law of economy of
growth. They, therefore, are transitory structures.
Tlie alveolar process exists to hold the teeth. If the
teeth be not present or if they be lost in the life-
time of the individual, the alveolar process dis-
appears. The bone appears and disapnears twice
during life, if the second teeth be lost. The alveolar
process, then, is a doubly transitory structure. The
alveolar process being an end organ, blood-vessels
and nerves extend through it as far as the peri-
dental membrane and stop. The tooth so fas as dis-
ease of the bone is concerned is a foreign body.
The alveolar process, the most sensitive structure
in the human, is the first to be involved when acid
or other autointoxication or chronic poisoning takes
place.

Lessened blood alkalinity affects the whole alve-
olar process by setting up an irritation and inflam-
mation of the coats of its arterioles and in the tooth
pulp (which is also an end organ), producing
endarteritis obliterans, arteriosclerosis, and nerve-
end degeneration. I have demonstrated those dis-
eases many times. Disease of the terminal nerves
and arteries causes absorption of the bone. The
inflammatory process has been termed interstitial
gingivitis : the bone absorption, osteomalacia, or
senile absorption, although it may occur early
in life.

j\Ia'- not osteomalacia in other parts of the bodv
be due to the same cause? The change which has
taken place in the blood owing to excessive aciditv ?
The change which has taken place in the blood
owing to excessive aciditv plays a verv important
part in the action of the heart, producing high
tension. It is supposed to act direct utwn the sub-
endocardiac ganglia and also bv the irritation di-
rectly through the coronary arteries and their

June I. 1907]

MEDICAL RECORD.

899

branches to those ganglia situated in the muscular
tissue.

Acids in the system must also influence the vaso-
motor supply causing contraction of the arterioles.
In the light of my own researches, another factor
must enter largely into the cause of the increased
action upon the heart for systolic force, nameh-,
endarteritis obliterans, arteriosclerosis ( thickening
of the arterial walls), and nerve-end degeneration.
Greater pressure is re(|uired of the heart to force
the blood through the arterioles to their extremi-
ties. To ascertain the blood pressure in my patients
suffering with interstitial -ingivitis, I used Cook's
modification of the Riva Rocci sphygmomanometer,
this instrument being best adapted for my con-
venience and exceedingly simple. The armlet used
was sold with the instrument and consists of a
rubber bag 4J/2 by 40 cm. The patients ranged
from twenty-seven to sixty-seven years of age. With
this instrument the normal adult female arterial
blood pressure is 115 to 125 mm.; adult male. 125
to 135 mm.

In twenty-six females there were three who
ranged between 115 mm. Hg. and 125 mm. Hg.
and therefore normal. Three ranged below 115
mm. Hg. and twenty from 133 mm. Hg. to 180
mm. Hg.

In twenty-four males there were eight who
ranged between 125 mm. Hg. and 135 mm. Hg. and
therefore normal. Three ranged below 125 mm.
Hg. and thirteen from 135 mm. Hg. and 160
mm. Hg.

When we consider that thirteen of these patients
were under forty-five years of age, the high blood
pressure is remarkable.

Other end organs and structures of the bodv,
such as the liver, kidney, eye, etc., are obviously
predisposed to affection in the same manner, leading
up to sclerosis of the liver. Bright's disease of the
kidney, and degeneration of arteries in the brain.

Kidney lesions, due to the eruptive fevers in
children, are influenced to a great extent by a high
degree of acidity in the system. The effects of
high degree of acidity in the mother on the fetus
in producing arrest of development at the senile
or first period of stress, causing deformities of the
child, merit investigation. Wild animals in cap-
tivity are very susceptible to deformities ; no other
etiological explanation has, so far, accounted for
them.

An abnormal degree of urinary acidity extending
over a period of nine months accounts for many
of the neuralgias, toothaches, destruction of teeth
by erosion, decay of the teeth and wasting of the
alveolar process, skin diseases, and many other
lesions so common in pregnancy which cease to
trouble after birth of the child. Mental strain due
to over.work, grief, shock, etc., check the secretions
causing an abnormal degree of urinary acidity
which eventually results in diabetes, Bright's dis-
ease, and arterial degeneration. There are many
other lesions traceable to or influenced by a high
acidity of the system.

\Miile uranalysis has onlv been made in few dis-
eases, enough has been demonstrated to show that
an excess of acidity is found in the urine of all
diseases. It will be noted that a high degree of acid-
ity is found in the more simple ailments, such as
head and backache and cold in the head, as well as
in the more severe diseases, such as pneumonia and
tvphoid fever. Especially is this true in pregnancv.
The abnormal degree of urinary acidity or reduced
alkalinity of the blood must of necessitv interfere

with nutrition as well as to prevent the proper action
of drugs. Enough has been mentioned to show the
relation of an abnormal degree of urinary acidity
and the necessity of uranalysis in every case to
ascertain the degree. The abnormal degree should
be restored to normal as part of the treatment.

Lately some very able papers have discussed ace-
tone bodies in the urine (acetone, diacetic, and
/i-oxybutyric acid) in relation to the anesthetic ad-
ministration of chloroform. Deaths have occurred
without apparent cause within a few days or weeks
after a successful operation.

A number of theories have been advanced as to
the cause, such as chloroform poisoning, nephritis,
acute yellow atrophy of the liver, acetone bodies,
etc ; the principal one shown by postmortem being
fattv degeneration of the liver and occasionally ne-
ohritis. Some other primary cause must exist to
bring about the changes in the kidney and liver
which would not result from chloroform acting up-
on a healthy organ.

In my diabetics a small per cent, of cases only
presented the acetone bodies. There was, however,
an abnormal degree of urinary acidity showing that
the liver and kidneys were overworked.

In the case of Drs. Bevan and Favill.'' the degree
of acidity was 11.6 degrees, or 18.4 degrees retained
in the system ( -io to 40 being normal). How long
this degree of acidity had been in the urine no one
knows, probably a lone: time. Examination of the
teeth, gums, and alveolar process by a skillful den-
tist would have determined. Such a degree of
acidity could not have occurred without a decided
imoression upon these structures as well as upon
the liver and kidneys. The diacetic acid which was
present gradually diminished until the day before
death, when it had disappeared altogether. This,
however, could not have been the case with the
degree of acidity, since it would require some davs
to reduce it to normal.

Autopsy showed "chronic nephritis (minimum
degree)" which together with the abnormal degree
of urinary aciditv would indicate renal insufficiency
for a long period. Retention of acid in the system,
no doubt, caused the neohritis. The lessened alka-
linity of the blood, together with other poisons, due
to renal insufificiency, was clearly the primary cause
of death, administration of chloroform being sec-
ondary.

In 1873, the late Prof. Freer sent a fifty-eight-
year-old man to me to have his teeth removed. He
had recovered from an attack of Bright's disease
sufficientlv to have this operation performed. The
man walked to my ofifice, had twenty-two loose teeth
removed under the influence of ether, recovered
from the operation, walked home eight blocks, had
regular meals, slent well two nights, became rest-
less on the third, and died without any apparent
svniptoms on the fourth day. Shock from the ex-
traction of the teeth could not have caused death.
The alveolar process was entirely destroyed. The
teeth were simply held in position by gum tissue.
All were loose and could have been removed without
forceps. An abnormal degree of urinary acidity
must have been present in this patient.

In 1882, I administered nitrous oxide gas to a
twenty-eight-year-old man for the extraction of a
tooth. The mouth was held open by means of a
cork between the teeth. Before I could get the pa-
tient under the influence of the gas the face and
lios became blue, a spasm of the muscles of the face
and jaws occurred, cutting the cork in two. The
muscles of the jaws and face became fixed and rigid

900

MEDICAL RECORD.

[June I, 1907

as did all the muscles of the body. After three
hours' labor, I was able to take the patient home.
He was sick in bed for four weeks and finally re-
covered.

People often have a bluish appearance of the face
and lips with spasmodic action of the muscles
of the face while going under the influence of
nitrous oxide gas. It was formerly supposed to be
due to impure gas. This, however, was shovvn to be
untrue after the process of compressing the gas in
cylinders, which must of necessity be pure.

Since, as I have shown, many individuals have
an abnormal degree of urinary acidity under which
destruction of the teeth and alveolar process results,
colds are contracted, headache and backache, and
many serious lesions develop in pregnancv to be
corrected by making the acidity normal, is here not
a positive index for prophylaxis? Should not the
surgeon, who operates upon a patient first, if time
permit, make the acidity normal? In every disease
to which the physician is called, should not the de-
p-ree of acidity of the urine and amount of indican
first be obtained to have some definite basis for
work? Will not drugs produce better results in
diseases if the urinarv acidity be normal? Fre-
quently the treatment of these two symotoms alone
restores the patient to health.

I am obligated to the following phvsicians for
their assistance: Dr. Sidney Kuh, Cook County
Hospital : Dr. S. M. Robin, Cook County Hospital
for the Insane and Poorhouse ; Dr. Robert Preble,
St. Luke's Hospital ; Drs. W. A. Evans and Adolph
Gehrmann, Columbus Medical Laboratories ; Dr.
J. F. Keefe, Dr. J. G. Kiernan, Dr. S. S. Bishop,
Dr. E. D. Howland, Dr. J. D. McGowan, Dr. J. C.
Gill, Dr. W. K. Harrison, Dr. Bertha Bush, Dr.
Vida A. Latham, all of Chicago.

REFERENCES.

1. International Dental lournnl, April, i8g6.

2. The Dental Digest, 1906.

3. "A Guide to the Qualitative and Quantitative Analysis
of the Urine." WiUiam Wood & Co., 1879.

4. "Uric Acid in the Causation of Disease."

5. International Dental Journal, April, 1896.

6. Journal of the American Medical Association. Sept 2,
1905.

A CASE OF INTESTINAL OBSTRUCTION
DUE TO PERSISTENCE AND ANOMA-
LY OF THE URACHUS ; OPERA-
TION ; RECOVERY.

By .ANTONIO FANONI. .\I.D..

• NEW YORK.

VISITING SURGEON TO THE ITALIAN HOSPITAL; INSTRUCTOR IN GENITO

URINARY SURGERY AT THE NEW YORK POST-GRADUATE MEDICAL

SCHOOL AND HOSPITAL.

On September 20, 1906, I was called to Portchester
to see a man, G. D. S., twenty-five years old, sin-
gle, carpenter. He had come to this country from
Italy in June, and had been in perfectly good hea'ih
until two years ago, when he was seized with an
attack of abdominal pain which lasted two or three
days, with constipation and vomiting. These svmp-
toms disappeared after three days, when his bowels
moved. In the early part of July, after his arrival
in America, he had another similar attack of pain
in the abdomen, vomiting partly digested food, but
his bowels continued to move. The attack again
subsided after four or five days.

He remained well until September 14, when he
was seized with abdominal pain more violent than
in any previous attack, with vomiting of stomach

contents. The pain subsided somew-hat after the
administration of morphine hypodermatically by a
local physician. Flis bowels did not move in spite
of the fact that every possible means suggested by
three physicians had been applied. On the day
following the onset of the attack the vomiting be-
came stercoraceous and remained so for six days.

When I first saw the patient I was struck by the
anxious, hollow-eyed, sallow, wax-like, and drawn
face, expressing intense suffering and exhaustion
from lack of sleep and nourishment. The skin was
dry and the tongue dry and coated. There were
spasmodic twitchings of the abdominal muscles^
The temperature was subnormal, and the pulse 115.
The pain, vomiting, and constipation had persisted
since the first day. While I was examining the
patient he was seized with excruciating pain and
piteously begged for morphine. On palliation I
found tympany above the umbilical line and dullness
below this line.

The diagnosis was intestinal obstruction, and im-
mediate, operation was advised. The patient was
at once transferred to the Italian Hospital and
was operated on the same evening. His pulse be-
fore operation was 128, temperature 100.6° F.,
respiration 28.

First Operation. — An incision was made on the
right side along the external border of the rec-
tus to the pubis, revealing one inch below the um-
bilicus a coil of intestine so large that it looked
like an overdistended stomach. This portion of
intestine was held between the anterior abdominal
wall and a stout fibrous cord the size of the little
finger, showing here and there a fine fringe of peri-
toneum. This cord was followed downward, and
was seen to be attached to the fundus of the blad-
der. It was followed upward w-here it wa^ attached
to the anterior abdominal wall one inch above and
tW'O inches to the right of the umbilicus. This cord
had no connection with the liver, and its upper
end divided into three branches w'hich spread out
in the shape of a fan.

The first thought on seeing this cord was that it
w-as either a remnant of an umbilical vessel ur of the
urachus. Having satisfied myself that it was not
a vital structure, it was ligated at both ends and
excised. This at once freed the intestine, which
was dark and congested in places, but did not rhovv
any gangrene. Owing to the patient's desperate
condition, no further attempt was made to handle
the intestines, although there w'as a small spot
which looked as though it had been considerably
damaged. The abdomen was closed in the usual
way.

First Pathological Report.- — A specimen of the
resected urachal tissue from the upper end of the
urachus (the lower and longer part resected was
unfortunately lost in the operating room) was sent
to Dr. H. T. Brooks of the Post Graduate Hos-
pital for histologic e.xamination. The following is
Dr. Brooks' report : "The specimen received from
vou a few days ago was composed of three layers.
(i) A thick, dense outer layer of concentrically
arranged fibrous connective tissue; (2) an equally
thick, perpendicularly arranged fibrous layer which
gradually merges with a (3) internal richly cellular
laver. This third laver extends to a centrally lo-
cated lumen, at which point it is markedly infil-
trated with round cells and polynuclear leucocytes.
Here, also, are a number of small areas of coagula-
tion necrosis near which occasional giant cells are
observed. There is no sign of a mucous lining.
The general structure of the tissue resembles a

June I, 1907]

MEDICAL RECORD.

901

duct, apparently the remains of the urachus. The
pathologic condition appears to me to be an acute
suppurative infection upon a probable tubercular
basis."

The slides were then also sent to Dr. James Ewing
of Cornell University Medical College, the follow-
ing being the report kindly rendered by Dr. Ewing :
"The wall of the structure is composed of dense
fibrous tissue circularly arranged and containing
a moderate supply of large and small vessels, ar-
teries, and veins. There are no definite remnants
of muscular tissue. The canal is lined bv a dense
layer of thick, granulation tissue in which are many
round cells and some giant cells. No tubercles are
seen. The histological structure is consistent with
an origin from a chronically inflamed patent urachus,
which is also strongly indicated by the anatomical
relations."

The slides were finally taken to Dr. T. M. Prud-
den of Columbia University, who agreed completely
with Dr. Ewing's statements, subscribing to the
same in full.

The patient had a spontaneous movement of the
bowels two hours after the operation, and had two
additional movements during the night.

Owing to the close relations of the urachus and
the bladder, it was thought advisable to cystoscope
the patient and see whether anything could be de-
tected that might throw light on his condition. The
bladder was normal. The left ureteral opening was
in the normal position, but about four times larger
than normal. The ureteral catheter passed readil>-
to the renal pelvis and there was no evidence of
narrowing. The right ureteral orifice was of about
normal size and there was some difficulty in finding
it. There was nothing to suggest an inflammatory
process. The catheter on the right side also easily
passed up to the renal pelvis. After three weeks
the patient left the hospital in perfect health. He
had gained a good deal in weight, especially as he
had been kept under general tonics.

The patient remained well until two months after
the operation, when I was again informed by tele-
phone, from Portchester, that he could not move his
bowels and that he had cramp-like pains in the ab-
domen. I suggested purgatives, which proved effec-
tive and relieved the pain. About two weeks later
he came to my ofiice and told me that every two
or three days he had a recurrence of pain and con-
stipation. He feared he would not improve and pre-
ferred to remain in New York where he could be
under my observation.

On examination a swelling was found in the
right hypochondriac region, over the side of the
stump of the urachus which had been left in the
abdomen. It was thought that some inflammatory
process existed in the roots of the urachus, as there
was some fluctuation in that region, and that a
recurrence of the obstruction might be due to ad-
hesions of the stump of the urachus to the intestine.
-At all events, every means of moving the bowels
was tried for several days without success. As
the pain was getting worse, it was decided not to
lose any valuable time, but to operate at once in
order, firstly, to relieve the obstruction, and sec-
ondly, to open the abscess.

Second Operation. — Accordingly, an incision was
made in the semilunar line, over the tumor. When
the structures down to the peritoneum had been
cut through, some cheesy material was found and
removed, together with the three remnants of the
roots of the urachus. After cleansing the field
thoroughly, the wound was packed with gauze and

closed, leaving sufficient ojiening for drainage.
Then, protecting the drains with gauze, the incision
was enlarged downward for three inches, and after
having freed numerous small adhesions, it was
found that a band of adhesions had formed between
the omentum and the urachal stump, and that a
loop of small intestine about fifteen inches long
had become gradually constricted by this adhesion,
so that the lumen at both the distal and proximal
ends of the loop permitted the passage only of
fluids. The narrowing at the ends of the loop was
largely due to hyperplasia of the wall of the gut,
caused by the compression of the band.

As there were no signs of necrosis in tlie gut, and
the blood supply was not markedly interfered with,
and as the two ends of the gut to be united differed
so greatly in caliber, a lateral intestinal anastomosis
was made, the coils of the intestine being placed
side by side and joined by a continuous, non-pene-
trating silk suture and finished in the usual way,
without removing the loop of intestine.

Owing to the proximity of an infected focus, a
cigarette drain was introduced down to the sutured
gut and the abdominal cavity closed in three tiers.
The drain was removed after four days and the pa-
tient made a rapid recovery, gaining nearly twenty
pounds in three weeks. He left the hospital four
weeks later in excellent condition.

There was no sign of tuberculosis in either the
intestines or the peritoneum. The cheesv masses
found in the roots of the urachus therefore seemed
to be evidence of a localized tuberculous process.

Second Pathological Report. — Specimens of the
urachal stump tissue were again submitted to Drs.
Brooks, Ew'ing, and Prudden for examination, and
the following are the reports of these pathologists :

"Microscopic examination of the urachus tissue
recently received from you showed the typical his-
tologic structure of tuberculosis and also tubercle
bacilli." — H. T. Brooks.

"In a small area in the stump of the urachus re-
moved at the second operation there is granula-
tion tissue containing many typical miliary tuber-
cles with characteristic giant cells. A stain for tu-
bercle bacilli would probablv render the diagnosis
positive." — J. EwiNG.

"The second specimen showed a small area oft
tuberculous inflammation." — T. M. Prudden.

The urachus is the remnant of the allantois of the
embryo, and connects the body of the bladder with
the umbilicus. It is widest at the bladder and
grows thinner as it ascends. In my patient the
urachus was abnormal in several respects. It start-
ed at the bladder, was free in the abdominal cavity,
and instead of ending at the umbilicus it passed
two inches to the right side of the navel to a point
one inch above the latter, and there divided into
three spreading branches, as already described. The
free part of the urachus formed the chord of an
arc made up by the abdominal wall and the bladder,
and in this arc the intestinal loop was caught.

The history of the patient points to the occur-
rence of an attack of obstruction in Italy two years
before I saw him. The intestine, however, suc-
ceeded in freeing itself, and he recovered from
this attack. The operation performed after his
second attack removed the cause of obstruction.

While in all abdominal work a_ certain degree
of speed is most desirable, this is imperative in
intestinal obstruction. For this reason I did not
cover the stump of the urachus with [peritoneum,
and this, perhaps, was the cause of the recurrence
of obstruction. Such recurrences are frequently

go2

MEDICAL RECORD.

[June I, 1907

met with, as the result of adhesions without the
presence of any stumps. I felt satisfied when I
had removed the cause of obstruction and that I
had better chances for a good result in this case if
I closed the alDdomen as soon as this had been done
instead of subjecting the frail, exhausted patient,
whose resistance was very low, to a more lengthy
operation.

As to the tuberculous condition found in the sec-
ond specimen of urachal tissue, I have every reason
to believe that it was purely local, namely, a tuber-
culous degeneration of the upper end of the urachus.
I cannot sav this positively, as the longest piece of
urachus was lost at the first operation. If the en-
tire urachus had been diseased, probably there would
have been more trouble by this time.

This case, so far as I know, is unique in that
the cause of obstruction was an abnormally attached,
persistent urachus : at least, a search of the literature
has failed to reveal a similar instance. The tuber-
culous condition of the stump and the good re-
very after the operations are features which add
interest to the case.

119 West Eleventh Street.

A COMMENT ON THE X-RAY AS APPLIED
TO PROSTATIC ENLARGEMENT.*

Bv L. BOLTO.\' B.WGS, .\I.D..

NEW YORK.

The following case is a typical, uncomplicated one
of enlargement of the prostate. It is presented to
illustrate a phase of the ".r-ray" movement.

The patient is a well nourished, vigorous subject
of sixty-four years of age, who gave me the fol-
lowing history of his symptoms and treatment prior
to coming under my care. Ten years ago he first
noticed a slight degree of dysuria and diminution
of the stream of urine. The dysuria gradually in-
creased, and frequency of urination developed, till
a little over two years ago he was urinating every
hour in the daytime and four times in the night.
At or about this time vesical tenesmus also began
to be a distressing symptom. He then received
treatment, which consisted of the systematic use of
the catheter and the passage of sounds. Under this
treatment there was gradual improvement. The
dysuria and frequency lessened and the tenesmus
disappeared. The amount of residual urine at first
was not stated, but there was a gradual diminution
in its amount till in February, 1905, it varied from
Yi oz. to 3 oz.. rarely as much as 3 oz., and his
nocturnal urination was usually once, occasionally
twice. There being no further improvement, the
average residual urine remaining at about ij'l oz.,
it was suggested to him to try the .r-ray treatment,
which was begun in Alarch, 1005. .\ month later.
in April, iqo.s, he ceased using the catheter, and
had received in all sixteen or eighteen treatments.
Accordinsr to his statement the .r-rav tube was
placed a few inches from the perineum. He de-
clares that he was inmiediatelv improved, the in-
tervals becoming from three to four hours, but
the nocturnal urination remained once and some-
times twice. .\lso at this time there was occasionallv
an annoving urgencv and, when his mind was oc-
cupied, the interval between urinations was longer;
but after such an interval the urgencv would be
distressing and imperative. In the autunm of 1905
he had another course of .r-ray treatment : but. not-

*Rea(I at a meetina; of the Practitioner^' Society of Xew
York. .April 5. 1007.

withstanding this, the return of cold weather caused
a mild relapse of his difficulties, and he spent the
winter of 1905 and 1906 in Egypt, with relief of
the symptoms, but with occasionally a little relapse
of frequency and tenesmus. In September of 1906
his symptoms returned with full force, the tenesmus
especially to such a degree that he had to sit down
to urinate, as his bowels would move at the same
time.

Toward the end of December, 1906, the .r-ray
treatment was resumed. He experienced some im-
provement, but after the twelfth treatment der-
matitis of the perineimi ensued which caused a
temporary suspension of the method. Notwith-
standing the treatment and his belief that he was
being improved, his symptoms persisted, sometimes
with marked severity.

He came to me on the i6th of last March, the last
.r-ray treatment having been given on the 12th of
March. At this time he had diurnal urination every
two or three hours : nocturnal, twice, and slight
tenesmus with occasional severe exacerbations. Rec-
tal palpation found the prostate svmmetrically en-
larged in all directions, say four times normal ; the
searcher showed a large median and right lobe in-
travesically and excluded stone, and by catheter
were obtained over eight oz. of sterile residual urine.
He is now under observation. He still has notable
organic enlargement of the prostate ; an average of
eight oz. of residual urine ; and, unless the bladder
is relieved bv the catheter, he has severe tenesmus
which provokes an involuntary emptying of the rec-
tum.

Inasmuch as from time to time I am hearing of,
or reading of, cases of prostatic enlargement pur-
porting to be cured by .r-rav treatment, it seemed
advisable to analyze one which has come under my
observation. The explanation of his relief is sim-
ple and is quite characteristic of many such cases.
The systematic use of the catheter relieved an
overdistended bladder with restoration of a certain
amount of its functional capacity. This restoration
persisted for over a vear with intercurrent attacks
of mild tenesmus and frequency due, no doubt, to
some sudden increase in the volume of his urine,
which suggested a winter in a mild and equable
climate. Finallv, there was gradually a refilling of
the bladder bevond the ability of its muscular wall
to contract upon its contents, with a relapse of all
his symptoms. Such cases should be kept steadily
under observation in order to determine how much
of the bladder function can be restored and main-
tained. If sufficient bladder function and asepsis
cannot be maintained, prostatectomy should be ad-
vised.

20 East Foktv-si.xth Street.

Alteration of the Liver in the Newborn Accompa-
nied by Incomplete Pulmonary Respiration. — E. .Alfieri
has examined tlie I'.vers of twenty-six new-born children
who died during labor or soon after birth, from a few
minntes to eight days. He found that the cells of the cen-
tral zone of the liver lobules were swollen and edematous
in all those cases in which the infant died without having
respired freely, or from prematurity, or from severe intra-
uterine asphyxia. .Xddin.g- to these facts the observations
that have been made in animals, the author believes that we
are justified in thinking that the retardation of the circu-
lation in the umbilical veins, and its cessation without the
establishment of respiration and active pulmonary circula-
tion caused the alterations in the liver. The swelling and
edema of the liver cells is an expression of the sufferitig
of the infant in the womb, whether death occurred within
the uterus, or the circulation was disturbed after deliverv
bv obstruction of pulmonary respiration. — La Rifonna
Mcdicd.

June I, 1907]

MEDICAL RECORD.

903

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMx\N, A.M., M.D., Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, June I, 1907.

THE MANAGEMENT OF THE AMERICAN
MEDICAL ASSOCIATION.

During the past year the Medical Record has on
several occasions called attention to certain abuses ii\
the management of the American JNIedical Associa-
tion and has insisted upon the necessity of reform
in the plan of organization of the Association in
order that those who have arrogated to themselves
the absolute control of this great body may be shorn
of some of their powers. The President-elect of the
Association, Dr. Joseph D. Bryant, has also ex-
pressed himself indirectly as strongly opposed to this
misuse of authority im the part of certain of the
officers, and in his annual address before the Med-
ical Society of the State of New York in January
of this year toolc occasion to warn his fellow mem-
bers of the danger of allowing such abuses to creep
into the management of their own organization.

In the May issue of American Medicine, a journal
whose loyalty to the Association is as firm as our
own, appears a temperate but scathing criticism
of the management of this afflicted body which
should be read and pondered by every member and
■ friend of the Association. The editor says that the
defects in the plan of organization of the Associa-
tion are now, becoming apparent and that it is a
sorry blunder on the part of the rulers to oppose
discussion of its weakness and to attempt to stifle
criticism of the manner in which they exercise the
power which this plan gives them. The evils of too
much ofScialism, he says, are generally recognized
throughout the profession and he quotes the admon-
ition of President-elect Bryant regarding what the
latter called "the grave perils begotten by the spirit
of paternalism which, not infrequentlv, is a per-
nicious by-product of organized power." .\s an
illustration of the lust for power which some of the
rulers of the .Association have conceived, the writer
cites the case of a certain trustee who "is said
to have spent in visiting delegates much of the three
months jireceding the meeting at which his re-
election or the election of his successor was due —
'mending fences' is the political phrase." It is pos-
sible this man was inspired with the belief that his
continuance in office was essential to the welfare of
the Association, but the uncharitable will be inclined
to think that he wanted to continue in power in
order to work, rather than work for. the .Associa-
tion.

The encroachment upon the liberty of the indi-
vidual members of the .Association, resulting from
"the increasing tendency of the 'leaders' toward

mere money-getting, monopoly, and trades-union-
ism," is dwelt upon, and in this connection Presi-
dent-elect Bryant is again quoted where he says :
"If on our part, a spirit of fraternal oppression of
any kind should develop as the outcome of organized
strength, then indeed will the day of consolidation
become one of mourning for the loss in fraternal
fellowship and in professional station." In noting
further the danger inherent in the plenary powers
conferred upon the trustees under the present plan
of organization, it is said: "These nine men (with
the President and Secretary) may divert portions
of the vast accumulations possible under the present
policies to ends not in accord with the original aims
of the .Association nor thoroughly representative of
the great body of the profession. One may instance
such steps as entering into competition with pub-
lishers of books or with the manufacturers of drugs
in the name of the Association and by use of its
funds. The real aims in such measures may be
masked by a specious pica for puritv and profession-
alism." Another evil, one might almost say the
evil, arising from the enslavement of the great
body of members of the .Association, whose
vocation is science, not politics, is the con-
centration of power in five officers, four of
whom are mit elected by the members of the Asso-
ciation or even by the representatives of the State
societies in the House of Delegates, but are ap-
pointed by the trustees. Two of these officials, the
Organizer and the .Advertising Manager, hold each
Init one office. The other lucrative offices, those of
General Business Manager, Secretary, and Editor,
are held by one man, and it is stated "that the in-
cumbent of these offices is present at all the meet-
ings in an attitude of practically determining all de-
cisions !" It is contended that this triple function
cannot be satisfactorily discharged by the present
incumbent, for "no one man can by any gifts of
nature or acquirement properly perform these di-
verse duties."

The reforms demanded in the interests of progress
by a large and increasing body of the profession,
among whom are many members of the Association,
and not a few of its officers, including, if his ad-
dress before the New York State Society had any
meaning whatever, the President-elect, are summar-
ized by American Medicine as follows:

(i) Verbatim reports of the proceedings of legis-
lative and governing bodies. (2) Itemization and
utmost publicity of financial matters. (3) Proper
representation in the offices of Secretary, of Editor,
and of Business Manager by separate individuals,
with proper compensation. (4) Nondiscretionary
power of the Editor, with government by the Sec-
tions of the published proceedings. (5) The render-
ing impossible of trades-unionism and monopolistic
methods. (6) Provision for general secret ballots
upon important questions of policy by means of the
machinery of the .Association and its journal,
through district and cijunty societies. (7) The ex-
tension of the referendum and initiative from the
optional legislative to the popular and obligatory
form. (8) In order to protect apparent minorities,
placing the vote necessarv for both referendum and
initiative upon a reasonable basis, (i)) The rights

904

MEDICAL RECORD.

[June I, 1907

of individual members must be held inviolate from
attack by those in power. ( 10) The Association and
its journal must be enjoined from entering into
purely commercial competition to the detriment of
its professional rivals. (11) No paid agent of the
Association should be permitted to be a member of,
or take part in the deliberations of, the bodies gov-
erning or directing his actions or compensation.

THE PROGRESS OF THE ANTITUBERCU-
LOSIS MOVEMENT IN NEW YORK.

Since tuberculosis has come to be regarded as a
preventable and in most instances a curable disease,
the crusade against its spread has become a world-
wide movement. In every civilized community it
has become an institution, which no longer assumes
the character of a visionary dream, but rather the
aspect of a practical every-day problem. This mod-
ern movement dates back to the year when the
germ of the disease was discovered by Robert Koch,
although the full meaning of this knowledge was
slow to be grasped and fully utilized. In this city
a signal advance may be ascribed to the action of
the local health board in iSqj in declaring tubercu-
losis to be an infectious and communicable disease,
and requiring a compulsory report of all cases. In
a recent article J. A. Miller {Columbia University
Quarterly, I\Iarch, IQ07) calls attention to the
further advances wliich have been made by the au-
thorities in their sanitary control of the disease,
which includes not only a complete register of all
the cases of tuberculosis in the city, but also an in-
spection of the homes of all those who do not come
under the care of a private physician. This is part
of an educational campaign, which also includes the
distribution of circulars and pamphlets in several
languages, the regular disinfection after every death
from tuberculosis and after every change of resi-
dence, and special prohibition in the sanitary code
against spitting in public places.

The work of the special committee of the Charity
Organization Society on the prevention of tubercu-
losis has also been a potent factor in the education
of the laity. This body has arranged public lecture^
and stereopticon exhibits, has distributed cards and
circulars of information, and by means of a traveling
exhibit it has shown in a graphic manner the vari-
ous aspects of the tuberculosis problem. The sana-
torium idea has in recent years been largely devel-
oped, and so iinportant has this matter become that
both municipal and state institutions have been es-
tablished for the care and treatment of the incipient
cases. These institutions exert a tremendous influ-
ence, and their- efforts in curing those in the early
stages of the disease have been crowned with great
success. Under the most favorable circumstances,
however, it is quite evident that by this means only a
comparatively limited number of patients can be
placed under treatment and, among the poor par-
ticularly, the vast majority must stay, be it to live
or to die. A fight against the disease in these quar-
ters is surrounded with many difficulties, and until
a few years ago was considered impracticable, gen-
eral inspection and occasional disinfection bv the
Health department being all that w^as attempted. But
now we find that special clinics have been established

by the larger public hospitals of which the main fea-
ture consists in teaching the patient afflicted with
tuberculosis how to live and to care for himself.
It means nractically the application of sanatorium
treatment to the unpromising conditions associated
with life in the tenements. This advice is reiterated
in the homes by the visiting nurse, so that a more
or less constant supervision is attained. The results
obtained can be characterized only as remarkable,
and show the value of concerted effort instead of the
desultory advice formerly given. Proper food and
air are prescribed instead of medicines, and as even
these are a luxury among the poorer classes, the
other charitable institutions have combined with the
special tuberculosis clinics to supply the deficiency
whenever possible. Common sense and humanity
are now made the principles of the treatment of this
disease, and as these are effective only when co-
operation exists between the properly constituted in-
stitutions, which strive to furnish this relief, it is a
matter of general congratulation that the object has
been attained.

THE ANESTHETIST.

In this age of specialists there has been developed
a field of work which although of limited applica-
tion is of extreme importance. Not so very long
ago the anesthetist as he now- exists was unknown.
The administration of an anesthetic in a surgical
operation was relegated to the junior staff in the
hospitals or to anybody who was willing to under-
take the task in private practice. With the advent
of the newer anesthetics and the mor^ complicated
methods of administering the old, either alone or
in combination, the specialist in anesthesia cam.e to
the fore, and, although many consider that his days
are numbered, he did succeed in instilling into the
minds of surgeons the necessity for a more careful
administration of the means without which their
operations could not be executed. In hospital prac-
tice particularly instruction in anesthetics is now
regularly nrovided for, and the junior on the house
staff no longer receives his instruction from his pre-
decessor, who is only too anxious to give up the
work, but is taught the proper use of anesthetics
and their importance by one especially appointed for
that purpose. The responsibilities of the anesthetist
should be fully annreciated, and in a recent edition
of his book on Anesthesia (London, 1907 1 Hewitt
refers to the necessity of legislative enactments to
control the administration of anesthetics. As the
law now stands in England, and it is probably the
same in this country, the legal responsibility in case
of accident lies with the operator, and not with
the anesthetist. The conditions of half a century
ago permitted this, but in the surgery of to-day the
role played by the anesthetist may be of even greater
imoortance than that played by the operator, and the
responsibility should therefore be shifted. In order
that this may be done, the anesthetist must be prop-
erly qualified.

In order that this important subject may be prop-
erly appreciated more attention should be given to
instruction on the administration of anesthetics in
our medical colleges. .\ special course of lectures
supplemented by appropriate physiological experi-

June I, 1907]

MEDICAL RECORD.

905

ments on animals and practical clinical application-,
should be made part of the curriculum. There are
many fads taught which could well be omitted or re-
duced and a practical branch of this kind substi-
tuted. .A. practical working knowledge of anesthesia
should form part of the equipment of every medical
graduate, for, as Hewitt very aptly says in his
book, "there is just as great a scope for profes-
sional skill and judgment when the respiratory, the
circulatory, and the nervous functions of a patient
are being profoundly modified by a general anes-
thetic as there is during enteric fever or some other
ailment for which the services of an experienced
physician are regarded as essential."

Thor.\cic Injuries and Abdomin.-\l Rigidity.

The value of unilateral or double rigidity of the
abdominal muscles, the defense muscniairc of the
French writers, as an indication of injury to or in-
flammation of the abdominal contents is beyond dis-
pute, and some sureeons go so far in doubtful cases
as to make its sole presence the indication for
laparotomy. Like most clinical signs, however, it
requires judgment for its interpretation and it may
exist in most pronounced forms entirely independ-
ently of any trauma to the structures below the dia-
phragm. Hildebrand {Berliner klinische Wochen-
sclirift, May 6, 1907) reports a number of cases of
gunshot wounds of the thorax, in which pronounced
unilateral rigidity of the abdominal muscles and
even abdominal pain were present without there
being any implication of the abdomen in the injury.
In order to explain this misleading state of affairs
he points out that the abdominal muscles are sup-
plied by the lower intercostal nerves and that a bul-
let entering the thorax, even though the wound of
entrance is high up, very often finds a resting place
in the posterior thoracic wall at a much lower point
and in close pro.ximity to the intercostal nerves, so
that injury or irritation of these readily results.
Under these conditions it is easy to understand that
reflex rigidity of the abdominal musculature might
be produced and also that the abdomen might be
the site of referred pains. It therefore behooves
the surgeon to keep this possibility in mind in deal-
ing with such injuries, and to remember that ab-
dominal rigidity may easily be present without the
slightest damage to this region.

Joint Mice.

While the diagnosis of the presence of detached
portions of cartilage free in the knee joint is usually
not difficult and the results of the operations for re-
moval of such movable bodies are usually excellent,
it is possible in such cases to fall into an error which
if not serious in its consequences is at least unpleas-
ant. This consists in removing the oft'ending par-
ticle and considering the operation completed with-
out a careful search for other movable bodies. Ewakl
{Deutsche medizinisclie Wochenschrift. May 2,
1907) reports such a case in which, after easily re-
moving one bit of cartilage from the knee joint of
an athlete, when the dressings were for the first
time removed on the ninth dav the operator was un-
pleasantly astonished to find another joint mouse
plainly palpable at the side of the joint onposite to
the incision. This was removed with equal ease and
the patient's subsequent complete freedom from
symptoms seems to prove that the conditions in the

joint had been restored to the normal. In order to
avoid such embarrassing contretemps as this Bud-
inger has recently recommended that in all cases
the knee joint be fully explored through a large
incision, but the risks attending such a method of
operating are so much greater that it would seem
preferable to rely on careful palpation at several
sessions, combined with radiography, and to e.xtract
any body or bodies that can be detected through
small incisions that involve practically no danger of
subsequent impairment of function.

A New Method for Examining the He.\rt.

The difficulties in mapping out the heart by percus-
sion are universally recognized and even experi-
enced clinicians are likely to differ somewhat in the
results they obtain. This is true particularly of
the relative cardiac dullness, and any procedure by
means of which the determination of the cardiac out-
lines is facilitated is to be welcomed. Such a sug-
gestion is made by Stern in the Miinchencr luedi-
zinische Wochenschrift, April 30, 1907, wdio.
states that he has derived much advantage
from examining the heart of his patients
in the elevated pelvis position. The right bor-
der especially can be determined with greater
ease, since the right heart in this position
comes more closely into contact with the anterior
thoracic wall and the edge of the right lung is
pushed somewhat outward. In answer to the ob-
jection that this method of examination yields
results due only to an abnormal displacement of the
organ, Stern avers that since it is possible by this
means to obtain more definite outlines for the organ
than in the usual positions the procedure aft'ords a
useful means of checking up the results obtained by
the ordinary method. He also recommends auscul-
tation in this position, and states that the dift'erence
in the character of murmurs, or the appearance of
sounds previously not audible resulting in this way,
may suffice to clear up an otherwise difficult diag-
nosis. The procedure is also to be recommended in
studying venous pulsation in the neck.

Washington Milk Committee's Report. — There-
port of the Committee on the Sanitary Relation of
the Milk Supply of the District of Columbia em-
bodies the opinion that the advantages of the pas-
teurization of milk outweigh its disadvantages, and
it is recommended that a central pasteurizing plant
be established and maintained under the supervision
of the Health Department. The committee states
that it is so strongly impressed with the manifold
dangers connected with the milk supply that until
the needful reforms in dairy methods are accom-
plished it recommends to the public the following
as immediate safeguards: i. Do not patronize a
milk dealer at any price whose milk after standing
for two hours reveals a visible sediment at the bot-
tom of the bottle. It is evidence of dirty habits,
extremely suggestive of danger, and entirely pre-
ventable by clean, decent methods without greatly
increasing the cost. 2. Subject all your milk to home
jiasteurization, by simply bringing it to the boiling
point, and after cooling keep the milk on ice ; this
will destroy germ life and reduce the chances of
milk-borne diseases to a minimum. 3. Your com-
mittee recommends that the result of the recent in-
vestigations into the milk- supi.ily conducted by the

9o6

MEDICAL RECORD.

[June I, 1907

Bureau of Public Health and Marine Hospital Ser-
vice, the r.ureau of Animal Industry, and the r>u-
reau of Chemistry of the Afjriculture Department,
with a view of supplementing the work of the
Health Department, which on account of its limited
force and laboratory facilities could not possibly
conduct such an exhaustive investigation, be placed
at the disposal of the Commissioners of the District,
4. In conclusion your committee recommends that,
until the Health Department shall be in control of
a bacteriological laboratory, and a sufficient number
of inspectors, the Health Officer request the con-
tinuance of tlie cooperation of the Bureau of
Public Health and Marine Hospital Service and the
Department of Agriculture for improving the local
milk supply. The members of the committee are
as follows: George M. Kober (chairman), Emile
Berliner, Dr. G. L. Magruder, Dr. C. F, Mason,
U. S. Army; Dr. A. D. Melvin, Chief Bureau of
Animal Industry; Dr. J. R. Mohler, Bureau of
Animal Industry ; Dr. M. J. Rosenau, Director Hy-
gienic Laboratory, Public Health Service ; Col. R. G.
Smith, E. H. Webster, Chief Dairy Division, De-
partment of Agriculture.

The New York City Milk Commission. — The re-
port of the commission consisting of Drs. L. E. Holt,
A. Jacobi, Joseph D. Bryant, T. ^^litchell Prudden,
and Rowland G. Freeman, appointed by Mayor Mc-
Clellan to investigate the conditions under which
milk is sold in this city, has submitted its report,
which is based on an investigation of every stage in
the passage of the milk from the cow to the con-
sumer. While admitting the advisability of pasteur-
izing all milk which is open to suspicion, the com-
mittee expresses the opinion that what is primarily
needed is the extension of the system of inspection at
the dairies and milk shipping centers. It is stated that
in order to have efficient inspection of the milk busi-
ness at least one hundred inspectors for the country
districts from which the supply is drawn, in ad-
dition to the fifteen now available, should be em-
ploved.

Result of the Bilibid Prison Inquiry. — Both the
committee of scientists and the committee of Fili-
pinos that have been investigating the inoculation of
prisoners at Bilibid prison with contaminated anti-
cholera serum have made reports exonerating Dr.
R. R. Strong of the Bureau of Science, under
whose direction the experiments were being con-
ducted, from all persona! responsibility and the
Attorney-General has found that there was no neg-
ligence on the part of those concerned in the work.
Last November thirteen out of twenty-four pris-
oners who were inoculated with the serum died,
as the result, it was afterwards discovered, of con-
tamination of the serum with attenuated plague cul-
tures. Much excitement over the incident was
caused among the Filipino population, but the mem-
bers of the native committee express themselves as
satisfied that no one was responsible for the acci-
dent and specificalN- exonerate Dr. Strong. The
families of the victims will be provided for by the
Philippine Commission.

Plague in India. — The efforts of the British
sanitary authorities in India are being greatly ham-
pered in their efforts to restrict the spread of the
plague bv a story that has been circulated among
the natives in the Punjab to the effect that there
is no such disease as the plague, but that the recent
mortality is all due to the fact that the government
has been despatching emissaries throughout the
country to poison the wells for the purpose of ex-
terminating the population. The author of the

story, who is a Hindu, has been captured by the
police and sentenced to two years imprisonment.
Thirty-three of his accomplices, who actually
dropped my.stcrious balls into wells, alleging that
they did so by the government's order, have been
sentenced to eighteen months' imprisonment. The
deaths by plague in India during the six weeks
ending Alay 11 were 451,892. In the Punjab alone
there were 286,777.

To Systematize the Treatment of the Tuber-
culous Poor. — The Committee on the Prevention
of Tuberculosis of the Charity Organization Society
announces that plans have been perfected for the
division of New York City into districts with a
special tuberculosis dispensary in each district to
take care of all consumptives applying for treat-
ment. Under this arrangement the patients are
able to obtain more individual care from the visit-
ing nurses, which each dispensary employs, and
more regular attendance of the patients is secured.
The following dispensaries have entered into the
plan : Department of Health, Bellevue Hospital
Dispensary, Gouverneur Hospital Dispensary, Pres-
byterian Hospital Dispensary, Harlem Hospital
Dispensary. Vanderbilt Clinic, New York Dispen-
sary, New York Hospital Dispensary, and Health
Department, the Bron.x. Patients are expected to
apply to the dispensary nearest their homes.

Health Conditions in the Isthmus. — The report
of the Sanitary Department of the Isthmian Canal
Commission shows a decrease in the death rate
for the month of April among the employees in the
Canal Zone. .Among 5,484 white Americans con-
nected with the commission there were only four
deaths in .April, which gave a death rate of 8.7 per
thousand. The decrease in mortality is due chiefly
to the falling oi¥ of the cases of pneumonia. From
this disease there were forty deaths in April, as
against fifty-three in ^larch, thirty-nine of the forty
being among negroes. There were twenty-one
deaths from typhoid, nineteen among the negroes
and one among the whites. The number of hospital
cases in April was about three-fourths the number
in March, while the sick rate is only twenty-one a
thousand.

Smallpox. — -According to the reports of the
Public Health and Alarine Hospital Service, in 1906
there were in the United States 12,503 cases of
smallpox and ninetv deaths, while in 1902 there were
55,857 cases, with 1,852 deaths. In Germany, where
vaccination is compulsory and universal, during 1906
there were only twenty-six cases, with five deaths,
in the whole empire.

Famine in China. — C)wing to the approaching
ripening of the new crops the famine in China is
said to be broken and the National Red Cross an-
nounces that further contributions of money and
supplies are no longer needed. The organization
has received in money contributions for Chinese
famine relief since the work was begun on Decem-
ber 24 last, $320,000, and has received, besides, a
large quantity of seed wheat and flour.

Illinois Optometry Bill Vetoed. — Governor
Deneen recently vetoed the optometry bill estab-
lishing a State Board of Optometn,- and requiring
examination and licensing of opticians. The bill
was vigorously opposed by members of the medical
profession, and notwithstanding delegations of op-
tometrists and members of the Chicago Optical
Society, who were given a hearing before the Gov-
ernor, he vetoed it.

The Optometry Bill. — The New York Senate
has passed the Optometry Bill creating an examin-

June I, 1907]

MEDICAL RECORD.

907

ing board for opticians, which really gives to tlicm
the right to practise in a limited way a specialty in
medicine, as medicine is defined in our new medical
law. Year after year the ^ledical Society of the
County of New York has had a Committee on
Legislation which has successfully fought these ef-
forts to create new boards, and it was hoped that
the law creating a single board for all sorts of prac-
titioners would do away with the need for such ef-
fort, but the refracting opticians seem not to lie
satisfied. The bill now goes to the Assembly for .
concurrence and an objection on the part of any
member of the Assembly will place it in the hands
of the Committee on Rules. The physicians of the
State are urged to write to the members of this
committee asking them to defeat this bill, and also
to the Governor, asking him to withhold his signa-
ture if the Committee on Rules fail to control it.
The following is a list of the persons to whom let-
ters are to be addressed : Hon. Charles E. Hughes,
Executive Chamber, Albany ; Hon. James W.
Wadsworth, Jr., Hon. Ezra P. Prentice, Hon. Ed-
win A. Merritt, Jr., Hon. Sherman Moreland, Hem.
James Oliver, Hon. William A. P)urns, Assembly
Chamber, Albany, N. Y.

Purchase of Property of Chicago College of
Physicians and Surgeons. — A couiinittee was ap-
pointed at the meeting of the Illinois State Medical
Society, consisting of Drs. C. S. Bacon, J. W.
Pettit, and J. Whitfield Smith, to ask Governor
Deneen to sign the bill for the purchase of the
property of the College of Physicians and Surgeons
by the Cniversity of Illinois.

Nurses Needed for the Poor. — The New York
Association for Improving the Condition of the
Poor calls for twenty trained nurses who will vol-
unteer for moderate compensation for its summer
work. Some are needed on the staff at Sea lireeze
hospitals for children and some for district work in
tenement homes. Applications should be addressed
to William H. Allen, General .\gent, 105 East
Twenty-second Street, New York City.

Reception to Professor Killian. — A reception
at which Professor Gustav Killian of Freiburg i. B.
was the guest of honor was given by Dr. Wolff
Freudenthal on last Tuesday evening.

Dr. Follen Cabot, Jr., was elected Professor of
Genitourinary Surgery at the last meeting of the
faculty of the New York Post-Graduate Medical
School and Hosnital.

Professor August Bier of Fx^nn has acceptcfl a
call to the Chair of Surgery in the University of
Berlin left vacant by the death of Professor von
Bergmann. The names of Professor Garre of
Breslau and Professor von Eiselsberg of \'ienna had
also been mentioned in connection with the I'o-
sition.

Association of Medical Librarians. — The tenth
annual meeting of this association will be held
at the Marlborough-Blenheim Hotel in .Atlantic
City on June 3, u)07, under the presidency of Dr.
George Dock of .Xnn Arbor. The secretary is Dr.
Albert T. Huntington of Brooklyn.

American Proctologic Society. — The ninth an-
nual meeting of this organization will be held in
Atlantic City at the Seaside Hou.se on June ;^ .nul }.
iqo". under the presidency of Dr. Samuel (i. ( uint
of this city. The secretary is Dr. .\. B. Cooke of
Nashville. Tenn.

National Confederation of State Medical Exam-
ining and Licensing Boards. — This organizati'm
will hold its seventeenth annual meeting in .\tl:\ntic
Citv at the Hotel Travmore on June 4, 1007. 'I In-

president is Dr. Edwin 1'.. Harve\- of Boston and the
secretary Dr. Murray Gait Motter of Washing-
ton, D.'C.

Iowa State Medical Society. — Officers as fol-
lows were elected at the meeting of this society
held in Cedar Falls, la., on May 17: President, Dr.
W. L. Biering of Iowa City; J'icc-Prcsidoit, Dr.
A. G. Shellito of Independence and Dr. H. B. Jen-
nings of Council Bluffs; Secretwy. Dr. V. L.
Treynor of Council Bluffs, reelected ; Treasurer,
Dr. W. B. Small of \^'aterloo, reelected. The next
meeting will be held in Des Moines.

The North Dakota State Medical Association.
— .\t its annual meeting held in Minot on May 15
officers for this association were elected as follows :
President, Dr. Laughlin of New Rockford ; l''iee-
Presidents, Dr. Campbell of Grand Forks, Dr.
Countryman of Grafton, Dr. H. A. Beaudou.x of
Farp-o, and Dr. H. W. Phillips of Hope ; Secretary,
Dr. J. H. Rowe of Castleton ; Treasurer, Dr. J. D.
Taylor of Minot.

West Virginia State Medical Association. —
-\t the fortieth session of this society held in Hunt-
ington on May 17 officers were elected as follows;
President, Dr. Flemming Howell ; / 'ice-Presidents,
Dr. C. O. Henry, Dr. Rader, and Dr. J. Schwinn ;
Secretary, Dr. L. W. Moore ; Treasurer, Dr. H. K.
Owens.

New Mexico Medical Association. — (Officers as
follows were elected at the meeting of this asso-
ciation held at Las Cruces on May 11: President,
Dr. R. E. McBride of Las Cruces; I'iee-Presidents,
Dr. .Angle of Silver City and Dr. P. M. Steed of
Deming; Secretary, Dr. G. S. McLandress of Albu-
(|uerque and Dr. C. I".. Duncan of .'^ocorro.

New Hampshire State Medical Society. — .\t
the annual meeting of this organization held on
May 17 in Concord officers were elected as follows:
President, Dr. John H. Neal of Rochester; / ';Vt'-
Prcsident. Dr. John M. Gile of Hanover ; Secretary,
Dr. D. E. Sullivan of Concord ; Treasurer, Dr.
D. M. Currier of Newport.

Polk County (Ark.) Medical Society. — .\t the
recent meeting of this society officers were elected
as follows: President. Dr. C. Cochran; J'ice-Presi-
deut. Dr. J. F. Rhodes; Secretary, Dr. C. C. Gun-
nels; Treasurer. Dr. D. W. Connelly.

Donation to Chicago Tuberculosis Institute. —
Mrs. Keith Spalding of Chicago recently gave to
the Chicago Tuberculosis Institute the Edward Tu-
lierculosis Sanitarium at Naperville, 111., which she
founded in November, igo6. She has also promised
to give this institution si.x thousand dollars a year.

Illinois State Medical Society. — The fifty-
seventh annual ineeting of this .\ssociation was
held at Rockford. May 21. 22. and 23, 1907. The
foll(Twing officers were elected for the ensuing year :
President. Dr. Wni. L. r.aum of Chicago; First
rice-Presideut, Dr. C. W. Lillie of East St. Louis;
Second rice-President. Dr. T. H. Culhane of Rock-
ford; Secretaiy. IV. E. W. Weis, (Ottawa, reelected;
I'reasin-cr. Dr. V.. ]. Brown. Decatur, reelected,
f i'/t'.^'(;/t\s- to the Ainericau Medical .Issociatioii.
Drs. Frank Billings of Chicago, J. R. Hollowbush
of Rock Island, and C. S. Bacrm of Cbica;i;o. .11-
ternatcs. Dr. G. D. Smith of Elizalieth. Dr. (". 1'..
Hiirrell of Galesburg, Dr. Robert T. C,illmi>re of
Chicago, Dr. E. B. Montgomer\- of Ouinc\-. Dr.
C. M. Jack of Decatur, Dr. W'm. L. Ballen!.:er of
Chicago, and Dr. S. C. Stremmcl of Macomb.
Peoria was selected as the next t'lace of meeting;
time, third Tuesday in May. inoS.
Obituary Noter.-- I'.rig.-Gen. Hkxrv S. TrRRir.,

9o8

MEDICAL RECORD.

[June I, 1907

U. S. A., retired, of New Milford, Conn., died sud-
denly of heart disease on May 24 in this city while
dictating material for a book he was about to pub-
lish. General Turril was born in New Alilford in
1842 and was graduated from the Yale Alcdical
School twenty-two years later. He was appointed
assistant surgeon to the Seventeenth Connecticut
Volunteer Infantry and served through the later
part of the Civil War. In 1875 he was appointed
assistant surgeon in the regular army and served
through the Indian Wars under General A. R.
Chaffee. He received the rank of Captain in 1880,
that of Major in 1883, Lieutenant-Colonel in 1892,
and Brigadier-General about a year ago, just before
his retirement.

Dr. Charles S.vmson Fere, for many years phy-
sician to THospice de Bicetre in Paris, died on
April 22 at the age of fifty-four years.

Sir Joseph Fayrer, formerly physician to Queen
Victoria and since 1901 physician extraordinary to
King Edward, died at Falmouth on Alay 21 at the
age of eighty-three years. In the middle of the
preceding century he served in a medical capacity
both in the army and the navy and was for a time
Professor of Surgery in the medical college at
Bengal, President "of the Medical Faculty of Cal-
cutta University, and successively Vice-President
and President of the Bengal Asiatic Society. He
was created a baronet in 1896. He was the author
of numerous works on medical topics and of a vol-
ume of "Recollections" of his life and times.

Dr. Clarence Tripp Gardner died of nephritis
on May 23 at his home in Seaconet, R. I., after an
illness of several months. He was born in Provi-
dence in 1844 and after having served in the First
Rhode Island Infantry as First Lieutenant he was
graduated from Harvard Medical School in 1866.
Dr. Guy D.wekport Lombard of this city died on
May 22 at the age of thirty-five years. He was born
in Northampton, Mass., and w^as graduated from the
New York University Medical School in 1896.
He served on the Bellevue Hospital interne staf?
and since 1898 has been Instructor in Histology in
the Cornell Medical School.

Dr. Augustus Charles Bernay's of St. Louis
died suddenly of apoplexy on ]^Iay 22. Dr. Bernays
was born in Highland, III, in 1854 and received
his medical degree from the University of Heidel-
berg in 1876. A year later he was made a member
of the Royal College of Surgeons in London, and
in 1878 he began practice in St. Louis. He was
the author of several works on surgery and was
active in introducing antiseptic methods into this
country.

Dr. Charles Simpson of Minneapolis died on
May 16 at the age of sixty-four years. He was
born in Scotland, was graduated from the Columbia
College of Medicine in 1871, and shortly afterward
began practice in Alinneapolis. He was Health
Commissioner of the city in 1875 and 1876, was the
fourth President of the Hennepin County ]\Iedical
Society, and a member of the State Board of Medi-
cal Examiners from 1895 to 1898.

Dr. John W. Suggs of Thomaston, Ga., died on
May 17 at the age of seventy-nine years. He had
practised in Thomaston for over fifty years.

Dr. Jordan Johnson, lately of Yoakum, died at
Taylor, Tex., on May 17 at the age of eighty-four
years. He had practised in Yoakum for many
\ears, but retired from active work some time ago.
Dr. George H. Watson of Brooklyn died on
Mav 26 at the age of sixty years. He was born in
Sedgewick, Me., and was graduated from Amherst

College in 1870. After receiving his medical educa-
tion in New York and Philadelphia he practised for
many years in Bridgewater, Mass. He retired from
active work in 1900 and since then had resided in
Brooklyn.

Dr. John Hooker Packard of Philadelphia died
at Atlantic City on May 20 at the age of seventy-
five years. He was graduated from the Medical De-
partment of the University of Pennsylvania in the
class of 1853. He was for many years one of the
surgeons to the Pennsylvania Hospital, but he with-
drew from active practice some ten years ago.

A NEW PL.AX OF SUTURING IN PERINEOR-
RHAPHY.

To THE Editor of the Medic.\l Record:

Sir: — To overcome the cutting of silk-worm gut sutures
in perineorrhaphy, the following plan has given excellent
results. Each needle which is ordinarily threaded with
one silk-worm gut suture is threaded with two strands of
silk- worm gut. When all the sutures have been introduced
there will therefore be two strands through each suture
line. Select one strand out of each pair and mark them
for identification by catching the ends in forceps.

Before tying said strands, by means of a needle "set
back" in sound skin the remaining strands for a distance
of about one-eighth of an inch from the edge of wound.
This may be easily and quickly done by threading an end
of each suture on a needle, introducing the needle through
the needle puncture in the skin and passing the needle sub-
cutancously beneath the skin until it emerges a short dis-
tance from the original opening. The sutures in the grasp
of the forceps are now tied in the usual way and the other
set, or those which include a trifle more of skin surface,
are not tied at this time. In four or five days, or at any
time when the tied sutures begin to "cut" and become
"buried," they are removed and the untied sutures are now
tied. It is important that as soon as one" suture is cut and
removed the one that is to take its place should be imme-
diately tied. This will prevent the strain on freshly-
adhered surfaces, which would occur if all the stitches
were removed before any of the new set were tied. The
second set may be removed at the end of ten or twelve
days from the date of operation.

The results from this plan have been excellent and the
patients have been far more comfortable. The infection,
which often starts along the suture line when the suture
begins to cut. is avoided by this plan.

William H. Bishop, M.D.

667 Madi.son .Avenue.

OUR LONDON LETTER.

(From Our Special Correspondent

PROBLEMS OF THE REORGANIZED UNIVERSITY — G.ARMENTS FOR

THE TROPICS — .\LC0HOL MANIFESTO CHEMISTS' EXPEDITION

— LFVERPOOL TROPICAL SCHOOL.

London. May lo. 1907.
The reorganization of the London University seems to
have given satisfaction to no one. The public has not
endowed it as liberally as its friends anticipated ; its own
alumni are torn by dissension as to the results of the
change and what they wish for the future, and much the
same may be said about outsiders concerned with educa-
tion in general. With regard to the medical faculty, there
are several points of dispute, and discussion has become
acrimonious, and personalities have been introduced. All
these I pass over, and will refer only to points of general
medical interest. First of all, the position as to students,
for pupillage must precede graduation — indeed, without a
supply of students there would be no graduates. It was
hoped that the medical students of London would be able
to graduate in the reorganized university as fully and, so
to say. as naturally as those of other university centers.
But no such result has followed the changes, and while
many lament the fact, others rather rejoice, protesting
that the obstacle they have leaped over shall not be dimin-
ished, forgetting or unconscious of the fact that some of
those obstacles were absurd hindrances to their intellectual
development, and merely matters of regulation. It is
really pitiable to hear a man who has taken a degree
object to a change in regulations which have been shown to
be useless hindrances, and to cry out that such changes
would lower the value of his degree. The truth seems to

June I, 1907]

MEDICAL RECORD.

909

be that many of the defects of the old constitution iiiliere
in the University, and it may be long before all are removed.
The University was established as an Examining Board,
and promised a degree to all who were able to pass the
tests. A person privately educated within the walls of a
scliool or college was promised equality with those taught
in academical institutions. The promise was broken by
regulations incompatible with the medical curriculum. The
most important of these was the insistence of matriculation
prior to entering a medical school and making tlie standard
of the matriculation examination that of a minor degree.
The student who began hospital work before he had found
out this strictly enforced rule, discovered too late that
he must sacrifice tlie time and money he had spent on th'e
hospital school, as none of that could count, because he had
not previously passed the matriculation. Here and there
such a student made the sacrifice, turned again to his earlier
subjects of instruction, and, after passing, came back to
the hospital and began again his first session's work in
order to secure certificates of attendance on first year's
lectures, etc. Thus much money and time was wasted, and
few could afi'ord it ; for one who could, dozens could not.
I know this from long experience as a teacher. The diffi-
culty of the examination, so much complained of, arose
from two causes, the first being the subjects were numer-
ous and must all be passed at the same time, rejection in
one being fatal in all ; the second, the constant effort of
examiners to keep up the standard, each examiner holding
his own subject as most important, and the constant change
of examiners exposing the student to new assessors of his
marks. The crotchets of examiners became a study for
crammers, who were so successful that the majority of
candidates called in their aid. The medical degrees of the
University attained a high reputation on the ground that
each stage the examination was difficult, but it was to so_
great an extent merely book work and cramming that
succeeded that the defects of young graduates in clinical
experience and practical knowledge became proverbial.

Now about the proposed Institute of the Medical
Sciences. You will remember that I wrote to you about
it at its inception. The Royal Commission recommended
the early subjects of the curriculum to be concentrated in
one or more centers. University College, as I reported to
you, is now such a center, and King's will soon complete
its arrangements. The third center was to be the Insti-
tute. An appeal for its endowment was issued, a site at
South Kensington was granted, estimated as worth about
fiSO.ooo. while nearly half as much cash was subscribed,
and the King and the Prince of Wales approved the
scheme. The medical faculty was understood to be satis-
fied with the prospect of a magnificent institution which
would serve as the third center, but lately diflferences have
arisen, and after acrimonious discussion the faculty has
voted the rejection of the scheme, the blame being cast
upon the hospital schools, which, it is said, cannot com-
pare their diflferences or, as some say, their jealousies.

The manifesto or joint testimonial to the value of alcohol,
which, as I told you some weeks since, was signed and
sent to the Lanci't by sixteen physicians and surgeons, as
if they represented the profession or could modify the
former declarations signed by thousands, has already begun
to produce evil fruit. It is issued by the Licensed Victual-
lers Central Protection Association and can be seen in
many a publican's bar. The Medical Press and Circular
has issued a countermanifesto, and is satisfied with tlie
response so far. but it will take some time to see what
comes of it. Men may be tired of manifesting and shun
entrance to the controversy.

The Chemists' Exhibition was opened on Monday and
closes this evening. It seems to have been as successful as
usual. Of course, it includes much that is of only secondary
interest to the medical profession, but a very large part
demands and receives its close attention and is well worth
seeing.

The Liverpool Tropical School has spent fSo.ooo on its
expeditions, with most important results. Sir A. Jones,
president, gave a farewell banquet to the new expedition
on sleeping sickness. The next step will be one for black-
water fever, and will probably start in August.

Tertiary Syphilitic Fever. — Luigi D'Amato publishes
three cases of tertiary svphilitic fever with the results of
treatment and gives us the results of his observation^ and
a review of the work of other authors. He states that
syphilitic fever may begin in the early secondary period
and last into the tertiary period. It may or may not be
accompanied by visceral manifestations, especially in the
liver, but the fever does not seem to be dependent on these
lesions. It mhy fall spontaneously without specific treat-
ment, but easily returns. When specific treatment is given
it falls by lysis. — La Riforma Mcdica.

THE PHILIPPINE ISLANDS MEDICAL ASSOCIA-
TION.

FOURTH ANNU.SL MEETING.
(From Our Special Correspom'.ent.)

.\t the fourth session of the Philippine Islands Medical
Association, held March i, the first paper read was entitled
"The Transmission of Leprosy to Apes," by Moses T,
Clegg, Biological Laboratory. Bureau of Science. The ex-
periments recorded were entirely negative, but it was in-
teresting to observe that at intervals of two weeks for a
period of three months acid-fast bacilli were found in the
adjacent glands near the site of the inoculation in the
monkey w-hicli was used for the experiments, and further
work with this particular animal was interrupted on ac-
count of its death from an intercurrent disease. He also
stated that organisms injected in symbiosis disappeared
from the site of the inoculation a few days afterward, but
those injected in pure cultures could be recovered from
three weeks to three months afterward.

The next paper, entitled "The Fate of the Agglutinins
Upon Filtering an Immune Serum," was read by Dr. Ralph
T. Edwards, Biological Laboratory, Bureau of Science.
This paper will be published in the Philippine Journal of
Science.

A paper entitled "On Cultivation of the Piroplasma"
was then read by Dr. Kannosuke Miyaiima, of tlie Insti-
tute of Infectious Diseases at Tokio, Delegate from His Im-
perial Japanese Majesty's Government. He stated that
whatever success he had had in accomplishing this was
due to the information he obtained from the work which
has been accomplished by Novey and McNeil in cultivating
the Trypanosoma Icwisii. He took for his investigation
the bovine piroplasma, which is very common in Japan.
He stated the parasites found were in apparently healthy
animals, were mostly of small bacillary forms, while the
larger piroforms were ring formed bodies and were only
seen occasionally. LIpon the full-grown state of the or-
ganism being reached, its length is found to be more than
three times the diameter of a red blood corpuscle. The
organism possesses a well-defined undulating membrane and
long, flat flagella ; moreover, the position of the nucleus
and blepharoplast of the body of the flagella renders it
impossible to distinguish the organism from typical trypan-
osomata. The infected blood was taken from the jugular
vein and quickly defibrinated under strict precautions to
avoid bacterial contamination. The blood thus obtained is
mi.xed with ordinary nutrient bouillon in proportions vary-
ing from one-fifth to one-tenth, and kept in sterile test tubes
at a temperature of 20° to 30° C. The development of the
parasite occurs as follows : On the first day no motile
form was seen in the culture ; second day there occurred
a certain number of peculiar cells, which occupied the upper
layer of the sedimented corpuscles and appeared macro-
scopically as whitish dots. After these cells were found,
motile forms resembling typical trypanosoma were visible,
upon the third day after inoculation. Thereafter the organ-
isms multiplied vigorously, and reached the maximum num-
ber somewhere between ten and fourteen days. The cul-
ture contained motile trypanosomata at room temperature
for at least forty-five days, after which most of them under-
went deterioration and resulted in irrecular granular glob-
ular cells. In cultures preserved at a lower temperature,
ranging from ten to twenty degrees C, the organsims re-
mained alive for three months. Sub-cultures were readily
obtained by inoculating from the original strain. The
number of native cattle in Japan which have so far been
examined microscopically already amounts to 200, but in
not one of these could trypanosomata be found. He also
invites attention to the fact that, so far, trypanosomiasis is
entirely unknown in Japan. He gave the following con-
clusions: I. That the kind of hemacryptozoa known as
Pirol^lasnia parvum can readily be cultivated outside of the
living body. 2. The parasites undergo a developmental
change in the bouillon and finally have the typical form of
tiypanosomata. which cannot be detected in the tlood of
the infected animals. 3. That a simple mixture of blood and
bouillon is the most suitable medium for the cultivation of
these parasites, Piroplasma parvum, and Trypanosoma lezv-
isii. In the preliminary experiments with the cultivation of
piroplasma different, culture media were tested, namely,
blood agar, sodium citrate, broth in acidulated and unacid-
ulated condition, beef broth, peptone, calf serum, physiolog-
ical salt solution, and common boijillon. On the 4th of
July, 1906, he found motile organisms in one test tube,
which contained a small amount of infected blood mixed
with sodium citrate solution, prepared after Rogers' method.
The entire series of cultures were then subjected to a care-
ful examination, but no motile organisms could be found
e>cept in the bouillon.

910

MEDICAL RECORD.

[June I, 1907

■J'he next paper, entitled "The Filtration of Antiserums,"
Mils read by Dr. E. H. Ruediger, Biological Laboratory, Bu-
rt an of Science. He stated that on account of the diffi-
culties met with in endeavoring to obtain antiserums for
prophylactic purposes, free from corpuscles, precipitate, and
uael'.ria, it was tliouglit advisable to study the effect of
passing the serums through a BerUfclt filter. This had pre-
viously been attempted by Woolley, of the I^ureau of Sci-
ence, with rinderpest scrum, but had been abandoned be-
cause the scrum would not pass througli the filter. Re-
cently, however, the method was again attempted, and it
was found that such serum would readily pass through,
provided the blood is free from blood corpuscles, precipi-
tate, and other extraneous matter which would clog the
filter. These substances were easily removed by centrifu-
gation for thirty minutes witli a speed of 3,000 revolutions
per minute. The serum thus obtained was perfectly pure,
free from bacteria, and apparently has lost none of its
efficacy. .\t the same time it reduces the danger by tiller-
ing the bacteria with which it may have become contam-
inated during the process of handling. He laid great
stress upon the fact that the filter must be cleaned imme-
diately after it has been used, otherwise the filter would
become clogged by the accumulation which necessarily
takes place during autoclaving. The best method of clean-
ing the filter has been found to scrub it with a brush in
running water and then passing through it a liter or more
of distilled water, and, before using it again, the filter
should be boiled for at least five minutes in distilled water
and then washed out by passing distilled water through it.

.\ paper on "An Experimental Investio'ation of the
Causation of Beriberi," by Dr. W. V. N. Koch, Medical
Ofticer in Charge of the Infectious Disease Hospital, Hong-
kong, was then read by Dr. J. M, Atkinson. He stated
that those observers who claimed to have found the micro-
coccus which was the cause of the disease were unquestion-
ably wrong in their views. In order to exclude the pos-
sibility of the existence of microorganisms, the following
work was undertaken : i. An examination of blood films
made from several hundred cases, stained by different
methods; also by 10 to 20 c.c. being withdrawii from pa-
tients and different culture methods used, and also by the
blood being transferred directly from patients to animals.
2. Spleen punctures w-ere made in nearly too cases, and
the blood treated as above. 3. Drops of fluids from the
subcutaneous tissues were examined culturally. 4. Cere-
brospinal fluid drawn by lumbar puncture. ' 5. Smears
and cultures from from organs and tissues of fresh
cadavers were made especially from gastroduodenal mu-
cous membrane. In all of the foregoing experiments
he failed to find any specific pathogenic organism. After
the failure of the above series of investigations, efforts
were made to demonstrate the possibility of infecting
monkeys by natural means. The rooms in an institution
at which an epidemic of beriberi broke out, which were
occupied by the inmates who had contracted the disease,
were allowed to remain exactly as they had been during
occupation, and the conditions maintained as near to norinal
as possible, except that shutters were closed and the doors
made fast. In each of the four rooms two monkeys were
turned loose and were kept incarcerated for nearly five
months, and were subsequently kept under observation for
one year. None of them, after most careful examination,
showed signs of beriberi. .Associated with these monkeys,
rabbits were also placed in the same rooms. After this,
some feeding experiments were undertaken. Monkevs were
fed from freshly drawn defibrinated blood from beriberi
cases, from 30 to 40 c.c. being used, the dose being repeated
a number of times. .An emulsion of the medulla and pons
varolii from recently fatal cases of beriberi were fed to a
monkey. .Afterward the monkey was inoculated subcu-
tancously with blood freshly drawn from a case of acute
beriberi, probably 5 c.c. were transferred directly from the
arm of the patient to the animal. This caused a slight rise
of temperature, which subsided, and the animal appeared
none the worse. He also inoculated spleen blood and an
injection of cerebrospinal fluid. Practically the same ex-
periments were repeated in pigs, sheep, calves, rabbits,
fowls, and horses, all with negative results. The conclu-
sions were as follows: i. Beriberi could not be conveved
to any of the animals used for experiments. 2. It would
appear that transference of beriberi infection from man
to animals is impossible. 3. In beriberi we are dealing
with an infectious disease, but with one of an entirely
different etiology.

The next paper was entitled "Leprosy in the Philippine
Islands and the Present Methods of Combatino' the Dis-
ease," by Dr. Victor G. Heiser, Director of Health. P. .A.
Surgeon U. S. P. H. and M. H. Service. This paper will
be published in full in the Medic.\l Record.

The next paper. "The Habitual L'se of Opium as a Fac-

tor in the Production of Disease Among Chinese," by Dr.
Tee Han Kce, Municipal Physician, City of Manila. He
stated more particularly that since the opium law in the
Philippines went into effect the Chinese had taken
more and more to the hypodermic use of the drug, and that
in his opinion the opium habit caused by the hypodermic
use was more difficult to cure than that of any other form.

OUR VIENNA LETTER.

(From Our SpecU! Correspondent )

DEATH OF MOSETIG MOORHOF — A SYMPTOM OF SCI.ATICA — THE

DIFFEKE.VTIAL DIAGNOSIS OF NEURALOI.\ AND TOOTHACHE —

THE ERUPTION OF S.MALLPOX — EPIUE.MIC CEREBROSPIXAL

MENINGITIS.

Vienna. .May i, 1907.
The tragic death of Prof. Albert Mosetig von Moorhof
occurred through accidental drowning in the Danube on
April 26. In him the faculty of Vienna loses a scientist
whose name has been an ornament to science. Hofrat von
Mosetig w-as one of the most prominent and popular
Viennese surgeons and was particularly renowned for the
advances he had brought about in military surgery. He '
gathered rich experiences in the Franco-Prussian war, in
the Bosnian campaign of 1878, and in the Servian war of
1885, which he utilized in numerous contributions to medi-
cal literature. He introduced iodoform into surgical prac-
tice in Vienna and was the inventor of the method of filling
bone cavities with an iodoform paraffin mixture. He was
born in Triest in i8'<8 and in 1861 received his medical
degree from the L'niversity of Vienna. .After serving for a
time as assistant to Dumreicher, he was, in 1874, appointed
Professor of Surgery. In 1871 he was made Chief Sur-
geon in the Wiedener Hospital, and twenty years later re-
ceived a similar appointment in the General Hospital.

Sigmund Gara has described a hitherto unknown symp-
tom of sciatica. He observed that patients frequently com-
plained that the onset of the sciatica had been preceded for
days or weeks by more or less severe backache, and it was
only on the subsidence of this that the pain appeared in the
lower extremities. He therefore examined the spine in
such cases and observed that on pressure over the spinous
process of the last lumbar vertebra very severe pain was
occasioned, which was less both above and below. Pa-
tients who did not complain of backache also exhibited
this symptom, Gara also treated a series of cases sup-
posed to be of sciatica in which there was carcinoma, frac-
ture of the neck of the femur, tumor of the prostate, etc.,
and in these the above mentioned symptom was either ab-
sent or a number of spinous processes were painful. He
accordingly claims that the painful point over the spinous
process of the last lumbar vertebra is to be regarded as
asign of sciatica only when no other vertebrae are painful.

Franz Berger has studied the problem of the differentia-
tion of neuralgia and toothache. He has found that the
faradic current offers an excellent means of detecting
diseased teeth. The faradic current, when applied to the
well-dried teeth, if they are healthy, causes only a tingling
sensation, but if the teeth are diseased severe pain is occa-
sioned. In the case of a woman whose teeth were hand-
some and appeared healthy, severe and intractable ncuralfic
pains had persisted for more than a year. By means of the
method just described it was discovered that two teeth
were diseased and on devitalizing their nerves the pain
promptly disappeared.

Carl von Pirquet has described a theory of the smallpox
eruption in a communication presented before the .Asso-
ciation of Physicians. He believes that in the early vac-
cinial eruption occurring within twenty-four hours the in-
flammation is caused through the contact of the lymph with
bacteriolytic antibodies present in the previously vaccinated
body. The inflammatory symptoms attending the first vac-
cination, which appear in from eight to ten days, such as
the areola and fever, are also to be regarded as caused by
toxic products formed through the action of newly devel-
oped antibodies. The antibodies which go to the forma-
tion of the eruption may be agglutinins through which the
causative agents of the disease circulating in the blood are
clumped together in the capillaries. This is also indicated
by the histological reports of Weigert, who found in the
blood-vessels under fresh papules and in the internal or-
gans tubular zoogloea-like masses. Measles resembles
smallpo.x not only in its incubation period, prodromal fever,
and leucocyte curve, but also in the fact that in cachectic in-
dividuals the exanthem is reduced in intensity and is more
pronounced the greater the powers of resistance of the pa-
tient.

For some weeks numerous cases of cerebrospinal menin-
gitis have been reported in Vienna. The cases are fre-

lune I, 1907]

MEDICAL RECORD.

911

quently atypical . or abortive and occur in all quarters of
the city. Most of them are severe, but under suitable treat-
ment— lumbar puncture and serum injections — give a sooJ
prognosis. In one of the southern Austrian provinces an
investigation has lately been held fo» the purpose of de-
termining tlie necessary prophylactic measures. One of tlie
most important of these is said to be the examination of
all persons coming in contact with the patient and who are
suffering from nasal catarrh, as many of these are found
to have meningococci in the nasopharynx. When tliese are
found, suitable disinfecting sprays ar.e to be used, and
disinfection of the body and bed linen of the patients is
also recommended.

Prngrpss of iHrbtral ^rintrr.

.Veil' Voil: Mcdiciil Journal. May iS, Itjoj,

Backward and Defective Children. — H. Shmniakcr
has examined many pupils during the last three
years in public and parochial schools and con-
siders that the greatest possible relief would
come to them by the adoption of the following
rules : First, the relief of all physical defects so far as
possible. Second, placine a teacher in charge of a limited
number of children. Third, in compelling a home report,
from personal observation of the teacher in charge of the
actual work, in order that cruelties and ne.glect may
receive proper investigation, or that a teacher may not
unwittingly be trving to force an infant mind. .Fourth,
in making the session shorter. Fifth, in demanding a
concession from the parents, which may be implied by
admission to the special class, for the corr.ection of all
physical defects in their children. Sixth, the employment
of manual training, wliich may create dexterity, even
though the power to originate is lacking. Seventh, physi-
cal culture and outdoor gymnastics, when possible.

External Hemorrhage with Ectopic Pregnancy. — J.
Oliver describes the customary cause and features of
ectopic pregnancy, noting that when the oosperm is ar-
rested permanently outside the uterus, especially in tlie
Fallopian tube, it experiences during the full six weeks of
its existence so much difficulty in obtaining nutrition by
osmosis that it is compelled to unduly hasten not only
the vascularization of the chorionic villi, but also the
transmutation of those structures which is the prelude to
the evolution of the true placenta. The acceleration of
these embryonic changes arouses unduly and hastens the
activity of the maternal tissues, hence the capillaries lo-
cated in the lining of an ectopic gestation sac begin to
enlarge earlier and are therefore prone to rupture much
earlier than the enlarging endometrial vessels of a normal
pregnancy. Thus influenced these capillaries become great-
ly dilated, and if their extrinsic support is weakened the
capillaries may rupture. .\ portion of this blood may
find its way to the external genitals. At other times, by
a process of vital thinning, a tubal gestation may invade
the broad ligament. The placenta may not be disturbed
by this invasion and the gestation proceeds uninterruptedly
to maturity in the tube and ligament conjointly. Under
sucli circumstances any external hemorrhage noted will
come solely from the vessels of the endometrium. The
author has already operated in five cases of full time ec-
topic gestation, extracting the child in each by abdominal
section. In two of these patients there was complete
amenorrhea during a period of nine months, in the remain-
ing three e.xternal hemorrhage was not an important
symptom: it was of infrequent occurrence and of short
duration, seldom lasting longer than a few hours.

Surgical Treatment of Fibroid Tumors of the Uterus
Complicated by Pregnancy. — J. \ance refers to the
statistics of this condition, analyzing seventy-two eases
collected from literature, reporting one personal case.
His general conclusions are thus summarized: (i) -A-ll
cases of fibroids complicated by pregnancy should be treat-
ed surgically and not obstetrically. (2) Myomectomy
should be performed only in such cases found suitable for
this operation. It is otherwise dangerous. {.^) Cesarean
section should be done for all cases of fibroids compli-
cated by pregnancy at term. (4") .All cases of abortion
or miscarriage which cannot be stopped should be imme-
di.itely submitted to hysterectomy. (5) All cases in
which the size of the tumor, pressure sypmtoms, or any
other cause endangers the life of the mother, should have
hysterectomy performed. (6) Craniotomy is bad practice
at any time and never justifiable on a viable child. (7^
.All these cases should be sent to the hospital for obser-
vation when threatened with abortion or miscarriage, and
likewise all full term cases a short time before term, so

that sur.gical procedure can be undertaken with all the
care and deliberation of every day major operations. When
the above rules are conformed to, many mothers and
children will be saved who are now lost.

Drainage in Operations upon the Biliary System, —
H. Lilienthal reports four cases, one recovering. He be-
lieves that in chronic, profound obstructive jaundice we
should secure gradual drainage and be careful not to too
suddenly relieve hepatic tension. If the size and condi-
tion of the gall-bladder permits, a simple cholecystostomy
should be performed as a temporary measure, making the
stoma very small so as to prevent the too sudden relief of
tension. The operation for radical cure by whatever
means may be necessary should be postponed until the
conditions have become favorable. In accomplishing this
temporary relief great precautions should be taken to pre-
vent the formation of adhesions which might embarrass
the operator at the subsequent step. Gauze iiackings should
be dispensed with, and there should be as little handling
of the viscera as possible, using the rubber gloved hand
without gauze during the manipulations. In infections
cholangitis, drainage as early and complete as possible
should be the rule. Here we have to do with an active
spreading infection and quick removal of as much of the
harmful material as rapidly as possible is desirable. In
noninfectious and acute (short of six weeks) jaundice
drainage by the natural channel into the bowel with suture
of the wound in the duct is the most desirable course to
follow. In acute obstruction of the cystic duct with no
antecedent jaundice, the removal of the cause will often
suffice. If the gall-bladder is distinctly diseased or if
there is stricture of the cystic duct cholecystectomy with
ordinary wound drainage is the best procedure. When
there is a history of jaundice, however, one should con-
tinue the incision into the common duct in order to be as
certain as possible that the way into the duodenum is
clear. Drainage will not be required if there has been
obstruction by a solitary non-facetted stone, but if the
calculus was soft and friable, perhaps a mass of bile sand,
very long continued drainage should be the rule. In
chronic jaundice with a small, thick gall-bladder contain-
ing no bile, it is best to perform cholecystectomy, explore,
and drain. In cholemia from obstructing new growth
external drainage of the gall-bladder is the correct pro--
cedure for the relief of the icterus. In pancreatitis, even
without jaundice, drainage by way of the gajl-bladder will
often effect an apparent cure.

Journal of the American Medical Association. May 25,
1907.

Medical Legislators of Two Republics. — C. A. L.
Reed draws a striking contrast between the proportions of
medical men in the legislative bodies of France and the
United States. There are ninety-two physicians in the
two houses of the present French Congress, the Ninth,
elected last year, while in our last Congress, the Fifty-
ninth, that has just adjourned, there were only four, one
in the Senate and three in the House. The contrast is the
more striking when we consider the respective populations
of the two countries. France, 38,000.000 in 1906, and the
United States, estimating on the basis of the census of
1900, approximately 85,000,000, and still more so when we
take into account the number of physicians in the two
countries — 122,000 in the United States and in France
hardly one-fourth of that number. Dr. Reed goes over
the list of French deputies and senators and shows how
many professionally prominent men it includes and how
high they stand in public estimation, judging from the
honors they have received. Special notice is given to
Drs. Clemenceau and Combes. Our present medical rep-
resentation in our own Congress, while eminently re-
spectable in quality, makes a very poor showing in quantity
as compared with that in France. It would seem, as Dr.
Reed says, that the medical profession in the United States
is not doinff its full duty in these higher activities of
.American citizenship. .A partial list of members in State
legislatures is also appended.

Isoagglutination of Human Corpuscles. — L. Hektoen
describes the phenomena of liuman isoagglutination, or the
clumping of the corpuscles of one person by the seruin
of another person. Three classes of persons exist as re-
gards isoagglutination: (il Those whose corpuscles are
not agglutinated by the sera of groups 2 and 3, but whose
sera agglutinate the corpuscles of groups 2 and 3: (2)
those whose corpuscles are agglutinated by the sera Qf
group ,3 (and group i) and whose sera agglutinate the
corpuscles of group 3; (3") those whose corpuscles are ag-
glutinated bv the sera of group 2 (and group i), and whose
sera agglutinate the corpuscles of group 2. There are the

912

MEDICAL RECORD.

[June I, 1907

three corresponding aggfliitinins, and others no doubt oc-
cur occasionally. Of 76 persons whose blood was studied
by Hektoen, 36 belonged to group i, 26 to group 2, and
14 to group 3. Of the 14 persons in group 3, 6 were with-
out any agglutinin, hence it appears that about 90 per
cent, of all persons possess isoagglutinin of one kind or
another. There is no striking alteration in the agglutina-
tive grouping of persons with various disease, more par-
ticularly pneumonia, typhoid fever, scarlet fever, and ad-
vanced pulmonary tuberculosis. That human isoagglutinins
are bodies with special aftinitics for the corpuscles on
which they act is evident because corpuscles absorb only
the agglutinins by which they are agglutinated. The
amount of agglutinin varies considerably in sera from
dit¥ercnt persons, and corpuscles of the same group vary
in their agglutinability by the same serum. Human ag-
glutinins are stable bodies; they resist heating to 60° C.
for thirty minutes, pass through porcelain filters, and per-
sist for months in serum kept in the icebox. They are
distinct from the isoheinopsonins of human serum. Their
practical importance is in connection with the determina-
tion of the opsonic index and the transfusion of blood.
The occurrence of isoagglutinins in human blood suggests
a danger in homologous transfusion by causing erythrocy-
tic agglutination within the vessels of the subiect trans-
fused. The possible danger can be avoided bv selecting
a donor whose corpuscles are not agglutinated by the
serum of the recipient and whose serum does not ag-
glutinate the corpuscles of the latter; that is, the donor
and recipient should belong to the same group and pref-
erably to group I or 2.

Typhoid Fever from Infected Milk. — J. V. Shoe-
maker reports an epidemic of typhoid fever occurring
in Philadelphia from infected milk. Over twenty patients
from one apartment house were taken with the disease
within two weeks. The board of health officials made
a thorough investigation of the premises and the sanitary
conditions. Inquiries concerning the drinking water w'ere
made, and it was found that all the patients used either
filtered or boiled water. The food and milk supply was
then considered. A culture made from the milk sho\ved
the presence of typhoid bacilli. It was found that the
same milkman su,oplied all the apartment and boarding
houses from which typhoid cases had been reported. The
proprietor and one of his servants were both ill with
typhoid ; the son was convalescing and was filling the
milk bottles from a tank by siphonage, starting the flow
by sucking with the mouth at one end of the tube. A
culture made from one end of this tube revealed typhoid
bacilli. Shoemaker states that he does not know of any
other case in which typhoid was transmitted through
the saliva.

Thymic Tracheostenosis. — Chevalier Jackson reports
the seventh case on record of the cure of "thymic asthma"
by thymectomy, the lirst demonstrated radiographically,
and the only one, he claims, in which the mechanical com-
pression pathology was proved by direct tracheoscopic
observation during life. He gives his conclusions, in
substance, as follows : i. Friedleben's dictum that there
is no thymic asthma is an error. The thymus in this
case did compress the trachea sufficiently to diminish and
to obliterate momentarily its lumen. Thymic tracheo-
stenosis seems a better name for these cases. 2. The
dyspnea in this condition is worse in the erect position,
and it is expiratory, as might be expected from the
increased intrathoracic expiratory pressure and as demon-
strated tracheoscopically in this case. The mechanism of
this was demonstrated by the flopping out and in of the
elevated gland before it was severed. 3. A radiograph is
a valuable diagnostic aid. 4. An absolutely positive diag-
nosis can be made with the tracheoscope. Upper tracheos-
tomy is probably not safe in these cases. Tracheostomy
should be done under infiltration anesthesia and should
be high, so as to be as far away as possible from the
thymectomy wound. 5. A long tracheal cannula, reaching
to within a centimeter of the bifurcation, renders the
breathing free and the operation of thymectomy safe from
risk of asphyxia. 6. The thymectomj' is indicated and
is best done by the insertion of the little finger from
above downward, behind the sternum through a transverse
incision, after double sternocleidomastoid tenotomy. The
insertion of the finger should be of brief duration, as,
though there is no danger of asphyxia, there seems to be
serious cardiac inhibition, probably from compression of
nerves about the esophagus. Care should be taken not to
injure the pleura. 7. An almost complete thymectomy is
without effect on either the blood or nutrition. The arti-
cle is illustrated.

The Lancet, .l/<iy 11, 1907.
Paratyphoid Fever Following Removal of an Ovarian
Cyst. — A case is reported by \V. Tliyne whose patient

was a woman of 38 years, from whom an ovarian cyst was
removed, the pedicle being doubly twisted and there being
omental adhesions. About two weeks after operation her
temperature began to rise and she entered on what was
apparently a typhoid stage, there being pea-soup stools and
rose-colored spots. No enlargement of the spleen could
be detected. No cause for these symptoms could be traced
to the operation. The serum did not show the reaction
characteristic of typhoid fever, but with certain strains of
paratyphoid cultures (though not with all the strains
employed), reaction was sufficiently definite to lead to the
diagnosis stated above. The author says that if in such
cases a diagnosis of typhoid is positive, and the treatment
is as customary, no harm results, but when reaction to the
Widal test is repeatedly found to be negative, and the case
runs a mild course, the diet may be less restricted than it
should be, disinfection may be neglected, and disastrous
results may follow. He adds that it is only by a bacterio-
logical examination of the blood that typhoid and para-
typhoid can be distinguished.

Perforation in Typhoid Fever in Relation to Blood
Pressure. — Five cases are summarized by A. L. Shep-
pard, who tabulates the prominent symptoms. It appears
that the pulse rose in 4, and in one was the only marked
feature. Peritoneal symptoms were diagnostic in one,
while some pain was present in all. The temperature rose
in 3. but fell later. Leucocytosis was marked in one, but
other signs made the diagnosis of perforation unmis-
takable. The blood pressure was in no instance the only
sign. The author's general conclusions are that the rise
of blood pressure is not as certain a diagnostic guide, as
some authors have claimed. The signs of perforation,
however, are notoriously uncertain, and in no case of
typhoid fever, with fairly sudden abdominal pain, combined
with any one well-recognized sign (providing there is no
other ascertainable cause), should we hesitate to diagnose
a perforation. Among these signs should certainly be placed
a rise of blood pressure. It seems quite as constant as leu-
cocytosis. and is certainly more easy to observe and chart
throughout the course of the disease. A disadvantage that
may arise is that owing to restlessness it may be impossi-
ble to make an accurate estimation. It will not be com-
mon to meet with cases in which violent hemorrhage oc-
curring with perforation renders the pulse imperceptible.
In any such case, however, the seriousness of the condition
is obvious and the loss of the knowledge of the blood
pressure immaterial. All the author's estimates were taken
with Martin's modification of a Riva-Rocci sphygmomano-
meter. In the diagnosis of perforation we must remem-
ber that the signs are nearly always most marked about
two hours after the accident has occurred, after which they
are usually found to return to their previous coivditions,
and consequently impressions likely to be made on those
who see the case at a later stage are often liable to be
misleading. The change in blood pressure is no exception
to this rule, as the tendency seems for it to fall again to
its original level as rapidly as it has risen. In conclusion,
one may generally regard, says the author, a rise in blood
pressure as positive evidence of perforation, although a
stationary pressure is no sign that the perforation has not
occurred.

Status Lymphaticus. — L. Vintras discusses the his-
tory of this symptom-complex in medical literature. The
lymphatic diathesis is not easy to determine. It occurs
mostly among tall, rather sparsely built subjects, with
fair, clear skins, rather pale, but not with the dead-white
pallor of anemia. These patients are of a slow sedentary
habit of life, are highly intelligent, self-concentrated, and
retiring among strangers. They are very sensitive to
climatic influences and they feel the cold keenly. In
appearance they are listless and careless, aad give the
imnression of being indifferent to things in which inwardly
they are greatly interested. They are emotional, but sup-
press their emotions. Their fits of anger are concentrated
and they are still and turn to a death-like pallor, where
others flush red and fly into a passion. There is nothing
about them of the spasmodic excitability of the nervous
temperainent, nor of the hopefulness of the tuberculous
temperament. Their rjulse is usually slow, sometimes very
slow, averaging as low as 45 to 50; but under the stress
of worry or emotion their pulse-rate will rise to above
100 and remain so for days and even weeks without any
apparent ill-effects. It is the same with the heart beats,
and it is this which constitutes one of the chief dangers
of this condition. Under some strong emotion, but often
without any cause, the ratio of the heart beats will double
or treble, not in the irregular way, tM^ical of nervous
palpitations, but with a steady rise, the heart maintaining
a perfectly regular but highly accelerated action. The au-
thor believes that in these cases the flabby walls of the
heart become suddenly dilated and as suddenly return to
their former state. It is quite comprehensible that during

June I. 1907]

MEDICAL RECORD.

913

such a paroxysm any interference with the nerve centers
may cause the dilated walls of the heart to cease con-
tractin.sf. He thinks that this accounts for many cases
of sudden death where no adequate pathological lesion
seems to exist. In such patients all catarrhal inflamma-
tions are apt to drag on for weeks. Gonorrhea degenerates
into gleet and after a long time may clear up or eventuate
in joint troubles. Pleurisies are obstinate and ,the pleurre
exudate will return again and again. Slight injuries may
lead to cold abscesses of a size out of all proportion to
the cause. Such patients are, on the other hand, less liable
to neurotic and tuberculous affections. They have a dis-
tinct tendency to improve with advancing years.

The Opsonic Index to Various Organisms in the
Sane and Insane. — This subject is discussed by C. J.
Shaw, who considers the question with special reference
to the results produced by injecting tuberculin, .^ftcr
detailing his experiments, he offers the following con-
clusions: (l) As .the insane are particularly liable to
tuberculous infection a comparison of the average indices
recorded in the sane and insane and also in the various
classes of insane patients would indicate that the opsonic
power of the blood serum can be used as a measure of
liability to infection and that a low opsonic index pre-
cedes infection. (2) The injection of a small dose of
tuberculin T. R. in healthy persons produces no negative
phase to the tubercle bacillus and therefore may be used
as a method of diagnosis. A smaller dose of tuberculin
will, however, produce a negative phase in a predisposed
person than in one less liable to tuberculous infection. (3)
To determine the value of a negative phase after in-
jection the daily variation in opsonic power as well as
its level at the time of injection must be estimated. For
this reason a number of consecutive observations are neces-
sary; a single, or a number of isolated observations is not
sufficient. (4) The average opsonic indices of healthy indi-
viduals vary little in different organisms. (s) The
injection of a large dose of tuberculin even in healthy
individuals causes a fall in opsonic power to other or-
ganisms than the tubercle bacillus. This explains the
liability of tuberculous cases to secondary infection. For
purposes of differential diagnosis by the production of a
negative phase a very small dose must be administered.
(6) Large doses of tuberculin can be injected into healthy
persons without producing constitutional symptoms.
Amount of dose may therefore be a matter of diagnostic
significance, as a small dose causes a reaction in infected
cases.

British Medical Journal, May 11, 1907.

Vicious Circles. — J. B. Hurry defines a vicious circle
as a morbid condition in which cause and effect are so cor-
related that cause becomes effect and effect cause. Mor-
bid processes are often but exaggerations of physiological
ones. A healthy cycle is shown in the processes of hemo-
genesis and hemolysis by which the adjustment between
the birth and destruction of the blood cells is eft'ected.
Vicious circles are grouped, according to the author, into
I. Organic: An example is seen in acute pneumonia.
Dilatation and consequent heart failure are one of the
chief dangers, being caused by the increased resistance in
the solidified lung. This retards the circulation through
the hmg, hence throwing more work on the heart, which
is already impaired. 2. Symptomatic: e.g. pulmonary
hemorrhage sets up coughing; result of cough is increased
hemorrhage. 3. Infective: Frequently in 2"'"io"^''i-
tuberculosis the patient inoculates himself afresh with
sputa from the primary tuberculous lesion. 4. Neu-
rotic : In neurasthenia protracted and uncontrolled repose
may set up a vicious circle by so deranging the digestive
system and affecting the general health that all inclina-
tion for physical and mental exertion vanishes. 5.
Chemical : A chemical vicious circle occurs in diabetes mel-
litus, in reference to the two important conditions of poly-
dipsia and polyuria. The polydipsia leads to dilution of
the patient's blood, and thus promotes the excretion of
sugar and the associated polyuria. The polyuria, on the
other hand (by depriving the system of a large quantity
of fluid), leads to greater concentration of the blood, and
consequently to thirst and polydipsia. 6. Mechanical:
A retroverted gravid uterus becomes so impacted in the
pelvis as to press on the urethra and cause retention of
urine. The distended bladder increases the retroversion
and the imoaction ; the retroversion increases the reten-
tion. Similar effects may be produced by myomata or
other pelvic tumors. In ascites pressure on the renal
veins may lead to ischuria, which in turn aggravates the
ascites.^ 7. Artificial : Alcoholism frequently induces
anorexia. This is followed by exhaustion and tempts the
victim to seek relief in further indulgence. .-Xgain, a

miserable home drives a laborer to the public house and
to alcoholism, with the result that he has less money than
before to maintain his home, which consequently becomes
still more miserable. In the case of chronic poisoning
of infants by opiates, the child, when not under the in-
fluence of'the sedative, is irritable and sleepless. Hence
the mother finds an excuse for continuing the drug, and
the vicious circle is complete. 8. Spurious: A so-
called vicious circle is occasionally met with after the
operation of gastroenterostomy, when the contents of the
afferent end of the jejunum (that is, the segment above
the artificial opening), instead of passing into the efferent
segment, return through the artificial opening into the
stomach and set up regurgitant vomiting. Or the con-
tents of the stomach may pass into the afferent loop
and back into the stomach instead of escaping through
the efferent loop. A "short-circuiting," in fact, takes place,
leading to grave difficulties for which a complementary
enteroenterostomy may be required.

Differential Diagnosis Between Meniere's Disease
and Other Cases Exhibiting Meniere's Complex of
Symptoms. — This subject is considered by T. \V. Parry
who makes some observations on the practical value
of the seton in both conditions and reports one case il-
lustrating the excellent results following the use of the
seton in the latter condition. True Meniere's disease oc-
curs in subjects with a normal auditory apparatus, has a
sudden onset of symptoms, and auditory nerve deafness.
Simulating states occur in patients with previously af-
fected auditory apparatus, and have a gradual onset of
symptoms, while deafness is not essential and, if present,
is not at the outset of nerve origin. Both states present
vertigo, tinnitus, and vomiting. Differential diagnosis,
therefore, is established on two points: (i) Examination
of the history of the case (whether onset of symptoms is
sudden or gradual), and (2) by the tuning fork (.whether
deafness is of nerve origin or otherwise). The author
would make two classes of the causes giving rise to
Meniere's symptoms : Class I. Primary Labyrinthine Lesion
or Irritation. — (a) An acute exudation or sudden hemor-
rhage into the labyrinth. This is the "(true) Meniere's
disease'' of all authors, (b) Chronic labyrinthine lesion,
not due to the above causes. The causes of the cases of
this class are usually obscure. This is the "Meniere's dis-
ease" of some authors and the "Meniere's symptoms" of
others. Class II. Secondary Labyrinthine Source of Irri-
tation.— In this class of cases labyrinthine disturbance is
produced by extralabyrinthine causes. They are chiefly
tympanic in origin. This is the "Meniere's symptoms" of
all writers. The use of the seton is highly conunended
by the author.

Carbolic Acid Gangrene. — Nine cases are summar-
ized by D. Wallace, all following common injuries with
carbolic dressings, generally one in twenty strength of
solution. In all the original injury or sepsis was trivial
in degree. The appearance of the gangrenous part in
such cases is characteristic. The skin at first is dry,
wrinkled, and grayish-white in color; later it becomes
darked and more shriveled. At the junction of the liv-
ing and dead tissue there is some hyperemia, and eventual-
ly a line of demarcation forms. As it is difficult to tell
how much is actually destroyed, it is proper to wait for
the line of demarcation before amputation is performed.
In no one of the cases the author has seen has there
been any swelling of the proximal part, but such swelling
has been described in some cases. The condition is, as
a rule, similar to a typical case of dry gangrene. Various
explanations have been given as to the occurrence of
gangrene under the conditions mentioned. It may follow
the use of solutions as weak as one or two per cent,
strength. It has been suggested that some individuals
have an idiosyncrasy, and are locally much more suscep-
tible to the hurtful action of carbolic acid than others,
and that in them stasis followed by thrombosis occurs
more readily, and gangrene results. It is the fact that
the portion which becomes gangrenous is generally a
terminal part of the body — for example, a finger or a
toe. That age. sex, or the physical condition of patients
do not apparently influence the production of the con-
dition is seen when we note that it occurs at any age,
in either sex, and in those who are in perfect health. Pa-
tients should always be warned that carbolic acid is a
dangerous substance and personally the author deprecates
its application of such a dressing to a finger under any
circumstances.

Berliner kliniselie IVoehenschrift. May 6, 1907.
Streptococcus Erythema and Its Relation to Scarlet
Fever. — Gabritschewsky. who hris been experimenting
with vaccines prepared from streptococci from cases of

914

MEDICAL RECORD.

[June I, 1907

erysipelas and scarlatina, believes that a good deal of
evidence exists in favor of the view that the streptococcus
is the specific causative agent in scarlatina. He has found
that in septic infections streptococci produce scarlatina
like rashes and that vaccines prepared from scarlatina
streptococci are also able to evoke similar scarlatina-like
exanthematous eruptions. The punctate rashes in scar-
latina and those resulting from the streptococcus vaccines
may be regarded as belonging to the class of infectious,
toxic dermatides and as being identical in nature. He
also is of the opinion that the fact that in man punctate
eruptions with all the other symptoms characteristic of
scarlatina may be evoked by vaccines made from the
scarlatina streptococcus forms an important and decisive
factor in favor of considering the streptococcus as the
causative agent of the disease. Accordingly he recom-
mends a further application of streptococcus serum therapy
and streptococcus vaccination not only for the complica-
tions, but also for the underlying process in scarlatina.

Miiiu-hou-r iiu'diciuischc ]]'ochcnschrift, April 30, 1907.

Observations on the Excretion in the Urine of the
Agglutinins in Typhoid Fever. — Hoesslin, in an at-
tempt to gain some information regarding the source of
manufacture of the agglutinins, investigated the aggluti-
nating power of the urine in a number of typhoid patients.
In fourteen cases the kidneys of the patients appeared
to be intact, while in ten others there were complications
referable to disorder of these organs. As a result of the
tests of the agglutinating .power of the urines obtained
from these two sets of patients it appeared that healthy
kidneys are impervious to agglutinins, for the urines that
contained no albumin were found to be without agglutinat-
ing power. On the other hand, agglutinins seemed to
pass through the diseased kidneys together with the al-
bumin, for the two were found associated in appro.xi-
mately relative proportions. These clinical results were
substantiated by animal experiments in which artificial
nephritis was induced in immunized rabbits. The author
further concludes that the excretion of agglutinin is with-
out effect on the quantity remaining in the body and that
the amount lost in this way is constantly replaced. It
also appears that the gradual disappearance of the ag-
glutinins occurs within the Ixidy itself.

The Interrelationship of the Diazo Reaction, Bac-
teriemia, and the Widal Reaction in Typhoid Fever. —
Genken contributes an article in which he discusses the
significance of the chronological element in the occurrence
of these three phenomena in the course of typhoid fever,
and bases his conclusions on a series of cases which were
investigated W'ith this end in view. He concludes that
the diazo reaction and bacteriemia run a parallel course
in cases of typhoid in which no drugs have been used
that conflict with the appearance of the diazo reaction.
This reaction occurs only in that period of the disease
during which bacilli are present in the blood. The elimi-
nation of the bacilli from the blood or their complete
agglutination leads to a decrease in the diazo reaction
and its ultimate complete disappearance in spite of the
fact that the fever continues and the patient exhibits the
picture of the typhoid state. At the same time the Widal
reaction, which represents antagonism to the bacteriemia.
is increasing in intensity. If such drugs as salol or calo-
mel are used the occurrence of this parallelism between
the diazo reaction and the bacteriemia is not noted since
these agents interfere with the development of the reac-
tion. The author suggests that these considerations may
lead to an advance in our knowledge of the nature of the
diazo reaction, which at present is very fragmentary,

Deutsche medizinisehe W'oehenschrift. May 2, 1907.

The Diagnosis of Subphrenic Abscess. — Determann
says that in spite of the efforts that numerous clinicians,
such as Leyden, have made to facilitate the diagnosis of
this condition, cases occur in which the means at our dis-
posal do not suffice and errors in dift'erential diagnosis
are made. He relates one such case in which the diag-
nosis of right sided empyema was made and at a thor-
acotomy a large amount of pus was evicuated. The
patient died of gradually increasing prostration, and at
the autopsy it was discovered that the operation wound
had really been carried through the diaphragm and a
larn-e subphrenic abscess communicating with an abscess
of the liver had been opened. Determann. in view of this
experience, recommends that in every case in which the
percussion sound tmdergoes a very gradual transition
from pulmonary resonance to extreme dullness or flatness,
or in which exudate is obtained from exploratory punc-
ture only in the lower part of the thorax and at a rela-
tively great depth, the possibility of a subphrenic collec-
tion of pus must be considered. If this doubt exists the

position of the diaphragm should be ascertained by means
of a radiograph, and tlie conical form of the diaphragm
shadow observed in cases of subphrenic abscess through
the pushing upward of the diaphragm be looked for.

Anguillula Intestinalis Associated with Chronic Diar-
rhea.— Trappe discusses at length the characteristics
of this parasite as well as the views that have been held
concerning its pathogenicity. Formerly regarded as the
cause of the so-called Cochin-China diarrhea from
which the French soldiery suffered, it was later con-
sidered to be a harmless parasite. More recently, how-
ever, the tendency seems to be once more to accord to
it a certain degree of pathogenicity, though the question
is still in an unsettled state. In Trapne's own case the
patient was a man of thirty years, a native and resident
of Silesia, who had always been well until about six
months previously, when he developed an obstinate diar-
rhea which was refractory to all treatment. The stools
contained large numbers of Anguillula intestinalis, but no
other cases of the disease had been reported in the dis-
trict. Under the administration of astringents the num-
ber of parasites in the stools gradually diminished and
the stools themselves became less frequent until the pa-
tient was enabled to return to work. While even in this
case there is no definite proof of the pathogenicity of
the parasite, the author considers that it is justifiable to
regard it as the cause of the patient's intestinal disorder.

French and Italian Journals.
Colopexy. — Ch. Lenormant considers colopexy the
best operation for restoring a prolapsed rectum to its nor-
mal position and function. The rectal prolapse must be
reducible, otherwise resection will be necessary. The op-
eration consists of reducing the prolapse and then fixing
the intestine to the abdominal wall or side of the pelvis.
In some cases the intestine is opened to allow of entire
rest to the rectum, at the same time that it is fixed, and
the artificial anus is afterward closed. Tw'O of the priii-
cipal factors in the descent of the intestine are the insufli-
ciency of the perineum and abnormal depth of Douglas'
cul-de-sac. To make the operation successful the adhesions
created with the abdominal wall must be strong and du-
rable. When attached to the side of the pelvis the position
of the rectum is more natural and the adhesions are
stronger. A long incision is made in the left iliac fossa
parallel to the crural arch, the intestine is drawn up so as
to reduce the prolapsus ; the lower portion is brought up
to the incision and fixed to the sides of the wound, includ-
ing the aponeurosis of the iliac muscles. The peritoneum
is opened so as to attach the intestine to the inner side of
the ileum. The wound is then closed. In the female with
prolapsus of the uterus hysteropexy must be done at the
same time. The immediate results of the operation are
excellent, it is easv to execute, and mortality is nil. There
is recurrence in about twenty-five per cent, of the cases. —
Revue de Cliirurgie. February 12. 1907.

Experiments with Colloidal Mercury. — G. .\stolfoni
has experimented to ascertain the toxic action of colloidal
mercury, its mode of elimination, and localization in vari-
ous organs. The author finds that the poisonous dose is
less than for the other forms of mercury. In whatever
way it is administered it is eliminated by the feces and
in small quantities by the urine. It is very soon found
in the feces and appears for from six to eighteen days
after administration. Post mortem the metal is found
localized in the liver, kidneys, intestinal walls, spleen, heart,
and lungs. There is little difference due to the different
modes of administration. It is not found in the bones. —
La Rifonua Mediea. Februarv 16. 1907.

Catalysis of Hydrogen Dioxide in the Presence of
Blood. — Eduardo Filippi opposes the belief that the
action of the hydrogen dioxide on the blood of different
animals mav be used as a means of distinguishing the
blood of different animals when found on fabrics. He has
made extensive experiments w-ith reference to the value
of such tests and finds them valueless. Human blood is a
little more active in decomposing hvdrogen dioxide than
that of the lower animals, but the differences are so slight
and inconstant that no reliable information can be obtained
in this way. Fresh blood is a little more active than de-
fibrinated blood, or that taken post mortem. Fibrin pre-
serves the decomposing power for a long time, as does
serum. Heinoflobin has no such effect. Heatin<» destroys
this power in blood and all its solutions. Diluting blood
with distilled water and evaporating it gives a material
that has the same activity as fresh blood. If mixed with
common salt before evaporation the decomposing power
is lost. .A.ny piece of cloth will decompose hydrogen di-
oxide as easily as blood itself, and for that reason the test
with cloths is valueless. It is useless to attach any medico-
legal value to these tests. — Archifio di Farmacologia Speri-
mcntale e Science AfHni. December, 1906.

June I, 1907]

MEDICAL RECORD.

915

Snnk SpinruiH,

The Practical Medkine Series. Under the General Edi-
torial Charge of Gustavus P. Head, M.D. Volume IX.
Anatomy, Piivsiolugy, Pathology, Dictionary. Edited
by ^\^ A. Evans, M.S., M.D.. .\dolph Gehrmann, M.D.,
and William Healy, A.B., M.D. Series 1906. Chicago:
The Yearbook Publishers, 1906.
The chief attraction in this present volume is the section
on patholo.gy and bacteriology. This part of the book is
full of njost interesting and practical information as to
recent advances in these fields. The general practitioner
can do nothing better, if he wishes to be up to date on
these themes, than read this very concise summary. Here
will be found much infonuation concerning the newest
methods of e.xamining the blood, the urine, etc.. and con-
cerning Wright's opsonic index. The sections on anti-
toxin and physiology and the list of new words are also
valuable. .Altogether this volume forms one of the most
interesting of this excellent series.

Plaster-of-Paris and How to Use It. By Martin H.
Ware. M.D., Sur.geon to the Good Samaritan Dispensary,
etc. Surgery Publishing Co., N. Y., 1906.
This is an excellent little book which contains within a
limited number of pages all that is necessary to know about
the use of plaster-of-Paris. There are many uses to which
this medium may be put. but the references to its use are
scattered throughout the literature and not available for
reference. The entire subject is discussed from the making
of the plaster bandage, a most important item, to the con-
struction of every form of snlint, corset, or dressing. There
is also a chapter on the use of plaster in dentistry. The
illustrations have been specially tuade in most instances
and are on the whole e.xcellent.

The Practical Medicine Series. Under the General Edi-
torial Management of Gustavus P. Head. M.D. Vol. X.
Skin and Venereal Diseases. Nervous and Mental
Diseases. Edited by W. L. Baum, M.D.. Hugh T. P.\t-
RiCK, M.D., and William He.\ly, A.B., M.D. Chicago:
Year Book Publishers, 1906.
In this, the last of the series of ten volumes comprising
this annual publication, the reader will find an abundance
of material on the specialties indicated in the title. In the
first part of the book much space is devoted to urethritis
and to syphilis. In the second part, devoted to neurology,
the general practitioner will find much that he could get
otherwise only by consulting the special journals and mon-
ographs devoted to this line of work. Barring some mis-
prints and some necessary inelegancies of diction which
have crept in as the result of the effort to condense the
matter into the space of this volume, the book is an excel-
lent example of a short and useful summary of a year's
progress in two very distinct lines of medical science.

A Textbook of Diseases of Women. By J. Clarence
Webster, B.A., M.D. (Edin.), F.R.C.P.E., F.R.S.E., Pro-
fessor of Obstetrics and Gynecology in Rush iSIedica!
College, in Affiliation with the University of Chicago;
Gynecologist to the Presbyterian Hospital and Central
Free Dispensary ; Consulting Gynecologist to the Passa-
vant and St. .Anthony's Hospitals, Chicago. Philadel-
phia and London : W. B. Saunders Company, 1907.
This is a very large book, too large to be used with any
comfort unless one has a conveniently-placed book-rest to
support it. It is of large octavo size, with 712 pages of
thick paper and ten plates of thicker paper. It is too bad
the book could not have been divided into two volumes
of convenient and portable size, for it contains so much of
value that it is a pity for readers to he frightened away
by the bulkiness of the tome. The publishers have also
sacrificed the author's text and his illustrations by printing
the book on such highly glazed paper that it can be studied,
especially at night, only by those whose love for knowl-
edge outweighs a prudent care for vision and ocular com-
fort. Dr. Webster's part has been done wonderfully well.
It may be asked of what use is another book on gvne-
cology, but the same doubt might be expressed regarding
the utility of new books in any other branch of mctlicine;
they are all covered and covered well : still it does no
harm to get a new point of view. That is what the reader
of this volume will get — at the same time that he gets a
headache from the glare of its shiny pa.ges. The author
protests against the notion that the pelvis constitutes the
whole of woman, and insists upon regarding woman and
her diseases through a lens of wider dispersion, taking
into account various physical and psychical facts inde-
pendent of the local pelvic conditons. In therapeutics he
is conservative, and deprecates a resort to new- and untried
measures when the recognized and proved methods cure

the patient. Dr. Webster writes in a pleasant and read-
able way, and as one assured of his position and with good
reasons for his beliefs. A large portion of the book is
given to an introductory section on the anatomy of the
female pelvic organs. Although this section is well pre-
sented and beautifully illustrated, it is not essential to a
treatise on the diseases of these organs, and its omission
would have very materially lightened and shortened the
book.

The illustrations are numerous and beautiful — 372 pic-
tures in the text and 10 colored plates. When one looks
at them one almost forgives the publishers for spoiling his
pleasure in the text in order to enhance that caused by the
soft halftone pictures.

A Textbook of Pathology. By Alfred Stengel, M.D.,
Professor of Clinical Medicine, University of Pennsyl-
vania; Physician to the Pennsylvania University, and
Philadelphia Hospitals. Fifth Edition. Thoroughly Re-
vised. Philadelphia and London : W. B. Saunders Com-
pany, 1906.
It is about eighteen months since the fourth edition of
Dr. Stengel's work appeared, yet in the present edition
the book has undergone quite extensive revision. The chap-
ters on Inflammation in the Diseases due to Bacteria, and
in those caused by Animal Parasites having received es-
pecial attention. The book is well adapted to the use of
students, as it is of convenient size, is well, though not
profusely, illustrated, and the text is amply descriptive,
the author not taking a positive stand in cases in which
opinions differ, preferring to state the case and the argu-
ments in favor of the different views, and not forcing the
reader to adopt any of them. In addition to the illustra-
tions in the text, three hundred in number, some printed in
colors, there are twelve chromolithographic plates. The
book has proved its value as a textbook of pathology — up
to date, well written, and interesting.

A Manual of Normal Histology and Organography.
By Charles Hill, Ph.D., M.D., Assistant Professor of
Histology and Embryology at th^. Northwestern Uni-
versity Kledical School. Chicago; formerly Professor of
Zoology, Lhiiversity of Washington. Illustrated. Phila-
delphia and London : W. B. Saunders Company, IQ06.
This is a handy little volume for the elementary student
or for rapid reference in the classroom or laboratory
for the beginner. The author has laid especial stress and
devoted much space to the teeth and oral cavity. He
has. perhaps, carried this feature of the inanual so far as
to lay undue emphasis upon its importance, and yet the
subject is no doubt one which is neglected in most text-
books. Considering the nature of the work, the text is
readable and. as the author intended, intelligible even to
a beginner.

Tropical Medicine. With special reference to the We>t
Indies. Central .A.n)erica, Hawaii, and the Philippines.
Including a General Consideration of Tropical Hygiene.
By Thomas W. Jackson. M.D.. Lecturer on Tropical
Medicine, Jefferson Medical College, Philadelphia ;
jNIember of the American Society of Tropical^ Medicine;
Lately Captain and Assistant Surgeon, United States
Volunteers. One hundred and six illustrations. Phila-
delphia : P. Blakiston's Son & Co., 1907.
This is, so far as we know, the first publication by an
American author treating of Tropical Diseases; and it
deals with such diseases as are found within the bound-
aries of the United States and its possessions. The vol-
ume commences with an interesting introductory chapter
on Tropical Hygiene. This is followed by Part I, in whicli
are discussed the Systemic Diseases — Cholera, Beriberi,
Plague, Dengue, Tropical Dysentery, Leprosy, Malari;d
Disease, Malta or Undulant Fever, and Yellow Fever.
Part II treats of .Animal Parasitic Diseases, with chapters
nn Ankylostomiasis, Filariasis, Trypanosomiasis, Bilharzia
Disease, and Schistosomum Japonicum, Endemic Hemop-
tvsis, Guinea Worm Disease, Liver and Intestinal Fluke
Worms, Intestinal Cestodes, and Nematodes. The last
fifty pages are devoted to Diseases of Undetermined or
Uncertain Causation, and Skin Diseases. Under this head-
ing will be found short chanters on .Acute Febrile Icterus,
Febrile Tropical Splenomegaly, Tick Fever. Epidemic
Dropsy. Tropical Ulcer, Yaws. Tropical Sloughing Phag-
edena, Mycetoma, Climatic Bubo, .Ainhutn, Goundou, and
Skin .Aiifections. The book contains a useful list of books
and pa.ners dealing with the subjects under discussion, and
due acknowledgment is made of the author's indebtedness
to the writings of previous workers in this field. The
work is well written, well printed, and sufficiently illus-
trated: and it should prove useful to all phvsicians in the
Southern States, Culia. Porto Rico, and Hawaii, and (he
Philippine Islands.

9i6

MEDICAL RECORD.

[June I, 1907

^nri^tg ISrports.

NATIONAL ASSOCIATION FOR THE STUDY AND
PREVENTION OF TUBERCULOSIS.

Third Annual Meeting, Held at Washington, D. C, May

6, 7, and 8, 1907.

(Special Report to the Medical Record.)

(Continued from page 834.)

SURGICAL SECTION.

Tuesday, May 7 — Second Day.
Dr. W. S. Halstead of Baltimore in the Chaik.
The Treatment of Surgical Tuberculosis by Hyperemia
(Bier). — Dr. V. Schmieden of Bonn, Germany, said that
he appeared in Dr. Bier's stead, in order to speak about
the treatment of surgical tuberculosis by means of hyper-
emia and to demonstrate the technique. He said that Pro-
fessor Bier's treatment of inflammatory processes was in
marked contrast to that of previous teaching, in that this
treatment did not combat the infection, but rather increased
the normal reaction of the part. Bier increased artificially
the redness, swelling, and heat, and these cardinal symptoms
of infection were none other than the natural weapons
of the organism. If Bier's teaching was founded upon facts,
then must its practical application be brought into sur-
gery. Since Bier's investigations they no longer suppressed
the inflammation ; rather they increased it. -A.t first Bier
found real difficulties only in the technique. He discovered
that they must use the blood for increasing the inflamma-
tion. Therefore, he augmented the hyperemia and, at the
same time, decreased the flow of blood, which was already
decreased in every inflammatory process. This was the
clear train of thought which gave rise to this treatment by
hyperemia. Tuberculosis, especially tuberculosis of joints,
was the first disease which Bier treated with his hyperemic
band. To-day this band was used in many other diseases.
One took a broad (6 cm.) soft rubber bandage, applying it
slowly and evenly around the extremity, centraKvards from
the tuberculous joint, but not too close to it. Each turn
overlapped the other. The bandage must not cause pain
either at the place of application, or in the diseased joint.
The extremity began to swell in a moderate degree and
assumed a bluish-red color, it remained warm, at least as
warm as the other limb, and the pulse remained entirely
unchanged. They had no stoppage of the blood current,
but an increase in its volume due to a diminution of its
flow. This simple technique was often poorly prac-
tised. The hyperemic bandage was applied in tuberculosis
only for a few hours per day. They applied it from one
to four hours in the following manner. Once for an hour
or once for two hours, or twice for two hours. If the
skin was tender, its location was changed. During the
hyperemia they removed all other bandages and over dis-
charging fistulas placed sterile gauze or a towel. A pressure
bandage of any sort would render the hyperemic treatment
impossible. Further, one should not have the joint in fixa-
tion. The tuberculous joint must be movable after the dis-
ease had healed. Bier stated that a stiff joint following
healing of tuberculosis was not a good result. The treat-
ment by hyperemia had a high purpose, the maintenance of
mobility, an anatomic healing. It was possible to restore
the function of a joint in which the disease had progressed
so far as to cause changes in the bone and cartilage with the
formation of multiple fistuls. Properly applied hyper-
emic treatment resulted first in the abeyance of the pain ;
this was a certain proof of the proper technique. Inflam-
matory contraeturts soon disappeared, and active as well
as passive movements were again possible. The old teach-
ing, fixation of tuberculous joints, had been pushed aside
by Bier. They believed that it was often not the tuber-
culosis which caused ankylosis, but the improper and over-
zealous treatment which prevented movements of the joint.

It was evident that Bier had revolutionized the treatment
of surgical tuberculosis. Naturally, vigorous movements of
the joint should be avoided ; the point was, through experi-
ence, to find the "happy medium" between rest and action.
During the course of the treatment other symptoms and
signs disappeared, namely, the swelling subsided and the
large fungus masses were transformed into hard connec-
tive tissue, which by further hyperemia treatment were
absorbed. The contour of the bones also again became dis-
tinctly visible. In fact, the mobility of the joint became
better and better ; also, the tuberculous fistulas, even though
they extended into the joint or bone focus, healed ; this
proved the healing power of the hypermia. But not always
did these cases run such a favorable course ; often cold
abscesses occurred, and with their evacuation much necrotic
tissue came away. The better the technique the less often
these abscesses occurred, and when they did occur they
should be recognized early. Cold abscesses, according to
Bier, were processes by which the organism cast oflf the
tissue incapable of healing. In any case, when they did
occur one should not interrupt the treatment. This treat-
ment was applicable to nearly all cases. It was to be re-
gretted that tuberculosis of the hip joint could not be
treated by hyperemia, because of technical difficulties. Hy-
peremia of the shoulder, however, was applicable. Es-
pecially favorable results followed in tuberculosis of the
ankle, elbow, and wrist. In consequence of treatment al-
most entirely by hyperemia, Bier very seldom was forced
to resect a tuberculous joint. Together with the hyper-
emia band they frequently used the cupping glasses which
Dr. Schmieden demonstrated on an individual. They
used them in all cases of beginning softening and of ab-
scesses, which might or might not have fistulous openings.
Every abscess occurring in the process of joint tuberculosis,
as well as in the tuberculosis of the soft parts, was opened
and without any fear of a mixed infection ; the proper ap-
plication of the cupping glasses prevented such an infec-
tion in almost every case. The two results obtained by the
proper use of the glasses, namely, hyperemia and discharge
from the fistula, tended to avoid a mixed infection. The
result is that after evacuating the detritus and pus the dis-
charge became serous, gradually became less and less, and
finally the fistula healed. In all cases of open tuberculosis
of joints they used both forms of hj'peremia. In general
the hyperemic band twice an hour, and the cupping
glasses forty-five minutes upon the fistulae. Dr. Schmieden
hoped that his remarks would help in introducing Bier's
method into .America. Its goal was none other than that of
healing without loss of function. Bier in his fifth edition
of his book, "Hj'peremie als Heilmittel," said : "Formerly
I considered the hj^peremia treatment good ; now I con-
sider it the best"

Dr. Willy Meyer of New York said that he had used
this method since Bier published his paper fifteen years ago.
A well-known pathologist in Vienna had stated that he
never had found a tuberculous lung in cases of valvular
heart disease which produced a venous stasis in the lungs,
and this was the starting point of Bier's studies. It was
to be regretted that the hip joint could not be made sub-
ject to this treatment. Dr. Meyer emphasized the point
already made by Dr. Schmieden that the patient should not
have pain when the rubber band was applied. There should
be a hot, and not a cold stasis. Bier's treatment should
not be considered a panacea ; one should not be too enthu-
siastic and believe that every case of joint or bone tuber-
culosis could be cured by this method. There should be
in the hospitals a special w-ard set apart for the treatment
of these cases. After relating the histories of two cases in
which most marked results followed this method of treat-
ment, Dr. Meyer said that the Bier treatment was a most
excellent help in surgical endeavors to cure tuberculosis of
bone and joint disease, and should be more extensively tried
and should be known by physicians and surgeons alike.

June I. 1907]

MEDICAL RECORD.

917

Present Status of the Opsonic Theory and the Treat-
ment of Tuberculosis. — Dr. RuFus I. Cole of Baltimore
read tins paper. He said that a specific treatment for in-
fectious disease must first have some theoretical foundation
based upon at least a little experimental evidence, and sec-
ondly, its value must finally depend upon clinical results.
In order, therefore, to discuss intelli.i;ently the present status
of the opsonic theory and its application, they should first
inquire as to the relation of this theory to vifhat was already
known regarding imnumity in tuberculosis. Upon this their
present conclusion should largely rest, since the collection
of clinical data required a great deal of time and labor, and
the method under discussion had not yet received a suf-
ficiently wide application to make such data of conclusive
importance. In the cure of tuberculosis one might either
try to put the body in such a condition that a slight balance
in its favor may occur, or one might attempt the production
of a very high grade of immunity to the bacillus or its
products. The former was what they probably did by rest
and fresh air. and possibly by the aid of tuberculin. If they
could, however, certainly induce this artificially by the
proper use of the bacillus or its products, they would at
least have partially solved the tuberculosis problem. This
was what Wright claimed to have done by the method
which bore his name. The ideal condition, of course, would
be the production of a fairly high degree of immunity, suf-
ficient to quickly and unquestionably kill the bacteria and
neutralize their effects. In tuberculosis this attempt had
been made by the effort to produce active or passive
immunization to the bacilli, or to their products.
Theoretically, the bacillary emulsion offered the most
suitable medium to use in order to produce
the most marked grade of immunity to the vari-
ous activities of the tubercle bacillus. ^^'hi!e Koch did
not so explicitly state in his paper, he must have had in
mind that antitoxic innnunity was produced by old tuber-
culin, bactericidal immunity by new. Being convinced that
the opsonins did really represent immune bodies, it was next
important to determine (l) whether they played any part
in tuberculosis immunity; (2) was the technique for their
quantitative estimation sufficiently accurate for them to de-
tect slight grades of difference; (3) what was the clinical
value of Wright's method of treatment with T. R. tuber-
clin ; (4) what were probably the best methods for pro-
ducing a high grade of opsonic immunity in tuberculosis.
They might conceive that even if it should be shown that
the opsonins played little part iu tuberculosis innnunity.
the opsonic index might form an accurate and suitable
guide for controlling other immunization processes. Theor-
etically the most suitable cases for treatment with tuberculin
would seem to be those cases of localized tuberculosis in
which the presence of secondary infection was unlikely or
even improbable. It seemed that the future studies in
opsonic immunity in tuberculosis must be along two linos:
(i) Experimental, to discover whether opsonic immunity
really plays any considerable role in tuberculosis, and (2)
whether it was possible in any way to produce a high grade
of opsonic immunity in this disease. As most investigators
have found, and especially as the experiments of Trudeau
have demonstrated, satisfactory immunity in tuberculosis
had hitherto been obtained only by the use of living bacilli,
and whether they were dealing with opsonic immunity or
immunity of whatever kind, the successful method would
probably be along this line.

Dr, N.'\TH,\xiEL B, Potter of New York said that the
technique was extremely difficult, but that, so far as the
preparation of the emulsion was concerned, they had been
materially aided in New York through the kindness of Dr.
Baldwin. Since they had used the little capsules prepared
by Dr. Baldwin the emulsion had been invariably constant
and uniform, giving excellent results. The emulsion was
made with the bacilli killed by heat. He called attention to
the fact that there was a variation even in the normals. It
was his belief that the leucocytes were not inert.

Dr. G. R. W'ebb of Colorado Springs s.iid that no men-
tion had been made of the opsonic index as a diagnostic aid.
In cases of tuberculous glands the injection of tuberculin
was not necessary; if one took the index before and after
massage a diagnosis could readily be made. Dr. Webb had
had many instances for using the tuberculosis vaccines with-
out the opsonic index and he could quote many cases of
tuberculosis, tuberculous cystitis, tuberculosis of the kid-
neys, of the joints, etc., which had done well without watch-
ing the opsonic index.

Dr. John B, Briggs of Washington, D, C., said that he
was rather surprised at the lack of Dr, Cole's results; he
had followed Wright's method in about one hundred cases
and had had surprising results. In many cases he was
enabled to correct an apparent error by a careful study
of the opsonic index,

Dr, E, R, Baldwin of Saranac Lake said that his ex-
perience had been chiefly with the technique and he had had
but little clinical experience. He had worked with Wright
for several years and he acknowledged the limitations in
the technique, saying they were rather wide, and the results
had to be interpreted with a good percentage of error,
Wright himself did not rely upon the opsonic index. The
emulsion Dr, Potter referred to was not difficult to pre-
pare. It was simply a broth culture, washed and sterilized,
rolled in a mould with porcelain balls; this muddy mass was
then measured off in glass capsules, in which it was sealed.
Formalin was added to insure preservation. At present it
did not seem that they were justified in recommending it
for diagnosis or for treatment in cases of pulmonary tuber-
culosis, and even Wright himself was not sanguine re-
garding this.

Dr, Edw,'\rd L, Trudeau of Saranac Lake said that he
had used none other than the clinical method for fifteen
years. There seemed to be a great deal of confusion re-
garding this subject. In using the tuberculin the dose, the
intervals between the doses, the size of the dose, all were
governed purely by the opsonic index. The question was.
Were they going to be guided by the opsonic index, or
the tuberculin immunity? Was there any formation of
antibodies in the blood? It was the consensus of opinion
that, whether they used the opsonic index, or the clinical
method, better results would follow the use of the tuber-
culin if only they knew how to use it.

Dr, Lawrason Brown of Saranac Lake also discussed
the paper,

Dr, RuFus I, Cole of Baltimore closed the discussion.
The Advantages and Limitations of the X-Ray in the
Treatment of Surgical Tuberculosis. — Dr. Henry K.Pan-
coast of Philadelphia read this paper. He said that the
success of the .r-ray treatment of tuberculosis, or any other
disease, depended upon the experience, common sense, and
good judgment of the Roentgenologist, and the close ob-
servation of certain cardinal principles which might be
enumerated as follows: i. A reaction of the tissues of the
body to the .r-ray was manifest in those tissues only in
which the rays were absorbed. By the use of a proper tube,
together w:ith the correct manipulation of the apparatus, the
degree of penetration of the greater number of the rays
generated could be recognized and controlled. 2. The first
effect of radiation upon normal tissues was stimulation, fol-
lowed by irritation, inflammation, and finally by cellular
destruction. 3. The applications should be so adminis-
tered as to secure that reaction which was necessary or
most efiicient in obtaining the desired results in the treat-
ment of any disease. 4. In normal tissues the destructive
effect was first manifest in those cells which were most
highly specialized, as the epithelium of the glands and hair
follicles of the skin, and the spermatogenic cells of the tes-
ticles. 5. In diseased structures it was first manifest, usu-
ally, in those cells which were distinctly pathological, and of
a lower vitality than the normal tissue cells. With the
knowledge derived from authentic reports, and from per-
sonal observations made by every member of the medical

9i8

MEDICAL RECORD.

[June I, 1907

profession, tlu-rc could be no doubting thi- fact tli:it tlic
x r . i.ii -...., { ivorablc or curative inlluencc upon
tuberculous lesions. In the treatment of some of tbcin they
might regard this agent almost as a specific remedy ; in
some manifestations its influence was much less uniformly
favorable, while in some of the lesions cures were excep-
tional or had never been obtained. In comparing the re-
actions of lupus vulgaris to light and the .f-ray Dr. Pan-
coast assumed that the light had far greater bactericidal
properties than the .r-ray, but the latter made up for this
deficiency through the greater inflammatory reaction it in-
duced, to the same end, and also througli the possibility of
a direct destruction of diseased cells. -After considering all
points of evidence, he thought the decision was decidedly
favorable to the .r-ray in the treatment of lupns, and that
it was gradually hut surely replacing the Finsen method.
The following conclusions as to the treatment of this dis-
ease, lupus vulgaris, referred to the .r-ra\' only: I. It had
supplanted surgical measures in the treatment of lupus
vulgaris, and the latter were now of value only as adjuncts
to the .r-ray. 2. In the treatment of this disease it acted
the part of a specific therapeutic agent. 3. The cosmetic re-
sults of .r-ray treatment were, on the whole, superior to
those of surgery. 4. Recurrences were less likely to fol-
low .r-ray treatment, but if they did they were easily con-
trolled. 5. When ulceration was present the .i--ray treat-
ment might be considered considerably assisted and short-
ened by partial e.xcision, curettment, or cauterization. 6. It
was not always necessary to produce an ulceration of the
tubercles, as they might be destroyed without. Neverthe-
less, a marked skin reaction was usually necessary, and a
second degree dermatitis might rarely be necessary, in
order to obtain an inflammatory reaction of sufficient in-
tensity to influence the deeper nodules. 7. The undesir-
able results which might follow .r-ray treatment were the
so-called ".r-ray burn," permanent telangiectasis, atrophy,
and more or less permanent pigmentation. The action of
the .v-ray upon chronic tubercular ulcerations was identical
with that observed in lupus. Tubercular sinuses frequently
responded well to .r-ray applications, provided the cause
was also removed by the same or other treatment. -Ac-
cording to its relation with surgical measures, they might
recognize three stages of adenitis in which the .f-ray was
applicable: i. When the glands were of relatively small
size, and had scarcely reached an operable stage. 2. Cases
in which the glands were of large size, and in an operable
stage. Here surgery would be given the preference. Such
cases could usually be improved, and might be cured by
the -V-ray, but the treatment was long, and the enlarge-
ment did not entirely disappear as a rule. 3. Cases in which
caseation had occurred with or without sinus. These cases
were primarily surgical, but the .r-ray might be employed
to great advantage in hastening the healing of ulcers and
sinuses, etc., and in producing better cosmetic effects. Lit-
erature did not credit the .v-ray with as much success in
the treatment of tubercular laryngitis as he thought was in
accordance with its possibilities. In his own experience
with a dozen cases he had not failed in a single instance to
observe some favorable results. -A large number of cases
of pulmonary tuberculosis had been reported as cured by
the -f-ray treatment, but these reports must be looked upon
with considerable scepticism. Personally he believed that
in some cases the .I'-ray applications were capable of some
benefit, in conjunction with the usual therapeutic and hy-
gienic measures. In advanced cases it was questionable
whether any benefit whatever was to be derived from their
application. Tuberculous peritonitis might be and had
been favorably influenced by the .r-ray treatment. He had
never seen any favorable results from the .r-ray treatment
of bone lesions, or in tubercular joint lesions. Judging
from reports, there was some likelihood of benefit being
derived from the .r-ray treatment of tuberculous orchitis.
Dr. WiLLMMS of Richmond discussed this paper.
(To be continued.)

-\.MERIC-\X SURGIC-\L -VSSOCI-ATION.

Tivenly-eighlli Annual Meeting, Held in IVashington,

D. C, May 7. 8, and 9, 1907, in Conjunction tvilli the

Congress of American Physicians and Surgeons.

(Special Report to the Medical Recokd.)
(Continued from page 839.)

Thursday, May g — Third Day.

End-Results Following Operations for Carcinoma of
the Breast. — iJr. F. S. Denxis of Xew York read this
paper reporting a series of fifty cases that had been well
at the end of three years, of which thirty-nine were well,
though some had had a second operation ; five to twenty-five
years had elapsed since the operation. Four cases had died
of independent causes after having been well three years or
more, and seven had died of metastases. In one case there
had been a return in the iliac glands after eight years. He
considered a ten-year limit for the time after operation
before calling the case cured as better than a three years'
limit. In one case he had had a recurrence after eighteen
years. In one case he had had a recurrence of carcinoma in
the opposite breast after eighteen years, which was removed
two years ago, and had not reappeared. .Another case had
sarcoma at the first operation, and fourteen years later car-
cinoma in the other breast. In the permanent cures most of
the cases had been operated on within si.x months of the
incipiency of the disease. He considered that the more
radical the operation, within reason, the better the prog-
nosis. He considered the minimum complete operation to
include removal of skin, breast, Cooper's ligament, muscle,
fat around breast, and axilla. He did not believe in pro-
longed operations, but he did not think that complete opera-
tions should be withheld from any patient.

Prof. E. KusTER of Marburg, Germany, opened the dis-
cussion on the series of papers. He spoke of the anatomy
of the breast region and the spread of the disease by the
lymphatics, the pathological classification of the tumors as
modifying the end results.

Dr. J. E. MooRE of Minneapolis said that surgeons some-
times censure themselves unjustly for the recurrences at
the periphery after complete operations. He cited one case
where, after complete operation, there had been a recurrence
at the end of two years in the periphery in spite of wide
skin removal and covering up of the defect by plastic skin
flaps. These recurrences were removed, and seven months
later there were again recurrences on the new flaps in skin
that at the time of the first operation had been over the
abdomen and back, and that later lay over just the same
spots as the first recurrences. He believed that there had
been a deep focus beneath the superficial tissues which had
infected both skin flaps, and that it would have been impos-
sible to remove the deep foci at the primary operation, so
that the surgeon was not in need of censure.

Dr. J. B. Roberts of Philadelphia thought the operations
were too limited, and that more cases needed the sacrifice
of the arm in order to get outside of the diseased tissue.

Dr. C. B. G. DE N.^xcREDE of -Ann -Arbor wished to warn
against too implicit belief in the microscopical diagnosis.
In one case he had made a clinical diagnosis of sarcoma,
and the pathologist had reported carcinoma. -A revision of
the pathologist's diagnosis had brought out the fact that
there were areas in the mass- some of which were typical
sarcoma and others typical carcinoma. He would explain
Dr. Dennis' case of recurrence of carcinoma after primary
sarcoma as a probable primary mixed sarcoma and carci-
noma. He would have more extensive examinations of the
tumors made by the pathologists.

Dr. -A. H. Fergusox of Chicago said that he did not see
how amputation of the arm would save recurrence from
glands in the neck. He had only one case in which he had
removed the arm on account of involvement of the axillary
artery with extensive edema in a case of recurrence after
one and a half years. Xo glands in the neck were found.

June I, 1907^

MEDICAL RECORD.

919

The patient had suddenly die<l on tlie tenth day after oper-
ation, so that no final result could be determined. All of
his neck cases had died within two years. He had removed
portions of ribs, lung, and sternum in his efiforts to j^et
beyond the seat of disease, but all had died. He had had
three cases of cancer of the breast in the male, one of whom
was alive at the end of fourteen years. In the e.xtensive
operations he believed that the patients would li\ e lnn;4er
and do better with less radical operations.

Dr. T. \V. Hi'NTiNCTON of San Francisco spoke of the
very extensive operations done by Dr. Rixford of his city,
who had done several very severe operations on pleura and
lung with improvement in the duration of the patient's
life. He had done one case himself of interscapulothoracic
amputation, and the patient was alive and well nine months
after.

Dr. W. B. CoLEV of New York had had three cases of
combined sarcoma and carcinoma. He cited the work of
Ehrlich, who from a simple cancer tumor in mice had later
produced mixed sarcoma and carcinoma, and still later ptire
sarcoma, all from injection of the same strain of mouse
tumor, but growing under different unappreciated condi-
tions. He did not regard the amputation of the arm a^
desirable on account of the bad effect it would have in
detering other patients with cancer from operation, espe-
cially if the arm amputation cases did not recover com-
pletely, as they probably would not.

Dr. W. L. Rodman of Philadelphia said that he did not
consider the three-year limit of nonrecurrence sufficient, as
15 per cent, had later recurrences. To show that the late
recurrences are true recurrences, he deemed it essential to
show a coincidence in the nature of the growth, and in
absence of this would call them new infections in a person
with a predisposition to cancer. In the prognosis the type
of the growth seemed very important. He was surprised
that Halstcd got better results in medullary than in scirrhus
growths. He believed that a most essential point in the
technique was the extensive removal of the skin. Only in
that way could he explain the good results of Gross' opera-
tions. Gross had been noted for his dinner-plate incision
that had jestingly been called a cartwheel incision.

Dr. S. H. Weeks of Portland, Maine, said he felt he had
done a complete operation wdien he had removed all the
diseased tissue. He removed the axillary glands only when
he could feel them through a special incision for that
purpose. He felt that the fat and the glands had a function
to serve and that they ought not to be removed unnecessar-
ily. He thought his position was backed up by the good
statistics of the incomplete operation done by Dr. Warren.

Dr. E. Eliot, Jr., of New York reported two cases of late
recurrence. In the first a scirrhus nodule had appeared in
the old scar after four years. This had been removed, and
there had been no sign of recurrence in the two years since.
This case he considered a scirrhus degeneration of an old
sear and not a recurrence. The pathological diagnosis of
the primary tumor was not recorded. The second case was
one where there had been a recurrence of a nodule two
inches above the old scar seven years after the primary
operation. Here the epitheliomatous tissue had a primary
focus in the subcutaneous fat, and as there was no normal
epithelial tissue in the fat he considered this a true recur-
rence. In another case five years after the primary opera-
tion there had been a reappearance of swelling in the arm
witho\it any external evidence of a tumor. At first the con-
dition had been considered a mediastinal recurrence, but
though there had been no operation the swelling had dis-
appeared, and had not appeared again in two years, so that
it could not well have been a recurrence. In another case
there was some persistent obscure lung trouble after the
operation, which had first been called a recurrence, but
this cleared up on antirheumatic treatment. He did not
think that all apparent recurrences were truly such. Unless
there is some definite additional risk he saw no reason for
not removing the axillarv glands in all cases.

Dr. J. C. Bloodgoou of IJaltunore thuut;lit that the most
important factor in determining the final outcome was the
character of the tumor. In sixteen cases of adenocarcinoma
all the subjects were well three years later, but one h:ul
died at the end of five years, and one died fifteen years
later. In five cases in which the breast only had been re-
moved, four had died and one was cured. Metastases in the
axilla were the most common. Of the scirrhus cases none
had been cured. Of the mixed scirrhus and medullary a
few had been cured. The only cases where recurrences had
appeared, and where there had been a cure, were in the
cases of adenocarcinoma. The recurrences had occurred
in cases where only a small area of skin had been removed
so .that the wound could be closed by suture.

Dr. B. F. Curtis of New York said that he believed that
^■ells in distant locations existed which had not grown, and
which had even retrogressed, ami that these explained the
very late recurrences.

Dr. W. H. C.\RM.\LT of New Haven said that he believed
that there were both sarcoma and carcinoma elements in
most growths. He reported a case where, after the removal
of a myoma (so reported) of the uterus, there had been a
recurrence of a sarcoma of the brain, and he associated the
two growths.

Dr. N. B. Carson of St. Louis said that while the sur-
geons recognized the late recurrences of cancers, yet the
laity held to three years as the limit of recurrence. That
the three years of suspense for the patient was long enough,
and that he did not think it wise to lengthen that period of
suspense for them.

E)r. S. J. MixTER of Boston said that he believed in a
thorough radical operation and that no mutilation was as
bad as the horror of having the disease return.

Subcutaneous Rupture of the Spleen. — Dr. Ells-
worth Eliot, Jr., of New York read this paper, reporting
two cases. The first was a man twenty-si.x years of age,
who fell five stories, fracturing the ninth rib and rupturing
the spleen. He was operated on nine hours later, a splenec-
tomy being done. The second case was a woman thirty-
four years of age, who fell nine feet. Splenectomy was
done there at the end of six hours. Both cases had serous
effusions into the left pleural cavity a few weeks after the
accident. Among the symptoms Dr. Eliot placed great
stress upon the rigidity of the wall of the thorax on the left
side at its lower margin, and over the upper portion of the
abdomen on the left side, also on the increasing area of
dullness in splenic region, as determined by auscultatory
percussion. 1 he costal resistance was of .great importance to
differentiate between rupture of the spleen and fracture of
the ribs, as in fracture of the ribs the eleventh and twelfth
ribs, being very rarely fractured, would not be rigid, while
in splenic injury they w-ould. In the operative treatment
pressure of the spleen against the diaphragm by tampon
is not permanent, cautery or suture of the wound is rarely
adequate, and splenectomy is the best treatment. The
choice of incision is one parallel to the left rectus with a
second limb along the lower costal margin, and resection of
the ribs if necessary. After removal of the spleen clamps
are left in situ on the pedicle to act as drainage, not only for
the splenic portion of the trouble, but also for any possible
pancreatic injury that might have occurred at the same
time. The objection to the removal of the spleen, that at
times it was followed by persistent anemia, was well
grounded, but the operation was followed by hypertrophy
of the lymph nodes, thyroid, and long bone marrow, which
compensated for the loss of the spIeeiL In animals after
splenectomy there was an increased resistance to infection?
and there had been reported one case of typhoid in a man
after splenectoiny, in which the disease ran a mild course.
In Dr. Eliot's second case, about a year after the splenec-
tomy, the patient had developed cholecystitis, becoming
drowsy and comatose for sixty hours, with an imperceptible
pulse, but she had recovered. She had again had pus in

920

MEDICAL RECORD.

[June I, 1907

the pleural cavity, which had been removed, with subse-
quent recovery.

Some Cases of Rupture of the Kidney, with Remarks
on Conservative Treatment. — Dr. T. R. Niklaon of Phil-
adelphia reported four cases treated by packing and drain-
age. The first two had a primary laparotomy done, and
then, after closure of that incision, lumb.ir exposure v ith
packing and drainage. The other two ca'^is had the lum-
bar incision only. Three of the cases reco%-erecl, and one
died of an incidental complication. All cases of rupture of
the kidney were not suited for this method of treatment, but
didactic classification w^as difficult. Where tncre were only
local symptoms, and the diagnosis was made on slight hem-
aturia, expectant treatment was in order; otherwise opera-
tive treatment was necessary. The lumbar incision could
be used only in the cases where there were no abdominal
symptoms. If the organ had been pulpified, or the pedicle
torn, nephrectomy must be done. If there were multiple
injuries, but still enough sound kidney tissue, to make a
possible functionating organ, conservative treatment should
be tried. Dr. Nielson placed loops of gauze under the poles
of the kidney to support and drain it. In some cases mat-
tress suture of the injuries might be desirable. In some
cases, after conservative treatment, a urinary fistula might
necessitate nephrectomy.

Primary Sarcoma of the Prostate.— Dr. C. A. Pow-
ers of Denver reported a case of enlargement of the prostate
in a man sixty years of age, who had had rapidly increas-
ing difficulty in urination for two months. He had no
residual urine. Tlie rectal examination showf-d a large
rounded prostate ballooning into the rectum. The mass
w-as uniform in consistency and very large. The urine
examination was negative. The perineal operation was
accompanied with alarming hemorrhage, the growth being
very friable. The upper part of the growth was adherent
and could not be removed. The patient died on the fifth
day of pneumonia. The pathological diagnosis was sni.all
round-celled sarcoma. The writer had collected nir.eteen
additional cases from literature, making twenty, in all of
which 12 were in patients under 15 years, four 15 to 30,
three 30 to 60, and one over 60. All died either from the
operation or from recurrence.

Prostatectomy. — Dr. Archib.xld M.'\cL.-\ren of St. Paul
read this paper, saying that both suprapubic and perineal
methods w-ere well established, that he had previously done
a combined operation, but that recently he had been doing
the perineal operation by a single median incision, the
advantage being that it gave better drainage than the srpra-
pubic, and did not give the wide exposure of tissues which
Dr. Young of Baltimore advocates. The time necessary
for the wide dissection was not compensated for by the
slight advantage in the field seen, as most of the work
was done by feel. And, again, the saving of tlie ejacula-
tory ducts in the old men scarcely compensated for the
danger of opening the rectum. He did prefer Young's
operation for cancer of the prostate.

Dr. C. L. Gibson of New York said that he could add
another case of sarcoma of the prostate to those reported
by Dr. Powers; that he had operated on a case that was
already septic, and that had died of sepsis three weeks
after the operation. In connection with Dr. MacLaren's
paper on prostatectomy, he said that he had formerly done
a very extensive dissection similar to Young's, but that now
he made a median incision in the perineum and quickly
shelled out the prostate, seldom taking as long as ten min-
utes; that he had not had a death in several years; that
the average age of his patients had been seventy-two years,
and that they were up and out of bed inside of a week.

Dr. J. C. MuNRO of Boston said that he had had a case
of sarcoma of the prostate which had been operated on.
but died of recurrence.

Further Consideration of the Surgical Treatment of
Cancer of the Head and Neck. — Dr. G. W. Crile of
Cleveland rtad this paper. He said that he put the patient

in the head-up position to save hemorrhage and shock,
packed and intubated the pharynx to eliminate post-oper-
ative pneumonia, and to get the anesthetizer away from
the field of operation. He considered that hemorrhage was
not only an immediate danger, but that it decreased the re-
sistance of the patient to the cancer. Therefore, he lost the
least blood possible, and gave early transfusion. He left
the wound open for 4r-ray treatment, which is promptly
carried to the point of erythema to get the superficial effect
of the A'-rays, and he felt that these cases had done better
than those not treated with the ;r-rays. In regard to the
tissues sacrificed, while he did not permanently close either
the common or internal carotid arteries (as he feared
embolism and had never seen recurrence of the cancer in
the sheath of the artery), yet he had not hesitated to excise
both jugular veins. Of the muscles, he had removed one
or both steniomastoids, omohyoids, sternothyroids, and
sternohyoids, and the platysmas, all of which were com-
pensated for by the action of the deeper muscles of the
neck. The scar was not complained of if the patient was
cured of his disease. Of the nerves, resection of one vagus,
one phrenic, or one hypoglossal he had done, but section
of any pair was fatal. He had done 150 operations on 139
patients, in which the primary foci had been in various
portions of the head and neck. Prior to 1900, when he
began this radical work, there had been only 15 per cent,
of the cases that had lived more than three years after
the operation. Since 1900, 31 cases, 39 per cent., had
passed the three-year limit. The operative mortality had
been steadily declining. He had lost none of the last 40
cases. He thought the operative results were as hopeful as
for cancer of the breast.

Dr. S. J. MixTER of Boston, in discussing the paper, said
that he, too, considered the ;r-ray applications to the open
wound a very valuable aid.

Dr. J. C. Bloodgood of Baltimore said that he agreed
with Dr. Crile in e.xcision of the veins and temporary liga-
tion of the arteries.

Dr. .A. V.xNDER Veer of Albany said that he did not
object to tying the common carotid artery, and thought
that at times it was necessary.

Acquired Diverticulitis of the Colon and Its Sur-
gical Treatment. — Dr. \V. J. Mayo of Rochester, Minn.,
presented this paper in collaboration with Drs. L. B. Wil-
son and H. Z. Griffin. Dr. Mayo presented five cases, all
w'ith the gross appearance of cancer of the colon, occurring
in patients forty-five years of age or over, three of them
males and two females. In some cases the trouble seemed
to start with a sudden attack, like acute peritonitis, and a
mass was found in the region of the splenic flexure or
sigmoid. In other cases the principal symptoms were those
of intestinal obstruction. There were still other cases
which had not come to operation in which the symptoms
had been mild, but of either type. The treatment in the
abscess cases was incision and drainage of the abscess; of
the obstruction cases, by resection of the colon. The path-
ological picture was one of multiple minute diverticuli of
the colon, in which the mucous membrane had pouched
through the muscular coat, usually at some distance from
the teniae. In one case there was a true diverticulum with
a muscular coat outside of the mucous coat of the diver-
ticulum. The other four cases had all been false diverticuli
in having only the mucous coat. Many of the diverticuli
contained fecal concretions, and these were surrounded by
inflammatory tissue forming a dense mass that had passed
the pathologist on gross inspection for cancer. In the
cases where the diverticuli had allowed their contents to
leak out there had been abscess formation. There had been
little tendency towards perforation and more to inflamma-
tory infiltration. The single case of true diverticulum had
been properly called a diverticulitis, but the other cases had
been peridiverticulitis.

The Diverticulum Ilei as a Cause of Complete Intes-
tinal Obstruction. — Dr. F. H. Gerrish of Portland,

June I. 1907]

MEDICAL RECORD.

921

Maine, presented this paper, giving the liistory uf a case
of intestinal obstruction of four days' duration, in which
a diverticukim arising 15 centimeters from the ileocecal
valve in the ileum had passed through a rent in the mesen-
tery, become adherent, and caused the obstruction. He did
not think the diagnosis possible before opening the abdo-
men. He considered the diverticulum ilei as one of the
gravest dangers, and urged that whenever found, acciden-
tally or otherwise, it be removed.

A Consideration of the Etiology of Certain Cases of
Left-Sided Intraabdominal Suppuration. — Dr. G. E.
Brewer of New York presented this paper, reporting si.\
cases of abscess in the lower left quadrant of the abdomen
closely resembling appendicitis abscesses, even to the find-
ing of fecal concretions in the pus or adhesions, but where
the appendix was normal. In four of the cases no exact
cause for the abscess had been found, but in two diverticuli
of the colon had been found, and as the six cases were all
so similar it seemed probable that the other four were also
due to diverticuli from the colon. He had found records
of eight cases of diverticuli of the colon, one in the ascend-
ing portion, two in the transverse portion, three in the
descending portion, and two in the sigmoid. In one of the
cases "9 pouches had been counted. These pouches were
due to pressure from the feces in constipation.

Dr. S. J. MiXTER of Boston saw one case of acute inflam-
mation of the sigmoid which was opened before rupture.
He had later seen two chronic cases which he considered
more common that had been diagnosed cancer and had
been cured by cancer quacks.

Dr. E. Eliot, Jr., of New York called attention to the
cases of left-sided intraabdominal suppuration that were
due to appendicitis, in which the appendix extended across
the middle line, and in one of his cases was adherent to
the sigmoid.

Dr. Reginald H. Fitz of Boston called attention to the
fact that -there were in the Warren Museum in Boston
several specimens of multiple diverticuli of the colon. He
thought that in the cases where patients passed fecal concre-
tions that resembled rabbit dung this condition might be
present. Dr. Fitz thought that this was a new disease and
that more cases would appear. In connection with Dr.
Gerrish's case of diverticulum ilei, Dr. Fitz said that the
persistence of the vitelline duct causing a diverticulum was
not rare; that most of the cases were harmless, though
this diverticulum might be the seat of a typhoid patch
or a tuberculous ulcer; that the adhesion of the tip of the
diverticulum was the remains of the omphalomesenteric
duct, which remained visible in all puppies until three or
four days old.

Dr. W. L. Estes of South Bethlehem said that he had
understood that the diverticuli of the colon occurred most
frequently in adipose people with myocarditis, in whom
the blood pressure was low, and that the diverticuli were
at points where the blood-vessels, piercing the denser layers
of the colon, left weak spots not filled by the vessels when
the pressure was so low, that most of the cases occurred at
the splenic flexure.

Dr. G. T. V.^UGHAN of Washington, D. C, said that
he remembered several cases where he had cut ofif copro-
liths with no bad effect, so that if they were in diverticuli
from the colon the lumen of these had become oblit-
erated.

Dr. H. Gushing of Baltimore said that he had seen some
experiments on animals where as much as 80 per cent, of
the intestine had been resected with a marked dilatation of
the bowel. In these cases diverticuli often occurred, but
there had been no diverticuli in the mesenteric border
where the blood vessels entered.

Dr. C. B. de Nancrede said that he had had two cases of
extraperitoneal abscess in obese men on the left side, that
there had been no bowel communication, but that both cases
Iiad had their origin from the sigmoid.

Dr. Mayo, in closing, said that he believed that nianv of

the cases where resection of the colon had been done with
the diagnosis of cancer but where the patient had had no
recurrence, were cases of diverticulitis and he would have
the old specimens examined anew. He said that there had
been no known myocarditis in his cases and that the diverti-
culi might occur anywhere on the lumen of the colon not
only at the mesentery.

Dr. L. B. Wilson- said that in 1904 Bier had reported
eighteen cases of diverticulitis, in one case diverticulitis and
cancer, but that such a combination had not been found at
the Mayo clinic.

Dr. Gerrish said that his case was peculiar in that the
diverticulum passed down on one side of the mesentery
through an aperature in it and then out on the other side
to become adherent to the abdominal wall. He did not
think that the adhesion in his case could have been an
omphalomesenteric duct.

Dr. Brewer said that if cancer occurred in association
with diverticulitis it might well be caused by the irri-
tation of the chronic inflammation.

Some Recent Modifications of the Gasserian Ganglion
Operation for Neuralgia, with a Report of Fifty Cases
of Operation Upon the Ganglion. — Dr. Harvey Gushing
of Baltimore presented tw-o cases, one of spasmodic tic, the
other of tic douloureux. In the first case he had resected
the facial nerve and then done an immediate anastomosis
with the spinal accessory. The patient had recovered emo-
tional control of the face within six months, though she
had a slight droop of the shoulder and a movement of the
face with the movements of the shoulder. These two symp-
toms were not as bad as the thickness of speech following
anastomosis of the facial with the hypoglossal nerve. In
the case of the tic douloureux the patient was an early case,
having had the pain only six months. In the operation he
had done the patient lost very little blood and got out of
the hospital in six days. He had a mortality of about 2 per
cent. He does not destroy the ganglion, but pulls out the
sensory fibers at the meninges. It is followed by no loss of
motion or atrophy of the muscles.

Dr. S. J. Mixter of Boston considered the operation
always a serious one. In the twenty cases that he had
done he had used a modified Abbe operation because the
results had been very satisfactory, there having been no re-
currence after three or four years. He injected osmic acid
into the nerves after dividing the second and third divisions
and then plugged the foramina and fossa with amalgam.
He had had one death.

Dr. M. A. Starr of New York congratulated Dr. Gushing
on the excellent results in the case of spasmodic tic. He
had never seen as good results from the anastomosis of the
seventh to the twelfth nerve. The neurologists believed
that the lesion in the case of tic douloureux lay in the
ganglion and that therefore it was futile to divide the
peripheral branches of the nerves. That Dr. Cushing's
evulsion of the nerve fibers from the ganglion was satisfac-
tory.

Dr. S. H. Weeks of Portland, Me., said that he lifted the
ganglion out of its fossa and cut it off, leaving the ophthal-
mic division and a part of the ganglion intact.

Dr. Gushing, in closing, said that he, too. believed that
the ganglion was the seat of war. and that the brain-ganglion
link should be severed. That if any of the branches were
left, recurrence in that branch would follow.

Early Operations Upon the Nerves in Ischemic Par-
alysis.— Dr. LrnN.\Rn Freeman read this paper. Of the
pathology he said that if the blood supply to the muscles
was cut off they would die in three hours and assume a
post-mortem rigidity, and then the fingers contract so that
they would dig into the palm of the hand. Later sensory
and trophic disturbances wniild set in. the nerves them-
selves showing the lesions. Massage and electricity helped
the hands to recnver. but the massage had to be vigorous
:iiiil persistert. That the muscle rigidity injured the ner\es
:iiiil the diseased nerves interfered with the use of the

922

MEDICAL RECORD.

[June I, 1907

muscles. That the indication was to operate on the nerve
and relieve its trunk from pressure. That the median nerve
was compressed most frequently in the pronator radii teres,
the radial in the supinator brevis, and the ulnar in the
flexor carpi ulnaris. The nerves should be exposed above
the point of compression and followed down, and then when
exposed buried, if necessary, in the subcutaneous fat. In
one case where trophic changes had begun in the hand,
making it useless, after operation the tingling of the fin-
gers appeared in about three months and in three years the
patient had good use of the hand. In two other cases of
late operation, in one he had had a relief of the pain and in
the other an improvement of sensation.

Dr. W. J. Mayo of Rochester, iMinn., said that the cases
were due to either bad splint application or to later swelling
of tissues causing the compression. That only a few cases
had been reported in the leg. That previously the treat-
ment had been orthopedic shortening of the bone to relieve
the muscle pressure, but that this nerve operation was a
great advance.

Dr. B. F. Curtis of New York said that he had seen one
case due to hemorrhage under the splint. That the bone
removal was very helpful but did not relieve the pain or
the trophic change.

Dr. H. L. BuRRELL of Boston said that he had seen a
number of cases of ischemic paralysis in children where the
results were not satisfactory, and he asked how early opera-
tion would be desirable.

Dr. Freeman, in closing, said that if a few weeks did not
improve the nerve symptoms, no matter what happened to
the muscles, operation would be desirable.

Officers were elected as follows: President, W. H. Car-
malt of New Haven; First Vice-President, W. G. Macdon-
ald of Albany; Second Vice-President, J. F. Binney of
Kansas City; Member of the Executive Council, D. P. Allen
of Cleveland.

THE PRACTITIONERS' SOCIETY OF NEW YORK.

Two Hundred and Ninth Regular Meeting. Held April 5,

1907.

The President, Dr. Robert Abbe, in the Chair.

Medical Inspection in the Public Schools. — Ur. Her-
mann M. Biggs, in this paper, said it seemed rather re-
markable, in view of the great importance of the subject,
that no systematic medical supervision of the children in the
public schools in the large cities of this country or Europe
was attempted until very recent years, and that even at the
present time such supervision was limited to a few cities,
and for the most part to a search for cases of infectious
disease. To the speaker's knowledge, there had been no
effort made in a large way to have a general physical ex-
amination of the children in the public schools of any large
city elsewhere than in New York. The first attempt at
medical supervision in a limited way of school children ap-
peared to have been in 1893. in Boston, during the preva-
lence of a severe epidemic of scarlet fever. Subsequent to
this, a number of physicians were appointed whose duties
were confined to the visiting of various schools upon the
request of the principals or teachers. This was the first
attempt at medical inspection of schools made in the United
States. In 1894 and 1895, in New York City, in the study
of the prevalence and extension of diphtheria and its spread
in the public schools, and in the effort to formulate a basis
on which bacteriological diagnosis could be made, it was
found that in many instances there were distinct school
outbreaks, which were largely confined to certain classes in
certain public schools. In 1896 the Board of Health de-
termined to make more extensive investigations to ascer-
tain to what extent the schools served in the spread of
contagious diseases. There had existed a long time previ-
ously a belief that the public schools played a very im-
portant part in the dissemination of contagious diseases, for

each year the morbidity curves with relation to measles,
diphtheria, whooping cough, etc., commenced rising soon
after the opening of the schools in the autumn, and con-
tinued to rise, as a rule, until March or April, when they
attained their maximum, and then, with the beginning of
warm weather, they fell until after the closing of the
schools, when a comparatively rapid decline followed. In
the preliminary investigations undertaken by the Depart-
ment of Health, a diagnostician was assigned to visit
schools which children reported as ill with contagious dis-
ease had attended. \ list of the absentees from the class
attended by the sick child was obtained, and these children
were visited at their homes. Further investigations showed
that in most of the public schools, lead and slate pencils,
pen holders, etc., were used in common by the children in a
certain classroom. These were collected at night and dis-
tributed again in the morning, indiscriminately, and bac-
teriological investigation indicated the presence of virulent
diphtheria bacilli on these writing utensils when they had
been placed in the mouths of children sick or convalescent
from diphtheria duringperiods of from five to eighteen days.
These, with numerous other findings, were incorporated in
a special report and forwarded to the Board of Estimate
and .Apportionment by the Board of Health, with the re-
quest for an appropriation to provide for a systematic in-
spection of the public schools for the exclusion of cases
of infectious disease. This appropriation was granted, and
in March, 1897, the system was inaugurated in the Boroughs
of Manhattan and the Bronx, constituting the old city of
New York. One hundred and fifty inspectors were ap-
pointed, at the rate of $30 per month, whose duties consisted
in visiting certain schools each morning and examining all
children set aside by the teachers as suspected of having
some infectious disease. The inspectors also examined
every child who had been excluded from school, or who
was absent from school for illness, before its re-admission
to the school. Essentially, this system obtained until 1902,
when it was modified by reducing the number of inspectors
to 50 and requiring their services for a longer time daily,
at the same time increasing the compensation to $100 per
month. Under the new plan, to each inspector was as-
signed a group of schools, the census of which was approx-
imately 5,000 children. The inspectors were required to
visit each of the schools under their supervision each morn-
ing before 10 o'clock. Dr. Biggs then described in detail
the duties of these inspectors, and stated that with the ex-
tension of the work it soon became evident that the pres-
ence of trained nurses in the public schools would be of
great value, especially as in some of the schools a very large
percentage of the children w-ere affected either with tra-
choma, acute conjunctivitis, pediculosis, or some contagious
disease of the skin, and the treatment which they received
at home or from dispensaries was often unsatisfactory and
inefficient, and their exclusion from school decimated some
of the classes and aroused a violent protest from the school
authorities. Therefore, on December i. 1902. eight nurses
were appointed, at a salarj' of $75 per month, and their
work proved so satisfactory that this number was soon in-
creased, and additions had been made from time to time
until now there were over 60 trained nurses working in the
public schools throughout the city.

Dr. John W. Branxan said he had known something of
the medical inspection of the schools, but had no idea of its
magnitude and importance. He had been familiar with
Dr. Biggs' campaign against tuberculosis during the past
fifteen years, and he was inclined to believe that the work
described this evening would prove even more valuable
in its far-reaching results. What Dr. Biggs had said of
trachoma carried the speaker back to the time when the
spread of this disease was first called to the attention of the
profession. Many physicians thought that its prevalence
was perhaps exaggerated, and for a time he himself shared
this opinion, but when he visited the clinic of the New York
Eye and Ear Infirmary and saw the children crowding

June I, 1907]

MEDICAL RECORD.

9^.5

about Dr. Derby in their desire to be operated on. he
changed his views, and subsequently, when tlie clinic was
opened at Gouverneur Hospital, he saw the same rush of
patients to get within reach of the surgeons. He had been
rather surprised to hear this evening that the disease was
still so prevalent, in spite of the energetic work of the
Health Department during the past four years, and he sug-
gested the possibility that fresh cases were slipping into
the city through Ellis Island. He had been told by surgeons
stationed at the island that occasionally aiTected immigrants,
instead of being excluded, as the law required, were ad-
mitted to the Government hospital, and after treatment
were permitted to land. Mild cases of the disease might
also be undetected by the surgeons, whose examination was
necessarily hasty when thousands of immigrants arrived in
one day.

Dr. Charles L. D.^na said he thought the importance of
the work of the Board of Health in connection with the
medical inspection in the public schools could not be over-
estimated. He was particularly interested in that pliase of
the subject that related to the effect of physical defects
upon the mentality of the children. More exaggerated
examples of this type came under observation at the clinics
and hospitals, and it would be extremely interesting to
study the ordinary school cases more specifically, in order to
learn exactly what was meant by the term defective men-
tality : whether it implied defective memory or some moral
defect, or perhaps some peculiar forms of defect in language
capacity, which in some children seemed to be very marked.
There was, for example, an apparent congenital defect in
the capacity to learn to read, or to understand syntax or
remember words, so that their vocabulary was extremely
small. Some of these cases could be much improved by
specialized forms of teaching. The more common defects
observed in the backward cliildren in nerve clinics were
those relating to the eyes, obstructions to breathing due to
adenoids or enlarged tonsils, and defects to nutrition, result-
ing in a poorly nourished general system as well as brain.
The latter type was not uncommon among the children of
the better class, and was sometimes associated with a form
of youthful neurasthenia.

Dr. William M. Polk said the information contained in
Dr. Biggs' paper was interesting not only from the stand-
point of the neurologist, but from every possible standpoint,
and especially that of good citizenship. The entire subject
was intermixed with one that was at present receiving tlie
attention of the American Medical Association, namely, the
enactment of legislation for the prevention of ophtlialmia
neonatorum. The plan would come up at the meeting in
Atlantic City.

Dr. George L. Peabody said the work undertaken by the
Board of Health was of such immense humanitarian im-
portance that it should be aided in every possible way. No
matter what the cost of the work might be, it would in time
save much more to us in making useful citizens of children
many of whom might otherwise have grown up to be not
only useless, but criminals. Dr. Peabody said that in liis
official connection with a large institution for the blind he
had become impressed with the fact that the number of
children affected with blindness, especially in this vicinity,
was steadily diminishing. This could probably be traced to
the more rigid rules that now prevailed regarding cleanli-
ness and to our knowledg* regarding the prevention of eye
diseases in the new-born. The speaker said he did not
believe that the prevalence of trachoma in New York City
to-day was due to fresh sources of infection in immigrants.
The steamship companies were very careful to exclude these
patients, as a fine of $100 was attached to each one they
brought over. and. furthermore, they were compelled to take
them back again.

Dr. L. Bolton Bangs asked if this work among the school
children produced any educational reaction amon.g the
parents? Did the latter learn anything from it? The
questions involved were not only hygienic and sanitary, but

socKilogical, wliich would have its influence upon the imme-
diate generation and succeeding ones, and in the course of
time this system of school inspection would effect a marked
diminution in the number of defective children.

Dr. Biggs said that while tlie medical inspection of the
public schools had been in force long enough to draw any
conclusions regarding its influence upon the parents of the
children, it undoubtedly did exert some such influence. For
example, in certain parts of the city entire families were
affected with pediculosis; the children in those families were
sent home on account of it; they came to regard this as
more or less of a stigma upon them, and they, in their turn,
converted their parents to regard it in the same light.

Dr. Joseph D. Bryant said that while he had been more
or less familiar with the general trend of this branch of
work of the Health Department, he had never before so
fully appreciated the beneficent iiillucnces arising from it.
It had impressed him more than ever before witfi the im-
portance of having a sound body in order to have a sound
mind. He thought no one would question tlie wisdom of
the very earliest possible detection of these physical defects
in children. Those of the spine were important, which later
became absolutely irremediable, so far as complete recovery
was concerned. In that connection he more especially had
in mind incipient Pott's disease. In regard to the proper
care of the eyes, particularly in the prevention of oph-
thalmia neonatorum. Dr. Bryant said he recently saw a
statement to the effect that 25 per cent, of blindness was
dependent upon preventable disease. He commended the
work earnestly, and hoped that it would be continued, say-
that the resulting increase in careful, self-suffering people
would lessen the census of public institutions of charity and
of punishment and add correspondingly to good citizenship.

Dr. Charles Stedman Bull said the medical inspection
in the public schools, as outlined by Dr. Biggs, was without
doubt the most colossal work that had ever been under-
taken by any municipality, and no matter what the cost
might be, the results would more than repay the money
spent. In referring to trachoma and its prevalence at the
present tiine in spite of the thousands of cases that had
luen treated during the past three or four years in this city,
Dr. Bull said there was a large percentage of these cases
that were inoperable ; they were the cases in which there
were no distinct granulations that could be taken hold of
by any method of operation, and while they could be
quickly cauterized, prolonged treatment was usually neces-
sary, while, on the contrary, those cases that presented dis-
tinct trachoma nodules could be operated on at once and
almost immediately cured, and they ceased to be con-
tagious then and there. Dr. Bull said that another far-
reaching effect of a proper system of medical inspection of
the public school children in its relation to the eye was in
the detection of errors of refraction or muscular anomalies
which were susceptible of correction by glasses. In that
connection, he did not have in mind the indirect influence
of the corrected eyesight upon the child's mentality, which
in itself was an important factor, but its even more far-
reaching influence as a prophylactic measure in the later
prevention of such destructive conditions as retinitis, cat-
aract, and choroiditis. The speaker said that during the
past fifteen years there had been a steady decrease in the
number of cases of cataract dependent on nutritional de-
fects of the lens, and he attributed that fact to the more
general use of proper glasses for the correction of anom-
alies of refraction. It was doubtless true that cases of
blindness in children were somewhat rapidly diminishing,
which was proliably traceable to tlie fact that the diseases
which caused it were earlier recognized and treated.

Dr. Biggs, in reply to the question of whether other mu-
nicipal bodies had taken up this work, said that something
had been done along these lines in Boston, especially in
reference to the contagious diseases and the eyes. It was
also taken up in Philadelphia, but subsequently abandoned.
In Berlin and other Continental cities the eves of children

924

MEDICAL RECORD.

[June I, 1907

had received considerable attention, but, so far as he knew,
there was no general physical examination. In England,
the supervision of the school boards was largely limited to
the infectious diseases and the eyes. 1 he work in New
York was more general and systematic than anywhere else.

The President, Dr. Abbe, said that as physicians we
should not lose sight of the tremendous degenerative force
that the defective element exerted on the community in
general, and the corresponding benelit that would accrue
from the correction of those deformities. One of the most
striking features of Dr. Biggs' report was the rapid im-
provement made by some of these l)ack\vard children after
their defects had been corrected.

Dr. Biggs closed the discussion and, in referring to a
riot that had taken place in one of the schools on the lower
East side, said the cause of the e.Kcitement was that many
of the children in that section of the city, on account of
their race, preferred to go to a certain hospital to have their
tonsils removed. The hospital was located at such a dis-
tance that a stafif of physicians was sent from the hospital
to one of the schools on a certain day with consent of the
Board of Education, and in the course of a few hours 85
pupils of that school were operated on and sent home. This
so alarmed the parents of the other children in the school
that the report spread that the Board of Health doctors
were cutting the children's throats, and a small riot ensued.
As a matter of fact, the Department of Health statf had
nothing to do with the operations.

A Comment on the X-Ray Applied to Prostatic En-
largement.— Reported by Dr. L. Bolton Bangs. (See
page 902.)

A Typhoid Fever Carrier. — Dr. Biggs said that on
March 12, 1907, the Health Department received a
communication to the effect that outbreaks of typhoid fever
had occurred in four families in this vicinity during the
past four and a half years, and that in each instance the
outbreak had occurred shortly after the employment of a
certain woman as cook. An investigation was instituted
which disclosed that in addition to these four families,
typhoid fever had occurred in several other families where
she had been employed in the same capacity. It was further
learned that this woman was an excellent cook, and on
that account had no difficulty in finding employment ; she
changed her position at frequent intervals, and would only
work when she was compelled by necessity to do so. At
one place where she had been employed she left the kitchen
in such a filthy condition that it required the services of a
scavenger to cleanse it. In several of her former places of
employment, three to seven cases of typhoid fever had
occurred, and in her last place there had been two cases,
one of which proved fatal. The cook was a perfect Am-
azon, weighing over 200 pounds, and when an investigator
tried to interview her he was ejected with very slight cere-
mony. A health inspector and officer were then sent to the
house, but they failed to see her, and the same thing oc-
curred to a female health inspector who had been advised
to use tactful methods. It was then considered justifiable
to employ force, and five police officers from the Sanitary-
Squad finally succeeded in taking the woman to the Recep-
tion Hospital, of which she is now an inmate. An exam-
ination of her urine gave negative results, but the feces
were found to be loaded with typhoid bacilli. At one time
nearly go per cent, of the organisms were typhoid bacilli.
The woman gave no definite history of typhoid fever, at
least not for the past five years. [See also Medic.\l Rec-
ord, May 18, 1907, page 818.]

Local Applications in Inoperable Breast Cancer.—

Any lotion or ointment containing morphine is suitable,
but I know few more soothing applications to an incurable
breast cancer than the old-fashioned conium poultice. This
may be made from the fresh leaves, or one-half ounce
cf the succus conii may be added to an ordin.iry breast
poultice. — Marmaduke Shield.

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital
Service, during the week ended May 24, 1907 :

SMALLPDX fXlTED STATES.

California. San Francisco Apr. 27-May 11.

Florida. Hillsboro County — Tampa May 4-11

Georgia, Augusta May 7-14

Illinois, Danville May 7-14

Indiana, Indianapolis May 5-12

La Fayette .May 6-13

Kansas, Kansas City May 4- 11

Topeka May 4-11

Kentucky. Louisville May 9-16. . .

Louisiana, New Orleans May 4- 1 1

Massachusetts. Chelsea .May 4-11

LawTcnce May 4-11

Michigan. Detroit .May 1 1-18

Grand Rapids .May 4-1 1

Highland Mar. i-May 14. .

Minnesota. 45 Counties Mar. i i~Apr. 30.

Missouri. St. Joseph .May 4-1 1

New York. New York Mav 4-11

North Carolina. Charlotte .May 11- 18

Greensboro May 4-11

Ohio, Cincinnati May 10-17

Columbus .Apr. 1-30

I Hamilton May 9-16

Tennessee. Nashville May 1 1-18

Virginia. Richmond May 4-1 1

Wisconsin. Milwaukee May 4-1 1

Washington, Spokane .May 4-11

Tacoma May 4-1 1

CASES.
5

3 2.i
18

SMALLPOX — FOREIGN.

.\frica. Lorenzo Marquez Mar.

Brazil. Pemambuco Mar,

Rio de Janeiro Apr.

Canada. Sherbrooke May

Chile, Coquimbo Apr.

Iquique .\pr.

Ch'na, Hankau .\pr.

Hongkong Mar.

Columbia. Barranquilla Apr.

Ecuador. Guayaquil .-^pr.

Egypt, Cairo Apr.

Germany. Bremen Apr.

Great Britain, London Apr.

Southampton .Apr.

India, Bombay Apr,

Calcutta .Apr.

Madras -Apr.

Rangoon .Apr.

Italy, General Apr.

Naples .Apr.

Rome Feb.

Java. Bata\-ia Mar-
Madeira. Funchal Apr.

Me.^ico. Aguas Calientes .Apr.

Mexico City -Apr,

Portugal. Lisbon Apr.

Russia, Moscow .Apr.

Riga Apr.

Siberia. Madivostok Mar.

San Feliu de Gui.xols -Apr.

Turkey. Bagdad Mar.

Bessorah .Apr.

I-3J...
1-15...
14-28..
11-18..

20

20. . . .

'i-13

3t-.Apr. 6..

20-27

20-27

15-22

20-27

20—27

20—27

16-23

16-23

13-19

6-13

25-.May 2. .
26- .May 4. .
23-Mar. 2 . .
30-Apr. 13.
2i-May 5. .
20-May 4. .

6-20

20-May 4. .

13-20

20-27

14-21

28-May 4. .
23-.Apr. 6..
13-20

18 2 Imported
3

5

72

3

6

Present

3
94

96

37
26

Present

YELLOW PEVER.

Brazil. Rio de Janeiro -Apr. 14-28 6 4

Brought from Union de Reyes.

Cuba. Havana May 16 i

Ecuador. Guayaquil -Apr. 13 6

Guatemala, Zacapa May 16 1

Venezuela. La Guaira Feb. 16-Mar. 30 Present

CHOLERA.

India. Bombay -Apr. 16-23

Calcutta -Apr. 6-13

Madras -Apr. 13-19

Rangoon -Apr. 13

Straits Settlements. Singapore Mar. 30- .Apr. 6. . . .

Hawaii. Honolulu..

LAGVE — INSULAR.

May 15-21.

PL.^GUE — FOREIGN.

Brazil. Pemambuco Mar. i-is

Rio de Janeiro .Apr 14-28

Chile. -Antofagasta .Apr 20

Santiago .Ai>r, 20

Taltal .Aor. 20

Egypt. Assiout Province .Apr. 22-30

Beni Souef Pro\'ince .Apr. 25-May 2.

Girgeh Pro\-ince \nr. 22-May i.

Keneh Province -^ -'r. 20-May i .

Minieh -Apr. 21-May I.

India, General .Aor. 6-13

Bombav .Apr. 16-23

Calcutta .Apr. 5-13

Rangoon .Apr. 6-13

Japan. Formosa .Apr. 6-13

Mauritius Mar. 7

Peru. Chenen -Apr, 17

Chiclayo .Apt. 17

Lima .Apr. 17

Mollendo .Apr. 17

Paita .Anr. 17

Trujillo -Apr. 17

6
Present
Present

61

75.472
376
383

9S

103
78

3

3

4

4

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 71, No. 23.
Whole No. J909.

New York, June 8, 1907.

$5.00 Per Annum.
Single Copies, (Oc.

(Original ArtirlrH.

THE AMERICAN MEDICAL ASSOCIATK )N,
ITS AIMS AND INTERESTS.*

By JOSEPH D. BRYANT. M.D,,

NEW YORK.

The fifty-eighth consecutive session of the Ameri-
can Medical Association is now at hand. Those
members whom you kindly honored one year ago
with your confidence in official station are now be-
fore you in token of their loyalty to your under-
takings and of their obedience to your behests.
These annual conferences are of prodigious mo-
ment to the entire medical profession and to the
country at large ; they serve to broaden the scope
of general understanding : they extend the sphere
and increase the vigor of professional fellowship
and of healthy civic brotherhood, and they corre-
spondingly elevate the station of our calling in the
appreciation of thoughtful rightminded ])eople
everywhere in the land. Who of us was not made a
better physician because of the visit to Boston a
year ago? Who of us, then inspired by patriotic
emotions, aroused by the memorable e.xamiiles so
abundantly at hand, did not again renew unalter-
able allegiance to the perpetuity of his country? In
whom of us was not incited a higher fraternal senti-
ment by the warrn grasps of fellowship which, while
inviting delay a bit, everywhere urged us on to a
completed hospitality ?

Again, for the third time in the dawn of the
twentieth century, we find ourselves in the warm
embraces of the hospitable people of Atlantic City.
Its wealth of sunshine and cheer, its pure and in-
vigorating eastern breezes, and the joyous acclaim
of its citizens assure us that we are in "honest
waters which ne'er left man i' the mire." and,
therefore, we feel entirely secure and correspond-
ingly happy. We who before never yielded to subtle
solicitation or to pressing demand now acknowl-
edge that we have the Atlantic City "habit," and
we refuse all treatment except that founded on
the therapeutic virtue of the hair of the canine
that inflicted the delightful traumatism ! In the
presence of such a felicitous environment as this,
who is there among us who would he so thoughtless.
or who could be so unfeeling, as to countenance a
trifling with the sense of justice by individual fa-
vor, or of cominendable desire by vain objection?

In looking about for a topic on which to base
my allotted remarks on this occasion, I am, per-
haps, unduly impressed with the idea that imper-
sonal openhearted introspection might not be amiss
at this period of the Association.

In this bearing I refer more especiallv, i, to the

♦President's .'Address at the Fifty-eighth .Annual Session
of the .'\merican Medical .Association at -Atlantic City.
N. J., June 4-7, 1907.— From advance proofs through the
courtesy of the Journal of the American Medical Associa-
tion.

organizing of the medical profession of the country
and its potential perplexities ; 2, to the elevating
of the standard of medical education and its pos-
sible afflictions, and, 3, to the urgent demand for
trustworthy medicinal means and of sincerer efforts
on the part of every physician in securing a better-
ment of therapeutic methods.

Equit)-, consequent power, and the durabilitv of
human designs are the legitimate assets of wisely
conceived organization. Power and durability, not
thus sustained, are of uncertain tenure and organ-
ization resting thereon can be likened to a house
of blocks tethered with ropes of sand. .\nd it
should be recognized at all times that the virile
activities of the principles of human justice are
wonderfully potent in all organized bodies of man-
kind.

The Object of the .■issociation. — It is of great
moment that this Association has (as set forth in
its constitution) but one significant object in view,
viz., The Promotion of the Science and Art of
Medicine. And it is purposed in attaining this
end "to unite into one compact organization the
medical profession of the United States," in order
to foster "the growth and diffusion of medical
knowledge"; to promote "friendly intercourse
among American physicians''; to safeguard "the
material interests of the medical profession" ; to
elevate "the standard of medical education" ; to se-
cure "the enactment and enforcement of just inedi-
cal laws" : to enlighten and direct "public opinion"
regarding the "broad problems of hygiene," and to
present "to the world the practical accomolishment
of scientific medicine.''

It follows, therefore, that the promotion of the
science and art of medicine as provided by the
constitution of the Association is, in effect, the pro-
motion of the methods and the development of the
means and the opf)ortunities for relieving human
suffering and thereby the adding of years and com-
fort to human existence. And true it is that to no
class of persons is fraternal spirit and vigilant co-
operation so essential as to those who are engaged
in combating the insidious and tireless encroach-
ments of the agents of human affliction and in re-
lieving the abundant miseries which they beget. A
transcendent service like this should be sheltered
by the zeal of healthful personal and professional
devotion and in no way depleted by the wiles of
business ambitions. Tliose who regard the prac-
tice of medicine as a business enterprise should
class themselves as brokers in a market of human
affliction. To those who would infect the sound
spirit of professional devotion and fellowship with
the virus of sordid gain little heed need be given
at the counsels of thoughtful men in the ranks of a
beneficent profession.

The uniting of the medical profession of the
United States into "one compact organization,"
making to the wise purposes already stated, is pro-

926

MEDICAL RECORD.

[June 8, 1907

gressing in a decided manner, guided by the earnest
activity and abundant exijerience of Dr. J. N. AIc-
Cormack of Kentucky. Alreadx- the constituent
members of the organization number nearly 65,000,
of which the fully constituted members are about
27,000, showing a substantial increase of the for-
mer class during the present year of about 10
plus per cent, and of the latter about 12.5 per cent.
And when it is recalled that the regular medical
profession of the United States numbers about
112,000 it is not difficult to understand that in the
near future the medical profession of these States
might easily be united into one compact organiza-
tion. But how compact it may be and how enduring
it may become will depend on the degree of wis-
dom exercised by its builders and on the measure of
justice dispensed by those in control of its affairs.

"Justice without wisdom is impossible." said
Froude. "Wisdom is only truth," said Goethe.
Therefore, justice and truth are inseparable, say
we all. The search for truth and understanding is
the inherent right of all men, and they who in-
hibit the effort are for some reason (or pretext)
opposed to justice and to knowledge. Obviously
the consensus of men of widely separated habita-
tion, of dift'erently constituted environment and
opinion, is a wiser and a safer guide in the conduct
of important and comprehensive human affairs than
is the consensus of men of contiguous localities.
The judgment of the former class renresents the
concentrated wisdom of the whole, of the latter
only that of a part of the country. The principle
of utterance or of action relating to matters of com-
mon interest and general eft'ect in organized bodies,
should in all cases be known and approved and be
coordinated through the deliberate wisdom of broad
constituted authority, rather than by the anxious
thought or the hasty vocabulary of a few persons,
no matter how experienced they may be or how wise
they may be regarded as being. History not in-
frequently has demonstrated by untoward results
the need of this rule of action in "-overnmental and
in other human affairs.

The lamented Lincoln emphasized the importance
of this principle in no uncertain manner by the
famous utterance, "The government of the people,
by the people, for the people, shall not perish from
the earth."

And in this relation it is well for us to keep in
mind that a failure on the part of the responsible
many, to plan and coordinate wisely the official acts
of the few, often renders effeminate and inoperative
the sub.sequent inhibitory efforts of those in estab-
lished control.

Among the inspiring benefits provided bv the
constitution of this Association is embraced the
fostering of the growth and the diffusing of medi-
cal knowledge and its beneficence, throughout the
various channels of human intercourse. The pro-
moting of the growth and the diffusing of medical
knowledge should appeal with equal vigor to the
people who experience relief and to those who
contribute the products of medical enlightenment.

Every physician can contribute a definite share
to the healthy growth and wise diffusion of medical
knowledge and to its bounties. Those who strive
in the workshops of medicine, the laboratories and
the hospitals, more especially the former, have al-
ready bestowed a bountiful portion toward the at-
tainment of this end. Scientific laboratory deduc-
tions, however, could not be regarded as final ;
they yet required the leavening proof from out the

complex laboratory of the human body, as demon-
strated by practical applications in the treatment of
disease, to establish their worth. To the general
and to the hospital practitioners of medicine be-
longed the duty of dispensing the fruits of labora-
tory research, and thus far so well has concurrent
effort accomplished its purpose, that life's expec-
tancy during the first forty years of existence has
been advanced quite 30 per cent. But following
this period only a little advance in this regard has
yet been made, and principally because of the dif-
ferences in the nature of the diseases which afflict
those of the earlier and of the later periods of
life.

The present and prospective civil worth of the
toll levied by disease on the wisdom and experience
of mankind, during the later period of life can not
well be estimated. But the physical sufferings of
this period are largely the characteristic outcome
of its peculiar diseases, many of which might be pre-
vented and perhaps cured by means of progressive
investigation and therapy related to a full term of
years, and thus life's span becomes yet longer
extended.

As just observed, every physician, if he will, can
contribute a definite share to this preeminent un-
dertaking. The opportunities of the country prac-
titioner in this regard are of special sienificance,
because of the knowledge gained through the dif-
fering effects of environment on the diseases of
country and urban patients. Painstaking cooper-
ative effort directed to the solution of the problems
of disease can be made wherever two or more phy-
sicians are in mutual contact with each other and
shall undertake the task.

Medical Education. — It can not be gainsaid that
comparatively few of the people constituting
the medical profession of this country are tireless
in their efforts to advance the scientific and prac-
tical status of medical knowledge. But what can
be said regarding the great multitude of others of
the people, referable to mutual response commen-
surate with the earthly blessings which they re-
ceive? As an earnest of the sentiments of those
persons who give bountifully to beneficent ends, I
quote from a comprehensive address delivered by
President Keen at the annual session of this Asso-
ciation, held here in June, 1900, and based on the
United Education Report of 1898. President Keen
presented to the audience the following startling
facts regarding the comparative endowments be-
stowed on theological and medical schools for
teaching (not foundation) purposes in this coun-
try. It was shown that each of the 8,000 theologi-
cal students had the income of $2,250 provided for
his instruction, and that each of the 2,400 medical
students had the income of $83 provided for the
same purpose. Also that of the 178 endowed chairs
in teaching, only five related to medicine. Then we
were solaced by the thought, "A hard beginning
maketh a good ending."

In this address President Keen gave as his opin-
ion that the dift'erence in the amounts of these en-
dowments was chiefly in consequence of the "vicious
methods of the conduct of medical teaching as rep-
resented in preparatory medical schools." .And it
is fair to say that many others were of the same
opinion. In view of this hypothesis, and of the
fact that since the time of the report on which it
was based up to the final one^ of five years later,
and notwithstanding that distinct improvement in
the administration and the teaching in medical col-

June 8, 1907]

MEDICx'\L RECORD.

927

leges had taken place, and broader laboratory ave-
nues of well-known scientific outcome were in opera-
tion, still it does not appear that a sufficient rising
in the tide of advancement was reached to influence
satisfactorily the inclination of munificent givers.
For, according to the report of 1903-4, each of the
7,400 theological students of 1904 had the income
of $3,031 provided for his instruction, and each of
the 27,000 medical students of that year had the
income of $54 provided for the same purpose, thus
showing a gain over the previous report in favor of
the theological student of $781 per capita, and a
loss to the medical student of $29 per capita, for
teaching purposes.

Endoimnents. — Substantially the benefit of $22,-
500,000 was available for the purposes of theologi-
cal education, as against the l.ienefit of $1,450,000
for medical educational use at the time of the report
of 1903. At this time, of the 153 theological schools
yj report endowments and 76 report no endow-
ments. And of the 152 medical schools 19 report
endowmeiits and 133 report no endowments. Also
five of the theological schools had endowments
varying in amount from $853,000 to $1,525,388
each. Now, more than ever, are we impressed with
the force of another expression, "Help yourself and
Heaven will help you."

In view of this later increase in the diiTerence
of the incomes bestowed for direct educational pur-
poses, and under improved medical conditions, it
seems quite likely that opposing factors more po-
tent than first assigned, are extant. When, how-
ever, it shall happen that bountiful givers regard us
in health as in acute affliction, perhaps greater heed
will be given to the wisdom of making larger med-
ical educational gifts. Irreverent comment has
hinted of another compelling influence, especially
related to generous adult minds, embodying the no-
tion that the hope and faith of celestial expectancy,
are more attractive than are the faith and outcome
of terrestrial realization. Whatever may be the rea-
son for the continued paucity of medical endow-
ment, I am not prepared to say, but I hope that
substantial improvement will be secured through
the convincing influence of beneficent subjective
and objective lessons, patiently, discreetly, and
thoughtfully impressed by us on the public mind.
Yet, confronting this hope, there appears an om-
inous specter pointing to the fact that only by
laborious eiifort, chiefly supported by the medical
profession, were the memory and brilliant services
of the late Dr. Walter Reed meagerly characterized.
Those who experienced the greatest blessings be-
cause of them gave the least to the care of those
whom he loved most.

The simple, commonplace remark, "the promoting
of friendly intercourse among American physi-
cians," I regard as the most important announce-
ment set forth in the opening declaration of the
constitution of the Association, looking to the "Pro-
motion of the Science and Art of Medicine." For.
without the stimulating and guiding support of pro-
fessional good-fellowship in all the term implies,
discord and discredit are likely to delay or cripple
the realization of this one great object in view.

Tlie Journal. — I know of no agent so well fitted
to contribute* to the fostering 01 the growth and
the diffusing of medical knowledge and the pro-
moting of friendly intercourse among American
physicians as rightly falls to the lot of The Journal
of^ the American Medical Association. A jotn-nal
with a weekly circulation of over 50.000 ami ac-

counted as the utterance of many more than this
number of the organized medical profession of
the country, may well be regarded in things of
professional concern as the voice of the multitude
proclaiming its will. Therefore, it is important that
the tone and wisdom of its speech be in accord
with the judgment of the great majority of our
profession. I am inclined to believe that when the
pages of our journal are the forum of temperate
and instructive discussion of the policies of common
interest to our membership greater impetus will be
given to just causes and a broader scope to fraternal
comfort among American physicians. One, how-
ever, can not be reminded of The Journal without be-
ing impressed by the creative aility, the abiding
energy, and overtaxed assent of the editor, the Sec-
■ retary of this Association.

I am deeply impressed with the belief that at this
time the greatest danger to continued harmonious
unity in the Association lies ill-hidden in the con-
stituted e.xpression, "to safeguard the material in-
terests of the medical profession." It requires no
special discriminating sense to foresee the devious
interpretations which eager desire might willingly
give to the phraseology of this declaration. For-
tunately, however, no rendering of the language of
this expression can be nroperly entertained which
conflicts with that of the antecedent one. "the pro-
motion of friendly intercourse among American
physicians." However this may be, the following
suggestive lines of Froude should not be over-
looked : "Where all are selfish the sage is no better
than the fool, and only rather more dangerous."

The War Against Disease. — The genuine prod-
ucts of completed organization of the medical pro-
fession are of infinite importance to the well-being
of the country. The potent factors of common pros-
perity will be encouraged and protected ; the hearts
and homes of the well-to-do and the hopes and
hovels of the needy will each reflect in joyous
ways the benefits of cooperative action in fixing
the nature, overcoming the causes, and lessening
the burdens of disease. The war now under way
against cancer and tuberculosis, two of the insa-
tiable inflictions of humanity, can, along with that
opposing ophthalmia, be waged with comprehensive
rational designs and improved prospective results.

The broader the field of opportunity in this re-
gard, and the greater the activity of the contest,
the more bounteous will be the return and the
greater a final victory. When, for instance, it is
recalled that for unknown reasons the death rate
from cancer is slowly advancing in spite of intelli-
gent, earnest opposition ; that acquired tuberculosis
yet adds 13 per cent, to the total death rate ; that
unrestrained ophthalriiia causes over 25 per cent,
of the blindness from disease ; that over ^o per cent,
of the school children of New York, and perhaps of
other large cities, suft'er from defective vision, and
that in 75 per cent, is their mentality impaired by
causes yielding to curative measures of a simple
and permanent nature, then, indeed, is the neces-
sity for united action relating to control of human
infliction emphatically demonstrated.

The alleviation and cure of such afflictions serve
to lighten the burdens of public care, to lessen the
tenantry of charitable and penal institutions, and
to lay the foundation of good citizenship.

A National Board of Health. — The fact that
communicable disease has no boundary restraints
in the presence of unguarded human pursuits is
quite as familiar to the lav as to the merlica! mind.

928

MEDICAL RECORD.

[June 8, 1907

Also that human indifference and human igno-
rance and established sectional state policy often
contribute an unfortunate share to human distress
is well known to the medical profession. It would
seem wise, therefore, that interstate sanitary rej^ula-
tions should be established, thus aiifording even-
handed opportunity of protecting interstate enter-
prise from the effects of current disease. Duties of
this nature and others of national sanitary import-
ance can be properly met when an awakened sense of
the need on the part of those controlling the affairs
of the country shall invite the cooperation of our
profession looking to the acquiring and preserv-
ing the best results, which wise statesmanship and
wise sanitation can jointly secure.

A national board of health having in charge such
things as properly fall under its consideration and
action would be a national blessing of ever-increas-
ing importance. But in this relation candor compels
me to state that I find little encouragement for those
of our profession who at the outset would demand
a seat in the executive council at the head of the
nation as an acknowledgment of professional ca-
pacity, or as a retainer for prospective service.
Instead, we and others laboring in mercy's cause
should be willing to serve in allotted capacitv as
Jacob served for Rachel, with unostentatious pa-
tience, tinctured perhaps with cruel disappoint-
ment, but leaving the results of our labors as an
earnest of our worth and of the reward which best
befits us.

Not a little has been said in the near past re-
garding the possibility of securing national incor-
poration of the American Medical Association, with
power to hold property and transact business anv-
where in the United States. The gaining of such
incorporation is no longer speculative, for within
the last year several charters of similar scope to that
framed by Judge Ray for us have been secured for
other organizations. I am inclined, however, to
hesitate in recommending a renewal of endeavor in
this respect until assurance can be had of earnest,
genuine effort on the part of all, looking to the
securing of incorporation and also cooperation in
the adjustment of the business matters essential to
a completed consummation of the act. A policy
which would contemplate the locating of the busi-
ness affairs of the .Association at Washington in
the event of incorporation, I regard as hostile to the
best interests of the profession and contributive to
the impairment of fraternal peace.

Medical Legislation. — The enactment and en-
forcement of just medical laws is a matter of super-
lative importance. Fair and equitable relations,
founded on uniform standards, should be estab-
lished between the respective States regarding the
requirements of medical education. L'nder this
arrangement, fully qualified phvsicians going from
one State to another would not be obliged to sub-
mit to annoying State board scrutiny concerning
fitness to practise medicine. Since no unusual pro-
fessional attainments are necessary to meet the ex-
igencies of practice in any State of the Union, but
little difficulty should be experienced in establish-
ing a grade of educational requirement, permitting
of practice through reciprocal comitv.

The unwelcome thought arises at this time that,
in the absence of equitable State reciprocity, one or
more States not blessed with first-class educational
opportunities might endeavor to protect their own
interests against the professional encroachments of
the graduates of first-class medical schools by re-

quirements to practice of such character as not to
merit serious thought on the part of the faculties
of highly reputable medical institutions. It is diffi-
cult, however, to conceive that this idea can be
more than a passing fancy, for how a course of this
kind could receive the sanction of good judgment
is not easily understood. Relative to competent
practitioners of long standing w-ho may desire to
change their State environment, a greater difficulty
attends a proper adjustment of their situation. It
seems to me, however, tliat common justice requires
that a form of examination should be given in these
instances, which in its scope is measured by prac-
tical methods consistent with the experience of the
applicant, rather than by one of modern require-
ment. For I am quite certain that if a member of
the teaching faculty of a modern medical school were
unexpectedl}- to find himself outside the halls of his
own institution, a creditable return through the en-
lightened channels prescribed by his catalogues for
students, would be shadowed with great doubt and
probably attended with lunniliating disaster.

Medical Education. — Beneath this opinion lies a
thought pregnant with imnortant professional re-
sponsibility relating to all those who have to do
with regulating the requirements to begin the studv
of medicine. Should it occur to them that ideals
may not everywhere be needed and that the object
might be to meet the requirements of the whole
country — a country yet comparatively new in pro-
fessional opportunities and rewards for ambitious
young men in a great part of its area? Should it
occur to them that the coming into the field of action
of vast business enterprises has begotten correspond-
ing opportunities attended with less prepara-
tory drudgery and expense and by greater pros-
pective rewards than generally attend the practice
of medicine ? Ought they to keep in mind that the
increase in educational requirements above a cer-
tain point has not resulted, at least in New York
State, in a corresponding increase in medicine of
those of the highest qualifications, but instead their
comparative numerical status (21 plus per cent.)
in this and in other common respects has remained
practically unchanged for the last ten years? Is it
not possible, therefore, that many worthy and able
young men who are less favored than their fellows
have sidestepped because of the comparative hard-
ships imposed by educational requirements and the
uncertain and delayed rewards that attend earnest
endeavor in the medical profession ?

Whether or not the standard of medical educa-
tion should soon be raised in this country to equal
that of the old world is a matter concerning which
honest differences of opinion are earnestly pro-
noimced. While no one can consistently contend
that knowledge is not power, yet the adjustment of
more than a requisite amount of knowledge in the
practice of medicine to the sparse occupancy of
many broad areas of this country is a matter which
for some time to come may concern the stern power
of economics more than the needs of ideal culture.
Possibly, therefore, those wdio are blessed with com-
mendable professional dignity and with pleasing
remunerative environment might willingly pause
for a time while giving thought to the demands for
professional care in broad necessitous surroundings.

The analytic work being done by the Council on
MedHcal Education is mercilessly disclosing the
comparative status of the medical schools in this
country, to the discredit of many heretofore differ-
ently regarded. The active manner in which the

June 8. 1907]

MEDICAL RECORD.

929

labor is carried on under the chairmanship of Dr.
Arthur D. Bevan is creditable to the committee and
to the cause in hand. Inasmuch as the standard of
suitable preparatory medical attainment dejiends
more on the capacity of a faculty to impart knowl-
edge and beget character than it does on the |)hrase-
ologv of the curriculum, the outcome of the com-
mittee's efforts is being watched with solicitous in-
terest by all concerned in honest standards of mora!
and medical qualifications.

Apropos of the importance that the faculties of
medical schools should lead the way to higher sta-
tion in professional ethical conduct, both by precept
and example, I am prompted to say that there ap-
pears to be no doubt that uncanny business in-
stincts are encroaching in the reciprocal vulgar ways
characteristic of lay methods not a little on the
sacred domain of professional propriety. I am of
the opinion that trespasses of this kind are chiefly
the outcome of acquisitive intentions based on de-
lusive selfseeking desires. The remedy for the cure
of this unprofessional propensity rests largely in the
hands of the faculties of medical schools. They
should inculcate a high sense of professional honor
in those who come under their tutelage. Ample in-
struction of medical students in the tenets of moral
philosophy, as applied to the practice of medicine.
and substantial disapprobation of oft'ending prac-
titioners by their colleagues will, in mv judgment,
hasten the reduction of this evil to a minimum.

In this glorious country of ours, "the will of the
people is the law- of the land." And in this bearing
it is needful that we should act with good sense
concerning our personnel in all matters which are
of special interest to the commonalty, so as not to
encounter the adverse activity of popular desire.
In this connection it is important to know that in
the United States there are about 84,000,000 people,
the great majority of whom are capable of satisfac-
torily judging of the practical things of life re-
lating to themselves as they come into tliought.
Also in the United States there are about 112.000
physicians who are eligible to membership in the
American .Medical Association, but of which as }et
little more than one-half are affiliated in an\ ca-
pacity with the organization. It logically follows,
therefore, that a judicious estimate should be made
of how the great majority of the 84,000,000 of
people plus nearly half of our own calling would
regard out intentions before venturing at all rather
than prematurely to court defeat and corresiMuiling
loss of station. The question is not altogether what
we think of ourselves and our causes, but the ques-
tion is how we ourselves and our causes may be
regarded by the people concerned and !.)\' their
friends, to say nothing of the balance of our own
profession. .And, too. it should be kept in mind
that it is not likely that general mutual accord will
prevail in all matters of common interest which arise
in organized bodies of men. In a humane jirofession
ap])eals should be made to judgment, not to passion
or prejudice. It is within the easv recollection of
most of us that sturdy eft'orts were made by the
united medical profession of a State in what was
regarded to be a justifiable cause, "^'et, as it appears,
decided defeat was the outcome, because the ma-
jority of the interested people were not in har-
mony with the contention. This suggestive lesson
should not pass unheeded, if experience and good
judgment are to become available assets in the
conduct of the affairs of medical organization.

The Xccd of Honest Dnio-s. — It is written tliat

Oliver Cromwell, while fording a river with his
army to attack the enemy, exclaimed, "Put your
trust in God, but mind to keep your powder dry !"
No less determined than Cromwell was, do many
physicians now feel on account of the fact that
their figurative powder (drugs) is quite apt to be
worse than wet, being alarmingly defective in
quality and fickle in strength. As an illustration
of these facts, no evidence more convincing can be
presented than that of the Health Department of
New York City. This efficient department has for
some time labored with discreet energy and with
astounding results in this heretofore comparatively
untilled field of interrogative scrutiny. That the
crude drugs and standard preparations approved by
the United States Pharmacopceia and prepared and
exploited by reputable pharmacists should, in all in-
stances, be found trustworthy admits of no denial.

It appears, however, from the reports of the
Board of Health of New York City, on the analytic
findings incident to the examination of crude drugs,
tinctures, fluid extracts, etc., as compared with cor-
responding standards adopted in the United States
Pharmacopceia, that reputable jiharmacists have, be-
cause of commercial indift'erence, or studied inten-
tion, not infrequently contributed to therapeutic
misfortune through the quality and strength of their
drugs. I will call your attention to only a few illus-
trations which are an emphatic earnest of the need
of general scrutiny of the pharmaceutical part of
our therapeutic armamentarium.

It is a matter of general knowledge that aconite
is a drug of potent nature and in comparatively
common use. Of this drug five of the thirteen sam-
ples analyzed were of the tincture and fluid extract
of the root. Of the three specimens of the tincture
one had 9 per cent, more, and of the remaining two
6 and 20 per cent., respectively, less of aconitin in
than the standard requires. Tiie two samples of
extract of the root had i3'-s and 251/.. respectively,
more aconite in than is required. The remaining
six samples were of the powdered root which in no
instance was sufficiently abnormal to call for ad-
monition. The samples of belladonna showed, re-
spectively, from 35 to 45 per cent, less of mydriatic
alkaloiils in the powdered extract of the leaves,
1 1 '2 per cent, less in the fluid extract of the root,
17 per cent, more in the tincture of the leaves, and
47/ i per cent, in the fluid extract of the leaves than
is required b\- the United States Pharmacopreia.
Powdered nu.x; vomica was found to be comparatively
worthless, but in the tincture and fluid extract was
revealed an excess of strychnine alwve the required
standard of 19 and 17 per cent., respectively. In
the tincture of opium was found, of morhpine 7 to 13
per cent, more than the accepted standard of com-
position.

In I -100 grain tablet triturate of nitroglycerin
was tliscovered only 1-1600 of a grain of the drug.
It is said that this preparation of nitroglycerin was
known by the manufacturers to be unreliable and,
therefore, should not have been exploited at all or
in a guarded manner. It is not difficult to foresee
how the failing to secure proper response from the
use of these or other tablets of uncertain strength
tiiat the substitution therefor (jf a fresh solution
of the drug might result unfortunately, especially
if the dose of the fresh preparation w-ere of the
same amount as was that of the tablet last given.
1 have in mind an instance of this kind in which
the use of a fresh solution of strychnine caused a
fatal result.

93°

MFniCAL RECORD.

[June 8, 1907

It further apjx'ars that of the first sixty-one
samples of drugs examined by the Health Depart-
ment, all of which "articles are of exceptional im-
portance, most of them potent poisons, and all are
represented by definite chemical standards in the
Pharmacopoeia," only about 28 per cent, of the
whole number was considered good and 16 per cent.
were so bad as to justify legal action. It is
proper to say that the majority of the manufacturers
recognizing the awkward position in which they
were placed, with a spirit of yielding opposition
complied with the reformatory demands of the
Health Department. This list of producers is small
in number compared with those who are engaged
in similar business in the United States, and, no
doubt, present as favorable picture of this class of
the drug evil as can be drawn.

Nor is the foregoing distress the only torment in
pharmacy with which the medical profession has
to contend. The idealized, savory products of phar-
macy with which the market is cloyed are often
quite as tickle in their nature and virtues as was a
certain ancient queen of the Nile. Discreditable
business thrift supplemented by cooperative pro-
fessional contentment and convenient indifference,
patronized by confiding and credulous people, yields
princely returns for the diminutive cash and equiv-
ocal integrity invested in it.

Not all of those, however, engaged in the phar-
macal trade are unworthy of the trust and con-
fidence given to men in other avenues of business.
\'ery many, indeed, thus engaged are as sincere
and trustworthy in their business affairs as are the
best of those in other undertakings. Therefore,
the old and revered principle of- common justice,
while ernphasizing the fact that every person should
. be regarded as being honest until the contrarv is
proven, should be kept in mind and action. Conse-
quently, in our conduct of matters imbued with
professional or business virtues, the resolution
should be to estimate uprightness of character by
the tenets of common justice, and not by precon-
ceived notions hostile to the principles of estab-
lished equity. Purposes thus graciously fortified
command respect, and gain in strength because of
opposition. The reverse, however, will beget dis-
trustful thought and may finally cause defeat. In
this recital I can not overcome the belief that we
ourselves contribute a major share to the inception
and success of many medicinal ventures by our in-
difference or ignorance relating to savory pre-
scribing and also by our thoughtless employment
of proprietary medicines. Here, too, is a chance
for medical teachers to instill proper notions re-
garding consistent ethical and therapeutic refine-
ments.

When John Dryden wrote, "virtue is her own re-
ward," he expressed a sentiment in keeping with
the self-sacrificing spirit characteristic of the mem-
bers of the Council on Pharmacy and Chemistry of
the American Medical Association. I am credit-
ably informed that these gentlemen are serving the
profession and the people in this labor without the
expectation of vulgar reward or the anticipation of
special favor. I desire to commend their motives,
approve of their work, and bespeak on the part of
the profession an earnest support of all wise conclu-
sions. Those who labor in a just cause without
stipend are deserving of great praise ; those, how-
ever, who serve for pay can only expect appro-
bation.

But little less important than the preceding, in

some respects, would be the careful scientific con-
sideration of the therapeutic value of the abundant
springs of our country. There is much, indeed, of
sjiecial significance regarding their popular use
which might well be garnered and put on a sound
basis. A scientific cooperation with those who are
in charge of certain baths possessed of traditional
specific value might readily guide to improved con-
ditions of significant importance to all those who
seek relief. A country as rich as ours in these spon-
taneous endowments can well afTord, in proper
ways, to court the attention and support of the
afflicted and to the decided advantage of all con-
cerned.

The Medical Profession in Civic Life. — The sin-
cere belief, on my part, that the outcome of pro-
fessional governing policies of common interest in
our afifairs are practically alike in county or State
prompted me in a recent parting address to the
united medical profession of the State of New York
to say : "The organization of the medical profes-
sion here and everywhere throughout the country
contemplates the realization of more than the scien-
tific advantages arising from personal contact and
local cooperative thought. It should be regarded
as an earnest that the medical profession intends to
take an active and controlling part, if possible, in
those affairs of civic life which relate to the well-
being of the body politic. There should be no ques-
tion regarding the status of the medical profession
in all matters relating to the securing of pure food,
pure drugs, and wise public sanitation." Also it
was said: "It would be sadly amiss, indeed, were I
not to admonish you at this time, the opening of a
united career, of the grave perils begotten by a
snirit of paternalism which not infrequently is a
pernicious byproduct of organized power. The se-
ductive and aggressive influence of this spirit often
usurps and may inhibit that nobler, more enduring,
and beneficent spirit characteristic of common man-
hood and professional brotherhood. And it should
not be forgotten that the greater and more extended
is the membership of a fraternal body the greater
and more extended are self-seeking desires apt to
be. Consequently the longer the chain of affilia-
tion is the weaker it may become, for. as you already
understand, "no chain is stronger than its weakest
link." I pause to inquire, is there any f^ood reason
to doubt that tlie medical organization of the nation
might not respond to similar influences ? Let us,
however, cherish the belief that wise discretion fit-
tingly stimulated by just conceptions of fraternal
spirit will gtiide us securely along the pathway of
increasing professional attainment and good fellow-
ship to the end of useful life.

And, finally, when by the aid of Divine Provf-
dence, the medical profession of the United States
shall have been made into "one compact organiza-
tion" and impelled in dutiful desires only by the
highest motives of professional purpose and of
public welfare, no enlightened opposition will op-
pose its desires, nor will irrational outcry, nor va-
grant motives, find patient listeners or available
foothold in the councils of the organization or in
those concerned in the requirements begetting of
public confidence and respect.

Earnings of German Physicians. — A report
by the Medical Chamber of Berlin and Brandenburg
shows that the average income of Berlin's doctors
is $2,250. In the case of 1,322 of them, however, it
is less than Si.2!;o.

June 8, 1907]

MEDICAL RECORD.

jji

THE EUSTACHIAN TUBE. ITS ANATOMY
AND ITS MOVEMENTS: WITH A DE-
SCRIPTION OF THE CARTILAGES,
MUSCLES, FASCLE, AND THE
FOSSA OF ROSENMULLER.

Bv \V. SOHIER BRYANT, AM.. M.D-,

N'EW YORK,

During the last twenty years the writer has paid
much attention, cHnically and anatomically, to the
tyrnpanopharyngcal tube, and long since noted cer-
tain physiological and anatomical points which are
not usually accepted but which, by clinical observa-
tion and post-mortem dissection, he has established
to his own satisfaction.

Movements. — The normal tube opens during
act of swallowing or gaping. It opens partially
during phonation, in proportion to the movement
backward of the velum palati, which is greatest with
the letters K. T, EE, etc., and least with M and N.
Inspection through the nasal fossje when the lower
turbinates have been removed (Fig. i), or through

HFiG. I. — Pharyngeal orifice of
the right tympanopharyngeal tube
at rest, seen from the anterior
nares in the living The lower tur-
binate has been removed, A —
Middle turbinate B — Fossa of
Rosenmuller C — Mouth of tube,
closed. D — Torus tubas.

Fit;. 2. — The same as Fig, i
during an act of swallowing, the
upper surface of the soft palate
has risen into \dew and occupies
the foreground. The ala cartilage
has swung inwards and upwards,
enlarging the orifice of the tube
A — Fossa of Rosenmuller. B —
Middle turbinate. C — Torus

tubt-e. D — Mouth of tube, opened.
E — Soft palate.

a salpingoscope (Fig. 3), discloses the pharyngeal
mouth of the tube and the torus tuber. The act of
swallowing, or an act which raises the soft palate
and applies it to the posterior pharyngeal wall, is
accompanied by movements of the ala tuba: in pro-
portion to the palatal movement (Fig. 2). The ala
is seen to rise, moving inward and backward, and
at the same time the mouth of the tube changes it-^
shape from a nearly vertical slit to a triangular
opening — formed by the backward movement of the
posterior wall of the closed tube (Fig. 4). The an-

FiG. 3, — The same tube as in
Fig. :. at rest, view through a
Eustachian salpingoscope. The
fossa of Rosenmuller is seen on
the left because the lenses reverse
the image. A — Fossa of Rosen-
muller. B — Torus tubfe. C —
Mouth of tube, closed.

Fig. 4. — The same as Fig_ 3.
during an act of swallowing. The
upper surface of the soft palate
occupies the foreground- The
fossa of Rosenmuller is nearly
closed by the backward and up-
ward movement of the ala c.ir-
tilage which has distended the
tube, A — Fossa of Rosenmuller.
B — Torus tuba-, C — Mouth of
tube, opened, D — Soft palate

tcrior wall remains stationary. The Inferior wall
of the open tube is formed by the stretched inferior
commissure of the closed tube. The motion of
the ala tubcc or cartilage takes place in the pharyn-
geal sinus or fossa of Rosenmuller. When the tube
is wide open at its mouth the depths may be seen
nearlv to the isthmus tuba.

*Thc following figures from the living .ind anatomical
preparations were drawn by Dr. .\. Braim of New York.

Anatomy. — The cartilaginous portion of the tuba
auditiva is very irregular in the arrangement of its
component parts. The posterior wall of this part
is composed of a plate of cartilage which has a
nearly right-triangular posterior surface and forms
the greater part of the anterior wall of the fossa of
Rosenmiiller. The apex of the triangle of cartilage
lies at the junction of the cartilaginous with the
osseous tube. The upper border of the cartilage is
attached to the skull and fits into a depression on
the sphenoid bone. The right angle of the triangle
is situated at the pharyngeal end of the upjier bor-
der of the cartilage, and is attached near the base
of the inner pterygoid process. The inner border of
the triangle forms the short limb or vertical side.
It is also the free border of the cartilage and forms
the tona tuber. Its lower extremity ends in the
angular process of the cartilage. The third and
lower side of the triangle is freely movable. This
triangular or alar cartila^-e passes above and forms
the hamular process, a small part of the anterior
wall of the tube. The cartilage as a whole is made
up of one large piece and several accessory ones.
The cartilage and its attachments are elastic and
\-ield readily to pressure, which allows fairly free
movements.

The greater part of the anterior wall of the tube
is a strong membrane. The lower wall of the open
tube is a loose elastic sheet of fibrous tissue which
contracts and folds together when the tube is closed.
The lumen of the inner third is obliterated by the
contact of the anterior and posterior surfaces when
the tube is closed. The upper and lower boundaries
of the external half of the cartilaginous tube are
formed by the concavity of the alar cartilages. The
tube always remains open because the anterior wall
does not wholly collapse against the concave pos-
terior wall. The outer part of the tube, which nor-
mally is open, has a rigid and comparatively non-
elastic wall, while the pharyngeal end is collapsible.
The mucous membrane of the closed tube lies in
longitudinal folds, especially toward the pharynx
and floor of the tube. Here the thickness of the sub-
mucous layer is much increased. When the tube
is dilated, these rugae mostly disappear. The long
diameter of the closed pharyngeal ostium measures,
on the average, 7 mm. The open ostium, an equi-
lateral triangular, averages 6 luiu. in height and
6 mm. in width.

The anterior wall of the tube rests upon the
tensor palati muscle, and that in turn on the in-
ternal pterygoid muscle and the intervening fasciae.
The pharyngeal ostium rests against the posterior
surface of the pterygoid process. This backing pre-
vents the collapse of the anterior wall. The cartil-
age of the posterior wall swings and bends easily
at its line of attachment, and allows considerable
increase in the lumen of the tube.

The tuba auditiva has two important fasciae al-
ternating with its two chief muscles. The fasciae
lie in the same plane as the axis of the tube and are
nearly parallel to each other. The fibers of the
fasciae are almost at right angles to the tubal axis.
The more important of these fasciae — the salpingo-
pharyngeal— lies between the levator and the tensor
tyiripani muscles. It is attached to the membranous
Eustachian tube at the angle between the anterior
and inferior walls of the open tube, or the lower
angle of the closed tube. It extends to the ham-
ular process of the sphenoid. The other fascia lies
posterior to the levator palati. and is attached to
the lower free edge of the alar cartilage, which

932

MEDICAL RECORD.

[June 8, 1907

prevents the levator palati muscle from slipping
off the angular process of the cartilage when the
muscle contracts.

Several muscles are situated on, or in the neigh-
borhood of the tube and affect it by their move-
ments. Chief of these are the levator palati or
dilator tubre, and the tensor palati. The fibers of
both these muscles run practically parallel to the
long axis of the tube. The levator lies below the
lumen of the tube and anterior to the angular pro-
cess of the alar cartilage (Fig. 8). It is attached
peripherally to the base of the skull at the edge
of the carotid canal. Sometimes the fibers are at-
tached to the lower border of the alar cartilage.
(Fig. 12). The sheath of the muscle is stronglv
attached to the perichondrium of the alar carti-
lage. Its muscular fibers form a strong round bellv.
Its inner e.xtremity is attached to the muscular mass
of the velum palati. This attachment moves with
the soft palate. When the soft jialate is relaxed and
hangs forw^ard, the palatal attachment of the leva-
tor is drawn downward and forward (Fig. 5). If

Fig. 5. — Shows the left post nasal space and soft palate which hangs
placid. The belly of the levator palati muscle has been uncovered and
hangs downward from the mouth of the jiharvngeal be .-V — Internal
auditory meatus. B — VII and VIII nerves, C — \'I nerve- D — Pos-
terior fossa of skull. E — IX. X. and XI nerves. F — XII nerve. G —
Posterior pharyngeal wall. H — Middle fossa of skull. I — Hypophysis
cerebri. J — Spheroidal sinus. K — Fossa of RosenmUUer. L — Nasal
septum. M — Torus tub^. N* — Mouth of tube, closed. O — Levator
Palati. P — Hard Palate. Q — Soft palate.

the palate is drawn upward and liackward. the inner
attachment of the levator is also drawn up and back
(Fig. 6). The levator palati muscle pushes the

Fig. 6. — The same specimen as Fig. 5. The soft palate has been
drawn up and back carrying with it the levator palati muscle whose
fibers now run downward and backward from the tubal mouth.
The tension of these fibers has swung the ala cartilage backwards
and upwards and opened the tube. A — Fossa of Rosenmuller. B —
Torus tubae. C — Mouth of tube, opened. D — Xasal septum. E —
Levator palati. F — Hard palate. G — Soft palate.

alar cartilage backward, upward, and inward, open-
ing the pharyngeal orifice of the tube (Fig. 9).
The muscle at rest forms an obtuse opening back-
ward at the point where it touches the angular proc-
ess of the cartilage. If the palatal attachment

of this muscle is drawn up and back, the angle is
made less obtuse. When the muscle contracts it
tends to straighten this angle and presses the angu-
lar process backward, upward, and inward. The
cartilage swings inward because of its oblique at-
tachment to the base of the skull.

Fig. t. — Base of the skull, lower jaw removed and part of the sphenoid
bone exposed. The phao'ngeal mouth of the left Eustachian tube is
seen in position The tensor and levator palati muscles are cut at the
level of the tubal mouth and dissected bare. Between them lies the
salpingopharyngeal fascia. The fibers of the tensor palati and levator
palati muscles are seen to run parallel to the axis of the tube. The
broad outer surface of the tensor is seen. The belly of the levator rests
against the lower part of the tube and anterior surface of the lower
angle of the cartilage. A — Sphenoida. sinus. B — Probe in tube.
C — Fossa of Rosenmuller. D — Torus tubte. E — Fascia between
levator and tensor palati. F — Levator palati. G — Soft palate. H —
Greater wing of spheroid. I — Foramen oval . J — Tensor palati
K — Foramen soinosum. L — Glenoid fossa.

The tensor palati is a thin muscular and apo-
neurotic sheet covering the anterior surface of the
tube. It varies more widely in its peripheral at-
tachment than the levator. It arises from the
sphenoid bone close to the outer side of the at-
tachment of the cartilage of tlie tube (Fig. 11), and
often extends by aponeurotic and muscular fibers to
the upper surface of the hanuilar process of the car-
tilage. In 20 per cent, of the specimens examined
the attachment spread downward, covering part of
the anterior membranous wall on w^hich the muscle
rests, but it was never attached as far as the inner
third of the tube. The muscle is often attached to
the fascia lying on its outer surface. The e.xternal
belly of the tensor palati is fixed by its tendon to
the hamuiar process of the sphenoid. The outer
e.xtremity is fixed at the base of the skull and to
the e.xternal fascia of the tensor. The direction of
the muscular fibers ranges from being absolutely
parallel to the tube to an angle of 10°, conse-
quently the>- cannot have a forward pull on the
anterior wall of the tube or a downward pull on
the hamuiar process (Figs. 7 and 10). In fact, the
contraction of the muscle can affect the lumen of
the tube but little, if at all. The muscle is firmly
supported anteriorly by the fascia which rests on
the internal ptervgoid muscle and the pterygoid
process.

The less important muscles connected with the
tube are inconstant. They are a slip from the palato-
glossus— the salpingoglossus — which is rerely pres-
ent, a slip from the superior constrictor of the
pharyn.x — the salpingopharyngeus — and a slip from

June 8, 1907]

MEDICAL RECORD.

9.:3

the palatopharyngeus. The last runs along the in-
ner border of the salpingopharyngeal ligament, and
is attached with it to the angle between the anterior
wall and the floor of the tube. It distends the
tubal mouth by a pull forward and downward at
tlic anterior angle. The fibers from the salpingo-
pharyngeus can only depress the ala and draw it
downward and forward, thus closing the tube. It
is attached to the angular process of the alar car-
tilage. The upper fibers of the constrictor of the
pharynx loop under the tubal mouth, and occasion-

The apex of the fossa reaches nearly to the lower
orifice of the carotid canal. The posterior wall is
supported b\- the vertebral muscles. The depth of

Fig. 8. — A similar specimen showng the tube in cross section. Two
mm. of the pharyngeal e.xtremity has been removed. The fibers of
both the tensor and levator muscles are seen running parallel to the
tube and are separated by the salpingopharngeyal fascia. The levator
palati is seen resting on the anterior surface of the angular process of
the cartilage, .i — Hamular process of cattilage B — Cross-section of
tube. C -Section of cartilage. D — Fossa of Rosenm Her. E —
Levator palati. F — -Condyle. G — Section of membranous portion of
tube. H — Tensor palati. I — Fascia between tensor and levator
palati.

ally run to the triangular cartilages and form the
salpingopharyngeus. Other fibers, twisting ex-
ternally to these, go to the back wall of the pharynx
behind the fossa of Rosenmiiller. The point of bi-
furcation of the muscular fibers forms the lower
commissure of the fossa of Rosenmiiller.

The fossa of Rosenmiiller, or the pharyngeal
sinus, is extremely variable, and does not exist in
the infant. It is lined bv the mucous membrane of
the pharynx and is rich in adenoid tissue. It fur-

FlG. 9. — The same. The levator palati has been drawn tense in
the backward direction which it occupies when the soft palate is
raised as shown in Fig. 6. It now pushes the angular process of the
cartilage upwards and backwards, encroaches upon the lumen of the
fossa of Rosenmuller. and opens the tube. The anterior wall of the
tube remains fixed. The increased circumference of the open tube
is furnished by the elasticity of the tubal wall between the cartilage
and the attachment of the salpingopharyngeal fascia. .-\ — Fossa of
Rosenmuller. B — Section of tube, opened. C — Cartilaginous portion
of tube. D — Levator palati. E — Hamular process of cartilage. F —
Membranous portion of tube.G — Tensor palati. H — Fascia between
tensor and levator palati.

nishes room for the movements of the alar carti-
lage, which lies on its anterior wall. On cross sec-
tion the fossa is somewhat lenticular in shape. Its
upper angle is formed by the angle of the attach-
ment of the alar cartilage to the base of the skull.
Its lower commissure is formed by the upper bor-
der of the superior constrictor of the pharynx, or
by the angle between the two slips of this muscle.

Fig. 10. — Similar specimen with more dissection of the structures at
the floor of the tube. The two mouths are seen running parallel to the
tube and between them the anterior wall of the tube; the attachment
of the fascia and part of the lower border of the cartilage against which
the levator palati rests. The thin, lower edge of the tensor is shown.
A — Palatal portion of tensor palati. B — Fossa of Rosenmuller. C —
Mouth of tube. D — Torus tub.-e. E — Cartilaginous portion of tube.
F — Levator palati. G — Soft palate. H — Tendon of tensor palati. I —
Hamular process. J — Tensor palati. K — Membranous portion of
tube. L — Attachment of fascia to tube. M — Internal pter>*goid.
N — Spinous process of sphenoid.

the sinus pharyngeus measured along its anterior
wall averaged i8 mm. in twenty-five cases. The dis-
tance from the upper to the lower commissure aver-

A
B

c

Fio. II. — Similar specimen of the right side. The tensor palati is
dissected and turned sharply outwards exposing its mner or posterior
surface and showing the anterior wall of the tube free from muscle
fibers, which in this case wer« not fastened to any part of the tube, but
passed beyond it to thoir attachment at the base of the skull. A —
Tensor palati. B— Cranial attachment of tensor palati. t— Mem-
branous portion of tube. D — Levator palati. E — Soft palate, t —
Sphenoidal cell. G— Fossa of Rosenmuller. H— Mouth of tube.
I— Edge of cartilage. J— Torus tubs. K— Angular process of car-
tilage. L — Fascia between levator and tensor palati. .\I — BasiUar
process of occipital bone. N — Condyle.

934

MEDICAL RECORD.

[June 8. UJ07

aged 26 mm. When the auditory tube was closed
the width of the sinus averaged 1 1 mm.

„-^ JS2

Fig I 2. — A nearly verticallsection of the right middle ear tract. The inner posterior half of
the Eustachian tube is shown with a concave wall. The levator palati muscle is seen below
the tube. It has been lifted from its bed along the floor, the tube against the cartilage and
show attachments to the cartilage. A — Canal for facial nen-e. B — Mastoid cells. C —
Pyramid. D — Facial nen,-e. E — Round window. F — Sigmoid sinus. G — Mastoid process.
H — Internal carotid artery. I — External semicircular canal. J — Stapedius muscle. K — Oval
window with stapes. L — Promontory. M — Crista falciformis. N — Canal for tensor tympani.
O— Bony portion of tube. P— Cartilaginous portion of tube. Q— Cut section of cartilaeg.
R — Fasciculus joining muscle to cartilage. S — Torus tubie. T — Fossa of RosenmuUer.
U — Levator palati. V — ."Vngular process of cartilage, W — Condyle.

Conclusion.— The physiological function of ven-
tilating the tympanic cavity is accomplished mainly
by the dilator tubse or levator palati. The mechan-
ism which allows the opening of the tuba auditiva
is the backward pressure of this muscle on the an-
gular process of the alar cartilage, which swings
backward, upward, and inward on its superior at-
tachment, dragging with it the floor of the tube
and forming a triangular ostium.

Through "the kindness of Prof. George S. Hunt-
ington, the author was allowed the privilege of com-
•pleting these investigations in the Anatomical
Laboratory of the College of Physicians and Sur-
geons of Columbia University.

LEPROSY IN THE PHILIPPINE ISL.\NDS

AND THE PRESENT METHODS OF

COMBATING THE DISEASE.*

By VICTOR G. HEISER. M.D.,

p. A. SURGEON, U. S. P. H. AND M. H. SERVICE; DIRECTOR OF HEALTH. AND
CHIEF QUARANTINE OFFICER FOR THE PHILIPPINE ISLANDS.

There has already been so much said and written
about leprosy in the Philippine Islands that it is
appropriate that I should ask your indulgence as I
enter the ranks of the contributors to the literature'
on this subject. If it were not that much of the
work which promises a solution for the leper prob-
lem in these islands was begun during the past year,
and that the details have not yet become generalh*
known, I would not have the temerity to write on
this subject for a Philippine audience.

Considering:: the disease historically, in its rela-
tion to these islands, it may be said that the data
are very meager, and that a careful search of libra-
ries, both public and private, and of the official
records fails to throw much light on the subject.
.\mong the royal documents on file in Sevilla, for
the period from 1590 to 1638, in Section 5, drawer
2. bundle 2.^. is a record that the King of Spain
acknowledged the receipt of a communication from
the Captain-General of the Philinpine Islands, on
June 8, 1632. in which His JNIajesty had been in-
formed that one hundred and thirty-four "converted
Christians" who had been sent over by the Emperor
of Japan had arrived in Manila Bay. The King di-

*Address delivered before the Philippine Islands Med-
i-.il Association.

pital in that
office of the

rected that the "converted Christians" should be
received with a parade, and that in addition to the
five hundred reales already set aside
by the Captain-General for their re-
ce])lion, two hundred reales be ex-
pended for their maintenance. In
a book by Felix Huerta, entitled
"The Geographical, Historical, Sta-
tistical, and the Religio-Historical
State of the Philippine Islands,"
Edition of 1865, page 67, it -is stated
that these people were lepers, and
were taken to the San Lazaro Hos-
pital. This statement finds con-
firmation in the "Ultima Pieza del
Expediente Institudo sobre la Or-
ganizacion del Hospital de San
Lazaro" (The Last Part of the Re-
port of the Investigation Made
Upon the Organization of the San
Lazaro Hospital), dated 1823,
which records that one hundred and
thirty lepers who arrived from
Japan in the year 1632 were ad-
mitted to the San Lazaro Hos-
year. There is also on file at the
Bureau of Health a letter from
the Honorable Goro Narita, formerly Japan-
ese Consul at Manila, to the effect that he had
referred the foregoing statements to his home gov-
ernment for investigation, and had received infor-
mation that the most minute researches had been
made to ascertain the truth of the allegations, but
the matter had not been definitely settled by the
investigation, although several records had been
found in ancient writings respecting the deportation
of Roman Catholic friars from Japan to Luzon, as
well as of the expulsion of Japanese believers in
Christianity who were afflicted with leprosy, but that
these records did not agree as to dates and other
important particulars with the statements under in-
quiry. He added that the opinicm of the governing
authorities was that no lepers had ever been de-
ported from Japan for sanitary reasons, but that
there might have been some among the Japanese
Christians who were banished when the feudal sys-
tem prevailed in the empire.

From the recorded data it is impossible to deter-
mine whether the disease existed in the Philippines
prior to the coming of the Japanese Christian con-
verts or not, but the fact remains that it is now
here in all its loathsome characteristics and men-
acing dangers, and the great problem is, how to
get rid of it

Before the American occupation, it was not so
much a question of eradicating the disease as it
was one of caring for the unfortunate victims of the
malady who were poor or had no friends to take
care of them. The care of lepers was a matter of
charitv rather than legal proscription, and was con-
trolled by the church authorities. This method of
dealing with leprous patients left many at large
to spread the disease without restraint. The excel-
lent work of the charitable orders that engaged in
this laudable cause should, however, not be underr
valued. The self-sacrifice and devotion of the
noble men and women who gave their talents and
their energies to the alleviation of the condition of
the poor victims of this loathsome disease will ever
stand as a monument to the greatness and godliness
of human character ; but such a policy, while paving
the wav for something better, could not in itself be
reckoned as a factor in the elimination of the

June 8, 1907]

MEDICAL RECORD.

-m

scourge. This feature of the work was not seriously
undertaken until after .American rule had been es-
tablished. .'Mmost at the very inception of the
Civil Government, nesjotiations were set in progress
by the Secretary of the Interior, which led to the
setting apart of Culion Island for the purpose of
establishing a leper colony and for the complete iso-
lation and segregation, not of the poor and outcasts,
but of all alike. This policy may seem cruel and
heartless, esjiecially to those who are directly affect-
ed by its operation, but it was hoped that the close
proximity of the island of Busuanga, where the
friends of the lepers might locate or at least find
temporary abode, and from which they could make
frequent visits to Culion, would do much to mitigate
this objection. Isolation is for the best interests
of all concerned, for the benefit of the patients and
for the protection of the public. But, unfortunately,
this is a case where the ends of science and senti-
ment diverge, and the policy is far from being
popular in the Philippine Islands, especially when
it affects the homes of the rich and influential. The
Government is proceeding slowly and cautiously,
with the full assurance that the wisdom of its
course will soon be manifest to all.

A study of the history of the war waged upon
leprosy during the past few centuries shows that
isolation oft'ers the only method which has been
consistently successful in eradicating or at least
greatly reducing the number of victims. Even
now, at the very beginning, a study of the statistics
of the Philippine Islands will show that leprosy has
already decreased to the extent to which the policy
has been put in practice. In the Philippines, for
the year ended August 31, 1904, there were 3,623
cases; for the year ended August 31, 1905, 3,580;
for the year ended June 30, 1906, 3,494; for the
quarter ended September 30, 1906, 3,473, and for
the quarter ended December 31, 1906, 3,225.

A study of the history of leprosy in Hawaii shows
that until isolation was carried out the number con-
stantly increased. In 1866 there were 105 lepers;
in 1894 there were 1,341; in 1900, 1,023; ''i 1901,
942; in 1902, 915; in 1903, 874; in 1905, 858, and
in 1906, 828. For the twenty years preceding 1900,
isolation was not verv rigidly enforced, and it was
not until after American occupation that the prac-
tice began to be systematically carried out ; the above
figures show that the disease has declined rapidly
since that time.

The present capacity of the Culion Leper Colony
is about 800. The actual number on the island
January i, 1907, was 546. In addition to the above,
219 are segregated in the San Lazaro Hospital,
Manila. The remaining are distributed throughout
the various provinces as shown in the table.

Undoubtedly, the simplest and easiest method of
stamping out the disease and protecting the public
would be to segregate all lepers at the colony, but
when it is remembered that it would require an
outlay of about 50 centavos (25 cents U. S. cur-
rency) per capita per diem to maintain the colonized
lepers, or about 800,000 pesos ($400,000 U. S. cur-
rency) annually, and that the entire receipts of the
Government are only about P20,ooo,ooo per annum,
it will be apparent that the financial difficulties are
practically insurmountable ; therefore, it has been
necessary to plan a campaign which would be com-
patible with the finances of the Government as well
as meet the requirements of practical sanitation.
Fortunately, the geography of the islands is such
that a plan could be put into operation at once,
which offers great hope of success from the verv

PR0VI\CKS

Race

"o £
o'fo

2:s

Chil-
dren

Sin- 1

aXe 1

.M:ir 1
riei i

'i

I
4

0

y

1
I

2
0

M.

F.

M.

F.

M,

I
t>

20

F,
3

H

Abra

Filip'o

Moro
Filip'o

I

(2)

6

31

53

16

■5

I
6

4
24

23

3
12

Albay . ...

47
68

Ambos. Camar-

Antique

Bataan

Batangas

Benguet (i). . . .

II
lb
32

78
27
48

b
11
II
.S5
15
40

I

1
5

2

I
3

I
1

6
15

I
34
1 1
ife

I
5

3«
g
It,

2

2

21

3 5
13

25

2
2
10
12
3
17

2
I
<)
4
3
3

3
4

I

2

12

17

2U
43
133
42
P4

Bulacan.

Cagayan

Cavit^ ....

43

24

^

3

27

15

10

5

3

I

67
307

546
118
235

Culion Leper

Colony (3).
ISocos Norte.. .

Ilocos Sur

lloilo

355
78
149

mi

40

78
I I

3C.

1

1S7
22
74

85
18
4(.

87
51

47

54
17

2()

23
3
17

16
4
12

Isabella

LaLaguna

Lepanto-

Bontoc ( I )
Leyte (4)

14

15
34

2
1 1

4
24

I

2

2

2

3

7

5
13

4

1
0

(1

8
17

2
3

8

I
2

2

3

5

1 1

2;

IQ

58

3

71J

220

Misamis

Moro (I )

Xegros, Occid'al
Negros. Oriental
Nueva Ecija. . .
Nueva

Vizcaya ( i )

Pampanga

Pangasinan

Rizal

Romblon

55
143

24

77

4
3

30
85

13
44

19

45

b
18

2
0

5

12

10

30
2

I;
61

i()

4
10
J 2
31

I

1
4

2

4

13

I
6
19
27

b

' '(,
8
y

■4
I

25
28

b

2
4
15
17

3
7
2

4

2

7
I

40

6
27
83
92

143

83

2

24
10

.io
23

1818

I 15
34

I
14

4
17

27

S5
1053

I

I

43
41

5°
18

74

38

43
b

20
4

2
2
2
I

10

148

21

I

5
4

16

154

«8

117
3
38
23
47
SO

2IQ

Sorsogon

Surigao

Tarlac{4)

Tayabas

Union

I

iS

145

I

12
76

4

g
11

12

68
824

b

2

8

14

35

4 80

18

7
iS
II

38

4
9

22
^34

Zambales

San Lazaro Hos-
pitals. Manila

Total .

(i) Re\'ised reports not received.

(2) Filipinos. 217: Chinese, 2.

(3) European, i; Filipinos, 544; Chinese. 1.

C4) Leyte: Fihpinos. %-,: Chinese, i. Tarlac: Filipinos. \t. Chi-
nese. I.

lieginning. This plan consists in removing all
lepers from those islands which are well isolated
and at the same time have only a few victims, and
subsequently, of removing all lepers from such
islands as soon as the disease is detected. In this
way a large amount of territory can be freed from
lepers in a very short time, and by thus removing
the principal sources of infection, there are good
grounds for believing that the early disappearance
of the disease will result.

The conclusion of the Germany Leprosy Confer-
ence of 1897, and also, more recently, that of Kolle
and Black, was that the initial lesion is a small ulcer
in the nasal mucous membrane. If this is true, it
is quite possible that many of the cases in which the
source of infection is so difficult to understand may
be explained upon the hypothesis that they came in
contact with lepers who were not known to have the
disease. In order that the policy outlined above may
have best hope of success, special attention is being
given to this matter.

The islands of Mindoro, Masbate, Romblon (in-
cluding Tablas and other islands of the same pro-
\incial government). Siquijor, Oriental and Occi-
dental Negros, Panay, Palawan, and Cuyo are now
practically free from lepers through the operation
of this plan. At the very inception of this work,
it became the fixed practice not to confine anyone
at Culion from whom leprosy bacilli cannot be re-
covered and demonstrated by microscopical exam-
ination. In pursuance of this plan, it is worthy of
record that a fair percentage of those who were re-
ported to be suffering from leprosy, in the islands
mentioned, were found to be negative on microscop-
ical examination, and that bv proper medical treat-
ment manv were cured of their ailments and re-

936

MEDICAL RECORD.

I June 8, 1907

stored to bociety. If this same proportion is found
to maintain in tlic remaining islands, the number
of lepers will be much smaller than heretofore esti-
mated and the solution of the leper problem will be
far less serious than it has been supposed to be.

The question of a self-supjwrting leper colony and
of lepers contributing to their support has received
most careful attention, with the result that very
little in this direction can be hoped for under the
present conditions. In the majority of persons, the
disease soon produces disabling deformities, with
destruction of tissue, loss of fingers and toes, serious
impairment of the nervous system, loss of muscular
power, and general debility, and renders the patients
incapable of performing the amount of manual labor
which would be required in the operations necessary
to support themselves in agricultural pursuits. They
are precluded from engaging in manufacturing on
account of the widespread prejudice against buying
articles that have been handled by lepers, even
though they may have been rendered safe by ster-
ilization ; then again, so many of the patients are
confined to their beds, and the wounds and ulcers
of others require so much attention, that a large pro-
portion of the services of those who are able to
work must be devoted to these duties, so that really
very few are in position to give their time to profit-
able pursuits. Considerable work is also necessi-
tated in the purely domestic duties, such as cooking,
the making of clothes, cleaning and taking care of
the houses, and in maintaining the streets, roads,
and other public utilities in a state of repair.

The industry of cattle raising seems to promise
better results than anything else that has been con-
sidered so far. The cattle could be shipped to
Iloilo, Cebu, Manila, or other markets for slaughter,
thus avoiding the prejudice that would naturally
obtain against prepared products or manufactured
articles. ' As cattle are not subject to the disease,
and as thev would not have to be handled by the
lepers, there would probably be very little danger
to the public in shipping them from the colony to
noninfected districts.

The colony at Culion has been in actual operation
since Mav 28, 1906, on which date 365 lepers from
the San Lazaro Hospital at Cebu, which had been
abandoned on the day before, were landed on the
island. Four Sisters of Charity, belonging to the
Order of St. Paul de Chartres, and a Jesuit priest,
who w-ere already at the colony, assisted in receiv-
ing the lepers, who were agreeably surprised and
very much delighted with their new home, and ex-
pressed themselves as thoroughly satisfied with the
provisions which had been made for them. After
the novelty of their surroundings ceased to attract
and divert them, many became oppressed with a
feeling of homesickness, and yearned for the old
familiar scenes to which they had been accustomed
all their fives, but at no time did they find fault with
the conditions at the colony.

The present colony consists of about 125 nipa
houses, each of which is large enough to accommo-
date from five to seven lepers. These houses have
been built with due reference to street lines, so that
svmmetrv and uniformity add to the natural beauty
of the "leper city." The new town is located on a
plateau, the highest portion of which is about 150
feet above the sea level. This plateau slopes in
all directions towards the sea. thus giving ideal
drainage conditions. A pipe line about a mile long
conducts water from a running stream to the colony.
and in addition there is a reservoir into which water

is forced from a spring by a gasoline water pump.
This reservoir has been constructed at a height of
more tlian 250 feet above the level of the sea, and
from it water is conducted through a modern system
of pipes to all ])arts of the town, and supplies the
kitchens, halls, bathrooms, modern water-closets,
and laundries. A complete sewer system with septic
tanks, through which the sewage passes before it is
finally conducted into the sea, has been installed.

The old town of Culion, which was purchased by
the Government, has still a sufficient number of
buildings standing to furnish a presidencia, or town
hall, and residences for the presidente and conse-
jales. The old stone church, built in Spanish times,
is still in a state of good repair, and is used as a
place of worship by the lepers. A band of forty
pieces has been organized and frequent concerts are
given.

The lepers are given the greatest possible liberty,
and are controlled largely by regulations for which
they themselves are responsible. They punish those
who commit misdemeanors, in accordance with their
own ideas of justice. The law-making power of
the colony is vested in a presidente (president) and
twelve consejales (councillors) who are elected by
the people, while the police power is administered
by twelve police who hold office by selection from
among their own people. The police force, under
the direction of the presidente, is charged also with
the maintenance of proper sanitary conditions in the
town, and with the arrest of offenders against the
local regulations. A government could not possibly
be more democratic than that which prevails at the
Culion Leper Colony.

Quarters have been provided for the nonleprous
employees at a distance of about a quarter of a mile
from the colony.

In addition to attempting to combat the disease
bv isolation, a great deal of attention is given to
every method of treatment that offers any hope of
curing the disease. So far, the only treatment that
has given an\_ hope of success is the application of
the .f-ray. Encouraged by the results obtained with
the Roentgen ray in the treatment of certain forms
of skin diseases, and of lupus and cancer, the Sec-
retary of the Interior and the Commissioner of
Public Health, in 1903, decided upon the purchase
of an .r-ray machine, and the treatment of leprosy
bv this method was begim for the first time in the
Philippine Islands, in January, 1904, by Dr. H. B.
Wilkinson, the resident physician at the San Lazaro
Leper Hospital. Dr. Wilkinson's method w-as to
select those cases which presented the greatest
amount of leprotic deposit, and expose the most
afflicted portions of the body to the rays for ten min-
utes, at a distance of from seven to ten inches, the
apparatus used being a ten-inch spark machine with
a bifocal tube exhausted for a ten-inch spark; the
distance and time of exposure being subject to such
variations as were indicated by the individual pe-
culiarities of the area under treatment, so as to
approach as nearly as possible the burning point
without actuallv inflicting injury. In only two
cases was the process carried sufficiently far to burn
the skin, and it is interesting to note that these two
cases were the first reported as cured. In all, three
cases were reported as recovered ; of these, the first
(latient died a few weeks afterward of atrophic cir-
rhosis of the liver. L'pon the completion of the au-
topsv in this case. Dr. Herzog of the Bureau of
Science reported that the histological and bacterio-
loeical examination furnished no evidence that the

June 8, 1907]

MEDICAL RECORD.

)y}

patient at the time of his death was suffering from
leprosy, either cutaneous or internal. The treat-
ment of the two remaining cured cases was inter-
rupted for a long time on account of the breaking
dow'n of the machine and the necessity of sending
to the United States for additional apparatus, which
could not be supplied in Manila. Before the treat-
ment could be resumed, the two cases relapsed, one
about six months after the original treatment was
stopped, and the other about nine months after-
ward.

The .I'-ray treatment is now in progress again, on
a larger scale, and a report will be published when
the data and results are sufficiently verified to justify
definite conclusions, but it may be of interest to
report here that one of the cases that was reported
cured before, and which later relapsed, and in which
leprosy bacilli were continuously found for a num-
ber of months, again, after treatment was resumed,
at the end of three months, shows an entire absence
of leprosy bacilli in the skin scrapings taken from
regions in which they were previously found.

Since the American occupation, there have been
only one .American and one European known to
have developed the disease. The cause of death is
almost invariably some intercurrent disease; tuber-
culosis and beriberi being the most frequent causes
during the present year.

The policy of the Bureau of Health aims at the
segregation of every leper in the Philippine Islands,
but until this becomes practicable the situation must
be handled so as to secure the greatest amount of
free territory possible in the shortest time. In the
colony and elsewhere, lepers are entitled to every
chance for their lives that science can give or sug-
gest, and it is the aim and purpose of the present
administration to secure to them every advantage
that can possibly accrue from a systematic plan of
action which has for its purpose the protection of
the public, the alleviation of the suffering of the
afflicted, with such chances for their lives as science
Can offer, and the ultimate eradication of the dis-
ease from the Philippine Islands.

In conclusion, it is submitted that whatever may
be the views of well informed persons with regard
to the communicabilitv of leprosy, and however
widely eminent medical men may differ upon his
question, yet the incontrovertible fact remains that
every leper who is capable of giving off leprosy ba-
cilli to the media which surrounds him is at least one
center of infection, and the utter hopelessness of
successfully eradicating the disease so long as the
exact mode of transmission is not conclusively
proven, will be apparent to all. Prophylactic med-
icine should not he permitted to be turned by a few
sentimentalists from its march to a goal which oft'ers
the magnificent victory of the eradication of this
plague from the face of the earth, and the saving of
hundreds of innocent human victims who are now
sacrificed annually to this most loathsome disease.

Manila. P. I.

Contribution to the Study of Facial Hemispasm of
Peripheral Nervous Origin. — Giuseppe Rcisenda pre-
sents five cases of facial hemispasm of peripheral ner\'Ous
origin. There is clonic spasm of the side of tlie face, O'f a
subacute nature, without pain in the mastoid region. Elec-
trical excitability is lessened, there being partial degenera-
tion reaction. There is absence of response to external
muscular stimuli, due to paresis of the muscles. The
muscles are not painful, which distinguishes the condition
from painful tic. These symptoms indicate a peripheral
origin for the disease. The treatment should be moderate
faradism of the side of the face, — R'rAsta Ncui-ohutclogica.

A NEW BLOOD TEST.*

Bv MAX EINHORN, M.D.,

NEW YORK.

PROFESSOR OF CLINICAL MEDICINE AT THE NEW YORK POST CRADUATE
MEDICAL SCHOOL

ExAMiN.\TiuKS for the presence of blood have re-
cently increased in significance ever since Boas'
reported the occurrence of occult blood as an almost
constant symptom in carcinoma of the stomach.
Usually the aloin or guaiacum test is employed for
the demonstration of the blood.

Recently a new test with benzidin has been de-
scribed by O. and R. Adler.- .Vccording to Schles-
inger and Holst^ it is made as follows: ( 1 ) A knife
point full of benzidin (Merck's) is added to two
c.c. of glacial acetic acid and allowed to stand. (2)
A small piece of feces (about the size of a pea) is
mixed with two c.c. of water and boiled in a test
tube closed with cotton. (3) Ten to twelve drops
of benzidin solution are added to two and a half to
three c.c. of a three per cent, peroxide of hydrogen
solution. (4) Three to four drops of the boiled
fecal solution are added to reagent three. In the
presence of blood a green or blue color results.

For the testing of stomach contents Schlesinger
and Plolst advise boiling the filtrate and jjroceeding
in a similar manner as in testing the feces.

The guaiacum-aloin, or benzidin test, require the
preparation of fresh solutions, which makes the
test more difficult. I tlierefore have tried to sim-
plify the test by making a reagent paper. I pre-
pared an aloin paper and a benzidin paper. Aloin
paper was inade by saturating ordinary filter paper
with a solution of aloin in seventy per cent, alco-
hol : the benzidin paper by moistening filter paper
with a saturated solution of benzidin and glacial
acetic acid, and drying it. In preparing the paper,
as well as in making the test, it is of importance
to avoid contact with the fingers, as a drop of per-
spiration causes a similar reaction. In handling the
paper it is best to use an ivory tipped forceps, or
protect the hand by means of a towel. Aloin paper
is much inferior in sensitiveness to benzidin paper;
I would, therefore, recommend the latter.

Mode of Procedure. — A piece of benzidin paper
is immersed in the solution to be examined and a
few drops of hydrogen peroxide are added. The
piece of paper is placed on a piece of white porcelain
and is exainined for the development of a blue
color. In tine presence of blood a green or blue
color arises in a few seconds to a minute.

Regarding the sensitiveness of the reaction it is
ereater, if we allow more time for its occurrence.
In dilutions of I part blood to 500 parts of water
a distinct reaction occurs in between thirty to sixty
seconds. In dilutions of i to 2,000 a trace of blue
occurs one to two minutes later. To wait longer
for the reaction does not seem advisable, as after
thirteen minutes the benzidin paper with hydrogen
peroxide alone without blood will yield a blue color.
For practical purposes it will be best to wait but one
minute for the occurrence of the reaction. If after
one minute there is no trace of blue, then the test
must be considered negative.

In examining for blood in stomach contents too
great a sensitiveness is not important, but rather
a certainty that the test will indicate only blood.
The longer we wait for the reaction the more sub-
stances besides blood may cause it. Benzidin paper
can be used for testing for blood in stomach con-
tents, urine, and feces. As all kinds of food may be

*Read before the German Medical Society of New York
on .'Vpril 15, 1907.

938

MEDICAL RECORD.

[June 8, 1907

met with in the stomach CDiitents. 1 have examined
varioii.s articles of diet wiili the lienzidin paper :

Benzidin paper + coffee + milk -{- sugar = o.
" + coffee = o.

+ pea soup = o.
■' + hoiled peas = o.
+ prune juice = o.
" " + jirunes = o.

" " + tea + sugar = o.

" " + red wine = o.

" '' + milk after one minute = o, after

one and one-half minutes =
trace ; aloin negative.
" " + milk ether extract after one

minute = o ; aloin negative.
" " + potato substance =^ + trace.

" " + water in which potatoes have

been boiled ^ o.
" " -J- farina boiled with milk (thick)

= + (at once).
" + farina l)oiled with water = +
(at once).
4- white bread steeped in water

" " + hard boiled white of egg ^ o.

" " + hard boiled yolk of egg = o.

" + boiled chicken = o.

I'arina and boiled potato applied to benzidin paper
in substance produce a reaction. Decoctions of
potato as well as thin gruels do not react. Milk
after one minute gives a trace of reaction. If, when
testing, we take the liquid part of the stomach con-
tents and do not use the firm substance, the occur-
rence of the above substances (farina, milk, potato)
would hardly influence the reaction.

To studv the action of HCl on the benzidin naper
the following experiment was made :

Benzidin paper + i to i.ooo HCl solution after
one minute ^ o, after two minutes = trace ( ?) ,
after three minutes -f green color.

Benzidin paper -\- i-io normal sodium hvdroxide
solution after thirtv minutes = O.

Benzidin paper -f- water after nine minutes = +
trace.

Benzidin paper + stomach contents free from
blood after three and a half minutes ^ +•

We can see, therefore, that HCl may cause the
reaction, usually only after two to three minutes.
If, therefore, we want to use the benzidin paper in
testing for blood, we must not w^ait for a reaction
lontrer than one minute.

I have made comparisons between the result ob-
tained by benzidin par>er and that bv the usual aloin
ether extract. It was as follows :

I.

T.ABLE OF Stomach Contents li;.\.\Mi.vED wlth Be.vzidin

Paper Alone, as Well as Those E.xamixed with

Benzidin Paper and .Aloin Ether Extract.

No. OF Stomach

Benzidin

Aloin Ether

C'nt'nts Exam'd

Paper Test

Extract Test

n

Negative.
Positive.

Not made.
Not made.

13

13

Negative.
Positive.

Negative
Positive.

2

' 4

2
2

Positive (strong).

Positive (trace).

Positive.

Test with ether ex-

Negative.
Negative.
Negative.

tract, negative.

Negative.

II.

Comparison of the Blood Tests with Benzidin Paper
and Aloin Ether E.xtract in Various Dis-
eases OF THE Stomach.

a. Functional IJ)iseases of the Stomacli and Catarrh of
the Stomach.

No.

Benzidin Paper

Aloin '

69

4

I

.\egati\-e.

Positive.

Positive.

Negative.

Positive.

Negative.

b. Organic Diseases of the Stomach.

Disease

No.

Benzidin Paper

Aloin

Ulcer of Stomach.

2

Negative.

Negative.

1 1

Positive.

Positive.

Positive.

Negative.

Cancer of Stfimach.

Negative.

Negative.

Positive.

Positive

Stenosis benigna.

Negative.

Negative.

Positive.

Positive

.-Vlthough there was no absolute coincidence be-
tween the benzidin and aloin test (see Table I), yet
in most cases the result was the same.

Table 11 shows that the stomach contents may
verv well be utilized for blood examinations for the
purpose of diagnosis instead of the more generally
employed methods of examination of the feces. The
frequent occurrence of occult blood was found, as
stated by Boas, in cases of ulcer and cancer of the
stomach.

The benzidin paper test can be recommended as a
preliminary test. If there is a strong reaction at
once or no reaction at all, we may regard the result
as reliable. If, after one minute only a trace of
reaction is present, then the aloin ether extract
method may be used. If we use the ether extract
for the benzidin test it makes it more sensitive and
certain.

In examining urine and feces for blood I have
also made use of the benzidin paper. For urine it
is not as sensitive as an aloin ether extract. Feces
of people living on common foods usually gives
the reaction. The stool of a patient on a milk-and-
egg diet does not give the reaction, except blood be
reallv present. The stool may be examined in the
following' manner:

A small piece of feces (the size of a pea) is rubbed
up with about two c.c. of water, the benzidin naoer
is immersed ; a drop of hvdrogen peroxide is added,
and it is examined for blue color. Several stools
of patients that have been on a diet free from
meat were tested with benzidin paper and for com-
parison with aloin ether extract and with one ex-
ception the same result was always obtained.

I do not hesitate, therefore, to recommend the
benzidin paper as a convenient method of testing-
for blood of the stomach contents, the urine, and
the stool.

REFERENCES.

1. Boas: Arcliiv fUr I'eidanuiigkranklieilen. 1902.

2. O. and R. .\dler : ZcitscJir. fiir Physiolog. Clicmie.
Bd. 41. Heft I and 2. p. 59.

3. E. Sclile.singer and F. Hol.^t : Vergleichende Unter-
suclunigen uber den Nachweis von Minimalbhitnngen in
den Faeces nebst einer neuen Modification der Benzidin-
probe. Deutsche mediziuische Wochenschrift. igo6, No. 36,
p. 1444-

20 East SixTV-THiKi) Street,

Too Much Civilization. — The South .\frican
Xativ;- Affairs Commission reports that while the
adoption of European clothing by the natives has
promoted public decency it has injured the health
of the wearers.

June 8. 1907]

MEDICAL RECORD.

939

SOME EFFECTS OF SPIRIT AND DRUG

TAKING ON THE UPPER AIR

PASSAGES.*

Bv T. D. CROTHERS, .M.D.,

HARTFORD, CONK.
SVFERINTtNDENT WALNUT LODGE HOSPITAL.

The object of this paper is to point out some facts
which have not been considered prominent in a
study of the causes of the inflammatory conditions
of the throat and nose. While speciahsts in this
field are familiar with these factors in the causa-
tion, they have not given them the importance which
they deserve, simply because they are not familiar
with the modern research work concerning the ef-
fects of alcohol and drug taking. The theory that
alcohol is purely a stimulant and in so-called moder-
ation has little or no influence on the membranes or
organs of the body, is considered a fact beyond
question, hence no in(|uiries have been made to de-
termine its correctness. The conclusions from mod-
ern research that alcohol is a narcotic and cor-
rosive in its action, particularly on the membranes,
will be new to the general profession, yet the evi-
dence on which it is based is voluminous and ex-
haustive. The multiplicity of new topics and tre-
mendous advances in all departments of medicines
are not only confusing to the general practitioner,
but frequently turn his attention away from matters
along every-day observation, and only when they
are particularly pointed out are they recognized.
The effects of spirits and drugs on the upper air
passages are very marked and common, and yet they
do not attract attention. It is always a question
whether these effects are due specifically to any one
cause or combination of causes, or are the results
of general conditions, one intensifying the othei ;
thus low vitality, sudden changes of temperature, re-
flex irritations, and congestions in distant parts,
may all combine to produce disturbances : ( i I The
direct irritant action on the bronchial, pharyngeal,
and nasal membranes, with thickening, anemia, and
congestion: (2) the reflex irritant action from gas-
tritis and other disturbances and irritations to other
parts: (3) organic changes and paralysis of nerve
tracts, cirrhotic states of tiie liver. kidite\s, and
mucous membranes generally. In my experience
of nearly thirty years in the constant study and
care of snirit and drug neurotics, it is an exception
to the rule to find persons w^ho have used spirit^
and drugs that do not suffer from catarrah and snli-
acute inflammations of the throat and nose.

It is always an interesting question whether these
inflammatory changes preceded the spirit and drue
taking as exciting and predisposing causes, or fol-
lowed as a natural result. Manv persons have a
historv of nasal and throat congestions due to direct
irritation, followed by exhaustion and debility, for
which spirits and narcotics have been found most
agreeable remedies. Common examples are of per-
sons breathing air containing irritants and exposed
to great change? of temperature, who have found
cocaine, morphine, and other narcotics to give great
relief. This is quickly followed bv an addiction and
a distinct drug neurosis in the future. Other per-
sons have bronchitis and inflammatory states of the
throat which are treated by spirits covered up with
syrups, and the narcotic effect is so plea.^ant that
the drugs are continued. .Ml specialists and gen-
eral physicians understand that there are degrees of
susceptibilitv to take on inflammatorv states of the

*Read before the Buffalo .Academy of Medicine. Febriiarv
12, 1907, Buffalo, N, Y.

membranes of the throat and nose from very slight
and apparently insignificant causes. There is pres-
ent a feeble resisting ]30wer in the mucous mem-
brane to any changes and irritations ; this is fre-
quently inherited and depends very largely on the
defective nerve centers controlling these parts, as
well as want of training, bad surroundings, bad
diet, etc. The direct irritant eft'ect from alcohol
on the membranes is well illustrated by comparison
with its effects on the surface of the hand or body.
Placing a drop of alcohol on the surface, a sensa-
tion of chill and irritation which follows will be
increased by more alcohol, until inflammation :'nd
destruction of the skin follows. This is an e-xamr)!,^
of its action on the mucous membrane of anv j^art
it comes in contact with. This is due specifically
to its rapid water-absorbing properties, abstracting
the moisture from the tissues with such rapidity as
to give a sense of chill, followed by irritation, and
finally ending in inflammation. These effects are
noted in alcohol taken as a beverage in any form
and the sense of irritation and burning in its passage
over the mucous membrane is due to its v.-ater-
abstracting property. Water is used before and
after spirits are taken to overcome the sensation;
the more pronounced the irritation, the greater the
amount of alcohol. It will be readily understood
that the frequent and continuous use of spirits, pro-
ducing a constant irritant action of a greater or
less degree, is a direct cause of inflammatory :tates
of the membrane. Clinical observation confirms
this, not only by examinations of the throats of
drinkers, but the changed tone of voice indicating
thickening and changes of the vocal cords. In
chronic cases, both the bronchial and nasal tones
are pronounced, the carrying properties of the voice
are markedly lowered, and its volume is diminished
and replaced by harsh, jerking, indistinct sounds,
and even beer drinkers who sing bass lose their
power of control and the tone becomes bn-ken and
harsh.

Leading singers quickly discover that alcohol aad
tobacco seriously impair and finally destroy their
vocal powers. We shall show that these effects are
due to both local and constitutional changes in the
blood-vessels and nerve filaments and absorbents.
It will be new to many persons that the congestion
of the face so common in spirit takers is an exact
duplication of what occurs in the membranes of
the brain and mucous surface of the throat and nose.
One with an intensely red or pallid face, showing
hyperemia or anemia, has deranged capillarv cii-cu-
lation of all the membranes, particulailv those rich
in blood-vessels. The vasomotor paralysis of the
facial nerves diminishing the contractile power of
the arteries on the face is the same in the thro.it and
nose. A recent German writer has declared that
"this palsy is followed by varicose states of both
veins and arteries in the membranes of the throat
and nose, accompanied with fibrinous de])Osits and
exudations." The supposed stimulant action of
alcohol is found to be an irritant and a inr?.hzant,
and also a narcotic. It is a chemical irritant alisorb-
ing the water from cell and tissue. The flushed
face of the spirit drinker is simply palsy and nar-
cotism of the vasomotor centers regulating the cir-
culation and the contraction and dilatation of the
walls of the blood-vessels. The heart is greitly
increased in activity by the use of spirits: more
blood is sent to the surface, but with it comes the
diminished contractile power of the nerves to force
the blood back again, hence the forcing of the blood
to the surface distends the blood-vessels and iJe-

940

MEDICAL RECORD.

[June 8, 1907

ranges the circulation more and more with each
repetition until permanent degeneration follows.
The whole capillary system of the membranes of
the brain, upper air passages, and face is disturbed,
deranged, and diseased. Drugs which produce an-
emia or blanching and diminution of the flow of
blood in the vascular structures are followed by the
same results. The nutrition suffers from this pro-
found derangement and the metabolic processes are
interfered with. The toxins and waste products are
retained and form new centers of irritation.

Elimination is checked and suppressed The mu-
cous membrane of the throat and nose is very vas-
cular and abundantly supplied with p.iteries, vein-;,
and nerves, and hence suffers more directly from
this cause. This is evident by the increased secre-
tion of water and mucus, .\fter a time the flushing
of the face by the use of spirits becomes permanent
and the walls of the arteries are hypertrophied, and
the nerves atrophied. The mucous membranes suf-
fer in the same way. In constant spirit drinkers
the burning sensation of the throat becomes less and
less, and strong spirits produce only slight sensa-
tions. Hypertrophv of the membranes and mucous
exudations with subacute inflammatorv states fol-
low, then come bronchial coughs and distressing ir-
ritations of the nose and throat, resisting all ordi-
narv treatment. In many instances these c 'dditions
are regarded as premonitory symptoms of tuber-
culosis and are treated with spirits, morphine, co-
caine, and other narcotics. Dr. McKenzie of Lon-
don remarked long ago that "it was comparatively
easy to cure bronchial and nasal inflamm-itovy states
in persons who abandoned all use of alcohol or nar-
cotics, but unless this was done the disease would
continue almost indefinitely.'' The changes in ihe
voice are very significant symptoms of both the in-
flammatory conditions of the nose and throat and
their influence on the vocal cords. Good judges as-
sert that it is possible from a study of the voice to
determine the health <ir disease of the membranes,
and also that there are certain peculiar sounds which
distinguish the spirit drinker from the opium or
cocaine taker. In a general way the spirit drinker
has a rasping, explosive echo, while the drug taker
has a tremulous, soft, muffled tone of voice. It is
very evident in a singer, in whom tobacco and spirits
sharpen and ruffle the timbre and volume of the
tone. A tenor singer invariably exhibits the use of
spirits or tobacco by his inabilitv to sustain high
or continuous notes, and by his constant tendency to
sharp the notes. Some very interesting studies have
been made with a phonograph to show the change of
the voice and improvement following total abstinence
in persons who have chronic inflammatory con-
ditions of the throat and nose. The patient talks
into the phonograph at different times, pronouncing
sentences, or singing bars : the notes, volume, and
timbre of the voice are thus accurately recorded.
Defects of the senses, particularly of taste, smell,
and hearing, following these inflammatory states of
the membranes, offer a most fascinating field of
study, because the changes and variations can be
noted with a degree of exactness : also perversions
of sight and mental changes due to these inflamma-
tions are of intense interest.

Many of these conditions are physiological varia-
tions, not only local but constitutional. There are
now certain conditions and effects which may be
considered positive from the amount of evidence
on which thev are based, thus the constitutional ac-
tion of alcohol, not only as a vasomotor paralyzer.
but as a disturber of nutrition, is continuous. The

result of capillary congestion and anemia is dimin-
ished osmosis between the veins and arterial capil-
laries, associated with defective oxygen-carryiijg
properties of the blood, and accumulation of car-
bon and fibrinous deposits. The blood corpuscles
are shrunken and deranged and do not take up
oxygen from the lungs freely, as is readily seen in
examination of the blood of persons who are using
spirits. In the blood currents the red corpuscles
are diminished in e.xact proportion as the system
becomes saturated with spirits. The phagocytes
are shriveled and diminished, the hyperemias and
anemias can be traced, not only in the blood counts
but in the blood-cells. Another fact equally well
established is that vascular congestion and defective
circulation due to alcohol are always followed by
accumulation of toxins, which form deposits and
foci for the development of inflammatory states,
and with this there is diminished power of resist-
ance and ability to neutralize and throw off the
germs lodged on the surface. Another fact is that
alcohol coming in contact and carried by the blood
vessels to the capillaries has a special corroding
action on the cells and dentrites, not only because
of its water-absorbing properties, but also by its
union with the granular matter of the cell. An-
other fact which has not been noted is this, that
when the system is saturated with spirits to a de-
gree it is exhaled from the lungs as vapors and
spirits, the mucous membranes of both throat and
nose suffer directly from its irritant action. This
point of saturation is not confined to local conges-
tions of any one part of the body, but extends to all
the organs, particularly the liver and kidneys. Its
action is both corrosive and erosive of the dentrites,
cells, and tissues, and is to all intents and purposes
a veritable neuritis. Recently we have recognized
that the so-called rheumatisms and pains, both local
and general, in the extremities, in persons who use
spirits, are due to inflammations of the nerve ex-
tremities, and are literally neuritis ; also that manj'
of the conditions termed la grippe, malaria, bilious-
ness, and other derangements associated with chills,
fevers, and exhaustions are purely toxemic. The
poisons from alcohol and other irritants have con-
centrated on the nerves of the extremity as well
as in the degeneration of the nerves of the mucous
membrane, checking elimination and practically en-
coOraging states of disease and inflammation.

The influences so prominent at this time of the
year are very pronounced and intractable in the
spirit and drug taker. Sir William Barlow declared
that "alcohol was the largest factor in the produc-
tion of la grippe and chronic catarrhs of the throat
and nose, by deranging the capillary circulation and
destroying the nutrition and vitality of the nerve
cells." The periodic drinker, who uses spirits to
excess, then abstains, recovers in some degree from
the damage and immediate effects of spirits, but
the continuous user of wine, or beer, or other spir-
its, in so-called moderate doses, has always pro-
nounced throat and nose affections. It may be of a
minor character, and not attract much attention at
first, and is treated by home or proprietary reme-
dies, but later, when the inflammatory conditions
become chronic, degenerations and growths follow,
and also ulcers and distinct local inflammatory con-
ditions. When the spirit is removed the improve-
ment is so marked as to prove beyond question the
intimate relation as cause and effect between the
akohol and these disorders.

Probably one of the most danp'erous and seductive
drugs is cocaine, which has come into very common

June 8, 1907]

MEDICAL RECORD.

941

use, both medically and surgically, for its analgesic
action. Its value depends on its sudden paralysis
of the nerve-fibers and capillary blood-vessels, pro-
ducing pronounced blanching and anemia. The
sensory fibers are suspended first and the walls
of the blood-vessels are paralyzed, the blood is
driven out, and then the motor nerves are checked
and slowed up. When this action passes oft" there
is an intense vascularization and secretion of water
and mucus and a degree of irritation that calls for
a repetition of the drug. It is asserted that this
action is due to the chemical combination of the
drug with the plasma and cell contents, suspending
their action at once, and this is reflected to the brain
and spinal cord. Later as an irritant, and still later
when the amount is large and the use continues, the
eft'ects are noted by peculiar hallucinations ; this par-
alyzing action becomes cirrhotic, the walls of the
blood-vessels retract and become varicose, nutrition
is lessened, and degeneration of a corrosive nature
follows. The blanching of the face is palsy of both
the constrictors and dilator nerves. All sensation is
cut off and this condition of the membranes of the
nose is followed by a deceptive sense of comfort.
The drug is literally a narcotic, suspending nerve
activity and nutritional force. After a time this
derangement extends to the higher cerebral func-
tions and becomes a neurosis of the most dangerous
and seductive character. Constant erosion follows,
wliich is concealed and covered up. Cocaine pre-
scriptions for diseased conditions of the throat and
nose have proved very useful and valuable remedies,
but they must be given with care and discretion.
The paralysis resulting from the constant use of this
drug in the nasal passages extends down to the
throat and larynx. .And the changed tone of the
voice registers this inflammatory condition. The
hearing is also aft'ected, and profound anemia of
the nasal passages is often a symptom of the use
of this drug. It should be remembered that many
persons take this drug secretly, but after a time
the mental and other symptoms betrav them.

Toabcco is another irritant and narcotic to the
upper air passages. Like cocaine, its effects are di-
rect and in chronic conditions, where the system is
thoroughly infected, it is an active cause of disease
of these membranes. One of the ,worst forms in
which it can be used is the cigarette, and this is due
specifically to the combustion taking place in close
proximity to the mouth, where all the gases and
products come in immediate contact with tlie mu-
cous membrane. In the case of the pipe and cigar,
many of these poison products are condensed and
deposited in the stem of the pipe and bodv of
the cigar, and only a small part is carried into the
mouth. In the cigarette, when the smoke is inhaled
and driven through the nose, its action is direct and
cumulative. The nicotine and other products are
corrosive and irritating, not onb- to the terminal
nerves, but the capillaries, and these poisons are ab-
sorbed and carried to all parts of the body. The in-
jury not only disturbs the surface circulation and
the osmotic and metabolic changes, but it destroys
nutrition and produces states of local starvation.
The cigarette smoker has both anemia and hyper-
emia of the mucous membrane of the throat and
nose. He complains of catarrh and defective smell
a-id change of voice, and his nerves become li\-per-
-cnsitive. By inhalation small quantities of smoke
and other products are more thoroughly absorbed
than if the quantity was larger and the smoking
more rapid. There are various degrees of resist-
ance to the poison of tobacco, but the eft'ect of its

continuous absorption is marked, not only on capil-
lary disturbances, but on the nerves and brain sooner
or later.

Morphine and other forms of opium have no
specific direct eft'ect on the upper air passages, ex-
cept that of a narcotic, and these effects are fol-
lowed by anemia and general pallor of the face and
eyes. The senses are diminished and low forms of
subacute inflammatory states of the membranes fol-
low. They are thickened, and fibrinous deposits
come on. The control of the voice is weakened and
general conditions of exhaustion appear. Other
drugs have a similar eft'ect, only more pronounced,
on the constitution.

In my particular work very marked changes are
noted in the disappearance and practical relief from
long-standing catarrhs and chronic inflammation of
the throat and nose by abstinence from spirits. I
have noted a number of cases of bronchial troubles
supposed to be tuberculosis occurring in moderate
drinkers. Removal of spirits, nerve rest, and con-
stitutional remedies are often followed by recovery.
A number of persons in these times of stress and
strain who are secret spirit and drug takers, and
who suft'er from throat and nasal troubles, are the
subject of much an.xiety to both physicians and
friends. When their real trouble is discovered and
the drugs removed, the obscuritv of the case clears
up. One is greatly impressed with this fact by the
number of persons supposed to be temperate who
have decided disorders of the voice and who fre-
quent the specialist for conditions that are very ill
defined. Eft'orts to give relief by catarrhal reme-
dies are unsuccessful, and a great variety of causes
are considered as active, together with degrees of
debility and general feebleness. Such persons go
to sanatoriums and recover ; in reality they have be-
come abstainers, and the degenerative action of al-
cohol has been removed. There can be no doubt
that rhinitis and bronchitis may precede tubercu-
losis, and the result of efforts to check these in-
flammatory states and prevent their so-called pass-
age downward is of great uncertainty, unless the
general constitutional condition of the person is
known and treated. The general fact is coming
more and more prominent, viz., that the eft'ects of
alcohol and drugs, taken either openly or secretly,
in small or large doses, falls most heavily on the
capillary circulation : this derangement predisposes
to the growth and development of bacteria, and with
this a diminution of the resisting forces of the
body ; these all form a chain of causes that should
never be overlooked or misunderstood. I conclude
with the statement made some years ago by the late
Dr. Gross of Philadelphia. "The upper air passages
reflect the damage of alcohol and tobacco, and
should always be considered in a study of inflamma-
tions of these parts."

Surgery of the Biliary Passages. — Lejars considers
cholcdochoenterostoniy a makeshift aniono; the various
methods for explorat'on and drainage of the chief biliary
passages. In one of his own cases, in which he had
intended to perform cholecystenterostomv, he found the
gall-bladder so small and retracted that he was not able to
make the desirable anastomosis with the intestine. He
ccnsequently did a choledochoenterostomy. Although the
patient seemed to improve, he died three days later. Lejars
believes that this operation should be employed only as a
last resort w-hen nothing else can be done. In a case of old
obstruction of the ductus conmuniis cholodochus. Lejars
had recourse to duodenotomy. The result was excellent,
the circulation of the ductus communis choledochus being
reestablished. Since his last report of three cases, this
operator has added to the list tliree more cases treated
according to Kehr's method. In these si.x cases recovery
took place. — Gaaettc des Hopitaux Ckils ct Militaircs.

942

MEDICAL RECORD.

[June 8, 1907

Medical Record.

A Weekly Journal of Medicine and Surgery.

THOMAS L. STEDMAN, A.M., M.D.. Editor.

PUBLISHERS
WM. WOOD &. CO., 91 FIFTH AVENUE.

New York, June 8, J907.

RECENT ADVANCES IN OUR KNOWLEDGE
OF SYPHILIS.

The theory of syphilis established by Ricord and
his school long remained unchallenged, but in the
last few years many discoveries have been made
which have greatly modified our conception of this
disease. Alehler, writing in Die Umschaii of March
16, 1907, briefly summarizes some of the more im-
portant work which has been done in this line. Ex-
perience had proved that syphilis is a contagious dis-
ease, communicable by direct contact, but the germ
of syphilis remained unknown until Schaudinn and
Hoffmann identified it, a few years ago, as a very
thin filiform protozoon, Spirochccta pallida. This
organism has been found in so many cases that there
is now little doubt that it is the cause of the dis-
ease. Greiif, a Berlin oculist, after producing syph-
ih.; in the eye of a rabbit by inserting a fragment
of a syphilitic inguinal gland, found the spirochete
in the rabbit's eye before any visible morbid change
liad occurred. But with the gradual accumulation
of white blood corpuscles the germs diminished in
number and ultimately vanished. This is a striking
confirmation of Metchnikoff's theory of the agency
of phagocytosis in the prevention of disease.

Now, although the spirochete can usually be
found, without difficulty, in the primary and sec-
ondary stages of syphilis, its occurrence in the ter-
tiary stage was not proved until very recently.
Doutrelepont of Bonn has. however, found the pro-
tozoa, though in small numbers, in four cases of
tertiary syphilis. Finally, in inherited syphilis, the
spirochete has been found, both in the child after
birth and in the fetus, in almost every organ, though
chiefly in the liver, stomach, and intestine.

According to Ehrmann of Vienna, the germs
spread from the focus of infection along and even
through the nerves. This is an important discovery,
which appears to confirm the current attribution of
certain serious nervous diseases to antecedent syph-
ilis, and as it is reasonablx' certain that the spirochete,
like typhoid and many other bacilli, may remain in
the organism for years in a latent state, we find
here strong support for the view that tabes, at least
in some of its forms, is a product of the syphilitic
virus.

Next in importance to the discovery of the germ
is that of the communicability of syphilis to mon-
keys. Neisser, in particular, has experimented on
a large scale in Java and produced symptoms very
similar to those of human syphilis in all species of
monkeys and apes, the closest approximation to the

human disease occurring in the highest species.
Last year (1906) Neisser and others finally suc-
ceeded in inoculating monkeys with tertiary syphilis.
Recent tertiary growths, in which suppuration had
not occurred, whether appearing late or soon after
the primary infection, produced typical primary
syphilis in monkeys to which they were transplanted.
The inoculation was not always successful, doubt-
less owing to the relatively sparse occurrence of the
spirochete in tertiary syphilis.

In the light of these experiments every person
showing even tertiary symptoms must be regarded
as a possible source of infection. The primary and
secondary products, however, are particularly dan-
gerous, because they contain greater numbers of
germs, occur on the genitals and mucous membranes
of the mouth, and often present a harmless appear-
ance. Inherited syphilis can also be transmitted by
inoculation and the nasal mucus of syphilitic chil-
dren is particularly virulent. Hoffmann has also
apparently proved, in contradiction to current opin-
ion, that the blood of recently infected patients is a
source of contagion. From all this follows the ex-
tremely important conclusion that syphilis is con-
tagious in every stage and type, and that every
organ of a syphilitic person may harbor the germs
of the disease.

It was formerly believed that a person who has
once had syphilis is henceforth immune to the dis-
ease and that this immunity is shared by children
of syphilitics, even if they have not inherited the
disease — a reversal of the law that the sins of the
fathers shall be visited upon the children, but this
last assumption has long been disproved by the fre-
quent occurrence of syphilis, acquired by contagion,
in children of syphilitics. The supposed impossibil-
ity of a second infection has also proved illusory in
numerous cases, although repeated infection is still
regarded as exceptional. Recently, however, so many
cases have been reported by competent observers
that we can no longer speak of permanent immun-
ity produced by a first infection. Finger and Land-
steiner assert that a second infection is possible even
before the first attack is cured. This second infec-
tion is not necessarily followed by the primary
symptoms which it would have caused in a pre-
viously healthy subject, but rather by an aggrava-
tion of the symptoms already present as a result of
the first infection. If the patient, therefore, is al-
ready in the secondary- or the tertiary stage, the
fresh infection simply increases the secondary or
tertiary symptoms. This view, however, is disputed
by some authorities.

Although these discoveries have thrown much
light on the origin and nature of syphilis, they have
suggested little in regard to treatment, except to
indorse most emphatically the classical method.
Mercury still remains the sovereign remedy for
syphilis. Every attempted serum treatment has
failed. Mercury alone is able to influence the dis-
ease in every stage, probably by paralyzing the
spirochete. But it must be remembered that
the administration of mercury simultaneously with
the introduction of the germ does not prevent the
outbreak of primary syphilis, although recent ex-
periments would seem to show that the hope is not

June 8, 1 907 J

MEDICAL RECORD.

943

without foundation that an effective serum will yet
be discovered and that the cure of syphilis, as of
other diseases, will ultimately result from the dis-
covery of its gferm.

THE TREATMENT OF CAISSON DISEASE.

The disease known by this name is not often seen
by the general practitioner, yet it is of considerable
interest, as the march of improvement has provided
more opportunities for its occurrence. Caisson
disease is met with in those who work in compressed
air at pressures greater than the normal fifteen
pounds to the square inch, and is believed to be due
to the presence of gas emboli in the circulation. The
liability and frequency of this condition make it
necessary to institute the proper prophylactic meas-
ures in every undertaking where caissons are em-
ployed as part of the construction work, and these
precautions are directed primarily to the physical
character and condition of the men employed. The
thoroughness of this examination may be appreci-
ated from a recent article on the subject by Pelton
(American Journal of the Medical Sciences, May,
1907), in which it is stated that the candidate's pre-
vious history with regard to ophthalmic, nasal,
aural, rheumatic, cardiac, pulmonary, hepatic, renal,
and venereal conditions and cranial injuries, is care-
fully inquired into. Observation has shown that
the Anglo-Saxon and the negro are less subject to
the evil effects of air pressure than are Italians,
Poles, and men of other races. It seems to be very
important to accustom the intended worker to the
increased air pressure gradually. This is done by
putting him in a pressure of from twenty-five to
thirty pounds for a time and then submitting him to
a second examination. Even if accepted for this
work, the men must observe especial precautions,
in w'hich they are carefully instructed. The change
from the caisson to the outer air must always be
gradual, and proper living in the intervals of work
must be insisted on. Four types of caisson disease
can be distinguished, which are termed bends, stag-
gers, paralytic, and comatose states, but no distinct
lines can be drawn to dift'erentiate these groups, the
symptoms of which are often closely interwoven.

In the treatment of this so often fatal disease the
first step is recompression of the patient — that is,
he must be again subjected to the influence of com-
pressed air— and this is accomplished in a specially
constructed chamber called the hospital lock. In
the milder cases this is usually sufficient to produce
relief from the pains, although the process may be
aided by the application of various counter-irritant
measures. Analgesics, including antipyrin, codeine,
and morphine, may be necessary, although aside
from recompression little can be done in the way
of specific treatment In the severer types, symn-
tomatic treatment is indicated, particularly as re-
gards stimulation of the heart and respiration. The
after-treatment is also very important, and in ad-
dition to the general tonic measures the paralysis
requires the routine measures applicable to the
chronic stage of peripheral neuritis. It will be seen
therefore that the treatment of this condition, which
so long as the present methods of constructing cer-

tain engineering works arc in vogue will be con-
stantly met with, is now fairly well understood. The
dangers connected with caisson work will not be
correspondingly diminished unless the workers can
be made to appreciate properly the necessary pre-
cautions, and this is apparently something which the
human mind, as exhibited in many of the workmen,
can only be made to realize with difficulty. We have
had numerous reports of fatal accidents in com-
pressed air workers which were distinctly due to
carelessness on the part of the workers or those
directly responsible for their welfare, but as we
are now sufficiently well acquainted with the con-
ditions, excuses for their occurrence cannot well be
tolerated.

THE CAUSE OF SUBCUTANEOUS HEMOR-
RHAGES.

Among the pathological conditions of which our
knowledge is still very unsatisfactory are the hemor-
rhagic lesions associated with certain forms of sep-
ticopyemia, purpura, and a number of dermatoses,
erythema nodosum among them. It has been as-
sumed that these phenomena are the local or distant
eft'ects of some irritant, but whether of bacterial or
other origin has never been satisfactorily ascer-
tained. Naturall\- enough, the attempt has been
made to reproduce these lesions in animals by the
injection of bacteria or their toxins, but thus far no
definite result has been obtained. The most recent
study is made by Heyrosky (iriencr klinische IVo-
chenschrift. No. 9, 1907), who used in his experi-
ments sterile filtrates of bacterial cultures, and by
inoculation in white mice produced hemorrhages
under the skin and mucous membranes. For the
purpose he employed glucose-bouillon cultures of
DiplococcHs pneumonia" and Streptococcus mucosus,
two varieties which are helieved to be closely related
in a biological sense. Within twelve hours ;ifter
the subcutaneous or intraperitoneal inoculation of
the filtrate the mice showed a localized hemorrhagic
exanthem over the parts thinly covered with hair,
while the more thickly covered parts were entirely
free from this lesion. They were also affected with
a more or less bloody diarrhea. The majority of the
animals, which had received but one injection of
from 0.2 to I c.c, recovered: when a second injec-
tion was given the mice either died or, in a number
of cases, survived and resisted further injections.

Autopsies showed extensive minute hemorrhages
in almost all the organs of the body, although those
in the skin, the lungs, and the rectum were the most
marked. Cultures made with the blood from these
animals remained sterile, and staining of the tissues
with methylene blue or the Gram-Wcigert failed to
show the presence of any bacteria. The report of
the histological examination of the specimens is re-
served for a later comnnmication, but the prelimi-
nary statement as to the possible specific toxic char-
acter of this hitherto obscure disease is to be re-
garded with considerable interest. If proved to be
true, it will not be long before an attempt will be
made to place the treatment of the condition upon a
more satisfactory and rational basis, the possibilities
of which are indicated by the explanation of the
etiology of the disease.

944

MEDICAL RECORD.

[June 8, 1907

The Treatment of Frost Bite by Artificial
Hyperemia.

While the number of plans of treatment recom-
mended for the relief of the immediate and secon-
dary results of the local action of excessive cold is
very large, it must be confessed that they still leave
much to be desired. It has been the object of some
of these measures at least to reduce the venous
stasis that forms so prominent a feature of the clin-
ical picture of pernio, but according to Ritter
(Miinchener medisinische Wochenschrift, May 7,
1907) this vascular condition is to be looked upon
as being a conservative process. In local freezing
both arterial and venous hyperemia have the same
object, that is, to protect the frost-bitten tissue with
more blood and to assist regeneration of the injured
cells. The stage of stasis is always preceded by a
period of anemia, and the hyperemia is a curative
effort. Ritter has employed artificial means to aug-
ment this natural hyperemia in about one hundred
and fifty cases of freezing of various degrees of in-
tensity, and recommends the method as being su-
perior to all others. Two methods are used, passive
congestion by means of Bier's bandage and the use
of the hot-air chamber. While the author thinks
highly of the former procedure, he states that he
considers the hot-air treatment the best of all, espe-
cially for chronic cases. Usually daily sessions in-
creasing in duration from fifteen minutes to one hour
are given, and cures of even extensive lesions about
the hands are to be expected in from three days to
two weeks. The effect is said to be especially bene-
ficial in promoting the healing of chillblains and
ulcers, and great relief is afforded from the itching
that is usually complained of by patients of this
class. One drawback that would seem to attend
this plan of treatment is the demands on the time
of the physician that it entails, but the lesions of
frost bite, while not ordinarily dangerous to life.
are often incapacitating and well worthy sacrifices
on the part of the patient and medical attendant for
their relief. One especially valuable feature of the
treatment is said to be the fact that it relieves the
affected parts from the heightened susceptibility to
cold that ordinarily persists for years after the origi-
nal freezing.

Sea Air ix the Treatment of Neurasthenia.

The value of climatic factors in the treatment of
the disease indicated has been frequently disputed,
mainly on account of the uncertainty of the results
obtained, and idiosyncrasy has apparently been
nowhere more marked than in this respect. In a
recent article on this subject in the Neurologischcs
Zentralblatt, Xo. 14, 1906, Ide acknowledges that
sea air has a two-fold action on the nervous system,
as it may act either as a sedative or a stimulant.
The sedative effect resides in the quality of the sea
air itself, which provides in the first place for an
equable and uniform evaporation of heat and mois-
ture from the body, and in the second place stimu-
lates the oxygen absorption. The latter, by in-
creasing oxidation, naturally aids the excretion of
various intermediary metabolic products which have
an influence in bringing about certain neurasthenic
symptoms. A stimulating effect, on the other hand,
is produced by the physical properties of the sea
air. Among these is the wind, and, further, the fact
that, owing to the readier conductivity of the sea
air. the warmth generated by the body is more
quickly dissipated. These factors exert, however, a
tonic effect on the svstem, and if the individual is

too weak, or if the stimulus is too strong, the seda-
tive is subordinated to the stimulating action, and
the result is unfavorable. The essential point in the
treatment, therefore, is properly to equalize the sed-
ative and stimulating factors. The former may be
brought out by rest cures, the latter by a gradual
but methodically increased sojourn in the open, in
the wind, and along the shore. It would appear,
therefore, that with a sea-shore climate we can at
will produce a sedative or a stimulating effect on
the nervous system and at the same time favorably
influence tissue metabolism.

Dissecting Puerpeilvl Metritis.

Although puerperal infections are fortunately de-
clining in frequency, severe types of the condition
are still encountered. One of the more unusual
forms is that known as dissecting metritis, and
Offergeld {Deutsche mediainische Wochenschrift,
May 9, 1907), as the result of an analysis of sixty-
three reported cases, describes it as being a destruc-
tive uterine infection in which, in consequence of
the necrosis of the deeper layers of the uterine wall,
the dead tissue is cast off in a continuous membrane
reproducing the form of the interior of the organ.
It is the result of a coccal infection in which the
organisms penetrate deeply into the substance of
the muscle, and by virtue of great virulence cause
e.xtensive death of tissue. The symptomatology
of the condition includes a progressive enlargement
of the uterus beginning shortly after delivery, and
accompanied by a moderate degree of fever. The
pulse is ver}- rapid, but is characterized by a better
quality than is that of sepsis. The lochia are fetid,
uterine tenderness and evidences of peritoneal irrita-
tion increase, and finally, in the course of the fourth
week, the gangrenous tissue is cast off. The prog-
nosis is bad, one patient in four succumbing, and,
even if death does not follow, the uterus is usually
so seriously damaged as to be incapable of function-
ating, and. owing to the stenosis of its lumen that is
likely to result, hematometra and hematosalpinx are
common sequel.';.

5^'ruts of thp mppk.

Dr. Wm. Kelly Simpson will give a clinical lec-
ture on "Intubation of the Larynx" in the amphi-
theatre of the X^anderbilt Clinic on ^londay after-
noon, June 10, at 4 o'clock, in connection with the
exercises celebrating the one hundredth anniversary
of the College of Physicians and Surgeons. Mem-
bers of the medical profession are cordially invited
to attend.

NewT York State Board of Medical Examiners.

— The Board oi Kegents has appointed the follow-
ing as members of the new State Board of Medical
Examiners provided for by the consolidation of the
three former boards : Drs. W. W. Potter and Lee
H. Smith of Buffalo and W. S. Searle of Brooklyn
for terms of three years ; Drs. W. S. Ely of Roches-
ter, Eugene Beach of Gloversville, and Floyd M.
Crandall of New York City, for two years ; Drs.
Frank \\'. Adriance of Elmira. Floyd S. Farnsworth
of Plattsburg. and Ralph H. Williams of Rochester,
for one year. The Board of Regents elected Dr.
Maurice K. Lewi of New York City, the present
secretary of the joint medical boards, as secretar\-
of the new medical board. Four members of the
board are regulars, three are homeopaths, one is' an
eclectic, and one is an osteopath.

June 8, 1907]

MEDICAL RECORD.

945

Public Health and Marine Hospital Service
Examinations. — A board of officers will be con-
vened to meet at the Bureau of Public Health and
Marine Hospital Service, Washington, D. C, on
Julv 15. 1907, for the purpose of examining candi-
dates for admission to the grade of assistant surgeon
in the Public Health and Marine Hospital Service.
Candidates must be between 22 and 30 years of age,
graduates of a reputable medical college, and must
furnish testimonials from responsible persons as to
their professional and moral character. Successful
candidates will be numbered according to their at-,
tainments on examination, and will be commissioned
in the same order as vacancies occur. Upon ap-
pointment the young officers are, as a rule, first
assigned to duty at one of the large hospitals, as at
Boston, New York, New Orleans, Chicago, or San
Francisco. After five years' service, assistant sur-
geons are entitled to examination for promotion to
the grade of passed assistant surgeon. Promotion
to the grade of surgeon is made according to senior-
ity, and after due examination, as vacancies occur
in that grade. Assistant surgeons receive $1,600.
passed assistant surgeons $2,000, and surgeons
$2,500 a year. When quarters are not provided,
commutation at the rate of thirty, forty, and fifty
dollars a month, according to grade, is allowed.
All grades above that of assistant surgeon receive
longevity pay, 10 per cent, in addition to the regular
salary for every five years' service up to 40 per
cent, after twenty years' service. Further informa-
tion may be obtained by addressing the Surgeon-
General, Public Health and INIarine Hospital Service,
\\'ashington, D. C.

Civil Service Examinations. — The State Civil
Service Commission will hold examinations on June
29, 1907, for the position of physician, sixth grade,
regular school. State and County Hospitals and In-
stitutions, with a salary of $900 and maintenance.
The last day for filing applications is June 22. Full
information and application forms may be obtained
by addressing Mr. Charles S. Fowler, the Chief
Examiner of the Commission at Albany.

To Restrict the Spread of Rabies. — At last
week's meeting of the Board of Health it was de-
cided to urge the Board of Aldermen to pass an
ordinance giving the police authority to shoot all
dogs without muzzles or collars found at large in
the city, and to prosecute all persons suffering such
dogs to roam at large.

Hospital Transfer Bill Passed. — Both the Sen-
ate and Assembly have passed over Mayor McClel-
lan's veto the bill making the transfer of seriouslv
ill patients from one hospital to another a misde-
meanor punishable by a fine of Sioc).

A New Measure for Identification. — M. Bertil-
lon, the Chief of the Intelligence Department of the
Paris detective service, has mtroduced a new fea-
ture into his system of irieasurements of criminals
by the aid of which the identification of suspects
may be facilitated. It consists of a specially con-
structed piece of photographic apparatus, by means
of which accurate measurements to scale of the pris-
oner's features may be obtained and recorded. In
this great importance is attached to the measure-
ment of the distance from the outer canthus of the
eye to the external auditory meatus.

Medical College at Manila. — A medical school
that is designed to be the first college of a future
University of the Philippine Islands is shortly to be
opened in Manila. The Philippine government has
appropriated the sum of $62,000 for the first year's

expenses, and a building formerly used by army
engineers is being remodeled and equipped for this
purpose.

Incoming Steamers Quarantined. — The liners
Kroonland and Statcndaui, from Antwerp and Rot-
terdam respectively, were retained at Quarantine
on account of the presence of smallpox and typhoid
fever among the steerage passengers. All of these
were transferred to Hoffman Island and the steerage
quarters were fumigated before the vessels were
allowed to dock.

Quarantine Against Havana. — The United
States Marine Hospital Service has imposed a quar-
antine against Havana to be effective throughout
the Gulf States.

Meningitis in Glasgow. — None of the medical
or nursing staff' of the Glasgow City Hospital have
contracted cerebrospinal meningitis during the re-
cent epidemic, although for weeks they had very
large numbers of such patients under their care.
Dr. Chalmers, the health ofificer of the city, as the
result of an investigation of the question, has come
to the conclusion that infection usually takes place
through the nasopharynx and that the practice of
promiscuous kissing, especially of infants and chil-
dren, should be discouraged.

Berlin's Declining Birth Rate. — The Municipal
Statistical Bureau draws attention to the decline in
the birth rate in Berlin, which has been almost con-
stant since 1876, when there were 240 births for
every 1,000 married women. In 1906 the rate was
only 10 per cent. Illegitimate births steadily in-
crease, being now nearly 17 per cent, of the whole,
compared with 15 per cent, in 1901 and 12 per cent,
in 1875.

An Examination of Canned Meats. — The State
Health Department has made an examination of
154 samples of roast, corned, dried, and potted beef,
potted and deviled ham, canned chicken, turkey, and
sausages. Twenty-five of the samples were found
to be preparations with low grade meat contents,
and seven with very poor meat contents, but one
can of potted ham was found to be a preparation
from diseased meat. Preservatives were found in
many of the samples and adulterants also existed.

To Restrict the Use of Tobacco by Minors. —
The Wisconsin Assembly has passed a bill pro-
hibiting the use of tobacco by boys under the age
of sixteen years.

A Title as a Fee. — According to the press de-
spatches, Dr. Guiterrez, the Spanish physician who,
with the English physician. Dr. Glendenning, was
in attendance upon Queen Victoria during her re-
cent accouchement, has refused to accept any pecu-
niary remuneration for his services, but will receive
the title of Marquis bestowed upon him by the King.

Post-Graduate Hospital Tuberculosis Annex. —
Owing to a lack of funds, the Post-Graduate Hos-
pital annex for the treatment of tuberculosis will
have to be restricted in scope or discontinued unless
financial aid is secured for this object.

Dr. Andrew P. Biddle, of Detroit, for the past
six years secretary of the Michigan State Medical
Society, on the occasion of his recent resignation
from that office was presented by the society with
a suitably inscribed platter of silver.

Dr. George Sumner Huntington, Professor of
Anatomy, College of Physicians and Surgeons,
Columbia University, New York, received the
honorary degree of Doctor of Laws at the eighty-
second annual commencement of the Jefferson

946

MEDICAL RECORD.

[June 8, 1907

Medical College of Philadelphia, held on June 3,
1907. Professor Huiitinolon delivered an ad-
dress on "Modern Advances in the Teaching of
Anatomy and Other Medical Sciences."

Dr. Robert Smart, Lieutenant and Assistant
Surgeon, has obtained an honorable discharge from
the Army and will engage in private practice. He
was admitted to the medical corps of the .\rmy in
1901.

Dr. J. Blake White of this city was recently
elected bv the Hoard of Trustees a member of the
consulting staff of the Littleton, X. H., Ho.spital.

Demonstration of Teaching Methods. — In con-
nection with the celebration of the one hundredth
anniversary of the College of Physicians and Sur-
geons, New York, a series of demonstrations illus-
trating some of the newer methods of teaching will
be held on Tuesday, June 11, as follows: 9-10
o'clock. Physiology : at the laboratory of the de-
partment, by Professor P.urton-C)pitz and Dr. Haven
Emerson : The action of the valves of the heart ;
the circulation of the blood in the capillaries ; clini-
cal methods of recording certain facts of circulation
and respiration, ic-ii o'clock. Surgery: at the
phvsiological laboratory, by Professor J. A. Blake
and Dr. J. W. D. Maury: Recent studies at the
surgical laboratory ; the technique of undergraduate
teaching in surgery. 11-12 o'clock. Biological Chem-
istry : at the laboratory of the department, by Pro-
fessor W. J. Gies and assistants : The action of
enzvmes : some of the chemical phases of the newer
physiology of digestion. 12-1 o'clock. Pharmacol-
ogy : at the recitation room of the department, by
Dr. .\. N. Richards : The action of certain common
drugs upon the heart.

Tuberculosis Camp. — A free sanatorium for
indigent tuberculous patients is to be established at
White Pine Camp, Mont Alto, Pa., at a cost of
$300,000 or more, out of an appropriation of $600,-
000 made by the Legislature. The site is an ad-
mirable one by reason of its elevation, atmospheric
conditions, and physical conformation.

American Gastroenterological Association. —
At the tenth annual meeting of this Association, held
in .Atlantic City, N. J., June 3 and 4, 1907, the fol-
lowing officers were elected for the ensuing year :
President, Dr. J. P. Sawyer of Cleveland; Vice-
Presidents, Dr. J. .\. Lichty of Pittsburg and Dr.
G. D. Kahlo of Indianapolis ; Secretary and Treas-
urer, Dr. Charles D. .Aaron of Detroit.

New Jersey State Medical Association. — The
coming meeting of this organization will be held at
Long Branch on June 25, 26, and 27, 1907, instead
of at Cape May as originally announced.

Middle Tennessee Medical Association. — Of-
ficers as follows were elected at the meeting of this
society held in Murfreesboro on May 17: Presi-
dent, Dr. R. Douglass of Nashville ; Vice-President,
Dr. E. Jones of Alurfreesboro ; Secretary and Treas-
urer, Dr. William Litterer of Nashville.

Wayne County (Michigan) Medical Society. —
Officers for the ensuing year were elected as fol-
lows by this society at its meeting held in Detroit
on May 20: President, Dr. A. N. Collins; Vice-
President, Dr. Kenneth Cunsolus; Secretary, Dr.
W. D. Ford.

Vermont State Homeopathic Medical Society.
^At the meeting of this society held in Montpelier
on May 22 officers as follows were elected : Presi-
dent, Dr. W^ E. Locke of Bradford ; Vice-President,
Dr. W. H. Everett of Castleton ; Secretary, Dr. G. L

Forbes of Burlington; Treasurer, Dr. F. E. Steele
of Montpelier.

Michigan Homeopathic State Medical Society.
— The thirty-eighth annual meeting of this organiza-
tion was held in Detroit on May 23, and officers
were elected as follows: President, Dr. S. H.
Knight of Detroit; Vice-Presidents, Dr. J. H. Ball
of Bay City and Dr. A. V. Avery of Parma ; General
Secretary, Dr. D. W. Myers of Grand Rapids ; Cor-
responding Secretary, Dr. F. A. Kelley of Detroit;
Treasurer, Dr. R. ^L Richards of Detroit. The
next meeting will be held in .\nn .Xrbor.

Connecticut State Homeopathic Medical So-
ciety.— At the twenty-seventh annual meeting of
this society held in Norwich on May 17 officers as
follows were elected : President, Dr. S. S. Ives of
Meriden ; Vice-President, Dr. S. Worcester of Stam-
ford ; Secretary. Dr. H. A. Cameron of Waterbury ;
Treasurer. Dr. E, J. Walker of New Haven.

Nebraska State Homeopathic Society. — At the
annual meeting of this Society, held May 21 and 22,
at Lincoln, the following officers were elected :
President, H. R. Miner, Falls City ; First Vice-
President, F. A. Marsh, Seward : Second Vice-
President, F. F. Teal, Omaha ; Corresponding Sec-
retary, W. K. Foote, Omaha ; Recording Secretary,
F. S. Whitman, Omaha ; Treasurer, O. S. Wood,
( )malia.

Obituary Notes. — Dr. Edw.\rd R. O'Reilly of
Elizabeth, N. J., died on Alay 27 of appendicitis, at
the age of forty-eight years. He was born in Nor-
walk. Conn., and after receiving his degree from
the New York University Medical School began
practice in Elizabeth in 1882. For five years he
was a member of the New Jersey Board of Health
and was for eight years City Physician of Elizabeth.
He was also at one time County Physician.

Dr. J. Fields H.^sty of Murray, la., died on May
21, at the age of forty-four years. .About a year ago
he was compelled to give up active work on account
of the development of a tumor of the brain, which
was the cause of his death.

Dr. Joseph D. M.\xsfield of Wakefield, Mass.,
died on May 22, at the age of ninety years. He was
born in Lynnfield, and received his medical educa-
tion at Dartmouth College and from the Vermont
Medical College at \\"oodstock, from which he was
graduated in 1841. Since the date of his gradua-
tion he had practised in ^^'akefield, and he had been
a member of the Massachusetts State ^Medical So-
ciety for more than half a century.

Dr. J. P. Lewis of Topeka, Kan., died on May 20,
at the age of fifty-eight years, after an illness of
several months. He was born in Sulphur Springs,
O., and in 1873 was graduated from the Ohio Medi-
cal College at Cincinnati. After practising for a
time in Lexington, and later at Pleasantville, O., he
came to Topeka in 1883. He served in numerous
public offices, and was the first county health officer
of Shawnee county.

Dr. George D. Duggins of Denver, Col., died on
May 17, at the age of sixty-seven years. He was
born in Saline county, Mo., and served through the
Civil War as regimental surgeon in McGruder's
division. At the close of the war he completed his
medical training at the St. Louis Medical College,
from which he was graduated in 1866. He practised
for a time at Fort Leavenworth and Miami, Mo.,
and in 1881 removed to Pueblo, Col., where he ha(i
remained until a few months before his death.

Dr. P. A. A. Collet of Fall River, Mass., died
on May 21, at the age of sixty years. He was bom

June 8, 1907]

MEDICAL RECORD.

947

in St. Henry, Can., and received Iiis medical degree
from Lavalle University in 1871. He came to b'all
River ten years later, and had served several term.s
as city physician and member of the Board of
Health.

Dr. Charles Simpson of Minneapolis, Minn.,
died on May 17, at the a.q:e of sixty-four years. He
was graduated from the College of Physicians and
Surgeons in 1871, and began practice in Minneapo-
lis shortly afterward. He served as Health Com-
missioner, was a member of the Board of Education,
and from 1895- 1898 was a member of the State
Board of Medical Examiners.

Dr. Edgar Poppleton of Portland, Ore, died on
May 16, at the age of seventy-four years. He was
graduated from a medical college in Cincinnati in
1854, and shortly afterward made the journey across
the Continent, settling at Lafayette, where he re-
sided for many years, afterward removing to Port-
land. He was the first coroner of Multnomah
county.

Dr. George Roice Durrie of this city died on
June I of heart disease. He was born in New
Haven, and served in the Twenty-seventh Con-
necticut Volunteers during the Civil War. After
the close of the war he completed his medical educa-
tion at Yale, from which he was graduated in 1865.
For thirty-five years he practised in this city, and
was formerly visiting physician to the Aletropolitan
and Hahnemann Hospitals.

Dr. Amasa M. Bucknum of Denver, Col., died
on May 25 at an advanced age. He was graduated
from Castleton Medical College in 1849 and prac-
tised for thirty-two years in the two towns of Spring
Harbor and Parma, Mich. In 1881 he went to
Denver, and had practised there since that time,
occupying several hospital and dispensary positions.

Dr. James B. Everett of Everett, Mass., died on
May 20, at the age of seventy-nine years. He was
graduated in medicine from Dartmouth College in
i860, and after practising for ten years in Falmouth,
N. H., removed to Everett.

THE TRYPANOSOME OF DOURINE.

To THE Editor of the Medic.-\l Record :

Sir: — Pathologists will be interested in the information
that the Trypanosoma equipcrdum has been found in a
mare clinically afifected with dourine, or maladie du coit,
at the Quarantine Station established by this Department
at Lethbridge, Alberta, in 1904. The first demonstration
was made by Drs. E. A. Watson and M. V. Gallivan on
February II, 1907, in material taken from a vesicle on the
mucous membrane of the vagina of the animal above re-
ferred to, which was found to be affected with dourine on
the premises of her owner, Mr. R. Tiffin, near Lethbridge,
on December 21, 1906, and subsequently removed to the
Quarantine Station for purposes of experimental observa-
tion.

The disease was successfully transmitted in February
to a yearling filly and the parasite subsequently observed
in preparations from a fresh plaque. The finding was
confirmed by Dr. C. H. Higgins, pathologist of the De-
partment, on March 21, and was further observed in prep-
arations taken by him on the 23d and 25th of the same
month.

The identity of dourine, or maladie du coit, as seen on
this Continent, and hitherto diagnosed by American and
Canadian veterinarians from clinical manifestations .ilone,
with the disease as known in Africa and .'Vsia. as well as
in southern Europe, is thus fully established. A detailed
report of the discovery and of the work which led up to it,
as well as of the steps subsequently taken, will be issued
at the earliest possible date.

J. G. Rutherford.

Veterinary Director General.
Ott.awa, Ontario.

"DIPSOPHILIA."
To THE Editor of the Medical Record;

Sir:— In Boswell's Life of Johnson, we read: "After
supper, Dr. Johnson told us that Isaac Hawkins Browne
drank freely for thirty years, and tliat he wrote his poem,
De Animi Immortatitatc. in some of the last of these years.
I listened to this with the eagerness of one who, conscious
of being fond of wine, is glad to find that a man of so
much genius and good-thinking as Browne, liad the same
propensity."

As 1 do not agree with the opinion of many eminent
members of the medical profession that alcoholism is a
disease, but consider it rather a propensity, hereditary or
acquired, I shall, for want of a better term, designate it
"dipsophilia," otherwise any similar addiction, or fondness,
for some inordinate passion, such as bridge-whist, golf, or
any sport or pastime, might, with equal justification, be
inserted in the index of morbid conditions. Any defect in
our nature which exhibits a tendency to withdraw us from
the path of morality or rectitude must not necessarily be
regarded as a diseased process, and to term alcoholism a
disease is an abortive attempt on the part of the profession
to elucidate a social problem in a manner altogether incon-
sistent with modern thought and progress.

I have always considered, regarding the regrettable
habit of indulging in alcoholic beverages, that those
who are thus afflicted are made infinitely worse by those
who themselves boast of their rigid adherence to total
abstinence or irreproachable sobriety. The man who takes
liquor is no more to be despised than the inveterate snufT-
taker, the confirmed tobacco-smoker, or the society sylph
who, weary and worn, is ushered into the Land of Dreams
by her familiar chloral hydrate or sulphonal. All are
equally guilty of moral turpitude— just the same as the poor
laboring man who "cannot do without his glass of ale."
Fierce and blatant harangues against drinking, in which
the unhappy toper is reviled, scorned, and painted by some
anemic orator as a foul and loathsome creature — a vam-
pire sucking the life's blood of his wife and children, and
a being altogether outside the pale of salvation — are un-
worthy of a moment's consideration. These enthusiasts
forget that Christ himself drank grape juice in moderation,
and that many of the ancient patriarclis were themselves
wine-bibbing profligates.

Let us take the percentage of suicides. We shall find
that no small number are recruited from the ranks of
drunkards. What does this teach us ? It discloses the
fact that some unstable individual, who has been unable
to control his irresistible and insatiable appetite for alco-
holic stimulation, has awakened from his debauch, and,
smitten with a horrible remorse, has sought to expiate
his downfall by "a sleep and a forgetting." Instead of
finding sympathy extended towards him ; instead of find-
ing his tremulous hand grasped by the firm fingers of an
honest brother, he too frequently awakes to find himself
battered, beaten, and bruised in the atrox spcluiica of a
modern dungeon. Then he is brought before a sleek and
sarcastic Recorder (probably no angel himself) and openly
proclaimed a hopeless and abandoned outcast. He is then
sentenced to a harsh term of imprisonment — instead of
some sequestered retreat — amid the jests of a ribald multi-
tude and the tears and anguish of his starving dependents.
Thus the last state of that man is worse than the first.

In order to improve this lamentable condition of affairs
we want no nauseating doggerels about "Father, dear
father, come home to us now," nor do we want to punish
the inebriate any more than the morphine-taker or the tea-
tippler — we want to find out how the evil can be remedied
without having to appeal to the justice of the Middle Ages.
We punish some poor, discouraged, and distraught wretch
for attempting to commit suicide, when a ten-dollar bill
would snatch him from the Stygian slough in which he is
engulfed. It is not the drunkard or the suicide that is to
blame ; it is "man's inhumanity to man." It is the State
which makes its citizens drunk; it is for the State not only
to sober them, but also to lead them into no further tempta-
tion. L'nder any conditions it is the Legislature that is
culpable and not the individual.

Ravmund H. Phillimore, M.D.

Montreal.

PILOCARPINE IN PRURITUS.

To the Editor of the Medical Record:

Sir: — Regarding the use of pilocarpine in pruritus, as
advised in the Medical Record of May 25. it has been the
writer's custom for many years to use this drug with ad-
vantage in cases of urticaria (so-called, really lichen urti-
catus), with intolerable itching. As these cases have usually

948

MEDICAL RECORD.

[June 8, 1907

a debilitated condition as their underlying cause, a mixture
containing quinine, arsenic, strychnine, and pilocarpine,
all in the form of the chloride with dilute hydrochloric
acid, has been found uniformly successful.

John- \V. McCl'llough, M.D.
.^LLIST0^•, Ont.ario.

OUR LONDON LETTER.

(From Our Special Correspondent.)

OLIVER-SHARPEY LECTURES; DEGENER.-\TION AND REGENERATION
OF NERVES — SANATORIA FOR WORKERS' ASS0CI.\TION ; PRINCE

OF WALES PRESIDING TEMPERANCE HOSPIT.-\L — TOTTENHAM

HOSPITAL — OBITLWRY.

Lo.\DOX. May 17, 1907.

Professor Halliburton delivered the Oliver-Sharpey lec-
tures at the Royal College of Physicians on the 29th and
30th ult., taking for subject "New Facts in Relation to
the Processes of Nervous Degeneration and Regeneration."
In the first of the two lectures, he dealt almost exclu-
sively with nerve degeneration from a chemical point of
view. He pointed out that the decomposition products
of lecithin, as shown by Dr. Mott and himself in previous
investigations, can be detected in the circulating fluids in
degenerative nervous diseases. Accordingly, taking cholin
as one such product, they suggested that if found in the
blood or cerebrospinal fluid it showed that nervous tissue
was breaking down, and therefore would help to distin-
guish organic lesions from functional disorders. The
methods first used for detecting cholin have been held by
some observers to be unreliable and further investigations
have been made. The plan now adopted by the lecturer is
to add a strong solution of iodine in potassium iodide to
cholin platinochloride, whereupon the crystals are re-
placed by dark-brown plates and prisms somewhat like
crystals of hemin. This periodide of cholin rapidly
changes into oily droplets of a brown color if the slide is
left to stand to evaporate. The addition of more solution
causes a repetition of the changes. The obtaining of a
large crop of crystals, whether of the cholin salt or a
mi.xture of potassium and cholin salts was stated to be
diagnostic of e.xtensive breakdown in nervous tissues. The
contrast between such cases and the insignificant yield
from normal blood was most striking. A further investi-
gation has been started for the estimation of the potassium
in the cerebrospinal fluid and blood in cases of acute de-
generative diseases of the nervous system in comparison
with the normal. At present no final figures were given,
but as far as the preliminary work has gone the lecturer
said it indicates a considerable increase of potassium in
those cases where disintegration has occurred and where
cholin is discoverable.

In his second lecture, Professor Halliburton turned to
the question of regeneration of nerves. He related experi-
ments designed to settle whether the autogenetic regenera-
tion theory, which has lately been revived in this country
and Germany could be maintained. His investigations,
and those of others working with him, led to the conclu-
sion that it cannot, and so far go to rehabilitate the Wal-
lerian theory. In no one case did he obtain any evidence
of autoregeneration. Rather, his facts taken in conjunc-
tion with those of Cajal, Langley, and Anderson are
strongly in favor of the Wallerian doctrine that new
nerve fibers are growths from the central ends of divided
nerve trunks. The facts recorded by Bethe and Kennedy
he held are easily explained on the lines emphasized by
Langley and Anderson of accidental, unnoticed connec-
tion of the peripheral segments with the central nervous
system by means of other nerves cut through in the experi-
ment. If such connection is effectually prevented, real
regeneration of structure and restoration of function never
occurs. Moreover, the regenerated fibers always degen-
erate in a peripheral direction, and that only when the link
binding them to the central nervous system is again sev-
ered. The most striking new fact brought forward by
the lecturer is in reference to the development of the me-
dullary sheath ; this appendage of the axis cylinder appears
earliest at situations near the point where the ends of a
nerve have been joined together and reaches the distal
portions later. In the peripheral segment of a divided
nerve there is multiplication, elongation, and union into
long chains of the neurilemma! cells, and the same chan.ge
occurs in the central end. but is more vigorous. Here the
nutritive function is effective, and provides for the nour-
ishment of the actively lengthening axis cylinders, while
at the peripheral end it is ineffective unless the axons
reach it.

The Prince of Wales presided on Tuesday evening at a
dinner in aid of the National Association for the establish-

ment of sanatoria for workers suffering from tuberculosis.
The gathering was a very influential one, including royal-
ties, ambassadors, and other notabilities. The health of
the King having been honored, the toast of the other
members of the royal family was proposed by the Ameri-
can ambassador, who said this was a toast always welcome
to more than British circles, there never having been a
time when .-Vmerican chivalry did not bow low in respect
to the Queen of England. Touching gracefully on the
advent of the Danish princess and subsequent events, he
passed on to say no characteristic has distinguished
the Queen, as well as the whole royal family, more than
their eager identification with every beneficent helping hand
held out by those who have to those who have not, and
particularly in the struggle by the well-to-do to sustain
hospitals for the poor — that tender recognition of the
common brotherhood of the human race which becomes
so strong a hope for the permanence of social order and
the development of human progress. Other equally felici-
tous expressions filled the Ambassador's speech, to which
the Prince replied, proposing success to the Association
which has established the first sanatorium, as I have pre-
viously informed you, and which is already in need of
enlargement. The subscriptions announced at the dinner
amounted to £13.261.

On Tuesday the Princess Louise opened a new out-
patient hall at the London Temperance Hospital. The
chairman, in an address, pointed out that last year the
patients attending averaged 220 a day, and, though no
charge was made and they were very poor, they had con-
tributed £300 to the funds. The Princess hoped the new
hall would enable the hospital to do tenfold the work it had
been doing. It is curious how managers still harp on the
large numbers they provide for, and yet the profession has
long been protesting against the abuse of the out-patients'
departments. A very different interpretation might be
placed on the figures with which the public is supplied.

The Prince of Wales opened new wards at the Totten-
ham Hospital last week, and announced that at the re-
quest of the Princess Louise, president, and the governors,
he was willing for the institution to be named after him.
.'\ccordingly. in future it will be known as the "Prince of
Wales' General Hospital."

The death of Dr. Robert Barnes, in his ninetieth year,
will recall to the oldest members of the profession one
whose name was among the most honored in their early
days. His M.D. Lond. dates from 1848. He was made
F.R.C.P. in 1859. and there are only three Fellows sur-
viving who were senior to him in the Fellowship. As
perhaps the foremost obstetrician of his time, he filled in
due course the various offices in his college, was examiner
from 1864 to 1876, Lumleian lecturer 1873, councillor 1876,
censor 1877-8. He was also F.R.C.S., Eng., 1883. and in
1887 the Irish College of Physicians conferred on him the
honorary Fellowship. The societies and academies at home
and abroad which conferred their highest distinctions upon
him are too numerous to mention. The Royal Maternity
Charity, the London Hospital, St. George's Hospital, the
Children's Hospital, the Seaman's Hospital, St.
Thomas's Hospital, and others had the benefit of his work,
and the attached schools that of his teaching. In all these
positions he was admired for his great acquirements, his
able teaching, and the high tone of his conduct, so that his
name was synonymous with all that is most learned and
most upright. His "Obstetric Medicine and Surgery" and
his lectures on "Obstetrical Operations" will be known to
your readers as the text-books of a generation. His "Clin-
ical Exposition of Diseases of Women" and his works on
"Placenta Prsevia and Fatty Degeneration of the Placenta"
may also be mentioned among his contributions to ob-
stetrical literature. The Transactions of the Obstetrical
and Gynecological Societies contain other valuable essays
from his pen. He was one of the principal founders of
both these societies, and retained his interest in them to
the last. He was a hale and healthy man, full of energy
in his ^old age. He had for some years retired to East-
bourne, but thought nothing of a run up to London when
his affairs seemed to him to need attention. He had a
cerebral attack some three or four weeks ago, but recov-
ered enough to drive out daily, and he came to London in
the first week of this month. On the loth, however, he
had another attack, and died on the 12th.

Mr. J. F. C. H. Macready, F.R.C.S., Consulting Surgeon
to the great Northern Central Hospital, died on the 29th
ult., aged fifty-seven. He was a son of the celebrated
actor. He became a student at St. Bartholomew's Hos-
pital, took his M.R.C.S. in 1874 and the Fellowship in 1876.
Two years later he was appointed surgeon to the Great
Northern, which he served through many years on the
committee as well as the staff. He was also surgeon to
the Truss Society, to the City of London Chief Hospital,

June 8, 1907]

MEDICAL RECORD.

949

and other institutions. He wrote a "Treatise on Ruptures"
in 1893 and contributed to the journals on this and allied
surgical topics.

Dr. John Mill Frodsharn, J. P., formerly Physician to
the North London Consumption Hospital and some other
institutions, died on the 12th inst., at the age of seventy-
two. He took the M.R.C.S. in 1856 and M.D.. Edin., the
next year. He was a King's College student, of which he
became Associate.

Dr. Samuel Lodge of Bradford died on the gth inst.,
aged eighty-three, after a long illness. He was many years
surgeon to the police, and on one occasion was stabbed
with a pen knife by a lunatic. Early in his practise he also
lost the sight of one eye, and later he broke a thigh, from
which he became permanently lame. He wrote on Wool-
sorter's disease, as to whicli hi.- had considerable experi-
ence ; also on hydrophobia, on china grass as an absorbent
and antiseptic, etc.

Surg.-Maj. L. Armstrong of the old Thirteenth Light
Dragoons (retired) died at Weston-supcr-mare on Satur-
day after a brief illness. The late officer, who was seventy-
seven years of age, served as an army surgeon throughout
the Crimean war and attended the wounded atnong the
survivors of the six hundred at Balaclava.

The death is also reported from Mentone of William
Higginbotham, M.D., in his ninety-fourth year.

PHILIPPINE ISLANDS MEDICAL ASSOCIATION.

FOURTH ANNU.»iL MEETING,
(From Our Special Correspondent.)

At the closing session of the Philippine Islands Medical
Association, held March 2, the lirst paper, entitled "Quan-
titative Investigations of the Plienomena of .Agglutination"
was read by Dr. Y. K. Ohno of the Biological Laboratory,
Bureau of Science. The next paper was entitled "Observa-
tions on the Etiology of Dengue Fever," by Captain P. M.
Ashburn, Assistant Surgeon V. S. Army, and First Lieu-
tenant Charles F. Craig, Assistant Surgeon, U. S. Army.
The principal feature of this paper may be summarized by
the statement that the authors have conclusively shown
that dengue can be transmitted by mosquitos, and that
in all probability the offending mosquito is the Culc.v fati-
gans; that the average incubation period of the disease is
three and a half days, and that eleven cases were pro-
duced experimentally in United States soldiers who volun-
teered for the experiment, and that the most painstaking
scientific research has failed to show any microorganism
as the causative factor of the disease. The authors were
further of the opinion that the organism must be ultra-
microscopic and to be classed in the same category as that
of yellow fever. They concurred in the findings of Stitt
that leucopenia is an important diagnostic aid.

The next paper, entitled "Some Remarks Concerning
Kubisagari, or Vertige Paralysant," by Kinnosuke Miura,
Professor of Internal Medicine in the Imperial Japanese
University at Tokio, was read by Dr. R. P. Strong. He
stated that this interesting disease had prevailed for a
considerable period among the peasant class of Japan, more
especially in the neighborhood of Homori and Iwatekin,
northern provinces. The principal symptoms are dimness
of vision, ptosis, diplopia, difficulty in speech, in degluti-
tion, and in mastication, weakness in the muscles of the
back of the neck and of the extremities. He stated that
this disease was identical with that observed by Gerlier in
Ferney, Switzerland. The disease was most common in
the summer time. He stated that the length of the attack
was short, not exceeding ten or fifteen minutes. The
patients were apparently perfectly well between the inter-
vals of the paroxysms. The causative factors of the dis-
ease are not definitely known, and are usually ascribed to
bodily exertion, especially to labor in a stooping position,
and repeated uniform movements. The attacks are usually
diminished, or stopped altogether by a change of climate
and by rest. Many superstitions have been ascribed as
being the cause of the disease. Gerlier was the first to
emphasize the close connection between those who work in
horse and cow stables, and pointed particularly to the fact
that it occurred in laborers and other persons employed in
the care of cows or horses, or who lived in houses in which
cows and horses are kept. The writer found that the dis-
ease occurred among the same class of people in Japan.
Prophyl.ictic measures consisted in removing from the
neighborhood of cow and horse stables, and the avoidance
of such places especially for the midday or night sleep.
Very little can be attained by the use of medicaments, but
potassium iodide and arsenic seem to give the best results.

"Infant Feeding in the Tropics" was the title of a paper
read by Dr. W. E. Musgrave, of the Biological Laboratory,

Bureau of Science. He quoted statistics from the Bureau
of Health, which showed that of 26,186 children born since
1903. 18.795 had died before they reached the age of one
year. This was a most appalling mortality. He attributed
it principally to the lack of knowledge in proper infant
feeding, and stated that the milk of the Filipino mothers
was entirely inadequate in quantity and in quality, in con-
sequence of which rice, and even sometimes meat, were
fed to the young offspring. In addition to the efforts
which were made by the Bureau of Health to spread
information of this kind throughout the islands by means
of circulars, and through instruction in the different
schools, he believed that a large public movement was
necessary before satisfactory results could be obtained.

Dr. Sia Tien Pao, Delegate from His Imperial Chinese
Majesty's government, delivered an address before the
Association which was not strictly of a medical nature,
yet was full of interest. He took occasion to justify the
American occupation of the Philippines, and stated that no
disinterested observer could come to the Philippines and
fail to be impressed with the grand work of beneficence
which was being carried on by the United States. He
believed that his country was now awakening, and that
the Chinese would naturally turn to the United States as
the fountain of higher learning, and to obtain therefrom
valuable aid necessary in the greater part of the work
along lines of medical reform.

The last paper before the Association was entitled "A
Summary of Some Experimental Work in Plague Immu-
nity," by Dr. R. P. Strong, Chief of the Biological Lab-
oratory, Bureau of Science. He stated that among prophy-
lactic and curative serums there were encountered those
which possessed antitoxic properties, of which diphtheria
serum might be named as a type ; those which manifest
a bactericidal power, an example of which is encountered
in immunization against cholera; those which combined
antitoxic and bactericidal power, such as one obtained
from animals immunized to the dysentery bacillus ; those
which possess antiinfectious power, of which plague serum
may be given as an example. With regard to opsonins, he
stated that much of the work that had recently been re-
ported upon \vas done by trained investigators, yet a con-
siderable proportion had been performed by men new to
the field, and he felt convinced that the claims by many
of the results attained would not be warranted by more
careful work in the future. He stated that there were
many sources of error in determining opsonic indexes and
the personal equation is of considerable importance. It
seemed to him not unlikely that in some of the experiments
performed in the study of opsonins it is sometimes the
action of the complement alone, and sometimes, although
more rarely, the action of the immune body which has been
considered to represent the opsonic action. He also inves-
tigated the question as to whether human beings and ani-
mals vaccinated against plague organisms, possess a higher
opsonic index against the organism than do normal human
and animal sera. His method was to take an unimmunized
animal, such as the guinea-pig and inoculate it intraperi-
toneally with 10 c.c. of a sterile suspension of aleuronat.
After from 12 to 16 hours the animal was killed with
chloroform. The abdominal exudate, if sterile, is col-
lected and mixed with a I per cent, of ammonium oxalate
solution in 0.85 per cent, sodium chloride solution and
thoroughly centrifuged. The packed corpuscles were then
washed several times in excess of saline solution, and
each time recentrifuged. In performing the tests one vol-
ume of leucocytes, plus one volume of the serum to be
tested, are thoroughly mixed and incubated for 30 minutes
at 37 degrees centigrade. After this, smears are prepared
and stained with methylene blue. Control experiments with
two normal sera of the same species of animal, as well as
the control of the nonphagocytic power of the washed leu-
cocytes, were prepared. The method of counting the
phagocytic cells, as suggested by Simon, rather than the
number of bacteria in each phagocyte, as recommended by
Wright, is simpler, and the error of variation between
repeated counts is obviously not so great._ In carrying out
the above experiments it has not been difficult to show that
the blood of an individual or animal immunized against
pest usually shows increased opsonic action over that of
normal human or animal blood. However, since the normal
opsonic index varies considerably in different individuals,
and in the same individual from time to time, variable
results may sometimes be encountered in a few instances.
The general law may be determined from the study of a
series of cases. In conclusion, he stated that plague immune
serum acts neither as an antitoxic nor typical bactericidal
serum, but that its action may be said to be antiinfectious
and opsonic in nature.

At the business meeting of the Association different re-
ports were read and a number of resolutions were passed.

950

MEDICAL RECORD.

[June <S, 1907

In connection witli the meetings of the Association, a
pathological exhibit, which was changed every day, was
also ready for examination at the Bureau of Science ; some
200 specimens were shown. Among other things shown
were piroplasmata, about which Dr. Kannusuke Myajima
read a paper, and excellent specimens of the disease gon-
gosa. which has recently been found in the Philippines, and
many other interesting specimens.

Several resolutions were passed to the effect that the
Committee on Public Policy and Legislation should report
to the commission the desirability of appointing a com-
mission to investigate uncinariasis in the Philippines, and
also that steps be taken to arouse public interest m connec-
tion with infant mortality.

The following officers were elected for the ensuing year:
Dr W. E. Musgrave, President; Dr. C. F. Craig, tirst
Vice-President: Dr. G. Singian de Miranda, Second Vue-
Presidenf Dr. Paul C. Freer. Councillor for five years.

New York Medical Journal, May 25, 1907.
A Case of Melanuria.— The patient of F. Bierhoflt was
a man nineteen years old in his first gonorrheal attack in
its fifth week. In addition he had a prostatic abscess.
After a steady improvement from three weeks treatment
in the author's hands, he passed, one morning, blackish,
sooty urine and examination showed that the color was
caused by granules and clumps of melanuria. 1 he patient
had been subjected to an intense nervous shock some
thirty-six hours before the melanuria was noticed. Its
occurrence did not lead the author to make any change in
his treatment of the gonorrheal condition, and m forty-
eight hours more the urine was clear. 1 he microscope
still showed granules of pigment, but even these disap-
peared in two days more. In all the patient remamed
under observation six weeks longer without any return of
the melanuria. The author makes some remarks as to
the occurrence of this condition, stating that the urine
may be dark on voiding, or it may in the presence of the
chromogen of melanuria become dark only after exposure
to the air. Under the lens the pigment is visible as dark
brown or perfectly black granules or masses, irregular in
shape, and usually of small size.

Congenital Stenosis of the Pylorus.— A case is re-
ported by J. J. Gilbride, who refers to recent literature
on the subject and gives a general description of the con-
dition His own patient was a male infant seven weeks
old who, after he had passed his fourteenth day of life,
began to vomit intermittently after nursing. The condition
gradually grew worse and finally everything was rejected
and he fell ofT from ten pounds, the weight at birth, to
five. The chest revealed nothing abnormal. Inspection
of the abdomen showed epigastric distention and the out-
line of a dilated stomach. Peristaltic waves passing from
left to right were distinctly visible. Abdominal wall was
thin and the pylorus palpable. A diagnosis of complete
pyloric stenosis was made and operation advised. The
parents wished that medical treatment should be followed
a few davs before surgical intervention. Lavage of the
stomach, small amounts of food by mouth, and nutrient
enemata brought no relief and the child died. No autopsy
was held. Medical treatment may be of benefit in cases
of partial stenosis only. Mortality from medical treatment
in complete stenosis is 100 per cent.; from surgical 4.65
per cent.

Serum Therapy and Serum Diagnosis in Syphilis.—
S Pollitzer reviews recent progress along the lines indi-
cated in his title. Space forbids the description of all the
laboratorv and clinical experiments which have led to our
present knowledge. It has been demonstrated (i) that the
immune serum of syphilitics contains antibodies and (2)
that the svphilitic extracts contain antigens. By way of
control it has been shown that (l) the immune serum of
apes gives the reaction only with the syphilitic material of
man or apes, not with the nonsyphilitic materials of either ;
(2) that normal nonsyphilitic ape serum is ineffective with
syphilitic material; (3) serum of apes treated with extracts
from the organs of nonsyphilitics gives no reaction w-ith
known svphilitic material. Finally the immune serum works
equally well whether prepared with human or simian syphi-
litic material, a striking corroboration of the identity of
human and simian apes. This, then, is a specific serodiag-
nostic reaction for syphilitic material which enables us to
determine in the laboratory i« vitro the presence of spe-
cific antibodies against the syphilitic organism in human
serum or in prepared immune serum, and, second, to show
the presence of syphilitic substances in a given organ.

The Results of Excision of the Hip in Tuberculosis
of the Joint.— C. Ogilvy discusses the relative values
of early and late excision, the bearing on the q'.iestion of
the age of the patient, etc. He prefers the Langenbeck
operation, which is thus described : A longitudinal incision
four to five inches long is made in the middle of the great
trochanter, extending upwards beyond the trochanter for
two to llirce inches, in a line the direction of which runs
towards the posterior spine of the ilium. The bone is im-
mediately exposed, the gluteal muscles are separated, and
the rotators now exposed are cut transversely. The finger
is passed along the neck of the bone. The capsule comes
into view as the superior external part of the acetabulum.
The capsule is split longitudinally, and the head exposed.
The muscles over the trochanter with tlieir attachments
are raised with the periosteum by the scalpel and elevator.
The cotyloid ligament is incised, the head rotated out and
the ligamentum teres cut. The head of the bone can
now be pushed through the opening in the capsule, and
the excision be completed. This can be done rapidly and
with very little hemorrhage ; sometimes without having
to ligate a single vessel, .-^fter operation, extensive im-
mobilization and protection should be continued for at
least a year. The length of time for continuance of me-
chanical treatment will depend upon the grouping of con-
ditions in each particular case. Passive and active motion
of the limb and, later, weight-bearing should be begun as
soon as possible, care being taken not to cause inflamma-
tory irritation sufficient to again light up the disease.
Mortality is always high. Statistics are given from dif-
ferent reporters. At least 10 per cent, of all deaths are
caused by general miliary tuberculosis. Excision is by no
means a prevention of systemic infection. It would even
seem at times that it was a cause rather than a preven-
tion if we consider the number of cases which develop
miliary tuberculosis after the operation.

Journal of the American Medical Association, June I, 1907.

The Final Triumph of Scientific Medicine. — N. Senn

reviews the progress of medicine, especially of late
3'ears, and says that there is no country, with the pos-
sible exception of Japan, in which the medical profes-
sion has made more rapid strides than in the United
States. As evidence of this he points out our many
thoroughly equipped medical schools and laboratories,
the activity of the profession as shown by the number
of medical societies and the interest in their meetings,
the reorganization of the American Medical Association
and consequent greater unity of the profession, the
higher status of American medical literature, and the
higher standards in medical education and in the con-
ditions for admission to practice. All these things, he
says, have been brought about in a very short time by
the voice and action of a hard-working united profes-
sion. The triumphs of preventive medicine are also re-
viewed from the discovery of vaccination, over a cen-
tury ago, to the more recent acquisitions in the prophy-
laxis of tetanus, typhoid fever, cholera, yellow fever,
malaria and bubonic plague. The medicine of the fu-
ture is preventive medicine, and its final triumph will
be the suppression of disease.

The March of Sanitation. — The progress of modern
sanitation and the duties of government, both as re-
gards their own special jurisdictions and their interna-
tional relations, form the subject of an address by
Surgeon-General Wyman of the Public Health and
Marine-Hospital Service. He refers to the numerous
recent advances that have been made, the lowering of
the death rates and the elimination of typhus in Eng-
lish towns, the disappearance of smallpox and typhoid
from Germany, the conquest of malaria in Italy and
elsewhere, the sanitary measures in Mexico and Bjazil,
the suppression of yellow fever, the passage of the
Food and Drugs Act, etc., and says that the nations are
now beginning to see that international cooperation is
required for complete success in the war against dis-
ease. This idea has found expression in the sugges-
tion of a combined effort against yellow fever in the
Western Continent, in the international conferences at
Venice and Paris, and in the sanitary convention of the
American republics in 1905. So far, the actual agree-
ments have related almost exclusively to quarantine
matters, but the idea of international sanitation as an
advance on international quarantine, was brought for-
ward in the Third International Conference of Ameri-
can States at Rio Janeiro in 1906, and resolutions were
passed recommending that the delegates to_ the next
international sanitary convention, to be held in Mexico
in December, 1907, be authorized to study and ascer-
tain the practical measures required for this purpose.

June 8, 1907]

MEDICAL RECORD.

951

Wyman offers the siigsestion that the subject might
also be considered to advantage in coming peace con-
ventions and that international hygienic work would
divert the energies now uselessly expended in war-
like matters. The sanitary awakening in this coun-
try is noticed as shown in the increased activities of
municipalities and State boards, in the antituberculosis
movement, etc. The well-to-do cannot afford to neg-
lect the poor in this matter: the disease germ is a
social clitnber and social position or wealth is no pro-
tection if disease-breeding slums are neglected.

Bimanual Vibratory Palpation. — H. A. Kelly finds
that the diffic\iltie.-; of accurately outlining a kidney
or uterine or ovarian tumor can be overcome by using
what he calls vibratory palpation. In the case of a
pelvic tumor, for example, the finger in the vagina rests
lightly on the cervix if it is uterine, or on its lower
pole if it is ovarian. Then the upper hand plays lightly
over the abdominal wall, over the tumor, toucliing first
its central portions and then advancing radially out to-
wiard its periphery, in all directions, communicating a
series of very rapid light vertical succession move-
ments. These little vibrating thrills are felt very dis-
tinctly by the finger in the vagina as long as the tumor
is played on. and are lost as soon as the vibrations fall
on the intestines or fat abdominal wall just beyond the
edge of the growth. The vibrations are communicated
by giving from three to five little tremulou> movements
every second to the palpating fingers. The actual to
and fro movement need not extend over one centi-
meter. In this way an accurate outline of the tumor
and its irregularities can be obtained.

Erythromelalgia. — I. W. Voorhees treats at some
length of the theories of this disorder and describes
what is known of its symptoms and treatment. He is
inclined from his investigation of the subject to agree
with Lewis and Benda that it is not a distinct disease
entity, but is a symptom-complex that may have either
a central or a peripheral origin, and with Eulenberg,
would put it in the same class with Raynaud's disease,
as simply different phases of the same condition, the
one being dependent on undue dilatation of the terminal
arterioles and the other to an undue contraction of
the same. They have been observed in the same pa-
tient by different observers, and there is not the slight-
est doubt, Voorhees says, that they exist together as
symptoms of some marked pathologic state and notably
in that disease of the blood-vessels, known as arterio-
sclerosis. Treatment has generally been ineffective,
and he considers that in intractable or specially dis-
tressing cases, even recourse to surgery would be ad-
visable.

Radical Cure of Umbilical Hernia. — W. J. Mayo de-
scribes his overlapping from above down method of
operation for the relief of umbilical hernia, by which
he finds the largest protrusions can be satisfactorily re-
duced and the hernial opening closed without tension.
The tendinous aponeurotic structures involved are
among the strongest in the body, and when over-
lapping is accomplished the resistance is nearly per-
fect. The sutures merely maintain the structures in
apposition, while the intraabdominal tension itself pre-
vents displacements. The operation is simple. Two
transverse elliptical incisions are made, cleanly ex-
posing the neck of the sac and the aponeurotic struc-
tures for several inches above and below it. The neck
of the hernial protrusion is cleared as high as the apo-
neurotic structures extend, the sac is then opened and
any contained intestine returned into the abdomen.
The contained omentum, if any, is ligated in sections
on a level with the abdominal orifice and the stumps
returned into the abdomen. The sac, with all adherent
omentum, including the skin, is cut away without fur-
ther manipulation. A stout curved needle threaded
with strong celluloiden linen is passed from without in
through the aponeurotic structures and peritoneum
from two to three inches above the margin of the open-
ing. A large tablespoon to guard the needle as it en-
ters the peritoneal cavity is a valuable aid. The needle
and thread are drawn down and out of the hernial
opening. A firm mattress stitch is then caught in the
upper edge of the lower flap about one-fourth of an
inch from the margin, the needle is then carried back
through the hernial opening into the peritoneal cavity
and made to emerge one-third of an inch lateral to the
point of original entrance. On each side of this is
introduced a similar mattress suture of strong chromi-
cised catgut. These three sutures are drawn tight, pull-
ing the entire thickness of the aponeurotic and peri-
toneal structures behind the upper flap. The margin

of the upper flap is now retracted to expose the suture
line, and what gaps exist are closed with catgut sutures.
The upper flap is now sutured to the surface of the
aponeurosis below by continuous chromicised catgut
suture and the skin and superficial fat closed. The pa-
tients are kept in bed for from twelve to twenty days.
It is thirteen years since this operation was first per-
formed and of the 88 patients operated on between 1894
and 1895, 75 were traced. One had a partial relapse
described by her physician as a boa-shaped stretching
at the site of the former operation, but giving no incon-
venience. Another patient supposed to have suffered
a relapse was operated on and a second opening found
to exist above and lateral to the umbilical opening
which was found closed. The operation is illustrated.
Hemoglobinuric Fever. — W. H. Deaderick holds that
hemoglobinuric fever is always malarial in the human
subject, and explains its pathogenesis substantially as
follows: The primary blood destruction is due directly
to the malarial parasite, chiefly through the act of spor-
ulation, possibly also by the production of a toxin,
though this has not been demonstrated. The hemo-
globin thus liberated is carried to the liver, where cer-
tain receptors of the liver cells are capable of trans-
forming free hemoglobin into bile pigment. When
these receptors are exhausted the deficiency is met by
overproduction, and when the cell becomes overfilled
some of these side-chains are cast off into the general
circulation, where the receptor becomes an amboceptor,
and meets the complement present in normal serum
and the complete hemolysin is formed. The nature of
the complement is unknown, but certain facts throw
suspicion on lecithin. It is highly probable that when
the production of the hemolysin is not too rapid there
is formed at the same time an antihemolysin that may
exactly balance the hemolysin without destroying it. So
long as this balance is maintained no hemolysis occurs,
but should the balance be greatly disturbed by fresh
malarial invasion, cold, fatigue, quinine or other and
probably unknown factors, hemolysis and hemoglobi-
nuria occur. Under this exact equilibrium the patient
is in a condition very similar to that of paro-xysmal
hemoglobinuria; a close relation between these two
affections has been claimed by Sambon. It is possible
that a slight and temporary loss of equilibrium may
result in a limited hemolysis, producing hemoglobin-
emia instead of hemoglobinuria. Some cases of anemia,
cachexia, and post malarial secondary fever can be ex-
plained in this way. Deaderick believes that this theory
"explains the occurrence of hemoglobinuric fever dur-
ing and after malarial infection, with or without the
use of quinine; it explains why the malarial attack may
precede by months the appearance of blackwater; why
cold, fatigue, etc., may bring on an atack; why the
hemolysis does not always coincide in time with the
sporulation of the parasites when the latter are present ;
it accounts in a measure for the complex relation with
quinine and explains obscure anemia and post malarial
secondary fever. Lastly, it coincides with the preva-
lent ideas of tropical physicians of an intimate relation
between hemoglobinuric fever and biliousness."

The Lancet, May 18, 1907.

On the Control of Supernormal Arterial Pressure. —

George Oliver notes that a persistent pressure rise may be
regarded generally as the outcome of some alteration in the
chemical composition of the plasma or of organic changes in
the circulatory mechanism. His own observations were made
by means of a special secondary instrument referred to
in his paper. Treatment of this abnormality should begin
with diet. The bulk of each meal should be reduced as
much as possible, and various salts, soluble extractives,
alcohol, etc., should be avoided, as they stimulate the cardio-
vascular apparatus. Fluids at meals should be cut down
to a minimum. Mildly alkaline waters are preferable. Tea
and coffee may be used in moderation, provided no dis-
turbing results, as palpitation, giddiness, etc., follow. Al-
cohol is better cut out altogether. .\ chloride-free diet
should be aimed at. Milk and vegetables are our chief
dependence. Cheese in moderation is the least objection-
able form of proteid. Boiled meats are preferable to roast
meats. Fresh water fish are allowable. Tobacco should
be cut off. Rest in bed plays an important part. The skin
must be kept active. Venesection may be of service in
some cases when vasodilator drugs fail to act. The au-
thor then passes in review the various drugs which have
been recommended, dwelling particularly on ingested thy-
roid. He finds that the ingestion of this substance increases
arterial caliber and lowers arterial pressure. He finds it
especially serviceable in gouty and obese patients from

MEDICAL RECORD.

[June 8, 1907

forty-five to fifty years, but it should not be given in a
more routine manner. Results with any plan of treatment
will depend greatly on the fact as to w^icther the patient
can completely rest or is compelled to follow his regular
avocation.

A Case of Chloroma. — .\ detailed history of the case
is Kiven by W. E. Reynolds, whose patient was a boy of
fourteen years with symptoms which led to a provisional
diagnosis "of acute leukemia. The whole period covered
from the initial symptoms till death was about ten weeks.
The terminal symptoms were a rapidly progressive anemia,
an irregular fever, and enlarged spleen. No progressive
glandular enlargement could be made out and with the
exception of the last day or two of life the patient did
not complain of any pain. Autopsy findings are given in
full and microscopical c.Namination was made of sections
of tissue from different parts of the body. The final diag-
nosis was chloroma. This disease, says the author, is often
classed with melanotic sarcoma. Some authorities regard
It as a form of leukemia. In this particular case the
history, clinical course, and distribution of gross lesions
suggested an infective process. The morbid histology
showed a general dissemination of what looked like
ivmphoma, but the blood-vessels were well formed and
the presence of newly formed capillaries indicated changes
analogous to those found in subacute and chronic infec-
tions; but in spite of this the characters of the cells and
their nuclei were indistinguishable from those found in
sarcoma. The quantity of the pigment found in the tissues
was greater than could be accounted for by hemolysis
alone. It was therefore evident that it was derived in
part from cellular and nuclear destruction. The pigment
appeared to be of the nature of a fatty acid combined
with iron, and it had very strong reducing power. The
whole case is fully worked' out from every point of view.

Diseases of the Upper Air Passages in Relation to
Life Assurance.— \V. H. Kelson dwells particularly on
paralysis of the larynx, laryngeal tubercle and syphilis,
nasal obstruction, the condition of the tongue, and nasal
discharge su.ggesting disease of the accessory sinuses. He
suggests that the life insurance examiner should include
in "ins categorv of questions such inquiries as "do you ever
suffer from hoarseness or difficult breathing," "can you
breathe freelv through the nose," "have you any mattery
discharge from it," "is your tongue sore," etc., and on the
replies obtained thereto advise his company as to the ac-
ceptance or postponement or rejection of a given risk.
He points out the possible dangers which might result m
case of an affirmative statement by the patient to the fore-
going questions. He considers the tongue condition as of
special importance. It may give valuable indications of the
applicant's past life history and habits, such as a tendency
to chronic alcoholism, as shown by the furred tongue in-
clined to tremor with a more or less characteristic odor of
the breath. In chronic superficial glossitis, also, we have
a complaint both common and important with its various
forms or stages, as leucoma, psoriasis of the tongue, and
the red glazed smooth form. Its exact etiology may be
somewhat obscure, but syphilis, excess in smoking, and
alcohol (especially spirits), stand out preeminently as con-
tributors to its development, and gout and rheumatism are
also believed to be factors. As regards leucoma and cancer
it may be said that leucoma is a very strong predisposing
cause of cancer, and if in a case of leucoma any ulceration
with induration is found, we may be pretty sure that the
carcinomatous stage has already been reached.

Clinical Observations on Mucomembranous Colitis. —

A general description of the disease is given by J. Liddell.
in 'considering treatment he refers particularly to that em-
ployed at Harrowgate. At the outset of treatment w-e
must naturally eliminate any known cause. The original
exciting cause may be no longer in operation. Xext one
must adopt the best means of overcoming the stasis of
the bowel and procure a regular and complete evacuation
of its contents. The necessity of this is apparent, since it
is the retention of mucous secretion, feces, products of
putrefaction, and microbes which causes the constitutional
disturbances and increases the local irritation. Moreover,
requisite means have to be taken to improve the mucous
membrane and the muscular coats of the intestine. For
evacuation of the bowel aperients prove unsatisfactory in
colitis. They never effectually clear the bow-el without
producing considerable local and general disturbance, and
really aggravate the condition. As they lose their power
in course of time the patient requires to take lar.ger quan-
tities and take them more frequently, thus making the local
condition increasingly worse. Probably the best means
of cvacuatin.g the bowel and at the same time lessening

its irritation is by colon irrigation. When this is properly
administered it clears the bowel more effectually than aperi-
ents do, and instead of having a pernicious effect its ac-
tion is most beneficial. A somewhat extensive experience
has taught the author the value of this method and that
it is by far the best way to commence the treatment of
colitis. It has to be carried out with very great care and
under certain restrictions, as it may do harm instead of
good. But properly administered its value is undoubted.
The fluid used must be of a bland unirritating nature. It
must also be given under a low and equable pressure or
painful spasm will occur and irritation of the colon. The
temperature and the quantity of the fluid are also matters
of importance. The remainder of the paper is occupied
with a description of the details followed out at the Har-
rowgate institutions.

British Medical Journal, May 18. 1907.

Calcium Salts in the Treatment of Certain Types of
Pneumonia. — J. D. Cree believes that it is quite as im-
portant to know when to withhold calcium salts in pneu-
monia as when to prescribe them. He gives the histories
of two cases. Case i was that of a stout woman of thirty-
eight years who was suffering from severe dyspnea, low
tension pulse, albuminuria, and vi'as raising over a pint
of watery hemorrhagic sputum in twenty-four hours. The
picture was that of a patient drowning in her own ex-
cretions rather than dying from a toxemia. She was of
the hydremic type and her condition was regarded as due
to an insufficiency in the coagulability of the blood. Diet
was restricted and she was given twenty grains of calcium
chloride in water by the mouth. Ten grain doses were
continued hourly for twelve hours, and were then reduced
to every four hours. Half a day showed a decided im-
provement in the patient's condition. The sputum in par-
ticular was reduced to half its previous amount, and the
bright hemorrhagic appearance gave way to a dull, rusty
color. In Case 2, that of a thin w'oman of twenty-five
years, the clinical course of the disease was from the
start very different, the case running throughout a "dry"
course. In this case thrombosis was feared and the aim
was to decrease or rather to prevent any increase in the
coagulability of the blood. The patient was allowed soft
diet and fruit, and was encouraged to drink lemon juice
in water. The author makes a plea against the unreasoning
use of the calcium salts in pneumonia. In the first type it
renders great service ; in the second there is no logical
reason for its administration and there is one very good
reason against it.

Morphinomania Treated Successfully with Atropine
and Strychnine. — ^I. S. P. Strangman reports one case,
that of a man addicted to over thirty years' use of the
drug. His latest allowance was two wineglassfuls of lau-
danum in the day and he presented the usual symptoms
of the habit. The treatment was begun with atropine sul-
phate i/loo grain and strychnine nitrate 1/60 grain three
times daily, increasing as rapidly as the patient could bear
until on the eighth day his dosage was atropine 1/50 and
strychnine 1/20, but it was soon necessary to reduce the
atropine to 1/60. Under this plan of treatment immediate
beneficial results were noted. Finally the atropine was
stopped and the strychnine continued a while longer. The
opium was suddenly withdrawn in this case with the usual
result of nausea, vomiting, and diarrhea, but the patient
finally weathered the storm.

Regeneration of Nerves with Regard to the Surgical
Treatment of Certain Paralyses. — The observations of
C. J. Bond center about the case of a man of forty-six
years who had been struck in the back by the buffer of
an engine twenty days previously, and sustained a fracture
dislocation of the lowest dorsal and first lumbar vertebrae,
with crushing of the cord and complete paraplegia. Lami-
nectomy was performed, the neural arches of the last two
dorsal and first two lumbar verterbrse being removed, and
the dura mater laid freely open. Finding that (as was
expected) the cord was completely divided, and acting on
a previously considered plan, the reporter divided the last
dorsal nerve-roots intact above the crush on the right side
as low down as possible before their exit through the theca,
and also similarly divided the first lumbar nerve roots ir»-
tact below the disorganized portion of cord, also within
the thecal canal, and turning these latter upwards he united
the cut proximal ends to the cut proximal ends of the dor-
sal nerve roots previously divided. A corresponding junc-
tion was also made in the left side. It was hoped that by
so doing a path might be provided for the possible trans-
ference of nerve impulses — afferent, efterent, and trophic —
across the gap caused by the crushed portion of the cord.

June 8, 1907]

MEDICAL RECORD.

953

The patient recovered from the operation and the wound
healed. He remained in the hospital until June 24, when
he left for his home, where he died seven weeks later,
and unfortunately no post-mortem examination was ob-
tained. During the three months of his stay in the hos-
pital there was no evidence of any return of voluntary
movement, though there was a transitory alteration in
the level of the anesthetic area. The bladder condition
remained as before.

The Physiological Action of Whiskey on the Circu-
lation.— Experiments have been made m this direction
by F. J. Charteris and E. P. Cathcart. They note that
many pharmacological experiments which have influenced
the ideas of physicians as to the effects of alcohol on
the system have been made with pure alcohol and not
with the forms in which it is employed in mediciiie, such
as brandy, whiskey, champagne, and port wine. It is diffi-
cult to define just what whiskey is. In Scotland it is the
pot-still product and not the patent-still product. The for-
mer is more complex in character and may contain sec-
ondary ethereal products ; the latter is a poorer and cheaper
substance. The authors made a series of experiments
on three men, practical abstainers, noting the relative ef-
fects on the circulation of absolute alcohol and whiskey.
The dose given corresponded to one ounce of absolute
alcohol and sufficient water was added to make the dilu-
tion of alcohol one to four. The conditions under which
the experiments were carried out are fully specified. In
general terms it may be said that the effect upon the
pulse and pressure of all three alcoholic preparations, in
the above dosage, was very slight, and that after the first
ten minutes practically no difference could be detected
in action between the absolute alcohol and the whiskies
examined. In other words, the action of whiskey on the
pulse and pressure depends upon its alcoholic content and
not upon any special body distilled over either in the
process employed in the manufacture of pot-still whiskey
or in that used in the preparation of the patent-still
whiskey. The same result was obtained in a series of
pneumonia cases and a series of intravenous injections on
rabbits.

Berliner kUnischc ll'ochcnschrift. May 13, 1907.

The Effect of Injections of Cocaine on the Sensibil-
ity of the Abdominal Organs. — Kast and Meltzer point
out the apparent discrepancy between the statements of
Lenander and other surgeons who have found that the
abdominal viscera, even in the inflamed state, have no sen-
sibility for painful stimuli, and the constantly occurring
clinical observation of severe abdominal pain in many dif-
ferent conditions. By an extensive series of animal experi-
ments the authors were able to show that while it was
true that surgeons who operated under local anesthesia did
not find that rjianipulation of the intestine or other abdom-
inal viscera was painful, this condition was the result of the
injections of cocaine used to anesthetize the skin lor the
abdominal incision. In animals (dogs and cats) the injec-
tion of 0.02 to 0.03 g. of cocaine sufficed to render pain-
less stimuli to the intestine that without the cocaine would
have been resented. It seemed to make little difference
whether the site of injection were close to the seat of oper-
ation or at a distant part of the body, such as the extremi-
ties. Intramuscular injections were found to be more
promptly effective than hypodermic injections, and the
authors express the view that the mode of action is through
the medium of the circulation. The sensibility of inflamed
organs in untreated animals was found to be greater than
that of uninfiamed organs, but the action of the cocaine
injections was equally pronounced in such cases. .Xnother
observation made was that the cocaine injections had a dis-
tinctly quieting eft'ect on the post operative restlessness
of animals that had been subjected to ether anesthesia.

The Nature of Carcinoma. — Westenhoeffer reviews
at length some of the considerations that lead to the view
that the malignant growths represent true parasitic cell
colonies which are at once anarchistic and despotic in na-
ture. While originating from the body cells, they are made
up of cells which have lost the normal characteristics that
belong to these and have become an entirely independent
type. This change the author endeavors to explain on the
assumption that there has been an atavistic reversion of
certain cells which have gone back to the primitive cell
type, which is the lowest form of life and is represented
by the unicellular animal and vegetable organisms. In
order to prove this hypothesis he has made many biological
experiments, one group of which was founded on the
method of anchoring the complement and by which he tries
to show that the cells of carcinoma metastases are hetero-
lytic to .animal and vegetable albumin of all varieties. The
manner in which certain cells are supposed to be liberated

from their normal restraints and rendered capable of this
reversion to the ancestral type is explained somewhat in
accordance with Ribbert's view of the effect in this regard
of chronic irritation and inflammation.

The Effect of Salt and Sugar Injections in Infants. —
Schaps found that the infants in the Berlin Asylum for
Children sometimes manifested elevations of temperature,
that appeared suddenly and disappeared quickly, in con-
junction with the addition of a larger quantity of sugar to
the food. He was led to believe that this did not depend
on any bacterial cause or the absorption of to.xins, but
rather was the result of the sudden increase in the carbo-
hydrate of the diet ; in other words, that an alimentary
fever is possible. In order to test this hypothesis he gave
infants infusions of glucose and lactose in a strength
isotonic with normal salt solution. He found that a typi-
cal febrile movement followed this procedure and that even
normal salt solution gave rise to an evanescent rise in
temperature. He therefore concludes that an alimentary
fever exists, and explains it as being due to the disorder of
cellular metabolism that is temporarily caused bv the alter-
ation in the tonicity of the fluid in which the cells are
bathed. The infant, with its imperfectly developed intes-
tinal tract, is especially prone to manifest fluctuations of
this nature.

Mihuhcncr mcdi::iiusrhc U'ochcnschrift, May 7, 1907.
Intestinal Obstruction Due to Gallstones. — Brentano,

m discussing the operative relief of this condition, calls
attention to the necessity for investigating the bile passages
and intestine for the existence of other calculi which
might give rise to serious complications during the pa-
tient's convalescence, as was the case in an instance that
he reports in which the patient died as the result of a sec-
ond obstruction caused by another stone about two weeks
after the original operation. He considers that in every
case of gallstone ileus the proximal portion of the intestine
should be palpated for the presence of other stones, and any
that are found should be removed if possible through the
same incision as the one that is impacted. If this seg-
ment of intestine is empty, but the gallstone removed dis-
plays facets indicating the presence of other stones in
the gall-bladder the incision must be prolonged so as to
give access to this viscus and permit of its being emptied.
This is particularly desirable if the stone removed has a
large round facet pointing to the presence of another
equally large calculus. In view of the possibility that it
may be necessary to invade the gall-bladder region, it is
wise in cases of suspected gallstone obstruction to open
the abdomen by an incision above the umbilicus. The in-
carcerated stone may easily be removed through this in-
cision, as it is usually in a coil of the ileum. Longitudinal
incision of the intestine is preferred to transverse incision
for the removal of the stone.

Observations on Anguillula Intestinalis. — Bruns re-
ports three cases of infection with this parasite and gives a
detailed review^ of what is known in regard to it. His own
patients were miners and apparently were not incommoded
by the presence of the parasites. The manner in which
these individuals became infected could not be determined.
As the result of his studies of the subject, Bruns is of the
opinion that it is impossible as yet to determine the rela-
tionship existing between the occurrence of intestinal dis-
orders and the presence of the parasites, that is, whether
intestinal catarrh encourages the multiplication of the
organisms or whether it is itself evoked by them. In view,
however, of the circumstances that the parasite lives in the
intestinal mucosa, that its youthful forms may occur in the
circulating blood, that infection may take place through the
uninjured skin, and that in its entire biological relationships
there are many points of similarity with the ankylostoma, it
is hardly justifiable to regard it as entirely without patho-
genic significance. All the cases that have so far been
reported in Germany have been sporadic, but it seems ad-
visable to cultivate the study of the parasite with greater
interest than has heretofore been the case.

A Study of Some Tropical Ulcerations of the Skin,
with Particular Reference to Their Etiology.— Richard
P. Strong's observations have led him to conclude that a
number of forms of chronic ulceration of the skin are to be
encountered in Manila, among which (after excluding cer-
tain ulcerative lesions of svphilis, yaws, leprosy, and lupus)
there still exist at least several tvpes of different etiology.
A somewhat rare form is evidently of blastomycetic origin,
in which the torula- encountered have somewhat the appear-
ance of the forms which have been described in certain
cases of Oriental boil or sore as species of protozoa related
to the Donovan-Leishman bodies.— T/a' Philifpinc Journal
of Science.

954

MEDICAL RECORD.

[June 8, 1907

#orirtg iSpportfi.

AMERICAN MEDICAL ASSOCIATION.

Fifty-eighth Annual Session, Held at Atlantic City, June
3, 4, 5. 6. and 7, 1907.

(Special Report to the Medical Record.)
HOUSE OF DELEGATES.

Monday, June 3 — First Day.

The President. Dr. William J. Mayo, of Rochester.
Minn., in the Chair.

The Committee on Credentials presented a preliminary re-
port. The minutes of the Fifty-seventh Annual Session
were read and adopted.

President's Address.— Dr. William J. Mavh. following
the custom of his predecessors, directed the attention of
the house to some of the more important matters to come
before it for decision. It was fortunate that as president he
was relieved of the business control of the Association by
the board of trustees, to whose wise control of its affairs
the Association owed its place as the largest and most pow-
erful medical organization in the world. Dr. George H.
Simmons of Chicago, the general secretary of the Associa-
tion, had won his admiration. Dr. Mayo spoke particularly
of the success of the Journal of the Association ; it had
brought to the Association a profit of over $50,000 during
the year. The president expressed his appreciation of the
ability witli which Dr. J. M. McCormack of Bowling Green,
Ky., had performed his duties as chairman of the committee
on organization. He called attention also to the evil of
medical schools owned by private corporations and con-
ducted for their own advantage, hoping that the moral
force of the Association might be lent to the correction
of this condition. The committee on life insurance
would make a report upon the vexing question of fees for
life insurance examinations, which was one causing much
dissatisfaction in the ranks of the profession, affecting at
least 10 per cent, of its members. The speaker thought
that physicians ■ were quite as unreasonable in the use of
proprietary preparations as were the public in the
use of patent medicines. The work of the Council on
Pharmacy and Chemistry deserved the support and en-
couragement of the profession. To expedite the business
of the House of Delegates, and thereby save the time of
its members, the president recommended the creation of a
new committee.

The president then announced the membership of com-
mittees.

Report of the General Secretary. — Dr. George H.Sim-
mons presented this report. The membership of the Amer-
ican Medical .Association on May i, 1906, was 23,636. Dur-
ing the year the names of 2,135 w-ere discontinued on ac-
count of deaths, resignations, nonpayment of dues, and non-
eligibility. To the list, however, had been added 6,014
names, giving a net gain of 3,879 for the year, and a pres-
ent membership of 27,515. The secretary had received of-
ficial advice of the amalgamation of the Oklahoma and In-
dian Territorial .Associations. Committees had been ap-
pointed in accordance with resolutions adopted at the Bos-
ton session as follows : Committee on Tropical Medicine,
Ludvig Hektoen of Chicago, Chairman ; Maximilian Her-
zog of Chicago, George Dock of .\nn .Arbor, Mich., Dr.
L. F. Barker of Baltimore, and Col. Wm. C. Gorgas of
Panama. Committee on Ophthalmia Neonatorum, F. P.
Lewis of Buffalo, chairman ; J. Clifton Edgar of New
York, and F. F. Westbrook of Minneapolis. In his report
of last year he had called attention to the ambiguity of the
provisions of the by-laws with reference to associate mem-
bership, it being claimed that those eligible to full mem-
bership, w'ut who did not care to avail themselves of it.

might acquire temporary membership. He thought it ob-
viously unjust to active members to permit those not caring
to assume the obligations of active membership to become
associate members, and thus obtain special privileges. On
the other hand, there was a distinct class who were not
licensed to practise medicine who should enjoy the advan-
tage of the membership without the formality of election
each year. He therefore proposed the amendment of the
by-laws to obviate the ambiguity and uncertainty. The rela-
tions between the secretaries of the various constituent as-
sociations and the General Secretary's office were con-
stantly becoming more intimate. The growth of the organ-
ization involved the necessity of a more accurate registra-
tion system, which, inaugurated two years ago, was proving
more and more valuable. Regular reports were received
during the past year from thirty-nine State secretaries, and
reports, though not regular, had been received in sufficient
fullness, with one exception, from the remaining secre-
taries to cover all membership transactions during the year.
The presidents and secretaries of county societies had been
receiving the Councillors' Bulletin, which, issued at intervals
during the past year, had contained much matter of im-
portance to them. The Bulletin now had a circulation of
nearly five thousand. The biographical card index of the
individual members of the profession was being constructed
from over si.xty thousand personal biographical reports now
in the hands of the Directory Department. Though the cor-
respondence with Porto Rican physicians had been con-
tinued, no success had yet met the efforts looking toward
the organization there of a constituent association. Organ-
ization matters generally had attracted increasing inter-
est throughout the country, more attention than ever having
been paid to the prerogatives and duties of physicians as
members of the community.

Report of the Board of Trustees. — Dr. T. J. HAPPELof
Tennessee, Chairman of the Board of Trustees, presented
their report for the last calendar year. The net revenue
had been $31,915.10. The net earnings of the Journal
amounted to $55,000 for the year. The Council on Phar-
macy and Chemistry had maintained its close censorship
of advertising matter, yet without an increase in the adver-
tising space the increased circulation of the Journal had
made possible an increase of $2,800 in the income of that
department. The experience of the .Association had justi-
fied the purchase of the buildings now owned by the .Asso-
ciation. Whereas formerly $5,000 annually had been ex-
pended for rent, the -Association now received the same
amount from the rental of space it possessed in excess of
its own needs. Thus Dr. Happel considered the Associa-
tion to be ten thousand dollars a year better off than it had
been before. Much money had been invested in the Direc-
tory, but its first edition having been completed and copies
delivered, the Association was now recouping itself. De-
spite the rather favorable financial showing, the Board of
Trustees felt it necessary to recommend the creation of a
smking fund of not less than a hundred and fifty thousand
dollars. Debts must be discounted and bills met promptlv
and a margin left for emergency. Heretofore the .Associa-
tion at its conventions had been dependent to a very con-
siderable extent upon the hospitality of the local body of
the profession. This year for the first time it had provided
its own meeting places, and had met the entire expenses
of the convention, save for the entertainment of the ladies
attending the sessions, for which it was indebted to the
local committee. This year also the manufacturers' exhibits
were closely supervised, and only such products accepted
as might be admitted to the advertising pages of the
Journal. A suspicion had existed in the minds of some
that the Council on Pharmacy and Chemistry had discrim-
inated against some manufacturers in favor of others.
This feeling had been dispelled, and the success of the
efforts of the Council was gratifying. Every member of
the medical profession throughout the country should be

June 8, 1907]

MEDICAL RECORD.

955

willing to lend his hearty support to the Council in this
work. The Committee on IMcdical Legislation had accom-
plished much. The full report which it would present to
the House of Delegates would justify the wisdom of the
appropriation of $4,500 for the committee's use during the
year. The Committee on Medical Legislation had kept the
Board of Trustees advised of its work, which, though re-
maining under the supervision of the chairman of the com-
mittee, would in future be carried on largely by one of the
assistant secretaries with headquarters in the building of
the Association. While the Board of Trustees was pre-
pared to furnish in detail desired information concerning
the present condition of all appropriations, it would con-
sider it poor policy to publish such details to the world.
The Board had been encouraged in its work by the diminu-
tion of captious criticism on the part of those less well in-
formed regarding the business of the Association. The
Trustees had at an annual meeting extended a vote of
thanks to the editor and general manager of the Journal.
Dr. George H. Simmons, for his painstaking and efficient
efforts.

Report of Committee on Senn Medal. — Dr A.F.Jon.\s
of Omaha. Neb., the chairman of the committee, being
absent, the secretary read his report for the committee.
Only two theses having been presented, neither of which
the committee considered of such merit as to deserve the
medal, the committee had determined to make no award.
A permanent notice was recommended to be inserted in the
Journal, setting forth the conditions attending the compe-
tition for the medal.

Of the appropriation of $5,000 for the relief of the Cali-
fornia earthquake sufferers, only $3,oco had been called for
during the calendar year. The chairman of the cotnmittee
had been advised informally that the $3,000 had since been
returned to the Association.

Report of the Council on Medical Education. — Dr.
.•\rthur N. Bevan of Chicago, Chairman, presented an e.K-
tended report, outlining what the Council had accomplished
so far and what it hoped for the near future. The Council
had been created in 1904 to take up the work which, up
to that time, had been carried on with indifferent success
by committees on education, which had labored under the
disadvantage of a rapidly changing membership. The Coun-
cil desired to see organized a permanent national bureau
on medical education, with an adequate clerical force, and
a permanent base. This bureau in giving publicity to
the evidence whicli it would collect would be effective in
producing reforms, even though it were without legal
powers. The Council had had two conferences with rep-
resentatives of State examining boards in April, 1905, and
May, 1906, respectively. .\t the first conference the ques-
tions of a standard of preliminary educational requirement,
the medical curriculum, and the relation of the college of
liberal arts to the medical school were discussed. As
a result of this conference the Council formulated a mini-
mum standard for the time being: A college preparatory
education, passed on by a State official, graduation from an
approved medical school having a course of four years
of thirty weeks with thirty hours' work in each week, and
a licensing examination. The Council also formulated an
ideal standard to work for in the future. .-Vt the second
annual conference, May, 1906, was considered the most
important subject of the relative standing of medical schools
based on the success their graduates had had before li-
censing boards. Schools were classified with reference to
the percentage of failures. Such tables, it was believed,
would, if published periodically, be of much service in
elevating medical standards. A personal inspection of medi-
cal scliools throughout the United States had been under-
taken during the past year in the attempt to ascertain
the exact character of their work and to mark them on
a civil service basis. The task had been found a large

one, but in its value would justify itself in enabling the
Council to form a better idea of existing conditions than
could otherwise have been obtained. The question of in-
creasing the requirements for matriculation had been pur-
sued with many colleges. A year ago only seven medical
schools in the United States demanded preliminary work
in a college of arts. Now forty-nine schools would, by
January I, 1910, require one or more years of college work
for admission. Furthermore, there were now only six
States where non-graduates might receive licenses to prac-
tise. Interstate reciprocity had made considerable strides
recently. Forty-five States now had State committees on
medical education, which in their reports to the State
.\ssociations had done good work in several instances. It
was thus that each State medical society would be kept
fully informed of the relative standing throughout the
country.

Report of the Committee on Medical Legislation. —
Dr. Ch.\s. a. L. Reed of Cincinnati, Chairman, outlined the
influence which the .\ssociation had exerted upon Congress,
resulting in the final passage of the Pure Food and Drug
Bill, despite serious obstacles. Through persistent presen-
tation of the case of Dr. James Carroll, who as the
result of his experiences with yellow fever in Cuba had
become largely incapacitated, had finally met success in
the promotion of Lieut. Carroll to be Major and Surgeon.
The project to secure an army general hospital had re-
sulted in an appropriation of two hundred thousand dollars.
The Army Medical Reorganization bill, though pressed as-
siduously, had met the determined opposition of the Speaker
of the House of Representatives, and in the opinion of
the committee had little chance of becoming law in the near
future. The disparity between the professional require-
ment for license between the United States and many for-
eign countries was emphasized in the course of an inves-
tigation of a report that the .Knglo-Japancse treaty discrimi-
nated against American practitioners in Hong Kong. It
was learned that licenses were there granted under the Im-
perial Medical Practice Act of Great Britain, which required
.1 five years' course of medical instruction previous to
graduation as a prerequisite to license. Thus .American
physicians, though not discriminated against as .Americans,
suffered in competition with the men of other nationalities.
The efforts which the Association had put forth in former
years to have the chief medical officer on the Isthmus of
Panama given coordinate rank on the Isthmian Canal Com-
mission recently met with success when the president
named Colonel Gorgas as a member of the coniinission
in charge of sanitation. Through the assistance of medical
men, members of Congress, the osteopathic practice bill
for the ni>trici of Coluniliia, which had passed the Senate,
was defeated in the House. 1 he subject of the creation of
a national department of public health was now in the
hands of a popular "committee of one hundred." Otlier
matters of legislation, National and State, were mentioned
by the committee as meriting attention.

Dr. Frank S. Billings -of Chicago offered a resolution
to communicate to the Director of the U. S. Census the
wish of the American Medical Association that an enumera-
tion of deformed and ruptured children in the United States
should be made in connection witli the next census.

Report of Committee on Organization. — Dr J. N.
McCoRMACK of Bowling Green. Ky.. chairman, reported
in some detail his conferences with various State officials.
Interest in county societies was waning, he believed, for
the need of a more systematic method of study. The com-
mittee favored the elaboration of a scheme of post-grad-
uate work, covering an extended course of study adapted
to the needs of the average county society, .\fter a full
consideration by the House, the cmnmittee hoped such a
system might be evolved a^ tn meet the needs of many
practicing physicians who at iire^ent did not attend any

956

MEDICAL RECORD.

[June 8, 1907

association meetings. The development of the idea would
require the e.xpenditure of perhaps $600, the appropriation
of which the committee suggested. Dr. McCormack point-
ed out the fact that the antagonism between certain merce-
nary interests and the profession at large had resulted in
a more or less open breach between the physician and the
druggist, which would merit the kindly and dispassionate
attention of the House of Delegates. The chairman of
the committee presented a second report recommending
the organization of branches of the American Medical As-
sociation, dividing the territory of the entire country into
seven geographical divisions. Membership in these
branches should be limited -to the members of the State
and County societies, and should be purely voluntary.
Meetings of the branch associations should be held co-
incidently in time and place with those of the State so-
cieties, and should so far as possible be held in the fall,
midway between the conventions of the National Associa-
tion. This plan would tend to diminish rather than to in-
crease the total number of the societies of the country,
and would afford to the younger men an opportunity for
activity not presented by the National .Association.

Report of the Committee on Ophthalmia Neona-
torum.—Dr. F. Park Lewis of Bufi'alo, chairman, pre-
sented a report discussing the etiology of blindness in the
United States. The purpose of the committee was not to
discriminate as to different methods of procedure, but to
solve the problem of how best to put into e.xecution a
course of procedure of known value. That the subject
of prevention of needless blindness had been sorely neg-
lected was shown by the statement that in New York
State, for instance, midwives had no legal status save in
a few of the western counties, and that forty-two per cent,
of the total number of births last year in Greater New
York were presided over by women required to have no
standard of efficiency and under no adequate supervision.
The committee reminded the House of Delegates of the
obvious duty of the State to protect the individual from
injury through needless exposure to disease, whether it be
smallpox, diphtheria, or ophthalmia, and that full respon-
. sibility must attach to any person caring for the mother
and her new-born babe. Extensive popular education as to
the dangers of the disease and the methods of its preven-
tion must be undertaken. Unwilling, without further ad-
vice, to recommend a detailed plan of procedure on so im-
portant a matter, the committee recommended that its
work be continued, and that it be permitted, with the ad-
vice and consent of the chairmen of the sections on
Ophthalmology', Obstetrics, and Hygiene and Sanitary
Science, to formulate a detailed plan of procedure, with the
cooperation of committees already appointed by the .Acad-
emy of Ophthalmology and Oto-Laryngolog>- and the .Amer-
ican Oplithalinological Society, in making effective such
a plan as may be determined upon. The committee also
recommended that the Health Officer of each State or
Federal Territory, and the president of each State Medical
Society be also invited to cooperate with the committee in
carrying these procedures into effect throughout the United
States. It was moved and seconded that the report of the
conmiittee be accepted and its recommendations carried out.
The motion was adopted.

Report of Committee on Section on Tropical Medi-
cine.— .\ communication from the chairman 01 the com-
mittee. Dr. LuDviG Hektoen. of Chicago, to the effect that
it was not in a position to make any report, was read by the
secretary, and the committee was continued.

Report of Committee on Plan of Organization of a
Department of Public Instruction.— Dr. Johx G. Cl.\uk
of Philadelphia, chairman, reported that the popularization
of knowledge on scientific subjects had not extended in
any marked degree to the field of medicine. Leading edi-
tors had found it difficult, largely through ethical con-

siderations, to obtain satisfactory matter for publication.
Inasmuch, however, as it was the citizen to whom we must
look of assistance, through his individual eflFort and
through legal means, to limit the ravages of disease, the
layman as well as the physician must have more or less
accurate information regarding its cause and prevention.
The American Medical Association was competent in-
deed to meet this need, through the assistance of the public
press. The investigations of the committee had led to
the conclusion that four separate means should be followed
to accomplish this education. First, the publication in the
daily press of timely articles, as for instance, during a pro-
longed heated period caution as to how to prevent sun
stroke; second, the organization of a central bureau to
distribute in pamphlet form information which should be
preserved by the laity for reference; third, the organiza-
tion of public lectures at medical colleges, and under the
auspices of the county societies, and, fourth, correspond-
ence by circular letters with the individual members of the
medical profession, thereby preventing professional lethargy.
In this latter category must be included the discussion of
venereal disease, uterine cancer, etc., which, from their
nature, it would not be feasible to accomplish by other
methods. The committee outlined the organization of a
board of public education, composed of seven representa-
tives, to be appointed by the President of the .Association,
and having a paid secretary to attend to editorial and exe-
cutive work. The authorship of published articles, the
committee thought, should not appear, the board accepting
the responsibility for the publication. An appropriation
would be necessary to meet the immediate expenses, and
the committee suggested the sum of $3,500 per year to
inaugurate the scheme, hoping that its continuance might
be accomplished by aid through philanthropic channels.
The report was referred to the Committee on Hygiene and
Sanitation, with instructions to confer with the Board of
Trustees as to the feasibility of the necessary appropria-
tion and to make a comprehensive report upon all matter.
Dr. Craig moved an amendment to the by-laws to pro-
vide for the creation of a Board on Public Instruction on
medical subjects.

Dr. Denslow Lewis of Chicago presented a resolution
commending to the public authorities the exception from
the category of obscene matter of all literature on matters
of sexual education.

Tuesday, June 4 — Second Day.

The meeting was called to order at 2:15 I'.M., by the
President, Dr. Joseph D. Bryant.

Report of the Reference Committee on Constitution
and By-Laws. — Dr. George W. Guthrie of Wilkes-
Barre, Pa., chairman, reported favorably upon amend-
ments to tlie by-laws providing that the admission of dental
and pharmaceutical members should be subject to
confirmation by the House of Delegates; that repre-
sentative teachers and students of the allied sciences
resident in the United States and not eligible to reg-
ular membership might become associate members on
the recommendation of the officers of a section and
on election by the House of Delegates, such associate
members to enjoy the same privileges and to be sub-
ject to the same conditions as regular members, and
that representative teachers, students of sciences al-
lied to medicine, and distinguished physicians of for-
eign counlries might be invited by the general officers
or bj' the officers or a section to attend the annual ses-
sion and to take part in the scientific work. They
should be designated invited guests, and should hold
their connection with the Association until the close
of the annual session to which they were invited. These
amendments were adopted on motion.

The committee reported unfavorably upon amendments

June 8. 1907]

MEDICAL RECORD.

V57

proposed by Dr. Grosvenor of New York providing
that all reports presented to the House of Delegates
should be acted on seriatim, except such reports as
contained only one proposition, and that in balloting
for all elective officers and for the place of meeting
of the Association each member of the House of Dele-
gates should cast his own ballot. A motion' was made
and seconded to accept the unfavorable report of the
Reference Committee.

Dr. Grosvenor then addressed the house. Cin the
former amendment he remarked that much criticism
had been heard in the past that committee reports had
been made rather by wholesale. The present constitu-
tion, he said, had been adopted without consideration
seriatim. To disarm such criticism, he thought the
by-laws should provide for consideration of reports
seriatim. Other members pointed out that the House
was competent at any time to consider reports in this
manner, but that a uniform rule would entail much need-
less loss of time. With reference to the second amendment
Dr. Grosvenor believed that it should not be neces-
sar\' for a member to present a formal objection to
the procedure of electing officers by means of a unani-
mous ballot of the House cast by the Secretary — prac-
tically election by acclamation — but that he should have
the privilege of balloting for whomever he chose, with-
out appearing openly to oppose a leading candidate.

Dr. Cantrell of Texas considered the amendment en-
tirely unnecessary, inasmuch as unanimous consent
was required for the suspension of the rule on indi-
vidual ballot.

Dr. Guthrie of Arkansas believed, on the other hand,
in the maintenance of the utmost respect for the bal-
lot, and approved the amendment.

The chairman of the Reporting Committee pointed
out that adoption of the amendment would deprive
the House of its own liberty of action. The report
of the committee was adopted and the proposed amend-
ment was defeated.

Report of the Committee on Scientific Research. —
The Secretary read the report of Dr. Alfred Stengel
of Philadelphia, chairman of the committee, showing
that four grants, aggregating $550, had been made by
the committee for the year 1907, to Drs. G. F. Ruediger
of Chicago, H. T. Ricketts, Richard M. Pearce of Al-
bany, and J. N. Wainwright of Scranton, Pa., for re-
search work on various lines. The committee had re-
stricted its grants as far as possible and had not used
all of its funds, but requested a continuance of the
same appropriation for the next year. On motion, the
report was accepted and referred to the Trustees.

The Judiciary Council, Dr. G. W. Guthrie of Penn-
sylvania, chairman, had no report to make.

Report of the Committee on the Davis Memorial. —
Dr. H. O. Makcy of Boston, chairman, presented a re-
port showing contributions received during the last
year, and asked that the committee be continued. It
would make a special effort during the coming year
and hoped to make a satisfactory showing next year.
On motion, the report of the committee was adopted.

The resolution presented at the Monday morning
session by Dr. Billings, requesting the Director of
the Census to conduct an enumeration of ruptured and
crippled children in the United States in connection
with the next census, was reported favorably by the
Reference Committee, and was adopted by the House
without objection.

The Reference Committee returned to the House
the report of the Committee on a Board of Public In-
struction, with a favorable recommendation, save for
that part relating to an appropriation, which was with-
out its province, and asked that the question of the

publication of the names C)f the authors of contribu-
tions to this work be laid before the House for its de-
cision. The report was adopted on motion. Dr. Wood-
ward recommended that the articles be unsigned, but
hoped the matter would be brought before the House
for a vote.

The resolution presented by Dr. Lewis of Chicago
with reference to the dissemination of information on
sexual hygiene and venereal prophylaxis, was reported
back from the Reference Committee with a recom-
mendation that it be referred to the Board of Public
Instruction. The resolution was so referred.

The Reference Committee on Sections and Section
Work reported back the proposition to insert in the
Journal an advertisement regarding the Senn Medal
award, recommending that the matter be referred to
the Executive Committee of the Section on Surgery.
The recommendation was adopted.

The Reference Committee on Legislation and Po-
litical Action reviewed the report of the Committee on
Legislation, recommended its adoption, and that a
vote of thanks of the House be extended to the Com-
mittee on Legislation. It also recommended that the
House of Delegates indorse again the Army Medical
r)rganization Bill and the bill for the restoration of
the army canteen; that the matter of a department of
public health be left in the hands of the "coinmittee
of one hundred," and the adoption of resolutions ex-
pressing appreciation of the efficient service to the
profession rendered by the medical members of the
House of Representatives. It favored the extension
iif the work of the Committee on Medical Legislation
into the field of legislation by the several States.

The Army Canteen. — Dr. Mills recommended the
adoption of the report as a whole, which motion was
seconded. Whereupon Dr. Grosvenor of New York
protested against the indorsement by the House of the
recommendation in the report respecting the restora-
tion of the army canteen, submitting his views and his
reasons for believing such restoration to be undesirable,
quoting General Sheridan and General Miles. Dr.
Solis-Cohen of Philadelphia did not believe the mat-
ter to be germane to the work of a scientific organiza-
tion, being essentially a moral question. Dr. Reed of
Ohio, the chairman of the Committee on Medical
Legislation, supported at length the recommendation
of the committee. Dr. Jones of California drew a com-
parison of conditions at the Presidio before and after
the abolition of the canteen, showing the great dis-
advantage, moral and physical, which had resulted
from the change. Dr. Rees of New York and Dr.
Guthrie of Arkansas opposed the restoration of the
canteen on moral grounds, w-hile Drs. Essig of Wash-
ington and Gile of New Hampshire were convinced
that the matter was not a proper one to receive se-
rious consideration by the House of Delegates. Dr.
Chas. Richard, Major and Surgeon, U. S. .\rmy, sought
to make clearer in the minds of the House the true
nature of the canteen, the advantages which the sol-
dier had derived from its social and restraining influ-
ences, showing how the physical and moral being of
the soldier had suffered since its abolition. The mat-
ter finally received a vote on an amendment to a motion
to accept the report, providing that the House ex-
pressed no opinion upon the question of the canteen,
and the report was so adopted.

Report of the Committee on Insurance. — Dr. John
LI. MrssER of Philadelphia, chairman, said the com-
mittee had at present nothing to add to its report, pub-
lished last December, in which it had set forth the
result of its conference with the officers of the life in-
surance companies in New York, who, though at first

958

MEDICAL RECORD.

June 8, 1907

declining to meet the members of the committee in
their official capacity and expressing their determina-
tion to negotiate with the individual examiners rather
than with the profession as a whole, had among them-
selves agreed upon a common course of action. The
Equitable and Mutual companies had declined to re-
store thi- $5 fee unless the New York Life did the same.
There the matter stood. The committee was con-
vinced that $5 should be the minimum fee for a life
insurance examination. It had now nothing further
to report and asked that it be discharged. Dr. Work
of Colorado offered a resolution approving the report
of the Committee on Insurance and urging action in
accordance therewith upon the county societies. Upon
the motion of Dr. Cantrell of Texas the matter was
referred to the proper Reference Committee.

Dr. Lund announced that the Reference Commit-
tee would be glad to hear all those who wished to
appear before it in connection with the report of the
Committee on Medical Education.

Tlie Reference Committee on Constitution and By-
Lau> presented an amendment providing for the
organization of a Board of Public Instruction to con-
sist of seven members, to be appointed by the Presi-
dent, the term of service to be four years.

Dr. Lewis of Chicago, on behalf of the Section on
Hygiene and Sanitary Science, and by its instruction,
requested a report on questions presented last year
upon matters of sexual hygiene, etc., and tlien re-
ferred to the Committee on a Board of Public In-
struction, .\fter some discussion, on motion of Dr.
Craig, these resolutions were recalled from the Com-
mittee and referred to the Committee on Sanitation and
Public Health.

It was announced that the sixteenth International
Medical Congress would be held in Budapest in 1909,
and that Dr. J. H. Musser of Philadelphia had been
appointed chairman of the American Committee on
the International Congress. A motion for confirma-
tion of Dr. Musser's appointment by the House of Dele-
gates was adopted.

Dr. D. A. T. Bristow of New York presented a reso-
lution providing for the appointment of a committee
of five on nomenclature and classification of disease
to cooperate with representatives from other bodies
interested, in order to send a suitable delegation to the
Paris Commission in 1909, which would revise the
international classification of causes of death. The
resolution was adopted.

Dr. RitH.-\Rc Cabot of Boston presented a resolution
aimed to eradicate rabies. The resolution was re-
ferred to tlie proper committee.

GENER.\L SESSION.

I'lifsdiiy. June 4 — Si'iroinl Djy.

The meeting was called to order by the retiring Presi-
dent of the Association, Dr. Wilu.\m J. Mavo, of Roches-
ter, Minn.

Prayer was offered by the Reverend H. M. Gessner,
Pastor of the First Presbyterian Church of Atlantic City.

His Honor the Mayor of the city, F. P. Stoy, in a grace-
ful address extended a cordial welcome to the convention,
presenting to President Mayo the key of the city.

Dr. Alexander Marcv, President of the Medical Society
of New Jersey, welcomed the Association, on behalf of the
medical profession of the State, on the occasion of its third
convention to be held in Atlantic City during seven years.
Owing to the rapid growth of the Association it would soon
be difficult to find elsewhere the necessary accommoda-
tions for the annual convention, and sooner or later a

permanent meeting place would have to be considered.
When that time should come New Jersey would offer its
incomparable Atlantic City, and say to the association :
"Come and abide with us forever." The time was not far
hence when no reputable physician could afford not to be
a member of the .'Vssociation.

The Pr«sident introduced to the convention the follow-
ing named foreign guests : Dr. Gustav Killian, Freiburg,
Germany; Dr. Charles Trow, Toronto; Dr. George T.
Ross. Montreal; Professor Kiister, Marburg, Germany;
Professor Kocher, Berne, Switzerland ; Dr. D. G. VVishart,
Toronto; Professor Hess, Wiirzburg; Dr. Reeves, Toronto;
Professor Adami. Montreal; Mr. Herbert J. Paterson,
London ; Professor Schmieden.

Reports were presented by Dr. Philip Marvel of Atlantic
City, Chairman of the Trustees' Committee of Arrange-
ments, and Dr. W. Blair S'tewart of Atlantic City, Chair-
man of the Local Committee of Arrangements, summariz-
ing their work, acknowledging the hospitality of the city,
and making necessary announcements.

Dr. Mayo then said that it was his pleasing duty to in-
troduce the incoming President, "a man who is so well
known in this country that although his home is in New
York his election came, not from New York, but from
the whole of America — author, teacher, and surgeon —
Joseph D. Bryant of New York."

President's Address. — Dr. Bryant then delivered the
Presidential .\ddress (see page 925).

Evening Session.

The second general session was held on Tuesday even-
ing, the order of business being the delivery of the general
addresses.

Oration on Medicine. — Dr. James B. Herrick of Chi-
cago took as his subject in this address "The Relation
of the Clinical Laboratory to the Practitioner of Medi-
cine." The change that had been brought about in our
conception of disease and in the manner of its detection
through the discovery and invention of instruments and
methods of precision and the application of improved
laboratory technique was one of the most striking char-
acteristics of the marvelous advance in medicine of the
last half century. To realize what this means, he said,
one had but to think for a moment how comparatively
helpless we should be were we suddenly deprived of bac-
teriological aid in diagnosis with its attendant specific
scrum reactions ; of the improvements in technique of the
last fifty years in the way of microscopy, stains, section
cutting, etc. ; of the study of the corpuscles of the blood
and the estimation of its hemoglobin ; of our knowledge
of the chemistry of the stomach ; of the cytological, bac-
teriological, chemical, and physical facts concerning nor-
mal and pathological fluids of the body ; of the means
of measuring blood pressure ; of the numerous electric
light appliances enabling us to explore nearly all the
orifices and cavities of the body ; of the Roentgen ray ; oj
the improved qualitative and quantitative chemistry of
the urine and feces ; of aids from physical chemistry.
Nothing had given a greater uplift to medical thought arid
practice, and especially to diagnosis, than the laboratory.
Its aid was indispensable. But it had its own proper
place. The earlier tendency to overvalue its work and to
undervalue that done at the bedside was having the natural
result in a swing back of the pendulum, and we were now
hearing voices on either side of the Atlantic cautioning
against the undue magnification of the laboratory at the
expense of other aids to diagnosis. In our own country
several writers had recently referred to the subject, and
within a few weeks a large body of select medical men
— the Congress of .-American Physicians and Surgeons-
had considered the subject in a symposium, "The Relative
Value of Laboratory and Clinical Methods in Diagnosis."

Certain mistaken notions had obtained regarding labora-

June 8. 1907]

MEDICAL RECORD.

959

tories, which had led at times to strained relations and
misunderstandings between the practitioner and the labora-
tory expert. These were due to faults that lay partly in
the laboratory worker, partly in the physician. There
was often a failure on the part of the laboratory worker
to acknowledge his limitations. He should bear in mind
the possibility of error in technique or of false interpre-
tation of the facts observed, and the fact that we were
more or less even yet ignorant of some of the common labo-
ratory reactions ; he should ever be on the lookout for arte-
facts; he should hesitate to assert positively from micro-
scopical examination alone that a smear from a throat
does, or especially does not, contain diphtheria bacilli, or
that a cellular form observed is the Aiiiwba coli. He
should always realize the gravity of the duty imposed upon
him by the practising physician ; he is often so remote
from the patient that he cloes not feel the personal re-
sponsibility that weighs upon the clinician, and so, not
realizing the importance which may attach to his decision,
he may make it on insufficient grounds. Were he to feel
the full import of this decision, in doubtful cases he
might admit more frankly to himself and to the physician
his inability to reach a positive conclusion. Repeated
or later examinations could then be made, thus clearing
up the diagnosis. Or, if the result were still inconclusive,
he should be ready frankly tn admit that he did not
know. Finally there was a tendency for some laboratory
workers to step beyond their province and make diagnoses
that were unwarranted by the facts and perhaps unasked
for, and even to advance a prognosis and advice as to
treatment. The laboratory's function ceased when its
findings were announced. The interpretation of the lab-
oratory findings rested with the practitioner. No sharp
line should be drawn here, for the man in the laboratory
and the clinician should work together; but Dr. Herrick
would criticise such a laboratory report which he had seen
more than once, as : "This urine is from a typical case
of chronic mterstitial nephritis" when it was not; it was
from a typhoid patient drinking huge quantities of water
and passing urine of low specific gravity and of large
amount, with a trace of albumin and an occasional cast.
Often he had ^'-en the positive diagnosis of pernicious or
secondary aneir.ia made from a blood smear alone sent
in to a laborat'-iry — a possible, but risky diagnosis. And
many times he had seen a report that said in substance,
often in so many words on tlie basis of a Widal reaction :
"This is (or is not) a ca■.^■ ,,f typhoid fever." And when
free hydrochloric acid had been found in the stomach
contents the statement was returned : "This is not a case
of carcinoma." Such reports were wholly unwarrantable
and inexcusable. Nothing had done more to bring the
laboratory into disrepute than this irrational, almost med-
dlesome, method of venturing a diagnosis on wholly insuffi-
cient grounds.

The physician had done his share in creating more or
less prejudice against the laboratory by failing to recog-
nize its limitations and by holding the notion that labora-
tory methods were infallible and rendered unnecessary
careful bedside observation. Consequently misinterpreta-
tion of laboratory findings by the practitioner was com-
mon and was grave. And this was due to no fault on the
part of the laboratory, but rather to the shortcomings of
the methods themselves and the failure on the part of
the practitioner to take cognizance of this fact. Many of
the aids to diagnosis were regarded as too far-reaching
and comprehensive ; they were looked on as pathognomonic
and as without exception infallible. This came about be-
cause earlier reports as to the value of these tests were often
rosy-hued and conclusions were sweepingly and definitely
stated. The later observations throwing doubt on the
method were slower to get into print and were less
likely to attract the attention of the busy practitioner than
was the favorable report. The physician, furthermore, had

no right to throw the entire responsibility of an important
decision on the laboratory. The decision in a perplexing
case should be a combined one, the men working as col-
leagues., and each man sharing in the iresponsibility.
These faults — of laboratory worker and of medical prac-
titioner— were not irremediable, the author maintained.
The solution lay in two directions — first, in a better prac-
tical training of the undergraduate in laboratory technique
and methods so that he might realize the difficulties, limi-
tations, and possibilities of the laboratory; second, in the
closer relation between the laboratory expert and the clin-
ician and when possible their union in the one individual.
ITie closer the laboratory and the patient the less the
liability to error. The less the scattering of responsibility
the surer was the responsibility to be met. To these ends
there should be laboratories in our medical colleges for
the training of undergraduates, and these should be as
closely connected with the wards of the hospital and the
clinic as possible. No modern hospital should be regarded
as well equipped that did not make provision for a labora-
tory. The ideal would be for each practitioner to have
his private laboratory, but practically for the majority of
physicians this was not feasible. Groups of men might,
however, combine to employ some young man to do their
laboratory work. Similarly the county medical society
might have its clinical laboratory under the charge of
some young man. paid a salary or fees for separate exami-
nations, who would conduct a laboratory to which anj
member might feel free to go for the help that for various
reasons he could not get in his own office. Laboratories
for counties had already been established and, if not too
much entangled in politics, ought to be successful, espe-
cially in the way of guarding the health of the com-
munity and in aiding in the diagnosis of charity cases.
In the same way municipal laboratories had become a
recognized feature of the modern city, though the care-
lessness of the political appointee or his incompetence
often detracted from the value of their results. Commer-
cial clinical laboratories in our large cities were of great
service and had a legitimate place, their value depending
on the personnel of their staiif and on how far they per-
mitted the commercial side to overshadow the scientific.
What the orator contended for, therefore, was not less
laboratory work, but more, more for the undergraduate
and more for the practitioner.

In concluding. Dr. Herrick said that one should not
look on the laboratory as a short cut to a diagnosis.
Sometimes it was, but often its workings were slow and
cumbersome, and because of their complexity the results
were not easily expressed in practical, every-day, usable
terms, and were, therefore, inconclusive or confusing. In
other words, the laboratory diagnosis was not yet one of
machine-like accuracy. The time had not yet come when
a diagnosis could be made without the exercise of brain
power. We did not wish our professional work to be
degraded by being "dementalized," to use Weir Mitchell's
expression. Anamnesis, physical, and laboratory findings
were to be studied and compared and a result reached that
not only gave a name to the disease, but gave a con-
ception of the disease as it existed in the particular indi-
vidual, with all that such a comprehensive diagnosis im-
plied in the way of prognosis and hints as to therapy.

Oration on Surgery. — Dr. Wiluam H. Wathen of
Louisville delivered this oration, taking as his title "Acute
Suppurative Peritonitis (Local, Spreading, Diffuse, and
General)." One reason for selecting this subject for an
address before a general medical audience was, he said,
the fact that the essential questions involved in the study
of the etiology, pathology, diagnosis, and treatment of
acute suppurative peritonitis were of equal interest to the
internist and the surgeon. The greatest success of surgery
in saving life in these cases depended on early surgical
diagnosis and timely operation, before pathological condi-

960

MEDICAL RECORD.

[June 8, 1907

tioiif could develop tliat might so impair the vital resist-
ance of the body tissues as to cause death of the patient
with or without surgical intervention ; and as these pa-
tients usually first consulted the internist, early operation
was impossible unless the surgeon was promptly associated
in consultation. The intrauterine life and at birth the in-
testinal canal was sterile and remained so until bacteria
had been introduced with the food. The bacteria ordi-
narily found in the alimentary canal varied according to
the food, but the one contsant normal inhabitant was some
type of the colon bacillus; in childhood the Bacillus lactis
ttcrogenes, closely related to the Bacillus coli, was also
normally present. These two germs, independently or
jointly, might conduce to health by aiding digestion, an-
tagonizing intestinal putrefaction, and inhibiting the growth
of pathogenic intestinal bacteria. In splitting carbohy-
drates they generated acids which limited intestinal putre-
faction by the proteolytic bacteria, and might prevent
pathological processes which would otherwise develop in
the existing alkaline fermentation. So long as there was
perfect digestion, absorption, and assimilation, the great
number and variety of bacteria living on the carbohydrates
and proteids were not only harmless but conducive to
health, but when some pathogenical condition in the gas-
trointestinal tract disturbed the circulation, digestion, and
nutrition, they might quickly become mildly or virulently
pathogenic, multiplying rapidly and generating to.xic sub-
stances in the tissues of the body, or causing peritonitis
by passing through injured walls or a perforation into the
peritoneal cavity.

Since bacteria were introduced with the food it might
be reasoned that the intestine when emptied of its con-
tents would become sterile, and experimental investiga-
tion had shown the truth of this assumption. It was
possible to utilize these facts in certain intraperitoneal
operations and sterilize the stomach and some part of the
upper intestine by giving the patient no food by the stom-
ach for several days before he was operated on ; or, when
the patient's condition would not admit of this, by giving
sterile liquid food, and have him cleanse his mouth fre-
quently with some efficient antiseptic liquid for a few
days.

The infectivity and virulence of bacterial invasion of the
peritoneum was measured by the relative number and
pathogenic powers of the bacteria that entered the peri-
toneum from the different parts of the gastrointestinal
tract, the virulence being greatest when the infection oc-
curred from the lower part of the ileum with the maximum
intensity at the ileocecal and appendicular region. In
perforative duodenal ulcer the leakage into the peritoneal
cavity was often free of pathogenic bacteria and did not
cause diffuse suppurative peritonitis, and when infective
bacteria were present they were usually so mildly patho-
genic that the resultant peritonitis remained local or
spread so slowly as to admit of successful surgical inter-
ference. This applied also in pyloric perforation, because
of the character of the contents in this part of the stom-
ach, and also because of its relation to adjacent structures
to which it might quickly form adhesions to close the
perforation, or to localize the infection. It was not true,
however, in ulcerative perforation of the cardiac end of
the stomach, because the anatomical relations were so
entirely different as to minimize the protecting infiuenco
of adhesions to adjacent structures in closing the gastric
opening or in limiting the area of infection, and also be-
cause of the greater number and virulence of the bacteria
in the leakage, for these perforations often occurred with
food in the stomach containing bacteria that acid secretion
had not destroyed.

As acute suppurative peritonitis was often caused by
the invasion of pathogenic bacteria from the organs con-
tained in the pelvis, it would be well to consider briefly the
bacteriobiology of the vagina, uterus. Fallopian tubes, and

urinary bladder. No pathogenic bacteria inhabited the
upper part of the vagina, the cavity of the cervix or
body of the uterus, or the bladder when these organs and
the kidneys were in a state of health, and pathogenic
bacteria were found only in diseased conditions of these
structures, having been introduced from without by in-
fected media. With an intact and normal epithelium of the
urinary tract, bacterial growth was inhibited and the urine
was free of bacteria and in no sense infective. But any
part of the tract or the entire tract might become infected
by the tubercle bacillus introduced through the kidneys,
or by pyogenic germs of any degree of infectivity in-
troduced through the urethra, and under such conditions
acute suppurative peritonitis might result from perfora-
tion or rupture of the bladder. Pathogenic bacteria might
be abundant at the vulva and in the lower part of the
vagina, but they could not be cultivated from the secre-
tions of the upper part of the vagina or in the neck or
body of the uterus, the acid secretions of the lower half
of the cervix and the vagina positively inhibiting bacterial
growth. The uterus and Fallopian tubes might be in-
fected, however, by bacteria of all degrees of pyogenic and
pathogenic virulence, resulting in mild or fatal forms of
toxemia or septicemia or local and diffuse acute suppura-
tive peritonitis.

In conclusion, Dr. Wathen emphasized in a general way
a few things, on the observance of which might mainly
depend success in the operative treatment of all perfora-
tions into the peritoneal cavity, and in the prevention and
treatment of local diffuse and general peritonitis from
any cause.

"i. Operate as soon as a surgical diagnosis is made
and avoid purgation and opium before and after the op-
eration. Give no food or liquid, and if there is no gas-
trict perforation empty the stomach by lavage, and remove
fecal matter from the colon by rectal enemata.

"2. Operate rapidly and, if possible, treat the foci of
infection by suturing gastrointestinal perforations, or blad-
der wounds, by cholecystectomy or cholecystostomy, by
appendectomy, or the removal of the uterus or its adnexa,
always remembering to avoid peritoneal traumatism so as
to protect peritoneal resistance to bacterial invasion and
toxemia.

"3. Expose or handle the intestines as little as possible,
and do not separate adhesions or irrigate or sponge the
peritoneal cavity. Establish drainage from the bottom of
the pelvis through a suprapubic incision, and, if indicated,
also drain the site of infection, using a large split rubber
tube with or without gauze, with the patient in nearly a
sitting posture.

"4. Pour into the peritoneal cavity, before closing the
abdominal wound, hot horse serum or saline solution to
stimulate Icucocytosis, and when the patient is returned
to bed use saline solution by rectum, after the fashion
of Murphy, and, if necessary, use the horse serum or saline
solution subcutaneously.

"5. Enterotomy is never indicated, except in some de-
layed cases of intestinal obstruction or paresis, and it
should then be performed quickly and with a minimum
exposure of the intestine ; enterostomy is contraindicated.

"6. Physicians should be educated to impress on their
patients the fact that acute diffuse and general peritonitis
may usually be prevented by the early surgical treatment
of gastric or duodenal ulcer, cholelithiasis and cholecystitis,
appendicitis, tubal and ovarian infections, and acute intes-
tinal obstruction ; also in many cases of gastric and duo-
denal perforations."

Finally, the orator insisted with special emphasis upon
the fact that the treatment by purgation, opium, and delay
of the pathological conditions that caused acute local,
diffuse, and general peritonitis, and bacteriemia and tox-
emia, had caused more deaths during the last ten years
than had been sacrificed on the battlefields of the world;

June 8, 1907]

MEDICAL RECORD.

961

and that in this progressive age of civilization he who
obstructed the progress of science, medicine, and surgery
in the prevention and cure of disease and the prolonga-
tion of life, was committing an offense against the State,
humanity, morals, and religion for which the ethics ot
his environment may cause the people to hold him to a
rigid accountability.

Wednesday, June 5 — Third Day.

Address on State Medicine. — Dr. S.\muei. G. Dixon of
Harrisburg, Commissioner of Health of Pennsylvania,
delivered this address, taking as his subject. "Law, the
Foundation of State Medicine." On State medicine, he
said, the happiness of the people and the prosperity of the
nation depended, for that nation would be strong which
was vigorous in the health of its individuals. The con-
tention that the enforcement of sanitary laws could be
an infringement of personal liberty was puerile, for. as
Parks has said, if we would aim to render growth more
perfect, decay less rapid, and life more vigorous, we must
give up many primitive or individual liberties. One factor
in bringing about the wonderful achievement of tlie Japan-
ese army was the high rank accorded to their medical and
sanitary departments. In their particular branch of the
service these men were supreme. In all great movements
they were consulted. Unless a military necessity pre-
vented, they supervised routes of march, sources of water
supply, and sites for encampment. So long as the medical
service was made subordinate to the strictly military ser-
vice in our own army, so long, the speaker said, would
repetitions of the disgraceful slaughter of Camp Alger
and Chickamauga be of common occurrence in our mili-
tary operations. In all matters pertaining to the health
of the troops the medical staff of an army should be the
authority, and in all councils of war their voice should be
of equal authority with those of the combatant officers.
It was only the skill of the medical officers of our army
that made the present occupation of Cuba by our forces
possible without frightful loss of life. It was only their
knowledge of the mysteries of the transmission of the
Plasmodium malaria: and the yellow fever microorganism
by mosquitos that had enabled us to undertake the con-
struction of the Panama canal and to convert the Canal
Zone from a valley of death into a region in which men
could live and labor in health and safety. Our legislators.
Dr. Dixon said, were in general striving to do what was
for the greatest good of the community in health matters,
but they could not always distinguish between the true
advisers and the false, between real scientists and pre-
tenders, and the only way was for the Government to call
upon educated medical and sanitary experts for advice ;
better yet it would be. if, as had been so often urged, there
were established a Department of Health with a Secretary,
a Cabinet Officer, at its head. The keynote of State Medi-
cine was, however, compulsion and not persuasion. With-
out the law to back it, State Medicine might be a beautiful
science, but it could never be a practical art. Certain pub-
lic health questions were of national concern, and such
matters as the prevention of the pollution of interstate
rivers and streams, the prevention of food adulteration, and
the sanitation of public conveyances on interstate lines of
travel, both by land and water, must be controlled by
federal law. The author then spoke of recent sanitary
legislation in Pennsylvania. The first noteworthy enact-
ment was the substitution in place of a State Board of
Health of a Department of Health with a single official
at its head, having a seat in the Governor's cabinet. The
same legislature which gave the commissioner such broad
powers also placed under his charge all the waters of the
State and laid on him the duty of reclaiming them from
pollution. No new system of water works for the supply
of water to the public, and no addition to a system already
existing, and no new sewerage system or addition to a

sewerage system already existing could be made without
a permit from the commissioner, in whose office must be
filed certified copies of the plans, surveys, and descriptions
of such systems. Pennsylvania was until recently without
a State system of registration of vital statistics, but this
was now no longer the case. The legislature had passed
an "Act for the Immediate Registration of Births and
Deaths," and to make this law eflfective in the rural dis-
tricts nearly a thousand local registrars and two hundred
subrcgistrars had been appointed.

An Epitome of Sanitary Legislation in the Several
States. — Dr. Dixon then presented a review of what
had recently been accomplished by other States in
the way of sanitary legislation, the data for which had
been furnished by a special bulletin of the State Board
of Health of Rhode Island and the Providence Planta-
tions compiled by Dr. Charles Y. Chapin. In 1905,
which w-as a year nf unusual activity in sanitary legisla-
tion, the matter of registration was taken up in Califor-
nia, Connecticut, Michigan, Minnesota, South Dakota,
Utah, Wisconsin, and Nebraska. In five of these States
a complete system was inaugurated. These were Cali-
fornia, South Dakota, Utah, Wisconsin, and Nebraska.
In the remaining three, the acts were intended to rem-
edy defects in systems already existing. These were<
Connecticut, Michigan, and Minnesota. In California,
m addition to the complete law for the registration of
deaths only, the old law for the registration of births
and marriages received several amendments. A law
establishing a State Board of Health or considerably
enlarging its powers was passed in Minnesota. Acts
establishing or regulating local boards of health were
enacted in Indiana, ;Minnesota, Nevada, New Jersey,
and Oregon. In Nevada and Oregon, county boards of
health were created. Legislation for the better control
of contagious diseases was accomplished in California,
South Carolina, Maine, Tennessee, Utah, and Wiscon-
sin. Emergency funds were established for special use
in epidemics in Maine, Pennsylvania, and Wisconsin.
Hospitals or sanitoria for consumptives were projected,
established, or aided in Massachusetts, Michigan, Mis-
souri. Rhode Island, Wisconsin, Georgia, Indiana, and
New Hampshire. Acts to regulate the practice of med-
icine were established in fifteen States — Colorado. In-
diana, Michigan, New York, Missouri, South Carolina,
South Dakota, Tennessee, Texas, Washington, Wyom-
ing, Florida, Michigan, North Dakota, and Wisconsin.
The action of Colorado, Michigan. Wyoming, Nevada,
and Wisconsin in forbidding the granting of licenses,
or certificates, or registration to persons guilty of im-
moral, dishonorable, or unprofessional conduct, and
empowering the State boards or courts to revoke and
annul any license or certificate issued to such persons,
cannot be too highly commended. Laws regulating the
practice of undertaking and embalming were adopted
in Illinois, Indiana, Massachusetts, New York, Penn-
sylvania, West Mrginia, Wisconsin, Minnesota, North
Dakota, and Oklahoma. Cigarette smoking was consid-
ered an evil of such magnitude as to require prohibition
in Arizona, Indiana, Nebraska, Oklahoma, and Penn-
sylvania. State laboratories for bacteriological or
chemical analysis were established in California, Con-
necticut, North Carolina, Wisconsin, and Pennsylvania.
The practice of osteopathy was legalized in Colorado,
Indiana, Montana, Nebraska, Tennessee, South Dakota,
and New Mexico. The examination and registration of
nurses was provided for in California. Colorado. Con-
necticut, and New Jersey. More stringent provisions
to regulate the sale of poisons and narcotic drugs were
adopted in Connecticut, Massachusetts, Minnesota, Ne-
braska, North Carolina, Texas, and Wyoming. .\n act
to provide a method for locating and destroying
mosquito-breeding areas had been adopted by the State

962

MFDICAL RECORD.

[June 8. 1907

of Xevv JtTsi-y. This li-t indicated an advance, but
there was always need of vigilance on the part of sani-
tarians. .Anyone who was on the ground during a ses-
sion of a State Legislature could but be struck with
the amount of crude, ill-digested, and even nefarious
legislation of this kind which was presented, and with
the necessity for having intelligent medical men on the
spot who could watch purely commercial schemes pre-
sented under the guise of sanitation and science and
inform the legislators of their true character. An in-
telligent and conscientious chief executive was. how-
ever, often the only bulwark against disaster.

The speaker then referred to the scheme now being
outlined in Pennsylvania for the limitation of tubercu-
losis. It contemplated utilizing the great forest reser-
vations of the State for the purpose of hospital or san-
atorium treatment. It was proposed to have two colo-
nies at widely separated points that they may be ac-
cessible from different parts of the State. Instead of
large and massive structures of brick or stone, there
would be erected a large number of frame cottages,
each of which w^uld accommodate a small number of
patients. Somewhat apart from these would be an in-
firmary for those in the more advanced stage of the
disease. In this building those to w'hom hopes of re-
covery could not be held out would be afforded shel-
ter and comfort in the closing days of life, and this ex-
tension of relief would be more than justified in the
fact that such patients would be removed from their
confined, crowded, ill-ventilated, and often impoverished
homes at the time when they would be most in danger
of communicating the disease to others. In addition
to this, it was planned to establish in each of the sixty-
six counties of the State a dispensary for tuberculosis,
under the direct supervision of the Department of
Health. The object of these dispensaries will be two-
fold: Many patients who might be unable to leave
their homes for a prolonged stay in a sanatorium could
frequently go there for advice in regard to matters
of diet, medication, and the open-air treatment, so far
as it was possible of being carried on at home. They
would also receive careful instruction in all the pre-
cautions necessary to be observed for the protection of
others. In this matter of the care for the tuberculous
and the limitation and prevention of the disease, the
speaker hoped to see a generous rivalry between the
States, so that 'each might deserve well of the republic.

SECTION" ON PR.\CTUE OF MEDICINE.

Tuesday, June 4 — First Day.
Dr. Thom.\s D. Coleman of Alglsta, Ga., in the Chair.

Early or Premonitory Symptoms of Pernicious Anemia.

— Dr. John H. Lichtv of Pittsburg read this paper, in
which he said, as far as we knew, pernicious anemia is the
result of a toxemia. The symptoms and course of the dis-
eases were clearly in accord with this, and the study of the
bothriocephalus anemias permitted scarcely any other con-
clusion. What the exact nature of this toxin was was
still a matter of speculation and doubt. It was generally
accepted that its origin was in the intestinal canal. In a
recent paper by Dr. C. A. Herter it was sliown that the
Bacillus acrogenes capsulatus was an active hemolytic
agent, and that when the Bacillus coli type was sufficiently
meagre to permit a very large growth of Ihe B. acrogenes
alterations appeared in the blood similar to a secondary or
pernicious anemia. The blood change was not the cause
of the symptoms — it was a part of tlie symptom complex
of pernicious anemia. Other prominent symptoms were
loss of muscular power, dyspnea and cardiac oppression,
pallor, edema, subcutaneous and submucous hemorrhage.

loss of appetite, achylia, diarrhea or alternate diarrhea and
constipation together with certain nervous manifestations.
From the literature on this subject it was evident that
there was no recognized regularity in the order of the
appearance of symptoms. The blood picture generally
gave a high color index, with megaloblasts and megalocytes,
and these were pathognomonic, but before this appeared
certain premonitory symptoms arose which would lead one
to make a most thorough blood examination. If the blood
examination was negative and other diseases could be ex-
cluded, a provisional diagnosis should be made and the
patient treated accordingly.

Dr. George B. Herrick of Chicago said that it was
necessary to look back into the patient's past his-
tory and find out about gastrointestinal symptoms, as
well as paresthesias. In case of changes in the cord, tin-
gling of the fingers or toes was frequently present. Hunter
had called attention to the fact that these cases often have
sore tongues and sore mouths.

Dr. W. S. Thaver of Baltimore said that pernicious
anemia was more common than was generally supposed.
He spoke of the importance of the early nervous symp-
toms, and particularly of paresthesias of the lower ex-
tremities with ataxia, while the upper extremities showed
increased refle.xes.

Dr. F. F. Goodwin of Mount Vernon, N. Y., said that
from a study of pernicious anemia he was led to believe
that all anemias arise from some disturbance in the gastro-
intestinal canal, such as the fermentation of carbohydrates
or the partial oxidation of protected substances like nucleo-
albumin.

Dr. G. W. McCaskev of Fort Wayne, Ind., said that all
were agreed that pernicious anemia was due to a toxemia,
but whether that to.xin came from the gastrointestinal
canal or some other part of the body was a question still
unanswered. He thought it was of great importance m
these cases to estimate the amount of iron excreted. If,
as is usual in these cases, there is a destruction of the red
blood corpuscles then there would be an increased amount
of iron excreted in the urine. This also was true in most
of the chronic nutritional diseases.

Dr. Max Einhorn of Xew York City spoke of a patient
with achylia who developed pernicious anemia. For three
years this condition was still unchanged. He was improved
somewhat on a liberal diet, low in meat.

Dr. H. S. .Anders of Philadelphia co-sidered floating
kidney an etiological factor.

Dr. N. S. D.wis of Chicago wished to speak of early
degenerative changes that took place in the spinal cord
in these cases. When one met with ;; case of ataxia
pernicious anemia should be thought of and the case
should be watched to see if this condition developed,
even if the blood examination showed only a moderate
anemia.

Dr. C. S. Hoover of Cleveland asked whetlier anyone
had .seen recovery in a case of pernicious anemia after
spinal cord symptoms had developed?

Dr. Frank Smithies of Ann Arbor said that many
physicians were apt to neglect the blood examinations.
Many cases would show cardiac disturbances. One ex-
amination of the blood was not enough, but five or six
examinations must be made. He had always found oval
cells in the early part of this disease. The doctor asked
Dr. Licht>- what was his interpretation of the so-called
"megaloblastic showers?"

Dr. Lichty closed the discussion by stating that the
"megaloblastic showers" were a sign of the approaching
end. He agreed with Dr. Davis and Dr. Hoover in regard
to the changes in the spinal cord, but did not think that
a movable kidney could cause pernicious anemia. He
wished to bring out one point, that of the occurrence of
cardiovascular symptoms in the early cases and the great
importance of blood examinations.

June 8. 1907]

MEDICAL RECORD.

'»'>3

Some Observations on Digestive Conditions in Pul-
monary Tuberculosis. — Or. Jamks R.\e Arnf.ill cii Um-
ver, Colorado, read this paper. He said that during the
last ten years he had been greatly interested in enteroptosis
and had been on the lookout for tliis coiulition in patients
of all classes. The frequency of this condition in slender
patients, suffering with malnutrition, psychoneuvose.s, and
tuberculosis was decidedly impressive. Most examina-
tions of tuberculous patients did not include an examina-
tion of the abdomen. If one palpated the kidneys, and
looked for Stiller's sign, the contracted colon, and the
succussion sound in the stomach and the large intestines.
he would find a surprising number of enteroptosis cases.
Patients born with the enteroptotic type of physique were
prone to malnutrition, psychoneuroses, and tuberculosis.
Analysis of the stomach contents and the motor power were
very often valuable aids in treatment. The most ef-
fective treatment was fresh air, absolute rest, generous
feeding, attention to the skin and bowels, optimistic sug-
gestion, and isolation with diversion and exercise. In tlie
consumptive the cure must be prolonged and modified
to meet conditions. Notwithstanding the remarkable work
done along the line of opsonic therapy, our sheet anchor
in the cure of tuberculosis must be the nutrition of the
patient. Gain in weight and increased adiposity were only
a part of nutrition. Rest, exercise, and fresh air were
all of value, because they increased the appetite and oxida-
tion. The average case of indigestion in the consumptive
could be treated on symptomatic lines. Bitter tonics,
hydrochloric acid and ferments, alkalies and antifermenta-
tives were used when indicated. Application of some
form of abdominal bandage was often of value in properly
selected cases. Operative interference was occasionally
necessary in the tuberculous patient, such as gastroenteros-
tomy and appendectomy, in order to correct serious diges-
tive disturbances. The successful treatment of tuberculo-
sis chiefly depended on intelligent guidance of spontaneous
resistance and recovery.

Dr. Woods Hutchinson of New York City opened the
discussion on this paper. He said that there was more in
pulmonary tuberculosis than the discovery of the germ or
the signs brought out by the stethoscope. The most im-
portant information was found outside of the chest. The
changes in the heart and abdomen were important. Often
the heart was distinctly undersized, the stomach dilated,
and the colon displaced.

Dr. JuDSON Deland of Philadelphia spoke of the im-
portance of the use of the .r-rays in diagnosis and as an
aid in determining whether the supporters were doing their
work by holding the organ in its proper place. He said
that graded courses of exercises were most beneficial.

Dr. M. G. LiCHTY of Cleveland brought out the relation
of consumption to gastrointestimal diseases.

Dr. J. H. Wetherspoon of Nashville, Tenn., said that
he thought hyperchloracidity was a much graver condition
than hypochlorhydria.

Dr. Arneill in closing the discussion spoke of the im-
portance of altitude in the treatment of these cases. He
referred to the experiments of four noted German phys-
iologists who made observations upon soldiers in the Alps.
They found that low barometric pressure was followed by
an increased proteid metabolism, also that low barometric
pressure increased the activity of the blood-forming organs.
-A high altitude gave 20 to $0 per cent, more hemoglobin.

The Continued Fevers of Southern Georgia. — Dr. H.
F. Harris of Atlanta, Ga., read this paper. He said that
this continued fever was known under dififerent names,
such as "slow fever," "Wallacoochee fever," and typho-
malarial fever. It lasted from one to ten weeks. It was
considered by some as malarial, by others as typhoid. The
onset often came with a chill, the temperature was com-
paratively high, and the usual manifestations of a malarial

paro.xysm were present, but Plasmodia were not found.
Other cases began like typhoid. The speaker had studied
forty-five cases, making observations of the blood, urine,
and feces, and in seventy-five per cent, typhoid or para-
typhoid bacilli were isolated. In some cases a mi.xed infec-
tion was present. The prognosis was good. He thought
medication did not modify the course of the disease,
nltliough some believed that large doses of (|uinme were
liencficial.

Dr. J. H. Wetherspoon of Nashville, Tenn., said ilieso
cases of continued fever were not similar to malarial fever
or typhoid and that quinine was not effectual. It began
with a chill, there was rapid prostration, and the patient
«as irritable. The tongue was not that of a typhoid case
neither was the pulse, which was rapid, and the belly was
not tympanitic. If tenderness was present, it was over
the liver or the sigmoid. This fever was not affected
liy the season of the year. The patient was constantly
hungry and there was a rapid change in temperature simi-
lar to that of a septic case.

Dr. Wood of Wilmington, N. C, said that these cases
were mild typhoid and gave a positive Widal reaction. It
was most important to teach people the great danger of
these cases.

Dr. John W. Litchv of Pittsburg said that a similar
discussion had taken place in Louisiana. In Pittsburg
where no malaria was they had "slow fever" cases and all
.uave positive Widal reaction.

Dr. Ale.xander Lambert of New York City asked if
blood cultures had been made in any of these cases which
were suspected as being typhoid. He said that in Bellevue
Hospital 90 per cent, of the doubtful cases gave a positive
culture of typhoid fever. Of course the Widal reaction
varied in individual cases.

Dr. Howard Fussell of Philadelphia said the typhoid
fever varied in form, but that the name typhomalarial was a
shield of ignorance and should be banished.

Dr. Harris, in closing, said he accepted the view that
this slow fever, so called, was a "mild" typhoid. In a few
cases blood cultures were taken and the positive reaction
obtained.

section on obstetrics, and diskases of wome.x.

Tuesday, June 4 — First Day.

Dr. J. Wesley Bovee. Chairman.

The Status of the Fight Against Cancer of the
Uterus. — Dr. J. Wesley Bovee of Washington delivered
the Chairman's address, taking this as his subject. He
said that from the many articles catalogued on the sub-
ject, the observer would think it was hackneyed and
that great enthusiasm existed in the professional ranks
concerning the treatment of cancer. There were many
remedies presented, from surgery to the use of the newer
remedies, .r-ray, radium, etc. W. Dean Blucher modestly
claimed a curative effect of radium on cancer, but did
not claim that it would benefit uterine cancer to any
great extent. The great things that have been claimed
for some of the new remedies were very far from the
actual facts. Those who were brought into actual con-
tact with cancer of the uterus knew that it was one
of the worst scourges flesh was heir to. It appeared that
in no country, race, or society were women free from
this disease. Some claimed immunity for the North
-American Indian, the inhabitants of Africa, and the
negro of this country, but such was not true. Seldom was
the speaker without a negro woman in his wards with
cancer of the breast or uterus. It usually occurred
during the few years preceding the menopause or after.
It should be remembered that cancer of the uterus,
whether of cervi.x or the body, was a local disease in

964

MEDICx^L RECORD.

[June 8, 1907

the beginning, but soon lost its local character, passing
to surrounding tissues. The cancerous tissue was often
isolated and at a distance from the focal point. It was
important that there be a uniform classification, and
Sampson of Albany had suggested a good working classi-
fication. Much work had been done to discover the
cause, but no conclusion had been reached. Much was
hoped from the bacteriological theory, and while it was
possible to transfer from one animal to another, it had not
been proved that the origin was a bacterial one. After
all the most that could be said was that it might have
its impetus from a chemical irritant circulating in the
blood. The cancer age was from near the menopause to
the end of life. This held true in the vertebrates other
than human. The element of heredity was a very im-
portant one. The question of contagion should not be
overlooked, for he had cases in which there seemed no
doubt that the disease was communicated from another
patient. Dr. Bovee quoted from A. Lapthorn Smith,
w'ho offered many instances in which cancer was com-
municated from one person to another and claimed that
cancer had increased thirty per cent, in a decade. The
question of vital import w^as the cure of cancer, and
since it was admitted that it started as a local disease,
there was great necessity of early diagnosis. The fact
that the uterus was a concealed organ, that women often
hesitated to have examinations, that the disease was one
occurring at times near the menopause (the physician
being often misled to think it was a condition associated
with that event and did not ' make an early diagnosis)
often prevented the early radical treatment. With the
many handicaps the surgeon had not been able to demon-
strate to the general practitioner that he could cure cancer
by radical operation if taken in the early stage, and in-
dustrious effort would be necessary for years to over-
come these obstacles. Women should submit to examina-
tions at regular intervals when they have reached the
cancerous period, the same as they would consult a den-
tist about their teeth. In this way they might be guarded
against a progressive condition that would prove obstinate
and fatal. All cervical tears or injuries should be re-
paired and prophylactic measures be employed. Radical
operations in early cases had proved quite satisfactory.
In the later stages of the disease Byrne's method of the
galvanocautery had been beneficial. Trypsin was now
much used in nonoperable cases. The uterus seemed too
deep seated for use of the ;r-rays. In conclusion Dr.
Bovee said stress should be placed on early diagnosis ;
special care in the classification of the varieties; .v-rays
and radium were of little use, and no time should be
wasted with these when the case was an operable one;
the cautery should not be used as a substitute for a radi-
cal operation, and the vaginal route did not oflter as good
results as the abdominal. He also suggested that all
rooms occupied by cancerous patients should be fumi-
gated before being occupied by the non-cancerous, and
everything possible should be done to stamp out the
disease.

How Can We Lessen the Mortality of Uterine
Cancer? — Dr. E. E. Montcomerv read this paper. He
said the bacterial origin of cancer had not been proved,
but the influence of heredity was an important factor as
was also the resisting power of the patient. The fact of
heredity might have to do with either the cancerous
tendency or diminished resisting power. Most cases of
cancer were found in women who had borne children and
one of the great causes was injury or long irritation of
the part affected. The damaged cervix was a factor to be
heeded and all such conditions should be attended to. The
treatment was preventive, curative and palliative and the
first two viere vital. Of course the early diagnosis was all
important and if the cervix or the body of the uterus was
in any way affected treatment should be directed to its

correction. The general health of the patient was of vital
importance and all gastrointestinal fermentation and irrita-
tion should be avoided and the patient should drink large
quantities of water and if necessary sleep in the open
air. E.xpericnce demonstrated that the earlier in life the
disease occurred the more rapid was its progress, and at all
times an accurate knowledge of the disease and its early
recognition were essential for its radical removal and cure.
Dr. Howard Kelley of Baltimore said he would em-
phasize the necessity of the early diagnosis. He thought
much could be gained by systematic classification, but found
many varying individual cases. He thought much harm
was often done to the patient by the length of the opera-
tion. That an operation requiring two or three hours was
too much of a drain on the power of the patient. By the
use of long clamps in clamping of the arteries the opera-
tion had been reduced in time.

Dr. M.^RSTEV said that he was using a modification of the
zinc-mercurial cauterization he presented at New Orleans
with good success in two cases. Instead of using a general
anesthetic he applied the cautery as long as the patient
could well bear it, one-half to one hour at 200 milliamperes
without great discomfort to the patient. One of the patients
had been well for over three years and the other for nine
months.

Dr. Margaret A. Cleaves made a plea for the use of
trypsin and said she had patients who according to all
rules of the disease should be dead, but were living with
no symptom of the disease. She had noticed that patients
in w^hom trypsin was injected often reacted in markedly
different manner. One presenting fever, chills, and all the
serious evidences of eosiuophilia and the other going along
in a normal way. She had found these cases were diflterent
in that the former were sufferers from a malignant con-
dition and the latter were not, although the diagnosis had
been the same in both cases. If trypsin were administered
many of the cases began to improve at once.

Dr. BoLDT said that in patients 30 years of age the vast
majority were doomed. It was important what route
should be pursued in the operation. In cases over 50 years
he advised the vaginal route as there was less shock to
the patient and in these cases his experience with the ab-
dominal route had not been good. He thought that radical
operation was the right method.

Dr. D. L. Craig said that three years ago he had reported
an investigation of cases treated in a hospital for women
and that in cases where there were no lacerations or the
cervix had been repaired there was no cancer, and he
thought many cases were due to some form of irritation.
The general practitioner could do much toward the preven-
tion of cancer.

Dr. Carson said there were two important things to keep
in mind ; how to prevent and how to save the patient. He
laid special stress on the fact that at some time it was a
local disease; perhaps as big as a pin point or as a pea,
but it was then a local disease and it was the physician's
place to keep a watch for a starting point.

Dr. Montgomery said in closing the discussion that he
agreed with the majority of the speakers and that other
methods than the radical operation might in time prove
to be preferable, but at the present and with the light we
now had he held to the radical operation in all operable
cases.

Parasitic Uterine Myomata. — Dr. Thomas S. Cullen
said that by the term he meant myomata that had become
completely or partially weaned away from the uterus and
got their blood supply from another source. These might
get the greater part from the omentum, the large or small
bowel, the bladder, mesenteric vessels, or Fallopian tubes,
or from several sources at the same time. In many cases
the omental adhesions were associated with pelvic adhesions
or with pus tubes. Sometimes the peduncle became very
small and most or all of the blood supply came from some

June 8, 1907]

MEDICAL RECORD.

965

other source. In cases where the blood supply was from
the omental vessels they became very large and turtuous,
but as a rule there were large arteries each accompanied by
two veins. At first there might be but little omental change
when the blood supply was from that source, but as the
tumor increased the omental fat gradually disappeared. The
function of the omentum seemed marvelous in some cases,
as in one where the tumor weighed 89 pounds and was
attached to the uterus by a very small pedicle, its chief
supply coming from the omentum. In the operative treat-
ment of these tumors one of the first things to do was to
control the omental vessels. This could be done by tying
off the omental vessels on the proximal and once on the
distal tumor side. They were so delicate that they should
be tied instead of using forceps. The arteries should be
tied under sight and one should not attempt to liberate ad-
hesions far under the abdominal wall as they might contain
blood-vessels that would give trouble. Dr. CuUen showed
illustrations of myomata and insisted that the greatest care
be exercised in the operation lest a blood-vessel be rup-
tured.

Dr. Is-\,AC S. Stone said that ten years ago he had writ-
ten on that subject, but it had been passed in the way of
many things. He thought it a most interesting subject and
the writer had presented the subject most interestingly. He
supposed that when a fibroid started on its way it might
take an exceedingly varying course.

Dr. BoLDT said the important point was the blood-vessels
and the greatest care should be taken that they he not in
jured or the tumor removed until all were secured.

Prevention of Peritoneal Adhesions by Adrenal Salt
Solution, with Especial Reference to the Pelvis. — Dr
Emery Marvel presented this paper. He said peritoneal
adhesions resulted from a pathological process active within
or adjoining to the peritoneum. Their formation was Na-
ture's effort to combat an injurious process in which
adhesions were good and a protection to the org:uis. In
many cases they were injurious and it was desired to pre-
vent them. The thin-walled vessels of the peritoneum
favored free exudation of serum and became the agent by
which the surfaces were united. Now in an operation the
dilated blood and lymph vessels gave a leaking orifice with
e.xudation that meant adhesions. To prevent adhesions the
purpose was to dilute the serum and thus hasten absorp-
tion and prevent further exudation. Then too the irritated
surfaces should be kept apart imtil partial repair had taken
place. In order to remove the irritant and release the parts
salt solution might be used, and then should be added to
this for the purpose of preventing further exudation adre-
halin chloride. The salt solution aided absorption of the
secretions and the adrenalin prevented the exudation of
further secretions. The bulk of the fluid kept the surfaces
apart and thus the threefold purpose was accomplished.

Dr. Lawrence said much of the trouble from adhesions
was due to the methods of operations. Too much was done
in the abdomen and with all the drainage tubes, the sponges,
the handling of the parts traumatism resulted and adhesions.
Much of the adhesion was defensive and Nature's method
of protecting herself, and as for himself he did not look
with great favor upon the method advocated by the writer.

SECTION ON SURGEKV .\ND .\N.\TOMV.

Tursilay. May 4 — First Diiy.

Address of the Chairman. — Dr. Arthlr Dean Bevan
of Chicago spoke on the importance of a further study
of anesthetics and anesthesia, and, after commenting
on the value of the findings of the British Commission,
urged the creation of a similar body in this country. The
use of gas as an anesthetic, he said, had until very re-
cently been relegated to the dental fraternity ; in the
more progressive surgical centers this was uliw very

generally bemg recognized as a great mistake. Cases
of aneuria, among many others, were singularly suitable
for the induction of anesthesia by gas — there was indeed
a very long list of capital operations in which for a half
hour or more anesthesia might, without detrimeiu to
the surgeon and with lasting benefit to the patient, be
used to the exclusion of ether or chloroform. Opera-
tions in two specific regions, namely, the perineum and
within the abdomen, were not favorably conducted under
gas. One objection to the employment of gas lay in its
relatively great cost. It averaged about two dollars an
hour. Certain savings in this cost might be effected,
however, if hospitals were to make their own gas — a
plan that was practical to follow.

Dr. Powers of Denver made a motion embodying the
suggestion of the chairman and requesting the section to
create a Commission on Anesthetics which should con-
sist of three or five men — one of them to be the chair-
man of the section, the others prominent men qualified
specially to carry on investigations along the lines of in-
terpreting and correlating the great mass of information
regarding anesthetics now' available at every hand, but
not made the fullest use of. This commission was to
have the power to create sub-commissions in special re-
gions and was to report to the Section on Surgery and
Anatomy the result of its findings every year. Its ex-
penses were to be paid by an appropriation to be voted
by the trustees.

Dr. Rodman of Philadelphia seconded the motion —
said he regarded the creation of an Anesthetic Com-
mission similar to that of the British Empire, and espe-
cially its reporting to the surgical section, as a most im-
portant and valuable departure.

Intestinal Perforation in Typhoid Fever; Its Sur-
gical Treatment, with Report of a Case. — Dr. J E.
.'Ku.ABEN of Rockford, III., read this paper. He gave a
full but concise summary of the literature of the subject.
He spoke of the improvement in the death rate, which
had been lowered by about ten per cent, during the past
four years. Fully ninety-five per cent, of the perforations
occurred in the ilium, although there were a suflicient
number in the colon to make every search which did
not fully include that organ incomplete. Coma had. in
earlier days, been considered a valuable point diaguos-
tically. but it was now well established that to wait for
its appearance in a suspected case was to sacrifice all
hope of saving the patient. Pain, rigidity, and tender-
ness to pressure were the cardinal symptoms calling for
operation. The value of the leucocyte count to which
Cushing had called attention was lessened by the fact
that it frequently occurred in transient waves. Buxton's
experiments, which showed the importance in germ ab-
sorption of the lymphatics of the diaphragm, proved that
flushing of the abdominal cavity after operation was not
alone not indicated, but was evidently positively danger-
ous, for it carried the germs to the diaphragm whence
they might easily be absorbed.

Dr. Murphy of Chicago laid great stress on the need
of early operation. Hyperleucocytosis was frequently ab-
sent. He urged the importance of washing the system
out by properly conducted and continuous proctolysis. This
to be well done should be induced by saline flowing con-
tinuously from a level just high enough to overcome intra-
abdominal pressure — not from a considerable height —
with the tube clamped so that the saline might run in
drop by drop. He urged, further, the wisdom and neces-
sity of a careful examination of the colon for perfora-
tion.

Dr. L. J. H.vMMONii of Philadelphia spoke of the value
of surgical prophylaxis. Most cases of perforation, he
thought, were due to the preexistence of some lesion —
such as adhesions or ulcers in the typhoidal bowel. He
believed th.it perforations in typhoid rarely occurred ex-

966

MEDICAL RECORD.

[June 8, 1907

ccpt in tlic prcfcncc of such antityplioiil ksioiis and ad-
vised, therefore, that in all individuals whose history was
known well enough to justify the supposition that lesions,
non-typhoidal. existed, should be subjected to operation
at once. Such lesions he thought were indicated by the
appearance of abdominal symptoms very early in typlioid
fever.

Dr. Allabcn in closing said that collapse was due to
the liberation of endoto.xins in the blood — due to break-
ing down of the bodies of bacteria.

An Operation for Exstrophy of the Bladder. — Dr.
John T. Bottomlev of Boston read this paper. He dis-
cussed the shortcomings of the three classic types of op-
eration for this abnormality and showed that in each there
seemed to be an insuperable difficulty yet to be overcome.
The first was the plastic, in which substitutes were made
for the deficient wall of the bladder. The second was the
making of a new reccptable. The tliird was the di-
version of the urinary stream. The operations on the pel-
vic girdle, many of which were brilliant, were neverthe-
less attended with a mortality of twenty-eight per cent.
As to the employment of the rectum as a reservoir of
urine, he said that even after the brilliant work of Madyl
we were still unable to do it satisfactorily and without
great danger, either of intestinal leakage or of ascending
infection. For nothing could be more surgically unclean
than the sigmoidal mucosa. Eight per cent, died of peri-
tonitis and the operation was dangerously long. It was
to be borne in mind, however, that by no means all cases
of pyelonephritis were due to operative intervention, for
the very nature of the abnormality itself predisposed to
such a condition. Patients suffering from it rarely at-
tained to their twentieth year. He urged the transplan-
tation in certain selected cases of the ureters to the loins
and the utilization by the patient of a well fitting rubber
girdle which kept the skin dry and was eminently prac-
tical. Loin skin, he said, could be kept clean and thus
much less septic and unsurgical than sigmoidal mucosa.

Dr. H. H. Young of Baltimore said that the subject was
still an open one, whether it were better to employ a
permanent drainage tube from the kidney, as he had fre-
quently done, or to make use of ureteral transplantation
to the skin.

Dr. Bottomlev in closing said that he never intended
to suggest that this operation should supersede certain
others, but that it be employed in specific chosen cases
which were suited to it.

How May Our Present Methods of Medical Illustra-
tions Be Improved? — Mr. M.\x Brodel of Baltimore
read this paper. He contrasted the excellent character
of some of the illustrations in the lay press with the in-
ferior work frequently appearing in the medical publica-
tions. .*\n important reason for this law in the inability
or unwillingness of the artist thoroughly to familiarize
himself with the subject of his work from both physiologi-
cal and pathological standpoints. The artist should know
more of science and the scientist more of art. He showed
how outline illustrations of specific regions might be use-
ful to surgeons in presenting important details to artists for
their elaboration.

Dr. \ViLLi.\M M.\Y0 said that the entire profession owed
Mr. Brodel a debt of gratitude for his development of
an entirely unique school of artists. He said that much
of the medical literature which had been so ably illus-
trated by Mr. Brodel had been intelligible to him only after
a study of the illustrations.

Gall-Duct Obstruction Caused by Movable Kidney. —
Dr. M.^RTIN B. Tinker of Ithaca. X. Y., read this paper.
He referred to the known frequent association of biliary
tract affections with diseases of the stomach, pancreas, and
appendix. The connection between these lesions and mov-
able kidney had, however, but in rare instances been dwelt
upon. His personal experience had led him to the con-

clusion that the movable kidney, pressing upon or ad-
herent to the duodenum and common duct, was a not
infrequent cause of biliary obstruction. He recited in
detail the history of two cases which illustrated and sup-
ported this belief. He believed that nephropexy com-
bined with cholccystostomy would almost always aflford
relief.

Bier's Treatment in Chronic and Acute Surgical
Aflections. — Dr. Willy Meyer of Xew York read this
paper. He said that even to-day, more than ten years
after its discovery, this admirable addition to the prophy-
lactic treatment of wounds had been but little employed
in America. During the past few years, however, its
advantages seemed to have become more generally ap-
preciated and as a consequence the literature of the
subject was growing at a very rapid rate. He considered
that the results following its employment in chronic bone
disease might be simply astonishing. He had seen a
tuberculous elbow recover in a few months under moderate
elastic compression of the arm and the results were equally
gratifying when the method was employed to combat
acute local extremity infections which were tending to
become generalized. He concluded that, however applied,
whether by compression by cups or by hot air, hyperemia
was a most valuable aid to surgical therapeutics.

Dr. S'cH.MiEDEN of Berlin, one of Bier's assistants, spoke
of the very general manner in which the treatment was
employed in Germany and expressed the hope that all the
.\merican hospitals would give it a trial.

Dr. HoLLisTER of Chicago said that hyperleucocytosis
was by no means so important a factor resulting from the
hyperemia as was hyperobsination. He cited a most in-
structive series of cases in which experimental observa-
tion had proven that the opsonic index of the serum ex-
uding from a sinus was below one, while after treatment
it rose to one or plus one. Further, the series show-ed
that by combining the congestion treatment with vaccine
therapy the best results were obtained.

Dr. SiMiTHiES of Ann Arbor said that there were very
marked limitations to the compression treatment — that it
was capable, if not properly employed, of causing much
damage. This was particularly to be feared in anemic
cases, such as arthritis deformans and chronic rheumatism.

SECTION ON DISE.^SES OF CHILDREN.

Tuesday, June 4 — First Day.

The Status of the Child. — Dr. J. Ross Snyder of Bir-
mingham. .Via., presented the Chairman's address. Cer-
tain changes in our way of living would seem impera-
tive if the integrity of the nation was to be preserved.
The rapid increase in the number of defective and
degenerate persons called for the better safeguarding
of the children of to-day in order to insure an oncom-
ing generation of well-equipped individuals. Some of
the evils that beset children were associated with their
home life, and in this connection the physician could
render lasting service to the country. The position
assumed by modern society with reference to the un-
born child had been such that physicians rather shrank
from approaching the subject. This should not be so,
however, and physicians should instruct the prospec-
tive mothers under their care in matters pertaining to
the care of the child. Enough consideration was not
given by physicians to the conditions which surrounded
the mothers of the country. .Attention was called to
the increasing tendency on the part of women to adopt
measures for the prevention of conception — a tendency
born, many times, of fear engendered in the minds of
newly married women by stories told by older women
of the horrors of child-bed. It should be the duty of
the physician to overcome this fear in the minds of
women, and to so educate and prepare the expectant

June S, 1907]

MEDICAL RECORD.

967

mothers in matters pertaining to the child's needs tliat
b.er later duties will be less arduous. A failure on tlio
part of tlie mother to furnish her child with a sufficient
supply of natural food tended to make motherhood
burdensome. A large proportion of defectives and
degenerates in America came not from homes of pov-
erty, but from homes of wealth, for the thoughtless
care of children was confined to no status of society.
A strong plea was made against child labor. Pliy-
^icians took just pride in the part they had played in
liringing about various reforms with reference to cliil-
dren; in the direction of .suppressing obscene litera-
ture, however — chief and probably most harmful of
which is the modern newspaper — it w^ould seem that all
efforts were unavailing.

Some Needs of Institution Children. — Dr. Joiis
Ruhr.Kh of Baltimore, Md., read this paper, in which
he outlined the general causes which led to failure on
the part of institutions to raise children coming under
their care. Certain requirements should be adhered to.
First of all, the matter of ventilation should be looked
after. One thousand cubic feet of air space should be
provided for a child under one year of age. Under no
circumstances should admission to the instiuuion be
allowed to exceed the capacity of the wards. Children
>hould be kept out of doors as much as possible. .\
strong plea was made for the separation of sick from
nell children and for the prompt isolation of infectious
diseases. A special ward, kept at a higher temperature
than the others, should be provided for congenitally
weak children. Each ward should have a competent
trained attendant. Babies should not be kept in bed
all the time, and should not be fed in bed. The nurses
should be allowed ample time for that most important
factor in the care of children in institutions — ^the
"mothering" of the child. He advocated simplicity in
diet.

Dr. Graham of Philadelphia emphasized the im-
portance of the requisite air space, and of out-door life.
This had not been appreciated in institutions until
within the past few years. He wished, also, to empha-
size what the reader of the paper had said about nurses.
In very few hospitals and institutions devoted to the
care of children would it be found that nurses were
allowed sufficient time for "mothering" the children
under her care. \'ct he considered this a very important
factor. The feeding of the infant in hospital and insti-
tutional practice was a subject to which much atten-
tion had been directed, and he was surprised to hear
what Dr. Ruhrah said on ibis subject.

Dr. Shaw of Albany. X. V.. thovight Dr. Fvuhrah had
idealized the requirements tor ihe institutional care of
children. One thousand cubic feet of air space might
be provided and yet the ward not have sufficient fresh
air. In the institution with which he was connected,
which received only children under one year of age, in
some of the wards there was not more than three hun-
dred feet of air space, yet results were very good, the
mortality being not more than seven per cent. .Ml of
the children were artifically fed. Great importance was
attached to ventilation in this institution. In the upper
sash of each window the glass was replaced by cheese-
cloth, which was true in winter as well as in summer.
and the difficulty had been nol in keeping the wards
w-arm, but in keeping them cool in winter. The small-
est ward accommodated three children and the largest
nine. In summer the children were kept out of doors.
He considered the separation of the sick from the well
children of the utmost importance. The individual
needs of the child should be studied with reference to
diet, as had been suggested by Dr. Graham, but he

agreed with Dr. Ruhrah with reference to simplicity in
the matter of feeding.

Dr. Knox of Baltimore, Md., advocated wards for not
more than three children, and as far as possible that each
infant should be in a separate room. Children slept
much better in small wards. In summer they should
be kept in the open air practically all the time.

Dr. C. G. Kerlev of New York City agreed with the
preceding speakers as to the importance of air space,
ventilation, attendance, out-of-door air, etc., but the
feature wdiicli seemed to him of the utmost importance
was the complete emptying of the ward during the day.
Places should be provided for the day and sleeping
rooms for the night. In institutions with which lie
had been connected the mortality had markedly de-
creased under this regime.

Dr. Ruhrah, in closing the discussion, said that the
point he wished to make with reference to feeding was
that it was much easier to feed a child who is well
taken care of than one who is not.

The Relation of the Physician to Defective School
Children. — Dr. W. C. Hollopeter of Philadelphia, Pa.,
in this paper contrasted the requirements for the fourth
grade child in the public schools of Philadelphia in
1888 with those for 1907, and showed that the school
life of the child of to-day is so complex that it leads to
great tension on the body as well as the mind. He con-
sidered this ever-increasing strain a menace to the
child's natural mental development and the cause of
serious impairment of health. This condition of affairs
was in a large measure the result of the modern tend-
ency to "child study"— a tendency which he was in-
clined to deprecate. He agred with the statement that
much of the delinquency of our time was the result of
what had been characterized as the "grinding monot-
ony of school life." He emphasized the fact that per-
fectly normal children develop different faculties at
different ages, and that this should be taken into
account in the grading of school children. The per-
sonal equation should be more fully studied as to phys-
ical and mental development. The danger of over-
reaching the child's capacity should be borne in mind.
The power of fixing the attention was an important
factor in the process of mental development, and
should really be the true standard of grading, regard-
less of the child's age. It was only wdthin recent years
that the physician had anything to do with the grading
of school children. Only within recent years had any
effort been made to deal with the distinctly defective
classes. This was a step in the right direction. Med-
ical inspection should be more thorough and the mental
and physical defects of school children should be re-
moved in early life.

Dr. A. C. Cotton of Chicago thought ihc Section
should go on record as formulating some plan for recti-
fying the abuses of modern education. He deprecated
the inefficiency of medical inspection of school children
as it is usually practised. He considered it the duty of
every medical organization that deals with the disorders
of children, particularly if it deals with the hygiene of
the developing period, to make itself heard on this
subject. It was the part of true economy to weed out
ihe defectives and place ihem in special grades to which
lliey properly belonged. He believed the time would come
when honest medical inspection will include the fitness
of the child for the mental work expected of him and
his readiness for promotion to a grade requiring dif-
ferent work.

Dr. A. W. Fairbank of Boston, .Mass., gave a preliminary
statement of the results of a clinical study of fifty back-
u-anl girls between the ages of twelve and sixteen, forty-six
per cent, of whom showed a marked discrepancy between

968

MEDICAL RECORD.

[June 8, 1907

the actual age and the development. N'iiiety-two per cent,
were of the age when puberty devekips. yet in tifty-two
per cent, there was no evidence of such deveU>pment. Only
four out of the fifty showed definite anatomical stigmata.

Dr. Brown of Elmira was of the opinion that the nervous
breakdowns in school children were not attributable to the
school work alone, but to various outside factors, — social
duties, music lessons, etc.

Dr. HoLiX)PETER, in closing the discussion, expressed the
opinion that teachers and boards of education were not to
be too severely criticised, as much of the fault of the pres-
ent conditions of affairs rested with physicians. He ad-
vocated paying more attention to physical development.

A Preliminary Report on the Etiology of Infantile
Atrophy. — Dr. A. H. Wentworth of Boston, Mass., said,
in this paper, that the etiology of infantile atrophy had long
been a mooted question, which is still far from settled. He
reviewed briefly the various theories, and outlined his in-
vestigations, which were undertaken upon a functional basis.
This series of comparative experiments consisted of twenty
observations. Cots were used for the purpose and the ex-
periments were conducted after Heidenhain's method.
Within a minute or two after the injections of secretin
pancreatin flowed out through the cannula. The total time
that the pancreatic juice ran was as important as the quan-
tity thereof. This varied from nine to fifteen minutes. The
theory upon which these experiments were based was that
in infantile atrophy the digestive functions are not normally
activated because infants do not obtain suitable food at an
early age, and that the derangement of one function upsets
another, and this in turn still another, until notliing goes
right.

Dr. A. \\". Fairb.^nks of Boston. Mass.. reviewed briefly
Edsall's theory which, he thought was reasonable. It was
based upon the fact that protein is more complex than
formerly thought, and that its end products constitute the
building blocks, so to speak, of the proteid molecule. Syph-
ilis was thought to be a factor in producing infantile
atrophy, and in all these cases this should be borne in mind.
He cited illustrative cases.

Dr. Gr.\h.\m of Philadelphia said it was not uncommon
to find cases in which the amount of atrophy was out of
proportion to the failure of digestion and absorption, and
it was interesting to note that autopsy in such cases gives
nothing upon which to base a diagnosis. He hoped Dr.
Wentworth would continue his experiments along this line.

Dr. Wentworth. in closing the discussion, said the
motif of the whole subject was to give the child suitable
milk.

The Ferments of Milk and Their Relation to Pasteur-
ization.— Dr. RciwL.\.ND G. Freem.vn ga\e. in this com-
munication, a brief resume of the history of the pasteuriza-
tion of milk, calling attention to the supposed injury to milk
by high temperatures. He emphasized the indisputable ad-
vantage of breast milk. Escherich's theory of the ferments
was outlined and tables were presented showing the fer-
ments of breast milk and cow's milk, and the tempera-
tures that destroy each. These facts were applied to
pasteurization.

This paper was discussed by Dr. Keki.ev. Dr. Cotton,
and others, and the discussion closed by Dr. Freeman.

A New Form of Amputation Stump. — \'anghetti has

successfully employed a new method of forming the stump
in two cases of amputation. Fhe procedure consists in
fashioning a loop lined with skin from the tendons of the
stump, through which loop a cord can be passed that is
fi.xed to the prosthesis and in this way a certain amount
of voluntary control over the latter may be secured. In
one case the tendons of the biceps and triceps were united
and the loop so formed converted into a permanent open-
ing by the transplantation of a skin flap, and in the other
the flexor and extensor tendons of the forearm were made
use of in a similar wav. .

^tatr Mthiitxi ICtrrttHtng Soarbfi.

STATE BOARD EXAMINATION QUESTIONS.*

Indiana State Bo.\rd of Medical Registration and
e.xamination.

October 23, 1906.

CHEMISTRY.

1. What is carbolic acid? Give antidote.

2. What is calomel?

3. What is the specific gravity of healthy urine? Give
test for albumen, sugar, blood.

4. What is double decomposition ?

5. What is the difference between the mercurous and
the mercuric compounds ?

MEDICAL JURISPRUDENCE.

1. What is rigor mortis? How soon after death does it
begin ?

2. How would you determine whether an infant was
still born or had been killed after birth?

NEUROLOGY.

1. Give cause, symptoms, and diagnosis of epilepsy.

2. Give the definition of dementia.

3. Give difference between concussion and compression
of the brain.

OPHTHALMOLOGY AND OTOLOGY.

1. How do you distinguish whether deafness is due to
nerve lesions or aural lesions?

2. Give etiology, diagnosis, terminations, and treatment
of chronic inflammation of the membrana tympani.

3. Give etiology, symptoms, and treatment of iritis.

PEDIATRICS.

1. Give cause and treatment for intestinal worms.

2. Give cause and treatment of nystagmus.

PHYSICAL DI.\GNOSIS.

1. Define the "Argyll-Robertson" pupil. In what dis-
ease is this condition often found?

2. How would you ascertain the shape and position of
the stomach?

3. At what age is the pulmonic second sound more in-
tense than the aortic? .■\t what age does the aortic second
sound predominate?

4. Give causes and symptoms of pulmonary atelectasis.

5. How would you diagnose alcoholic coma from the
coma of epilepsy?

PHYSIOLOGY.

1. Explain cell division.

2. What are the elementary tissues or structures of
which the human organism is composed?

3. Give the physiologic composition of the blood with
the function of each part.

4. If a sympathetic nerve be divided, what is the effect
upon the blood-vessels in the parts to which the nerve is
distributed, and why?

5. How long will an animal survive deprived of water?

6. Give the manner of the transmission of motor im-
pressions.

7. Give the origin, course, and distribution of the motor
impressions that effect respiratory movements.

RHINOLOGY AND LARYNGOLOGY.

1. Give some of the constitutional causes of epistaxis.

2. Give symptoms and treatment of chronic rhinitis.

AN.\TOMV.

I. Give diagram or brief description of (a) simple tubu-
lar, (b) simple convoluted, (c) compound racemose, and
(d) coiripound tubular glands.

•It Is proposed In this department to publish from time to
time the examination papers of the various State BoardB,
In order that a candidate may become familiar with th«
character of the examination and so in some measure free
himself In advance from the ner^'ousness and dread which
the unknown inspires. In furtherance of the same object
answers to some of the questions will be published In order
to show the candidate what the examiners expect of him.
Not all the questions of all the papers will be so treated,
for the answers to many, especially in the anatomical papers,
are obvious or can be found in the Index of any text-
oook on the subject; the answers to other questions. especlaJly
In the surgrlcal papers, must sometimes be omitted because of
the space they would demand. The candidate for a medical
license will not find In these answers a short and easy road to
success in the examination, for he Is not likely to meet the
same questions in the papers placed before him by the
examiners. The object of publishing the questions and
answers Is only, as noted above, to acquaint the candidate
with the general character of these examinations and to
Inspire him with confidence In the result of hts trlaL

June 8, 1907]

MEDICAL RECORD.

969

2. Give the boundaries of the thorax.

3. Give the muscles of the orbital region.

4. Give, in the order of their origin, the branches of the
external carotid artery.

5. Give, in the order of their origin, the branches of the
femoral artery.

6. From what regions do the lymphatic vessels convey
lymph to the axillary glands?

7. Give the openings communicating with the pharynx,

8. What muscles attach to the trochanter major?

9. Give general description of the spinal cord.

10. Give the principal nerve trunks of the arm, with
location of each.

ETIOLOGY AND HYGIENE.

Give cause and hygienic measures for the prevention of
(l) tuberculosis, (2) typhoid fever, (3) diphtheria, (4)
scarlatina, (s) variola (smallpox).

GYNECOLOGY.

1. Give pathology, etiology, and treatment of pelvic
peritonitis.

2. How would you conduct a physical examination? In
what position would you place your patient?

3. Describe the operation of trachelorrhaphy.

4. What are the indications for dilatation of the uterus?
Give technique of dilatation.

5. Give after-treatment in major operations (abdominal
sections)..

6. Define chronic metritis. Give etiology and patliology.

INTERNAL MEDICINE.

1. Define inherent body resistance to disease, and state
how it may be increased.

2. Give source, habitat, symptoms, and treatment of
taenia solium (tapeworm).

3. Give symptoms of true angina pectoris, and the
pathological conditions causing it.

4. Give clinical history of gastric ulcer, and dififerentiato
from (a) gastric carcinoma, (b) duodenal ulcer.

5. Give causes, symptoms, remote results, and treatment
of cirrhosis of the liver.

6. Define hematuria, and state how you would determine
the probable source of the hemorrhage.

7. Give cause, means of prevention, and treatment of
bed sores.

8. In what class of diseases is general aching a pro-
nounced symptom ?

9. Give etiology, symptoms, and treatment of dysentery
occurring in the temperate zones.

10. Give diagnosis and treatment of pertussis (whooping
cough).

MATERIA MEDICA AND THERAPEUTICS.

1. Define preventive medicine, and give illu.^tration of
its application.

2. Give derivation of ichthyol, and its therapeutic appli-
cation.

3. Give technique of introducing medicinal agents into
the organism hypodermatically.

4. Name three therapeutic agents which increase the
renal function.

5. Name three therapeutic agents which increase the
hepatic function.

6. Name some therapeutic agents which promote con-
structive metabolism.

7. Name some therapeutic agents which promote de-
structive metabolism.

8. Name some therapeutic agents which excite the func-
tions of the spinal cord and sympathetic.

9. Name some therapeutic agents which depress the
functions of the spinal cord and sympathetic.

10. Name some therapeutic agents which are germicidal
in their action.

PATHOLOGY AND BACTERIOLOGY.

1. Explain the difference between active and passive
hyperemia.

2. Give the modes of infection by the tubercle bacilli;
by the malarial hematozoa.

3. To what pathological conditions may passive hypere-
mia of the stomach be due, and to what may it lead ?

4. What pathological conditions may result from abnor-
mal conditions of the thyroid gland?

5. Give the conditions of the urine in nephritis.

6. Describe in detail the various forms of bacteria which
are known to be the cause of pneumonia.

7. Name the bacteria which may cause meningitis.

8. What tissues are usually invaded by the typhoid
bacilli during typhoid fever?

g. How would you prepare Loffler's blood serum ?

10. Describe the staining properties of the smegma
bacillus.

OBSTETRICS.

1. Describe the fetal circulation.

2. How and when should the umbilical cord be ligated
and cut?

3. State causes of the rupture of the perineum and how
prevented.

4. Give diagnosis and probable cause of tubal preg-
nancy.

5. Name diseases most commonly affecting the mammae
of the nursing mother.

6. Give cause and treatment of aphthre.

7. Give indications and contraindications for the em-
ployment of chloroform in labor.

8. When should ergot be employed in obstetric practice?

9. State cause, diagnosis, and treatment of porrigo lar-
valis. or crusta lactea.

10. Give cause and treatment of vomiting of pregnancy.

1. What is a compound fracture?

2. Give diagnosis of inguinal hernia.

3. What is an aneurysm?

4. Give diagnosis and treatment of appendicitis.

5. What conditions justify amputation of a limb?

6. Give symptoms and treatment of intestinal obstruc-
tion.

7. Give a description of Chopart's operation.

8. What are the symptoms and treatment of depressed
fracture of skull ?

g. Give symptoms and treatment of hydrocele.

ID. Give symjitoms and treatment of downward disloca-
lion of head of humerus.

.\NSWERS TO STATE BOARD EXAMINATION
QUESTIONS.

Indiana State Board of Medical Recistratidn and
Examination.

October 23, 1906.

CHEMISTRY.

1. Carbolic acid is phenyl hydroxide : CeHjOH. Its anti-
dote is alcohol or magnesium sulphate.

2. Calomel is mercurous chloride : HgsCU.

3. The specific gravity of healthy urine is from 1015 to
1025.

Test for Albumin. — The urine must be perfectly clear.
If not so, it is to be filtered, and. if this does not render it
transparent, it is to be treated with a few drops of magnesia
mixture, and again filtered. The reaction is then observed.
If it be acid, the urine is simply heated to near the boiling
point. If the urine be neutral or alkaline, it is rendered
faintly acid by the addition of dilute acetic acid, and
heated. If albumin be present, a coagulum is formed, vary-
ing in quantity from a faint cloudiness to entire solidifica-
tion, according to the quantity of albumin present. The
coagulum is not redissolvcd upon the addition of HXOj.

Test for Sugar. — Render the urine strongly alkaline by
addition of Na-COj. Divide about 6 c.c. of the alkaline
liquid in two test tubes. To one test tube add a very minute
quantity of powdered subnitrate of bismuth, to the other as
much powdered litharge. Boil the contents of both tubes.
The presence of glucose is indicated by a dark or black
color of the bismuth powder, the litharge retaining its nat-
ural color.

Test for Blood. — To the urine add a solution of p<.)tas-
sium hydroxide to distinct alkaline reaction; heat nearly to
boiling (do not boil). A red precipitate is produced.
(W^itthaus' Essentials of Chemistry.)

4. Double decomposition is a reaction in which both of
the reacting compounds are decomposed to form two new
compounds.

.=;. The mercurous compounds contain the bivalent group

I i / jorl Hg.2 I ; whereas th

e mercuric compounds con-

tain the single, bivalent atom Hg". They also differ in their
analytic characters ; thus with potassium hydroxide the mer-
curous salts give a black precipitate, and the mercuric salts
a yeltozc precipitate.

medical JUKISPRL'DENCE.

I. Rigor mortis is the condition of rigidity or contraction
into which the muscles of the body pass after death. It
begins at a period varying from about fifteen minutes to
about six hours.

9/0

m?:dical record.

[June 8, 1907

NEUROIXICY.

2. "Dementia, when confirmed, consists in a total ab-
sence of all reasoning power, and an incapacity to perceive
the true relations of things; the language is incoherent,
and the actions are inconsistent ; the patient speaks without
being conscious of the meaning of what he is saying; mem-
ory is lost, and sometimes the same word or phrase is re-
peated for many hours together ; words arc no longer con-
nected in meaning, as they are in mania and monomania.'
(Taylor's Medical Jurisprudence.)

3 —

CONCUSSION OF THE BRAIN.

Unconsciousness is incom-
plete; patient can be
made to answer, though
it may be briefly, and in
simple words.

Special senses, though
greatly blunted, arc not
abolished.

Power of movement not
destroyed ; if the po-
sition of a limb be
changed the patient will
resist or brin"- it imme-
diately into the original
position.

Respiration is quiet and
feeble.

Pulse feeble, frequent, and
intermittent.

The stomach sickens and
rejects its contents.

The feces may be dis-
charged incontinently,
as may also the urine,
though not usually.

Deglutition little impaired.

Pupils variable, though

generally cont r ac t e d ;

the eyelids somewhat

open.
Temperature of the body

less than natural.

COMPRESSION UK THE BRAIN.

Complete unconsciousness ;
may scream into patient's
ear at the top of the
voice, but will receive no
answer.

Special senses entirely sus-
pended.

Complete or partial paral-
yis; in most cases hemi-
plegia.

Respiration full and noisy.

Pulse full and slow, and
sometimes laboring.

The stomach is insensible
to any impression ; no
nausea or vomiting.

Bowels are torpid, and the
bladder incapable of emp-
tying itself, though the
urine may escape by
overflow.

Deglutition difficult or im-
possible.

Pupils variable, though
generally much dilated,
and the eyelids closed.

Temperature almost nat-
ural, a little below the
normal standard.

(From Treves' Manual of Surgery.)

OPHTHALMOLOGY AND OTOLOGY.

I. "If the ticking of a watch or the vibrations of a
tuning fork are heard faintly or not at all when held at
varying distances from the ear (aerial conduction), but
become distinctly audible when the watch or the handle
of the fork is placed in contact with the skull or mastoid
process (bone conduction), the deafness is of the ordinary
variety and due to aural disease. If, on the other hand,
watch and fork are heard indistinctly or not at all, both in
contact and at a distance, the deafness is due to some lesion
of the nerve or its connections. In the first case the nerve
is norma! and can appreciate vibrations brought by the bone,
while, through some fault in the mechanism, aerial vibra-
tions are not transmitted to the nerve endings. In the
second case the nerve is at fault and cannot appreciate vi-
brations, no matter how well they m.ay be conducted."
(P.utler's Diagnostics of Internal Medicine.)

PEDIATRICS.

1. Tapezvorm is caused by eating raw or insufliciently
cooked meat containing cysticerci. Treatment: Give a
dose of castor oil at night, and the following morning give
half a dram of freshly prepared extract of male fern, and
a few hours later give another dose of castor oil.

Round'^i'orm is caused by swallowing with the food the
ova of the ascaris lumbricoides. Treatment: .\ dose of
santonin and calomel should be given at bedtime for a
few nights, and a dose of castor oil the morning after the
last powder.

Scatiuorm, or Pinworm, is caused by swallowing the ova
of the oxyuris vennicularis with the food or water, or it
may be conveyed to the mouth by the fingers. Treatment:
A large enema of a cold infusion of quassia. Care must be
taken to prevent reinfection.

2. Nystagmus is caused by some irritation affecting the
muscles of the eye. It may be vertical or lateral, and may
be due to the eye or to the central nervous system. The
cause can only be determined by a study of the other symp-

toms associated with it. Treatment : Tonics or bromides
are sometimes useful. Remove the cause if possible. If
due to occupation, the w ork must be chanced ; strabismus,
or errors of refraction, must be corrected.

PHYSICAL DIAGNOSIS.

1. Argyll-Robertson pupil is a condition in which the
pupil accommodates for distance but not for light. The
condition is chiefly found in locomotor ataxia and paretic
dementia.

3. The pulmonic second sound is more accentuated in
childhood ; the aortic second sound is more accentuated in
adult life.

S. Alcoholic coma : The patient can generally be
aroused ; the coma is not, as a rule, complete ; the face may
be flushed; the pupils are normal or dilated; the respira-
tions are normal in frequency, but deep ; the skin is cool
and moist, and the body temperature may be below normal.

Coma of epilepsy: History of attack, with previous con-
vulsion ; the coma is of brief duration, and the unconscious-
ness Tradually becomes less ; there may be a bitten tongue
or other scars.

PHYSIOLOGY.

2. Epithelial tissues, connective tissues, muscular tis-
sues, and nervous tissues.

3. Physiological composition of the blood :

1. Plasma.

i Colored.

2. Corpuscles -! Colorless.

( Blood-plates.

Functions :

Plasm conveys nutriment to the tissues ; it holds in
solution the carbon dioxide and water which it receives
from the tissues, and takes them to be eliminated by the
lungs, kidneys, and skin ; it also holds in solution urea and
other nitrogenous substances that are taken to and excreted
by the liver or kidneys.

Colored corpuscles carry oxygen from the lungs to the
various tissues of the body.

Colorless corpuscles act as a protection against bacterial
invasion.

Blood-plates are supposed to take some part in the
process of coagulation.

4. If a vasoconstrictor nerve is divided, the arteries sup-
plied by it are relaxed, more blood flows to the part, the
blood current is accelerated, and congestion results. If a
vasodilator nerve is divided, there is little or no change in
the blood-vessels supplied by it.

5. From seven to ten days, without either water or food.

6. Motor impressions travel from the cortex of the
cerebrum, through the corona radiata, internal capsule,
crus, pons, medulla, crossed or direct pyramidal columns,
to the motor cells in the anterior horn of the spinal cord;
thence through the motor nerves to the muscles indicated.

7. The origin of the impulses is at the respirator>- cen-
ter in the medulla. The phrenics and intercostals are the
chief nerves conveying the impulses; and they are distrib-
uted to the diaphragm and intercostal muscles, respectively.

RHINOLOCY AND LARYNGOLOGY.

I. Some of the constitutional causes of epistaxis are :
Hemophilia, pernicious anemia, leukemia, scurvy, purpura
hjemorrhagica, cerebral congestion, hypertrophy, and
valvular lesions of the heart.

ETIOLOGY AND HYGIENE.

Tuberculosis
Typhoid fever
Diphtheria
Scarlatina
Variola

Caused by.

Bacillus tuberculosis, of Koch.
Bacillus typhosus, of Eberth.
Bacillus diphtheriae, of Klebs-Loeffler.
Microorganism not yet ascertained.
Microorganism not yet ascertained.

INTERNAL MEDICINE.

2. Tcenia Solium. Source: The encysted larvse or
scolices, which come from the proscolices, which in turn
are derived from the ova of the tapeworm. Habitat : In the
larval state this parasite exists in the hog. Symptoms:
Often there are no subjective symptoms; there may be
dyspepsia, emaciation, ravenous appetite, nausea, vomiting,
colicky pains, vertigo, chorea, itching of the nose. The
diagnosis is made from finding segments or eggs in the
dejecta. Treatment: The patient should be limited to a
liquid diet for two days ; salines should then be adminis-
tered : then the oleoresin of aspidium in a dose of one to
two drams, followed in a few hours by another saline. The
treatment can only be considered successful when the head
of the worm is found in the dejecta.

3. The symptoms of true angina pectoris are : Excru-

June 8, 1907]

MEDICAL RECORD.

97'

tiating pain radiating from the heart to the neck, shoulder,
and arm (generally the left) ; a sense of impending death;
cardiac constriction ; the face is anxious and pale ; cold
perspiration and sometimes dyspnea

The pathological conditions causing it are : Arterio-
sclerosis, chiefly of aorta and coronary arteries ; there may
be myocarditis and endocarditis, chiefly associated with
aortic regurgitation or adherent pericardium ; the predis-
posing causes of arteriosclerosis may also be present, chiefly
syphilis, alcoholism, and gout.

'4. Diagnosis: Gastric uUcr is general'-- caused by in-
jury or bacteria. 15 most apt to occur between the ages of
twenty and forty-live; after eating there is pain localized
in the stomach, vomiting occurs soon after eating,
hematemesis is common, there is localized tenderness over
the stomach, and examination of the gastric contents shows
an excess of free HCl.

Gastric carcinoma does not usually occur before forty
years of age. is more common in males, the pain is localized
and constant, vomiting is copious and occurs some time
after eating; the vomitus contains "coft'ee ground" material ;
hemorrhages are common ; a tumor may be palpated, and
examination of the gastric contents shows absence of free
HCI and presence of lactic acid; severe anemia and ca-
chexia are also present.

In Duodenal tdcer the pain is apt to be more to the right,
and to occur at an interval of two or three hours after
meals ; the hemorrhages will be intestinal, and the blood
will be passed by way of the bowels, and not vomited. In
many cases the symptoms are identical with those of gastric
ulcer.

6. Hematuria means blood in the urine. In renal hema-
turia the blood and urine are intimately mixed, tube casts
are apt to be present, and there may be renal colic or pain
in the lumbar region. In vesical hematuria the blood and
urine are not so well mixed, and pure blood is apt to be
passed at the end of urination. In urethral hematuria the
urine first passed is bloody.

7. Bedsores may be caused by undue pressure and irri-
tating secretions; a crease or fold in a sheet, a crumb of
bread, a feather, or a bit of string on the sheet may cause
them. Especially is this so when the skin is irritable from
excessive perspiration, inefficient washing, or involuntary
passages of urine. Bedsores are particularlv common in
spinal affections and in wasting diseases.

Prevention consists in reducing the pressure, careful re-
peated washing, drying, and dusting with zinc oxide, and
subsequent protection with lint or cotton-w-ool. etc. Leather-
backed adhesive plaster may be applied over bony promi-
nences, or, if seen early, collodion may be used. Frequent
rubbing with alcohol may prove a preventive. When con-
gestion appears, a w-ater-bed or air-cushion may be used.
Spirits of camphor or glycerol of tannin may be rubbed in
twice daily, to harden the skin. Salt and alcohol (two
drams to the pint) may also be used.

Treatment : A solution of silver nitrate may be used
when the skin is about to break, in the strength of gr. 20 to
the ounce; and in solution of gr. 10, daily, when the skin
breaks. The sloughs should be removed as fast as they
form. Stimulation, good nourishment, and sleep are valu-
able in treatment. ( From Gould and Pyle's Cyclopedia of
Medicine and Surgery.)

8. General aching is a pronounced symptom in some of
the acute infectious fevers such as influenza, dengue, and
smallpox. It may also be present in tonsilitis, rheumatism,
and syphilis ; also in poisoning by lead or mercury.

M.^TERIA MEDICO AND THERAPEUTICS.

T. Preventive medicine is the application of medical sci-
eace to the task of preventing or mitigating disease. Ex-
ample : Vaccination to prevent smallpox.

2. Ichthyol is obtained from ichthyosulphuric acid, which
comes from a crude oil obtained by destructive distillation
of fossil fish found in the earth in the mountains of Tyrol.
It is used in inflammatory conditions generally, erysipelas,
rheumatism, and certain chronic skin diseases.

4. Three therapeutic agents which increase the renal
function: (i) Water, (2) alcohol, i^i) spirits of nitrous
ether.

5. Three therapeutic agents which increase the hepatic
function: (i) Sodium salicylate, (2) corrosive sublimate,
(3) podophyllin.

6. Some therapeutic agents which promote constructive
metabolisip : Iron and its preparations, potassium perman-
ganate, bismuth, arsenic, cinchona and its preparations,
mineral acids, phosphorus, massage, fresh air.

7. Some therapeutic agents which -^romote destructive
metabolisrti : Iodine, potassium, sodium, lithium, mer-
cury, calcium, barium and their preparations; vegetable
acids.

8. Some therapeutic agents which excite the functions of
the spinal cord and sympathetic : Alcohol, strvchnine, elec-

tricity, massage, ether, camphor, digitalis, sparteine, ergot.

9. Some therapeutic agents which depress the functions
of the spinal cord and sympathetic: Opium, belladonna,
large quantities of alcohol, chloral hydrate, aconite, physos-
tigma, pilocarpus, tobacco, amyl nitrite.

10. Some therapeutic agents which have a germicidal
action: Oxygen, sulphur, corrosive sublimate, carbolic acid,
iodine, chlorine, staphisagria, heat, formaldehyde, creolin.

PATHOLOGY AND BACTERIOLOGY.

1. Active hyperemia means that there is an excess of
arterial blood in a part, and is generally accompanied by an
increase in the rate of blood flow. In passive hyperemia
there is still an excess of blood, but it is in the veins and
capillaries ; and the blood flow is retarded.

2. Modes of infection by the tubercle bacilli: (i) By
inhalation, (2) by inoculation, (3) by being taken in with
food.

Mode of infection by the malarial hematozoa : By the
bite of the anopheles mosquito.

3. Passive hyperemia of the stomach may be due to
cirrhosis or other hepatic diseases causing portal obstruc-
tion, also to some pulmonary disorders which interfere with
the flow of blood from the right ventricle. It may lead to
chronic gastritis.

4. Cretinism, goiter, myxedema, cachexia strumipriva.

5. "Acute Diffuse Nephritis. — The urine is <?reatly dimin-
ished in amount (four or five ounces in twenty-four
hours), or is even totally suppressed. It is smoky, black-
ish, or of a chocolate color. The specific gravity is high.
Albumin is found in laree amount, and the heavy deposit
contains abundant red corpuscles, blood, hyaline, and epi-
thelial tube casts. The total urea is lessened.

"Chronic Diffuse Nephritis. — The quantity of urine is
diminished, it is cloudv from urates, the specific gravity
may be high in the early, but is low in the later stages.
Albumin is abundant, sometimes more so than in any other
disease. The heavy sediment contains large numbers of
nearly all the varieties of tube casts, hyaline, epithelial,
granular, and fatty. The latter are especially characteristic.
Occasional red corpuscles, many leucocytes, and numbers
of degenerated epithelial cells are also found. The amount
of urea is decreased.

"Chronic Interstitial Nephritis. — The urine is increased
in quantity, light yellow, clear, with a persistently low spe-
cific gravity. Albumin is scanty, occurring in traces, and
is sometimes absent. A few narrow hyaline casts are al-
most constantly found in the very small deposit. Cellular
elements are as a rule no more abundant than in normal
urine. Polyuria, persistent low specific gravity, and the
presence of a few hyaline casts constitute the urinary signs
of this disease. Albumin may or may not be present in
small quantity." (Butler's Diagnostics of Internal Medi-
cine.)

7. The bacteria which may cause meningitis are: (i)
Diplococcus intracellularis meningitidis, (2) tbe pneumo-
coccus, (3) Streptococcus pyogenes.

8. The tissues usually invaded by the typhoid bacilli dur-
ing typhoid fever are : The lymphoid tissue of the small
intestine, lymph nodes of the mesentery, the spleen, gall-
bladder, urinary bladder.

9. Loffler's blood serum consists of one part of bouillon
(containing one per cent, of glucose) and three parts of
liquid blood serum. This should be well mixed, poured into
tubes, and sterilized, or raised to 65° C. one hour a day for
three days.

10. The smegma bacillus is like the tubercle bacillus in
that it stains with carbolfuchsin and resists the decolor-
izing action of dilute mineral acids. But it is decolorized
by absolute alcohol.

OBSTE-TRICS.

4. Diagnosis : "When extrauterine pregnancy exists
there are: (l) The general and reflex symptoms of preg-
nancy; they have often come on after an uncertain period
of sterility; nausea and vomiting appear a'-'"-ravated. (2)
Then comes a disordered menstruation, especially metror-
rhagia, accompanied with gushes of blood, and with pelvic
pain coincident with the above symptoms of nregnancy;
pains are often very severe, with marked tenderness within
the pelvis; such symptoms are highly suggestive. (3) There
is the presence of a pelvic tumor characterized as a tense
cyst, sensitive to the touch, actively pulsatine; this tumor
has a steady and progressive growth. In the first two
months it has the size of a pigeon's egg; in the third month
it has the size of a hen's eg?; in the fourth month it has
the size of two fists. (4) The os uteri is natulous; the
uterus is displaced, but is slightly enlarged and etnnty. ( =; >
Symptoms No. 2 may be absent until the end of the third
month, when suddenly they become severe, with spasmodic
pains, followed by the general symptoms of collapse. (6)
Expulsion of the decidua. in part or w-hole. Nos. I and 2

972

MEDICAL RECORD.

[June 8, 1907

are presumptive sisns;. Nos. 3 and 4 are probable ^'S>'s:
Nos. 5 and 6 are positive signs." (^American Text-Book
of Obstetrics.) . .

Probable cause: Some pathological condition in the
Fallopian tube which obstructs the passage of the teciin-
dated ovum. The most common condition is salpingitis,
especially of the gonorrheal variety.

5. Sore nipples; caked breast; mastitis, which may be
subcutaneous, parenchymatous, or submammary; galacto-
cele. ,

6. Cause of Aphtlus: Predi5.posing causes are unclcan-
liness, lack of hygienic conditions, improper feeding. The
exciting cause is unknown; various micro<irganisms have
been found in this condition, but none of them is recog-
nized as the etiological factor.

Treatment: Cleanliness, proper hygiene, proper feeding,
mouth wash of salt solution or boric acid : the ulcers may
be brushed with a nitrate of silver solution (S to 10 grains
to the ounce), and a dose of castor oil or a few grains of
calomel (in divided doses) should be administered.

SURGERY.

5. Conditions which justify amputation of a limb are:
"Any injury, disease, or malformation rendering retention
of the limb incompatible with life or comfort; avulsion of
limb; compound fracture; compound dislocation; fracture
with great comminution of bone; laceration of important
vessels; extensive contusion: extensive laceration; gunshot
injuries; aneurysm; effects of heat and cold; gangrene; ex-
tensive bone disease ; tumors ; elephantiasis : tetanus ;
bite; deformities." (Bickham's Operative Surgery.)

iHelitral dltftna.

• Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious disease reported to the
Sanitarv Bureau, Health Department, New York City, for
the week ending May 25, 1907 :

snake

BULLETIN OF APPROACHING EXAMINATIONS.t

TATE.

NAME AND ADDRESS OP PLACE AND DATE OF

SECRETARY. NEXT EXAMINATION.

Alabama* W. H. Sanders, Montgomery. . Montgomery . . Ju y 1

Arizona* Ancil Martin, Phoenix F^oenix. ... . Ju y

Arkansas* F. T. Murphy. Brinkley Little Rock, . -July

California Chas. L. Tisdale. Alameda.. . .San Francisco . August

Colorado S. D. Van Meter. 1723 Tre-

mont Street. Denver Denver July

Connecticut*.. .Chas. A. Tuttle. New Haven. .New Haven. . .July

Delaware J. H. Wilson. Dover Dover. June

Dis of Col'bia. .W.C.Woodward. Washington. W ashington.. .July

Florida* J. D. Fernandez. Jacksonville. Jackson\T]Ie. . . >>oy.

Georgia E. R. Anthony, Griffin Atlanta X^°C^'

IdahS J. L Conant, Jr.. Genesee Boise October

Illinois J. A. Egan, Springfield Chica

Indiana W. T. Gott. 120 State House, r^ . %.„

Indianapolis Indianapohs. ..October

Iowa LouisA.Thomas.Des Moines. . Des Moines.. . .June

Kansas T. E. Raines, Cotcordia Topeka June

Kentucky*.. ..J. N. McCormack, Bowling ^ . i,

' ... J ^^^^^ Louisville October

Louisiana F. A. La Rue. 311 Camp St... .New Orleans.. .October

•.Maybury, Saco .\ugusta July

Scott, Hagerstown. . ..Baltimore June

„ Harvey. State House.

Boston Boston

Michigan B. D. Harrison. 205 Whitney

Building. Detroit Ann Arbor. . . June

Minnesota. . . . -.W. S. Fullerton. St. Paul St. Paul 0"°^"

Mississippi J. F. Hunter. Jackson.. . . .Jackson October

Missouri J.A B.Adcock. Warrensb g. . .Mexico fc7„v„

Montana* Wm. C. Riddell. Helena Helena October

Nebraska Geo. H. Brash. Beatrice Lincoln.. ..

Nevada S. L. Lee. Carson City .Carson City

N. HamDs're*..Henr>' C. Morrison. State Li-

brary. Concord Concord July 9

.J. W. Bennett. Long Branch. .Trenton June i8

.6. D. Black. Las Vegas Santa Fe December 2

/ New York. ■ ■ . 1
C F.Wheelock.Unv.of State ) .\lbany. ( j^ne j,

of New York. Albany. . . . ) SyTacuse. f

\ Buffalo. )

. .G. T Sikes. Grissom J.'o"';'?;'' *r'*'' i 1

i, i^«,.,^,. H M Wheeler. Grand Forks. .Grand Forks. .July 3

Ohio ■"■; '.Geo. H.Matson. Columbus.... Columbus June 11

oSahomai: . . J. W. Baker. Enid.. Guthrie June ..

O^^o- ^- E- Miller^Pon^and. . . . ■ PoTt^^nd^j,^; ; ,

Pennsylvania . .N. C. Schaeffer. Homsburg. ^ pjttsburg J ^""^

Rhode Island.. G T. Swartz. Providence Providence.. . .July

Louisiana r . a. i-a

Maine Wm. J. !

Maryland J. McP.

Massachusetts*. E. B. I

.July

. . August

New Jersey. .
New Mexico..

New York. . .

N. Carolina*..
N. Dakota.

Week of May 2^
Cases Deaths

Week of June 1
Cases Deaths

Tuberculosis Pulmonalis . .
DiDhtheria

437
.^ ' },

,So5

494

4
120

40

184
27
19

1 5

S
14
.30

328
332
623

5"
I

129

33
40

19

173

31

Measles

21

Scarlet Fever

29

Smallpox

Varicella

Typhoid Fever

WhooDinp Couffh

5
9

Cerebrospinal Meningitis . .

21

Totals

2286

297

20l6

289

i

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital
Service, during the week ended May 24, 1907 :

SMALLPOX V NIT ED STATES

-18..
-18..
-25- ■

16—23..
16-2J. .

-18..

-20. ,

-18.

-25.

19

18

S. Carolina..
S. Dakota..

25

California. San Francisco .May 1 1

Florida. Duval County — Jackson-

\'ille May ii

HillsboTO County— TampaMay 1 1

Illinois. Chicago May

Danville May

Springfield May

Indiana. Elkhart May 1 1

La Fayette May 13-

South Bend May ii-

Kansas. Kansas City May j i

Kentucky. Co\-ington May 15-22.

Louisville May 16-23.

Louisiana. New Orleans May 1 1-18.

Massachusetts. Lawrence May 1 1-18.

Michigan. Detroit May 18-25.

Saginaw May 1 j-i8.

New York, Niagara Falls May 11-18.

North Carolina. Greensboro May 1 1-18.

South Carolina. Camden May 12-19.

Texas. Galveston May 17-24 -. . i

Imported on o
Laredo May 13-17

San .\ntonio May 4-11

Washington. Spokane May n-i8 2

Wisconsin. Milwaukee May 1 1-18

S.MALLPOX — FOREIGN.

Brazil. Manaos Apr. 27-May 4 >

Para Apr. 27-May ii . . .

Pernambuco Mar. 15-31

Chile, Coquimbo Apr- 27

Iquique Apr. 27

China. Hongkong -^Pr. 6-13 J

Egypt, Cairo Apr- 23-29

France. Marseilles Apr. 1-30

Nice Apr. 1-30 1

Paris May 4-11- 1

Germany. General Apr. 28-May 4

Great Britain. Cardiff May 4-11

Southampton May 4-11

India. Bombay Apr. 23-30.

Italy. General May 3-9 ■

Madeira. Funchal May 5-12..

.Mexico, Mexico City -"^pr. 20-27

Portugal. Lisbon May 4- -

Russia. Odessa -Apr.

T3 . I Feb.

R'Sa I Apr.

Spain, Barcelona May

Cadiz Apr.

Huelva Apr.

Se\-ille Apr.

Valencia Apr.

Turkey. Bagdad ^ . - Apr.

20—27

1-28

27-May II.

7 4 imported

I

4

S ■ ■

1
8
I

:o
S. Hanover
I
Imported

> I imported

Present
16

so
31

W M. Lester. Columbia Columbia. . . . .June

' '.H. E. McNutt. Aberdeen Sioux Falls.. . . July

XI

Tennessee* T.J. Happel, Trenton .

Texas.

Utah*

f Memphis..

. I :

Nashville * May

I. Knox\Hlle I

. .T. T. Jackson. San Antonio. . -Austin. . . . ..June

u iBH' R W Fisher. Salt Lake City . Salt Lake City .July

Vemont '. ! ! W. Scott Nay. Underbill Burlington. . . .July

Vir™iSa . . . .R. S. Martin. Stuart. Lynchburg.. . .June

Walhinirton* C W. Sharpies. Seattle Seattle Ju y

W VirlSa*:; .H. A. Barbee. Point Pleasant. Charleston. . . .July

Wisconsin J. V. Stevens Jefferson lf?^'^Jl-- ' ' ' ■■',"l?l

Wyoming S. B. Miller. Laramie Cheyenna June

• No reciorocity recognised by these States. . « , ,.,,

t A^pStrshould i^every case write to tlje secretary fo. latest
details regarding the examinatiol. in any particular State

Texas.— The new medical law of this State goes into
effect on Tulv 12. 1907. This law provides for a mixed
Board and also provides that no one who is not a
graduate of a reputable medical college with a four
years' course can take the examination.

1-30

1-30

1-30

28-May 12.
6-13

YELLOW FEVER.

Brazil. Manaos Apr. 20-27

Para Apr. 28-May 12.

Cuba San Nicolas .Habana Prov-
ince May 21

West Indies. Trinidad— Port of

Spain May 4-11

CHOLERA.

India. Bombay -^pr. 23-30

Rangoon Apr. 13-20

PLAGVE — INSULAR.

Hawaii. Honolulu May 22

PLAGVE — FOREIGN.

\rabia. Bahrien Island Apr. 21-27

Camaran Apr. 19-30

B/azil. Para May 4-11

Pernambuco May 15-31

Chile. Antofag,asta Apr. 27

China. Hongkong Apr. 6-13.

India. General Apr

Bombay -^pr.

Rangoon Apr.

Peru. Chiclavo Apr.

Chosica Apr.

Ferrenhafe Apr.

Lima Ap'-

Paita Apr.

Truxillo Apr.

Turkey in Asia. Djeddah .'^pr.

9
16

Present

16

6-20 86.901

23-30

18

18

18

. 18

18

18

, 15-May 5.

36

6

3

76.647

343

99

3
34

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 7 J, No. 24.
Whole No. J9I0.

New York, June 15, 1907.

$5.00 Per Annum.
Single Copies, (Oc.

(irigiual Artirlra.

AUTOINTOXICATION IN ITS MEDICO-
LEGAL ASPECTS.

By HEINRICH STERN, PH.D.. M.D..

NEW YORK.

To iny knowledge, autointoxication has never been
the subject of medico-legal inquiry ; however, a num-
ber of pathological states, the origin of which has
been assigned of late to intrabiontic poisons, have
frequently found forensic consideration. Modern
toxicology has begun to conceive certain conditions
and diseases as expressions of autointoxication ;
medical jurisprudence, slowly but inevitably, will
also come to recognize autointoxication as a possible
factor in the causation of abnormal physical and
nsychical states and of death. Many a toxicologist
prophetically, if not clearly, foresees tiie importance
of the intrabiontically formed poisons in forensic
battles of the future. Says Lewin, in the preface of
the second edition of his "Lehrbuch der Toxikol-
ogie" : "The time will arrive when it will have been
definitely settled that intoxication is a local or gen-
eral disease, and that genuine disease is a local or
general intoxication."

However, it is a melancholy fact that the experi-
ence and the knowledge of a period is but rarely
reflected in the prevailing law ; that the law is be-
hind the spirit of the times, hardly ever taking into
full account the scientific acquisition of to-day, is a
circumstance only too well known to the legal prac-
titioner. We cannot often subscribe to Samuel
Johnson's affirmation, "The law is the last result of
human wisdom acting upon human experienie for
the benefit of the public," but are inclined to side
with Goethe, himself a jurist, who puts in the mouth
of Mephistopheles the poetic words :*

Like a disease of infinite duration

Custom and laws descend from race to race.

Clinging to each succeeding generation.

And creeping stealthily from place to place.

Reason to nonsense they distort, to blame turn charity.

Woe to thee if thou a grandson art,

For rights, which thy time should award,

Remain unborn to serve posterity.

Autointoxication as a disease has become a fad
with many. I do not believe in fadism, hence the
conservative standpoint from which I shall view the
legal aspects of autointoxication. I shall not attempt
to bring the ptomaines and other poisons of bac-
terial origin, or the so-called intestinal poisons,
which are mostly derived from without, in connec-
tion with genuine autointoxication. I limit myself
to a consideration of the catabolic poisons, as far as
they have any bearing upon legal medicine.

The most simple and yet the most authentic of the
catabolic, hence of all autointoxications, is the reten-
tion of carbon dioxide in the blood and tissues of the
organism. It is characterized by cyanosis, slowing

* Translation by Selma Stern.

of the pulse, difficulty in breathing, and convulsions.
In extreme instances death will ensue. Death by
strangulation or uncomplicated suffocation is pre-
eminently a death by carbon dioxide poisoning. How-
ever, there seems to exist a form of carbonic acid
intoxication which does not depend upon an obstruc-
tion in soine part of the respiratory organs but upon
the non-liberation of the carbon dioxide from a com-
bination into which it has entered. This form of
carbon dioxide poisoning may be at the fotij.dation
of some of the well-known pathological states and
may thus attain importance quite frequently. Sup-
pose now, an individual who is living near the
gas works or some chemical factory, chances to
become affected with carbon dioxide retention. Is it
not likely that he. his family, and the attending phy-
sician attribute his untoward symptoms to the nox-
ious fumes coming froin these places of industry,
when, as a matter of fact, not sufficient carbonic
acid gas to produce intoxication is found in these
vapors? Is it not likely that the average jury will
render judgment for the plaintiff if he sees fit to sue
the owners of these manufacturing establishments?
Are they not known to be public nuisances the
world over? Ergo, they must be the cause of the
plaintiff's suft'ering and inability to earn his liveli-
hood.

Carbon dioxide retention without the occurrence
of a respiratory obstruction is, indeed, a very in-
teresting phenomenon, which is destined to alter our
views as regards the etiology of a nutnber of af-
fections. At the bottom of certain chronic diseases,
as well as of many instances of so-called heart fail-
ure, apoplexy, and other forms of sudden death, we
may find carbon dioxide retention in various de-
grees. The importance of this simple form of auto-
intoxication for all the branches of legal medicine
ought not to be underestimated.

The condition known as acidosis should command
the earnest attention of the medical jurist. Under
acidosis, or acid intoxication, is understood poison-
ing by overproduction or deficient neutralization,
or abnormal retention of normal, or by pathological,
acid principles (Stern). Catabolic acidosis super-
venes in some pathological states characterized by
loss of body substance. Its most frequent occur-
rence is in the later stages of diabetes. The acetone
bodies, betaoxybutyric acid, acetoacetic acid, and
acetone, are always present in the m-ine of persons
wjth acidosis, and are therefore pathognomonic of
the condition, but they are not the cause of the pe-
culiar train of symptoms, as I have pointed out on
various occasions. The following instance of this
type of autointoxication requiring legal inquiry
came under my observation :

About ten years ago a diabetic patient of mine,
exhibiting acetoacetic acid and acetone in his urine,
on his way from my office to his home became sud-
denly vertiginous and took refuge in the rear room
of a liquor saloon. When he was found by the bar-
keeper he was in a deep stupor, his clothes were

97^

MEDICAL RECORD.

[June 15, 1907

disarranged, and his cuffs, minus the buttons, were
lying in a corner. A search plainly revealed that
a robbery had been committed ; policemen and de-
tectives declared that the victim had received
"knockout drops" and that he was still under their
influence. The patient being well known in the
neighborhood, his family, when notified, iusisted ujion
his transportation to their home. A short time after-
ward I was summoned to the house. There a police-
man informed me that the ambulance surgeon had
already administered an antidote for tli3 ""knockout
drops." The patient, true enough, presented the
more prominent symptoms of poisoning with chloral
hydrate. There were the stupor, dyspnea, dimin-
ished cardiac action, and lowered temperature. I
was satisfied that a large dose of chloral h\drate
had been administered to the patient, and I pre-
scribed accordingly. On my way home it struck
me that fhe symptoms displayed by the patient were
also those of acid into.xication (diabetic coma).
Early the next morning I found the patient greatly
improved, but dull and ajjhasic. In the afternoon
of the same day the patient became very restless
and irritated. Afterwards he had some attacks of
vertigo, which were followed by delirium of a low
degree. A slight stupor persisted throughout the
afternoon and evening. The urine continued to ex-
hibit glucose, acetoacetic acid, and acetone, and also
contained betaoxybutyric acid (polariscopically de-
termined), and large amounts of ammonia. In view
of the urinary findings I now considered his con-
dition as one of acid intoxication. This diagnosis
was positively confirmed by the subsequent behavior
of the patient : frequent recurrences of the phenom-
ena just described, and lethal exit in fully developed
diabetic coma after five days.

The facts in this matter proved very simple : The
patient, in a bewildered and staggering condition,
was followed by two toughs when he entered the
liquor saloon by the side door. They took his val-
uables when he began to become sLuporcus, and
neither handled him roughly nor used "knockout
drops." Had the victim died then and there, the
people, without a shadow of a doubt, would have
charged the thieves with murder in the first de-
gree, and the electric chair, in all likelihood, would
have expedited them into a better world.

To this instance of unrecognized autointoxication
jeopardizing the life of the supposed murderers I
could add another similar case of personal experi-
ence when the accused was actualh. convicted of
murder on his first trial, but — for some altogether
extraneous reasons — was found not guilty on a sub-
sequent trial in another county.

The so-called constitutional diseases, originating
from or giving rise to autointoxication, interest not
only the physician but the surgeon as well. The
surgeon, for instance, is loath to operate upon a
hemophilic : he takes special care when he has to
perform a bloody operation upon a rachitic or scor-
butic child : he prefers to limit his work, both in
extent and duration, when his patient has diabetes,
and he may refuse to operate altogether when con-
fronted with a condition of acetonemia.

There are a number of autotoxic conditions which
may more or less interfere with the repair of tis-
sues after accidents and operations. . The surgeon
frequentlv receives the blame when injuries do not
heal properly, or when operations are not followed
by the desired results. .\s a matter of fact, the
cause for the defective repair of the body structures
oftentimes originates within the organism. Were it
known bv the legal profession that catabolic sub-

stances could exert a similar influence upon the heal-
ing process, as does the svnhilitic poison, the num-
ber of suits for malpractice would dwindle rapidly
and different verdicts would be rendered in many
instances. The following instance will illustrate my
contention :

Some years ago, on the instigation of his lawyer,
a man about forty years old consulted, among some
other physicians, also me. He had sustained an
oblique fracture of the tibia and fibula about nine
months before ; however, perfect bony union had not
as yet taken place, and he suffered much pain at
the seat of the fracture. The patient, contending
that unskillful management of his fracture pre-
vented complete bony consolidation, contemplated
suing for damages the surgeon who put up the
injured limb. The presence of syohilitic disease
being positively denied, I questioned the patient as
to his medical history. I elicited, among other facts,
that he had been rachitic in childhood, and that
he had a tendency to ".gout" during the last two
or three years. We know that rachitis affects detri-
mentally the formation of the granulation substance
by which the fractured bone ends unite. This man,
it is true, had no noticeable rachitic symptoms any
longer, but a nutritive disorder like rachitis may,
in a modified form, appear also in adult life, es-
pecially when callus production is taking place.
The defective callus formation in this particular in-
stance, however, I concluded was due almost en-
tirely to abnormal nucleolysis, or, better, to deficient
dissolving qualities of his blood serum, which per-
mitted the deposition of purins and xanthins at
the seat of the fracture. These catabolic substances
perhaps prevented the osteoblasts from engaging in
a normal process of cell proliferation. Undoubtedly,
however, they disturbed or checked the chemical
processes which lead to ossification. The pains at
the location of the injury I attributed to the self-
same causes. I pointed out to the man that the de-
layed union of the bone ends was very likely due
to systemic conditions, preeminently to that which
he called his "gouty" affection, and that he had
no case against the surgeon. My supposition as to
the causative factors of the delated c^sification
proved only too true after treatment for perverted
nucleolysis, consisting in the main in the adminis-
tration of potassium iodide and colchicum. had been
instituted, for the pain ceased very soon, the pa-
tient began to feel more cheerful and became
stronger from day to day. the callus material be-
came more abundant, and comple'ic bony union was
secured after about fourteen weeks, \^'hen we re-
member the long row of discrepant diseases which
have been, and still are, ascribed to uric acid and its
salts, or to the alloxur bases, there can be no doubt
that nucleolvtic autointixocation offers many othei
medico-legal aspects besides the one just al-
luded to.

The last word concerning all those occurrences
which we classify as histoenzvmic autotoxicoses has
as yet not been said, ^fuch that has been advanced
during the last decade which bears upon the connec-
tion of certain abnormal bodily conditions with
pathological histoenzymes or perverted "internal se-
cretions," is undoubtedly premature, hypothetical,
and nonconvincing. One "internal secretion." how-
ever, the one of which least has been written, namely
that of the ovarv, seems to stand in causative rela-
tionship to manv ills, and hence to manv abnormal
mental conditions of w-omankind. The perverse
psychical states so often supervening during the
adolescent period, the hysterical and epileptiform

June 15, 1907]

MEDICAL RECORD.

975

attacks of middle life, the mental aberrations of the
menopause point to the ovary as a principal partici-
pant in their production.

It would be carrying coals to Newcastle were I
to recount on this occasion specific instances of dis-
ease or crime which could be adduced to a faulty
ovarian internal secretion. The frequency of psy-
choses, the number of wrong and rash acts attribut-
able to thisone cause, is verily appalling. The legal
bearings of this undisputable autotoxic factor are
so numerous and manifold that one is astonished
to see the entire question ignored in the courts of
justice.

That wdiich I have termed "physical autointoxica-
tion" is the consequence of the retention in the blood
of normal products of dissimilation. It finds its
principal expression in the so-called uremic state.
Again, it may give rise to various other abnormal
conditions, for instance to narcolepsy. This is a
sudden uncontrollable inclination to sleep, recur-
ring at irregular intervals. One of the most inter-
esting cases of narcolepsy on record, which, how-
ever, did not then offer any medico-legal aspects.
was reported by me some years ago.* Another in-
stance of the same affection, a phase of which is re-
lated in the following, should prove very interesting
to the medical jurist.

The patient, forty-three years old and weighing
about 2/8 pounds, consulted me first in October,
1904. He was then a well-known member of the
San Francisco bar. He had been affected with sud-
den sleeping seizures for a number of years. He
would be seized by this uncontrollable desire to
sleep at any time of the day. He would fall asleep
in the restaurant, but also while pleading a case in
court. I refrain from going into the details of the
history of the case at this time, nor is this the place
to give an account of the pathological findings. Suf-
fice it to know' that it was an instance of well-defined
physical autointo.xication. The patient acted as
legal adviser of a former champion pugilist in a suit
which the latter had won against a dishonest referee.
This referee, a notorious character, wanted to have
it out with the victorious lawyer, and, with his six-
shooter in his hip pocket, he went to look for him in
the evening. He found him in the hotel, called him
to a side room, pulled his revolver, aimed, and at
the sight of the gun the lawyer, still standing on his
feet, began to sleep and to snore sonorously. At
this unprecedented miracle the would-be murderer
took to flight and was not heard of for many a day.

Thus far the facts in the case. Now let us con-
sider some of its medico-legal aspects. Suppose the
narcoleptic attacks of the lawyer had not been the
talk of the town, what conclusions wnuki the police
have drawn when they found him unconscious and
in apparent stupor after the attempted murder?

I have put this question to a number of experi-
enced police officials and the answer of each and
every one was that impulsively he would have looked
for the marks of another weapon which kills without
making noise ; failing to find any. he would, at first,
have thought of poison, and then of apoplexy or
something similar. Supposing that the lawyer,
when seized by the morbid sleepiness, should have
fallen on his head in such a way that he had frac-
tured the base of the skull, would not everybody
have been convinced that the ill-reputed referee had
actually committed a crime? Supposing again that
the lawyer (whose weight, we must not forget,
amounted to 278 pounds), when seized by the nar-

*A contribution to the Pathogenesis of Narcolepsy ami
other Forms of Morbid Sleepiness; Medic.il Record, Janu-
ary II, 1902.

coleptic fit, had fallen upon the revengeful referee
in a manner so that the latter's pistol had gone off,
thereby discharging a bullet which had penetrated
the lawyer's heart or lungs, wouid any district at-
torney have given credence to the statement of the
malicious referee that he meant only to frighten the
lawyer? This case of narcolepsy offers still more
hypothetical suppositions from which tlie possible
legal consequences may be deduced. All the pos-
sible legal inquiries which may arise out of the
type of autointo.xications occasioning morbid sleep-
iness have their analogues in the forensic ques-
tions pertaining to the toxic states underlying epi-
lepsy and epileptiform conditions.

On the hand of our present, still meager, knowl-
edge concerning pathological physiology it is, of
course, extremely difficult to prove the connection
of a given instance of a neuropathic or psychopathic
state with a catabolic poison or with a disturbance of
the intrasystemic osmotic equilibrium. That we
may have epileptic conditions without anatomical
substrates is a fact known for many years. Certain
forms of alcoholic epilepsy, for instance, are the
direct consequence of alcohol or its normal or ab-
normal decomposition products. If we are satis-
fied that certain substances introduced into the or-
ganism may occasion epileptic or epileptiform at-
tacks, why should not we also accept that certain
to.xic states of intrabiontic origin may manifest
themselves by similar nervous phenomena?

At any rate, the medical jurist who holds that a
specific instance of epileptic equivalent or of acute or
cyclical insanity, proceeded from a well-defined auto-
toxic condition, stands on much firmer soil than the
one who nonchalantly asserts that a "nerve crisis,"
or a "brain storm," is due to a family taint.

Chronic renal disease is sooner or later fol-
lowed by a general autotoxicosis of the organism.
This toxic state is due to the relative impermeabil-
ity of the kidneys and the synchronous incompe-
tence of the other emunctories. The substances ac-
cumulating in the blood serum exhibit little or no
chemico-toxicity ; they exert a no.xious influence
simply by their retention. The long-continued poi-
sonous state arising on the basis of histolytic re-
tention is generally referred to as chronic uremia.
This condition, with its protean symptoms, oft'ers
ever so many and manifold legal aspects and com-
plications. I know of a case of chronic uremia
which was diagnosed as "ptomaine poisoning" by
one of our leading physicians. An acute exacerba-
tion of the chronic condition was pronounced a case
of opium poisoning in the absence of the regular
attendant by the hurriedly summoned physician of
the neighborhood, with the result that the former
had a suit for malpractice on his hands for over a
year. I have seen uremic poisoning to be taken
for fusel oil intoxication, and for poisoning with
belladonna and aconite.

Some of the gastrointestinal concomitants of
chronic uremia — nausea, vomiting, and diarrhea —
are often referred to the ingestion of tainted food :
disturbances of the nervous system as headache, ver-
tigo, insomnia, are frequently looked upon as the
result of medication : neuralgia, muscular craiups,
and paresthesia are in manv instances ascribed to
injuries received lately or in years gone bv.

Every one of these symptoms is a manifestation
of the specific autotoxicosis, and. if the circum-
stances arise, each one may prove of decided medico-
legal interest. However, of still greater importance
for forensic medicine are the cerebral symptoms
such as mania, melancholia, and delusional insanity,
which are apt to accompany chronic uremia.

976

MEDICAL RECORD.

[June 15, 1907

These cerebral manifestations occur principally
in uremia on the basis of chronic parenchymatous
nephritis, the only renal affection which should be
designated as Bright's disease. Among all mental
diseases the psychoses of Bright"s disease alone are
truly autotoxic in character. They are the ex-
pression of a poisonous state of autochthonous for-
mation and are not the result of morphological
changes in the brain.

The delusional insanity of Bright's disease, the
Folie Brighiiquc of the French, has undoubtedly a
greater forensic bearing than any of the other uremic
psychoses. Instances of Folie Bri^htique occur in
the practice of almost every physician, but are often
overlooked in the milder forms, or not recognized
as such when the insanity attains a severer degree.

This specific mental aberration of Bright's dis-
ease which, in the majority of instances, is delusional
in character, is not due to molecular changes in the
brain matter, but due to the impairment of the
physico-electric conditions in the body liquids, an
autotoxic state, the minute etiolo'^-- and pathology
of which I described some years ago.* How-
ever, the average alienist, although admitting a toxic
insanity, has not progressed far enough to recognize
an autotoxic insanity. Says Hamilton in his "Sys-
tem of Legal Medicine" (Vol. H., p. 120) :

"Such somatic insanities as that due to Bright's
disease are frequently referred to, but often great
stress is laid by counsel upon the existence of the
cerebral symptoms of this and other diseases, and

their effect upon the conduct of the individual

Beyond the irritability, stupidity, aphasia, and very
rare epileptic conditions, nothing can be shown ; but
when we consider the renal disease, with cardiac
disease, as precursors of actual degeneration of the
cerebral vessels, it has a decided nnp'jitance." He
concludes as follows : "The demonstration of the
connection between embolism, or cardiac disease,
WMth cerebral softening and dementia, of syphilis
with paretic dementia, or epilepsy, is of the great-
est moment."

These statements are utterly devoid of any insight
into the nature of chronic uremia, that is into the
latter phases of Bright's disease. Cases of uremic
insanity with lethal exit show cerebral changes only
in the very rarest of instances. Even the edema of
the brain, by which Traube wanted to explain the
uremic phenomena, is vvantin"- in many cases. A
degeneration of the cerebral vessels has nothinp-
whatever to do with the Folic Brightique, the delu-
sional insanity of Bright's disease, which is and re-
mains an autotoxic phenomenon. If we wish to
study the delusional insanity of Bright's disease we
have to view it as a manifestation of an autotoxic
process ; analogously do we have to treat it as an
expression of an autotoxicosis when we make use
of it as a defense or when we question the indi-
vidual's testamentary capacity. Cellular pathology
has still a raison d'etre in surgery, for the scientific
investigation of many psychoses it is absolutely
useless. Were the mental aberrations of Bright's
disease explained on the autotoxic basis, I am sat-
isfied there would be fewer petitioners sadly wend-
ing their way homeward from ilie Surrogate's
Court.

It is a fact, which is ever corroborated, that the
individual with uremic delusions is easily influenced
by his latest acquaintance to whom he has taken
a liking. This explains in a measure why the chronic
nephritic so often disposes of his propertv in r.n

*A Contribution to the Pathogenesis of the Uremic State ;
the Probability of its Physico-EIectric Substratum ; Medi-
cal Record. January 24, 1903.

erratic manner, why he leaves the bulk of his es-
tate to his nurse or the chance companion of his
latter days. As the law holds in great esteem the
right of an individual to make his own will — requir-
ing, for instance, less mental capacity to make a
will tlian to make a contract — it is in almost every
contest a difficult task to disprove the testamentary
capacity of the deceased. But why, we may ask,
should not a person with uremic delusions while
alive be adjudged non compos mentis? An indi-
vidual thus afflicted, of course, has relatively h"-' '
intervals, on which, according to law, the testament-
ary capacity may depend ; however, the autotoxic
process underlying the mental aberration is chronic
and its fluctuations, as far as they pertain to its
diminution, are only limited in degree. Thus the
chronic uremic is always kept in a more or less
abnormal state of mind, which fact ought to be
taken into consideration at the inquest.

This brings to a conclusion my discourse on the
forensic importance of the autotoxicoses. I have
dwelt upon the topic in a brief and conservative
manner; some subjects, I am fully av.are, have been
treated rather fragmentarily, others I have pur-
posely refrained from entering into on this occa-
sion. I believe, however, to have demonstrated :

1. That certain pathological conditions as well
as certain forms of death demanding legal inquiry
are due to autotoxic processes of catabolic origin.

2. That the catabolic autotoxicoses offer many
and discrepant legal aspects.

3. That the time has arrived when the catabolic
autotoxicoses should obtain legal status and citizen-
ship in our courts of justice.

250 West Seventy-third Street.

SOME OBSERVATIONS ON THE TREAT-
MENT OF GRAVES' DISEASE.*

By J. ARTHUR BOOTH, M.D.,

NEW YORK.

In a paper which was read before the American
Neurological Association in June, 1894, I presented
certain views, which were in support of the theory
that the symptom complex of Graves' disease ob-
tained its fullest explanation by the presence of
some morbid change in the thyroid gland or its se-
cretion, this important advance in our knowdedge
of the interesting and puzzling malady having been
brought to our attention by the very valuable con-
tributions of Victor Horsley, Moebius, and Kocher.
Within recent years still further evidence has ac-
cumulated, so that at the present time it is the
general belief that the thyroid gland dominates tne
disease. Permit me now to ask your attention to
a brief review of some of this evidence, together
with the results of my observations in tweiity-five
patients, who presented the different clinical types
of the disease. The changes in vascularity and con-
sistency of the gland were first noted and then fol-
lowed the obser\-ation that there were also certain
specific changes in the parenchyma and secreting
cells, differing somewhat in degree in the various
stages of the disorder. This enlarged, vascular
gland, then, with its vesicles assuming other shapes
than the round or square, together with a most
marked development in the epithelium, now cylin-
drical instead of columnar, seems to justify the view
that there is an increased or altered activity of its
parenchyma and secreting cells.

*Read before the Philadelphia Neurological Society and
the Kew York Neurological Society, March 16, 1907.

June 15, 1907]

MEDICAL RECORD.

977

These changes will be readily appreciated by com-
paring a section from the normal human thyroid
gland (Fig. i) with that from a case of Graves' dis-
ease (Fig. 2). The specimens removed by thyroid-
ectomy in my cases varied in vascularity and con-
sistency. Microscopically the alveoli were distended

system, and upon the nutrition of many tissues in
the body. What it is that starts the hypertrophy of
the thyroid and neighboring glands, or what part
the parathyroids or persistent thymus plays, are
questions yet to be answered. Perhaps fright, some
shock, emotion, microbic infection, or some heredi-

FiG. I. — Section of normal human IhjToid gland. (Kocher )

with hyaline material and the tissue thickly crowded
with round cells both in the alveoli and stroma.
This evidence is satisfactory except in those pa-
tients who do not show any visible enlargement of
the gland ; and here we may assume that there is
too slight an enlargement to be positively made out,
or that the above morbid changes may be present
without increase in size. Personally I have found
it quite difficult to discover a slightly enlarged thy-
roid and in several of the operative cases noted how

Fig. 3. — Case I.

tary taint may prove to be the exciting cause. In
the present series of cases emotional disturbance
seemed to be the exciting factor, as there was a dis-
tinct history of fright from burglars and fire in
ten patients, and from first menstruation in one.
Three patients had a good deal of mental worry.

4,— Case II

SS3

much larger the gland really was after exposure by
the incision. It is believed that this changed gland
produces an increased or perverted secretion, which,
being absorbed into the blood by the veins and
lymphatics, acts as an irritant directly or indirectly,
like many other poisons, upon the heart, the nervous

Three had chorea in childhood. The symptoms
followed an attack of rheumatism in two patients.
In four there was a family history of the disease,
and in two there was a record of simple goiter in
the family. Our former knowledge being deficient
concerning the etiology and pathology of the affec-

978

MEDICAL RECORD.

[June 15, 1907

tion, necessarily made the treatment difficult and un-
certain ; now, however, with the results of recent
investigation before us, we are in a position for a
more intelligent treatment both by therapeutics and
surgery. Bue even at the present time, when an at-
tempt is made to outline any specific line of treat-

Case HI.

ment, one of the difficulties met with is the fact that
the disease is represented by so many different types.
For example, in the present series of cases there
were three males and twenty-two females : seven
were married and eighteen single. The average age

in four. Tachycardia and nervous symptoms alone
in four. Tremor was present in ten. Intestinal dis-
turbances in only four patients. Fever was present
in ten ; noted as absent in six and no record in the
others.

Assuming the truth of the thyroid theory, it is

Fin. 7. — Case V,

probable that these different clinical types repre-
sent various degrees of intoxication and thus ex-
plains this diverse symptomatology. These differ-
ent clinical types being recognized, it is necessary
and of great importance to have some form of
classification as an aid to prognosis and the proper
treatment of the disease ; so with this object in view
a division into three classes has been suggested,

Fig. b. — Case IV.

Fig. 8.— Case VI.

was twenty-one, the oldest being forty and the
youngest twelve years of age.

Enlargement of thyroid, followed by tachycardia
and exophthalmos, in ten. Tachycardia, followed
by exophthalmos and thyroid enlargement, in seven.
Exophthalmos, followed by enlargement of thyroid.

which I will now give, illustrating the same with a
few photographs.

First Group. — Here the clinical picture indicates
a mild form of the disease. Marked toxemia is ab-
sent, as well as one of the cardinal symptoms, usu-
ally the exophthalmos : and we find a slightly en-

JUIIL' 15, 1907 I

MEDICAL RECORD.

979

larged thyroid, with a moderately increased heart
action. Many of these cases do well under treat-
ment by rest and drugs and a few are cured. In
those in which this method of treatment fails, oper-
ative treatment should be considered.

Case I. — Enlargement of thyroid and exophthal-
mos slight. Tremor : edema of the eyelids. Pulse,

Fig.

100 to 118. Thyroidectomy. Decembe'r, 1895.
Cured.

Case II. — Exophthalmos and enlargement of thy-
roid slight. Pulse, 98 to no. Thyroidectomy.
April, 1893. Cured.

Second Group. — Simple chronic exophthalmic
goiter or thyroidism of moderate severity, with all
the symptoms which give origin to the name. The
clinical picture is that of an advanced stage, and
here medicinal measures give only temporary relief,
but by thyroidectomy and the use of serum good re-
sults are obtained. In these cases it is not wise to
delay operation too long.

Case III. — Decided exophthalmos and enlarge-
ment of the thyroid. Tremor and all the nervous
symptoms. Pulse. 140 to 160. Thyroidectomy.
November, 1893, Cured.

Case IV. — Patient is only twelve years old, and
has all the clinical symptoms of the disease. Pulse,
120 to 140. Exophthalmos and enlargement of thy-
roid marked. At present under treatment by rest in
bed and ice bag to chest. Medication, antithyroid
serum and phosphate of soda. Is more comfortable.
Pulse rate reduced to 110-118.

Case V. — Enlargement of thyroid and exophthal-
mos marked. Pulse, 120 to 140. Tremor and all
the nervous symptoms. Thyroidectomy, November,
1895. Cured.

Third Group. — In this class we find a still further
advance in the intoxication. Fever is a prominent
symptom and may be quite high. The circulatory
and nen-ous system are also markedly involved.
Here operation is not profitable, as they are poor
subjects for a shock of any kind, especiallv from an
operation under general anesthesia. Dr. Rogers re-
ports good results from the use of a cytotoxic serum
in this class, but my experience in its use is too
limited to give any definite conclusions.

Case VI. — This patient had all the symptoms of
the disease in a severe form and finally died in an
attack nf acute mania.

Case Vil. — Had all the s)mptoms of the disease
for many years, with attacks of fever and a history
of diabetes. Thyroidectomy, October, 1894. Death
twenty-four hours after the operation.

Case VHI. — The advanced stage of the disease
is well shown in this patient. Bilateral e.xsection of
the sympathetic was performed by Dr. Curtis in
January, 1893. There was rapid improvement in
the exophthalmos and a reduction in the pulse rate
to 100. She unfortunately died from pneumonia
and nephritis two months after leaving the hospital.

The diagnosis of Graves' disease being made, the
following details of treatment should receive atten-
tion :

(i) Rest; (2) electricity; (3) medication; (4)
the consideration of operative interference by partial
thyroidectomy, ligature of arteries, and sympathec-
tomy; (5) the use of cytotoxic serum.

It is not necessary to consider here in detail the
first three means of treatment, except to say that per-
severance and strict attention to detail, placing the
patient under the best hygienic conditions, with rest
and plenty of fresh air, will accomplish a great deal
towards mitigating the intensity of the symptoms
and a cure may result in a certain number of pa-
tients, especially when the diagnosis is made early in
the disease. In a record of eighteen cases, three
were cured, five improved, and ten received no bene-
fit from the treatment.

Operative Interference. — If as a result of our
present knowledge we are justified in believing that
a changed or excessive secretion is the causative
factor of Graves' disease, then a rational therapy
would seem to turn itself into one or two directions :
either towards a positive limitation of the secretion
by the partial resection of the gland, or a neutraliza-

FiG. 10 —Case VIII.

tion of the toxins by the use of an antitoxic serum.
By the first method we have now sufficient data to
clearly show that a more rapid and greater benefit
occurs in a larger number of cases through operation
than under medicinal treatment, and this is espe-
cially so in those patients who show the marked

98o

MEDICAL RECORD.

[June

1907

symptoms of Group 2 in the above classification.
Nine of my cases were treated by operation ; thyroid-
ectomy being performed in eight patients and bilat-
eral e.Ksection of the sympathetic in one. The opera-
tive work was skilfully performed by Dr. B.F.Curtis,
with the following results: In the thyroidectomy
cases the right lobe was removed in five and the left
in three cases. Six were pennanently cured, one
was improved, and one died twenty-four hours after
the operation with symptoms of acute to-xemia.
(Case VII.) Two of the operations were done in
1893, two in 1895, one in 1896, and one in 1897;
being thirteen, eleven, ten and nine years ago respec-
tively. Four of the patients have been seen and ex-
amined quite recently and are well, though in two of
them there is still present a slight prominence of the
eyes. The other two patients were well two years
ago.

Antitoxic Serum. — From recent clinical studies of
the thyroid gland in simple goiter and Graves" dis-
ease, there have been found some definite indications
for serum therapv and good results have been re-
ported by a number of writers. Recently Drs. Rog-
ers and S. P. Beebe have introduced a specific serum
and the results they have obtained by its use in over
ninetv cases warrant the conclusion that it is an
agent of great value, especially in those patients
showing symptoms of marked toxemia. One of the
patients recorded by me as improved by thyroidec-
tomy relapsed after a time and later was treated by
Dr. Rogers. No improvement followed and the re-
sult was a failure in this case.

Conclusions. — (i) -Mthough Graves' disease is
recognized bv the ijrominence of four symptoms,
tachvcardia, exophthalmos, goiter, and tremor, this
symptom complex may be incomplete in the develop-
rnental stage of the disease and here the other symp-
toms are sufficient for the diagnosis. (2) At the time
of the first examination the degree of thyroid intoxi-
cation should be noted and the patient then placed if
possible under one of the three clinical groups. (3)
The prognosis depends upon the hereditary, the so-
cial position of the individual, the type of the dis-
ease, and its early recognition. All these conditions
being favorable, with good care and perseverance,
there is a fair chance of recovery in those patients
classed in the first group. The more advanced cases
stand a better chance of recovery by operation, but
this must not be delayed too long when organic
changes have already set in. (4) Recent clinical
and experimental data still further emphasize the
general belief that overactivity of the thyroid gland
is quite sufficient to explain the appearance of the
svmptoms of Graves' disease and their disappear-
ance after operation. (5) Thyroidectomy should be
the operation of choice, as giving the best results.
(61 Death following operation is due to shock and
the use of a general anesthetic ; therefore this should
be placed in only expert hands and local anesthesia
employed when possible. (7) The introduction of
the cytotoxic serum marks an important advance in
the treatment of the disease, and perhaps may ulti-
mately prove to be the only rational therapeutic
method.

Stricture in Children. — The possibility of urethr.-!!
stricture in ynunc; children siififering from urinary dis-
turbances (frequent micturition, vesical tenesmus, re-
tention of urine, etc.) should always be considered even
in the absence of a traumatic cause or gonorrheal infec-
tion. Internal urethrotomy followed by systematic dila-
tation is as successful in these cases as in older persons. —
International Journal of Surgery.

INDICANURIA, ITS ETIOLOGY AND PRAC-
TICAL SIGNIFICANCE.*

By WILLIAM HENRY PORTER, M.D.

PROFESSOR OF PATHOLOGY AND GE.VERAL MEDICINE AT THE NEW YORK

POST-GRADUATE MEDICAL SHOOL AND HOSPITAL: ATTE.N'DING

PHYSICIAN TO THE POST-GRADCATE HOSPITAL, ETC.

At the present time there is no condition in pathol-
ogy and general medicine the interpretation of which
is of greater importance to the general practitioner
and surgeon than that of indican in the urine.
While indican, like the overproduced uric acid^
found in the urine, is a symptom only, it is highly
important that we should correctly apprehend its
true significance. To accomplish this necessitates a
clear and comprehensive understanding of the meth-
od of its formation and the various conditions that
give rise to its presence in the system.

As early as 1840 Prout" discovered a blue coloring
material in the urine, to which he gave the name
indigo, hence to him is due the credit of discovery.
Long before this date, however, and for several years
thereafter, many observations are recorded in refer-
ence to finding blue urine, and of sediments in the
urine having a decided blue coloration. Even from
the time of Hippocrates and Galenus down, similar
observations are recorded.^ It was not, however,
until Prout announced his discovery, that indigo
became a recognized factor in connection with the
urine.

From 1840 to 1857, many obser\-ers recorded sim-
ilar cases, but all were of the opinion that the blue
coloring'material discovered by Prout was identical
with the indigo blue or indican found in plant life.

Schunck,^ in 1857, demonstrated, as he thought,
the constant presence of a substance in the urine
which yields indigo blue on boiling the urine with
mineral acid. This substance he called indican, and
was of the same opinion as previous observers —
that it was identical with vegetable indican.

Baumann,' about 1879, first demonstrated that no
sugar was formed by the decomposition of animal
indican, but that there was formed sulphuric acid
and a compound belonging to the indigo group.

Prior to this, however, Nencki" had demonstrated
the fact that indigo was one of the decomposition
products of a still more complex body.

It was not, however, until the researches of Bau-
mann and Breiger" that the exact composition of the
urinary indican was first accurately determined.
Thev proved that urinary indican was a combination
of the conjugate sulphur of a hydroxylated indol
with an alkali (potassium), to which they gave the
name indoxylsulphate, and suggested that the term
indican be restricted to the indigo-yielding substance
of plant life. This suggestion, however, does not
appear to have been adopted.

Shortly after this. Baeyer* demonstrated that a
more simple substance was the antecedent to the
more complex body indoxylsulphate of potassium,
(TsH^NO SO,,K. This simple mother substance,
indol or indole, CgH-N, is formed in the lumen of
the intestinal tract. It has since been demonstrated,
beyond a question of doubt, by Nencki" and other
obsen'ers, that indol is produced always and only
bv bacterial putrefactive decomposition of the pro-
teid elements of the food stuffs during their passage
through the alimentan- tract. It has also been
shown that the animal proteids are more likely to
undergo this change than are the vegetable class.
This is due to the fact that the animal proteid is a
free and single moleaile. one easily acted upon, both

*Read before the Xew York Medico-Surgical So-
cietj-, March 16. 1007.

June 15, 1907]

MEDICAL RECORD.

981

by the unorganized and the org-anized ferments.
On the other hand, the veg-etable proteid is a multi-
ple molecule, and is encased in a capsule of cellulose,
neither of which is easily acted upon either by the
unorganized or the organized ferments. Hence the
vegetable proteid passes through the alimentary
tract in a large measure untrans formed, acting sim- ,
ply as an irritant to the mucous membrane of the
intestinal tract. As a natural sequence, the animal
proteid is easily acted upon in the one case by the
unorganized ferment, yielding a large quota of nu-
trition pabulum : on the other hand, if acted upon
by the bacteria of putrefaction, it yields a large per-
centage of indol, and subsequently of indoxylsul-
phate of potassium.

.A.S the vegetable proteid is not easily acted upon
bv either form of ferment bodies, it is difficult of
digestion ; it is also less likely to be acted upon by
the bacteria of putrefaction, hence it decreases the

TEST FOR INDICAN

TAKE SC.C.OFURINE

5C.C.HCL %.SOROPS OF 2;?
SOL. POTAS.PERMANGAN.VSHAKE
ADD IC.C.CHLOROFQRM V SHAKE
BLUE COLORATION ^CHLOROFORM
SHOWS PRESENCE ' INDICAN

URIC ACID

AFTER BOILING THE UP-
PER STRATA > URINE

ADO A FEW DROPS ?•' 4^
ACETIC ACID.LET IT
STAND-^3-4H0URS y
^ , ^ EXCESS"- URIC ACID WILL
y CRYSTALLIZE OUT

CALCIUM OXALATE

tendency to the formation of indol and subsequently
the formation of the indoxylsulphate of potassium.
While it does cut down the tendency to the forma-
tion of indol, it does not prevent it absolutely. Fur-
ther than this, the overtaxation of the digestive
system, when on a purely vegetable diet, and the re-
duction in the supply of the nutritive pabulum cause
profound disturbance in the metabolic cavity of
the system, which is often more detrimental than
the toxemia of the indicanuria.

Hopper-Seyler and his pupils" were of the opin-
ion, from their observations, that indol could be pro-
duced by the action of the unorganized, as well as
the organized, ferments. They also claimed that
indol was produced in the intrinsic proteid tissues
of the body, as well as from the extrinsic proteid
contained in the food stufi's in the lumen of the
alimentary tract.

The observations of Senator," in connection with

the urine and meconium of newly-born children,
support conclusively the contention of Nencki that
bacterial action is required for the production of
indol. Hence indol cannot be formed in the in-
trinsic tissues of the body except through the action
of the bacteria of putrefaction. That this does oc-
cur in some rare instances cannot be doubted.

Just how and when indol is joined to the sulphur-
ous acid molecule and the potassium atom, is not
clearly stated by any of the investigators. Neither
are we informed fully as to when the sulphurous
acid molecule takes its origin from the proteid mole-
cule. All observers agree, however, that it comes
from the sulphur of the proteid molecule, and that
it enters into the formation of the indoxylsulphate.
One thing seems to be certain, that it is not formed
in the renal structures. ''

Baumann,'' having found a much larger amount
of ethereal sulphates in the liver than in the blood,
was of the opinion that the synthesis of the indol
into an ethereal sulphate took place in the hepatic
cells. The larger amount of ethereal sulphates in
the liver as compared with the blood does not prove
conclusively their formation in the liver. The
ethereal sulphate being a foreign substance to the
normal physiological economy, the liver in its sen-
tinel-like function may exercise its guardianship
I iver the general circulation and, in a measure, pre-
vent the passage of the ethereal sulphates into the
hepatic blood stream ; hence the finding of the larger
amount in the liver. Thus we have a logical and
well-founded physiological explanation for the larger
amount in the hepatic organ without assuming that
it is produced in the liver cells.

On the other hand, it seems hardly possible that
such active chemical action as the splitting ofif of the
sulphur atom from the proteid molecule, with the
formation of sulphurous acifl, the decomposition cf
one of the stable potassium salts, and the synthesis
of these three simpler elements (sulphurous acid,
indol, and potassium) into the highly complex
indoxylsulphate, could occur in the protoplasm of
the hepatic cell without destroying its functional
activity. If the change occurred at the edge, or bile-
duct surface, of the hepatic cell, and the newly
formed compound was at once discharged into the
lumen of the bile duct, such a theory might be ac-
cepted, especially as it has been proven that sul-
phuric acid is so formed in the cells of the mucous
membrane of the stomach" in the production of
the HCl.

Viewed in this light, there are two theories to
choose from regarding the formation of the sul-
phurous acid and its combination with the simple
compounds, indol and potassium, to form the more
complex substance, the etherial sulphate.

First: The sulphurous acid may be formed pri-
marily by the same bacterial action that decomposes
the proteid molecule to form the indol in the in-
testinal canal, following which the acid attacks one
of the potassium salts, liberating: the potassium atom
to enter into combination with the acid and indol to
form the indoxylsulphate of potassium in the intes-
tinal tract. When thus formed this ethereal sul-
phate obeys the law common to all mineral salts.
The indoxylsulphate is absorbed unchanged into
the enterohepatic circulation, passes on to the liver,
then to the general circulation, and finally reappears
without being changed, and under its own form, in
the urine. When this occurs the .presence of the
ethereal sulphate is easily demonstrated in the urine
by its oxidation into indigo blue by some one of the
various methods recommended.

The following method has proved the most reli-

982

MEDICAL RECORD.

[June 15, 1907

able in the hands of the author. Add in a test tube
equal quantities of urine and chemically pure hydro-
chloric acid. To this nii.xture add three drops of
a y2 per cent, solution of potassium permanganate.
If indican is present in the urine, there will be
formed a purplish cloud in the fluid in the test tube.
Then add a few drops of chloroform, then one drop
more of the permanganate of potash solution, and
a few more drops of the chloroform ; then shake
vigorously. As a result this purplish coloration will
be replaced by a deep blue, which is due to precipi-
tation of the indican by the chloroform. The amount
and intensity of the precipitated indican determine
the extent of the putrefactive changes going on in
the alimentary tract. (See the accompanying illus-
tration.)

One other point should also be noted in this con-
nection, which is that the shade of color varies very
much — ranging from a deep blue to a decided green-
ish, or even black, coloration, the later colorations
being found in connection with varying degrees of
interlobular compression jaundice. It has also been
found tliat a close analysis of the color enables one
to judge quite accurately regarding the varying
metabolic conditions of the system.

There is still one other fact of especial importance
in connection with this test, which is, that the asso-
ciated toxicity of the system is not always in direct
proportion to the intensity of the indicanuria. For
it often happens that a considerable portion of the
indican escapes with the feces, while the toxins
are absorbed into the circulation.

Un the other hand, a close analysis of the different
shadings in the color reaction, when correctly inter-
preted, is a very close guide as to the intensity of
the associated toxemia.

Second: The indol formed in the intestinal tract
is absorbed as such from the alimentary canal, and
carried by the entero hepatic blood stream to the
hepatic glands. Having reached the liver, the indol
is drawn from the blood stream of the intralobular
plexus of capillaries into the protoplasm of the he-
patic cells. .\t the same time, proteid molecules are
also drawn into the protoplasm of the same cells,
together with oxygen. This results in a splitting
ofi of a sulphur atom and the o.xidization of the
same into sulphurous acid, while the remainder
of the proteid molecule breaks up into other forms
of byproducts. The sulphurous acid now combines
with the indol and the potassium atom, but where
the potassium atom comes from is not indicated by
any of the observers. If this theory is accepted, the
sulphurous acid must decompose a potassium salt,
thus liberating a potassium atom before the syn-
thesis is completed. Having formed the idoxyl-
sulphate of potassium in this manner, instead of
flowing out of the cells with the bile, what would be
the natural course for an oxidation product to pur-
sue? It is dropped back into the intralobular capil-
lars- blood stream, or the lymphatic channels. From
this point it flows out of the liver, in either the blood
or Ivmph, and ultimately reaches the general cir-
culation. Finally the renal glands are reached, by
which organs it is excreted together with the urine.
Neither of these theoretical methods of forma-
tion has been actually proved. The intestinal theory
of formation is the more probable one, from the
well-known fact that the intestinal tract is the great
chemical beaker of the system ; that in this intestinal
beaker chemical activity of a high order is constantly
occurring, while' there is no proof that such action
occurs in tlie deeper structures of the body."*

* At the time that the author penned the above sentences
he was not aware that Neumei?ter had in a large measure
advanced the same theory in regard to the synthesis of

Neither does it seem possible to have the formation
of sulphurous acid in the hepatic cells, the splitting
of the fixed potassium salts, and the combining of
these three substances into one complex whole in so
delicate a protoplasmic substance as that of the
hepatic cells. Were this to occur, we should expect
an absolute destruction of the protoplasm of the
cell structure and the formation of a permanent
lesion of the liver cells, the same as occurs in the
joint structures in gout when the proteid molecule
is vicariously oxidized into uric acid in the cartilage
cells."

By either method of formation the chemical evi-
dence proves conclusively that the other by-products
formed by the decomposition of the proteid mole-
cule are varied and often highly toxic in nature. It
is also probable that in connection with these ab-
normal chemical changes in the contents of the ali-
mentary tract, many of the undecomposed proteid
molecules are isomerically transformed and con-
verted into toxalbumins. The reason for this latter
assumption is the great difficulty of recognizing the
toxin in the blood. Were the toxin in all cases a by-
product of proteid decomposition, judging by those
that we are more familiar with, it ought to be easy
of recognition. As the toxins are not easily recog-
nized, only two methods of explanation are left:
one, that the toxin is unstable and volatile in nature;
or that it is an isomeric form of the proteid mole-
cule-^both of which are difficult to recognize and
analyze accurately.

When these toxic substances, no matter how
formed, reach the general circulation, and finally
the nervous system, they give rise to an almost end-
less variety of symptoms, depending upon the na-
ture and the amount of the poison entering the ani-
mal economy, and the inherent ability of the system
to resist their toxic action. The intestinal method of
formation conforms more closely to the general plan
of chemical activity constituting animal life than
does the hepatic theory. In all probability the in-
testinal explanation for the synthetic formation of
the indoxylsulphate and the associated toxic prod-
ucts is the correct solution of this problem. As the
indoxyl potassium sulphate is produced by the action
of the bacteria of putrefaction only, its presence in
the system and urine must be regarded always as a
pathological product, and can never be classed as
physiological and normal in amount. No deviation
from an ideal standard can be classed as normal.
The chemical processes of animal life must be per-
fect, and any deviation therefrom is indicative of an
abnormal state. Evidence of this kind must be
classed as a danger signal, that indicates the neces-
sity for speedy correction if more serious deviations
are to be prevented — such as may be recognized as
absolutely pathological conditions.

With this conception of the production of ethereal
sulphate or indican, as it is more commonly classi-
fied, we are in a position to consider the conditions
that favor its production and the correct interpreta-
tion to be placed upon its presence in the urine.

.\s the production of the ethereal sulphates is
always due to the action of the bacteria of putre-
faction, we must determine the conditions favorable
to the growth and development of these micro-
organisms. As a first promise, it may be stated
that so long as the digestive secretions are normal
in amount and composition, a decidedly restraining
action is maintained over all forms of pathogenic
bacteria, without inhibiting those that are essential

this simple substance.' He therefore calls attention to the
fact that Neumeister was of the opinion that the ethereal
sulphate was formed in the intestinal tract as the result
of svnthetic action excited by the bacteria.

June 15, 1907]

MEDICAL RECORD.

98,1

for the normal dig-estive action. Therefore, it is
common to speak of the gastric juice, the bile, and
pancreatic secretion as beino- antiseptic in their
actions, althoug-h this is not true in the stricter sense
if closely apjilied to any single constituent of these
secretions. But taken as a whole, this is unques-
tionably true ; therefore, anything that tends to de-
crease the total quantity or the perfection of the
digestive secretions, favors the growth and develop-
ment of the bacteria of putrefaction and the forma-
tion of the ethereal sulphates.

The three fundamental factors in predisposing or
leading up to a state of the alimentary tract favor-
able to the growth of pathogenic bacteria that give
rise to the condition classed as indicanuria are ;
First, eating and drinking too much, or taking food
of a faulty composition ; second, a decrease in the
amount or perfection of the digestive secretion.- :
and, third, a faulty innervation of the glandular
system as a whole.

Eating too much of any kind of food, or too large-
ly of the vegetable class, simply overtaxes the di-
gestive powers and ultimately decreases the so-
called antiseptic qualities of the secretions poured
into the intestinal tract. Too free use of the vege-
table class, coupled with the fact that many are high-
ly fermentable, causes undue irritation ; all due !■ :>
their great indigestibility — which ranges from 10
to 80 per cent — are highly irritable on account of
this large undigested residue, and therefore prone to
excite putrefaction.

This continued irritation of the intestinal tract
tends also to produce an excessive secretion of a
thick, tenacious mucus, instead of the normal
amount, which is just sufficient to act as a natural
lubricant. When the secretion of mucus is over-
abundant and viscid, it acts as a culture medium
for the growth of the bacteria of putrefaction, and
thus we have developed a putrefactive fermentation
of the proteid constituents of the food, the forma-
tion of indol, phenol, skatol, etc., and finally the
ethereal sulphates derived from indol.

The constant overtaxing of the digestive organs
by simple overfeeding ultimately results in a de-
fective secretion of the ferment substances, even
though the food be of good quality awd composition.
When this occurs, the intestinal canal contains an
undue amount of undigested material, which now
acts upon the mucous membrane in a manner similar
to what is noticed when too much food is taken of
the vegetable class, or the food is imperfect in com-
position. In one case there is no defect primarily
in the output of the digestive secretions ; while in
the other, the primary fault is more particularly ::.
the secretions of the digestive glands.

When for any reason the nervous system becomes
overtaxed and poorly nourished, there may be de-
fective innervation of the digestive organs, and this
is at once followed by a decrease in the quantity and
composition of the digestive ferments poured into
the alimentary canal. This in turn is followed by all
the changes already described. Overeating at a
time when one has for a long time used the nervoi'S
or muscular system unduly, is often the cause of an
incomplete innervation of the digestive system, and
produces changes which permit of the action of the
bacteria of putrefaction. Simple overworking of
the nervous mechanism, and particularly prolonged
and severe mental activity, is often the only appar-
ent cause of the incomplete innervation, decreased
digestive secretions, and putrefactive changes in the
intestinal tract.

But even in these instances a careful analysis of
the case almost always reveals a preceding period of

faulty feeding, an imperfect digestion, a faulty me-
tabolism, and especially so in connection with the
nervous mechanism. In cases of this nature, even
after the indicanuria has been brought under con-
trol, and when every function of the body is being
perfectly effected, any severe or prolonged mental
exertion will speedily arrest the perfection of the
digestive secretions and the indicanuria will at once
recur, even though the patient strictly adheres to a
well-regulated diet and may be still taking the re-
quisite amount of out-of-door exercise.

The one exception to the almost universal rule
that there must be errors in diet and a faulty diges-
tion before the disturbances in the nervous mechan-
ism will excite indicanuria, is in connection with
those instances in which the nervous system has
been subjected (when the whole system is otherwise
in an apparently normal state) to a severe injury
or shock. When this occurs there may be almost
complete arrest of nerve innervation to the diges-
tive organs, at a time when they are acting normal-
ly. In such an instance the primary defect may be
traced to the nervous mechanism, and, secondarily,
to the digestive organs. .As a rule, however, the
primary defect is found to be in connection with
the diet and digestive system, and, secondarily, in
the nervous mechanism. In most instances it is very
difficult to draw a sharp line of demarkation be-
tween the two systems, yet the distinction can be
made if each case is accurately studied by itself.

From this it is easy to see that we are dealing
with a very complicated situation, one that gives rise
to an endless variety of symptoms, one in which, at
the beginning, so far as the deeper structures are
concerned, no microscopic lesions can be detected.
Later on, if the conditions persist, the development
of easily recognizable lesions in one or all structures
of the animal economy is of fre(|uent occurrence.
Whichever organ of the body is the most vulner-
able will be the one to give way to the prolonged
toxemia.

Before actual changes are developed in the ana-
tomical structures of the body, the symptoms asso-
ciated with the presence of indican in the urine art
largely nervous in character and often very poorly
defined. This is undoubtedly due to the large vari-
ety of toxins that are developed in connection with
the putrefactive changes going on in the intestinal
tract. There may be vague and ill-defined mani-
festations at various parts of the body. There are
often neuralgic symptoms. There may be convul-
sions, coma, and even death in some rare instances.
Not infrequently there are convulsive attacks that
so closely resemble those of the so-called central
epilepsy that it is almost impossible to distinguish
the one from the other, except as the result of treat-
ment. There are often headache, vertigo, insomnia,
— an endless train of symptoms. When there is an
associated intralobular compression jaundice, there
is apt to be a persistent nausea.

There are no specific symptoms that can be classed
as distinctive of indicanuria save the presence of
indican in the urine. Considerable emphasis is given
by some observers to the absence of free hydro-
chloric acid in this class of cases, as a causative fac-
tor in the development of the putrefactive changes
in the intestinal tract. On the other hand, others
claim that the presence of indican in the urine is
evidence of free hydrochloric acid in the gastric
secretion. The author is nf the opinion that free
hydrochloric acid is not always absent from tl'.e
gastric secretion in these cases, and that when it is
absent it is a secondary and not a primary condition,
except in so far as all the digestive secretions are

984

MEDICAL RECORD.

[June 15, 1907

decreased in quality and quantity, as already ex-
plained.

From these data it is clearly apparent that in-
dican in the urine is always secondary to the action
of the bacteria of putrefaction, acting usually upon
the proteid elements contained in the alimentary
tract; that the conditions favoring this abnormal
fermentation are varied and multiple ; that every case
must be studied by itself and the relative importance
of each one of these predisposing factors taken
strictly into account; if absolutely perfect success
is to follow our therapeutic endeavors. Owing to
these varied conditions it is no easy matter to cor-
rect these defects when once well established.

The diet must be regulated in accordance with'
the well-known physiological law, so that the food
taken will not be unduly irritative or fermentable.
It must be of an easily digestible character, so that
digestive energ)' will be conserved in the highest
degree, and everything must be done to secure a per-
fect nerve innervation of the glandular svstem when
it is below the normal standard. It is unwise —
even if it were possible as some have claimed — to
render the alimentary canal antiseptic. ?kluch can
be done in the line of decreasing the excessive fer-
mentation of the viscid mucus, which is the medium
that supports the growth of the pathogenic bacteria.
This can be accomplished by the judicious admin-
istration of tanalbin. In so far as we succeed in
this line, do we bring about practically a condition
which is equivalent to rendering the alimentary canal
antiseptic.

When these varied conditions are kept constantly
in mind and each one given its proper importance,
and treatment instituted to correct each one in the
order of its importance, some wonderful cures are
effected, and many serious chronic affections are
prevented.

Time will not permit taking up every little detail
of treatment, nor can a general detail be given of
all the medication which can be brought into play
in the management of these cases, for the simple
reason that no two cases are alike. For this reason,
what will give good results in one case may fail in
another, and vice versa. Therefore, all that can be
done is to point out, as we have attempted to do. the
various methods by which the abnormal conditions
lead up to and produce this complex condition cov-
ered by the simple term indicanuria, and to suggest
from the data the general lines of treatment that
must be followed to secure the desired results.

The minute details of treatment, such as the se'ec-
tion of the medicinal remedies and diet to be em-
ployed, must be left to the judgment of the individ-
ual practitioner, for each case must be studied
separately and treated according to the special in-
dications presented by the individuality of the pa-
tient.

The chief points in this discussion are as follows :
^ I. Indicanuria is one of the most important con-
ditions in connection with clinical medicine.

2. Indican was discovered by Prout in 1840.

3. Blue substances have been recorded in the urine
from the time of Hippocrates to the present.

4. Baumann and Breiger were the first to deter-
mine accurately the composition of indican.

5. Baeyer demonstrated that a more simple sub-
stance, indol, was the antecedent of the more com-
plex bod\- known as indican.

6. Nencki and others demonstrated beyond a ques-
tion of doubt that indican is always the result of
putrefactive fermentation.

7. Animal proteids are more likely to undergo
putrefactive fermentation than the vegetable class.

8. Vegetable proteids are much more difficult of
digestion than are the animal class, hence they are
less economic, and often detrimental to the system.

9. Senator has proved conclusively that bacterial
action is required to produce putrefactive fermenta-
tion in connection with the production of indican.

10. The sulphur atom in connection with the for-
mation of indo.xyl potassium sulphate comes from
the proteid molecule as the result of its oxidation
reduction.

11. Indican is primarily formed in the intestinal
tract, and not in the liver.

12. Numerous toxins are formed at the same time
that the indican is produced.

12. These toxins are absorbed into the circulatio;>
from the alimentary tract, and by their action upon
the nervous system excite an almost endless variety
of symptoms.

14. The conditions favoring the production of
indican are errors in diet, lack of outdoor exercise,
defective digestive secretions, and profound dis-
turbances in the working of the nervous mechanism.

15. Indican in the urine is never normal, but al-
ways indicates an abnormal condition, because a
putrefactive process can never be regarded as a nor-
mal or physiological phenomenon.

16. Successful treatment of these conditions de-
pends absolutelv upon an accurate apprehension of
the etiological factors entering into the production
of indicanuria. and also the be.'^t methods for the re-
moval of those factors.

BIBLIOGR.\PHY.

1. Porter : A'fw York Medical Journal, 1096, p. 949. The
Post-Graduate, 1907, Vol. XXII., No. 2, p. 105.

2. Front : Nature and Treatment of Stomach and
Urinary .\t¥ectious, London, 1840, p. 96: also 5th edition,
1848, p. 567.

3. Martin: Heller's .\rchives, 1846. p. 191, giving lit-
erature from Hippocrates' time down.

4. Schunck: Mem. of Lit. and Phil. Soc. of Manches-
ter, Vol. XIV., p. 239; Philadclt'hia Magazine and Journal
of Sciences. 4th series. Vol. XIV, p. 288. Chem. Chi., 1857,
P- 957; Jahresb. d. Chem., 1853. p. 659; 1857, p. 564; 1858,
p. 465.

5. Baumann : Ber. der Deutsch. Chem. Gessellsch., Vol.
IX., p. 54; Pflueger's .\rchiv.. Vol. XIII., p. 307; Zeitsch.
fiir Physiol. Chem., Vol. i, p. 60.

6. Nencki : Ber. der Deutsch. Chem. Bessellsch., Berlin,
1875, Bd. VIII., s. 722.

7. Baumann and Breiger : Zeitsch. f. Physiol. Chem.,
Strasburg, 1879, Bd. III., s. 254, to which the older lit-
erature on the indigo-forming substances of the urine is ap-
pended.

8. Baeyer : Ber. der Deutsch. Chem. Gessellsch., 1880,
Vol. XIII., p. 2254; and 1S81, Vol. XIV, p. 1741.

9. Nencki : Ber. der Deutsch. Chem. Gessellsch., Vol.
IX., p. 299. p. 1593. S. Radziejeiosky. DuBois' Archiv.,
P- 37, 1870. W. Kiihne. Ber. der Deutsch. Chem. Ges.. Vol.
VIII., p. 206, 1875. Salkowski, Zeitsch. f. Phvsiol. Chem.,
Vol. VIII., p. 417: and Vol. XXII.. p. 8, 1884.

10. Tuebinger : Med. Chem. Untersuchungen, Vol. IV.
Pflueger's .^rchiv.. Vol. XII., p. I.

11. Senator: Zeitsch. fiir Phvsiol. Chemie., 1880, Vol.
IV., p. I.

12. Baumann : Zeitsch. fiir Physiol. Chemie., Stras-
burg, Bd. X., s. 123.

14. Porter: Merck's Bulletin. 1892, Vol. V. p. 192.

15. Porter : International Clinics, 1906, Vol. II., 16th
series, p. 71. Merck's Bulletin. 1892, Vol. V., No. I, p. 8.

16. Simon: American Journal of Medical Science, iSgs,
Vol. ex.. No. I. No. 2/9. pp. 48-9. In which is to be found
a complete resume of the literature.

17. M. Joffe : Virchow's .A.rchiv., Vol. LXX.. p. 72, 1877.

18. Baumann: Zeitsch. f. Physiol. Chem., Vol. X., pp.
123-133. 1886.

19. A. Kast: Festschr. z. Eroffnung d. nenen allg.
Krankenhauses zu Hamburg-Eppendorf, 1889. .\bst. Nealy's
Jahrensbericht. f.. 1899. *

20. A. Kast and H. Baas: Miinchener medizinische
Wochenschrift. No. 4, 1888.

21. Baeyer: .\nn. Chem. u. Pharm., Vol. CXL., p.
295, and A. Emmulina and C. Engler, Ber. der Deutsch.
Chem. Gesell, Vol I..~p. 17: Vol. III., p. 885.

Tune 15. 1907]

MEDICAL RECORD.

985

22. M. Nencki : Ber. d. Deutsch. Chem. Gessellsch.,
Vol. VIII.. 187s, p. 336.

23. M. Nencki : "Ueber das Ludal." Ber. d. Deutsch.
Chem. Gesellesch., 1875, Vol. VIII., p. 722.

24. Kiihne: Ber. der. Deutsch. Chem. Gessellsch., 1875,
Vol. VIII., p. 206.

25. Salkowski, E. : Zeitsch. f. Physiol. Chera.. 1883, p. 41.
Vol. VIII., pp. 417-466; Sub. VIII.. op. cit., pp. 454-457.

26. Odermatt: Jour. f. prakt. Chem., 1878, Vol. XVIII.,
p. 249.

27. Nencki : Centralb. f. d. Med. Wiss., 1878, No. 47.

28. Breiger: Zeitsch. f. Phys. Chem., 1879, Vol. III.,
p. 134 et seq. See p. 139.

29. Salkowski: Opt. cit. Zeitsch. f. Phys. Chemie., p.
557 et seq.

30. Dr. Th. Weyl : Lehrbuch d. Org. Chemie., Berlin,
1891, p. 452.

31. (Legal's reaction.) Breslauer iirtzlich Zeitsch., 1884,
Nos. 3 and 4, quoted by Salkowski.

32. Salkowski: Opt. cit. Zeitsch. f. Phys., Vol. VIII.,

p. 447-

33. Rich. Heniala : Kur. Kenntruss der in der chem-
ischen Physiologie zur. Anwendung gekommenen Nitro-
prussidsalzreactionen Krukenberg's Untersuch. Heft 2, pp.
117-136. See p. 134, Jena, 1888.

34. Seyler: Handbuch d. physiol. u. path. chem. Anal..
6te. Auli., Berlin, p. 163.

35. V. D. Harris: Journal Pathology and Bacteriology,
Edinburgh and London, 1895, Vol. III., p. 310.

36. O. Emmerlung : Ber. d. Deutsch. Chem. Gesselsch..
Berlin, 1896. Bd. XXIX., s. 2721.

37. Zumft : Arch. d. sc. Biol. St. Petersburg, 1892. Vol.
I- p. 407-,,-;=.-

^8. Baumann : Ber. d. Deutsch. Chem. Gessellsch., Ber-
lin, 1880. Bd. XIIL, s. 284.

39. E. and H. Salkowski: Zeitsch. f. Phvsiol. Chem.
Strasburg, 1884. VIII., s. 454.

40. Nencki and Bovet : Monatsch. f. Chem. Wien.,
1889, Bd. X., s. 506.

41. Neumeister : Lehrbuch. d. Physiol. Chem., Jena,
1893. Th. 1. s. 209.

42. Nencki : Ber. d. Deutsch. Chem. Gessellsch., Berlin,
1875, Bd. VIII., s. 722.

43. Baumaim u. Breiger: Zeitsch. f. Physiol. Chem.
Strasburg, 1879, Bd. III., s. 254.

44. Baeyer : Ann. d. Chem. Leipzig. Bd. CXL., s.
295; supp. Bd. VII., s. 56.

45. Gamgee : Physiological Chemistry of the Animal
Body. London, 1893, Vol. II., p. 421.

46. E. and H. Salkowski: Seitsch. f. Physiol. Chem.
Strasburg. Bd. VIII., s. 417.

47.- Jaffe: Pfliiger's Archiv., Vol. III., p. 448.

48. McAIann : Clinical Chem. of Urine, p. 97.

49. Salkowski : Ber. d. Deutsch. Chem. Gesellsch.. Vol.
IX.. p. 1,39.

50. Jaffe: Centr. f. d. Med. Wiss., 1872, No. i.

51. Nencki and Mosson : Malv's Jahresb., 1874, p. 221.

52. Christiani : Zeit. Physiol. Chem., Vol. II., 273.

53. Porter: 3'i7/c Medical Journal, October. 1905.

LOCOMOTOR ATAXIA; A NEW THEORY
AS TO ITS CAUSE.*

By L. N. DENSLOW. M.D..

NEW YORK.

There has, as yet, been no explanation as to the
exciting cause of the changes that take place in
the nervous system in this disease. It is in the
hope of throwing some Hght on the subject that
the present article is submitted.

In the light of my clinical experience I am of
the opinion that the changes that occur in this dis-
ease are due primarily to irritation of peripheral
nerves, producing reflex disturbances in the spinal
cord and brain, and that such irritation kept up con-
tinuously for a sufficient length of time can and
does produce pathological changes in the cord, al-
though such irritation it has been supposed could
only bring about functional disorders.

Under certain conditions of tissue either syphilitic
or non-syphilitic pathological changes do begin and

*Read before a stated meeting of the New York Acad-
emy of Medicine. Thursday, May 16, 1007.

continue until grave conditions exist. It would seem
that the nerve tissues are subject to degeneration
from peripheral irritation only under certain con-
ditions and exempt from it in others. From the
fact that almost all authorities agree that there is a
primary or inherited syphilitic history in the greater
number of cases of tabes, it is possible that that dis-
ease is most frequently responsible for tissue condi-
tion necessary for its developinent.

The highly neurotic temperament would seem
also at times to furnish a fertile soil, it having been
met with in my experience in such cases a number
of times and in those where there was no history;
of syphilis either acquired or hereditary, but always
a positive peripheral irritation.

Exposure to cold, overexertion, sexual excesses,
and alcoholism all have been given as contributory
causes, but when one takes into consideration the
thousands who suffer from all these occurrences
and the comparative rarity of the disease, it would
seem that there must be some other necessary factor.

In all my cases some source of peripheral irrita-
tion was found, and wherever corrected marked re-
lief ensued. This would lead one to infer that, no
matter what the condition of tissue, without the
addition of the peripheral irritation, and that long
continued, the tabes was not set up.

Trauma has been found in several instances to
have been followed by tabes with more or less seri-
ous symptoms supervening very early in the dis-
ease. It has been thought that in such cases the
shock of the injury only precipitated the disease,
as irritation was always found and the symptoms
yielded quickly upon relieving the irritation.

It was not the writer's experience to find a syphi-
litic history in every case, but in all without excep-
tion some source of peripheral irritation was found,
and when amenable to treatment more or less re-
lief was experienced.

According to Tuczek chronic ergotin poisoning in-
duces a degeneration of the posterior columns of
the cord in all points analogous to that which con-
stitutes the anatomical lesions in tabes. This would
appear to have a special bearing on the theory in
hand from the well-known action of ergot on the
unstriped muscular fibers ; there from their gen-
eral distribution over the body in the skin, could
so be acted unon by the drug as to set up a general
peripheral disturbance by their alternate contrac-
tions and relaxation acting upon the nerves and
capillary vessels. The writer's article, "The Eti-
ology and Treatment of Acne" (by Ergot), Nezv
York Medical Journal, February, 1881, bears di-
rectly on this subject. The observations of Dejerine
have shown that a neuritis of the peripheral nerves
may produce a symptom complex very similar to
that of tabes dorsalis (peripheral neurotabes).

Thus we have two exciting causes of tabes: (i)
Long continued peripheral irritation causing it with
and without a prior syphilitic infection, and {2)
chronic ergotin poisoning; and there is also a third
cause, peripheral neuritis, producing a symptom
complex very similar to that of tabes dorsalis.

From this would it not be fair to presume that in
the case of a disease which is produced by agencies
quite other than syphilis, and where syphilis is
known not to have entered into the condition, and
where the pathological changes do not resemble
in their inception, course, or form any of the mani-
fold and characteristically usual ones of syphilis, the
disease is not primarily due to syphilis, but that
other agencies enter into its causation.

986

MEDICAL RECORD.

(June 15, 1907

If we allow for the ])resent that peripheral irri-
tation is the cause of the chanties in tabes, I would
submit a possible explanation of the mode whereby
these chang-cs may be accomplished. It is known
that the conductinjj nerve substance is a very simple
tissue, almost protoplasmic, being; little more than
highly phosphorized fats in a weak saline solution.
In other words, this portion of the nerves consists
of colloid particles in susjiension. Xow, if we apply
Prof. Mathews" theory that when a nerve is stimu-
lated electrically the colloid particles of these fats
are precipitated and that coas^ulation to a certain
extent takes place, we have a working hypothesis.

The peripheral irritation referred to in this arti-
cle is that which is and has been constant for a
period of time longer or shorter, as the case may
be, but above all persistent and producing continu-
ous, unconscious nervous stimulation. This irrita-
tion may exist for years without being known to
the patient; in other words, without ever producing
any local symptom. Such nervous action would
keep up a condition of chronic coagulation, which in
time w'ould become permanent. This condition ac-
cords well with the actual first change that is fomul.
Given this change the subsequent alterations of
nerve tissue are but natural sequelze, for with the
increased sensory irritability consequent upon such
coagulation, and the disturbance of the orderly ac-
tion and balance of both the sensory nerves and
their ganglionic cells, with their trophic connections,
and given the continued persistence of the initial
peripheral irritation, it would seem that there was
sufificient to account for the perpetuation and pro-
gress of all the pathological changes that take place
in the disease.

In connection with the foregoing theory it is inter-
esting to note that it does not conflict with Marie's
view, modified by Oppenheim,* that "the exciting
cause of tabes acts upon the spinal ganglia and their
homologues and injures them without at first altering
them structurally," and that "this is sufficient to
cause atrophy of the sensory fibers of the spinal cord.
of the medulla, and of the periphery, which come
from the ganglia. This atrophy gradually ascends,
i.e. towards the ganglion cells, until their fibers are
also involved." Also of special significance is the
fact that \\'ollenberg and Stroebe discovered degen-
eration changes in the nerve-cells even in incipient
cases of tabes.

I believe this theory of the etiology of tabes to
be correct. It is based upon a considerable clinical
experience. I am further of the opinion that if this
is found to be the case it must create a basis for a
new etiology in tabes, anrl possibly for other nerv-
ous diseases of unknown origin.

It has been considered bv the writer sufticient at
the present time simply to advance his theorv in
general. But in order to give other investigators
the benefit of his experience he would state that
the location of the irritation was genitourinarv in
both sexes in the cases examinefl. although it is
believed that the causes mav be as varied as those
known to produce the wide range of functional dis-
orders.

It would be of interest to know whether evestrain
was the primary cause or perhaps a contributing
cause in those cases of the disease in which atrophv
of the optic nerve takes place. It is proper to
add that the theorv advanced and these views are the
result of clinical experience with a number of
cases which have been observed and treated for a
siderable period — some of them having been rc-

*Oppcnhcim'« Diseases of the Nervous System. 1004.

lievcd in varying degree of their distressing symp-
toms, while others have been apparently cured, in
so far at least as that all symptoms disappeared
and that healtli and strength were regained, enabling
them to return to their former mode of life and
occupation.

This would lead us to infer that symptoms occur
in many cases of this disease with a severity out
of all proportion to the actual change in the cord
and consequentlv that there must be a wide sphere
of functional disorder in these cases beyond such,
change.

IS East Fortv-eighth Street.

THK MILK SUPPLY OF VIENNA.

l|Bv KK.N'ST J. LEDERER. M.D..

VIENNA.

The dairy company of lower Austria which sup-
plies the greater amount of the milk consumed in
Vienna is subject to control by the provincial diet
of lower Austria. The central depot in Vienna re-
ceives the milk from seventy-six affiliated dairies
throughout the province, and these in turn receive
the daily supply from a total number of 5,222 indi-
vidual producers. The principal aim of the organ-

FlG. I. — Cooling apparatus of a milk receiving station in the country.

ization has been to regulate the methods of obtain-
ing and handling the milk at the various places of
production, an object which experience has show-n
to be especially important since farm milk, although
superior in other respects, lacked that keeping
quality which is one of the essential requirements
in milk intended for city consumption. This aim
was attained by making it immediately incumbent
upon the directors of the affiliated dairies to inspect
the milk at the sources of supplv according to defi-
nite instructions given them by the Government In-
spector of Dairies. The inspectors visit the various
stables, criticise the condition of the stock and the
cleanliness of the barn, etc., and make the owners
remedy any existing defects or introduce needed im-
provements. Thev also supervise the feeding and
care of the cows, as well as the milking. The funda-
mental principles which must govern the manner of
feeding, tending, and milking the cows are thor-
oughly explained by the Government Inspector to
the members of an affiliated dairy when such a one
is established. Each member is supplied with a book
in which is entered the daily amount of milk deliv-
ered, and to this hook is appended a printed list of
regulations, compliance with which is legallv obli-

fuiie 15. 1907]

MEDICAL RECORD.

087

Satory. The Governnieiit Inspector furtlier has the
duty of visiting and insjjecting the various dairies
at regular intervals, and of rendering reports of such
visits both to the provincial diet and to the director-
ate of the Dairy Company of Lower Austria. Vet-
erinary inspection of the milch cows has likewise
been introduced.

Fig — 2. Laboratory-

The new-drawn milk must be delivered at the
local depot after each milking, if possible while still
warm from the cows. It is then measured, tested,
purified, and cooled, and if not sent ofif immediately
it is placed in the front compartment of the re-
frigerating room until shipped. The local depot
in which the milk is received and treated is a build-
ing which in every [)articular conforms to modern
requirements. Each affiliated dairy has such a
depot, which comnrises ice-house, cooling compart-
ment, wash-house, and the necessary apparatus, such
as pipe systems for cooling, strainers for purifying
the milk, apparatus for determining the percentage
of fat, lactometers and thermometers for testing the
milk, as well as centrifuges and the requisite appli-
ances and apparatus for butfer-making. .Since the
milk delivered to the local depots by the various
members must be transported to the railway station
to be shipped to the central depot in ^'ienna, the
affiliated dairies Iiave wagons which can be covered
to protect the milk against the heat of the sun. The
value is fi:;ed according to quantity and percentage
of fat, the latter being determined by the Govern-
ment agricultural chemical laboratory in Vienna.
The average contents of fat, according to the labor-
atorv's finding'-, are as follows :

..\r i:.\.STi-:i;.
No. of Percentage

-Affiliated Dairies. of Fat.

5 :y57

5 3-fi'

5 3.^)5

5 i.6o

5 ^>5

.■\veragf 3.(1 J

.•\T niRI.STMAS.

No. of IV-rcentage

.Affiliated Dairies. of Fat.

5 411

5 4.00

5 4-12

5 3-07

5 ^.Sq

Average 4.02

The amount oi impuritie.-, cnntained in the milk
from each producer furnishes ;i criterinn by which
are judged the care and cleanliness observed in
milking. The high state of purity m which the milk
from the various dairies reaches \ iemia may be
seen from the following table, which gives (in milli-
grams) the amount of impurities contained in one
liter of milk, and showing comparison with various
I ierman cities. These investigations were likewise
II liicted by the agricultural chemical laboratory in
'. iina :

Minimum. Ala.ximum.

^'ienna 0.5 7.5

Wiirzburg •. . . . 3.02 8.10

Lcipsic 3.80 1 1.50

Munich 9.00 27,90

Berlin 10.30 50.00

Halle 14.9- 72.50

In the central depot, however, the milk under-
goes still further purification, so that on reaching the
consumers it contains only a mere fraction of a
milligram of impurities per liter.

When the milk reaches the central depot in Vien-
na, it is poured into a large vat and weighed. The
vat is provided with a system of strainers and close-
meshed gauze for purifying the milk. The gauze
is renewed every time after it has been used, and
before being used again it is carefully washed and
sterilized in live steam. The purification process
gives very gratifying results. The milk, which is
already in a high state of purity when it reaches
the central depot, contains only from 0.3 to i milli-
gram of impurities per liter after having under-
gone the additional purifying process in the cen-
tral depot. From the weighing-vat the milk is led
into the pasteurization apparatus where it is heated
to 70° C. The receiving hall contains three such
pasteurizers.

Although the control exercised by the affiliated
dairies, the government inspector, and the veter-
inary surgeons aims at excluding milk from farms
or barns in which contagious diseases prevail, it is
not impossible, in view of the great prevalence of

Fig — 3 Pasteuri2inj^ room

tuberculosis among milch cows, that milk from dis-
eased cows may reach the dairy. For this reason
the entire (|uantity of milk intended for direct con-
sumption is pasteurized at 70° C, whereby all dis-
ease-producing organisms that may be present, but
especially the tubercle bacillus, are rendered harm-
less without the milk undergoing any essential

988

MEDICAL RECORD.

[June 15, 1907

changes, either physically or chemically. After pas-
teurization the milk is pumped on to the pipe coolers^,
where it is rapidly chilled to from 2° to 4° C. (35-6
to 39.2° F.) arid thoroughly aired. From the
coolers the milk is run into large galyan-
ized-iron vats, from which it is poured into

Fig.-

Hall for reception and distribution of mi'.k.

cans or bottles. The latter process takes place
bv means of bottling apparatus. Immediately after
having been filled the bottles are stoppered — by
means of machinery — -with paraffined paper stoppers
which bear the date of bottling.

.'\fter pasteurization a certain quantity of the milk
is creamed through two centrifuges, and divided
into whipping cream (30 per cent, fat), tea cream
(16 per cent.), and coffee cream (10 per cent.), as
well as skimmed milk. These products are each
cooled to a low temperature in separate apparatus
immediately after the centrifugal process. The
various kinds of cream are bottled by machinery,
while the skimmed milk is led into a separate com-
partment and poured into cans which are plainly

Before Pasteurization.
A

ical examination room in which all employees who
handle the milk are periodically examined by a
inunicipal health officer. Persons suffering from
tuberculosis or other contagious diseases are ex-
cluded. Both male and female employees are en-
jojned to bathe regularly.

Separate from tlie other departments is the room
in which the milk for children is handled. For this
purpose is used the milk from only one dairy, the
cows supplying which are tested with tuberculin
to make certain that they are free from tuberculosis,
and kept under rigid inspection by the Veterinary
Board of Lower .Austria. This milk very closely
resembles human milk in its chemical composition.
It is sterilized at 102° C.

The process of pasteurization has absolutely no
effect on the nutritive value of the milk, while ren-
dering its taste more pleasant. Neither does it
affect the formation of cream. The system has been
in use for seven years ; and the beneficial effects of
the improved milk supply, especially with regard to
the feeding of infants, are demonstrated by the sta-
tistical data. (See Chart.) The proportion be-
tween the mortality rates for breast-fed and bottle-
fed children was formerly (especially in the summer
months) i :20, while it is now from i :5 to i :8. The
circumstance that bottle-fed children are given bet-
ter milk reduces the rate of mortality for those in
the second year of life also. Regarding the cost
of the milk, the process of pasteurization in-
creases the price from 3-10 to i heller per liter (1-13
to 1-4 cent per quart).

:st Year of Life.

2nd Year of Life.

A

J \

1 \

) ^

^'^^-^

Since Pasteurization.

ist Year of Li;e. 2nd Year of Life.

-^-^^^

Chart showing the mortality of bottle-fed inf.inis in Vienna i.. ....i-i since the system o:

pasteurization was introduced. The dotted line in the first column indicates
the mortality of breast-fed children

marked "Skimmed ]\Iilk" in red labels. The
skimmed milk is utilized by bakers in the making of
fine pastry, etc., any surplus amount being made
into whey cheese. Unsold cream is made into
butter.

The central depot contains bathrooms, and a med-

PILOC.ARPIXE AS AN ADJUVANT IN THE
TREATMENT OF SYPHILIS.

Bv WILLI.A..M J. ROBINSON, M.D.,

XEW YORK.

The use of pilocarpine in the treatment of syphilis
is probably not entirely unknown. But the drug is
so seldom mentioned in treatises on the subject
and it has given the writer such remarkable results
in certain cases which refused to
be further influenced by the mer-
curials and iodides that he considers
it his duty to bring it before the
notice of the profession in this pre-
liminary note, in advance of a more
detailed contribution.

I have not the slightest intention,
of course, of recommending pilo-
carpine as a substitute for mercury
and iodine. But there are certain
cases of lues which seem to be
supersaturated with mercurv and
which no longer respond to the
drug. We may change the com-
bination of the mercury, w^e may
change the method and avenue of
introduction — the symptoms fail to
be influenced, or even become ag-
gravated. The submaxillary, axil-
lary, and inguinal glands instead
of diminishing in size uder the in-
fluence of mercury, as they gener-
ally do, become larger and even painful. Such cases
are particularly apt to be met with in patients in
whom sufficient attention has not been paid to gas-
trointestinal elimination, to hepatic, renal, and der-
mic activity. .-Mmost every physician has come in
contact with such cases in his practice.

June 15, 1907]

MEDICAL RECORD.

989

Now, try in such cases a few doses of ];)ilocar-
pine and you will be .c;ratifvin.e:ly astonished at the
results. JNIost remarkable is the efifect of pilocar-
pine on salivation and stomatitis. One mio;ht think
it rather strange to administer a powerful sialogogue
in salivation. But the fact remains that nothing
will stop mercurial salivation so eftectually as will
small doses — say two milligrams — of pilocarpine.
It is much more efficient in this respect than atro-
pine or potassium chlorate. And the rationale is not
difficult to understand. Salivation and stomatitis
are caused by an excess of mercury, imbedded in
the glands and acting as a toxic foreign body. Pilo-
carpine, being one of our most powerful glandular
eliminants, acting both as a sialogogue and a diapho-
retic, removes the useless excess of mercury, and
thus cures the trouble by removing the cause. (At-
ropine, on the other hand, merely masks the symp-
tom of mercurial salivation.) Another fact of which
the writer has convinced himself again and again :
Cutaneous syphilides which will obstinately resist
the persistent administration of mercury will dis-
annear rapidly, if pilocarpine be administered for
several days, either in addition to the mercur\-. or
even if the mercury be discontinued altogether
(provided of course the patient has had sufficient
mercurial treatment). I explain the modus oper-
andi of pilocarpine in such cases as follows: In
most cases the greater part of the mercury admin-
istered is eliminated through the bowels and kid-
neys. If the amount to be eliminated is too large
or if the ratio of elimination is too rapid, we get
cramps and diarrhea on the one hand and mercurial
nephritis on the other. \'ery little or no mercury
is eliminated through the skin and sudoriparous
glands, unless si:)ecial care is taken to keep them
at a high state of functional activity. The pilocar-
pine does just that. The svstem mav be "saturated"
with mercury, but the mercurv may remain dormant
and therefore useless. The pilocarpine, increasing
enormously the activitv of the skin, brings the mer-
cury to the surface, the skin lesions are directly af-
fected, and the syphilides therefore disappear. If
pilocarpine be given for a week or two and then dis-
continued, it w'ill be found that much smaller doses
of mercury will be necessary in order to produce
the desired efifect.

Method of Adininistratiou. — The pilocarpine
should never be prescribed in combination with
other remedies — alwavs alone. We can then in-
crease or diminish the dose, or discontinue it alto-
gether, at pleasure. I prescribe the alkaloidal -salt
either in the form of pihs. containing two milli-
grams each (1-32 grain), and of these I order two
pills three times a day, sometimes increasing to three
or four pills per dose : or I prescribe it in the follow-
ing solution :

Pilocarpina? Indrochlor 0.12 {z grs.)

Aqure chloroformi 120.0 (4 oz. )

Detur in vitro nigro.

S. 5i to ."ii t.i.d.

In not a single case have I observed any unde-
sirable by-efifects, and in no case could I find, though
I carefully watched, symptoms of cardiac depres-
sion.

I have careful notes of a rather considerable num-
ber of cases, in which the beneficial efifects of pilo-
carpine were unmistakable : and I guarded carefully
against falling into post hoc-propter-hoc fallacy.
But I will report those cases at a later date. In
the meantime, asking the profession to give pilocar-
pine a careful trial as an adjuvant in the treatment

of syphilis, I will lay down the following proposi-
tions :

1. Pilocarpine is a most remarkable glandular
eliminant, and glandular elimination is one of the
most important factors in the successful treatment
of syphilis.

2. Pilocarpine is of value in all secondary mani-
festations of the disease.

3. There are many cases which become intoler-
ant to the further use of mercury ; the system
seems supersaturated and continuing the mercury
in such cases means injuring the patient. Discon-
tinuing the mercurv, giving pilocarpine in the in-
ter\'al, enables us to resinne the former drug with
excellent effect.

4. Pilocarpine should be prescribed alone, either
in pills or solution, and should be given in doses of
two to eight milligrams (1-.32 to y& gr. ) two to
three times a day.

12 MouxT Morris Park West.

Two Hundred Scopolamine Narcoses. — Parlavecchio
reports 200 cases of operation undor narcosis with scopola-
mine, many of them being of grave nature. The technique
of Tufficr was used in all cases by the author, three injec-
tions being given during two hours before operation, of
three millegrams and a half of the drug. Often after the
second injection, sometimes after the first, anesthesia was
complete and continued for from six to ten hours. Sco-
polamine should not be used under the age of ten years,
while it is well tolerated by persons of advanced age, by
those with nepliritis, arteriosclerosis, and other conditions
in which ether is contraindicatcd. The advantages of
scopolamine are that it avoids the vomiting which is present
after ether or chloroform, and permits of operation in
persons of small vitality. It is convenient to operate in
the lateral position or on the back, as may be desired, and
is especially valuable in operations on the head or neck. —
La Riforma Mcdica.

The Saturday Night Tub.— Mr. Sidney Young has
recently delivered an interesting lecture on the "Relations
Anciently Existing Between Barbers and Sur.geons." From
the facts adduced one learns that it was the custom of no
less a person than King Henry VHI, to perform partial
ablutions on occasional Saturday evenings. The "King's
barber," one John Pen, Penn. or Penne, an ancestor of
the famous Quaker of fliat name, was expected to be pres-
ent at these august ceremonies, when the Defender of the
Faith was pleased "to cleanse his head, legs, or feet." The
regulation requiring the barber's attendance was a stand-
ing order, dating apparently from the reign of Edward
IV. It is preserved in the "Liber Niger Domus Regis"
(Harl. MS.. 642), and its wording seems to imply that
the solemn washings were partial and special rather than
thorough, and that the king's niaiesty often did without
them. The royal barber, who was also a groom of the
privy chamber and one of the fifteen persons allowed to
enter it. was also required to shave the king daily, "hav-
ing in readiness his water, basons, knives, combs, scissours,
and such other stuffe as to his roome doth appcrtaine for
trimmin.g and dressing of the king's head and beard." He
was further required to "take a special regard to the pure
and clean keeping of his own person and apparel, using
himself always honestly in his conversation without resort-
ing to the conrpanv of vile persons." and so on. Thus
we have the beginning of asepsis. When he was shaving
the king a knight of tlie chamber or squire of the body,
or both, were required to be present in order to prevent
foul play. The portrait of Pen figures prominently in
Holbein's famous picture of Henry VIII. delivering a
charter to the barbers and surgeons on the occasion of
their union in one body. — The Lancet.

99°

MEDICAL RECORD.

[June 15, 1907

Medical Record.

A Weekly Journal of Medicine and Surgery,

THOMAS L. STEDMAN, A.M., M.D., Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, June 15, J907.

PASTEURIZED MILK.

It lias been decided by the New York City Board of
Aldermen that the pasteurization of the substandard
milk offered for sale in tliis city is neither necessary
nor desirable, and the importation and distribution
of various pathogenic microorganisms will therefore
g-o on for the present. The agitation of the subject
has, however, already borne fruit in opening the
eyes of the public and directing more forcibly the
thoughts of the profession to the vital importance
of a pure milk supply. The first requisite to this is
cleanliness at the source, for no amount of pasteuri-
zation or even of boiling will convert a milk full of
gross impurities into an acceptable food. All that
pasteurization aims to do is to destroy the germs
which even the best of milk contains in greater or
lesser numbers, and with which milk, carelessly han-
dled, drawn from diseased cows, or carried in im-
perfectly sterilized bottles or cans, actually swarms.
Therefore, if the immediate result of the agitation
in and out of the public press is only a more careful
inspection of the farms and creameries at the source
of our milk supply, it will not have been in vain.

The opponents of pasteurization contend that the
process renders milk unfit, or at least less fit, for
consumption, since it destroys the contained enzymes
and so causes a deterioration in its nutritive qual-
ities. Without attaching too much importance to
this theoretical objection, it may be conceded that
untreated milk, if absolutely free from the germs of
tuberculosis, -^us cocci, and other pathogenic micro-
organisms, is preferable to the sterilized (boiled) or
even pasteurized fluid. Doubtless raw meat from
the recently killed animal contains certain nutritive
principles which are destroyed by heat, but there
are advantages in cooking meat which by universal
consent outweic^h the loss in nutritive properties
which it may sustain in the process. It is also al-
leged, as though this were an argument against the
principle of pasteurization, that the agitation is fur-
thered by the makers of pasteurizing apparatus. It
is not unlikely that these manufacturers are alive
to the possible benefit they may derive therefrom,
and if they are thereby stimulated to -^erfect their
apparatus the community will profit as well as them-
selves. The fundamental question is whether pas-
teurization does or does not prevent disease, and its
determination can be arrived at only bv discussion
and study, so that the present agitation of the sub-
ject, even if it were of purely commercial origin, as
it is not. can but be productive of good.

In the present issue of the Medic.\i- Record are
three articles bearing on this subject which are
worthy of attention by those interested. In the
Copenhagen letter our correspondent describes the
measures which have been taken to procure a pure
milk supply for that city. There is probably no
large city in the world which can boast of a purer
raw milk supply than Copenhagen, and it is inter-
esting to note that this has been brought about
by private initiative, the milk merchants having had
the wisdom to see that it was to their own advan-
tage to supply their customers with the best wares
procurable. Concerning the London supply, little
need be said ; the milk is neither pure nor purified,
although there is a prospect that the present public
discussion started by the Lancet investigation may
result in some improvement. On page 986 a
Viennese contributor describes the measures that
have been taken to protect the inhabitants
of that city from milk poisoning. There
pasteurization is now the rule, and the com-
parative infant mortality curves show what
the saving of life has been since a system of
general pasteurization was instituted. But infants,
although the chief, are not the only sufferers from
an impure milk supply. In a recent report on the
milk problem issued by the Washington, D. C, Milk
Commission it is stated that during the past twenty-
five years the medical journals have published the
histories of 10^ enidemics of typhoid fever, in ad-
dition to 99 of scarlet fever and 36 of diphtheria,
traceable to milk. One can imagine, though exact
statistics are wanting, how many deaths, how much
suffering, and how many unproductive days of ill-
ness might have been saved had the germs of
typhoid fever, scarlatina, and diphtheria been de-
stroyed by pasteurization before this poisoned milk
was ingested. To this may be added the fact, dem-
onstrated by E. C. Schroeder. Calmette and Guerin,
and others, that one of the most potent sources of
infection b\- tuberculosis is milk drawn from tuber-
culous cows.

Referring to the milk supply of Washington, this
Commission reports: "It must be apparent that it
will require time and education to secure compli-
ance with even reasonable safeguards, and it is
equally evident that the number of dairy farms now
in a position to live up to sanitary requirements will
supply but a small percentage of the pooulation, al-
though it is hoped that they will be stimulated into
existence by trade competition and the refusal of
the public to buy dirty milk at any price. Until this
is accomi)lislied. the committee, in the interest of
public health, stronglv advocates clarification and
pasteurization of all milk : this, to be sure, will not
make bad milk good, but it will at least destroy its
power to transmit disease germs." The men who
have signed this report are not uninstructed laymen
or persons interested in the manufacture of pasteur-
izing apparatus, but men who know whereof they
speak. The constitution of the committee is as fol-
lows : Dr. George M. Kober, Chairman : Emil Ber-
liner : Dr. G. L. Magruder: Dr. C. F. Mason. U. S.
Army: Dr. A. D. Melvin. Chief of the Bureau of
Animal Industry : Dr. J. R. Mohler of the Bureau
of Animal Industry ; Dr. M. J. Rosenau, Director of

June 15, 1907]

MEDICAL RECORD.

991

the Hygienic Laboratory of the Public Health and
Marine Hospital Service ; Col. R. G. Smith of the
U. S. Army, and E. H. Webster, Chief of the Dairy
Division of the Department of Agriculture. The
conclusions of tliis committee apply with equal force
to the milk supply of New York and all other large
cities, and they add weight to the arguments of those
who believe that the only safety for all consumers
of milk in this city, for many years to come, will
lie in the pasteurization of the bulk of milk offered
for sale, only excepting that supplied by dairies cer-
tified by the Milk Commission of the County Society
or some other competent authority.

This is not in disparagement of the laudable ef-
forts of the Health Commissioner of this city to bet-
ter the milk supply by a system of inspection of the
dairy farms. Such inspection is absolutely neces-
sary, but it will be many years before perfection can
be secured in this way. Moreover, political con-
siderations may at any time lead to the supersession
of the present Commissioner by one more
subservient to the demands of the "district
leaders," and when this change comes, what
will become of the elaborate system of dairy
inspection which he is building uj)? Unfortunatel}',
little confidence can be placed in the permanence of
any efficient system of inspection under political con-
trol. The present Commissioner of Health is doing
what he can, with about one-tenth of the necessary
force of inspectors, to insure a pure milk supply, but
no man knows what his successor will do. Until
the political millennium, and until model dairies can
be conducted as cheaply as ordinary cow farms,
the only safety for the mass of milk consumers will
lie in public or private pasteurization.

THE MEETING OF THE AMERICAN MEDI-
CAL ASSOCIATION.

The Atlantic City meeting of the American Medical
Association, held last week, was quite successful,
and, excepting a personal encounter in one of the
Section meetings, fairly harmonious. The scientific
work in the various Sections was up to the average,
though it suffered somewhat from the fact that
the Congress of American Physicians and Surgeons,
held a month before in Washington, had taken the
cream of what those who are members of both or-
ganizations had to offer. The weather was cold and
did not tempt to board-walk life, but this served to
increase attendance at the Section meetings, so, in
the interest of the scientific work, it was perhaps not
to be regretted. The public addresses were good,
that on State Medicine being especially interesting,
and the thoughts expressed in the President's ad-
dress were sound. The suggestions as to reform in
the management, foreshadowed in Dr. Brvant's ad-
dress to the Medical Societv of the State of Xew
York in Albany last January, were for the most
part omitted at x^tlantic City. The President did.
however, offer what may be construed as a i.irotesi
against the suppression of criticism in the columns
of the official Journal, and he hinted that there might
be danger in the wording of the constitution, which
declares one of the objects of the Association to be
"to safeguard the material interests of the medical

profession." "It requires no special discriminating
sense," he said, "to foresee the devious interpreta-
tions which eager desire might willingl\ give to the
]jhraseology of this declaration."

The protest of the Mkdic.m. Record last
year against secrecy in the financial affairs of
the Association has borne some fruit, tor the
Trustees announced that all details of the expense
account will be furnished verbally on request, though
they said it was inexpedient to state what wages are
paid the linotype workers or the girls employed in
wrapping the Journal for mailing. The three Trus-
tees whose terms of office expired this year were re-
elected, somewhat to the disappointment of those
who do not favor the close corporation principle in
the management of scientific bodies. It was urged
that the members of the Association give their cor-
tlial support only to those journals which carry the
advertisements approved by the Council on Phar-
macy and Chemistry. This suggestion, if acted
upon, would exclude from favor all the independent
journals, among them several edited by members
of the Board of Trustees, as well as a number of the
best of the State journals.

Dr. Burrell of Boston was elected President of
the Association, to take office at the next annual
meeting, which will be held in Chicago. This is
doubtless in recognition of Dr. Burrell's excellent
work in connection with the Boston meeting in 1906,
one of the largest and best conducted meetings in
the history of the Association. The choice is in
every way most commendable. The selection of
Chicago for the next place of meeting was wise,
for it will give the members in attendance the op-
portunity to see the headquarters of the Association
and to gain an idea of the practical workings of the
business part of the organization.

On the whole, the meeting gave evidence
that the Association is prospering ui material
affairs and that its membership is increasing satis-
factorilv, notwithstanding the defection of over two
thousand during the year. This is a matter of con-
gratulation to all loyal members, even to those who
believe that a still greater measure of prosperity
would follow upon a change in men and methods
which would recall those who have left, prevent
future defections, and bring into the fold the great
mass of the profession of the country which is op-
posed to the system of oppressive paternalism
against which the President of the .\ssociation so
eloquentlv warned his hearers in the New York
.State Society a few months ago.

The Coron.\rv Arteries.

The literature relating to the anatomy and physiol-
ogy of the coronary arteries represents an unusu-
ally extensive field of investigation, but the results
have so far been more or less unsatisfactory in that
they have been full of contradictions. The ordinar-
ily accepted view that the coronary arteries are end
arteries — if not in the strict sense of Cohnheim, at
least from a functional standpoint — has been con-
tested by numerous observers, and in a recent con-
tribution by Hirsch and .Siialteholz in the
Deutsche niediciiiiselie Woehciischyift . .May 16,

992

MEDICAL RECORD.

[June 15, 1907

1907, appears to be definitely disproven. Spalte-
holz, who studied the problem from the an-
atomical standpoint, by means of a specially
devised injection method combined with a
process for renderine the tissues translucent,
comes to the conclusion that the coronary arteries,
far from being end arteries, possess numerous an-
astomoses both on the surface of the organ and in
the substance of the myocardium. Each papillary
muscle is supplied by several afferent vessels com-
municating with each other by numerous branches.
These studies for the most part were made on the
hearts of dogs and monkeys, but comparisons
showed that the results could legitimately be trans-
ferred to the human organ as well. The fact having
been established that the heart is not deficient in
arterial anastomoses, but, on the contrary, is re-
markably rich in these, the clinical applica-
tion of this observation had to be deter-
mined by experiments on the living organ.
Bier has' already shown that the different or-
gans behave very difl'erently in regard to the con-
sequences of ligation of their arterial trunks and
that the anatomical picture alone does not suffice to
explain the results of the occlusion of the afferent
vessel. This part of the investigation was conducted
by Hirsch. who found by work on dogs that in the
heart muscle the conditions attending coronary ob-
struction or occlusion depend largely on the anatom-
ical or functional state of the vessels, and to a
still greater degree on the I'is a tcrgo or cardiac
power. The sudden blockage of a coronary artery
is therefore a particularly serious occurrence, if
the vessel is arteriosclerotic, and observations of
the blood pressure in these cases are practically im-
portant as affording an insight into the force of the
heart's action. In angina pectoris associated with
a low blood pressure the use of rapidly acting heart
stimulants is likely to restrict the dimensions of a
resulting infarct, but if there is increased vascular
tension any further elevation of pressure must be
avoided and morphine and the vasodilators are in-
dicated.

Hypertrophy of the Prostate.

The operative treatment of hypertrophy of tlie pros-
tate has now, at least in the hands of certain oper-
ators, reached a highly satisfactory state of devel-
opment— so much so that a German surgeon of in-
ternational reputation is reported to have said that
now that prostatectomy is available it is a pleasure
to grow old. None the less the mortality of the
operation is still comparatively high and there are
many contraindications to its performance, so that
nonoperative measures must continue to bulk largely
in the treatment of the condition. Among these,
p>ermanent drainage of the bladder by a soft rub-
ber catheter is highly commended by \'ogel {Ber-
liner klinische Wochenschrift, May 20, 1907), who
says that the results of the use of this procedure in
the stage of congestion are often astonishingly good,
particularly if the patient is in the stage of conges-
tion. In these cases there is a vicious circle in which
the enlargement of the gland causes retention of
urine, and this in turn occasions congestion of all
the pelvic viscera and so contributes to the increase
in size of the prostate. Continuous catheterization
bv relieving the vesical distention brings about a
general improvement, which often continues for a
considerable length of time, and even in the later
stages of the malady great relief may attend the

occasional resort to this measure. The patient may
in this way reacquire the power of emptying his
bladder unaided, or if the improvement is of short
duration benefit may follow leaving the catheter in
place for an hour or two a day, or every other day.
It is of great importance that the catheter be in-
serted into the bladder only far enough to allow its
eye to be just beyond the sphincter, and it must be
firmly fixed in this position. Numerous methods
have been sugeested for this purpose, but the one
preferred by the author is as follows: Two strips
of adhesive plaster about .5 cm. in width and 15 cm.
in length are applied at their middles to the catheter
at the meatus in such a way that their ends form a
cross. These four ends are fastened to the glans,
and are further secured by a strip passing circularly
around the coronary sulcus, though this must not
constrict the organ. The dangers of cystitis must of
course be reckoned with in resorting to this method,
and tlie most scrupulous asepsis is an essential.

Protection" Ag.mxst Ixfection from the Ixtes-
tin.\l Caxal.

A problem that has been made the subject of
much research is that of determining the conditions
under which the passage of bacteria from the in-
testinal tract into the blood stream is facilitated or
impeded, but the results so far have not been very
conclusive. A recent contribution of considerable
interest is that of Uffenheimer (Miinchener medi-
zinische Wochenschrift, May 14, 1907), who found
that the intestinal tract of the new-born guinea pig
is resistant to the passage of all bacteria and genuine
albumins, except the tubercle bacillus and antitoxins.
On repeating the experiments with new-born rab-
bits, however, it was found that these animals ex-
hibited a greater degree of susceptibility to the
passage of bacteria and albumins through the gas-
trointestinal mucosa. By a series of ingenious ex-
periments the author was led to the conclusion that
this disparity depended in general on a fundamental
difference in the bactericidal properties of the blood,
and particularly on the amount of alexin in the
serum. On removing the alexin from the serum
of rabbits by saturation with goat erythrocytes he
uniformly succeeded in causing the passage of pro-
digious bacilli into the blood of the experiment ani-
mals, and he expresses the conclusion that the
amount of alexin in the serum of an individual is
the decisive factor in determining whether or not
bacteria gaining access to the intestinal canal are to
succeed in gaining a foothold in the circulating
blood. If this conception proves to be well founded,
its bearing on the mechanism of infection in such
diseases as typhoid fever is self-evident, and ad-
ditional light is thrown on the protective agencies
of the bodv.

Chemically" Tre.\ted Ro.adway's.

A RECENT issue of the Lancet calls attention to a
practice, evidently extensively followed in England,
of sprinkling roadways with a solution of calcium
chloride. The increasing motor traffic has made
the question of dust a more pressing one than ever
before, and the immediate results of the new prac-
tice seem very satisfactory. The roadbed thus
sprinkled is converted more or less into a perma-
nently moist state on account of the hygroscopic
properties of the salt. The latter is cheap and its

June 15, 1907]

MEDICAL KELOKU.

993

supply abundant. But, as the Lancet states, we have
yet to learn of the permanency of its good efifects
and have yet to find if it has any drawbacks. Is it
free from corrosive properties ? Our contemporary
asks : "Will it afifect the feet of the horse, sheep,
or ox? Will it attack the rubber tire? Will splash-
ings containing calcium chloride corrode clothes,
the skin, woodwork, and so on ? Perhaps also some
risk may be involved in inhaling a dust impregnated
with an irritating salt. As is well known, a solu-
tion of calcium chloride practically acts as an acid
and readily attacks iron and other metals, so that it
is possible that the use of calcium chloride as a
dust preventer on the roads may prove to be a rem-
edy worse than the disease. A shower of rain, of
course, is calculated to wash out the calcium
chloride, so that the moment dry weather succeeds
wet the application of the salt would have to be re-
newed." The problem of the new dust-layer is man-
ifestly not yet reduced to its lowest terms.

Red Cross Congress. — The formal ooening of
the eighth international Red Cross conference took
place in London on June 11. Lord Roberts wel-
comed the delegates and read communications from
the Queen, from the Dowager Empress of Rus-
sia, and from the Florence Nightingale Assembly.
The congress closes to-day with a reception to the
delegates at Buckingham Palace, at which the King
and Queen, General Robert M. O'Reilly. U.S.A.;
Col. William C. Sanger, and naval and military at-
taches will be present. The United States, in ad-
dition to General O'Reilly, is represented officially
by Medical Director John C. Wise, U.S.N., while
the American Red Cross delegates are Colonel San-
ger, Miss ^label T. Boardman, and Ernest P. Bick-
nell.

For a National Department of Sanitation. —
At the banquet of the Practitioners" Club of Jersey
City, held in this city on June 11, Congressman
Eugene Leake of Jersey City announced that at the
next session of Congress a bill would be introduced
providing for the establishment of a Federal sani-
tary bureau to take over the health problems now
scattered among several departments, and to cen-
tralize and coordinate the work of --'blic sanitation.
The bill will probablv include the appointment of a
medical member of the Cabinet.

The Correction of Medical Nomenclature. —
The Medical Society of Athens, in the endeavor to
assist in the formation of a system of classical
Greek medical nomenclature, for the guidance of
men of science who use chieflv the Greek language
for scientific terms, has appointed a committee, of
which Professor S. Mangina is chairman, entrust-
ing this committee with the collection of the classi-
cal Greek definitions to be proposed as substitutes
for irregular terms newly introduced into medical
literature and in use both in Greece and in for-
eign lands. Dr. Achilles Rose of this city has been
unanimously elected a member of this committee.

Coroner's Physicians Bill. — Governor Hughes
has vetoed the bill increasing the number of Coro-
ner's physicians in Brooklyn. In doing so he points
out that if the law is to be amended at all it should
provide that the number of Coroner's physicians
within the Greater New York should be fixed by
the local authorities and not by the Legislature.

Suicides in Chicago. — An unusually large num-
ber of suicides was reported in Chicago during the

past month. January had twenty-five cases of sui-
cide, February twenty, March thirty-seven, April
forty-six, and May fifty-five. In the first five months
of the year there were seventy-five murders, twenty-
two of which were committed in May.

Hygienic Cigars. — Cigars are now made in Ger-
many which are free from the danger of transmit-
ting infectious diseases from the workman to the
smoker through the practice of gumming the wrap-
per. In the new method the wrapper is held in po-
sition by a tinfoil ring, removable before smoking.

A Conference of Physicians Interested in Hy-
drotherapy was held at Atlantic City on June 4,
1907. Dr. Simon Baruch was called to the chair and
Dr. Frank E. Brown appointed secretary. Repre-
sentative physicians from several States discussed
the importance of furthering the study, teaching,
and practice of hydrotherapy and other physiological
methods. A committee consisting of Drs. Hare of
Jefferson, Thayer of Johns Hopkins, Baruch of
Columbia, and F. E. Brown of Baltimore were ap-
pointed to formulate a symposium on these subjects
for the next meeting of the American Medical As-
sociation.

Louisiana State University Medical School. —
At a recent meeting of the Board of Supervisors
of the Louisiana State University, held in Baton
Rouge, the charter and by-laws of the new medical
college of the University, to be established in New
Orleans, and the contract of assimilation between
the University and the Medical Department were
submitted to the Supervisors and approved. It is
the general understanding that this medical depart-
ment is to be ready for opening during 1908.

McGill University Medical Building. — It is
planned to rebuild the medical building of McGill
University, which was recently destroyed by fire, on
a plot of ground immediately opposite the Roval
Victoria Hospital. The ground is owned by Lord
Strathcona, who bought it for the purpose of pre-
venting residences being built opposite the hos-
pital, and is believed to be willing to place it at the
disposal of McGill. The laboratory, which prac-
tically escaped the flames, will remain where it is,
but the plot on which the medical building proper
stood will be cleared and left for the general beau-
tification of the grounds.

Columbia University. — On the recommendation
of the faculty of medicine, Dr. James D. Voorhees
has been made adjunct professor of obstetrics. Dr.
Royal Whitman adjunct professor of orthopedic
surgery and Drs. George R. Lockwood, William K.
Draper, and Van Home Norrie adjunct professors
of clinical medicine. Plans have been filed for the
partial remodeling of the Vanderbilt Clinic building
of the College of Physicians and Surgeons at the
southeast corner of Amsterdam avenue and Six-
tieth street for the establishment of a department of
hydrotherapy.

The New Civic Health Commission of Chicago,
recently appointed by Mayor Busse, is composed
of the following: Mrs. Marshall Field, Dr. Nich-
olas Senn, Dr.'^Frank Billings', Dr. C. E. Kahlke,
Dr. W. E. Ouine, and Dr. C. H. McKenna. During
periods of high mortality in the city Dr. Evans,
Health Commissioner, will consult with the com-
mission as to the best means of checking the death
rate.

For a Street Cleaning Commission. — Mayor
McClellan has asked the Board of Estimate to ap-
propriate $10,000 to be used for the expenses of

994

MF.DICAL RECORD.

[June 13, 1907

a commission of three engineers whom he will ap-
point to investigate and report at an early date on
an improved system of street cleaning, and a bet-
ter method of disposing of the city's waste. The
following are suggested by the Mayor as suitable
members of such a commission : H. de B. Parsons,
Esq., S. S, Whinerv, Ks(|., and Rudolph Hering,
Esq.

Chicago Death Rate in May. — During May
there were 3.028 deaths reported in Chicago from
all causes, this being equivalent to an annual death
rate of 16.91 per 1,000. Pneumonia led the death
causes with 685 ; consumption, 352 ; heart diseases,
243; nephritis, 215, and violence f including sui-
cide), 201.

New Nursery and Hospital for the Cribside So-
ciety.— The new building for the nursery and hos-
pital for the Cribside Society, to be erected at Full-
erton avenue and Orchard street, Chicago, will be
ready for occupancy January i. This building will
be a two-story red brick structure, built on strict
colonial lines. Its dimensions will be 41 by 37 feet.

Quarantine Against Cuba. — Passengers arriv-
ing in this port from Cuba now have their temper-
atures taken at Quarantine and if thought advisable
are kept under observation for a day or tw'O at
Hofifman Island. An arrangement has been made
in Havana under the sanction of the United States
jMarine Hospital Service to enable passengers to
the Southern States to avoid detention on landing
by spending several days under observation in a
quarantine camp before sailing. It is planned to
centralize the sanitation of the whole island under
Major Kean, United States Sanitary Supervisor.
An executive department of sanitation may be cre-
ated later.

Plague in Trinidad.— Two fatal cases of bu-
bonic plague in negro children have been officially
reported from the Island of Trinidad. The health
authorities have cabled to this city a request for
antiplague serum.

Gifts to Hebrew Charities. — The will of the late
Louis Josephthal, filed for probate last week, leaves
$5,000 to Mount Sinai Hospital to found a bed in
his memory, and $2,500 to the Montefiore Home for
Chronic Invalids.

The British Royal Institute has awarded the
.\ctonian prize of one hundred guineas to Madajne
Curie, in recognition of her researches in the field of
radiology.

Illinois Bill against Cigarettes. — Governor
Deneen has approved the Berry anticigarette bill,
forbidding the use of cigarettes in public by minors
under eighteen years of age, and also forbidding
the sale of cigarettes to minors under that age. A
fine of Sioo or jail for thirty days is provided for
those who adulterate cigarettes.

Japanese Gastroenterological Association. — Dr.
J. Takaminc and Dr. Max Einhorn. both of this
city, ha\c been made honorarv members of this
.\ssociation.

Optometry Bill. — The bill permitting the practice
of optometry under certain restrictions having

passed the Legislature, a hearing on the b' ■

held by Governor Hughes on June 17. l
takes final action on it.

Bequest to St. Luke's Hospital. — The will of
Mr. James Morris of Ridgefield. Conn., which was
probated last week, leaves $18,000 to St. Luke's
Hospital, the income to be used in providing rides
for sick children in Central Park, .\nother bequest

of $iy,ooo is also made to the same hospital, to be
added to $6,000 already given, in memory of the
testator's son, Marion Gray Morris. The income
from this is to provide for the services of a voice
to sing hymns in the children's ward. Mr. Morris
and his wife had already given 82,000 to provide
rides for sick children.

The Eleventh Antialcoholic Congress will be
held at .Stockholm, Sweden, July 28, 1907. These
meetings, held in different cities of Europe during
the past few years, have attracted a great deal of
attention. The Swedish Government, through its
State and Educational Departments, has taken full
control of this Congress and formally invited every
country in Europe, as well as the United States and
Canada, to send representatives and eminent per-
sons interested in and acquainted with the subject.
The State Department at Washington has appointed
as delegates to this Congress, for the Government,
Surgeon-General O'Reilly of the U. S. Army and
Medical Inspector Beyer of the Navy. Drs. T. D.
Crothers of Hartford, Conn., and T. A. McNicholl
of New York City, to represent the medical pro-
fession, and Mr. B. A. Hockhart of Hartford, Conn.,
to represent the temperance organizations and the
Swedish people of this country.

International Congress of Psychiatry, Neurol-
ogy, Psychology, and Nursing of the Insane. —
The second provisional program of this Congress,
which is to be held in Amsterdam, September 2 to
7, 1907, has been issued and is printed in Dutch,
French, German, and English. Detailed informa-
tion is given regarding the general arrangements for
the Congress, the subjects for discussion, etc. The
president is Professor G. Jelgersma of the Univer-
sity of Leyden, and the general secretaries are Drs.
G. A. M. von Wayenburg. and J. Van Deventer,
Prinsengracht 717, Amsterdam.

Boston University Medical School. — Dr. John
P. Sutherland, Dean of the Boston University Med-
ical School, has announced that, beginning next
year, the course at the school for the M.D. degree
will be increased from four to five years.

Dr. I. Boas of Berlin, editor of the Archiv fiir
Verdanungskrankhciten and author of numerous
works on gastrointestinal disorders, has been ap-
pointed to a professorship in the Universitv of Ber-
lin.

American Academy of Medicine. — .A.t its At-
lantic City meeting this organization elected the fol-
lowing officers: President, Dr. Thomas E. Davis,
Pittsburg; Vice-Presidents, Drs. James K. Mc-
Bride, Pasadena, Cal. , F. P. Rogers, Providence,
R. I., L. F. McMurtry, Louisville, Ky. , A. M.
Holmes. Denver: Secretary and Treasurer, Dr.
Charles Mclntvre, Easton, Pa. : Assistant Secretarv,
Dr. A. R. Craig. Philadelphia.

South Dakota Medical Association. — At the
twentv-sixth annual meeting of this organization,
held in Sioux Falls on May 23, Yankton was se-
lected as the next meeting place. Officers were
elected as follows: President, Dr. L. C. Mead of
Yankton : Vice-Presidents. Dr. S. A. Brown, Sioux
Falls, and Dr. C. R. Wright of Huron: Secretary-
Treasurer, Dr. R. D. Alway of Aberdeen.

Upper Cumberland (Tenn.) Medical Associa-
tion.— At the meeting of this .A-Ssociation. held in
Carthage on May 30. officers as follows were elected
for the ensuing year : President, Dr. Sam Denton
of Bui?alo Valley: \' ice-President, Dr. J. Howard
King of Chestnut Mound : Secretary, Dr. L. D. Cot-

June 15, i()oj

MEDICAL RECORD.

995

ton of \Vhite county. The ne.xt meeting will be held
at Sparta.

Southern Railway Surgeons' Association. — Of-
ticers as follows w^ere elected at the meeting of this
organization, held in Washington, D C, on May
30: President, Dr. H. T. A. Lemon of Washing-
ton ; / 'ice-President, Dr. C. H. Starkel and Dr. T. J.
Happel : Secretary and Treasurer, Dr. J. U. Ray,
reelected. The next meeting will be held at Bir-
mingham, Ala.

Arizona Medical Association. — The officers
elected at the sixteenth annual meeting of this or-
ganization, held in Bisbee on June 30, are as fol-
lows: President, Dr. A. R. Hickman, Douglas;
Vice-Presidents, Drs. A. W. Alcott of Tucson, J. E.
Drane, Jr., of Mesa, and L. P. Kendall of Jerome ;
Secretary, John W. Foss of I'hoenix ; Treasurer.
E. B. Kitcherside of Globe.

Medical Society of Northern Virginia. — At the
.meeting of this society held in Alexandria on May
2^ officers as follows were elected: President, Dr.
Timis C. Quick of Falls Church; Vice-Presidents.
Dr. G. T. Vaughn of Washington and Dr. F. M.
Brooks of Fairfax ; Secretary, Dr. Avery A. Ritte-
nour of .-Me.xandria.

Arkansas State Medical Society. — These of-
ficers were elected at the meeting of this organiza-
tion held in Little Rock on May 17: President,
Dr. C. C. Stephenson of Little Rock ; Vice-President.
Dr. H. Fink of Helena, Dr. J. L. Butler of Sheri-
dan, and Dr. C. B. Stevens of Magnolia; Secretary,
Dr. Morgan Smith of Little Rock; Treasurer. Dr.
J. W. Scales of Pine Blufif.

West Tennessee Medical Association. — This
association, at its meeting held in Jackson on May
17, elected the following as officers: President. Dr.
H. Hawkins of Jackson; Vice-President, Dr. F. D.
Smith of Memphis ; Secretary and Treasurer, Dr.
A. L McSwain of Paris.

Montana State Medical Society. — At the meet-
ing of this society held in Billings on May 16 of-
ficers were elected as follows: President, Dr. W.
W. Tavlor of Kalispell ; Vice-President, Dr. J. C.
ShafT of Butte, Dr. R. A. Monohan of Butte, and
Dr. G. G. Cogswell of Livingston ; Secretary, Dr.
Grace W. Cahoon of Butte ; Treasurer, Dr. D. A.
Donovan of Butte. Butte was selected as the place
for the next annual meeting.

Physicians' Club of Chicago. — .\t its annual
meeting, held JNLiy 28. the f. illowing officers were
elected: President, Dr. Daniel R. Brower ; J 'ice-
President. Dr. Edwin B. Tuteur; Secretar\. Dr.
Wni. T. Belfield; Directors. Drs. .A.. C. Croftan, C.
L. Mix, C. E. Paddock, and D. A. K. Steele.

Obituary Notes. — Dr. Felix Formento of New
Orleans died on June 2. at the age of seventy years.
He w-as born in New Orleans, but was educated in
Italy and was graduated from the LIniversity of
Turin at the time of the movement for Italian unity.
He served as a surgeon in the Sardinian Army and
received numerous distitictions from both the Ital-
ian and the French Governments. He returned to
Louisiana in i860 and was prominent in organizing
the army hospital service in Missouri. He was
vice-president of the International Congress of Hy-
giene at Geneva and was the author of several
works on military surgery

Dr. Robert Augustus M.'\rmion, Medical Direc-
tor, U.S.N. . retired, of Washington. D. C, died of
apoplexy on June 8. He was born at Harper's
Ferry, Va., in 1844, and entered the navv as a.ssist-

ant surgeon at the age of twenty-four years. From
1894 to 1896 he was a fleet surgeon of the South
.Atlantic Station. Since his retirement in Septem-
ber, 1906, he had lived in Washington.

Dr. J. H. Hammond of Minneapolis, Minn., was
found dead of heart disease on June i at the age
of sixty years. He had practised in Minneapolis
for twenty-five years, but of late had been obliged
to give up active work on account of ill health.

Dr. William H. Banks of Kansas City, Mo.,
died on June i after a long illness. He was a grad-
uate of Missouri University in the class of 1891.
He had practised in Texas and had served as army
surgeon in the Spanish-American war. He was
born in Columbia, Mo.

Dr. L. A. Fecteau of Natick, R. I., died on June
2, at the age of fifty years. He was a native of
Canada and was a graduate of the New York Col-
lege of Physicians and Surgeons.

Dr. M. D. Baldridge of Batavia, la., died sud-
denly on June i at the age of eighty-two years. He
was born in Guernsey county, O., but had lived in
Batavia for over fifty years.

Dr. George F. Fuerth of Detroit, Mich., died
suddenly of heart disease on June 3 at the age of
forty-eight years. He was born in Germany and
after receiving his degree from the University of
Halle practised for some years in Germany. He
came to America in 1893 and since that time had
practised in Detroit.

Dr. Alonzo Laurence Stickney of Ashburn-
ham, Mass., died on June 4 of heart disease. He
was graduated from Harvard Medical School in
the class of 1862 and two years later was made as-
sistant surgeon in the regular army, a position which
he held till the close of the Civil War. After prac-
tising for a time in Sutton, he removed to Ash-
burnham in 1871 and had resided there ever since.

Dr. N. K. Whittemore of Elk River, Minn., died
on May 31 of nephritis. He was born at Temple,
Me., in 1848 and had practised in Elk River thirty-
four years. For years he was medical examiner of
the Government pension board.

Dr. \'alentine Mott Francis, formerly of
Newport, died June 7 in West Roxbury, Mass., at
the age of seventy-four years. He w'as born in New
York and received his degree at the New York
University Medical College in 1859. He practised
several years in this city and was a life member of
the New York Historical Society. He was con-
nected with the Newport Hospital, and was presi-
dent of the Newport Medical Society and Newport
Historical Societv.

(EatvsBpmihtmf,

THE MILK SUPPLY OF COPENH.\GE.V.

(From Our Special Correspondent.)

Copenhagen. May 21, igo:

.As the question of the milk supply of great cities is now
being hotly discussed not only in New York, but in many
other parts of tlie civilized world, it may perhaps be of
some interest to your readers to hear a little about the way
in which this question is solved in Copenhagen,

The quantity of milk sold in Copenhagen has undergone
a very considerable increase during the last half of a cen-
tury. While in 1840 about 3,000 gallons of milk were sold
a day, now more than 40.000 gallons are daily consumed.
The daily average a head is estimated at 8/11 pints or
about four times the quantity consumed by a Londoner.
But this increase has only been possible because, as far
back as 1878, the milk trade in Copenhagen was arranged
according to the strict demands of hygiene. Perhaps the

996

MEDICAL RECORD.

[June 15, 1907

most remarkable fact regardins this is that |)rivate
initiative has proved strong enough to revolutionize the
milk supply of a great city like Copenhagen and to place
it on the high level it now occupies. The merit of having
accomplished this feat undoubtedly appertains to the Koben-
havns Moelkcforsvning (the Copenhagen iSIilk Supply
Company), founded in 1878 by Mr. G. Busck in company
with the late Prof. Panuni, Drs. Borch and Engclsted, and
other prominent men. The guiding principle of the com-
pany has been from the very first "pure milk from healthy
cows," and later events have proved how right it was
in accepting this rule for its work. By unswerving ad-
herence to this principle it has indirectly forced other simi-
lar enterprises, since sprung up, to follow in its wake
and has thereby conferred an incalculable benefit on the
public.

Thirty years ago the milk supply of Copenhagen was in
a deplorable .state. The milk was furnished by farmers
in the environs of the metropolis, feeding their cows on
all sorts of inferior fodder, or by distillers of spirits in the
city of Copenhagen itself, who kept cows in order
to utilize the residual products of the distillation.
If the sanitary state of the cows and the handling of the
milk in the country left nmch to be desired, it will easily
be believed that it fared far worse with the milk produced
within the walls of Copenhagen, where the cows were
never let out into the open air, and where some of them
were kept in stables in the second stories of houses in the
oldest and most crowded part of the town.

No wonder that the milk was nearly always adulterated
and most often tainted and infected. In 1876 of in
samples of cream only two contained the necessary amount
of fat, and 24 had been adulterated by the addition of
starch. Of 52 samples of sweet milk only S turned out
to be what they were sold for.

On this dark background the milk supply of to-day
stands out in a very flattering light. But I think that a
perusal of the precautions taken by the Kobenhavns
Moelkeforsyning w'ill prove this contention better than
many flourishes of rhetoric. All the purveyors to the
company engage themselves to feed their cows on forage
of only the best quality. All cows used in the production
of the so-called "infant's milk" are to be submitted to
the tuberculin test at least once a year and must not have
shown any reaction. All calves reared by the^ farmers with
a view to" milk production are also tested with tuberculin.

Before the return to the stable in the fall the tail, the
udder, and the hind quarters of the cows have to be
shaved.

Seven veterinarv surgeons, appointed and paid by the
company, ensure the observance by the farmers of these
regulations by visiting the farms fortnightly, and they
report once a month to the company on the composition
and quantity of the fodder, as on the number and state
of health of the cattle. They are also empowered to exam-
ine the cows as often as they deem it desirable.

The milking has to be done with the utmost cleanliness.
During this operation, therefore, every person of the milk-
ing staff must wear a special dress, exclusively reserved
for this use : he is provided with water and a towel, so
that he can keep his hands clean. The lighting of the
stable must be so good as to permit the operator to do
his work with the necessary care. Inmiediately after the
milking the milk is strained and cooled down to a tem-
perature of 5° C, usually by means of the Lawrence appa-
ratus. At this temperature it is kept until the transport to
the railway station takes place.

The milk is conveyed from the farms to the factory
of the company in Copenhagen in milk cans belonging to
the company and j-eturned daily to the farmers after hav-
ing been cleaned and sterilized in Copenhagen. The cans
hold, as a rule, eleven gallons. The consigner plumbs
the cans sent by him with a seal of lead bearing the name
of his farm, so that the contents cannot be tampered with.
In the summer the milk vans of the farms must be pro-
vided with an awning protecting the cans against the sun
during their transport to the railway station, where the
milk arrives shortly before the departure of the train.
The milk cans are then conveyed to the city in special
cold storage vans belonging to the State or to the com-
pany.. The trains arrive at Copenhagen at ten o'clock in
the morning and at the same hour in the evening, carrying
about 600 cans with a content of more than 6.000 gallons
of milk and cream. The cans are weighed and a sample
is taken of the contents of every can. The samples are
analyzed and tasted by specially trained women experts.
If there is the least thing abnormal about the taste of
the milk the contents of the can in question are not sold,
but used for the manufacture of butter and cheese. The
temperature of the milk is also measured and. if found

too elevated, the attention of the farmer concerned is
drawn thereto.

After this first examination the milk, cream, etc., is
passed through a filter of sterilized sand and gravel, cooled
down, and put into cans, which are subsequently
sealed by the company. From these cans the
milk is later on distributed in the various parts of the
town, the cream, however, being sold in stoppered bottles
of a liter, half a liter, etc., as is also the so-called "in-
fant's milk," intended for the nourishment of babies. This
milk is treated with still greater precautions, the milking,
for example, taking place into specially constructed milk
pails containing a refrigerating apparatus, whereby the
temperature of the milk is already considerably reduced
during the milking operation. As experiments have
shown, this procedure increases very effectually the period
during which the milk keeps sweet and unaltered.

The sale of most of the milk is effectuated from the milk
vans of the company circulating throughout all quarters
of the town and into some of the suburban districts in
the vicinity of Copenhagen. With each van go a driver
and from three to five boys. The latter distribute the
milk in the houses, fetching and bringing the buyers' ves-
sels, into which the desired quantity is drawn off from the
cans. The cream and the infants' milk are sold, as before
mentioned, in bottles sealed by the company.

In this way an excellent milk supply is furnished to the
population of Copenhagen. Notwithstanding the great
care given to the article it has not been necessary to raise
the price above what was paid before the company came
into existence. A pint of the best quality of cream, w-ar-
ranted to contain twenty-nine per cent, fat, costs fifteen
cents, while cream with only fourteen to fifteen per cent,
of fat may be had for nine cents a pint. The price of a
pint of sweet milk is two and one-half cents.

Only a minimal part of the milk is pasteurized by heat-
ing it to 85° C. for twenty minutes. Experiments have
shown that milk is undoubtedly deteriorated by heat-
ing, the enzymes being destroyed, and that even if pas-
teurization may do away with certain bacteria, as those
of typhoid, scarlet fever, diphtheria, tuberculosis, and
lactic acid fermentation the bacteria of putrefaction are
able to resist the procedure and multiply rapidly after-
wards. Such a nimbus adhered, however, to the name
of Pasteur, that some years ago there was a certain amount
of uncertainty whether it was not better that all milk
offered for sale should be pasteurized. But as far as
regards Copenhagen, the contest has now come to a close
with an undoubted victory for the non-pasteurization side.

THE MILK SUPPLY OF LONDON.

(From an Occasional Correspondent,")

London, May 20. 1907.

As in New York, so in London, the question of the milk-
supply is coming to be a matter of interest not only to
medical men and sanitarians, but to the general public as
well. For long the fact has been notorious that the con-
ditions governing the milk supply of London are defective
in very many respects. A certain number of ardent and
strenuous sanitary reformers, among whom were some of
the metropolitan health officers, have striven to arouse the
inhabitants of London to a sense of the dangers to health
involved in a more or less polluted milk supply. Up to
quite a recent date such efforts have been in vain. How-
ever, within the past few months some of the lay journals
of London have taken the matter up, and the importance
of pure milk is now generally attracting the attention it
deserves.

The Lancet during the past year has made somewhat of
a feature of the milk question, and especially so far as
London is concerned. Some six months ago the manner
in which milk was retailed in small provision shops in
London was dealt with in a fairly exhaustive way. It was
pointed out that 80 per cent, of the shops in which milk
was sold were small provision shops, and it was also
shown that such shops were, as a rule, dirtj' and unsani-
tary, and that the sale of milk therefrom was a distinct
menace to the public health, and a fruitful cause of infan-
tile sickness and mortality. Since the publication of these
articles the lay journals of London have devoted a con-
siderable portion of their space to a consideration of the
milk question, and many schemes have been suggested cal-
culated to ameliorate existing conditions. In the articles
above mentioned, the methods of railroad transport
are discussed, and many interesting facts in connection
with this part of the subject are treated in detail.

The last of this series of articles is of local interest, as
in it is made a comparison between the milk supply of

June 15. 1907]

MEDICAL RECORD.

997

London and that of New York. Tlie dwellers in New
York consume per capita far more milk than do the citi-
zens of London. London's daily consumption of milk per
capita is about 0,20 pint, while that of New York, according
to Dr. G. M. Whitaker, is considerably more than half a
pint. Consequently, the quantity of milk conveyed by rail
into New York exceeds the amount carried into London by
similar means of transport. The mode in which the New
York milk is transported by rail is compared with the
methods of rail transport which prevail in the London
districts, the comparison being greatly in favor of the
American methods. For instance, no milk is pasteurized
or sterilized before being put on the trains bound for
London, nor is any milk conveyed by rail in bottles.
Indeed, it appears that the custom of bottling milk is
almost unknown in London. Again the vans used by the
railroads for conveying milk to New York are. generally
speaking, much superior to those used to transport milk by
rail to London. Although some of the railroad companies
which are large transporters of milk to the British metrop-
olis supply specially built and suitable vans, on the other
hand, a large proportion of the milk which is carried into
London by rail comes in vans badly ventilated, and in many
respects ill-adapted for the purpose, while a not inconsider-
able quantity of the London milk is brought in on the
guards' vans of passenger trains, in company with a hetero-
genous mass of material, some of which should not be in
close pro.\imity to a product so susceptible to pollution as
is milk.

The writer of the Lancet article expresses the opinion
that what can be done towards insuring a fairly pure milk
supply in the State of New York could be done in England.
At any rate, it is stated emphatically that milk cans, before
they leave the dairy farms from which they are sent,
should be locked or sealed, and that the number of special
milk trains should be increased. The suggestion is also
advanced that refrigerating methods should be brought
into practice in England by the railroad companies when
conveying milk. Finally, the advice is given that the
London County Council should look into the American
system of milk stations on the railroads, where milk is
received from the farmer of the locality, kept in a proper
manner, handled in a proper manner, and placed in a proper
manner upon the special trains. It should be flattering to
the New Yorker's self esteem that London should wish to
take example from this city in regard to mod^ of milk
control. The contributor to the Lancet is well acquainted
with the conditions governing the milk supply of both New
York and London, and he states that the milk supply of
New York is better managed in nearly every respect than
is that of London.

The British medical and sanitary authorities are, as a
rule, opposed to the pasteurization and sterilization of
milk, believing that a pure and nourishing milk can be
better obtained by paying close attention to the sources of
supply, means of transport, and sanitary measures in gen-
eral than by relying on pasteurization or sterilization. Until
such methods have been brought into general use. it would
appear to the unprejudiced observer that pasteurization or
sterilization, although undoubtedly of the nature of make-
shifts, are better than serving milk which is dirty or germ-
laden. The hopeful feature of the situation is that in both
New York and London, and in fact in all large cities
of .A.merica and of Great Britain, the public conscience is
becoming aroused to a keener sense of the menace to life,
and to child life in particular, of a polluted milk supply.

OUR LONDON LETTER.

''From Our Special Correspondent.)

THE .\LC0H0LIC ST.ATEMENT — FRACTURES OF ODONTOID PROCESS
— HE.\LED ULCER AFTER GASTROENTEROSTOMY — DURATION OF
WIDAL's REACTION — PRECOCIOUS OBESITY — VIVISECTION, RE-
PORT. AND DEBATE — ITEMS — OBITUARY, SIR JOSEPH FA\'RER,
DR. GROVES. J. P.

LoN'i'ON. .Mav ?j, 1007.

The seed sown by the statement on alcohol, about which
I wrote to you last month, continues to produce an abund-
ant crop, but I think the nature of the harvest must be a
source of regret. The sixteen signatories, articles, cor-
respondence, and advertisements in the newspapers, of
course, were to be expected as the first fruits. Now fol-
low on circulars of all shapes, containing assertions of
varying degrees of credibility as to the views of the medi-
cal faculty, backed up by facsimiles of a pa.ge of the Lancet
and similar reproductions, all of course intended to im-
press the recipients with the value of alcohol, whether as
wines, beers, or spirits. I hope the sixteen gentlemen who
signed the joint statement get even a largernumberof these

circulars than have encumbered my letter box, that they
may be aware of the extent to which their names are being
advertised by "the trade" as the leaders of medical opinion.
They need not then have to visit taverns, where their
statement is exposed, to convince themselves of the use
to which it is being put and to open their eyes to what
they must have been blind not to see when they signed
their testimonial. They are "all— all honorable men," and
the wonder is that the perspicacity with which it is natural
to credit them did not save them from committing them-
selves to such a document. If a few general practitioners
had done so what would have been said? It is now gen-
erally admitted that a person "in the interests of trade,"
not a doctor, originated the scheme, and was successful in
obtaining the sixteen signatures. The exact manner of his
procedure is not worth inquiring into.

Mr. E. M. Corner has devoted great attention to frac-
tures of the odontoid process of the axis, and examined
the specimens in all the museums of these islands. From
his study of these and the records of all the histories ob-
tainable of fatal and non-fatal cases he has contributed a
paper to the Royal Medico-Chirurgical Society. He says
there is no reason why a patient who has sustained such
a fracture should not recover without any spinal symptoms ;
in fact, with nothing more than a painful, stiff neck. In
such a case there would seem to be more danger from over-
looking the fracture than from the injury itself. That was
the happy side of the clinical picture; the other was instant
death if the injury were overlooked. In fact, these frac-
tures fell into line with what he has shown to be the case
m other fractures of the upper cervical spine, viz. : that the
patients may suffer only a painful stiff neck. He, therefore,
concluded that all injuries of the neck should be skia-
graphed and examined by a skilled radiographer, for it is
very easy for an unskilled observer to overlook the injury.
The skiagraph should be taken through the open mouth,

Mr. Warrington Howard remarked on the importance of
recognizing the possible consequences of such an injury,
for a patient might fracture his odontoid process and, 'feel-
ing no more discomfort than a few days' stiffness of the
neck, might go about his ordinary work for months and
then die suddenly. Two such cases had occurred. He
also referred to a case of extensive disease of the odontoid
process without any symptoms except wryneck. The pa-
tient was a child and recovered, but tuberculous meningitis
came on, and at the post mortem the process was repre-
sented by a mere spicule of bone. The moral was to have
a skiagraph taken, and preferably through the mouth.

Dr. A. J. Whiting remarked on the contrast between
these cases, whether there was instant death or practical
immunity of the spine, at any rate for a time, and cases
of fracture— dislocation of the lower cervical spine, which
usually produced complete paralysis of all four limbs and
of the sphincters, though life of a sort continued for
months, so that the patients with the upper injury seemed
better off. Probably the transverse ligament of the atlas
protected the upper vital part of the cord. The absence of
symptoms was no reason why sudden death should not
supervene at any time.

At the Clinical Society, on Friday, Mr. Sherren gave an
account of a case of gastroenterostomy for chronic ulcer,
in which healing was verified at the post mortem twenty-
ei.ght months after operation, the patient having at that
date become^ melancholic and cut his throat. The anterior
operation with no loop was done, the posterior being im-
practicable on account of adhesions. There was a large
ulcer on the lesser curvature. At the post mortem the
operation opening admitted two fingers and the pylorus
was patent. Microscopical examination showed the healing
was complete. Mr. Sherren commented on the good re-
sults of gastroenterostomy even when the ulcer was dis-
tant from the pylorus, so that excision was not the opera-
tion of choice even in such a case.

Mr. Glutton, president, asked if Mayo's method of fixing
the jejunum so as to make it lie from left to right had
been adopted. He had used it for the past eighteen months.
Mr. Sherren replied in the negative; he had' tried the plan
in some cases, but had given it up.

_ Drs. H. French and G. Louisson read a paper on the
time that Widal's reaction persists after typhoid. They
had traced 135 patients who. while in hospital, had given
the reaction — the standard being clumping within half an
hour in a dilution of i in 200. The test was repeated after
the illness at periods from two months to ten years. They
obtained in 7.5 per cent, complete reaction, in 22.5 per cent,
incomplete, and in 70 per cent. none. The interval after
the illness made little difference, and it almost seemed as
if when cases persisted they did so indefinitely — several
lasted eight years. The president said he had found the
bacilli in some complicatiens three years after the fever,

998

MEDICAL RECORD.

[June 15, 1907

and Dr. French replied that he had not examined for
bacilluria. Perhaps the persistence of bacilh and agglu-
tinative power were correlated.

A paper on precocious obesity and hirsuties with hyperne-
phroma, by Drs. Cjuthrie and I-'mery, described the case of
a boy at four and three-fourth years, thirty-six inches high,
weighing over four stone. After death, from puhiionary
tuberculosis, the hypernephroma was found on the left side.
The second case was a girl of three and a half years, thirty
inches high, wei.gbing thirty-seven pounds. In both cases
the pulse was intermittent and the intelligence good. Other
cases were mentioned by several speakers; some with great
muscular development (the informal Hercules type), others
only obesity and hirsuties. Ilyperpliroma was not always
present.

The Vivisection Commission has issued a second report
containing the evidence taken in February and March.
Among the witnesses examined were Mr. Power, C.B.,
Chief Medical Officer of the local Government Board; Pro-
fessor Cushing. F.R.S., Sir Douglas Powell, Bart., Presi-
dent R.C.P., and Dr. F. Taylor. Tliese jepresented sane
medical opinion. In opposition, Miss Kenealy and Mr.
Graham offered the usual prejudices of the antis. On
Tuesday the antis achieved a sort of success by having in-
duced Professor Halliburton to condescend to engage in
a public debate with one of their lecturers. Notices of the
matter were, of course, secured in the newspapers the
next day, and those who think guinea-n-'-^s. rats, and other
creatures ought not to be sacrificed in the interests of
humanity have started a few more "horrors." The ladies
who assembled to support their champion showed what
they were by shoutin.g "brute !" when the name of Lord
Lister was mentioned. Such ignorance and prejudice will
scarcely be enlightened by the facts put forward by Dr.
Halliburton or any amount of scientific reasoning.

Cases of cerebrospinal meningitis continue to occur in
various localities. One was reported last week in Notting-
ham, which had not previously been invaded. The origin
of the infection has not been traced. Manchester, Wrex-
ham and Pilsby report cases, and eighteen deaths were
registered in Scotland during the week.

Dr. E. C. Seaton, M.O.H. for Surrey, in his annual re-
port considers the causation of typhoid in the country in
1895-1906. and concludes that polluted and infected foods
are more frequently the cause than water supply. He is
doubtfill whether 10 per cent, of the cases can be due
to water infection.

The Edalji case has at length been decided. Acting on
the recommendation of the committee he appointed to con-
sider all the circumstances, the Home Secretary has recom-
mended His Majesty to grant a free pardon, as the com-
mittee considered the prisoner had contributed by his own
foolish letters toward his conviction. The Home Secretary
decides that it is not a case for compensation.

Sir Joseph Fayrer. Bart., K.C.S.I.. etc., died on Tuesday,
full of years and full of honors. He had been ailing for
some time, but his indisposition took a grave turn ten
days ago and he passed away, in his eighty-third year.
He began medical study in the Bermuda Naval Hospital
and continued in various schools, British and Continental.
In 184- he took M.R.C.S. ; the Fellowship in 1878; in the
meantime having taken the Edinburgh M.D. and Fellow-
ship and then elected F.R.C.P. Lond. At the age of 23 he
was assistant surgeon on H.M. ship the Victory, but two
years later he transferred from the naval to the army ser-
vice, and after a year in that to H.E.I.S. His Indian ca-
reer thus begun in 1850 and continued to 1874, when he
returned to England as Surgeon-General and was made
President of the Indian Medical Board. From this time
he had a position as a leading consultant in London until
1904. when he retired to Falmouth, where he died. He
filled, as it were, three careers, viz. : military surgeon, uni-
versity professor in Calcutta and administrator and con-
sultant in London. As a military surgeon he saw field
service in 1847 as a volunteer in the hospitals during the
sie.ges of Rome and Palermo, three years later in Burma
and the capture of Rangoon. He was ne.xt appointed to
Lucknow, and was senior medical officer there during the
siege. Later on he was at Cawnpore. For his ser\'ices in
the mutiny he was promoted and received the thanks of
the Governor-General in Council. In 1858 he came home
on sick leave, and on returning to India was appointed
professor of surgery at the University of Calcutta, of which
he afterward became president of the medical faculty and
served on the senate and in various other positions in the
university school and the hospitals. He accompanied the
Duke of Edinburgh during his tour, and later went to
India once more with the King, then Prince of Wales. He
had been appointed Honorary Physician to the late Queen
Victoria, and the King, on his ascension to the throne.

made him Physician Extraordinary. His scientific work
had secured him the Fellowship of the Royal Society and
that of many other medical and scientific organizations,
the presidency of several being offered him. Edinburgh and
St. Andrew's universities conferred their honorary LL.D.
His son Joseph, who succeeds to the Baronetcy, is Lieu-
tenant-Colonel in the R.A.M.C. He leaves three other sons
and a daughter. His writings were numerous on many
departments of Indian medicine, surgery, toxicology, and
climates. His "Thanatophobia of India" appeared in 1881.
and must be known to you, as must many of his contribu-
tions to tropical diseases. In 1897 he wrote the life of
"Sir Ronald Martin," and in 1900 "Recollections of Mv
Life."

Dr. Joseph Groves, J.P., Medical Officer of Health for
the Isle of Wight, Rural District, died on Tuesday, in his
sixty-eighth year. He was a Kings College student and
graduated at the London University, B.A., 1859; M.B., 1867.
He also took the L.R.C.P the next year. In the 1866 epi-
demic of cholera he acted as M.O.H. in the Second District.
For twenty years he had held his office in the Isle of Wight.
He wrote an account of that district as a liealth resort,
and also a work on the "Treatment of Insanity." He had
been President of the Society of Medical Officers of Health.

OUR LETTER FROM THE PHILIPPINES.

(.From Our Special Correspondent ^

DISAPPEARANCE OF CHOLER.^i — SEWERS AS BREEDING P1_\CES FOR
MOSQUITOS — TYPHOID FEVER — BERIBXRI — RELAX.^TION OF
QUARANTINE RESTRICTIONS — PERSONAL.

.M.\.n:!..\. .-^r-'ril is. 1007.

A CAREFUL review of the available data on hand at the
present time would seem to indicate that cholera has en-
tirely disappeared from the Philippine Islands. A few
scattered cases are being reported from northern Samar,
the province of Capiz, and the province of Occidental
Negros. The total num.ber of cases and deaths, however,
does not amount to more than approximately five cases
per week. The Bureau of Health has made repeated efforts
to obtain specimens for laboratory investigations from
such cases, but generally only one case occurs in a lo-
cality, and the places are so remote that before a person
competeijt to make a microscopical examination can arrive
on the scene, the person is either dead or has recovered.
From the fewness of the cases and the entire lack of
any spread of the disease, it would seem that the diagnoses
of cholera are extremely problematical, especially in view
of the fact that the various forms of poisonings of the
ptomaine order, caused by eating decomposed fish and
others foods in which virulent poisons are frequently en-
countered, are so common, it w'ould seem that such cases
are not cholera, but are due to the poisons mentioned
above.

The extensive excavations which are being made at the
present time in the city of Manila for the purpose of
installing a new- sewer system have thrown considerable
light upon the failures of the campaigns conducted by
the Bureau of Health in the past against mosquitos. At
certain seasons of the year, notably in the dry season,
it has been practically impossible to free even such a
well paved section of the city as the walled city from
mosquitos. The conclusion was almost reached that unless
the walled city could be freed from mosquitos with com-
paratively sm.-iU outlay, that it would be practically use-
less to attempt a general mosquito eradicating plan in
the islands. Owing to the failure of the repeated efforts
of the Bureau of Health, the question of mosquito exter-
mination outside of Manila has not received much atten-
tion during the past vear. It seems now that this matter
is satisfactorily explained by the slow velocity of the
water in the storm sewers in the walled city. In the
rainy season, contrary to expectations, the walled city
is almost entirely free from mosquitos. This is explained
by the fact that large quantities of water pass through
the sewers in this time of the year, and the velocity of
the current is such that mosquitos are unable to breed;
whereas, in the dry season, no water entering the sewer,
the current becomes more and more sluggish, until finally
the flow ceases alto.gether and only a series of pools re-
main, which are due to the inequality of the levels of the
the drain. Such pools offer excellent breeding grounds
for mosquitos; in fact, large numbers of wigglers have
been found in the sewers. Many of the present storm
sewers will be relaid with better levels, and it is probable
that some relief may be expected in the future. The new
sewer plans, however, do not contemplate any extensive
chan,ges in the storm water sewers, the new system being
only for house drainage.

June 15, 1907]

MEDICAL RECORD.

999

Typhoid fever seems to be obtaining a firmer foothold
in the Philippines than has heretofore been the case. As
the changes which ordinarily accompany an introduction
of increased civilization are being more and more intro-
duced in these islands, it is becoming more apparent that
this disease is constantly affecting more persons. .\t the
present time the construction of the new railroads in the
islands is responsible for the gradual introduction of
typhoid in many places at which it has not been encoun-
tered heretofore. Fortunately, so far, the disease lias ap-
parently been due to direct importation, it having occurred
almost entirely among Americans and Japanese who have
only recently come to the country, and either arrive in
the incubation period or have ingested infected foods ob-
tained in the countries from which these new arrivals
come. At the present time, at the railroad hospital at
CebiJ, there are three cases of typhoid, and about twenty-
five cases have occurred in Manila during the past month.
It seems probable that the reasons why typhoid has not
spread more heretofore in the Philippines are not so much
because of the tropical climate, but because the ordinary
vehicles by which the disease spreads have not been
present. For instance, it is only a few years since milk
of local production has been used in the islands; there
were practically no general water distributing systems or
reservoirs; in the absence of sewer systems it was prac
tically impossible to infect places in which oysters and
other shellfish grow; and the comparative absence of flies
during the greater portion of the year are all explana-
tions as to why there has not been a more general spread
of the disease heretofore.

Beriberi, which a few years ago seemed to defy all
efforts toward its eradication among persons connected
with the light house service, and more particularly among
employees who are engaged at isolated houses, seems now
to be thoroughly eradicated. The measures taken con-
sisted in adding more meat to the ration issued, and in-
sisting upon making of rigid rules w-ith regard to em-
ployees eating with knives, forks, and spoons instead of
with their fingers. Which of these two measures is re-
sponsible for the disappearance of the disease is not
actually known, but from the favorable experience at the
Culion Leper Colony, where a serious outbreak occurred,
and which was not arrested until an increased proportion
of meat was added to the diet, would seem to indicate
that in spite of the assertions of laboratory workers that
the cause is not to be found in the diet, that this form
of treatment is an important element in its eradication.

Owing to the very favorable condition of public health
in the islands, the quarantine restrictions are to be still
further reduced. Hereafter all vessels engaged in inter-
island fade will not be required to obtain bills of health,
beginning May i, 1907. If the present favorable condi-
tions with re.gard to public health continue, it is understood
that still further restrictions will be removed in the fu-
ture.

There has been no case of plague reported in the
Philippines since April, igo6.

Dr. George D. Fairbanks, who has been connected with
the Bureau of Health since 1903. and who. during the
past two years has been house surgeon at the Civil Hos-
pital, has resigned his ^losition and will return to his
former home in Texas.

Ncw York Medical Journal. June i, 1007.
Eyestrain in School Children. — W. S. CoincU has
made a study of this subject as concerns school children
in Philadelphia. In 1,156 children he found normal vision
in 66 per cent. The test consisted simply in distance vision
with the Sneller types with the best natural light obtainable.
Of the .3+ per cent, of defectives about 6 per cent, had only
one-half normal vision or less. About 70 per cent, of the
defectives were not wearing glasses. This state of affairs
is due, he thinks, first, to the medical profession who
ignore the fact that the vast majority of refle.x head-
aches in children are due to eyestrain, and who ignore the
round-shouldered delicate children, making no systeni.itic
effort to find out the cause of their condition; second, to
the teaching profession whose knowledge of anatomy
and physiology is unpractical. They spend much time in
telliti_g the children about the effects of alcohol on the
stomach and liver and almost no time at all in looking
out for departures from normal of the needful sense-func-
tions, and third, to the parents who assume an attitude of
indifference and resentment. Cornell finds that girls suffer
more than boys from eyestrain and that there is a direct
relation between poor vision and scholarship.

Pyocyaneous Ulcer of the Cornea. — P. Fridenbcrg
reports the case of a girl of si.xtcen years who had been
staying at the seashore and who, after an automobile ride,
complained of irritation and some pain in the right eye.
An ulcer appeared the next day, which, in spite of all
treatment, completely destroyed the cornea. Scrapings
from the cornea and the contents of the conjunctival sac
revealed a pure culture of the Bacillus pyocyancus. The
interesting features of the case are first the lack of any
determinable injury. Pyocyaneous infection is generally
traumatic in origin, the injury having been inflicted with
a soiled weapon or with dirt, (hie would hardly expect
to find the Bacillus pyocyancus far removed from crowded
habitations, out doors at the seashore. The bacillus was
found in pure culture, and the matter from both ulcer
and conjunctival sac was otherwise sterile. In spite of
this, there was nothing characteristic in the local condi-
tions. The ulcerated area was a dirty gray. There was
no green discoloration whatever which mi.ght have led us
to suspect the nature of the pathogenic organism. The
course of the ulceration was rapid and malignant. There
was no perforation; the cornea liecanie entirely shrunken
and opaque and then gave way to intraocular pressure.
After the development of the ulcer there was no pain.
The patient did not feci the cauterization with pure tinc-
ture of iodine, ordinarily quite painful, and had little or
no discomfort, even from the application of the actual
cautery.

Morphological Diagnosis of Pathogenic Protozoa. —

J. Ewing notes that the great point of disagreement among
zoologists is not so much with reference to the existence
of a certain protozoon. but with reference to the right
of certain intracellular bodies to be included in the cycle
and the relations of one set of forms to another. This
matter has come up especially in the search for protozoa
in cancer, rabies, and the exanthemata. The mere recog-
nition of protozoa mav be an easy matter, but the identi-
fication of cellular degenerative products is most diffi-
cult. Ewing's object is to urge that serious dangers are
inherent in the mere morphological diagnosis of protozoa
in diseased human tissues, and he declares that the col-
lateral evidence must be favorable before new and very
peculiar protozoa can be established as the cause of dis-
ease. The great danger surrounding the morphological
diagnosis of protozoa in human tissues lies in the fact that
in many diseases, some of bacterial origin, intracellular
processes give rise to structures closely resembling pro-
tozoa. This fact is then presented by the author with
reference to variola, scarlatina, measles, rabies, .glanders,
and cancer. He says that collateral evidence is almost
conclusive against the protozoan origin of malignant neo-
plasms since no parasitic invasion can explain the au-
tonomy and organoid character of many tumors and there
is no parallel protozoan disease anywhere in the animal
or vegetable kingdom. The present state of our knowl-
cd,ge points to the conclusion that the virus of variola
aiid rabies and possibly of measles is intimately connected
with the tissue proteids which form the bulk of the specific
cell inclusions of these diseases, biit is itself of a nature
not vet understood and not vet paralleled among known
protozoa.

Journal of flic A)ncrican Medical Association, June 8, 1907.

Prostatitis. — E. G. Ballenger bases his paper largely
on the facts observed or confirmed by the study of over
one hundred prostates. More than half of these were
chronically inflamed and nearly one-third of them were
normal. He devotes special attention to the chronic in-
flammations, in nearly 80 per cent, of which the patients
.gave a history of a previous gonorrhea. In one of his
patients were found large numbers of colon-like bacillus
in the prostatic secretion, but no gonococci. The average
age of the patients was ,30, the ages varying between 19 and
50 years. Ballenger's experience leads him to believe that
in the majority of patients chronic prostatitis and seminal
vesiculitis are insidious, the patient being unaware of the
fact that his prostate is involved. He concludes his article
as follows: "The prostate gland is without doubt the cause
of the majority of obscure urinary and sexual symptoms,
and should always be examined where there is any uncer-
tainty as to their origin. Among the factors that tend to
perpetuate a chronic or recurrent gonorrhea a nidus of
infection or irritation in the prostate is the most frequent
cause. It is in this variety of prostatic inflammation that
the largest number of errors are made in the diagnosis.
Palpation, pus and proteid arc the three things to rely on in
reaching a conclusion as to the condition of the prostate.
By palpation through the rectum the gland, if diseased, may
be found enlarged, nodular, irregular, boggy, or apparently
normal. Pus in the secretion expressed from the meatus
or found in the urine or fluid voided after massage, when

lOOO

MEDICAL RECORD.

[June 15, 1907

the urethra and bladder are excluded as possible sources,
is positive proof that the prostate is inflamed. Proteid
in the fluid passed after massage is equally as reliable as
pus in the diagnosis of prostatitis.

The Diagnosis of Pyelonephritis. — E. Beer publishes
the histories of two cases which seem to point to a new-
diagnostic sign of the involvement of the kidney paren-
chyma. In the first case the patient discharged methylene
blue stained pus in the urine at intervals up to two and
three-fourths years after the last administration of the
drug. The second patient had pyelonephritis (verified by
nephrotomy), and had recurrent discharges of methylene
blue stained pus over a month after the last administra-
tion of the drug. Me is of the opinion that the pigment is
fixed in the pus in great part, if not wholly, in the leuco
form, and that its presence in the abscesses is the result
of the e.xcrction of the renal epithelial cells. He produced
a pyelonephritis in a dog and then for several days ad-
ministered methylene blue. The kidney was removed two
weeks later and. after treatment with oxidizing agents,
showed multiple bluish-gray pus foci throughout its sub-
stance. He summarizes his conclusions derived from the
facts so far as follows : I. There is no dififerential diag-
nostic sign between simple pyelitis and pyelonephritis. 2.
Pyuria from the upper urinary tract may be due to either
of these conditions. 3. By the use of the above described
methylene blue test it would seem that a differential diag-
nosis may be made. 4. Methylene blue is deposited in the
parenchymatous abscesses and may be stored in these for
years. 5. A late discharge of methylene blue, bound to the
pus, is indicative of the rupture of such parenchymatous
abscesses into the pelvis of the kidney and is consequently
diagnostic of pyelonephritis.

Meningococcus Septicemia. — C. E. Simon reports a
case of meningococcus infection in which the organism was
found in the blood, the eighth on record and the first in
which it could be demonstrated directly in the blood smear
taken from the ear. There was a very high grade of
leucocytosis — 50.000 as a conservative estimate, and an esti-
mated ratio of 7,380,000 per cubic centimeter of blood. A
noteworthy feature was that the large mononuclears were
engaged in phagocytosis almost as much as the
polynuclears. and their increase, both actual and
relative, was especially worthy of note. In his
former differential counts in meningococcus men-
ingitis cases there was always a marked polynucleosis
with low mononuclear values. The previously published
cases in which the meningococcus has been found in the
blood are reviewed, and Simon hints that this is possibly
e.xplained by the rarity of blood examinations that have
probably been made, and advises, since negative findings
in the meningeal fluid are not unusual, that the blood be
also examined in all doubtful cases. Culture methods with
bouillon, blood serum, hydrocele agar, and blood agar
should be employed. He hardly thinks his own method
with blood smears as likely to be successful.

The Lancet, May 25, 1907.

Hypopharyngoscopy. — P. T. Hald enumerates the
various divisions of the pharynx and points to the matter
of inspecting its laryngeal portion and especially that
portion behind the lamina of the cricoid cartilage. Vari-
ous methods of passing instruments into this section have
been in vogue for a long time, but all have their dis-
advantages and even dangers. The author has therefore
been led to follow the plan devised by von Eicken of Frei-
burg. The patient's fauces, root of the tongue, and larynx
are cocainized, he sits in a high chair while the examiner
kneels before him. Then a stout laryngeal probe is intro-
duced through the rima into the subglotic space and the
larynx is pulled forward and upward, the proximal straight
part of the probe resting against the upper teeth, so that it
acts as a lever. In the mirror it may tlien be observed
that the larynx is drawn from one and a half to two cen-
timeters away from the posterior pharyngeal wall, the
two pyriform recesses joining in a common cavity. Often a
facetting of the lamina of the cricoid is visible through
the mucosa, laterally to a median prominence. Occa-
sionally it is observed how part of the mucosa loosely ex-
tended over the lamina of the cricoid cartilage and its
muscles becomes drawn out to a fold stretching back-
wards w-hen the larynx is lifted away from the posterior
pharyngeal wall ; when the pull becomes stronger the
fold disengages itself from the posterior w-all of the
pharynx and sinks back to a level w-ith the rest of the
mucosa on the lamina of the cricoid. Occasionally the
author has been able to see the gullet open up during
vocalization and has been able to inspect its upper por-
tion.

Two Cases of Pulmonary Regurgitation. — Detailed
clinical histories of the cases with, pn«t-mortcni findings

are given by D. B. Lees and V. Z. Cope. Case one was
one of infective endocarditis affecting only the pulmonary
valves and occurring in a single woman of twenty-four
years. Case two was that of a man of thirty-nine years
with an aortic aneurysm which ruptured into the pul-
monary artery and caused regurgitation. The authors
make an analytical study of ninety-nine recorded cases.
In fourteen of these the incompetency was due to an
aortic aneurysm rupturing into the pulmonary artery and
causing the valves to adhere to the walls of the artery.
The lesion is said not to be very uncommon. The diag-
nosis was made difficult by the accompanying aortic re-
gurgitation. The presence of an aneurysm was regarded
as certain, but the extraordinarj' nature of the sounds,
both as to intensity and continuity, made those who saw
the case confident that there was something in addition to
aortic incompetence and this lesion. The suggestion was
discussed as to whether the aneurysm had broken through
into the pulmonarv artery, but no certain conclusion was
arrived at on this point. During life the pulmonary in-^
competence was not differentiated from the accompanying
aortic regurgitation. In this case also there was a dis-
tinct history of a sudden muscular overexertion. The
patient was a heavy smoker, but the authors are not pre-
pared to say how much of a factor this habit was in this
special case. They note that infective endocarditis of the
pidmonary valve is most frequently of gonorrheal origin,
thoi'gh in their own case (case one) this fact could not be
demonstrated.

Acute and Chronic Appendicular Pain: Medical and
Surgical Treatment. — A general consideration of this
subject is made by Saint-Rene Bonnet. He gives the his-
tories of (i) a typical case of chronic appendicitis wuthout
mucomembranous enterocolitis cured by medical treat-
ment alone, (2) a case of mucomembranous colitis in the
course of which painful secondary reflexes arising from the
appendix quite disabled the patient and called for surgical
intervention, and (3) a case of chronic mucomembranous
enterocolitis in the course of which acute appendicular pain,
due to a supervening cause — a large appendicular calculus
— necessitated operation, which was successful. The author
calls attention to the following causes which have induced
medical men to restrict surgical treatment (l) in the
course of operations, the appendi.x has often been found
to be quite normal or only slightly involved. It seems,
therefore, quite difficult to consider it the cause of the
trouble w-hich had necessitated the operation. (2) Some-
times when the appendix, whether healthy or not, has been
removed, chronic pain persists just as before ; even fresh
attacks similar to that of relapsing appendicitis occurs.
(3) In spite of the general tendency to resort to surgical
treatment, there are many cases where the symptoms seem
to point to a fatal termination, but in which, however,
recovery is obtained without surgical interference. (4)
These strictly medical cures assume greater importance
when the results of operating during the acute period of
the affection, with all the risks it entails become better
known. These facts at first puzzled both physicians and
surgeons, but most of them were e.xplained when careful
studies of the morbid syndrome, now so frequently met
with and which is called mucomembranous enterocolitis,
were made, the intestinal symptoms of which may be thus
tabulated. The author states that in well-characterized
mucomembranous enterocolitis we find chronic constipa-
tion with or without occasional attacks of diarrhea : diar-
rhea, which may become chronic, and is observed in the
place of chronic constipation more than is generally sup-
posed: spasmodic contractions of the large bowel which
alternate or coexist with dilatation of one or more of its
portions ; persistent pain which becomes intense during the
acute periods of the afifection : passage of mucus and casts
with occasional intestinal hemorrhages, and in some cases
abundant evacuations of intestinal gravel. He adds that
there are two important signs which must always be kept
in mind, for they are practically never absent. Firstly,
when paroxysms of mucomembranous enterocolitis are
localized or predominate in the right iliac fossa at, and
around, McBurney's point, they present symptoms which
may resemble exactly those of an acute attack of appendi-
citis, and when there are no acute paroxysms of the dis-
ease there may be persistent pain w'hich simulates that of
chronic appendicitis. As in true appendicitis, the pain,
whether acute or chronic, is of a shooting, stabbing, or
colicky character, or is replaced by a more or less marked
sensitiveness in the right iliac region. This pain is in-
creased by movement. Secondly, experience teaches that
when in the course of supposed acute appendicitis or of
chronic appendicular pain, mucous casts are passed in the
stools the physician is bound to feel entirely reassured as
to the nature of the trouble, and is enabled to give a good
prognosis.

June 15, 1907]

MEDICAL RECORD.

lOOI

British Medical Journ-al, May 25, igo".

Sudden Death at the Climacteric. — E. Pratt reports
the case of a woman of forty-five years to whom he was
hastily summoned, but who was found dead on his arrival.
Inquiry developed the fact that inside of two hours she
had "felt queer," vomited, was faint, and one hour or so
later the hands suddenly clenched, the face grew dusky,
nails were discolored, she felt very cold, became uncon-
scious, gave three blowing expirations, and then seemed
as if dead. For the previous year she had suffered from
occasional severe headache ; for the last si.x months she
had been subject to "fainting turns," with frequent retch-
ing, such attacks lasting half an hour to an hour, wlien she
would be all right again ; the attacks always occurred
early in the morning. The frequent flushes and cold
sweats of the climacteric were experienced, and irregular
catamenia, of late every two weeks or so, not much loss,
but extending over a longer period than normally. The
last menstrual period was a week previous to the fatal
attack. She was a healthy, cheerful, bright, and happy
woman. She had borne seven children, five now living.
Her father died suddenly at the age of sixty. The au-
topsy revealed nothing, all organs and structures being
normal, with no signs of internal hemorrhage or of poison-
ing. The author notes that attacks similar to those just
mentioned are common enough at the climacteric, but he
believes that such an attack originating in the genitalia
might so act reflexly that the balan.ce would turn toward
death instead of loss and recovery. He gave, at the in-
quest, as the cause of death "asthenic syncope," and has
been unable to find any record of an exactly similar case.

Tubercle and Erysipelas. — C. B. Whitehead reports
the case of a three-year-old child with enlargement of the
neck glands. The group chiefly affected was the pos-
terior cervical and there was no difficulty in diagnosing
an ordinary tuberculous adenitis. There was no improve-
ment after a month's medicinal treatment, together with
the application of a liniment containing potassium iodide;
in fact, one of the glands near the surface seemed to be
softening rapidly, so that he decided to remove them. The
operation, however, had to be postponed, as the child sud-
denly developed an attack of facial erysipelas, which start-
ed iust over the most prominent part of the glandular
swelling; possibly the micrococcus gained entrance here
through some abrasion caused by the rubbing. The ery-
sipelas pursued a favorable course; it spread all over the
face, the only bad symptom being albuminuria, which did
not last long. The interesting point was that during the
attack the enlarged glands, which formed a very prominentt
tumor, entirely disappeared.

Unnoticed Lateral Curvature. — W. J. Somerville says
that he has been surprised to find how seldom deformities
of the back are recognized by the family physician unless
his attention is called to the condition by the patient's
mother. Frequently, he says, he is consulted by a mother
in regard to some faulty attitude on the part of her daugh-
ter or son. on account of "one shoulder drooping." "both
shoulder blades prominent," "one hip sticking out," etc.
On examination a lateral curvature of the spine is easily
discovered. Too frequentlv the deformity is so marked
that a cure is impossible, the bodies of the vertebr;e hav-
ing become altered in shape. Had such a child been prop-
erly treated, say at eight or nine years of age, wdien the
slight deformity was due to simple muscular weakness, the
gross and permanent deformity might have been avoided.
Again, he is occasionally told by mothers that when the
doctor had been spoken to on the subject his reply was
that the child would "grow out of it." Whoever, he
asks, saw a child "grow out" of a lateral curvature w'ith-
out careful and appropriate treatment? As an alterna-
tive a poroplastic jacket is frequently suggested. But this,
by freeing the spinal muscles from responsibility and move-
ment, simply encourages the deformity to become more
marked. He would, therefore, venture to urge the pro-
fession to be on the lookout for "a drooping shoulder,"
chiefly the right, and when this is observed, to ask per-
mission of the mother to expose and examine the child's
back. In nine cases out of ten it will be found that a
lateral curvature exists. Suitable medical g>:mnastics under
medical supervision, and not merely under the care of an
unqualified man or woman, will, as a rule, cure early cases,
or will, at any rate, either lessen the deformitv or deprive
it of its more obvious and conspicuous proportions.

The Microorganism Isolated from Acute Rheumatism.

— This questiipn is reviewed by E. W. A. Walker, who
dwells particularly on the relation of this particular strep-
tococcus to the other members of the streptococcus group.
His own studies refer particularly to a group of fifteen
rheumatic cases from ten of which a constant streptococ-
cus was obtained in pure culture. In two cases the origi-

nal cultures were contaminated with Staphylococcus albus
from the skin and in the other three cases, which were
post-mortem specimens, with a motile bacillus judged to be
the Bacterium coli, but this fact was not worked out in
detail. In eight of the cases the organism was isolated
during life, while in the remaining seven it was found in
the heart's blood post mortem. Experiments on animals,
details of which are given, produced the morbid lesions of
rheumatism. The differences m culture, behavior, etc.,
from other streptococci are given, and it is worthy of note
that while this special germ produced invariably fever
and acute arthritis, and occasionally in addition peri- or
endocarditis, or both, and in large doses a fatal result,
it never produced pyemia or pyemic abscesses as is fre-
quently the case with ordinary streptococci. Summariz-
ing then his own results and those of other observers,
he notes that this organism has been isolated in pure cul-
ture from subjects of the disease, both during life and on
post-mortem examination, by a succession of observers on
a relatively large number of occasions; that it has been
seen microscopically in rheumatic lesions — in the synovial
membrane of joints in the cardiac valves, and in the men-
inges in cases of acute rheumatic chorea ; and that it was
both seen in a rheumatic nodule, and cultivated from it
in pure culture by Paine and Poynton. On injection into
animals it produces morbid lesions similar to those of
acute rheumatism. It has the appearances and general
cultural characters of a streptococcus. But it produces in
considerable amount an acid, formic acid, which is not
known to be produced in like amount by streptococci from
any other source. And this appears to afford a specific
distinction. Walker notes some objections to the accep-
tance of the causal theory of this particular organism. It
has not bees found by all observers. It has be'en sug-
gested that the organism was either a contamination or a
terminal or agonal infection or a secondary infection, but
against the latter theory is the fact that the organism
has been isolated during life. It has been further sug-
gested that the organism was the occasion of a secondary
infection superposed on the rheumatism. This view, says
the author, is conditioned on one's conception of what true
rheumatism consists in. In general, he regards the case
in favor of the organism as not yet absolutely proven.

Berliner kliiiischc IVochetischrift, May 20, i<)07.

Oxygen Baths. — Franze and Pohlmann report the re-
sults obtained by the use of oxygen baths prepared accord-
ing to the method suggested by Sarason. To prepare such
a bath 300 g. of sodium biborate is dumped into the tub
containing the water at the desired temperature. A small
quantity of borate of manganese, as catalyzing agent, is
then sprinkled over the surface of the water. The forma-
tion of oxygen begins in from one to three minutes and
lasts for about a quarter of an hour. Shortly after enter-
ing the tub the surface of the bather is covered with
extremely small bubbles of oxygen, and black flakes of
manganese peroxide are precipitated and settle on the skin,
but these are readily wiped off. The authors used the
baths for si.x patients, who received thirty-five treatments.
Two of the patients were in normal health, three suffered
from heart lesions of various sorts, and one suffered from
neurasthenia. In all cases there was a reduction of blood
pressure and of the pulse rate. Four additional baths were
given to two patients suffering from arteriosclerosis, but
were not well borne, the already high blood pressure was
much elevated, and dyspnea, palpitation, and subjective
discomfort compelled abandonment of the treatment. The
authors consider that the oxygen bath is not a suitable sub-
stitute for the carbon dioxide bath, but that it is likely to
be of value in the treatment of neurasthenic patients, in
certain forms of heart disease accompanied by irritability,
and in painful neuritic affections. It should he used with
care, however, if arteriosclerosis cxi'^ts.

Presence of Spirochsta Pallida in Physiological
Secretions of Persons Affected with Hereditary Syphilis.
— A. Pasini demonstrated the presence of Spirochicla pal-
lida in the epithelium and lumen of the alveoli of the
lungs, the bronchi, the convoluted tubules of the kidneys,
and the sweat glands in two babies subject to hereditary
syphilis, but showing no manifestation of it at the time of
death. He believes that Spirochata pallida has the povver
of penetrating the epithelia of various organs during life
by means of active movements. The cells penetrated then
undergo degeneration. The author concludes that the
sputum, urine, and sweat of the hereditary syphilitic may
contain the spirochetes, even when the organs present no
manifestations of the disease. It seems logical to deduce
from these facts that the secretions of these organs are
contagions. — La Rifonua Medica.

1002

MEDICAL RECORD.

[June 15, 1907

look iSrutriuH.

Diagnose und Therame der Anamien. Nach funktionel-
len Gcsichtspiinkten auf Grundlage qualitativer Blutiin-
tersuchung. Besonders fiir Arzte und Studicrende.
Von Dr. Joseph Arnetii, Privatdozent an der Kgl.,
Universitjit VViirzburg. Drci lithograpliische Tafeln
mit iibcr 210 Einzclbliilzellcn (in Farbcn), 12 andcr-
weitigc Tafeln mit Bkitbildern. Wiirzburg: -A Stuber's
Verlag (Curt Kabitzscb), 1907.
The author of this monograph on tlie diagnosis and treat-
ment of anemia enjoys a considerable reputation in Ger-
many for his discoveries in the field of hematology. He
lias developed a complicated method of classifying the
polymorphonuclear cells of the blood according to the
tiumber and arrangement of the nuclei, and has also pub-
lished the first case of leukanemia. Such" qualitications,
and the clinical opportunities offered under von l.eube at
Wiirzburg. would lead one to expect a thorough piece of
work. 'J"he volume is, indeed, excellent, althougli it is
certainly not for the student, but for the specialist. The
title is al<o somewhat misleading, as not only the anemias,
but the leukcniias as well, are included in the discussion.
The only criticism to be offered is that the tendency is shown
to discuss obscure and unimportant points to the exclusion
of a clear, full perspt^rtive of each disease type; so that
while the expert hematoloist might read the volume to
advantage, the beginner could not always obtain a clear
picture of the blood disease from the description. The
second part of the volume, on the treatment of anemia and
leukemia, is very interesting in many respects, especially
as a full discussion is given of the results of the treatment
of leukemia by the .r-ray. The drawbacks and dangers
of .-iuclf treatment are clearly presented and emphasis is
laid upon the disappointing phases of this form of therapy,
in which the results are not permanent. A series of excel-
lent colored plates of various blood cells is appended to
the text.

A CoMPEND ox Bacteriology. Including Animal Parasites.
By Robert L. Pitfield, M.D., Pathologist to the Ger-
mantown Hospital ; Pathologist to the Hospital for
Lung Diseases. Chestnut Hill; Pathologist to the Wid-
ener Memorial School ; Late Demonstrator of Bac-
teriology at the Medico-Chirurgical College, Philadel-
phia. With four plates and eighty other illustrations.
Philadelphia: P, Blakiston's Son & Co., 1907.
This compend is similar to others in this well known
series. The essentials of the subject are here presented
in an accessible form, and there are chapters on infection
and immunit3'. The book will be of service to medical
students preparing for examination.

Diseases of the Nose and Throat. By J. Bruce Fergu-
son', M.D., Instructor in Diseases of the Nose and
Throat in the Post-Graduatc Medical School and Hos-
pital, New York. Scries edited by Victor Cox Peder-
SEN, A.M.. M.D. Philadelphia and New York: Lea
Brothers & Co.
This epitome gives clearly and concisely the diagnosis and
treatment of the various diseases of the nose and throat.
It is, throughout, practical ; and is intended for medical
students, both undergraduate and postgraduate. The
only criticism we have to make is on the language of
several of the prescriptions; there is room for improve-
ment here, particularly as the book is written for students.

Manuel Pr.\tique de Massage et de Gymnastique Medi-
cale Suedoise. Par J. E. Marfort, ex-Professeur de
Massage et de Gymnastiquc Medicate et Orthopedique a
ITnstitut de I'Empereur Nicolas l er. Troisieme fidition.
Avec III figures intercalees dans le texte. Paris: X'igot
Freres, 1907.
This new edition difTers so much from the former ones
that it is practically a new work. It has been recast, much
enlarged, and contains more than twice as many illustra-
tions. In its present form it is a fairly complete manual
of the subject and will compare favorably with many more
pretentious works.

Der Tripper. Laienverstandlich dargcstellt. \'on Dr. Or-
LOWSKI, Spezialarzt in Berlin. Wiirzburg: Curt Kab-
itzsch, 1007.

Die Syphilis. Laienverstandlich dargestcUt. Von Dr.
Orlowski, Specialarzt in Berlin. Wiirzburg: Curt Kab-
itzscb, 1907.
These two pamphlets, about forty octavo pages each,
present all that the layman needs to know of the two
venereal diseases. Patients afflicted with these troubles
ask many questions during their visits at the office. The
busy doctor has no time to answer all of these, yet he
would like to gratify the intelligent patient's natural curi-

osity. This is the avowed purpose of the pamphlets. They
possess a high educational value and may serve as a pat-
tern for similar tracts in English.

On Tabes Dorsalis. The Lumleian Lectures Delivered
before the Royal College of Physicians, London, March,
1906. By David Fekrier, M.D., LL.D., F.R.S., Fellow of
the College, Professor of Neuropathology in King's Col-
lege, etc. New York : William Wood & Company, 1906.
In these three lectures Ferrier covers the entire ground
of tabes dorsalis from the viewpoint of etiology' and of
anatomical and physiological pathology, the latter including
a study of the .symptoms from the scientific viewpoint. The
lectures arc illustrated by a number of drawings and dia-
grams, and a bibliography which will nrove of great help
to the student is appended. The subject is treated in the
lucid, systematic style of thoroughly prepared didactic lec-
tures and the book makes excellent reading for those who
like a thorough yet not a cumbersome treatment of such
a complex theme as our modern knowledge of tabes.

A Study of the Hu.man Blood-ntssels in Health and
Disease. A supplement to "The Origin of Disease." By
Arthur V. Meigs, M.D., Physician to the Pennsylvania
Hospital. With 103 original illustrations. Philadelphia
and London : J. B. Lippincott Company.
In his book, "The Origin of Disease," the author consid-
ers the anatomy and pathology of the blood-vessels in a
very incomplete and very brief manner. The present mono-
graph is the outcome of the studies which Dr. Meigs has
pursued since the appearance of his earlier book, and con-
tains a considerable number of illustrations beautifully
printed on special paper from stones, after pencil drawings
which are distinguished for their delicacy of touch and
their clearness of minute detail. The work is not a sys-
tematic text book on the diseases of blood-vessels, but
rather a collection of the author's specimens illustrated
and described, and arranged in as orderly a manner as
possible. The introductory chapters deal with the minute
anatomy of arteries, veins, and capillaries, and the genesis
of new blood-vessels. Then follow chapters on the pathol-
ogy, general and special, of the blood-vessels. The third
and last group of chapters deals with the diseases of vessels
in various organs and tissues of the body.

The diseases of the blood-vessels are so intimately con-
nected with organic disease in general, with tuberculosis,
syphilis, and "old age" in particular, that their study, how-
ever tedious and however minute it may be, is of the ut-
most value. It is to be regretted, perhaps, that Dr. Meigs
has not condensed his material into more easily digestible
forni. The book abounds in valuable facts, and the illus-
trations are very elaborate, but there is a certain
prolixity of style which makes the book difficult to read
through. Dr. Meigs deserves credit, however, for his
original work, and his book undoubtedly contributes a
great deal to our knowledge of the blood-vessels.

L'Ataxie Tabetique. Les Origines, son Traitement par
la Reeducation des Mouvements. Par le Dr. H. S.
Frenkel, Directeur de I'Etablissement pour la reeduca-
tion motrice a Heiden (Suisse), etc. Traduit de I'AUe-
mand par le Dr. von Biervliet (de Bruxelles). Preface
de M. le Professeur Raymond. Avec 132 figures dans
le texte. Paris : Felix Alcan, 1907.
This is a French translation of Dr. Frenkel's book on the
treatment of tabes by sj'stematized motor exercises. The
work is divided into two parts ; the introductory chapters
deal with ' the historical data, the types of locomotor
ataxia, the etiology, the diagnosis, and the theoretical basis
of the treatment. The second part deals with the technique
of the reeducation treatment of Frenkel. Here the prac-
titioner will find a well-illustrated detailed description of
the various exercises, and the manner of applying them
in tabetic patients. These exercises are not difficult to
learn, and require but simple apparatus. The book is
therefore of much practical value to those who are willing
to devote their time to the systematic treatment of loco-
motor ataxia.

Beitr.age zur Di.\gnostik und Therapie der Geschwulste
IM Bereich des zentralen Ner\-ensystems. Von Prof.
Dr. H. QppENHEiM. Mit 20 Abbildungen im Text und 6
Tafeln. Berlin : Verlag von S. Karger, 1907.
This book is a special treatise based on the writer's per-
sonal observations in this field and includes only those
cases which were susceptible to surgical treatment. The
author of the book has had innumerable opportunities to
study this class of diseases during his association with
V. Bergmann, Sonnenburg, and F. Krause, and his work
is essentially a personal record. There are a number of
excellent plates appended to the text, both in colors and
half tone.

June 15, 1907]

MEDICAL RECORD.

100;

AMERICAN MEDICAL ASSOCIATION.

Fifty-eighth Annual Session, Held at Atlantic City. June
3, 4, 5, 6, and 7, ipo/-

(Special Report to the Medical Recohd.)
(Continued from page 968.)

HOUSE OF DELEGATES.

Thursday, June 6 — Fourth Day.

Report of Reference Committee on Amendments to
Constitution and By-Laws. — Dr. George W. Guthrie, ch
man, read this report, which recommended an amend-
ment to section 4, chapter 10 of the by-laws by striking
out all of the section after the words "five members" and
substituting the words, "to be appointed by the Presi-
dent on the first day of each annual session." On motion
the report was adopted.

Report of the Reference Committee on Section Work.
— This committee reported with reference to the Senn
medal that, as it was a surgical matter and the committee
was unable to get access to individuals who read essays,
it should be referred to the Executive Committee of the
Section on Surgery, and the committee so recommended.
On motion the report was so referred. The committee
to which was referred the resolution of Dr. Richard Cabot
of Boston as to the eradication of rabies, recommended
acquiescence in the resolution; that it be transmitted to
the Committee on Medical Legislation, and that a reso-
lution be adopted leaving the control of the disease to the
Bureau of Animal Industry of the Department of Agri-
culture at Washington ; that the committee act in harmony
with that bureau ; and that public instruction relative to
the disease be left in the hands of the Board of Public
Instruction. The report was adopted.

Report of the Committee on Scientific Exhibit. — Dr.
F. B. Wynn, chairman, read the report. He recalled the
fact that the first scientific exhibit was at the Atlantic City
meeting of the Association seven years ago. The scien-
tific exhibit had proved of great practical utility. Its aim
was the objective demonstration of the work accomplished
in the different departments of the Association, as well as
of progress the world over. The committee recommended
that, ill recognition of conspicuous service, neatly engraved
certificates of award might be given, say, to the three labor-
atories or institutions presenting the best exhibits, and to
encourage original investigation that a gold medal be
awarded for the best exhibit of original research. It es-
pecially recommended that for the ensuing year a gold
medal be awarded to the best tuberculosis exhibit, the ex-
hibit to be compact, and designed to educate the public.
On motion the reprri ua- adopted.

Report of Reference Committee on Reports of Offi-
cers.— Dr. P. M. Jones of California, the Secretary, read
this report, stating that it was unanimous, As to medical
education, the committee indorsed the opposition to that
course of certain physicians in organizing or conducting
incompetent medical schools. The committee commended
the work of the Council on Pharmacy and Chemistry, and
strongly recommended that the members of the Association
confine their prescriptions to articles contained in the 11. S.
Pharmacopceia, the National Formulary, or such as had
been approved by the Council on Pharmacy and Chem-
istry. The committee believed that a minimum fee of
$5 for life insurance examinations was just and fair, and
deprecated the organized eflfort of certain companies to
compel the acceptance of a lesser fee. The committee
agreed with the view that present conditions would event-
ually be amicably settled, and concurred in tlic recom-

mendation that the committee be discharged. It recom-
mended that the various reference committees be ap-
pointed two months in advance of the annual meeting, and
that the reports referred to these committees early enough
for consideration. This recommendation caused consid-
erable discussion, and finally, on motion of Dr. Hall, this
part of the report was changed to read : "That at least
two weeks before the annual meeting of the Association
printed reports be sent to every member of the House
of Delegates, and that reference committees be appointed
on the first day." The report commended the manner in
which the Board of Trustees had conducted the afifairs
of the .\ssociation. The committee believed that the
statement of audit was sufficiently definite and compre-
hensive, and that to make public further the more intimate
business details would be unwise and poor business policy.
It considered the compilation and publication of the
.A.merican Medical Directory an undertaking of the great-
est value to the .Association and to the entire medical pro-
fession, and considered the financial status of this portion
of the .Association's work eminently satisfactory. At this
point a long discussion arose as to the statement of audit,
several gentlemen speaking in favor of a more detailed
report. Dr. Harris, on the part of the Board of Trustees,
gave at length the reasons for not making a report in
more detail. The question had been studied very care-
fully, and the method adopted was the one in use in most
of the large business concerns of the country. Dr. Sim-
mons also spoke in explanation of the methods adopted by
the Association for carrying on its business afifairs. On
motion of Dr. McMurtry of Louisville a vote of confidence
was tendered Dr. Simmons, and he was praised for his tri-
ple services as Secretary. Editor, and General Manager.
The committee recommended that Dr. McCormack continue
his work, and that the Board of Trustees appropriate $600
for that purpose. It earnestly recommended that every efifort
be made to stimulate interest and activity in county society
work. The committee recommended that the report on
branch associations be referred to the State associations by
the General Secretary, with a request for an expression of
their views, to be presented at the next annual meeting.
The committee offered a resolution most earnestly request-
ing all medical journals to refuse to aid in promoting the
sale of preparations which had not been approved by the
Council by refusing advertising space to such prepara-
tions, and requesting the moral and financial support of
the members for those medical journals, whether pri-
vately owned or controlled by medical organizations, which
disregarded commercialism and stood firm for honesty and
right dealing, thus sustaining the Council in its great work
for the medical profession. Finally, the committee moved
the adoption of a vote of thanks to the officers of the .As-
sociation for thtir valuable and efificient services. On
motion the report as a wliole was adopted.

Report of Reference Committee on Medical Educa-
tion.— Dr. Lu.N'D, the Chairman, read this report. The
committee specifically indorsed the compilation of tables
showing the standing of medical schools. While the
House of Delegates still adhered to the requirements of
a high school course of four years before entrance into
a medical college, it thought that as soon as possible the
requirement should include a knowledge of physics, chem-
istry, and biology. The committee recommended that
night schools should not be in good standing before the
Association. The licensing boards of the States should
have charge of the preliminary requirement instead of
that being determined by the schools themselves. The
committee was in favor of the rapid extension of recip-
rocity in medical licensure. The report closed by compli-
menting the Council on Medical Education, and recom-
mending a vote of thanks for its work. On motion, the
report was adopted. .'\ resolution was offered relative

I004

MEDICAL RECORD.

[June 15, 1907

to the high schools in the South, where there were only
three or four high schools with a course of over three
years. The object of the resolution was to endeavor to in-
duce the high schools in the South to raise their course to
four years. The resolution was adopted.

A resolution was adopted providing that the journal of
the Association be sent free to all medical libraries in
the Medical Library Association, the names of the libraries
to be submitted to the Secretary of the Medical Library
Association.

Application was made by the Southern Medical .Asso-
ciation for recognition by the .\merican Medical Asso-
ciation as a branch association. The report was re-
ferred to the appropriate committee.

The Committee on the Davis Memorial asked that the
request for an appropriation of $5,000 be referred to the
Board of Trustees. On motion, the report was so re-
ferred.

Election of Officers. — The following officers were
elected for the ensuing year: President, Dr. Herbert L.
Burrell of Boston; First Vice-President, Dr. Edwin
Walker of Evansville, Ind. ; Second Vice-President, Hon.
Hiram R. Burton, M.C., of Delaware; Third Vice-Presi-
dent, Dr. George W. Crile of Cleveland, O. ; Fourth Vice-
President, Dr. \V. Blair Stewart of .Atlantic City, N. J.;
General Secretary, Dr. George H. Simmons of Chicago;
Treasurer, Dr. Frank Billings of Chicago. The three
Trustees whose term expired this year, namely, Drs. T. J.
Happel of Tennessee, W. \V. Grant of Colorado, and
Philip Marvel of Xew Jersey, were reelected.

A resolution was offered and adopted providing that
recognition be given to the branch associations applying
for the same, subject to the adoption of a uniform con-
stitution and by-laws, to be prepared by the Committee on
Organization of this Association.

It was decided to hold the ne.\t annual meeting in Chi-
cago, 111.

Dr. Happel stated that the request for an appropriation
of $5,000 for the Davis Memorial had been referred to the
Board of Trustees without a recommendation by the House
of Delegates. The Trustees did not wish to assume the
responsibility, and he wished some action taken by the
House. After much discussion it was decided to post-
pone the matter until ne.xt year.

After a resolution thanking the President for the im-
partial and honest way in which he had presided over the
deliberations of the body, the House of Delegates ad-
journed.

SECTION ON SURGERY .AND .\NAT0MY.

IVednesday, June 5 — Second Day.

Physiology of Exophthalmic Goiter.— Dr. S. B. Beebe
of Xew York read this paper. He said that the title of
it should rather have been ''Physiology of the Thyroid
Gland in Its Relation to Exophthalmic Goiter." He said
that recent work had definitely shown the thyroid to belong
to the so-called vital organs. There was very little actual
scientific knowledge of the gland. He then spoke of the
recent positive proof that had been developed of the es-
sential differences between the thyroid and the parathy-
roid— myxedema developing after removal of the first and
tetany after removal of the second. He said that in his
experimental work with Dr. Rogers he had been able, by
the employment of beef parathyroid nucleoproteid suitably
administered to save animals from tetany even after they
had gone into profound convulsions one, two, and even
three times, but that death could nc. ^ ' orted for

more than three weeks. That this wa the toxic

condition of the blood was shown by the fact that heavv
feeding of meat would cause convulsions earlier after
parathyroidectomy than in animals in normal condition.

He spoke of the detoxication theory and mentioned that
thyroid feeding stimulated metabolic activity. During some
stages of the disease it was unquestionable that large
quantities of nitrogen were necessary to maintain normal
body weight.

Pathology of Exophthalmic Goiter. — Dr. W. G.
M.\cC.\LLUM of Baltimore read this paper. He said that
as yet there was no unanimity of opinion as to the degree
of change which took place in the thyroid. It was un-
questioned, however, that many of the changes found had
not the characteristics of primary changes. Neither was
it yet determined whether the well known disturbances
in metabolism were the cause or the effect of the disease
in the thyroid or in the central nervous system. Classify-
ing the gross changes he enumerated them as follows :
Enlargement of the gland not always great. Dilatation of
veins usually marked and very characteristic. Interior
of tumor not hyperemic. Loss of elasticity. Color an
opaque gray. The amount of colloid varied, but it was
characteristically diminished in amount, its place being
taken by a fine network of fibrous tissue. The acini
were lined with characteristic high cylindrical epithelium
instead of the fiat form of normal cell. Mitotic figures
were frequent. Adenomata occurring in these glands in
conjunction with the e.xophthalmic lesion were not un-
common. They were advantageous and had nothing spe-
cial to do with the disease. The thymus was usually
considerably enlarged. In sixteen cases the parathyroids
had been examined and found normal. In the two or
three cases e.xamined the sympathetic nervous system had
been found normal. This was also true of the central
nervous system. Thyroid, lymphoid, and thymus changes
were the only ones constantly observed.

Diagnosis of Exophthalmic Goiter. — Dr. L. F.
B.ARKER of Baltimore read this paper. He said that some
observers had gone so far as to deny the existence of
struma, but careful study had always shown it to be pres-
ent. As a rule he said the swelling was not large, par-
ticularly in the early stages of the disease. The isthmus
of the gland was generally broad and thick and the pyra-
midal lobe was increased. In acute cases the tumor was
often softer than the normal gland. There was a charac-
teristic granulation of the surface. Most important of
all were the vascular characteristics. Pulsation was in
many cases visible, and by the palpable expansion and the
bruit invaluable assistance could be obtained in making the
diagno'sis. Tachycardia was the most constant symptom ;
the heart always running above 90 and sometimes ap-
proaching 200. Under the latter conditions the patients
frequently complained of subjective feelings of cardiac
distress. The exophthalmos was the most striking symp-
tom. It was absent in its true form in about one-third of
the cases. A differential diagnosis of the character of the
exophthalmos was to be arrived at by the use of the
e.xophthalmometer. If present the true form was bilateral
and continuous. Tremors were so invariably present that
some observers had considered them the fourth sign.
They were characterized by a rather constant vibration of
eight to ten per second. These tremors were not con-
fined solely to the extremities, but extended frequently to
the muscles of the trunk. The digestive apparatus often
was involved — diarrhea and vomiting being quite charac-
teristic occurrences in advanced stages of the disease.
Dyspnea was a late symptom and generally of cardiac
origin. The genitourinary system presented no constant
findings. The psychic phenomena were marked and often
the very first to be observed. They might be so marked
as to necessitate the regulation of the patient under de-
tention. He recited the eleven signs which, besides exoph-
thalmos, might not infrequently be seen in the eyes. In
closing he said it should not be forgotten that all pul-
sating strumata were not Basedowean.
Medical Treatment of Exophthalmic Goiter. — Dr. R.

June 15, 1907]

MEDICAL RECORD.

100;

B. Preble of Chicago read this paper. He said that treat-
ment must be directed to the correction of neuroses and
of individual symptoms and to the improvement of thyroid
metabolism. Rest should be physical and mental ; it should
be general and it should be complete. The diet was of
particular importance and should be suited to the par-
ticular case. Certain advantages could be gained by vari-
ous changes in climatic conditions, some doing well in
mountains, some at the sea coast. All forms of electrical
and hydrotherapeutical treatment undoubtedly acted only
by suggestion, and it must not be forgotten that these
people of all others were most liable to suggestion. Of
drugs, opium was the most valuable, although the most
dangerous. .-Ml gland extracts were probably valueless
and thyroid extract was unquestionably harmless. Cyto-
toxic preparations were still under trial. In conclusion
he said it was far better to operate too early than too late.

Surgical Treatment of Exophthalmic Goiter. — Dr.
Albert Kocher of Berne, Switzerland, read this paper.
He spoke from the experience derived by himself and his
father in a series of 3,460 cases of operation for goiter.
Of these, 315 were for Graves' disease. He stated that
their results to date had been so satisfactory that there
seemed no need of changing the method. He referred in
passing to the operation of sympathectomy and stated
that it wa? useless. In the last 91 operations there had
not been a single death and before this the mortality
was but 3V2 per cent. This he said would be lower.
Decreased mortality was due to a wider recognition of
the necessity' of prudence in h.mdling the tissues. Prior
to operation a careful study should be made of the strength
of the heart with a special reference to determining
whether the existing enlargement were of a compensa-
tory or dilatational type. The blood pressure determined
by the Riva-Rocci instrument was of very great impor-
tance. If it was low it was necessary to study the effect
of exercise upon the patient. They should always be
prepared most carefully for operations even if such were
to consist solely in the ligation of one vessel. A second
thing studied was the degree of intoxication. Another
important point and one most recently developed was the
examination of the blood. In his last fifty-eight cases
there had been a marked increase of lymphocytes and a
diminution of polymorphonuclears. The leucocyte count
itself was normal, the increase of lymphocytes being pro-
portional to the degree of disease. Nothing was known
as yet of the cause of this lymphocytosis. It was different
from that which accompanied pus formation. It explained
the danger of the very slightest infection in these cases.
In answer to the question, does the operation cure, he
said that the symptoms were often increased after op-
eration. This was due mainly to hemorrhage and to gland
injury. Eighty-three per cent, had been cured, some of
these as long as seventeen years without recurrence. The
heart and the eyes took longest to recover. As to tech-
nic he said that more than two arteries should never be
ligated at once. Never more than one-half the gland
should be removed except for special reasons. The sur-
geons and the physicians must work together in order to
obtain the best results.

Dr. W. S. H.IlLSTED of Baltimore said that in future he
believed much good would be derived from the serum of
Beebe and Rogers. It would some day make a most accep-
table substitute for the surgical work, which, at best, was
crude and maiming. As to the danger of postoperative
tetany, he said that during the past two or three years it
had become relatively frequent owing to the increased num-
ber of glands resected. The pathology of tetany had been
made comprehensible by the discovery of the parathyroids.
Each gland — there were usually four — was separate and
had a separate blood supply ; and it might well be said
that their protected position was indicative of their extraor-
dinarv value to the individual. The sneaker believed that

these glands could be seen at operation. Less often were
they removed bodily than was their circulation interfered
with. Certain observations recently made at the Johns
Hopkins Laboratory seemed to contraindicate the strip-
ping of the posterior capsule as advised by Charles Mayo.
Ligation of the thyroid even might cut off the tiny blood
supply of these minute but valuable glands. As to the
possibilities of successful parathyroid transplantation he
said that we were still in doubt. So far as their observa-
tion had gone, the transplanted organs had been absorbed
with but certain exceptions. These occurred when the
organ had been placed on or near the surface of the
spleen rather than in its substance.

Dr. Fr.\nk Billings of Chicago asked how any logical
and satisfactory treatment of the disease could possibly
be formulated in our present lack of knowledge of the dis-
order. One thing known about it was that in certain
places it was endemic. He said that the medical results
obtained by specific individual treatment were sometimes
good, but that surgical therapy must in most cases be
employed. He cited the history of a woman who had
apparently recovered after eight months' rest in bed.

Dr. William Mavo of Rochester said that what he had
to say would be spoken for his brother. He paid high
tribute to the value of Kocher's hyperthyroidism theory. It
had given to the surgical world a working pathological basis.
Three types might be recognized clinically : The vascular
goiter, the solid goiter, and those cases in which hyper-
thyroidism developed late. There was a pseudohypertrophic
type. This called for the removal of the tumor, not the
thyroid. As to the operative relief obtained, it depended
upon the removal of sufficient glandular tissue and was
characterized by a long continued convalescence. Their
operative mortality in 170 cases had been nine, but four
of these had occurred in the first sixteen cases, there hav-
ing been but one in the last seventy-five cases. The lesion
was surgically curable if operation was not undertaken
too late.

Osteoplastic Operations.— Prof. E. KOster of Mar-
burg, Germany, read this paper. He detailed the history
of osteoplastic methods from the time of origin in Germany
until the present day. He said that preeminently the con-
ditions of success in all bone work were absolute asepsis
and a contact of the bone fragment with other bones. He
showed numerous specimens illustrative of his work and
the instruments .which he devised for its execution.

The Technique of Appendectomy. — Dr. John A.
Wyeth of New York read this paper. He paid tribute to
the men whose courage and resource had given the op-
eration to the world. He lamented the fact that there
were still so great a diversity in the technique and urged
that the operation be put on a better defined basis. He
advised the perpendicular incision with separation of the
rectus. The length of incision through the peritoneum
should average four inches. The primary incision of peri-
toneum one inch, to be enlarged if necessary. The par-
ticular point which he brought forward with much em-
phasis was the necessity of ligating the appendix itself with
strong silk. He would disinfect the stump with carbolic
acid and alcohol. He objected very strenuously to the
employment of the purse-string suture or any form of su-
ture of the intestinal wall. This was because the blood
supply of the appendix in a large number of cases came
not through the mesentery, but crossing through the wall
of tlie cecum passed directly into the appendix itself. He
gave a long list of recorded cases in which there had been
serious hemorrhage, the result of the use of the purse-
string suture.

Dr. Dawbarx of New York said that the cause of post-
operative hemorrhage was to be found in the failure of
the operators to apply the technique of the purse-string su-
ture properly. He advised the use of linen thread and

ioo6

MEDICAL RECORD.

[June 15, 1907

stated that if after an operation for gangrenous appen-
dicitis a fecal fistula developed it was the operator's fault.
Like Kraske's treatment for erysipelas, he interrupted
lymphatic continuity and provoked leucocytosis by the in-
troduction of a double suture line.

Dr. Emory Marvel of Atlantic City said that he con-
sidered the small incision to be the best in the male, where-
as the long perpendicular incision found best use in the
female. He did not agree with Dr. Wyeth in the neces-
sity for tying off the appendix.

Dr. C. VON Zw.\LENBURG of Riverside, Cal., said that the
blood supply of the appendix was often anomalous. He
recited a most interesting description of a scries of experi-
ments which he had made upon the effect of dilatation in
the dog's appendi.x. At thirty millimeters pressure there
was a decided slowing in the circulation; at si.xly there
was partial stasis ; at one hundred this was complete.

The Operation of Gastrojejunostromy and the Physi-
ological Results. — Dr. H. J. Paterson of London, Eng-
land, spoke of the great importance of further knowledge
on this important subject. The amount of bile which re-
gurgitated into the stomach after this operation had been
much exaggerated, for it probably did not represent more
than five or six per cent, of the gastric contents. Obvi-
ously, if bile were present pancreatic juice must also be
present. A diminution of gastric acidity was the first effect
of the operation. This was not due to the presence of
alkaline fluids which had entered the stomach from the
duodenum. The average diminution was thirty-five per
cent. This was obviously too great to be entirely a chemi-
cal reaction. There was also a diminution of chlorides.
This was due to diminished secretion. Some acid undoubt-
edly was squeezed out of the stoma. This led to an
earlier secretion of pancreatic fluid. There might also
be a reduced secretion of secretin. As to the effect on
gastric digestion, he believed that a diminution of the
chlorides was not an indication of diminished digestion and
as proof cited the examination of feces. The effect on the
gastric motility was not so great as to make it of patho-
logic import. Before operation, if impaired by stenosis
movement, it increased postoperatively. If unimpaired, it
may be increased or diminished, but always within physio-
logical limits. .*\s to the question of drainage he said
that the size of the opening probably determined a certain
amount of drainage. If it were not drainage which caused
the obvious improvement in many of these patients, what
was it? If only drainage, why not use stomach tube? Hy-
peracidity was always diminished not because of drainage
he believed, but owing to a diminution of the chlorides.
Metabolism was not affected. Whether the food passed
through the stoma or not. he considered still to be an
open question and of academic interest only.

Dr. J. T. GiLBKiDE of Philadelphia said that the (ipcra-
tion was now on a physiologic basis and expressed the
thanks of the section for the manner in which it had been
presented.

Dr. W. B. Cannon of Boston said that he was particu-
larly interested in the question of whether or not this
was a drainage operation. According to his results, which
were obtained by fluoroscopic observation, the pressure at
the pylorus was throe or four times greater than at the
stoma: this was due to peristaltic waves, which not only
compressed the food, but liquefied it as it pressed against
the pylorus. He referred to the corrotorative findings
which had been reported from the Surgical Research La-
boratory of Columbia University.

Dr. J. W. Draper Maury reviewed the work referred to
by Dr. Cannon and stated that if dogs were fed a string
to which a bag of shot had been tied, when gastroenteros-
tomy was performed, positive observation could be made
as to the function of the pylorus and the stoma. This
could also be done by observing the weight in dog? after
low gastroilcostomT.

Vaccine Therapy of Surgical Infections Controlled by
the Opsonic Index, with Reports of Results. — Dr. L. L.

McArthur of Chicago said this subject was of particular
interest to surgeons because of the fact that the ordinary
infections they met with were the particular ones de-
stroyed by phagocytosis. If the phagocytic capacity could
be increased and if at the same time vaccines could be
employed to raise the systemic index, the result ought to
be promising. In general he summed up as follows: The
opsonic index of Wright offered valuable assistance in the
diagnosis of the nature of many obscure infections. That
it was at present the most accurate method of controlling
the dosage of vaccine therapy, but might later be re-
placed by a simpler technique. That sufficiently gratifying
results had been obtained to encourage others to use vac-
cine therapy in conjunction with the recognized treatment
of the given ailment and in particular in conjunction with
Bier's treatment.

The Pelvic Articulations, with Especial Reference to
the Differentiations Between Lesions of These Articula-
tions and Other Surgical Conditions. — Dr. J. E. Gold-
tuwait of Boston read this paper. He said that the pelvic
bones were held together by ligaments and that the articu-
lations were true joints ; they had, because of their lack
of cupping and because of their oblique position and the
irregular manner in which weight was applied to them, a
singular liability to strains and to disease; he said that
this was particularly true of the sacroiliac joint. The
pain in this region was produced by a slipping of the two
bones. An important point made was that the backache so
characteristic after prolonged operations could be entirely
relieved by proper support during the operation to the
lumbar spine.

Foreign Bodies Lost in the Peritoneal Cavity. — Dr.
.\rchibald M.\claren of St. Paul, Minn., said that the five-
yard sponge and long hemostatic forceps were the most
important factors in preventing this serious accident. He
cited a series of cases in which all manner of materials
had been left within the abdomen and urged a continuance
of the vigilance which was being universally practised.

Local Anesthesia in General Surgery. — Dr. James F.
Mitchell of Washington, D. C, said that the chief reason
for the employment of a general anesthetic in more than
one-half the average run of major operations in hospitals
was the time element ; local anesthesia was slow, success
could be obtained only by great patience and by a thorough
knowledge of the varying sensibility of the tissues. He re-
cited a long series of operations which he had performed
under local anesthesia and urged its more general employ-
ment.

SECTION ON OBSTETRICS AND DISEASES OF WOMEN.

Wednesday, June 5 — Second Day.

Early Postoperative Intestinal Obstruction. — Dr. C.

C. Frederics of ButTalo read this paper. He said post-
operative ileus was one 01 "lie serious sequelse following
abdominal operation. Intestinal obstruction following ab-
dominal operations of all kinds was quite frequent. He
divided post operative obstructions for convenience into
early and late, the early including those occurring pre-
vious to the patient's discharge from the hospital, that is,
within about two or three weeks. In the earlier cases it
was often difficult to make the diagnosis, for failure of
the bowels to move, the flatulence, temperature, and many
things called for great care in making a diagnosis. The
passing of gas, or of some feces, should not lull into a
feeling of safety, for careful observation would show no
real improvement in the patient's condition, no decrease of
distention or vomiting, no improvement in pulse or gen-
eral condition. There were three well-recognized forms of
intraperitoneal lesions which accounted for these con-

June 15, 1907]

MEDICAL RECORD.

1CXD7

ditions, viz., septic peritonitis, meclianical obstruction by
adhesions or bands, and organic spasm of the bowel. Many
of the symptoms of obstruction and septic peritonitis were
the same and the differentiation was of vital importance to
the patient and the surgeon. In mechanical ileus the peri-
stalsis was accompanied with griping pain corning on in
paroxysms. Many cases had been reported by different
observers in which tonic spasm of the bowel had caused
occlusion and on operating or at autopsy no other cause
for obstruction was found. The surgeon often had to
shoulder the responsibility of an exploratory incision.
The vomiting of obstruction had been called reversed
peristalsis, but this explanation for the profuse vomiting
was an incorrect assumption.

Dr. Frederics said that every operation should be done
with the object not only of relieving the patient of his ail-
ments, but of protecting him against postoperative sequels
of every kind. In most cases adhesions of some form ex-
isting prior to operation or produced by the pathological
process present, or as a result of the operation, were the
cause, and to prevent these as much as possible was the
work of the surgeon. In operating the intestines should
be handled as little as possible; large flat gauze sponges
or towels should be used to isolate the intestines, and
these would irritate less if wrung out of warm sterile
salt solution before use. One should avoid unnecessary
tearing of the peritoneum, the spreading of pus, and if
possible aspiration. Denuded points of peritoneum, es-
pecially the stump of broad ligaments, tumors, etc., should
be covered. In all pelvic operations in women drainage
could best be done through the vagina, the cigarette drain
filling all demands. If necessary the omentum should be
stitched where the operator wanted it to remain, but drain-
age should be avoided when possible. Where old adhesions
existed between the bowels it was a question whether it
was best to break them up and thus make opportunity for
new and probably worse adhesions. It was the consensus
of opinion ainong surgeons that too early or too strenuous
efforts to move the bowels should not be made, for the
whole nervous apparatus had received a shock at operation.
Rest was indicated and only the lower bowel should be
stimulated to pass gas for the relief and coinfort of the
patient. Some would forbid morphine on account of the
after effects, but if the operator had to suffer the pains
himself he would probably give the patient relief. These
patients should have an anodyne, and codeine phosphate,
I to I 1-2 grains, hypodermically, would quiet the pain and
cause no nausea. This was in line with withholding ca-
thartics that the patient might get in shape for her organs
to begin function again. If a cathartic did not give good
results it might be concluded that it was harmful. .Atro-
pine, eserine, and physostigmine in large doses had not
done what was hoped for them. Enemata might be used a?
less harmful. Change of the patient's position was ad-
visable. In these cases early operation was the watch-
word. The largest mortality was within three or four
days. In some cases the patient was killed by the lethal
dose of the toxins locked up in the bowels, and when the
obstruction was relieved this accumulation was released,
to be absorbed with fatal results. It might be well to bring
a knuckle of the gut into the wound, incise, clean out. use
lavage into both afferent and efferent loops. How and how
much was to be done depended on each case and must
be determined by the operator. There was little doubt that
in the future when the patint was in extremis the opera-
tion would be to do an enterostomy at the most promi-
nent point of distention or to one side of the original
incision.

Prevention and Treatment o£ Postoperative Intes-
tinal Obstruction. — Dr. D.iniel H. Craig presented this
paper. After referring to his previous articles on the sub-
ject and reviewing the action of eserine upon the intes-

tines. Dr. Craig described the anatomy of the intestinal
walls and the nerve plexes that were involved in the
action of the drug. Postoperative paralysis was probably
due to the dual influence ; inhibition from stimulation of
the splanchnic fibers and exhaustion from overstimula-
tion, and hence fatigue of the ganglia in Aurbach's and
Meisner's plexes. To regulate peristalsis it was neces-
sary to stimulate spinal reflexes acting through the
splanchnics and restore the energj' to the intestinal nerve
ending and muscles. To meet this condition eserine sal-
icylate was found fitted and a continued use of it with
study of its action had borne out the assumption that its
action in intestinal obstruction was very valuable. .As the
cases classed here were the recent ones, the factors to be
considered as causative of postoperative obstruction were
reduced to paresis, volvulus, thrombosis of the intestinal
vessels, and adhesions in connection with kinks and slight
local infection. Then the diagnosis of postoperative in-
testmal obstruction within the first few days resolved itself
practically into the differentiation between mechanical ob-
struction, paresis, septic peritonitis, and shock. Dr. Craig
said that for six years it had been his custom to give
the patient a hypodermic injection of atropine sulphate pre-
ceding the anesthetic, and upon the operating table, as
soon as it could be determined that it was not contra-
indicated, from two to five minutes after the opening of
the abdominal cavity, he gave an injection of eserine sal-
icylate in fresh solution. Constant employment of this
method had made him more enthusiastic in its employ-
ment than ever. Two arguments had been presented
against it, one that fatal intestinal paresis was too uncom-
mon to necessitate its prophylaxis in every case by this
procedure. While in a measure that was true, the fact re-
mained that such cases did arise and moreover the means
used to prevent the condition also added to the comfort
of the patient. The other objection was that the preven-
tion of adhesions interfered with nature's process of preser-
vation by walling off by adhesions. We might say that
these adhesions were pathological and not protective. The
eserine prevented enterospasm or overcame it when ex-
isting by producing the peristaltic wave. The eserine also
prevented meteorism and thus added much to the com-
fort of the patient. Even when eserine was not used as
a prophylactic it was often used to cure postoperative
intestinal obstruction by setting up peristalsis, thus straight-
ening out the kinks and the obstruction. As to the dosage.
Dr. Craig said he used 1-40 gr. on the operating table,
but meteorism and abdominal distention could be pro-
duced by too large or too frequent doses of the drug. The
keynote of success in the after-treatment of cases in which
prophylactic doses had been used was to let the patient
alone, for cathartics and enemata w'ere unnecessary.

Successful Treatment of Acute Postoperative Ileus
by Incision and Drainage of the Intestine. — Dr. Fran-
cis D. DoNOHtJE presented this paper. He said some par-
alysis of peristaltic activity usually followed surgical in-
terference in the abdominal cavity. The milder forms
were readily overcome by the usual methods, but those that
did not yield presented a most dangerous complication.
Peristaltic inertia often caused "kinking" and serious con-
ditions might result. The symptoms developed early and
in twenty-four to thirty-six hours mi.ght be well marked.
Persistent vomiting, changing from bilious to stercoraceous,
should cause anxiety. With this came abdominal disten-
tion not relieved by enemata and the vomiting was not
controlled by gastric lavage. The treatment by eserine and
physiological doses of atropine might occasionally prove
useful, but when a case had reached a critical stage me-
chanical treatment offered the best chance for recovery. The
value of enterostomy in postoperative procedure was yet
to be fully appreciated. It afforded a means for escape
of gas and feces, it afforded an opportunity by the injec-

looS

MEDICAL RECORD.

[June 15, 1907

tion of a solution of magnesium sulphate to provoke peri-
stalsis at considerable distance from the point where
the tube was placed, and by it stimulating fluids and food
might be introduced. In all cases preliminary to drainage
by the tube all loops of markedly distended intestine should
be mcised, the liquid contents and gas emptied out, and
the opening closed by continuous intestinal suture. The
resulting fecal fistula might be closed or left to nature.
Irrespective of where the distended loops occurred, a per-
manent tube should be left in the cecum for drainage and
for other treatment.

Dr. XoBLE of Philadelphia said he was pleased with the
optimism of Dr. Donohue, but his experience was such that
he devoted every energy to preventing obstruction. He
took pains at the operation and did not operate in acute
conditions. He did the same thing in appendicitis where
it was possible. Often the patient was put on the table too
quickly without the surgeon taking enough time to study
the case. Years ago he lost patients who died from septic
peritonitis. He found in one case that the stomach occu-
pied nearly the whole abdomen, and since then he had re-
lied much on the stomach tube. As far as the treatment
of postoperative intestinal obstruction was concerned,
nearly every real case ended fatally.

Dr. Montgomery of Philadelphia said the important
point was the scarring of as little surface as possible for
adhesions, and he did not permit the patient to remain in
one position, When there were symptoms of obstruction
he used lavage and enemata, and sometimes operation had
to be resorted to. He had a patient now that was adverse
to an operation, but when enemata and lavage failed he
opened the abdomen and found a twist in the intestine.
He favored washing out the intestine and leaving it open
for lavage.

Dr. Tabor Johnston said an important point was the
preparing for the original operation by thorough study of
the patient's condition, for often the patient was hurried
into the hospital and operated upon the next morning and
thus prophylactic measures were neglected. The fate of
the patient was virtually settled when she was taken from
the table. By doing work carefully and leavingJout no
detail there would be little need for secondary operation.

Dr. Stone said he thought it was seldom necessary to re-
open a patient's abdomen, and when she was put to bed her
fate was virtually settled. The reader of the paper did not
mention enemata of alum water. Dr. Stone said he would
use eserine. He called the condition where the intestine
was paralyzed to an extent of about six feet and vomit-
ing took place, "reversed peristalsis." He thought that
peristalsis was a wave going along the intestine and not
50 much the side movements. He believed in making the
incision large enough to do the work well.

Dr. Gordon of Portland, Me., said he believed in making
haste slowly. He had few cases of intestinal obstruction,
but cases with lots of germs inside, and he liked to go
after them. He was a believer in the use of eserine. but
he thought operators were a little hasty in many of the
cases. Even if there were exciting conditions the patient
would likely come around all right. In many cases he
used a high enema of quinine sulphate or sometimes a
low enema with a bulb syringe. He used 20 to 30 grains
in two ounces of water. If the patient vomited, he used
the stomach pump, for one could thus work at each end
of the canal at the same time. He believed in letting the
patient drink all the water desired.

Dr. GoLDSPOON of Chicago said he believed in prevent-
ing the trouble and gave a large dose of castor oil before
operation, as much as ten ounces, and large enemas. The
patient was allowed liquid diet to within eight hours of
operation and plenty of water all the time. He gave
.^trvchnine twelve hours before the operation, and if the
heart was feeble two minims of camphorated oil. It had

been shown that to expose the intestine to the air was
injurious and in operating he did not want to see an in-
testine any more than a snake. He used wet cloths to pro-
tect the intestines, dipped in a bicarbonate solution. The
covering of denuded surface was all-important, but he did
not fix by the omentum.

Dr. De.wer of Philadelphia said the discussion sounded
like one on wind colic rather than obstruction. When
operating, he believed in quick work. Get in quick and
get out quick. Many of the patients had accumulation of
gas and in ordinary practice he did not see many cases of
postoperative intestinal > The cases he saw

were after bad septic co:.,..l._.. . as in appendicitis. He
never got obstruction in chronic appendicitis, but in the
acute cases seven in ten patients recover and three die.

Dr. Fry of Washington said he had a case after cesarean
section in which he gave eserine and the bowels moved,
but the condition recurred and the patient died. He be-
lieved in the use of the stomach pump, but he also gave
alum enemas.

Dr. Carsons of Troy asked why one should handle the
intestines and said it was because the patient was not un-
der full anesthesia. If the patient was in profound an-
esth,esia the bowels would drop down out of the way and
there would not be the sudden spasms that come by con-
traction. The bowels shoud be let alone for forty-eight
hours. Once in a while he had —"^ '• -'"-Tuction in the
pelvis and by manipulation g " ' and the pa-

tient recovered. Sometimes sepsis gave tiie symptom of
obstruction, and this might produce the gastric symptoms
on account of toxin absorption. Atropine aided in some
cases and he believed eserine was beneficial.

Dr. BoNAFiELD said he had unbounded faith in eserine.
In one case the house physician gave 1-30 of a grain to a
woman weighing about eighty-five pounds and things
looked bad for a time, but she came out of it all right. He
thought peritonitis was confused with obstruction.

Dr. Bandi.er of New York said that he did not always
get the desired results with eserine, but in most cases it
was an aid.

Dr. Fisher of Philadelphia said he was confident that
50 per cent, of the cases were due to conditions of the
stomach and he found that 1-8 grain of morphine was
useful at times. Interfering to move the 'oowels too soon
often made trouble: in case of distention of the stomach
he used the stomach pump.

Dr. Frederics said he did not mean to go into the ques-
tion of antiseptics, distention of the stomach, etc., but he
did contend that when postoperative obstruction of the
bowel occurred it was necessary to act promptly, for if
one waited the patient would die.

Dr. Cr.mg said he did not wish anyone to think that he
would use eserine in mechanical obstruction. In driving a
horse the question was, which was the best — a whip or
oats. Eserine was the oats and milk of magnesia was the
whip. One should not be in a hurry to make the bowels
move if the patient was doing well.

SECTION ON diseases OF CHILDREN.

Wednesday, June 5 — Second Day.

The Greatest Menace to Whole Milk in City Supplies. —
Dr. Alexander McAllister of Camden, X. J., read this
paper. The cry of the day was for whole milk, whereas
in the past it had been for pure milk. Pure milk might
be far removed from whole milk. Whole milk, on the
other hand, was always pure milk — milk whose integrity
was untouched by age, science, or knavery. Legislation
and eternal vigilance had gone far to give our cities pure
milk. The former menaces to pure milk had become largely
matters of history in consequence of improvement in trans-

June 15, 1907]

MEDICAL RECORD.

1CX39

portation, the employment of ice, inspection, etc., but a new
danger had arisen in the wholesale pasteurization of milk.
This was to be very much deprecated.

Certified Milk and the General Milk Supply of Louis-
ville.— Dr. Henry Enos Tuley of Louisville, Ky., detailed
in this paper the work accomplished in Louisville within
the last ten years along the line of bettering conditions
in the dairies and improving the milk supply. Political
influences had hampered the work of putting an end to
distillery-fed dairies, which had been the most serious
menace to the health of the community, particularly the
children. The bacterial content of milk from swill-fed
cows was enormous, as could readily be imagined from
the condition of filth in which such cows were kept. The
swill caused a persistent diarrhea and the cows fairly
reeked in tlieir own foul liquid discharges. The result was
appalling. At present, however, as an outcome of per-
sistent efTort on the part of those who had undertaken the
work, not a gallon of swill was used, the dairies were kept
under proper condition, and the milk supply vastly im-
proved. Inspection was not yet perfected, however. The
sale of milk from tuberculous cows could, with proper
laws properly enforced, be entirely stopped. He outlined
the scope of the work of milk commissions, and made a
plea for certified milk — for pure milk, rather than impure
milk pasteurized.

Dr. Alfred Friedl.\nder of Cincinnati, O., said that the
chief difficulties encountered in Cincinnati resulted from
' the fact that the majority of cows were slop-fed, and
the distillery interests had been powerful enough to check
any move to put a stop to this practice. It had been ac-
complished, however, and the commission now certified two
grades of milk, viz., the certified milk, and the inspected
milk. The requirements for these were just the same ex-
cept as to bacterial content. Certificates were now given
to dairymen who wished to deliver milk in cans to the
hospitals under the requirements of inspected milk.

Dr. Thomas S. Southworth of New York City called
attention to the three classes of individuals who advo-
cated the pasteurization of the entire milk supply of New
York City. These were: (i) Those who conscientiously
believed that pasteurized milk was even more of a life-
saver than modified milk ; (2) those dealers who were
planning to put out pasteurized milk in large amounts, and
who therefore wished to create a large demand; and (3J
the manufacturers of pasteurizing apparatus.

Dr. C. K. Johnson of Burlington, Vt., was of the opin-
ion that a large, perhaps the largest, part of the trouble
with the milk supply rested with the small corner grocery
or creamery, where the cans were allowed to stand open
much of the time. He thought much could be accom-
plished by cooperating with the dairymen and stimulating
them by joint meetings and in other ways to take an in-
terest in the matter of furnishing pure milk.

Dr. Walter G. Murphy of Hartford, Conn., cited two
cases of tuberculosis in cows that were giving milk up tcfe
the time of their slaughter. In one autopsy revealed a
tuberculous abscess, containing half a pint of pus, imme-
diately attached to a milk duct.

The paper was further discussed by Dr. Louis C. Acer
of Brooklyn, N. Y. ; Dr. S. McC. Hamill of Philadelphia,
Pa.; Dr. C. W. Brown of Elmira, N. Y. ; Dr. C. G. Kerlev
of New York City, and others, and the discussion was
closed by Dr. McAllister and Dr. Tulev.

The Disadvantages of Low Proteids in Infant Feed-
ing.—Dr. Alfred Hand, Jr., of Philadelphia, Pa., who read
this paper, said the term "low proteid" was used by him
to mean any percentage below 1.8 per cent., or half of that
present in the whole cow's milk. When low percentages
were given for a prolonged period there was risk of various
conditions developing, such as constipation, failure to gain

in weight properly, irregular sleep, colic, indigestion, and
increased susceptibility to various infections. In avoiding
the dangers of overfeeding there seemed to be a tendency
to go to the other extreme and to feed infants on too
weak a mi.xture. The aim should be not to ovcrta.x the
digestive powers, but at the same time not to leave too
wide a margin of unused power.

Dr. Thomas S. SbuTHwoRTH of New York City thought
the normal child at the end of the first si.x months should
be given a higher percentage of proteids than the two
per cent, mentioned by Dr. Hand.

Dr. John Lovett Morse of Boston, Mass., did not be-
lieve that a baby of a given age should have a given amount
of proteid in its food. It was true that it must have a
certain amount of proteid, but this should depend upon its
weight and not upon its age. It must have two grams
per kilo in order to thrive.

Dr. G. R. PiSEK of New York City emphasized the im-
portance of the proper examination of the stools as an in-
dex to digestive power of the child.

Dr. Hand closed the discussion.

The Importance of the Early Recognition and Treat-
ment of Rachitis. — Dr. Thomas S. Southworth of New
York City presented this paper. It had been claimed by
some that all bottle-fed infants are rachitic. This did not
apply to those whose food is properly controlled, or whose
digestion is good. Rachitis developed because of parental
blindness in many instances, the parents failing to recog-
nize peculiarities in the child which needed special atten-
tion. Many times, too, physicians failed to recognize the
early symptoms of the disease. Rachitic deformities were
often far advanced before medical aid is sought, and the
early signs were often unrecognized and untreated. Evi-
dences of rachitis might easily be overlooked upon super-
ficial examination. There was great variation in the in-
cidence of the symptoms. While rachitis- might undoubtedly
begin before the fifth month, yet in his experience this was
exceptionally the case. The grouping of the symptoms
was also subject to great variation. Rachitis was of very
frequent occurrence among infants, .\cute rachitis was a
menace to infancy, and rachitic deformities a menace to the
adult. Prophylaxis should therefore be strongly urged.
Racial predisposition had been noted, negroes and the poor
children of foreign parents seeming particularly susceptible
to the condition. The dietetic treatment in the first and
second years was of great importance. The use of cod-
liver oil and phosphorus, singly or together, was advocated.
Phosphorus was of great value in cutting short the acute
and progressive symptoms of the disease.

Dr. A. W. Fairbanks of Boston, Mass.. asked Dr. South-
worth whether he attributed the inability of rachitic chil-
dren to walk to weakness of the musculature of the liga-
ments, or of the bones. He also asked whether organic
phosphorus had any advantage over inorganic phosphorus.

Dr. John Lovett Morse of Boston, Mass.. agreed with
Dr. Southworth as to the frequency of rachitis. In an in-
vestigation at the Infants' Hospital in Boston it had been
found that 80 per cent, of the infants showed bony signs
of the disease, and he believed that such signs could be
found in 50 per cent, in private practice. The only pathog-
nomic signs were to be found in the bony skeleton. Im-
proper hygienic surroundings played as important a role as
did food. He believed that bony tenderness to which Dr.
Southworth referred was due to scurvy and not to rachitis.
He took issue with the reader of the paper concerning
the value of phosphorus in these cases. It was of prime
importance to keep such infants out of doors and to feed
them properly.

Dr. Isaac .A.. Abt of Chicago did not concur in the view-
that rachitis is due to an excess of fat, but rather in-
clined to the belief that it was due to a general to.xemia,
a chemical poisoning produced as the result of faulty met-

lOlO

MEDICAL RECORD.

[June 15, 1907

abolism. Rachitis might be congenital, particularly in the
case of colored and Italian children. Heredity probably
played some part, certain infants having a rachitic ten-
dency. They do not inherit the disease itself. He agreed
with Dr. Southworth as to treatment, except that he did
not begin sufficiently early to give something more than
milk. Some rachitic children at the end of eight or nine
months might be given any of the animal broths with vege-
tables boiled in it. Heubner advocated this with un-
doubted success.

Dr. C. G. Kesley of New York City believed rachitis to
be a disease of malnutrition. Malnutrition, with bony
changes predominant, was always found in rachitic chil-
dren. Hygienic conditions certainly played an important
part, and while fresh air and proper hygienic surround-
ings were of more importance in these children than in
others, yet the question practically resolved itself into the
child's ability to take care of its food. It was not uncom-
mon to see rachitis in children who were ideally cared for
in every way ; in such children, however, faulty nutrition
was a factor. He thought infection could be ruled out in
rachitis. Granting that it is a nutritional disorder, the treat-
ment should be instituted accordingly. Codliver oil was
beneficial, but he had failed to see any good results from
the use of phosphorus.

Dr. S. McC. Hamill of Philadelphia, Pa., said that his
experience was somewhat at variance with that of other
speakers concerning the matter of the relationship of these
manifestations to the nutrition of the child. He had seen
children brought up under the most ideal hygienic sur-
roundings, whose health was perfect, develop rachitic man-
ifestations. He emphasized the importance of fresh air
both night and day.

Dr. R. B. Gilbert of Louisville, Ky., considered rickets
due to a deficiency in lime salts and thought the treatment
should be in accordance with this factor. He did not
advocate the use of phosphorus, but phosphate of lime
would bring about an improvement.

Dr. Southworth. in closing the discussion, said the va-
rious structures— muscles, ligaments, and bones— as well as
the nervous system, were involved. He used the official
oil of phosphorus and insisted that its administration would
cut short, as he had said, the acute symptom. He consid-
ered dietitic measures more important than hygienic. The
tenderness mentioned might be scorbutic, as suggested— that
was still a mooted question.

The New Era in Pediatrics; Its Causes and Scien-
tific Foundations. — Dr. G. R. Pisek of New York City
called attention in this paper to the fact that a revolution is
taking place in pediatrics. Men of broad training had gone
beyond clinical observations and had tried to establish
the principles that cover these clinical facts. The training
and education of the younger physicians in the modern
medical college made them capable of working along scien-
tific lines, and these facts were modifying practice and
teaching. The utilization of the sciences allied to medicine
had tended to remove medicine from the realms of empiri-
cism. The newer chemistry of milk had upset the older
theories concerning milk. The general laws of animal nu-
trition had been found to apply to infants and the broad
principles of nutrition established by vast numbers of e.x-
periments on animajs could be used as a basis for teach-
ing. The fundamental laws of animal life, adaptation to
environment, inherent protective ability, and immunity,
were assuming greater value and had a direct bearing
upon the field of pediatrics.

The Relation of Pathological Conditions of the Naso-
pharynx to the Dental Arch. — Dr. E. A. Bogue of New
York City presented this communication. The etiology of
narrow dental arches and adenoids was apparently identical,
both arising from stoppage of the nose and inflammation
of the mucous surfaces. The withdrawal of the infant's

tongue from the roof of the mouth, m order to breathe, was
the main cause of narrow dental arches. Nasal stenosis
was a concomitant of mouth breathing. The treatment
should consist of the expansion of the dental arch and
ablation of hypertrophicd lymphoids. When taken at about
the sixth year and undcrstandingly treated, the results
would be : Proper articulation of all the teeth with each
other, giving as perfect masticatory surfaces as possible ;
power of correct enunciation and vocal resonance; ample
nasal passages and apparent enlargement up to the normal
of all the bones and sinuses of the face.

Dr. H. L. LowENBURG of Philadelphia and others dis-
cussed the paper.

Adenoids in Infancy. — Dr. John Lovett Morse of Bos-
ton, Mass., said, in this paper, that the general impression
among rhinologists was that adenoids in young children
should not be removed, as they will surely recur and neces-
sitate a second operation. He did not agree with this.
Adenoids were very common among infants and should be
removed without delay. The symptomatology of adenoids
in infants was characteristic, but different from that in
childhood. They produced marked disturbance of nu-
trition, rickets and deformities of the chest. They were
the most important cause of recurrent "colds in the head"
and chronic "snuffles." They often caused an irritating
cough without physical signs, and were frequently accom-
panied by attacks of catarrhal laryngitis and spasmodic
croup. Restlessness and sleeplessness were often ex-
plained by the presence of adenoids. Otitis media in in-
fants was almost invariably caused by adenoids. Various
illustrative cases were cited.

Dr. G. L. Richards of Fall River, Mass., called atten-
tion to the low position of the open end of the Eustachian
tube in young infants and to the fact that a very small
amount of adenoid tissue would cause trouble, leading ulti-
mately to otitis media and further to mastoditis.

Dr. T. W. Kilmer of New York City and others con-
tinued the discussion, which was closed by Dr. Morse.

Prophylaxis in Cerebrospinal Meningitis. — Dr. A.
Seibert of New York City read this paper, in which he
advocated the disinfection of the nasopharynx in all per-
sons coming in contact with meningitis patients by means
of a 50 per cent, resorcin-alcohol solution, applied with ab-
sorbent cotton. He was not satisfied with his results un-
til a bacteriological report on the efficiency of the method
had been made. He presented a chart giving the finding
of this bacteriological investigation. Recent epidemics had
shown that this disease is transmitted by persons harbor-
ing the meningococcus in. the catarrhal mucosa of the naso-
pharynx.

Dr. F. S. Churchill of Chicago, Dr. Alfred Hand, Jr..
of Philadelphia; Dr. A. W. Fairbanks of Boston; Dr.
Louis C. Acer of Brooklyn, N. Y., and others engaged in
the further discussion, which was closed by Dr. Seibert.

Empyema in Children. — Dr. Melvin M. Frankun of
Philadelphia emphasized, in this paper, the importance of
|arly diagnosis. Exploratory puncture aided in this. He
recommended incision in children under six years of age;
in older cases resection was to be recommended. The fre-
quency of the nonrecognition was a cause of death other-
wise ascribed to pneumonia. He emphasized the value of
the aspiration syringe as a positive aid in diagnosis, and of
immediate surgical intervention.

Dr. W. C. Hallopeter of Philadelphia called attention
to the importance of having the transverse colon empty
when making an examination of a case of suspected em-
pyema. It was of the utmost importance that effusion be
recognized early.

Dr. H. L. LowENBURG of Philadelphia spoke of the un-
satisfactory results of physical examination in these cases.
Signs in the chest were not always positive. In large
effusions very little was gotten from percussion. The reso-

June 15, 1907]

MEDICAL RECORD.

lOI I

nance which was obtained posteriorly and high up, close
to the vertebral column, was important, and flatness in one
axilla was almost pathognomonic. Palpation gave little
information. .'Auscultation gave the best results. A case
which would recover as a result of simple puncture would
get well anyhow.

Dr. A. C. Cotton of Chicago recalled a number of cases
in which he had reason to believe that a cure had resulted
from lumbar puncture. The statement that the presence
of pus always pointed to surgical interference did not al-
ways hold true. When the aspirating needle showed pneu-
mococcus pus, pure culture, one need not be in a hurry
to operate; if it showed streptococcic pus, operation was
required at once. He still believed that it was not ad-
vantageous to admit air into the pleural cavity.

Dr. A. H. Wentworth of Boston, Mass., advocated im-
mediate surgical treatment in the event of empyema, re-
gardless of the nature of the bacteria found.

Dr. G. R. PisEK of New York City suggested that if
empyema were always regarded as an abscess no one would
hesitate to advise operation. If thorough drainage be insti-
tuted convalescence was very rapid.'

Dr. A. Seibert of New York City recalled two cases
of infants in whom he had resected a rib with satisfactory
results.

The discussion was continued by Dr. A. W. F.\irb.\nks
of Boston, Mass ; Dr. Thom.^s D. Parke of Birmingham.
Ala., and others, and closed by Dr. Franklin.

Urinary Infection in Children. — Dr. Isaac A. Abt of
Chicago read this paper. He called attention to the rela-
tive frequeny of cystitis and pyelitis in young children. The
colon bacillus was the organism most frequently found,
though the germs of typhoid fever, tuberculosis, and gon-
orrhea, and the pyogenic micrococci might produce the
disease. Infants who were suffering from persistent tem-
perature for a succession of days should in every case
have the benefit of a urinary analysis, both chemical and
microscopic. The symptoms of the disease, the findings
of urinary examination, the differentiation of cystitis and
pyelitis, the complications, prognosis, and treatment were
detailed in the paper.

Dr. Cotton, Dr. Graham. Dr. Morse and others dis-
cussed the paper, and Dr. .\bt closed the discussion.

SECTION ON practice OF .MEDICINE.

IVediu'sday, June 5 — Second Day.
Dr. Thomas D. Coleman, .A.ucusta, Ga.. Chair.man.

The Abdominal Symptoms of Thoracic Disease. — Dr.

Allen A. Jones of Buffalo read this paper. He said that
acute pleuritis was sometimes accompanied by pain referred
to the hypochondriac region of the affected side, and a
peculiarity of the pain was its constancy. It was not merely
felt upon deep breathing, nor more severely upon uwiura
tion, as was so commonly the ca-.e with pleuritic pam.
The abdominal pain that was iiresent in si^nie cases of lobar
pneumonia was striking in its deceptive characteristics.
Not only might the pain of lobar pneumonia be felt in the
epigastrium or hypochondrium, but in rare instances it
might be present in the inguinal region. If in the right
inguinal region the disease might resemble appendicitis so
closely as to render the diagnosis difficult, .\niong the
more acute diseases of the lungs or pleura that brought
out the point in his paper, none showed better than
empyema. This might give rise to symptoms of an acute
inflammatory or suppurative condition of a part below
the diaphragm. The explanation of the transference of
pain to the abdomen in thoracic disease was clear when
they recalled the anatomy of the six lower intercostal
nerves. .Abdominal tympanites constituted one of the

annoying symptoms of the disease. A light ice-bag over
the epigastrium might impart tone to the abdominal sym-
pathetics. In regard to abdominal symptoms in cardiac
disease, one of the most common was epigastric pain result-
ing from myocardial disease. It was frequently seen in
angina pectoris. The patient complained of flatus. It was
to be noted that the stomach symptoms did not yield to
digestants, but under the effects of iodides and nitroglycerin.
Doubtless aortitis was the fundamental fault in not a few
patients, as the pain caused by thoracic aortitis might be
felt in the epigastrium. An important factor existed also
in the dilated and over-distended superior mesenteric vein.
Dr. C. F. Hoover of Cleveland said that this subject was
an interesting one, and, in looking over the literature in the
Surgeon-General's library, he found mention of reflex
pain in thoracic disease made by a Frenchman as far back
as 1858. In considering these cases he thought that the
phrenic nerve was involved, and that there were three
points of tenderness which were of great importance in
differentiating between intrathoracic and intraabdominal
disease, (a) along the phrenic trunk, between the two
heads of the sternoclavicular muscle, (b) just above and
external to the umbilicus, (c) the left intercostal space ex-
ternal to the border of the erector spinal muscle.

Dr. Stengel of Philadelphia spoke of a case of pneumonia
being operated upon for appendicitis. He said that pain in
the abdomen was more frequently seen in children. Ex-
treme tympanites occurred more frequently in pneumonia
with diaphragmatic pleurisy. In these cases probably the
splanchnic nerves were involved, as they passed through
the diaphragm.

Dr. Alexander Lambert of New York said that the
paper of Dr. Jones was a timely one, and he referred to
cases mistaken for appendicitis. He said that when the
pain was due to pleurisy or pneumonia there was an
appreciable time between inspiration and expiration when
the rectus muscle relaxed. When it was not relaxed it was
difficult to distinguish between pleuritic or other involve-
ment-

Dr. W. S. Th.wer of Baltimore referred to a very
nervous patient, who sent for his physician at any time,
day or night. He complained of excruciating pain in the
chest at the third intercostal space. Morphine was given
several times during the night. The pain was very indefi-
nite. The patient said he was going to die. In a few
days the patient went into a state of collapse. There was a
marked leucocytosis of 20,000 and the patient gave a clini-
cal picture of a perforative peritonitis. Dr. Halsted oper-
ated and found the colon enormously distended with gas.
Two days later the patient died. The autopsy showed a
large thoracic dissecting aneurysm.

Dr. Neilson of Milwaukee referred to a lad\ whose
symptoms were similar to those described by Dr. Thayer.
She complained of pain over the sternum and stomach.
Several diagnoses had been made. He called it aortitis,
and three weeks later the p.itient was in a comatose condi-
tion and liemiplegic.

Cardiac and Vascular Accompaniments of Diabetes
Mellitus. — Dr. .-Arthur R. Elli.tt uf Chicago presented
this paper. He considered his clinical observations treating
particularly of the blood pressure. In many of the cases
the condition of the heart was normal. Out of twenty-five
cases of diabetes, in 17 per cent, (average") the heart was
enlarged. In a few cases renal changes, hyaline degenera-
tion, and chronic nejihritis were present. The myocardial
changes were mostly fatty, together with brown atrophy.
'I'he state of the circulation was a very important one.
One hundred and fifty observations were made on this series
of cases ; thirteen were males, twelve females, and of all
ages. The average blood pressure was 127 mm. The
age was the most important factor in influencing the type
of diabetes. It was less severe and progressive in the
stout and elderlv than in tlie young. Weight exerted a

IOI2

MEDICAL RECORD.

[June 15, 1907

marked influence in determining the blood pressure. Acid
intoxication (diaceturia) was observed in nine cases. Al-
buminuria associated with diabetes, when due to chronic
nephritis or renal sclerosis, showed increased pressure
values, although toxic albuminuria exerted no such in-
fluence. There was nothing to show that the myocardial
and vascular degenerations of the chronic types of dia-
betes were essential to that disease. There was no such
thing as the "diabetic heart." Such complications were
only factors in increased arterial sclerosis. Obesity and
gout generally preceded cardiovascular degeneration.

Dr. H. S. Stark of New York said that the efforts to
establish a relationship between cardiac and muscular dis-
ease to diabetes had failed. lie believed that diabetes
was not a pathological disease per se, but that it was an
overactivity of an organ which produced not only renal, but
circulatory disturbances.

Dr. Heinrich Stern of New York City said that he had
studied diabetes for a number of years, and that he had
never found any great blood pressure. As to acetone, like
cardiac and vascular condition, all were found in the
course of the disease, and were not its causes.

Dr. Elliott closed the discussion.

The Venous Pulse and Some of Its Applications. — Dr.
L. G. Grosh of Toledo and Dr. Arthur R. Cushny of Lon-
don, England, presented this communication. They spoke
of the research work of Mackenzie and of the importance
of considering cardiac activity from the standpoint of its
physiological properties of rhythmicity, excitability, con-
tractibility, conductivity, and tonicity. In a number of
experiments the venous pulse taken before and after open-
ing the thorax was found unchanged. In the jugular
tracing, as a rule, a series of elevations separated by deep
depressions were seen. One of the waves corresponded to
the auricular contraction. Tracings from the jugular
veins of dogs, as compared with tracings procured from
the pulsations in the neck of man, were shown. Vagus
stimulation arrested the auricular contraction completely,
while the ventricle was aroused to contraction by a series
of shocks. This was of interest because of the action of
drugs on the auricles or ventricles. It was thought that
much attention might be directed to the form of the auricu-
lar wave in the jugular pulse, that much information as to
the state of the heart might be derived from this source, as
had occurred from the study of its time relations.

Dr. George Dock of Ann Arbor said that it was only a
few years ago that the heart was looked on simply as
a contracting muscle. In the last eight years much had
been written about Stokes-Adams disease. The heart was
certainly a complicated organ, and the fibers of His played
an important part in irregular cardiac cases. Much of
this advance had been due to experimental physiological
investigation.

Dr. Hirschfelder of Baltimore spoke of the interrupted
"sea- wave" and of the different interpretations of it. When-
ever the tricuspid valve opened there was a fall in the
curve. Tricuspid insufficiency meant cardiac breakdown.
The nature and origin of this irregularity was important.
If it could be proven that it originated in the ventricle then
digitalis could be used.

Dr. George Norris of Philadelphia spoke of the necessity
of studying heart diseases by recent methods and of the
need of the cardiosphygmograph.

Dr. Grosh closed the discussion. He spoke of the im-
portance in measuring the auricular activity and of Pulsus
irregulosis in "heart block." In conditions like general
sepsis there was a marked irrcgiilar ventricular contrac-
tion.

The Tone of the Respiratory Center in Tabes Dorsalis.
— Dr. C. F. Hoover of Cleveland presented this paper. He
spoke of apnea and its relation to the preataxic period of
tabes dorsalis and reported three cases, all exhibiting un-
questionable signs of tabes, which developed apnea. Two

patients had each two attacks of apnea, which followed in
every instance a hypodermic injection of a small dose of
morphine. In these cases there was a vasomotor relaxa-
tion of both the arteries and veins, but there was an
apparent disproportion between the suspended respiration
and the cyanosis. He was unable to find any reference to
cases of apnea with tabes dorsalis in the library of the
Surgeon-General. A fourth case with chronic aortitis,
diffuse arterial sclerosis, and chronic nephritis had attacks
of apnea whenever he fell asleep, and was then awakened
with air hunger and hyperapnea. Sometimes the apnea
lasted for several seconds before respiration became auto-
matic.

Dr. A. A. Jones of Buffalo said that in speaking of re-
spiratory failure in tabes he had seen a case of a middle-
aged man who was addicted to the use of morphine. He
drank whiskey and smoked. Suddenly he had an attack
of apnea which lasted two hours. Camphor and strych-
nine were given and he recovered. In a day or two he had
another attack, not breathing for three minutes. He re-
sponded to active stimulation.

Dr. Hoover, in closing, said that tabes dorsalis had been
overlooked in these cases of apnea. He suggested in treat-
ing these cases that the patients should be inverted as one
resuscitates the new-born child. Recently he had tried this
treatment in a case of tachycardia. The pulse was 244 per
minute, and with this treatment, together with deep in-
spirations, pulse rate was reduced one-half.

Physiological and Clinical Observations upon the
Alimentary Canal by Means of the Roentgen Rays. —
Dr. G. E. Pfahler of Philadelphia read this paper, and
concluded as follows: (l) The roentgenoscopic and the
roentgenographic method of examination each had its ad-
vantages. Roentgenoscopically, they studied the motion
of the viscera, while roentgenographically they recorded
the finer details. (2) The roentgenoscopic method was a
dangerous procedure to the operator unless he was prop-
erly protected, and even then the amount of exposure should
be reduced to the minimum. (3) The bismuth-kefir mix-
ture (bismuth subnitrate i ounce, and kefir I pint) was the
best medium to render the alimentary canal opaque, because
it was easily digested, held the bismuth in suspension almost
perfectly, and because it tended to counterbalance the con-
stipating effect of the bismuth. (4) The Roentgen exami-
nation would demonstrate obstructive disease anywhere
along the alimentary canal, and much information as to the
character of these obstructions could be obtained. (5)
The esophagus could best be studied by oblique illumina-
tion. Peristaltic movement could be seen carrying the
food downward. Solids were likely to lodge for a short
time at the level of the arch of the aorta, but passed quickly
through the cardiac orifice. A swallow of liquid, on the
other hand, lodged in the lower third of the esophagus for
a period of about seven second? before all of it passed into
the stomach. It was probably detained at this point by the
sphincteric action of the cardiac orifice which only allowed
the liquid to pass in slowly. The capsule dropped through
probably before the sphincter had had a chance to act.
(6) The Roentgen method of examination was probably
most useful in the study of the stomach. By this means the
size, form, position, its motility, its mobility, and the effects
of massage, respiratory movements, abdominal contractions,
peristaltic action, and the effects of food could best be
studied. (7) The normal stomach was slightly oblique in
the standing posture. Approximately, its upper two-thirds
was vertical, and its lower third was nearly horizontal.
Essentially the pylorus must be on a level with the lower
pole. Its lower pole was usually an inch above the umbili-
cus. The stomach was normally a very movable organ, as
was shown by the fact that about two-thirds of it crosses
the median line when the patient lies upon the right side, as
was demonstrated by one of my roentgenographs. When
distended with food, the pylorus was carried downward

June 15, igoj]

MEDICAL RECORD.

1013

and to the right. (8) The respiratory movements caused
the upper pole to move to the extent of the movements of
the diaphragm. The lower pole moved from one-half to
one inch between forced inspiration and forced expiration.
With deep inspiration the fundus was increased in diameter
and the pylorus moved to the right. (9) The contraction
of the abdominal muscles would cause the stomach to rise
from one to five or six inches, depending upon their
strength and the degree of ptosis ; however, in extreme
gastroptosis the stomach might lie below the elevating
force of these contractions, as he had observed in one
case. (10) These abdominal contractions might be used
to mix the food in the stomach. If a person ate an ordi-
nary meal and then took an ounce of bismuth it could be
thoroughly mixed with the food in a minute or two, and
then studied by the rays. (11) These abdominal contrac-
tions seemed to stimulate the peristaltic movements. There-
fore, they assisted in emptying the stomach by raising it
so that it served as a reservoir, by removing the obstruc-
tion which was caused by the kink in the duodenum, and by
stimulating the peristaltic movements. (12) These con-
tractions caused not only the stomach to rise, but the
entire abdominal viscera. The lower portion of the chest
expanded and the diaphragm rose. (13) The reverse con-
ditions developed when the abdominal wall was relaxed.
In other words, the tendency in a normal person to splanch-
noptosis might be seen when these walls were relaxed.
(14) Therefore he believed, first, that the abdominal wall
was the main support of the abdominal viscera; second,
that the elongated chest might be secondary to the descent
of the viscera, and third, that the most important element
in the treatment of the gastroptosis and the phthisical client
was the strengthening and toning of the abdominal wall
and the correction of posture. (15) In severe grades of
gastroptosis, the portion of the stomach that rested below
the level of the pylorus served as a retention sack, but the
point of actual obstruction to the passage of the food was
a kink formed in the duodenum about one inch from the
pylorus, where it was firmly attached to the spinal column.
The food lying between this kink and the pylorus was
usually separated from the food in the stomach by a sharp
line. This would serve as a differential point between
this form of obstruction and that caused by carcinoma.
(16) The Roentgen rays were of value in collecting addi-
tional information in the diagnosis of carcinoma of the
stomach, but should not be depended upon to make an abso-
lute diagnosis. (17) When a supporting bandage was
applied in the treatment of gastroptosis there should if
possible be a Roentgen examination to determine whether
it was properly applied and whetlier it was serving its pur-
pose. (18) A moderate gastroptosis might be present and
not produce symptoms as long as the motility of the
stomach was good. If, however, the motility of the
stomach be disturbed by some intercurrent cause, then
symptoms would be produced.

Dr. Steele of Philadelphia spoke of the morbid physi-
ology of tlie stomach and of the great chnical aid the .r-ray
had been, particularly in gastroptosis. It was of great
usefulness in those minor cases of atony and insufficiency
of the stomach. Formerly it was thought that all stomach
diseases were due to faulty secretion. .\t present one had
no reliable method of determining tlie motor condition.
The normal gastric activity and mixing of foods, together
witli opening of the pylorus, were now studied. Functional
disturbances did not bel'mg to gastroptosis, for they were
also acquired. There ^ecmed to be some ground for Iiold-
ing that these cases might be of congenital origin. There
were certain cases that sliowed gastroptosis by the .v-rays
without giving rise to any symptoms, and others had very
marked symptoms. The best form of treatment was that
wliich improved the general nervous condition.
(To be continued.)

NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Held May 16, 1907.

First Vice-President, Dr. Wendell C. Phillits, in
THE Chair.

Sins of Omission and Sins of Commission in Gyne-
cology.— Dr. G. H. B.\LLERAY read this paper. He said
that those who engaged in the practice of gynecology had
a great number of sins to answer for; the sins of omission
were credited to the general practitioner, and the sins
of commission to the specialist. The sins of omission
began in the lying-in room, and many of the diseases that
the cliild-bearing woman suffered from were due to the
negligence of the medical attendant during the two or
three weeks immediately following delivery. Lesions of
the genital tract were overlooked, the vagina was not
douched, and the patient was allowed to leave the bed
about the ninth day and at once assumed the upright po-
sition and generally returned to her usual occupation,
besides enclosing her chest and abdomen with a corset.
.'\s a result the vaginal outlet, owing to possibly a non-
union of a perineal wound, was large ; the vagina had
not undergone involution; the uterus was large and heavy,
and the cervix lacerated. When on her feet the uterus
sagged down, and the uterine ligaments, having not yet
recovered their tonicity, offered but little resistance to
its descent. In addition tlie tight corset and the consti-
pated condition brought about complete procidentia of the
uterus. If flexion was produced, it induced venous stasis
and interfered with the process of involution, led to
catarrhal endometritis, salpingitis, and chronic invalidism.
The medical attendant had done nothing to obviate this
deplorable condition. Had he repaired the lacerations of
perineum and vagina, kept the woman in the recumbent
posture for about four weeks, having during this time
administered three large and hot vaginal douches daily,
the patient might have assumed the erect posture and
engaged in her ordinary occupations without detriment.
Dr. Balleray believed that all of the recent lacera-
tions of the cervi.x, or nearly all, would heal spon-
taneously, if the patient retained the recumbent posture for
a month and the vagina was kept thoroughly clean. Pri-
mary suturing of a lacerated perineum had proved a very
successful operation and it should be practised in nearly
every case. Some authors had stated that in all primi-
parae the cervix was more or less lacerated ; if this state-
ment was true he thought it to be a sad commentary on
their obstetric skill, or the degeneration of tissue, result-
ing from civilization. After the patient was up and about,
she should wear the weight of her skirts suspended from
the shoulders. No corset should be worn. The period
immediately following delivery was not the one in which
the women should practise calisthenics. He could not too
strongly insist upon the fact that in the treatment of re-
cent lacerations, the results of labor, rest, and cleanliness
were of the greatest importance. Cancer of the cervix,
which constituted fully go per cent, of all forms of cancer
of the uterus, never occurred e.xcept in those cases in
which some form of traumatism had been applied to the
cervix. He did not believe that there was a well authen-
ticated case of cancer of the truly virginal cervix on
record. Neglected lacerations of the cervix were respon-
sible for the occurrence of cancer of that portion of the
uterus. The physician should examine every woman he
had attended in labor to ascertain if she was suffering
from any lesion of the genital canal. It was only neces-
sary for the profession to be imbued with the necessity of
such an examination in order to make it popular. One
of the greatest difficulties in carrying out this in private
practice was the ill-conceived amour propre of the attend-
in" physician who was apt tn feel that tlie revelation that a
lesion of the genitals existed would be regarded by

IOI4

MEDICAL RECORD.

[June 15, 1907

the patient and her friends as evidence of lack of savoir
faire on his part. When the operative gj'necologist was
consulted in cases of this kind, he should explain to the
patients that the lesions of the genital tract sometimes
occurred in childbirth even under the most skilful treat-
ment. As a factor in the causation of pelvic disease in
women, gonorrheal infection occupied a prominent position
and at least 40 per cent, of all women suffering from
diseases peculiar to their sex owed their invalidism to
the baneful influence of the gonococcus. That nearly all
such women could be promptly cured in the early stages
of the disease, if properly treated, did not admit of a
doubt. If the time ever came when the family physician
would take the trouble to examine into the nature of every
case of purulent discharge, and would resort promptly
to efficient means of treatment, they would then meet with
very few of those cases of destructive inflammatory le-
sions of the female pelvic organs. It was to be hoped
that the time would soon come when the family physician
would familiarize himself with the means of diagnosis in
the incipient cases of cancer. Dr. Balleray said that the
sins of commission were the sins of the operative gyne-
cologist. At times he was thoroughly honest in his con-
viction that he was doing right, but in many cases muti-
lating operations were performed which were unjustifiable,
and had absolutely no raison d'etre except in the love ol
eclat, and the undying fondness which some men cherished
for operative gynecology.

Dr. Edward A. Ayers said that what he would have to
say would be limited to obstetrical errors. Obstet-
rical work had in many instances been simply an annex to
gj-necological work, and being a poor paying field had
not been even fairly mastered by its followers in the gen-
eral class of practitioners. He was inclined to think that
the average results obtained in obstetrical work were lower
than in any other branch of medicine or surgery. The
most effective service a physician could render a pregnant
woman lay in a thorough antepartum diagnosis. Given
an abnormality which might be expected to vary the
physiological rule, foreknowledge of its existence would
enable the obstetrician to minimize its evil effect. Second-
class skill would get better results applied in advance
than first-class skill applied in emergency. The chief
dangers that might develop in pregnant patients were from
placenta previa, eclampsia, malpositions, pelvic insufficiency,
and infection. In placenta previa a good prognosis was
greatly favored by full preparation for either vaginal or
cesarean delivery. Location of the placenta during preg-
nancy was usually impossible when normally implanted,
but central cases would generally cause sufficient enlarg-
ment of the os and lower segment softening, with possible
direct palpation of the placenta at the internal os, to
afford a diagnosis after the seventh month. In practice
most cases were unfortunately announced by hemorrhage.
Eclampsia threatened by signs well known in urine and
nervous system in over 90 per cent, of cases, and in the
majority of cases these symptoms could be expelled or
delivery induced. The fetus had no established attitude
but would gradually take the most comfortable position,
that of least pressure and constraint, and ordinarily this
was with back forward to fit the maternal lumbar curve
and head down which was less neck flexing than the
reverse. Whatever position they might find at the seventh
month, if they found the pelvic inlet too small to allow
head and cervix descent later they should anticipate a
shoulder, transverse, or breech presentation. If they
found a sagging abdominal wall and uterus with long
transverse and short axial diameters, a face, shoulder, or
transverse presentation should be anticipated. This sag-
ging, if not correctable during pregnancy by corset support,
should lead us to prompt attendance at labor and adjust-
ment of the presentation. Pelvic insufficiency which oc-
curred in about !,•? per cent, of all cases required skill

in diagnosis. Anyone could recognize a two and one-half-
inch conjugata vera after a few examinations of pregnant
women, but it required experience to foretell successful for-
ceps delivery in borderland pelvic insufficiency. A full pre-
liminary diagnosis that would give the expert more than a
peep into the future removed most dangers of infection.
There were many other important details worthy of men-
tion, but those just cited covered most of the field of our
"sins of omission" in obstetrics. A study of vital sta-
tistics impressed one with the thought that a peculiarly
vitalized responsibility was fast falling on obstetrical ser-
vice. This was due to our declining birth rate, which
if it were not for immigration would be on a par with
that of France. The decline in the number of children
per family was not due to obstetrical shortcomings, and
could not be removed by preaching against reproductive
restriction, but it lay within the power of the obstetrician
to reduce fetal and early infant mortality. With a still-
birth mortality of 6 or 7 per cent, added to an infant
mortality of 10 per cent, during the first month and 15
per cent, additional by the end of the first year, or one
reproductive failure to two successes, one could readily see
how large an impress could be made on declining birth
rates by improving obstetrical work. As to the "sins
of commission," he said that an obstetrical meddler might
be defined as one who assisted nature at the wrong time.
To give ergot at any time, or to rupture the membranes
without knowing how or when labor should be ter-
minated ; to institute artificial dilation of the cervi.x for
reasons of impatience, or misinterpretation of preliminary
for strenuous contractions ; to apply forceps traction with
greater regard for securing fetal advance than for cervical
endurance ; to make any greater compression of the fetal
head with forceps blades than blade slipping problems
required; to needlessly use forceps; to allow a womb and
its voluntary reinforcements to decide speed rates when
fetal heads are coming around the curve; to keep the
knees fle.xed against the abdomen when the head crowns
the perineum ; to try to preserve perineal integrity without
seeing the parts ; not to know that a uterus is exhausted
and to allow it to bleed first and each time make compres-
sion afterwards : to postpone perineal stitching when it
could be done at the time ; to douch an aseptic vagina ;
to keep a postpartum patient on her back when uterine
circulation is stagnant, or to sit her up when it will in-
crease lochial flow ; to allow quiescent breasts to fill up
and cake: to omit treating nipples as open wounds; to
curette a clean uterus, or not to curette away placental
remnants ; to allow a milk-full mother to avoid suckling
her child without protest are a few things that to omit
is to fall short of our opportunities for good. Judgment,
art, diagnosis, but the greatest of these is diagnosis, early,
accurate, and full.

Dr. WrLLiAM M. Polk said that proof was to be had
that the doctor was in error when he stated that cancer
of the virginal cervix had never occurred. There were
other causative factors than trauma of the cervix. Then
the statement that the patient should remain in bed one
month after delivery was not exactly correct; here the
personal equation came in : each case should be treated
on its individual merits. All should agree with Dr. Avers
that an antepartum diagnosis was very important. The
systematic scraping of the interior of the uterus recently
pregnant was a villainous procedure.

Dr. Edwi.v B. Cr.vcin believed it would be better to
speak of the sins of omission in obstetrics and the sins
of commission in gj'necology. In looking over the work
at the Sloan Maternity they had been led to get the
patients up a little early rather than to keep them in
bed beyond the normal time of nine or ten days, for the
reason they found that retroversions were extremely
common. If they sent these patients out in two weeks.
which was their rule, many would go with retroversion?

June 15, 1907]

MEDICAL RECORD.

10!

if most of the time was spent in bed. At present all
sat up in bed as early as the fifth day, and were out of
bed on the ninth day, and it was observed that posterior
displacements of the uterus were less common than when
they remained in bed longer. With regard to healing of
the cervix, he believed it was better if the patient was
allowed to get up so that the parturient canal would drain
and keep clean ; this was better than the use of douches
with their possible risk of infection. As Dr. Polk had
stated, each case must be decided upon its merits. With
regard to repair of lacerations of the cervi.x. Dr. Cragin
said he was afraid to teach students to make repairs of
these immediately after labor. If it was an operative
case, with assistants, full anesthesia, with a good light,
repair of these cases immediately after labor should be
done if the tear was extensive. But without proper as-
sistants, with poor light, to expos ethat cervix tn see if
it was lacerated, and then to repair it, was, he thought,
accompanied by danger and students should not be taught
to do it. One of the greatest sins in gynecology had to
deal with the repair of a little bit of a laceration of the
cervix. If a woman had a little nick in her cervix, with
the squamous epithelium covering it nicely, with no sub-
involution of the uterus, with no increase in menstruation
or cervical catarrh. Dr. Cragin's practice was to leave it
alone. These women did better without having their cer-
vical canals narrowed and drainage interfered with.

Dr. J. Riddle Goffe said he did not fancy the title of
Dr. Balleray's paper because he had not brought out the
sins of omission of the gynecologist, but the sins of com-
mission of the obstetrician. The importance of involu-
tion of the uterus should not only be emphasized, but the
involution of the ligaments, which were in truth prolonga-
tions of uterine tissue, should also be emphasized. These
ligaments hypertrophied as the uterus hypertrophied, and
involuted as the uterus involuted. Dr. Goffe did not be-
lieve that, when the abdomen was opened for any purpose,
the healthy or normal appendix should be removed. No
tissue or organ that did not offend shoidd be removed.
The removal. of a normal appendix was an added danger.
He wished to call a halt in this practice of removing
healthy appendages.

Dr. Brooks H. Wei.ls said that if the labor was man-
aged with ordinary skill and care as to the maintenance
of asepsis, if the attendant refrained from unnecessary
vaginal examinations or manipulations of the cervix and
kept the external parts clean during the puerperium by in-
structing the nurse as to the manner and intervals of wash-
ing and the frequency with which the vulvar pads were to
be changed, he would not often have fetid lochia or sepsis,
and the average patient he believed would be better off
without the vaginal douche. Tears of the perineum and
vagina should be looked for at the end of labor, and
sutured if found, except when the pafts were so contused
and edematous that operation seemed to be out of the
question. Tears of the cervix did not require immediate
suture unless so deep as to cause persistent hemorrhage.
When the patient had suffered deep perineal tears she
should be kept off her feet until the laceration was healed ;
otherwise she was better if allowed to sit up in bed or
on a commode during defecation and micturition, as this
posture effectually freed the vagina from clots and lochia.
Where retroversion and prolapse was found after labor
Dr. Wells did not believe the attendant should be often
blamed for it, or that it was caused by too tight a binder
or too early rising from bed. In the great majority of the
cases the displacement was present before. The causes
of deep laceration of the cervix he divided into two
groups, the traumatic or instrumental or manual delivery
and chronic endometritis, or more properly, metritis. The
tear in a healthy cervix from external force would often
heal, especially when favored by asepsis and rest ; the
tear from chronic disease was not apt to heal. Gonorrhea

when limited to the vulva and vagina, if rigorously at-
tacked, could be promptly cured, but such limitations were
rarely met with. The statement made by Dr. Balleray that
"neglected laceration of the cervi.x was responsible for the
occurrence of cancer of that portion of the uterus," and
that "where there is no traumatism there is no cancer,"
was true to only a very limited e-xtcnt. He had personally
seen three cases of cancer in undoubtedly nuUiparous
cervices ; two of the women were virgins and the third
had only had se.xual intercourse for a short time. Cer-
vical injuries should not be overestimated in their in-
fluence in the causation of cancer.

Dr. Louis J. Ladinski believed that if a lacerated cervix
had not healed within one week it would not heal at all
whether the patient was in bed or not. Therefore, he
could not agree with Dr. Balleray that keeping the pa-
tient in bed for weeks would favor the healing of a torn
cervix, nor did he agree that vaginal douches would tend
to promote union ; repeated douching, on the contrary,
would only interfere with the adaptation of the lacerated
surfaces of the cervix. With regard to immediate trache-
lorrhapy, this should not be attempted unless under tlie
most favorable conditions as regarded asepsis, equipment,
and assistants. It was different, however, with lacerations
of the perineum if the work was done by those who had
sufficient experience in this line of work. Dr. Ladinski
said that if lacerations of the cervix was a factor in the
production of carcinoma of the cervix even to a slight
degree, he would certainly have seen a much larger num-
ber of cases than he had. Of the few cases seen by him,
two were observed in positively nuUiparous women, one
of which was seen with him by the late Dr. Munde. With
the exception of the slight tears mentioned by Dr. Cragin
he was in favor of repairing every cervix that was lac-
erated, hypertrophied, or everted. With regard to gon-
orrheal infection, he said that frequently without any
external evidences they found that not only the endome-
trium was the seat of infection, but the tubes, and even
the peritoneal cavity had also been involved. He re-
lated a case that showed that the gonococci might infect
the tubes, and the pus leak into the peritoneal cavity pro-
ducing a general peritonitis, without any external signs
whatever. He closed his discussion by stating that it
required no emphasis on his part to say that there was
absolutely no justification in removing uteri containing
a little nodule, or a little fibroid, or an absolutely or
nearly normal ovary.

Dr. Robert T. Morris believed that an unnecessary
death rate would follow the removal of normal appendices.
When they opened the lumen of a normal appendix, they
opened a direct spigot of infection for the peritoneum,
at a time when the peritoneum was not prepared for self-
protection. When there was a real infection of the
appendix, be it ever so slight, a protective leucocytosis
was called out rapidly, and then they could do a great
deal with the appendix safely. With regard to primary
trachelorrhaphy, if one closed a tear in the cervix imme-
diately after delivery, and included a little nidus of in-
fection in the depths of the wound, he placed it out of the
current of protection from the lochia ; this lochia was the
patient's protection, loaded as it was with nucleins and other
elements prepared by nature. With regard to repairing
old scars of the cervix, he asked what had become of
Emmet's sign. If they pressed the finger or probe against
a cervix scar, and there followed an immediate reflex
to the lumbar plexuses, or if local pain was complained of,
then there was good presumptive evidence that the scar
was a persistent source of disturbance, and that it had
entrapped nerve filaments, and required surgical repair.

Dr. Charles I^. Dana said that a large per cent, of
backward children, imbeciles and idiots was the result of
some defect in the condition of the mother during the
parturient process ; therefore, it became necessary not

ioi6

MEDICAL RECORD.

[June 15, 1907

only to examine the urine, measure the pelvic diameters,
etc., but they should see if there was anything in the life
of the parent that might influence the condition of the
child. An interesting point to him was that the bilateral
arm palsies, epileptics, cerebral hemorrhages, hemiplegias,
defective mental development, etc., were, in many cases,
due to conditions which might be relieved by surgical
interference. When a child was born and had general
convulsions on the second, third, fourth, or fifth day, the
cause was probably meningeal hemorrhage, and Gushing
advised opening the skull, and washing the hemorrhage
out, claiming that this would bring the child to its normal
condition. In regard to the work of the gynecologist, Dr.
Dana said that he remembered the time when all sought
him with the hope that he could relieve the women of
their neuroses or psychoses ; they were choked with atten-
tion.

Finally the neurologists had to take the defensive,
and assumed the attitude of open hostility against the
gynecologists. They were operating upon uteri, curetting,
sewing up tears, etc., but they were not curing the nervous
manifestations. To-day the attitude had been changed.
He had often asked neurotic patients what had been the
result of operations, and he had come to the conclusion
that, in a large proportion of the cases of so-called psycho-
neuroses, operations for the relief of subinvolution, tears,
the removal of scars, did not really do any good, but often
did harm. In the psychoneuroses group of patients, those
with obsessions, operations were generally unsafe ; they
might cure them of back or pelvic pains, but they got up
something else. In the hypochrondiacal group of pa-
tients, operation might relieve the local condition, but not
the psychic condition. In the simple neurasthenic group
of cases, where the patients were made ill by irritations
in the pelvis, operations were extremely helpful.

Dr. Edward A. Ayers said that everj'where, throughout
the world, the cases of epilepsy averaged one to si.x per
thousand. The statistics of the English lying-in institu-
tions showed that where the mothers, during the pregnant
state, were accustomed to overindulgence in alcohol,
the per cent, of epileptics was from 40 to 50 per thousand
among the infants born. It was also shown that, when
the mother was intoxicated, the fetus in utero might
absorb seven-eighths of an ounce of alcohol. This evi-
dence showed that certain forms of nervous maladies
had a direct relationship to the condition of the mother.
Dr. George H. Baller.^y said that after abortions or
miscarriages there could be no objection to passing the
finger, or the hand if necessary, into the uterus to remove
secundines. The curette he believed was not justified,
and should be condemned in the hands of the general
practitioner. In regard to cancer of the cervix, he said
he had never seen a case in a virgin uterus. When the
abdomen was opened for pelvic conditions and the appen-
dix was normal, he thought it meddlesome surgery to
attempt its removal. He believed in keeping the patients
with extensive laceration of the cervix, of the perineum.
or of the vagina, but especially in the former, in bed.
He employed douches in these cases, because, as in gen-
eral surgery, wounds would not heal unless kept clean.
With regard to the gonorrheal cases, the women should be
kept as quiet as possible and the vagina should be thor-
oughly cleansed. Sulphuric acid 1-30, or bichloride 1-4000
should be given, not less than two gallons, and as hot as
110° F. If this treatment was carried out every day,
with the woman kept in the recumbent posture, one could
get control of the disease in two weeks. The tendency was
for gonorrhea to travel up ; therefore, the treatment should
• be early and pursued energetically.

Locomotor Ataxia. A New Theory as to Its Cause.
— Dr. L. N. Dekslovv presented this communication. (See
page 985.)

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital
Service, during the week ended June 7, 1907 :

SMALLPOX — CSITUU STATES.

California. San Francisco May 18-25

Illinois. Chicago May 2s-June i. .

-Moline May 19-26'

Springfield May 23-30

Indiana, Indianapolis May 12-26

La Fayette May 20-27

Iowa, Davenport May 17-31

Kentuck>-, Louisville May 23-30

Louisiana, New Orleans May 114-25 43 imported

Shreveport May 18-25

Massachusetts. Lawrence May 18-25

Michigan. Detroit May 25-June i.

- ;_^Fenton To May 25

Minnesota, Winona May 4- 11

Mississippi. Natchez May 18-25

Missouri. St. Joseph May 11-25

St. Louis May 18-25

New York, Buffalo May 18-25

New York May 18-25

Niagara Falls May 18-25

North Carolina. Greensboro .May 18-25

Ohio. Da>^on May 18-25

Toledo May 4-18

South Carolina, Camden May 18-25

Tennessee. Nashville May 18-25

Virginia. Richmond May 18-25

Washington, Spokane May 18-25

Tacoma May 1&-25

SMALLPOX — INSULAR

Philippine Islands. Manila .\pr. 13-20..

SMALLPOX — FOREIGN.

Austria. Trieste May 4-18

Brazil, Para May 11-18

China. Tientsin Apr. 21-28

Colombia, Barranquilla May 11-18

Cartagena Apr. 20-May 11.

France. Paris Apr. 27-May 1 1 .

Germany, General May 5-11

Manheim May 11-18

Great Britain, Liverpool May 11-18

London May

Southampton May

India, Bombay .-^pr.

Calcutta Apr.

Madras Apr.

Italy General May

Naples May

Txirin Apr.

Java. Bata\-ia Apr.

.Manchuria. Dalney -\pr.

.Mexico, .\guas Calientes -j i^jP^

Mexico .\pr.

Monterey May

Nuevo Laredo May

Sonora .\pr.

Portugal. Lisbon May

Russia, Odessa .\pr.

Riga May

St. Petersburg Apr.

Spain. Barcelona May

Carthagena Apr.

Valencia May

Turkey in Asia. Bagdad .-^pr.

Bassorah .\pr.

Constantinople. . | ^,P';

Venezuela, La Guira Mar.

Maracaibo May

4-1 1

11-18

30-May 7.

20—27

20-May 3 .

7-16

4-18

28-May 12

20-27

20—27

20-27

11-25

27-May 4.

12-19

II-18

6-20

l-I

28-May 1 1 .

2S-May 4. .

13-20

2S-May 4. .

12-19

13-27

29-May 4 . . .
21-28

4-12

31-May 25.

4-12

Brazil. Para May 11-18

Cuba, Habana : May 25, . .

Guatemala. Gualan May 21

Venezuela. La Guira May 4-

CHOLERA.

Ceylon, Colombo .\pr.

India. Calcutta .\pr.

Rangoon .\pr.

6-13..

20-27..
20-27.,

32
32

28

Present

6

From
vessel

67
3

33

5

Present

Present

1 From
San Nicolas
3 t

Eg>'pt, .Alexandria May 0-16 21

Beni Souef Province May 9-16 19

Girgeh Province May 9-16 30

Keneh ProWnce May 0-16 12

Minieh Pro\-ince May q-16 22

Samallut Pro\-ince ^lay 0—16 15

Formosa .Aor. 20-May 4. . . . 236

India, Genera! Apr. 20-27 87.394

Bombay Apr. 30-May 7

Calcutta Ape. 20-27

Rangoon .\pr. 20-27

Straits Settlements. Singapore .\pr. 13-20

34

9

29

210

76,711

230

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 71, No. 25.
Whole No. J9n.

New York, June 22, 1907.

$5.00 Per Annum.
Single Copies, lOc.

(Original Artirlpa.

STERILIZED HORSE SERUM IN SURGERY.

By RAYMOND PETIT. .M.D..

PARIS.
LATE ADJUNCT CHIEF OF CLINIC TO THE FACULTY OF PARIS.

When isotonic saline solution is injected into the
peritoneal cavity there is produced an afflux of a
considerable number of polynuclear white blood cells
to the spot, and the natural resistance of the serous
membrane to any infection is markedly increased.
Such is the experimental fact that has been broug-ht
to light by the e.xperiments of IssaetT. This author
found that in a peritoneum prepared by the injection
of isotonic salt solution he could inoculate several
lethal doses of the cholera vibrio without there being
any bad results, while uninjected animals succumbed
to a single dose in twenty-four hours.

At the request of ^I. JNIetchnikoff, I have
repeated these e.xperiments with various chenio-
tactic substances and with several species of patho-
genic microbes. It has been found after several at-
tempts that boiled horse serum is the substance
which is of the most use for inducing polynucleosis.
Many other substances may be used to produce poly-
nucleosis by chemota.xis, such as physiological salt
solution, peptonized bouillon, aleurone,nucleinic acid,
and various normal sera ; but they do not produce the
desired afflux of leucocytes to the same degree nor
with identical effects. Aleurone, for example, draws
a large number of polynuclear leucocytes, but hun-
gry for grains of aleurone, they gorge themselves
and have not the same appetite for phagocytosis
with reference to microbes.

The normal sera have seemed to produce the
greatest polynucleosis which may be utilized for
phagocytosis, and that of the horse is the best, since
it is less toxic than that of the cow, and can be made
almost entirely inoffensive by heating it in a water
bath for two hours, for three consecutive days, at
a temperature of 90° C, to destroy the alexin with-
out altering the natural sensibilization.

After having thus produced a polynucleosis in the
peritoneum of animals, it has been found possible
to inoculate with impunity into the serous mem-
branes a number of letlial doses of cultures of chol-
era vibrios, typhoid bacilli, Bacterium coli. Staphylo-
coccus pyogenes, etc.

The results of these experiments led to the attempt
to use this method in the treatment of infections
in man. The results obtained have been excellent,
and since igoo sterilized horse serum has been em-
ployed in suitable cases in private practice, as well
as in the Hospital for the Treatment of Industrial
Accidents. I have become convinced that we can
cure by phagocytosis and that the afflux of polynu-
clears by means of sterilized horse serum takes place
not only in the peritoneum, but in all the serous
cavities, in the mucous membranes, and in wounds

of all regions. More than a hundred cases can be
cited, some of which have already been published,
in the Revue de Gynecologie et de Chirurgie Abdom-
iimle, by Pozzi (July and August, 1906), and in the
Bulletin de la Societe d'Obstetrique de Paris (Feb-
ruary 19, 1906).

The cases treated may be summarized as follows :

I. Abdominal Surgery. — The sterilized horse
serum has been used as a prophylactic measure in
operations of a non-septic character, and as a cura-
tive measure in cases characterized bv infection.
Cases in which it was used as a curative measure
include appendicitis with abscess, operated on in
the active stage, general peritonitis, and suppurative
salpingitis with pelvic peritonitis, and suppurating
cholecystitis with pericholecystitis. In all these oj>-
erations we have made the usual interventions, with
the usual aseptic precautions. In all cases of acute
appendicitis the appendix has been removed at one
sitting. After the operation drainage has been em-
ployed and the serous cavity has been lightly packed
with gauze impregnated with sterilized horse serum ;
horse serum has also been poured into the peritoneal
cavity through the drainage tube. The do.se
usually employed was 30 cubic centimeters. On the
following day the same dose was repeated, through
the drain. Under these conditions the temperature
was slightly elevated at first, and then fell to about
normal. The character of the pus was at once
changed ; instead of a serous fluid, a creamy, thick
pus appeared, the "laudable pus" of the ancients.
The pus before the operation examined under the
microscope contained but few elements of defense
(leucocytes and polynuclears), with a considerable
number of free microbes ; after the use of the serum
innumerable phagocytes were found gorged with
microbes, and few free microbes. Suppuration di-
minished rapidly, and the case entered at once
upon a phase of active granulation, continuing until
cicatrization was complete. A case of acute ap-
pendicitis with large prerenal and subhepatic ab-
scesses was cured completely in three weeks, with
a good cicatrix.

Under the head of prophylaxis the serum was
made use of in two ways. In the course of opera-
tions for ovarian cysts, epithelioma of the ovaries,
abdominal hysterectomy for cancer, and extrauterine
pregnancy, ruptured or unruptured, when a fault
in the asepsis was feared, or after a prolonged opera-
tion with adhesions, the serum was poured into the
peritoneal cavity in doses of 30 cubic centimeters.
Drainage was instituted and gauze saturated with
the serum was left in place, or immediate suture of
the entire incision was made. In all the cases thus
treated there were no bad results.

In cases of gastroenterostomy or enteroanastomo- '
sis a different procedure was employed. The evening
before the operation there was injected into the peri-
toneum 30 cubic centimeters of the serum, a punc-
ture being made with a special trochar, constructed

ioi8

MEDICAL RECORD.

[June 22, 1907

by Galantc. which protects the abdominal organs
from injury. Injections made in this manner have
never caused anv trouble, and the i)rocedure allows
an operation on a ])eritoneum that is protected by a
reinforced resistance due to the presence of the
polynuclears.

2. Gynecology. — Most of the cases under this
category are puerperal infections, post-partmn or
post-abortum, very characteristic, accompanied by
high temperature and even the presence of thick
false membranes over the cervix, vaginal walls, and
vulva. The procedure is as follows : It is first
ascertained that the uterus is empty, by removal of
placental debris with the curette or of membranes
with forceps ; the uterus is then cleansed by means
of two or three hundred grams of physiological
salt solution and swabbing the interior of the uterus
and the vagina with a piece of heavy, sterilized
gauze on forceps. A piece of sterile gauze is im-
pregnated with the serum and in the center of the
folded strip is placed, as if in a pocket, one to three
grams of serum evaporated in a vacuum. This
pocket is introduced to the fundus of the uterus,
placed transversely from one horn to the other, and
the remainder of the strip is packed into the uterine
and vaginal cavity without making any pressure.
This packing is left in for twentv-four hours and
renewed daily for three to eight davs thereafter.
The strips when drawn out are sticky, having taken
up a liquid which is thick and gray, like a solution
of rubber, of a strong and peculiar odor, extremely
rich in polynuclear leucocytes in full phagocytic ac-
tion.

The temperature after being somewhat elevated
for a few hours falls after the first packing. At
the same time the false membranes and eschars
come away, the wounds granulate actively, and
the general condition rapidly improves.

3. Purulent Pleurisy. — Two exceptionally grave
cases of purulent pleurisy have been treated, one
in an infant (staphylococci and streptococci), the
other in an adult (staphylococci, streptococci, and
anaerobic bacteria) with pulmonary gangrene. In
both cases, after resection of ribs with drainage,
there was poured into the pleura thirty cubic centi-
meters of serum each day for several days. Both
patients were raJDidly cured, and the pus presented
the same transformations as have been noted above.

4. Various Phlegmonous Infectious. — In this
group are included severe subma.xillary phlegmon,
diffuse phlegmons of the limbs and trunk, anthrax,
furuncles, tendinous phlegmons, erysipelatous phleg-
mon, edematous gangrene, septic injuries of the
fingers, etc. In all these cases multiple incisions
and drainage were made use of: then the serum
was poured into the drains and the wounds tam-
poned with gauze soaked in serum, after powder-
ing them with serum dried into powder. Rapid
healing with excellent cicatrices was the result.

5. Burns. — Several cases of burns have been
treated, those produced by fire as well as by chem-
ical agents (vitriol). In these cases moist com-
presses were employed of aseptic gauze soaked in
serum. Burns of the second degree, dressed after
evacuating the serum from the blisters, were cured
in one week. In burns of the third and fourth
degree with eschars the latter became detached in
three or four days and left behind a pink, granu-
lating surface. In one case there were bums of the
third and fourth degree on both legs and one arm.
.\t the same time dressings were employed of phenic
acid on one leg. horse serum on the other, and
sterilized water on the arm. The eschars treated
with horse seumi separated first : one week later

those treated with sterilized water separated, while
those on tlie leg. treated with phenic acid, persisted
several days longer. The same rapid separation
of the tenacious eschars which form after acid burns
w^as observed. A case of eschars after a trophoneu-
rosis should be added to these cases, which was as
happily modified by the treatment as the others.

6. Repair of Wounds by Second Intention. — It has
been observed that abscesses, granulating wounds,
atonic wounds, such as old varicose ulcers, etc., are
rai;)idly modified under moist compresses of horse
serum. After the second dressing the wound be-
comes rosy, and an active granulation invades it ;
it bleeds easily, and soon begins the formation of
new skin.

It is not well to apply this dressing more than
once, and if it is continued there is soon produced
an arrest of the process of skin formation. A very
rapid formation of skin is obtained by using for
compresses a solution of bicarbonate of sodium,
I -100. The best of results have been obtained by
the use of semi-moist compresses, that is, by em-
ploying moist compresses without covering them
with impermeable silk tissue.

To sum up, there have been obtained with ster-
ilized horse serum, healing and cicatrization, both
excellent and rapid, in severe cases and even in
desperate diseases, after failure with the ordinary
methods of treatment. These results have caused
the systematic trial of this treatment, based on
chemotactic and phagocytic properties, as well in
hospital as in private practice : and for the last two
years the statistics have left nothing to be desired
to convince one of the value of the treatment.

The use of sterilized horse serum is but a means
to realize a new method, a means that has been
made use of because it presented the best vehicle for
the use of phagocytosis by formation of polynucle-
ars, a vehicle most favorable to the life of the
cells of the organism. As soon as a better method
has been arrived at that method should at once be
substituted.

What is desired is rather to establish this new
method of treatment, based on the discoveries of
Metchnikoff. laboratory experiments, and clinical
cases, than to exploit the value of sterilized horse
serum. This method of surgical treatment of in-
fections is concerned above all with the organism
afifected ; it seeks above all to utilize the resources
of the organism itself, to increase to a maximum
its natural means of defense, and place the tissues
in a condition of offense under the best and most
favorable conditions for repair. Differing entirely
from antisepsis and asepsis, which always retain
their indications, this method seeks not to destroy
the microbes in a wound bv the aid of chemical
agents and caustics, which alter the vitalitv of the
cells; it no longer contents itself with placing a
boundary to the approach of the germs : on the con-
trary it seeks to aid the organism to make its own
defense and repair, .^septic in its application, since
the horse serum is sterile and is used on sterilized
gauze, this method has for its object to create anti-
sepsis by phagocytosis and to favor the life of the
cells bv cicatrization.

Ophthalmia Neonatorum. — J. Clifton Edgar advises
the preparation of the vagina in all suspected cases by the
nse of a douche of a mild alkaline solution, followed by one
of a I to 5,000 bichloride of mercury solution. In addition
to this Crede's treatment of the eyes should be carried out.
namely : Wash of? each eye with a separate boric acid
wipe ; into each eye instill, two drops of a 2 per cent, solu-
tion of silver nitrate : in about thirty seconds wash out the
excess with saline solution. — Colorado Medical Journal.

June 22, 1907]

MEDICAL RECORD.

1019

PYREXIA IN TUBERCULOSIS.*

WHAT IT TELLS US AND HOW IT MAY BE CONTROLLED.
Bv HENRY P. LOOMIS. M.D .

NEW YORK.

\\'e have in the thermometer a most important aid
in the diag^iosis of certain obscure cases of tuber-
culosis, as well as the orreatest help in estimating
the character and activity of tubercular prcx'esses
when once established. It is especially the day
temperature by which this indication is given.

The thermometer tells us when our cases are
arrested or cured. It aids us in many of our plans
of treatment : without it tuberculosis would be a
much more difficult disease to handle than it is.
It is as a plea for its more general and systematic
use that I venture to bring to your attention certain
facts in reference to the temperature in pulmonary
tuberculosis. One who watches phthisis in hospi-
tals and sanatoriums quickly learns how important
the daily temperature curve is, how its variations
are to be interpreted, and how it modifies treatment.
The practitioner who sees the case only in his office
or possibly once a day at the patient's home, and
then without a continued temperature record, is at
a great disadvantage. Often if the temperature is
taken it is found to be normal, and the patient is
allowed to go about, although during most of the
rest of the twenty-four hours the temperature may
range above 102°.

All persons with phthisis can be taught to take
their temperature regularl)- and keep accurate rec-
ords of the same. This is a plan I have long adopted
with patients who are seen only at stated intervals.
I have found it of great help — it enables them under
directions to regulate their exercise and often
change the time of taking the medicine. It may be
argued that neurotic individuals would be unfavor-
ably afi'ected by this constant knowledge of the
amount of fever they have. I have found this the
case only in a very small number of individuals
— after the reason of this temperature taking has
been explained. If it is not advisable for the
patient to take his temperature, some member of
the familv can do it, if the patient is not sick enough
to have a trained nurse. Since I have adopted this
plan I have been surprised at the amount of tem-
nerature certain cases were running who were going
about, often attending to their business, and whom
I supposed had no elevation of temperature tn
amount to anything.

I believe the temperature should be taken at least
every four hours from the time of awakening to
going to bed, to give us a temperature curve of
value. Dr. Brehmer insists that a two-hourly tem-
perature curve is much better. While it is advisable
to take the temperature per rectum when it is con-
venient, this I do not think is absolutely neces-
sary if care is used in taking mouth temperature.
I have compared the two curves in a large num-
ber of cases, temperature being taken both liy the
mouth and rectum, and the variation is al\va\ s
constant and usuallv one-half degree. The fever in
phthisis is no doubt dependent uixjn two causes, one
the absorption of the proteins of the tubercle bacilli,
the other the absorption of the toxin.s fn >ni the
secondary bacteria (mixed infection).

The range of temperature during the progess of
active pulmonarv tuberculosis is one of the most
important indications we have of the specific morbid

*Read at a meeting of the Section on General Medicine
of the New York .\cadcniy of Medicine, March 19. 1907.

process. By means of the temperature range we
can in some instances suspect tuberculosis and make
a tentative diagnosis long before physical signs and
symptoms are sufficient to justify such a diagnosis.
By the temperature alone almost any case can be
diagnosed within three weeks from its onset, for
by that time other causes for the rise in temperature,
such as typhoid fever, scarlet fever, pus formation,
etc., can be excluded. Although the temperature
affords a very accurate measure of the activity of
pulmonary tuberculosis, it does not follow that
when fever is absent we are to conclude that the
patient is free from the disease. It does enable us,
however, to interpret the physical signs which are
present.

A?ain the range of temperature during the prog-
ress of tuberculosis is one of the most important
indications which we have of the activity or sub-
sidence of the specific morbid process. It is some-
times a more precise indication of the amount of
tuberculosis than either the symptoms or physical
signs. In the presence of an active disease the
temperature rarely touches or even reaches the nor-
mal hne. Fluctuations take place in every twenty-
four tiours, but the lowest temperature recorded is
febrile. The higher the day temperature the more
active generally is the process and the more un-
favorable the prognosis. So long as there is an
active temperature range it may safelv be assumed
that a deposit of tubercles is taking place, even
though the physical signs remain for a time unal-
tered, I might make two exceptions to the above
statement.

1. It must be remembered that a large amount of
tuberculous deposit, such as is seen in so-called fi-
broid phthisis, may be present in the lungs without
causing any rise of temperature, but this prove,
that the morbid process is quiescent and localized,
and that no systemic poisoning is taking place. In
these cases tubercle bacilli may be f'-i.nil m the
sputum even in large numbers : but a normal tem-
perature is by no means the rule in fibroid, for there
is generally a slight rise reaching to 100° or loi''
P.. continuing for a time, and then the temperature
mav become normal for a time only to rise again
for a varying period. This alteration may endure
for years, slowly undermining the health. In other
cases of disease of this type the disease progresses
so slowly and the deposit at any one time is so
slight that it is insufficient to elevate the tempera-
ture to any extent. Towards the close of life in
certain chronic cases the temperature not uncom-
monly becomes normal and so continues until death.
These people die from irreparably broken down
health or serious secondary disease rather than
friim the active tuberculosis disease. .Although the
course of the temperature is a rough indication of
the course of the disease, it must be remembered
that other factors are at work in the production
of pyrexia in addition to the actual tuberculou'^
])rocess.

2. It must not be forgotten that personal idio-
svncrasies mav affect tempertaure. It is a well
known fact that febrile reaction set up by similar
agencies varies greatlv in different individuals.
Some have an unusually high temperature from
trivial causes, while others are only slightly affected.
These form an exceptional class of cases and in
them the temperature chart may be equivocal, and
b.ence must not be too closely regarded if other
s\mDtoms point to different conclusi(Tns. such as
wasting, nieht sweats, anorexia, diarrhea, etc.

lOJO

MEDICAL RECORD.

[June 22, 1907

Although the temperature affords a very precise
measure of the activity of a tuberculosis, still, in
forming a prognosis, we must be careful not to
overestimate it, for other circumstances must be
taken into consideration. In many cases, although
the temperature is high, the disease after a time
declines and the patient recovers. In forming a
prognosis in cases with elevation of temperature

a case of phthisis, during active stages of the dis-
ease, may be roughly summed up as follows :

I. If the dailv temperature is high and never
touches the normal, and especially when accom-
panied by a rise of two or three degrees at night,
the case is prnliablv one of acute localized miliary
deposit, or possibly of acute general pulmonary tu-
berculosis.

Chart 1. — Showng the effects of the drug when administered continuously; the diinethylamido-pyrazolon
was given every four hours, beginning on the second day.

we must be governed by the effect of absolute rest
and treatment. If in spite of this the temperature
continues high, the prognosis is bad. If the appe-
tite and power of assimilation, in spite of the tem-
perature, remain srood, the prognosis is good. These
cases often gain in weight in spite of more or less
fever, but usually a temperature precludes a gain
in weight in spite of the appetite.

2. If the daily temperature is irregular, some-
times normal, and at other times ranges between
100° F. and loi^ F., and associated with an even-
ing rise, it may be inferred that a slow and inactive
deposit of tubercle is taking place. A general gain
in weight and general improvement would be ob-
served as long as the evening temperature remains
below 101.5° F.

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Chart 2. — Showing the effects of the dn;g administered for three days; the dimethylamido-p^Tazolon was
given every lour hours on the seventh, eighth, and ninth days only.

The thermometer is a very important aid in es-
timating the seriousness of a pulmonary hemor-
rhage : if accompanied by high temperature it in-
dicates that when the hemorrhage stops the evidence
of marked destructive changes will be recognized at
an apex bv physical examination. Hemorrhages
with but little or no fever, even if severe, are of
little importance unless the case is one of fibroid
phthisis.

The diagnostic value of the temperature ransje in

3. If the temperature during most of the day
remains about normal and the evening rise does not
exceed iot° F.. one mav infer that the tuberculous
process has advanced very slowly if at all.

4. If the day temperature remains always normal
and the evening rise does not exceed 99.5° F., one
may infer that the tuberculous process is quiescent.

Treatment of Pyrexia. — In the treatment of py-
rexia in pulmonary tuberculosis it should be borne
in mind that a natient does not suffer or show the

June 22, 1907]

MEDICAL RECORD.

1021

constitutional disturbances at all compared with
patients sufferinsr from other active diseases, such
as those with pneumonia or tvphoid fever. This
applies even to those cases of phthisis with a ma.xi-
mum temperature fully as high as that of other
fever patients, and at the same time it must be
remembered that a reduction of fever in phthisis
cases does not offer the same amount of relief as it
does in oflier cases — notably typhoid fever. In
fact, cold sponp-es, which are so effective in every
acute disease, are very apt to be followed by chilly
feelings which mav persist for a long time and
render the patient very uncomfortable. It is also
well to remember that the maximum temperature
seen in phthisis is apt to be much less prolonged
than it is in other fever cases, but at the same time
it should be kept in mind that many of the symp-
toms seen in cases of phthisis can be referred di-
rectly to the effects of the fever, such as anorexia,
loss of weight, and night sweats. While the cold
sponges are not ordinarily advisable as a means of
reducing temoerature in phthisis, still the spong-
in^^ of the surfaces night and morning in luke-
warm water to which an equal quantity of alcohol
has been added should be followed in almost
every case of fever, as it is not only exceedingly
grateful to the patient, but will modify or control
to a certain extent not only the temperature, but
many of the other symptoms, especially the night
sweats. It is only in those cases of phthisis with
a persistently high temperature that the fever should
be directly treated, and in most other cases the
various measures^ adopted to improve the person's
health will in time have a controlling effect upon
a moderate fever. In cases of phthisis in which
the temnerature range is distinctly an unfavorable
element, the fever should be treated in the follow-
ing manner :

We should bear in mind the fact that the patient
should be treated exactly as if he was suffering
from an acute inflammatory disease, such as lobar
pneumonia. The patient should be kept absolntel\
still in bed and should use the bed pan and the
urinal. The reason for this is that "the fever in
itself denotes loss of bodily substance; if to this is
added further loss through movements, the loss is
as a rule too great to be covered by nutritive proc-
esses which are depressed by fever — the result is a
waste of body substance and increased absorption
not only of fat and albumen, but also of the proteins
which set up more fever. It is above all important
to break this vicious circle." This can only be
accomplished by rest in bed. It has been found in
sanatoriums that fever can be much more readily
controlled where arrangements can be made so
that the bed can be wheeled out upon the piazza.
The patient lies in the open air and is always com-
pletely protected from the rays of the sun. My
experience has proven that the direct sun rays have
in the majority of cases of phthisis, even in those
in whom the disease is quiescent, a tendency to
elevate the temperature. A modification of this
plan can be adopted in private houses by bringing
the bed close to an open window in suitable weather
and thoroup-hly protecting the patient from draught.
A tuberculous patient with a high temperature
should be kept not only physically, but mentally
quiet. Visits from friends and long conversations
should be prohibited. The diet should be the same
as in acute nneumonia. The patient should be fed
on what is known as "soft diet"' every two or three
hours in a small quantity. The diet should con-
sist of milk modified by lime water or vichy water,

or better, peptonized. Beef tea to which has been
added a small quantity of one of the meat extracts
can be given. Soups, such as chicken or mutton
broth, are suitable in these cases. Stimulants should
be given at regular intervals, but in small quanti-
ties. Four teaspoonfuls of whiskey to a glass of
milk makes a good combination. In ordinary cases
four ounces of whiskey or brandy may be given
daily. Dr. Brehmer considers wine much more ad-
visable for this class of cases and is in the habit
of giving Hungarian wine, or a stronger wine (8-
12 per cent, alcohol) about thret wine-glasses a day.
Many patients who do not take whiskey readily can
find a substitute in a good wine, such as port,
sherry, or Madeira. No objection can be made
to the use of tea or coffee in moderation, especially
the early morning cup. If the digestive organs are
in exceedingly good condition an ordinary diet with
three meals daily may sometimes be given even
with high fever. Forgetfulness of the fact that
high temperature in tuberculous cases should be
treated exactly as in cases suffering from an acute
or infectious disease is the reason more than any
other why so unsatisfactory results are obtained
and why the temperature is looked upon as a part
of the disease and necessarily uncontrollable. It is
my experience that most antipyretics do more harm
than good in cases of phthisis ; and while an ele-
vation of temperature can often be controlled by
large doses of antipyrin, antifebrin, or phenacetin,
the effects are only temporary and at the expense
of the patient's vitality and general comfort. When
the temperature of tuberculous patients cannot be
modified or to a certain extent controlled by the
indirect methods which I have suggested, the use
of quinine and codeine, given in combination, is
sometimes attended with the most gratifying re-
sults. Five grains of quinine in a capsule with a
one-quarter grain of codeine ordered every four
hours is continued until the patient has taken a
drachm of nuinine. When an effect has been pro-
duced upon the temperature range the quinine is
reduced to every six hours and later three times
a (lay. The only other drug I am in the habit of.
using is dimethvl-amido pyrazolon (pyramidon).
Professor Robert, who has tested this drug in a
large number of cases of tuberculosis, reports that
he has never seen any depression or unpleasant
effects follow its use. In his report he compared
its effects in a number of cases with quinine,
euquinine. antipyrin, antifebrin, and the salicylates,
and found it superior to any of them. At the sana-
torium at Liberty it is extensively used to control
tuberculous temperatures. In fact it is practically
the only drug now used. When it is effective the
disappearance of the fever is gradual and the sub-
sequent rise in temperature as its effects pass off is
slow. The abatement of the fever of consumption
in the early morning is often accompanied by vio-
lent sweats. In order to control these sweats, which
are not onlv very unpleasant, but also distinctly
harmful. I am in the habit of using one of the salts
instead of the drug itself — namely, the acid cam-
phorate. Whether the salt or the drug itself is
used the dose which T have found most effective
is ten grains every four hours. The drug occurs as
a tasteless white powder very soluble in water. As
I have said, you will find the effects of this drug
on temperature to be gradual, and three or four
days must elapse before marked effect is noted.
Then the temperature in cases in which it is effec-
tive will be noted to be gradually coming down.
It is now a generally accepted fact that most of

1022

MEDICAL RECORD.

[June 22, 1907

the fever proceeds from the absorption of the sep-
tic by-products, generally of the ordinary septic
microbes. We have two means at hand which are
claimed by some to diminish the septic chantjes
which usually occur in the diseased area : ( i ) The
inhalation of various volatile drugs; (2) the use
of antistreptococcus serum.

Of the former I often make use, and it seems to
me with extremely satisfactory effects upon tem-
perature in some cases. The patient can wear an
oronasal respirator at times during;' the day and
often it is possible to wear it at night. I have found
that a mixture of equal parts of creosote, alcohol,
and chloroform, ten drops on the sponge of the in-
haler, gives the best result.

There are a number of antistreptococcus sera on
the market and when they are prepared by well
known houses are reliable. I have made repeated
trials of them in a number of cases of mixed infec-
tion with fever, but never have I been able to
satisfy myself that they have any controlling effect
upon the temperature. I cannot recommend them.

The freer the elimination of the purulent material
from the diseased area the less likelihood there is
of septic infection and fever. Therefore to bring
about this we rather encourage expectoration and
do not stop the cough by cough mixtures unless
it becomes verv troublesome at night : the morning
cough should be esoeciallv encouraged, as tiiat
serves to "-et rid of the secretion which has accumu-
lated during the night. This can often be encour-
aged and made much easier for the patient by giving
early in the morning a glass of hot scalded milk
to which seltzer water has been added.

An important practical point to decide is often
presented to the phvsician, namely, shall a febrile
patient undertake a change of climate? I do not
know in certain cases of tuberculosis a more difficult
problem to decide. So much depends upon the cle-
cision. We would naturally say that cases of active
temperature should not be moved. Still, I have
seen, as you all have, patients with tuberculosis that
have run high temperatures for weeks which have
resisted all treatment show a marked improvement
with a quick reduction of their temperature upon
chang-e of climate. These are the exceptions, how-
ever. My rule has been in the ordinary febrile
cases, after the temperature has been below 100°
for three days, to allow the patient to get up at
first for an hour or so a day, then longer. .\s soon
as the patient is able to go about the house without
having a temperature of over ioi° at any time
within the twentv-four hours to say that a change
of climate can with safety be made if it is deemed
advisable from a general consideration of the cases.
I believe patients running a higher temperature
should not be sent away unless the physical and
local conditions both warrant the change, and then
onlv when the case is put directlv under the care
of a phvsician where the patient is going.

I would summarize the treatment of pvrexia as
rest, mental and phvsical, in the open air if pos-
sible ; liquid nourishment and alcohol in a form
most agreeable to the patient : tepid spongings
with alcohol and water, equal parts, ancf if these
means fail, nvramidon or quinine and codeine.

sS East Thirtv-fovrth Street.

Obstetric Pads. — M. \'. MacDonald says that a good
grade of cotton waste, at seven or eight cents a pound,
such as is used by engineers for cleaning purposes, can be
made absorbent by boihng in a soda solution, and makes an
excellent foundation for obstetrical delivery pads. — Xurscs'
Journal of the Pacific Coast.

THE PROBLEM OF INFANT FEEDING.

By O. HEUBNER. M.D.,

BERLIN'.

PRIVY MEDICAL COUNCILLOR; PROFESSOR OP PEDIATRICS AT THE U.VI-
VERSITV op BERLIN; DIRECTOR OF THE UNIVERSITY CLINIC FOR
children's diseases IN THE CHARITE HOSPITAL.

As a text for the following remarks I will relate the
histories of two children recently examined in my
clinic at the Charite. These two little patients,
twins, were one month old. Both showed inferior
bodily development. The elder but weaker child, the
boy, was artificially nourished from birth. He re-
ceived at first 60 to 100 grams of milk six times a
day, and afterward a smaller amount every two
hours ; but he did not thrive on this quantity. The
child's weight at birth was 3,150 grams, and at one
month of age 2,550 grams. He had had disturb-
ances of nutrition from the very beginning. The
stools became greenish, and vomiting occurred. Cal-
omel caused improvement in the stools, but the vom-
iting continued. That is the typical pathological
history of a large number of children artificially
nourished from birth ; it has been the usual case in
our clinic for a decade and a half, and it is probably
the customary experience in general practice. Since
he was received into the clinic the child has been
given the breast.

The child was poorly nourished, its entire body
being generally lean and unpadded, and the face
bore the expression of suffering. It was, so to
speak, a child whose own condition made it sad.
One may say as a general rule that so long as chil-
dren do not feel well they take no interest in their
surroundings. When they cry they show deep
wrinkles about the nose and mouth. This child
may afford me an opportunity to discuss the ques-
tion of feeding during the first davs and weeks of
life.

It is just at this period that the nourishment of
children is of the greatest importance for their en-
tire future. One-third of all the children who die
in the first year of life succumb during the first
month. It may safely be said that the artificial
nourishment of children is attended with much
greater difficulties during the first fortnight or
month than later on, and that disturbances of nu-
trition are much more frequent and severe during
this period.

Scarcely were the first days passed in the life of
this little one before the various troubles began, in
spite of careful attention in the clinic. The child's
mother was unable to nurse it, because she was at
first afflicted with parametritis and afterward showed
signs of renal disease. The kidney affection in
itself is no contraindication to nursing, for the loss
of albumin is not so great but that it can be com-
pensated for; and if the mother had only been able
to nurse the child during the first four weeks a
great deal would have been gained.

\\'hat, now, are the measures to which a physician
must resort in order to educate a weak mother to
nurse her own child ? By careful observation
of newlv-delivered women we have learned much in
regard to this question during the last ten years—I
may even say during the last five years. We know-
now that women whose breasts, during the first
week, do not yield the quantity needed by the child,
may in the course of time, by quiet waiting, become
fully capable of nursing. As long a period as four
weeks may elapse without the child thriving at the
mother's breast. I am able to give a typical exam-
ple from a case occurring in my private practice.

June 22, 1907]

MEDICAL RECORD.

1023

A young mother, at her first delivery, had a robust
child! On the first day I let the mother rest com-
pletely, and the child also. As a general thing it
may be said that a child remains much more quiet
when it is given nothing, or perhaps only a little
tea, on the first day. The mother rested for two
days, and the child slept. On the third day the
child drank altogether 40 grams (twide 20), on
the fourth day 115 g., on the fifth day 115 g., and on
the sixth day 120 g. Now, nurse and mother be-
gan to despair. To this came the additional trouble
that the mother develojied fissures on her nipples,
which also were somewhat retracted. I must here
interpolate that fissures do not constitute a reason
for suspension of nursing, and that, aside from
careful treatment, no attention should be paid to
such. Before and after putting the child to the
breast the nipples should be painted with a weak
solution of silver nitrate, and with this precaution
nursing may safely be continued. In the case of
which I speak the pains attending the nursing be-
came so severe that, instead of silver nitrate, I em-
ployed a I per cent, solution of cocaine, without any
ill effect on the child. By this means the mother
was able to stand it, although the child on one day
sucked out a whole mouthful of blood. While the
milk secretion remained so inadequate, however, the
child was given one small additional meal a day ( at
first 60 g., later 80), containing one-third cows' milk.
Such mixed nourishment is far superior to wholly
artificial feeding. On the seventh dav, in addition
to the 150 g. of mother's milk which it then ob-
tained, the child was given 20 g. of cows' milk with
40 g. of water in one meal. It is advisable not to
give the artificial food after each nursing, but rather
to give it alone in one dose. This has the double
advantage of sparing the mother once a day, and of
avoiding overfeeding the infant. The number of
meals may be placed very low. Five to six a day are
quite sufficient, and satisfy a normal nursling. That
this child was insufficiently nourished, however, ap-
peared from the fact that it passed no stools. The
addition of cow's milk need not be large enough to
furnish the entire amount of calories required. By
proceeding in this manner the secretion of milk in-
creased gradually, and on the eighth day the breasts
yielded 320 g. The fissures healed. By the end of
the third week the one artificial meal could be with-
drawn ; and at the end of the fifth week the milk
supply was 600 g. and the child's weight was in-
creasing more than 200 g. a week.

I have reported this at some length, because in
such cases the technique of feeding is of the great-
est importance. The loss in the weight of the child
during the first fourteen days was no greater than
is usual, amounting to less than 300 g. Under cer-
tain conditions it is necessary, when the infant will
not nurse properly at first, to resort to artificial
means to make it take the breast.

What is the principal factor in making a breast
which gives insufficient milk functionate properly?
First, the stimulus of sucking; second, good nour-
ishment for the mother. It is always advisable to
give the mother plenty of milk in addition to her
other food. In the case of premature birth nursing
is difficult because the mother's breast cannot be
stimulated to secretion by the sucking of the child.
In such cases it is best temporarily to engage a wet-
nurse li'ith her child. The vigorous child of the wet-
nurse is then put to the breast of the weak mother,
while the latter's infant is fed with milk drawn from
the nurse's breast. Where this is not Dossible a
breast pump must be used as frequently as the

child, under normal conditions, would have taken the
breast, and as soon as the weak infant can begin
to suck a little the breast pump must be used be-
fore the child is put to the breast. The experience
gained in the homes for nurslings, to which mothers
and children are admitted, has gradually taught us
to avail ourselves of all these "tricks."

I have, however, a chart from a case in the clinic,
which proves that a perfectly satisfactory nutrition
may be obtained even in a case where it is neces-
sary to wait a whole month before the mother's
breast > ields sufficient nourishment for the child.
This child received, during the month of May, an
insufficient amount of nourishment from the mother
(70-80 calories per kilogram). With an increased
secretion from the breast it gained regularly ; and
at the age of eleven months it ran about freely, and
was in an excellent state of nutrition.

From such experiences we naturalh' learn how to
reassure anxious mothers in cases in which the milk
secretion is insufficient in the beginning .Subjec-
tively considered, children will feel much better with
scant nourishment than when plentifully fed.

The only exception to the rule that a mother
should always nurse her child is when she is suf-
fering from tuberculosis. The argument that even
this might be permitted, because nursing renders the
tuberculous mother stronger, is not valid, since one
must take into consideration the period after the
cessation of lactation. At this period, to mention
an example, the sudden appearance of miliary tuber-
culosis was noticed in a wetnurse who had nursed
for a long time. Other contraindications I do not
recognize.

To demonstrate by an example that the acute in-
fectious diseases do not constitute contraindications
to nursing, I may mention that in the Charite we
have let a mother who suffered from scarlet fever
nurse her child immediately after the febrile stage
was passed. In another case, in the second medical
clinic, a typhoid patient nursed her child during
the entire period of the disease, and both mother and
child were the better for it. In febrile diseases, how-
ever, it is generally advisable to take the child away
while fever is present, but to let it be nursed again
as soon as the temperature has become normal. The
breasts then begin to secrete anew. In the (Hiarite
we have observed a case in which the glands began
to give milk again si.x weeks after suspension of
nursing, the children (twins) being them nursed un-
til the end of the normal period of lactation. These
are all facts which make it the urgent duty of phy-
sicians always to urge mothers to nurse their chil-
dren. In the case of the twins mentioned at the Ije-
ginning of this paper, a comparative e.xperiment
was made. The weaker child — the boy — was
nursed by the wetnurse, while the stronger child —
the girl — was given artificial food, consisting of ex-
tra good, diluted cows' milk. The breast-fed child
progressed at once, while the bottle-fed infant did
not develop at all during the early period, when it
received an abnormally low amount of calories.
Even in the further course of the treatment the
originally robust bottle-fed child developed rncjre
slowly than the I>reast-fed child, which was weaker
at birth.

I would therefore urge, in cunclusiun, f)n all who
find themselves in the position of advisers to yijung
mothers to be insistent in counseling their charges
to do their duty in the matter of breast feeding, no
matter what may be the initial difficulties, and thus
to help them to achieve this blessing c-f true moth-
erhood.

I024

MEDICAL RECORD.

[June 22, 1907

SOME ASPECTS OF STERILITY AND ITS
TREATMENT.*

By a. J. RO.XGIXSKY, M.D..

NEW YORK.

INSTRUCTOR I.V DISEASES OP WOMEN AT THE POST-GRADUATE MEDICAL
SCHOOL, ADJUNCT GYNECOLOGIST. LEBANON HOSPITAL.

In writing on the subject of sterility in women one
is embarrassed by dealing mainly with one half of
the matter, as those who have had a wide experience
are more and more convinced of the greatness of the
part playing by the male, not only in absolute sterili-
ty, but in all the other forms. It is not only im-
portant from a medical standpoint, but the sociolo-
gist should be equally interested, as it is a matter
of no small importance to the community at large,
that at least one million women in this country are
absolutf ly sterile. These women sooner or later seek
the advice of the physician. The subject is therefore
of prime importance to the general practitioner as
well as the specialist. Personally, in the short time
that I have been engaged in the practice of medicine,
I have had a fairly wide experience with this par-
ticular gynecological condition, and the greater my
experience the more I have been impressed with how
little our knowledge extends in this direction and
what an amount of scientific work yet remains to be
done.

Sterility is equalh- dominant in all classes, particu-
larly in the absolute form, but it seems to me that the
greater the intellectual faculties of a woman the
more likely is she to be relatively sterile. In the
lower classes absolute sterility sooner or later will
interfere with the general morale of the home, and
if the woman is religiously inclined she considers
herself as one cursed by Providence, and at times
as one unworthy of enjoying the pleasures of life of
this world and the world to come. This condition
constantly preys upon her mind, so that eventually
it becomes more or less in a state of perversion, and
quackery in all its forms very naturally has its great-
est outlet among this class of patients. Even the
Bible has an authentic case in which prayers helped
to open a womb that had been shut, the woman
conceived and Samuel was born as a result.

Sterility is generally divided into absolute and
relative. By absolute is meant when the individual
is incapable of bearing a child to the period of
viability. It is termed relative when child-bearing
is not in accordance with the length of time the
individual has been married. Ordinarily a woman
should give birth to a child every three years during
her child-bearing period.

From the above you will see that the question of
conception is entirely left out from the discussion,
and therefore, I think the definition is not entirely
complete either from a scientific or a clinical stand-
point. A more scientific classification would be to
term sterility complete when the woman has never
conceived, incom[>lcte when she does conceive but
habitually aborts before the child is viable ; and rela-
tive when children are not produced in a number,
in accordance with her condition, age, and length of
married life.

Before we commence to consider the causes that
may prevent conception, we must decide that no two
cases have the same etiological or pathological fac-
tors— at least this has been my experience in about
sixty cases that I have seen both in clinical and pri-
vate practice. And the sooner one is able to appre-
ciate it the more apt is he to cure the patient —

*Read at a meeting of the Alumni Society of the Leb-
anon Hospital, February 5, 1907.

Sterility and curettement have been too long asso-
ciated in the minds of medical men, and the result
of this association I need not tell you.

In order that conception may take place, the most
essential factors are, first the deposit of healthy
semen in the upper segment of the vagina, second
an uninterru]jted passage, or still more definitely, a
patent, relatively healthy female genital tract, at
some point of which the spermatozoon and ovum
may meet and find a resting place for their growth.
From the above it can be seen that any thing that
will interfere with the general health, or any local
pathological condition of both the male and the fe-
male, may either prevent or postpone conception.

The male aspect of this condition is not as com-
plicated as the female. Here our diagnosis can be
more exact and our line of treatment more definite.
Aside from the many organic lesions in the male
that cause sterility, I find that sterility is very com-
mon among habitual masturbators, who by virtue
of their having practised masturbation for a long
time, have suffered the glandular structures of the
testicles to become functional!}- inactive, and on ex-
amination one finds that the semen of this class of
patients contains no, or very few, small, dead sper-
matozoa. Again excessive coitus, especially prac-
tised by recently married couples, leaves the male
partly in the same condition as that of the mastur-
bator. This is very well illustrated clinically, when
one observes that if conception does not take place
soon after marriage, it is usually postponed until a
time when probably the husband is taking the proper
rest and during which time the glandular structures
of the testicles become reinvigorated and commence
to secrete healthy spermatozoa.

The so-called vague term of incompatibility or
want of sexual affinity is a very important factor in
sterility. I find among some patients that either the
husband or the wife is sexually weaker, — usually
it is the husband. The act of copulation is not
satisfying to both alike, an element which is very
essential and must not be overlooked. Our duty in
such cases is to try to equalize conditions, either by
building up the one who is weaker, or if that is
impossible, we have to go to the extreme, of depress-
ing the one whose sexual powers are stronger. I
have carried out this mode of treatment in one of my
cases with the result that the woman conceived at
the end of nine weeks after being sterile over five
years.

Occupations which ta.x the nervous system, so
that the individual is mentally tired on completing
the days work, are also conducive to sterility. Such
a state of the nervous system is not conducive to
healthy intercourse, and sterility is quite likely to
be prevalent among this class. \\'e can readily over-
come it by instructing patients to have no intercourse
before some rest in the form of sleep is taken, dur-
ing which time the general nervous system is likely
to have resumed its normal state. A man with a
congenitally small penis, especially when the woman
is of large stature, finds it difficult to perform the act
of copulation, with the result that conception does
not take place. This condition is almost always re-
lieved, bv instructing the woman to have it so ar-
ranged that her pelvis is on higher plane than the
rest of the body during intercourse and also to re-
main perfectly quiet for at least one hour after, as
the semen is probably deposited very low in the
vagina and any undue motion on her part may cause
its escape from the vaginal vault.

Another important element of sterility in the male
is varicocele of one or both sides, no matter how

June 22, 1907]

iMEDICAL RECORD.

I02!

small it may appear to be, but which still may pro-
duce enough passive congestion of the testicle to
render it functionally inactive. I had this con-
dition most beautifully illustrated in one of my
patients only a short time ago. The wife of the
patient came to see me about her sterility with the
following history : twenty-eight years old, menses
began at the age of fourteen years, were regular
every four weeks, of three days duration. Married
six years and never conceived. Two years ago the
cervix was dilated and curetted by a prominent
gynecologist of this city with no beneficial results.
On examination I found her genital organs appar-
ently normal. I immediately asked to see the hus-
band and a specimen of the semen. On physical
examiation I found that he had a small varicocele on
the left side. The semen on repeated examinations
showed no spermatozoa. I suggested to him that
his varicocele might be a cause of his azoospermia
and advised removal of the same. He was operated
in this hospital last July, and three months later his
wife conceived, and now is in her fourth month of
pregnancy (spermatozoa were present after opera-
tion).

Finally it is the duty of the physician to examine
a great number of seminal specimens, in order
thoroughly to familiarize himself with the micro-
scopical appearance of spermatozoa and to be able
to satisfactorily pronounce a given specimen as be-
ing normal, for it is not sufficient that spermatozoa
are found. It should as far as possible be established
that some of the spermatozoa will reach their point
of destination fully viable, active, and in condition
to impregnate the ovum. Many specimens that are
examined are found to contain spermatozoa tliat ap-
pear very feeble, some that hardly posesss life at
all, some that are broken up and some that are dead.
With such semen no matter how normal the woman
may be, conception may not take place, for in order
to impregnate the ovum, the individual spermato-
zoon will have to travel a distance of at least 24 cen-
timeters and the time it will consume in doing so,
no matter how moderately rapid it will progress,
will be one hour and a half. Many obstacles will
delay its journey and the time consumed will be
much longer. Now many specimens of semen that
I have examined and which showed living sper-
matozoa although not of the very active variety,
when the same specimens were examined two hours
later after keeping them in a warm, normal salt solu-
tion, showed no trace of a living spermatozoon,
would it not be logical to conclude that such sper-
matozoa will die during their travels before they will
meet the ovum to impregnate it ? Such a condition
is generally the result of a debilitated state of the
individual and naturally calls for treatment that will
improve the general condition of patient, but in addi-
tion to it, die patient must have thorough sexual
rest for a given time. Usually I prohibit any sexual
excitement for at least ten weeks.

In seeking the cause of sterility in women not only
the whole range of diseases peculiar to women must
be considered, but as well the phvsical and social
conditions of the individual. Xo other condition re-
quires a more detailed knowledge of the physiologi-
cal and pathological processes that take place in the
female genital tract, and depending upon one's
ability to dififerentiate the various processes will de-
pend the success met in the treatment. Once healthy
semen is deposited in the upper segment of the vagi-
na and conception does not take place, clinically the
•woman is at fault. At times the cause is very ob-
scure, but aside from the many pathological lesions

that may be present, functional disturbance no mat-
ter of how mild a nature will cause the woman to
be sterile. Particularly is this true in that class of
women who suflfer from a general muscular relaxa-
tion, are ill nourished, and highly nervous. For in
order that tlie spermatozoon may reach its destina-
tion, two mechanical forces besides its own motile
power are directl)- engaged in compelling it to travel
in the direction of the uterine cavity. From below
we find that the perineal body or pelvic floor by the
constant contraction and relaxation of its muscular
structure produces a wave in the direction of the cer-
vix, hence the spermatozoa are carried along witli
this wave. This function of the perineum is prob-
ably one of the most important factors in holding
the uterus in its normal position. From above the
uterus constantly undergoing some contractions,
must, by virtue of its being hollow, have some suc-
tion power which also aids the spermatozoon in its
uphill travel. In patients who suffer from a general
muscular relaxation these mechanical processes are
greatly diminished with tlie result that conception
does not take place, for in addition to it, we must
not overlook the fact that the wave produced by the
ciliated epithelium lining the uterus is outward, and
certainly must hinder such a minute body as the
spermatozoon from progressing in an opposite direc-
tion.

In patients in whom I suspect this to be the con-
dition my aim is to improve the local muscular struc-
ture, and the method I adopt is as follows: The
patient is instructed to loosen all her bands, particu-
larly the waist bands ; to stand on the floor in an
erect posture, hands elevated above head, feet drawn
together, then take a deep inspiration to be followed
by a sitting posture with body hanging on the knees ;
remain in this position for about five seconds and
then return to the original erect position. This is
to be performed three times daily for about ten
minutes at a time. You can very readily see how this
form of exercise not only acts upon the pelvic floor
but will also indirectly make the uterus and practi-
cally all the abdominal viscera functionate more
properly. This form of treatment I have recently
followed out in a patient who after being married
three and a half years never conceived. She ap-
peared at my office about six months ago. On ex-_
amination I found nothing that seemed abnormal,
her husband also being in perfect health. After fol-
lowing this plan of treatment for about three months
she became pregnant and is now in her tenth week
of pregnancy. In addition to the exercise I gave
her 6 grs. of the black oxide of manganese per day.

Another class of patients who require a good deal
of attention are those women who marry at an ad-
vanced age ; whose generative organs are likely to
have undergone some changes, at any rate they do
not functionate well. This class of patients I in-
struct to have intercouse during the week preceding
menstruation only, when the generative organs are
at the height of functional activity, and therefore
conception is more prone to take place.

In the course of our work we meet a class of
patients in whom the relation of the cervix to the
posterior vaginal wall is changed, due either to
malposition of the uterus, to a large elongated cer-
vix, or to a particularly small vagina. In these con-
ditions correction of the deformity is always the in-
dication, but we are all aware how unkindly such
a suggestion is received, especially if one happens
to be first to give such advice. In these conditions
we must search for some means that will bring the
spermatozoa nearer the external os. This can be

I026

MEDICAL RECORD.

[June 22, 1907

accomplished by advising the husband to have inter-
course with the woman in the knee chest position
at least twice a month during the week preceding
menstruation. You can readily see how the relation
of the spermatozoa with the external os is changed
in the same manner as if the a.xis of cervix had been
corrected by some operative interference. Such ad-
vice certainly does not appeal to one's esthetic senses,
but in the practice of medicine we are very often
compelled to overlook it. This method of treatment,
although very simple, has brought on conception in
two of my patients, one giving birth to a mature
tiable child, while the other aborted in the third
month. One had been sterile four years, the other
two and a half years. I admit that these patients
might have suffered from some slight organic lesion
causing obstruction at some point of the genital
tract, which has cured itself during the interval ; but
from a clinical if not from a scientific standpoint
it certainly cured these patients.

The marriage of near relatives is said to be a
cause of sterility. Personally I do not find this to
be true, and in races where the religion permits the
marriage of near relatives, sterility is not more prev-
alent. On the other hand some of the women are
very prolific.

The lack of sexual desire or the absence of sensa-
iion of pleasure during intercourse are also given
as causes of sterility. Personally I have had no ex-
perience with this class of patients, but I believe that
it is not purely a functional disturbance as is gener-
ally assumed, but that there is some organic lesion
underlying this condition which we at present are
not able to diagnose. Excess of sexual excitement
on the other hand is certainly prejudicial to fertility
in so far as it induces certain pathological results,
such as congestion of the uterus and its appendages,
leading to ovaritis and defective ovulation ; or to
salpingitis and with it to more or less obstruction
to the descent of the ova and ascent of spermatozoa,
or to metritis and with it a tendency to the occur-
rence of abortion.

The organic lesions that cause sterility may be
divided into congenital defects of an irremedial
character and acquired abnormalities. The congeni-
tal causes we may dismiss from our discussion as
at present we are not in a position to improve tlie
condition. The operation of transplantation of a
section of the human dvary is yet in its infancy, al-
though the case of Dr. Alorris has proved success-
ful, but I think that the time is not very far off when
many more authentic cases will be reported. It is
.lot very difficult to diagnosticate these congenital
cases. Usually these patients show a train of
symptoms which are quite characteristic. The mas-
culine appearance, the small undeveloped mammary
glands, associated with an irregular menstrual his-
tory regarding the age of onset, the intervals at
which it appears, the scanty flow and its duration,
all these together with a small vagina, particularly a
short anterior wall, at once establish to my mind the
fact that the patient is suffering from a lack of
development of some part of the genital tract and
mv prognosis is unfavorable.

Of the acquired causes .of sterility the whole
range of diseases of women must be considered. I
shall only touch upon a few. which I believe are
the most important to the general practitioner. I
believe that one of the most frequent causes of both
the complete and relative forms of sterility are the
various leucorrheas, whether specific or not. A
vaginal leucorrhea of a strong acid reaction will
certainly kill the spermatozoa in a short time. I

usually test the degree of acidity with a piece of
litmus paper, and if found markedly acid the indi-
cation of course is to neutralize the secretion, which
is best done by tamponing the vagina with equal
parts of bismuth subnitrate and sodium bicarbonate
on a non-absorbent cotton tampon every other day
for two weeks. The patient is not allowed to re-
move the tampons until one hour before she is sup-
posed to call again. At the end of a short time you
will find the degree of acidity quite changed. It is
necessary that these patients douche themselves
with some mild alkaline fluid, sodium bicarbonate
usually answering the purpose, and in addition to
their general douching a small douche of sodium
bicarbonate must be taken a short time before inter-
course to make sure that the secretion of the vagina
is of an alkaline reaction.

Stenosis of some part of the cervical canal is surely
an important factor, but I believe it is not as com-
mon as it is generally supposed to be. Complete
stenosis cannot exist as long as menstruation takes
place, and if menstrual blood escapes through the
canal the spermatozoa can certainly pass through it.
Clinically I have not seen a case where the os has
been so completely obstructed that I could not intro-
duce a small probe into the uterus. What is usually
associated with a small cervical opening is an en-
docervicitis. It may be of a very mild degree, hardly
perceptible, but enough is secreted by the mucous
membrane to occlude this small opening, making it
impossible for the spermatozoa to pass through.
This condition is verv common, and these are the
patients that we are able to cure. I have operated
on a number of patients for sterility due to this con-
dition with great success. The method I used was
simple dilatation of tlie cervix, scraping it somewhat
if found necessary, and introducing a small intra-
cervical pessarv' whicli I have kept in from two to
three months, removing it when necessary and in-
troducing it again. The pessary prevents the cer-
vix from contracting again and sooner or later the
muscular structure in the cervix accommodates itself
to its new surroundings, with the result that the
canal remains a good deal enlarged long after the
pessary has been removed. If the endocervicitis still
persists, it is very readily cured by intracervical ap-
plications of some astringent ; usually 6 per cent.
solution of silver nitrate will answer the purpose.

The infantile uterus, unless associated with other
conditions, does not cause sterility as often as is
attributed to it. .\ small uterus is only a relative
term. The smallest uterus that I have seen was in
a woman who gave birth to a child and since then
has conceived again.

The various displacements of the uterus with the
probable exception of extreme antefle.xion are sel-
dom causes of absolute sterility. Conception in these
conditions does not take place on account of the
change of the axis of the body of the uterus, but is
due in the majority of cases to a change of axis of
the cervix. It is certainly one of the most important
causes of incomplete sterility and therefore should
be corrected.

Recent investigations by competent observers have
pro^■tn that in the majoritv of cases, inflammatory
processes of the lining membrane of the genital tract
are of gonorrheal origin, and it is a ver\- singular
fact that at times these gonorrheal inflammations
are so mild that the woman is troubled very little,
and the nhysician is not consulted early enough to
prevent further progress of the disease. The Fal-
lopian tubes, if already attacked, will surely cause the
woman to be sterile in the majority of cases. Women

June 22, 1907]

MEDICAL RECORD.

1027

who are apparently normal may fail to conceive
on account of some slight tubal attection which can
only be detected after the abdomen is opened at the
time of an operation. There are two main indica-
tions in the treatment of these patients sufifering
from gonorrheal infection of a milder degree, first
to reduce the existing inflammation ; second to pre-
vent reinfection. In all our therapeutics for reducing
inflammations of the pelvic organ nothing equals
glycerin, if properly used ; glycerin as generally used
in various clinics is absolutely useless. In order that
the patient may derive any benefit from it, large
quantities must be used, a cupful at a time, that will
fill up the entire upper portion of the vaginal vault,
to be followed by a gauze or non-absorbent cotton
tampon to prevent the escape of the glycerin. This
is repeated every other day until the active inflam-
mation or congestion is removed. To prevent rein-
fection intercourse must be strictiv forbidden for at
least six months.

In conclusion I want to say that although with
the lapse of every succeeding year after the third
from marriage, without the occurrence of conception
the prospect of child-bearing becomes less, yet if no
apparent cause for sterility is discovered the patient
should be encouraged to entertain some hope. Any
improvement in the local condition, which time in
itself may rectify, will result in conception. With
our present knowledge of the subject we are not in
a position to make a positive prognosis, for as long
as our diagnosis is not always accurate it follows
that our prognosis cannot be exact, but it is the
duty of every physician to try to convince these
patients that the earlier they carry out the doctor's
advice the more likely are they to be cured, and that
a lapse of a little time may cause permanent sterility.
Personally, from the number of cases I have already
seen, I am thoroughly convinced that gonorrhea in
all its forms is the greatest factor in the production
of sterility, and that if anything is to be done to re-
lieve this condition the education of the future hus-
band must be commenced at an early date, that
parents, teachers, and educators must constantly
point out to the young adult the danger to which
he is exposing himself, his future wife, and prob-
ably the offspring. As long as these dangers are
not realized by the public at large, so long will
sterility be on the increase.

154 Henry Street.

WHAT ARE ACID FASTS?*

By STEPHEN J. M.\HER, M,D ,

NEW HAVEN', CONX.

A FEW years ago Koch himself maintained that the
only bacilli likely to be confounded with the tubercle
bacillus were the bacillus of leprosy and the smegma
bacillus. All the world held with him that when
one had eliminated the possibility that the material
under consideration had been contaminated by the
leprous or by smegma, any slender rod-shaped
germ, one-half or one-quarter as long as a red blood
cell, that retained the fuchsin red after half a min-
ute's decolorizing with twenty-five per cent, mineral
acid was the tubercle bacillus.

An immense amount of time and energy was ex-
pended in elaborating modifications of the ordinary
carbol-fuchsin and methylene blue staining meth-
ods for the purpose of differentiating the tubercle
bacillus from the lepra bacillus in order that the

*Read before the New Haven Medical .Association.
April 3. 1907.

tragic diagnosis of tuberculosis might be free of
every shadow of doubt. The result of all this work
was not entirely satisfactory, but still the profes-
sion had settled back into a somewhat smug con-
viction that since as a rule the smegma bacillus was
more readily decolorized, and the lepra bacillus less
readily decolorized, than the tubercle bacillus, the
microscope was a sufficiently reliable guide.

Nine years ago Petri and Lydia Rabinowitsch
while searching for tubercle bacilli in the butter and
milk of Berlin discovered and isolated a bacillus
which answered the staining requirements of tuber-
cle bacilli, but which did not cause tuberculosis in
injected guinea pigs, and which dift'ered from tuber-
cle bacilli in many cultural ways. About the same
time A. Moeller at Gorbersdorf discovered that a
flask of bouillon into which a few days before he
had put some green timothy grass from his garden
contained a great number of bacilli which in shape
and size and staining were like tubercle bacilli, but
which on isolation seemed to have markedly dift'er-
ent biological characters. These two discoveries
were quickly followed by confirmatory and sup-
plemental findings by bacteriological workers in
various parts of the world. During the last few
years a whole literature has grown up about the
subject, whose importance and interest are every-
where recognized. All these germs which, with the
ordinary staining methods, resemble the tubercle
bacillus are now known in English as "acid fasts,"
in German as "saurefesten Bacillen," and in French
as "bacilles acido-resistants." They have now been
found in so many places and under such dift'erent
conditions that it seems desirable to classify them
according to their various sources :

Class I. — The acid fasts found in nature. Moel-
ler's timothy bacillus is the type of this class. It
or bacilli closely akin to it have been found in hay
and dung and street dust, wherever it has been
looked for, and it has been cultivated from various
kinds of grasses. Moeller has found acid fasts also
in sand, soil, and mold. They can readily be found
in the dust in dark barns and chicken coops. Moeller
claims that in all the researches he has made he
has never found the tubercle bacillus in nature. The
acid fasts he has found have always been the quick-
ly vegetating timothy bacillus or some of its rela-
tions. This timothy bacillus is not distinguishable
from the tubercle bacillus in form, size, or staining,
except in very old cultures when it loses some or all
of its acid resistance. Like the tubercle bacillus it
does not change milk nor liquefy gelatine. It dif-
fers from the tubercle bacillus in that it grows as
much in twenty-four hours as the tubercle bacillus
does in two weeks. It grows also at room tempera-
ture, and does not need sweetened media for its
sustenance. Its colonies vary from a deep vellow to
a brick red or even a rose red, and by a little
sophistication they can be made to grow white or
grav.

Class II.— The acid fasts of milk and butter. How
frequently acid fasts can be found in milk and
butter has been a subject of dispute. They have
been isolated from the butter of Milan by Coggi ;
from the butter of Fribourg-en-Brisgau by Korn ;
the butter of Zurich by Mme. Marie Tobler ; from
the butter of Vienna by Markl : from the butter of
Paris bv J. Binot, and from the milk of Belzig by
Moeller. The technique of finding these acid fasts
consists in injecting the suspected butter or milk
into guinea pigs and after a few days planting the
resulting pus or peritoneal exudate on various cul-

I028

MEDICAL RECORD.

[June 22. 1907

ture media. Lately Rabinowitsch, Grassberger, and
Markl have isolated acid fasts from oleomargarine.

These butter and milk acid fasts often differ from
one another in morphology and in the color of their
cultures and in their resistance to the decolorizing
power of acids and alcohol. Some of them are as
acid fast as the hardiest tubercle bacilli, while others
seem to have no acid resistance unless they have
been cultivated in milk. They all grow best at 37°
C. in from two to five days. All develop slowly
at room temperature except the one isolated from
the milk of Zurich by Mme. Tobler, which usually
does not grow at room temperature.

Class III. — The harmless acid fasts of man.
These consist of the well known smegma bacillus
first described by Alvarez and Tafel in 1885; and
the cerumen bacillus — possibly the same organism
as the smegma bacillus — found by Gottstein in
1886: and the bacilli found by Karlinski in 1901
in nasal mucus in fifteen out of twenty cases ex-
amined ; and the various acid fasts found in come-
dones, in the secretion about the toes, on coated
toneues and teeth, in the tonsillar crypts, and in
saliva by Laabs, A. Moeller, and Rabinowitsch.
Moeller, by injecting smepma bacilli under his own
skin, was able to procure a pure culture, and Lazer
and Czaplewski have, according to Cornet, been
able to grow the smegma bacillus on agar mixed
with human blood. Karlinski, himself, has recently
shown that his bacillus is the same organism as that
isolated from butter by Petri, Rabinowitsch, and
Korn. The others have not been grown in pure
culture. The fact that they do not cause lesions
when injected into guinea pies of course offers a
reliable method of differentiating them from the
tubercle bacillus.

Class IV. — The pathogenic acid fasts of man
and beast. The tubercle bacillus and the lepra ba-
cillus are the most important of this class, but their
consideration is not within the scope of this paper.
Stefansky has described a short acid fast bacillus
that he found in the giant cells of the rats of Odessa
sick with a disease that looked like leprosy, but
he was not able to infect guinea pigs or other rats
with injections of this organism. In 1900 A. Moel-
ler made an interesting find in the depths of the
tuberculous nodules on the breasts of cattle and
hogs. He isolated and cultivated a beautiful acid
fast rod larger than the bovine tubercle bacillus,
which grew at 18° as well as at 37°. At th.e latter
temperature the culture reached its full develop-
ment in twelve hours. This bacillus is very patho-
genic for guinea pigs, but kills them on hypodermic
injection, as do so many other of the acid fasts,
without anv signs of the development of tuberculo-
sis. Moeller claims that if it be mixed with butter
before injection, this bacillus will cause the for-
mation of true tubercles in guinea pigs. Potet re-
peated the experiment and failed to get any nodules
in his guinea pigs. Nobody has yet been able to
cultivate the true Hansen bacillus of leprosy, but
many workers have isolated and cultivated from
the leprous nodes a bacillus that grows well at room
temperature, is poorly acid fast, and in old cultures
loses entirely its power of resisting acid. It is im-
portant to remember these two findings, for they
have been and thev still are the foundation for
many attempts at explaining the acid fast prob-
lems.

When acid fast bacilli are found in great num-
ber at or near a seat of disease in human beings
not sick with tuberculosis they have been until re-
cently considered to be smegma bacilli, but as smeg-

ma bacilli cannot be grown on ordinary media, and
as in many cases these other bacilli have been readily
isolated and cultivated, much discredit has lately been
thrown on the old, simple classification. For in-
stance, acid fasts, not tubercle bacilli, have been
found on the surface of chancres and mucous
patches by Lustgarten ; in gonorrheal pus by Lazer
and Czaplewski ; in urine of the syphilitic by Rap-
pin and Hernot ; in a suppurating ovarian cyst by
Dietrich ; in the urethra of a woman suffering from
a post-partum ascending pyelonephritis by Stolz;
in two cases of panophthalmia showing non-caseous
giant cells in the nodules in the retina and iris by
Ginsberg; in the sputa of a patient suffering from
a disease that clinically seemed to be tuberculosis,
but whose autopsv revealed no tubercles, by Zalin ;
in a case of bronchial dilatation by Melchner; in
acute bronchitis by A. Moeller. Of course there is
no satisfactory proof that in any of these cases
the acid fasts were the cause of the diseased con-
ditions, in which they occurred.

Rannin three years ago isolated from the filtering
beds of the water system of Xantes an acid fast
streptothrix which was feebly pathogenic for labo-
ratorv animals. Flexner has reported a case in
which the patient had all the symptoms of tuber-
culosis and post mortem had nodules in lungs, liver,
and peritoneum that contained no giant cells, but
did contain a beautiful acid fast branching strepto-
thrix.

In non-tuberculous gangrene of the lung acid
fasts, some resembling the smegma bacillus |nd
some the Rabinowitsch butter bacillus, and others
having only- a slight resistance to acids, have been
found by various observers, Folli, Ophuls, Pap-
penheim. Benenuto, and Fraenkel. Klein of Am-
sterdam and his assistants claim that from prac-
tically all cases of pleurisy thev are able to cultivate
acid fasts closely resembling tubercle bacilli, but
having much less, and often no pathogenic power
for guinea nigs. ?ilany other workers, Besan<;on,
Grififon, Philibert, have found acid fasts, probably
not tubercle bacilli, in serous effusions and in blood
clots.

In view of all these facts, how shall we differen-
tiate the tubercle bacillus from the other acid fasts?

Xot by its staining reactions alone. Many of the
others are just as resistant to the decolorizing
power of nitric, sulphuric, or acetic acid, or alcohol,
as the most typical tubercle bacillus. And the tu-
bercle bacillus can be deprived of most or even all
of its acid resistance, as has been conclusively proven
b}- Arloing and Courmont and bv Auclair. Again
such common bacilli as the anthrax and subtilis,
it grown on agar to which butter or fat has been
added, take on a waxy capsule that makes them acid
fast. (Flexner. Brenstock, Gottstein, and Gibier.)
I have reneatedly conferred acid fast properties on
a large proportion of Klebs-Loefiler bacilli by sim-
plv growing them for two weeks at room tempera-
ture in equal parts of sugar bouillon and normal
salt solution.

I treated a patient last year with signs of apical
and laryngeal disease who for several months ex-
pectorated an almost pure culture of pseudo-Klebs-
Loeffier bacilli until I gave her some intracheal in-
jections of sterile oil and ordered her to use this
oil in an atomizer. Then I began to get specimens
that contained what apparently were tubercle bacilli.
When the treatments with oil were stopped the acid
fasts disappeared from the spittle. The experiment
was repeated later with the same result.

Xot by the form alone. The shape and size of

June 22, 1907]

MEDICAL RECORD.

1029

the tubercle bacillus vary greatly according to its
age and environment from short rods, almost cocci,
to actinomycotic branches. Many of the other acid
fasts are morphologically identical with the tubercle
bacillus.

Not by the appearance of the cultures alone.
Usually the other acid fasts have more chromogenic
power than the tubercle bacillus, and their cultures
are usually more moist. But the tubercle bacilli
transplanted on to solid media from homogeneous
fluid cultures develop in moist creamy heaps like
many of the other acid fasts.

Courmont exhibited at the last international con- .
gress cultures of human and avian tubercle bacillus,
some red and some yellow, exactly like many of the
butter and grass bacilli.

Not alone by the determination of the tempera-
ture necessary for growth. The tubercle bacillus
usually will not vegetate on ordinary media below
37° C, whereas most of the acid fasts will develop
slowly at 18°. Nevertheless, even on ordinary
media, the tubercle bacillus, by careful cultivation,
has been led to grow below 30°, and the bacillus
of fish tuberculosis grows at much lower tempera-
ture. The tubercle bacillus of human type injected
by Moeller into slow worms and frogs and after-
wards recovered from these animals was found to
grow luxuriantly at room temperature and poorly
or not at all at 37°. I have grown these slow worm
and frog tubercle bacilli many times on various or-
dinary media, not onlv at room temperature, but
exposed during all their period of vegetation in the
bright light of the laboratory windows.

Not alone by agglutination tests. Courmont and
Descos claim, that the serum of tuberculous animals
fails to agglutinate many of the acid fasts and that
the serum of animals injected with acid fasts fails
to agglutinate the tubercle bacillus. But they also
admit that many strains of even homogenized tuber-
cle bacilli are not ap'p'lutinated by the serum of
tuberculous patients. Koch, Moeller, Nobele and
Beyer, Becker and Rabinowitsch, have held that all
the acid fasts are agglutinated by the serum of the
tuberculous.

Not alone by consideration of the lesions pro-
duced in guinea pigs. Of course, ordinarily there is
a marked difference. The tubercle bacillus pro-
duces tubercles, and when recovered from these
tubercles can be again injected and again recovered,
and so on, indefinitely, whereas the acid fasts usual-
ly produce onlv a local abscess with or without en-
larged glands and acute septicemia when injected
under the skin, and a general peritonitis when in-
jected into the peritoneum. The mixing of the
acid fasts wdth butter before injection intensifies
their pathogenic power.

Nevertheless, Moeller, Korn, Mayer, and Lubarsh
caused the development of true tubercles with giant
cells in guinea pigs injected with the timothy or
Korn bacillus, and Abbot and Gildersleeve and
Schultze have shown that the intrarenal or intra-
venous injection of the timothy bacillus into rabbits
causes the production of true tubercles with giant
cells. As I reported last year, I have been able to
produce tuberculous nodules in rabbits by the in-
traperitoneal injections of acid fast rods and cocci
developed from Baccillus mycoides and to cause
other tubercles in a second series of rabbits by in-
jecting the recovered acid fasts into the second
series. Courmont and Descos have produced a gen-
eralized tuberculosis without giant ceils by inject-
ing small doses of Binot's bacillus into a dog.

On the other hand, the tubercle bacilli of the
homogenic cultures of Courmont can be entirely
deprived of their power to produce tubercles on sub-
cutaneous injection.

Practically one must, here as in most other diag-
noses, consider not only one, but all the facts of
the problem in order to decide wisely whether or
not the bacillus in question is the tubercle bacillus
or one of the less important acid fasts.

The subject of the relationship of the tubercle
Ijacillus to the other acid fasts, and the arguments
that have been advanced for and against the theory
that tubercle bacilli are merely saphroph\tic acid
fasts which have evolved special characters neces-
sary for their existence and growth in animal cells,
I refrain from discussing to-night. It is too big a
subject, and it demands much more study before
one man's opinion of it will be worth more than
the opinion of any other man.

212 Orange Street.

RE:\rARKS ON THE TREAT?>IENT OF DIS-
EASE AND SO-CALLED "AUTHORITIES."

Bv GEO. F. BUTLER. M.D..

PROFESSOR A^^D HEAD OF THE DEPARTMENT OF THERAPEUTICS AND

PROFESSOR OP CLINICAL MEDICINE. CHICAGO COLLEGE OF MEDICINE

AND SURGERY (MEDICAL DEPARTMENT. VALPARAISO UNIVERSITY).

"M.VSTERY of all the sciences upon which medicine
is founded does not make the physician. He would
he helpless without them, but he is worse than help-
less with them until he learns how to use them,
how to construct out of them the special art which
enables him to cure disease." So said Draper, and
never was there a truer utterance. Yet there are
men in the profession — men who like to be looked
upon as authorities in medicine — who belittle thera-
peutics and oppose nearly every therapeutic sugges-
tion not offered by a member of the "Four Hun-
dred."

I believe, however, that the great majority of
practising phvsicians heartilv endorse the words of
the late j. Milner Fothergill. M.D., M.R.C.P., who
said in the very first paragraph of "'The Practition-
er's Handbook of Treatment" : "The ultimate aim
of all medical research is the treatment and preven-
tion of disease. It is eminently desirable that a
medical man should be generally well informed : but
what is to be still more devoutly wished for is
that he should be a skilful practitioner. It is quite
possible to be the one without being the other. The
combination is what we hope to see accomplished.
The tendenc}' of modern medical teaching has been
rather to produce the first, leaving the second qual-
ity to develop itself, or to remain in a condition of
imperfect evolution, ^^'e constantly hear it asserted
that the highly educated medical men of the pres-
ent generation are not more, successful in practice
than their less accomplished but more practical
predecessors. Even members of the profession
are to be found who assert that the man under
whose treatment they would place themselves, if
seriously ill, is the old-fashioned general practi-
tioner. This is a serious reproach to our recent
advances in scientific medicine ; to our modern in-
struments of precision in diagnosis ; and even to
our progress in rational therapeutics, in late years."

With the marvelous progress in diagnosis, and
under the influence of the German school, we have
come to attach, not perhaps an exaggerated import-
ance to diagnosis, but an importance which has re-

1030

MEDICAL RECORD.

[June 22, 1907

suited in placing therapeutics in a very subordinate
position. It is all very well for a patient to feel
that his medical man is a skilful diagnostician, but
the essential thing after all is confidence in his power
to aid him when stricken and prostrated by disease
or accident. It will occur to the minds of most
men that the physician's principal duties are to
prevent and cure disease. "The real physician,"
said Rroussais, "is the one who cures ; the observa-
tion which does not teach the art of healing is not
that of the jjhysician, but of the naturalist."

Wc sl'.ould do more than classify diseases, as a
botanist might sort and classify plants and attach
to them their proper names. We are dealing with
human beings, not some dried specimens which we
laliel and place in their proper places in a herbarium.
Although I sometimes think there are many ultra
scientific physicians who would prefer to confirm
their diagnosis by an autopsy, and preserve some of
the pathological specimens than to assist the patient
to recover when the diagnosis is in doubt.

I remember a story told by "Uncle" Allen, for-
merly president of Rush Medical College. He was
being shown through a large pathological labora-
tory in Paris, and was wearied looking at shelf after
shelf loaded with pickled specimens of organs and
tissues from people long since dead. .\t last he
turned to the great pathologist and said: "Great
God ! Where are the people you have cured ?"

To prevent and cure disease is the physician's
actual business in life ; and it is here that success
is most to be desired. Our success is measured by
our ability in this direction, for the public cannot
be expected to estimate us by any other measure than
that of our usefulness. Even Dr. Osier, who is not
much of a believer in therapeutics, says : "There is
no one measure which can compare with the de-
crease of physical suffering in man. woman, and
child when striken by disease or accident. This
is the one fact of supreme personal import to every
one of us. This is the Promethean gift of the cen-
tury to man."

We should not look upon each patient who calls
upon us for aid as a "case" of this or that "dis-
ease," of interest only as the victim of some morbid
process furnishing us an opportunity to demonstrate
our diagnostic skill, but as a suft'ering human being
possessing the attributes of humanity collectively,
together with some variations which form individual
peculiarities, and who should be relieved if in our
power to relieve him. Shall we be so "scientific"
that wc shall refuse to treat symptoms because we
may be unable to name the "disease," or because,
for instance, the patient is suffering from pneu-
monia, or some other acute, self-limiting disease,
so called?

It is rarely possible to destroy the cause of dis-
ease. In the majority of diseases, perhaps, it is
impossible to overcome or remove the cause, but
we can counterbalance many of the primarv eft'ects.
For example, since we are unable to dissolve a
urinary calculus, we must endeavor to annul the
spasm and the pain which are due to the presence
of the calculus, and by proper diet and therapv do
something, not against the calculus itself, ' but
against the causes which have made it grow. Al-
though we cannot make new heart valves out of
imperfect ones, nor rarely restore a degenerated
heart muscle, we can by proper treatment relieve
the symptoms resulting from failing compensation.
We often see certain symptoms accompanied by
certain others, and we observe, in general, a constant

succession in certain groups of symptoms. Disease
is nothing but a new manner of being of the or-
,gans, v.'hich present either new phenomena or dif-
ferent modalities of normal ones. Herein lies the
difl'erence between clinical medicine and pathology:
The latter shows us the species and genera of dis-
ease; the former compels us to bear in mind that
it is not a disease, but diseased persons, with whom
we have to deal.

The morbid phenomena determined by numerous
and different conditions vary unceasingly, according
to the varying combinations of these conditions ;
it is, therefore, impossible to refer diseased condi-
tions to certain types which shall be invariable and
uniform. If all individuals had organs constituted
in the same manner, and endowed with the same
dynamic energ}-, if climacteric conditions were the
same for all, and all could be subjected to the
same physicopsychical life, the same perturbation
would then produce the same effects in all, in the
same invariable order of succession. In such a
case there would be as many diseases as there are
varieties of initial perturbations, and they could be
classified as one classifies chemical reactions.

Indeed, no less an "authority" than a Committee
of the Royal College of Physicians, London, has
arbitrarily given us a grand total of one thousand
one hundred and forty-six (I wonder they didn't
make it an even fifty) variations from health as
making up the conditions and the phenomena of
disease to which the human family, at this period
of its civilization, may be subjected. And to these
"diseases" have been given grotesque and fantastic
names, as if they were entities, or individuals. In-
deed, we rather look upon them as personalities.
"Pneumonia attacked him." "He had an attack"
of this or that. It is like a "footpad" "attacking"
one. A classification of diseases, of some sort,
however, has an advantage : it is, that the presence
of certain symptoms and signs leads us to anticipate
others, and that their order of succession reveals
to us the existence of latent perturbations, as well
as the nature of the causes which have aroused
them.

Disease is made up of morbid symptoms and ef-
fects. But the relation of causality and dependence
which unites these elements often requires that a
system of treatment should take cognizance prin-
cipally of symptoms, not so much on account of the
value of the symptom in itself, as on account of the
symptoms which depend upon it, and the morbid
eft'ects which it may produce,

Every symptom represents a constituent element
of disease, but all symptoms have not the same
hierarchical value, and do not all deserve to be
placed in the class of morbid elements. In annulling
a symptom one does not confine himself to destroy-
ing its effect, and to simplifying the morbid condi-
tions, for by this means many others can be avoided,
which would naturally and physiologically follow
from the existence of the one which was to be sup-
pressed. Symptomatic therapeutics is, therefore, in
my opinion, not only curative of a portion of the
disease, but preventive besides, of ulterior morbid
phenomena, complications, and aggravations.

If we are called to treat a sick person, our first
thought should be to discover the cause of the dis-
ease. That cause, when discovered, will be either
still in existence or will have passed away. If it
still exists we must do our best to destroy it, to
neutralize it. or to prevent its results. If the orig-
inal cause has disappeared or if it is not amenable

June 22, 1907]

MEDICAL RECORD.

to treatment, we can not operate upon it, but we
can and should direct our ettorts upon its results.
These results may be primary, secondary, tertiary,
etc., and it will be our duty to fight them, choosing
for particular attention ones which are the most
grave, the most perturbant, and the most insup-
portable.

By drugs alone we can restore some of the normal
constituents of the blood when they are defective ;
we can remove abnormal substances present in the
blood, and if we have reason to suppose that the
products of imperfect metabolism are present we
can greatly facilitate their excretion by the kidneys
and bowels. We can antagonize and destroy the
effects of certain toxic matters w-hich cause dis-
ease. We can mitigate or limit both external and
internal inflammations. We can act, for example,
on the inflamed mucous membrane of the bladder
by sedatives, or stimulating germicidal substances ;
we can also influence the lining membrane of the
tubes of an inflamed kidney. We can increase se-
cretion in the neighborhood of an inflamed part,
and can alter the general tension of the vascular
system. The local vascular condition can be mod-
ified by dilating vessels in adjacent parts, and we
can exercise a sedative influence on the mechanical
conditions affecting an inflamed part. It is thus
that morphine is used in peritonitis.

The products of ordinary inflammation w^iich in-
terfere with the functions of tissues may, when
consisting of cell growths, be broken up and ab-
sorbed under the influence of mercury and potas-
sium iodide, as the products of syphilitic inflamma-
tion certainly are. There is reason to believe also
that we can cause the absorption of inflammatory
deposits by stimulating the nerve endings in adja-
cent areas. Arsenic can be shown to have a very
decided effect on the nutrition of the skin, and it
often distinctly influences inflammatory deposits
therein.

Drugs such as chloral, atropine, physostigmine,
and strychnine act on the tissues of certain parts of
the brain and spinal cord, and thereby increase or
decrease the functions of those parts. We can de-
press the functions of the motor nerve endings with
conine, and the sensory nerve endings with aconi-
tine. We can paralyze the involuntary muscle fibers
directly with the nitrites or indirectly with chloral
hydrate, drugs which depress the functions of the
vasomotor center. In valvular affections of the
heart we cannot remove the chief pathological con-
dition, but by acting on the cardiac muscle and its
ganglia we can so strengthen and moderate the beat
as practically to restore its normal function. We
can stimulate or depress the tissues of the various
glands. We can improve the nutrition, and there-
fore the function of almost all the tissues. I might
go on for almost an indefinite period telling what
can be done in the treatment of disease. In short,
we can do as much with our medical cases as sur-
geons can do with surgical cases. Yet surgeons,
as a rule, and many so-called authorities among
medical men belittle therapeutics.

With the evolution of medicine from fetichism,
medicine developed into lay and clerical practice,
the ecclesiastic being forbidden to shed blood, nat-
urally tended to internal medication, while surgery
became the province of the layman. This separa-
' tion of the branches of the profession led to the
surgeons being affiliated with the barbers, while
the internal medicine men became apothecaries and
through plutocratic influences were at one time affil-

iated with the grocers. Through this evolution, the
mutual contempt of the cleric and the layman per-
sisted. As the search for truth became the object
of the medical man, surgical and medicinal thera-
peutics as the end of medicine sank into the back-
ground and were overshadowed by diagnosis. Un-
der this principle receipt-book therapy gave way to
the science of internal medicine. The physician
then appeared and drove commercial quackery from
both surgery and pharmacy. The gap that had been
created between the two branches of the healing
art is w-ell illustrated in the chaotic titles given in
England to medical men. There are members of the
colleges of physicians and surgeons and licentiates
of the society of apothecaries practising side by side
with AI.D.'s. Surgery dominated for awhile thera-
peutics and led to the abuses of venesection. Of
necessity surgery adopts either the wild reflex
theory or the equally abused gross lesion, these two
being the most profitable from the monetary stand-
point. It requires less diagnostic skill and less
scientific acumen to discover a gross lesion or a
refle.K disorder than it does to find remediable de-
rangements of physiological balance. The gross
lesion and the reflex have a good deal of the me-
chanical principle of the nickel-in-the-slot machine.
The body on this principle is not a delicately bal-
anced mechanism, but an appendix to some of its
organs, removal of which or of a gross lesion in
which will create recovery. The surgeon ignores
the metabolic changes produced by an operation
irrespective of its seat. He owes his mimunity from
malpractice and other serious consequences be-
cause medicine has found for him antiseptic^ and
anesthetics. This gift of medicine has been notor-
iously abused for the benefit of the surgeon. Per-
haps no greater evidence of this can be found than
the marked change which has occurred in the posi-
tion of the greater surgeons toward oophorectomy
and allied genital surgery performed for nonsurgical
reasons. From the outset of Battey's operation it
wqs opposed by neurologists and internists as dan-
gerously and brutally useless. This position is ac-
cepted by all great surgeons, although for years
the evil results of oophorectomy were suppressed
by "authority."

Authority in medicine, as in science, does not ex-
ist. No man in science is justified in claiming aught
that will not be supported by control experiments.
"Authorities" are men who have written textbooks
most of which are antiquated when they appear
and most of which are published througli favor.
For this reason the courts will not receive any book
as authority, regarding it as a mere expression of
individual opinion. The scientific spirit of the day
disclaims as false and misleading authority which
will not submit to test and criticism of its truth.

The self-constituted authorities in medicine have
opposed every advance in therapeutics, e\ery rem-
edy, every method. The introduction of such valu-
able drugs as cinchona, colchicum, mercury, and
nearly all our indigenous drugs encountered violent
opposition by the alleged "authorities" of the reg-
ular school. So-called physiologic therapeutics, such
as electricitv. massage, hydrotherapy, were first
used by "irregulars" and opposed by the "author-
ities." And only when they were forced to recog-
nize their value did they "get into line." Even
"suggestive therapeutics" and hypnotism, now rec-
ognized as valuable, were once denounced a= un-
scientific and "quackish" by the "authorities." It
is a strange irony of fate that resuscitates with

I03-:

MEDICAL RECORD.

[June 22, 1907

honor a discovery once buried in disgrace. iMesnier
published his theory of animal magnetism in I775-
Ten \ears later the F"rench Government appointed
a commission composed of eminent physicians and
savants ("authorities") to investigate his system;
an adverse report brought irretrievable disrepute
upon its author, and Mesmer returned to Germany
to perish in oblivion. To-day his apotheosis is
sealed in the generally admitted fact of the power
of one mind over another, and in hypnotism is rec-
ognized a positive therapeutic force. Strangest of
all, th.e very nation which laughed to scorn the early
promulgator of this mysterious agency, but lately
claimed its most ardent advocate — Charcot.

"The world moves" in medicine as in other things.
The treatment by drugs becomes more simple and
direct every year ; in place of the old unreliable
Galenical preparations, the active principles used
with definite intention and a distinct aim to produce
a certain effect, are being generally employed by
"up-to-date"' practising physicians. The raison
d'etre of the bulk of the Pharmacopoeia has passed
away. The active principles are now being recog-
nized as the fixed stars in the firmament of medi-
cine, around v.-hich a multitude of inferior lights
revolve in various subordinate relations. To these
remedies of unvaried and uniform strength we may
trust implicitly. Contrast with these the alarming
acray of nauseous, unreliable mixtures, recom-
mended from week to week in the department of
"Therapeutics" in the Journal of the American
Medical Association. Yet the erudite editor of the
above-named journal and its corps of pharmacists
constituting the Council of Pharmacy and Chemistry
of the -Vmerican Medical Association, together with
a few bacteriological enthusiasts and profes-
sors assuming an omniscience prompted by lim-
ited experience, assume to dictate to the great body
of active practising physicians what they should
and what they should not use in the treatment of
the sick. These "authorities" look upon alkaloidal
medication as a menace to humanity. The learned
"Council" says that up to date there are 250 odd
preparations we may use. Of these there are but
sixty American products and twenty-three of these
are from one manufacturer. No active principles
are mentioned — to me a very significant fact. If
we use a remedy not "passed" upon or endorsed
by these "authorities," we are considered to be "un-
scientific," if not an actual menace to the people
generall}'.

Not infrequently we find that certain "profes-
sors," to say nothing of editors of medical journals
and pharmacists, are men of restricted observation
and not nearly so well versed in clinical experience
as the average doctor who is actively engaged in
bedside practice.

The time has passed when a few men can suc-
cessfully set themselves up as authorities, or dic-
tators, or arrogate to themselves any special theory
or procedure. Candid practitioners to-day recog-
nize good in all systems based upon scientific
thought and pursued with intelligence and sincerity.
By means of release from the shibboleths of the
past, and adherence to a given "authority" or
"school" the freedom of present practice is greatly
enhanced, to the immense benefit of the patient and
the lasting honor of the physician.

I cannot too strongly deprecate any tendency to
discord and contention among a body of men to
whom is accorded the highest privilege decreed bv
the genius of science — that of alleviating human

misery. Whenever the physician's range of study
and practice becomes limited by prejudice, or nar-
rowness of intellectual vision, he falls below the
standard set by the canons of Christian sympathy
and the dictates of steadfast devotion to the amplest
interpretation of his calling.

ABNORMAL RESPONSE TO AN IRRITA-
TION OF THE MOTOR AREA
OF THE BRAIN.*

By ALFRED GORDOX. M.D.,

PHILADELPHIA.

ASSOCIATE I.N' NERVOUS AND MENTAL DISEASES. JEFFERSON MEDICAL

COLLEGE. EXAMINER OF THE INSANE AT THE PHILADELPHIA

GE.VERAL HOSPITAL.

The present contribution is for the purpose of plac-
ing on record a very interesting and curious obser-
vation concerning an abnormal response to an irri-
tation of the motor area of the brain.

It is a case of Jacksonian epilepsy in a boy of
sixteen. At the age of twelve he began to have
convulsive movements which from the beginning
up to the time of the operation have been confined
to the arm, neck, and face, on the left side. He
never lost consciousness, and always witnessed the
seizures. At first they would occur once a month,
but later they became more frequent.

The patient's general condition was fairly good.
In view of the strict localization of the symptoms,
an exploratory operation was decided upon. A
large osteoplastic flap was made on the right side of
the cranium and the largest part of the Rolandic
area was exposed. Dilated and tortuous veins, re-
minding one of angiomatous blood-vessels, were
found over the upper part of the uncovered area,
but the corte.x appeared normal.

Dr. Da Costa, who performed the operation, put
a number of ligatures on these dilated blood-vessels.

For the purpose of studying the e.xact localiza-
tion of tlie motor area, I decided to irritate the cor-
tex with a faradic current.

The unipolar method was used, as advised by
Sherrington and Griinbaum. The blunt end of a
very small metallic electrode was covered with a
very thin layer of absorbent cotton, and during the
procedure was carefully and very superficially ap-
plied to the cortex. An extremely small current
was used. Every time the electrode would touch
the brain tissue, contractions would be noticed on
the same side. Application to the upper angle of
the exposed area would produce distinct contrac-
tions in the arm and very slight in the leg; when
the electrode was applied to the middle area, the
arm alone would twitch and faradization of the
lower angle brought on contractions of tlie arm,
neck, and face. The remarkable phenomenon was
the fact that at no moment convulsions or any
twitching was noticeable on the left side. Inci-
dentally I may add that the application of the elec-
trode was made on the ascending frontal convolution
as well as in the fissure of Rolando, and on the
ascending parietal convolution. While the response
was decidedly marked upon irritation of the as-
cending frontal, it was much less pronounced when
the ascending parietal was faradized. Neverthe-
less, irritation of the latter gave some twitching of
the extremities. I wish also to mention that, in
view of the well-known precaution indicated by
Griinbaum and Sherrington, the application was

*Read before the Philadelphia Neurological Societ>-,
April 23, 1907.

June 22, 1907]

MEDICAL RECORD.

1033

first made to the ascending parietal, and only tlien
to the ascending frontal.

The striking feature in this case is the muscular
contractions on the same side where the motor area
was irritated. The only explanation, in my judg-
ment, is an anomaly of the pyramidal tract. There
are two kinds of abnormal arrangements of this
tract. One is a bilateral absence of decussation : the
crossed bundles are wanting on both sides of the
cord, and the pyramidal bundles are represented by
very enlarged Tiirck's columns. This is a very
rare occurrence. The other is a unilateral absence
of decussation ; the crossed bundle is absent only oh
one side ; the pyramid has never been divided, and
forms one large bundle of direct fibers. This is
also not frequent.

As the opposite hemisphere in my case was not
exposed, and therefore not experimented upon, it
is diflicult to say which of the two anomalies may
be the cause of the unusual phenomenon. All mam-
mifera possess a decussation of nvramidal bundles
except the elephant, but in man it is extremely rare.

1430 Pine Street.

A CASE OF MULTILOCULAR GLANDULAR
CYSTO^L\ COMPLICATING PREG-
NANCY.*

By B. S. TALMEY. M.D.,

NEW YORK.

GYNECOLOGIST TO THE YORKVILLE HOSPITAL, FORMER P.^THOLOOIST TO

THE mother's and BABIEs' HOSPITAL.

Mrs. M., 24 years of age, mother of three chil-
dren, was always healthy. Her menstruation was
always regular since her fourteenth year. Five
weeks previous to her coming to my office she had
given birth to a healthy child, the labor having been
perfectly normal, assisted only by a midwife. The
patient was able to sit up in bed three days after
her confinement, and a week later she left her bed
and attended to her regular duties. Five weeks
after her confinement the patient was suddenly
seized with acute violent pains in the right inguinal
region, extending to the back. The physician called
in thought of appendicitis and advised the patient
to go to New York to be ready for an operation.

Upon her arrival in New York she consulted
Dr. M. Cisin, who felt a tumor in the pelvis, which
appeared to be the subinvoluted uterus, and he sent
the patient to me for treatment.

At the examination on September 16, 1906, I
found the patient to be a well-nourished woman, the
face somewhat flushed and respiration quickened.
She was suffering from constant pain, mostly in the
back, but not so excruciating as on the first dav of
the attack. The abdomen was somewhat enlarged
and tympanitic. The entire lower abdomen was very
sensitive to the touch. The combined examination
showed the tumor to be distinct from the uterus,
which was in a normal position, the tumor lying
higher up on the right side. It was composed of
several lobules of varying consistencv and size.
Some of them showed distinct fluctuation, others
were soft to the touch, while the rest was of a solid,
hard consistency. My diagnosis, therefore, was
multilocular glandular cystoma of the right ovary,
and I recommended an operation. Two days later
the patient was seized with another attack, with
almost unbearable pains in the back and in the right
inguinal region, and she then entered the hospital.

The abdomen was greatly distended and tympan-
itic, with ascites on both sides when the patient was
lying on her back. The pulse was now 1 10, the tem-
perature 102° F., and the patient showed symptoms

*Read before the Medical Society of the County of New
York, March 25, 1907.

of a beginning general peritonitis. The diagnosis
was "torsion of the pedicle of the cystoma."

The next morning, September 19, the patient was
operated upon, with the usual incision in the linea
alba. Upon opening the peritoneal cavity about a
quart of a bloody fluid escaped, so that the assist-
ants at the first sight exclaimed "extrauterine gesta-
tion." The tumor was now freed from its bed and
brought forward to the abdominal opening. It was
of the size of a child's head and could not pass the
comparatively small incision until I perforated the
longest cystic lobe and allowed the amber colored
serum to escape. The entire tumor was thereupon
brought outside of the abdominal incision, wdien it
was found that the long pedicle was twisted, having
two corkscrew turns and causing gangrene of some
parts of the tumor. The pedicle was now com-
pressed with the angiotribe, ligated, and the cystoma
excised. The stump was thereupon covered with
peritoneum by embedding it beneath the ligamentum
latum, after Segond's method.

The examination of the tumor showed a number
of dififerent lobes, two of tliem were cystic in char-
acter, containing a clear amber-colored fluid, one
lobe enclosed in its cavity a gelatine-like mass and
another one had a very stnall cavity with tliick
fibrous walls, containing calcareous incrustations on
the interior surface. Some lobes were almost solid.
The entire tumor w'as, therefore, unmistakably a
multilocular glandular cystoma of the ovary.

The case is interesting from the point of view
of the previous delivery. The patient was confined
by a midwife without any artificial aid, and a few
hours after the labor pains had begun, five weeks
previously. Yet she had within her abdomen a
tumor of the size of a child's head. For it is scarcely
probable that the glandular cystoma had materially
increased within the last few weeks after the con-
finement. The only explanation why this large tu-
mor did not cause any dystocia is that the rising
uterus gradually raised the tumor above the pelvis.
Thus the location of the tumor at the time of de-
livery was high above the pelvic rim and did not
interfere with the child's head. After the confine-
ment the normally involuted uterus dropped back
within the small pelvis and with it also the tumor,
the latter now being located in the right pelvic fossa,
directly upon the muscles ischio-coccygeus and
coccygeus. In this position the torsion of the pedicle
is not to be wondered at. The two attacks coincided
with the two turns of the pedicle.

The historv of this case shows that even large
tumors do not always cause dystocia. In Niebergall's
case* of a fibroid complicating pregnancy a spon-
taneous delivery also took place after the tumor was
raised out of the pelvis in the seventh month of
pregnancy. In Pollosson's casef a dermoid cyst was
diagnosed during the first pregnancy and its re-
moval advised. This pregnancy ended with an abor-
tion in the fifth month. But the second and third
pregnancies terminated normally and only during
the third month of her fourth pregnancy a torsion
of the pedicle took place, and the patient had to be
operated upon.

Such cases serve to show that even large tumors
complicating pregnancies are not always an indi-
cation for the removal of the tumor during the pe-
riod of gestation, thus endangering the lives of
mother and child by the complication of a possible
miscarriage.

62 West One Hundred and Twenty-sixth Street.

*Xicbergall : Cor. Bl. f. Schweitz. Aerzte, 1905, p. 525.
tPolIosson; Lyo)i Med., 1905, p. 1085.

1034

MEDICAL RECORD.

[June 22. 1907

Medical Record.

A Weekly 'Journal of Medicine and Surgery.

THOMAS L. STEDMAX. A.M., M.D., Editor.

PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.

New York, June 22, J907.

ARE THE SETTLERS UF WESTERN CAN-
ADA DOO^IED TO FAILURE?

A FEW years ago little was known of the Canadian
provinces to the west of Manitoba, and indeed of
Manitoba itself, and all this vast region was thought
of only as a frigid waste from which came the cold
waves which periodically sweep across the United
States, carrying frost into Texas and even to the
orange groves of Florida. But lately it has been
found that that country is one of exceeding fer-
tility, the richness of soil and the brightness of
sunshine combining to make it admirably adapted
to the growing of wheat, despite the pitiful brevity
■of its summer. A migration of large proportions has
been setting in from the United States and Europe,
and this region now promises to become one of
the great granaries of the world. The cold of win-
ter is long continued and intense, but the heat of
summer is ample in intensity and duration for the
ripening of grain, the soil is rich, and the unoccupied
land is of almost limitless extent and capable of sup-
porting a very large population, so that the pros-
perity of this new territory would seem to be as-
sured. There is but one cloud overshadowing this
hoped-for prosperity, and this is, to abandon the
language of metaphor for that of fact, the absence
of cloud. The country is one of almost continuous
sunshine, the brilliancy of the light equaling that of
the tropics, and if it is really the light rather than
the heat which bars tropical lands to the white man,
as ^^"oodruff contends, the prosperity of the Cana-
dian Northwest promises to be shortlived.

As those who have read Major Woodruff's inter-
esting book* know, he holds that the failure of the
white races to colonize the tropics is due, not to the
heat of these regions, but to the excess of light which
there prevails. The Europeans who have been most
successful in colonizing tropical regions, that is, who
have themselves peopled the colonies and not merely
ruled them by a constantly changing stafif of officials,
are the natives of the Iberian Peninsula, a dark-
skinned race ; and to blonds, Woodruff asserts, trop-
ical lands are fatal. If it is the heat rather than
the light that is injurious, the white man should
prosper more than the black man, and the blond
more than the brunette, since the presence of pig-
ment in the skin distinctly favors the penetration
of the heat rays. But the white man, especially

*The Effects of Tropical Light on White Men. by Major
Charles E. Woodruff, A.M., M.D., Surgeon, U. S. Army.
New York : Rebman Company, 1905.

the blond, suffers in the tropics ; after a period of
exhilaration and sense of well-being, he becomes
disinclined to labor, grows neurasthenic, and finally
breaks down physically and mentally. This Wood-
ruff attributes to the action of the actinic rays of
light, which penetrate the more readily the less of
pigment there is in the skin and hair, and he there-
fore concludes that it is the light rather than the
heat which bars the white man from the tropics.

In the Western Canada Medical Joitrnal for Feb-
ruary, 1907, the Rev. E. C. Heustis asserts that the
inhabitants of Manitoba and the adjacent territories
are unduly neurasthenic, and, adopting Woodruff's
theory, attributes this condition to the excess of
sunshine with which that country is blessed — or
cursed, according to the point of view. In the issue
of the same journal for May of this year. Dr. A. G.
Welsford controverts Mr. Heustis' contention, and
asserts that sunlight is a blessing. He concedes that
sunlight is destructive to protoplasm, but says that
the actinic rays do not penetrate the skin to any ex-
tent, the deeper tissues being protected by the epi-
dermis and especially by the dermis, which is suf-
fused with red blood offering a barrier as effective
as the black pigment of the negro's skin. The rea-
son why Europeans do not thrive in the tropics is,
he maintains, that they are attuned to colder cli-
mates, and when transplanted to warm regions live
under abnormal conditions of heat rather than of
light. He does not denv that the denizens of the
sunlit regions of Northern Canada suffer from neu-
rasthenic states, but he asserts that these depend
'"in no way upon the sunshine," except as this may
have an indirect effect by reason of its tonic proper-
ties which lead to the undue expenditure of energy.
In another part of his article he admits, indeed, that
intense and long continued sunshine may prove ex-
hausting, but he rejects Woodruff's theory of its
action, attributing its possible evil effects to eye-
strain, resulting from the glare. We fear Dr. Wels-
ford has not proved his case, for he concedes that
intense sunlight may be injurious, differing from
Woodruff and Heustis onlv in his explanation of its
action. The farmers who are now peopling western
Canada are not .going to wear colored glasses to
prevent eyestrain, and they are not going to take
life easy, for they must work hard to reap their
harvest before the winter frost, and they will not
work the less hard because the light stimulates them
to greater endeavor.

An interesting experiment is being worked out in
Manitoba, and it is one which should in its results
confirm or refute Woodruff's theory. If he is cor-
rect, the movement of wheat growers, most of whom
are Scandinavians or men of other blond races, to
northwest Canada is doomed to failure. Those who
are now building up the country will fall by the
way and their farms will be abandoned or will be
taken by fresh immigrants ignorant of the forces
against which they will in vain contend. If the
prosperity of the Northwest continues, if the popula-
tion is permanent, and if success rewards the labors
of the settlers in this land of sunshine, IMajor Wood-
ruff will have to add a chapter to his interesting
book explaining the antidotal effect of cold, or of
some other natural force, upon the deleterious action
of sunlight.

June 2.2, 1907J

MEDICAL RECORD.

10

00

AX UNOCCUPIED FIELD OF PRACTICE.

There is an enornious amount of suffering among
the rural population of this country, especially the
wives and daughters of farmers, due to uncorrected
astigmatism and other ocular defects. On first
thought one may be inclined to doubt the correct-
ness of this statement, for the farmer is supposed
to lead an outdoor life and to be little given to
literary pursuits. But this is not true of many, if
not the majority, of the rural population. In most
farm houses of the better class one will find the
weekly political paper and one or more agricultural
or poultry journals, and in not a few several of the
magazines and weekly story papers are also taken
and faithfull}- read from cover to cover. Moreover,
the women have their sewin<^ and their mending and
their fancy work — more eyestrain, in fact, than
man}- of their well-to-do and perhaps better edu-
cated sisters in the city. Numbers of these poor
women are martyrs to headache, gastric disorders,
and other ocular reflexes, ignorant for the most part
of the cause of their suffering and unable, even if
they suspect that their eyes are "weak," to obtain
relief. At the best, or worst, they go to the country
store and select from a small assortment the spec-
tacles which they think they need, and their last
state is perhaps worse than the first. The country
doctor is seldom able to help them, for as a rule, up-
to-date, sensible, and skillful practitioner as he is,
he lacks the practical training and experience neces-
sary for the correction of errors of refraction, and
even if he has the qualifications needed for such
work the demands of a country practice leave him
no time for the tedious work of testing eyes.

Herein lies an opportunity for relieving suffering
and attaining material success which is worthy of
the consideration of the recent graduate in medi-
cine. Specialists must, from the nature of their re-
stricted practice, live only in the cities and larger
towns, where the number of consultations are suf-
ficient to occupy their time and afford them a living
practice. But in the case of refractive errors es-
pecially, which are still so wrongly regarded as
among the minor ills, the farmer and his women folk
cannot afford the time and expense of a journey to
the city in search of relief. There is need here for
missionary effort, and, contrary to the rule of most
missionary endeavor, the man who undertakes such
a needed work will reap an ample reward. There
is an opening in nearly every county of every State
in the Union for a thoroughly trained and skillful
oculist who will establish a circuit of small towns
in each of which he has an office in which he may be
consulted, say two days a month or a fortnight, by
the country people in the district. The man should
be an educated physician, with hospital training —
as should be every specialist — and preferably with
an experience of several years in general practice,
during which time he has devoted, his unoccupied
hours to a study of the eye and its diseases and of
refractive errors and the means of tlicir detection
and correction. He should indeed, be the equal of
any of his fellow specialists practising in the city.
His way at first niav not be easy, for he will lie a
missionary and his task will be to educate the ]:)eo-
ple, through their medical advisers, to an apiirecia-
tion of the role of evestrain in the causatinn ^f main-

of the headaches and "dyspensias" from which they
suffer. He must be tactful in his relations with the
practitioners in the towns embraced in his circuit
and should of course confine himself strictly to his
specialty and not encroach on the general practice of
his colleagues. It will not be long, however, before
such an "itinerant oculist," if he is skillful, and as
honest and tactful as he is skillful, will make his
way. One successful case in each tow'n will estab-
lish his reputation, for farmers' wives are great gos-
sips, and if he is careful to respect the rights of
the local physicians they will be only too ^leased to
send him their teazing cases and "chronics" that
their medicines liave not relieved and which tlie\'
will themselves soon learn to recognize as "eye-
strain" cases and gladh' refer to the oculist for re-
lief.

There is nothing unethical in such a practice.
Traveling quacks have caused honest plnsicians
and intelligent laymen to regard the "itinerant" with
suspicion, but the origin of all specialism was in
quackery and it was only when reputable practition-
ers began to devote themselves exclusiveh' to a
study of special diseases that the stigma attaching
to special practice w-as removed. There are even
now many reputable physicians and specialists who
have offices in two or more places in the same citv
or in different cities, and a slight extension of this
principle by educated, earnest, and honest younf
ophthalmologists will cause the itinerant oculist ("not
optician) to be re^^arded as a valued and honorable
member of his profession.

THE SIGNIFICANCE OF (Jl ''^'Q^Al'D'S
SIGN.

The sign to which the above title was given b\- Mar-
idort after the death of Ouinquaud consists in an
exceedingly fine crepitation to be perceived when
the person under examination places the tips of his
slightly separated fingers against the palm of the
examiner's hand which is held horizontally. Ac-
cording to its originator this crepitation is to be
perceived only when the patient is a chronic alco-
holic, and numerous observers who have tested the
matter on large numbers of persons of various types
have concurred in this statement. For example,
Fiirbringer who examined 468 persons, Levicnik
who examined 200 persons, and Hoft'mann and
Marx who examined 1,018 persons, all expressed
themselves favorably in regard to the sign, though
with certain reservations. Contrary opinions have
W'A been lacking, however, and Lauschner has as-
serted that neither the presence nor the absence
of Quinquaud's sign has any bearing on the ques-
tiu'i of the amount of alcohol consumed by the
patient.

A recent and very exhaustive consideration of tli':
question is that of IMinor of Moscow (reported in
the Berliner kliiiisclic IVochcnsclirift, May 6, iqo/).
who has investigated the sul.iject on a very large
number of persons of all classes and types, includin,:;-
many patients suffering from a variety of nervous
diseases. This author has sought to simplifv the
matter by rendering the detection of the phenome-
non independent of the observer's tactile sense.
This is accomplished li\ tr.insiorniing the sign int';>

1036

MEDICAL RECORD.

[June 22, 1907

an auditory phenomenon. The patient's fingers are
applied to a small wooden resonator which is in con-
tact with the diaphragm of a phonendoscope, and in
this wav the experiment is" always carried out under
similar conditions, and the existence or absence of
the crepitations is rendered unequivocal. Minor
comes to the conclusion that Quinquaud's phenom-
enon is neither specific nor pathognoiponic for al-
coholism, and that it is frequently present in well-
marked form in moderate drinkers and total ab-
stainers. It is rarely seen in exophthalmic goiter,
paralysis agitans, arthritis deformans, hemiplegia,
and Dupuytren's contraction, but is exceedingly
frequent in tabes. Hysteria comes next to tabes in
the frequency and intensity with which the crepita-
tions are to be detected, and alcoholism occupies only
the third or fourth place. .Alcoholic tremor of the
permanent form, as distinguished from the trem-
bling immediately consequent on a debauch, is less
often encountered than the phalangeal crepitations,
and is entirely independent of these in nature and
causation.

Apparently this phenomenon is one of hypo-
tonicity and is a very delicate test for neuromuscular
fatigue. What muscles are concerned in its causa-
tion is still an open question, but the fact that it
sometimes is present when there is extreme atrophy
of the interossei seems to indicate that the long
forearm muscles are implicated in its causation.

THE C.\USE OF ASEPTIC PURULENT IN-
FLAMMATION.

IxFLAMMATiox may be caused by bacteria, chemical
substances, or traumata. While, as a general rule,
the time-honored dictum, "no pus without bacteria,"
holds good, it has long since been proven that cer-
tain chemical substances injected into the tissues
can cause an aseptic purulent inflammation. Here-
tofore no experiments have absolutely proven that a
purulent inflammation can be brought about by the
products of an aseptic disintegration of tissue,
caused by a trauma. As all purulent inflammations
are caused by the chemotactic influence of the pyo-
genic substances on cells, the question arises whether
aseptically destroyed tissue contains positive chemo-
tactic substances. To determine this point, L. Burk-
hardt (Deutsche Zcitschrift fiir Chiritrgie, Vol. 85,
1907) has conducted several interesting experiments.
Under aseptic precautions a piece of muscle tissue
was removed from a rabbit and ground up into a
pulp, decinormal salt solution was added to it, and
the mixture was allowed to stand for 24 hours.
At the end of that time it was filtered and the ex-
tract of the muscle pulp was carefully sealed in
small sterile tubes. Cultures of this extract on
bouillon, agar, and gelatin showed no grow^th. The
small tubes were buried under the skin of otlier
rabbits and their ends were broken off subcuta-
neously. In all cases, a.septic pus was found at the
€nds of these tubes after three days. Control tests
were made with tubes containing decinormal salt so-
lution and an extract obtained by immersing intact
muscle tissue in salt solution ; in neither case was
anv pus found. Crushed muscle tissue therefore
contains substances which have a positive chem-
otactic action, the extent of the aseptic purulent in-

flammation depending, as these experiments would
appear to prove, upon the degree of trauma and the
rapidity of resorption.

Eurkhardt also made similar experiments to ascer-
tain what effect heat had in the production of posi-
tive chemotactic substances. A piece of muscle
was charred superficially and an extract obtained
and enclosed in sealed tubes as before. The tubes
were again placed under the skin of rabbits, where
they were broken subcutaneously. .After from four
to six days aseptic pus was found at the ends of
the tubes. The fact that crushed and charred tissues
were found to contain positive chemotactic sub-
stances, which, experimentally at least, produced
an aseptic purulent inflammation, should be borne
in mind during the course of an operation, in which
the excessive use of sharp retractors and much
unnecessary handling of the tissues, as well as an
unduly extensive employment of the galvanocautery,
may sometimes be the cause of a local purulent
inflammation.

Septic Infectioxs .^nd Acute Leukemi.\.

A NUMBER of observers have reported cases in which
septic infections of various sorts were associated
with blood pictures corresponding to that of acute
lymphatic leukemia, and it has been suggested, for
example by Tiirk, that in these cases the septic con-
dition is primary and stands in a certain etiological
relationship to the blood disease. This opinion has
not as yet, however, been universally accepted, and
Erb in a posthumous communication {Deutsche
mcdizinische Wochenschrift, May 23, 1907) ex-
presses the opinion that so far there is no conclusive
experimental or clinical evidence to prove that sepsis
may give rise to general lymphomatosis. He pre-
fers to accept the view that the septic infections
sometimes associated with acute leukemia are sec-
ondary complications, and points out that patients
suffering from this blood disease are unusually prone
to such infections. Why this should be so is diffi-
cult to say, but it is not impossible that the reduc-
tion in the number of polymorphonuclear leucocytes
mav in some cases favor the invasion of infectious
organisms.

The Etiology of Pemphigus Neon.\torum.

It is sometimes considered that this afTection, leav-
ing aside the syphilitic form, is not a disease per se,
but is a condition of complex etiology representing
simply the reaction of the infantile organism to
infectious agents of various sorts. A case in point
is reported by Kaupe {Miinchener mediziuische
Wochenschrift, May 21, 1907), who found a ten-
days-old child exhibiting the classical picture of
pemphigus neonatorum. There were no indications
of syphilis in the other members of the family, and
on investigating it was discovered that at the time
of the infant's birth the mother was sufifering from
an eruption which was later found to be chickenpox.
The infection had been brought into the house by
the midwife, and two other children also were sub-
sequently infected. In this case it appeared that the
pemphigus eruption represented the varicella exan-
them in an infant whose blood had not yet developed
sufficient protective substances to cause the lesion
to assume its ordinarv form.

June 22, 1907]

iMEDICAL RECORD.

1037

Thymol in the Treatment of Goiter.

In the treatment of cases of endemic goiter, the use
of a pure water and removal from the affected lo-
calities are recognized as among the most important
steps, and have given better results than most of
the drug treatments. According to McCarrison,
however, thymol may be employed with good suc-
cess in this type of goiter, its action being explained
by the fact that it is an intestinal antiseptic, for the
disease is regarded by many as parasitic in character
with the infection taking place through the medium
of the digestive tract. McCarrison reports twenty-
five cases successfully treated by this drug, and. in
especially favorable instances a disappearance of
the struma was noted within seventeen days after
the beginning of treatment. The thymol is given
in doses of 1.8 gram twice a week, followed by a
cathartic in the evening, and on the intervening days
it is given in doses of 0.6 gram morning and even-
ing. Its administration may be continued until the
goiter has disappeared. In none of the cases thus
treated by the writer did a period of more than two
months elapse before a favorable effect was evident.

A Rare Histological Finding.

It is very often by mere chance that microscopical
structures of great interest and value are discovered.
As an instance of this attention is directed to a
recent communication by Welch (Bulletin of the
New York Lying-in Hospital, March, iqovl in
which he describes and illustrates a human Graafian
follicle containing two ova. Considering the man-
ner of development of these structures, it is rather
surprising that multiple ova are not more frequently
found. The description of this process given in
Quain's textbook leaves the impression that where
there is more than one primordial ovum included
in the Graafian follicle fusion results. And most
writers state that only one ovum occurs, although a
few others deny this without, however, citing con-
crete instances in which such a condition has been
found. Dr. Welch's discovery is of considerable in-
terest from the embryological standpoint.

Nputg af tl)p Herk.

Retirement of Dr. Andrew H. Smith — Dr. An-
drew H. Smith, for manv years one of the fore-
most practitioners and consultants of this city, has
retired from practice and removed his residence to
Geneva, N. Y. Dr. Smith began his professional
career as an army surgeon and upon his return to
civilian life, soon after the close of the Civil War,
entered upon practice in this city, where he has
filled many positions of prominence in the profes-
sion, including the presidency of the New York
Academy of Medicine. He was also attending phy-
sician to St. Luke's and the Presbyterian hospitals
and surgeon to the Manhattan Eye, Ear, and Throat
Hospital, and held the position of consultant in a
large number of institutions. He has been a fre-
quent contributor to medical literature.

Centennial Anniversary of the College of
Physicians and Surgeons. — Over two hundred
guests were present at the dinner of the alumni as-
sociation of the College of Physicians and Surgeons
of Columbia University given last week in honor
of the hundredth anniversary of the school. Dr.
T. AI. Chcesman presided and among the speakers
were President Nicholas M. Butler,' Dean S. W.

Lambert, Rev. Dr. Aked, Dr. Darlington, and Mr.
Geo. L. Rives. In connection with the anniversary
celebration demonstrations and clinics were held in
the college building, in the Vanderbilt Clinic, and
in the Roosevelt and other hospitals. Addresses
were also delivered at the college by President But-
ler, Prof. John G. Curtis, and Professor W. H.
Welch of Johns Hopkins University.

Compliment to Dr. Grenfell.— Mr. Wilfred T.
Grenfell, L.R.C.P., M.R.C.S., on May 28 received
from the University of Oxford the honorary degree
of M.D. ; this is said to be the first time in the
history of the university that this honorary degree
has been conferred. The honor was given in recog-
nition of Dr. Grenfell's self-sacrificing work among
the fisherfolk of the Labrador coast. At first he
worked on board tlie mission vessels in the North
Sea, but in 1892 he initiated work of a similar
kind among the fishermen in Labrador, where, hav-
ing obtained his certificate as a master mariner, he
commanded his own vessel. In Labrador and New-
foundland he has helped in establishing four hos-
pitals, besides various cooperative stores atid other
institutions for the good of the inhabitants. Re-
cently Dr. Grenfell delivered several lectures in this
city descriptive of the life of the people among
whom he does his work.

Strauss Milk Booths. — The fifteenth season of
the Strauss pasteurized milk booths began on Mon-
day, when eleven new booths were opened in ad-
dition to the six that were operated last year. The
stations are located as follows: 151 Avenue C, 47
Monroe street, 441 West Thirty-third street, 329
East FiftA'-ninth street, 303 East iiith street,"38
Macdougal street, Battery Park, City Hall Park,
Tompkins Square, Central Park, Mount Morris
Park, Hebrew Educational Alliance. East Broad-
way and Jefferson street. Recreation Pier, East
Third street : Recreation Pier, East Twenty-fourth
street; Recreation Pier, East 112th street: Recrea-
tion Pier, Barrow street ; Recreation pier. West
Fiftieth street.

International Red Cross Conference. — At the

final session of the International Red Cross Confer-
ence in London, Lieutenant-General Bessim Omar
Pasha announced that he represented the Moham-
medans and owing to the fact that the symbol of
the cross opposed every religious belief of his peo-
ple, he demanded that the organization in future
adopt the crescent as a symbol instead of the cross
and be called the Red Crescent instead of the Red
Cross. The proposition was disposed of bv ruling
the speaker out of order. In addressing the con-
ference Baron Ozawa, Vice-President of the Red
Cross Society of Japan, said the Japanese Am-
bulance Corps during the Russo-Japanese War had
to deal with 622,688 cases, and the number succored
in hostile camps and on hostile ships raised the
number to far above a million. This was all done
at an expenditure of less than $2,500,000. The small
cost was due mainly to the strict centralization of
the Japanese system. No women nurses were em-
plo\-ed. The conference also passed resolutions de-
claring it within the province of tlie socictv to care
for and succor prisoners as well as the ill and
wounded, and relating to the treatment of soldiers
discovered to have tuberculosis.

Charcot's Library. — Dr. Jean Charcot has pre-
sented to the Salpetriere in Paris the entire library
of his father, which is considered one of the fore-
most collections of neurolo<;ical literature in the
world. Dr Charcot has also presented to the same

1038

MEDICAL RECORD.

[June 22. 1907

inslimtion, with which the elder Charcot was so
lonj"^ connected, the furniture of the celebrated scien-
tist's stnrly.

To Destroy Anthrax Germs. — A technical
chemist 01 Dewsbury, England, has discovered an
electrolytic process by means of which it is possible
to sterilize rags, etc., in large quantities, and it is
claiincd that in this way wool workers may be freed
from the risk of contracting anthra.x, as the process
can be u^ed to kill the anthrax bacilli and spores in
the crude material.

Eyeglasses for School Children. — The Board of
Education has passed a series of resolutions re-
questing the Board of Health to make a systematic
investigation of the eyesight of the children in the
public schools, with a view to the free dis-
tribution of eyeglasses to those whose sight is found
defective.

Mechanotherapy Appliances for the German
Hospital. — The German Hospital has installed in
the g_\'mnasium of the dispensary in the Anna Ot-
tendorfer Building of the hospital at Seventy-sixth
street and Park avenue, twenty-four pieces of ap-
paratus for the purpose of giving mechanical treat-
ment and medical gymnastics.

Typhoid Fever in Pittsburg. — The occurrence
of numerous cases of typhoid fever at several up-
ri\er points has alarmed the health authorities of
Pittsburg and warnings have been issued to the
people to use only boiled water. On June 18, forty-
one new cases of the disease were reported in the
city, and during the first eighteen days in this month
there were 228 cases.

Plague in Trinidad. — fJwing to the increase of
bubonic plague in Trinidad, \'enezuela has sus-
pended traffic with the island.

The New Harlem Hospital. — The new Harlem
Hospital at Leno.x avenue and 136th street was
formally opened on June 13, although it has actu-
ally been in operation for some weeks and nearly a
hundred patients are at present in its wards. Dr.
John W. Brannon, president of the board of trus-
tees of Bellevue and Allied Hospitals, presided, and
C'imptroller Metz made the principal address. The
hospital is a large five-story brick building, accom-
modating 150 patients. Its cost, including that of
the power house and ambulance stables, was $624,-
000. In the fall the erection of another building on
the same plot for a nurses' ward is to be com-
menced.

American Association of Medical Examiners. —
At the meeting of this organization, held in Atlantic
City on June 3 and 4, the question as to the amount
of the fees that should be allowed by life insurance,
companies for the proper examination of an appli-
cant was considered and it was the unanimous opin-
iun of the association that life insurance companies
should pay a minimum fee of five dollars for each
and e\ery examination. A resolution was presented
and arlopted in which the Association recorded itself
as being in favor of a portfolio of Health to be es-
tabh'sb.cci by the Federal Government, with the Sec-
retary a physician and ranking in authority with
the other members of the President's Cabinet. It
was decided to hold the ne.xt annual meeting of the
.Association at Chicago, the time to be determined
upon later. The following officers were elected to
serve for the ensuing years : President. C. H. Har-
lia;'.L;li. Philadelphia: Vice-Presidents. Liston H.
Montgomery. Chicago. Frank E. Allard, Boston.
P>. J. O'Connor. Louisville. Kv.. E. O. Kinne. Svra-
cusc. X. Y.. T. Millman, Toronto. Canada: Sccrc-
tar\-Trcasnrcr. John Guv Monihan. New York.

Association of American Physicians. — The
ne.xt meeting of this organization will be held in
Washington, D. C, May 12 and 13, 1908. The
president is Dr. James Tyson of Philadelphia and
the secretary remains Dr. Henry Hun, 149 Wash-
ington avenue, Albany, X. Y.

Toronto Academy of Medicine. — Under this
title the Toronto Pathological Society, the Toronto
Clinical Society, the Toronto Medical Society, and
the Ontario Library .Association have been united
in a single organization and the separate constituent
societies have been disbanded. The officers of the
new .Academy are as follows: President, Dr. J. F.
W. Ross; Vice-President, Dr. McPhedran; Hon.
Secretary, Dr. H. J. Hamilton ; Hon. Treasurer, Dr.
D. J. G. Wishart; Council, the above mentioned of-
ficers and Drs. Irving H. Cameron, H. A. Reeve,
H. A. Bruce, J. T. Fotheringham, A. A. Macdon-
ald. H. P. Anderson, \V. P. Caven, E. E. King,
John Amyot. F. M. G. Starr, R. D. Rudolf, R. J.
Dw-yer.

Maine State Homeopathic Society. — The forty-
first annual meeting of this organization was held
in Augusta on June 11. It w-as decided to hold
the next meeting in Portland, and officers were
elected as follows : President, Dr. R. S. Graves,
Saco ; Vice-Presidents, Drs. John T. Palmer, Port-
land, and W. H. Kennison, Madison ; Recording
Secretary, Dr. Luther A. Brow^n, Portland ; Corre-
sponding Secretary, Dr. Carrie E. N^ewton, Brewer ;
Treasurer, Dr. William .S. Thompson, Augusta.

New Hampshire State Homeopathic Medical
Association. — .At the annual meeting of this organ-
ization, held in Concord, officers were elected as
follows: President, Dr. J. E. Willis, Somersworth ;
Vice-President, Dr. C. A. Sturtevant, Manchester;
Treasurer, Dr. Herman Christophe, Manchester ;
Secretary. Dr. R. V. .Sweet. Rochester.

Dr. William Seaman Bainbridge of Xew York
City received the degree of Doctor of Science at
the annual commencement of the \\'estern Univer-
sity of Pennsylvania, June 7.

Obituary Notes. — Dr. L.am.\r Seeley of Port-
land, Ore., died suddenly on June 14 in St. Luke's
Hospital at the age of twenty-six years. Dr. Seeley
was a graduate of Williams College and received
his medical education at Johns Hopkins University,
from which he was graduated in the class of 1906.
He had been an interne in St. Luke's Hospital
for about six months.

Dr. S.\MUEL S. Walli.\n of this city died of
pneumonia on June 12. He was born in Brookfield.
O., in 1835 ''"d spent his early life in \\'isconsin.
He served through the Civil War and subsequently
studied medicine. He had practised in this city
for over twenty years.

Dr. John A. Robinson of Elmira, N. Y., died
on June 14, ten days after an operation for appendi-
citis. -At the time of his death he was City Coroner
of Elmira.

Dr. Cyrenus A. D.wid of Chicago died on June
12 of septicemia due to an infection received in the
course of an operation. He was born at Olney, 111.,
and was sixty-two years of age.

Dr. Ch.\RLES Evert C.'\dw al.^der of Philadel-
phia lately a resident of London, England, died
suddenly of heart disease in that city on June 12.

Dr. WiLLr.\M J. SwiNTON of Somer\'ille. N. J--
died on June 14 at the acre of fiftv-eight vears. He
was born at Florida Springs, X. L. and received his
earlv education in France. In 1872 he was sfradu-
ated from Bellevue Hospital Medical College and

June 22, 1907]

MEDICAL RECORD.

103Q

he then completed his medical training in Paris.
For many years he was physician for the Central
Railroad of New Jersey.

Dr. John J. Morrissev of this city died on June
14. following an operation for depressed fracture of
the skull. While attempting to board a car last
IMonday he fell and received the injury. Dr. Mor-
rissev was born in Hartford. Conn., forty-eight
vears ago, and was graduated from Villanova Col-
lege and the College of Physicians and .Surgeons.
He was visiting physician to St. Joseph's, St. Vin-
cent's, and St. Francis' Hospitals, and the Metro-
politan Hospital and Dispensary.

Dr. George Emerson King of Kalamazoo, Mich.,
died suddenly on June 6 of apoplexy. He was born
in Erie, Pa.,' forty-seven years ago, and was gradu-
ated from the Western Reserve Medical College at
Cleveland in 1882. He began practice in Mattawan,
where he resided for fifteen years, and then re-
moved to Kalamazoo.

Dr. J. P. H.AMPTOX of Meridianville, Ala., died
on June 8, after a long illness. Dr. Hampton was
eighty-two years of age and had served with dis-
tinction in the Civil War as captain in the Forty-
third Mississippi Infantry. He was several times
representative for Madison county in the State Leg-
islature and served many terms as president of the
JNIadison Countv Medical Society.

Dr. Henry C. Ide of Mclndoes, Vt., died in Bur-
lington on June 5 at the age of thirty-eight years.
He was a graduate of Dartmouth Medical College
and Bellevue Hospital. He had practised in Mc-
lndoes for about ten years.

Dr. Sylvester D. Lewis, formerly of Amster-
dam, N. Y., died on June 16 at the home of his son.
Dr. George Griffin Lewis, in Syracuse, at the age of
seventy-nine years. Dr. Lewis was a member of
the class of 1857 of Union College and received
his medical education in the Albany Medical Col-
lege.

(Cnrrrsiinniintrr.

IXDIC.-\XURI.\.

To THE Editor of the Medic.\l Record:

Sin : — The article by Dr. Porter on Indicanuria in your
issue of June 15 is on a subject to which, I think, too httle
attention has hitherto been paid. This article, read in con-
nection with Herter's recently published "Bacterial Infec-
tions of the Digestive Tract" (New York, The Macmillan
Co., 1907), sufficiently indicates the importance of the sub-
ject. For a long time I knew of no means of combating
the condition other than restriction of the amount of pro-
tein in the diet, and it was not until I read the following
in Metchnikoff's "The Nature of Man" that it occurred
to me to use any other means. This writer says : "Inves-
tigations recently made by Bienstock and confirmed by
Tissier and Martelly have proved the existence of certain
microbes that sour milk, i.e. cause the formation of lactic
acid, and which are antagonistic to the microbes of putre-
faction. The latter multiply only in an alkaline mediun>.
The lactic acid microbes produce large quantities of acid
and so hinder the multiplication of the organisms of
putrefaction. . . . -Such facts explain how it is that lactic
acid frequently stops some cases of diarrhea, and why
treatment with lactic acid is so useful in maladies asso-
ciated with putrefaction of the intestinal contents. It
makes intellisrible, moreover, the medjcinal value of fer-
mented milk."

This suggested the thought that possibly the lactic bac-
teria would measiirablv control the indicanuria. For some
time past I have used them with this object in view, au'l
am now thorouehly satisfied that they accomplish the
object soueht. The observations have been made both on
myself and on patients, and the result has been a notable
decrease of the indicanuria in the majority of cases. I
have experimented with several different bacteria of the
ac-difving tvoe — both coccal and rod forms — and have
taken and administered the pure cultures direct; but pre-

fer to "dope," say a quart bottle of sweet milk with the
culture. If this be kept for twenty-four hours or so at a
temperature of 80° to 85' F. it will be ready for use.
.\ little of this (15 to 20 c.c. ) added to a bottle of fresh
milk will acidify it in like manner. This may be kept up
for a week or ten days, when it will be well to start a
fresh series by resort to a pure culture.

It is only recently that I learned that Dr. C. A. Herter
ten years ago, experimenting with dogs, markedly reduced
the amount of indican in the urine by feeding them with,
cultures of lactic bacteria. Dr. Herter's observations were
published in the British Medical Journct, December 25.
1897. Here was a discovery made by a physiological
chemist that appears to have been passed unnoticed by the
majority of clinicians. I have not looked very thoroughly
into the literature of indicanuria, and it is possible that
some may have made practical clinical use of Herter's ob-
servations, or, like myself, have been led in the same
direction through the influence of Metchnikoff's writings.

Henry G. Piffard, M.D.

New York.

OUR LONDON LETTER,

(From Our Special Correspondent.)

GENERAL MEDICAL COUNCIL — GOVERNMENT VACCINATION BILL
— MEDICAL SOCIETY ;THE ORATION, HEART DISEASE, MOVABLE
KIDNEY' — MALTA FEVER — DR. WOLLASTON's RETURN FROM
CENTRAL AFRICA.

London. May 31, 1907.
The General Medical Council met for the summer session
on Tuesday, when the president, Principal Macalister,
delivered an address, in which he expressed satisfaction at
the completion of the negotiations for reciprocity with
Nova Scotia. The provincial authorities had shown every
desire to meet the requirements of the Council, and Nova
Scotian degrees will now be registrable. An incidental
consequence is that Canadian medical graduates who have
complied with the conditions applicable to the Maritime
Provinces will be eligible for commissions in the R. A.
M. C. As to the Province of Quebec some further inquiry
respecting the conditions of admission to its register is
being made through the proper channels.

The International agreement on the unification of Phar-
macopoeia formulse will necessitate some alterations to the
British Pharmacopoeia, but probably not so many as some
other countries will have to make. The action of the
British Medical .Association in becoming complainants in
cases that may be brought before the Council has been
submitted to the legal advisers, who have recommended
that Councillors should withdraw from the .Association.

The old dispute about the Apothecaries' Hall of Dublin
again came up, and a good deal was said about the returns
asked for as to the number of licenses of that body.
Several regarded it as a flank attack. The truth is that
the Council has no authority to consider whether the Hall
should be a qualifying body or not. That has been decided
by Parliament, and although I know of no one who would
assert that it is a necessary, or even a useful institution,
I know many who would say that there are other authorities
represented on the Council which they look upon as of about
the same value.

There was also a discussion on clinical teaching, in which
it was alleged that practitioners are turned out by the
licensing bodies full of theoretical knowledge, but sadly
deficient in practical resources. No doubt much is to be
said on this point, but the discussion at the Council con-
tributed nothing of importance.

The Government Vaccination Bill has been read a second
time. It aptly illustrates the way in which the boasted
"strongest government" panders to any .group of fanatics
who make noisy assertions. Sir J. R. Tupe pointed out the
many objections to the measure and the utterly illogical
character of its provisions. No honest, "conscientic js
objector" would be materially affected, as he was willing
to take the trouble to obtain the exemption ijrovided tr.r,
but a great number of people were dragged in his train
who had no convictions, but followed the agitators to the
danger of the public. Then- was no justification for
endangering the whole people at the request of a small
number of persons.

Sir H. Craik, another University member, denounced the
bill as a dangerous concession to prejudice and ignf. ance.
The investigations of science should have some weight.
He asked how far we were to go in concessions to wh il
this or that man might call a conscientious objection. ?>!r.
John Burns, who defended the bill for the govein.ii..-n:,
made rather an apology for it than a defence, and one, too,
which shows that it is a mere party move to conciliate the
faddists, with utter carelessness as to the danger to the

I040

MEDICAL RECORD.

[June 22, 1907

people. He said they had promised a redaction 'n cost;
they had also promised some form of declarition, inslcjd
of the magistrate's certificate; they had also promised the
postponement of vaccination to a later period. Thc^e
promises (made to get votes) are obviously the only
reasons why the government has brought forward the bill,
unless perhaps the hope he expressed that it would go far
to end the nuisance of the controversy. It seems a shocking
instance of setting the success of party before the good
of the country, and the indifference of politicians to the
public health.

The reception of the Medical Society of London on
Monday evening was attended by some 200 fellows and
members of this and sister societies. In the absence of
the president, Mr. C. A. Ballance, through illness, which
was much regretted, the guests were received by Sir John
Tweedy and Sir E. Venning, the first named of whom
made sympathetic reference to the loss lately sustained by
the Society through the death of Sir Joseph Fayrer, one
of its most distinguished past presidents. The oration was
delivered by Dr. George A. Gibson of Edinbur.gh, who took
for his subject "The Cause of the Heart Beat," after which
there was the conversazione with music. Dr. Gibson has
taken a share in recent researches on the subject of his
oration, and was therefore prepared to speak with some
authority, and was naturally listened to with special inter-
est. He gave an account of the two opposing theories —
the muscle and nerve origin, as one may say. The former,
Engelmann, Gaskell, and others have upheld with no little
ability, and their views were fairly considered, but the evi-
dence in favor of myogenesis was not satisfactory, and at
present the conclusion seems to be for neurogenesis. Em-
bryology cannot decide on either side, for neither muscle
nor nerve are to be found when the heart begins to beat.
So anatomy supports neither view, ner\'e and muscle being
too closely interwoven. Pathology is equally indecisive.
Clinical observation, however, the orator pronounced to be
distinctly in favor of neurogenesis, the esoteric cause of
contraction seeming to him the rhythmic discharge of the
nervous elements.

At the previous ordinary meeting of this Society, Dr.
Walter Broadbent read a paper on some heart affections
without murmurs. He dealt with myocarditis, fatty degen-
eration, and cloudy swelling. He insisted on the gravity
of changes in the condition of the cardiac walls, and said
that during acute diseases whenever the heart was weak
from any previous cause there was great danger from the
supervention of distention of the stomach.

Dr. Hector Mackenzie also communicated to the Society
a paper on the mobility of the kidneys based on an exami-
nation of nearly 4,000 persons. He seems to have found
an abnormal degree of mobility far more frequently than
many observers seem to have thought possible. He admits
that the kidneys may be abnormally movable without caus-
ing symptoms, and indeed that most cases require no treat-
ment. He gave elaborate directions for palpation. When
able to feel the greater part of the organ he called the case
"palpable" kidney, reserving the term "movable" for case?
in which he could feel above the upper border. In 2.801
women he found palpable cases in 16 per cent, and movable
in 18.4 per cent. In 1.067 males there were 2.3 per cent,
palpable and l per cent, movable.

The Commission on Malta fever which was arranged
three years ago by the Royal Society at the request of the
War Office, has lately comp'eted its labors, and the net
result seems to be that the disease will soon be itamp;:d
out. The Commission consisted of medical officers of the
Army and Navy under the direction of a committee of the
Royal Society, and though from time to time we have had
statements as to some lines of research with which it was
occupied, we have only lately received full reports. The
discovery of the Micrococcus melitensis in 1887 was a start-
ing point, as it were, for further research, and it was long
before the additional discovery was made as to its mode of
entrance into the body. When it was shown that goats
were liable to the disease, a key was furnished to the
mystery, for there are some 20,000 goats in Malta, and
they supply the milk consumed on the island. Tlie Com-
mission found that 50 per cent, of these animals were
affected by the fever, and that in about 10 per cent, the
microbe can be found almost constantly in their i-nilk,
although there may be no other symptoms of the fever.
The crucial test thus became to eliminate goats' milk from
the dietary, and this could be done effectively so far as
the soldiers and sailors were concerned. In June, 1906, this
was done, and the fever cases thereupon fell to one-tenth
of their average number. The enormous gain from a mere
financial point of view should satisfy the government —
bent as it is on cutting down expenses — that a few thousands
spent on scientific research may prove a most profitable
investment.

Dr. A. F. R. Wollaston has returned to England after
a journey through central .A.frica, traversing much unknown
country. In the region devastated by the sleeping sick-
ness he describes the roads as peopled with the dead and
dying, almost every village presenting a revolting spectacle,
as it is the custom to drive out the victims of the disease
to die. The population of an extensive region is thus
dying in thousands in utter destitution. In Uganda, since
the disease broke out a few years ago, he estimates that
over a quarter of a million of the natives have succumbed
to sleeping sickness. In the Manyuema country it would
seem that the scourge threatens to completely depopulate
vast regions.

OUR VIEXXA LETTER.
(From Our Special Correspondent.)

THE B.^CTERIOLOCV OF WHOOPING COUCH — F.^T.^L HEMORRHAGE

FROM THE EAR HYDROPHOBIA IN FROGS — GASTRIC SYMP-

TO.MS FROM A FOREIGN BODY IN THE NOSE — PU-KSTIC OPERA-
TIONS FOR INFANTILE PARALYSIS — INFANTILE TETANY.

Vienna, May. i.^;. loor.

Albrecht has carried out a series of observations re-
lating to the bacteriology of whooping cough. In 200
cases of pneumonia in pertussis patients and in 70 cases
of pertussis he found the Bacillus Eppendorf in the
sputum. This bacillus does not differ from that of
influenza, so that it may possibly be identical with
this. It also appears to play a role in measles, for it
was found in 80 per cent, of children dying from this
disease. By injecting rabbits with the bacillus it was
found possible to secure a serum which agglutinated
the same strain in a dilution of 1-1400 and other strains
in a dilution of 1-800. The animals so treated devel-
oped a well-marked degeneration of the right ventricle,
accompanied by calcific areas in the muscles, and simi-
lar changes were found in the liver. After several
months i"abbits treated with influenza material showed
endocarditic vegetations of the mitral valve containing
influenza bacilli. This observation is of interest in
view of the well-known deleterious effect of influenza
on the heart.

Torok has recently observed a case of fatal carotid
hemorrhage from the ear. In dangerous hemorrhages
from the ear the carotid and sigmoid sinus maj^ be in-
volved. Erosion of the carotid may be caused by malig-
nant growths, cholesteatoma, syphilis, scarlatina, and
in the greater proportion of cases by tuberculous ne-
crosis of the bones. The patient, who was a man of
fifty years, was suffering from advanced tuberculosis
on admission. For several years there had been a
discharge from the right auditory meatus and the in-
ternal ear was seen to be filled with thin, fetid pus.
The drum and ossicles were missing and the walls of
the internal ear were devoid of covering. The carotid
artery was not visible and there was no pronounced
pulsation of the pus to be seen, as has often been de-
scribed. As the patient was too weak and cachectic to
stand an operation the ear w-as irri"-ated several times
a day with boric acid solution. Suddenly a profuse
pulsating hemorrhage burst from the ear without any
premonitory symptoms, and at the same time blood
poured from the nose, the mouth, and even the auditory
meatus of the opposite side. The bleeding was con-
trolled by packing both auditory canals and the nose,
after the patient had lost about a liter of blood. It
was later found that the bleeding on the left side had
taken place through an old perforation of the drum
after the blood had entered the ear through the Eus-
tachian tube. The patient died suddenly some hours
after the hemorrhage. At the autopsy there were found
large pulmonary cavities, tuberculosis of the intes-
tine, tuberculous erosion of the bones of the middle
ear. and a large defect in the wall of the carotid artery.

The question of whether or not hydrophobia is trans-
missible to the frog has been investigated by Lote in
the University of Klausenberg. This observer inocu-
lated 83 frogs in six series with the brains of rab-
bits dying of rabies. On the death of the frogs control
inoculations were made in order to prove thaf no other
infection had caused the death of the animal. Then
rabbits or guinea pigs were inoculated with the brains
of the animals and tyoical rabies was caused. Of the
S3 frogs 73 died of rabies. It is plainly shown by these
experiments that hydrophobia may be transferred from
warm-blooded animals to frogs, from frog to fro.g,
and from the frog again to the warm-blooded animal.
The course of the disease is much prolonged in the
frog and the virus in its passage through this animal

June 22, 1907]

MEDICAL RECORD.

104 1

undergoes a considerable attenuation in virulence.
Dr. Glas presented before the medical society a man
suffering from gastric disturbance as the result of the
presence of a foreign body in the nose. For more than
a year the patient had complained of eructations of
foul-smelling gas and the vomiting of fetid material,
which symptoms had developed since an attack of pneii-
monia. The gastric function was not impaired and it
was found that the symptoms referred to this orsran
were caused through swallowing the fetid secretion
originating in a suppurative process in the left nasal
passage. This had resulted from the presence of an
inverted tooth which had broken through into the nasal
cavity, had been loosened by a blow on the nose, and
had lodged below the lower turbinated bone, where it
gave rise to the formation of a rhinolith, accompanied
by purulent secretion. On removal of the tooth the
gastric symptoms disappeared.

Mosckowicz has operated on a boy of seven years
who was unable either to walk or to stand in conse-
quence of paralysis of the lower extremities and was
obliged to crawl like a four-footed animal. The right
lower extremity was completely flaccid, but on the left
side the muscles of the leg were normal, except the
tibialis anticus, and the muscles of the thigh were all
normal. The glutei of both sides were paralyzed. The
right leg was converted into a useful member by
arthrodesis of the knee joint and the hip joint, to.gether
with tendon shortening of the muscles of the foot. The
child was still unable to stand, however, as the ex-
tensors of the hip joint, the glutei, were lacking. On
the left side the gluteus maximus was then replaced
by the flexors of the knee joint by transplanting the in-
sertion of these muscles from the tuber ischii to the
ileum. The child can now walk with two canes and is
able to stand unaided.

Escherich deinonstrated in the Society for Internal
Medicine and Pediatrics a child with infantile tetany
accompanied by excessive mechanical and electrical ir-
ritability. For two months it had been suffering from
digestive disturbances, vomitin"' and emaciation. For
three days there had been short convulsive seizures, in
which there was spasm of the glottis with stridulous
breathing. At the same time there was a high degree
of mechanical and electrical irritability, so that touch-
ing the cheek caused active facial contortions and gen-
tle percussion of a muscle evoked forcible contractions.
The statement of Finkelstein that in such cases the
elimination of milk from the diet is a certain means
for reducing the hyperexcitability did not apply in
this case, for, on the contrary, the symptoms were in-
creased in severity by this measure. Nevertheless, in
most cases of tetany improvement follows resort to a
carbohydrate diet or starvation.

New York Medical Journal, June 8, 1907.
Open-Air Treatment of Tuberculous Bone and Joint
Disease. — J. Carling claims that statistics of cure show,
as between seaside and inland resorts, a preference in
favor of the latter. His ideal location is a moderate
altitude away from the seashore, and he advances the
following reasons: (l) The air is more invigorating:
(2) the absence of dampness and fog; (3) more days of
sunshine; (4) better natural drainage; (5) a firmer soil
for locomotion. The advantages of such an environ-
ment over home treatment are: (l) The patient is
always surrounded with pure air and a maximum
amount of sunshine; (2) his diet, rest, bathing, and ex-
ercise are carefully regulated; {?,) he is under constant
medical supervision; (4) he is educated and disciplined
in the care of himself. The daily routine of life is as
follows: The children are kept out of doors all day
except in very stormy weather, and sleep in rooms and
wards with the windows wide open. Those who are
unable to walk are wheeled out in beds or invalid
chairs, and the presence of fever is no bar to their go-
ing out. Not only is pure cold air not jnjtirious to
these latter cases, but it is decidedly beneficial in reduc-
ing temperature and dispelling nervous symptoms.
Those who are able to go about on crutches or braces
are allowed walking in moderation, others are drilled
in light calisthenics, while all are taught the impor-
tance of deep breathing. Protected from the strong
winds of winter and warmly wrapped in woolen^ blan-
kets, patients are given sun baths when practicable,
which in this clear atmosphere can be had almost daily.
No medicines and no special diet are reauired except
in emergencies.

Impetigo Contagiosa. — N. T. Beers notes the frequent
occurrence of this disease, which frequentlv occurs in
an epidemic form with symptoms analogous to those
of the common eruptive fevers, most closely resem-
bling, in fact, practically identical with the onset of
varicella. When the case comes under observation, it
is usually in the stage of scab formation and the full
course of the eruption through the successive stages —
vesicles, turning dark, and drying; up — entirely discrete
and with no surrounding induration or redness — is not
seen. The pus from the scabs may inoculate other
areas. The disease shows little tendency to itch unless
the scabs are disturbed. As to differential diagnosis
from pustular eczema and scabies, it may be said that
eczema shows an areola of inflammation about the
lesion: it is inclined to become confluent' itching is
often intense; but it is not autoinoculable. Scabies is
accompanied always by intense itching, especially at
night; lesions are small, in large numbers and multi-
form, pustules, papules, and vesicles all appearing: it
lasts for months: presence of burrows, and a parasite
may be demonstrated: there are no constitutional symp-
toms. Impetigo is not communicable; it commences as
pustules; lesions are deep and pustules elevated and
rounded: general health is good. The treatment is
even simpler: A grain of calomel in broken doses, a
saline to complete its action, and then some consti-
tutional tonic to increase the general resistance. Ex-
ternally, the treatment consists in softening the crusts
with olive oil and their removal with warm water
and soap. As soon as this is accomplished an oint-
ment consisting of ten grains of ammoniated mercury
to the ounce is all that usually is required to complete
the cure.

Case of Eyestrain Mistaken for Appendicitis and
Cholelithiasis. — E. M. .Mger refers to the claim of
Gould that abdominal pains and functional disorders of
digestion may arise from ej'estrain. He refers to the
unsatisfactory results frequently following operations
for the relief of abdominal symptoms and declares that
the whole training of the modern surgeon tends to cul-
tivate operative skill rather than diagnostic ability. He
gives the detailed history of the case of a young man
of nineteen years in whom the chief symptom was
chronic severe abdominal pain of several months' dura-
tion; the diagnosis of the first surgeon was appendi-
citis; of the second, gallstones: and of the third, eye-
strain. The pain was completely relieved by the
glasses of the first ophthalmologist for a period of
nearh' three years; recurred when they were lost; was
aggravated by the prescription of the second; and
finally completely relieved again by the glasses of the
third.

Amyotrophic Lateral Sclerosis with Bulbar Onset. —
A. Gordon refers to the various types of this nervous
affection with reference to mode of onset. The most
frequent is that presenting a paretic condition, with
some spasticity and amyotrophy with reaction of de-
generation. Or one may have a progressive muscular
atrophy with the spastic element not marked, but the
reflexes exaggerated. In a third form the spasticity
appears first and the amyotrophy later. In all the fr.re-
going bulbar symptoms may be a late feature. Finally
a few cases have been reported presenting bulbar symp-
toms as the initial feature. One such case is reported
by the author, whose patient was a married woman
of fifty 3'ears whose trouble began with stiffness of the
neck, soon followed by pain in the throat, dysphagia,
and difiicult speaking, with some trouble in holding up
her head. When seen, certain sounds were emitted
with difficulty, there was trouble in blowing and
whistling and atrophy of the tongue with fibrillar
twitchings. The initial symptoms were also progress-
ive. Fifteen months after the onset of the bulbar
symptoms muscular weakness and atrophy of the
thenar, hypothenar, deltoid, supra and infraspinate mus-
cles began to develop and showed R. D. The disease
in this case was decided to be of spinal origin and it
was believed that the motor bulbar, neurons opened
the pathological process.

Journal of the American Medical Association, June 15, 1907.
The Duality of Man. — G. C. Savage discusses the re-
lations of the mind with the body in the light of the
neuron theory. He argues that acceptance of this
theory excludes the possibility of the nervous system,
being in itself a self-acting mechanism of afferent cur-
rents directly transforming themselves into efferent
ones: "The power that can make or break contact of
dendrites or collateral branches, and can even present
such contact, needs no physical connection, either by

I042

MF.DICAL RECORD.

[June 22, 1907

continuity or contact, between afferent and eiterent
centers that it may control the physical being." The
afferent and efferent currents are not, he thinks, directly
transformable one into the other; there must be some
power supervising and regulating the change, and if
contact is necessary in order that there be any efferent
current of neuricity, this power must bring it about.
In this way the study of retlex neuroses can be cleared
up, the phenomena of hypnotism and suggestion e.x-
plained. According to this explanation, every function
and organ of the body is directly under the control of
this higher power, the mind. Hence when germs and
toxins cause disease, mental stimulation can reinforce,
under proper direction, the weakened bodily resistance.
If the attack is too overwhelming, such external means
as arc suited to the case will have to be invoked. The
grain of truth in Eddyism and like delusions is the fact
that the mind can influence the body, but with this
grain there is a ton of error. The external laboratories,
under the guidance of trained minds, are supplying
agents as specific, and often more effective than those
the internal laboratories of the body, controlled by the
mind, can supply in the fight against disease. The phy-
sician, nevertheless, should never overlook the fact that
man is a dual creature, spirit as well as matter, and
that the mind, through the nervous system, itself ma-
terial, can influence the bodily organs.

Obscure Gastrointestinal Cases. — J. Hoelscher gives
case histories of three patients suffering with inter-
mittent gastrointestinal attacks characterized by gas-
eous distention, hyperacidity, pain or nausea, and vom-
iting; all were resistant to medical treatment. In one
case there was no history of any causal disease, but
there were severe pain and jaundice; cholecystenteros-
tomy, however, revealed no gallstones. In the second
case the disorder followed typhoid fever, in the third
there had been a severe burn and traumatisms and the
symptoms justified the diagnosis, confirmed by opera-
tion, of healed duodenal ulcer and partial obstruction.
In the first two cases there were found gastric dila-
tions and displacement, and adhesions of the stomach
and intestines, which were released; in the third case
a gastroenterostomy was performed. Improvement re-
sulted in all three after operation. Hoelscher calls
attention to the fact that an intestinal lesion may give
rise almost exclusively to gastric symptoms, and says
that the diagnosis of gastric neuroses and chronic gas-
tric catarrhs will become fewer when surgery is re-
sorted to. It may give prompt and complete relief,
though usually the changes that have taken place in the
musculature and glands of the stomach are such that
it may be a long time before the patient will be al-
together normal. The differential diagnosis calls for
careful distinction as regards gastric ulcer, chronic
cholecystitis, gallstones, and gastroptosis. Proper sur-
gical interference gives better results than long-con-
tinued medical treatment. The usual secondary symp-
toms of faulty gastrointestinal chemistry included
under autointoxications should not be overlooked.

Venous Angioma of Skin Showing Beginning Malig-
nancy.— R. R. Campbell discusses the subiect of venous
angioma in its relation to malignant growths. He re-
ports a case with microscopic examination of the ex-
cised tumor, which suggested epithelioma, though the
absence of nests and of epithelial formation on the lat-
eral walls or base precluded a malignant growth. He
also abstracts several other cases reported by other
authors and discusses the origin and varieties of these
tumors. In conclusion he expresses the opinion that
venous angiomas do not take on malignancy, but that,
on account of the constant irritation due to their pres-
ence, the overlying epithelium may undergo carcino-
matous changes.

Remote Effects of Tonsillar Infection. — P. K. Brown
savs that the importance of the source of infection for
heart disease has been well shown. He has observed
recurrent endocarditis, cholera, and muscular rheu-
matism occurring in certain of his old patients, and he
considers that continued slight fever in children is
probably a comiTion result of tonsillar disease in San
Francisco. A rather oeculiar complication of pericar-
ditis, pneumonia, and lung abscess is reported. Ne-
phritis after tonsillitis without rheumatism is. he thinks,
a commoner complication than is generally supposed,
and has occurred four limes in his cases. One of these
complicated by acute mania, is reported, as also one of
fatal staphylococcic septicemia and one diagnosed as
leukemia occurring in connection with, and presumably
as the result of. tonsillar disease. The evidence, he
thinks, clinical and exoerimental. tends to shov.- that
more an<l more connection is being established between

the tonsillar cervical route and lung tuberculosis. His-
tological studies alone are insufficient, the proportion
of tonsillar involvement, as shown by Lartigau's results,
in which tubercle bacilli were found in only 2 cases
out of 135, and then only in small numbers, while 12 out
of 75 inoculation experiments gave positive results.
Brown concludes with the statement: "In the study of
portals of entry of disease into the human body, the
pharyngeal and especially the faucial tonsils have an
importance not well enough recognized or understood,
but increasingly appreciated in the light of each new
clinical or experimental study."

The Lancet. June i, 190-.

Multilocular Ovarian Cyst Successfully Removed
from an Infant Aged Eleven Months. — The case is re-
ported by C. W. McCjillivray, into whose hospital
service the child was sent with the diagnosis of tuber-
culous peritonitis calling for surgical intervention. .The
child was ill-nourished, cyanotic, w-ith rapid pulse, dysp-
nea, some diarrhea, and marked abdominal distention.
Nothing could be made out as to the abdominal con-
tents, as the walls were of drum-like hardness. Some
clear yellow- fluid was withdrawn from the abdominal
cavity and finally it was determined that the whole
abdomen from diaphragm to pelvis was filled with a
mass containing separate cavities filled with fluid.
Under chloroform an incision was made to the left
of the middle line just below the umbilicus. A large
cyst came into view and w-as punctured, but only a lit-
tle fluid escaped. The poor condition of the patient
and the fact that a more extensive operation was evi-
dently needed led to a prolongation of the incision up-
ward to nearly the ensiform cartilage. A large double
multilocular cyst was found, the two halves being nearlv
equal in size and attached to each other by loose con-
nective tissue betw-een their fibrous walls. Length, on
removal, was nearly eleven inches and thickness four
to five inches. In spite of the desperate condition of
the child at the close of operation it eventually recov-
ered. The author closes with some remarks on this
class of grnw-ths in young children. Only one younger
•^atient of this class is on record, as the intraabdominal
condition began at the third month of life. .Another
feature was the retroperitoneal position of the tumor,
as shown by the appendi.x, cecum, and ascending colon
lying in front of it and stretched over its surface, and
the fact that the posterior layer of the peritoneum had
to be torn through in order to enucleate the tumor.

Congenital Piles. — J. V. Milward reports three cases
in which a pile-like condition was noted from birth.
Patient i was a male child, aged eleven weeks. There
was a tumor of the size of a large pea, soft in struc-
ture and not inflamed, situated at the anterior margin
of the anus, its posterior margin being flush with the
anal canal. The latter was slightly narrower than nor-
mal, and I dilated it with the finger. The mother stated
that the little lump had been present since birth and
was giving the child pain. It was removed with scis-
sors. Patient 2 was a female, aged four months. The
tumor was situated in the same place as in patient I and
was of about the same size. It was partially destroyed
by ulceration and was somewhat indurated for the
same reason. No stricture of the anus was present.
The growth was snipped off. Patient 3 was a female,
acred eleven weeks. The pile was in the same olace and
was of about the same size as in the other two cases.
Its structure was perfectly healthy and consisted of
fibrous and adipose tissue. The author regards these
small masses as rather of the nature of a malformation
than an outgrowth originating in a dilated venous
radicle.

Value of the High Frequency Spark as a Local Ap-
plication.— E. R. Morton refers to the benefits derived
from the high frequency spark in a certain case of
alopecia areata, and in certain cases also of port wine
marks. In the first case the author used a vacuum
glass electrode connected to the top of the resonator,
rubbing the electrode over the bald patches until a
bright erythema was produced, taking three or four
minutes for each patch. Results were surprisingly
good and after about six months the patient had a
fine head of hair. The effect of the spark is merely
that of a local stimulant. In the port w-ine mark cases
the author used a metallic point electrode mounted on
an insulated handle and connected with the top of the
resonator. The point was held about one inch from
the surface so that a hot white spark jumped across
the intervening space. This was continued for several
minutes until vesication w-as produced over the entire

June 22, 1907]

MEDICAL RECORD.

104.^

surface of the patch. There was no soreness after-
wards worth mentioning and in about eight days the
old epidermis peeled off, leaving a smooth surface, pink
from the remains of intiammatory reaction, but other-
wise quite like normal skin. One great advantage in
such cases is that the normal texture of the skin is
quite unimpaired. There is nothing approaching a
scar — thus diflfering from chemical agents and electro-
lysis. A further advantage is that it is under the
most perfect control and no further reaction takes
place than is desired.

Antityphoid Inoculation. — A recent editorial in the
Lancet (June Ij calls attention to reports by three
English army surgeons. This method, introduced by
Wright in 1897, was tried on a large scale in India and
Egypt with most encouraging results, but after the
Boer war it fell into temporar)' abeyance. In spite of
some opposition the method seems to be winning its
way. Certainly collective evidence is in its favor. Cer-
tain improvements in the preparation of the vaccine
have led to a much milder "local reaction." Inocula-
tion is no longer made in the flank and hence there is
no nain or stififness in walking. Inoculation is now-
made in the arm or pectoral region. The dosage of
the vaccine employed has been fi.\ed at one-half c.c,
containing 500,000,000 bacteria, and for the second in-
oculation the quantitv is doubled. This has been found
to give a maximum protection with a minimum severity
of reaction. It has thus far been found impossible to
standardize the serum. There are now on record a
sufficient number of histories of protective inoculations
to make a very strong showing in favor of the vaccine.
Inoculation does not. it is true, invariably protect, but
it does so to a very large degree. The writer in the
Lancet considers it in every way as necessary for the
protection of the health of the English soldiers in
India as is vaccination against smallpox.

British Medical Journal, June I, 1907.

Two Cases of Multiple Intestinal Obstruction. — The

cases are reported by R. Ramsey, whose first patient
was an old man of eighty-one, who had had a hernia
for many years. Sudden abdominal pains with fecal
vomiting suggested strangulation, but operation re-
vealed no condition connected with the hernia suf-
ficient to account for the fecal vomiting, although the
hernia was found irreducible and was easily, on open-
ing the sac, returned to the abdominal cavity. .V
median laparotomy was done and distended sinall gut
presented. This was followed down and led to a loop
of ileum fixed tightly behind the cecum, evidently be-
ing of the nature of an internal hernia; this loop was
almost black in color, but on reduction appeared viable,
so the abdomen was closed and the patient put back to
bed. Fecal vomiting continued all night, and, as the
patient was rapidly sinking, the abdomen was again
opened in the morning, eight hours having elapsed
since the former operation. Another imnacted and
strangulated internal hernia was discovered, this time
up in the region of the splenic flexure, where the bowel
had got cauffht in a peritoneal pocket; this bowel was
also nearly black, but was treated by simply replacing
it in the abdoinen. Death occurred from pneumonia on
the fourth day. The second patient was a boy of sev-
enteen years, with usual symptoms of intestinal ob-
struction, although the abdomen was not markedly
distended and no local tumor could be felt. On ab-
dominal incision, small intestine, somewhat distended,
presented and on following this down it was found to
go in at the foramen of Winslow; almost three feet of
bowel was pulled out through this foramen; at one
part there was a slight mark of constriction, but there
was nothing which seemed sufficient to account for
the symptoms, so a further search was made and a
long, inflamed appendix was discovered twisted firmly
round a part of the .sinall intestine and evidently com-
pletely blocking it. The adhesions were broken through
and the appendix removed; the small bowel thus freed
was about six inches away from the ileocecal valve, and
it was much congested. Result. — He lived about six
hours after the operation, and during that time his
bowels moved slightly, but the patient failed to rally.
Two New Genera of Nematodes Occasionally Para-
sitic in Man. — R. T. Leiper refers to a certain parasite,
Asccris mystax. which infests our common dogs and
cats and probably most carnivora. Its especial feature
is the spatulate shape of the head produced by two
lateral membranous expansions of the cuticle. The
name given above refers especially to the species found
in the cat. Oth.er species of the same genus are found

in the dog, fox, etc. The author also refers to cer-
tain specimens resembling the .S. mystax found on
post-mortem examination of human cadavers. There
were certain differences, however, and he believes that
the various varieties found are several species belong-
ing to two distinct genera.

Urticaria and Influenza. — J. Reid refers to the case
of a girl of eight years, with an inflamed throat and
consolidation of the base of the right lung. In ad-
dition she presented in front of the neck and on the
nucha large boggv- urticarial patches. Other similar
areas were found on the left shoulder and in the upper
third of the right thigh at its inner aspect. On the
following day no trace of the foregoing rash was vis-
ible, but fresh smaller spots appeared on the right
abdomen. The consolidation had disappeared. On
the next or third day there was no rash and the throat
was but slightly red. The patient was given magnesia
and a simple diet. There was some constitutional
weakness, possibly rheumatic. The child had not been
well suice a diphtheritic attack four years previously,
in which antitoxin had been given, but no rash then
appeared, so far as the author could learn. He re-
gards these localized symptoms as on a par with the
ischemic processes found in connection with influ-
enza, especially convulsive cases.

Eggs in the Diet of Infants. — W. J. Midelton re-
gards milk as a very difficult article of diet to handle
in case of sick children. He now relies largely on eggs
and gives the following proportions for an infant
weighing si.x pounds or more at birth: During the first
two days after birth beat up the raw white of a lara:e
new laid hen's egg, add to this water to make 8 ounces,
also 40 grains of pure cane sugar. Strain through but-
ter muslin. Put i ounce of this into the feeding bottle,
stand it in hot water at 110° until the food is raised to
98° F. Feed every hour and a half. On the third or
fourth day add 5 minims of the yolk of the egg and S
minims of raw meat juice to each feed. Increase the
quantities graduallj' as the child grows older, and also
add codliver oil emulsion to each feed, say 5 minims
of a 40 per cent, preparation. He says that he has
yet to see an infant unable to digest these ingredients
carefully adjusted to the needs of each case.

Berliner klinische IVochenschrift, May 27, 1907.
Clinical Observations of the Index of Refraction of
the Blood Serum, — Engel has carried out a series of
observations on the coeflicient of refraction of the
blood serum of a large number of patients suffering
from such conditions as nephritis, cardiac disorders,
diabetes, mellitus and insipidus, pulmonary tubercu-
losis, liver diseases, etc. The index of refraction has
been shown to be quantitatively commensurate with
the albumin content of the serum and therefore to give
a fairly correct guide to the degree of hydremia. Engel
expresses himself as convinced of the value of the
method, which requires only a single drop of blood,
can be <iuickly carried out, and yields results which
equal in accuracy those obtained by much more com-
plicated procedures. While it does not obviate the
necessity for performing the usual blood examinations,
it supplements these in a useful manner and in many
cases affords diagnostic and prognostic data of consid-
erable importance. By means of a refractomcter it is
possible to carry out accurate observations on the pro-
portion of water present in the blood scrum, which
by other methods is rarely practicable.

Miinchener medizinische IVochenschrift. May 14 and 21,
1907.

The Treatment of Delirium Tremens. — Eichelberg
presents the statistics of the cases of this sort treated in
the Eppendorf Hospital of Hamburg m the past eleven
years. These number in all 1,574, of which 1,043, t!iat is
about a third, were uncomplicated, whereas 531, or one-
third, were attended by more or less serious complications.
Of the total number of cases, 2.4 per cent, ended fatally,
and, including the cases in which there was also pneumonia,
the death rate was 5.5 per cent. The death rate in 173
cases complicated by pneumonia was 33 per cent. In
regard to the treatment the author states that it is cus-
tomary in this institution to withdraw the alcohol at once
and to lay great stress on sustaining the heart action by
the use of digitalis and other stimulants. Diuresis also is
to be encouraged, and in cases complicated by pneumonia
both digitalis and alcohol are resorted to.

Manganese Poisoning. — R. von Jaksch describes four
cases of a peculiar nervous affection occurring in workmen
engaged in the manufacture of permanganate of potas-
sium. The most prominent symptoms are monotonous

1044

MEDICAL RECORD.

[June 22, 1907

scanning speech, uncontrollable weeping or laughing, pal-
sies or contractures of the lower extremities, disorders of
gait, retropulsion. psychical degeneration, and increased
knee jerks. Babinski's sign, nystagmus, and contractures
of the visual fields are not present. The author considers
that this affection of the nervous system is caused by the
inhalation of dust containing subo.xide of manganese,
although other factors may possibly play a role in its eti-
ology. The author also describes another case in which
the patient exhibited a neurosis somewhat resembling the
condition just described, but which was apparently the
result of autosuggestion. For cases of this sort the author
proposes the name of manganophobia.

The Dorsal Foot Reflex. — Lissmann says that in-
sufScient attention has been paid to this refle.x, which
apparently was discovered independently by Bechterew
and Mendel. It is elicited by tapping the dorsum of
the foot on its lateral aspect in the neighborhood of
the cuboid and third cuneiform bones. It is best to use
a percussion hammer and to deliver a blow of moder-
ate intensity. In healthy persons a reflex dorsal tlcxion
of the second to the fifth, or sometimes only 01 the
second and third, toes results, but in organic nerve
diseases accompanied by spastic paralysis plantar flex-
ion results. Lissmann tested the reflex in over 900
persons free from nervous disease and found that in
every instance the dorsal extension was caused. This
was also the case in forty-one tabetic patients, two
cases of paralysis agitans, and eight cases of sciatica.
The reflex was absent in five cases of spinal infantile
paralysis and in general the results corresponded with
those of the Babinski reaction. Contrary to the state-
ments made by- some authors, the refle.x did not appear
in any cases in which the Babinski was negative. By
examining a large number of infants the author learned
that the disappearance of the dorsal foot reflex in
young children corresnonds w-ith the time of disappear-
ance of the- Babinski reflex — that is, about the third or
fourth month. This association of the two reflexes
seems to indicate that, like the Babinski, it depends on
the integrity of the pyramidal tracts and that it there-
fore deserves recognition as a diagnostic sign.

Doderlein's Method of Skin Sterilization. — Littauer
says that in spite of the various methods of sterilizing
the skin that have been proposed, it is still impossible
to free the parts surrounding the operative field from
germs with sufficient thoroughness to insure uncom-
plicated healing of the incision. \'arious methods of
coating the skin with impervious substances have been
proposed, but the most effective is that of Doderlein,
because in this the skin is tanned as w-ell as covered
with a protective layer. The fluid used is a solution
of rubber in benzine, to which formaline has been
added, and the resulting membrane is easily soluble
in ether, benzine, and chloroform. Doderlein's method
of disinfecting the skin is as follows: The evening be-
fore the operation the patient is bathed and the opera-
tive area is shaved; a I per cent, formaline compress
is applied to the area in question and left on over night.
On removing the compress the skin is brushed over
with I per cent, formalin-benzine and tincture of iodine
is painted on. As soon as this is dry the rubber solu-
tion is applied; when the benzine has evaporated the
sticky film of rubber is sprinkled with sterilized talcum
powder and the excess of this is brushed away with a
piece o! sterile gauze. The results obtained by the
use of this method are excellent and by' its means all
skin germs are effectually prevented from entering the
wound.

Deulsche mediciitischt' Wochenschrift, May 9, 16, and 23,
IG07.

Abscess of the Liver Following Influenza. — Karewskj

says that Langenbach and Korte have called attention to
the fact that abscess of the liver sometimes occurs as a
sequel of influenza, and he reports a case of his own which
was attended by this complication. The patient was a
man of twenty-five years, who fourteen days before com-
ing under Karewski's otsservation had suffered from an
attack of influenza. This subsided in the usual way. but
the patient failed to regain his strength and on examina-
tion of the chest signs were discovered pointing to empyema
of the right side. After resecting a portion of the tenth
rib and incising the costal pleura, a considerable quantity-
of sero-purulent fluid escaped and from one angle of the
wound thick pus could be seen welling up from below. The
pleural cavity was closed by suture and tamponade and the
deeper collection of pus. which was found to come from
an abscess cavity in the liver, was evacuated. After a
protracted convalescence the patient recovered completely.

In this case there were no other etiological factors to ac-
count for the hepatic abscess and the patient's subsequent
freedom from all symptoms makes it seem certain that
the suppurative process in the liver was the result of the
grip infection.

Acute Myelogenous Leukemia. — Ziegler and Joch-
mann are of the opinion that in many cases of leukemia
there is a relationship between bacterial infection and the
origin of acute, and probably also of chronic, forms of
the disease. This may not be the result of specific action,
but may be induced through damage to such organs as the
spleen or bone marrow, a.s the result of which myelogenous
leukemia may develop. They report a case in support of
this view, the patient being a boy of fifteen years, who suf-
fered from a staphylococcus sepsis apparently resulting
from a throat infection. This led to a hemorrhagic peri-
carditis, and fourteen days after the onset of the acute
infection the blood was suddenly flooded with myelocytes,
so that two days after having contained only 18,000 leuco-
cytes to the cubic mm. the blood count revealed 240,000
leucocytes to the cubic mm. Death took place two days
later and at autopsy the spleen showed myeloid changes
and hyperplasia of the bone marrow.

A Skin Disease in Man Caused by a Parasite of the
Dog. — Lewandowsky says that while it has usually
been considered that the Demodex foUicularis hominis is
a harmless saprophyte present in the hair follicles of a
large proportion of the population, it now appears that in
some instances it is able to give rise to pathological changes
in the skin. Several instances of peculiar circumscribed
areas of facial pigmentation have been described which
were apparently due to the presence of large numbers of
this parasite. In one instance a peculiar form of blephari-
tis was caused in which the demodex was present in great
number in the follicles of the eyelashes. The author's own
case was peculiar in that the organism giving rise to the
lesions w-as of the canine type, Demodex foUicularis canis.
The patient was an Italian laborer suffering from an
impetigo-like eruption about the face. On examination of
material taken from the lesions the organism above men-
tioned was readily discovered. Under the application of a
mild antiseptic powder the condition quickly improved.
The manner in which infection took place could not be
ascertained.

The Treatment of Leprosy. — Diesing speaks highly of
the use of iodoform injections in leprosy, and says that by
their means all the lighter uncomplicated cases and a large
proportion of the advanced cases may be cured. The prep-
aration used consists of a mixture of 30 g. of iodoform in
90 c.c. of pure olive oil sterilized for ten minutes on the
v/ater bath. Before beginning the treatment the patient's
susceptibility to iodoform is tested by giving two injections
two days apart of .5 c.c. each of the emulsion. If the de-
velopment of eczema or fever indicates an idiosyncrasy on
the part of the patient it will be necessary to use caution
in gradually increasing the dosage to the normal amount of
2 c.c, but otherwise daily injections of this amount may
be commenced with at once. These are continued for fif-
teen or ti.venty days with occasional intermissions, so that
a month is consumed, and then after a rest of two weeks
a second course is given. Certain patients do not do well
under the injections, and for them the method is contra-
indicated ; such are patients with mental disorders, those
showing leukemic changes in the blood, and patients with
weak hearts.

The Traumatic Causation and Operative Treatment
of Paralysis of the Serratus. — Samter discusses the sub-
ject of traumatic paralysis of the serratus magnus and
comes to the conclusion that in most cases it is caused
in the following way: The long thoracic nerve as it
descends vertically over the side of the thorax is in
such a position that it can be pinched between the
coracoid process and the first rib if the scapula is
forcibly pressed against the chest wall. In this way
the nerve, particularly in persons in whom the muscle
is poorly developed and there is inadequate padding
of fat. may be damaged seriously enough to occasion
a paralysis of the muscle, and somewhat sim)Jar con-
ditions obtain in certain cases of so-called congenital
serratus palsy, which probably result from manipula-
tions during labor such as are necessary when an arm
has to be brought down. The author was able to treat
successfully, by means of a plastic operation, a trau-
matic serratus palsy occurring in a girl of eleven years,
who had fallen against a ladder. After eleveri months
of unsuccessful electrical and other conseri-ative treat-
ment, the long thoracic nerve was exposed by a verti-
cal axillary incision, but was found electrically in-
active. The lower half of the brachial attachment of
the pectoralis major was removed with a periosteal flap

June 22, 1907]

MEDICAL RECORD.

1045

from the humerus and transplanted to the angle of the
scapula. The functional result of the operation was
excellent and the deformity was almost completely
eliminated. The author recommends the procedure in
all traumatic palsies of the serratus, in congenital de-
fects of the muscle, and in other forms of palsy of this
type, unless there is present a rapidly progressive
causati\e nerve lesion.

French and Italian Journals.
Inflammatory Neoplasms of the Pelvic Colon. — P.
Cavaillon and Bardin include in inrtaminatory neoplasms
tuberculous neoplasms with and without tubercles, syphi-
litic neoplasms, and true inflammatory neoplasms, due gen-
erally to infection by germs within the intestinal lumen.
The tubercular lesions may be in the active stage, with
bacilli included in tubercles, or in the cacatricial stage,
when the original tissue has been displaced by sclerosed
masses. These scleroses may be produced by toxins alone
without bacilli themselves being present. The endoiiites-
tinal and periintestinal inflammations that occur aside from
syphilis and tubercle result from the microbes habitually
present in the intestine, and ordinarily harmless. They
are associated with infection in the intestinal diverticula
and inflammatory pericolitis. The diagnosis of inflamma-
tory neoplasms is rarely made until the abdomen has been
opened for operation, or at the autopsy. Cancerous growths
are small, circumscribed, and produce marked stenosis,
while the inflammatory growth is much more diffused,
involves a longer section of bowel, and the infiltration of
the coats is more marked and of uniform contour. The
bowel feels thick and softer, though coarser. The peri-
toneal reaction about the tumor is marked, the omentum
is adherent, and there may be small abscesses in its mass.
The walls are very thick and partially close the lumen,
while above them the intestine is dilated and the mucous
membrane ulcerated. All the coats in simple inflammatory
neoplasm present lesions of simple inflammation, but the
jiost marked are in the submucous layer, arising from
mucous diverticula and glandular culs-de-sac. There are
three types of tuberculosis in the sigmoid fle.Kure : ulcer-
ated tubercles, hypertrophic tuberculosis, with or without
specific lesions, and plain inflammatory tuberculosis. In
the hypertrophic form there may or may not be tubercles
present. The walls are much thickened, especially the
submucous layer ; there is sclerolipomatous change in the
walls, adhesions, and enlarged glands. The characteristic
of tuberculosis without tubercles is that of submucous
sclerosis with rare giant cells. Inflammatory tuberculosis
arises from the defensive reactions of the intestine, and
is characterized by cicatrization. Such lesions may result
from retrograde changes in tubercular tissues, or from the
simple action of the tubercular toxins. Syphilitic neo-
plasms with inflammatory tumors are most marked in the
submucosa, and the sclerotic changes begin about the ves-
sels. The pathologic differences between these types of
chronic inflammation are marked. The simple inflamma-
tory growths arise around glandular tubes and diverticula.
In syphilis sclerosis is perivascular; in tuberculosis there
are localized lesions in the submucosa, or diffused lesions
unlocalized. The same symptoms are common to all : oc-
clusion of the pelvic colon, or suppuration in the iliac
fossa, alternating diarrhea and constipation, blood and
mucus in the stools, sometimes tenesmus and distention
of the intestine above the growth. Cachexia may be
marked. These tumors are benign in themselves, malig-
nant in their evolution. Treatment is generally operative.
Suppuration requires drainage ; perforation requires lapa-
rotomy : acute occlusion requires an artificial anus. Radi-
cal operation is satisfactory in theory, and many cases re-
cover after laparotomy with colectomy. Some recover
without operation bv retrograde metamorphosis under pal-
liative treatment. Inflammatory tumors require incision
when pus collects and medical treatment afterward. Acci-
dents demand ileoresection. Tuberculoma, outside of com-
plications, or cicatricial metamorphosis, requires ablation
in three stages. — Gazette dcs Hopitaux, February 5 and
12, IQ07.

Treatment of Ophthalmic Migraine and Ocular
Troubles of Dyspeptic Origin. — Albert Robin describes
several varieties of ophthalmic migraine. In the most
severe the migraine is preceded by a singular aura
of lightness and levity some hours after a meal;
suddenly vision recedes as if a thick shadow had
passed over the patient. A portion of the vis-
ual field is obscured and there is hemianopsia,
temporal generally, sometimes horizontal. There is painful
cardiac palpitation and agonizing intermittence. Brilliant
lines appear before the eyes, which form quickly changing
geometrical figures. The eye becomes painful and seems
pulled into the orbit. There is formication of the opposite
side of the body, the limbs weaken, speech is embarrassed.

and memory fails. Gastric cramps come on and a violent
migraine. In other cases the symptoms are similar but less
severe. The treatment of this condition should not be
given to the oculist, since the seat of the trouble is in the
digestive canal rather than in the eye. In other persons
who read or write much dyspepsia brings on muscular
and accommodative asthenopia, which is only temporary.
There is congestion of the lids, and a feeling of sand in
the eye. There may be slow and painful accommodation,
sensation of fog before the eyes, or abnormal perception of
colors. The author rejects the theory of autointoxication
as a cause of these symptoms, and believes them to be
reflexes of the vasomotor enervation of the optic nerve,
dut to tetanizing of the walls of the vessels supplied by
the great sympathetic. These patients should be placed on
a strict diet and hygiene. They should stop mental work
and take physical exercise, eat plain food, and omit cof-
fee, tea, alcoholics, and tobacco. Bitter tonics and nux
vomica should be given before meals, alkalies after eating.
The bowels should be kept in order and a daily bath or
hot douche enjoined. For the attack large doses of bro-
mide of potassium, washing out the stomach, antipyrin, and
massage are the best remedies. For muscular asthenopia
rest and prisms with the base in should be used. — Le
Progrcs Medical. February 16, 1007.

Treatment of Cancer of the Cervix. — Joseph Godart
says that recurrences in cancer of the cervix occur in the
neighboring glands rather early, due to insufficient removal.
The glands that are first invaded in this form of cancer are
the juxtauterine, sacral, iliac, and hypogastric; next come
the lumbar ; last, the inguinal and peri-inguinal. The glands
are involved in twenty per cent, of all cases. The para-
metrium is involved in seventy per cent, of the cases, and
should always be removed. The tendency is to more thor-
or.gh removal of the glands and all structures that can
possibly be involved. In some cases glands that are en-
larged are only the seat of inflammatory lesions. Contra-
indications to hysterectomy are anemic cachexia in old
subjects, albumin in urine, uremia, and edema of the legs.
Hydronephrosis and pyonephrosis due to involvement of
the ureters and extension to the bladder contraindicate
operation. If only the vagina is involved aside from the
uterus, operation may be done. Fifty-si.x per cent, of all
cases may be operated on by the abdomen, and only thir-
teen per cent, by the vagina. The best method for opera-
tion is abdominal hysterectomy. A prclimiiiary curetting
will remove edema and permit of better antisepsis. This
should be done a week before operation. Abdominal op-
eration enables the surgeon to judge better of the involve-
ment above the cervix, the condition of the adnexa, intes-
tine, and bladder. When there is too great involvement
to permit of successful removal the incision may be only
exploratory. Increased gynecological knowledge among
physicians, with an earlier diagnosis, and a belief in the
curability of cancer, and greater knowledge on the part of
women in general of the importance of medical advice for
irregular hemorrhages will improve the results of opera-
tion on cancer of the cervix. — La Polielinique. January 15,
IQ07.

Interauricular Insufficiency. — H. Roger describes
a syndrome in which there is no sign of cardiac insuf-
ficiency discoverable by auscultation, but still the integu-
ment of face, hands, and feet are of an intense blue, the
lips are swollen and cyanotic, and this cyanosis persists.
Examination of heart, lungs, and other organs gives no
clue to the cause of the symptom. The condition may go
on progressively increasing until death occurs. In such a
case observed by the author the autopsy revealed an open-
ing of the nature of a canal between the two auricles. It
was discovered by pouring water into one auricle and al-
lowing it to flow toward the other, when it was found to
flow into the second auricle, from right to left. In most
published cases of auricular insufficiency a canal has beeti
found directed from behind forward, from right to left,
and from below upward. The walls are formed by the
muscular ring which surrounds the fossa ovalis and the
valve of Vieussens. The valve, instead of becoming ad-
herent, remains free. When there is pulmonary stasis the
pressure rises in the ri.ght auricle, the blood is pressed
back behind the valve, opens the orifice, and a communica-
tion is produced between the auricle, a current flowing from
right to left. The mixing of venous and arterial blood
explains the cyanosis. In order that the difliculty may
occur the blood pressure must rise in the right auricle, as
happens in pulmonary troubles, especially emphysema. The
author believes that many apparently normal individuals
have a patulous canal, and are thus exposed to these symp-
toms in the event of pulmonarv trouble. In them we may
diagnose interauricular insufliciency in the presence of an
inexplicable cyanosis. — La Presse Medieale, February 6,
1907.

1046

MEDICAL RECORD.

[June 22, 1907

iSnnk SrutPUJs.

La Stekilite chez la Femme. Son Traitement par les
Agents Physiques. Par le Dr. E. HuGON, Ancien Chef de
Cliniqne Gynecologique. Paris ; Vigot Freres, 1907.
This brochure enumerates the various conditions which
are responsible for sterility in woman ; it also gives sug-
gestions for the treatment of the same by means of mas-
sage, electricity, or hydrotherapy.

Die Roentgenstrahlen im Dienste der Neurologie. Von
Dr. WiLHELM FuRNROHR, Nervenarzt in Niirnberg,
Friiher Assistant der Prof. Oppenheim'schen Ner-
venpoliklinik in Berlin. Mit einem Vorwort von Prof.
Dr. H. Oppenheim. Mit 28 Abbildungen. Berlin: S.
Karger, 1906.

The majority of text-books on the Roentgen rays deal
so largely in the general technique and general applica-
tions of the method that they find but little room for the
special details of interest solely to the neurologist, which
concern the diagnosis of diseases of the cerebrospinal and
nervous systems. This defect has been amply supplied in
Dr. Ftirnrohr's excellent monograph. He deals with the
applications of the ^--rays in injuries as well as in diseases
of the brain, the cord, the nerves, etc., and thus his book is
of interest to surgeons as well as to neurologists. It is
now over ten years since Roentgen told the world of his
wonderful rays, and in these years an enormous amount
of work has been done with this new tool of the physician.
That much of this work is applied in neurology is shown
very clearly in the present volume.

Beginning with some elementary anatomical notes, the
author passes on to acute bone atrophy as a subject worth
considering in view of the fact that this condition was but
recently described (1900) by Ludek, who found that certain
bones, as those of the hand, atrophy rapidly in the presence
of inflammatory joint affections, etc. The next chapters
deal with diseases of the cranium, brain, cord, etc., the
spine, the limbs, etc. (as connected with neurological condi-
tions) and such diseases as acromegaly and myxedema. The
book shows well how much neurology owes to the .r-rays.
Thus these rays showed that the sella turcica becomes
broadened in acromegaly ; that in myxedema there is a re-
tarded bone development, etc. There is no doubt that in
the future the neurologist will gain much information as to
the exact progress of arthropathies, etc., with the aid of
the .r-rays.

Anesthetics and their .A.dministr.\tion. A Text-book for
Medical and Dental Practitioners and Students. By
Frederic W. Hewitt, M.V.O., M.A., M.D. Third
edition. London: Macmillan & Co., 1907.
Dr. Hewitt's name is probably more closely connected
with the science of modern anesthetics than that of any
other man. The third edition of his book contains all that
has been done during the last six years in this branch, the
new chapters taking up ethyl chloride, the addition of many
fresh and important clinical facts regarding surgical shock,
and a careful resume of the important question of the rela-
tion between general anesthesia and "acid intoxication."
Dr. Hewitt's work is in a sense a demand for a more gen-
eral recognition of the value of the anesthetist. The book
contains practically everything of value on the subject
which would be of service to the student or the prac-
titioner. The American reader will miss, however, some
of the forms of apparatus which are widely used in this
country, but otherwise the work is very complete and con-
stitutes an excellent manual on what is daily becoming a
more important specialty.

Studies in Urological Surgery. The Johns Hopkins
Hospital Reports. Volume XHL Baltimore: The Johns
Hopkins Press, 1906.

These studies are edited by Professor Hugh Young of
Johns Hopkins, with the collaboration of his associates at
the University and the Hospital. Some of the articles are
reprinted from the journals in which they appeared origi-
nally, and there are in all twenty-one papers in the volume.
It is only at such an institution as Johns Hopkins Hos-
pital, where all the equipment, all the trained assistance, and
all the material support needed are available, that such
magnificent original work can be produced. Some
of the papers are in truth classics of their kind, and while
it is impossible to give the entire list, we must mention the
papers on stricture by Hugh Young and John J. Ger-
aghtj-, and on chronic prostatitis by Young. Geraghty-, and
A. R. Stevens. There is also the very thorough study' en-
titled "The Seven-Glass Test" by Young, which opens the
volume. These three articles are remarkable for the e.x-
haustiveness, completeness, and thoroughness with which
they cover their themes. The minute and painstaking re-

search on prostatitis, with a tabulation of 358 cases, is
especially worthy of notice as a most important contribu-
tion to this rather obscure subject. A detailed description
of the genitourinary department of the Johns Hopkins
Hospital is given in an appendix to the volume, and makes
interesting reading for those who would like to know the
conditions under which .such excellent work as this can
be done.

Xervenkranheit vsu Lekture; Nervenleiden und Erzie-
hung; die ersten Zeichen der Nervositat des Kindesalters.
Drei Vortrage von Prof. Dr. H. Oppenheim. Zweite
Auflage. Berlin : Verlag von S. Karger, 1907.
These are three lectures delivered at various times and
constitute excellent sermons on the relation of a number
of influences during childhood on the production of nervous
states. He shows that the latter may be fully controlled
by proper educational means. In the third lecture it is
shown that the child manifests evidences of neurasthenic
states at a very early age which should be immediately rec-
ognized. Particular instruction in these symptoms should
be given to those in charge of children, the knowledge of
which should serve as warnings, so that proper medical
authority and advice may be consulted in time to accomplish
immediate good. Although it may be impossible to cor-
rect an hereditary or congenital neuropathic constitution,
much may be done to reduce the chances of a further devel-
opment of these latent symptoms by the application of
proper educational measures.

Nierenchirurgie, Ein Handbuch fiir Praktiker. Von
Prof. Dr. C. Garre und Dr. O. Ehrhardt. Berlin : S.
Karger, 1907.

This excellent German manual is intended to furnish the
general practitioner with a complete resume of the sub-
ject of renal surgery. The writers have drawn largely
from their own experience in gathering the material for
the work, which is thus given a more or less personal char-
acter. Only those facts are included which have shown to
be true by actual test. The illustrations are new and well
selected and considerably better than those met with in
most German medical books. The te.xt is clear and concise
and the book constitutes a valuable rr/anual on the subject.
A good English translation would undoubtedly meet with
a favorable reception.

Medical Diagnosis. A Manual of Clinical Methods for
Practitioners and Students. Fifth Edition. Greatly En-
larged and Revised to Date. By J. J. Gr.\ham Brown,
M.D., F.R.C.P.E., F.R.S.E., Assistant Physician, Royal
Infirmary of Edinburgh, and W. J. Ritchie, M.D.,
F.R.C.P.E., F.R.S.E.. Clinical Assistant Pathologist
Royal Infirmary of Edinburgh. With 200 Illustrations
and eight full-page Plates. New York : Imperial Pub-
lishing Company, 1907.
The well-known manual of diagnosis by Brown and
Ritchie appears in a new, thoroughly revised edition, add-
ing to the already comprehensive material of the former
issues the latest advances in its rather wide field. The
revision has really been done with much care and with
excellent judgment, and we know of no single volume that
can give the practitioner and the student a more compact,
yet sufficiently complete body of facts and figures, covering
every important diagnostic method. The book combines
the diagnostic methods used at the bedside and in the
physician's office with the methods employed in the labora-
tory, and covers every phase of the subject of physical
diagnosis, chemical, microscopical, and bacteriological ex-
aminations. Naturally, it does not go into the minutest
details on some of the topics, but it is more than suffi-
cient for all practical purposes, especially for the physician
who does his own laboratory work. We might mention
as an example of its up-to-dateness that Wright's method
of opsonic inde-x is quite fully described, the technique
being given with sufficient detail to enable one to under-
stand the process quite dearly-. We find nothing said, how-
ever, of the spirochete in syphilis.

Regimes Pathologiques et Regime P.\rfait. Par Dr. F.
Cayla, Ancien Chef de Clinique a la Faculte de Bor-
deaux. Paris : Vigot ;Freres, 1907.

Cayl.Vs manual differs from other works on diet, in that
it consists largely of menus for the various meals of
patients with dififerent diseases. In addition, under the
heading "the perfect diet," there are given dietetic direc-
tions for convalescents and for people who are e.xposed to,
or predisposed to, diseases of the gastrointestinal tract,
etc. In the concluding chapters are given the chief facts
of interest concerning the various classes of food prod-
ucts. But little attention is paid to ultrascientific methods,
measurin.g calories, and the like, and the book is primarily
designed for busy physicians.

June 22. 1907]

MEDICAL RECORD.

1047

AMERICAN PEDIATRIC SOCIETY.
Nimteenth Annual Meeting, Held in Washington, D. C,

May 7, 8, and 9, 1907, in Conjunction zvith the Congress
of Americc.n Physicians and Surgeons.
(Special Report to the Medical Rfcurd )
President B. K. Rachford, IM.D., of Cincinnati.
(^Continued front page 874.)
Wednesday, May 8 — Second Day.
Pseudomasturbarion in Infancy. — Dr. B. K. Rachford
of Cincinnati read this, tlie President's address. The de-
tailed cases upon which it was founded included the speak-
er's own cases and a number reported to him by members
of the Society in response to letters addressed to them.
In the discussion of the disease the writer considered age
the most important etiological factor, and nearly all of the
cases occurred in female children. The anatomical and
physiological condition of the organs of generation of the
infant were considered in detail. The external genital or-
gans were well developed in physiological function from
birth, although the internal organs were not. For this
reason there could be a syndrome complex closely resem-
bling the sexual feeling. True masturbation occurred after
the age of ten. True masturbation occurred oftener in
males ; pseudomasturbation oftener in females. Later it
could be classed among the habit neuroses. Environment
was of the greatest importance in keeping up the habit.
Heredity played a large part in establishing the predispo-
sition, and gouty inheritance might be one of the predis-
posing causes. Acid condition of the urine had been found
to be a frequent cause, as was also constipation. Of fifty-
two cases presented, twenty-five were cured, and in only
two was treatment of no avail. The writer was convinced
that pseudomasturbation occurring in children under two
would in time get well under almost any form of treatment ;
the tendency was to spontaneous recovery. There was no
connection between pseudomasturbation in infancy and true
masturbation in later life, though the former might tend to
develop the latter. There was no connection between
pseudomasturbation and epilepsy, and the writer had never
seen these two neuroses coexist.

Dr. Jacobi of New York did not agree with the essayist
that masturbation in infancy and childhood was not the
same as the masturbation of adult life; he believed it
should be classified with masturbation of more mature life.
It showed itself by the same excitement — interrupted res-
piration, redness of the face, staring eyes, large immobile
pupils, perspiration, and convulsive twitchings, as in the
adult, and he looked upon it as the same condition.

Dr. L. Emmett Holt of New York referred to the fre-
quency of the habit in mentally defective children, and
considered it the rule with them rather than the exception.
He thought the mental defect the cause rather than the
result in these cases. He had not seen any case where the
mental defect was traceable to tlie habit. He did not look
with favor upon the appliances for mechanical restraint in
these cases, nor upon the metliods of stripping back the
preputial hood. His cases had l)een nearly all in females.

Dr. Henry Koplik of New York did not believe tliat true
masturbation could exist in the infant because it pre-
supposed intention and a resulting nervous explosion. He
had found, as the other speakers had, that the great major-
ity of cases were in females. He considered that the neu-
rotic tendency was the chief factor.

Dr. C. G. Kerley of New York was in accord witli the
views expressed in the paper, except that he thought that
in patients over four years of age the prognosis was not so
favorable. The cases were often discouraging, and treat-
ment had to be carried out for a long time. He exhibited
an appliance for mechanical restraint that he had found
useful.

Dr. Maynard Ladd of Boston showed a device for
mechanical restraint similar to that employed by Dr.

Kerley, consisting of a long section with two cross bars,
which kept the thighs about one and a half inches apart,
while allowing free movement of the legs.

Kernig's Sign in Infancy — A Study of Two Thou-
sand Cases. — Dr. John Lovett Morse of Boston presented
this paper, in which he concludes that Kernig's sign is
almost never found in infancy, except in tneningitis; that
its presence in an acute disease justifies, so far as one sign
can, the diagnosis of meningitis ; that it occurs with equal
frequency in all stages of the disease and has no connection
with the degree of intracranial pressure. It has no value
in diagnosticating between cerebrospinal and tuberculous
forms of meningitis.

Dr. Henry Koplik of New York agreed with Dr. Morse
that Kernig's sign as a diagnostic element in forms of
meningitis in infants under two years of age is of very
little clinical value. He said the sign should not be con-
fused with a condition of myotonic contraction.

Bacteriology of Meningitis. — Dr. F. S. Churchill of
Chicago read this paper. Only the known bacterial cases
were reviewed. Six cases showed meningococcus ; one
case pneumococcus ; one case pneumococcus in the spinal
fluid ; one case primary tubercle bacilli ; one Klebs-Loeffler
b.Tcillus; one case syphilitic; four undetermined cocci; four
no organisms in the spinal fluid. The meninges, like other
parts of the body, might be attacked by a variety of organ-
isms; 80 per cent, of the trouble due to meningococcus.
Next to the meningococcus, pneumococcus was the most
frequent cause. Mode of access to the meninges through
the throat and nose. Diagnosis between the different tj-pes
could not be made from the clinical picture, but only from
spinal puncture. Mixed infections were infrequent. The
organism could be found in the nose and throat of healthy
individuals living in close proximity to patients ill with
meningitis, and these patients should be isolated. The
meningococcic cases should always be quarantined, and
probably the pneumococcic ones.

Grip Meningitis. — Dr. Samuel S. Adams of Washing-
ton reported this case, the child when first seen being
supposed to have an attack of indigestion, had a temperature
of 106°, pulse 140, and the writer made the diagnosis of
grip, which was confirmed by several eminent consultants.
Complained of headache and of being tired. Blood exami-
nation showed nothing of importance. An otologist ex-
cluded any disease of the middle ear. Then Kernig's sign
developed; symptoms of meningitis; lumbar puncture per-
formed ; two ounces of fluid withdrawn, wdiich showed the
presence of influenza bacillus. This was the first case
reported by an American in which the diagnosis had been
confirmed by finding the organism in the fluid of lumbar
puncture.

Dr. Henry Koplik of New York said he had before
mentioned a case similar to this of Dr. Adams, and had
since had another case.

Dr. L. E. LaFetra of New York reported a case of tuber-
culous meningitis with a terminal infection of pneumo-
coccus : also a case in which at autopsy the influenza bacillus
was recovered in the pus.

Dr. L. Lovett Morse of Boston disagreed with Dr.
Churchill as to the necessity of isolating meningitis cases ;
he did not believe the danger of contagion was very great.

Dr. Hamill of Boston reported a case in which the tuber-
cle bacillus was isolated from the spinal fluid, with recovery
of the patient. He agreed with Dr. Churchill as to the
necessity of isolating these cases.

Dr. Jacobi of New York agreed with Dr. Morse that it
was not practicable to isolate these cases.

Congenital Stenosis of the Duodenum. — Dr. H. L. K.
Shaw and Dr. Leon Baldauf of .\lbany presented this
case of congenital stenosis of the duodenum, exhibiting
photographs of the condition and the specimen. Child born
after normal labor; twelve hours after birth passed me-
conium; placed at breast and vomited small amount of
greenish fluid some time later. During next two days

1048

MEDICAL RECORD.

[June 22, 1907

vomited greenish fluid a number of times; seemed hungry
and cried as if in severe pain; nursing discontinued, and
barley water and whey substituted; meconium and some
brownish fluid passed. Operative procedure postponed in
the hope that the condition might be spastic. Ten days
after birth had lost 2;4 pounds. Died thirteenth day after
birth. There was stenosis of the bowel below the opening
of the bile duct.

Thursday, May 9 — Third Day.

The Caloric Value of Modified Milk in Its Relation
to Infant Feeding. — Dr. Maynard Ladd of Boston read
this paper, which consisted of a series of cases studied by
the writer, in which the rate of growth in relation to the
number of calories taken had been estimated. The series
comprised twenty cases, and tables were shown exhibiting
the weight development. Great variation was noted be-
tween the calories taken and the gain in weight, and the
writer concluded that the calories in the food of the infant
in the first year of life could not be furnished by fats and
proteids vicariously; that a given number of calories did
not necessarily cause the same rate of growth, even when
of the same age and development; that the caloric value
of the food is not the most important consideration in de-
termining the quality of the infant's food. Neither the
number of calories, nor the energy quotient, could be deter-
mined accurately.

Dr. L. LovETT Morse of Boston considered the American
method of feeding better than the German, but thought the
good points should be taken from both. He estimated the
food in calories from time to time chiefly to make sure in
cases of difficult feeding that he did not get the total
amount too low.

Dr. Henry Koplik of New York called attention to the
amount of waste in the gut. which he said was absolutely
undeterminable. He thought that the percentage method
was not the only way of feeding a baby successfully ; in
buttermilk feeding, even though the percentage food con-
tained more calories, the waste in the gut in liberating the
food was such that the baby might do better on buttermilk.
Dr. Freeman of New York deprecated the tendency to
feed the babies on proteids of less than i per cent., and
thought that if attention were paid to the matter of caloric
values better standards would be obtained.

Dr. L. E. LaFetra of New York emphasized the points
made by Dr. Morse and Dr. Freeman, and thought it would
be enlightening if we could determine the lower limits of
caloric value to be supplied by the proteids; the upper
limits could be determined by the digestive capacity of the
infant.

Dr. Thomas Morgan Rotch of Boston protested against
the habit of speaking of any method as an ideal method.
Cases should not be treated with any one method alone.
\\'hat should be insisted upon was that the method used
should be exact.

A Case of Myxedema. — Dr. Geo. N. Acker of Wash-
ington presented this case, which was a child healthy until
eighteen months of age, when he presented it to the society
in Raleigh in 1903 ; it was then a typical case of myxedema.
It had been upon thyroid gland treatment since, and was
now a well developed child and in good condition ; gained
seven inches during the first year; height now forty-one
inches.

The Symptoms of Status Lymphaticus in Infants and
Young Children. — Dr. John Howland of New York had
observed over twenty-five cases during the last year. No
gland weighing less than 10 gm. was considered pathologi-
cal; the average weight of the gland during the first two
years being 6 gm. To be on the safe side he had included
none weighing less than 15 gm. .Ml the tissues of the
body were hyperplastic, including tonsils and adenoids.
The changes consisted of a hj'pcrplasia of tissue normally
present. Symptoms were sudden death at beginning of an-
esthesia, administration of antitoxin, or tlie child might die

suddenly in bed ; in another group, the characteristic symp-
toms were, with or without some indisposition the child
becomes suddenly ill ; rapid, gasping respiration, with cya-
nosis ; attacks of convulsions ; temperature in majority
very high, 104° to 107°. The dyspnea not an obstructive
dyspnea, but toxic in character. These cases were usually
called acute congestive bronchopneumonia. A rarer form
were those cases associated with purpura.

Dr. Blackader of Montreal had had a very painful ex-
perience with one of these obscure cases, in which death
had been attributed to change of nurses; autopsy showed
a greatly enlarged thymus, 18 or 20 grams.

Dr. Thomas Morgan Rotch of Boston said this was a
subject the knowledge of which should be more widespread,
as the cases were often not recognized.

Dr. S. M. Hamill of Boston was glad to hear the writer
take the view that these cases were of toxic origin. There
was great similarity between the condition and the infec-
tions— in the character of the dyspnea, its irregular nature,
and in the cyanosis and convulsive seizures.

Dr. Howland, in closing, said he had not observed a
case that had recovered, except the one in which the thymus
acted as a foreign body, obstructing respiration.

A Study of the Early Conditions of Osteomyelitis in
Young Children by the Roentgen Ray.— Dr. Thomas
Morgan Rotch of Boston had been making a study of
this condition by means of the .r-ray, for he had concluded
that delay in diagnosis, as in appendicitis, might mean
death, or deformity that could not be remedied. To ac-
complish this early diagnosis the .I'-ray was of inestimable
value and in a number of cases it could only be diagnosed
by that means. The .r-ray should be used at once with
the earliest appearance of the symptoms. Photographs
illustrating the writer's remarks were shown and he
enunciated the importance of remembering that cases of
osteomyelitis were not so rare and that in most cases
early operation was what would save the limb from de-
formity and in many cases save the child's life.

Dr. Samuel .'\dams of \^'ashington thought that in most
cases the physician was more capable of making a correct
diagnosis in these cases than the surgeon and deprecated
the habit of turning the cases over to the surgeon until
every means of clinical diagnosis, including the .v-ray, had
been utilized.

Dr. F. S. Churchill of Chicago agreed with Dr. .■\daras
as to the attitude of the physician towards the surgeon in
these cases, and reported a case occurring in a girl of
eight }'ears, involving both tibia, both radia and the fore-
head, following in the wake of a severe typhoid. Tj-phoid
bacilli were recovered from the pus at operation.

Dr. L, E. La Fetra of New York emphasized the fact
that these cases are not infrequent ; he had seen ten in the
last five years. Early treatment in these cases would save
the limb.

Dr. Rotch thought the expert opinion of both surgeon
and laboratory man was of the greatest importance, and he
had a very strong faith in the surgeon. It was only by a
combination of all these opinions that the best results could
be obtained.

A Case of Chylothorax. — Dr. C. G. Jennings of Cin-
cinnati reported this case, an infant, nine years of age,
presented with dyspnea. .An acute catarrhal affection some
weeks before and following that persistent fever and symp-
toms that pointed to pneumonia. There were physical
signs of pleural exudate and it was thought to be a case
of empyema. Aspiration revealed instead of pus, chjde ; first
aspiration, 12 ounces. Chest aspired thirteen times and peri-
toneal cavity once. The child presented practically no
sjTiiptoms when the fluid was not present. Tuberculin
used without reaction. The fluid had all the chemical qual-
ities of chyle and the microscopic picture was that of chyle.
The Need of Greater Accuracy in Prescribing Starch
in Infant Feeding. — Dr. Maynard Ladd of Boston read
this paper, which was designed to bring out one point, the

June 22, 1907]

MEDICAL RECORD.

104c

great indefiniteness of physicians in the use of the cereals.
The paper presented a plea for more accurate methods of
prescribing starches in percentages as with fats and pro-
teids. In the barley water mixtures there was great varia-
tion in the amount of starch contained, and the inaccuracy
due to this was responsible for many of the cases in which
the child was not supposed to be able to digest starches at
all. Formulas varied from 0.64 to 6 per cent. Using the
minimum or maximum solutions as diluents the amount of
starch varied from 0.51 to 4.8 per cent. The rational thing
to do was to give the minimum starch solution in the early
months and gradually increase with the age

.\MERICAN GYNECOLOGIC.\L SOCIETY.

Thirty-second Annual Meeting, Held at Washington, D. C,

May 7, 8, and 9, 1907, in Conjunction tvith the Congress

of American Physicians and Surgeons.

{Continued from page 795.)

Dr. Clement Clevel.\nd of New Yokk, President^ in the
Ch.\ir.

IVednesday, May 8 — Second Day.

Ovarian Pregnancy. — Dr. J. Clarence Webster of Chi-
cago presented a specimen of ovarian pregnancy. The case
was almost identical with the one he reported three years
ago. though more interesting, in that the embryo was in
position in this specimen. One could see the amniotic cav-
ity with the embryo in position. The thickness of the ova-
rian tissue averaged about half an inch, except the placental
area, where it was thicker. There were several hemor-
rhages in tlie ovarian tissue, especially in the position of
the placenta.

Unique Specimen. — Dr. Webster presented another
specimen, which he obtained two years ago while on a va-
cation in New Brunswick from Drs. White and Ferguson.
The patient from whom the specimen was removed was a
man thirty-three years of age, who was admitted to the
hospital with symptoms of acute peritonitis. He had had
for many years an irreducible scrotal hernia, and it was
supposed there was strangulation. The man had been
kicked by a horse. An incision was made in the left
inguinal region; no hernia was found, but a structure which
looked like an adult uterus, tubes, and ovaries. The uterus
was removed, and what appeared to be a cervix. It was
adherent around the inguinal ring; the abdomen was rap-
idly opened, the patient being practically moribund by that
time. The incision was closed, and nothing more was done.
Patient died. No autopsy was made. The specimen was
given to Dr. Webster, and he had carefully worked it up.
On first presentation it seemed like the adult female geni-
talia, but careful dissection and microscopical study dis-
closed uterus and tubes, and what appeared to be ovaries
were testicles, but occupying exactly the same position
as the ovaries in the female. The mucosa resembled that
found in the adult female. Microscopical examination
showed the glands were complex. He emphasized particu-
larly the adult uterus. The tubes had the characteristics
of those of an adult female, except the fimbri.ie were not so
complex. There were fewer fimbri.n?. but the relationship
of the testicle was exactly the same. On one side there was
more marked ovarian or testicular fimbria. On examina-
tion of the broad ligaments he found on one side there was
a cyst. Both round ligaments were present, but on the
side on which the cyst existed the round ligament was flat-
tened out and thin. On careful dissection of the broad
ligaments there was a marked tube, about four millimeters
in diameter, sliglitly convoluted, extending from the upper
inner portion of the broad ligament towards the cervix.
It was quite firm, and had the consistence of a pipe-stem.
He pointed out the WolflSan duct, and the vas deferens,
also the cervix and prostate. The patient was the father
of twin children.

Dr. E. W. CusHiNG of Boston narrated a case of a man
operated on for hernia, in which a uterus was found in the
hernia.

Dr. Thom.^s S. Cullen of Baltimore said that some
years ago in Baltimore there was found at autopsy in a
child a complete set of both female and male pelvic organs.

The Care of the Wound and the After-Treatment
of Laparotomies. — There was a symposium on this
subject.

The Method of Closing the Wound. — Dr. Seth C.
Gordon of Portland, Maine, read a paper on this subject.
He spoke of the time required for perfect union of abdomi-
nal wounds, and also pointed out the necessity of using
such sutures as can be retained at least two weeks without
absorption. He emphasized the use of suture material
which is not absorbable, and which can be removed at the
end of two weeks, as well as the use of suture material that
was least liable to infection.

The Comparative Advantages of Catgut and Silver
Wire Sutures for Closing the Fascia after abdominal
Incisions. — Dr. Hunter Robb of Cleveland, Ohio, said the
ideal suture material should be smooth, pliable, but not
brittle, not too costly, easy to obtain on short notice, and,
above all. readily rendered completely sterile. Catgut would
be an almost ideal material, but when we sterilize it to a
degree short of rendering it brittle, and consequently
useless, some few of the inner strands may
not be absolutely aseptic; and. in fact. not
a few cases of suppuration, and even death, have
been directly traceable to the use of catgut ligatures. The
cumol method probably gave the best results, but f ir he
past few years he had had excellent results with the vidi-
nary and chromicized catgut as prepared by Van Horn of
New York, especially when the smaller sizes were used.
When, however, the larger sizes of chromicized catgut were
employed, the sutures were not always absorbed, out fre-
quently gradually worked their way to the surface of the
wound, and were then discharged. They were not always
sterile. Bacteriological tests made in his service had
shown that the knots and end of catgut sutures, even when
the wound had healed by first intention, teemed with bac-
teria, and he felt sure that chromicized catgut was responsi-
ble for many of the skin infections encountered. In one
case of phlebitis following an amputation of the cervix, in
which chromicized catgut was used, he was inclined to
attribute this complication to the suture material. He now
preferred to use for the skin and peritoneum small sires
of sterilized catgut, but for the fascia he believed that
silver wire offered advantages over the larger sizes of plain
or chromicized catgut. These results had been deduced
from recent experience, and largely also from an analysis
of two series of 100 cases each, in which silver wire and
chromicized catgut respectively were used in bringing
together the deep fascia. This analysis showed that the
relative incidence of infection in the deep fascia occurring
after the use of catgut and silver wire respectively was as
two to one. Moreover, it was noted that when suppuration
occurred it was always larger in amount and extent in thn:
catgut cases than in the infections met with after the U5e
of silver wire. The main objection against the use of silver
wire for bringing the fascia together was that one left in
the wound a substance that might annoy the patient by
sticking into the surrounding tissues. This trouble, how-
ever, could be readily averted if the suture was properly
applied and the ends were turned over with a pair of thin-
jawed hemostatic forceps, so that they form a ball-like end
to the suture. This annoyance had to be remedied in only
four out of four hundred of the silver wire sutures.
Removal tinder cocaine was always easy and painless. So
far as the occurrence of hernia was concerned, a priori
this accident should be less likely to occur after the use of
silver wire, as this material undoubtedly approximated the
tissues for a greater length of time, and in his experience
had given rise to suppuration less often. Hernia was not

I050

iMEDICAL RECORD.

[Tune 22, 1907

noted in a single case in either series, but the separation
of the fascia and muscle often did not take place within
the first few weeks after operation, and yet sometimes if
these patients were examined some months or a year after-
wards a smaller or larger protrusion would sometimes be
apparent. He had not infrequently noted such an occur-
rence in patients who had been operated upon by other men,
and he had no doubt that others had met with th;^ same
thing in some of his cases. Consequently, so far as hernia
was concerned, he did not believe that we should judge of
the relative value of the suture material except in ca=es
examined at an interval of six months or a year after oper-
ation.

Dr. Leroy Broux of New York said it was his custom,
in closing a wound, to bring together the fascial edges with
chromicized catgut. He did not rely on this entirely, but
introduced, at the same time, some safety sutures of silk-
worm gut at about an inch and a half apart, and he s:iw
that these were kept in for .at least two weeks to guard
against the opening of the wound by coughing, a sudden
jar, or sneezing.

The Use of Laxatives in the After-Treatment of
Laparotomy. — Dr. Henry T. Byford of Chicago said that
some laparotomies were of such a simple nature that the
functions of the abdominal viscera were not materially dis
turbed thereby, and need not be disturbed afterwards by
medicine. Exploratory peritoneal section, and the removal
of nonadherent ovaries, were apt to be of this nature. But
the majority of laparotomies represented a different prob-
lem. When there had been considerable trauma during
the operation, with consequent soreness and inability to
endure the pains, he applied an icebag to the abdomen
rather than give opiates. The icebag and an enema con-
taining thirty grains of chloral would usually alleviate the
pain and nervousness, and sometimes the nausea, without
inhibiting peristalsis. If his only object were to save life
he should not bother the patient with the laxatives unless
abraded or injured tissues had been left to form adhesions;
but he confessed, at the risk of being considered meddle-
some, that he gave laxatives in all but the simplest cases,
because in those who did not really need them the bowels
were more quickly relieved of the gas, and the patient then
felt much better than wh''n not so treated. Patients who
had undergone a previous laparotomy generally remarked,
without being asked, that they were having a much more
comfortable convalescence than after the previous one in
which they had either taken no laxatives, or had taken
opiates for the pains.

Care of Stomach and Bowels; Position and Rest in
Bed. — Dr. L.apthorn Smith of Montreal did not allow
anything whatever to go into the stomach of a patient dur-
ing the first twenty-four hours. The bowels were moved
by enema on the third day and every day after, unless they
moved naturally. If there was vomiting, calomel was used
generally with bicarbonate of soda. Position depended on
the severity of the case. In hemorrhagic cases the foot of
the bed was raised, or, in septic cases, especially after
appendicitis, the head was raised. Rest in bed for three
weeks was the safest so as to improve digestion and nu-
trition. Twenty-one days after operation the patient was
allowed to get up and to begin gentle exercise, so that by
twenty-eight days she could walk about freely.

Eserine Salicylate as a Prophylactic Against Atony
of the Bowels. — Dr. Hir.^m N. Vineberg of New York re-
ferred to the use of this agent, saying it had a beneficial
effect when given to a patient before coming out of anes-
thesia. It w'as given in doses of one-fortieth of a grain.
It was the custom to give 1-4 or 1-8 of a grain of mor-
phine, with 1-40 of a grain of salicylate of eserine. He
thought there was less distention of the abdomen after the
use of eserine in this manner.

The Incision and After-Treatment. — Dr. W. Gnx
Wyue of New York said the location of the incision varied
with the internal condition. The method of closure varied

according to the site of the incision. Method also varied
with the condition of the bowels due to preliminary prepara-
tion.

The After-Care of the Patient.— Dr. Herma.-^ J.
BoLDT of New York said that mobility of the patient was
begun as early as was consistent with the patient's general
condition. The greater number of patients might be out
of bed with advantage to them within three days. A large
number, even those upon extensive and technically difficult
operations had been done, might be out of bed and
placed in a comfortable chair within from twenty-
four to thirty-six hours after the operation. A prop-
erly adjusted plaster bandage, adhesive, was essential
for the safety of the wound. Neither the stomach nor the
bowels required any special consideration unless there was
some particular indication for it.

The After-Care of the Patient. — Dr. J. Montgomery
B.\ldy of Philadelphia said that rest in bed, good hygiene,
diet and nursing were the principal factors in the end
results. Moderate early getting up after operations was
all right for patients in good general condition, but it was
bad for others. There was nothing to recommend getting
up in twenty-four or forty-eight hours. There was nothing
to be gained, but much to be lost. That prolonged stay in
bed increased the frequency of embolism and thrombosis
was not true. He would admit that a surgical case might
be gotten out of bed and home in a week or ten days, but
he denied that this was best for the patient, or that this
meant that convalescence had been more rapid. The aim
should not be to get patients home in the quickest possible
time, but to give them the best amount of stored-up health
and energy with which to successfully meet the future.
One who had gotten out of bed with health fully restored
was surely more competent to meet the necessities of every-
day resistance than one who had been quickly put upon his
feet with little regard to his general condition.

The Prophylaxis of Venereal Disease from the
Standpoint of the Gynecologist. — Dr. Clement ClevE'
L.\ND of New York took this as the subject for his Presi-
dential address. He said the position of the gj-necologist
regarding venereal disease was one of greater enlighten-
ment than that of his brother of the general profession,
because of his greater opportunity for observing it. His
responsibility was, therefore, proportionately greater.
From g)-necolog>' had come all the present-day knowledge
of the effects of gonorrhea in women, and the msprration
for all that was known of its lasting effects upon men.
The responsibility of enlightening the public did not rest
with the medical profession alone. It was not a medical or
sanitary problem merely, as the causes were dependent
upon social conditions beyond control of the physician. By
constant study and agitation the best methods for reaching
the people would be evolved. All medical schools should
pay the greatest attention to instruction in veneral diseases
and their consequences, and some were doing so. The
student and physician could not be too often reminded of
the responsibilitj' that rested upon them, not only in the
treatment of these diseases, but as regards prognosis, and
sanction of marriage. Many thousands of young men with
a gonorrhea uncured married, and w-ith the sanction of their
physicians, who had not been as careful as they should have
been in giving approval. For himself, he w-as positively
convinced that the g)-necologist should not play over the
surface of the subject, but should get right down to the
foundation of the matter and display it in all its ugliness.
In this way only could there be an}- hope of making
influence felt and expect to reach any moral advancement.
To overcome indifference and arouse an urgent public
sentiment in favor of the movement, there was no more
powerful argument than the fact that the greatest sufferers
from these diseases were innocent women and children.
Constant preaching of this one fact alone would gain more
supporters for the cause than all others combined. In
closing. Dr. Cleveland thought n would be well to have a

June 22, 1 907 J

MEDICAL RECORD.

1051

standing committee to report each year, to arrange for
papers in symposium, to invite prominent men to read
papers before the society, or in other ways to make promi-
nent the vital interest that was felt. By so doing gynecolo-
gists would acquit themselves of any charge of inactivity,
and at the same time have the satisfaction of feeling that
they were doing their share in helping on the good work.

Work of Henry Garrigues Appreciated. — Dr.
Brooks H. Wells of New York dtlivered an oration on
Dr. Garrigues in appreciation of his work in introducing
asepsis into obstetric practice in America.

(To be continued.)

NATIONAL ASSOCIATION FOR THE STUDY AND
PREVENTION OF TUBERCULOSIS.

Third Annual Meeting, Held at IVashington, D. C, May

6, 7, and 8, 1907.

(Special Report to the Medical Record)

(Continued front page 918.)

p.^tholocic.^l .\nd b.\cteriol0gic.«il section.

Dr. F. F. Westbrook of Minneapolis, Ch.^ir.man.

Split Products of the Tubercle Bacillus and Their Ef-
fects Upon Animals. — Dr. Victor C. \^\ugh.\n and Sybil
M.AY Wheeler of Ann Arbor presented this connnunica-
tion. They split up the tubercle cell into two portions —
the cell poison and the cell residue. The culture mediimi
had been concentrated and then precipitated with five times
its volume of absolute alcohol and this precipitate had been
broken up into two portions — the precipitate poison and the
precipitate residue; and the portion of the culture medium
left after the removal of the alcoholic precipitate they had
designated as the final filtrate. In considering the effect of
the cellular substance on animals it should be borne in
mind that the cellular substance with which they were then
dealing was that of a tubercle bacillus that was virulent
to rabbits and guinea pigs, and that it had been thoroughly
extracted with alcohol and ether. There remained, as it
were, only the proteid skeleton of the bacillus. They had
injected into the abdominal cavities of twenty-four guinea
pigs single doses, varying in amount from 5 to 200 mg. of
the cellular substance and from these experiments they
made the following statements: (i) In no case was death
caused directly by the injection ; animals that received from
100 to 200 mg. remained apparently well four months after
the injection. (2) It gave in guinea pigs no immunity
to a subsequent inoculation with a virulent bacillus. (3)
It did, for a short time at least, sensitize guinea pigs to
the tuberculosis bacillus, an interesting and a hopeful point.
The effect of the cell poison on animals was shown to be
a poisonous one to the respiratory center. It developed
three stages of peripheral irritation, partial paralysis, and
terminal convulsions. When given in sufficient quantities
it killed within an hour both healthy and tubercular ani-
mals. There was no evidence that it elaborated any anti-
toxin and it was harmful, with nothing to recommend i;.
What was true of the cell poison was equally true of the
precipitate poison, and the final filtrate. The effects of
the cell residue on animals were practically nil. This was
the non-poisonous group obtained by splitting up the cel-
lular substance with alkali in absolute alcohol. In this
method there was one ray of hope of finding among the
Fplit products a body that might possibly be of service in
the treatment of incipient and localized tuberculosis. One
of the most interesting studies regarding the split proiiucts
of the tubercle bacillus was that of the effect of the pre-
cipitate residue on animals. On healthy animals it had no
recognizable ill effects in either single or repeated doses,
large or small. Experiment showed that the precipitate
residue had some specific effect upon tuberculous animals.
The precipitate sensitized guinea pigs to the tubercle bacil-

lus just as the cell residue did. Evidently their so-called
residues were much alike and it was more than probable
that they contained the same active constituent. Of one
thing they were satisfied, and that was that no preparation
from the tubercle bacillus should be used in the treatment
of tuberculosis until the poisonous group of the tuberculous
proteid and other proteids in the culture medium were re-
moved. During the past two years one of them used
solutions of tlie cell residue in the tuberculosis in man and
the following statements seemed justified: (i) It was of
no value in advanced cases of pulmonary tuberculosis. (2)
It might prove harmful even in initial cases if the dose be
too large or if small doses be too frequently repeated. (3)
When properly used in initial or in localized tuberculosis its
action was apparently prompt and specific. (4) When
given to an individual with pulmonary tuberculosis its ef-
fect upon the sputum should be watched and should guide
further treatment. He wished it to be clearly understood
that in well-established cases of pulmonary tuberculosis no
benefit from this treatment could be expected. He be-
lieved that in initial cases this preparation was preferable
to any form of tuberculin.

Further Notes on the Technique of the Tuberculo-
Opsonic Test. — Drs. Hugh i\I. Ki.nghorn, D.wid C.
TwicHELL and Norm.\n M. Carter presented this
communication from the Saranac Laboratory, of
which Dr. E. L. Trudeau was Director. .A.fter
calling attention to the technique reported at last
year's meeting (see Medical Record, Vol. 70, No. 5, Au-
gust 4, 1906, page 190), they said they wished to describe
the technique as they now used it, hoping that it might
help other investigators in this particular line of work.
The following conclusions were offered: (i) The tuber-
culo-opsonic test was probably one of but fair accuracy.
While several control tests of one serum might be almost
the same, one or more of the tests was very apt to be
considerably too high or too low, and they, therefore, al-
lowed for a ''probable cure" of from 15 to 20 per cent. (2)
In their own judgment, based on a large number of counts,
they thought that at least 100 polymorphonuclear leucocytes
should be counted, and that any less number tlian this
might not give an accurate estimation. (3) L'nder favor-
able conditions, the time required to make five opsonic tests
was about one and a half hours, not estimating the time
necessary to count these.

Homologous Bacteria as a Vaccine in Tuberculosis. —
Dr. .\lbert H. .\llen of Saranac Lake presented this
paper, which was read by Dr. Lawrason Brown of Saranac
Lake. This was a preliminary report. The object of this
investigation was to obtain from sputum a standardized
vaccine for tuberculosis. The product was called tubercle
vaccine since it resembled closely an emulsion of a tubercle.
In brief, these were the following steps: (l) Fresh s-putuni
was carefully washed through si.x normal salt solutions.
(2) The sputum was then thoroughly homogenized with
an ordinary egg beater for ten to fifteen minutes. (3) It
was then attempted to separate the tubercle bacilli from
the pus cells. The least unsatisfactory method was to col-
lect the foam after homogenizing. This foam seemed to he
freer of cells and at the same time richer in tubercle bacilli.
Foam was quickly liquefied by placing it under an exhaust
pump. (4) Emulsion from (3) was concentrated by cen-
trifugalization. (5) This emulsion was then standardized
by a modification of A. E. Wright's method. (6) The
emulsion was then sterilized by heating on two successive
days for two hours at 60° C. and D.25 per cent. lysol was
added for preservation, (y) In order to preserve tlie tox-
ins and ferments present from heat, a portion of the emul-
sion before sterilization was passed through a Berkefield
filter. It would seem hard to standardize this filtrate,
which might be an important adjuvant to the vaccine. This
filtrate was either to be added to the vaccine or injected
separately at the same time. To test the sterilization, on

I0^2

MEDICAL RECORD.

[June 22, 1907

March 16 one healthy guinea pig was injected with I c.c.
of the 175 million emulsion that had been heated two hours
at 60° C. one day. Another healthy guinea pig (half
grown) received 0.5 c.c. of this emulsion, heated thus on
two successive days. After six weeks the autopsies showed
in the first guinea pig tubercle lesions, in the second guinea
pig none. The injection of unaltered tubercle bacilli in
considerable numbers into tuberculous animals produced
ulcers at the site of injection. To test this point with
tubercle vaccine, two supposedly tuberculous guinea pigs
were inoculated. No ulcers resulted, but autopsies at the
end of six weeks showed no lesions except caseous glands
near the site of injection in the guinea pig receiving the
vaccine heated only once. The influence of opsonification
on the immunizing power of bacteria was still an unsettled
question. To see if the tubercle bacilli in tubercle vaccine
were opsonified, tubercle vaccines, sterilized and unsteril-
ized, were added to unwashed leucocytes, appropriate con-
trols having been made; no phagocytosis resulted; after
adding serum, phagocytosis did occur. Only two such tests
had been made so far. They proposed to study the action
of the vaccine by various experiments on animals. Dr.
Trudeau had suggested that since one of its main advan-
tages lay in its being liomologous, animal tests would not
be entirely fair. He further suggested that the homologous
feature could be approximated by infecting the animals
to be treated with the unsterilized vaccine to be used.

Dr. Milton J. Rosen.'vu of Washington asked whether
tuberculin was present in one or all of the split products
that Dr. Vaughan had used.

Dr. William H. Park of New York said that he re-
cently had a personal letter from Dr. Wright regarding
his pessimistic attitude on the subject of the occasional in-
accuracies ; he believed that there might be some error
in the technique. All seemed to get wild counts. He used
the glycerin-agar for the tubercle bacilli ; the development
seemed shorter. He asked Dr. Vaughan whether or not
the animals receiving these large doses were afterwards im-
mune.

Dr. E. R. Baldwin of Saranac Lake believed that the
use of the poisonous part of the tubercle bacilli was un-
justified; they knew that in hypersusceptibility the poison-
ous part of the tubercle bacilli could be removed. As a
matter of clinical observation and of experimental work,
they knew that animals inoculated with non-virulent bacilli,
or their products, might overcome susceptibility to these
products in the course of time, provided they were not
overdosed in the beginning. It did not appeal to him that,
after excluding the toxic part of the tubercle bacillus, it
could be used as a possible therapeutic agent.

Dr. G. B. Webb of Colorado Springs recently took twelve
healthy students in Colorado and made some observations.
They were sent to Pike's Peak, a distance of about twelve
miles, and only one failed to get there ; ten came out nor-
mally.

Dr. RuFus I. Cole asked Dr. Kinghorn if the addition
of formalin had any effect upon the phagocytosis.

Dr. Victor C. Vaughn of Ann Arbor, in answer to Dr.
Rosenau's query, said that if he would tell vi-hat was meant
by the word "tuberculin," he might be able to answer the
question. He could not answer Dr. Park's question, for
he had not made enough experiments to warrant a state-
ment. So far as his experience went, he had never been
able to produce anaphyloxia or hypersusceptibility with the
poisonous part of a proteid.

Dr. Hugh M. Kinghorn of Saranac Lake said that
formalin in a 1-1250 proportion did not influence phagocy-
tosis.

Dr. RLwzcK P. Ravenel of Philadelphia and Dr. Na-
thaniel B. Potter of New York discussed the paper.

The Pleural Pressure after Death from Tuberculosis.
A Preliminary Study. — Dr. W. B. Stanton of Phila-
delphia read this paper. He said that the existence of

minus or negative intrathoracic pressure was first noted by
Carson in 1819, and the subject had since been further
studied by Donders, Hutchinson, Heynsius, Perle, and
others, and the existence of a negative intrapleural pres-
sure might be considered as proven. This negative pres-
sure was due to the fact that the lungs were constantly
distended, and the elastic fibers of the lungs were con-
stantly striving to regain a condition of non-tension.
Hence, the amount of intrapleural pressure under normal
conditions would show the amount of elastic tension of
the lung. This tension of the lung and its tendency to
become smaller was well shown by the collapse of the
lungs when the chest was opened, either during life or
after death. It was because of this condition of a negative
intrapleural pressure that a pneumothorax occurred when
the lung ruptured or the chest w-as perforated from with-
out. The observations he reported were made upon patients
dying at the Henry Phipps Institute as a part of a study of
the pleura and its behavior in tuberculosis. The method
employed consisted in the insertion of a hollow needle
which was connected with a mercury manometer into each
of the first five interspaces. This was done before the
body had been touched by the pathologist. All examina-
tions were made within twelve hours after death and one or
two while the body was yet warm. When the pressure was
negative the needle w^as pushed still further into the chest
to find, if possible, the pressure conditions within the
lungs. The punctures were made anteriorly along the
anterior axillary margin. The skin was pulled as far as
possible to one side and the puncture made through the
tense tissues. The return of these tissues to a natural
position acted as a valve to prevent ingress of air after
the needle was removed. From these 23 cases certain
preliminary deductions were justifiable: (i) In cases
dying of tuberculosis, pleural adhesions of greater or less
extent were practically constant over the upper lobe. The
lower lobes were free in about one-half the cases. (2)
The intrapleural pressure might vary in the different in-
terspaces of the same chest. This variation was most
often due to pleural adhesions which obliterated the pleural
cavity at the point of tapping; it was less often due to
lung conditions. (3) The intrapleural pressure varied
widely in different subjects, from minus 24 mm. to plus
10 mm. (4) The intrapleural pressure might be negative
or minus, while the pulmonary pressure was positive or
plus. (s) The minus intrapleural pressure found in
tuberculous subjects were much increased when compared
with text-book standards. (6) Zero pressures were found
in one-half the cases in the first two interspaces.

Dr. Lawrence F. Flick of Philadelphia said this was a
subject that had been too much ignored in the past. The
study of the pleura in those dying of tuberculosis had
opened his eyes ; they found that there was perhaps less
healthy tissue left after death in the pleura than in any
organ or tissue of the body. In other words, when a case
of tuberculosis had reached its normal termination in
death, the pleura was shown to have borne the brunt of
battle to a greater degree than any tissue in the body.
He believed the top of the pleura was the primary seat of
the disease, and Calmet also believed and proved that the
parietal layer of the pleura, in animals he had injected,
showed the primary focus.

Dr. La\vr.\son Brown of Saranac Lake asked Dr. Stan-
ton if he noticed in cases of pneumothorax any displace-
ment of the heart. In one of his cases the pressure was
so great that the heart was displaced to the right of the
sternum.

Dr. Stanton said that he had made a large number of
such observations, in which there was a displacement to
the right in left pneumothorax cases, and to the left in
right pneumothora.x cases, and this was quite constant.

Dr. Leonard Weber of New York said that the top of
the pleura could not well be the primary focus of tuber-

June 22, 1907]

MEDICAL RECORD.

1053

culosis, and in all the post mortems that he had witnessed,
or had himself made, he was convinced that the infec-
tion of the pleura was secondary in a large proportion of
the cases. He did not mean to deny that primary tuber-
culosis of the pleura might not occur.

Disseminated Focal Necroses Due to Tubercle Bacilli
(Acute Miliary Tuberculosis without Tubercle Forma-
tion).— Dr. A. S. Warthix of Ann Arbor presented this
communication.

The Frequency of Occurrence of Tubercles in the
Liver in the Absence of Tuberculous Lesions Elsewhere
in the Body. — Dr. A. S. Warthin of Ann Arbor pre-
sented this communication.

Dr. S. Marx White of Minneapolis and Dr. Alfred
Meyer of New York discussed these papers.

The Leucocytes in Various Complications of Pul-
monary Tuberculosis. — Dr. Frank A. Craig of Phila-
delphia read this paper. His study was based upon the
examination of the blood in forty-five cases of pulmonary
tuberculosis in the Henry Phipps Institute during the past
year. In summing up the findings one was forced to the
conclusion that the relation of the leucocyte count to the
complication could only be considered in a very general
way. The average findings in the uncomplicated cases of
the groups showed a tendency to a decrease in the lympho-
cytes and a corresponding increase in the polymorphonu-
clears in the more advanced cases, with a decrease in the
color-inde.x, an increase in the number of red corpuscles
and an increase in the number of leucocytes. These find-
ings, he said, should not be taken too strictly, as individual
cases in any group might resemble the findings of any
other group. This variation from the average type, how-
ever, did not bear any definite relation to the progress of
the case. The various complications, therefore, could be
said to have no effect upon the blood in producing charac-
teristic pictures, although the decrease in lymphocytes and
the increase in polymorphonuclears were associated with
many of the complications.

Occult Blood Findings in Tuberculous Ulceration of
the Intestines. — Dr.H. R. M. Landis of Philadelphia read
this paper. He said that statistics as to the relative fre-
quency of intestinal ulceration in pulmonary tuberculosis
varied, but he believed that a conservative estimate would
place it not lower than 60 per cent. The one symptom
upon which it was based was diarrhea. Among the thirty-
three autopsied cases which he reported, four had loose
bowel movements, from six to nine stools daily, for several
weeks before death, and yet at autopsy no evidence was
shown of intestinal ulceration. On the other hand, no less
than thirteen, showing ulceration at autopsy, had but one or
three movements daily. From his study he was able to
confirm Louis' observation, that where the diarrhea ante-
dated death but a short time the ulcers were small in size
and few in number. Also that the longer the diarrhea
lasted, and the more frequent its occurrence, the greater
was the ulceration. Abdominal pain was rarely present.
Thirteen of the thirty-three cases were examined for
tubercle bacilli, and found in every instance; two of these
eases showed no ulceration at autopsy. The present study
represented the examination of 222 stools in 109 patients.
.\ great part of this work was not checked up by autopsy
findings, and while he gave the results of the entire series
the conclusions were based only on the cases coming to
autopsy, numbering 33. Taking the entire series, but one
examination was made in 75 cases ; of these 10 were posi-
tive and 65 were negative. In 12 two examinations each
were made; of these a positive reaction was obtained
in 6, negative in 7. In 22 the stools were examined three
or more times. These cases, which included the six with-
out ulceration, gave 8 positive and 14 negative results. Con-
sidering the 33 autopsied cases alone one, which gave a
positive test, was omitted because of hemorrhage and a
history of the presence of blood after defecation for some
months prior to admission to the hospital. Of the re-

maining 32 cases, 26 had ulcers and 6 were free from ulcer-
ation. The si.x cases without ulceration were repeatedly
examined, and always with a negative result. Twelve of
the remaining 26 cases showed the presence of occult
blood at least once, and in four instances from two to
four times each. In 7 the tests were positive at the first
examination; in 12 the feces were e.xamined from one to
three times with negative results. The greatest number of
negative tests showing ulcers was six. While the intensity
of the color reaction was an indication of the severity of
the hemorrhage, it afforded no clue as to the amount of
ulceration present. The case with six negative tests had
a large number of ulcers. The results as indicated by
these autopsied cases showed that in every instance in
which occult blood was found ulcers were present in the
intestines.

Dr. Lawrence F. Flick of Philadelphia said that it had
been demonstrated that the tubercle bacillus could be elim-
inated by the bowels without an open lesion in the kidney.
Some of the work done by Dr. Walsh of Philadelphia left
no doubt about this. Now, if it was true that the tubercle
bacilli could be eliminated by the kidneys without an open
lesion, by analogj' it might be reasoned that the same thing
could occur by the bowels; if it was possible to have an
excretion of the tubercle bacilli by one organ, he believed
this was possible by another.

Dr. Alfred Meyer of New York questioned the value
of evidence presented from the study of one case. The
possibility of the individual swallowing tubercle bacilli in
the sputum should be considered.

NEW YORK ACADEMY OF MEDICINE.

section on general medicine.

Stated Meeting, Held March 19, 1907.

Dr. Warren Coleman in the Chair.

Demonstration of Method of Weighing Patients in Bed.

— Dr. Charles P. Bull made this demonstration.

Pyrexia in Tuberculosis. What It Tells Us and How
It May Be Controlled.— Dr. Henry P. Loo.mis read this
paper. (See page 1019.)

Aerotherapy in Cold Weather, with Particular Refer-
ence to Tuberculous Diseases, and Demonstration of a
New Model Window-Tent. — Dr. S. A. Knopf read this
paper. He said that the reason consumptive patients did
better in winter than in summer was because cold air con-
tained more oxygen to the cubic inch than warm air. The
volume of air was reduced one five-hundredth part for
each degree of reduction in temperature. Even if the
temperature was only at freezing point the body took in
one-seventh more oxygen than on a summer's day when
the thermometer was at ninety degrees. This greater ab-
sorption of oxygen meant an increase in the number of
red blood corpuscles. Dr. Lawrason Brown, of the Adir-
ondack Cottage Sanatorium, had just written him regard-
ing the endurance of outdoor life by consumptive patients,
that 60 to 75 per cent, of all their patients slept outdoors
and more would do so had they the opportunity. More
slept out in the summer than in the winter. No difference
was made as to the degree of cold. The patients had slept
out when it was 20 and 30 degrees below zero. Dr.
Herbert M. King, of the Loomis Sanatorium, where pa-
tients were received in all stages of the disease, said that
50 per cent, slept out this winter and 100 per cent, of in-
cipient cases slept out. All those who slept on the veran-
das managed to be outdoors twenty-two hours out of
twenty-four. The profession had at last learned to appre-
ciate the value of cold air, not only in tuberculosis, but in
pneumonia and certain nervous affections. The rest or
"Liege" cure was best carried out in winter on a veranda
with southern exposure, where the body could have the
sun and the head remain in the shade. The patient de-

1054

MEDICAL RECORD.

[June 22, 1907

rived no benefit from the cold air if he was chilled, and
hence should be warmly clad and give special attention to
keeping the feet warm. The "Liege" cure should be
alternated every hour or two by short walks and breathing
exercises with or without movements of the arms. Even
the febrile patient should not lie for hours on his back
with shallow breathing if he wished to avoid hypostatic
pulmonary congestion. He should change his position fre-
quently and take a few deep inspirations every half hour
or so. During drives or sleighrides the patient should be
comfortably warm, and should refrain from conversation,
so as to breathe as far as possible through the nose. The
walking e.\ercise should begin on graded walks of varying
inclinations, and should never be long enough to overtire
the patient. The selection of patients for walking or mild
sports, the duration and kind of e.xercise permissible,
should be guided by the temperature, the rectal tempera-
ture when feasible. All those who had e.xamined the
value of respiratory exercises with unprejudiced mind
had agreed to their beneficent local and general effect.
The seemingly slight local harm or temporary pain was
amply compensated by general improvement, owing to the
increased supply of oxygen, the greater facility of getting
rid of tenacious mucus, and the consequent diminution of
the dyspneic condition. An important effect often over-
looked was that these exercises counteracted loss of co-
ordination of thoracic muscles. He added to each inspira-
tion and corresponding expiration a second expiratory
effort for the purpose of expelling as much of the sup-
plemental air as possible. This meant an additional amount
of a thousand cubic inches of fresh, pure air entering
the system for every six respiratory movements. As to
the class of patients that could be permitted to w-alk, take
breathing exercises, and pursue light winter sports, one
could not lay down absolute rules, yet one might say in a
general way the incipient patient might walk and take
breathing exercises when he was afebrile, when he was
gaining in weight or holding his own in a general way, and
if too markedly dyspneic he might try breathing exercises,
but should not walk. Highly febrile acute pleuritic or very
recent henioptic cases should not take any breathing exer-
cises at all. Skating, tobogganing, and skeeing were per-
missible in only a few selected incipient cases. A chronic
temperature of 99.5° was indication for rest in the reclin-
ing chair in the open air, and a temperature of 100.5 called
for the recumbent position. A temperature of 101° or
more meant rest in bed in a well ventilated room, but such
patients should gradually become accustomed to sleeping
outdoors. The most important feature of aerotherapy for
the tuberculous was sleeping outdoors. The requisites for
this were specially built verandas communicating with bed-
rooms, or lean-tos, with heated dressing rooms, as were to
be had in sanatoriums. In private homes the veranda should
be so protected that the patient was not exposed to the
wind. The sleeping shack was only desirable w'hen it had
a compartment that could be heated. A lean-to was a
structure costing about S18.30, and would accommodate
sixteen patients, making the cost per patient only a little
more than $1.14. The lean-tos were grouped around a
central administration building, and a sanatorium on thi;
plan W'ith a capacity for 150 patients under municipal,
county, or State control and designed for early cases among
the poor would cost about $80,000, exclusive of land, or
about $533 per patient, much less than the present cost in
sanatoriums. For those compelled to remain in the city
iome form of window- tent was best suited for outdoor
sleeping. Dr. Knopf presented a new model of a window
tent which he described in detail. The advantages of this
last model over form.er ones were that it was far simpler
and cheaper in construction, offered greater facility for
cleaning and disinfecting, and had a method of attach-
ment which permitted of its removal from the window
when not in use. Drop infection was limited to a mini-
mum and the canvas could e^iily be removed and th ■

steel frame washed. With this tent there was no possi-
bility of a draft, but the patient should be warmly clad
when sleeping in the window tent. Warm night gowns and
coverings were not enough. Heavy weight linen-mesh
union suits seemed to him best, though wool might be
preferable. To prevent cold from coming through the
mattress from below several layers of newspapers laid
over the springs, or a layer of linoleum, were useful. Be-
sides this there should be a plentiful supply of blankets.
Where there was a shortage in this direction several layers
of newspaper sewed between two layers of blanket were of
service. The covering should not be so heavy as to
weigh down the body. Tightly woven blankets seemed
to be better protection than loosely woven ones. The
feet should be kept warm by means of hot sandbags or
hot water bottles. In extremely cold weather the head
should be protected by a woolen cap, shawl, or helmet. If
the tip of the nose became too cold it might be protected
by a piece of absorbent cotton fastened with a strip of
adhesive plaster along the crest of the nose, taking care
not to occlude the nostrils. If the bright light early in
the morning kept the patient awake some light weight but
dark colored material could be put over the eyes. Patients
should always dress and undress, for a sojourn in the cold
air, in a warm room. The window tent could be used
for a rest cure during the day if necessary, a reclining
chair being put before the wandow instead of the bed.
There were limitations to outdoor resting and sleeping.
One unaccustomed to outdoor life or outdoor sleeping, or
even sleeping with the windows open, should begin with
an hour before and an hour or two after the principal mid-
day meal. Little by little the time outdoors should be in-
creased. Outdoor sleeping should be begun with a few
hours at a time. If a patient became chilled after taking
all precaution the process of hardening must go on more
slowly. In his own experience he had never noticed that
a chronic catarrhal condition of the upper air passages
had been brought about or if present had been increased
through pure, cold air; but, on the contrary, had always
found the condition to be benefited by judicious sleeping
outdoors. He was, however, convinced that an acute
coryza or acute grippe in its early stages w'as better treated
in a moderately warm, but well ventilated room. The
same might be said of an acute pleurisy or a severe hemop-
tysis. L^nless a patient far advanced with tuberculosis
wished it or felt better for it one should not insist that he
?Ieep outdoors. When it was evident that a patient had
no chance of recovery, sleeping outdoors against his in-
clinations was utterly useless, unscientific, and inhumane.

Dr. W. P. NoRTHRUP said he was always interested in
every device which gave a sick individual the benefit of
cold, fresh air. He asked Dr. Knopf what he meant by
fresh air? Dr. Xorthrup maintained that patients were
greatly benefited by cold, fresh air. They did better dur-
ing the winter than the summer months. He was skep-
tical regarding what had been said of oxygen. The value
to patients was in the cold fresh air. He asked Dr. Knopf
if only the head and neck were exposed.

Dr. Knopf replied that one-half the body was exposed.

Dr. NoRTHRUP then maintained that if it was a ques-
tion of head and neck in the tent and the rest of the body
in the room, or the head and neck in the room and the
rest of the body in the tent, he would prefer the trunk
and legs in the tent and the head and neck in the room.
He maintained that the body breathed as much as the
lungs; and the question of cold fresh air was as impor-
tant for the skin of the body as it was for the lungs. He
referred to the experiment made with a kitten. \\'hen the
kitten's head was placed in a rubber pouch, with body
outside, it breathed without harm ; but when the kitten's
body was in the pouch and the head outside, it graduaii..
began to stow heat and suffered from heat stowing.

Dr. Theodore C. Jaxeway said that they wereMndebted
to Dr. Knopf for what he had done in the field of thera-

June 22, 1907]

MEDICAL RECORD.

1055

peutics. He was impressed with what had been done last
fall in Boston in the Outdoor Department of the Massa-
chusetts General Hospital in caring for the tuberculous
patients in their homes. Dr. Pratt and Dr. Cabot ran
large classes of tuberculosis, and the cases were treated
on the roofs, and in the back yards. Many patients had
been refused admission to Rutland because they were con-
sidered to be too far advanced. In spite of that the per-
centage of arrested cases in the clinic he thought would
compare favorably with the statistics of the sanatoria.
The whole matter rested in the conscientiously carrying out
of sanatorium methods and treatment with rest, care in
the open air. breathing and exercise such as Dr. Knopf
had told them of. In New York City it was difficult to
utilize the roofs; therefore, the device presented by Dr.
Knopf was of special value. Two or three years ago Dr.
King told very strikingly about the patients who slept out
at liberty in the lean-to. Forty patients were out of doors
in the annex. Influenza struck Liberty and most of the
tuberculous patients in Liberty contracted influenza. In
the sanatorium there were only nine cases, and seven of
these occurred amongst the servants who were not under
sanitary regime. The other two patients were very ill
patients in tlie Infirmary. Among the forty patients in
the lean-to not a case occurred.

Dr. Keyes said that from an experience in his own
family he believed that acute coryza could occur from fresh
cold air admitted through the window. To prevent the
cold air getting down over the neck and shoulders he told
of a trick he had of taking two pillows, arranging them
in a V-form. and then having the covers tucked around the
neck; this would keep the possible draughts from chilling
one. Patients did better in cold than in w'arm air. The
beneficial effects he believed were due to the stimulation
of the nervous system which resulted in very marked and
rapid changes in the blood distribution ; also coincidently
there was a vasomotor stimulation.

Dr. Henry G. Piffard presented photographs taken in
Germany, and also some taken last summer in New Jersey,
where patients spent several hours each day perfectly nude
and in the open with beneficial results.

Dr. Henky W. Fr.\uenth.\l said that patients in the
higher altitudes developed their chest measurement and
with it there was an increased ability to take up oxygen.
With regard to the breathing exercises, he had found that
by their use patients witli lateral curvature improved, and
now a number of his nurses had given up nursing and
taken up teaching breathing e.xercises.

Dr. Henry P. Loomis said that there was one thing that
Dr. Knopf had not spoken of. the possibility of doing
away with the fad which was so apparent in the medical
profession of sleeping out of doors ; he meant out of
doors in New York City. In suitable climates it would
be different. One could not incorporate in the cities the
methods employed in the country; if tried it would be
dangerous. This device of Dr. Knopf's would enable the
patient to sleep in the room and do away with the idea
of sleeping out of doors. .At Bellevue this had been trie.l
by the staff, patients, and nurses, and Dr. Loomis had
made visits at night and had found that the nurses, when
night came on, had their tents perfectly tight. They could
not stand tlie cold. Dr. Loomis hoped that the time would
come when the pendulum would swing the other way.

Dr. Geor(;e M.\nxheimkk said that it made a differ-
ence whether the patient had fever or not. and that the
patients should have their temperature taken every three
hours. Those patients that awakened in the morning witli
general malaise, etc.. had nightly fever. There was a self-
retaining thermometer for use in the rectum which sli' '
the nightly temperatures m these cases. He also calleil
attention to the possible use uf old trolley cars or horse
cars, which woulil be excellent, and could be had almost
for the asking from street car companies. He did not
think that massage of the intercostal spaces was of much

value. The device of Dr. Knopfs was the best thing yet
accomplished.

Dr. Warren Coleman recalled the observations made
by Darwin about the skin temperature. Observations were
made in Patagonia, where the individuals wore no cloth-
ing or covering of the skin, and all were diminished in
stature. The conclusion was reached that because of the
amount of energy required to keep alive and keep warm,
they could not grow.

Dr. Knopf said that they could not treat patients with-
out clothes. Patients must be kept warm, especially the
lower extremities. They tnight breathe cold air, but the
body should be warm, and the feet particularly. The open-
air treatment of the fever was the best. He emphasized
the fact, and strongly, that massage had developed the
thoracic muscles and helped in the chest expansion an.,
in the general improvement of the cases.

#lat* Mpiiiral iCirftising SnariJfi.

ST.\TE BOARD EXAMINATION QUESTIONS.*

Idaho State Board of Medical Examiners.

October 2. 190(3.

1. Spondylitis deformans : (a) How is it characterized?
(b) Symptoms and pathology?

2. Bilateral dislocation of lower jaw : Give symptoms,
causes, and treatment. Is the capsular ligament usually
ruptured ?

3. Fracture through surgical neck, and head of humerus.
Give diagnosis, treatment, exciting, and predisposing causes.

4. (a) From what source of blood supply is extradural
hemorrhage due? Subdural" (b) What are the symptoms
of general brain compression from hemorrhage ? Give
special symptoms.

5. Castration; (a) What are the indications for the
removal of the testicles? (b) Describe the method of
castration in aseptic and septic cases.

6. Strangulated Hernia: (a) What three conditions
constitute a strangulated hernia? (b) Where is the seat
of most marked pathologic changes? and why? (c) Give
the local and general symptoms.

7. Describe the operation you would employ for ectro-
pion.

8. Tracheotomy: (a) State methods employed in this
operation. What is the after-treatment? (b) Which is
the more dangerous and difficult, tracheotomy or laryn-
gotomy. and why?

9. Suppurative otitis media: (a) In a mixed infection
what bacteria are usually present? (b) What is the treat-
ment indicated?

10. Cholecystotomy : (a) Give technique, position of
patient, line of selection for incision: (b) how are stones
from the duct removed? (c) What are the complications
to be ascertained and removed? (d) What is the defini-
tion of "Ideal" cholecystotomy?

OBSTETRICS.

1. Give differential diagnoses of pregnancy.

2. On what signs is multiple pregnancy diagnosed?

3. Give treatment of pernicious vomiting of pregnancy.

4. Give five things to be observed by a pregnant woman.

5. How do you treat threatened abortion ?

6. How secure asepsis in confinements as to external
maternal parts? How maintain asepsis during labor? after
labor? Why is a routine jiostpartum douche a bad prac-
tice? i\lention the indications for a postpartum douche.

•It is proposed In this department to publish from time to
time the examination papers of the various State Boards,
tn order that a candidate may become familiar with the
character of the examination and so in some measure free
himself In advance from the nervousness and dread which
the unknown inspires. In furtherance of the same object
answers to some of the questions will be published In order
to show the candidate what the examiners expect of him.
Not all the questions of all the papers will be so treated,
for the answers to many, especially In the anatomical papers,
are obvious or can be found In the Index of any teit-
oook on the subject; the answers to other questions, especially
in the surgical papers, must sometimes be omitted because of
the space they would demand. The candidate for a medical
license will not find in these answers a short and easy road to
success In the examination, for he is not likely to meet the
same questions in the papers placed before him by the
examiners. The object of publishing the questions and
answers Is only, as noted above, to acquaint the candidate
with the general character of these examinations and to
Inspire him with confidence in the result of his trial.

1056

MEDICAL RECORD.

[June 22, 1907

7. Describe treatment for puerperal eclampsia.

8. Give treatment for placenta previa.

9. Define dystocia, hydrocephalus, funis phlebitis, caput
succedaneum, ectopic gestation, hyperemesis, polyhydram-
nios, sapremia, gastrohystcrotomy.

10. Forceps, (a) Indications for use; (b) conditions
necessary for use; (c) describe preparation of patient; (d)
use of anesthetic; (e) describe application of forceps and
extraction of fetus.

PRACTICE.

1. Describe three varieties of intestinal obstruction, and
give the treatment in each case.

2. Give the etiology, symptoms, and treatment of ex-
ophthalmic goiter.

3. Give the etiologv. symptoms, and treatment of hay
fever.

4. Make a differential diagnosis between ulcer and
carcinoma of the stomach.

5. Give the etiology and treatment of chloasma.

6. Give etiolog}', symptoms, and treatment of cystitis.

7. Describe the symptoms and treatment of laryngismus
stridulus.

8. Give the symptoms and treatment of aortic regurgita-
tion.

9. Give the symptoms and treatment of spotted fever
(tick fever) of the Rocky Mountains.

10. Describe the dietetic treatment of diabetes mellitus.

GYNECOLOGY.

1. Name five prmiary causes of menorrhagia. Detail
the treatment of the torm due to subinvolution.

2. Name the varieties of dysmenorrhea. Give the treat-
ment of mechanical dysmenorrhea.

3. Outline the treatment of gonorrheal endometritis^

4. Give the etiology and treatment of acute oophoritis

5. Make a differential diagnosis between fecal impao
tion and an inflamed ovary.

6. Give etiology, symptoms, and treatment of pelvic
cellulitis.

7. Name the uses of the uterine sound. Enumerate
contraindications and dangers attending its use.

8. Give etiology, symptoms, and treatment of vulvo-
/aginal cyst.

9. Name five genital fistuloe.

10. Describe symptoms and treatment of uterine cpr
cmoma.

AN.^TOMY.

1. Bones. Name five foramina and give structures pass
ing through them.

2. Muscles. Give origin and insertion of ten muscles.

3. Nerves. Give the distribution of the cranial nerves

4. Circulation. Give the blood supply of ten structures
of the body.

5. Special, (a) Name three fissures of the brain, (b)
What are the chords tendines? (c) Pineal body? (d)
Describe the course of the vas deferens, (e) Locate corpus
callosum.

HISTOLOGY.

1. Name the three primary blastogenic layers.

2. Name the structures derived from each.

3. Describe the minute structure of the kidney.

4. Give variety of glands with example of each.

5. Define leucocyte, osteoblast, stroma, dentine, perios-
teum, circumvallate papills, Peyer's patches, discus pro-
ligerus, zona pellucida, corpus hiteum.

DIAGNOSIS.

1. What is meant by the term pathogfnomonic ? Give
four examples.

2. Give methods of handling sputum to determine,
microscopically, if (a) tuberculosis exists; (b) pneumonia.

3. What would be the findings in an examination of the
blood in pernicious anemia.

4. Differentiate the mitral lesions of the heart.

5. Differentiate the diseases of which dropsy is a
symptom.

6. In what diseases are the following conditions found :
(a) Clubbing of the fingers; (b) loss of patellar reflex;
(c) Cheyne-Stokes respiration; (d) wrist-drop: (e) pain
in the knee; (f) barrel-shaped chest; (g) Koplik's spots;
(h) pain in testicle and glans penis; (i) Argyll-Robertson
pupil; (j) strawberry tongue.

7. On what signs would you base a diagnosis of large
left-sided pleural effusion wMthout resorting to puncture?

8. Give the differential diagnosis between mastoiditis
and acute inflammation of the middle ear.

9. Give diagnosis of acute cystitis in a female.

10. Differentiate intestinal colic from other lesions which
might be mistaken for it.

1. Name some diseases, one attack of which ordinaril);
renders the subject immune from subsequent attacks.

2. Name and describe the principal chemical element!
of food, giving the use of each class.

3. Indicate the proper diet in a case of diabetes mellitus,
obesity, typhoid fever, tuberculosis.

4. What relation have certain insects to the cause and
spread of disease?

5. Give some directions for the sanitary care of a small
city.

6. What is the difference between an infectious and
contagious disease? Name two of each class.

7. Give some directions for the disposal of sewage and
other waste matter from farm houses, and the proper pro-
tection of drinking water.

8. What is the influence of climate and altitude on
health?

9. Name some diseases which may be to a large extent
prevented by proper hygienic care.

10. What is the effect of alcohol upon the nerve cen-
ters, upon the circulation?

PHYSIOLOGY.

1. Describe the change that takes place in the eye in

changing from far to near vision.

2. Describe the patellar reflex and state upon what its
integrity depends.

3. Locate the motcr centers of the brain.

4. What is the lymphatic system and what is its office?

5. Of what is the pancreatic juice composed and what
part docs it play in digestion?

6. How is inspiration accomplished?

7. Describe minutely the formation, elimination and
passage of urine.

8. Give time and order of eruption of both temporary
and permanent teeth. Tabulate, if you wish.

9. Name the different portions of the alimentary canal
in order from mouth to anus.

10. What are the functions of the skin?

CHEMISTRY AND TO.XICOLOCY.

1. What are (a) carbohydrates? (b) proteids?

2. What is the difference between a physical and a
chemical change? To which does the emulsification 01
fats belong?

3. Define organic and inorganic chemistry.

4. Starch (GHioOs). grape sugar (C«Hi:0«), alcohol
(CjHeO). Show the chemical reaction and equivalents in
the change of starch to grape sugar and of grape sugar to
alcohol.

5. Give in detail two reliable tests for sugar in the urine.

6. Give chemical test for pus in the urine.

7. Give antidote for each of the following: (a) corrosive
sublimate, (b) arsenicum, (c) silver nitrate, (d) iodine,
(e) phosphorus.

8. Give a reliable test for arsenic in contents of stomach.

9. In what class of poisons would you consider the
stomach pump contraindicated?

10. What would you consider the maximum safe adult
dose hypodermically of (a) atropine, (b) morphine, (c)
strj'chnine, (d) apomorphia, (e) nitroglycerine?

PATHOLOGY.

1. Micrococcus lanceolatus : (a) Describe process of
staining, (b) What is its significance, and in what inflam-
matory conditions is it often observed?

2. Describe the pathological changes that take place in
the liver from the effects of chronic interstitial hepatitis.

3. What are the alterations or changes that take place
in a muscle while undergoing progressive muscular atrophy?

4. Carcinoma of stomach: (a) Is it usually primary,
or secondary to carcinoma elsewhere? (b) Where is it
usually situated, and give most common type.

5. Tuberculous enteritis : (a) What particular parts are
usually involved ? ,(b) Describe the degenerative changes,
(c) In which direction to the axis of the gut does ulcera-
tion extend most rapidly?

6. Write the characters of the Bacillus anthracis, ray
fungus, Bacillus typhosus.

7. (a) What is a thrombus? (b) What is thrombosis?
(c) Describe the three changes that may take place in a
thrombus.

8. What is your method of making a postmortem exami-
nation?

9. What is understood by the terms pathological physi-
oIog3', pathological morphology, special pathology?

10. The etiology of tumors. (a"l What influence has
age especially as to the connective-tissue type? (b) Sex,
if a significant factor, denotes a predisposition to what?

Inne 22, 1907]

MEDICAL RECORD.

1057

(c) Heredity, and local predisposing factors, (d") What
proportion of malignant tumors in males compared to fe-
males?

MATERIA MEDICA AND THERAPEUTICS.

1. Under what conditions would you prescribe, (a)
ergot; (b) bromide of potassium; (c) iodine; (d) hyos-
cyamus ?

2. Treat a case of apoplexy.

3. Name five sedatives and give indications for the use
of each.

4. Give complete treatment for a case of dysentery.

5. Name four methods of introducing medicine into
the system and give relative dose by each method.

6. Give classification, properties, dose, physiological
action, and therapeutic use of Fowler's solution.

7. Same of belladonna.

8. Give treatment for vomiting of cerebral origin; (b")
acute gastritis.

9. What are the therapeutic uses of iron?

10. Give official terms, the part used, and the active
principles of deadly nightshade, henbane, foxglove, monks-
hood, dogbutton.

-WSWERS TO STATE BO.\RD EX.^MINATION

QUESTIONS.

Idaho State Board of AIedical Examiners.

October 2, 1906.

1. ''Spondylitis deformans is the name given to a disease
which affects the vertebral column, and is the same, or of
the same nature, as that termed 'chronic rheumatic arthritis'
when affecting other parts. As a consequence of absorp-
tion of the articular cartilages and of the intervertebral
discs, and the development of osteophytic prominences
from the edges of the vertebral bodies, and ossification of
the ligaments, especially the anterior common ligament, the
spine becomes bent and rigid, and a very characteristic de-
formity is the result.

"Kyphosis is produced, and as the disease frequently
aft'ects the whole or major part of the column, there is
one long antero-posterior curve, the patient has a constant
stoop, his stature is diminished, there is complete rigidity
of his spine, and his movements are awkward and con-
strained. In lesser grades of the disease the cervicodorsal
or the lumbodorsal regions may be alone affected, and the
signs are less pronounced. With advance of the disease
the spinal muscles waste, and the curvature becomes more
prominent, the head is poked forward, the shoulders
appear unusually round, and the patient is obliged to sup-
port himself with a stick." (Treves' Manual of Surgery.)

2. As a rule the capsular ligament is not ruptured.

4. (a) Extra-dural hemorrhage is generally from the
middle meningeal artery or one of its branches, or the su-
perior longitudinal, lateral, or occipital sinus : occasionally
it is from the internal carotid artery.

Sub-dtiral hemorrhage is generally from the middle men-
ingeal artery or one of its branches, small veins, capillaries,
or one of the sinuses.

(b) "If after an injury to the head a patient be found
absolutely unconscious, it beiiig imposible to arouse him or
to make him answer questions, with fixed dilated pupils.
slow. deep, stertorous breathing with flapping of the cheeks
during expiration, slow, full, labored pulse, retention of
urine and involuntary passage of feces, and paralysis, gen-
eral or of one side of the body only, these symptoms are
caused by eompression of the brain. ... If the symp-
toms have come on gradually and at short intervals after
the accident ''an interval during which the patient may have
been quite conscious, or showing more or less evidence of
brain concussion'), or if while under observation it be noted
that the signs of compression are increasing, the coma be-
coming more deep and the paralysis more extensive, it
clearly indicates intracranial hemorrhage. When there has
been an interval of consciousness between the iniury and
the oncoming of the symptoms of concussion, showing that
the brain has not been seriously shaken or contused : and.
further, if the paralysis is or was at first unilateral, we
may diagnose that the hemorrhage has taken place betweeen
the bone and the dura mater from rupture of a meningeal
artery or wound of a sinus ; while under the other con-
ditions we have evidence of more severe direct iniurv to
the brain, making it probable that the blood clot is situated
on or in the brain." (Gould's Surgical Diagnosis.)

S- The indications for castration are: — malposition of
the testicle, tuberculous disease, old standing hematocele,
cancer, or other tumors, and chronic enlargement of the
prostate gland.

6. (a) The three conditions which constitute a strangu-
lated hernia are: i. A constriction so tight that reduction
is impossible; 2. Interference with the circulation, which
may possibly lead to gangrene; 3. If intestine is present,
gas and feces are unable to pass.

(b) The most marked p.itliological changes are found
inside the sac — on account of pressure and the interference
with the circulation.

8. (b) Tracheotomy is the more dangerous and diffi-
cult operation as a rule, it takes longer, and requires more
assistance. But laryngotomy cannot be performed on a
patient under thirteen years of age owing to the smallness
of the crico-thyroid membrane ; it is also more dilficult to
insert a laryngotomy tube than a tracheotomy tube.

p. (a) The Staphylococcus pyogenes aureus and albus,
Streptococcus pyogenes: sometimes the tubercle bacillus,
bacillus of influenza, Friedlandcr's bacillus. Fraenkel's
pneumococcus.

10. (d) Ideal clwlccystotoniy is an operation which in-
cludes opening the gall-bladder, removing the calculi, and
suturing the incision.

OBSTETRICS.

2. Multiple pregnancy may be diagnosed by the follow-
ing signs: (i) The abdomen may be irregular in shape
and may show a sulcus indicating the space between the
two fetal sacs; (2) persistent and increased tension of the
uterine walls; (3) two fetal heart sounds may be heard;
(4) multiplicity of small pajts ; (5) two fetal heads or
backs may be palpated; (6) diminished fetal mobility
Sometimes it is difficult to diagnose the condition before
the birth of one child.

4. (i) The diet should be easily digestible and nutritious;
(2) the clothing should be warm, and free from con-
strictions; (3) gentle and moderate exercise should be in-
dulged in, if possible in the open air; (4) the bowels and
bladder should be kept properly regulated; (5) sexual inter-
course should cease.

5. Absolute rest in bed, with head lowered, and in a
darkened room ;' opium or chloral should be administered ;
the diet should be liquid; the bowels and bladder should be
attend'id to; if the hemorrhage is excessive the pelvis may
be elevated; but ergot and tampons are contraindicated.

g. Dystocia means diliicult or obstructed labor.

Hydrocephalus is a condition in which there is marked
enlargement of the head ducts to serous effusion within the
cranium.

Funis is the umbilical cord.

Phlebitis is an inflammation of the veins, generally
septic.

Caput succedaneum is an edematous swelling developed
on the presenting part of the fetus during birth.

Ectopic gestation is a pregnancy in which the fetus is
elsewhere than in the uterine cavity.

Hyperemcsis is an extreme and exaggerated condition
of nausea and vomiting.

Polyhydramnios is an increased amount of liquor amnii.

Sapremia is a septic condition due to the entrance into
the blood of the products of putrefactive bacteria.

Gastrohysterotomy is another name for cesarean sec-
tion, or the delivery of a fetus through an incision in the
walls of the abdomen and the uterus.

10. (a) Indications for the use of forceps are: "l.
Forces at fault: Inertia uteri in the presence of con-
ditions likely to jeopardize the interests of mother or child.
((7) Impending exhaustion ; (/;) arrest of head, from feeble
pains. 2. Passages at fault: Moderate narrowing. 3'4 to
3M inches, true conjugate; moderate obstruction in the
soft parts. 3. Passenger at fault: A. Dystocia due to (a)
occipito-postenor, (b) mcnto-anterior face, (r) breech ar-
rested in cavity. B. Evidence of fetal exhaustion (pulse
above 160 or below 100 per minute). 4. Accidental compli-
cations: Hemorrhage; prolapsus funis; eclampsia. All
acute or chronic diseases or complications in which imme-
diate delivery is required in the interest of mother or child,
or both/' (From Jewell's Practice of Obstetrics.

(b) Conditions necessary for the use of forceps are: (1)
The rectum and bladder must be empty; (2) the os uteri
must be fully dilated; (3) the membranes must be rup-
tured; (4) the pelvis must be of sufficient size.

4. Ulcer of stomach is generally caused by injury or
bacteria, is most apt to occur between the ages of twenty
and forty-five : after eating there is pain localized in the
stomach, vomiting occurs soon after eating, hematemesis is
common, there is localized tenderness over the stomach,
and examination of the gastric contents shows an excess
of free HCl.

Cancer of stomach does not usually occur before fortv
years of age. is more common in males, the pain is local-

I058

MEDICAL RECORD.

[June 22, 1907

ized and constant, vomiting is copious and occurs some-
time after eating; the vomitus contains "cofifec ground"
material; hemorrhages are common; a tuinor may be pal-
pated, and examination of the gastric contents shows ab-
sence of free llCl and presence of lactic acid; there is pro-
gressive emaciation ; severe anemia and cachexia are also
present.

5. The etiology of chloasma is unknown. The pigmen-
tation may be due to the chemical action of the rays of
the sun upon the constituents of the blood; another theory
is that it is due to extravasated blood under-'oing changes;
there is also a relation between chloasma uterinum and the
uterus, as is shown by the fact that the chloasma usually
disappears either after parturition, the cure of the uterine
disorder, or the attainment of the menopause.

'Jhe treatment is unsatisfactory. If possible remove the
cause. Glacial acetic acid, or bichloride of mercury in one
or two per cent, solution may remove the spots, but they
are apt to return. Pure carbolic acid applied with a swab
has been recommended. The part may be washed with
alcohol, and a mercurial plaster applied. (From Jack-
son's Diseases of the Skin.)

7. The symlyloms of laryngismus stridulus are : The child
holds his breath, the face becomes congested and cyanotic,
the glottis is closed, inspiration is suddenly arrested, and
ends in a shrill crowing sound; there may be spasms or
convulsions ; the attack is sudden, and may be repeated ;
there is no fever, coryza, nor cough.

Treatment: Cold water should be dashed on the face
and chest; ammonia may be applied to the nostrils; an
emetic may be administered, bromides or chloral should be
given; attention must be paid to the diet and general
hygiene of the child.

8. The syml'toms of aortic regurgitation are: Palpi-
tation on slight exertion ; dsypnea, headache ; dizziness
with faintness, most marked on rising quickly ; precordial
pain ; the apex-beat is displaced downward and to the left ;
the heart is hypertrophied ; there is a diastolic murmur
over the aortic area; pulsation is observed in the carotids;
the oulse has the water-hammer characteristic.

9. Symptoms of tick fever of the Rocky Mountains;
"There" is a period of incubation of about a week. The
patient complains of nausea, general malaise, and a chill;
this latter is followed by a fever which reaches its highest
point about the tenth day. is characterized by evening rise
and morning remissions, lasts about two weeks, and may
be followed by subnormal temperature. In severe cases
the morning remissions may be absent, and the fever re-
mains high (from 104° to 106^ F.). There are general
pain and soreness, particularly during the first week, coated
tongue with red edges, sordes, constipation, nausea which
persists in severe cases, scanty urine with albumin and
casts, and epistaxis. The liver and snleen may be en-
larged. The pulse is high, and out of all proportion to the
fever; the respiration is also increased. An examina-
tion of the blood shows (i) the parasite, (2) a decrease
in the percentage of hemoglobin, (3) a decrease in the
number of the red blood cells, (4) a slight leucocytosis,
chiefly of the large mononuclears. Bronchitis is present dur-
ing the second week ; and in severe cases lobar pneumonia
supervenes, with a grave prognosis.

"The eruption appears usually on the third day. first
on the wrists and ankles, then on arms, legs, forehead,
back, chest, and, last and least, on the abdomen. It is
never very abundant on the abdomen, but the other por-
tions of the body, in some cases, are literally covered by
the eruption.

"At first the spots are of a bright red color, macular at
all times, from a pin point to a split pea in size. At first
they disappear readily on pressure and return quickly;
but if the case is a severe one they soon become darker
and in some cases are almost purple. From about the
sixth to the tenth day of the disease they fail to disap-
pear on pressure and are distinctly petechial in character.
In favorable cases, about the fourteenth day, they begin
to lose their petechial character and disappear slowly on
pressure. In some cases the eruption consists of small,
brow'uish spots, giving a turkey-eea appearance.

"As the fever declines the eruption begins to fade ; but a
slight return of fever or a free perspiration will cause it
to show distinctly."

"Treatment is unsatisfactory. Quinine in large doses has
been tried with some success, but must be given persist-
ently. The treatment is otherwise symptomatic and in-
cludes cardiac stimulants, Dovers' powder for the pains
and soreness, tepid baths for the fever, and plenty of
water to flush out the kidneys. The site of the tick-bite
should be cauterized with 95 per cent, carbolic acid."
(From Reference Handbook of the Medical Sciences.)

10. The dietetic treatment of diabetes mellitus: "All
sugars should be rejected. The same is true of starches.

Bread is the most difficult of foods to deal with. The
purer gluten flours may be used, but they are difficult to
obtain. Aleuronat or almond flour may be substituted.
Most meats and fish are permissible, and the greens and
relishes may be taken freely. Farinaceous foods and pota-
toes or other vegetables rich in carbohydrates must be
avoided. Eggs, butter, cheese, and milk are allowed. Sac-
charin may be used in place of sugar for sweetening.

"The chief articles prohibited are liver, wheat bread,
corn flour, rice, sago, arrow-root, barley, oatmeal, tapioca,
macaroni, puddings, beet root, sweet vegetables, potatoes,
carrots, peas, beans, parsnips, turnips, all sweet fruits, ap-
ples, pears, plums, grapes, oranges, apricots, peaches,
gooseberries, dates, watermelon, sweet wines, cordials,
porter, lager beer, cider, mustard, honey, sweets, ices, jams,
treacle." ( Gould and Pyle's Cyclopedia of Medicine and
Surgery.)

GYNECOIXIGY.

1. Five primary causes of menorrhagia : Tumors, uter-
ine displacements, endometritis, tubal and ovarian diseases,
and subinvolution.

2. The varieties of dysmenorrhea are: Congestive,
neuralgic, obstructive, ovarian, and membranous.

3. Dilatation of the cervix; curettage; the uterine cavity
is then to be flushed out with some antiseptic solution,
and then sw'abbed with iodine or carbolic acid to prevent
reinfection ; the patient must remain in bed for from seven
to ten days after the operation.

5. In fecal impaction there will be a history of consti-
pation: a vaginal examination will also demonstrate the
presence of this condition; active purgation will clear up
any doubt on the subject.

7. The uses of the uterine sound are: (i) To demon-
strate the mobility of the uterus; (2) to show the size of
the uterus; (3) the presence of intrauterine growths; (4)
deviations in the cervical canal; and (5) as an aid in the
diagnosis of uterine displacements.

Contraindications : ( i ) The least suspicion of even the
possibility of pregnancy; (2) menstruation; (3) acute
endometritis; (4) malignant disease of the uterus or
vagina; (5) acute pelvic inflammation.

Dangers: (i) Abortion; (2) sepsis; (3) peritonitis;
(4) hemorrhage; (5) perforation of the uterus.

9. (l) Vesicovaginal; (2) rectovaginal; (3) vesico-
uterine; (4) urethrovaginal; (5) vesicouterovaginal.

10. Symptoms of uterine carcinoma: Irregular hem-
orrhages, pain, and offensive discharge; advancing years;
microscopic examination of intrauterine scrapings will
clinch the diagnosis.

Treatment: Complete abdominal hysterectomy, unless
contraindicatcd by the debilitated condition of the pa-
tient.

ANATOMY.

I. (i) Foramen mag)iu)n: The medulla and its mem-
branes, vertebral arteries, spinal accessory nerves, anterior
and posterior spinal arteries, and the occipitoaxial liga-
ment.

(2) Jugular foramen : Inferior petrosal sinus, lateral
sinus, meningeal branches of occipital and ascending
pharyngeal arteries; glossopharyngeal, pneumogastric, and
spinal accessory nerves.

(3) Inferior dental foramen: Inferior dental vessels
and ner\e.

(4) Foramen rolunduni : Superior maxillary division
of fifth cranial nerve.

(5) Foramen oz'ale: Inferior maxillary division of
fifth cranial nerve.

5. (a) Fissure of Rolando; fissure of Sylvius; parieto-
occipital fissure.

(b) The chordce tendinca: are tendinous cords attached
above to the .segments of the tricuspid and mitral valves,
and below to the inusculi papillares of the ventricles of the
heart.

(c) The pineal body is a small conical body situated in
the brain, between the anterior corpora quadrigemina and
immediately behind the posterior commissure.

(d) The %'as deferens begins at the lower part of the
globus minor of the testis and proceeds along the posterior
border of the testis and inner side of the epididvmis. alon"
the back part of the spermatic cord, through the ex-
ternal abdominal ring, inguinal canal, and the internal ab-
dominal ring. It then curves round the outer side of the
epigastric artery, crosses the external iliac vessels, and
goes to the side and base of the bladder, passing to the
inner side of the ureter. It lies between the base of the
bladder and the rectum.

(e") Corpus callosum is situated at the anterior part
of the base of the great longitudinal fissure of the cere-
bium, and connects the two hemispheres together.

June 22, 1907]

MEDICAL RECORD.

1059

DIAGNOSIS.

I. Pathognomonic is a term applied to signs and symp-
toms which are specially characteristic of a disease, and
the presence of which makes its diagnosis absolute.

Examples: (i) Escape of cerebrospinal fluid in frac-
tures of the base of the skull: (2) Koplik"s spots in
measles; (3) hearing the fetal heart sound in pregnancy;
(4) water-liammer or Corrigan's pulse in aortic regurgita-
tion.

3. In pernicious anemia the blood would show: (i) A
diminution ni the number of red corpuscles: (2) a rela-
tive increase in the amount of hemoglobin: (3) poikilo-
cytosis; (4) the presence of nucleated red cells; (5)
variation in the size of the red cells: (6) the leucocytes
may be diminished.

6. (a) Clubbing of the fingers is found in pulmonary
phthisis, emphysema, pulmonary osteoarthropathy, valvu-
lar cardiac disease (sometimes).

(b) Loss of patellar reflex, in locomotor ataxia, anterior
poliomyelitis, peripheral neuritis.

(c) Cheyne-Stokes respiratuni, in apoplexy, uremia, cere-
bral tumors, tuberculous meningitis.

(d) ll'rist drop, in lead, or arsenic, or alcohol poison-
ing, multiple neuritis, pressure from crutches, etc.

(e) Pain in the knee, in hip joint disease, obturator her-
nia.

(f) Barrel-shaped chest, in emphysema, chronic bron-
chitis, bronchial asthma.

(g) Koplik's spots, in measles.

(h) Pain in testicle and glans penis, in renal calculus,
(i) Argyll-Robertson pupil, in locomotor ataxia, cerebral
syphilis, progressive paralysis of the insane,
(j) Stratvberry tongue, in scarlet fever.

HYGIENE.

I. .As a rule one attack of the following diseases con-
veys immunity : Whooping cough, rothcln. scarlet fever,
typhoid, typhus, smallpox, varioloid, chickenpo.x, yellow
fever, mumps.

4. Malaria and yellow fever are transmitted by the
mosquito : bubonic plague may be conveyed by fleas, flies,
and bugs; typhoid may be conveyed by flies: tick fever (or
spotted fever) is carried by the tick; sleeping sickness is
generally transmitted by a biting fly.

9. Typhoid, tuberculosis, smallpox, cholera, yellow
fever, ophthalmia neonatorum.

PHYSIOLOGY.

1. In accommodating the eye for near vision the ciliary
muscle contracts, the suspensory ligament relaxes, and the
lens bulges and becomes more convex.

2. The patellar reflex consists of a contraction of the
extensor muscles of the leg and a movement of the foot
forward when the ligamentum patella is struck ; the quad-
riceps extensor must first be slightly stretched by putting
one knee over the other. Its integrity depends upon a
healthy condition of the entire reflex arc, consisting of
tendon, afferent or sensory nerve, posterior roots, and
anterior horn of the spinal cord, the efferent or motor
nerve, and the muscle itself.

10. The functions of the skin are : Protection, sense
of touch, excretion, regulation of body temperature, ab-
sorption, and respiration.

CHEMISTRY .AND TO.XICOLOGV.

1. (a) Carbohydrates were formerly defined as sub-
stances of unknown constitution, composed of carbon,
hydrogen, and oxygen : the last two being in the propor-
tion to form water.

(b) Proteids are substances of very complex compo-
sition and of unknown constitution, and are necessary to
the phenomena of life. The molecule contains carbon,
hydrogen, o.xygen, nitrogen, sulphur, and sometimes phos-
phorus, iron, or some other element.

2. In a physical change the composition of the sub-
stance is not altered. In a chemical chann-e the compo-
sition of the substance is altered. The emulsification of
fats is a physical change.

3. Organic chemistry is the chemistry of substances
which contain carlwn. Inorganic chemistry is llie chem-
istry of substances which do not contain carbon.

4. (l) QHk,05+H.0=GH,:0c.
(2) C6H,:0„=2CO=+2GH,0.

5. The urine should first be tested for albumin. If this
be present, it should be removed by heatino- the urine to
near the boiling point, and filtering from the coagulum.

(l.) Fehlin.!;'s test: Place in a test-tube a few c.c. of the
liquid prepared as stated below, and boil ; no reddish tinge
should be observable, even after five minutes' repose. Add
the liquid under examination gradually, and boil after each
addition. In the presence of sugar a yellow or red precipi-

tate is formed. In the presence of traces of glucose, only
a small amount of precipitate is produced, which adheres
to the glass, and is best seen when the blue liquid is poured
out.

(The reagent must be kept in two solutions, which are to
be mi.xed immediately before use. Solution I consists of
34.653 gms. of crystallized CuSOi, dissolved in water to
500 c.c; and Solution II of 130 gms. of Rochelle salt dis-
solved to 500 c.c. in NaHO solution of sp. gr. 1.12. When
required for use equal volumes of the two solutions are
mi.xed, and the mixture diluted with four volumes of
water.]

(2.) Boettgci-'s test: Render the urine strongly alkaline
by addition of NaiCOa. Di\ide about 6 c.c. of the alkaline
liquid in two test-tubes. To one test-tube add a very
minute quantity of powdered subnitrate of bismuth, to the
'other as much powdered litharge. Boil the contents of both
tubes. The presence of glucose is indicated by a dark or
black color of the bismuth powder, the lithar.ge retaining
its natural color. (From \\'itthaus' Essentials of Chem-
istry. )

6. Chemical test for pus in the urine: Acidify the
urine with acetic acid, then tiller it, and treat the filter
with a few drops of freshly prepared tincture of guaiacum ;
a deep blue color denotes the presence of pus.

7. The antidote for (a) corrosive sublimate is white
of egg. in not too great a quantity: for (b) arsenicum is
freshly prepared ferric hydroxide; for (3) silver nitrate is
salt and water and white of egg: for (.it iodine is starch
solution and emetics: for (5) phosphorus is old French
oil of turpentine.

8. Test for arsenic : Reinsch's test is as follows : To
the suspected fluid add a little pure HCl; suspend in the
fluid a small strip of bright copper foil, and boil. If a deposit
forms on the copper, remove the copper, wash it with pure
water, dry on filter paper, but be careful not to rub ofiF
the deposit. Coil up the copper, and put it into a clean dry
glass tube, open at both ends, and apply heat at the part
where the copper is. If arsenic is present there will ap-
pear in the cold part of the tube a mirror, which will be
found on microscopical examination to consist of octa-
hedral crj'stals of arsenic trioxide.

9. The stomach pump is contraindicated when cor-
rosives have liccn taken.

P.^THOLOGV.

I. The .Micrococcus lanceolatus is better known as the
Diplococcus lanceolatus. or the pncumococcus of Fraenkel
and W'eichelbaum.

(a") Process of staining: Spread a cover glass with a
smear containing the bacteria, dry it, then fix it in a flame.
It can then be stained for from five to ten minutes in
Ehrlich's solution : it is then to be washed in water and
afterwards immersed in (jram's solution for two or three
minutes. It is then washed in 95 per cent, alcohol. While
in the Gram's solution the specimen is very dark brown,
but it becomes violet or blue again on application of the
alcohol.

(b) It is found in lobar pneumonia; it has also been
found occasionally in cerebrospinal meningitis, pleurisy,
peritonitis, pericarditis, acute abscesses, otitis media, and
other conditions.

3. The alterations or changes that take place in a
muscle while undergoing progressive muscular atrophy are
as follows : "The muscles become pale and rather flabby.
Microscopically the fibers show various forms of degener-
ation. Fragmentation in a longitudinal or in a transverse
direction, coagulation necrosis, and occasionally fatty de-
generation of the fibers may be seen. Sometimes the fibers
seem to grow smaller by a simple atrophic process. Coin-
cidently reactive proliferation is seen in the connective
tissue between fibers, and doubtless this to some extent
causes further muscular degeneration. The muscle cells
themselves may proliferate quite extensively."' (Stengel's
Pathology.)

4. Carcinoma of the stomach (a) is usually primary,
(b) It is usually situated at or near the pylorus, and the
most common type is the cylindrical celled adenocar-
cinoma.

5. According to Osier, "The affection begins in the soli-
tary and agminated glands or on the surface of or within
the mucosa. The caseation and necrosis lead to ulceration,
which may be very extensive and involve the greater por-
tion of tile mucosa of the large and small bowels. In
the ileum the Peyer's patches are chiefly involved, and the
ulcers may be ovoid, but in the jejunum and colon they
are usually round or transverse to the long axis."

7. (a) A thrombus is a plug or clot in a blood-vessel
remaining at the site of its formation.

(b) Thrombosis is the coagulation of the blood within
the vessels or heart during life. The changes that may

io6o

MEDICAL RECORD.

[June 22, 1907

take place in a thrombus are : Organization, calcifica-
tion, softening, infection, and putrefaction.

9. Pathological physiology is that branch of science
which deals with the study of disturbances of function.

Pathological morphology is that branch of science which
deals with the study of the structural changes in disease.

Special pathology deals with pathological processes in
individual or special diseases, or organs or parts.

10. Tumors: (a) Connective tissue tumors are most
common in early life when the connective tissues grow
most vigorously.

(b) Sex has little bearing on the etiology of tumors,
except in the case of cancer, which is more common in
females.

(c) Heredity is considered by some to be an etiological
factor ; but the more probable view is that the predispo-
sition to tumors and the -weakened resistance of the tissues
are hereditary.

Local predisposing factors are slight. Places where
various different embryological structures meet are the
most liable to malignant tumors.

(d) Malignant tumors are more common in females than
in males.

MATERI.\ MEMCA AND THERAPEUTICS.

5. By mouth, by hypodermic injection, by rectum, and
by inhalation. If the dose by mouth is one grain, the
hypodermic dose would be about one-half a grain, and
the dose by rectum about one and a half grains.

10. —

Mthitni 3ltpma.

Official Name.

Deadly night Atropa Belladon- Leaves and root
shade. na.

Henbane Hyoscyamus Ni- Leaves and tiow

ger I ering tops.
Foxglove. . , [Digitalis Purpurea Leaves

Part Used.

Monkshood. , |Aconitum Xapel- Root-

I lus.
Dogbutton.. .jSto'chnos nuxjSeeds..
j vomica.

Active Principle.

Atropine and Bella-

donnine.
Hyoscyamine and

Hyoscine.
Digitahn. Digitalein.

Digitin. Digitonin

and Digitoxin.
Aconitine.

Str>'chnine and Bru-
cine.

BULLETIN OF APPROACHLNG EXAMINATIONS. t

STATE.

Alabama*. .

NAME AND ADDRESS OP PLACE AXD DATE OF

SECRETARY. NEXT EXAMINATION.

. ..W. H. Sanders. Montgomery. .Montgomery. .July 1-6

Arizona* Ancil Martin. Phoenix Phoenix July i

Arkansas* F. T. Murphy. Brinkley Little Rock. . .July o

California Chas. L. Tisdale. 1879 Sutter

Street. San Francisco San Francisco . August 6

Colorado S. D. Van Meter. 1723 Tre-

mont Street, Denver Denver

Connecticut*.. .Chas. A. Tuttle, New Haven. .New Haven. .

Delaware J. H. Wilson, Dover Dover

Dis. of Col'bia. .W.C.Woodward. Washington. Washington.. -July 11

Florida* i- ^ Fernandez. Jacksonville. Jacksonville. . .Nov. 20

Georgia E. R. Anthony. Griffin Atlanta October 8

Idaho J. L. Conant, Jr., Genesee Boise October i

Illinois J. A. Egan. Springfield Chicago

Indiana W. T. Gott. 120 State House.

Indianapolis Indianapolis, ..October 2 2

Iowa LouisA Thomas. Des Moines. . Des Moines.. . .Sept. —

Kansas T. E. Raines. Concordia Topeka October 3

Kentucky* J. N. McCormack, Bowling

Green Louisville October 22

Louisiana F.A. La Rue. 211 Camp Street,

New Orleans New Orleans. ..October 15

Maine Wm. J. Maybury. Saco Augusta July 9

Maryland J. Mc P. Scott. Hagerstown. . ..Baltimore

Massachusetts*. E. B. Harvey. State House.

Boston Boston July 9

. .. -B. D. Harrison. 205 Whitney

Building, Detroit Lansing October 8

W. S. FuUerton. St. Paul St. Paul October i

... .J. F. Hunter, Jackson lackson October 8

. . . .J.A.B.Adcock. Warrensb'g. . .Mexico. July 0

Montana* Wm. C. Riddell. Helena Helena October i

Nebraska Geo. H. Brash. Beatrice Lincoln

Nevada S. L. Lee. Carson City Carson City.. .August 5

N. Hamps're*. .Henry C Morrison, State Li-
brary. Concord Concord X^^V 9

. .J. W. Bennett, Long Branch. .Trenton October 22

. .B. D. Black, Las Vegas Santa Fe December a

( New York
. -C.F.Wheelock.Unv.of State 1 Albany.
of New York. Albany.. ..J Syracuse,
( Buffalo.

..G. T Sikes, Grissom

.H. M. Wheeler. Grand Forks. .Grand Fork's. .July

Michigan. ,

Minnesota .
Mississippi.
Missouri .

New Jersey. .
New Mexico..

New York. . .

N.Carolina*..
N. Dakota.

June

Ohio Geo. H. Matson, Columbus. . . .Columbus Dec

Oklahoma*
Oregon

Pennsylvania

Rhode Island.
S. Carolina.. .
S. Dakota

. W. Baker. Enid Guthrie..

. E. Miller. Portland Portland ,

.N. C. Schaeffer. Horrisburg. { ^f^Wg^^;; } -J""
.G T. Swarts. Pro\-idence Providence.. . .July

oS

Tennessee*..
Texas.

I

W. M. Lester. Columbia Columbia June g

H. E. McNutt, .\berdeen Sioux Falls July lo

r Memphis ]

T. J. Happel. Trenton I Nash\-i!le J May. 1908

[ Knoxville I

T. T. Jackson. San Antonio. . ..Austin June 25

Utah* R. W. Fisher. Salt Lake City .Salt Lake City.July 7

Vermont W. Scott Nay. Underbill Burlington. . . .July g

.R.S. Martin. Stuart Lynchburg..,.

.C. W. Sharpies, Seattle Seattle July 2

,H. A. Barbee, Point Pleasant , Charleston, . , , July g

, J. V. Stevens, JefEerson Madison July 9

Wyoming S. B. Miller, Laramie Cheyenne

• .^lo reciprocity recognized by these States.

t -Applicants should in every case write to the secretarj* for latest
details regarding the examinatioti in any particular State

Virginia
Washington*
W Virginia*
Wisconsin

Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious disease reported to the
Sanitary Bureau, Health Department, New York City, for

the week ending June 15, 1907 :

Tuberculosis Pulmonalis

Diphtheria

Measles

Scarlet Fever

Smallpo.x

Varicella ,

Typhoid Fever

Whooping Cough

Cerebrospinal Meningitis
Malarial Fever

Totals

Week of Jtme 8
Cases Deaths

393

306

681

543

5

105

55

51

2162

175
37
21
24

293

Week of June 15
Cases Deaths

318
393
777
541
2
100

39
22
20

166
48
26

28

9

12

10

300

Empyema. — By connecting a Politzer bag vi^ith the
drainage tube in cases of empyema the discharge of pus is
greatly facilitated. The bag is compressed and its tip
inserted into the end of the drainage tube, a short section
of rubber tubing intervening if necessary. The bag in ex-
panding exerts constant aspiration in the abscess cavity,
and the discharge is all collected in the bag, which is
emptied at regular intervals.

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital

Service, during the week ended June 14, 1907 :

SMALLPOX VNITED STATES.

Illinois, Chicago June 1-8

Indiana, Evans\-ille June 6

Kansas, Kansas City June 1-8

Kentucky, Covington June i-S

Henderson May 1-3 1

Louisville May 31-June 6. ,

Iowa, Ida County May 1-31

Michigan, Saginaw May 25-June i , ,

New York, .New Yo k June i-S

North Carolina, 22 counties April 1-30

Charlotte June 1-8

Ohio, Cincinnati May 3 i-June - , ,

Columbus May 1-3 1

Texas, Galveston May 24- June i . .

Washington, Spokane May 2s-June i . .

SMALLPOX FOREIGN.

China. Hankau .\pril 20-27

Shanghai April 20-27

Tientsin April 20-27

France, Paris May 11-18

Germany. General - May 11-18

Mannheim May 11-18

Great Britain, Southampton May iS-25

India, Bombay May 7-14

Italy. General May 16-23

Torre .\nnunziata May 10-20

Turin May i2-ig

Japan, Nagoya.. May 15

Madeira, Funchal May 12-26

Mexico, Aguas Calientes May 25-June i . .

Russia, Moscow April 20-May 4 . ,

Odessa May 11-18

Spain, Valencia May 19-26

Turkey, Bassorah May 4-n

CASES, DEATHS.
7

iS
4 I (From S.
S. Hannover)
6

[

Present

1.1

I

17

I

X

3

19

a

Epidemic

25

3

YELLOW FEVER.

Brazil, Manaos May 4-11

Cuba. Habana June 6,,..

San Nicholas June 7 . . . .

Guatemala, Gualan May 29 , , . .

Zacapa May 29 ... ,

West Indies, Trinidad, Port of

Spain May 11-18.

I From San-
ta Clara Province

Present
Present

India, Bombay May 11-14

Rangoon April 2--May 4 , ,

.-Vfrica, Cape Colony, King William's

Town .April 22-May 4, . 3 2 ^

Germany. Groden June 3 i on S.b.

Wharf edale from Buenos Aires

India, Bombay May 7-14 ,. 188

Rangoon Aoril 27-May 4.. .. 58

Japan, Osaka May 15 s

Yokahama May 30 Present

Turkev, Dieidah May 6-1 1 13 12

Island of Bahrein May 22 ,. Epidemic

West Indies. Trinidad Tune 11 2 2

Medical Record

A Weekly JflU7-nal of Medici7ie and Sjiri^cry

Vol. 71, No. 26.
Whole No. I9I2.

New York, June 29, 1907.

$5.00 Per Annum.
Single Copies, lOc.

(Original Artirba.

MASSAGE OF THE PROSTATE AND STRIP-
PING THE SEMINAL VESICLES.*

By FERD. C. valentine. M.D.,

AND t

TERRY M. TOWNSEND, M.D.,

NEW YORK.

The usefulness of massage of the prostate and strip-
ping the seminal vesicles is daily in evidence, when
these organs are involved in acute, subacute, or
chronic urethritis. Indeed, the urethra is not safe
from autoreinfection while its adnexa harbor no.x-
ious bacteria. Massage of the prostate has a place
also early in prostatic hypertrophy. This naturally
embraces no claim for complete restitutio ad inte-
grum, but experience shows many a case in which
judicious massage, with other treatment, has saved
the risks of a cutting operation.

}ilassage of the prostate and stripping the vesicles
are not negligible in the first evidences of abscess
of these organs. True, it is unsurgical to attempt to
empty pus from the adnexa through the urethra, yet
there are enough successful cases in every prac-
titioner's experience to justify the procedure, when
the patient's condition makes operation hazardous,
or when he refuses to take the risks thereof. Nat-
urally when rupture of an abscess into the tissues
is imminent, none but operative intervention may be
considered.

The value of prostatic massage and stripping the
vesicles in aberrations of the sexual function is still
suh judiee. Yet the practice forms a useful adjuvant
to other treatment in these cases.

The present paper does not embrace recital of the
indications for massage and stripping, further than
the above mere suggestions. The exclusive object
in view at present is a studv of methods used in
the procedures indicated by the title.

Standard writers assume that every practitioner
is familiar with the technique under consideration.
The consequence has been the evolution of several
methods, most of which are unnecessarily difficult
and painful, to a degree dangerous, and nidre or less
ineffective. These results have led many prac-
titioners to discard altogether digital treatment of
these adnexa to their patients' disadvantage.

The various methods alluded to will be sketched
to illustrate the value of the procedure which per-
sonal practice has shown to be most recommend-
able.

In the knec-elho%v position the patient rests upon
the operating table, his chest placed upon his crossed
arms, his pelvis supported bv his thighs, the knees
resting upon the lower margin of the tabic. This
position promptly causes b'-^eremia of the facial and

*Read before the Manhattan CHnical Society. March 15,
1907.

cerebral vessels and painful throbbing thereof, dif-
ficulty of breathing, due to compression of the chest
contents from pressure of the abdominal viscera on
the diaphragm, and gravitation of the prostate and
seminal vesicles following the abdominal and other
pelvic contents, thus so increasing their distance
from the anus as often to place them beyond the
reach of the finger in the rectum. This latter fact
gives the patient unnecessary pain from the opera-
tor's efforts to push the perineum upward, in en-
deavoring to express the contents of the prostate
and vesicles.

It is self-evident that the knee-elbow position in-
creases the surgeon's work and diiuinishes its ef-
ficacy. The augmentation of effort would not be
objectionable, were its effectiveness increased or
the patient's coinfort enhanced thereby. The pros-
tate and vesicles gravitate away from the finger's
tip and the abdominal walls, becoming pendulous,
offer a distinct impediment to that counter-pressure
which is essential in fixation of the organs.

It is small wonder, then, that patients who have
been examined, or for whom treatment has been at-
tempted in this position, are apprehensive when
brought for consultation involving examination of
the major adnexa. The inefficiency of work in the
knee-elbow position is well demonstrated when the
patient's physician reports his inability to express
any of the contents of the organs mentioned, and
when, the patient being conveniently placed, a
copious extrusion is easily and relatively painlessly
obtained.

In the Si})is position the patient is placed on his
right side, with his buttocks at the edge of the table.
It certainly is not nearly so uncomfortable for the
patient as the position before described. In it, how-
ever, the surgeon's work is rendered difficult, as he
is obliged to use his left fist to make counterpressure
upon the prevesical region, to force the prostate and
seminal vesicles towards the finger in the rectum
seeking them. Moreover, the thighs being drawn
up upon the abdomen, serve as a hindrance to free
action of the left arm that partly encircles the pa-
tient's body.

The erect flexed position is the one most in use.
The patient stands before the operator, bends over
the back of a chair, or over a table, or rests his
hands upon his knees. To appro.ximate the prostate
and vesicles to the finger pushing up in the rectum,
the operator must pull the pelvic contents towards
it with his left hand. Some works recommend that
the operator, to give greater force to his right index
finger, rest his right foot upon the rung of a chair
and let the knee give the elbow increased propulsive
power.

Aside from the unnecessary difficulty that this
position puts upon the operator, it is a strain upon
the patient which does anything but contribute to
the muscular relaxation which must be invited to aid
in the work. Moreover, there is alwavs a danger

10t)2

MEDICAL RECORD.

[June 29, 1907

that the patient will faint and pitch forward or side-
wise upon the floor. This occurred in the experi-
ence of a colleague who was endeavoring to demon-
strate to us the superiority of this position over the
one we advocate. The patient lost consciousness
and in falling thrust his face through the window of
an instrument cabinet before he reached the floor.
Numerous large scars on the patient's head and face
loudly protest against this method of examining and
treating the prostate and seminal vesicles.

The gynecological position is in all regards the
normal one for the class of work now under consid-
eration. Its steps may be concisely laid down as
follows :

I. Preparation of the operator. The physician
should be prepared for this class of work, as for
any other genitourinary procedure. The principal
points to be kept in view are that a patient with-
out urethral discharge or other manifestations of
disease may harbor gonococci in the prostate or sem-
inal vesicles or both. Moreover, in some cases the
prostate or the posterior urethra and the detrusors
have acquired an extraordinary projectile power.
In that event the merest touch of the prostatic re-
gion through the rectum may send forth to quite
a distance drops or even small streams of prostatic
juice. If the operator's garments are not protected
they may become soiled with this sort of "ejacula-
tion." It may, and probably will, not be convenient
to change garments at once, while the soiled ones
are sent to be cleaned. The possibility of infection
from such a source is not remote, when keeping in
mind that most of us unconsciously pass our hands
over our garments and with equal recklessness wipe
our eyes with our fingers. The manifest indication
herefrom is that no genitourinary work should be
performed unless when properly dressed in a gown.
The choice of the gown is purely one of personal
taste. Even at the risk of exposure to facetiae we
confess preference for what is known in the cloth-
ing trade as "market coats." The white material is
sufficiently dense to protect the ordinary garments
in the frequent hand washings extensive genito-
urinary work entails, and the form is such as to
make a change easy whenever one garment becomes
soiled.

As desirable as it is to keep one's clothing cov-
ered, so imperative is it also to have the hands and
forearms bare to the elbows. Pus, blood, or infected
secretions soiling any part of the exposed skin may
be at once washed off, which would not be feasible
if the arms were covered by sleeves. The arms can be
conveniently bared for our work if the shirt sleeves
aj;e especially made for the purpose. Their ordinary
slit is extended to 2 1-2 inches beyond the olecranon;
the cuff should not be over 2 1-2 inches wide. To
keep the sleeve out of the way of the day's work, the
cuff is opened and not turned upon itself, as is usu-
ally done when rolling up the sleeve. On the con-
trary, its anterior margin is kept downward as the
cuff is laid in its normal position, as close to the
shoulder as possible. The shirt sleeve projecting be-
neath is then smoothly folded twice or three times,
according to its length, around the cuff, as it lies
upon the arm. The undershirt sleeve is then so
folded around the cuff and turned over the shirt
sleeve that the lower part (cuff) of the undershirt
is reversed upon the entire mass. The operator who
devotes fifteen seconds to deliberately preparing each
arm as above suggested will not be encumbered with
his shirt sleeves throughout the day. W'hen the
work is finished, merely reversing the undershirt's

cuff will allow the entire sleeve to drop to its place,
without any crumpling of tlie starched cuff.

An important advantage of the careful prepara-
tion suggested is that, with arms bare and garments
covered, the operator has no hesitancy in closely
approaching his work. The thoroughness thereof is
consequently greater than if he were risking infec-
tion, as before detailed.

2. Protecting the hands. The operator accus-
tomed by long practice to the use of very thin rub-
ber gauntlets will be adequately protected thereby.
Of course, they must be in perfect condition and
properly sterilized. The sense of touch will not be
impeded if the operator uses a very tight glove,
while it will be if he endeavors working with a glove
that is too large for his hand. Whether a glove or
the finger varnish (to be described) is used, the
nails of the genitourinary specialist should always be
kept so closely filed as to entirely obliterate the sub-
ungual space. Moreover, the skin about the nail
beds should always be kept free from rough projec-
tions or irregularities (agnail, or hangnail) which
may tear the glove or render finger varnishing suf-
ficiently ineffective, to add to the patient's discom-
fort.

Those not accustomed to the use of gloves can
perfectly protect the examining finger by dipping
it into the finger varnish alluded to above. This con-
sists of: Copal, 2.0; Venetian turpentine, 4.0; sul-
phuric ether, loo.o; collodion, loo.o; acetone, 8.0.

This varnish dries almost instantly into a perfect
sheath for the finger, and in nowise obtunds its
tactile sense. It does not break when the finger is
bent or manipulated in any manner. After the w'ork
in view is finished, the finger varnish can be scrubbed
off with a brush with soap and hot water. Any
small flakes that may remain adherent to the skin
can be readily rubbed off with a towel moistened
with alcohol.

3. Preparation of the table. Common cleanliness
commands that a fresh towel be placed upon the
pillow to receive the patient's head and another upon
the lower edge of the body of the table, where his
buttocks are to rest. It is a crude but effective les-
son in caution to place these clean towels as above
suggested, in the patient's presence.

4. Preparation of the patient. It is wise to ap-
point a time for examination of the prostate and
vesicles or for their treatment, shortly after the rec-
tum has been evacuated. The presence of fecal
masses primarily increases the inevitable unsavori-
ness of the procedure and further disturbs pre-
cision of work by the finger impinging upon them.
It is true that such masses, if present, usually keep
moving above and behind the finger's tip, still their
presence is annoying enough to cause one to hasten
his w-ork.

The unesthetic character of the procedure need
not be enhanced by an occasional patient's lack of
cleanliness. One may find such disregard of
cleanliness in particles of dried excrement adherent
to the anal hairs, even among men whose garments
portray the most fastidious care. It is charitable to
say to such a patient that the hard fecal bits, if car-
ried into the rectum, would injure it and to refer
him to the toilet room, where he may cleanse him-
self with soap and hot water. The senior writer,
confessedly less cautious than his associate, gave an
unclean patient a handful of gauze squares to use in
the suggested cleansing. His lesson came in a
plumber's bill for $15, charged to remove the gauze
with which the patient clogged the water closet.

June 29, 1907]

MEDICAL RECORD.

1063

Another, a smaller matter, in which the patient is
not at fault, may assist to render the work unpleas-
ant. It is a fecal soiling of the undergarments by
patients with hemorrhoids. The obtrusiveness
thereof is remediable in a manner that will be men-
tioned when discussing disposal of the patient's gar-
ments on the table.

5. The patient's garments. The patient's com-
fort demands removal of his coat and vest; these
may be substituted, if he feels chilly on the table,
by covering his chest and abdomen with an exam-
ining sheet or a light blanket. His trousers and
drawers are dropped midway to his knees and he is
requested to sit upon the clean towel placed to re-
ceive his bare buttocks. While he lies down the
footboard of the table is raised to support his legs.
The trousers and drawers are drawn down to the
patient's ankles and a towel placed upon the thus
exposed fundament of the drawers, so that no soil-
ing thereof be perceptible and to protect the oper-
ator's elbow from contact therewith.

6. The patient's posture. The head should rest
upon the towel covering the pillow, whose lower
margin supports the patient's neck. The shoul-
ders, however, must rest f^at upon the table ; the
whole body so placed that the spine is in perfect
line with the mesial line of the table.

The knees are well bent and allowed to hang
apart as widely as they will fall. The left foot is
rested on its outer margin, and the heel of the right
foot is placed in the hollow of the left.

Both hands are closed into fists and stood upright
on the table, beneath the buttocks. The fists are so
held that the circles made by the thumbs and index
fingers receive the tuberosities of the ischia of the
corresoonding sides.

This posture not only makes the perineum non-
resistant, but by the upward bend given the pelvis
relaxes the abdominal walls.

7. The operator's position may be at either side
of the table if he is ambidextrous, as he should be.
As the majority, however, can do more effective
work with the right hand, it will be well to stand
at the right of the patient, facing him. The exact
place for the physician to stand is so that his chest
is diagonally transversed by the patient's bent right
leg.

8. Preparations for penetrating the anus. Be-
fore inserting the finger, it will be well to separate
the anal hairs to avoid the unnecessary pain that
would be produced by dragging them into the anus.
The left fingers then raise the penis and scrotum, to
save their being soiled with the lubricant used on
the right index finger.

9. The lubricant must be sufficiently coherent
that much of it will be carried into the rectum by
the finger and not swept ofif as the anus is pene-
trated. Glycerin is too hygroscopic for this pur-
pose and in some cases acts as quite an irritant to
the rectal mucosa. Olive oil is very much thinned
by the temperature of the rectum and thus loses
much of its efficiency as a lubricant. Gomenol, 33
per cent., serves both as a lubricant and local an-
esthetic in hypersensitive cases. Gouley's lubricant,
however, serves admirably in the majority of pa-
tients. If properly prepared, it has all the charac-
teristics required.

10. Ltibricating the finger. Whatever lubricant is
employed, as large a quantity as possible is taken on
the finger and the excess deposited upon the anus.

11. Inserting the finger. The prepared index
finger is thrust through the mass of lubricant that

has been placed upon the anus and pushed into the
rectum without gyratory motions, following the
curve of the sacrum, and slightly to the patient's
right side. It will be observed that if the finger
traversing the- rectum is pressed against the posterior
aspect thereof, the discomfort of the procedure will
be materially reduced. When the finger is inserted
as deeply as possible, the left hand releases the penis
and scrotum, allowing them to hang towards or rest
upon the right hand.

.■\s the index finger progresses upward into the
rectum the tips of the other right fingers are closed
upon the palm, while the thumb is extended to reach
as high as possible alongside the left side of the pa-
tient's scrotum. The right wrist is held as straight
as possible, and the elbow brought as close to the
table as is necessary to maintain this position.

12. Counter-pressure. The prostate and seminal
vesicles being movable organs, it is necessary to
fix them and while doing so to press them as far as
possible toward the finger in the rectum. This fixa-
tion and pressure are attained by the left fingers.
These are curved and their tips held readv to push
down upon the prevesical region. The patient is
then ordered to take a very deep breath and just
as he has finished the following expiration, the finger
tips are sunk into the relaxed lower abdominal walls,
about an inch above the insertion of the recti into
the pubis. The palm rests over and barely touches
the pubic hairs. The finger tips are firmly pressed
into the pelvis, as if to force its contents out through
the perineum. At first efforts of this kind some
patients develop quite a rigidity of the recti and
other abdominal muscles. After a few treatments,
however, they learn to so completely relax as to
satisfactorily cooperate with the surgeon.

13. Locating the prostate and vesicles. The
operator continually occupied in this class of work
and he who has recently refreshed his studies of
anatomical relations, will recognize the apex of the
prostate the instant his finger tip has traversed the
rectal covering of the pars nuda urethra:. The fin-
ger then passes successively around each outer mar-
gin of the organ to its base and then down between
the lobes to outline the interlobular cleft, when it
exists.

The finger will then pass up from one outer side
of the prostate's base to search for the seminal
vesicle of that side, repeating the procedure for
the opposite side. In health, these organs can be
felt only with great difficulty, and then only as
soft strings.

In disease the vesicles may be considerably en-
larged and yet not be palpable, when a very much
enlarged prostate rises as an obstacle below them.
It must be kept in mind also that the ampullae of
the vasa deferentia lie close to the seminal vesicles
and in fact join them to form the common ejacu-
latory ducts. In consequence, inflammatory swelling
of the ampulla of a vas, which exceptionally occurs,
may convey to the examining finger all the appear-
ances of a vesiculitis.

14. Order of stripping and massage. It is gen-
erally accepted that the vesicles should be stripped
and the prostate massaged in the order mentioned.
This proves erroneous in practice. When the pros-
tate requires massage it holds material which it is
unable to unload witliout mechanical aid. It then is
likely by pressure to occlude the common ejacula-
tory duct ; consequently it should first be emptied as
much as possible, to allow free transit through the
ducts of such contents of the vesicles as can be

1064

MEDICAL RECORD.

[June 29, 1907

stripped therefrom. It is therefore wise to massage
the prostate, before stripping- the vesicles.

15. Technique of prostatic massage. The apex
of the prostate should be the first point of attack.
The finger is partly bent and slightly withdrawn
with each downward stroke. The strokes at first
are performed very gently and their force grad-
ually increased until the point massaged is felt to
grow softer under the compressing finger. The
same process is repeated for each lobe, extending
the manipulations higher and higher until the base
of the organ is reached, whenever this is possible.
Ordinarily extrusion of prostatic juice from the
meatus will begin before the finger has attained the
middle of either lobe.

16. Stripping the vesicles. After the prostate has
been sufficiently massaged, stripping the vesicles is
performed in the same manner, except that lateral
strokes are added to those from above downward.
These lateral strippings must be performed on each
side from without to the median line, on account of
the angle which each vesicle forms upon itself.
Without these lateral strippings only the lower part
of the vesicles could be relieved.

17. The force to be employed in massage and
stripping is incapable of general description. Ex-
perience and judgment can be our only gfuides. It
is safe to let each patient's sensations govern the
work. If the finger's contact with certain points in
the prostate and vesicles give more pain than when
other parts are treated, the sensitive ones should be
more lightly pressed upon. Under cautious digitiza-
tion the sensitiveness of these points will soon dis-
appear. As in all similar procedures, gentleness
does not exclude thoroughness. Indeed, special cau-
tion should be exercised, lest excessive zeal and en-
ergy convert subacute or chronic prostatitis, or ves-
iculitis, into acute inflammation of these organs.

18. The number of strokes to be employed in
massage and stripping is governed by the local ef-
fect. When a region stroked upon is felt to yield its
hardness, even to a slight degree, attention may be
given to other parts of the organ, in the succession
mentioned before.

19. Duration of each stroke. According to the
region massaged or stripped, one to two seconds
are devoted to each stroke.

20. Length of seances. The success attained and
the patient's tolerance are the guides for the length
of each seance in the beginning. Later, when
the patient is well on the road to recovery, his tol-
erance to stripping and massage may exceed the
operator's physical endurance.

21. Interz'als betxveen seances. In exceptionally
acute cases the treatments may demand daily, very
gentle repetition. As the acuity subsides, the in-
tervals will advantageously be extended to every
two or three days, and in chronic cases, every four
or five days is the period that will be required.

22. Immediate results. When the prostate or
vesicles are found to yield to digitization, it is due
to extrusion of their contents into the posterior ure-
thra. \\'hen there has been no recent coitus or sem-
inal emission, the quantity of these contents mav be
so large that the merest contact will produce a
copious overflow. Even without such an excess, the
detrusors may be so active as to violently force the
expressed juice through the urethra and out of the
meatus. This is more likely to occur when posterior
urethritis coexists. In other cases, especiallv while
acute prostatitis or vesiculitis renders the organs
tense, no visible juice can be immediately expressed

from the adnexa in the first or second seance. This
also happens in mild chronic prostatitis or vesicu-
litis.

In every case it is well to let the patient lie on
the table for a few minutes after treatment, for
the reason to be mentioned later. Juice will
then generally ooze or drip from the meatus,
having been retained by reflex spasm of the com-
pressor, evoked by digitization. In some cases no
e.xternal evidence of success is manifest before the
patient's first urination after treatment. The urine,
which may have been clear before, will then be
turbid and contain coarse flakes, filaments, and
shreds, in accord with the condition of the adnexa
and the amount of juice expressed therefrom. Some
patients never present the contents of the pros-
tate or seminal vesicles except in urine as above con-
veyed.

23. Massage on a sound. When the posterior
urethra is not especially sensitive, and when the
condition to be overcome causes the prostate to pro-
ject more into the bladder than into the rectum, it
will be well to perform massage, while as large a
sound as can comfortably be inserted is held against
the lobe that is being treated. Effective as this aid
to treatment is, its use cannot be recommended to
any except those who have gained considerable ex-
perience in genitourinary instrumentation.

24. Danger of syncope. Some patients, who
have never fainted before, may lose consciousness
if allowed to arise from the table immediately after
massage or stripping. It is therefore a wise rule not
to allow a patient even to raise his head until the
pulse has regained its regularity and vigor, and the
pupils react promptly to light. No matter how
staunchly the patient may assert his perfect well-
being, this precaution should always be observed.

25. Spasm of the compressor. Whatever be the
after-treatment indicated, the patient should empty
the urine that has accumulated in the bladder while
he has been on the table. In so doing he washes
away any of the expressed juice that may remain
in the urethra, or may have regurgitated into the
bladder. If irrigation or instillation with silver
nitrate is to follow the massage, its efficacy would
be much reduced if not entirely inhibited by the
thick precipitates that will be produced with the re-
sidual expressed juice. It must be remembered,
however, that in most patients reflex spasm of the
compressor has been induced by the digitization.
This spasm rarely ceases in less than five minutes
after treatment. This condition is productive of
considerable unnecessary alarm, especially when a
desire to urinate is present. The desire is apt to be
very marked in neurasthenics whose kidneys at
times excrete an immense amount of urine, es-
pecially under the excitement of being treated.
When assured, however, that it will be impossible
for them to urinate until after the time mentioned,
their fears will diminish and upon the expiration of
the given time they will void their bladder contents
satisfactorily.

26. After-treatment. The conditions for which
massage or stripping or both are required must
govern whether there shall be any treatment at all
thereafter, or whether irrigations or instillations
with silver nitrate, protargol, or any other of the
silver salts, or potassium pyermanganate shall be em-
ployed. The indications for each belong in separate
chapters on diseases of the prostate and seminal
vesicles and not in a paper like this, devoted ex-
clusively to the technique of massage and stripping.

June 29, 1907]

MEDICAL RECORD.

1065

27. Over-treatment. As in all affections of the
organs under consideration, much harm can be done
by over-treatment. Singularly enough the patients
in this regard are most at fault. Past experience
having shown them that the general depression,
lassitude, etc., that accompanied their condition was
promptly relieved by the massage or stripping then
required, they are wont to attribute for a more or
less extended' period after discharge from treatment
all the unpleasant manifestations that may be due
to business cares, family annoyances, indigestion,
constipation, etc., to engorgement of the urethral
adnexa. Then they importune their physician- for
massage or strioning. To these importunities the
experienced operator will not yield when no such
treatment is needed.

The complete indications and contraindications
for massage and stripping, and the collateral med-
ication required therein, are subjects for separate
consideration.

No pretense at instructing or imparting any-
thing new to the urological specialist is embraced
in this paper, except perhaps to remind him that
the office of specialist is largely educational. Pro-
gressive general practitioners study the writings
of specialists. If the patients of but one of these
colleagues derive benefit herefrom, the authors'
hopes will be realized.

In order to evolve a method which might over-
come these drawbacks. I have for several years ex-
amined the impressions made by human jaws. I
have collected several hundreds of such impressions,
principally of the upper jaw : and whenever I make

A NEW METHOD OF IDENTIFICATION
SUPERSEDING DACTYLOSCOPY.

By PAUL PR.\GER, M.D..

VIENNA, AUSTRIA.

REGIMENTAL SURGEON OF THE IMPERIAL AND ROYAL ARMY OF AUSTRIA-
HUNGARY.

I HAVE made numerous investigations regarding
dactyloscopy and its employment for purposes of
identification, but it has always appeared to me that
it suffers from drawbacks which are due partly to
the ready changeability of the epidermis of the
fingers and partly to the difffculty encountered and
large amount of experience necessary in correctly
reading dactylograms.

It is possible for the epidermis of the fingers to
be changed in various ways — pathologically because
the hands, and especially the fingers, are subject to
injuries which, upon healing, leave scar tissue ; and
artificially because a person whose finger imprints
have been taken may readily obliterate the dacty-

FlG.

comparative examinations of these it becomes more
and more evident to me how distinctive and charac-
teristic is the impression made by the upper jaw
of each and every individual. Not two impressions
among thousands are alike in regard to the num-

FlG.

ber, length, and breadth of the teeth, and the curva-
ture and radius of the maxillary arch. The height,
breadth, and depth of the upper jaw present equally
many striking and readily recognized differences.

loscopic picture by means of acids or other re-
agents, thus rendering reidentification impossible.

It may also happen that a criminal, availing him-
self of a previous experience with dactyloscopy, in
his future operations renders the imprint deceptive
by wearing gloves.

Fig. 4.

To these distinguishing features may be added
also the possible gaps in a row of teeth, with their
innumerable variations. The formation of the pala-
tine membrane, which shows plainly on each impres-
sion, likewise constitutes a feature which is distinc-
tive in each individual, never being alike in any two

io66

MEDICAL RECORD.

[June 29, 1907

cases, and reniaininj^ unchanged all through life.
The circumstance that each individual jaw impres-
sion presents so many characteristics insures that,
even though one or more lines may be obliterated or
rendered unrecognizable during life, either by the

can readily learn the manipulation. By taking a
plaster cast of such an impression, inscribing it with
the necessary data, and keeping- it on record, one
obtains an incomparable identification mark of a
human being.

Fir,. 5-

action of time or through pathological changes,
there will always remain a sufficient number of in-
effaceable characteristics to render absolute identi-
fication possible.

I have in my possession impressions taken from
the jaws of the same persons at intervals of about

Fig. 6.

ten years (see Figs, i and 2) and they present
absolutely no divereences. The following illustra-
tions show different jaw impressions as they appear
at daily observations. What enormous differences
in general aspect, form, and size! And this fact I

Fig.

have demonstrated repeatedly, day in and day out.
Never yet have I seen two impressions which were
even approximately alike.

To take the impression is a very simple matter.
Every physician can attend to it, and every layman

Fir-.. 8.

If the system were introduced so that people who
follow dangerous callings should put by an im-
pression of the upper jaw, it would undoubtedly be
feasible, even in the skeleton, to establish the iden-
tity of a person who had met death by drowning, or
by falling from a height, or by a mine accident, etc.
While I was engaged upon this study I received
from a colleague the information that a Paris den-
tist had succeeded in identifying the corpse of a
female patient by means of a jaw impression which
he had kept, although her body was almost entirely
burned to coal.

DIAGNOSIS AND TREATMENT OF GAS-
TRIC ULCER.*

BvlWM. A. DICKEY, A.M., M.D..

TOLEDO, OHIO.

PROFBSSORJoP THB PRACTICS op medicine and CLINICAL HBDICIKB,
TOLEDO MEDICAL COLLEGE.

There are many inherent difficulties and perplexi-
ties to contend with in the treatment of gastric
ulcer. They are so numerous, indeed, as often
to enshroud the physician in a maze of doubt and
uncertainty as to what is the proper course to pur-
sue. The anatomy and physiolog\' of the stomach
are of such a character as to make this true. We
cannot change the one nor materially modify the
other, hence we have no specific for the disease
and in the very nature of things cannot have. How-
ever, within recent years our knowledge of how
to meet these morbid conditions has given us a
more comprehensive idea of the best means of
placing the stomach in such a condition as to bring
about a reparative process. The time is not yet far
removed when the physician looked upon the treat-
ment of gastric ulcer as falling wholly within his
sphere of action, but in an iconoclastic age like the
present, when old ideas are rudely cast aside and
new ones put in their places, we must now look
at this subject from an entirely different and broader
viewpoint. \\'ith the rapid advances of modern
surgen,^ and the certain conviction that physiologi-
cal rest is to be obtained as soon as possible, and
as far as possible, the clinician must now concede
the fact that the surgeon is at times to take his
place.

Just when a peptic ulcer should pass from the
hands of the one to the other is a matter about
which there may be room for an honest difference

*Read at a meeting of the Northern Tri-State Medical
.\ssociation of Ohio. Indiana, and Michigan, at Elkhart.
Indiana. Januarj- 8, 1907.

June 29, 1907]

MEDICAL RECORD.

1067

of opinion. When a perforation has occurred, or
marked dilatation has taken place as a result of
stenosis, or the motility of the stomach is markedly
interfered with as the result of adhesions, or pos-
sibly, though exceedingly rarely, in certain cases
of severe and persistent hemorrhage, then of course
there would not be a dissenting voice as to what
was the wise thing to do. As physicians, I fear,
we are too prone to treat the ulcer too much and
the patient too little ; that we lose sight of the im-
fwrtant fact that an individual who is anemic, whose
nutrition is much below par, as a consequence of
lack of good and properly cooked food, or of. the
inordinate consumption of alcoholic beverages, or
who lives in damp, illy ventilated quarters, is in
poor condition to respond to direct treatment of the
ulcer, no matter how canonically done, nor how
thoroughly his environments may be changed, for
ulcer of the stomach does not differ essentially from
ulcer in any other part of the body. These cases
should be viewed in the concrete, not in the abstract ;
should be individualized, not classified, and if this
important fact is borne in mind I think the percent-
age of recoveries of acute gastric ulcer will be ma-
terially augmented. It is in the acute form of the
disease that the internest must expect to record
his greatest success, because when an ulcer has be-
come chronic the muscularis invaded, with edges
n^ore or less indurated, medicine, even if supple-
mented with as near rest as the stomach can be
given, will prove of but little avail.

In a series of 493 cases reported by van Leube 74
per cent were cured by medical means, 21 per cent,
were improved, 24 per cent, died, and 2 6-10 per
cent, were unimproved. Of the 21 per cent, that
were reported as improved the results showed that
the pain and discomfort returned as soon as they re-
sumed work and their ordinary diet. The question
arises, What are we to do with this 26 per cent, of
cases? Shall we allow them to drift along in this
uncertain and unsatisfactory condition, or shall we
turn them over to the surgeon? The Mayos report
an operative mortality of about 2 per cent., so that
of the 26 per cent, only 2 per cent, will die from
the operation, while the remainder will either be
entirely cured or so much improved as to make a
return to their former pursuits quite probable.

To my mind our duty toward this latter class of
cases is a very plain one, and while a mortality rate
of 2 per cent., or indeed even more, is a very small
one, still with wider experience and more improved
technique the knife may yet show a larger percent-
age of cures than at present. Then, too, the ten-
dency for chronic ulcer to become carcinomatous
must not be lost sight of, for the earlier the cure
the less liable is this to occur. Unless my memory
is treacherous, the Mayos have demonstrated that
the starting point of carcinoma is usually an ulcer.
Mouillin claims that this is true in probably 90 per
cent, of cases. The early diagnosis of ulcus, then,
is of the utmost importance, because the more early
the diagnosis is made the more certain will be a
Dermanent cure by medical means. This is not al-
ways an easy matter, if indeed not at times impos-
sible, because postmortem findings give positive
evidence of a healed ulcer that during life gave no in-
dication of its presence. When there is pain on
pressure over the stomach, constantly localized, aug-
mented after a full meal, with lumbar pain and vom-
iting, the vomitus tinged with blood, no matter how
little, or melena, hyperacidity with deficient motor
function, the diagnosis is easy, but an ulcer may be
present and not a single one of these symptoms man-

ifest, rhere are those of wide clinical experience
who claim that hypersecretion in a stomach not con-
taining food is strongly indicative of an ulcer. If
to this you add the deficient motility already spoken
of, you have almost positive evidence of gas-
tric ulcer, this deficiency being shown by the stom-
ach not being empty seven hours after a heavy meal
(Schmidt). Occult hemorrhage, in a meat-free
diet, is another valuable aid to diagnosis, but un-
fortunately it is sometimes not available, unless all
the stools are saved and examined during the time
the patient is under observation. Again, the ulcus
will not bleed continuously and the stools may be
examined during intervals of cessation. Occult hem-
orrhage is much more frequent in carcinoma than in
ulcer ; except during the early period it is always
present in carcinoma, and only in 51.4 per cent, of
the ulcers, according to Rutimeyer of 13asel. The
hemaglobin in ulcer is reduced to about 80 per cent.,
although it may be much less in those cases in which
the nutrition is low, and in whom there is more or
less bleeding. Saloman's test, which was originally
proposed and primarily used as a diagnosis for car-
cinoma, may prove to be of inestimable value as
an aid in the early recop-nition, if not the earliest
symptom, of gastric ulcer, as it is a strong indicator
of a defect in the mucous membrane of the stomach.
This test consists of the demonstration of albumin-
ous bodies in the rinsing water after washing out
the empty stomach. Gastric ulcer may be mistaken
for renal or biliary colic as well as inflammation of
the appendix. With the former a careful micro-
scopical examination of the urine for blood, lime
crystals, etc., to say nothing of nausea, vomiting,
and constipation, will make a diagnosis reasonably
sure. With the two latter we have tenderness, dis-
turbances of the stomach, much pain, more or less
fever, and usually a history of former attacks. I
am in thorough accord with the statement of Hem-
meter, made at a recent meeting of the American
Medical Association, when he said there was no
symptom of gallstone colic that might not be pres-
ent in gastric ulcer. A diagnosis of ulcus ven-
tricula by the .r-ray after the deposit of bismuth
subnitrate in the ulcer is extremely difficult and
would be of little practical value except in the hands
of an e.xpert. A differential diagnosis between pep-
tic and duodenal ulcer is not always possible nor
indeed necessary, for the treatment of one is es-
sentially the treatment of the other. A positive
diagnosis having been made, the best means of treat-
ment at once becomes a subject of grave considera-
tion. The results obtained will depend entirely
upon the thoroughness with which the treatment is
carried out, and the length of time in which it is
persisted in, as well as the subsequent mode of liv-
ing of the individual. These are all important fac-
tors in determining the permanency of the cure.
The patient should be put to bed at once and kept
there for at least ten days, and much longer in not
a few cases. This alone, according to van Leube,
will often stop the pain, which in very many cases is
such a prominent symptom, and so intense at times
as to require morphine subcutaneously to relieve it.
.lust how rest in bed will stop the pain of gastric
ulcer is not easy to explain. Ageron considers that
the absence of food pressure on the larger curve of
the stomach, and particularly the antrum pyloricum,
is one factor and possibly the first one. The recum-
bent position also does av;ay in a large measure with
the pulling and pressing influence of other organs,
such as the liver, spleen, and intestines, and pos-
sibly the kidneys, as these organs possess in cer-

io68

MEDICAL RECORD.

[June 29, 1907

tain individuals a wonderful degree of motility. But
no matter how accomplished, the fact remains that
rest in bed has a beneficial influence on ulcer of the
stomach, therefore evervone must be put to bed and
kept there from ten days to three weeks. If there
is a tendency to hemorrhage, as indicated by hema-
temesis or melena, the patient must not be allowed to
assume the upright position, nor, indeed, any po-
sition that requires exertion. If there is vomit-
ing, particularly if it is accompanied by particles
of food, the stomach should be washed out by means
of a tube with a weak alkaline solution, until the
water comes away perfectly clear. No food should
be allowed for five davs, except in rare instances.
Thirst may be allayed by rinsing out the mouth
with cold water or pellets of ice may be held in
the mouth. The hyperchlorhydria, which is such a
well-nigh constant accompaniment of ulcus ventri-
culi, and which not only prevents its healing, but
possibly causes an extension of the ulcer, should be
arrested by the administration of such alkalies as
sodium bicarbonate and subnitrate of bismuth.
Kussmaul recommends that the bismuth be given
at first daily and then every other day in doses of
ten to twenty grains in 200 c.c. of water through a
stomach tube. The stomach is first washed out,
and thew the patient is placed on the side in which the
ulcer is suspected in order that the bismuth may
settle in the bottom of the ulcer, and the tube i.^
closed by a clamp. When sufficient time has elapsed
for the bismuth to settle, the water is allowed to run
out, and the tube is removed. This method has a
serious drawback in the constant retching to which
the patient will be subjected by the presence of the
tube, particularly in those in which there is a tend-
ency to hemorrhage. Half-teaspoonful doses of
subnitrate of bismuth suspended in water may be
given daily, or twice daily with practically, I think,
as good results. The bismuth settles in the ulcer
and thus protects it from the irritating influence of
the gastric juice and any food that may be admin-
istered, and is also an antacid and antiseptic. Ni-
trate of silver is another remedy of much potency
according to the statement of clinicians of wide ex-
perience, and yet it is difficult to say just how it
acts, because only a small amount of the salt can be
used. It is most efficacious in those cases in which
pain is a prominent symptom. It probably acts
either as an antacid or as an antiseptic or both.
It may be given in tablespoonful doses of a i-io of
I per cent, solution. It is particularly valuable
during the period of convalescence, or in the mild
or ambulatory forms. Schmidt and van Leube
lay much stress upon the administration of Carls-
bad salt in the morning on an empty stomach. Com-
posed as it is largely of alkalies, it probably acts
as an antacid as well as a cathartic. Other reme-
dies of greater or less potency are used, but time
will not permit me to discuss them in this paper.
The best method of treating the hemorrhage of gas-
tric ulcer is sometimes difficult to decide. Local
application of ice to the epigastrium in the form
of an ice bag or Leiter's coil is often beneficial and
is to be used, and pellets of ice may be swallowed if
they do not cause vomiting when melted. Just how
local applications, either cold or hot, to the epigas-
trium can influence the blood supply to an internal
organ with which the blood-vessels of the skin have
no direct connection is difficult to understand. In-
deed, I have always been skeptical as to their in-
fluencing it at all, and yet such men as Schmidt
and van Leube not only use them, but speak well
of their results ; van Leube alternates them without

intermission, while Schmidt so far modifies this
process as to make hourly intermissions. The Priess-
nitz alone are used at night. Schmidt maintains
that the physiological action of the blood-vessels
is better preserved by hourly intervals. In those
cases in which the patient is weak and anemic, and
strenuous objections are raised to the use of cold,
equal parts of water and alcohol may be used in-
stead. This line of treatment is available not only
for the bleeding but in those cases also which give
evidences of the presence of some inflammatory con-
dition. The use of such drugs as opium, acetate of
lead, ergot, and adrenalin in the treatment of gas-
tric hemorrhage is of questionable utility. What
influence they can have on the severed end of a
blood-vessel is not clear to my mind, nor can I see
how they can in any way hasten clot forniation.
Too much reliance then must not be placed on these
remedies in the treatment of the severe forms of
bleeding. It is in this class of cases that the services
of a surgeon may be demanded, and yet I have seen
the most alarming hemorrhages cease without opera-
tion and the patient finally recover. As I have said
elsewhere, the one great object to be attained in
the treatment of all forms of ulcus ventriculi is rest.
Theoretically, the only way to accomplish this is
to put nothing into the stomach. Cases will arise,
however, from time to time, in which the nutrition
of the individual will be at such low ebb that the
rectal feeding will not be sufficient. Say what we
will, and theorize as much as we like, the patient
must receive a requisite number of calories each
day to maintain a fair degree of nutrition, or we
cannot hope for good results, if indeed the patient
does not reach the danger point. In cases of this
kind it will be well to risk a small amount of food
by the stomach after the original five days' fasting.
Years ago Da Costa recommended, if my memory is
not at fault, a tentative amount of icecream, which
if no bad results follow may be supplemented by
other food. However, our principal reliance must
be on rectal feeding. I hardly need more than men-
tion tlie fact, that before giving the nutrient clysma
the bowel should be well washed out with warm soap
suds, so that the material injected may be the better
absorbed. Just what shall be used as a nutrient
enema will depend largely upon the teaching or
peculiar belief of the physician. I doubt, however,
if any will be found more efficacious than milk and
ejgs, and occasionally meat powder, and if a stim-
ulant is wanted, wine or brandy, to all of which
should be added a pinch of salt. Nor is it absolutely
necessary to predigest the clyster, as it is not proven
that the predigested albumins are more readily ab-
sorbed than the native. If there is a tendency for
the bowel to expel the enema, which there often is
after the method has been used for a time, fifteen
or twenty drops of tincture of opium may be added.
The temperature of the clysma should not be less
than that of the body. It should be given through a
tube inserted as far up the colon as possible. The
patient should not be disturbed during the night,
hence the last clysma should be given not later than
eight or nine o'clock. Each morning the bowel
should be washed out with a liter of warm salt solu-
tion that any remnants of the previous day's feeding
may be removed, thus securing better absorption
and preventing bowel distention as a result of de-
composition. The intense thirst that is sometimes,
indeed usually, met with in these cases may be
allayed by injecting into the rectum one-half liter
of physiological salt solution. Recta! injections
should not be given more than three times a dav.

June 29, 1907]

MEDICAL RECORD.

1069

at equal intervals, because if they are too often re-
peated the bowel becomes irritable and expels its
contents. Moreover, the constant irritation of the
intestine causes stomach secretion, the very thing
we are ajixious to avoid. On return to stomach
feeding-, much care will be necessary for a time,
that this organ be not distended and that the food
taken is properly digested. Small quantities of ice-
cold milk, a tablespoonful of milk and lime water
(three parts milk and one part lime water) may be
given at two-hour intervals. The addition of the
lime water will often prevent vomiting that might
otherwise occur, and at the same time prevent, the
formation of curds. At this early period, enough
milk cannot be given by the mouth to maintain nu-
trition, without disturbing and overtaxing the stom-
ach. Hence, the addition of something bland be-
comes necessary. Meat jelly as recommended by
van Leub'e and Fleiner may be added. This is made
by boiling beef with calf's foot until it is thoroughly
done, when a gelatinous mass is formed. While
cooking, an egg is added, stirring the whole mean-
while, and the mixture strained. Salt is added to suit
the taste and the food is given cold. Of this a tea-
spoonful may be administered at three-hour inter-
vals. As time goes by, other easily digested and
nonirritating foods may be added. The more food
that is given by the stomach, the less will be neces-
sary by the rectum. As one of the objects to be
attained during the early feeding is to diminish as
far as possible hyperacidity, care must be taken in
the adminstration of the albumins. It may be neces-
sary to administer some carbohydrates. Senator
gives gluten, fat, and sugar with small quantities
of albuminoids and decoction of gelatin. For the
fats he uses, in addition to cream, small bits of
frozen butter. His theory is that gelatin prevents
hemorrhage and at the same time replaces in a de-
gree the albumin. It would be imnossible in the
time allotted to this paper to give in detail the
various articles of diet that may be used. Suffice it
to say that the return to a mixed diet must be slow
and gradual, reserving the meats for the last ; and
yet so good authority as Lenhartz allows a more
liberal diet of the albuminoids such as milk, eggs,
rice, scraped raw beef, ham, butter, zwiebach, and
the like, claiming that they combine with the acids
of the stomach, and thus hasten ^vre better than
the somewhat strict diet of van Leube. And yet a
glance at the diet list of van Leube shows it to be
sufficiently protean in character. He divides the
feeding into four periods or sections which I believe
he strictly adheres to. The first section comprises
a period of ten days, the second seven days, third
six, fourth seven, first period, boiled milk ; meat
solution ; beef tea, two zwiebach soaked, four cakes.
Second period, in addition to number one, slimy
soups, rice and sago in milk cooked soft with the
whites of four eges : raw and soft-boiled eggs,
cooked calf's brain or sweetbread, boiled chicken
and pigeon (without skin or fat). Third period,
in addition to number two, boiled calf's feet, scraped
raw ham, scraped beefsteak (half done), mashed
potatoes, boiled rice in bouillon, a little cofTee and
tea. Fourth period, added to number three, tender
roast beef (half done), roasted chicken or pigeon
(without gravy), venison or partridge which has
been killed some time, macaroni, noodles (sieved
through), and a little white bread. From the fifth
week on, slow return to solid and heavier food. He
advises that the patient take his daily food in five
meals, thus not getting too much at a time. Dur-
ing the rest in bed period the patient must have

daily sponge baths and muscular massage, avoiding
of course the abdomen.

On getting out of the bed, the individual is to
be instructed as to his daily mode of living and par-
ticularly his eating and drinking. He should eat
slowly, masticate his food thoroughly, and avoid
completely all articles of diet that will in any way
bruise or lacerate the stomach mucosa. He must
also avoid all forms of alcoholic bsverages. if there
should be relapses, which there sometimes will be,
or if the patient goes from bad to worse and com-
plications arise, the services of a surgeon must be
invoked. We can, in these latter days, survey this
entire field with a calmer and more unbiased judg-
ment and readily concede the fact that the treat-
ment of ulcus ventriculi has a surgical as well as a
medical side. A discussion of the former I leave to
those who do that work, realizing that it is both
interesting and instructive to the purely medical
man.

ASTHMA: OBSERVATIONS ON 300 CASES.

By E.MMET L. smith, M.D.,

CHICAGO, ILL.

AsTHM.v is a spasmodic afTection of the involun-
tary muscular fibers of the small bronchial tubes,
caused by a reflex irritation of the pneumogastric
nerve which contracts these muscular fibers and
gives rise to dyspnea of a paroxysmal character.
This definition will harmonize the different theories
on this subject, explain the action of various reme-
dies and conditions, and prove out in the clinical
test and in the permanent cure of this disease.

By the contraction of the bronchial muscles it is
not intended to mean that part called the extra-
pulmonary bronchi, but the intrapulmonary bronchi
or bronchioles, of which the physiologists estimate
there are seven hundred and fifty millions in the
lungs. In the extrapulmonary bronchi the carti-
lage and glands exist, but in the small bronchi and
bronchioles, the involuntary circular muscles are
well developed, and are controlled by the pneumo-
gastric nerve. Of this nerve Ranney wrote : "Owing
to the numerous connections of the pneumogastric
with other nerves, its varied and extensive distri-
bution, and the important character of its functions,
this may properly be regarded as one of the most
remarkable nerves of the whole body. It has been
often known by the name of the 'par vagum,' from
the wandering course of its fibers, which are dis-
tributed to five different vital organs, vi::., the heart,
lungs, stomach, liver, and intestines, as well as to
many other parts of secondary importance."

Cases of asthma have vasomotor disturbances, but
to claim that true asthma is due to a vascular dis-
tention in the bronchial mucosa does not apoear to
harmonize with the classical physiological experi-
ments or to prove out in the clinical tests. Spasms
of the blood-vessels or even a turgescence of the
mucosa of the bronchial tubes could not produce
the phenomena of true asthma. Again, if turges-
cence of the bronchial mucosa was the cause of
the asthma, then the use of atropine would be non-
effective.

Acute bronchitis, fibrinous bronchitis, or angio-
neurotic edema of the bronchial mucosa may ob-
struct the bronchial tubes, but in these cases the
rales indicate the obstruction is in a fixed locality,
while in true asthma the obstruction is rapidly
chancring its location.

While it is evident that even in true asthma there
is vasomotor disturbances, it is not the vasomotor

1070

MEDICAL RECORD.

[June 29, 1907

distention in the bronchial mucosa, but the asthma
is due to the pressure on die asthmatoj^enous points
(Brug'elmann) in the nasal fossce. This acts on
the pneumogastric nerve and explains the various
phenomena of true asthma. This pressure irrita-
tion may be on the nasal septum or rarelv there may
be no occlusion of the nares, and it may be due
to a closed empyema of the ethmoid cells or sinus-
itis. This is the patholo,c;y of true asthma and it is
confirmed by physiological experiments. It also
can be confirmed in every case of true asthma by
relieving the pressure on these areas, which gives
almost instant relief to the spasm. The relief is
made permanent by such treatment as will prevent
such pressure.

Among the exciting causes given are inhalation
of dust, certain powdered drues, flowers, hay, and
emanations from feather beds or pillows, horses,
cats, and parrots. These, as well as others of simi-
lar character, cause or aggravate asthma by irrita-
tion, congestion, and pressure on the asthmatogenic
areas in the nasal cavities. By wearing plugs of
cotton in the anterior part of the nostrils or me-
chanical air filters, these excitin"- causes are non-
effective. However, if these asthmatogenic areas
are treated so that pressure cannot take place, then
these e.xciting causes cannot cause asthma.

The following observations are common to
asthmatic patients and are easily explained on this
theory. If a person is chilled, or has cold, wet feet,
or if the air is cold, or cold water is applied to the
entire bodily surface, the result is vasoconstriction
of the skin, and as the blood leaves the skin it
causes internal congestion and increases the nasal
pressure, which aggravates the asthma. However,
if the skin circulation is normal, the effect of in-
haling cold, dry air is to contract the nasal mucous
membrane and to relieve the dyspnea in proportion
as the nasal engorgement is relieved. Moist heat
to the skin surface produces vasodilatation and as
the skin reddens the nasal engorgement is relieved.

Cold, damp days aggravate most asthmatic con-
ditions, and, conversely, dry weather, or the dry cli-
mate of .\rizona, gives temporary relief in some
cases. This is because the nasal membranes swell
in damp weather^ — a condition which is observed not
only in asthmatics, but in the great majority of
people. Localities having dry air reduce the nasal
swelling and give relief in proportion as the swell-
ing (or pressure) is relieved. Not all persons get
relief by change of climate, but upon examination of
such as do not it will be found that there is a local
reason.

The inhalation of chloroform for asthma may act
(t) by local anesthesia on nasal turgescence, (2)
by lowering arterial pressure (English Chloroform
Commission), or (3) by the inhibition of the heart
(Wood).

The action of iodine in asthma, when favorable, I
believe is due to its well known action in reducing
glandular il:)ronchial) swelling and pressure, and
to its specific action on the nasal tissues. In cases
of arteriosclerosis there are attacks of dyspnea sim-
ulating asthma, and the action of iodine in these
cases has often been credited as helping asthma.
According to M. Huchard "iodine medication is
indicated w-hen there is confirmed sclerosis, in which
case the resolvent action of iodine on the sclerosed-
tissues may be explained by phagocytosis." He
also states that "in the period preceding sclerosis
iodine medication for high arterial tension is use-
less, and it is better to have recourse to essential
vasodilators (nitrites)."

The nitrites are general vasodilators, and amyl
nitrite nitroglycerin, sodium nitrite, and erythrol
tetranitrate act as such for from one minue to
six hours. Any relief from the use of these in true
asthma comes from their action in equalizing the
entire vascular system and relieving the pressure
on the asthmatogenic areas.

The use of adrenalin in asthma acts only as a
local vasoconstrictor, and gives temporary relief
in proportion as the turgescence in the nose is re-
lieved. The internal or hypodermic use of adrenalin
in asthma has been entirely unsatisfactory in my
observation. Sprays or nebulized solutions in the
nasal cavities act by relieving the pressure on the
asthmatogenous areas.

Atropine in maximum doses, as advocated by von
Noorden, Riegel, Campanella, and Rossbach, dimin-
ish the reflex excitability of the pneumogastric
nerve. This not only gives temporary relief in
asthma, but is useful in other conditions controlled
by the pneumogastric nerve. During the paroxysm
as much as one-eighth of a grain is given in twenty-
four hours. The study of the solonaceous alkaloids
is very interesting, but the trouble is that the chem-
ists are unable to label these different alkaloids
properly, as they generally all revert to atropine.
I have used over 100 grains of the different Ger-
man solonaceous alkaloids in the treatment of
asthma. Daturine and hyoscyamine acted best, but
their action was not uniform. Thus some observ-
ers may get better results than others, if their atro-
pine should contain some daturine or hyoscyamine.

Berkart in his book on "Bronchial Asthma" says:
"The frmos of burning nitre paper and smoke of
cigarettes or powder, of which strammonium and
nitre are the chief ingredients, act merely by the
forcible cough which they excite when inhaled.'
Then again, according to a recent paper by Francis
Hare, these inhalations act by producing bronchial
vasoconstriction. I have observed acute attacks
in which the nasal cavities had been so completely
stopped up with the accompanying acute rhinitis
that the usual inhaling of smoke was without bene-
fit. I have also plugged up the anterior part of the
nasal cavities so that no smoke could be inhaled
through the nose and the result was the same. I
believe the temporary relief obtained by the use of
these inhalations is due to the local vasoconstriction
on the asthmatogenic areas. This exolains why in
some cases the use of the inhalations "wear out" —
that is, that after a time they do not constrict, and
consequently do not give the relief they did at first.
Berkart says of these inhalations that tliey irritate
the mucous membranes of the nose, pharynx, and
bronchi, prolong the disease indefinitely, and par-
alyze tlie action of the heart.

If when asthma is treated as an uric acid con-
dition there are favorable results, I believe the same
are due to the giving up of sweets and other articles
upon the antiuric acid diet list, as these have the
tendency as well to engorge the nasal tissues and
aggravate the asthma. In the so-called peptic
asthma the stomach disturbance is a secondary
cause. These peptic cases do not act directly
through the pneumogastric nerve, but by engorging
the nasal areas. These peptic cases and uric acid con-
ditions aggravate asthma in proportion to the nasal
engorgement they produce. The uric acid condition
in the one and the disturbance of the stomach in
the other may be the starting point, but neither is
the real cause. The real cause is in the nasal
foss£e, and this can be easily proven; and it can
also be proven that the uric acid condition and

June 29, 1907]

MEDICAL RECORD.

1071

the stomach disturbance may be allowed to exist and
yet there will be no asthma, if the nasal pressure
is relieved. In any case of true asthma, where the
nasal treatment has been to relieve all pressure on
the asthmatogenic areas, I have found that articles of
diet may be taken with no bad efl'ect which formerly
were certain to cause asthma. This I have proven
time and again, and in cases where this treatment
has been carried out I have even advised that
the patients take such articles as had formerly
caused their asthma, in order that they might test
the result of treatment. In the treatment of these
asthma cases I formerly used a special diet list, but
now I give no dietary directions, and after the treat-
ment has been started and the case is getting along
satisfactorily I recommend the eating of different
articles of food and the doing of those things that
formerly brought on an attack. Patients are even
advised to take a cold in the head, which i^ the cru-
cial test for any line of treatment.

•J2 Madison Street.

AIEXTAL SYMPTOMS IN NASAL AFFEC-
TIONS.

By PERCY FRIDE.'^JBERG. M.D..

NEW YORK.
ASSISTANT SURGEON, NEW YORK EYE AND EAR INFIRMARY. FTC.

"The exhilaration which comes from pure and re-
freshing air has a marked influence on our apprecia-
tions. To it is largely due the beauty of the morn-
ing, and the entirely different charm it has from the
evening. It would be curious and probably sur-
prising to discover how much the pleasure of breath-
ing has xo do with our highest and most transcen-
dental ideas. It is not merely a metaphor that makes
us couple airiness with exquisiteness, and breathless-
ness with awe : it is the actual recurrence of a sensa-
tion in the throat and lungs that gives those im-
pressions an immediate power, prior to all reflection
upon their significance. It is, therefore, to this vital
sensation of deep or of arrested breathing that the
irapressiveness of those objects is immediately due."

In his charming essay on "The Sense of Beauty,"
from which the preceding paragraph is quoted, San-
tayana has touched on the physiological aspect of
an interesting theme. The converse, it seems to
me, offers phenomena of at least as great practical
importance, and has been studied but little. The
effect on mental processes and attitude, of deficient
breathing or of vitiated air, offers a wide field for
observation, and one from which it may be possible
to glean some points in the treatment and propliy-
laxis of neuroses on the one hand and of nasal
disease, on the other.

Nervous disturbances and psychical symptoms
may have a two-fold bearing on nasal disease, ac-
cording as they are in the nature of cause or of
effect. The former are of subordinate importance
from the practical side, although clinically at least
as interesting. It is sometimes difficult to decide
whether a patient is neurasthenic or hypochondriacal
on account of old nasal trouble, or whether his viti-
ated nervous system has lowered resistance and in-
creased irritability, so that there is morbid reaction
to slight discomfort stimuli originating in the nose.
However it may be. many rhinopathics, to coin a
term, are also neurotic. Even the cocaine habit,
which not infrequently becomes established in the
effort to relieve nasal obstruction, may be consid-
ered as an indirect result of nasal disease or as a
symptoms of a neurosis underlying both manifesta-

cions. In actual insanity the hallucinations of smell
are much less frequent than those of sight and hear-
ing, as might be expected from the comparative un-
importance of the former function in soul life and
cerebration. The relations of the sexual sense to
that of smell have been studied by a number of
scientists, and sexual osphresiology offers many in-
teresting phenomena. In the lower animals the
sense of smell is of great importance, not only in
this connection, but in relation to perception of ob-
jects in the external world, self-protection, taste,
nutrition, and other functions, and is, as we know,
much more highly developed than in man. It would
be as interesting as it is probably difficult to deter-
mine the influence of mental disturbances in these
animals on the sense of smell and on the ftmctions
dominated by it.

Local symptoms are the most common manifesta-
tion of nervous disturbances in nasal disease. Neu-
ralgic pain and headache are frequent accompani-
ments of obstructive forms, and more particularly
of accessory sinus involvement. Face ache of a
pronounced type, radiating to the teeth, ears, and
brow, is common in acute antral suppuration, and
even in serous effusion with increased tension. Re-
tention of secretion and chronic hypertrophic in-
flammation with the production of granulations and
polypoid growths, particularly those of the frontal
sinus, may produce a dull, intermittent frontal or
supraorbital ache which simulates malarial hemi-
crania closely, particularly as it is temporarily re-
lieved by quinine. A diagnosis, ex jnvantihxis, is am-
biguous here, as quinine has a marked effect in
constricting blood-vessels, lessening secretion from
mucous membranes and thus promoting drainage
and reducing tumefaction. Many coal tar products,
notably antipyrine, have a similar action.

In the field of motor disturbances, the most varied
symptoms may be presented. L^sually they are slight.
Muscular unrest and slight twitching of individual
facial muscles, either as an involuntary reflex,
or as the expression of an habitual motion,
is found in various forms of nasal disease,
and produces an almost pathognomonic facies
in many cases of adenoid hypertrophy with middle,
ear involvement. Pronounced facial tic and epilep-
tiform seizures have been observed in cases of pen-
dulous uvula embarrassing respiration, in foreign
bodies of the nose or rhinoliths. The most marked
mental complication is that observed in young
mouth-breathers afflicted with adenoids, and known
as aprosexia. The children are inattentive, listless,
dull, do not seem to hear well if spoken to, or, if
they give heed for a moment, soon relapse into a sort
of day-dream.

The children fall behind their classes, and do not
seem to be able to concentrate their minds on school
work. Although this symptom complex may be
partially explained by the diminution of hearing con-
sequent on secondary involvement of the Eustachian
tube and middle ear. it is a noteworthy fact that deaf-
ness alone does not produce intellectual torpor, nor
seriously affect the ability to study or to concentrate
attention. It has been said that these children use
up all their nerve force, mental energy, and volition
in getting air, leaving no reserve for cerebration.
I have elsewhere* called attention to the fact that in
mouth breathing less effort is actually required to
fill the lungs than with nasal respiration. On the
contrary it is just the ease of breathing which en-
courages superficial, lazy breathing which soon be-

*Nasal Obstruction as a Cause of Disorders of Nutrition,
New York Medical Journal, April 22, igos.

I07

MEDICAL RECORD.

[June 29, 1907

comes habitual, and later insufficient. When these
children are bent over their books the motion of the
thorax becomes still more inadequate, and a decided
non-aeration is the result. Autointoxication may
have something to do with the mental hebetude ob-
served in these cases. That habitual superficial
respiration is at fault is shown quite clearly by the
after histon.', when the adenoids have been removed
by operation. In many cases, after complete re-
moval of the hypertrophies, mental hebetude, sub-
normal vitality, and susceptibility to colds and in-
fection have persisted, until the habit of mouth
breathing was broken up by exercise.

Stucky claims that acute or chronic disease of the
nasal accessor)' sinuses frequently gives rise to seri-
ous forms of mental disturbance, as shown by the
numerous cases of melancholia and suicide attributed
to grippe. W. Sohier Bryant says that we have
not yet determined whether these symptoms and
conditions are due to intracranial pressure, direct
or indirect meningeal irritation, reflex nervous con-
ditions, disturbed cerebral circulation, or toxemia.
The fact remains that in these cases ventilation of
the occluded sinuses or cure of the purulent process
often cures the psychosis. On the other hand, re-
tention of secretion aggravated the mental defect, or
return of the purulent infection in the sinus was ac-
companied by a return or aggravation of the psy-
chosis.

60 East Fifty-eighth Street.

THE EXPERIMEXTAL EFFECTS OF TO-
BACCO UPON THE NERVOUS SYSTEM.*

By L. PIERCE CL.\RK. M.D.,

NEW YORK.

VISITING NEUROLOGIST TO THE RAND.\LL'S ISLAND HOSPITALS AND SCHOOLS ■
CON'SLLTING NEITROLOGIST AT THE MANHATTAN STATE HOSPITAL.
N. v.; CONSULTING NEUROLOGIST AT THE CRAIG COLONY FOR
EPILEPTICS. SONYEA. N. Y.; ASSISTANT NEUROLOGIST
AT THE VANDERBILT CLINIC (COLUMBIA UNIVER-
SITY). NEW YORK.

There is great need of careful and exhaustive
study of tlie efi'ects of tobacco upon the nervous
system. The general prevalence of the habit, espe-
cially in the young, shows that we should have a
full and sane knowledge of the effects of tobacco
on the nervous system. Observations upon the
subject in future should try to parallel the taking
of tobacco as in common practice. Much data of
older experiments has been found of little use
because this fact has not been kept in mind. We
hope some modern research laboratory may cor-
rect this defect at an early date.

A variety of substances have been found in to-
bacco aside from nicotine. Some of these are
pvridin, picolin, tulidin, parvolin, collodin, rubidin.
varidin ; also carbolic acid and marsh gas. Krouse
states that cyanogen is also present in considerable
quantity. None of the above, aside from nicotine
and pyridin, have been thoroughly studied. No
little of the differences of opinion which observers
have held regarding the action of nicotine may be
due to the lack of exclusion of the other products
in crude tobacco. This statement is particularly
pertinent in studying the eflfects of tobacco on the
nervous system. Tobacco only registers a perma-
nent and definite impression in ner\'ous structures
when it is used for months or years. Tobacco de-
prived of nicotine mav be made to produce con-
traction of the pupil, dyspnea, general convulsions,
and death in animals. The neural action of pvridin

*Read before the joint meetina: of the New York and
Philadelphia Neurological Societ>'. March r6. 1907.

is that of a respiratory paralysant and spinal cord
depressor.

Inasmuch as it is fairly well proven that tobacco
is a cardiovascular poison, many attempts to make
tobacco substitutes have been undertaken, but it may
be said that none has been successful. Not a few
efforts of late years have been directed toward
making a tobacco, nicotine-poor. One of the latest
and most interesting experiments is that of the
.Austrian government, which, it will be remembered,
has a monopoly of the tobacco trade. It has manu-
factured tobacco brands which are made almost
entirely free from nicotine, but they did not meet
with satisfaction, as the flavor suffered a marked
loss ; besides, the sedative effects were not obtained
as formerly from the consumption of crude tobacco.
Nevertheless, the government holds patents for
reducing the nicotine and pyridin of tobacco at least
fifty per cent, by means of a lime or potash treat-
ment. A still better method has, however, been
employed during the past year. It consists in heat-
ing ready-made cigars and cigarettes to a tempera-
ture of 200° C. ; thus twenty to fifty per cent, of
the nicotine is driven off at a single treatment.
Physiological studies have already proven that this
nicotine-Door tobacco is very much less harmful on
the nervous and vascular systems. The latter ex-
periments are the more interestine as it has been
lieretofore held that the intense action of smoking
tobacco on the nervous system is due to the pres-
ence of the bases of the pyridin series, and not to
alkaloid nicotine itself. However, it is not yet
proven that all the essential alkaloidal series of
tobacco do not suffer loss in this caloric or cheraic
treatment.

The experimental effects of tobacco on the nerv-
ous system may be divided into acute and chronic.
It acts both on the peripheral organs and nerve cen-
ters. In its action on the cardiovascular apparatus
i*s ma-ximum effects are registered on the aorta
and coronary arteries, producing, when taken in
habitual excess, arterial sclerosis of these parts.*
It induces also a peculiar form of cirrhosis of the
liver, which does not immediately concern the main
purpose of this paper. Nearly all the experimental
work done on tobacco has been done by the use
of graduated doses of nicotine.

The alkaloids of tobacco are chiefly absorbed by
the mucous membranes, although it may be taken

*Drs. .\dler and Hensel have recently reported some
pioneer work (Jour. Med. Research, September, 1906) on
the ability of nicotine to induce atheroma of the aorta.
They appear to have been unaware of the work done in
this field by Anstio (Italian) about a year earlier. These
.\merican authors seem only to have been aware of some
negative results obtained by Josne in this field (Arch. sen.
lie Med., 1904, November i). The authors used Vj c.cm.
of a 54 per cent, of nicotine in water, which was injected
daily into the ear vein of the rabbit. Ten minutes after
c?.ch injection each animal had a violent and typical con-
vulsion, lasting several minutes. But after such convul-
sion the animal behaved normally until following day,
when injection was repeated. There developed neither
cumulative action nor tolerance. Some animals received
a hundred consecutive injections without any change what-
ever in die typical effects as detailed above.

The chief aim of the article is to show that by such in-
travenous injection rabbits, after a very variable interval,
may develop lesions of the aorta. These greatly resemble
those caused by adrenalin and digitalen. The first lesions
appear as calcareous areas, which differ greatly as to size,
shape, etc.

With progressive injections the areas continue to spread
to the thoracic and abdominal aortas, and even to the
iliacs. Naturally these areas tend to become the seat of
aneurysms. The nicotine lesions are primarily necrotic in
character. While closely resembling the lesions of human
arteriosclerosis, there are many differences.

June 29, 1907]

MEDICAL RECORD.

1073

ufi by the skin. Animals have been killed by the
latter method of administration.

The acute effects from toxic doses of nicotine
administration are fairly well known to all ; they
embrace horrible nausea, vomitin.sf, giddiness, in-
tense malaise, with weakness, followed, if the dose
has been sufficient, by burning pains in the stom-
ach, purging, free urination, extreme giddiness
passing into delirium, a rapid running and finally
imperceptible pulse, cramps in the limbs, absolute
loss of strength, a cold, clammy skin, and finally
complete collapse and death. In the lower animals,
especially in the frog — aside from the symptoms
just enumerated, which have been encountered in
man — violent convulsions of spinal origin are super-
added, followed after a time by spinal paresis.

Tobacco is a powerful depressant to the motor or
eft'erent nerves, acting primarily upon their pe-
ripheral filaments. The afferent or sensory nerves
are much less affected, but are probably also de-
pressed. The sympathetic ganglia are first stimu-
lated and then depressed by nicotine. To these
actions are probably due the increase of saliva and
other secretions caused by small doses, and the
lessened gland activity produced by large doses.
The acuter effect of nicotine upon the nervous
mechanism of the heart and circulation is very pro-
nounced. While the initial rise in blood pressure
is certainly due in part to direct stimulation of the
heart muscle and a stimulating contraction of the
peripheral vessels, the heart ganglia receive the
greater part of the excitation. As is well known,
the contrary holds good for alcohol. It is further
probable that the final paralysis of the heart in
nicotine poisoning is due to a double depressing in-
fluence upon the heart and arterial walls.

The acute toxic effects of tobacco upon the
pupil induce a myosis, probably paralyzing the pe-
ripheral ends of the sympathetic ; and it almost cer-
tainly stimulates the oculomotor nerve.

It first excites, then paralyzes the respiratory
center. Prag states that retardation is universal
in the animal kingdom, while among mammals ac-
celeration is found. Traube teaches that the lungs
aiwavs give out before the heart in acute nicotine
poisoning; this he ascribes to paralysis of the re-
spiratory center. Rosenthal has induced inspiratory
cramp and death by sufficient doses of nicotine.
However, no little dift'erence of opinion exists
among experimenters as to whether the final paraly-
.sis of the nervous mechanism of respiration is cen-
tral or peripheral. Probably both are right. Ac-
cording to Mittenberg's experiments upon dogs,
nicotine acts in accordance with the dose, either as
a pure excitant to the respiration or as a first ex-
citant and then paralysant, or as a primary paraly;
sant. Excitation of the center in general means
accelerated respiration, and paralysis means retarda-
tion of respiration, with long expiratory pauses.
Death occurs through primary arrest of respiration.

In feeding the animals either crude tobacco mixed
with food or the alkaloid nicotine, tolerance is easily
and early established, requiring but two or three
days. The animals lose neither flesh nor appetite.
Adler fed four cigars daily to a female rabbit for
six months ; everything proceeded as in health ; the
rabbit became pregnant, giving birth to seven young,
which she nursed successfully.

Cats are the most susceptible to nicotine of all
mammalia. Birds are also easily affected. One
drop of nicotine given to a pigeon will cause col-
lapse, tetanic convulsions, and death in a minute. A
sort of tobacco chorea has been induced in some

horses. However, the toxic coefficient or the amount
necessary to produce death has never been defi-
nitely determined.

In chronic poisoning there is more or less gastro-
enteritis of a hemorrhagic character. Ecchymosis
occurs in the pleura and peritoneum. Hyperemia
of the lungs, brain, and cord is found. There is
a lowering of the hemoglobin content of the blood,
which has been reported as low as forty per cent. ;
there is also a diminution of red corpuscles. Coarse
lesions have been found in the brain and spinal cord.
Walicka claims to have seen peripheral neuritis in
animals which on autopsy showed the same changes
in the peripheral nerves as that noted for the optic
nerve in tobacco amblyopia. In Australia the horses
which eat a variety of tobacco known as Nicotiana
anavcolens develop severe chronic ocular disturb-
ances analogous to tobacco amblyopia in man, and in
extreme cases, at autopsy, the optic nerve is found
degenerated. Virginia deer eat this tobacco plant
without harm. Possibly they grow immune. Horses
are more affected than cattle and sheep, to which
latter class deer belong. Vas has shown that in
the rabbit there are well defined abnormalities in
the chromatin distribution and swelling of the cell
body in the ganglion cells of the spinal cord. This
change was uniformly found in all the spinal and
large sympathetic ganglia. Parsons and Pandi
claim to have seen degeneration of nerve fibers
similar to that noted by Walicka.

In the experimental induction of nicotine poison-
ing in rabbits Papow and Modeston have frequent-
ly seen distinct pathological alterations in the re-
tina of rabbits. Curiously enough no systematic
study of the ocular lesions of tobacco poisoning has
ever been undertaken. It is an interesting fact
that tobacco abstinence in animals, previously made
tolerant of toxic doses, is attended by symptoms
analogous to those seen in man. The animals are
extremely restless, irritable, insomnic, apprehensive,
and subject to violent fits of anger.

A study of Robert's work leads one back to our
original view that the subject of tobacco poisoning
on the nervous system, especially in its chronic (al-
though also in acute) phases, is fraught with con-
tradictions. An attempt to schematize the subject
matter has been foiled by the facts. Why should
one pharmacological authoritv class nicotine with
muscatine, another with conine, and a third with
pilocarpine? This alone teaches us the status of
the action of tobacco. At the same time these in-
compatibilities give an independent observer some
certain light and a chance to find facts suited to his
individual views — a study in pragmatic philosophv.

From the animal experiments upon tobacco poi-
soning the following conclusions may be drawn :

1. It is fairly proven that tobacco is primarily
a cardiovascular poison.

2. Its acute toxic effects on the neuromuscular
apparatus are, first, as an excitant and mild con-
vulsant; second, motor nerve depressant, and finally
a paralysant of the central and peripheral nerves of
the heart and lungs.

3. Its chronic toxic effect on the nervous system
(as yet so inaccurately studied) is to induce toxic
congestion of the brain, spinal cord, and peripheral
nerves ; inducing finally in the latter, a mild type
of degenerative neuritis.

4- The toxic coefficient, even in animals, under
strict test, is so very variable as to vitiate much
of the attempt to derive any definite Cinclnsions
of its effects on the nervous system in man.

»3 West Fifty-Eighth Street.

10/4

MEDICAL RECORD.

[June 29, 1907

DIET IN PULMONARY TUBERCULOSIS.

By HERBERT C. CLAPP, M.D.,

BOSTON.

VISITING PHYSICIAN TO THE MASSACHUSETTS STATE SANATORIUM FOR
INCIPIENT CONSUMPTIVES, AT RUTLAND. MASS.

Diet is an extremely important factor in the treat-
ment of tuberculosis. Nothing is so discouraging to
the physician as a persistently rebellious stomach or
bowels, and nothing so decidedly interferes with the
recovery of the patient. Thanks, however, to the
modern fresh air treatment, which stimulates the
appetite and digestion, these difficulties are as noth-
ing to what they were formerly. Nevertheless, it
often requires much tact, patience, and good gen-
eralship to make a patient eat properly.

The big difference between the new system of
feeding and the old is in the amount of food to be
taken. Now we resolutely insist that the patient
who is under weight shall eat large quantities of
food up to the limit of his digestive powers ; and
if fresh air and rest do not enable him to assimi-
late of this enough to gain steadily up to his nor-
mal point or a little above, we must invoke special
medicinal aid. Overfeeding, as it is often called,
is so important that some in their eagerness to suc-
ceed overdo the matter, and from their results seem
to aim to produce fat folks instead of well folks.
While the gaining of flesh is generally an indica-
tion of an improvement in lung condition, it is not
necessarily so, as some hopeless cases may become
quite fat for awhile ; and even when the lungs are
getting into good condition, if the stuffing process
is carried to tlie extreme, we may be confronted by
the dangers (as in overfeeding well people) of in-
ducing dyspepsia, gastric dilatation, lithemia, or the
uric acid condition with its pseudorheumatism, intes-
tinal putrefaction, etc., with gout, gravel, hepatic
congestion, arterial and kidney degeneration, dia-
betes, obesity, etc. Besides, the carrying around of
an e.xcessive amount of fat brings /too great a strain
on the already weakened heart. These dangers, how-
ever, although real and occasionally met with, less
often confront us than that of insufficient nourish-
ment. The great problem generally is to make
people eat enough. Appetite is no guide. It is al-
most invariably found that a consumptive can digest
far more food than his appetite demands, and it is
the physician's duty to show him how he can do
this. Some patients think they cannot take milk,
others that they cannot digest eggs, others meat,
etc. In a few rare cases this may be so, but with
the vast majority it can be done in one way or an-
other, if die right methods are employed. If a
patient can eat at a table where others are eating
heartily, he will generally do better than if he eats
alone. If on the day in each week when he is
weighed he shows an increase, this will encourage
him anew. The palatability of food is important in
gaining weight, as is also the attractiveness of its
serving. A cheerful dining room, a clean tablecloth
and napkins, pretty dishes and thin glass tumblers
are almost necessities as well as luxuries. Small,
steady gains are better than large, irregular ones.
When the patient weighs enough, he should be
instructed to eat less.

When the overweighted patient who has been dis-
charged with his disease arrested goes to work, he
is apt to lose his superfluous flesh. If not, he should
reduce his diet for the good of his general health.
It is too much tax on his digestive and assimilative
power to maintain this increased weight. In some
cases w'here, from a varietv of causes it is difficult

for the patient to take sufficient food, the employ-
ment of a tactful trained nurse, if it can be afforded,
will be a great help, even if she is not otherwise
needed. Meals should be served with the greatest
regularity. Only the pleasantest conversation should
be allowed at the table. The patient should partic-
ularly avoid worry. He should eat slowly and mas-
ticate thoroughly, remembering that by doing so he
ought to secrete and utilize for important digestive
purposes a large amount (one quart, perhaps) of
saliva each day. Gladstone used to chew each
mouthful thirty-two times, once for each tooth in
his head. The patient should not eat when very
tired, nor exercise on a full stomach ; and therefore,
if necessary, he should rest both before and after
eating. He should surely lie down for the quiet hour
after his noon meal. If the symptoms of overeating
come on, such as great fulness of the stomach,
sleepiness after meals, flatulence, vomiting, diar-
rhea, muddv urine, intestinal fermentation, etc., and
do not yield to medicines, the diet should be les-
sened in amount.

As to just what the food should be there is no
invariable rule. Patients differ, and the physician
should individualize. One man may do well on the
coarse fare of a Western ranch or of the Maine
woods, while another may need the most tempting
viands prepared with the greatest skill and delicacy.

The diet should be mixed. No exclusive fads
should be indulged, like the grape cure, the milk
cure, the raw-meat cure. No one article of food
contains the proteids, fats, and carbohydrates in
proper proportion to be sufficient alone. Besides,
a single food becomes after a while painfully monot-
onous and repulsive. Rubner estimates that a per-
son of average weight (150 pounds) in health needs
differing amounts of food according to his occu-
pation. Twenty-five liundred calories would do for
a clerk at the desk, while a blacksmith might need
5.200. The average man without much exercise
might need about 3,000, and the average consump-
tive would need much more, especially if his disease
were active and he were much under weight. A
calorie (we must not forget) is the amount of heat
reauired to raise one kilo of water one degree cen-
tigrade. Theoreticallv we ought to be able to figura
out first for the healthv man and then for the con-
sumptive in dift'erent stages and conditions just the
amount and the relative proportions of proteids,
fats and carbohydrates, mineral salts, and water
which he needs. Practically, this theoretical diet
often fails because we never know just how much
of each of these classes of foods a defective alimen-
tary tract may assimilate. Many experiments have
been tried and are being tried along these lines, but
so far without much success. Perhaps some time
we mav learn enough for a good working basis, but
hitherto most of our good results have been empir-
ical rather than derived from scientific deductions.
In general, a consumptive's diet may for the present
be considered fairly correct, if he regains flesh and
strength after having lost both.

Exceot when we are makino- experiments there is
no need to weigh the food eaten. It is easier, pleas-
anter, and better to weigh the patient once a week.
Thus we can estimate the amount really assimilated,
which is far more important than the amount in-
gested. He often gains for a while two or three
pounds a week.

All of the necessary nutritive elements are in
milk and in certain other foods, but their propor-
tions vary. The proteids predominate in eggs, meat,

June 29, 1907]

MEDICAL RECORD.

1075

cheese and fish, the carbohydrates in sugars and
starches. The fats are found in the flesh of animals
and fishes, in cream and butter, in ohve and cotton-
seed oil and in nuts, and the mineral salts in veg-
etables. Fats are especially needed by consump-
tives, and they seem to be assimilated easily, if well
chosen. The followino- proportion has been sug-
gested, subject to further experimentation: Pro-
teids 120 grams, fat 140, and carbohydrates 300.
In caloric value a glass of milk is said to be equal
to one ounce of cheese or to two eggs or to two
ounces of bread, three ounces of lean meat, or six-
teen ounces of oysters. W'e depend upon the pro-
teids to build up the tissues, and these can be
helped out by the fats and carbohydrates, the latter
being better proteid sparers than the fats, and also
being cheaper, but unfortunately being too bulky
and hard to digest, if used in sufficient quantities
without much fat.

In establishing a dietary there is no one routine
advisable for all cases. In actual practice great
variation occurs. But on one point there seems to
be a wonderful unanimity of opinion among those
who have helped the largest number of tuberculosis
cases to recovery. The constant and e.xtensive use
of milk and eggs is deemed by all well-nigh essen-
tial. After one has got well started in the right way,
he can be expected to take from two to three quarts
of milk and from four to six eggs a day in addition
to his regular meals of solid food. If he is not able
at first to take these with his solid food, it may be
wise to leave out the latter for a while and confine
himself entirely to the milk and eggs. If he has,
a ereat reougnance to these, he can begin with very
small quantities, an ounce or even less of milk
and one egg, for example, to be taken at more fre-
quent intervals. Tlie milk should be taken in sips,
very slowly, and the eggs should be tossed ofT
whole, perhaps adding a little lemon juice or salt
for a relish. The eggs should be as fresh as pos-
sible and the milk pure, unboiled, hot or cold, clean,
rich, and daintily served. Cream may be added if
desirable. Small quantities of milk may be consti-
pating to some extent, but the large amounts which
consumptives require, on account of the fat and
water contained, are slightly laxative. Milk and
eggs are usually taken for lunches between meals
and before bed. Some who claim to be familiar
with them think that the milks from asses and mares
are more digestible and the best ; but most of us, I
fancy, even if we could get them easily, would be
quite content with good cows' milk.

If necessary, the milk can be peptonized. Kumyss
and buttermilk may help out our menu. Milk will
sometimes digest better if a little salt is added. It
will relieve the tediousness of raw eggs if the flavor
is changed now and then.

Some physicians advocate three square meals a
day with three lunches interspersed, and some only
one hearty meal at noon ; in the latter case more milk
and eggs being taken at other times. A few advo-
cate leaving out the lunches and eating only three
times a dav, including the milk and eggs at these
meals. Most, however, believe in eating five or
six times a day. Although milk and eggs come
nearer to the ideal diet for consumptives than any-
thing else, yet it is certainly unwise to use them ex-
clusively. Even in fever up to 102° a solid diet is
better, giving way to milk, malted milk, gruels, and
broths if the temperature is higher. If for any
reason we have to leave the solid and mixed diet,
we like to get back to it as soon as possible.

The very best way to get in the necessary amount

of fat required is bv means of milk, cream, and
butter. Every consumptive should eat large quan-
tities of butter, preferably not cooked. Cod-liver
oil, until lately so much used, is so nauseating to
most that it should not be thought of. A little olive
oil on salads or on other foods or alone is better,
and many enjoy it or learn to like it. Cotton-
seed oil is much the same and is cheaper. Bacon
for breakfast is very appetizing, and sardines and
salmon also contain much fat.

Most consumptives need a great deal of fresh
meat, and should have it two or three times a day.
It is much better rare than well-done, and should
not be twice cooked. Raw beef would be better
still if people would be willing to eat it. Some
do and grow to like it after a while. It is more
digestible and is often good for diarrhea. When
scraned it may be rolled into balls easy to swallow,
or put into sandwiches with anchovy paste or salt
herring to give it a flavor. The yolk of raw eggs
mav be added. To tempt children it may be mixed
with sweets, or when made into balls the outside
of it may be cooked just enough over a quick fire
to take away the raw taste of the whole. Thin
soups or meat extracts do not contain much nourish-
ment, but are appetizing and excite the flow of the
gastric juice. Meat juice, on the contrary, is nour-
ishing. It is pressed out of raw or slightly browned
beef cut into small pieces after it has steeped for a
while in an equal weight of warm water (a little
salt being added), and should be freshly prepared.
To make a good raw meat soup mix half a pint of
finely minced fresh meat with enough milk to make
a thick paste. When ready to serve add half a
pint of hot milk or chicken or veal stock. Mutton,
lamb, chicken and other poultry, game and venison
are also to be included, and even veal and fresh
pork are allowable if the patient has a very strong
digestion. Pastry, candy, fried foods, and cabbage
should very seldom be eaten.

Tea, coffee, cocoa, and chocolate may be allowed
in moderation if they seem to agree. Excessive
smoking should be discouraged, but a moderate
amount out of doors may be allowed to those who
have long been used to it and feel dependent on it.
Alcoholic stimulants should be positively forbidden.
Alcohol is now universally recognized as a very
frequent cause of tuberculosis, and the treatment, of
the disease can surely be conducted far better with-
out it.

The following dietary, subject to modifications,
will convey some idea of how consumptives with
good digestion should be fed, if under weight :

Breakfast. — 7 130 a.m. Fruit, cereal, coffee, toast
or muffins, one raw egg, two glasses of milk.

Lunch. — ID A.M. Two raw eggs, two glasses of
milk, crackers.

Dinner. — 12:30 p.m. Soup: rare roast beef, or
lamb, mutton, chicken, turkev. steak, chops, sweet-
breads, or raw chopped beef; potatoes, two veg-
etables chosen from among stewed tomatoes, corn,
peas, beans, squash, spinach, beets, onions, turnips,
asparagus, cauliflower, celery etc. ; salad ; baked or
stewed apples or a simple pudding, custard, corn-
starch, farina, rice, junket, or bread pudding.

Lunch. — 4 P.M. Two raw eggs, two glasses of
milk, bread or cheese sandwich.

Supper. — 6:30 P.M. Hot or cold meat, bread,
milk-toast, fruit or sauce, tea, one raw egg, and
two glasses of milk.

Lunch. — 9 P.M. Two glasses of milk.

334 COUUONWIALTH AVBNUS.

10/6

MEDICAL RECORD.

[June 29, 1907

Medical Record.

A Weekly Journal of Medicine and Surgery.

THC)MAS L. STEDMAN, A.M., M.D., Editor.

PUBLISHERS
WM. WOOD A CO., 51 FIFTH AVENUE.

New York, June 29, t907.

THE CANCER PROBLEM.

It must be confessed that in spite of the time, brains,
energy, and money which have been expended dur-
ing the past few years in the attempt to solve the
problem of cancer, in almost all parts of the civilized
world, little or no apparent progress has been made.
Of course, this is not to say that the research \vork
which has been carried on so earnestly by skilled
investigators in America and elsewhere has been in
vain, for many important and new facts relating to
malignant tumors have been unearthed. But insofar
as a hnal elucidation of the many obscure points
which still wrap the mysterious disease known as
cancer is concerned, the end is not yet even in
sight. Theories in regard to its etiology have been
abundant within the decade just gone by, some of
which have been extravagant, some plausible, and
one or two have been almost accepted as clinching
the matter once and for all. However, a closer
analysis of every theory as to the causation of malig-
nant tumor has revealed a weak link in the chain of
argument, and one after the other each theory has
been rejected.

At the present time, tlie situation is this : In the
United States, in Great Britain, and in Germany,
research work having as its object the discovery of
the nature and cause of the malignant growths, is
being eagerly prosecuted by bands of skilled and
energetic investigators : and now and then from one
or other of these laboratories comes the news that
a forward step has been made in the direction of
the goal. It must not be forgotten also that there
are in the field many independent investigators, and
many scientific men, botli surgeons and physicians,
who, while they do not make a special study of
cancer, at the same time miss no opportunity that
mav come in their way of increasing their knowl-
edge of the disease.

To this latter class belongs j\lr. Bland-Sutton,
one of the best known of English surgeons, and
who recently delivered an illuminative address on
"The Cancer Problem" at the Institute of Hygiene
in London. Mr. Sutton began his address by point-
ing out that while the public is persistently asking
the profession to explain the nature and cause of the
tumor diseases, grouped together for clinical con-
venience under the general term cancer, some ob-
servations have been made which tend to show that
physicians and surgeons have failed to grasp the
subject in its full meaning. ^Ir. Sutton is of the
opinion that investigators would do well not to
rely on histological methods alone for distinguishing

between the various groups of malignant tumors, but
to consider the larger structural details which serve
for the identification of these neoplasms.

There are five distinct groups of malignant tu-
mors, and Mr. Sutton draws attention to the fact
that in dealing with these tumors the position is
such that we are unable to point to any absolute
histological indication of malignancy, and that clin-
ical and histological characters must be considered
together. Microscopical examination, even when
conducted by the most expert microscopist, cannot
determine with precise certainty whether a tumor
be malignant or not. "The true character of such
tumors can only be determined by careful observa-
tion of the patient." In the course of his address
jMr. Sutton gave examples drawn from his own wide
experience of the futility of relying wholly on his-
tological methods to determine the nature of a
tumor.

Perhaps the most interesting part of Mr. Sutton's
lecture was that which related to the permeation of
the cancer poison through the body. The old idea
was that such dissemination depended on the in-
vasion of the blood, but Mr. W. S. Handley showed
that cancer was spread by way of the lymphatics.
Mr. Sutton himself has always been puzzled by the
fact that although, when cancer arises in organs
such as the breast, eyeball, testicle, tongue, or lip,
it is invariably unilateral, yet in the case of the ovary
carcinoma is usually bilateral. This led him to sus-
pect that in many instances bilateral cancer of the
ovaries might be secondary, and further experience
and observation have so strengthened his belief that
it practically amounts now to conviction.

The point, however, of Mr. Sutton's address was
that histological methods alone are not sufficient or
accurate enough to determine clearly the nature of a
tumor, but that these must be supplemented by care-
ful observation of the patient in order to gain a
correct diagnosis. In a few words this means that
laboratory methods are not by themselves to be
relied upon in order to determine the nature of tu-
mors, but that practical bedside observation in this
connection has a very important part to play.

BLOOD-PRESSL'RE APPARATUS.

Now that the determination of the blood pressure
has established itself as an indispensable routine
procedure in a very great variety of conditions it is
natural that efforts should be made to improve the
existing apparatus, both in accuracy and simplicity.
\Miile instruments of the Riva-Rocci type, particu-
larly the Janeway sphygmomanometer, apparently
leave but little to be desired in the way of accuracy,
the records obtained with them when properly used
probably not being more open to criticism than those
furnished by the clinical thermometer, they suffer
to some extent from structural disadvantages that
justify efforts to produce a nearer approach to the
ideal. Two new forms of apparatus for measuring
the blood pressure are described in a recent issue of
the Berliner klinische Wochenschrift (Tune 3, 1907).
one of w^hich is presented by its originator as being
an advance in the direction of exactness, while the
other has been devised as an improvement in me-
chanical construction.

June 29, 1907]

MEDICAL RECORD.

1077

Bing considers that it is preferable if possible
to determine the end pressure in the axillary
artery rather than the lateral pressure, which
is the one usually measured by instruments
in which an armlet is employed, since the
latter is, theoretically at least, susceptible of modi-
fication by the deo-ree of contraction of the vessels
peripheral to the constricted district. In order to
gauge this pressure, he employs two armlets, which
are applied side by side above the elbow. The upper
of these corresponds to the one in ordinary use,
while the lower and narrower one is intended for the
purpose of securing complete closure of the artery
immediately below the point at which the pressure
is being measured. The tubes from these two arm-
lets enter a two-way stop cock, by means of which
either one can be put in communication with the
ordinary manometer and inflating bulb. Communi-
cating with the lower armlet is a tube terminating in
a U-shaped capillary tube containing a droplet of
petroleum colored red. In order to use the appa-
ratus the lower armlet is inflated to a point 20-30
mm. higher than that required to secure obliteration
of the radial pulse. The stop cock is then adjusted
in such a way as to permit inflation of the upper
annlet. This is carried to a point at which the fluc-
tuations of the red index in the capillary tube caused
by the end impact against the upper border of the
lower armlet disappear. The pressure is slowly
lowered, and the point at which the pulsation as
evidenced by the fluctuations of the index reappears
is read as the systolic pressure. Systematic com-
parisons between this apparatus and the Riva-Rocci
instrument gave readings that were consistently
higher for the former: the difference usually being
in the neighborhood of 10 mm.

Stillmark claims as the chief advantage of
his instrument that no rubber is used in its
construction, and that it is therefore practi-
cally indestructible under ordinary use, and that
inaccuracies due to variations in the elasticity of
the rubber components of the usual sphygmomanom-
eter are eliminated. The instrument consists of a
lever with unequal arms, the shorter of which is
provided with a weight of 500 g. and has projecting
from its lower surface a short vertical arm bearing a
conical knob intended to serve for the compression
of the vessel. The long arm of the lever is provided
with a graduated scale and a sliding weight. At its
extremity is a concave mirror having a focus of
about 3 m. The instrument is used by placing a
weight at the short end of the lever sufficiently great
to cause complete obliteration of the patient's radial
pulse. As an index of this the image of a lamp
reflected by the concave mirror remains motionless.
The sliding weight is now moved along the long
arm until the blood wave just overcomes the com-
pressing force, as is sliown by a sudden oscillation
of the light image. By means of a formula, the
result in grams obtained in this way can be trans-
posed into millimeters of mercury.

In regard to the first instrument, it may be said
that it is somewhat questionable whether the
advantage of measuring the end pressure in-
stead of the lateral pressure is sufticiently
great to offset the increased complexity of
apparatus which it entails. Stillmark's instru-

ment also does not appear to oft'er very decided
advantages since it is open to serious criticism on
the score of the fundamental principle of its con-
struction, and certainly it is not adapted for use at
the bedside.

OPERATIVE TREATMENT OF CARCINOMA
OF THE STOMACH.

The operative treatment of carcinoma of the stom-
ach may be radical or palliative, but unfortunately
the mode »f procedure can be decided upon only
when the abdomen is opened, for only then can we
see whether there are metastatic nodules in the liver
or peritoneum. An exploratory laparotomy is in-
dicated in almost all cases, but the only successful
treatment is radical removal of the new growth.
Of late the indications for radical removal have cer-
tainly become more numerous, as a few statistics
go to show. From 1881 to 1898 Broquet operated
in 52 cases; from 189S to 1904 Matti made 45 re-
sections of the stomach : and now Kocher, in an
article in the Corrcspondcnz-Blatt fiir Schzvcicer
Aerzte, No. 9, 1907, reports 25 cases covering a
period of only 23.2 years. As regards the mortality,
Broquet's was 34.6 per cent., Alatti's 17.7 per cent.,
while Kocher had only four deaths, or a mortality
of 16 per cent. In three of the latter's cases, the
transverse colon was involved and required resec-
tion ; in the fourth fatal case an abscess of the
pancreas existed as a complication. Two advanced
cases, with resection of the transverse colon, and
the remaining nineteen uncomplicated cases of
Kocher all terminated in recovery. As regards
radical cure, much depends upon the possibility of
making an early diagnosis. Makkas, in a series of
130 cases, reported a radical cure {i.e. freedom from
recurrence three years after operation) in 18.4 per
cent. ; Matti reported 19.3 per cent, cured out of
95 patients operated upon, or 26 per cent, of those
who survived the operation.

Kocher believes that the method of operation is of
importance as regards both mortality and radical
cure. Guinard collected statistics of 291 pylorus
resections, of which 148 were performed according
to the Billroth method No. i, with a mortality of
35.3 per cent., and 64 according to Kocher, with a
mortality of only 13.6 per cent.

Matti reported 97 resections (1881 to 1904), of
wliich 71 were done according to Kocher, with a
mortality of 16.9 per cent. Of the 25 cases re-
ported by Kocher himself, 21 were operated upon
according to his own method, with a mortality of
9.5 per cent. Of the patients reported radically
cured by Matti, all but three were operated on by
the Kocher method, i.e. a gastroduodenostomy was
done each time when the pylorus was involved, a
sure sign that recurrences do not appear in the
duodenum, in spite of the arguments of the op-
ponents of this method, who claim that enough tis-
sue cannot be removed. According to Kocher the
duodenum can be made more movable by cutting
the parietal peritoneum on its right side. Further-
more, if a gastrojejunostomy is performed, the duo-
denum and stomach must first be closed separately,
and through poor closure numerous patients have

10/8

MEDICAL RECORD.

[June 29, 1907

dierl. Resection with .s^astroduodenostomy brings
about more natural conditions than the other opera-
tive procedures, which explains the fact that patients
feel well soon after the operation, and remain in
good health for some time, even though recurrences
take place.

Le.\D T'oIHONIXG FROMENCArSULATED PROJECTILES.

It is ordinarily considered that aside from the pos-
sible mechanical disturbances they may induce, pro-
jectiles encapsulated in the tissues are more or less
harmless. The possibility of systemic lead poison-
ing from this source is hardly thought of, though it
is a rare, but still occasionally occurring, contingency.
Braatz {Miinchener medizinische IVochenschrift,
May 28, 1907) has discovered records of six such
cases, from a study of which it appears that neither
the length of time that the tissues have harbored
the foreign body nor the amount of metallic lead
present is of importance in regard to the develop-
ment of symptoms of plumbism. In making the
diagnosis the blood examination is of the greatest
value, and the detection of basophilic granules in the
red cells, as described by Grawitz, affords a valuable
diagnostic hint, providing that the few other condi-
tions leading to this appearance, such as malignant
disease, pernicious anemia, sepsis, and malaria, can
be excluded. While the remote danger of plumbism
will probably not cause any modification in the
surgical maxim not to resort to extreme measures
in endeavors to remove more or less inaccessible
projectiles, it is evidently the part of wisdom to
examine the blood with this idea in view in cases
of obscure illness occurring in those known to be
the carriers of such foreign bodies, and if indica-
tions of lead absorption are present to proceed at
once to operation for removal of the offending bod\'.

The ruHi.ic Attitude Toward Consumptives.

Ax editorial in the Lancet of June 8, 1907, calls
attention to a timely article in the Westminster
Gazette by Mr. A. K. ]\IcClure, who, writing under
the heading '"Panic and Prejudice," says that a
wider recognition of the fact that infection is chiefly
conveyed by careless expectoration, would "do far
more to prevent the spread of consumption than the
callous ignorance which brands all consumptives
as outcasts." This callous ignorance is already
working hardships on many patients who are in-
telligent, fully understand their potential danger to
the community, and most carefully observe every
sanitary precaution. Many health resorts are
already closed to them. Alere pleasure seekers
appear to have ordained that all sufferers from tuber-
culosis who leave home must go to some sanatorium,
whether they want to or ought to, or not. Persons
who have the disease in a slight degree, and are
careful, are discharged from their positions, forced
to leave the wage-earners' ranks, and thus become
dependent. The profession has labored loi\g and
earnestlv to inform the laity of the dangers of the
disease, but as so frequently happens the latter have
misinterpreted the advice and drawn conclusions
which are working an injustice to many worthy
persons. How to adjust the balance is a very
urgent problem before the numerous agencies now
engaged in combating tuberculosis. We feel that
much of the present unreasoning alarm is due to
loose statements in some of the daily journals, and
might be corrected by a more temperate and careful
treatment of the subject in these organs of public
opinion.

An Operation for Prolapsus Uteri.

At a recent meeting of the British Gynecological
.Society, Dr. Macnaughton-Jones presented for Prof.
Jacobs of Brussels a paper (British Medical Jour-
nal, April 20, 1907) describing a radical treatment
for prolapsus uteri as tried in seventy-seven cases,
the ages of the patients averaging from forty-three
to seventy-one years. The operation was named
abdominal colpopexy, and consisted in exposing the
uterus by a median incision and then exercising
strong traction on it in an upward direction. The
uterus was then carefully released from its attach-
ments until held only by the vagina. Section of the
latter was then made at a point lower or higher,
according as the prolapse was pronounced, by V-
shaped anterior and posterior incisions with wide-
Iv separated limbs above at the junction of the va-
gina and the uterus. The margins of the incision^
were then united by sutures, the knots turned into
the vagina, and the pelvic floor reconstructed by
whipping together the cut surfaces of the broad and
round ligaments on each side so as to unite them
above the newly formed vaginal vault. To prevent
any return of prolapse the round and uterosacral
ligaments on both sides were united to the vaginal
stump, which was thus raised up in the middle of
the pelvic cavity. The results in the small number
of cases in which the operation was tried do not
seem to have been very encouraging, as a perfect
mass was obtained in but one case out of seven. In
five cases there was a slight relapse consisting in
cystocele wdth prolapse of the anterior vaginal wall,
and one patient died from stomachic causes.

Exploratory Puncture of the Br-ain.

OPER.A.TIONS for the relief of cerebral tumors are
very often unsuccessful because the operation is not
undertaken until the growth has extended beyond
all hope of complete removal. Had a diagnosis
been made earlier the result might have been differ-
ent, but statistics show that in from twenty to thirty
per cent, of all the cases a mistake is made in the
diagnosis of the locality in which the tumor is situ-
ated. The successful surgical treatment of cerebral
neoplasms depends principally on the perfection of
diagnostic methods. Pfeiflter {Archiv fiir Psychia-
tric und Nervenkrajtkheiten, Vol. 42, No. 2) consid-
ers that exploratory puncture of the brain affords the
best means of determining the status of the case.
He reports five instances in which a satisfactory
early diagnosis was made, the exact locality of the
lesion being determined. Naturally the results ob-
tained by this procedure must be supported by a
careful neurological examination and a clinical lo-
calization of the growth. In such cases cerebral
puncture is practically without danger and affords
a means of dift'erentiating a tumor from other con-
ditions present in the cranium, particularly hydro-
cephalus, whether external or internal. The fluid
from a cyst or distended ventricle may also be
evacuated by this means, and thus the latter be-
comes in effect a therapeutic as well as a diagnostic
measure.

Low Arterial Tension as a Diagnostic Sign of
Renal Tuberculosis.

Many investigators have found a lowered arterial
tension in patients aft'ected with tuberculosis of the
lungs, and there seems to be no reason why the same
condition should not be present in patients with

June 29, 1907]

MEDICAL RECORD.

107c

tuberculosis of other organs. K. Reitter {Zeitschrift
fi'ir klinische Medizin, Vol. 62) found a constantly
lowered arterial tension in a patient who showed all
the symptoms of a chronic parenchymatous nephritis,
but later turned out to have a tuberculous kidney.
After this experience he tested the blood pressure
in ten undisputed cases of tuberculous kidney, and
found the arterial tension diminished in all. Con-
trol tests in cases of nontuberculous pyuria showed
no such diminished tension. His examinations led
him to conclude that the urine of all patients suffer-
ing from kidney disease, whose arterial tension is at
the same time lowered, should be examined for
tubercle bacilli.

55'nus of tlip Wnk.

Quiet for the Hospitals. — At the instance of the
Society for the Suppression of Unnecessary Noises,
of which Mrs. Isaac L. Rice is president, Alderman
Sullivan recently introduced an ordinance providing
thatsigns, reading "Hospital Street," be placed at the
corners of all streets on which hospitals are situated.
The areas bounded by these signs will be known as
hospital zones, and within them drivers will be com-
pelled to walk their horses, motormen must send
their cars as slowly and quietly as possible and re-
frain from clanging the gongs or suddenly applying
the brakes except in case of absolute necessity,
hucksters will not be allowed to cry their wares, the
hurdy-gurdy and the hand-organ will be silenced,
newsboys must refrain from calling their extras, and
children and hoodlums will be kept away. The plan
has the indorsement of Police Commissioner Bing-
ham, who will see that the law is enforced, and of
Health Commissioner Darlington. Fourteen hos-
pital superintendents signed a petition urging the
passage of the ordinance, which went through
without serious opposition. Anyone making unnec-
essary noises within these areas of silence will be
liable to a fine of $10.

Institute of Pathology for the City Hospital.
— Mrs. Russell Sage has given the sum of $300,000
to found an adjunct to the City Hospital on Black-
well's Island to be known as the Russell Sage Insti-
tute of Pathology. It was largely through the efforts
of Dr. T. C. Janeway that the desirability of estab-
lishing such fund was brought before Mrs. .Sage,
and the new institute is to be organized according
to the plans and under the direction of Drs. E. G.
and T. C. Janeway, with whom are to be associated
on the Board of Trustees, as ex-officio members, the
Commissioner of Public Charities of the City of
New York and the President of the Medical Board
of the City Hospital, and as individual members Dr.
D. Bryson Delavan, Dr. Simon Flexner, and Prof.
Graham Lusk. One of the objects of the institute
will be to make use of the unexampled material of
the city institutions on Blackwell's Island for the
purpose of investigating heart and kidney diseases
and the other morbid conditions attendant on ad-
vanced age.

Pasteurization of Milk. — In a report recently
issued with the indorsement of the Secretary of
Agriculture, the pasteurization of all milk is strongly
advocated. The advantages and disadvantages have
been studied by Dr. M. J. Rosenau, Director of the
Hygienic Laboratory of the Public Health and Ma-
rine Hospital Service, and in his opinion the advan-
tages so far outweigh the disadvantages that he
"unhesitatinglv recommends compulsory pasteuriza-
tion of all milk not certified." Even in the case of
certified milk home pasteurization is urged in order

to guard against the slight risk of occasional con-
tamination.

Health in the Canal Zone. — According to the

latest report of Col. Gorgas to the Canal Commis-
sion, the health conditions in the Zone are better
than ever before. The largest percentage of malaria
for any week in the month of May was 65-100 of i
per cent., and it has been as low as 52-100 of i per
cent. The percentage of all disease has ranged from
a minimum of 96-100 of i per cent, to i i-io per
cent. The prolonged dry season and the late be-
ginning of the general summer rains have been pro-
ductive of conditions unusually favorable to the
rapid breeding of mosquitos, so that it has been
necessary to carry out the work of mosquito exter-
mination with greater activity than ever before.

New York City's New Water Supply. — On
June 20 the work of excavation for the Catskill
Aqueduct of the city's new water supply system was
formallv begun by Mayor McClellan at a point
about two miles from the town of Cold Spring. The
water is to come from the three reservoirs up in the
Catskills in aqueducts which will pass under the
Hudson at Storm King at a depth of about 700 feet
and come up at Breakneck on the other side of the
river. From here they will cross gullies and pierce
hills in three conduits which enter the ground at
the spot where the formal excavation was started.
The new system is designed to deliver 600,000,000
gallons daily, and its estimated cost is $161,000,000,

Ambulance Accidents. — A Lebanon Hospital
ambulance, in charge of Dr. Rottnoss, was run into
by a junk wagon at the corner of Brook avenue and
\Vestchester avenue and overturned, and wrecked.
The patient, a child with meningitis, and the sur-
geon were thrown into the street, and the child died
a few minutes later. An ambulance of the Hudson
Street Hospital, in charge of Dr. Elliott C. Bur-
rowes, was smashed at West Broadway and Worth
street by a collision with a trolley car. The surgeon
and driver were badly bruised and cut and the horse
was killed.

St. John's Guild Ship and Hospital.— The St.
John's Guild floating hospital, the Helen t. Jiiilliard,
has been thoroughly renovated since last year, and
will begin its regular work on July 5. The Guild's
Seaside Hospital at Xew Dorp, Staten Island, is also
ready for the simimer season.

Civil Service Examinations. — The State Civil
Service Commission will hold examinations July
13, 1907, for the following positions: .A^ssistant
in Clinical Laboratory, Manhattan State Hospital,
$900 and maintenance; Medical Inspector of Fac-
tories, $2,400; Trained Nurse, State Institutions
(men and women). $420 to $600 and mainte-
nance; Woman Physician, State Hospitals and
Institutions, $1,000 and maintenance. The last
day for filing applications for these positions is
Tulv 6. Full information and application forms
mav be obtained bv addressing Mr. Charles S.
Fowler, Chief Examiner of the Commission in
Albanv.

St. Vincent de Paul Fresh Air Farm.— The
children's free summer vacation season at the St.
\^incent de Paul Fresh -Air Farm at Spring X'alley
was opened on June 18 with a party of about 200
vounger children from the day nurseries. The first
partv of school children will go on July 5, and the
season will close late in September, when another
partv of children will be sent.

Automobile Accidents in Germany. — The Im-
perial German Statistical Bureau has published fig-
ures showing that on January i there were 27,026

ro8o

MEDICAL RECORD.

[June 29, 1907

automobiles in the country. According' to these
figures in the half year ended September 30 last
there were 2, 2(50 automobile accidents in Germany,
of which 673 caused injury to persons. The number
of persons killed and injured amounted to 1,570,
including- 51 killed. Of the latter, 9 were chauf-
feurs, 9 passenf^ers of automobiles, and 33 other
persons. In 1,024 cases the cause of the accident
was determined, and in 478 of these too rapid run-
nina: or failure to give the alarm signal was given
as the cause, while 220 were caused by unskillful
steering, 26 through disregard of stop signals, 53
through failure of brakes, 174 tlirough lack of proper
precaution on the part of persons in the streets or
roads, 48 through slippery pavements, 20 through
breakage of parts of the machine, and 5 through
explosions. Suits were brought in the courts in 695
cases, and of these 625 were against chauffeurs.

Optometry Bill. — At the hearing on this bill
before Governor Hughes last week, the measure
was strongly opposed by the State Medical Society
through Dr. H. L. Shaw of Albany, and others.
The (jovernor reserved decision on the bill.

Opium Restriction in Shanghai. — In accordance
with the recent imperial decree against the con-
sumption, sale, or cultivation of opium, the opium
shops in the native quarter of Shanghai were closed
on June 22, and similar action is soon to be taken
in the surrounding districts. Contrary to expecta-
tion, no trouble was encountered from the popu-
lace.

To Quarantine Consumptives. — Dr. W. H.
Brumby, State Health Officer of Texas, has an-
nounced his intention of issuing a proclamation
quarantining all persons suffering from advanced
tuberculosis.

Commencement Exercises of the Chicago Col-
lege of Physicians and Surgeons. — These were
held .June 4, when a class of 165 was graduated,
the degrees having been conferred by President
Edmund J. James of the University of Illinois.
The doctorate address was delivered bv Rev. Rufus
A. ^\"hite.

A Medical Night School. — Under the title of
the Hippocratean College of Medicine a night school
for the study of medicine has been opened in St.
Louis.

Dedication of Michael Reese Hospital. — This
new hospital, recentl_\' built at a cost of more than
$700,000, was dedicated and opened for the care of
patients June 16. It is said that the new hospital
will accommodate 300 patients and 100 nurses. It is
six stories in height, fireproof throughout, and is
fitted with every modern equipment.

A Hospital in Dover, N. J. — .V number of the
residents of Do\er. X. J., are planning to establish
a hospital in that place, and a committee has been
appointed to devise ways and means of carr\ing out
the project.

Sanatorium for Hebrew Children. — The sana-
torium for Hebrew children at Rockaway Park,
L. I., has been opened, and now- has more than
200 inmates.

Dr. James Packard Mann has been elected
professor of orthopedic surgery in the Medico-
Chirurgical College of Philadelphia. He has held
the position of clinical professor in the same
branch for ten years.

Dr. Harmon Smith has been appointed Surgeon
to the Throat Department of the Manhattan Eye,
Ear. and Throat Hospital.

Ambulance for Beth Israel Hospital. — An am-
bulance costing $700 was presented to this hos-
pital last week by an organization of young
women and girls who had raised the necessary
sum of money.

Greenport Hospital Opened. — The new hospital
of the Eastern Long Island Hospital Association
has been opened at Greenport and is ready for pa-
tients.

Chicago Medical Society. — The annual meeting
of this Society was held June 19, 1907, with Dr.
George W. Webster in the chair. Reports w-ere
received and read of the work done by the thirteen
branches of the Society. Dr. Harold N. Moyer
reported that the Medico-Legal Committee had con-
sidered seventy-nine items. He used the word items
advisedly because they could not be dignified as
suits. These items varied all the way from com-
plaints to threats and suits of malpractice. In four
cases the committee won after legal battles. The
committee had disposed definitely of eight cases,
and he thought that nine-tenths of the others would
not be heard of again. No judgment had been ren-
dered against a doctor for malpractice in Cook
County, and no compromise had been made by the
committee in any malpractice case in four years,
excepting in three instances. In one of tliese, clearly
a malpractice suit, although trivial, liability was
certain. The other two cases were disposed of in
an amicable manner. The following officers were
elected for the ensuing year : President, Dr. H. B.
Favill ; Secretary, Dr. Robert T. Gillmore ; Coun-
cillors for three years, Drs. Adolph Gehrmann,
William L. Noble, George Bell, Frank X. Walls,
and William L. Baum ; Alternates for three years,
Drs. Heman Spalding, Charles E. Paddock, A. B.
Keves, W. E. Pickard. and E. C. Riebel.

Franklin County (Vt.) Medical Society. — At
the annual meeting of this society, held in St. Albans
on June 5, the election of officers resulted as follows:
President, Dr. F. S. Hutchinson of Enosburg Falls ;
Vice-President, Dr. A. L. Cross of Swanton ; Secre-
tary and Treasurer, Dr. E. A. Hyatt of St. .\lbans.

Maine State Medical Association. — At the an-
nual meeting of this organization held on June 13
in Portland diese officers were elected: President,
Dr. B. B. Fuller of Portland; Vice-President, Dr.
Albert D. Sawyer of Fort Fairfield and Dr. O. C. S.
Davies of Portland ; Secretary, Dr. Walter L. Tobie
of Portland ; Treasurer, Dr. Arthur S. Gillson of
Portland.

Rhode Island State Medical Association. — The
ninety-sixth annual meeting of this association was
held in Providence on June 13. The officers elected
for the ensuing year were as follows : President,
Dr. C. y. Chapin ; Vice-Presidents, Dr. F. B. Fuller
and Dr. Eugene Kingman : Secretary, Dr. S. A.
Welch : Treasurer. Dr. G. S. Mathews.

Chattahoochee Valley Medical and Surgical
Association. — The semi-annual meeting of this
organization will be held at Opelika, Ala., July
9 and 10, 1907. Dr. J. A. Goggans of .Alexander
City is the President and Dr. W. J. Love of Ope-
lika is the Secretary.

New Haven County (Conn.) Anti-Tuberculosis
Association. — At a meeting of this society, held in
New Haven on June 13, the following were elected
officers for the ensuing year: President, Dr. Fran-
cis Bacon ; Vice-Presidents, Professor Henry W.
Farnam, Dr. C. W. Gaylord. and Dr. H. L. Swain;
Recordinti Secretary. Professor Irving Fisher;
Financial Secretary, E. L. Chapman : Treasurer, W.
Perrv Curtiss.

June 29, 1907]

MEDICAL RECORD.

1081

Obituary Notes. — Dr. Charles L. Mullhol-
L.\XD nf Brnijklyn died on June 18 at his home in
that city. He had practised for many years in the
lower section of Brooklyn and was a graduate of
St. John's College and the University of Xew York.
Dr. \\'iLL.\RD P.-\RKER died at his home in this city
on June 24. He was a graduate in arts of Colum-
bia College in 1866, and in medicine of the College
of Physicians and Surgeons in 1870. He was a son
of the late Dr. W'illard Parker, who was for years a
leader of the profession in this city, one of the first
American surgeons to operate for appendicitis, and
the organizer of the first college clinic in this coun-
try. Dr. Parker was buried at New Canaan, Conn.,
on Thursday of this week.

Dr. Thomas Hill of Brooklyn died on June 20,
at the age of sixty-two years. He was born in
Ireland and was a graduate of Niagara University.

Dr. S. H. Frazier of Crescent, Mo., died sud-
denlv at Lilbourn on June 8. He was graduated
from a St. Louis college seven years ago.

Dr. George J. Buckn.vll of San Francisco died
on June 11 at the age of seventy-one years. He
was a native of New York State and had practised
in San Francisco since 1856.

Dr. Edward H. Birckhead of Albemarle County,
Va., died on June 14, at the age of forty-eight years.
He was born in Proffit, Va., and received his medical
education at the University of Virginia and the
Bellevue Medical College, from which he was grad-
uated in 1S83.

Dr. Charles B. Gilbert of Washington, D. C,
died on June 13, at the age of sixty years. He
was born in Bath, Me., and received his medical
education in Philadelphia. He had practised in
^^'ashington for over thirty vears.

Dr. R. D. Wilkin of Cass County, la., died on
June 6 after an illness of several weeks. He was
sixty-nine years of age and had practised in the
county since 1875.

Dr. C. L. Lewis of Nashville, Tenn., died sud-
denly on June 12, at the age of seventy-five years.
He received his degree from the University of Vir-
ginia and had practised for many years in Nash-
ville. A few years ago he retired from active work.

Dr. Arthur D. Hayes of Hartford, Conn., died
on June 17 of tuberculosis, at the age of forty-one
years. Dr. Hayes was bom in Evansville, N. Y.,
and received his medical degree from the Dart-
mouth Medical College.

Dr. Henry E. Muhlenberg died at Lancaster,
Pa., on June 17, at the age of fifty-seven years. He
was descended from a long line of distinguished
physicians and ministers. As a young man he
entered the U. S. Naval Academy as a cadet, but
he resigned before he had fully completed the course
of study. He was graduated from the Medical De-
partment of the University of Pennsylvania in the
class of 1871 and entered the U. S. Marine Hospital
Service, from which, however, he resigned after
four years to enter upon the practice of medicine
in his native city of Lancaster. He was in time
elected to City Councils and in igoo Mayor of Lan-
caster.

Dr. Charles J. Schltlze, the oldest practising
physician in Bucks County, died at Reading. Pa.,
on June 16, at the age of eighty-nine years. He was
a native of Germany and was a graduate of the
University of Greifswald in 1846.

Dr. Isr-^el Hart of Pennington, N. J., died on
June 23, at the age of seventy-nine vears. He prac-
tised medicine in Pennington until 1S63, when he
was appointed assistant surgeon in the army, where
he remained until the close of the war. He then
returned home and continued in practice until a few
vears ago.

OUR LONDON LETTER,

(From Our Special Correspondent.)

GENERAL MEDICAL COUNCU, — HOSPITAL .\BUSE — CH.UUTY
organizations' CONFERE.NCE — MVELOP.MHIC TRICHOSIS —
PERSISTENT URINAKV FISTULA — PROLONGED PYREXIA — HEART-
BLOCK — ITEMS — OBITUARY.

London, June 7, 1907.

The session of the General Medical Council was con-
cluded witliin the week. The proceedings, subsequent to
those I mentioned in my last, comprised a good deal of
penal business, a discussion on the teachings of midwifery
and gynccoiogy, examination on these subjects, the presenta-
tion of reports of committees, and the usual closing for-
malities.

The G,ue?tiou of medical and dental practice by companies
has passed from the Council to Parliament, and on Monday
the select committee of the House of Lords began to take
evidence upon the bill. The president of the Conned and
Mr. Tomes gave evidence, and the committee examined
some other witnesses yesterday and adjourned.

Last night the Metropolitan Branch of the B. M. A. held
a meeting respecting hospital abuse. By dint of an urgent
whip a fair attendance was obtained, and a resolution
passed that a Central Hospital Authority for London should
be constituted, on which the profession should be ade-
quately represented. Drs. Knowslcy Sibley, Lewiston Shaw,
Forbes Ross. Southcombe, McCann, Heslip, F. J. Smith,
Roche, Surgeon-Colonel Myers, and Mr. D'Arcy Power
took part in the proceedings. Some other meetings have
taken place in support of this view, but what will be the
result is very uncertain. The British Medical Association
will, no doubt, make every effort to dominate any repre-
sentation the profession may obtain. Tliat may not be
much, considering how tlie lay element has hitherto monop-
olized all power.

The Charity Organization Societies have been holding a
conference at Norwich, when the abuse of hospitals, the
work of provident dispensaries, and kindred topics were
discussed. In a paper, read by Lieutenant-Colonel Monte-
fiore in place of Dr. Gray, who was detained in London,
the cooperation between hospitals and dispensaries was
held to be most important, but to attain the object many
more provident dispensaries are required. The plan of
appointing almoners, or inquiry officers, was commended.
It was, however, said that at present many patients, find-
ing such an officer at a hospital, left it and went to another
where inconvenient inquiries were not made. When almon-
ers are appointed at all hospitals their value will be realized.
It was further said that cooperation between dispensaries
should be .general, so that a member having to move to
another district could be transferred without loss of benefit.
Dr. Beverley of Norwich said the working classes had for
so many years had recourse to hospitals that they had
ceased to regard themselves as objeets of charity, to which
the present rates of wages did not entitle them. He had
had abundant opportunity of seeing the abuse of hospitals,
both in London and the provinces.

Dr. Ballance gave the particulars of the working of the
Norwich Public Medical Service, a society instituted to
provide the working classes with attendance in sickness.
The class thev desired to aid was that just below the one
that could pay minimum medical fees. Such people would
be thrust on charity in illness, unless they had provided by
contract for the help they needed in illness. The society
was entirely provident — had no contributions from outside.
There was no wish to impose a wage limit on entrance,
but it found that some who benefited from the society when
poor, and afterward became better off, would go on obtain-
ing medical attendance at the trivial contribution when they
could afford to pay a general practitioner.

Mr. Henderson raised the socialist issue, asserting that
the whole thing should be put on the basis of citizenship,
and every citizen who liked be able to avail himself of a
public medical service. He was supported by a clergyman,
when Mr. Loch protested that such a thing would be an
extended poor law and the antithesis of the history of med-
ical relief in this country. Mr. Day said if charity was bad so
was the work of the provincial medical societies. This
part of the discussion was, on further protest, ruled out of
order; but on another day Mr. Henderson returned to the
attack and said that IMr. Loch and the organization society
only persecuted the shabby, begging-letter iinposters, while
landowners did the same thing in a wholesale way.

Sir Wm. Cowers has contributed to the Medico-Chirurgi-
cal a rare cast of cervical myelopathic triciiosis in a man of
41. Unequivocal symptoms of syringomyelia were asso-
ciated with a growth of hair, which occupied a triangle, of
which the inner side was along the middle line of the spine
from the sixth cervical to die third dorsal vertebra. It

io82

MEDICAL RECORD.

[June 29, 1907

extended at one point nearly two inches from the spine.
The condition, he said, pointed to a disproportion between
the inner and outer layers of the epiblast in the lower
cervical region. A notable feature was that the growth of
hair was of greatest vertical extent at the middle line, cor-
responding to the edge of the neural ridge of the epiblast.
Had the other side been affected also the area of trichosis
would have presented a lozenge-shape, which was strikingly
present in some of the recorded cases of lumbar trichosis
in spina bilida occulta.

Mr. Haward, president, mentioned a case in which no
defect in the vertebrx was detected, but the patient had loss
of power and talipes, loss of sensation, and a great tend-
ency to ulceration of the toes, leading to exposure of bone,
requiring removal of the toes. The patient, now a young
man, is still troubled with ulceration and. discomfort of
the foot.

Mr. Pernst thought the case must be unique. There were
however, cases of artificial hypertrichosis recorded — one in
which it followed an injury to a nerve in one upper limb.

Dr. Grainger Stewart had seen a similar case, under Dr.
Ormerod, in a miner who had wasting and weakness of the
right arm, with spasticity of that and both lower limbs. He
had also dissociated sensibilit>'. The seventh cervical spine
was suspiciously prominent, and when a baby he had had a
growth of hair in the cervical region, with a bag-like forma-
tion. It was thought the seventh spine was bifid. There
was a scar in the middle line, or slightly to the right 1%
inches broad.

Sir William Gowers remarked that he doubted whether
a bag connected with the spinal canal could fail to prevent
closure of the arches.

A paper was then read by Major M. P. Holt on a case
of persistent urinary renal fistula. Rupture of the kidney
had been followed by extensive suppurations, and attempts
to perform nephrectomy had had to be abandoned on ac-
count of furious hemorrhage. Supposing the secretion of
urine in the abscess to be the sole hindrance to healing.
Major Holt ligated all the renal vessels on that side through
the transperitoneal route. Within five days urine ceased to
be present in the discharge, and by the fifty-seventh day
the sinus was completely healed — after two and three-fourth
years' persistence. The patient has remained quite well up
to the present time, nearly two years since the operation.

The concluding annual meeting of the Clinical Society
was held on the 24th ult.. prior to a special general meeting,
when the final arrangements will be made for its becoming
the Clinical Section of the Royal Society of Medicine.

Dr. de Haviland Hall read notes of two cases of pro-
longed pyrexia, one connected with tuberculosis, the other
With ulcerative endocarditis. It was remarked that these
h-ere the most frequent causes, and in arriving at a diag-
nosis the family history was important. On the one hand
hemoptysis, enlarged glands, and other suspicious symp-
toms in near relatives suggested tubercle, while a rheumatic
family history pointed to the possibility of endocarditis.
This would be more likely if the patient had been attacked
with acute rheumatism, followed by cardiac trouble.

Dr. Sidney Phillips had turned to the list prepared by
Murchison of conditions accompanied by continuous
pyrexia ; he found syphilis named. So, in a doubtful case,
he had given mercury and the temperature at once fell.
Ulcerative arteritis without endocarditis was another cause ;
so was ulcerative colitis.

Dr. Walter Carr mentioned a case in which no cause
could be assigned, when insensibility suddenly supervened,
and death in four days. A mass of vegetation was found
at the post mortem on the mitral valve, which had caused
no murmur during life. Dr. Box cited a case connected
with basic meningitis, and Dr. Glover one of rheumatic
origin.

Dr. A-. M. Gossage read a paper on heart-block, and il-
lustrated it by sphygmographic tracings on the screen. He
pointed out that conductivity might be affected separately
from other functions of cardiac muscle and that depression
of conductivity showed itself in the fibers which connect
the auricles and ventricles. Such depression was illustrated
by tracings showing a lengthening of the normal interval
between the contraction of the auricles and ventricles.
Still further depression was shown by the dropping out of
ventricular beats. This might occur as an effect of dig-
italis or be due to the action of the vagus. Tracings were
exhibited where there were three auricular beats to every
two ventricular, two auricular to one ventricular, and three
auricular to one ventricular.

A new medical scholarship at O.xford, of the value of
£100 a year, tenable for four years, has been founded by
Dr. C. Theodore Williams.

The late Lady Kortright has left to the London Hospital
£10,000. and also a share in her residuary estate.

Sir T. Barlow presided on Wednesday evening at a
meeting on behalf of the Medical Missions of the Wes-
leyan Methodist Societ>-. He announced a gift of £500 from
a friend of the society toward a new hospital in Central
China. Mr. Pearce Gould said nothing broke down the
prejudice and superstition of heathen races so much as
medical skill, combined with Christian charity and kind-
ness. Dr. J. B. Hellier maintained that it was the presence
of medical missionaries in lands like China that made it
possible for other missionaries to be there.

Dr. Maxwell Tylden Masters, whose death has occurred
at the age of 74 from heart failure, although he practised
medicine for some years, was best known as a botanist
For forty-one years he edited the Gardeners' Chronicle, in
which his most important contributions to botany appeared.
From 1865 to 1868 he lectured on the subject at St. George's
Hospital. He also served as an examiner at the London
University. He was a fellow of a number of learned so-
cieties, including the. Royal and the Linnean. an officer of
the Leopold Order, and a corresponding member of the
Institute of France. He took L.S..^., 1854; M.R.C.S., 1856,
and M.D.St.And., 1862.

OUR BERLIN LETTER.

(From Our Special Correspondent.)

SURGERY OF THE HEART — SURGERY OF THE VESSELS — PULMO-
NARY SURGERY — SURGERY OF THE LIVER — FRACTURES OF THE

THIGH HYPERTROPHY OF THE PROSTATE — CONGRESS OF THE

ROENTGEN R.\V SOCIETY.

Berlin, May 15. 1907.
A FEW notes relative to the Surgical Congress held last
month may be of interest.

A review of the suljject of surgery of the heart was
given by Rehn of Frankfurt, who was the first to perforin
suture of this organ, and was able to report 124 cases. In
regard to the operative technique, he said that any tendency
to stereotyped methods was to be deprecated, and the main
object was to avoid injury to the pleura and to make the
incision in such a way as to render satisfactory drainage
possible. If the hemorrhage was abundant compression
of the venous trunks leading to the right auricle might be
tried. Interrupted sutures of fine silk and cylindrical
needles were most satisfactory. Sauerbruch of Greifswald
explained that pneumothorax in cases of heart injury at
first had a hemostatic effect, but later induced cardiac
weakness, and he therefore recommended the use of the
pneumatic cabinet for such operations. Numerous speakers
recommended resort to cardiac massage through a laparot-
omy wound in cases of chloroform syncope.

To the subject of surgery of the vascular system. Lexer
of Konigsberg contributed reports of two cases, in one of
which after extirpating an aneurysmal sac he had been
able to do an end-to-end anastomosis of the popliteal artery,
and in the other he had restored the continuity of the sub-
clavian artery through implantation of a piece of the
patient's saphenous vein. Kiittner of Marburg reported two
cases of splenectomy, one of which was for a gunshot
wound, while the other was one of extirpation o£ a greatly
enlarged spleen in myelogenous leukemia. In the first
case polycythemia resulted, but in the other there was no
effect on the blood picture.

Friedrich of Greifswald discussed the surgery of the
lungs, and said that echinococcus, pulmonary- abscess, and
gangrene afforded the best opportunities for operative
interference. The operation should be performed at one
session and the incision should be made with a knife
rather than with the cautery. As the prognosis is good
in acute cases, the results should be satisfactory in about
70 per cent. Injuries should be treated expectantly. Sev-
eral speakers spoke in favor of the Brauer method of hyper-
pressure for use in operations on ihe lung. Gluck of Berlin
presented a patient from whom ten years previously he had
resected the entire lower lobe of one lung. Sinuses after
pulmonary operations or injuries were discussed by Garre
of Breslau, who said that, like bronchiectases, they were
often very difficult to cure. In chronic cases extensive
resection was often necessary. Lenhartz of Hamburg
reported eighty-five cases of gangrene with fifty-three cures,
and five abscesses with four cures. The presence of glob-
ules of fat in the sputum in 93 per cent, of the cases points
to the presence of a new growth. Brauer of Marburg re-
ported good results from the induction of artificial pneumo-
thorax in cases of contraction of the pleura such as accom-
panies pulmonary tuberculosis. Schlange of Hanover has
treated severe hemor'-hage from tuberculous cavities by
resecting the third rib and packing the resulting opening.

In discussing si-irgery of the liver and bile passages,
S'prengel of Braunschweig described the formation of a

June 29, 1907]

MEDICAL RECORD.

1085

retroperitoneal abscess secondary to perforation of the
cystic duct by a stone, and expressed tlie opinion that such
an occurrence was not uncommon. Anschutz of Breslau
reported twenty cases of resection of the liver and said that
the danger of liemorrhage was not very great, for the
operation itself had never caused death in his experience.
In resecting small portions the vessels are ligated, but if
larger areas are to be removed the tissues must be tied off
en masse, the ligatures being slowly tightened. By incising
the triangular ligament and resecting the costal arch the
operative field is rendered much more accessible.

The treatment of fractures of the thigh was discussed
by Bardenheuer of Cologne, who recommended his method
of multiple extension with heavy weights. In 179 cases
of this sort, union was secured without shortening in 159.
Konig of Altona was in favor of operative interference,
especially in dealing with younger patients. In the dis-
cussion it was stated that results like those of Bardenheuer
could be obtained only by the closest attention to the details
of the method, which preferably should be learned in Bar-
denheuer's own clinic.

Kiimmell of Hamburg stated that in hypertrophy of the
prostate operation was indicated only in the severest cases
that required frequent catheterization, in which the bladder
was infected, or stones were present. Prostatectomy was
to be preferred to all other methods on account of the
freedom from relapses. In most cases the vesical route
was preferable to the perineal operation. His mortality was
22 per cent. Most of the speakers were in favor of supra-
pubic prostatectomy and recommended local and lumbar
anesthesia. Pulmonary emboli from the prostatic plexus
were a frequent cause of death. Rovsing of Copenhagen
resorts to prostatectomy only after resection of the vas
or the formation of a vesical fistula has been without
result. This speaker has also performed total extirpation
of the bladder in three cases of carcinoma, the urine being
collected in a satisfactory manner in a suitable apparatus.

The third Congress of the German Roentgen Ray Society
expressed the official opinion that the use of the Roentgen
rays for diagnostic and therapeutic purposes by individuals
not qualified as physicians was an infraction of the laws
regulating medical practice. It was also decided that in
therapeutic radiations the degree of hardness of the tubes
used should be noted, and one of the approved direct or
indirect methods of measurement of the rays should be
employed. A case of death after insufflation of oxygen into
the knee joint was reported by Jacobsohn of Breslau. A
few hours after the procedure cyanosis and death occurred.
No gas emboli could be discovered, though it is possible
that the oxygen might have been absorbed before the
autopsy, which was not performed until twenty-four hours
after death. Holzknecht of Vienna reported a similar case
in which a considerable amount of gas was found in the
heart. In regard to the value of the Roentgen rays in the
diagnosis of brain tumors, it was concluded that in this
direction there was but little to be hoped for from their
use. Krause of Breslau stated that metabolism was
modified through the Roentgen rays and that healthy
persons when exposed to them acquired a hyperleucocytosis
followed by a leucopenia. Forsterling found that the limbs
of young animals exposed to the rays were backward in
growth. By exposing the head to the rays the development
of the entire body of the animal was impaired. Hahn of
Hamburg had treated two boys for lupus, and found, as a
result, that one-half of the face remained smaller than the
other and that the development of the teeth was defective.
Kohler of Wiesbaden presented cinematographic presenta-
tions of the act of respiration ; these pictures had been
obtained by taking separate views of the phases of the
respiratory act and then combining these in the cinemato-
graph.

OUR LETTER FROM THE PHILIPPINES.

(From Our Special Correspondent.)

COLLECTING THE PHILIPPINE LEPERS CHOLERA CASES TREATED

AT THE SAN LAZARO HOSPITALS — LOCO-WEED DISEASE —
QUARANTINE AGAINST CHINA — E.XAMINATION OF THE MILK
SUPPLY OF MANILA — A NAVAL HOSPITAL AT BAGUIO.

Manmla, p. I., May i, igo?.""'
The work \vhich was recently undertaken by the Bureau
of Health in concentrating the lepers upon the islands of
Samar and Leyte for the purpose of transferring them to
the Culion leper colony, located on the island of Culion.
afforded considerable additional evidence tliat the number
of lepers in the Philiopincs is probably not as high as has
been thouglit heretofore to have been the case. In order
that the matter might be placed on a definite, scientific
basis, the steamer which was sent out for the purpose of
collecting the lepers was fully equipped with a bacteriologi-

cal outfit, and several competent microscopists accompanied
it for the purpose of making microscopical examinations
of all cases before they were taken aboard, and also for
the purpose of studying some of the skin lesions which are
so frequently encountered, and many of which have no
doubt beep erroneously classed as leprous. In this way
the mistake of taking nonleprous persons from their homes
and segregating them in the Culion colony was avoided,
while at the same time none of those actually infected with
the lepra bacillus were left behind to serve as centers of
infection.

In order to aid this work as much as possible, and with
the hope of having an opportunity to see as many of the
skin lesions as possible, instructions were sent out in
advance to the local officials to have all present themselves
for microscopical examination who showed any evidence,
even though slight, of being afflicted with leprosy, or who
had any ulcers or contractions of any sort. In this way
several hundred persons were brought, who, in many
cases presented a most repulsive appearance, but who, on
careful examination, were found to be afflicted with trop-
ical ulcers, phagedenas, or syphilis. Quite a number of
cases of the latter were found, particularly on the island
of S'amar. at places where troops had been stationed here-
tofore. The spirochete was demonstrated in quite a num-
ber of cases.

In concentrating the lepers no serious difficulty was
encountered, and so far this feature of the work has given
rise to less friction than would ordinarily be expected to
be the case. This attitude of the people is, how^ever, no
doubt largely brought about by the excelleiiit accommoda-
tions and care that is given the lepers at Culion. In the
great majority of eases they, no doubt, have better houses,
better clothing, and more food than they enjoyed before
their incarceration, and this, coupled with the fact that they
are not compelled to work, has a strong tendency to make
them contented. In this connection it is interesting to
observe that the steady decrease in the number of lepers
in the islands still seems to continue. For the quarter ended
December 31, 1906, there were 3.225, and for the quarter
ended March 31, 1907, there were 3,151 as against 3,580
reported August 31, 1905.

A review of the record of the cholera cases treated at
the San Lazaro hospitals during the past year shows that
of 100 cases in which the diagnosis was actually verified
by laboratory methods, 46 had a temperature of normal or
above, several reaching 103^, and 54 had a subnormal tem-
perature. These figures would indicate that, while a sub-
normal temperature is an excellent symptom in making
a diagnosis, yet it is not so certain as the average text-
book would have it appear.

The regular monthly meeting of the Manila Medical
Society was held at the St. Paul's Hospital on the evening
of April 8. A case of Weil's disease was reported upon
by Dr. Thornburg. Dr. H. T. INIarshall, Pathologist of
the Bureau of Science, read a paper on "The Loco-weed
Disease in Sheep." from which he concluded that no such
disease existed as a specific entity; that the term "loco-weed
disease" was a name given to a number of different kinds
of disorders that occurred in animals.

The LInited States Quarantine Service, on account of
the appearance of plague in different places of China, and
in accordance with the usual annual custom which has been
observed since 1900, has declared a seven days' quarantine
against vessels arriving from that country, which is to date
from the time the disinfection is completed in the Philip-
pines. It is provided, however, that vessels coming from
ports in China at which regular officers of that Service are
stationed, and when proper facilities for disinfection exist,
that the quarantine will be waived. The quarantine became
effective May 10, 1907.

About ten days ago the Bureau of Health started to make
a systematic laboratory examination of the milk sold in
the city of Manila. Reports of the analyses are being
awaited with much interest.

pr._ H. G. Beyer, Medical Inspector and Fleet S'urgeon,
Asiatic Fleet, has proceeded to Baguio, Benguet. upon
instructions of the Admiral of the Pacific Squadron, with
a view to reporting upon the desirability of establishing m
Naval Hospital or sanatorium at that Philippine health
resort. It will be remembered that the Army and the Civil
Government have already established hospitals at that
place, and reports have been made from both these inde-
pendent sources, which indicate that Baguio possesses great
advantages for the cure of certain forms of tropical dis-
ease, and more particularly amebic dysentery.

The report of the committee which was named for the
purpose of investigating the deaths which occurred at
Bilibid prison among some prisoners who were inoculated
by Dr. R. P. Strong is now in the hands of the Governor-
General. It is generally understood that at least one report
is favorable to Dr. Strong.

1084

MEDICAL RECORD.

[June 29, 1907

Progrrss nf illr^tral ^rtrnrr.

New York Medical Journal, June 15, 1907.

Traumatism as an Etiological Factor in Appendicitis

— 1 his subject is considered at length by J. B. Deaver,
whose conclusions are thus summarized: (1) From per-
sonal experience and from a study of the cases found in
the literature the author does not consider that trauma
is ever the direct exciting cause of acute appendicitis in a
perfectly normal appendix. (2) He believes that an acute
attack of appendicitis can follow a severe blow upon the
abdomen or fall upon the abdomen, or be due to muscular
contractions of the ileopsoas muscle in an appendix which
has been previously inflamed only under the following con-
ditions: (o) In a latent or residual abscess or extensive
pathological lesion of the appendix, where the appendix
does not occupy a deep pelvic position, but i^ in close prox-
imity' to the anterior abdominal wall, severe direct trau-
matism may precipitate an acute attack, (b) Strong con-
tractions of the ileopsoas muscle cannot in my opinion
be the immediate cause of an acute attack of appendicitis,
where the appendix is chronically diseased or where it has
extensive pathological lesions, unless it is firmly ad-
herent to and not simply in apposition to the peritoneum
overlying this muscle. (f) The degree of traumatism
to be a factor in the causation of appendicitis must be
direct and of considerable force; such force applied to the
right iliac fossa may tear the underlying parietal peritoneum
and so simulate an acute attack of appendicitis that only
opening the abdomen and exposing the appendix could defi-
nitely settle the matter. (3) The acute attack of appendi-
citis of traumatic origin is observed more frequently in
males than in females on account of their more active life
and greater liability to injury and strains, and between the
ages of ten and twenty-five years. (4) In an appendix
previously diseased the liability to an acute attack of ap-
pendicitis supervening upon injury is in direct ratio to the
degree of injury, and depends entirely upon the pathological
changes present in the appendix at the time of injury. (5)
He maintains that it is exceedingly rare to find a case of
acute appendicitis in which it can be definitely stated that
traumatism is the direct exciting factor. This statement
is borne out by a review of 1400 cases. (6) The mortality
is very hiih in these cases, on account of (a) the failure
to recognize the condition until the disease is well ad-
vanced, (b) the rapid gangrene and perforation which
come on, and (c) the delay in operation. (7) The author
stronglv urges a more careful study of this class of cases,
and insists "as soon as a diagnosis has been made, upon an
immediate operation if the best results are to be attained.

The Bubonic Plague As Seen in Siam. — Some notes
are presented by C. S. Braddock, Jr., who was formerly
the chief medical inspector of the Siamese Government,
The disease presents no peculiarities in the locality named.
The author considers that the best work done in checking
Its ravages in the Far East has been done by the American
physicians in the Philippines. In his own attendance on
plague cases he always used plenty of coal oil on his
shoes, stockings, and leggings, as this kept the infecting
fleas away. He also noted that the coolie employees of
the oil companies did not contract the disease. The fleas
leave an infected scab as soon as the animal dies, and are
apt to settle on the pariah dogs. These are fed and petted
by children, and among the latter the disease was espe-
cially common. One of the most effective measures to
stop the disease after all disinfection and sanitation was
accomplished was to wash all floors and furniture with
crude coal oil. and sprinkle it with a watering pot in large
quantities under the houses and over the ground in the
vicinity. He never found medicine to be of any use. In
the detention camps on his daily morning and evening
rnimds he alwavs used quinine as a diagnostic agent. On
examining suspects and finding any one with fever, either
with or without pain or soreness in groin or axilla, he
was at once given twentv to thirty grains of quinine at one
dose Six hours later if the fever was less in the slightest
deo-ree it was not plague. If the fever was higher it was
pla"<^ue and the patient was at once sent to the detention
hospital. In all of his patients this proved an infallible
test.

The X-ray, Ultraviolet-ray, and High Frequency Cur-
rents in Diagnosis and Treatment.— S. Tousey gives ?.
general description of these remedial agents from both the
phvsical and therapeutic points of vie%v. He calls atten-
tion amon<T other matters to the importance of the proper
quality of'.r-rav in therapeutics. He states that the least
penetrating ravs are arrested and absorbed by the skin.
Thev produce 'a therapeutical or a pathological effect de-
pendent upon the condition of the skin and the distance,
intensity duration, and frequency of the application. These

soft rays, as they are called, are useful in treating eczema,
psoriasis, ringworm of the scalp, and some cases of lupus
and epithelioma. In some cases the tube may advanta-
geously be regulated so as to produce only soft rays. They
are the rays which produce ;r-ray burns, if the exposure
is too great. These rays, which would be absorbed by the
skin and would cause an 4--ray burn in case of over ex-
posure, may be arrested by interposing a piece of sole
leather between the .r-ray tube and the patient. Such a
sliield should always be used when making ;i--ray examina-
ti'ins and in j--ray treatment, especially about the face.
This has reference to cases in which the tube has a medium
degree of vacuum and is giving out rays of various degrees
of penetration and in which the rays which are desired are
those which will penetrate the flesh and produce a picture
or an effect upon the deep tissues. Rays of medium
penetration are beneficial in cancer, tuberculosis, leukemia,
colitis, rheumatism, neuralgia, glandular swellings, and
similar conditions. Rays of very great penetration are of
little or no use for therapeutic or radiographic purposes,
but overexposure to these will produce a dermatitis or
even a periostitis.

Journal of the American Medical Association, June 22, 1907.

Sodium Cacodylate.- — S. L. Dawes and H. C. Jackson

found that sodium cacodylate could be detected in the
urine after hypodermic injection of daily doses of from
050 to .200 gm. within periods ranging from ten to
thirty-six days or more, and that organic arsenic was
rliminated in two cases under observation in twenty-
two and forty-four days respectively. The amount elim-
inated was small, and personal idiosyncrasy seemed to
play a considerable part. The authors feel sure
that cacodylic acid is deposited in the tissues. That
such large doses are required to produce effects is
undoubtedly due to the fact that the drug is only
partially decomposed to inorganic arsenic, and the
beneficial effects are to be ascribed to a self-regula-
tion and automatic immunity which the organism ac-
quires by the constant presence and new formation of
arsenic of the inorganic type in the body. The produc-
tion of arsenious or arsenic acid in a nascent state is prob-
ably not an unimportant factor, as in this condition
smaller amounts of the ions become more active and
give better results than arsenic given as such per os. It
is not impossible, however, that cacodyl or its oxide,
which IS also produced, may have an action of its own.
and not unlike that of the inorganic arsenic compounds.
The blood picture when the drug is given is a very con-
stant one. In anemic cases there is always an increase
of hemoglobin, usually a small increase of red cells,
Ijut little variation in the number of whites; an increase
in the percentage of polymorphonuclears and large mo-
nonuclears, with a corresponding decrease in the small
mononuclears. In nonanemic cases there seems to be no
special effect on the hemoglobin or red cells, but there is
usually an increase of the polymorphonuclears. Thera-
peutic results in fortv-five cases, including eczema, pso-
riasis, anemia of different tj'pes, Hodgkin's disease,
gastralgia, and various neuroses, are reported. Thirty-
four patients were cured or very much benefited, eleven
were not helped, and two were apparently made worse.
In several of the second class the dose used w'as prob-
ably too small and the technique faulty, they being among
the first treated with the remedy. The authors' present
practice is to dissolve the drug in the syringe with hot
water just before injecting, as solutions do not seem to
keep well. The effective dose in the reported cases
seems to average between 0.05 and 0.15 gm., though very
much larger ones were emploj'ed in one case of anemia
reported.

Typhoid Perforations. — C. D. Selby remarks on the
almost uniform fatality of typhoid perforation as com-
pared with the better results obtained in the similar
surgical condition of bowel perforation in appendicitis.
Of the 400 cases of operation reported in the literature,
recovery took place in 25 per cent. .Nevertheless, it has
been statistically demonstrated that the mortality from
typhoid perforation runs from 8,000 to 16,000 annually
in the United States. The conclusion inevitably follows
that the vast majority of cases are either not diagnosed
or diagnosed so late that operation is hopeless. The
mitigating circumstances for the physician are that the
text-books are not sufficiently definite on the subject;
that the accident occurs in a disease «-ith infinite varia-
tions in its symptoms, severely testing the diagnostic
ability of the medical attendant, the blunted sensibility
of the patient rendering subjective symptoms unavail-
able and frequently also masking, to a great extent, the
early objective ones, on which a timely diagnosis de-
pends. Selby points out the various 'indications and

June 29, 1907]

MEDICAL RECORD.

1085

their value in some detail, but says that, unfortunately,
there is no one symptom, nor syndrome, indicating with
certainty the existence of perforation. The diagnosis
must be based largely on the judgment of the physician,
who has watched the case and its variations so atten-
tively that he subconsciously recognizes the changes
brought about by the perforation, and the surgeon, see-
ing the case for the first time, must be guided by the
opinion of the physician. But when the three cardinal
symptoms — suddenly appearing abdominal pain, rigidity
of the muscle wall, and tenderness on pressure — appear
in any case of typhoid fever, the assumption is war-
ranted that perforation has occurred, and operation is
not only indicated, but demanded.

The "Open Method" Treatment of Cancer.— W. D.
Witherbee advocates the treatment of cancer by first
enucleating the growth and involved glands, and then,
instead of closing the wound, leaving it open to heal by
granulation and giving daily ,r-ray treatments until the
wound has healed. He claims for this method the ad-
vantages of perfect drainage of the whole infected region
and the changing of a deep or subcutaneous cancer into
a superficial one, which gan be more directly attacked
by the rays, the value of which in superficial growths
has been demonstrated. He has had very favorable re-
sults with this method in a number of cases, four of
which are reported. The same has been the case in one
case of tuberculous ulceration of the skin.

The Lancet, June S, 1907.

The Nature of Infectivity in Relation to Tumor
Growth. — D. A. Welsh says the essence of infection is
that bacterial cells have entered the tissues and there be-
gun to multiply. As regards cancer, it may be said that
its cells become differentiated at a very early stage and
sharply marked off from all other cells of the organism.
The growth of cancer cells proceeds independently of apd
at variance with the requirements of the organism and or-
derly growth in parent tissue is replaced by the unregu-
lated and disorderly growth of the tumor. Cancer cells
grow also independently of one another, particularly at the
margin of a cancerous deposit. They are essentially para-
sites and have the attribute of infectivity. The autlior de-
clares that all growths are essentially malignant and that
the so-called benign tumors represent merely a difference
in degree and not in kind. Clinically, malignant growths
are made up of cells whose infective capacity is high,
whereas benign growths are made up of cells of low in-
fective capacity. Cancer cells are endowed with great
vitality and longevity. They appear to possess a reserve
of vital energy in excess of that retained by the natural
tissues of the body. In their growth they appear to be free
from the laws governing the growth of tissues in general.
Certain forms of nuclear division appear early in cancer
cells. Such nuclear divisions are found only in cells of
reproduction tissues preliminary to maturation (and in
leucocytes) and nuclear exchanges take place between
wandering leucocytes and developing cancer cells. Is there
any condition, asks the author, which might predispose a
group of tissue cells to assume the character of repro-
ductive cells? -As a matter of fact, there is evidence that
two conditions are commonly present — one general and
the other local — both of which may possibly influence this
transformation. The general condition is a chemical
change in the reaction of the body fluids. It has been
shown that developing cells may be induced to undergo in-
creased and abnormal nuclear divisions when the chemical
reaction of their environment is altered and when, in par-
ticular, the alkalinity of the medium is increased, and there
is evidence that the body fluids of a cancer patient com-
monly exhibit this increased alkalinity. Hence it may at
least be said that the body fluids of a cancerous subject
are commonly in a condition which independent biological
research has shown to be favorable to abnormal nuclear
transformations.

Two Cases of Infection by the Paratyphoid B. Bacil-
lus.— The cases are reported by E. A. Gates. In case
I, that of a woman of 54 years, there was a continued
fever with four relapses, venous thrombosis, acute bron-
chitis, cholecystitis, lentigines, and agglutinative reaction,
with parat.vphoid B. baiilliis. Recovery followed. Case 2,
a young woman of 21 years, the daughter of the foregoing
patient, presented catarrhal jaundice, slight fever, and the
agglutinative reaction. This patient also recovered.

Ligature of the Renal Vessels by the Transperitoneal
Method for the Cure of Persistent Urinary Fistula.—
One case is reported by M. P. Holt. His patient was a
sturdy young man who nine months previously had sus-
tained a rupture of the left kidney from a kick at football.
His very short subcostal space was filled with scar tissue

and a sinus through which pus and urine were freely dis-
charged. Concerning the technical feature of the opera-
tion, the author notes the necessity of a careful search for
accessory or abdominal renal afferent vessels. Asepsis can
be secured only by avoiding the suppurating area at all
costs ; this is effected by keeping as far from the kidney
as possible and as close to the aorta and vena cava as is
safe to apply a ligature. Access to the renal pedicle in
abdominal nephrectomy is claimed to be safer when made
through the outer layer of the mesocolon by reason of less
danger to the colic blood supply ; to follow this route, how-
ever, would almost certainly open up the septic area, and,
moreover, Uie colon may be found inseparably united to
the kidney. In his case no evil resulted from approach-
ing the renal vessels through the inner mesocolic layer, and
this notwithstanding that a search was made for possible
renal afferent vessels. The advantages claimed for this
method are that if it is properly carried out there is little
or no risk from hemorrhage, shock, or sepsis. As rcg.Ttrds
(a) hemorrhage, this method is in great contrast to any
form of piecemeal nephrectomy; (b) it is an aseptic opera-
tion which nephrectomy would certainly not be; and (c)
subcapsular or piecemeal nephrectomy is at best a very
severe operation ; ligature is not so and shock should not
occur; there is inappreciable risk as regards possible dam-
age to the colon or other surrounding organs and serous
cavities (septic infection). The author concludes by say-
ing that he would not hesitate to employ renal vessel liga-
tion as a substitute for nephrectomy where this latter
operation promised great difficulty and the likelihood of
such severe hemorrhage as would suffice to tiirn the scale
between life and death in an exhausted patient. More-
over, as a preliminary to a subsequent nephrectomy (a sep-
tic operation) an aseptic ligation of the renal vessels would
be sound surgery, though the author claims that nephrec-
tomy would then be unnecessary, as the ligature would
be followed by rapid .and permanent cure. Ligature of
the renal vessels is surely a great improvement on any
form of subcapsular piecemeal nephrectomy or raorcelle-
ment. The former is a simple and the latter a very se-
rious, procedure, and both effect the same result.

British Medical Journal. June 8, 1907.

Asthma Caused by Impacted Tooth.— A. J. Rice Oxley
reports the case of a housemaid who went to have some
teeth extracted, and took gas rather badly. Directly
after she began to have the typical symptoms of asthmaj
which were reheved by belladonna tincture and tlie iodides.
They continued, however, in varying degrees for nearly
eighteen months, when, in a paroxysm of cough, the
patient expectorated a fairly large portion of tooth, with
immediate relief and permanent cure of the asthmatic
attacks.

Treatment of Birth Asphyxia.— J. W. Malini relates
that in a recent case the child was born in a state of
white asphyxia. He tried the Sylvester and Schultze
methods of recuscitation without avail, and then mouth-
to-mouth inflation. The child was pale and limp; there
was no attempt at respiration, and apparently the heart
was not beating; but a little dark blood oozed from the
child's untied cord. The baby being wrapped in a warm
blanket, he breathed into' the mouth and inflated the
lungs, and at the same time attempted to compress the
heart externally by placing the right thumb parallel to
and below the left costal arch, with the fingers extended
over the precordia; simultaneously the left hand was
applied to the right side of the chest in order to express
the air froin the lungs. No air appeared to pass into
the stomach, but perhaps his hand prevented it. .After
a few minutes the child's skin flushed and the luitied
cord had to be secured owing to the commencement r.f
hemorrhage. Natural respiration started after about a
quarter of an hour.

Aortic Pressure in Post-Partum Hemorrhage. — In a
recent case under the care of M. Henry, he relates that
after the head had been for one hour on the perineum
without making any progress he gave chloroform, ap-
plied forceps, and delivered easily. The body - followed
shortly after. There was very little hemorrhage before
the third stage was completed, but the uterus remained
flabby and did not contract for about twenty minutes
after the second stage. He held it firmly all the time.
An enormous gush of blood came away with the
placenta, and was followed by a very copious flow. The
handy woman who was assisting, and who is accustomed
to attend labor cases among the working classes,
fainted when she saw such an amount of blood, and he
was left to his own resources, as there was no one else
in the house. He turned the patient on her back and
pressed on the abdominal aorta, which at once con-
trolled the hemorrhage. In about half an hour tlie

io86

MEDICAL RECORD.

[June 29, 1907

uterus began to contract, and in one hour it was firm
and hard He gave her two or three grains of
ergot, when the placenta, which came away entire, was
born. The puerperium was satisfactory and the patient
is now well, though somewhat anemic.

Complete Vocal Rest During the Sanatorium Treat-
ment of Laryngeal Tuberculosis. — The paper of N.
Bardswell and B. Adams is based mainly on six per-
sonal cases, the symptoms of which are preserved in
tabulated form. Patients on the silent treatment are
allowed to take their walks with other patients and to
eat at the common table. Care should be taken in choos-
ing companions for silence cases, as on the common-
sense of these companions is largely conditioned the
ability of the silence patients to maintain the observance
of the restrictions under which they are placed. The
silence treatment, carried out under the circumstances
above referred to, is much less irksome than when the
patients are isolated, for by signs and scribbling pads
the patients can, to a considerable degree, take part in
the conversation and amusements around them. In the
cases referred to, the silence treatment carried on for
a period of five months, the laryngeal disease immense-
ly improved. Four of the six patients had ulceration of
the cords in addition to their congestion. The remain-
ing two had swelling and congestion of the cords, and
of the arytenoid mucosa or interarytcnoid region. The
ulcers all cicatrized in the first group, while the swell-
ing and congestion very much diminshed or greatly
cleared up. In the fifth case normal voice was restored
after previous hoarseness, while in the sixth case the
hoarseness was greatly lessened. In all the cases the
laryngeal improvement was associated with great im-
provement in the lungs and in general health.

M:ini:hener medizinische IVochenschrift. May 28, 1907.

Phimosis as a Cause of General Disturbances. — Wit-
zenhausen says that while attention has already been di-
rected to phimosis as a possible etiological factor in the
causation of urinary disturbances and nervous symptoms
m children, it has not been recognized to a sufficient degree
that other conditions may also be referable to this ab-
normality of the prepuce. He reports a number of cases
in which constipation in infants was relieved by the opera-
tion of circumcision, and explains the beneficial eiTect of
the procedure as follows. As a result of the stenosis of
the preputial opening the act of urination is rendered dif-
ficult and ultimately the bladder is imperfectly emptied,
becomes dilated, and a more or less serious state of over-
flow incontinence results. As a consequence of this the
pelvic organs are crowded by the enlarged bladder, the
rectum is pressed upon and constipation results. In con-
sequence of this early perversion of function more or less
serious and persistent disturbances are caused which may
require a long time to subside even after the initial source
of the trouble has been relieved by circumcision.

Examinations of the Urine in Practice. — Grube says
that the habit of having urinary examinations carried out
by others than the attending physician is one that is to be
seriously deprecated. It is open to numerous objections,
among which are the facts that the patient loses confidence
in a physician who does not earn,' out the examination
himself, and then it is not always wise to have the patient
know the results of the analysis, as is the case when he is
told to take the specimen to a laboratory himself. The
author takes the stand that it is not necessary to carry out
the elaborate analyses that chemists are in the habit of sup-
plying and states that in practice the most important sub-
stances for determination are sugar, albumin, diacetic acid,
bile pigment, and indican. Of these the only one that re-
quires quantitative estimation with any great degree of
accuracy is the sugar. For this the Pavy method is ex-
cellent, but the author describes a still simpler procedure
by means of which sufficiently exact results for practice
may be obtained. For the albumin determination the rough
method of estimating the amount of precipitate resulting
from the heat and acid test is practically as satisfactory as
the more elaborate analytical methods.

Deutsche medicinische Wochenschrift, May 30, 1907.

The Technique of Symphyseotomy and Heboste-
otomy. — Sellheim, under the latter terms, designates what
is usually spoken of as hebotomy or pubiotomy. He de-
scribes the various misadventures that may assail the
operator in performing the operation, such as snapping of
the saw, uncontrollable hemorrhage, cutting through only
one ramus of the pubis, omission to cut through the liga-
ments, etc. He emphasizes the fact that the inexperienced
operator is likely to encounter many difficulties and sug-
gests that theoretical instruction, watching others operate.

and operating on the cadaver, be supplemented by opera-
tions on the living body of an animal. For this purpose
the sheep is particularly suitable, as the dimensions of
the anterior part of its pelvis and other anatomical consid-
erations render it in this regard particularly similar to the
human female. The inguinal region is not excessively
fatty and the vagina is sufficiently spacious to allow the
necessary control of the steps of the operation from this
direction. The time during which the animal lies uncon-
scious as the result of the violent blow on the head given
it by the butcher before slaughtering may be utilized for
the performance of the operation, and the condition of the
parts may be scciirately studied at the subsequent dismem-
berment of the animal.

The Use of the Murphy Button in the Large Intestine.
— Vogel says that while the Murphy button may safely be
employed in operations about the stomach and small in-
testine, its use in dealing with conditions in the large
intestine, particularly its lower part, should be avoided.
He describes two cases of resection of the splenic flexure
in which the Murphy button was used, but in which a fatal
termination was caused through the formation of a fecal
abscess about the anastomosis. In the one case the in-
testinal stumps were united end to end and in the othfer a
lateral anastomosis was done. In each instance the per-
foration was found in the same relative position, viz., just
at the point where the intestine passed over the rounded
shoulder of the proximal half of the button. The lumen
of the button was completely occluded by a plug of feces
The author considers that as a result of this obstruction
the proximal intestine becomes much distended and the
pressure of the gut against the button leads to necrosis
and perforation.

Freneh and Italian Journals.

Therapeutic Indications in Cancer of the Uterus Com-
plicating Pregnancy. — Oui considers the influence of
cancer of the uterus on the course of pregnancy and the
life of the fetus, as well as the eflfect of pregnancy on
the development of the cancer. The author considers it very
doubtful whether pregnancy does in reality cause a more
rapid development of the cancer. The mortality of the
mothers after labor is not from the presence of a rapidly
developed cancer, but from puerperal infection. The in-
fant is sacrificed in about one-quarter of the cases, but this
might in many cases be prevented by a cesarean section
done before the child had been exhausted by prolonged
labor. In inoperable cases we should not undertake any
but palliative treatment, giving to the child the chance of
delivery. In operable cases, during the first two months
it is justifiable to perform hysterectomy in small cancers
that are distinctly limited. Induction of premature labor
is useless to the mother and deleterious to the child. Cu-
rettage of fungosities with cauterization will in all prob-
ability sacrifice the child by producing interruption of the
pregnancy. If the pregnancy has reached term and the
cervix is little involved it may dilate, and delivery take
place normally. If the cervix is rigid a cesarean section
should be done early enough to save the child, and in
inoperable cases a Porro operation done at once will pro-
long the life of the mother. In operable cases an imme-
diate hysterectomy should be done, thus removing at once
the growth and the source of infection. — Annates de Gyne-
cologic et d'Obstctriquc. April. 1007.

Prolonged Retention of the Ovimi after Abortion. —
R. Garipuy states that complete or partial retention of the
ovum after abortion has been threatened forms a con-
dition that is exceedingly difficult of diagnosis. The pla-
centa alone may be retained, and hemorrhage and infection
may both be absent. The placenta not being separated, the
circulation is maintained and no changes may go on, or
there may be a gradual transformation into a malignant
growth. Again, the placenta may be eliminated in pieces
at stool without the knowledge of the patient. If the entire
ovum is retained it will be expelled intact without any
transformation. The uterus will close on the ovum as if it
were alive, there being absolutely no symptoms to guide
the diagnostician. If pregnancy has been previously diag-
nosticated, this is an aid in diagnosis, but if there has
never been any examination made previously the diagnosis
is still more obscure. There is no hemorrhage and no pain
or contractions. The cervi.x may be closed, and there may
be little modification in form of the uterus. The only re-
liable sign is the consistency of the uterus, which an ex-
perienced touch will reveal. It is neither of the peculiar
softness of pregnancy nor of the normal hardness, but of
a consistency between the two. Metritis and subinvolution
must be diflferentiated. but in them there is generally some
tenderness. It is justifiable, having excluded pregnancy, to
dilate the cervix and remove all that is found in the
uterus. — La Prcssc Medicate, April 24. 1907.

June 29, 1907]

MEDICAL RECORD.

1087

ASSOCIATION OF AMERICAN PHYSICIANS.

Ttventy-second Annual Meeting, Held in IVashington, D.C.,
May 7, 8 and g, 1907, in Conjunction With the Con-
gress of American Physicians and Surgeons.

Francis P. Kinnicutt, M.D., New York, President, in
THE Chair.

(Special Report to the Medical Recokd.)
{Concluded from page 837.)

Thursday, May 9 — Third Day. -

Pathological Anatomy of Lymphosarcoma; Its Status
with Relation to Hodgkin's Disease. — Dr. W. G. Mac-
Callum of Baltimore, Md., discussed in this paper the
status of lymphosarcoma in relation to Hodgkin's disease.
A fairly constant and characteristic histological picture had
been shown by the study of a series of cases of lymphosar-
coma. This had been described by Kundrat and others.
This histological picture, together with the mode of origin
and distribution of the new tissue, and with the examina-
tion of the blood, made it possible to arrive at a definite
diagnosis of the condition. It might be distinguished from
true sarcomata on the one hand, and from lymphatic
leukemia and the lymphosarcomatosis of Sternberg on the
other. The histological description of the lesions of
Hodgkin's disease given by Dr. Reed rendered it easy to
differentiate lymphosarcoma from that condition. Of six
cases studied at Johns Hopkins Hospital three agreed fully
with what Dr. Reed had said in his paper. He detailed
briefly the histories of these cases.

Dr. H. A. Christian of Boston thought the distinction
which Dr. MacCallum, Dr. Reed, and others had drawn
between lymphosarcoma and Hodgkin's disease was rather
sharper than could be applied clinically. Hodgkin's disease,
as described by Reed, was a perfectly definite entity, but
from the clinical point of view this distinction could not
be borne out. In 1895, at the Boston General Hospital, he
saw a number of cases which clinically were Hodgkin's
disease, but none of these had the cytological characters
described by Reed and others. There were border-line
cases and others which were closely related to the leukemia
group.

Dr. MacCallum, in closing the discussion, said that he
had hardly seen a case in which the appearance and dis-
tribution of the lesion resembled that of Hodgkin's disease
which did not, upon microscopic examination, differ ma-
terially from it, and he had no hesitation in making the
distinction. He had not seen a case in which the cytolog-
ical features were like those of Hodgkin's disease which
did not resemble it clinically. Lymphosarcoma, as he
had seen it, was always sharply differentiated.

Chylous Ascites and Chylous Pleurisy in a Case of
Lymphocytoma Involving the Thoracic Duct. — Dr.
George Dock of Ann .^rbor, Mich, read this paper, in
which he detailed briefly the history of a case, under ob-
servation only for a short time, in which there were chylous
exudates in the peritoneum and pleural cavities. There
was moderate enlargement of the superficial lymphatic
glands. A tumor mass, resembling an enlarged spleen, filled
half the abdomen, and there were other smaller abdominal
tumors. There was a relative increase of lymphocytes in
the blood. Autopsy revealed the following : Lympliocytoma
("lymphosarcoma"), causing enormous thickening of the
thoracic duct; a large mass in the abdomen of similar tis-
sue, filling the mesentery; lymphocytomatous change in
numerous abdominal and superficial glands.

Dr. W. G. MacCallum of Baltimore, Md., said this case
fell very well into the class of leukosarcoma. He cited two
cases and emphasized the importance of systematic classi-
fication of these cases.

Dr. Alfred S. Warthin of .A.nn .^rbor. Mich, had seen
four cases of lymphosarcoma which, followed out several
years, became leukemic. He took issue with Dr. MacCal-
lum in his attempt to differentiate between cases of the
large-celled type and those of the lymphoid type, citing a
list of thirty-seven cases. He had also had interesting
cases of the myeloid type.

The Histological Lesions in Experimental Glanders.
Dr. C. W. Duval of Montreal, Canada, in this paper re-
viewed the opinions held by different authors as to the
cytogenesis of glanders, and presented a series of lantern-
slide sections from the pathological and bacteriological
laboratories of McGill University showing the various le-
sions produced by the glanders bacillus. He called atten-
tion to the analog>- between the proliferative changes pro-
duced by the glanders bacillus and miliary tubercle.

Dr. W. G. MacCallum of Baltimore, Md., cited a case
which died of pneumonia in which the cytological study
showed the glanders bacillus, and showed that the lesions
in the lungs were those of bronchopneumonia.

Multiple Myeloma; the Histological Comparison ot
Six Cases. — Dr. Henry A. Christian of Boston pre-
sented this paper, illustrating it with lantern slides. He
said the cells in myelomata are premyelocytes, myelocytes,
lymphocytes, plasma cells, or erythroblasts according to
the interpretation of the individual observer. Almost all
agreed that myelomata form a distinct class of tumor
and have their origin from the bone marrow. These dif-
ferences of opinion as to the nature of the tumor cells
must have arisen either from the fact that a variety of
tumors are included under the term myeloma, or from
the fact that different observers have assigned different
origins to cells possessing similar histological characteris-
tics. The latter explanation seemed preferable. Few ob-
servers had studied as many as two cases. He had com-
pared six cases, finding that they possessed many char-
acteristics in common, and that there were minor indi-
vidual differences, which, however, were no greater than
occur in individual examples of other tumor groups. The
tumor originated from cells of the bone marrow. In
normal bone marrow a few cells occurred which bore
close resemblance to the cells of these six myelomata, and
could be regarded as the ancestral cell from which the
tumor cells originated. It did not seem possible to ex-
actly determine the nature of this cell type. It bore a
strong resemblance to a plasma cell, but presented certain
differences. The latter were prominent in some of the
tumors. There was no evidence of an erythroblastic ori-
gin.

Typhoid Endaortitis. — Dr. Alfred S. W.\rthin of
.\nn Arbor, Mich., in this paper, detailed two cases which
he had carefully studied. The gross lesion was what is
usually called fatty degeneration, and in each case these
areas corresponded to the axis of the vessel. The changes
in the aorta showed the various stages of arteriosclerosis.
In many of the areas it was possible to demonstrate bacilli
corresponding to typhoid bacilli. A number of lantern
slides were shown, and in only a few of the sections
did the lesion extend through the intima and involve the
media.

The Antagonistic Action of Alcohol and Carbolic
Acid. — Dr. .\lonzo Englehart Taylor of Berkeley,
Cal., said, in this communication, that the statement com-
monly made, to the effect that alcohol exerts an antago-
nistic action upon carbolic acid, might be tested directly
by the following procedure ; The antiseptic action of car-
bolic acid is employed as the medium of measurement.
A yeast, known to be tolerant to alcohol up to a con-
centration of nearly fifteen per cent., serves as the object
of the experiment. By the froth of this yeast upon a
standard solution of sugar, with relative and varying
quantities of carbolic acid and alcohol, the measurement

io88

MEDICAL RECORD.

[June 29, 1907

of the carbonic acid evolved in the fermentation will be
the index of the activity of the yeast and, conversely,
of the action of the carbolic acid upon the yeast, and of
the effect of the alcohol upon the antiseptic influence of
the carbolic acid. The experiment indicated that alcohol
has no direct antagonistic action to carbolic acid; it does
not lessen the antiseptic action of carbolic acid.

Dr. T. SoLLMON of Cleveland, Ohio, said that alcohol
favored absorption, its action being not physical, but
physiological, and that carbolic acid was slightly more
toxic in the presence of alcohol.

Demonstration of Large Phagocytic Cells from the
Circulating Blood. — Dr. H. A. Christi.\n, for Dr. F.
V.^x Xuvs of Boston, Mass., presented pictures of these
cells. The patient from whom the blood was taken was
a Russian Jew, who was suffering from aortic insufficiency,
bronchitis, and a tumor. It was not known whether the
cells originated from the tumor or from some leukemic
condition. The cells were interesting in that they varied
from ten thousand to ninety-eight thousand in twenty-four
hours.

Dr. RicH.\RD C. Cabot of Boston, Mass., cited another
case which Dr. Van Nuys will report later. This pa-
tient was a Russian Jew, suffering from aortic regurgita-
tion, but with no evidence of tumor. The variation in the
blood count was the result of technique. The high cotmts
were from the ear, not from the finger or toe, being eighty
thousand from the ear and ten thousand from the finger.
Just why there should be such an enormous difference be-
tween the ear and any other part of the body was not
known. The ear itself was perfectly normal.

Unclassifiable Fevers. — Dr. James Tyson of Philadel-
phia, Pa., presented short reports of a few typical cases,
illustrating the difficulty in classification which grow-s out
of the occurrence of certain cases of fever which do not
meet the requirements of a diagnosis for typhoid fever,
influenza, malarial fever, or other fever due to discoverable
irritative causes.

A Contribution to the Study of Long Continued
Fevers. — Dr. Herbert C. Moffitt of San Francisco, Cal.,
detailed in this paper the history of a woman, forty-seven
years of age, in whom recurrent fever had been the chief
symptom over a period of ten months. The attacks at
first were of a few days' duration, separated by an interval
of ten to fourteen days of apparent perfect health. Sub-
sequently the periods of fever lasted for twenty-two days,
with an interval of seven days, and finally fever of remit-
tent-intermittent type lasted for twenty-seven days. There
were occasional chills and frequent sweats. A history of
lues thirteen years before was obtained, of cough every
winter for ten years, of an appendix operation eight years
before, of several attacks of abdominal pain in the last two
years, suggesting cholelithiasis. The patient had traveled
extensively during the past three years. During the first
attacks there w-as aching in the muscles and bones, but
later no symptoms were manifest other than fever and
weakness. The temperature was chiefly remittent, occa-
sionally intermittent, 103° or 104° in the afternoon hours.
There was evidence of an old process, slight, at both apices.
Extreme myosis was evident, the pupils were irregular, re-
action to light very slow. No other signs of lues. The
heart was markedly dilated, and a systolic murmur was
heard over the precordia. No glands palpable; spleen
never palpated. Abdomen distended ; no tenderness. No
pigmentation. There was a peculiar enlargement of the
liver upward ; the edge not felt. Dullness at fourth rib,
and at angle of scapula behind. Moderate secondary
anemia; leukopenia 2,600 to 5. 500; large mononuclears 9
to 18 per cent. ; blood culture negative. Mercury, iodide,
and later arsenic, were employed in the treatment. .'Au-
topsy revealed the following: Lymphosarcoma of one re-
troperitoneal gland near the right kidney, multiple nodules
in the liver.

Dr. Richard C. Cabot of Boston, Mass., said he had
recently gone over the records of the Massachusetts Gen-
eral Hospital with reference to long continued fevers,
and had found that over ninety per cent, of fevers
of over two weeks' duration fell under one of three heads,
viz., typhoid, sepsis, and tuberculosis in one form or an-
other.

Dr. Alfred Stengel of Philadelphia, Pa., cited the case
of a young man who had had typhoid fever of several
months' almost continuous duration, with slight fluctua-
tions. He had lost fifty or sixty pounds. Previously he
had been in perfect health apparently, with no indication
for the development of the disease so far as was known.
He had emaciated sufficiently for Dr. Stengel to follow
up a mass in the abdomen which he thought to be a tumor
at the head of the pancreas. The abdomen was opened
and a mass of retroperitoneal glands the size of the fist
were found. A small nodule was taken, the rest of the
mass left, and the abdomen closed. The patient improved,
ani was seen again two weeks before, having gained
si.xty pounds in weight. This tumor was slightly palpable
at that time. This was a case of retroperitoneal tuber-
culosis. Dr. Stengel cited a number of other cases.

Dr. S. Weir Mitchell of Philadelphia, Pa., asked if
there were not individuals in whom the temperature
normally was higher than what is usually attributed as
normal to man. He cited a number of cases ir which the
temperature normal to the individual was higher or lower
than the generally accepted normal.

Dr. George Dock of .\nn Arbor, Mich, cited a case of a
n-.an operated upon for gallstones. The gall-bladder was
found to be perfectly normal, but over the surface of the
liver were found tumors, thought to be secondary car-
cinomatous masses. One of the masses was removed and
the wound closed. The diagnosis of tuberculosis was made
by a pathologist. The man subsequently consulted Dr.
Dock, who asked to see the pathological specimens. There
was absolutely no obtainable history of syphilis, but upon
examination of the specimens Dr. Dock found not tuber-
culosis and not cancer, but a large gumma. He subse-
quently obtained from the family physician a history of
syphilis eleven years before, when he had treated the
patient for a primary sore. Antisyphilitic treatment
brought about complete recovery. The case emphasized
the importance of old syphilitic lesions, which should be
thought of in connection with these cases of long con-
tinued fever. He called attention to the still continued
use of quinine in long continued recurring fever, which
he deprecated.

Dr. \V. S. Thayer of Baltimore, Md., cited two cases
of recurrent fever diagnosed as typhoid which subse-
quently proved to be carcinoma of the liver.

Dr. Reginald H. Fitz of Boston, Mass., cited the case
of a man, under observation for the last two months, who
had recurring attacks of fever. Examination revealed an
enormous enlargement of the spleen, moderate abdominal
distention, and somewhat symmetrical enlargement of the
liver. There was a deficiency in hemoglobin. He had
been treated with large doses of quinine and arsenic. Dur-
ing the greater part of the time he had show-n no diminu-
tion of nutrition, and for the past six months had been
at work. The temperature was high and irregular. The
diagnosis of splenic pseudoleukemia was suggested.

Dr. Joseph Sailer of Philadelphia, Pa., cited a case in
which a woman, thirty years of age, had had chronic re-
lapsing fever for over a year. The causal factor in this
instance was a dermoid C3"st. The patient made a com-
plete recovery.

Further Studies on the Spirilla of Relapsing Fever.—
Dr. F. G. NovY of .-Kun .-^rbor, Mich., presented this paper.
Since the preparation of the paper at the last meeting of
this association, showing the existence of two and pos-
sibly three distinct relapsing fevers, several foreign work-

June 29, 1907]

MEDICAL RECORD.

1089

ers had confirmed the specific differences between the
Spirillum Obermeier and the Spirillum Duttoni. The
eastern relapsing fever, as met with in Russia and India,
was probably equally distinct. The cultivation in vitro
had not been accomplished, but it was now possible to
grow both of these organisms in collodion sacs in the,
peritoneal cavity of certain animals. Some immunity ex-
periments and further facts relating to the nature of
the spirochetes were detailed.

The Measurement of Functional Heart Power. — Dr.
Richard C. Cabot of Boston, Mass., presented in this
paper the results of his attempts to measure the func-
tional heart power by the methods of Graupner, Herz, and
Levy. Direct examination of the heart, that is, by auscul-
tation and percussion, even when supplemented by radios-
copy, the study of the pulse and blood pressure move-
ments, revealed but little as to the amount of power pos-
sessed by the heart. The evidence of peripheral conges-
tion (lungs, liver, kidneys, stomach, extremities) came
relatively late, after the damage which it was desired to
prevent had already occurred. The strength of the heart
muscle and of the whole circulatory apparatus should be
measured early in the course of both functional and or-
ganic diseases.

The paper was discussed by Dr. W. S. Thayer of Bal-
timore, Dr. Charles G. Stockton of Buflfalo, N. Y. ; Dr.
Henry Sew-ell of Ann Arbor, Mich, and Dr. Cabot clos-
ing the discussion.

Observations Upon Certain Reflexes, Lowering
Blood Pressure, which Arise from Stimulation of the
Inflamed Pleura. — Dr. Joseph A. Capps and Dr. DeaN'
D. Lewis of Chicago detailed in this paper, which was
read by Dr. Capps, the results of their experiments along
the line indicated by the title of the paper. In healthy
dogs it was found that irritation of the pleura by mechani-
cal, chemical, thermal, and electrical stimuli caused very
little change in blood pressure. In dogs with artificially
produced pleurisy, stimulation of the pleura sometimes
gave rise to a marked or even fatal fall in blood pressure.
Analogous conditions were seen in man during operation
upon the thorax.

Clinical and Pathological Studies of Arteriosclerosis.
Dr. W. S. Thayer and Dr. Marshall Fabyan of Balti-
more, Md., presented in this communication, read by Dr.
Thayer, a study, clinical and pathological, of the radial
arteries in forty cases. The distribution of the arterio-
sclerotic changes in the various cases was given in detail.

Cerebral Types of Arteriosclerosis. — Dr. Alfred
Stengel of Philadelphia, Pa., read this paper, in which
he discussed the subject under the following heads: (i)
Convulsive attacks, local or general, due to cerebral ar-
teriosclerosis with or without thrombosis. (2) Stupor
and coma. (3) Psychic manifestations. (4) Differential
diagnosis from brain disorders, toxic conditions, and vari-
ous neuroses. He emphasized the fact that the diagnosis
of uremia is exceedingly difficult, and that undoubtedly
many cases of supposed uremia, particularly those treated
in large hospitals, are not uremia at all, or if uremia the
uremia is a terminal condition rather than the principal
condition. He believed it to be not uncommon that per-
sons dying slowly from any cause may become uremic at
the end. This would apply to persons with arteriosclerosis.
Just before death uremia might develop, in proportion,
of course, as the kidneys had been affected by the pre-
ceding disease. The same might be said of gastrointes-
tinal troubles.

Further Studies on Experimental Arteriosclerosis. —
Dr. I. Adler and Dr. O. Hensel presented in this paper,
which was read by Dr. Adler, the results of further ex-
periments with nicotine, alone and in combination with
other substances. The total material employed in these
experiments consisted of ninety rabbits, which were treated
with nicotine in various combinations; of these there were
only twelve which showed macroscopic lesions.

Dr. Hen-ry Sewall of Ann Arbor, Mich., in discussing
the three papers on arteriosclerosis, asked what part of
the arterial system was involved specifically, if tliere was a
specific local involvement in producing the functional
changes which depend upon arterial elasticity and its loss
— in other words, what is arteriosclerosis?

Dr. A. Jacobi of New York City said just what it meant
could not be decided in every case. Arteriosclerosis
might be in the brain, it might be renal ; it would never
be a uniform process. He called attention to one symp-
tom of senility which he had long noted, and which
was perhaps less intellectual than moral, viz., a sudden
change of temperament. In a person of advanced age a
sudden, marked change of temperament was certainly in-
dicative of arteriosclerosis of the brain, and meant ap-
proaching death.

The three papers were further discussed by Dr. Joseph
We.«iVer and Dr. Joseph Sailer, and the discussion closed
by the readers thereof.

Motor Insufficiency Due to Perigastric and Duodenal
Adhesions. — Dr. Frank Billings of Chicago presented
this contribution. Among the causes of perigastric and
duodenal adhesions might be mentioned infection of the
stomach, duodenum, or some neighboring organ or organs,
most frequently the gall-bladder ; chronic ulcer of the
stomach ; surgical procedure, etc. Of these the most im-
portant might be said to be the gall-bladder, second, sur-
gical procedure, third, ulcer of the stomach. He outlined
the methods of detecting disturbed motility resulting from
these conditions, and suggested that the indications for
treatment pointed to processes underlying the condition.

Dr. J. H. Musser of Philadelphia, Pa., cited three cases
of pyloric and duodenal obstruction, with vomiting, oc-
curring in early convalescence from typhoid fever.

Gastric Disturbances Associated with the Presence
of an Excess of Acid. — Dr. Joseph Sailer of Philadel-
phia, Pa., in this paper outlined the methods of deter-
mining approximately the total quantity of hydrochloric
acid secreted by the stomach, and the distinction be-
tween actual and relative excess. He also spoke of the
irritability of the secretory apparatus of the stomach; ex-
cessive secretion, associated with hypermotility, approxi-
mately normal motility, and retention; and the apparent
excess of hydrochloric acid, found in cases of retention
of the stomach contents.

On the Lenhartz Treatment of Gastric Ulcer and
Hyperchlorhydria.— Dr. S. W. Lambert of New York
City gave in this paper some of the practical objections to
the older methods of treatment, and the principles upon
which the Lenhartz treatment is founded. He detailed
briefly the method of Lenhartz, discussing some of the
special points of interest in cases reported, and the con-
clusions to be drawn therefrom, the claims advanced by
Lenhartz in favor of his method and the relation of the
method to surgical treatment.

The Effect on Blood Pressure of Nauheim Baths
in Various Types of Heart Disease. — Dr. Philip King
Brown of San Francisco, Cal., presented statistical results
showing that, contrary to the accepted view at Bad Nau-
heim, blood pressure is raised by the baths, except in
cases of very advanced myocarditis, arteriosclerosis, and
the arteriosclerotic renal conditions. The conditions under
which the blood pressure may be increased or lowered by
tlie treatment were detailed.

MEDICAL SOCIETY OF THE COUNTY OF NEW
YORK.

Stated Meeting, Held April 22, 1907.

The President, Dr. Walter Lester Carr, in the Chair.

Cardiac Hydrothorax. Report of a Case Aspirated
311 Times. — Dr. \V. Travis Gibb reported this case, which
was interesting on account of the large number of times
the man's chest was aspirated and the enormous quantity

1090

MEDICAL RECORD.

[June 29, 1907

of serum withdrawn in a comparatively short space of
time. The patient was a physician, forty-six years old,
not in active practice, and who had always led a fairly
active, more or less outdoor life, and, while not in robust
health, had never had any serious illness. At the age of
twenty he discovered that his urine contained a small per-
centage of albumin. At twenty-five years of age he con-
tracted syphilis. His family history was excellent. When
Dr. Gibb first examined him in 1903 he found the heart
greatly hypertrophied with obstructive murmurs at both
mitral and aortic valves. There was no fluid in the chest
or abdomen at that time. The urine contained .5 per cent
of albumin and a few hyaline casts. During the summer
of 1903 and 1904 he sailed a small yacht, and on several
occasions, especially in 1904, he was in considerable danger
and compelled to overexert himself. Shortly after a par-
ticularly severe exertion, when his boat went ashore in a
storm, dyspnea on the slightest exertion began to develop,
his feet and legs became edematous, and he found a small
amount of fluid in both pleural cavities. His condition
became rapidly worse, the fluid in his chest increased,
ascites appeared, and the edema reached his buttocks. He
aspirated the chest for the first time October 15, 1904, and
from that time until he died on May 19, 1906 (580 days),
he aspirated his chest 311 times, averaging one aspiration
every 1.9 days for the entire nineteen months. The total
amount of fluid withdrawn was 10,690 ounces, or about 83
gallons, weighing nearly 700 pounds. The amount of fluid
withdrawn at each aspiration varied from 12 to no ounces,
averaging 34 ounces. There was an average daily loss
through this channel of about igV^ ounces. As he aver-
aged less than 16 ounces of urine each day, he passed more
fluid through the aspirating needle than through his kid-
neys. The patient's average weight throughout his illness
was about 140 pounds, and as he withdrew about 700
pounds of fluid from his chest in nineteen months, there
was a loss through this channel of an amount equal to his
body weight every 118 days. Of the last 200 tappings, 103
were on the left and 97 on the right side. The 103 left
side tappings yielded about 3,100 ounces, an average of 30
ounces, and the 97 right side tapping yielded about 2,700
ounces, an average of almost 28 ounces for each tapping.
These frequent operations were of necessity a great tax
upon his time, but he found that by simplifying and sys-
tematizing the procedure he could sterilize the instruments,
his hands, and the site of puncture, and complete the tap-
ping in about twenty-five minutes, at the same time doing
the operation aseptically. ."Mthough the chest wall was
punctured more than 400 times there never was the slight-
est evidence of infection. So far as he could ascertain
from the medical literature at his disposal, this record of
311 aspirations of the pleural cavities, with the withdrawal
of 10,690 ounces of serum in nineteen months, was one
which had never been surpassed.

Heart Disease Complicating the Infectious Diseases
of Infancy and Childhood. — Dr. Henry Koplik read
this paper. He said that it should be recognized at the
outset that in infancy and childhood the peculiar conditions,
anatomical and dynamic, made the heart a favorite object
of attack in any infectious conditions. That organ was
working under a constant physiological strain ; its larger
size, as compared to the body weight, seemed one of th«
provisions of nature to meet the great excess of energy put
forth with every bodily movement at this period of life.
The greater activity of this organ in a normal state was
still greater in conditions of disease. The very anatomical
and dynamic conditions peculiar to the heart in infants and
childhood made a diagnosis of lesions much more difficult
than at a later period of life, especially in young infants
the differentiation of certain rare murmurs as to their con-
genital or acquired origin. The myocardium was peculiarly
open to attack in the acute infectious diseases, and in a
much more dangerous manner than either the peri- or
endocardium. In preparing his paper Dr. Koplik studied

a group of 100 cases of cardiac disease, valvular in char-
acter, occurring in his hospital service. Sixty-two per cent,
of the cases were rheumatic; with these rheumatic cases
there was concomitant chorea in four. Thus the exanthe-
mata could not be considered as a potent factor in the
causation of valvulitis in children. In passing through the
latest report of the scarlet fever hospital, the absence of
valvular cardiac affection in some 300 cases was striking.
On the other hand, affections of the heart muscle in con-
ditions of profound sepsis was frequent Even in mild or
moderately severe cases of the exanthemata, it was quite
common to obtain murmurs over the pulmonic and at the
apex, which subsequently disappeared, and which might
partly have been due to a relative insufficiency, as well as
hemic in origin. These murmurs were also frequent in
other infectious diseases, such as typhoid fever. In the
severe states of toxemia, as in a complicating peritonitis
of typhoid fever, the myocardial infection was quite
marked. Valvulitis or pericarditis were , uncommon in
typhoid fever as they were in the exanthemata. The grip-
pal or catarrhal infections of the tonsils and nasopharynx
were often the starting point of the severer affections of
the heart. Of the 100 cases of cardiac disease a distinct
history of a tonsillitis preceding the invasion of the joint
and endocardial disease was found in 13; in many others
there was a history in the past of repeated attacks of
tonsillitis. Among the infectious diseases pne;jmonia had
attracted most unexpected attention as a causative agent
in endocardial affections. Cases of endocarditis occurring
in the course of pneumonia had been published and had
been said to originate in a pneumococcus, or a strepto- or
staphylococcus infection, originating from the brachial
nodes. It was quite common in children to find, after a
pneumonia had run its course, an aft'ection of the myo-
cardium manifested in cardiac weakness. The innervation
of the myocardium was affected, and cases of so-called
infectious or toxic bradycardia were not infrequent. He
had never seen attacks of syncope or tachycardia or cardiac
paralysis similar to what was so much feared in diphtheria.
Many cases in infants failed to rally at the lysis or crisis
because the heart muscle had become overwhelmed with
the poison of the disease, and failed the patient at the most
needed period. Of all the diseases pneumonia placed the
greatest tax upon the heart. A pneumonic endocarditis
was infrequent in children. That the malignant forms of
endocarditis, with all the septic and pyemic symptoms de-
scribed by Litten in the adult, did occur in children, he
showed by citing a case. It followed and complicated an
unresolved pneumonia. In closing, he said that it was
striking that in the exanthemata the fevers, such as typhoid
fever, the endocardium, and thus the valvular apparatus,
should escape injury, whereas the mj'ocardium bore most
of the burden of the toxemic infections. The explanation
of this was that, with the exception of scarlet fever, bac-
teriemia was uncommon in these diseases, and the endo-
and pericardium was not as susceptible to infections as in
other conditions, such as grippe and pneumonia.

The Heart in Infectious Diseases; Adult Life.— Dr.
C. H. B. C.\m.\c presented this communication. He said
that Dr. Koplik, in treating this subject in its relation to
childhood, with his extensive clinical experience, had given
them much information applicable to the adult life, as well
as that of childhood. In the brief time in which it was
possible to speak. Dr. Camac said it w-ould be practical to
treat of but one aspect of this broad subject. The child,
having passed through a cardiac complication in an infec-
tious disease under the care of a pediatrician, came to the
internist in adult or early adult life. The questions which
were of paramount importance were the mechanism of
compensation and the integritj- of those structures by which
this was accomplished. Compensation was, therefore, the
part of the subject Dr. Camac selected for consideration.

The Vascular System as a Factor in Compensa-
tion.— In analyzing 799 autopsy records at the New

June 29, 1907]

MEDICAL RECORD.

1091

York Foundling Asylum (the opportunity having been
afforded by the courtesy of Drs. Bishop, Bovaird, and
Mathias Nicoll), the writer found not a single case of
vascular disease in children under ten years of age. In
childhood the healthy vascular system, together with a
greater reserve force in the heart muscle, was a great fac-
tor in aiding compensation. The vascular and cardiac sys-
tems should be considered as one. In adult life the condi-
tion of the vascular system in the question of compensa-
tion should be our first consideration.

Part of the Heart Involved; Power of Compen-
sation Varied According to Part Involved. — While the
vascular system and heart should be considered as .one,
the pericardium, myocardium, and endocardium should be
considered separately owing to the great diversity of com-
pensating power, as one or the other of these was the seat
of disease. Dr. Camac here reviewed the anatomical ar-
rangement of these structures, showing the relation of the
diaphragm and pleura with the pericardium, and therefore
tlie greater tendency of the latter to become infected in
pleurisy and pneumonia. The endocardium, including the
valves, being continuous with the intima of the blood-
vessels, was more exposed to bacterial infection circulating
in the blood. He showed preparations of the sheep's heart,
demonstrating the complete separation between auricles
and ventricles, except for the bundle of His, and the con-
tinuous "S"-shaped arrangement of the ventricular mus-
cles. This unity of the right and left side of the heart
was a very important feature of the myocardium, which
if involved proved the most incapable of compensation.

Diseases Which Show a Selective Power Over
These Portions of the Heart. — Dr. Camac here gave
a clinical subdivision of the infectious diseases in accord-
ance with their present knowdedge of their etiology. These
were grouped under the three following main headings :

(i) Rheumatic group; (2) septic group; (3) infectious
diseases not included in (i) and (2), keeping in mind that
(a) power of compensation differed according to the part
of heart involved, and that (b) diseases showed tendency
to select various parts of heart. Clinical experience gave
the following:

Pericardium — Rheumatic group. Pneumonia — relative to
extent of lung involved, and whether right or left lobes.
Scarlet fever. »

Endocardium — Including valves, benign, malignant.
Common — Septic group, scarlet fever, rheumatic group.
Uncommon — Diphtheria, typhoid, tuberculosis. Rare —
Smallpox, measles, chickenpox.

Myocardium — Typhoid, diphtheria, tuberculosis, scarlet
fever.

It was this last group which compensated least thor-
oughly. In the pericardial and endocardial group, com-
pensation was usually good and of long standing. Fatal
cases in these latter, as a rule, were due to the severity of
the infection, and not to heart failure. Dr. Camac then
illustrated on the blackboard the histological changes
which took place in the myocardium.. These in the fatal
cases were usually diffuse, in those which reach adult life
they were focal and militated against compensation, being
often the direct cause of fatal heart failure.

The Rate, Rhythm, and Intensity as Index of
Compensatory Power. — These were considered and
Professor Wenckeback's admirable work on "Arhythmia"'
referred to.

Relation of Right Heart to Left in Compensation.
— The work of McCallum at Johns Hopkins and Haven
Emerson at the College of Physicians and Surgeons, New
York, was referred to as experimental evidence that the
right heart promptly aided the left in establishing equi-
librium. Dr. Camac reported six cases followed by him
during the past winter, in which this "safety valve action"
of the tricuspid valve was directly concerned in maintain-
ing the compensation. Five of these were walking about
during this right heart involvement, without detriment.

He gave the signs by which tricuspid regurgitation could
early be detected. From the anatomical facts demon-
strated earlier in this communication, together with the
experimental evidence just given, it was clear that we
should no longer regard the right and the left heart as
separate, but as essentially one structure.

The following summary was then given : In weighing
the ability and means of the heart to compensate, (i)
heart and vascular system should be considered as one ;
(2) the pericardium, the endocardium, and the myocardium
should be considered as separate structures ; (3) the se-
lective power of the infectious diseases for these structures,
especially those attacking the myocardium, should be re-
membered; (4) the unity of the right and left heart should
be recognized and the "safety-valve action" of the tricuspid
early detected, and nature cooperated with in this effort
to establish compensation.

The Treatment of Cardiac Conditions of the Acute
Infectious Diseases. — Dr. D.^vid Bov.mrd, Jr., read this
paper. He confined his remarks to a consideration of the
conditions resulting from changes in the cardiac walls, the
condition which they grouped under the heading of myo-
carditis, including the degenerative or inflammatory
changes in the cardiac muscle and in the interstitial tissue
of the heart walls. It seemed best to limit himself to the
more common diseases, such as measles, scarlet fever, diph-
theria, pneumonia, typhoid, and septicemia. The discussion
of the subject was taken up under the following heads:
(i) Circulatory failure at the height of the acute infectious
diseases; (2) cardiac dilatation (acute); (3) bradycardia
irregular or intermittent heart action; (4) asystole.

Circulatory Failure at the Height of Infectious
Diseases. — Certain observers had studied the effects of
infections with pneumococci, diphtheria bacilli, and the
Bacillus pyocyaneus in various animals. Of these only the
diphtheria bacillus produced definite changes in the myo-
cardium, and their careful experiments demonstrated fully
that the circulatory failures seen in fatal cases of such in-
fections was the result, not of cardiac failure properly
speaking, but of a vasomotor paralysis produced by the
effect of the toxins on the vasomotor center in the
medulla. The vasomotor paralysis affected especially the
vessels of the splanchnic area ; the animal, as it were, bled
into his own veins, thus depriving the vital parts of an
adequate blood supply. The heart failed because of a lack
of blood to act upon. To strengthen cardiac action, there-
fore, one must restore the tone of the vessels, particularly
the splanchnics. According to experimental investigations,
the remedies most efficient were caffein, camphor, infusion
of normal salt solution, and abdominal massage. .Although
neither caffein nor camphor was readily soluble, both
could be given hypodermatically, as was usually required,
camphor in the form of a 10 per cent, solution in olive oil,
and caffein as a sodiosalicylate made according to Tanret's
formula. Dr. Bovaird's own experience with these two
remedies had not led him to put great confidence in them.
Especially in children were they likely to fail. Theoreti-
cally, adrenalin chloride met the indications better than
any of the drugs named but its action was very transient
and uncertain. H. C. Wood said that he had seen patients
who he thought were being killed by trusting to the
powers of adrenalin as a circulatory stimulant. Dr. Bovaird
had never seen the beneficial effects claimed for adrenalin.
The remote dangers, however, of producing atheromatous
changes in the arteries should not prevent its use in the
crisis of infectious diseases if it had real benefit. All were
convinced of the value of normal saline solutions to help
the failing circulation but there was good reason for cau-
tion in its use in pneumonia else they only added to the
burden of an overta.xed right heart. Despite the apparent
failure in experimental work the best clinicians still relied
upon alcohol, strychnine, and digitalis to meet this circula-
tory failure of the acute infections. With the value of
abdominal massage to improve the tone of the splanchnic

iog2

MEDICAL RECORD.

[June 29, 1907

vessels he said he had had no experience. As a substitute
for this Forchheimer advised the appHcation of two or
three icebags to the abdomen to act upon the abdominal
reflexes, increase the blood pressure, and reduce the fre-
quency of systole.

Acute Dilatation of the Heart. — This, resulting from
myocardial changes directly, might occur at the height of
any of the acute infectious diseases, but it was more fre-
quently seen during the period of convalescence. In most
cases it might be avoided by proper care of the patient
after the subsidence of the fever, such cases requiring rest
in bed until the pulse had been normal for some days. The
danger of acute dilatation was greatest from diphtheria.
It might come on independently of exertion of any kind.
It might occur suddenly with intense symptoms of cardiac
failure, increased rapiditv' of the pulse, but with no marked
systemic disturbance. The treatment of this emergency
demanded the most rapid and vigorous stimulation of the
heart. For this purpose they employed first camphor and
ether, and whiskey, given hypodermatically, then strj'ch-
nine and digitalis. Caffein might also be given, or strong
black coffee. Once the crisis of the onset had passed they
relied upon the systematic use of strychnine and digitalis.
On account of the liabilit>' to vomiting in these cases, it
was desirable to avoid the administration of any medicine
by mouth for some days. As a substitute for the tincture
of digitalis, they had used with satisfaction a soluble prep-
aration of digitoxin. The general care of these
patients was of the utmost importance. If there
was restlessness or pain, morphine or opium was of great
help, especially in children. This aided the laboring heart.
The convalescence of these patients often presented diffi-
cult problems. Often a point was reached where progress
ceased. The safest plan was to keep these patients quiet
until tlie heart and pulse returned to normal, and then to
gradually allow the patient to get up and about. So long
as there were signs of cardiac weakness there was a risk
in allowing any liberty, especially in children. After get-
ting up they should be cautioned against unusual e.xer-
tions.

Irregular or Intermittent Heart Action and Brady-
cardia.— In certain cases of acute infectious disease the
heart action was modified in force and rhythm without in-
crease in the size of the heart, or increase in the pulse rate.
In some instances there was a notable slowing, with or
without irregularity, the pulse dropping to 50, 40, or even
30 beats per minute. This was most commonly seen during
convalescence, and perhaps most frequently met with in
diphtheria. The gravity of this disturbance varied greatly.
Occurring during the height of diphtheria or pneumonia
they excited the greatest alarm. In the convalescence from
pneumonia or typhoid fever, bradycardia was quite harm-
less. In diphtheria, however, any disturbance of the pulse
must always be viewed with concern, and every effort made
to prevent possible serious cardiac failure. These patients
should be managed as carefully as those in which acute
dilatation had already occurred, and their convalescence
should be watched with the same care. Medication was of
secondary importance. If there was faintness or prostra-
tion associated with any irregularity, give alcohol, caffein,
or strychnine. Digitalis or strophanthus w'ere not of ser-
vice in these conditions.

Asystole. — The sudden stopping of the heart was a
rare climax of the myocardial changes in the acute infec-
tious diseases. It might occur in any of them, but was
fortunately infrequent except in diphtheria or pneumonia.
The possibility of its occurrence was the final argument of
a careful observation of the heart in all cases of acute
infectious diseases, and for care in the transition from
rest in bed to active effort The responsibility rested with
the patients after they had been warned. Once disaster
came there was no opportunity to retrieve it. death being
instantaneous.

Dr. A. J.\coEi said there was no such thing as a hemic

murmur in the very young. He had heard a few murmurs
in small babies which he had reason to believe were not
organic because, a few years after, they had disappeared
without any change in the heart muscle. But they were
very rare. When one found a murmur in a baby of one
or two years it should not be considered functional, but an
organic murmur, or valvular murmur. Later in life, when
dealing with murmurs, they knew they might be endocar-
dial in typt. What had been said regarding the heart
changes in infectious diseases he agreed with, and diph-
theria was the worst of all ; in this disease it was a com-
mon thing to find a myocardial murmur which might last
a long time. When it lasted one year the case might be
considered as hopeless, for the patient was liable to die of
pneumonia or some intercurrent disease. In diagnosing a
myocardial from an endocardial murmur an important
point was that endocardial murmurs were found posteriorly,
but not myocardial murmurs. So far as the myocardial
changes were concerned, there was a hyaline degeneration,
but no fragmentation ; the latter was only found in the
dead. There were myocardial changes which resulted in
embolic deposits in the heart muscle, the changes in the
heart being mostly found in those who had the right to
atheromatous degeneration. Adrenalin had but little if any
effect when given internally. Since he began teaching in
the 6o's he employed camphor; it was his standby, and he,
always carried it in his emergency satchel in solution, one
part camphor to four parts sweet almond oil. Camphor
might be used in emulsion.

Dr. Beverley Robinson said that in many instances of
pneumonia, influenza, diphtheria, acute articular rheuma-
tism, etc., unquestionably at times one could learn by
physical examination that there was a certain amount of
dilatation of the heart. Sometimes it seemed as if it was
limited to the left ventricle. Again it seemed as if the
right heart was particularly attacked as in pneumonia.
These cases were handled differently. There was one
agent he relied upon a great deal, strophanthus. If there
was a considerable rise of temperature, the icebag applied
locally was of value; but, if there was much depression, the
hot water bag. He also relied upon the best alcohol, that
was the best brandy. This gave the patient the best
fighting chance, especially when there was consolidation
of pneumonia. He was confident that if they used more
local blood letting, but in a moderate way with children,
and more aggressively in adults, over the heart or right
lobe of the liver, a flip might be given to the heart's con-
traction which could not be started in any other way.

Dr. Henry Dwight Chapin said that an irregular and
intermitting heart was not a bad condition especially, and
was improved often by letting the patient out of bed, while
another child would present more distress, even thougli
the physical signs were the same in each case. One child
would be improved by getting up; the other not. In his
opinion the greatest danger was when the heart became
slowed. In one of his cases the heart dropped to 25 beats;
invariably these cases were followed by death. In some
cases the heart might become suddenly very fast, and
these were bad cases as well. When the heart and stomach
together were affected, a fatal result was apt to follow,
i.e. if the jnilse was quick and weak, and the child vomited.
He emphasized tlie importance of using morphine in small,
nonnarcotic doses; this was a sheet anchor in cases of fail-
ing heart. It caught hold of the heart like digitalis and
strengthened systole. It controlled the restlessness, par-
ticularly in children with we.^k and irregular hearts.

Dr. Charles E. Nammack said that, judging from hij
clinical experience, his results were the same as Dr. Kop-
lik's, except in reference to the use of digitalis in the
pneumonias of children ; in view of its unreliability, he
thought it better to use other drugs belonging to the same
class as digitalis. He heartily agreed with Dr. Robinson
when he said he preferred to use strophanthus in those
cases where it seemed that digitalis was indicated. The

June 2g, 1907]

MEDICAL RECORD.

1093

heart should not only he studied in the acute and general
infections, but the condition of the blood-vessels as well,
and the blood pressure in particular. They were too apt
to regard the blood-vessels as appendages of the heart,
when in truth the heart was an appendage of the blood-
vessels. .\t Bellevue Hospital adrenalin was much used in
cases of heart failure: it was used in cases of pulmonary
edema and collapse in the acute infectious diseases in which
it seemed desirable to raise the blood pressure.
Dr. Bovaird closed the discussion.

College of PHvsiaANS of Philadelphia.

At a stated meeting, held May i, Dr. William h. Rodman
presented a communication entitled "Complete E.xcision of
the Tongue by Kocher's Latest Method," and he exhibited
a man, 46 years old, from whom he had amputated the
tongue for carcinoma of four years' standing, attributed to
the irritation caused by a jagged tooth. Dr. Rodman re-
cited the several operations that had been proposed and
performed successively for the relief of carcinoma of the
tongue, referring especially to ligation of the lingual or
external carotid arteries for the control of hemorrhage or
the purpose of star\'ing out the growth. In some operations
the tongue is approached directly through the mouth; in
others an opening is made in the cheek; in still others re-
moval is effected through the floor of the mouth, also
resection of the inferior maxilla through the symphysis
has been practised. A modification of this last method,
extensively practised by Kocher, has yielded admirable re-
sults, and it is this operation that Dr. Rodman performed.
An incision is made to one side of the median line from
the mucous margin of the lip down to the hyoid bone,
and, after the removal of one or two teeth, the bone Is
sawed through in this plane with the aid of a Gigli or a
Hay saw. The floor of the mouth is incised through the
lingual inversion and the tongue is thus rendered accessi-
ble, without division of important muscles or nerves, and
the hemorrage is inconsiderable. In Dr. Rodman's case
the tongue was divided as far back as possible, after a
median incision had shown that the growth could not be
included in a hemisection, and removal was effected by
means of the thermocautery. There was little bleeding
except from the bone. The patient was able to swallow on
the day after the operation, and he was soon encouraged
to sit up. Primary union took place, except at the point
where a drainage tube had been introduced, and the align-
ment of the teeth was perfect. The danger of aspiration
pneumonia, so common after other operations on the tongue,
is largely obviated by the operation described by reason
of the preservation of important muscles and nerves, ren-
dering swallowing possible early and permitting free use
of the stump of the tongue left behind. When glands in
the neck are enlarged, as in the case reported, they are re-
moved at a secondary operation. The enlarged glands are
to be removed within a day or two. Operating in two
stages is to be preferred to making so large an incision as
would be required in a single operation, with the resulting
grave dangers of infection and imperfect union. In the
case exhibited union ensued without complication, and the
result, in so far as it has gone, has been excellent.

Subinvolution of the Uterus. — Dr. Joseph B. De Lee
advises the following to prevent subinvolution of the
uterus : Avoid sepsis ; conduct the labor with the same
antiseptic precautions that one uses in laparotomies. Leave
the case to nature as much as possible. Avoid practices to
shorten the duration of normal labors. Avoid lacerations
of the cervix ; repair them if deep or if they bleed ; repair
the torn perineum accurately. Leave the uterus empty of
clots, membrane, and placenta; therefore conduct the third
stage of labor properly. If the uterus does not decrease in
size rapidly in the early puerperium, give ergot. Don't
allow the patient to lie on her back too long. Build up the
general system. — Southern Medicine and Surgery.

Induction of Labor. — Joseph B. Cooke recommends
for this purpose in the case of a multigravida with short,
softened, and dilated cervix, so-called expansion rings,
which the obstetrician can easily make for himself. The
appliance consists simply of a soft rubber catheter with the
tip cut off, into which is passed a long spiral watch spring
of the cheaper grade. This forms a circle when in place,
and the approximate ends of the catheter are sewn together.
When boiled the instrument is sterile and ready for use.
It is then pinched up at one point and tied with bobbin
tape, in a bowknot, with short loops and long ends, and
grasped with a bullet forceps. The anterior lip of the
cervix is now drawn down and held by an assistant or nurse,
and the constricted se.gment of the ring, guided by the
lingers of the left hand of the operator, is introduced by
means of the bullet forceps into the cervix and just through
the internal os. The nurse now pulls on the long end of
die tape, unties the knot, and releases the spring. The
operator, still holding the bullet forceps firmly in place
while the anterior cervical lip is steadied by the nurse,
grasps one side of the ring between his thumb and fore-
finger and pushes it slowly and gently into the uterus,
until about half has passed the internal os. This is ac-
complished without pain or discomfort to the patient and
with absolutely no danger of rupturing the membranes.
When the ring is in place, in the form pf a figure 8, with
its greatest constriction at the level of the internal os uteri
the vagina is packed with gauze and labor may be expected
to begin within a few hours or even minutes. It is well
to attach a tape to the vaginal portion of the ring, lest it
work its way into the uterine cavity. — American Journal of
Obstetrics.

Turpentine for the Hands. — Pure turpentine is a
strong antiseptic and is very useful in cleaning the hands
for operation, when one cannot use the permanganate of
potassium and oxalic acid method (which ought to be em-
ployed when one has recently had the hands in pus and
yet must operate). It is generally used improperly. The
correct procedure is to scrub the hands with soft soap
and warm water — running water if possible; if not, the
bowl emptied and refilled at least twice — for at least five
minutes; then to dry the hands thoroughly upon a clean,
(but not necessarily sterile) towel; and then to cut the
finger nails "to the quick." The turpentine is then poured
over the hands and rubbed in thoroughly around the roots
and ends of the nails and between the fingers, two minutes
at least being devoted to this. Finally the hands and finger-
nails are to be scrubbed in soap and clean warm water and
then soaked two. minutes (by the watch) in 65 per cent,
alcohol. They are then ready for immersion in the I to
2.000 sublimate solution. — American Journal of Clinical
Medicine.

Tracheotomy. — Many valuable lives have been lost
by the practice of sucking a tracheotomy wound in cases
of emergency ; but there can hardly be any case in which
a surgeon is justified in resorting to such a dangerous
method, which is almost certain to infect him with a very
Serious disease. The immediate dangers of a tracheotomy
always seem greater than they are in reality. Even when
the patient has ceased to breathe during the operation, the
opening of the trachea with all convenient speed and the
subsequent performance of artificial respiration, without
attempting to introduce a tube, but merely with the edges
of the trachea held apart, nearly always restore the patient
to life. Blood can be prevented from entering the trachea
by making the opening in it sufiiciently large and bringing
it up to the edges of the skin incision at once. Blockage of
the tube by membrane is more difficult to treat, but it is
generally sufficient to remove the membrance with a feather
and to pick it out with a pair of laryngeal forceps. — The
Hospital.

Surgical Observations in Manchuria. — From practical
experience in the Russo-Japanese war. von Manteuffel of
Dorpat would operate in neck wounds for hemorrhage only.
In the thorax await effusion, and then in evacuating do it
gradually, as otherwise infection may be sucked from the
lung. Wounds of heart, "touch not." Manteuffel has seen
seven shot wounds of heart heal smoothly. The spine
gives nothing new; only the old. gloomy picture. In trans-
verse palsy do not operate. If the palsy is not exactly
transverse but irregular, laminectomy may be done. Im-
provements were few. Generally one should await possible
absorption of blood clot. Shrapnel wounds are generally
infected. Bladder wounds heal smoothly. With the ex-
tremities, follow the old von Bergmann precept — do not
disturb and plaster-of- Paris at once; this is established by
both positive and negative trials. — .4nnals of Surgery.

1094

MEDICAL RECORD.

[June 29, 1907

While the Medical Record is pleased to receive all new
pttblications tcliich may be scitt to it, and an acknoivledg-
iiiciit will be promptly made of their receipt under this
heading, it must be with the distinct understanding that its
necessities are such that it cannot be considered under
obligation to notice or review any publication received by it
which in the judgment of its editor will not be of interest
to its readers.

Mthimi itpms.

Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported to
the Surgeon-General, Public Health and Marine-Hospital
Service, during the week ended June 21, 1907:

SMALLPOX — UNITED STATES.

Precis de Pathologie Interne. lamo, illustrated, paper.
G. Steinheil, Editeur, Paris. Vols. I, II, III, and IV.

The Rontcex R.ws in Medical Work. Fourth Edition.
By D.wiD Walsh, M.D., Ed. 8vo, 433 pages, illustrated,
muslin. William Wood & Company. Price $4.00.

Hints on the Management of the Commoner Infec-
tions. By R. W. Marsden, M.D., M.R.C.P., D.P.H 8vo,
128 pages, muslin. E. B. Treat & Companv, New York.
Price $1.50.

Etude Experimentale de la Pleuresie Sero-Fibrineuse
TuBERCULEUSE. Par M. le Docteur P. Cartier. 8vo, 100
pages, illustrated, paper. G. Steinheil, Editeur, Paris.

Les Autoplasties. Par Ch. Nelaton et L. Ombredanne.
4to, 199 pages, illustrated, paper. G. Steinheil, Editeur,
Paris.

Epilepsy, a Study of the Idiopathic Disease. By
William Aldren Turner, M.D., Edin. 8vo, 272 pages,
illustrated, muslin. Macmillan & Company, New York.
Price $3.25.

Surgical Diseases of the Chest. By Carl Beck, M.D.
8vo, 371 pages, illustrated, muslin. P. Blakiston's Son &
Company, Philadelphia.

A Manual of Obstetrics. By A. F. A. King, A.M.,
M.D.. LL.D. 8vo, 688 pages, illustrated, muslin. Lea
Brothers & Company, New York. Tenth Edition, Re-
vised and Enlarged.

International Clinics. By Leading Members of the
Medical Profession Throughout the World. Volume I,
Seventh Series. 1907. 8vo, 318 pages, illustrated, muslin.
J. B. Lippincott, Philadelphia.

The Abdominal and Pelvic Brain. By Byron Robinson,
E.S.. yiD. Svo, 671 pages, illustrated, muslin. Frank S.
Betz, Hammond, Ind.

American Medical Directory. Volume I. 4to, 1.4S2
pages, muslin. American Medical Association Press, Chi
cago.

The Technic of Modern Operations for Hernia. Bv
Ale.xaxder Hugh Ferguson, M.B., M.D.. CM., F.T.M.S.
4to. 366 pages, illustrated, muslin. Cleveland Press, Chi-
cago.

A System of Medicine. By Many Writers. Volume II,
Part I. 8vo, 1,987 pages, illustrated, muslin. Macmillan
& Company, London. $5.00.

A System of jNIedicine. By Many Writers. 8vo, 1.055
pages, illustrated, muslin. Volume H, Part II. Macmillan
& Company, London. $5.00.

The Treatment of Disease. Bv Reynold Webb Wil-
cox, M..A.., M.D., LL.D. 8vo. g'n pages, muslin. P.
Blakiston's Son & Company, Philadelphia. Price $6.00.

Transactions of the American Clim.\tological -Asso-
ciation for the Year 1906. Volume XXII. Svo, 303 pages,
muslin. Printed for the Association, Philadelphia.

Diagnosis of Organic Nervous Diseases. By Christian
A. Herter, M.D. Second Edition. i2mo, 690 pages, illus-
trated, muslin. G. P. Putnam's Sons, New York.

The Control of a Scourge. By Charles P. Childe,
B.A.. F.R.C.S. 8vo, 299 pages, muslin. E. P. Dutton &
Co., New York. Price, $2.50 net.

The Drink Problem. By fourteen medical authorities.
Svo, 300 pages, muslin. E. P. Dutton & Co., New York.

Transactions of the Thirty-setcnth .Annual Ses-
sion OF the Medical Society of Virginia, held in Char-
lottesville, Va., October 9-11, 1906. Svo, 367 pages. Will-
iams Printing Co., Richmond, Va.

^Modern Medicine. Edited by William Osler, :M.D.
Vol. I., Svo, 937 pages, illustrated, muslin. Lea Brothers &
Co.. New York.

The Treatment of Skin Cancers. By W. S. Gottheil,
M.D. Third edition, revised and enlarged. i2mo, 89
pages, muslin, illustrated. International journal of Sur-
gery Co., New York.

Die Zuckerkrankheit und Ihre Behandlung. Von
Prof. Dr. Carl von Noorden. Svo. 367 pages, paper. Ver-
lag von .August Hirschwald, Berlin, 1907.

Metabousm and Practical AIedicine. Bv Carl von
Noorden. Vol. I., Svo, 452 pages, muslin. W. T. Keener
& Co., Chicago. Price, $4.

Metabolism. Physiology, and Pathology. By Carl
VON Noorden. Vol. II., Svo, 525 pages, muslin. 'W. T.
Keener & Co.. Chicago. Price. $6.

California. Berkley May 2s-June i.

Los Angeles June i-8

Illinois, Chicago June 8-15

Springfield June 6-13

Indiana. Elkhart June 1-8

Evansville June 1-8

Indianapolis June 2-9

South Bend June 1-8

Iowa, Jessup May i6-June 12

Keokuk May 1-31

Kentucky, Louisville June 6-13

Louisiana, Kew Orleans June 1-8

Shreveport June 1-8

Massachusetts, Lawrence June 1-8

.Michigan, Detroit June 1-8

Huron County June 12

Saginaw June 1-15

Minnesota, Stillwater May 1-3 1

Winona June 1—8

Missouri. St. Louis June 1-8

-Morth Carolina, Charlotte June 8-15

Ohio, Cincinnati June 7-14

Pennsylvania. Homestead May 29-June 7.

Tennessee. Xashville June 8-15

Texas. Galveston .May 3 i-June 7 .

Utah. Ogden May 1-31

Washington. Spokane June 1-8

West Virginia, Charleston, Kana-

wah County Jan. i-June r4.

Wisconsin, Milwaukee June 1-8

S,\IALLPOX — FOREIGN,

Brazil, Bahia May

Para May

Rio de Janeiro Apr,

Canada, Halifax June

Toronto Apr,

Chile. Iquique May

China. Hongkong Apr,

Colombia, Cartagena May

France. Paris May

Germany, General May

Dreat Britain, Southampton May

India, Calcutta A pr.

Italy. General May

Florence May

Messina May

Java. Bata\-ia .^pr.

Madeira. Funchal May

Mexico. .Aguas Calientes June

Monterey May

Nuevo I^aredo June

Portugal. Lisbon May

Russia, Moscow May

Odessa May

Warsaw May

Spain, Barcelona May

Valencia May

i8-25

i8-June I.
29-May 1 2

9-iS

28— June I .

6-13

6-27

25- June I.

18-25

2!:-June i.
28-May 4.

26— June 2.

18-25

27-May 4.
2 6- June 2.

1-8

26- June 2.

25-June r.

9-18

18-25

4-1 1

21-31

26-June 2.

YELLOW FEVER.

Brazil, Para May i8-June r. .

Rio de Janeiro .^pr. 29-May 12.

Cuba, San Xicolas June i2-iS

West Indies. Trinidad. Port of

Spain May 18-25

India, Calcutta.

CHOLESA.

.\pr. 28-^^ay 4 .

PLAGUE — UNITED STATES.

California. San Francisco May 23-26.. .

PLAGUE — FOREIGN.

Chile,
China,

Australia, Brisbane Apr.

Port Douglas .\pr,

Sydney .■\pr,

Brazil, Bahla .May

Rio de Janeiro .Apr.

Para : May

.\ntofagasta May

Hongkong Apr.

Egypt, Alexandria May

Provinces — .Assiout May

Beni Souef May

Girgeh May

Keneh May

Minieh May

Formosa. General May

India, Calcutta .Apr,

Mauritius Mar,

Peru. Callao Apr.

Chiclayo -Apr.

Ferrenafe .Apr.

Lima .Apr.

Paita -Apr.

Pimentel .Apr.

Tambo .Apr.

Trujillo .Apr.

6—20

6-13

6-20

18-25

2Q-^iay 5 .
25-June I .

6-13

20—27

18-23

16-23

16-23

16-23

16-23

16-23

S-J2

28-May 4 .

2S-Apr. 25
24-May T .
24-May I .
24-May I.
24-May I.
24-May I.
24-May I ,
24-May I,
24-May I,

16

3

Present

68 Present in
county

Present

53
Present

20 13

13
I
2 Imported

3
18

16
162

as
I
7
7
0
J3»
344

S
14

INDEX TO PAGES.

Pages. Date of Issue. No.

1-44 Jan. 5 1887

45-84 Jan. 12 1888

85-128 Jan. 19 1889

129-168 Jan. 26 1890

169-212 Feb. 2 1891

213-252 Feb. 9 1892

253-296 Feb. 16 1893

297-336 Feb. 23 1894

337-380 Mar. 2 1895

Pages. Date of Issue. No.

381-420 Mar. 9 1896

421-464 Mar. 16 1897

465-504 Mar. 23 1898

505-54S Mar. 30 1899

549-588 Apr. 6 1900

589-632 Apr. 13 1901

633-672 Apr. 20 1902

673-716 Apr. 27 1903

717-756 May 4 1904

Pages. Date of Issue. No.

757-800 May II 190S

801-S40 May 18 1906

841-884 May 25 1907

885-924 June 1 1908

925-972 June 8 1909

973-1016 June 15 1910

1017-1060 June 22 1911

1061-1108 June 29 1912

INDEX.

Abdominal quadrant, the right upper,
690; suppuration, left sided, 921.

Abortionists, decision regarding, 736.

Abscess, intraabdominal complicating
pregnancy, 396; of the liver, 736;
puncture and disinfection for, 828";
the diagnosis of subphrenic, 914.

Absinthe, to be tabooed in France, 528.

Academy of Medicine, reminiscences of
practitioners in New York during
the early history of the, 129, 161.

Acetone in the urine, tests for, 619.

Acetonuria in children, 817.

Acid fasts, what are? 1027; intoxica-
tions, 289; or acidosis a factor in
disease, 895.

Acne keratosa, 415.

Addison's disease, suprarenal extract
in, 12S.

Adenoids in infancy, 1010.

Adrenalin in renal hematuria, 868;
therapeutic applications of, 875.

Aerotherapy in cold weather, 1053.

Air, fresh, treatment in hospital wards,
213, 246; passages, diseases of the
upper, in relation to life assurance,
952.

Albuminuria, functional in athletes,
146, 158; juvenile physiological,
367; prostatic and seminal, 112;
orthostatic, 654 ; postural, 188.

Alcohol and carbonic acid, the antago-
nistic action of, 1087 ; in the treat-
ment of diabetics, 315; its relation
to degeneracy, 241 ; the physiolog-
ical action of, 241.

Alcoholism, speed mania and objectless
activities, 481.

Alexander-.A.dam's operation, the, 702.

Alimentary canal, Rontgen ray obser-
vations on the, 1012.

Alkaloidal salts, physiological action of,
660.

Alkaloids, the function of in plant life,
733-

Alopecia areata, a case of complete,
455.

Alvarenga prize, 150, 737.

American Academy of Medicine, 994.

American Antituberculosis League, 319,
570.

American Association for the Advance-
ment of Science, 21.

-\merican Association of Medical Ex-
aminers, 1038.

American Gastroenterological Associa-
tion, 946.

American Hospital for Diseases of the
Stomach, 67.

American International Congress on
Tuberculosis, 109.

American Laryngological Association,
863.

American Medical Association, its aims
and interests, 925, 958; manage-
ment of the, 903 ; the meeting of
the, 991.

American Mosquito Extermination So-
ciety, 694.

American National Red Cross, 66.

American Physiotherapeutic Associa-
tion, 67.

American Society of Sanitary and
Moral Prophylaxis, 738.

Amniotic liquid, method of infection
of the, 103.

.imputation stump, a new form of, 968.

.\myotrophic lateral sclerosis, 1041.

Anatomy, normal in the first twelve
years of life, 834.

Anemia, anomalous cases of pernicious,
198; early symptoms of pernicious,
962; hemolysis in pernicious, 782;
the theory of the toxic origin of
pernicious, 175; treatment of se-
vere with transfusion, 830.

-Anesthesia, an ideal local for sub-
mucous resection, 311; concerning
local, 352; for nasal and aural
operations, 404; infiltration in sur-
gery, 6C2; lumbar, 796; ocular par-
alysis after spinal, 702.

Anesthetist, the, 904.

.Aneurysm, a case of, 79; multiple, of
the aorta, 700; of the aorta, a case
of ruptured, 595, 622.

Angioma, of skin, malignant, 1042 ;
the treatment of, 535.

Atiguillula intcstinalis and chronic diar-
rhea, 914; observations on, 953.

Annals of Otology, Rhinology. and
Laryngology, Festschrift of the,
1 40.

Anorexia nervosa in children, 874.

Anthracosis, pulmonary, 451; of in-
testinal origin, 496.

.Anthrax, germs, to destroy, 1038; re-
sistance of the spores of the
bacillus of, 17; the treatment of,
32, 785.

.Antialcoholic Congress, the eleventh,
994-

Antinoise bill favorably reported, 150;
passed, 234.

.Antismoke League, work of the, 655.

Antitoxin and postdiphtheritic par-
alysis, 836; for free distribution,
822 ; from convicts, 486.

.Antivaccination in California, 274.

Antivivisection bill killed in Pennsyl-
vania, 777; in this State, 571; pe-
tition, 66.

.Anuria, calculus, and ureteral catheter-
ism, 75.

Aorta, rupture of the, 494; rupture of
'dilated, 450; spontaneous rupture
of the, 800.

Aphasia, the clinical study of, 792.

•Appendectomy, phlebitis of the lower
e.\tremity after, 75 ; the technique
of. 1005 ; and obstruction of the
ileocecal orifice, 212; and jaundice,
232; and twisted ovarian pedicle,
29 ; as a cause of intussusception,
30 ; cases of, 743 ; chronic, 870 ; in
infants and children, 759; in nurs-
lings, 252; in pregnancy, 867; in the
negro, 165 ; medical treatment of,
322; nonsurgical treatment of, 271;
the pathology of, 367; the state
preceding, 732; verminous, 380.

Appendicitis, traumatism in causation
of, 1084.

.Appendicoslomy. 385.

.Appendicular pain, acute and chronic,
1000.

-Appendix and laparotomy, the. 147;
gallstones in the, 197; harmful in-
volution of the. 555 ; intestinal
worms in the, 578; preventive sur-
gery in epithelioma of the, 785 ; pri-
mary carcinoma of the, 20; the eti-
ology of the punctiform hemor-
rhages in the, 588.

.Arcquipa, letters from, 112.

.Argyria, a case of, 34.

Arizona Medical Association, 995.

-Arkansas State Medical Society. 995.

-Army medical corps examinations, 356;
surgeons, a proposed organization
of, 231.

.Arsenic, the therapeutic application of,
828.

Arseniuretted hydrogen poisoning. 577.

Arterial pressure, the control of high,
951.

.Arteriosclerosis, 395; blood pressure in,
6C10; experimental, 568, 1089; expe-
rimental by adrenalin inoculations,
144 ; observations on. 673 ; sympo-
sium on, 453 ; the ocular lesions of,
408, 421, 454.

-Arthropathies, syphilitic, 451.

Ascites, operative treatment of, 662.

-Association of American Physicians,
1038.

-Asthma, a sure cure for, 830; infantile
and its treatment, 716; 300 cases
of, 1068.

-Ataxia, a new type of, 804.

-Athletes, the longevity of college, 62.

.Atmospheric pressure, the mechanical
action on the bodv of lowering the,
328.

-Auditory sclerosis, the treatment of,

317.
-Aural affections in relation to mental

disturbances, 500, 576; examina-

1096

INDEX.

[June 29, 1907

tions, the importance of, for

healthy people, 200.
Auricular extrasystoles, blocking of,

828.
Autointoxication in its medico-legal

aspects, 973; in relation to the eye,

281.
Automobile accidents, errors of vision

as a factor in, 30; in Germany,

1079.

B

Bacteria, efTect of the tropical sun on,

64.
Baginsky, Adolf, treatment of acute
cardiac affections in childhood,

589.
Bailey, Pearce, pathological changes m
fracture dislocations of the spine,

471-

Baldness, the cause of common, 220.

Ballenger, Edgar G., an unusual nidus
for gonoccoccic infection, 142.

Balleray, G. H., unnecessary operations
the opprobrium of modern sur-
gery, 238.

Bangs, L. Bolton, a comment on the
.r-ray as applied to prostatic en-
largement, 902.

Barlow's disease in the Island of Cuba,
464.

Barringer, Benjamin S., the diagnostic
value of the cystoscopic examina-
tion in carcinoma cervicis uteri,
805.

Barringer, Theodore B., some unusual
results of intrathoracic compres-
sion, 637.

Baths, the temperature of Japanese hot,
328.

Beans, a lacteal fluid from, 108.

Beard, John, the interlude of cancer,
169 ; the scientific criterion of a
malignant tumor, 24; the scientific
criterion of a malignant tumor and
the nature of Jensen's mouse tu-
mor, 403.

Beck, Carl, a new method of operation
for epispadias, 505.

Bee stings as a cure for rheumatism,
149-

Behring's tuberculosis cure, 190.

Belfield, VV. T., pus tubes in the male,
731.

Bell, Robert, the approaching conquest
of cancer, 258.

Bellevue Hospital plans filed, 273.

Benedict, Charles S., retirement of Dr.,
20.

Bennett, A. B., symptomless mastoid-
itis, followed by meningitis and
death, 600.

Benzidin test, the, 569.

Berg. A. A., the diagnosis and surgi-
cal treatment of gastric and duo-
denal ulcer and their complications,
85.

Bergmann, death of Prof., 529.

Berlin, declining birth rate in. 945 :
information bureau in. 442 ; letters
from, 71, 323, 491, 781, 1082; mu-
nicipal positions in, 442.

Berthelot, death of Prof., 489.

Beth-Israel Hospital, 21.

Bier, appointment of Prof. August, 907.

Bier's Method, amputation of the leg
by, 582; method in acute suppura-
tive conditions, 754; treatment, the.
639; treatment in acute otitis, 212;
treatment in surgical aflections,
966.

Bilharziosis, 313.

Biliary colic, cardiac murmurs during,
827; passages, surgery of the. 940;
system, drainage in operations on
the, 749, 911.

Bilihid prison inquiry, result of the
906.

Birchmore. Woodbridge H., is an her-
petic origin of pleurisy possible?
769; the hyoscine sleep in obstetric
practice, 58.

Birth rate, the lowered, among prosper-
ous nations, 482; the relation of to
population, 356.
Bishop, William H., a new plan of su-
turing in perineorrhaphy, go6.
Bladder, air distention of the, 321 ; dis-
tention of the, with oxygen, 188;
hernia of the, 582; operation for
exstrophy of the, 966; simple ulcer
of the, 5.32 ; symposium on new
growths of the, 665 ; the treatment
of benign tumors of the, 354.
Bleyer, J. Mount, prognosis in the con-
sumptive, 95.
Blind, census of the, 149; magazine for

the, 441.
Blindness, legislation and methods for

the prevention of, 200.
Blood cells, origin of the red in mam-
mals, 114; clinical observations of
the index of refraction of the,
1043; count, the clinical value of
the. in otology, 196; cultures in
children, 156; examinations in
otology, 78 ; examinations in sur-
gical diseases, "jy; examinations in
surgery, 280; pressure apparatus,
1076; pressure, a study of, in com-
pressed air workers, 855, 875 ;
pressure determination in man, 115 ;
pressure in arteriosclerosis and
Bright's disease, 660; pressure, low
as a sign of renal tuberculosis, 1078;
pressure study, 204; pressure, the
renal origin of increased, 233 ;'
serum, animal, in surgery, 858 ;
test, a new, 937; test, the specific
solubility, 496.
Blumgart, Leonard, observations on
the diagnostic and prognostic value
of the eosinophiles in the circu-
lating blood, 560.
Board of Health inspectors, reform

urged in the, 667.
Bone lesions, posture as an aid in the
diagnosis of, 669; tumors, multiple,
455 ; tumors, the diagnosis of by
examination of the blood, 568.
Book Notices.

Abdominal operations, by G. A. Moy-
nihan, 33.

Ame et le systeme nerveux, by Au-
gust Forel, 872.

Anamien, die Diagnose und Therapie
der, by Joseph Arneth, 1002.

Anatomy, atlas and text-book of hu-
man, by J. P. Johannes Sobotta
and J. Playfair McMurrich, 581.

Anatomy for nurses, a text-book of,
by Elizabeth R. Bundy, 664.

Anesthetics and their administration,
by F. W. Hewitt, 1046.

Association of American Physicians,
transactions of the. Vol. XXL, 329.

Ataxic tabetique, by H. S. Frenkel,
1002.

Autointoxication intestinale, by A.
Combe, 245.

Baby, the health-care of the, by Louis
Fischer, 117.

Bacteriology, a compend on, by Rob-
ert E. Pitfield. 1002.

Biographic clinics, by George M.
Gould, 497, 831.

Blakiston's quiz compends, genito-
urinary diseases and syphilis, by
Charles F. Hirsch, 159.

Blood-vessels, a study of the human
in health and disease, by Arthur
V. Meigs, 1002.

Buff, by a physiopath. 159.

Chemistry, the medical student's
manual of, by R. A. Witthaus, 159.

Children, diseases of, by George M.
Tuttle, 703.

Chirurgie, travaux de, by Henri
Hartmann, 284.

Deformities, the nature, cause, va-
riety, and treatment of bodily, by
E. J. Chance and John Poland. 664.

De I'apepsie. by Henri Fran<;ais. 284.

Dental surgery, aids to, by Arthur S.

Underwood and Douglas Gabel,

872.
Dermatology, elementary manual of

regional, by R. Sabouraud, 664.
Dcs llaarschwunds Ursachen und

Bchandlung, by S. Jcssner, 329.
Dictionary, the practitioner's medical,

by George M. Gould, 452.
Dictionnaire de medecine et de thera-

petique medicale et chirurgicale, by

Armand Despres, G. Marion, and

F. Bouchut, 872.
Die Therapie der Haut und Gesch-

lechtskrankheiten, by R. Leder-

mann, 368.
Die Tuberkulose der menschlichen

Gclenke sowie der Brustwand und

des Schadels, by Franz Konig, 329.
Diet in health and disease, by J.

Friedenwald and Tohn Ruhrah, 452.
Dietetics, practical, by Alida F.

Pattee, 368.
Digestive system, diseases of the, ed-
ited by Frank Billings and Julius

L. Selinger, 117.
Digestive system, the treatment of

diseases of the, by Robert Saundby,

329.

Diseases of children, aids to the
diagnosis and treatment of, by
John McCaw, 872.

Diseases of women, a text-book of,
by J. Clarence Webster, 915.

Diseases of women, the, by J.
Bland Sutton and Arthur E. Giles,
329.

Ear, the and its diseases, by Seth
Scott Bishop, 117.

Electricity, essentials of medical, by
Edward R. Morton, 747.

Encyclopedia and dictionary of med-
icine and surgery. Green's, 411.

Embryology, syllabus of lectures on
human, by Walter P. Manton, 664.

Esperanto, practical and theoretical,
by Max Talmey, 536.

Evaluation des incapacites perma-
nentes, by C. H. Remy, 747.

Exploration de I'appareil urinaire, by
Georges Luys, 872.

Eye, prevalent diseases of the, 159.

Eye, the pathology of the, by J. Her-
bert Parsons, 159.

Eyes, a treatise on the motor appa-
ratus of the, 411.

Fate, the masters of, by Sophia P.
Shaler, 245.

Formulary-, Saunders' pocket medi-
cal, by William H. Powell, 159.

Gastric and intestinal diseases, the
chemical investigation of by the
aid of test meals, by Vaughan Har-
ley and Francis W. Goodbody. 536.

Genitourinary diseases and syphilis,
by Henry H. IMorton, 368.

Gesammelte Beitrage aus dem
Gebiete der Physiologie, Patholo-
gic, und Therapie der Verdauung,
by I. Boas, 284, 452.

Geschwiilste. Beitrage zur Diagnos-
tik und Therapie der, by H. Op-
penheim, 1002.

Guide pratique pour le choix des
lunettes, by A. Trousseau, 245.

Gynecolog3% aids to, by Alfred S.
Gubb. 159.

Gynecology and electrotherapeutics,
conservative, by G. B. Massey, 747.

Hernia, retroperitoneal, by B. G. A.
Moynihan, 581.

High frequency currents, by H.
Evelyn Crook, 787.

Histology and organography, a man-
ual of normal, by Chas. Hill. 915.

Histology, a text-book of, by Fred-
erick R. Bailey, 452.

Histo!og%-. Stohr's. bv F. T. Lewis
and P.' Stohr, 787. '

Hygiene, the new. by Elie Metchnik-
oflf, S36.

June 29, 1907'

INDEX.

1097

Indications for operation in disease

of the internal organs, by Herman

Schlesinger, translated by K. W.

Monsarrat, 747.

International clinics, edited by A. O.

J. Kelly, 245.
International medical annual, 536.
Intestine and stomach, the technique
of operations on the, by Alfred H.
Gould. 747.
Jahresbericlit iiber die Leistungen
und Fortschritte auf dem Gebiete
der Erkrankungen des Urogenital-
apparattes, 747.
Kosmetische Hautleiden, by S. Jess-

ner, 329.
Letters from a surgeon of the Civil
War, compiled by Martha D.
Perry, 76.
Lungs, lectures on diseases of the, by

James A. Linsay, 787.
Malpractice suit, how to suppress a,

by Thomas H. Shastid, 831.
Manuel d'histologie pathologique, by

V. Corneil and L. Ranvier, 620.
Massage et gyranastique medicale,
manuel pratique de, by J. E. Mar-
fort, 1002.
Materia medica, a syllabus of, by

Warren Coleman, 245.
Materia medica and therapeutics, a
practical treatise on, by John V.
Shoemaker, 368.
Materia medica, practical, for nurses,

by Emily A. M. Stoney, 664.
Medical diagnosis, by Charles L.

Greene, 831.
Medical diagnosis, by J. J. G. Brown

and W. J. Ritchie, 1046.
Medical diagnosis, aids to, by Ar-
thur Whiting, 872.
Medical epitome series ; Pathology,
general and special, by John Sten-
house and John Ferguson, 411.
Medicine, elements of practical, by

Alfred H. Carter, 284.
Mercer's company lectures on recent
advances in the physiology of di-
gestion, by E. H. Starling. 620.
Micrology, animal, by IMichae! F.

Guyer, 703.
Minor maladies and their treatment,

by Leonard Williams, 581.
Moral philosophy of medicine, con-
ferences on the, 117.
Kervenkrankheit und Lektijre, by H.

Oppenheim, 1046.
Nervous diseases, the diagnosis of,

by Purves Stewart, 284.
Nierenchirurgie, by C. Garre and

0. Ehrhardt, 1046.
Nose and throat, a guide to diseases
of the, by Charles A. Parker, 411.
Nose and throat, diseases of the, by

J. B. Ferguson. 1002.
Nose, throat, and ear, diseases of

the, by Charles P. Grayson, 284.

Nouveau traite de medecine et de

therapeutique. Intoxications, by

P. Carnot and collaborators, 620.

Nurses, lectures for, 36S,

Obstetrics, aids to. by Samuel Nail,

245-
Obstetrics, a text-book of, by Berton

C. Hirst, 33.
Obstetrics for nurses, by Joseph B.

De Lee, 329.
Obstetrics, the practice of, by J. Clif-
ton Edgar, 620.
Obstetrics, the practice of, by Reu-
ben Peterson. 411.
Ohr, Operationen am. by B. Heine,

Ophthalmic operations, a text-book
of, by Harold Grimsdale and El-
more Brewerton. 872.

Organotherapy, rational, with refer-
ence to urosemiology. by A. von
Poehl and collaborators, translated
by Karl Schiilin, 33.

Orthopedic surgery, treatise on, by
Royal \\'hitman. 581.

Pain, abdominal, by A. E. Maylard,

284.
Pastoral medicine, essays on, by

Austin O'Malley and J. J. Walsh,

33-
Pathology, a manual of, by G. i\Ic-

Connell, S3 1.
Pathology, a text-book of, by Alfred

Stengel, 915.
Pathology, text-book of comparative,
by Th. Kitt and W. C. Cadbury,
329-
Photoscopy, skiascopy, or retinoscopy,

by Mark D. Stevenson, 117.
Phthisis, pulmonary, its diagnosis,
prognosis, and treatment, by H. H.
Thompson, 284.
Physiology, an introduction to, by

William C. Porter, 76.
Physiology, essentials of human, by

D. Noel Patton, 497,
Plaster-of-Paris and how to use it,

by Martin H. Ware, 915.
Practical medicine series ; Anatomy,
physiology, pathology, dictionary,
t>y Gustavus P. Head, W. A. Ev-
ans, Adolph Gehrmann, and Will-
iam Healy, 915 ; Pediatrics, Ortho-
pedic Surgery, edited by Gustavus
P. Head, Isaac A. Abt. John
Ridlon, and Gilbert L. Bailey, 245 ;
Skin and venereal diseases, nerv-
ous and mental diseases, by Gus-
tavus P. Head, W. L. Baum, Hugh
T. Patrick, and William Healv,
915. .
Prescription writing, a manual of, by
Mathew D. Mann and Edward C.
Mann, 787.
Progressive medicine, edited by Ho-

bart Amory Hare, 581.
Prostate, clinical lectures on enlarge-
ment of the, by P. J. Freyer, 581.
Psychology, experimental, by Ed-
ward B. Tichener, 329.
Regeneration des families et races

tarees, by E. Contet, 747.
Regime pathologique et regime par-

fait, by F. Cayla, 1046.

Retinoscopy in the determination of

refraction, by James Thorington,

24s.

Roentgen Strahlen im Dienste der

Neurologie, by W. Fiirnrohr, 1046.

Rythmotherapy, by Samuel S. Wall-

ian, 497.
Sauerstofftherapie, Handbuch der,

by Max Michaelis, 787.
Self-propelled vehicles, by James E.

Homans, 620.
Sex, studies in the physiology of, by

Havelock Ellis, 411.
Sterilite chez le femme, bv E. Hu-

gon, 1046.
Stomach and intestines, diseases, by

Boardman Reed, 536.
Stomach, diseases of the, by Max

Einhorn, 76.
Surgery. American practice of, edited
by Joseph D. Bryant and Albert
H. Buck, 497.
Surgery, its principles and practice
edited by William Williams Keen,
664.
Syphilis, die, by Dr. Orlowski, 1002.
Syphilis du poumon, bv Dr Beriel

703-
Syphilis, the treatment and prophy-
laxis of, by Alfred Fournier, trans-
lated by C. F. Marshall, 76.
Tabes dorsalis, by David Ferrier,

1002.
This labyrinthine life, bv George A.

Fischer, 872.
Toxins and venoms and their anti-
bodies, by E. Pozzi-Escot. trans-
lated by Alfred I. Cohn, 620.
Traite d'hygiene. Vol. III., by
P. Brouardel and collaborators. 76.
Tripper, der. by Dr. Orlowski, 1002.
Tropical medicine, by Thomas W.
Jackson, 915.

Tuberculosis, pulmonary, by Albert

P. Francine, 703.
Tuberkulose, die, by G. Cornet, 33.
Tumors, innocent and malignant, by

J. Bland-Sutton, 452.
Urines, analyse des, by Ern. Gerard,

,58'-
Lrological surgery, studies in, Johns

Hopkins Hospital reports, Vol.
XIII, 1046.
Vertebrates, the nervous system of,

by J. B. Johnston, 703.
Voice production in singing and

speaking, by Wesley Mills, i6&.
Water supplies, the bacteriological
examination of, by William G.
Savage, 368.
Weigert, Karl und seine Bedeutung
fur die medizinische Wissenschaft,
by Robert Rieder, 831.
Who's who, 620, 1907.
Woman, by Bernard S. Talmey, 787.
Booth, J. Arthur, some observations on
the treatment of Graves' disease,
976.
Boston, L. Napoleon, typhoid fever
complicated by multiple abscesses
of the kidneys and by lobar pneu-
monia, 390.
Boston Society of Examining Phy-
sicians and Surgeons, 612.
Boston LTniversity Medical School, 994.
Bowel, mimicry of malignant disease of

the, 64.
Brachial plexus, paralysis of the, 30.
Bradycardia, the effect of a salt-free

diet in, 438.
Brain, abnormal response by the motor
area of the, 1032; and skull, se-
questration anemia in operations
on the, 438; exploratory puncture
of the, 64, 1078; successful removal
of a tumor of the, 74; surgery and
moral qualities, 21.
Erandegee. the late Dr. William P.,

236.
Breast, early diagnosis of cancer of
the. 5S4; the technique of ablation
of the, 3206.
Brewer, Isaac W., observations on the
treatment of tuberculosis in Ari-
zona. 646.
British Tuberculosis Commission, re-
port of, 235.
Bronchiectasis in childhood, 158.
Bronchitis, the treatment of chronic

with the A--rays, 784.
Bronchopneumonia, the continuous use

of oxygen in, 366.
Bronchoscope, removal of a foreign

body with the, 410.
Brooklyn contagious diseases, hospital

for, 442.
Brooklyn Medical Journal, 21.
Brooks, Harlow, a study of blood
pressure in compressed air work-
ers, 585.
Brothers, Abram, the early mobiliza-
tion of patients after major gyne-
cological operations, 476.
Brown, Robert C, the relation of the
tonsil to infection and infectious
diseases, 341.

Brown, Wallace E., twenty-five years'
experience in the treatment of
malignant new growths with es-
charotics, 812.

Brownson, J. J., treatment of acute
septic perforative peritonitis, 277.

Brown-tail moth, the dermatitis caused
by the, 606.

Bryant. Joseph D., honors for Dr., 777 :
statement by, 358; the American
Medical Association, its aims and
interests, 925.

Bryant, W. Sohier, the Eustachian
tube, its anatomy and its move-
ments, with a description of the
cartila,ges, muscles, fasciae, and the
fossa of Rosenmiiller, 931; the
preservation of hearing, 349.

1098

INDEX.

[June 29, 1907

Bull, Charles S., rare forms of chorio-
ditis, 728.

Burial, to prevent premature, 653.

Burns, the pathology of, 692.

Burt, Stephen Smith, pneumonia, with
especial reference to the use of
fresh air and a saline solution, and
the abuse of alcohol, opium, and
other drugs in its treatment, 507.

Butler, George F., remarks on the
treatment of disease and so-called
"authorities," 1029.

Buttermilk as an infant food, 515;
feeding, 827; modified in infant
feeding, 743.

Caisson disease, the treatment of, 943.

Calcium chloride, the influence of on
the agglutination of vibrios, 74;
iodide in leg ulcers, 829; salts as
heart tonics, the, 662 ; salts in the
blood, 784.

California, biological station of the
University of, 528.

Calomel as an antiseptic, 451.

Canada, are the settlers of western,
doomed to failure? 1034.

Cancer and malaria. 678; and the
Rontgen rays, 196; a case of sec-
ondary, 835 ; a case of treated by
trypsin, 493 ; class incidence in,
578; errors in the treatment of,
72; fever in, 410; healing of a by
sunlight, 702; homes, lectures for,
234; immunity in mice against. 75;
infected cages for rats, 73 ; multiple
primary, 198 ; of the breast, end
results in, 918; of the breast, end
results following operations for,
837; of the breast in the mouse,
619; of the breast, local ap-
plications in inoperable, 924;
of the breast, .r-ray treatment
of, 327; of the cervix, the
diagnosis of, 786; of the cheek,
plastic repair after removal of, 413 :
of the head and neck, surgical
treatment of, 920; of the male
breast, 30; of the pylorus, 116; of
the stomach, operative treatment
of. 1077 ; of the uterus, cysto-
scopic examination in, 805 ; of
the uterus, the fight against,
963 ; of the uterus, the rela-
tionship of clinical symptoms to
microscopical findings in. 518;
papain in. 243; parasites, 527; pre-
operative radiation and surgical
treatment of, 815; primary, of the
inferior turbinate, 432 ; problem,
the, 1076; radiotherapy of, 113; re-
search work, the relation of en-
dothelioma to, 523; symposium on
the etiology and nature of, 202 ; the
approaching conquest of, 258; the
cause and care of. 558; the dis-
semination of abdominal. 366: the
early diagnosis of. 148; the game-
toid theory of. 398; the interlude
of, 169, 402; the mimicry of, 692;
the modern treatment of. 31 ; the
nature of, 053 ; the scientific cri-
terion of a, 24; trypsin in, 69, no,
152, 407, 448; the .T-ray treatment
of, 282; twenty-five years experi-
ence in the treatment of, with es-
charotics, 812.

Cancroin case nonsuited, 862.

Canteen, the army. 108, 326.

Carbolic acid gangrene, 913.

Cardiac remedy, a new, 31.

Carroll, promotion of Lieutenant, 400;
the recognition by Congress of the
services of Dr., 234.

Carter, William W., primary carcinoma
of the inferior turbinate, with re-
port of a case, 432.

Cartwright prize, the. 66.

Car wheels, flat, removed, 109.

Casts, the origin of urinary, 128.

Cataract, 130 cases of, 744; the ripen-
ing operation for senile, 449; treat-
ment of unripe, 114; what stage in
the development of is most suit-
able for operation? 617.

Catgut, iodine spirit, 701 ; ligature, a
substitute for the, 353; sterilization

of. 555-

Cecum, tuberculosis of the, 321.

Centenarians, 358.

Cerebellum, Jackson's views of the
functions of the, 701.

Cerebrospinal fluid, cytodiagnosis of,
817.

Cervical rib, a case of, 621 ; super-
numerary and their effects on the
brachial plexus, 253.

Cervix, amputation of the during preg-
nancy, 115.

Cesarean section, a study of vaginal,
163 ; the indications for, 794.

Chancre, a case of multiple, 37.

Chapman, H. W., hyoscine and scopo-
lamine, 153.

Charcot's Library, 1037.

Charities, report of the State Board of,
272.

Chenopodium, the oil of, as a vermi-
fuge, 663.

Chicago ambulance surgeons, 572; ap-
propriation for medical inspectors
in, 190; contagious diseases in, 235,
401 : emergency health conference
in. 318; emergency hospital in, 527;
health matters in, 441 ; hospital for
tuberculosis. 694; infectious dis-
eases in, 273 ; medical colleges to
be inspected, 528; mortality in,
610, 994 ; new health commission
of. 993 ; scarlet fever in, 572 ; sui-
cides in. 993 : the Children's Hos-
pital Society of. 401.

Chicago Medical Society. 1080.

Child birth, invalidism following. 326;
labor bill. 655 ; labor bill, a new, 190 ;
labor bill signed, 820; labor law,
Xew York State. 234: the relation
of the physician to the defective
school. 967 ; the status of the, 966.

Children, backward. 911 ; etiological
factors in backward, 226.

Children's Hospital Society of Chicago,

. J57-

Chimpanzee, yellow fever in the, 243.

China, attempted reform in, 107 ; fam-
ine in, 906.

Chloroanemia of infants. 871.

Chloroform anesthesia, muscular spasm
under. 829 ; the decomposition of,
861.

Chloroma, a case of. 952 ; with ocular
symptoms, 200.

Cholecystectomy, indications for, 120.

Cholera, bacterial diagnosis of, 662;
the treatment of, 783.

Cholin and the jr-rays, the effect of
on pregnancy, 579.

Chorea, an unusual symptom in, 782;
maniacal, 829.

Chorioiditis, rare forms of, 728.

Christian Science in Delaware, 611;
science in Delaware, 487.

Christian Scientists, an endeavor to
save the lives of. 862.

Chroniatophore cells and Langerhans'
cells in the skin, 619.

Chylothorax. a cose of, 1048.

Cigarettes, Illinois bill against, 994.

Cigars, hygienic. 993.

Cincinnati Academy of Medicine, 358,
442.

Circulation, misconceptions in the path-
ological physiology of the, 280.

Clapp. Herbert C. diet in pulmonary
tuberculosis. 1074: pulmonary tu-
berculosis : some of the details of
its modern hygienic treatment
which can be applied in treating
the patient in his own home, "17.

Clark, L. Pierce, the experimental ef-

fects of tobacco upon the nervous
system. 1072.

Clavicle, fracture of the, 161.

Cleaves, Margaret A., the physiological
action of the pancreatic enzymes,
with special reference to hematol-
ogy, urinology, and clinical pathol-
ogy-, 88s.

Cleghorn, Charles D., notes on 6,000
cases of neurasthenia, 681.

Climate, the search for a suitable, 839.

Climatotherapy and urban hygiene, con-
gress on, 67.

Clinical society, a new, 737.

Clinical Society of the Jewish Hospital,
778.

Cocaine bill, 777; bill restnctmg sale
of, passed, 571 ; in India, 235 ; sell-
ing and bottle washing, 234; sub-
stitutes, the value of, 147 ; the ef-
fect of injections of on the sensi-
bility of the abdominal organs, 953.

Coe, H. C, pathology of gonorrhea in
women. 684 ; report of a case of in-
operable round-celled sarcoma of
the ovary, 436.

Coley, William B., report of a case of
inoperable round-celled sarcoma of
the ovary, 436.

Colitis, mucous and membranous, 826,
952.

College of Physicians and Surgeons,
the. 651; centenary of, 862, 1037.

Colles' fractures, a method of reducing
old. 833.

Collins, Joseph, influenza in its relation
to diseases of the nervous system,

337-
Colon, bacillus, general infection by the,
532; diverticulitis of the, 920; idio-
pathic dilatation of the, 495 ; in-
flammatory new growths of the,

1045-

Colopexy, 914.

Colored physicians, exhibit of, at
Jamestown, 655.

Colostomy, practical points in the oper-
ation of, 49.

Columbia University, 993 ; faculty,
changes in the, 822.

Coming events cast their shadows be-
fore, 358.

Connecticut, insanity in, 235.

Connecticut State Homeopathic Med-
ical Society, 946.

Constantinople, letters from, 324.

Consumption, the pretuberculous stage
of. 494-

Consumptives, the public attitude to-
ward, 1078.

Copenhagen, letters from, 279. 447. 742.

995-

Coprologj', the application of the new
methods of to the diagnosis of in-
testinal diseases, 773.

Cord lesions, bladder symptoms in re-
lation to, 532; surgery of the
spinal, 408.

Cornea, pyocyaneus ulcer of the, 999.

Corneal grafting, 314.

Coronary arteries, the, 991.

Coroner's office, statistics of the, (A;
physician's bill, 993.

Correspondence, Areouipa. 112; Berlin,
71. 323, 491, 781. 1082; Constanti-
nople, 324; Copenhagen, 279, 447,
742, 995; London, 25, 69. in. 153,
193, 239, 277, 322, 362, 405, 455. 490,
530. 574. 614. 657. 697, 740, 779. 824,
864. 908, 948, 996. 997, 1039. 1081 ;
Manila. 27, 155, 195, 325. 363. 492-
6?8. 825. 865. 909, 949, 998. 1083;
Paris, 70, 278, 446, 741. 825: Vi-
enna, 154, 406, 492. 616, 910. 1040.

Coryza. recurrent in children, 239.

Cotarnine phthalate. observations on
the use of, 493.

Cottam. Gilbert G., the specific gravity
of the urine, 362.

Cough, the education of the, in tuber-
culous patients, 233.

June 2(j. 1907]

INDEX.

1099

Counter prescriber prosecuted, 357.

Coyle, John G., venereal disease in the
Continental Army, 779.

Criminals, a bill to prevent procreation
of, 486.

Crothers, T. D., a medico-legal study
of a morphiamaniac, 99; some ef-
fects of spirit and drug taking on
the upper air passages, 939.

Crutcher, Howard, operation for in-
testinal obstruction in a child of
fifty-five hours, death in seventeen
hours, 650.

Cuba, quarantine against, 994.

Curtis, G. Lenox, the abortive treat-
ment of pneumonia, 428.

Cyanosis, the treatment of general, 113.

Cysticercus cellulose in the tongue of
a child, 419-

Cystine calculi two cases of, 495.

Cystocele, a new operation for, 749.

Cystoscopy in urinary tuberculosis, 782.

Cytodiagnosis in tuberculous menin-
gitis, 892.

D.

Dana, Charles L., brachial neuralgia

and arm pains, 297.
Dare's hemoalkalinoraeter, inaccuracy

of, 858.
Death, acidification of the viscera as a

sign of, 128; certificates defective,

106; penalty abolished in .Kansas,

235-

Delirunn tremens, the treatnuiit of,
283, 1043.

Dementia paralytica, report of two
cases of, S; precox, a general con-
sideration of, S3.

Denslow, L. N., locomotor ataxia ; a
new theory as to its cause, 985.

Dentists, none for the naval service,
318.

Dermatitis, Japanese lacquer, 657 ; pap-
illaris capillitii, 374.

Derniatological congress in New York,
the, 485 ; transitions, 640.

Desmoid test again, the, 526.

Diabetes, a case of phosphatic, 792; al-
cohol in nutrition in, 315; and
pregnancy, the relations between,
703 ; cardiac and vascular accom-
paniments of, loi'i; experimental
researches on, 830; insipidus, a
case of, 331 ; mellitus, a case of,
331 ; pancreatic due to autoinfec-
tion, 272 ; surgery in, 722.

Diabetic gangrene, indications for oper-
ation in, 609.

Diagnosis, symposium on, 788.

Diaphragm, the height of the, as a
guide to the circulation, 829.

Diarrhea and dysentery, the turnip-top
treatment for, 449; the treatment
of nervous, 785.

Dickey, W. A., diagnosis and treatment
of gastric ulcer, 1066.

Dickinson, G. K., the house fly and its
connection with disease dissemina-
tion. 134.

Dictatorial methods, the offensiveness
of in editing official journals, 486.

Dietetics, a graphic method in, 690.

Digestion, nervous disturbances accom-
' panying, 409.

Digitalis heart block, 7^ ; preparations,
the efficiency of, 356.

Dillon, Charles J., report of three epi-
demics of measles with particular
reference to Koplik's symptom and
its relation to the rash and the in-
itial fever, 264 ; working formula;
to facilitate the percentage modifi-
cation of milk, 60.

Diphtheria, formic acid in, :86; of
birds, the serum treatment of, S70;
toxin, duodenal lesions in guinea
pigs inoculated with, 617; toxin,
the presence of in the blood, 244 ;
unrecognized in children, 867.

Uipsophilia, 947.

Disease, remarks on the treatment of

and so-called "authorities," 1029;

the prevention of, 391.
Ditman, Norman E., the theory of the

toxic origin of pernicious anemia,

175- ^ „

Diuresis, the life saving value of, 835.

Diver's paralysis with scarlet fever, 73.

Dock, George, Dr. Knopf misquoted,
864.

Dorsal foot reflex, the, 1044.

Doty, appointment of Dr., 402.

Douglas. Richard, the treatment of
acute diffuse peritonitis, 302.

Dourine, the trypanosome of. 947.

Doyen, the suit against Dr., 319. 357. _

Dracontiasis, etiology and prophylaxis
of, 243.

Dropsy, the causation of renal, 817.

Drug eruption, with unusual manifesta-
tions, 869.

Drum membrane, paracentesis of the,
626.

Duality of man, the, 104 1.

Duodenal fistula, its surgical treatment,
412.

Duodenum, congenital stenosis of the,
1046 ; myxofibroma of the, 582 ;
perforation of the by a hairpin,
115; ulcer of the, diagnosis and
treatment of, 85.

Dupuytren's contraction cured by med-
ical moans, 144.

Dusts, industrial, 611.

Dutton memorial, for a, 612.

Dysenterv, tli' scruni trc itimrt of. 399.

Erdmann, John F., appendicitis in in-
fants and children, 759.

Eructations in heart patients, 660.

Erysipelas, tubercle and, looi.

Erythema induratum, 783 ; nodosum,
the etiology of. 4Si-

Erythromelalgia, 951.

Esophagus, cured stricture of the, 413 ;
diverticulum of the, 496; the re-
moval of foreign bodies from the,
672 ; the surgical anatomy of the,
750.

Esperanto, 437, 614.

Ethyl chloride, the present status of, as
an anesthetic, 570.

Eustachian tube, the, its anatomy,
movements, etc., 931.

Examinations, the evils of, in medical
education, 523.

Expert testimony, remarks on medical,
181 ; to control, 655.

Eye bath, a sterile, 212.

Eyeglasses for school children, 571.

Eyelids, syphilitic lesions of the, 202.

Eyes, the examination of students', S^'S-

Eyesight in relation to compensation,
114-

Eyestrain and epilepsy, 783 ; and other
diseases due to crossing, crowding,
and damming of the retinal ves-
sels, 893 ; as the cause of headache,
72, 533; "1 school children, 999;
mistaken for appendicitis and gall-
stones, 1041.

Ear, hints on the treatment of the
middle, 564; intranasal conditions
in the etiology of diseases of the,
261.

Eclampsia, renal decapsulation in, 290;
renal decapsulation for, 859 ; the
connection of lactic acid with, 534.

Eczema, diet in the treatment of, 44;
neurotic, 34; neurotic, with general
alopecia, 373.

Edema, acute pulmonary, 776; angio-
neurotic and other essential in chil-
dren, 625.

Edgar. J. Clifton, gonorrhea during
pregnancy, 687.

Education considered from a medical
point of view, 196; popular in mat-
ters medical, 857.

Ege white, the effects of on animals,
836.

Einhorn, Max, a new blood test, 937.

Electrntraumata, somatic and psychic,
588.

Elixir?, the dangers of, 609.

Embalming fluids, poisonous, 235.

Embolism. 434: coincident of several
arteries, 701.

Empyema in children, loio; the surgi-
cal treatment of, 4.^6. 1060.

Endocarditis, chronic bacterial, 8r,
acetosalicylic acid in rheumatic,
577 : infective, cured by a vaccine,
449: mycotic with emboli, 455,

Endothelioma of the skin, 112.

Endurance and diet, 525.

Enteritis and appendicitis, 746.

Enzymes, the physiological action of
the pancreatic, 885.

Eosinophilcs, diagnostic value of the,
in the blood, 560.

Epididymitis, antigonococcus serum in,
197 ; treatment of gonorrheal, 63.

Epilepsy, strontium bromide in the
treatment of. 608: the etiologv of,
189.

Epispadias, a new method of operation
for, 505.

Epithelioma of the eyelid treated by
radium. 330.

Facial hemispasm of peripheral origin,
937-

Famine in China, 235.

Fanoni, Antonio, a case of intestinal
obstruction due to persistence and
anomaly of the urachus ; opera-
tion; recovery; 900.

Farmers, rebellious, 572.

Fat necrosis, observations on, 243.

Federal Food and Drugs Act, the scope
of the. 28.

Federal Health Board, for a, 693.

Feild, Edward E., the prevention of
disease, 391.

Femur, fractures of the, 113.

Feuger, memorial to Dr. Christian, 20,
108.

Ferrer, Jose M., brief report of a case
of trichiniasis, 351.

Fetal malformations, 62.

Fever, hemoglobinuric, 951 ; hysterical,
736; long continued, 1088; the con-
tinued, of Georgia, 963.

Fibroid, degenerating, complicating
pregnancy, 622.

Field, C. Everett, a sterile eye bath,
212.

Filaria among the troops in Jamaica,
158.

Finger, traumatic amputation of. 412.

Fire department, board of surgeons for
the, 822.

Fischer, Louis, recurrent cory-za in
children. 239.

Fisher, Jessie W., report of two cases
of dementia paralytica, one asso-
ciated vv-ith a large hemorrhagic
lesion, the other with atrophy of
the optic tract, 5.

Fist foot from the viewpoint of neurol-
ogy, 57-

Florida State Medical Association, 739.

Fly, the house, and disease dissemina-
tion, 134.

Food and drug inspection, board of,
7.37-

Food, and drug inspectors needed, 108;
factor, the, of the twentieth cen-
tury, 283.

Forceps, a pair of, in the abdominal
cavity for ten years, 366.

IIOO

INDEX.

[June 29, 1907

Formal deliyde, ammonia for counter-
acting the fumes of, 576; disinfec-
tion, dangers of fire in, 867; in the
disinfection of rooms, 112.

Foster, death of Sir Michael, 236.

Foster, Nellis B., the stomach tube in
diagnosis.

Fowler, in memory of Dr., 529, 612,
696.

Fractures, delayed union in, 797; motor
boat. 412.

France, foreign physicians in, 611.

Frankfort, a new university in, 236.

Fresh air treatment in hospital wards,
213, 246.

Fridenberg. Percy, mental symptoms in
nasal affections, 1071.

Friedman, G. A., on localization in
multiple intestinal obstruction, with
illustrative case, 512.

Frischbier, Charles P., pes planus from
the viewpoint of neurology, S7-

Frontal lobes, the right and left, 196.

Frost bite, the treatment of by hyper-
emia, 944.

Frozen feet, the treatment of by therm-
aerotherapy, 127.

Funk, W. A., the venereal peril, 613.

Furniss, Henry D., a new gas ether in-
haler, 755.

Furniss, John P., uterus of the opos-
sum, 770.

Furunculosis, antistaphylococcic serum
ill. 450.

Gall-bladder, hernia of the, 784.

Gall-duct obstruction caused by mov-
able kidney, 966.

Gallstones, intestinal obstruction due
to, 953-

Gangrene, the treatment of, 783 ; treat-
ment of, 746; the treatment of se-
nile, 122.

Gas ether inhaler, a new, 755 ; the ef-
fect of cooking by, 317; poisoning,
the differential diagnosis of, 116.

Gastric chemisra, changes in, following
gastroenterostomy, 115; disorders,
the medical and surgical treatment
of. 250; muscle, insufficiency of
the, 765.

Gastritis, chronic, 699.

Gastroenterostomy, the dangers of, 231 ;

the effect of on gastric digestion,

315-
Gastrointestinal cases, obscure, 1042;

diseases of infants, weight and

temperature in, 870.
Gastrojejunostomy, the results of, 1006.
Gastroptosis as a factor in tachycardia,

195-
Gastroscopy, 549.

Gates, Manley F., Japanese lacquer
dermatitis, 657.

Genius and hydrocephalus, 821.

Georgia State Medical Association, 739.

German Hospital and Dispensary
prizes, 694; mechano-therapy ap-
pliances for the. 103S.

Gibb, W. Travis, criminal aspect of
venereal diseases in children, 643.

Gigantism, resection of a femur tor,
797-

Gilbert, J. L., sulphate of copper in ty-
phoid fever, 531.

Glands, enlargement of the epitro-

chlear in children, 332.
Glove of rubber, the hand of iron in

the, 394. 415; the use of rubber,

410.
Glycosuria, the prognosis of transient

spontaneous. 82: the refraction

changes dependent on, 633.

Goiter, aberrant, 535; bilateral, 582; ex-
ophthalmic, 484 ; exophthalmic and
pseudoleukemia, 869; exophthal-
mic, observations on the treatment
of, 976; exophthalmic. Roentgen
ray treatment of, 869; exophthal-
mic, symposium on, 1004; exoph-
thalmic, the heart in, 75; removed
under cocaine anesthesia, 828; the
surgical treatment of, 206; thymol
in the treatment of, 1037.

Gonococcus serum, specific bodies in,
32.

Gonorrhea during pregnancy, 687, 708;
in women, pathologi,' of, 684, 706;
in women, symposium on, 706; the
effects of maternal on the off-
spring, 606; the ocular complica-
tions of, 197 ; the treatmyit of, 439.

Gonorrheal invasion of the uterus and
Fallopian tubes, 706.

Gordon, Alfred, abnormal response to
an irritation of the motor area of
the brain, 1032.

Georges, W. C, sanitary work on the
Isthmus of Panama during the last
three years. 801.

Gould, George M., eyestrain and other
diseases due to crossing, crowding,
and damming the retinal vessels,
893 ; the refraction changes depend-
ent upon glycosuria. 633.

Gout, suppressed, 672.

Gouty diathesis, treatment of the. 830.

Grsef. Charles, the eye and ear compli-
cations of influenza, 688.

Greek medical writers, a complete edi-
tion of the ancient, 153.

Grenfell, compliment to Dr., 1037.

Grifiith, Frederic, fiddle-bow surgical
drill, 296.

Gross. M.. insufficiency of the gastric
muscle, 765.

Gynecology, sins of omission and com-
mission in, 1013.

H.

Hall, James K., prolapse of the rec-
tum, an operation for, 601.

Hands, operations on the, 410.

Harlem and Fordham Hospitals, 738;
hospital, a new, 1038.

Harlem Eye, Ear and Throat Infirm-
ary. 191.

Hartzell. M. B., a case of extensive leu-
coplakia beginning in childhood, ac-
companied in the early stages by
follicular keratosis of the skin, and
followed by carcinoma of the
tongue, 229.

Harvey Society lectures. 150. 402 ; the
fifth. 22: the sixth. 151; the sev-
enth. 192; the eighth. 320; the
ninth, 360; the tenth, 488.

Hawaii, medical legislation in. 190.

Hay fever, observations on. 451 ; the
antrum of Highmore in the produc-
tion of. 841 ; the treatment of. 701.

Haynes, Irving S., the treatment of
fracture dislocations of the spine,
472.

Headache and eyestrain. 276; causation
.Tud treatment of. 327.

Health Defense Lea.gue incorporated,
487.

Health Department, dispensary, a new,
234; public control of disease
through a national, 102.

Health, insurance in Holland. 777; lec-
tures on public, .=;7i.

Hearing, the preservation of. 349.

Heart, acute overstrain of the, 744; a
method for determinin.g the mobil-
ity of the, 8,w; a new method for
e.xamining the, 905 : beat, natholog\'
of the. 535 ; block, inspection of the
jugular vein in. 577: changes in
the position of the, in hydrothorax.
671 ; chronic muscular diseases of

the, 867; disease, electricity in
the treatment of, 399; disease,
treatment of, by removal of chlo-
rides, 580; diseases, treatment of
chronic, 543; sounds, reduplication
of the, 29; rupture of the, 579; su-
ture of the, 316; the effect of Ger-
man university life on the, 820 ;
trauma of the, 148; treatment of
acute affections of the, in child-
hood, 589.

Heel, painful, 157.

Heineman, H. Newton, observations on
arteriosclerosis, 673.

Heiser, Victor G., leprosy in the Phil-
ippine Islands and the present
methods of combating the disease,
934-

Heller's test, a simplification of, 283.

Helminthiasis, the diagnosis of, 569.

Hematocolpos and hematometra, 106.

Hemiatrophy, the pathogenesis of fa-
cial, 156.

Hemolysin, a complex from the pan-
creas, 785.

Hemoptysis, amyl nitrite in, 440, 700.

Hemorrhages, the cause of subcuta-
enous, 943 ; the treatment of by di-
rect transfusion of similar blood,
121 ; the treatment of gastric and
intestinal with gelatin, 244.

Hemorrhoids and prolapsus ani, the
cure of, 74; congenital, 1042; the
treatment of, by injections of car-
bolic acid, 496; treatment of bleed-
ing. 544-

Hemothorax, a case of, 874.

Hepatic autolysis, the influence of col-
loidal metals on, 328.

Heredity, recent studies in, 826.

Hernia, a new operation for the
radical cure of. 207 ; opera-
tion for strangulated, on shipboard,
4o8;operations. local anesthesia in,
583 ; radical cure of umbilical. 951 ;
the diagnosis of femoral, 75 ; treat-
ment of large umbilical, 283.

Herpes simplex, 407.

Heubner. O.. the. problem of infant
feeding. 1022.

Hip, the bloodless treatment of congen-
ital dislocation of the, 668.

Histological finding, a rare, 1037.

Hodgen. in honor of Dr., 656.

Hodgkin's disease and sarcoma, 617; a
type of sarcoma. 163.

Hollis. Austin W., the theory of the
toxic origin of pernicious anemia,
175-

Hospital conference, 359; construction,
modern, 418; gifts to, 109, 529. 573,
612; system, for New York, a plan
of organizing a, l; transfers, 357;
transfer bill passed, 402. 945 ; trans-
fer bill vetoed, 820.

Hospital Saturday and Sunday Associ-
ation. 738.

Hudson-Makuen. G., intranasal condi-
tions as bearing upon the etiology
of the diseases of the ear, 261.

Hydrastis, the value of, 518.

Hydrocephalus, internal, 660.

Hydrogen dioxide, catalysis of, 914.

Hydrops, intermittent articular, 702.

Hydrosalpinx, torsion of a, 522.

Hydropathy, a chair of. 654; a chair of.
at Columbia. 402 : a conference on.
993 ; during the climacteric, 663.

Hydrothorax, cardiac, 1089.

Hyoid bone, injuries and diseases of
the. 165.

Hyoscine and scopolamine, 1.^3 ; sleep,
the. in obstetric practice, 58.

Hypertonia vasorum. the southern
Maine climate for, 700.

Hypolaryngoscopy, 1000.

Hysterectomy, comparative advantages
and disadvantages of, 118: vaginal
for peritonitis following abortion,
334-

Hysteria in children, 365.

June 29, 1907]

INDEX.

IIOI

International Congress of Physio-
Chemistry, 738.

International Congress of Physiolo-
gists, 822.

1 Congress of Physiothera-
py. t3io.

International Congress on School
Hygiene, 275.

International Congress on 1 ubcrculo-
sis, 778.

International Dermatological Congress,
the sixth, 109.

International Medical Congress, the
sixteenth, 610.

I.

Ice, Hudson River, 317. 40i, 441 ; to tes; ^^^^

Hudson River, 235; inspection, for Internationa
State, 273 ; the State s supply, 570.

Ichthyosis and its treatment, 409-

Identification, a new system of, 611,
1065.

Idiocy, epileptic, with cerebral sclero-
sis, 29.

Illinois State Board of Health confer-
ence, 737.

Illinois State Medical Society, 907. ^...,^.„...,

Illinois State University Medical international language, for an. 821,

School, 441- International Laryngo-Rliinological

Illustrations for medical journals, 521; Congress; 863.

how may medical be improved? international Medical Association for
966. the Prevention of War, 778.

Immigrants, medical inspection of. 73S- international Medical Society for the

Immigration statistics, 67; the relation Suppression of War, 655.

of, to the prevalence of insanity, international Red Cross conference,
651 ; to control, 21.

Immunity and infection, the physical
processes of, 364.

Impetigo contagiosa. 1041.

Incurables, a new home for the, 655.

Infectious diseases, the heart in, 1090.

Index Medictts, the, 861.

Indian Territory twenty-third district
Medical Society, 191

^°i7- . . . ,
Intestinal antisepsis in fevers, 401 ; an-
tiseptics, the action of. 835; atony,
localized, and neurasthenia, 289;
bacteria; the toxicity of and how
to determine this, 7; canal, protec-
tion against infection from the, 99,
992; disturbances, the blood in in-

-- ,, - J ■ -c fantile, 29.

Indicanuria, its etiology and signih- intestinal obstruction, clinical observa-
tions on, 206; diagnosis and treat-
ment of acute, 290; due to per-
sistence of the urachus, 900; in a

cance. gtio. 1039.

Indigestion, its significance and diag-
nosis, 493.

Industrial diseases, 526.

Inebriety, the insanity of, 155-

Infant feeding, eggs in, 1043; starch
in. 1048; symposium on, 873; mor-
tality in large cities, 690; sanitary

K.

Kakels, M. S., a new .v-ray table, 586.

Kansas State Medical Society, 863.

Keen, honors for Prof, William, 655.

Kelsey, Charles B., practical points in
the operation of colostomy, 49.

Keratosis from arsenic, 415; of the
oalms, 415, 416.

Kernigs sign in infancy, 1047.

Kidney and spleen, hydatid cysts of
the. 485; disease, diagnosis of, 662 ;
rupture of the, 920 ; stone, a gigan-
tic, 75; stones, surgical treatment
of, 115; traumatic decapsulation of
the 168.

Kieffer, iMajor Charles F., an early case
of formal operation for the separa-
tion of joined twins (xiphopagus),
566; a new streptothrix. patho-
genic for cattle, 346; malignant dis-
ease and malaria, 678.
Knee jerk, an aid in eliciting the, 440;

methods for reinforcing the, 244.
Knopf. Dr., misquoted, 820, 864.

Labors, difficult, and epilepsy, 148.
Lacquer, dermatitis, from Japanese, 657.
Lacrymal apparatus, atfections of the,

265; sac, epithelioma of the, 800;

sac, extirpation of the, 663.

child of fifty-five hours, operation Ladinski, Louis J., diagnosis of early

and death, 650; in children, 405;
localization in multiple, with a case,
512, 1043; symposium on postoper-
ative, 1006.

conditions in relation to, 366; the Intussusception, acute, 450,

problem of, 1022.
Infantile atrophy, the etiology of, 967-
Infants, alteration of nutrition of, 17;

lungs, the flotation test of, 283 ; the

breast feeding of. 654.
Infection, steam in the local treatment

of. 407.
Infectious diseases, domestic animals in

Iowa State Homeopathic Medical Asso-
ciation, 863.
Iowa S'tate Medical Society, 907.
Iroquois Memorial Hospital in Chicago,

'^'54- ., - . . -

Isaacs, A. E., treatment of acute septic Laryngology, new prize fund in, 822,
perforative peritonitis, 68, 575- Laryngoscopy, subglottic, 271.

pregnancy with reference to a par-
ticular sign, 597-

Laminectomy, 448.

Laparotomy, autointoxication follow-
ing, 440 ; how long shall the patient
stay in bed after? 364; patients, the
management of, 122, 241, 1049; pa-
tients, when should they get up?
198; vascular lesions following. 868.

Laryngeal stenosis, the treatment of,
'496.

the etiology of. 693 ; further study isoa„gii,tination of human corpuscles. Larynx, partial discoloration of the

of the new, 242; in schools, 318;
the treatment of certain chronic,

123-

Inflammation, the cause of aseptic pu-
rulent. 1036.

Inflammatory masses in the abdomen
simulating malignant growths. 792.

Influenza, a complicated case of, with Italian hospital, for new, 7/8; pnzes
autopsy, 385; and epistaxis, 366; 737-

Andrew Lang on, 316; an original Italy, bloodshed in, 656.

198; the diagnosis and treatment
Isopral and chloral, comparative actions ^^^°^ ^"grans^Viasef f, 874.

°'' °77- Lead poisoning from projectiles, 1078;

Isthmus of Panama, health conditions the early diagnosis of, 399-

on the, 737: sanitary work on the. Lectures, public, at the Academy of
during the last three years. 801. Medicine, 148.

Lederer, Ernst J., the milk supply of

J.

investigation of an epidemic of,
followed by many cases of pneumo-
nia, 11; hepatic abscess following.
1044; in Baltimore, 108; in its
relation to the diseases of the
nervous svstem. 337, 369; severe
ocular pain in, 782: symposium on, Jackson, Chevalier, gastroscopy, 54Q.

Jacobi, A., reminiscences of medical
practitioners in New York during

Vienna, 986.
Leg, reunion of an almost severed, 408.
Legislators, medical, of tw^o republics,

911.

369; the eve and ear complications
of, 688; 'the treatment of. 312;
treatment of in children, 840.
Inguinal canal, tumors in the, 449

Ivy, poison, 61.

Leishmann-Donovan disease, 840,
Lepers, Chinese, in Canada, 821.
Leprosv, a suggestion in regard to the
treatment of, 775. 1044; inocula-
tion of animals with, 830; in Rus-
sia, 108; in the Philippine Islands,
934; intestinal origin of, 784.
the period of the earlv history o'^f Leucocyte counts in gynecology, 78; the
the Academy 129 value of differential, 493.

Insane, overcrowding in hospitals for Jacobi, in memor'y of Dr. Mary P.. 66. Leucopjak.^a a case of beginni^^^^
the. ISO; patients, attacks on. 528; Jacobson, Arthur C, the cause and cure ^f the ton-ue '29

patients, transfer of, 655. of cancer, 558. "

Insanity in murder trials. 693 ; in wom- Janet. Pierre, a disturbance of vision
en, 533 ; lectures on, 66, 189, 272, due to exaggeration of binocular

357; the early diagnosis of, 499; association, 757.

the treatment of incipient cases of jg^vish Hospital for Deformities and
in general practice. .534. joint Diseases, 191.

Inspectors, new medical, appointed. 235. j^j^^j disease, diagnosis of rheumatoid,
Interauricular insufficiency. 1045. 241 ; diseases, osteoatrophic changes

International Congress of First Aid to in chronic, 196; infections, non-

the Injured 737 tuberculous. 200; mice. 905; views

International Congress of Hygiene and on diseases of the, .^o.

Demography, 610. Journal of Inebriety, the, 319.

International Congress of Infant Hy- Journal of the American Medical Asso-
ffiene 318 elation, how the earnings of the

Inteniational Congress of Psychiatry, should be expended, 527.

etc, 655, 994. Journals, new, 487.

Leuf, A. H. P., headache and eye-
strain, 276.

Leukemia, acute, 1044; and septic infec-
tions, 1036 ; with attacks of fever,
746.

Leukoplasia of the vulva, vagina, and
uterus, 296.

Lewis. Bransford. air distention of the
bladder. 321.

Licensing Board, bill for the creation
of a single in New York State, 499.

Light, the action of baths of, on the
blood, 663.

Limbs, conservative surgery of the,
827.

II02

INDEX.

[June 29, 1907

Lincoln Hospital, new property for, 694.

Link, Goethe, acute edema of the phar-
ynx, with report of a case requiring
rapid tracheotomy, 350.

Linne, the bicentennary of, 821.

Lip, a method of operation on the. III.

Lister, birthday of Lord, 611; in honor
of Lord, 694.

Little's disease, a case of, 455.

Liver, alteration of the, in the new-
born, 902 ; patholoCT of the, in car-
diac disease, 157; protective func-
tion of the, against intestinal tox-
ins, 619; the temperature in cancer
of the, 366; typhoid abscess of the,
663.

Lloyd, Samuel, fracture dislocation of
the spine, 465.

Lodgings, filth in cheap, 821.

London, letters from, 25, 69, 11 1, 153,
193, 239, 277, 322, 362, 405, 445, 490,
530, 574, 614, 657, 697, 740. 779, 824,
864, 908, 948, 996, 1039, 108 1.

Long Island Medical Journal, 359,

Loomis, Henry P., pyrexia in tubercu-
losis, 1019.

Los Angeles medical library, 357.

Louisiana State University Medical
School. 993.

Lunacy Commission, report of the
State, 190.

Lunatic, the criminal, 205.

Lupulin, 311.

Lupus erythematosus disseminatus, 38;
vulgaris, 73, 374 ; vulgaris, the x-
rays in, 241.

Lymphatic infections, the course of,
567.

Lymphoid changes in infectious dis-
eases, 576.

Lymphosarcoma and Hodgkin's disease,
1087.

M.

MacKee, George M., a report of four
luetic cases unassociated with ob-
servable secondary manifestations,
563.

MacMurrough, F. K., ten years a nasal
patient, 143.

McCampbell, Eugene F., a general con-
sideration of dementia praecox, 53.

McCaskey, G. W., streptococcus pneu-
monia, 262.

McCourt, P. J., the treatment of la
grippe, 312.

McCullough, John \V., pilocarpine in
pruritis, 947.

McGill University, another fire at, 693;
medical building. 993 ; Medical
School, 528.

McGrath, John J., resection of the sig-
moid flexure, 216.

McWilliams, Clarence A., a method of
reducing old CoUes' fractures;
stiffness following apparent contu-
sions of the elbow, 853.

Macdonald, memorial to the late Dr.,
191.

Magnet operations on the eye, 450.

Maher, Stephen J., what are acid fasts?
1027.

Malaria, 494; and cancer, 67S; menin-
go-cerebellar sjmdrome in, 870; sul-
phur in the treatment of, 483 ; the
cerebellar syndrome in, 116.

Manganese poisoning, 1043.

Manila, letters from, 27, 155, 195, 325,
363, 492, 658, 82s, 865, 909. 949, 998;
medical college at, 945, 1083.

Marine Hospital examinations, 356.

Marple, Wilbur, B., the ocular lesions
of general arteriosclerosis, 421.

Martin, A. J., illustrations for medical
journals, 521.

Mason, Robert, aromatic sulphuric acid
in toxemia, 448.

Massachusetts Homeopathic Society,
696.

Massachusetts, medical practice bill in,
149-

Massage, physiological action of, 139.

Mastitis, the Bier treatment of, 398,
785 ; the prevention of puerperal,
756.

Mastoid operation, the, for the cure of
chronic middle ear disease, 425;
the radical, 577.

Mastoiditis, symptomless, followed by
meningitis and death, 600.

Masturbation, pseudo, in infancy, 1047.

Measles in the navy, 528; Koplik's
symptom in three epidemics of, 264,
286.

Meat diet, the influence of excessive on
the osseous system, 29; examina-
tion of canned, 945 ; poisoning in
Berlin, 663.

Mediastinal tumors, the x-ray treat-
ment of, 746.

Medical bill, the New York, 353 ; cases,
the hygiene of, 835; evidence, lim-
itations of. 242; examination law,
the new, 820; libraries. State aid
for, 201 ; news in the daily press,
107 ; organizations, the evil con-
sequences of bossism and oppres-
sion in, 570 ; society, what a, should
be, 400; staff, the, in hospitals, sym-
posium on, 371 ; unification bill,
777-

Medical Society of the County of
Kings, officers of the, 236.

Medical Society of the County of West-
chester, 4815.

Medical Society of the State of New
York, 189.

Medicine, address on State, 961 ; an im-
portant decision regarding the
practice of, 270; education, and
social work, their relations, 542;
oration on, 958; the evolution of
the idea of experiment in. 788; the
triumph of scientific, 950.

Melanotic growths, the pathology of,
700; pathology of, 745-

Melanuria, 050.

Mendeleef, death of Prof. Dmitri. 236.

Meniere's disease, differential diagnosis

?^- .913-

Meningism as distinguished from men-
ingitis, 576.

Meningitis, bacteriology of, 1047; cere-
brospinal. 345 : cerebrospinal, the
opsonic power of the serum in,
86g; cerebrospinal, two cases of,
288; diphtheria bacili in, 28; in
Glasgow. 94,S : in Great Britain.
235, 258; the prophylaxis of, 691,
loio; the suppression of, 655; tu-
berculous. 617; tuberculous with-
out tubercles, 736.

Meningococcus and the gonococcus, the.
146; the presence of the. in the
circulating blood, 526.

Menopause, death at the, looi.

Menstruation, acute illness during. 282.

Mental development, arrested, 604 ; re-
sponsibility and crime, 826.

Mentally unstable, the, in Illinois. 189.

Mercury, experiments with colloidal,
914; the passage of from mother to
fetus, 400.

Merycism in man. 4.S0.

Mesentery, holes in the, 660.

Methylene blue, the passage of. from
mother to fetus, 494-

Metric system, the, 868.

^fetritis, dissecting puerperal, 944.

Mexican Medical Congress, 610.

Meyer. William, Koch's emulsion of
v-.-.n; ;„ jj^g diajrnosis of incipient
-.ibercuiosis, 307.

Michigan S'tate Board of Health, 738.

Michigan State Homeopathic Medical
Society, 946.

Midwife convicted as a nuisance, 67.

Midwifery, resolutions endorsing State
laws to regulate, 369.

Migraine, ophthalmophelegic, of hered-
itary origin, 330; treatment of.
1045.

Migrainic psychoses, 73.

Milk as a carrier of infection, 500, 699;
as a hemostatic, 107 ; booths for
park, 737, 1037 ; commission, a new,
610; commissions, medical, 86i ;
Commission, the New York City.
906; Committee, report of the
Washington, 905 ; infection as a
cause of tuberculosis in children,
.367 ; modification, formulae to fa-
cilitate, 60; pasteurized, 990, 1079;
question, the, 400, 486; question in
Illinois, the, 318; question in New
York, the, 318; symposium on,
877 ; the absorption of odors by,
61 ; the caloric value of, in infant
feeding, 1048; the digestion of by
infants. 743; the ferments of, and
pasteurization, 968; the importance
of mother's in infancy, 451; the
pasteurization of for New York
City. 501 ; the problem of pure,
269.

Milk supply of cities, 1008; of Copen-
hagen, the, 995; of London, the.
996; of New York, the, 524; of
Vienna, 986; report on, 272; reso-
lutions regarding the, 527.

Miller, F. E., local anesthesia for nasal
and aural operations, 404; observa-
tions on an ideal local anethesia for
submucous resection, 301.

Mills. H. Brooker, influenza; mastoid
abscess ; leptomeningitis ; nine-day
unconsciousness; three operations;
death; autopsy, 385.

Mississippi State Medical Association,
69s.

Mitral valves, pseudostenosis of the,
569.

Mobilization of patients, the early,
after major operations, 476.

Mobius. in memory of. 656.

Montana State Medical Society, 995.

Morphea, 416.

Morphiamaniac, a medicolegal study of
a. 99.

Morphinomania, treated with atropine
and strychnine, 952.

"Morris appendix," the true, 823.

Morris, Robert T., harmless involution
of the appendix. 355 ; medical treat-
ment of appendicitis. 322 ; the hand
of iron in the glove of rubber 394;
the true "Morris appendix." 823.

Morton, William James, preoperative
radiation and surgical treatment of
cancer, 815; trypsin for the cure of
cancer, no.

Moschcowitz. A. V., the radical cure of
trigeminal neuralgia, 360; the rad-
ical cure of trigeminal neuralgia by
means of peripheral operations.

265.

Moseti.g-Moorhof, death of. 739.

Mosquito extermination in New Jer-
sey, 528.

Mothers, clinic for, 822.

Mt. Sinai Hospital appointments, 611;
report of the, 109.

Mountain sickness, a remedy for, 21.

Mouse tumor, the nature of Jensen's,
237-

Mumps, the ocular complications of,
195.

Murphy button, the, 185.

Muscular contractures, the treatment
of ischemic, 870.

June 29, 1907]

INDEX.

1 103

Myasthenia gravis psuedoparalytica,

244.
Myxedema, deafness in, 409. 534.

N.

Narcosis, the effect of, on the blood,
534-

Nasal affections, mental symptoms in,
1071 ; conditions in the etiology of
diseases of the ear, 261 ; patient, ten
years a, 143 ; respiration, why de-
fective impedes development, 650;
sinus and eye diseases, 532; sinuses,
empyema of the, complicated by
orbital abscess, 240; sinuses, the
accessory, 448.

Nasopharynx, the relation of the to the
dental arch, loio.

National Association for the Study of
Epilepsy, 359.

National Association for the S'tudy and
Prevention of Tuberculosis, 358.

National Association of U. S. Pension
Examining Surgeons, 863.

Naval medical service, the, 104; vacan-
cies in the, 821.

Nebraska State Homeopathic Society,
946.

Nebraska State Medical Association,
863.

Nematodes, two new parasitic, 1043.

Nephritis, decapsulation in, 116; ex-
perimental chronic, 280; of pre-
natal origin in the young, 186; the
salt-free diet in chronic, 381, 417;
toxic, 207.

Nephropexy, thirty cases of, 672.

Nerve fibers, regeneration of, 451.

Nerves, lesions of, experimentally pro-
duced by toxins, 829 ; regeneration
of, in paralysis, 952.

Nervous breakdown, the treatment of,
791 ; disease in general practice,
499; system, acute infective condi-
tions of the, 661.

Neuralgia, brachial, and arm pains,
297, 3.^0: facial, and radiotherapy,
615 ; modifications of the Gasserian
ganglion operation for, 921 ; the
galvanic current in trigeminal, 871 ;
the radical cure of trigeminal, 265.
321, 360.

Neurasthenia, notes on 6,000 cases of.
681 ; sea air in the treatment of,
944; tropical. 733.

Neuritis, endemic, 659; in children,
744; multiple, simulating progres-
sive muscular atrophy, 448.

Neurofibromatosis, diffuse. 115.

Neurology, the physiological concep-
tion of disease in, 365.

Neuronophagia, 65.

Neustaedter, M.. some potent etiologi-
cal factors in backward children.
226.

New Hampshire State Medical Soci-
ety, 907.

New Jersey, health statistics in, 821.

New Mexico State Medical .\ssocia-
tion^ 907.

New York Academy of Medicine, the
Section on Public Health of the,
189.

New York City, vital statistics of. 66,

New York Neurological Society. 65.

New York Physico-Therapeutic Asso-
ciation, 3.^8.

New York Skin and Cancer Hospital,
441.

New York State Board of Medical
Examiners, 944.

New York State health report, 317.

New York State library, the medical
department of the, 201.

Nipple, some dangers of the rubber,
775.

Nitric acid from the atmosphere, 190.

Noise, society for the prevention of un-
necessary, 108, 527, 1079.

Nomenclature, the correction of medi-
cal, 993-

Norstrom, Gustav, physiological action
of massage, 139.

North Dakota State Medical Associa-
tion, 907.

Northwest Arkansas Medical Associa-
tion, 573.

Nose, the importance of microscopical
examination of growths removed
from the, 352.

Nurses, State registration of, 401 ; the
untrained, new field and opportuni-
ties, 155..

Nutrition, commission on problems of,
572.

Oak Park Hospital and Training

School for Nurses, 273.
Oatmeal in the dietary of children, 829.
Oditiiaries :

Adair, .A.bsolom W., 237.

Adams. Daniel S'., no.
Aldrich, Joseph A., 68.

Alley, A. R., 359.

Ard, W. E., 237.

.\rnett, Robert C, 573.

Babcock, L. W., 22.

Bachman, Gustave A., no.

Raker. Dicia H., 656.

Baldridge, M. D., 995.

Banks. William H., 995.

Barker, John, 320.

Barnes, Justin L., 657.

Bartlett, Cyrus K., 68.

Bartow, George W., 573.

Beckwith, Frank E., 22.

Belt. Edward C, 68.

Bennett, E. 0., no.

Berger, H. C, no,

Bcrnays, Augustus C, 908.

Berry, Lawrence. 657.

Bickel, Samuel D., 574.

Biggers, George W., 657.

Birckhead, Edward H., 1081.

Bishop, Timothy H., 22.

Blackiock, John J., 151.

Bliss, Lyman T., 443.

Brennan, John W.. 823.

Brinton, John H., 529.

Broadnax, John G., 864.

Brokaw, Augustus V. E., 237.

Brown, Charles R., 573.

Bryant, Edward G.. no.

Buckley, Clarence E. A., 613.

Bucknall, Geo. J., 1081.

Bucknuni, Amasa M., 947.

Burdett, Harry E., 612.

Burton, Reuben B., 740.

Butler, Winthrop, 739.

Butler, W. J„ 443.

Butnian, William A., 359.

Buttles, Marvin S., 823.

Cadwallader. Charles E., IO38.

Campbell, L. .S.. 320.

Campbell, William R., 697.

Carpenter, Edward L., 612.

Casey. James E., 864.

Cassel, J. K.. 443.

Chappell. William J., 275.

Charlton, J. B.. 779.

Christensen, M. C, 740.

Church, George T,, 443.

Clarke. Samuel, 574.

Clements. J.S.. 151.

Cleveland. Joseph M., 192.

Coghan. Richard M.. 68.

Collet. P A. A.. 946.

Collins. David A., 275.

Combe, Charles B., 657.

Combes. R. C. F., 530.

Comfort. R. P.. 275.

Cowles. F. S.. 359.

Craft, Shuler, 864.

Grain, William B., 443.
Crawford, J. P., 613.
Crawford, W. N., 151.
Crummer, B. F., 237.
Culpepper. Charles, 68.
Cununins, J. A., 864.
Currier, C. B., 779.
David, C. A., 1038.
De Paul, Stanley A., 697.
Din.gee, William H., 68.
Donnelly, William H., 320.
Dooley, A, J., 22.
Doughty, Francis E., 22.
Douglass, George, 237.
Du Clos, E. A., 740.
Dudley, Henry W., 68.
Dudley, Pemberton, 573.
Duggins, George B., 947.
Durrie, George B., 947.
Edgar, J. L., 530.
English, John F., 320.
Evarts, Henry P., 657.
Everett, James B., 947.
Parries, Robert, 573.
Fayrcr, S'ir Joseph, 908.
Fecteau. L. A., 995.
Fenn. Charles M., 488.
Fere, Charles H., 908.
Ferriere, Feli.x, 779.
Fletcher, W. B., 739.
Formento, Feli.x, 995.
Fossard, George H., 779.
Foster, Jo Charles A., 864.
Fountaine, Clement O., 573.
Fowler, George B., 403.
Fox, Albert, 573.
Francis, Valantine M., 995.
Frazier, S. H., 1081.
Fuerth, George F., 995.
Fuller. Francis Van Cleve, 573.
Gaffney, Henry A., 320.
Gale, George F., 696.
Gardner, Clarence T, 908.
Gaudet, Oscar, 359.
Genge, William W.. 697.
Gilbert, Chas. B.. 1081.
Gill. Henry Z., 359.
Gill, H. Z., 320.
Glynn, Joseph W., 68.
Goodwillie, David H., 864.
Gray, Robert W., 192.
Greenfield, C. B., 3S9.
Grinnell, Ashbell P.. 613.
Groot, Simon L, no.
Gunthcr, Dr. E. E. C, 237.
Hammond, J. H., 995.
Hampton. J. P., 1039-
Harlow, John M., 664.
Harris, W. H., 657.
Hart. Israel, 1081.
Hasty, J. Fields, 946.
Hayden, Henry R.. 779.
Haves, A. D., 1081.
Hill, Thos., 1081. ^
Hingston. Sir William, 403.
Hipp, William H., 22.
Hixon, Columbus, 488.
Hopkins, J. J.. 530.
Hotchkiss. William H., 779.
Hovey, William F., 192.
Hubbard. Benjamin, 192.
Huger, William H., 22.
Humes, Albert H., 864.
Ide, Henry C, 1039.
Jenks, Halsey B , 237.
Johnson, Benjamin P., no.
Johnson, Jordan. 908.
Johnson. J. W., 151.
Johnson, Philip E., no.
Johnston, W. M., no.
Jones, I^eander P., 530.
Jopes. W. H., 6q7.
Joy. Henry fSeWitf, 657.
Judson, Walter. 22.
Justice, August L.. 275.
Keith. John G., 403.
Kendall, W. J., 403.
Kennedy. William E.. ^rg,
Kern. W. M., 607.
Kilgore. J. C, 697
King, George E., 1039.

II04

Knight, J. N., 6l2.
Korn, J. S., 697.
Kost, Henry, 151.
Kuckein, Franz, 192.
Laight, Charles, 779.
Lame, William, 488.
Lathrop, James R., 488.
Learnard, Noyes N., 864.
Leavitt, Clark, 22.
Le Barbier, Henry A., 192.
Lechtman, Isaac, 697.
Lehardy, Julius C., no.
Leonard, William H., 823.
Lewis, C. L., 1081.
Lewis, J. F,, 946.
Lewis, Sylvester D., 1039.
Loeb, Joseph A., 403.
Lombard, Guy D., 908.
Lothrop, J. E., 488.
Lott, William C, 237.
MacDonald, John, 22.
MacGregor, Robert S., 530.
Macintosh, Alexander, 443
MacMillan. John, 823.
McAdams, Charles A., 573
McCarthy, William D., 612.
McConnell, J. W., 573.
McCune, Olive F., 68,
McDonald, Edward W., 488.
McDonald, R. H., 151.
McNeel. J. Henry, 237.
Main, John T., 823.
Mansfield, Joseph D., 946.
Marcellus, Thomas M., 823.
March, John Edgar, 657.
Marmion, Robert A., 995
Marsh, J. T., 359.
Mattison, Charles D., 739.
Mayham, Thomas R, 237.
Medberry, J. M., 823.
Meredith, Solomon D., is I.
Merrill, Frederick G., 403.
Merwin, Everett H., 275.
Michell. R. F., 606.
Miller, W, H. H., 237.
Mills. Andrew M., 740.
Milne!-, S. G., S23.
Mitchell, Joseph, 320.
Morrissey, John j., 1039.
l\Iorrison, W'. Frank, 696.
Mount, J. W., 22.
Muhlenberg. H. E., 1081
Mullholland, Chas. L., 1081.
Muller, .'\lphonse. no.
Myers, William H., no.
Neill, Charles, 864.
Nichols, George H., 359
Nott, T. E., 192.
Noyes, Lyman A._, 151.
Olney, Herbert S., 739.
Orbin. Francis E., 740.
O'Reilly, Edward R., 946.
Oronhyalekha. Dr., 488.
O'Shea, Joseph, 359.
O'Sullivan, James S., 613.
Ottley. Charles W.. 864.
Packard, John H., 908.
Parker. J. W., 44-^
Parker. Willard. io8i.
Pendleton, James D., 697.
Perrv, Laurence P., 574
Pickett. W. C, 275. "
Poppleton, Edsiar, 047.
Price. R. B.. 151.
Proegler. Carl P.. T02.
Provan. Robert. 443.
Randolph. Wilson C. N 779
Ray. Joseph C. B.. 488.
Reed. Charles, 44'?
Reilly, Charles ¥., 612.
Reilly. Frank. 656.
Rickerts. Edmund C, no.
Ridee. Isaac M.. 863.
Ritchie. A. F.. 656.
Robbins. Ray P., 779.
Robinson. John A.. 1038.
Rose. Gilbert L., no.
Routhier. Omar. 320.
Rupn. .^dolph. 319.
Sanders. John C.. 22.
Schoenberg. Gustave. 740.

INDEX.

Schulze, C. J., 1081.
Scott, Clifton, 443.
Seeley, Lamar, 1038.
Shaw, E. M., 151.
Sheffield, M. A., 612.
S'henk, David H., 530.
Shepherd, George R., 613.
Sheridan, O. M., 275.
Shirk, Adam, 192.
Simpson, Charles, 908.
Simonton, A. C, 612.
Sin'-lair, A. C, 275.
Skillman, Thomas A., 443.
Slayton, E. W., 573.
Smith, George W., 740.
Smith, Henry Clay, 488.
Smith, Junius F., 739.
Sneed, W. J., 530.
Southworth, Makel A., 403.
Spence, Arnot, 191.
Spillman, Henry W., 656.
Standlev, J. W., 68.
Steele, J. W., 443.
Stein, Herman, iioo.
S'teward, William, 22.
Stickney, Alonzo L., 995.
Strachn, John B., 320.
Sturges, John C, 864.
Style?, Herbert K., 779.
Suesseroth, Fred., 443.
Sugg, Josiah P., 237.
Suggs, John W., 908.
Swartzlander. Frank, 613.
Swinton, William J., 10.^8.

Talley, Frank W., 359.
Taylor, J. N., 613.
Taylor, William M., 696.
Thoma. George H., 275.
Thomas, J. Qark, 359.
Thomas, William B., 530.
Tinsley, Austin S., 697.
Tomlin, B. F., 779.
Townsend, Charles W., 192.
Turril, Henry S., 907.

Utley, James, 530.

Waggoner, F. A., no.
Wakeman, William J., 530.
Wakley, Thomas H., 69/-
Wallace, Ellerslie, 359.
Wallian, Samuel S., 1038.
Warner, Albert M., 612.
Watson. George H., 908.
Webster, Frank P., 779.
Weigand. Otto A.. 573.
Welch. Jeannette C, 68.
Wemple, E. L., 192.
Wheeler, Franklin, 275.
Wheelock, George G., 530.
Whittemore, N. K., 995.
Wiley, Eugene, 864.
Wilkin, R. D., 1081.
W^illard, A. J., 573.
Williams, Herbert B., 40'?
Willis, J. M.. 443.
Wilson, John, 779.
Winfree. John M.. 613
Wolf. Jacob G., 68.
Wood, Robert T., 2-5.
Woodson, Thomas M., 359.
Woodward. E. A.. 697.
Woolsey, Elliott H., 237.

Yancey, Charles K., 320.
Yost, Alfred J., 697.
Young. I. D., 739.

Obstetric forceps, a modification of
the, 165 ; knowledge, the nurse's,
689; pads, 1022; technique, mod-
ern, 167.

Occipital lobes, the connection of the.
to the visual functions, 791.

O'Connor, P. T., varicose veins of the
lower extremities and their treat-
ment, 183.

O'Crowley, C. R., the internal and ex-
ternal remedies in urinary diseases
and their comparative value, 800.

Omentum, torsion of the, 827.

[June 29, 1907

Open-air wards on Metropolitan Hos-
pital, 246.
Operations, the early mobilization of
patients after major, 476; unnec-
essary, the opprobrium of modern
surgery, 238.
Ophthalmia neonatorum, the prophy-
laxis of, 579, 1018.
Opium restrictions in China, 862.
Oposstnn. uterus of the. 770.
Oppenlicimcr. Seymour, some remarks
on the radical mastoid operation
for the cure of chronic suppuration
of the middle ear, 425.
Opsonic content of the blood of in-
fants, 196; index, in the diagnosis
of tuberculosis, 692; index, the, in
the sane and insane, 913 ; index
the, in tuberculous peritonitis, 522;
index, the tuberculous, 570; power
of blood serum and milk, 745^ the-
ory, the present status of the, in
tuberculosis, 917; treatment of
surgical diseases, 326.
Opsonins and immunity, 619 : and
treatment by bacterial vaccines,
242: and the opsonic index, 327;
further experience with, 147;
in tuberculosis, 1051 ; points re-
garding, 661; symposium on, 836;
the present status of, 397.

Optotnetry bill, the, 906, 994 ; vetoed in
Illinois, 906.

Organism, the factors of safety in the,

364.
Ossining Hospital, dedication of the,

191.
Osteomyelitis, in children, 1048.
Osteopathy bill. 273, 487; in Illinois,

defeated, 820; vetoed, 777.
Otis, the late Dr. W. K., 823.
Otitis media, acute. 660; aspiration in

acute 603.

Otologi,- improved technique in, 156.

Ovarian cyst in an infant. 1042; para-
typhoid fever following the re-
moval of an, 912.

Ovary, a case of inoperable sarcoma of
the, 4.36 ; specimen of calcified, 286.

Ovum, retention of the after abortion,
1086.

Oxygen baths. looi ; injections of, in-
to the knee joint, 70L

Ozena, packing the nose in. 32 ; the
cause of the odor of. 654.

Painful points, the efJect on the cir-
culation of pressure on, 316.

Palier, E.. the intestinal bacteria; how
they acquire toxicity, and how to
determine this experimentally for
clinical purposes, 7.

Palpation, bimanual vibratory. 951.

Palsies, cerebral, of children, 29.

Paludism, a typical manifestation of,
326

Panama, death rate at. 20; health con-
ditions in, 274, 906. 1070.

Pancreas, the cause of death in acute
diseases of the, 483 ; the treatment
of injuries of the, 495.

Pancreatectomy in the dog. 535.

Pancreatic digestion in man. 232; en-
zymes, the physiolo.gical a«tion of
the. 885.

Paralysis agitans. the patholo.gy of
660; operations on the nerves in
ischemic. 921 ; the gradual cure of
hysterical, 827.

Paranoia, the curability of, 567: the
psychogenetic factors in, with sug-
gestions for prophylaxis and treat-
ment. 708.

June 29, 1907]

INDEX.

1 105

Parasites, the staining of animal, 534.

Pardee, a testimonial to Dr., 274.

Paris, letters from, 70, 278, 446, 741,
82s.

Parker, Delos L., the cause of com-
mon baldness, 220.

Pasteur Institute, bequest to the, 274.

Pasteurization, advantages and disad-
vantages of, 576; bill at Albany,
443; bill introduced, 357; defeat
of. 862.

Patella, the catgut suture in fracture
of the. 32; the treatment of frac-
ture of the, 748.

Paternalism in medical organizations,
the evil of, 440.

Pathology, institute of for the City
Hospital, 1079.

Pauper cases, the treatment of, 862.

Peabody, George L.. aneujysm of the
arch of the aorta, a case of rup-
tured, 595; the salt-free diet in
chronic parenchvmatous nephritis,
381.

Peck, Dr. Charles H.. honor for, 737.

Pediatrics, the new era in. loio.

Peet, Edward W., trypsin for the cure
of cancer, 69, 152.

Peliosis rheumatica, 198.

Pelvic and renal tumors. 750; articu-
lations, diseases of the, 1006.

Pemphigus neonatorum, the etiology of,
1036.

Pennsylvania, medical legislation in,

I49-

Pennsylvania State Hospital for the
Criminal Insane. 610.

Pericarditis, pathology and symptom-
atology of chronic adhesive, 80;
with efision, pulsus paradoxus in,
618.

Pericolitis, hyperplastic tuberculous,

15;-

Perineal nerve, fiaralysis of the. fol-
lowing childbirth. 28.

Perineorrhaphy, a new plan of sutur-
ing in. 908.

Perineum, immediate repair of the,
after labor, 166; to avoid lacera-
tions of the. 701.

Peritoneal adhesions, prevention of, by
adrenal salt solution. 965.

Peritoneum, certain diseases of the,

156. ,

Peritonitis, acute, perforative, 575 : so-
lar baths in tuberculous. 775: the
treatment of acute. 302 ; treatment
of acute septic. 277: treatment of
acute suppurative. 68. 113. 207; tu-
berculous. 742.

Pes planus from the viewpoint of neu-
rology. 57.

Peterson. Frederick, a thermesthesi-
ometer and a pocket egthesiometer.
459: the electric psychometer. J70.

Petit. Raymond, sterilized horse serum
in surgery. 1017.

Phagocytic cells, atypical, in the blood,

699'

Pharmacopeias, uniformitv in. 607.

Pharynx, acute edema of the. with a
case requiring rapid tracheotomy,
350.

Philadelphia County Medical Society.
150.

Philadelphia Pathological Society. 604.

Philadelphia Polyclinic, new dispen-
sary for the. 777.

Phillimore. Raymund H.. dipsophilia,

047-
Phimosis a? a cause of disease. 1086.
Phlebitis after laparotomy. 326.
Phlebosclerosis. 756.
Phototherapy in nervous disease. 474,

500.
Phvsician. the income of the practicing.

" 314-
Pick's disease, a case of, 212.
Piffard, Henry G., indicanuria, 1039.
Pigmented spots in the sacral region

of white and negro children. 456

Pilocarpine in pruritus, 858, 947; in the
treatment of syphilis, 988.

Pityriasis rosea, a report of several
cases mistaken for syphilis, 761.

Placenta, premature detachment of the,
699; prxvia, 751; retention of the,
484.

Plague, accidental inocculation with,
661 ; bubonic in Siam, 1084 ; ex-
pcrmienter contracts, 401 ; gland-
ular extract from immunized an-
imals as a curative agent in, 261 ;
in America, 365 ; in East Africa,
401; in India, 695, 862, 906; in
Rio Janeiro, 150; in Russia, 442;
in Trinidad. 1038; to combat the.
882.

Plastic operations, causes of failure in,
623.

Pleuris)', experimental, fibrous, 8.34 ; is
an herpetic origin of possible?
769; the treatment of with iodide
of potassium. 263.

Pneumococcus and typhoid infections,
200.

Pneumonia, a case of apyretic. 332;
and heart disease, the use of calcium
salts in. 578; and typhoid fever,
the treatment of, 729; calcium
salts in the treatment of, 952; car-
diac dilatation in, 439; contusion.
702, in children, the hydriatic
treatment of, 267; paralyses, 65;
poisoning by CO: in. 870; patho-
genic. 158; streptococcus, 262; the
abortive treatment of. 426 ; the
fresh air treatment of, 614; the
quinine treatment of. 113: the
treatment of. by fresh air and sa-
line solution. 507.

Poison squad tests, an inquiry into
the. 108.

Polish Pliysicians and Scientists, Con-
gress of. 359. 822.

Politzer. retirement of Prof.. 69,.

Polvomvelitis. electrical treatment of.
185:

Polyserositis, 663.

Pooley. Thomas R.. a method of op-
eration on the lip. III.

Porter. William Henry, indicanuria. its
etiology and practical significance,
980.

Practice, an unoccupied field of. 1035.

Practitioners, reminiscences of early,
in New York. 129. i6t.

Prager. Paul a new method of identi-
fication superseding dactyloscopy.
1065.

Pregnancy, abdominal, with fetal re-
tention for 21 vears, 75 ; cystoma
complicating, 1033 ; diagnosis of
earlv, with reference to a par-
ticular sign, 597. 624: extrauterine
an unusual, a specimen of. 333 :
extrauterine, external hemorrhage
with. 911: extrauterine, laparot-
omy for infected. 334 ; multiple.
3.=;8: ovarian. 286. T044; the fever
of. 63: the pathogenesis of the
vomiting of. 65; toxemia of. 120;
vomiting of. 662.

Proprietary medicines. 141.

Prostate, electrical treatment of con-
gestion of the, 744 : hypertrophy
of the. 992; massage of the and
seminal vesicles, 1061 ; sarcoma of
the. 920.

Prostatectomy. 920.

Prostatitis. 09Q.

Proteids. the disadvantage? nf low in
infant feeding. 1000.

Protozoa and disease. 699; diagnosis
of pathogenic. 909.

Psoriasis, atypical. 36; of the scalp and
hands only. 335; the urine in. 63

Psychiatry, open-air treatment of. 246.

Psychometer. the electric, 179.

Psychosis, operative treatment of trau-
matic. 533.

Pubiotomy, 580, 617, 794.

Public Health Defense League, 145.

Puerperal thrombophlebitis of the pel-
vic veins, 162.

Puerperium. h>-pothermia with slow
pulse in the, 756.

Pulmonary diseases in relation to life
in assurance. 952; edema, death
from, in periamygdalitis. 115; re-
gurgitation, two cases of. 1000.

Pulsus bisferiens. 784.

Pupillary reaction, a new, 654.

Pure food bill, a State, 400.

Pus tubes in the male, 731.

Pyelitis in childhood, 734: in infancy
and childhood, with remarks on
the urine, 285.

Pyelonephritis, the diagnosis of, 1000.

Pyloric stenosis, the medical treatment
nf congenital. 577.

Pylorus, congenital stenosis of the,
Qio: stenosis of the. following the
absorption of caustics. 33,5.

Q.

Quinine injections and tetanus. 493;

is the efficacy of in malaria more

apparent than real? 28.
Quinquaud's sign, the significance of,

1035-

Rabies, 67; the fallacy of the rapid

diagnosis of, 407; to restrict the

spread of, 945-
Race suicide, 187.
Rachitis, the diagnosis and treatment

of, 1000; the etiology of, 860.
Radius, dislocation of the semilunar

bone complicating fracture of the,

=53^; fracture of the upper end of

the. .=;82.
Railway accident mortality. 777.
Ray Brook Tuberculosis Sanatorium,

486.
R.iynaud's disease. 826; of syphditic

origin. 374.
Recompense, a heraldic. 694.
Rectum, an operation for prolapse 9f

the. 601 ; the after-treatment in

excision of the, 608.
Red Cross Congress. 572. 903; aid to

China, 109.
Reid. John J., the use of pilocarpine

for the relief of pruritus, especially

in regard to pruritus vulvae, 858.
Resniratorv tract, bacteriology of the,

827; catarrh of the upper, 584: the

surgery of foreign bodies in the,

307.

Retropharyngeal growths. 578.

Retroversion operation, a new, 194.

Rheumatism and its treatment. 89;
chronic articular and arthritis de-
formans, 746; in children. 281; the
microorganism of, looi.

Rheumatoid diseases, 201.

Rhinitis, atrophic. 73: in children, 28.

Rhinopharyngitis mutilans. 464.

Rhinoplasty, a new method of. 797- _

Rhinoscleroma. improved under radio-
therapy. 36; treated with the .r-ray,

Rhode Island State Medical Society,
1080.

Richardson. Hubert., arrested mental
development. 604.

Richardson, resignation of Dr. W. L.,
822.

Roadways chemically treated. 992.

Robinson. Beverley, proprietary medi-
cines. 141.

Robinson. Jubilee of Dr. Byron. 319.

Robinson. William J., pilocarpine as an
adjuvant in the treatment of syph-
ilis. 088.

Rockefeller Institute, scholarships and
fellowships of the. 234.

Rockwell. A. D., phototherapy in nerv-
ous disease, 474.

iio6

INDEX.

[June 29, 1907

Roentgen ray, a comment on the, as
applied to prostatic enlargement,
902, 924 ; a method of locating for-
eign bodies with the, 119; table, a
new, 586; applications of the, in
dermatology, 782; complications
caused by the application of, 410;
death from, 738 ; findings, 743 ; the
toxic reaction following exposure
to the, 773 ; transparency of the
cranial bones to, 535 ; treatment
of Hodgkin's disease, etc., 352;
treatment, rule as to negligence
in, 444.

Ronginsky, A, J., some aspects of ster-
ility and its treatment, 1024.

Rose, A., a complete edition of the an-
cient Greek medical writers, 153 ;
election of, to a Greek society, 822.

Roseola, venous compression as a di-
agnostic method in latent, 61.

Round ligaments, finding the. 283.

Rubella, severe types of, 860.

Russell, Colin K., supernumerary cer-
vical ribs and their effect on the
brachial plexus and subclavian ar-
tery, 253.

Russell, the late Dr. Julia W., 402.

Rutherford. J. G., the trypanosome of
dourine, 947.

St. Gregory's Hospital, a charter for,
27s.

St. Luke's Hospital, bequest to, 994.

Sacroiliac joints, affections of the, 412
668.

Safety, the factors of in the organism,
.364.

Sahli's desmoid reaction, 61, 204.

Saline infusions, the action of, in bac-
terial toxemia, 570.

Saliva, the effect of on bacteria, 18.

Salt and sugar injections in infants,
953-

Salt solution as an irrigating fluid,
355; the subcutaneous injection of,
in children, 819.

Sanatorium Gabriels, 529; treatment
the physiological therapy of, 202.

Sanitation, for a national department
of, 993 ; the march of, 950.

Sarcoma of the liver in a child, 869;
of the tendon sheaths. 579; uveal,
29.

Sausage, standardized. 528.

Scarlatina, complications of. 451 ; in
Boston, 108; incubation of, 282; is
it a streptococcus disease? 618;
persistency of infection in. 197 ;
streptococcus erythema and, 913 ;
the e.xanthcm of and its counter-
feits, 74.

Schadle, Jacob E., the antrum of High-
more as an etiological factor in
the production of hav fever (so-
called). 841.

School children, eyeglasses for. 1038:
statistics relating to. 402; children,
the inspection of. 441 ; hygiene, de-
partment of. 318: medical inspec-
tion in public. 992.

Schwann, a monument to Theodor,

Sciatica, the injection treatment of,
232 ; treatment of chronic, 197.

Scleroderma and myositis. 197; cured
by mercurial treatment, 496.

Scopolamine anesthesia in obstetric
practice. 367: morphine anesthe-
sia. 671 ; morphine-chloroform nar-
cosis. =;'^;; morphine narcosis in
labor. 663: narcoses. two hundred
089; poisoning. 783.

Scorbutic symptoms caused by the ty-
phoid bacillus. 185.

S'cranton. typhoid epidemic, the, 21,
326.

Scripture. E. W.. the treatment of
stuttering, 771.

Scurvy in Russia. 862.

Seasickness, to prevent. 528.

Sea water, hypodermic injections of,
580.

Sediments, a convenience in examin-
ing, 32.

Senility, premature, 109.

■Septicemia in lying-in hospitals, the
open-air treatment of, 246; menin-
gococcus, 1000.

Scrratus, causation and treatment of
paralysis of the, 1044.

Serum, sterilized horse in surgery, 1017.

Sewage disposal problem, the, 108.

S'ex, determining the, of the fetus, 325.

Sheffield, Herman B., vulvovaginitis in
children, with special reference to
the gonorrheal variety and its
complications, 767.

Sheldon, John G., the preappendicitis
state, 732.

Shellfish from polluted waters, 571.

Shiels, George P., a few remarks on
medical expert testimony, 181.

Shock, conditions of the vessels dur-
ing, 449-

Sigmoid flexure, resection of the, 216.

Sinus, variations in the frontal, 196.

Skin, danger signals from the. 199:
disease of the. caused by a canine
parasite, 1044 : diseases, electricity
in the treatment of, 75 ; tropical
ulcerations of the, 953.

Skull, a case of depressed fracture of
the, 748.

Slander, a suit for, 821.

Sleep, the reflexes during, 410.

Sleeping sickness, 578; the present
means of combating, 327.

Smallpox, cases of, 528. 655. 906; in
Missouri. 358.

Smith. Emmet L., asthma, observations
on 300 cases. 1068.

Smith, retirement of Dr. Andrew H..
1037-

Smith. Stephen, suggestions of a plan
of organizing a hospital system for
the city of New York, I.

Smoke nuisance award, 694.

Snake bite, deaths from, in India. 66;
the treatment of, 828.

Society for the .Suppression of Un-
necessary Noises, 108, 527. 1079;
of Sanitary and Moral Prophy-
laxis, 572.

Society Reports :
-American Climatologica! .Associa-
tion. 839.
American Gynecological Society, 793.

1049.
.American Medical Association,
Council on Medical Education of
the. 776; General Session, 958;
House of Delegates. 954. 1003 ;
Section on Diseases of Children.
066. T008: Section on Obstetrics
and Diseases of Women. 963.
1006: Section on Practice of Medi-
cine. 962. loii ; Section on Surgery
and Anatomy, 965, 1004.
American Pediatric Society, 873,

1047.
American Surgical Association, 795

837. 918.
Association of .American Physicians

791, 834, 1087.
Chicago Laryngological and Otolog-

ical Society. 660.
Chicago Medical Society. .'^O. 82, 251,

585. 627. 66g.
Chicago Pediatric Society. 58?.
Chicago Sureical Society. 503. 670.
College of Physicians of Philadel-
phia. 418. 1003: Section on General
Medicine. 252.
Congress of .American Physicians

and S'urgeons. 78S.
Medical .Association of the Greater
Citv of New York. 16=;. 4S3. 499,
667. 877.
^fedi<•al Jurisprudence Society of

Philadelohia. 754.
Medical Society of the County of
Kings. 122. 250. 542. T089.

Medical Society of the County of

New York, 247, 371, 498, 706.
Medical Society of the State of New
York, House of Delegates, 199;
Scientific Section, 199.
National Association for the Study
and Prevention of Tuberculosis,
707 ; Pathological and Bacteriolo-
gical Section, 1050; Section on
Tuberculosis in Children, 832;
Surgical Section, 916.
New York Academy of Medicine, 77,
160, 246, 369. 537. 665, 704, 1013;
Section on Dermatology, 34, 36,
373. 415; Section on Medicine, 79,
288, 874, 1053 ; Section on Obstetrics
and Gynecology, 286, 333, 622, 750 ;
Section on Pediatrics, ''85, 331,
455, 625 ; Section on Public Health,
500; Section on Surgery, 412, 582,
.748.
New York Psychiatrical Society,

708.
Philadephia County Medical Soci-
ety, 753.
Philadelphia Neurological Society,

83, 671.
Philadelphia Pathological Society,

753. 799.
Philippine Islands Medical Associa-
tion, 865, 909. 949.
Practitioners' Society of New York,

330, 417, 621, 922.
St. Louis Medical Society of Mis-
souri, 671.
S'outhern Surgical and Gynecological

Association, 118, 162.
Williamsburg Medical Society, ■?".
502, 584.

Sodium cocodylate, 1084; salicylate,
hematuria from, 327.

Soldiers' Homes, no canteen for, 358.

Solly, the late Dr., 863.

Sound, a suction and instillation, for
the treatment of urethritis, 419.

South Carolina State Medical Asso-
ciation, 739.

South Dakota Medical Association, 994.

Southern Railway Surgeons' Associa-
tion, 995.

Spark, value of the high-frequency,
1042.

Spermatic cord, cellulitis of the, 449.

Sphygmoscope, the, 409.

Snina bifida, 577.

Spinal anesthesia, meningeal irritation
from, 735 ; anesthesia, . the tech-
nique of, 106; curvature, unno-
ticed, lOOI.

Spine, fracture dislocation of the, 465,
498: fracture dislocation of the,
symposium on. 49S ; pathological
changes in fracture dislocations of
the, 471, 498; the treatment of
fracture dislocations of the 472,
498.

Spirit and drug taking, effects of on
the upper air passages, 939.

Spirochirta pallida in a pigmentary
macule, 496; staining the, 869; the
in hereditary svihilis. lOOi.

Spirochetes in framboesia tropica, 702;
question, the. 114 : the. of relapsing
fever. 1088; the technique of stain-
ing for, 115.

Spitters. street, arrested. 401.

Splanchnoptosis from the standpoint of
the physician. 364.

Spleen, subcutaneous rupture of the,
919.

Splenectomv. five successful cases of,
,164

Splenomegaly, the etiology of, 285.

Spondylose rhizomelique, 659.

Sport, a healthful. S3i ; age limitation
of. 280

Sprains and their consequences, 31, 701.

Springfield Academv of Medicine. 236.

655.
Sprue treated by strawberries. 30
Stammering, the physiology of lan-
guage and its relation to. 72.

June 29, 1907]

INDEX.

1 107

Starr, M. Allen, a new type of ataxia,
804; the radical cure of trigeminal
neuralgia, 321.

Starvation cure, dangers associated
with the, 527.

State Board Examination questions
and answers, Florida, 125; Idaho,
1055; Indiana, 968; Kansas, 41;
Nevada, 628; New York, 460;
Ohio, 881 ; Oklahoma, 701 ; Penn-
sylvania, 545; Texas, 208; Ver-
mont, 377; Virginia, 291.

State Examining Board, a single for
New York, 275.

State Hospital, for a new, 572.

State institutions, appropriations for,

6S5-

State medical examining boards, con-
federation of, 776.

Staten Island Tuberculosis Hospital,
objection to, 694.

Status lymphaticus, 912 ; its signifi-
cance in sudden death following
serum injections, 376; the symp-
toms of in infants, 1848.

Sterility, the treatment of, 1024.

Sterilization, Doderlein's method of,
1044.

Stern, Arthur, the fresh air treatment
of pneumonia, 614.

Stern, Heinrich, autointoxication in its
medicolegal aspects, 973.

Stethoscope, certain limitations of the.
83J

Stomach, acute dilatation of the, 819;
a clinical view of ulcer of the, 850;
diagnosis and treatment of ulcer of
the, 1066; hereditary in ulcer of the
.S55 ; pyloric tumor of the, 582; re-
peated laparotomy for perforation
of ulcer of the, 328; surgery in
ulcer of the. 790; surgical aspects
of cancer of the, 164; the age in-
cidence of ulcer of the, 158; the
distribution of ulcer of the, 20;
the lymphatic system of the, 784;
the medicinal treatment of ulcer
of the, 789; the relation of the to
labor pains, 400; tube, the in diag-
nosis, 649; ulcer of the, diagnosis
and surgical treatment of. 85 ; ul-
cer of the. in children. 354;
wounds of the, treated by laparot-
omy, 116.

Stone, William S.. gonorrhea in
women, 685.

Stony Wold sanatorium, 191.

Strauch. August, buttermilk as an in-
fant food. 515.

Straus. S.. intrabdominal abscess due
to gonorrheal and bacterium coli
infections complicating pregnancy;
operation with combined vaginal
and abdominal drainage : recov-
ery, 396.

Street cleaning commission, for a. 993;
symposium on. 704.

Street dirt and public health. 704.

Streptothrix, a new, pathogenic for
cattle. 346.

Stricture in children. 980.

.'^trophanthin. intravenous .ndministra-
tion of. 702.

Strophanthus, tincture of. 618.

Struma, the result of the diplococcus
of Fraenkel. 116.

Study. Joseph N.. embolism. 434.

Stuttering, the treatment of. 771.

Suicide bureau in New York. 401 : bu-
reaus to prevent, 23? : in Japan
7,^8; in Vienna. 140.

Sugar test, a new, 281,

Sulphuric acid, aromatic, in toxemia,
448.

Suprarenal extract, effect of injec-
tions of on the rabbit's aorta. 244;
insufficiency, acute. 601.

Surgeon, the claim of the to conduct
the after-treatment of operative
cases, 366.

Surgery, conservative, in affections of
the uterine adnexa, 217, 287; ora-
tion on. 959.

Surgical drill, fiddle-bow. 296 ; practice,
reminiscences of early in New
York, 161 ; suggestions, 127, 376,
458, 628.

Surra in the Philippines, 190.

Suture material, a new, 19; metallic,
652; the comparative advantages of,
1049.

Synthetic chemicals and the food and
drugs act, 618.

Syphilis, a case of congenital, 285 ; and
cancer and some protozoa, 313 ;
and tabes. 693 ; a study of con-
genital, ,332; four cases of heredi-
tary, 870; four cases of unasso-
ciated with observable secondary
manifestations, 563; in monkeys
821; prophylaxis of, 871; recent
advances in our knowledge of,
942; serum therapy in. 950; the
transmission of to dogs. 746; two
cases of. 36; visceral in children.
332.

Syphilitic fever, tertiary, ^"'. 909.

Syphilodernia frambcesiodes, 37.

Tabes dorsalis. Abadie's symptom in,
767 ; a new theory as to its cause,
985. 1016; the respiratory center
in. 1012.

Tachypnea, hysterical. 871,

Tania nana, spontaneous cure of. 871.

Talbot. Eugene S'.. acid intoxication or
acidosis, a factor in disease, 895.

Talmey. B. S., a case of multilocular
glandular systoma complicating
pregnancy, 1033.

Talmey, Max. Esperanto, 614.

Tea as a beverage for soldiers. I49-

Teaching methods, demonstration of,
946.

Temperance movement, a, 821.

Tennessee State Medical Association,
officers of the. 656.

Tenotomy, of inferior oblique and its
indications. 114,

Testicular atrophy, 579.

Tetanus neonatorum, Baccelli's treat-
ment of, 116; the treatment of
410.

Tetrachlormethan as a solvent. 785,

Texas State Medical Association. 863.

Thayer. A. E.. study of a case of yel-
low fever. 45-

Therapeutic hints. 40. 29=;. 459. 548
s8o.

Therapeutics, advanced, in a gover-
nor's message. 104: skepticism in,
242.

Thcrme=thesiometer and pocket esthe-
siometer, 459.'

Thermometer, the clinical. 653.

Thermotherapv. local. 592. 621.

Thienhaus, C. O.. the relationship^ of
clinical symptoms to microscopical
findings in cases of carcinoma of
the uterus. 518,

Thompson. W. Gilman. fresh air treat-
ment in hospital wards. 213: local
thermotherapy. 502.

Thoracentecis. accidents following
145-

Thoracic compression, some unusual
results of. 637; disease, abdominal
symptoms of. ion; duct, a new
disease of the. 204: injuries and
abdominal rigidity. 005.

Thorax, a simnle method for perform-
ing resection of the. 700

Throat diseases caused bv misuse of
the voice. 16.

Thyroid activity, the relation of diet
to. 578: disease, the surgical treat-
ment of, no: extract, the influence
of on the development of the em-
bryo. 188.

Thyroidectomy, the technique of. """

Tick fever, intermittent. 618.

Tics in children and their treatment.
313.

Tobacco factories, pregnancies, and
abortions of women employed in,
17; legislation against, 694; nico-
tine-free, 611; smoke, the pun-
gency of, 776; smoking in Austria
67 ; the experimental effects of on
the nervous system, 1072; to re-
strict the use of, 945,

Tongue, neuralgia of the, 75 ; the scro-
tal, 7,'?5-

Tonsillar infection, remote eflfects of,
1042,

Tonsils, relation of the to infection
and infectious diseases, 341 ; re-
moval of enlarged, 661.

Townsend. Terry M.. massage of the
prostate and seminal vesicles, 1061.

Toronto Academy of Medicine, 1038.

Tracheostenosis, thymic, 912.

Trachoma in school children. 777; ra-
diotherapy in. 189.

Transposition of the viscera, 754-

Trenwith, W. D., a suction and in-
stillation sound, for _ use in the
treatment of chronic posterior
urethritis with involvement of the
prostatic follicles, 4x9-

Trichiniasis, brief report of a Q3se of,
351: on the East Side. 358.

Trinidad, plague in, 994-

Tropics, clothing for the, 653-

Trypanosomes. 113.

Tsetse flv disease, to study the. 821.

Tub. the' Saturday night. 089,

Tubercle bacilli, split products of the,
1051 : stains for distinguishing
from perlsucht bacilli, 535; the
rapid demonstration of, 860,

Tuberculide, 35.

Tuberculin test, the 868.

Tuberculosis aerotherapy in, i57.
1053; a committee on bovine, 834;
and milk, 105, 672; and the rail-
roads, 156; are children with, lia-
ble to be sources of infection?
833 ; control of, 273 ; crusade, the
sanatorium in the, 157; diet in
pulmonary, 1074; digestive con-
ditions in pulmonary, 963; ex-
perimental in the rabbit, 871;
human and animal, 355; in _ Chi-
cago, the fight against, 527 ; in in-
fancy, 834; in the navy, 318;
Koch's emulsion of bacilli in the
diagnosis of incipient, .307; laryn-
geal. 267 ; mistakes in the diag-
nosis of pulmonary, 327; move-
ment in New York, progress of
the, against, 904 ; observations on
the treatment of in Arizona. 646;
of earlv life, advances in the
knowledge of, 832; of the bron-
chial glands, 860; of the eye,
treated with tuberculin. 746; of
the hip joint, excision in. 950; of
the intestine, occult blood in. 1053 ;
of the kidney, surgical treatment
of. 162; of the tongue, 39; open
air treatment of bone and joint.
1041 ; opsonins in. 745. 746; pleural
pressure after death from, 1052;
prognosis in pulmonary, 95 : pul-
monary, the modern hygienic home
treatment of 717: pyrexia in, loig;
State sanatorium for in Illi-
nois. 235; suboccipital. 20; the
action of garlic in, 861 ; the early
diagnosis of pulmonary. 244; the
economic aspects of bovine. 608;
the frequency of. 189; the home
sanatorium treatment of. 313; the
induction of autovaccination in. by
the .r-rays. 282; the leucocytes in
complications of, 1053; the prog-
nostic value of the diazo reaction in
480; the public control of . 820: the
serum diagnosis of. 198; the trans-
missibility of bovine, 833; the
treatment of, 107; the treatment
of surgical by hyperemia, 830. 016;
the use of the .r-ray in surgical,
917; treatment of surgical at the

iio8

INDEX.

[June 29, 1907

seaside, 786; vaccines in, 1051;
:i--ray findings in, 785.
Tuberculous cows in New Jersey, 571 ;
glands, the j;-ray treatment of,
112; infection of the lung, the
manner in which it takes place,
270; municipal care of the, 18;
poor, the treatment of the, 906;
pus, a method of identifying, 439;
ulceration, the treatment of, 148.
Tumors, growth and infectivity of,
1085 ; immediate microscopical
diagnosis of, 243 ; malignant, the
scientific criterion of, and Jen-
sen's mouse tumor, 24, 403 ; mul-
tiple, 35 ; the transference of in
dogs by the sexual act, 31.
Turbinate hypertrophy, 408; primary

cancer of the, 432.
Turck, Fenton B., a clinical view of

ulcer of the stomach, 850.
Twins, an early case of operation for

the separation of joined, 566.
Typhoid bacilli carriers, 32, 818, 924.
Typhoid fever, appendicitis in, 365 ;
and pneumonia, the treatment of,
729 ; bacteriological examinations
of the blood in, 408, 541 ; compli-
cated by abscesses of the kidney
and pneumonia, 390; epidemics in
Berwick, Pa., Scranton. and Pitts-
burg. 66, 108, 326, 53, 1038; excre-
tion of the agglutinins of, in the
urine. 914: from infected milk. 912 :
in children, 874; inoculation in the
English army, 609, 1043; in Penn-
sylvania, 149; intestinal perforation
in, 965 ; management of the intes-
tinal tract in, 538 ; nitrogenous
metabolism in, 537 ; on the Con-
necticut. 401 ; operations during.
605 : perforations in, 1084 ; per-
foration in, and blood pres-
sure. 912; quinine in, 144; simu-
lating meningitis, 409; spine,
treatment of. 743 : spine, the treat-
ment of, 539 : sulphate of copper
in, 531 ; the diagnosis of perfora-
tion in, 414; the diazo reaction,
bacteriemia, and the Widal reac-
tion in, 914; the responsibility of
the country practitioner for the
existence of, 859.

Urine of children, albumin and casts
in the, 24S; shreds in the, in rela-
tion to diagnosis, 448; the, in early
life, 247; the, in infectious dis-
eases, 248 ; the, in pregnancy, 167,
249; the specific gravity of, 272.

Urobilinuria in typhoid, 663.

Urticaria and influenza, 1043.

Utah State Medical Association, 863.

Uterine adne.xa, conservative surgery
on the, 217, 287; contractions, the
effect of quinine on, 355 ; relaxa-
tion, 19.

Uterus, clinical symptoms and micro-
scopical findings in cancer of the,
.S18; dilating the gravid. 700; dys-
tocia following fixation of the.
163 ; fibroids of the. complicated
by pregnancy. 911; fibroma of the,
with anemia. 871 ; fibromyomata
of the. 715: foreign bodies in the.
207 ; four specimens of fibroids of
the, 334 ; galvanism in the treat-
ment of fibroids of the, 352; inop-
erable cancer of the. 744; in-
version of the, 754: metastatic car-
cinoma of the. 793 ■ operation for
prolapse of the. 1078; parasitic myo-
mata of the. 964; subinvolution of
the in g>'necoIoe\-. 407 : the sur-
gical treatment of fibroids of the,
335 : the value of the cystoscopic
examination in cancer of the, 805;
treatment of cancer of the. 1045 ;
treatment of inversion of the. 861 ;
treatment of myoma of the. 282.

U.

Ulcer, the treatment of rodent, by zinc
ions, 409; ulnar nerve, analgesia of
the from pressure and in tabes,
32- .

Underfeeding and its associated ills,
205.

Ureteral calculus, three cases of de-
tected by .r-ray and removed by
operation, 330.

Urethra, congenital stricture of the.
701.

Urethral abscess and calculi, 282; dis-
charge, treatment of chronic, 240

Uric acid, the influence of chocolate
and coffee on, i8,^.

Urinary diseases, the internal and ex-
ternal remedies in, 809; fistula, lig-
ature of the renal vessels for. 1085,

Vaccination, compulsory and anti-
vaccination. 251. 44t.

Vaccine therapy of surgical infections,
1006.

Vaginal entrance, anomalies of, 671;
section as an operation of choice,
164.

Vaginitis in children, gonorrheal, and
its complications. 767.

Vale. Frank P., inaccuracy of Dare's
hemoalkalinometer. 858.

Valentine. Ferd. C massage of the
prostate and seminal vesicles, 1061.

Van Bafsen, N. T. Poock. throat dis-
eases caused by the misuse of the
voice. 16.

\'an Fleet. Frank, a single examining
board for New York, 2'$.

Varicella, the lesions in, 313,

Varicose veins and their treatment,
183.485.

Vegetarian recruits in Germany. 821.

Venereal diseases in children, crim-
inal aspect of, 643 : disease in the
Continental Army. 779; peril, the,
613 ; the prophylaxis of. 1050.

Venous pulse, the. 1012.

Vermont State Homeopathic Medical
Society. 046.

Version, a new method of. 794.

Vicious circles. 913.

Vienna, letters from, 154. 406, 492, 6t6,
910. 1040.

Vinebere. Hiram N.. conservative sur-
gery in severe inflammatory in-

fections of the uterine adnexa,

Vision, disturbance of, due to exagger-
ration of binocular association,
757-

Visions of Mary Czajka, the, 205.

Vivisection, against, 402.

Volkmann's ischemic paralysis, 408.

Von Bergmann"s last illness, 774.

W.

Walter, F. J., "rheumatism" and its
treatment, 89.

Ward, Nathan G., influenza, mastoid
abscess, leptomeningitis, nine-day
unconsciousness, three operations,
death, autopsy, 385.

Water supply, the, of New York, 122;
the fermentation test for drinking,
482.

Weak foot and its treatment, 667.

Weber, Leonard, the treatment of ty-
phoid fever and pneumonia, 729.

Weber-Parke's prize and medals, 20.

West Virginia State Medical Associa-
tion. 907.

Western Reserve University of Cleve-
land, 21.

Whiskey, physiological action of, 9.S3.

Whistling nuisance, the steamboat, 318.

Wiener. Joseph, surgery in diabetes,
722.

Williams. John Roy, the prognostic
value of the diazo reaction in tu-
berculosis, 480.

Williams, W, Roger, the nature of
Jensen's mouse tumor, 237.

Wilson, Omar M., dermatological
transitions, 640.

Wise. Fred, pityriasis rosea, with re-
port of several cases of this dis-
ease mistaken for cutaneous syphi-
lis. 761.

Woldert, Albert, an original investi-
gation of an epidemic of grip fol-
lowed by a large number of cases
of pneumonia. 11.

Women's Medical Society of New
York State. 656.

Wood. Percy R.. aspiration in otitis
media acuta. 603.

Wood, William C, a healthful sport,

Worster, W. P.. pneumonia in chil-
dren, its successful management
by hydriatic measures. 267.

Wounds, closing aseptic abdominal.
28.

Wright. H. W.. popular education in
matters medical. 8.^7: public con-
trol of disease through a national
department of health. 102.

X.

Xiphopagus, an early case of opera-
tion on a, s66.

Yellow fever, 655; study of a case of.
4S-

t

i

R
11

H433
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